Transcript
By Dr Abid rizvi
M.D
REGISTRAR
DEPARTMENT OF PSYCHIATRY.
Jnmch
ALIGARH MUSLIM UNIVERSITY
INTRODUCTION
Freud
Unconscious mental processes employed by the ego to reduce
anxiety
Orign in the study of hysterical patients.
Freud topographical theory
unconscious(repressed)
conscious(repressing)
STRUCTURAL THEORY OF THE MIND
Id ego and the superego.
Freud :: repression defense.
Repression directed primarily direct expression of the sexual instinct.
after Freud had formulated his final theory of anxiety, it was possible to study the operation of the various defense mechanisms in light of their mobilization in response to danger signals.
Anxiety and tension
major drive is the reduction in tension, and that a major cause of tension was anxiety. He identified three different types of anxiety.
Reality Anxiety.
most basic anxiety, based on fears of real & plausible events, ( being bitten by a dog)
most common is taking oneself away from the situation, (running away from the dog).
Neurotic Anxiety.
unconscious fear that the basic impulses of the ID will take control of the person, leading to eventual punishment.
(this is thus a form of Moral Anxiety).
Moral Anxiety.
This form of anxiety comes from a fear of violating values and moral codes, and appears as feelings of guilt or shame.
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.
Systematic & comprehensive study of ego defenses Anna Freud.
“ everyone, whether normal or neurotic, uses a characteristic repertoire of defense mechanisms but to varying degrees.”
anxiety occurs the mind responds by increase in problem-solving seeking rational ways of escaping the situation.
If this is not fruitful, a range of defense mechanisms may be triggered.
“tactics which the Ego develops to help deal with the Id and the Supego.”
sigmond freud.
All Defense Mechanisms share two common properties :
They often appear unconsciously.
They tend to distort, transform, or otherwise falsify reality.
“ 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.
mediate the individual's reaction to emotional conflicts and to internal and external stressors “
Level I - pathological defences (i.e. psychotic denial, delusional projection,distortion)
Level II - immature defences (i.e. fantasy, projection, passive aggression, acting out)
Level III - neurotic defences (i.e. intellectualization, reaction formation, dissociation, displacement, repression)
Level IV - mature defences (i.e. humour, sublimation, suppression, altruism, anticipation)
The defense mechanism
An attractive 28 years highly seducing female wasunaware of her flirtarious behavior.She was confusedabout the sexual advances shown by so many menand explained it by their animalistic tendencies, beinginterested in sex rather than the whole person.
conscious aspect of her sexual feeling has been REPRESSED and were expressed unconsciously through her behavoir.
Main mechanism of defense.
“exclusion from awareness(consciousness) of urges, thought, fantasies feeling, and memories that would be threatening if allowed into consciousness”
Assessment of dangerousness is unconscious and at times irrrational (eg a impulse dangerous in childhood, naive now ,still been perceived as dangerous and mobilization of defense just as real threat)
Its automatic, spontaneous, unconscious ego action that prevents awareness of an intolerable internal state, ideas or feeling.
Buried into deep recesses of unconscious .
Not destroyed but blocked ,strive for awareness .
Depletes energy- ego energy.
Basic DM,WORKS in conjuction of others.
Others come in scene repression fails.
In normal individual during childhood .whole of the oedipal complex is repressed.
Frequent brief lapses of memory.
Freudian slips episodic failure of repression.
An elderly widowed male always carried a gun with him and had riot control bombs at home and warned others about the possibility of approaching danger. He has been such suspicious when her wife died accidently by his pulling the trigger.
He was handling his feeling of anger towards himself by PROJECTING it to several outside agency, and reacted to them as real treats of the outside world.
“refers to disowning one’s attitude ,feeling and urgess, and attributing them to some other person to or object.”
Anxiety diminished (person no longer responsible for the possession of the unacceptable urges).
High price is paid perceptual distortion.
Like denial – one of the primitive mechanism.
Used excessively dellusion & hallucination.
Major role in personality development(child cast out their anger onto their parents )
Projection can be used in different grades.
Normally used at time of stress and fleetingly.
More a person relies on it more distorted will be his perception of the external world.
Beyond a certain point – paranoid delusion.
“in case of paranoia, the projection of the accusation onto other, without any alteration
of content and thus with no reference to reality, become manifest as delusional process”
sigmond freud(fragment of an analysis of hysteria CASE OF DORA)
A 35 YEARS old female lost her only child in acute illness. She was in a shock like state for few days. After this she started behaving as though nothing has happened .She washed his clothes, prepared meals cleaned the dead child’s room and talked to others as though nothing has happened. She did’nt respond to any attempt to correct her thinking.
Death of the child could not be tolerated –extreme DENIAL.
PROTECTED HER FEELING but grossly distorted her perception of reality.
“excluding from awareness some aspect of disturbing reality”
A young and immature ego delays awareness of a threatening world until greater level of maturity is reached.
Childhood fantasies.
Normal in time of stress(eg war )or excessively used in psychosis.
Repression defends against affects and drive while, denial abolishes external reality.
A 30 years old male was convinced that he was the best musician(in reality very mediocre). HE sent his tapes to music industry and when they were rejected he said that they don’t want him to hijack the entire music market.
He did’nt do to his regular work as that was the would be a waste of time.
His mediocre musical abilities were casting serious doubt about his value as a person.
He used distortion and distorted the rejection of his recording in order to satisfy his internal need.
This protected his ego against feeling of worthlessness.
“reshaping external reality to satisfy inner need”
Seen in childhood fantasies and wish full filling dreams.
Denial denies the existence of reality while distortion distorts external reality
Unrealistic megalomania, hallucination, delusion.
A 14 years old boy was a good student. His performance deteriorated. His father spent most of the time on business trip and mother only emphasized on his studies with no emotional support. The more she worked hard on his studies the more he would fail. More she was aggressive more he would under achive.This was very shameful for the mother and she would feel humiliated among her friends.
Had multiple issues ,not taken care by her mother.
Her aggression towards her mother was expressed in a was that was not threatening to his ego.
Feeling of aggression was expressed through his PASSIVELY turning against the self
Unconscious expression of aggression towards others expressed indirectly, through passivity, masochism, and turning against the self.
PAB CONVERTS anger at others into silly, provocative behavior or failure that bothers other more than the individual.
A married woman could not tolerate it if things were disorderly or un kept. Her insistence on order, promptness, and attention to detail made her a successful at work. But at home life of family and friends was hell. Entire household was tormented by her behavior.
A 35 old male vehemently opposes homosexual relationships. He thrashed his boss and consequently had to loose his job on learning that boss was gay. Beside this he had a number of hetrosexual relationships with a large number of females. One day his girlfriend came to know that his only permanent affair was with a man.??
Patient had difficulty in toilet training and conforming in general.
Her instinctual drive to dirty up his surrounding had been defended against by reaction formation and been retained as part of his personality.
Refers to converting disturbing attitude, behavior and feeling into the opposite.
OCD
“the existence of extreme of behaiour always leads one to suspect the opposite. Those who make too great an issue of their virtue may reveal how formidable temptation has become.”
Realted to rigorous self decipline.
Useful in many profession but emotionally draining.
A child suddenly starts to wet the bed after years of not doing so, this happened after the arrival of new sibling.
one of Freud's original defense mechanisms, is a form of retreat, going back to a time when the person felt safer and where the stresses in question were not known, or where an all-powerful parent would take them away.
The stress of fixations used to explain a range of regressive behaviors
Oral fixation can lead to increase smoking .
• anal fixation can lead to anal retentive behaviors
Tidying and fastidiousness.
• Phallic fixation can lead to conversion hysteria.
a 35 year old army jawan was out of his home most of the time. Once on returning home after a long posting he started having recurrent thought of killing his wife.
He had continuous thought, without any feeling ,and was very anxious because those came against his wish . He was anxious as to what would happen if he actually kill his wife.
Wife, having AFFAIR, husband discovered.
Recent discovery was anxiety provoking and threatening to the integrity of ego.
ISOLATED feeling(anger) from the idea(killing his wife) repressed feeling in his unconscious, while the idea saperated from feeling was less threatening and allowed into consiousness.
“Separation of idea from its appropriate affect”
The idea deprived of its affective tone enters conscious awareness , but the affect is repressed.
Protective due to the repression of the affect.
The idea itself may be tormenting, guilt producing, but the discomfort is not as that if the affect is suddenly made conscious.
Seen in obsessional thinking.
Initial numb like feeling following trauma, person is consciously aware of the incident but it feel to him as unreal and foreign.
If feelings allowed into consciousness person is better able to deal with the situation.
A medical student was caught smoking in his room by his father. On being caught he gave explanation for his smoking as being protecting against ulcerative colitis . His gave father advise to smoke as it is also protective against Alzheimer's..
Act of giving logical believable explanations for behaviors that is in fact irrational.
Unconscious urges that are unacceptable& provides a acceptable tolerant reason for the behavior.
Not conscious lying or excuse giving(unconsciously motivated).
A newly married female has been recently diagnosed with breast cancer. After a phase of denial she start discussing the odds of her survival with her oncologist in an unemotional way . Further more she started calculating the odds that her husband would divorce her onces she undergoes mastectomy. she talked about these emotionally laden topics plainly and in great detail.
Excessively using intellectual processes to avoid affective expression or experience.
Attention is paid to external reality to avoid the expression of inner feelings, and stress is excessively placed on irrelevant details to avoid perceiving the whole.
Intellectualization is closely allied rationalization.
Heavy use of jargon when ordinary language would suffice is often used as a device of intellectualization.
By using complex terminology, the focus becomes on the words and finer definitions rather than the human effects.
Freud believed that memories have both conscious and unconscious aspects, and that intellectualization allows for the conscious analysis of an event in a way that does not provoke anxiety.
A 40 year old male kicked his dog when ever he had an argument with his wife. He was upset by his unacceptable rage toward her. On one occasion he tried to strangulate it. Dog happened to the favorateof his wife. He was unaware of his anger towards his wife.
He displaced the anger (wife) onto the family dog and kicked it.
Anger at dog was less threatening & most importantly , could be tolerated within his conscious awareness.
“Shifting an emotion or drive cathexis from an idea or object to another that resembles in some aspect”
.
Allows symbolic expression of idea or drive that is less distressing.
Angry feeling for one person may be displaced onto other that have some degree of similarity.
Seen in phobic reaction in which particular situation provokes anxiety, displaced from unconscious sources
Assures the coherent functioning of ego by circumscribing the anxiety producing situation which the ego tends to avoid.
Displacement may involve retaining the action and simply shifting the target of that action.
Where this is not feasible, the action itself may also change.
Thus there is a transfer of energy from a repressed object-cathexis to a more acceptable object.
Before going to school each day, a 13 year old male went through elaborate series of rituals . He checked his closet & checked under his bed exactly 3 times; he straightened a picture on the leaving room wall. On his way to & from school, he walked in definite path ways in relation to several telephone polls he passed. If he deviated from this routine, he became quite anxious.
He was sexually inhibited, & experiencing guilt about masturbatory fantasies. His ritualistic behavior served the purpose of decreasing(UNDO) guilt & anxiety by magically undoing his unacceptable sexual fantasies & urges.
“ACT which magically cancel out or reverse a previous act or thought.”
Previous act or thought was motivated by unconscious unacceptable urges, and undoing serves the puspose of temporalily abolishing the urges.
A strong fixation to magical thinking.
Religious ritual.
16/f returning late night from movie was robbed of all her belonging at gun point. She called her father and narrated whole story who came on the scene and took her to the cops. There she denied anything that had happened. She had no signs of anxiety and said she might have dropped all her belongings.
This is example of dissociative amnesia
temporarily but drasticallly modifying a person’s character or one’s sense of personal identity to avoid emotional distress.
Seen as dissociative amnesia , DID,
In german concentration camps, certain prisoners began to behave arrogantly, just like their germancaptors. They would behave in a way that would seem unappealing & undesirable to them.
On august 1973 two thieves Jan-Erik Olsson and Clark Olofsson held four Stockholm bank employees hostage at gunpoint in a vault. When the victims were released, their reaction shocked the world. They displayed behavior patters as their captors, refused to cooperate and make charges against the captors. One female victim went on to have relationship with the captor.
“internalizing attitude or behavior pattern of significant people’s in one’s life”
Important early in life and in the maturation of ego.
A developing child identifies with the values, attitude and behavior of the paarent, and these memories become part of his personality.
Hence the environment of the child must be healthy and of desirable people.
During oedipal conflict boy identifies with the father.
“I’ll be like u than be afraid of u.”
important in ending the oedipal complex and child taking the value and beliefs of father.
IDENTIFICATION WITH THE AGRESSOR
Gives inner feeling of being as strong as the aggressor and so decreases anxiety.
A 44 year old successful bussinessman achieved considerable success in bussiness then he began to devote time to philanthropic & organizations, specialy those that assisted underprevelaged children. He enjoyed seeing the children lives improved through his efforts.
He himself was poor in his childhood. Clearly he channeled many aggressive feelings into this work. His altruism, offered intrapsychic assistance in dealing with his aggressive drives.
high adaptive defense mechanism against feelings of inferiority or a lack of fulfillment.
“using constructive and instinctually gratifying service to other to undergo a vicarious experience”.
The service rendered to others offers real benefit. and the id impulse is atleast partially gratified by the behavior.
Altuistic surrender.-(self sacrifice).
if an individual becomes dependent upon these acts in order to maintain a feeling of worth, altruism is no longer a high adaptive defense mechanism.
A 25 year old female student was having exam. she had been invovled in romantic relationship, but had developed serious questions about her feelings for him. She wanted time to think before making a decision . She postponed dealing with the relationship question
This was accomplished in reasonable period of time & allowed her to deal more affectively with the important personal issues with young man. The problem was not avoided but had been postponed to a more advantagious time.
“Consciously or semiconsciously postponing attention to a conscious conflict to a more suitable time”
Conflict is postponed but not avoided.
Not a true defense mechanism.
A 53/m had anticipated the possibility of serious illness at some point in life, & the problems that would be created on an emotional as well as practical level. He had made good, common practical arrangements in terms of medical insurance.
When he had develop a serious medical problem requiring surgery, he was naturally upset, but not nearly so much as if he had not anticipated.
His physical recovery was assisted by his emotionally mature way of dealing with the illness.
“realistically anticipting and planning for future inner disscomfort”
A brilliant student with strong urge to control people finds himself attracted to careers in medicine in which he can have great power and control over patients and staff in the context of doing good for people. The underlying aggressive urge might sometimes be seen in mistreatment of nurses.
“ channeling of unwanted impulses into something less harmful and socially acceptable. This can simply be a distracting release or may be a constructive and valuable piece of work”.
faced with the dissonance of uncomfortable thoughts, we create psychic energy. This has to go somewhere.
Sublimation channels this energy away from destructive acts and into something that is socially acceptable and/or creatively effective.
Many sports and games are sublimations of aggressive urges,
most useful and constructive of the defense mechanisms.
“greatest achievements in civilization were due to the effective sublimation of our sexual and aggressive urges that are sourced in the Id and then channeled by the Ego as directed by the Super ego”.
ACTING OUT
The direct expression of an unconscious wish or impulse in action to avoid being conscious of the accompanying affect.
chronic level, acting out involves giving in to impulses to avoid the tension that results from postponement of expression
Hypochondriasis
Transformation of reproach toward others arising from bereavement, loneliness, or unacceptable aggressive impulses into self-reproach and somatic complaints of pain, illness, and so forth.
Affiliation
Influence diagnostic condition and impede progress
It is very important for the practitioner to be aware and recognize how they influence treatment (APA, 2000).
DSM-III was the first to included a multiaxialsystem
3 optional axes(APPENDEX B) in DSM 4 TR . DFS,SOFAS,GARF.
DFS on axis 2 along with pd and mental retardation.
Benefit increases information conveyed
Loss crushes under its own weight.
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:
result in optimal adaptation to stress.
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 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
Fully functioning mature adults are flexible capable of range of defensive maneuvers
They are able to meet their needs through this flexibility - the need to protect themselves, and the need to connect with others to satisfy intimate and economic needs
S.freud --anna freud ---george valliant.
???unconscious mind.
Orign of behaviorism and death knell of psychoanalysis.
D. S. Holmes et all (1972, 1974, 1990) published various studies negating unconscious mental operations.
In the past decade, new ideas about defense mechanisms have begun to develop.
classical psychoanalytic theory had explained defenses as
counterforces to the expression of instinctual drives, contemporary psychoanalytic self-psychology and object relations theory broadened the role of defense to include the maintenance of self-esteem and the protection of selforganization.
Baumeister et al. (1998) discussed research from modern social psychology that provides evidence for the use of defense mechanisms in situations where there is a threat to self-esteem.
increasing body of evidence for psychological functioning outside of awareness and for defenses important implications for anyone involved in the treatment of patients, either medical/psychiatric.
Therapeutic Noncompliance
Pts serious medical conditions with bad compliance ,strong use of DM
Premature termination /avoidance of therapy may be significantly influenced by dm.
"By thoughtlessly challenging irritating, but partly adaptive, immature defenses, a clinician can evoke enormous anxiety and depression in a patient and rupture the [therapeutic] alliance" (Vaillant, 1994)
Assessment of Coping Strategies
and Outcomes.
Defense mechanisms have been found to make independent contributions to the prediction of adjustment.
Relying solely on self-report measures for this purpose is questionable, for it ignores the possibility that either intentionally or unintentionally, the self-report is biased.
Facilitating Differential Diagnosis.
use of immature defenses BPD
patients with psychoses use defenses that are
less mature than those used by patients with personality
Demonstrating the Benefits of Psychotherapy
or Other Interventions.
The relation between therapeutic benefits and defense use has been demonstrated in several clinical studies.
After 15 months of intensive therapy, hospitalized patients showed a significant decrease in immature defenses.
PSYCHOSES:
*In the acute stage complete loss of the ego’s DMDisturbing thoughts, feelings, and impulses intrude into
the consciousness*As the individual gradually improves defenses appear
Projection Delusional denial Distortion Regression
NEUROTIC CONDITIONS:
(Anxiety Disorders; Somatoform Disorders; Dissociative Disorders in DSM IV R)
*defenses are used non-adaptively in social interaction
*they are stereotyped and repeated
Phobia: Displacement
Avoidance
Symbolization
Restriction of the Ego
Somatoform Disorders:
Somatization
Conversion
Passivity
Dissociative Disorders:
Dissociation
Denial
DEPRESSION
--Turning against the self
--Passivity
--Isolation
--Identification
Obsessive-Compulsive Disorder
--Isolation
--Intellectualization
--Reaction formation
--undoing
MATURE BEHAVIOR
--Suppression
--Humor and wit
--Sublimation
--Intellectualization
--Asceticism
"Today, no mental status or clinical formulation should be considered complete without an effort to identify the patient's dominant defense mechanism" (Vaillant, 1992, p. 3).
“SOMETIMES A CIGAR IS JUST A CIGAR”
---SIGMOND FREUD.
Comprehensive textbook of psychiatry.
Ego and the mechanism of defense(anna freud).
Ego and the id (sigmond freud).
Biography of sigmund freud (ernest jones).
Psychoneurosis and the mechanism of defense(freud).
Defense Mechanisms in Psychology Today
(Phebe Cramer Williams College).
Seven Pillars of Defense Mechanism Theory*
(Phebe Cramer).
Defense Mechanisms(http://changingminds.org/explanations/behaviors/coping/defense_mechanisms.htm)
DSM 4 tr classification of defense.
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