An empirical study of defense mechanisms in panic disorder

ABSTRACT

Abstract: Panic disorder is present in 2.9% of females and 1.3% of males in the Mexican urban population; about two thirds of these patients have an associated depressive disorder. Genetics and psy-chosocial factors are intertwined in the etiology of this disorder. There are several studies related to the role of defense mechanisms in the pathogenesis of psychiatric disorders. Few studies of anxiety disorders have been conducted in Mexico, and there is little evidence about the importance of the defense mechanisms that are present in these disorders. In the DSM-IV-TR, defense mechanisms or coping styles are defined as "automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals are often unaware of the processes as they operate". The purpose of the present research was to identify the differential use of the defense mechanisms in normal controls and in patients with panic disorder alone or complicated mainly with mood disorders, and the patients who responded or did not respond to psychopharmacological treatment. Method. The sample of this study comprised 48 consecutive outpatients with panic disorder from the Instituto Nacional de Psiquiatría, Ramón de la Fuente Muñiz. All of them were evaluated three times: first by a third grade psychiatry resident, in second place by a specialist in psychiatry and finally by one of the authors. After the patients agreed to participate, they completed a demographic questionnaire, the Hopkins Symptom Check List (SCL-90), and the Defense Style Questionnaire (DSQ, Spanish Version). To evaluate the intensity of anxiety and depression, the Anxiety Hamilton Scale and the Hamilton Scale for Depression were used in their first appointment. Patients were treated as usual with a tricyclic antidepressant, a benzodiazepine, or both, during an eight week period. Then they were evaluated again with the same instruments and scales. The Defense Style Questionnaire (DSQ) is a self-report instrument of common defense styles, which are empirically validated clusters of perceived defense mechanisms. Subjects rate their degree of agreement with 88 statements designed to tap defense or coping mechanisms on a ninepoint scale. The DSQ is a widely used measure of empirically derived groupings of defense mechanisms ranking an adaptive hierarchy. A review of published studies, indicates strong evidence that adaptiveness of defense style correlates with mental health, and that some diagnoses are correlated with specific defense patterns (borderline personality disorder correlates with greater use of both, maladaptive and image-distorting defenses, and less use of adaptive defenses). For other diagnoses, the pattern of defenses is less clear. The validity and the reliability of the DSQ Spanish Version were established before its application, in a sample of 261 psychiatric patients and controls. Two factors were obtained in the factor analysis. The first was denominated Mature Style. This category included: suppression, working orientation, sublimation, anticipation, affiliation, reactive formation, altruism, and humor. The Immature Style was the second factor; it included projection, acting out, repression, somatization, autistic fantasy, affective isolation and social withdrawal, inhibition, help rejection, splitting, undoing, consume, idealization, denial, projective identification, passive-aggression, and omnipotence. Higher mean scores indicated greater use of the individual defense mechanism and style. The mean scores for individual DSQ defense mechanisms and styles were calculated by adding and averaging the scores. The reliability calculated was .89 (Cronbach alpha) for the items cor-responding to the 25 defense mechanisms. Axis I was ascertained reliably with face-to-face interview and a list of the DSM-III-R criteria. This group had 32 patients with panic disorder and 16 patients with panic disorder associated to mood comorbidity or alcohol dependence, in persistent remission for at least one year; 32 subjects were included in the normal control group. Results. The comparison of patients with panic disorder, pa-tients with panic disorder associated to mood disorders and controls, showed that both groups of patients used more projection, regression, inhibition, acting out, fantasy, splitting, help rejection, undoing, and reactive formation (p<.01), than the control group. The patients with panic disorder alone, used more somatization and denial (p<.01) than controls, but not more than the group of patients with panic and mood disorders. They also used less humor and sublimation as defenses than the control group (p=.03). The defense mechanisms of the patients who responded to pharmacological treatment were similar to the defenses of patients who did not improve or deserted. The only defense used more by the patients who responded to treatment was undoing. Conclusions. Overall, the results of this study on panic disorder draw us to the conclusion that patients with this disorder make more use of immature and neurotic defenses than nonpatients. It is clear that maladaptive defenses, measured with this version of the DSQ, are related to mental illness and greater symptomatology, and adapative defenses are related to a better health. There was a clear difference in the use of defense mechanisms between the groups with illnesses and the control group. The clinical value of these observations depends on the relationship of the defenses with the symptoms. In this survey it is not possible to propose that defense mechanisms are the cause of the panic disorder, the reaction to the disease, or just a manifestation of the illness. The theory which establishes that the predominant use of certain defenses predisposes an individual to the development of specific illnesses, is attractive, but there is no evidence to support this hypothesis at present. In order to determine whether specific defenses or defense styles create vulnerability for the development of specific illnesses, the ideal study would be a prospective and longitudinal one; it would measure defenses in childhood, in adolescence, and at several points in adulthood, and would note whether there were significant correlations between preexisting defenses and specific illnesses. Such a study has yet to be under-taken. It is intriguing to speculate if an assessment of defenses could guide to treatment choices. Therapists do tend to consider diagnosis, ego strength, symptoms, behavior, and defenses when planning treatment, but a systematic assessment of defenses is not used as a basis for planning specific interventions. Although several studies have examined the relationship among defenses, alliance, therapist interventions, and outcome, more studies looking at a wider range of specific diagnoses are necessary.

RESUMEN

resumen está disponible en el texto completo