The Arabic Version of Defense Style Questionnaire-40 II- Defense Style in Major Depressive Disorder Hanaa

The Arabic Version of Defense Style Questionnaire-40 II- Defense Style in Major Depressive Disorder Hanaa. Soliman

The aim of this work was to investigate whether patients with major depres- she disorder use a defense style different from that of normal subjects. 28 patients with major depressive disorder and 27 age and sex matched normal subjects completed the Arabic version of DSQ-40. The results showed that patients tend to use less mature defenses (anticipation, suppression, humor& sublimationt than normal subjects, while they use more immature defenses (projection, passive aggression, devaluation, autistic fantasy and somatization). Reaction formation, a neurotic defense, was also higher in the depressive group. The significance of the findings to the psychopathology of depression, especially in terms of cognitive theories, and the implications for psychotherapy are considered. investigating defense style related to other axis-I diagnosis and its correlation wifh symptom patterns was recommended. (EgyptJ. Psychiat., 1997,20: 75-83).

Introduction demonstrated that patients wiih specific Though the concept of defense mech- anxiety disorders endorse specific defense style that is consistent with the di- anisms abounds in psychiatric and psy- choanzlytic literature, there is still confu- agnosis. However, contamination with sion and inconsistency ahout their the 'state', i.e., symptoms characteristic definit'on and relation to diagnosis of the clinicai picture might have con- (Bond et al, 1982). A great advance in tributed to those results. Removing the symptom items from the 72-item DSQ, this field, however, was the intrtxluctioli of valid methods of ausessment of de- the instrument used in the above men- tioned study, patients with anxiety disor- fense mechanisms (Bond et al, 1983; rlers still showed differences from nor- Andrew et al, 1993). mal subjecls. hut no differences between subcategories of anxiety disorders were Sound. The results of research on defense style in depressed pnlienls are aIso co11- mwersial. Whik Bond and Sagala '\'ail- !ant (1086) found that !he partem of dc- lenses did not differ in depressi~e ';'!I:. question whether a pr!i~ui;ir ik palirnrs, as a~n?pareclto norn~ai sub- the U!ri' LW - agnoi., 1s a.;scxiatutl wit$ of' jects, Akkcrrn;.~~et 21 11992) demon- ixin delence mechanisms rem:im c(1nin.i- strated that paiients with major depres- \;ci;?,ial '130110ck anti Anchews ( 1980) sive disorder. tcndcd to use less rna:urt' and inore immature defenses. The aim of the present work was to on mature defenses), table 2 demonstrat- investigate whether patienrs with major ing differences on iinmature defenses), depressive disorder use a defense style and table 3 (showing differences on neu- different from that of normal subjects. rotic defenses). In comparison to nonnal Subjects and Methods subjects, depressive patients showed markedly lower scores on all mature de- 28 patients attending outpatient clin- fenses, viz., sublimation, suppression, ic (El-Minia university hospital) over humor and anticipation, and more so in the time period from August to October, tbe latter. As regards immature defenses, 1996 who fulfilled criteria for major de- the depressive patients scored higher pressive disorder (DSM-IV), completed than normal subjects on projection, pas- the Arabic version of Defense Style sive aggression, somatization, devalua- Questionnaire-40 (Andrews et al,1993; tion of the self (devaluation2) and autis- Soliman, 1996) (Appendix). The pa- tic fantasy. On the other hand, they tients had a current depressive episode. showed less devaluation of others (&- Mean age (GD) was 31.6 k11.9). valuation I). Reaction formation was the Most of the subjects were females only neurotic defense mechanism where (n=24), while the saxnple included 4 patients differed significantly from con- male patients. trol group, as they seem to endorse this 27 age-and sex-matched nonnal sub- defense more often than normal subjects were remiled from the population jects. in the same area served by the clinic. Results of discriminant function Comparison between the two groups analysis are displayed in table4. the sen- on all items of the DSQ was carried out sitivity of the DSQ-40 to discriminate using two-tailrd T-test. To test the sen- patienls was very high (85.7%). Its spec- sitivity of the DSQ in detecting subjects ificity was also high, as 88.9% of the with psychopathology, discriminant control group were ceorrectly identified function analysis was performed. a$ normal. The variables that discrimi- Results: nated between the two groups were an- The differences between the depres- ticipation, devaluation of the self, somat- sive patients and control group are ization, prqjection, autistic fantasy and shown in tahle 1 (showing differences passive aggression.

Table 1 Differences Between Groups on Mature Defenses Defense Mechanism Depressive Patients Control Group Mean & SD) Mean (It SD) Sublimation 1 Humor 2 Anticipation 1 Suppression 1

Egypt. J. Psychiat. 20: 1. January 1997 Table 2 Differences Between Groups on Immature Defenses Defense Mechanism Depressive Patients Control Group Mean & SD) Mean & SD)

Projection 1 4.4 (3.28) 2.4 (1.934)** Projection 2 7.2 (2.29) 4.5 (2.77) * Passive aggression 1 4.1 (2.76) 2.4 (1.76) ** Passive aggression 2 6.3 (3.07) 5.0 (2.7)* Devaluation 1 4.4 (3.08) 6.07 (2.5)* Devaluation 2 7.5 (2.44) 4.4 (3.04)*** Autistic Fantasy 1 6.8 (2.28) 5.1 (2.85)* AutisticFantasy 2 6.1 (2.73) 4.5 (2.97)* Somatizaion 1 7.6 (2.07) 5.4 (3.44)*** - Somatization 2 7.7 (2.35) 4.89**

Table 3 - Differences Between Groups on Neurotic Defenses Defense Mechanism Depressive Patients Control Group - Mean (2SD) Mean @ SD) Reaction formation 1 5.3 (3.26) 3.5 (2.45)* Reaction formation 2 7.1 (2.34) 5.9 (2.94)*

Table 4 Results of Discriminant Function Analysis Actual group Predicted group membership Control Patient Control group 24 (88.9%) 3 (11 -1%) patients 4 (14.3 %) 24 (85.7%) coefficient Anticipation 1 - .66 Devaluation 2 38 Somatization 1 .39 Somatization 2 .35 Projection 1 38 Autistic fantasy 1 37 Passive aggression I -29 Passive aggression 2 .28

Egypt. J. Psychiat. 20: 1. January 1997 77 Discussion sponse one can make will change the Defenses are major means of manag- probability of these items. Such cogni- ing instinct and affect. Although they tive views account for predisposition to are adaptive in nature, they can as well depression. It seems that deficient use of be pathological (Vaillant, 1988). In the anticipation is more specific to and present work, depressive patients were characteristic of depression than other characterized by using less mature de- mature defenses (humor, suppression fenses, more immature and neurotic de- and sublimation) which were found to fenses, when compared with normal suh- be less unlikely endorsed by depressive jects. patients in the present study, but also by anxiety patients in a study by Andrews In spite of the fact that mature defenses distort reality, they are still hetter, et al(1993). morally accepted, more successfuI The only neurotic defense mecha- modes of accommodation with painful nism on which depressive patients dif- situations or emotions. Anticipation was fered from normal subjects is reaction the mature defense that highly differed formation. Unlike undoing and displace- between the groups and also correctly ment which are essential for discrete identified depressive patients in discrim- symptom formation, reaction formation inant function analysis. In the DSM-IV is a defense mechanism that results in (1994), the proposed scale for defensive the creation of enduring behaviour pat- functioning includes anticipation in the terns determining the individual's char- high adaptive level defense mechanisms. acter structure and personality (Nemiah, Such defenses usually maximize gratifi- 1988). According to Nemiah, reaction cation ,and allow the ' conscious' aware- formation against aggression leads to be- ness of feelings, ideas and their conse- haviour characterized hy excessive con- quences. This is different , to some cern for other people and by an undue exent from the classical psychoanalytic tolerance of unpleasantness in &em. The view of defencse mechanisms as uncon- role of aggressive feelings towards the scious. Vaillant (1988) recognized vol- object in the depressive situation and de- untary cognitive effectors like informa- pressive psychopathology was stressed tion gathering, anticipating danger, and by Rakhawy (1979). The aggression, in- rehearsing responses to danger as aa stead of being directed towards others, component of coping, hut their place might also be directed unto oneself, in was in the midway between defense the defense mechanism known as pas- mechanisms and mobilizing social re- sive aggression which was more en- sources. Whatever its place might be, dorsed in depressive patients in the depressive patients are deficient in using present study. anticipation as a coping style. This is In accordance with other studies on consistent with the 'helplessness' atti- patient populations (Andrews et al, tude of those patients, which is one of 1993; Brennan et al, 1990) the depres- Beck's cognitive triad of depression (Al- sive patients scored higher on the imma- loy et al, 1988). One of the hasic as- ture defenses as compared to tbe control sumptions of the hopelessness theory of group. However, the pattern of imma- depression (Ahramson et al, 1988) is ture defenses in depressive patients in that highly desired outcomes are unlike- the present work is not the same as that ly to occur, or that highly aversive out- demonstrated by Andrews et a1 (1993) in comes are probable, and that no re- patients with anxiety disorders. While

78 Egypt. J. Psychiat. 20: 1. January 1997 both groups share endorsement of pro- pressive patients demons~ated iu the jectiorr and somatization,the depressive present study is consistent with the psy- group xe also characterized by passive chopalhology of depression, investiga- aggrestion, as noted earlier, as well a\ tion of defense style in other patient devaleition and autistic fantasy. groups is needed to conclude Ihat it is Thc relationship between sornatiza- specific lo this disorder. tion and depmsion is well documented. 2- A study of defense mechanisms af- In a sludy by Soliman (1997) on Egyp- ter recovery is also needed before cxuap- tian p5 ychiauic patients, depressed md olation on the aetiological significance of cone1;lted with the number of somatic the findings is made. symptoms, especially pain symptoms. A 3- A more depth study of the correla- numb:r of writers have stressed the im- tion between symptom profile and de- protarrce of viewing pain as a mullidi- fense style is also needed. mensi onal experience with more similar- ity to emotional states than sensory processing (Pearce & Miles, 1993). Ac- References cording to Ahrens and Lamparter (1089) the inner organization of pain is fonned Ahramson, L.Y. Alloy. L.B. Metalsky, G.I. in compliance with the pattern of an "in- (1988) The cognitive diathesis stress theo- ner &ject choice". The pain, thus, is ries of depression. Toward an adequate func,ioning as a personalized, imagin'uy evaluation of the theories' validity. In Al- internal object. Such an "internal suuc- loy L.B. (ed) Cognitive Processes in De- turirg" has a depression reducing quali- pression. The Guilford Press: New York. tY. pp 3-30. As we preferred to analyze individual Ahrens, S. Lamparter, U. (1989) object re- items, rather than Lhe mean on two items lated fucntion of pain and depression. Psy- to cpresent one defense mechanism, de- chrhcr-Psychosor~z-Med-Psychol.; 39 pressed patients showed higher devalua- (6):219-22. tion of the self, but less devaluation of others, as compared to normal subjects Akkerman, K. Cam, V. Lewin, T. (1992) (talde2).The role of low self-esteem as a Changes in ego defenses with recovery crucial aetiolog,gical factor in depression from depression. J New. & Meru. Dis., was stressed by Brown and Harris 180: 634-638. (1978) and more recently by Brown et al Alloy, L.B. Hartlage, S. Abramson. L. (1!)90). Low self-esteem is also a hall- (1988). Testing the cognitive diathesis m:uk among the cognitive symptoms of stress theories of depression. Issues of re- depression (Musson & Alloy, 1988). search design, conceptualization and as- In spite of the fact that the DSQ-40 sessment. In Alloy L.B.(ed)Cognitive Pro- has a high sensitivity in detecting de- cesses in Depression. The Guilford Press: pressive patients and also high specifici- New York. pp 31-70, 1). as indicated by high identification of American Psychiatric Association (1994) Di- nmxmal sunjects. It is still not clear agnostic and Statistical Manual of Mental whether it will be sensitive in discrirni- Disorders. 4th edition (DSM- IV). nating patients with different diagnoses. Andrews, G. Singh, M. Bond, M. (1993). The Limitation of the Study and Rec- Defense Style Questionnaire. J. Nerv. dr c~mmendations: Ment. Dis., 181:246-254. 1- Although the defense style of de-

Egypt. J. Psychiat. 20: 1. January 1997 H. Soliman

Bond. M. Gardner, ST. Christian J, Sigal JJ Nemiah, J.C. (1988) The psychodynamic ba- (1982) Empirical study of self rated de- sis of psychopathology. In Nicholi E.M. fense styles. Arch Gen Psychiarry. 40: Jr. (Ed), The New Harvard Guide to Psy- 333-338. chiatry. Belknap Press of Harvard univ., Bond, M. Sagala. Vail1an.t J. (1986) An em- Carribrirlgc. pp. 208-233. pirical study of the relationship Between Pearce, S. Miles, A. (1993) Chronic pain. In diagnosis and defense style. Arch Gen Granville- Grossman (ed): Recent Ad- Psychiatry, 43: 285-288. vances in Clinical Psychiatry. Churchill Bond. M. Gardner, T. Christian, J. Sigal, J. Livingstone. Edinburgh. (1983). Empirical study of self rated de- Pollock, C. Andrews, G. (1989) Defense fense styles. Arch Gen. P.ychiat~y. styles associated with specific anxiety dis- 40:333-338. orders. Art1 J. Psyrkiatry, 145: 1500-1502. Brennan, 1. Andrews. G. Morris- Yates. A. Rakhawy, Y. (i979) A Study in PSychopa- Pollock, C. (1990) An examination of de- thology. Dar Al- Ghud: Cairo. p 195. (In fense style in parents who ahuse children. Arabic). J. Nen~& Ment. Dis., 178592-595. Solunan, H. (1996) The Arabic version of Brown, GW. Harris, T. (1978) Social Origins DSQ-40. I-A study of ego defenses in of Depression. Tavistnck Press: Lnndon. medical students. Egypt. J. Psychiat., Brown, G.W. Anclrews, B. Difuclo. A.Veie1. 19:129-136. H. (1990) Self- esteem and depression. 1. Solunan H. ( 1997) Coinorhidity of scnato- Measurement issues and prediction of on- fcxm disorders. Egypt. .l. Psychiat (in this set. Soc Psychiatry K Psychiatr Epiderrri- issue). 01, 29200-209. Vail!ani G. (1988) Defense mechanisms. In Musson, R.F. .411oy, LB. (1988) Depression Nicholi E.M. Jr. (Ed), The New Harvard and self-directed atten!ion. In Alloy L.B. Guide to Psychiatry. Bclknap Press of (4)Cognitive Processes in Depression. ffalvard Univ.,Cnrithridge. The Grrilford Press: New York. pp 193- 215.

Egypt. J. Psychiat. 20: 1. January 1997 Appendix E. -Q%.pI

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Egypt. J. Psychiat. 20: 1. January 1997 The Arabic Version of Defense Style Questionnaire- 40

La version Arabe de I'Cchelle de Mechanismes de d6fCnse (DSQ-40) 11- Le style de difense chez les malades avec la diprksion te but de cette rechreche itait d'e'tudier le style de difense chez les maladas avec la dbpression. On a 6tudid 28 malades pendant \'&pisode de dihprission et 27 personnes normales du mfme iige et sexe. 11s ont rempli la version Arabe de DSQ-40. Les risultats ont montre que les malades utilisent moins de dife'nses m0rs (I'anticipation, la suppr&sion, la sublimation et I'humeur) et plus d2 dCf6nses non - mQrs (la proje'ction, I'aggre'ssion passive, la fantasie au- tistique et la somatization) que le groupe de contr81. La dCfense 'formation de la riaction, un mCchanisnle neurotique, est aussi utilisCe beacoup par les malades. La significantion des rbu1tat.s pour comprendre la psychopathlogie de la de'pre'ssion est propsie.

Erratum In part I of this work (issue No:19), table 3 was not complete. It is as follows: Table 3 - Differences Between the two groups classified by cluster analysis Cluster 1 Cluster 2 ANOVA - Defense Mechanism Number = 21 Number = 43 P Value Immature factor Projection Passive aggression act in^ Out Isolatron Devaluation Autistic fantasy Denial S~littinc. ~eurot

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