Continuing Education Activity

Anna Freud defined defense mechanisms as "unconscious resources used by the ego" to decrease internal stress ultimately. Patients often devise these unconscious mechanisms to decrease conflict within themselves, specifically between the superego and id. Psychodynamic therapy is used by clinicians to help orient patients to their own unconscious processes. By recognizing and identifying these processes, patients improve their self-awareness and gain a new understanding of their own behaviors. This activity defines major defense mechanisms to increase clinician's understanding of their patients during patient encounters and the role of the interprofessional team in the care of these patients.

Objectives:

• Identify and define the common psychological defense mechanisms.
• Describe the goal of psychodynamic therapy in relation to defense mechanisms.
• Review the clinical significance of defense mechanisms in relation to psychodynamic therapy.
• Outline interprofessional team strategies for improving coordination and communication in the care of patients with defense mechanisms.

Introduction

Sigmund Freud, known as the father of psychoanalysis, began the discussion of defense mechanisms in the nineteenth century in relation to the subconscious defenses of the id, ego, and superego.[1] These initial defense mechanisms were more clearly defined and analyzed by his daughter, Anna Freud, in the twentieth century. She created 10 major defense mechanisms, but the number of mechanisms has since been increased by later psychoanalysts.

Function

Anna Freud defined these defense mechanisms as "unconscious resources used by the ego" to decrease internal stress ultimately.[2] Patients often devise these unconscious mechanisms to decrease conflict within themselves, specifically between the superego and id. Psychodynamic therapy is used by clinicians to help orient patients to their own unconscious processes. By recognizing and identifying these processes, patients improve their self-awareness and gain a new understanding of their own behaviors. These insights can be helpful to patients with a variety of mental health disorders, including depression, anxiety, eating disorders, and personality disorders.[3] 

Issues of Concern

As we progress from childhood to adolescence and then progress from adolescence into adulthood, these psychological defense mechanisms can persist from one phase to the next, regress to earlier phases in response to stressors, or can evolve over time.[4] Defense mechanisms can be internalized or externalized, resulting in corresponding behavior problems, which can complicate psychiatric treatment.[5] Having a thorough understanding of defense mechanisms can help clinicians progress through treatment and avoid pitfalls. For example, recognizing the presence of defense mechanisms during a patient encounter can help maintain an appropriate therapeutic and professional relationship.[6]

Clinical Significance

If defense mechanisms are identified and adolescence, it can help predict further development of personality disorders.[7] Therefore, the early identification of defense mechanisms can have great clinical significance. Depending on the context and the severity, defense mechanisms can be either maladaptive or adaptive.[8]

Primitive Defense Mechanisms[1][9]

Acting out: The development of detrimental behaviors that distract attention and energy away from other stressors. This defense mechanism may be present in conduct disorder, antisocial personality disorder, or oppositional defiant disorder. 

Avoidance: Dismissing thoughts or feelings that are uncomfortable or keeping away from people, places, or situations associated with uncomfortable thoughts or feelings. This defense mechanism may be present in post-traumatic stress disorder, where one avoids the location of a traumatic motor vehicle accident or avoids driving completely. 

Conversion: The development of physical symptoms that cannot be explained by pathophysiology or physical injury. This defense mechanism is recognized in conversion disorder, also known as functional neurologic symptom disorder. 

Denial: Dismissing external reality and instead focusing on internal explanations or fallacies and thereby avoiding the uncomfortable reality of a situation. This defense mechanism may be present in someone who continues to shop for expensive designer clothes despite being in serious financial debt. 

Identification: The internalization or reproduction of behaviors observed in others, such as a child developing the behavior of his or her parents without conscious realization of this process. Identification is also known as introjection. 

Projection: Attributing one’s own maladaptive inner impulses to someone else. For example, someone who commits an episode of infidelity in their marriage may then accuse their partner of infidelity or may become more suspicious of their partner. 

Regression: Adapting one’s behavior to earlier levels of psychosocial development. For example, a stressful event may cause an individual to regress to bed-wetting after they have already outgrown this behavior. 

Repression: Subconsciously blocking ideas or impulses that are undesirable. This defense mechanism may be present in someone who has no recollection of a traumatic event, even though they were conscious and aware during the event. 

Schizoid fantasy: Creating an internal retreat into one’s imagination to avoid uncomfortable situations. This defense mechanism may present commonly in children or later in development, may be present in schizoid personality disorder. 

Splitting: Failing to reconcile both positive and negative attributes into a whole understanding of a person or situation, resulting in all-or-none thinking. Splitting is commonly associated with borderline personality disorder. 

Higher-level Defense Mechanisms[10]

Anticipation: The devotion of one’s effort to solving problems before they arise. This defense mechanism may be present in someone who prepares for an important job interview by practicing their answers to the toughest questions. 

Compensation: Focusing on achievement in one area of life in order to distract attention away from the inadequacy or fear of inadequacy in another area of life. This defense mechanism may be present in a student who receives poor grades on their report card and then devotes more time and effort to extracurricular clubs and activities. 

Displacement: Transferring one’s emotional burden or emotional reaction from one entity to another. This defense mechanism may be present in someone who has a stressful day at work and then lashes out against their family at home. 

Humor: Decreasing or combating the negative emotions associated with a situation by using comedy. For example, telling a funny story about someone during a eulogy. 

Intellectualization: The development of patterns of excessive thinking or over-analyzing, which may increase the distance from one's emotions. For example, someone diagnosed with a terminal illness does not show emotion after the diagnosis is given but instead starts to research every source they can find about the illness. 

Isolation of Affect: Avoiding the experience of an emotion associated with a person, idea, or situation. This defense mechanism may be present in someone who describes the day their house burnt down in a factual way without displaying any emotion. 

Rationalization: The justification of one’s behavior through attempts at a rational explanation. This defense mechanism may be present in someone who steals money but feels justified in doing so because they needed the money more than the person from whom they stole. 

Reaction formation: Replacing one’s initial impulse toward a situation or idea with the opposite impulse. This defense mechanism may be present in someone who teases or insults a romantic interest whom they like. Conversely, reaction formation may be present in someone who is overly kind to someone whom they dislike. 

Sexualization: Associating sexual aspects to one’s experience of certain people, places, objects, or ideas. Sexualization can refer to the development of one’s sexual identity in general. Alternatively, sexualization can refer to the development of specific fetishes or sexual references to conventionally non-sexual entities. 

Sublimation: Transforming one’s anxiety or emotions into pursuits considered by societal or cultural norms to be more useful. This defense mechanism may be present in someone who channels their aggression and energy into playing sports. 

Suppression: Consciously choosing to block ideas or impulses that are undesirable, as opposed to repression, a subconscious process. This defense mechanism may be present in someone who has intrusive thoughts about a traumatic event but pushes these thoughts out of their mind.

Enhancing Healthcare Team Outcomes

Recognition and interpersonal communication about any defense mechanisms the patient is using amongst the psychiatrist, psychologist, social worker, primary care provider, nurse, and family can help to orient the team and enhance patient-centered care. Psychodynamic therapy can involve the patient in their own care by achieving greater awareness of their own patterns of psychological defense mechanisms. Some meta-analysis studies have shown psychodynamic therapy to have equal efficacy compared to cognitive behavioral therapy and pharmacotherapy in the treatment of mild to moderate mood disorders. It is important to recognize that therapeutic treatments based on self-awareness and communication will avoid the possible complications of pharmacotherapy, such as side effects and drug-to-drug interactions, and some patients may be more willing to try these therapies compared to pharmacotherapy.[11]