Case report: Changes in defense mechanisms, personality functioning, and body mass index during psychotherapy with patients with anorexia nervosa

Therapists' defense use impacts their patients' defensive functioning: a systematic case study

Research into defensive functioning in psychotherapy has thus far focused on patients' defense use. However, also the defensive functioning of therapists might be significant because of its potential in promoting changes in the patient's overall defensive functioning by sharing their higher-level understanding of a given situation and letting the patient have the opportunity to learn how to cope more successfully. This exploratory case study is the first to examine therapist's defense mechanisms and their relationship to changes in the patient's defensive functioning evaluated at different times throughout psychoanalytic treatment. We assessed the use of defense mechanisms with the Defense Mechanisms Rating Scales in 20 sessions collected at three phases (early, middle and late) of the psychoanalytic treatment. For each session, we identified therapist's and patient's defenses, defense levels and overall defensive functioning, with particular attention to the sequence of consecutively activated defenses within the therapeutic dyad. Results showed that the patient's defensive functioning tended to gradually improve over the course of the treatment, with a slight decrease at the end. Therapists' overall defensive functioning remained stable throughout the treatment with values in the range of high-neurotic and mature defenses. Assessment of the dyadic interaction between therapist and patient's use of defenses showed that within-session, the patient tended to use the same individual defenses that the therapist used, which was especially pronounced in the initial phases of the treatment. Towards the end of the treatment, once there was a stable shared knowledge, the patient started to explore using new, higher-level defenses on her own, independent from what defenses the therapist used. Our findings emphasized the analyst's role in encouraging the development of more effective ways of coping in the patient, confirming previous theoretical and empirical research regarding the improvement of patient's defensive functioning in psychotherapy. The alterations in these coping strategies, also called high-adaptive defenses, as part of the therapist-patient interaction demonstrate the importance of studying defenses as an excellent process-based outcome measure. The measurement of the degree to which the analyst models and illustrates these superior coping methods to the patient is a prime vehicle for supporting internalization of these skills by the patient.

Defensive functioning in individuals with depressive disorders: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to address the limited generalizability of studies on defense mechanisms in depression by comparing depressive individuals with non-clinical controls (aim a) and examining changes throughout psychological interventions (aim b) (PROSPERO CRD42023442620).

METHODS

We followed PRISMA 2020 guidelines, searching PubMed/Web of Science/(EBSCO)PsycINFO until 13/04/2023 for studies evaluating defense mechanisms with measures based on the hierarchical model in depressive patients versus non-clinical controls or throughout psychological intervention. We conducted random-effect meta-analyses for mature defenses/non-mature (neurotic/immature) defenses/overall defensive functioning (ODF), with standardized mean difference (SMD) as outcome measure metric. Meta-regression/sub-group/sensitivity analyses were conducted. Study quality was appraised using the Newcastle-Ottawa Scale (NOS), and certainty of evidence for aim b outcomes was evaluated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations).

RESULTS

18 studies were included (mean NOS score = 5.56). Depressive patients used significantly more non-mature defenses than non-clinical controls (SMD = 0.74; k = 13). Non-clinical controls did not significantly differ in use of mature defenses compared to depressive patients (SMD = 0.33; k = 14). Significant moderators were publication year/NOS score/geographical distribution/mean age for non-mature defenses and NOS score/geographical distribution for mature defenses. Throughout psychological interventions, only ODF significantly increased (SMD = 0.55; k = 2) (GRADE = very low).

LIMITATIONS

Quality of many studies was medium/sub-optimal, and longitudinal studies were scarce.

CONCLUSION

Individuals with depressive disorders show a high use of non-mature defenses that could be assessed and targeted in psychological interventions, especially in younger patients.

Initial validation of the Turkish version of the defense mechanisms rating scales-self-report-30

The Defense Mechanisms Rating Scales-Self Report-30 (DMRS-SR-30) was recently developed to add a self-report alternative to the assessment of defenses, reflecting their generally accepted hierarchical organization. In this study, we aimed to examine psychometric properties and factor structure of the Turkish language version of the DMRS-SR-30. The sample consisted of 1.002 participants who filled out a survey comprising the DMRS-SR-30, the Brief Symptom Inventory, and the Inventory of Personality Organization through Qualtrics. Confirmatory Factor Analysis indicated a three-factor structure (CFI = 0.89, RMSEA = 0.05) that confirms the DMRS theoretical frame with a relatively acceptable fit. Defensive categories and total scale scores showed good to excellent reliability (α values ranging from 0.64 to 0.89). Correlations between defenses, symptoms, and personality functioning demonstrated good convergent and discriminant validity. The individuals with clinically significant BSI scores (T-score ≥ 63) differed on the DMRS-SR-30 scores from the individuals in the non-clinical range. The Turkish version of the DMRS-SR-30 is a reliable and valid instrument to self-assess the hierarchy of defense mechanisms and overall defensive functioning. Moreover, the current study supports the validity of the tripartite model of defenses in a language and culture different from the origins of the DMRS and DMRS-SR-30.

Transference interpretation and psychotherapy outcome: a systematic review of a no-consensus relationship

Despite its well-established importance in psychoanalytic theory, there is a scarcity of empirical evidence on the relationship between a therapist's transference interpretation (TI) and therapeutic outcome. The current scientific literature shows no consensus on the existence and nature of such an association. Therefore, the present study aimed to systematically review the literature on the link between TI and outcomes in psychodynamic psychotherapies. The American Psychological Association PsycInfo, MEDLINE, and the Web of Science Core Collection were selected as the primary databases for the literature search. Studies were included if they measured the frequency/ concentration of TI in psychodynamic psychotherapy [e.g., transference focused psychotherapy (TFP), supportive-expressive therapy] or compared a treatment group (e.g., high in TI and TFP) with a control group (e.g., low in TI supportive therapy) in an adult population with psychiatric symptoms. Out of 825 retrieved abstracts, 25 articles (21 studies) were included in the final synthesis. 13 out of 21 (62%) studies showed a significant improvement in at least one therapy outcome measure following the use of TI. The present systematic review also revealed high heterogeneity across studies in terms of TI measurement, outcome assessment (e.g., psychiatric symptoms, dynamic change, interpersonal functioning, therapeutic alliance), study design (e.g., experimental, quasi-experimental, naturalistic), patient population (e.g., anxiety disorders, personality disorders), and types of treatment (e.g., TFP, supportive-expressive therapy), preventing researchers from asserting solid conclusions. The results strongly highlight the urgent need for highquality research to understand which types of patients, how, and when TIs could be effective throughout the therapy process.

Reduction in Pappalysin-2 Levels and Lower IGF-I Bioavailability in Female Adolescents With Anorexia Nervosa

CONTEXT

Anorexia nervosa (AN) can cause severe undernutrition associated with alterations in the IGF axis. Pappalysins (PAPP-A, PAPP-A2) and stanniocalcins (STC-1, STC-2) modulate IGF binding-protein (IGFBP) cleavage and IGF bioavailability, but their implications in AN are unknown.

OBJECTIVE

We determined serum levels of PAPP-As and STCs in relationship with classical IGF axis parameters in female adolescents with AN and their association with nutritional status and secondary amenorrhea.

METHODS

Parameters of the IGF axis were determined in fasting serum samples of 68 female adolescents with AN at diagnosis and 62 sex- and age-matched controls. Standardized body mass index (BMI) and bone mineral density (BMD) were calculated.

RESULTS

Patients with AN had lower concentrations of total and free IGF-I, total IGFBP-3, acid-labile subunit (ALS), insulin, PAPP-A2, STC-1, and STC-2 and higher levels of IGF-II and IGFBP-2. Their free/total IGF-I ratio was decreased and the intact/total IGFBP-3 and -4 ratios increased. BMI was directly related to total IGF-I and intact IGFBP-3 and inversely with IGFBP-2 and intact IGFBP-4. Weight loss was directly correlated with intact IGFBP-4 and negatively with intact IGFBP-3, ALS, STC-2, and PAPP-A2 concentrations. BMD was directly related to intact IGFBP-3 and inversely with intact IGFBP-4 and PAPP-A2 levels. Patients with amenorrhea had lower levels of total IGF-I and IGFBP-3 than those with menses.

CONCLUSION

The reduction of PAPP-A2 in patients with AN may be involved in a decline in IGFBP cleavage, which could underlie the decrease in IGF-I bioavailability that is influenced by nutritional status and amenorrhea.

Psychological impairment in inflammatory bowel diseases: the key role of coping and defense mechanisms

A comprehensive investigation of psychological features in chronic patients is very important for tailoring effective treatments. In this study we tested anxiety, depression, health related quality of life (HR-QoL), alexithymia, coping styles, and defense mechanisms, in eighty-four patients with Crohn disease (CD) and ulcerative colitis (UC). Participants reported low to moderate HRQoL and anxiety, apart from alexithymia. Women experienced lower QoL and higher levels of anxiety and depressive symptoms. Coping and defense strategies were related to distress symptoms and QoL. Positive attitude and principalization, showed negative associations with depression, anxiety and alexithymia and were also found to be associated with mental health. CD patients used significantly more turning against objects (p=0.02) and projections (p=0.01) and UC patients used more reversal (p=0.04). Elderly women showed higher anxiety symptoms and lower perceived QoL. Multiple regression analysis revealed anxiety and depression were independently associated with QoL. Significant differences emerged in defense styles among CD and UC. CD participants used more maladaptive coping and defense styles which were related to mental distress, depression and anxiety, together with higher level of alexithymia. Findings suggest that psychological aspects play a key role in mental health in patients suffering from inflammatory bowel diseases. A multi-integrated clinical strategy including psychotherapeutic interventions should be considered in treating CD and UC.

Defense mechanisms are associated with mental health symptoms across six countries

Defense mechanisms are adaptative processes that are related to mental health and psychological functioning and may play an important role in adaptation to distress, as well as in mental health interventions. The present study aimed to compare the use of defense mechanisms and their relationship to mental health symptoms across six countries. In a large-scale descriptive study, we collected data from community- based individuals (N=19,860) in the United States, Australia, Canada, Germany, Italy, and the United Kingdom about the use of defense mechanisms and experienced mental health symptoms during the early phase of the pandemic. We found that the use of defense mechanism categories was similar across countries. Moreover, lower defensive functioning, specifically, neurotic and immature defenses were related to experiencing higher distress across countries, whereas mature defenses were generally inversely related to symptoms. Furthermore, these findings were relatively similar across the six countries. Cross-cultural research on defense mechanisms and mental health has important clinical implications. Our results are consistent with the goal of promoting more adaptive defensive functioning to increase psychological well-being and mitigate the detrimental impact of situational stress.