DEFENSE MECHANISMS In psychiatric medicine.pptx

Psychiatry

1. DEFENSE MECHANISMS PROFESSOR & HEAD PSYCHIATRY Dr. Rakesh Yaduvanshi MODERATORS Assistant Professor Dr. Raies Ahmed Senior Resident Dr. Gajal Gupta By -Tushar Yadav

2. CONTENT INTRODUCTION 1 GENESIS 2 CLASSIFICATIONS 3 CLINICAL ASPECTS 4

3. DEFINATION According to Freud’s Psychoanalytic Theory, defense mechanisms are unconsciou s, psychological strategies brought into play by various entitiese to cop e w ith reality and to maintain self image . Freud (1923) clarified about the nature of defense mechanisms. The neurotic conflict takes place between the ego and the id , the ego seeking to bar the expression of certain instinctual impulses by using defense mechanisms.

4. INTRODUCTION Defence mechanisms may result in healthy or unhealthy consequences depending on the circumstances and frequency with which it is used . In psychoanalytic theory, repression is considered as the basis for other defence mechanisms. Healthy people normally use different defence mechanisms throughout life. A defence mechanism becomes pathological only when its persistent use leads to maladaptive behaviour . One resource used to evaluate these mechanisms is the Defense Style Questionnaire .

5. In the first definitive book on defence mechanisms, “ The Ego and the Mechanisms of Defence (1936) ” Anna Freud enumerated the ten defence mechanisms that appear in the works of her father,Sigmund Freud . Sigmund Freud posited that defence mechanisms work by distorting id impulses into acceptable forms , or by unconscious or conscious blockage of these impulses. Anna Freud considered defense mechanisms as intellectual and motor automatisms of various degrees of complexity, that arose in the process of involuntary and voluntary learning. Anna Freud introduced the concept of signal anxiety ; she stated that it was "not directly a conflicted instinctual tension but a signal occurring in the ego of an anticipated instinctual tension ".

6. GENESIS OF DEFENSE MECHANISM ID The id is the instinctual component of personality that is present at birth and is the source of bodily needs , emotional impulses & desires , especially aggression and the libido . The id acts according to the pleasure principle . Freud said that the Id is unconscious. EGO Superego is roughly equal to conscience. determines that some needs are not consistent with an underline view of one’s self ( Ego ideal ). SUPER EGO Ego is the realistic part that mediates between the desires of the Id and Superego . i.e. when in conflict , the person experiences anxiety and ego makes it less threatening by techniques called Defense Mechanisms.

7. CLASSIFICATION OF DEFENSE MECHANISM

8. G EORGE V ALLIANT ’ S C LASSIFICATION (according to relative degree of maturity) Most primitive . Usually found as part of psychotic proces s , but may also occur in dreams or fantasies . ( children & young adult ) Share common note of avoiding, negating, or distorting reality . . F airly common in adults. Such defences have short-term advantages in coping . B ut can often cause long-term problems in relationships, work and life when used as one's primary style of coping . . O ften present in preadolscent & adults . These mechanisms lessen distress and anxiety produced by threat or by an uncomfortable reality . T hey are immature, difficult to deal with & out of touch with reality. F ound in emotionally healthy adults . H ave their origins in an immature stage of development. U se of these defences enhances pleasure and feelings of control . PATHOLOGICAL IMMATURE NEUROTIC MATURE

9. PATHOLOGICAL PROJECTION The attribution of one's own unacknowledged ideas and feelings to others is called projection. Excessive faultfinding and sensitive to criticism . Strict honesty, concern for the patient’s rights and maintaining formal distance are helful for raport. Confrontation guarantees lasting enimity and early termination of contact with the patient. This defense, together with reaction formation , is involved in the delusional persecutions of paranoia . ( DELUSIONAL PROJECTION ). Example : a cheating spouse who suspects their partner is being unfaithful without any evidence.

10. DENIAL In denial, the ego wards off ( by literally denying them ) some perceptions from the external world that would be painfu l . or resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality. U nlike repression , it affects perception of external reality > perception of internal reality . A ll DENIA L aren’t necessarily psychotic. When a t the psychotic level , the denied reality may be replaced by fantasy or delusion . Example : Alocholic denying having alcohol use disorder because they can still function and go to work each day.

11. DISTORTION A gross reshaping of external reality to meet internal needs . I ncluding unrealistic megalomanic beliefs, hallucinations, wish-fulfilling delusions, and employing sustained feelings of delusion of grandiosity . Devaluation, disavowal, exaggeration , and minimization are its forms. Example : a person may believe that they failed a test because of difficult questions, not because they did not prepare fully.

12. IMMAURE ACTING OUT Direct expression of an unconscious wish or impulse in action , without conscious awareness of the emotion that drives the expressive behavior. since it occurs outside the awareness it appears to be unaccompanied by guilt , but when the acting out is impossible, conflict behind it may be accesible. in this state patient will mishear anything, hence getting the patient’s attention is most important. Self injury may also be form of acting out , expressing in terms of physical pain what one can’t feel emotionally. Tantrums, motiveless assault on the interviewer while examination in the wards. a person who is angry and frustrated with their circumstances at home might act out by punching a hole in a wall.

13. HYPOCHONDRIASIS An excessive preoccupation or worry about having a serious illness , for the purpose of evasion and regression. In Hypochondriasis, responsibility , guilt & instinctual impulses may be warded off. Example: intensely focusing on physical symptoms and their potential manifestation may be a relief from feeling dissatisfied in your life.

14. PASSIVE AGRESSIVE BEHAVIOUR Indirect & ineffective expression of hostility in form of passivity, machoism and turning against the self. Stress and conflict are dealt with by indirectly expressing aggression toward others . Examples : being sarcastic, talking behind back, displaying negative body language & giving the silent treatment.

15. INTROJECTION Identifying with some idea or object so deeply that it becomes a part of that person . The goal is to ensur e closeness to and constant presence of the object. C onsequent a nxiety or tension arising out of separation or ambivalence toward the object is thus diminished. If the object is lost , introjection nullifies or negates the loss by taking on characteristics of the object . and if the object is not lost , the internalization usually involves a shift of investmen t reflecting a significant alteration in the object relationship .

16. The aggression is no longer felt as coming from outside, but is taken within and utilized defensively, thus turning the subject's weak passive position into an active strong one . The anti-Semitism of Jews is an example of this defense. Stockholm syndrome is also an example of this . a dad telling his son “boys don't cry” an idea that a person might take in from their environment and internalize into their way of thinking.

17. REGRESSION Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way . This reflects a basic tendency to achieve instinctual gratification or to escape the instinctual tension by returning to earlier modes and levels of gratification. Example : An adult has temper tantrums when stuck in traffic. A child suddenly starts to wet the bed after years of not doing so, this happened after arrival of new sibling.

18. SCHIZOID FANTASY Tendency to retreat into fantasy in order to resolve inner and outer conflicts . seek solace & satisfaction by creating imaginary life and friends. Unsocialableness rests on fear of intimacy . Maintaining a quiet, reassuring and considerate interest without reciprocal responses are helful. Example : wishful day dreaming of adolscents over pornographic material middle aged wish to be youthful & alluring.

19. SOMATIZATION The transformation of uncomfortable feelings towards others into uncomfortable feelings toward oneself : pain, illness, and anxiety. Example : Getting stomach cramps everytime exams are scheduled.

20. SPLITTING A primitive defence. Both harmful and helpful impulses are split off and segregated , frequently projected onto someone else. The defended individual segregates experiences into all-good and all-bad categories , with no room for ambiguity and ambivalence. so anticipation of the process and gentle confrontation with facts that no one is all good or all bad can be helful in dealing with the defense. Example : Believing that all men without mustache are feminine In an inpatient setting, a patient may idealize some & disparge other staff members.

21. PROJECTIVE IDENTIFICATION Appears mainly in borderline personality disorder & consist of 3 steps. STEP 1 : patient projects an aspect of self on someone else. STEP 2 : projecter tries to convince the projectee into identifying what was projected. STEP 3 : both feels a sense of oneness .

22. NEUROTIC DISPLACEMENT purposeful , unconscious shifting of impulses or affective investment from one object to another in the interest of solving aconflict. Although the object is changed, the instinctual nature of the impulse and its aim remain unchanged. Example : fear of father displaced to animals .

23. DISSOCIATION An unconscious defense mechanism that involves seperating a mental or behavioural process from rest of person’s psychic activity. conflicts and stress are dealt with by temporary failure of consciousness to integrate the dangerous material. Example : Patient with borderline personality may demonstrate dissociation including depersonalization & derealization. hysterical conversion reactions & Somnambulism.

24. INTELLECTUALIZATION Emotional implications of a topic are avoided by treating it on a purely intellectual level to block out conflicting or disturbing feelings or thoughts. involves reasoning . control of affects and impulses by way of thinking about them instead of experiencing them . Example : A doctor may describe an encounter with a dying or an angry patient in an unemotional way.

25. ISOLATION OF AFFECT The detachment of emotion from an idea or memory , making it "flat." Characterstic of obsessive–compulsive personalities , and in people following traumatic events. Examples:- The isolation of sexuality from the rest of life, which allows men to express their sexuality without guilt . Describing a murder with graphic details with no emotional response.

26. REACTION FORMATION Converting unconscious wishes or impulses that are perceived to be dangerous or unacceptable into their opposites . Or taking the opposite belief because the true belief causes anxiety . Example : The classic example is when you treat someone you strongly dislike in an excessively friendly manner to hide your true feelings.

27. REPRESSION The process of attempting to repel desires towards pleasurable instincts , caused by a threat of suffering if the desire is satisfied . T he desire is moved to the unconscious in an attempt to prevent it from entering consciousness .(PRIMARY REPRESSION) OR may operate by excluding from awareness what was once experienced on a conscious level . (SECONADARY REPRESSION) The “forgetting”association with repression is unique in that it is often accompanied by highly symbolic behavior , which suggests that the repressed is not really forgotten . A child who is abused by a parent though later has no recollection of the events, but has trouble forming relationships.

28. RATIONALIZATION This defense mechanism substitutes an unacceptable conscious motive for an unacceptable unconscious one. Convincing oneself that no wrong has been done and that all is or was all right through faulty and false reasoning . Rationalization is not lying ; it just means that one believes in their explanations . An indicator of this defence mechanism can be seen socially as the formulation of convenient excuses. Example : someone who was rejected for a date might rationalize by telling themself they didn’t find the other person attractive.

29. UNDOING Undoing is a defense characteristic of obsessional neurosis A person tries to 'undo' an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable. Involves symbolically nullifying an unacceptable or guilt provoking thought, idea, or feeling by confession or atonement. E xample : a person who has unintentionally insulted a friend might feel guilty for doing so, but rather than apologize for the comment, they make up for it by giving compliments.

30. MATURE ALTRUISM Constructive service to others that brings pleasure and personal satisfaction rather than one’s own. must be distinguished from ‘masochistic surrender’ Example : A person whose parents died in a road traffic accident forms an organisation for creating public awareness about traffic rules and road traffic accidents.

31. ANTICIPATION Realistic planning for future discomfort . Implies overly concerned planning, worrying, and anticipation of dire and dreadful possible outcome. Example : planning for retirement when still young. prepraring all difficult answers before an interview.

32. HUMOUR Overt expression of ideas and feelings that gives pleasure to others . E specially those that are unpleasant to focus on or too terrible to talk about directly . The thoughts retain a portion of their innate distress, but they are "skirted around" by witticism, Example : self-deprecation in a witty way i.e, making fun of youself after getting trashed in viva. A nervous patient joking about upcoming operation.

33. SUBLIMATION Transformation of unhelpful emotions or instincts into healthy actions, behaviours, or emotions . The gratification of an impulse, whose goal is retained , but whose aim or object is changed from a socially objectionable one to a socially valued one . For Freud sublimation was highest level of ego defense that consisted of redirection of sexual impulses to a socially valued activities and goals. for example : playing a heavy contact sport such as football or rugby can transform aggression into a game . An angry man doing pushups or punching a sandbag to work off his temper.

34. SUPRESSION The conscious or semi-concious decision to delay paying attention to a thought, emotion, or need in order to cope with the present reality . making it possible later to access uncomfortable or distressing emotions whilst accepting them . Intentionally avoiding thinking about the source of pain. Example : A medical student who is extremely stressed out because of an upcoming entrance examination decides to take one day break during which he does not think about the examination at all.

35. Sr. no. DISORDERS DEFENSE MECHANISM 1) PERSONALITY DISORDER a) Cluster A projection, Fantasy. b) Cluster B Acting out , Splitting , Dissociation & Projective identification. c) Cluster C passive aggression , Isolation & Undoing. 2) ANXIETY Repression 3) PHOBIA Displacement (anxiety displace by phobia) , Regression 4) OCD Isolation (responsible for obsessional thoughts) undoing (creates compulsive acts) reaction formation (accounts for exaggerated characteristics of cleanliness ) 5) DEPRESSION Regression 6) MANIA denial, projection & regression 7) SCHIZOPHRENIA regression, delusional projection & isolation CLINICAL ASPECT

36. Common Defense mechanisms in substance abuse The substance abuser will apologize , makes promises and try to act normally in an attempt to undo the previous bad behavior. Undoing : Substance abusers will have temper tantrums instead of saying “I am angry” . Self injury is another way to act out,as they can't stand to feel their own feelings. Acting out : First line of defense for the addicts. It is the act of denying that problem even exist , because they feel they are doing so well in other aspects of li fe . Denial : It emerges as a refusal to leave the bed or house to engage in a normal activities. The y isolates themselves from their friends i n order to perceive their addiction wihout judgment Regression :

37. SUMMARY Defense mechanism are unconsciou s, psychological strategies to cop e w ith conflicts (between id & ego) in reality . But they don’t usually get rid of the problem. first work on defense mechanism was by Sigmund Freud and further elaborated by Anna Freud. There are many classification of defense mechanism but Valliant’s classification based on degree of maturity is the most sought after. He divided it into 4: Pathological, Immature, Neurostic and Mature. Helping in adapting mature forms improves mental health & decrease reliance on substance. Denial , Regression , Acting out & Undoing are commonly used defenses in substance abuse.

38. THANK YOU