Defense mechanisms are a type of process or coping that results in automatic psychological responses exhibited as a means of protecting the individual against anxiety (Dziegielewski 2010).

Identification and notation of defense mechanisms can be an important part of the psychological assessment and influence on the treatment process

Since it is believed that many individuals either consciously or unconsciously develop defense mechanisms that can influence the diagnostic condition and impede progress, these psychological occurrences, when noted in a client should be listed in Axis II.

It is very important for the practitioner to be aware and recognize how they influence treatment (APA, 2000).

FreudUnconscious mental processes

employed by the ego to reduce anxiety

What is the relation between defense mechanisms and diagnosis – DSM IV - TR

Freud's Defense Mechanisms include: Denial: claiming/believing that what is true to be

actually false. Displacement: redirecting emotions to a substitute

target. Intellectualization: taking an objective viewpoint. Projection: attributing uncomfortable feelings to others. Rationalization: creating false but credible

justifications. Reaction Formation: overacting in the opposite way to

the fear. Regression: going back to acting as a child. Repression: pushing uncomfortable thoughts into the

subconscious. Sublimation: redirecting 'wrong' urges into socially

acceptable actions.

    DSM-III was the first to included a multiaxial system for assessment of the client as an individual as well as a family and community member. 

Although widely accepted, DSM-III and DSM-III-R were also widely criticized. 

The Multiaxial system prevented efficiency in diagnosis.  Additionally, DSM offered a different amount of support

and direction for each axis.  While there were 300 pages of description for Axis I and 39

pages for Axis II, Axes IV and V were given only 2 pages each (Blashfield, 1998). 

The rating scale format of IV and V was also foreign to many professionals. 

The axes themselves were problematic for many practitioners because no one seemed to know how those particular areas were chosen. 

Psychoanalysts began to argue for an axis on defense mechanisms, and nurses wanted an axis for level of care.

Like its predecessors, DSM-IV was criticized.  The axes problem remained unsolved, with 3 candidates (defense mechanisms, interpersonal functioning, and occupational functioning) still in the running (Blashfield, 1998.)

What will DSM-V be like regarding axis?  Fogel (in Brendel, 2001) suggests that it might become more descriptive. This might lend support for the arguments of inclusion of defense mechanisms.

The controversies over social diagnoses and the multiaxial system must also be addressed in DSM-V (Blashfield, 1998, DSM-IV-TR, Scotti and Morris, 2000).

Defense mechanisms (or coping styles) taken from Appendix B in DSM IV – TR are 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 these processes as they operate.

Defense mechanisms can be classified into groups or levels that indicate how they affect an individual's functioning High Adaptive Level Mental Inhibition Level Minor Image-distorting Level Disavowal Level Major Image-distorting Level Action Level

High Adaptive Level: Defense mechanisms in this group result in optimal adaptation to stress.

The defenses usually maximize feelings of well being and

Allow the conscious awareness of feelings, ideas, and their consequences.

promote an optimum balance among conflicting motives

anticipation affiliation altruism humor self-assertion self-observation sublimation suppression

Mental Inhibition Level: Defense mechanisms in this group keep potentially threatening ideas, feelings, memories, wishes, or fears out of awareness. Diminished awareness can affect the person's ability to relate to others. displacement dissociation intellectualization isolation of affect reaction formation repression undoing

Minor image-distorting level. This level is characterized by distortions in the image of the self, body, or others that may be employed to regulate self-esteem. Examples are

devaluation idealization omnipotence

Disavowal level. This level is characterized by keeping unpleasant or unacceptable stressors, impulses, ideas, affects, or responsibility out of awareness with or without a misattribution of these to external causes. Examples are

denial projection rationalization

Major image-distorting level. This level is characterized by gross distortion or misattribution of the image of self or others. Examples are

autistic fantasy projective identification splitting of self-image or image of others

Action Level: This level is characterized by defenses that deal with internal or external stressors by action or withdrawal.

acting out apathetic withdrawal help-rejecting complaining passive aggression

Level of defensive dysregulation. This level is characterized by failure of defensive regulation to contain the individual's reaction to stressors,

lead ins to a pronounced break with objective reality. Examples are

delusional projection psychotic denial psychotic distortion

•Affiliation - involves dealing with stressors by turning to others for help or support. This involves sharing problems with others but not trying to make someone else responsible for them.

•Altruism - involves dealing with stressors by dedicating yourself to meeting the needs of others. The individual receives satisfaction vicariously or from the response of others.

•Anticipation - involves dealing with stressors by anticipating the consequences and feelings associated with possible future events and considering realistic solutions.

•Humor - involves dealing with stress by emphasizing the amusing or ironic aspects of the situation.

•Self-Assertion - involves dealing with stress by expressing your feelings and thoughts directly in a way that is not aggressive, coercive, or manipulative.

•Self-Observation - involves dealing with stress by reflecting on your own thoughts, feelings, motivation, and behavior, and then responding appropriately.

•Sublimation - involves dealing with stress by channeling potentially disruptive feelings or impulses into socially acceptable behavior (e.g., playing rugby to channel angry impulses).

•Suppression involves dealing with stress by intentionally avoiding thinking about disturbing problems, wishes, feelings, or experiences.

•Displacement - involves dealing with stress by transferring strong feelings about on situation onto another (usually less threatening) substitute situation.

•Dissociation - involves dealing with stress by breaking off part of memory, consciousness, or perception of self or the environment to avoid a problem situation (e.g., amnesia).

•Intellectualization - involves dealing with stress by excessively using abstract thinking and generalizations to avoid or minimize unpleasant feelings.

•Reaction - Formation involves dealing with stress by substituting behavior, thoughts, or feelings that are the exact opposite of your own unacceptable thoughts or feelings (which the person is usually not aware of).

•Repression - involves dealing with stress by removing disturbing wishes, thoughts, or experiences from conscious awareness. The person may still be aware of the feelings associated with the repressed issue, but will not know where the feelings come from.

•Undoing - involves dealing with stress by using words or behaviors designed to negate or make amends symbolically for unacceptable thoughts, feelings, or actions.

Devaluation - Involves dealing with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others.

Idealization - Involves dealing with emotional conflict or internal or external stressors by attributing exaggerated positive qualities to others.

Omnipotence - Involves dealing with emotional conflict or internal or external stressors by feeling or acting as if he or she possesses special powers or abilities and is superior to others.

•Denial - involves dealing with stress by refusing to acknowledge some painful aspect of reality or experience that is apparent to others.

•Projection - involves dealing with stress by falsely attributing your own unacceptable feelings, impulses, or thoughts to another person.

•Rationalization - involves dealing with stress by concealing the true motivations for a thought, action, or feeling by using elaborate, reassuring, and self-serving (but incorrect) explanations.

Autistic fantasy - Involves dealing with emotional conflict or internal or external stressors by excessive daydreaming as a substitute for human relationships, more effective action, or problem solving.

Projective identification - As in projection, the individual deals with emotional conflict or internal or external stressors by falsely attributing to another his or her own unacceptable feelings, impulses, or thoughts. Unlike simple projection, the individual does not fully disavow what is projected. Instead, the individual remains aware of his or her own affects or impulses but misattributes them as justifiable reactions to the other person. Not infrequently, the individual induces the very feelings in others that were first mistakenly believed to be there, making it difficult to clarify who did what to whom first.

Splitting - Involves dealing with emotional conflict or internal or external stressors by compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of the self or others into cohesive images. Because ambivalent affects cannot be experienced simultaneously, more balanced views and expectations of self or others are excluded from emotional awareness. Self and object images tend to alternate between polar opposites: exclusively loving, powerful, worthy, nurturing, and kind or exclusively bad, hateful, angry, destructive, rejecting, or worthless.

•Acting Out - involves dealing with stress by using action rather than reflection or feeling. Defensive acting out is often associated with "bad behavior" when there are underlying emotional conflicts.

•Help-Rejecting Complaining - involves dealing with stress by complaining and making repeated requests for help that disguise hidden feelings of hostility toward others, which is then expressed by rejecting the suggestions, advice, or help that others offer. The complaints may involve physical or psychological symptoms or life problems.

•Passive Aggression - involves dealing with stress by indirectly and unassertively expressing aggression toward others. The person displays an outward superficial cooperativeness that masks the underlying resistance, resentment, and hostility. This defense may be adaptive in situations where direct and assertive communication is punished (e.g., abusive relationships).

A. Current Defenses or Coping Styles: List in order, beginning with most prominent defenses or coping styles.

1. __________________________________________ 2. __________________________________________ 3. __________________________________________ 4. __________________________________________ 5. __________________________________________ 6. __________________________________________ 7. __________________________________________

B. Predominant Current Defense Level: _____________________________

A. Current Defenses or Coping Styles: splitting projection identification acting out devaluation omnipotence denial projection

B. Predominant Current Defense Level: major image-distorting level

A variety of instruments to help in the diagnosis and assessment of Anxiety and Depression

One new approach that is becoming popular is the use of RAIs.

Becoming popular as they are standardized instruments that allow greater accuracy and objectivity in attempts to measure clinical problems (Dziegielewski 2010)

Common characteristics: Brief -Most are done in 15 minutes Easy to administer Easy to score Easy to interpret Little knowledge of testing procedure

needed Most are self-report Most are done in 15 minutes Reliability and Validity measures are usually

presented Easily accessible and generally free or

available at low cost

They are generally free of any theoretical orientation so they can be used in a variety of intervention methods

The score that is generated can provide an operational index of the frequency, duration and intensity of the problem which is good for progress measures along the course of the treatment.

The Measures for Clinical Practice by Fischer and Corcoran (2007a, 2007b)