Defense Mechanism in Patient with Major Depressive and Obsessive Compulsive Disorder

Sidra Tanvir *

*Correspondence to: Sidra Tanvir.

Copyright

© 2024 Sidra Tanvir., This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 22 February 2024

Published: 01 March 2024

DOI: https://doi.org/10.5281/zenodo.10848050

Abstract

The purpose of the present study was to explore the defense mechanisms which are used by the patients of Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD) in Pakistan. Sample of 60 patients (MDD= 30; OCD= 30) were obtained from different psychiatric units in hospitals of Lahore. The results indicated that immature defenses were more commonly employed by the patients of Major Depressive Disorder while patients with OCD used more neurotic defense. It was also revealed that patients with OCD used the defense mechanism of acting out, undoing, intellectualization, splitting others more than the patients of Major Depressive Disorder.

Key words: Defense Mechanism, OCD, MDD.

Introduction

Defense mechanisms are the mental processes that remove unpleasant affect from conscious awareness and modify the human behavior, their thinking and perception of reality. Diagnostic and Statistical Manual (DSM) also highlight the importance of defense mechanisms  and consider them as automatic psychological processes which are out of awareness (William, 1996).  Sigmund Freud indicated that people use different strategies to protect themselves from psychological suffering (Freud, 1926). He regarded this phenomenon as defense mechanisms and become the first one to acknowledge the existence of defense mechanisms. Ana Freud (1992) explained that defense mechanisms of regression, sublimation, repression, reaction formation, turning against the self, introjections, undoing, isolation and projection emerged from Freud’s work. 

Valliant (1993) consider defense mechanisms as regulatory self-descriptions that work as immune system for the ego, it protect the human mind from different emotional states. He proposed a hierarchy for the defense mechanisms and categories them into four categories; mature, immature, neurotic and pathological. He named this hierarchy as defense styles (Valliant, 1977). He stated that matures defense styles were associated with the better adaptive functioning whereas the immature defense style is opposite to it but they are less distressing. While, neurotic defense style was correlated with high levels of distress and pathological defense style caused severe distress in normal functioning (Hentschel, Smith, Draguns, & Ehlers, 2004).

Several studies also indicated the role of defense mechanism in Axis I and Axis II disorders (Maffei, Fossati, Lingiardi, & Madeddu, 1995). Empirical evidences also yield the relationship between defense mechanisms, Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD). Nishimura (1998) studied the psychiatric symptoms among university students and the findings indicated that immature defenses were commonly employed by the patient of major depressive disorder.

In another study, it was revealed that neurotic defenses were more associated with the anxiety disorders while the use of immature defenses was linked with major depressive disorder (Hoglend & Perry, 1998).  Similar study was done with young adults to explore the relationship between behavior and affect in the use of defense mechanism. The findings of the study suggested that anxiety and major depressive disorder were related to the use of immature defense style (Cramer, 2002).

Several studies have been done in Pakistan to explore the phenomena of major depressive disorder and obsessive compulsive disorder. Empirical evidences also suggest the increasing rates of major depressive disorder and obsessive compulsive disorder in Pakistan (Husain, Creed & Tomenson, 2000; Naqvi, 2007; Mirza, 2004). It highlights the need to study these phenomena more deeply. Thus, the main objective of this study was to assess different defense mechanism which used by the patient of MDD and OCD. The findings of this study would provide help to the clinicians in devising the therapeutic plans in the management of these disorders. Moreover, it would be a significant contribution for the literature.

Method

Sample

The purposive sampling technique was used and a sample of 60 patients diagnosed with Major Depressive Disorder (n=30) and Obsessive Compulsive Disorder (n=30) was obtained from both in and out patient departments of psychiatric units in five hospitals of Lahore. The sample specifically consisted of only those patients who were diagnosed with MDD and OCD, as referred by the Psychiatrist and Clinical Psychologist. The inclusions criteria includes only those patients who were 18 or above and didn’t exceed the age range of 35 years.

Instruments

Following instruments were used to measure the variables including: Major Depressive Disorder (MDD) and Obsessive Compulsive Disorder (OCD) and defense mechanisms.

Demographic sheet. On the basis of the literature the demographic variables of age, gender, duration of illness, marital status, education, family size and number of family members were explored.

Defense Style Questionnaire (DSQ-60). Translated version of DSQ-60  was use in the research but as the target population don’t have command on English.

This scale was originally developed by Thygesen, Drapeau, Trijsburg, Lecours and Roten (2008) and it was translated into Urdu according to Mapi Guidelines (Acquadro, Conway, Giroudet, Mear, 2004). The first step was forward translation of the scales which was carried out by three qualified professional in the field of psychology consisting of 2 clinical psychologists and a university lecturer of psychology. These professional were the native speakers of the target language (Urdu) and had good command on both English and Urdu. When the translations were received then the next step was to review the translations by the two bilingual experts, having command on both languages. The forward translations were discussed to compare and assess whether the translated version had the clear conceptual clarity and comprehensibility. Most appropriate and culturally relevant translation was selected.

After forward translations of the scale backward translations were carried out, in order to access the conceptual clarity and equivalence of the forward translated items. This was done by three bilinguals who has good command on both English and Urdu language. In order to judge the appropriateness of the forward translation, backward translation was received by three bilingual experts.

In the next step of the study, try out of the Defense Style Questionnaire (DSQ-60) translated version was conducted. The reason behind try out was to explore conceptual clarity and comprehensibility of the original English and translated Urdu version of the scale and to find out the reliability of the translated scale. It was also conducted to find out the difficulties which the participants might have to face during the administration of the scale. 

Random sampling method was used and the sample of 20 university students was obtained from Government College University including 10male and 10 females. Only those participants who were 18 or above and didn’t exceed the age range of 35 years. The participants must be bilingual in order to be selected for the try out.

Individual administration was done. Each participant was given English version of the scale. They were allowed to ask any question, if they have problem in comprehending the statements but no such issue were reported. After one week gap the Urdu version of the scale was administered by using the similar procedure. Inter-item correlations were find out and the result shows that correlation ranges from .34 to .90 which shows that translated version is reliable. Cronbach’s alpha for the three defense styles was .85, .80 and .82 which shows that the scale is reliable and valid tool for research.

DSQ-60 consist of 60 questions where the participants have to rate themselves on 9-point Likert scale which ranged from strongly agree to strongly disagree. The defense mechanisms assessed include: acting-out, affiliation, altruism, anticipation, denial, devaluation of self, devaluation of other, displacement, dissociation, fantasy, help-rejecting complaining, humor, idealization, intellectualization, isolation, omnipotence, passive-aggressive, projection, projective identification, rationalization, reaction formation, repression, self-assertion, self- observation, splitting of self, splitting of other, sublimation, suppression, undoing, and withdrawal.

Siddiqui Shah Depression Scale (SSDS). Siddiqui Shah Depression Scale (SSDS) was developed by Siddiqui and Shah (1997) to identify the intensity of depression symptoms among elderly. It was used to screen out the patient with major depressive disorder. The participant have to rate themselves on 4 point scale ranging from 0 (not at all) to 4 (every time). The split-half reliability of this scale for clinical and non-clinical population is .79 and .84 representatively. Moreover, alpha coefficient for the clinical population is .90 and for nonclinical is .89 which shows that the scale is reliable and valid tool for research.

Symptom Checklist-R (OCD Subscale). Symptom Checklist-R was developed by Rahman, Dawood, Jagir, Rehman and Mansoor (2000). The symptom checklist-R consist of six sub scale consisting of Somatoform disorders, Depression, Anxiety, Obsessive Compulsive Disorder (OCD), Schizophrenia and Low Frustration Tolerance. The Obsessive Compulsive Disorder (OCD) subscale of the checklist was used in research to screen out the patient with Obsessive Compulsive Disorder (OCD). The reliability and concurrent validity of the checklist are 0.71 and 0.61 representatively.

Procedure

The sample of the study was taken from different psychiatric units in hospitals of Lahore. Permissions were taken from Mayo hospital, Punjab Institute of Mental Health, Fountain House, Ganga Ram and Services Hospital. After the permissions researcher inform the participants about the aim of the study. Each participant was asked about their willingness to participate in the study and written consent was taken from them. They were ensured about the confidentiality and were assured that the data would only be used for the research purpose. The scales were given to participants and they were asked to provide the required information. At the end participants were thanked for participating in research and they were also provided with brief counseling about their problems.

Results

Hypothesis 1: Patient with Depression will score higher on immature defense as compare to neurotic and mature defense

Paired Sample t-test was used to compare the mean score of immature, mature and neurotic defenses in patient with MDD, where the independent variable is patients with depression and dependent variables are immature, mature and neurotic defenses.

Table 1 Means, Standard Deviation and t-values of MDD (N=30) on Immature, Mature and Neurotic defenses.

Table 1 reveals that the mean scores of the patients with Major Depressive Disorder are higher on immature defenses than mature and neurotic defenses. It indicates that the results are significant which reveals that the patients with MDD used immature defense style more than mature and neurotic defenses.

Hypothesis 2: Patients with OCD will score higher on neurotic defenses as compare to the immature and mature defenses. 

Paired Sample t-test was used to compare the mean score of neurotic, mature and immature defenses in patient with OCD. Where the independent variable of this hypothesis is patients with OCD and dependent variables are immature, mature and neurotic defenses

Table 2: Means, Standard Deviation and t-values of OCD (N=30) on Neurotic, Mature and Immature defenses

Table 2 shows that the mean scores of the patients with Obsessive Compulsive Disorder are higher on neurotic defenses than mature and immature defenses. It indicates that the results are significant which reveals that the patients with OCD used neurotic defense style more as compare to mature and immature defenses.

Hypothesis 3&4: Patients with OCD will score higher on the defense mechanism of acting out, undoing, splitting, projection and intellectualization more than the patients with MDD and Patient with MDD will use the defense mechanism of self-observation more than the patient with OCD.

Independent Sample t-test was used to compare the mean score of acting out, undoing, splitting others, projection, intellectualization and self-observation in patient with MDD and OCD.

Table 3: Means, Standard Deviation and t-values of OCD (N=30) and MDD (N=30) on Acting Out, Undoing, Splitting Others, Projection, Intellectualization and Self Observation

Table 3 shows that the mean differences are present between MDD and OCD. The mean scores of OCD are higher than MDD and the result indicate that patient with OCD use the mechanism of acting out, undoing, splitting others, projection and intellectualization more than the patient with MDD. While, there are no means differences are present in the use of defense mechanism of self-observation between MDD and OCD. Although the mean scores of OCD are higher than MDD but the overall result indicate that there are no such differences was reported in the use the mechanism of self-observation between the patients of MDD and OCD.

Discussion

The present study investigates the different defense mechanisms which are employed by the patients of Major Depressive Disorder and Obsessive Compulsive Disorder.

Findings of the study indicated that patients with depression score high on immature defenses as compare to neurotic and mature defenses. Empirical evidences also support the result findings as Kneepkens and Oakley (1996) investigate the rapid improvement in the defense style of depressed women and men. The result findings of the study indicated that after the therapy there was change in the defense style, as there was a significant decrease in immature defense, and significant increase in mature defenses. No change was reported in neurotic level defenses. Similarly in another study defense styles and their association with depression and anxiety was investigated, the result findings suggest that depressive patients scored significantly higher on immature defenses (Spinhoven & Kooiman, 1997; Andrew, Pollock, & Stewart, 1989).

It was also revealed that OCD patients score higher on neurotic defenses than immature and mature defenses. The result was supported by the evidence that neurotic defenses were associated with anxiety disorder particularly with OCD (Hoglend & Perry, 1998). Similarly in another study by Spinhoven and Kooimen (1997) it was found out that patient with Obsessive Compulsive Disorder (OCD) obtained significantly higher scores on neurotic defenses than other defense style. A possible explanation of these results may be the fact that in OCD neurotic defense help individual in preventing excessive level of anxiety, distress, negative effects and persistent thoughts and socially unacceptable drives thus patients with OCD tend to use neurotic defense more than any other defense style (Rishipal, 2012). 

Another possible reason is that there is a lack of understanding of the problems and fear of acceptance of a psychological problem in Pakistani population because in Pakistan, there is a lack mental health awareness due to which people are reluctant and afraid to accept psychopathologies. This explanation can also be supported by the research evidences as in one study, Suhail (2005) assess public mental health beliefs in Pakistan and the result findings indicated that there is a need to increase mental health awareness in Pakistan, as there is lack understanding in people regarding to their illness.

Another interesting finding was the increased use of defense mechanism of acting out in OCD patients as compare to MDD. The results were supported by the evidence that patient with OCD have high tendencies of employing the mechanism of acting out than depressive patients (Blaya et al., 2006). The possible reason behind it could be that people with OCD are preoccupied with intrusive thoughts which evoke the urge of repeating some acts again and again that reduce their distress (American Psychological Association, 2013). Another conclusion could be that patients with OCD are mostly concern with the recent event and try to avoid future harm. They act out because they want to reduce the distress which they experience due to their obsessional thoughts (Davison & Neale, 2012).  Whereas the patients with MDD are mostly preoccupied with their past mistakes and regrets due to this, the tendency of acting out is lower in them.

Another significant finding of the study was the frequent use of defense mechanism of undoing in OCD patients. Although, undoing is considered to be a common reaction of the individual with OCD but in Pakistani population the increase use of this defense mechanism can be related to the psychosocial factors such as marriage related issues, domestic violence, socioeconomic issues and low education. This explanation is also strengthened with the support of research evidences as marriage related issues, domestic violence factors are considered to be related with females and low level of education and socioeconomic issues were related to males with anxiety disorders (Mirza, 2004). Here, using the mechanism of OCD help individuals to do away the unpleasant experiences and distress. By using this defense mechanism they undo the negative experiences and worries (Comer, 2013).

The findings of the study also indicated that patient with OCD use the mechanism of splitting others, projection and intellectualization more than the patients of MDD. Empirical evidences also validate the research findings as in a study ego defense mechanisms were compared in psychiatric patients and healthy adolescent. The results of the study suggested that patient with OCD use the ego defense mechanism of acting out, undoing, splitting others, projection and intellectualization very frequently (Offer, Lavie, Gothelf, & Apter, 2000; Nasab, 2006). Similarly, in another study by Andrew, Pollock and Stewart (1989) it was found out that patients with OCD use excessively the defense mechanisms of undoing, acting out and projection.

The possible explanation of splitting others is that patients with OCD are unable to make distinctions between polarities. In different situations, they are unable to understand the different opinion, attitude and unable to grasp the complexities of situation. This raises anxiety as they are unable to face the reality which affects their ability of maintaining relationships. On the contrary, the ability if maintaining relationships in MDD is not much distorted because these relations help them to restore their previous level of functioning (Burton, 2012).

However, it is believed that OCD patients frequently use the defense mechanism of intellectualization to dealing with emotional stressors by excessive use of thinking or complex explanation to control or minimize disturbing feelings (Hentschel, Smith, Draguns & Ehlers, 2004). The reason behind the use of projection is that many patients with OCD are unable to make and maintain relationships because they are unable to integrate their thoughts, feelings and actions. This failure creates inner conflicts in them which unconsciously produces anxiety and to reduce the anxiety, they tend to use the defense mechanism of projection (Sadock & Sadock, 2007; Hamidi & Motlagh, 2010).

It was proposed that the defense mechanism of self-observation is more likely to be used by the patients of Major Depressive Disorder (MDD) as compare to the patients with Obsessive Compulsive Disorder (OCD). But the findings indicated that the results are non-significant as there are no such differences reported among the use of defense mechanism of self-observation among these two populations. The present study has limitations as well that should be taken into consideration when interpreting the results such as the number of sample was limited.

Conclusion

The present study was designed to reveal the defense mechanism employed by the patients of Major Depressive Disorder and Obsessive Compulsive Disorder. The defense mechanisms of acting out, undoing, reaction formation, intellectualization, projection and splitting others is more used by the patients of OCD as compare to the patients of major depressive disorder. Inspite of the defense mechanism, the study also revealed the defense style of the both groups. The patient of major depressive disorder used the immature defenses more than other defense styles while, patients with OCD use neurotic defense more than other defense style.

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