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Look to patient's ego defense for diagnostic clues. (Three-Step Approach).

SAN ANTONIO -- Analysis of a patient's ego defense mechanisms can provide valuable clues to diagnosis, Dr. Thomas P. Beresford said at the annual meeting of the Academy of Psychosomatic Medicine.

Different defense mechanisms are characteristic of different levels of psychological functioning, from primitive through mature, and they can allow for a practical and rapid way of determining how well adjusted a patient is, said Dr. Beresford, director of the Laboratory for Clinical Research in Psychiatry at the University of Colorado Health Sciences Center in Denver.

According to a model first advanced by Anna Freud, stress causes perturbations in the ego's homeostasis, causing anxiety. The unconscious mind chimes in with ego defense mechanisms, which allow the ego to deal with the anxiety and respond to the stress.

Dr. Beresford recommends a three-step approach in determining whether a given defense mechanism is primitive, immature, neurotic, or mature. (See chart.)

First, the psychiatrist should determine whether the patient recognizes whether there's a problem. If so, the psychiatrist should determine whether the patient recognizes that the problem is his or her problem. If so, the psychiatrist should determine whether or not the patient is properly integrating the affect and the cognition associated with the problem.

People operating at a primitive level will refuse to acknowledge the existence of the stressor. This is normal in young children. When a child is asked whether he has defecated in his pants, he might respond simply by running away (avoidance) or by saying no in the face of obvious contrary evidence (concrete denial). In a young child, these defense mechanisms are normal, but in an adult they may indicate psychosis, delirium, dementia, or organic brain pathology People operating at an immature level will acknowledge the existence of a stressor but will insist that the problem belongs to someone else.

Dr. Beresford advised, "If someone is acting like a jerk, do a cognitive exam." He shared, by example. the story of a patient who was disliked by the entire medical team but was found, on further examination, to exhibit some cognitive deficits. As it happened, he recently had been given a tracheotomy that was too small, so he e was not getting enough oxygen. After the tracheotomy was enlarged, his cognitive state improved.

People operating at a neurotic level will acknowledge the existence of a stressor and will agree that the problem belongs to them, but they will not be able to integrate the associated affect and cognition. Such a patient might have an overly intellectual response to being told that she has a serious illness (isolation of affect), or might respond to a fear of heights by becoming a skydiver (reaction formation).

Finally, those who operate at a mature level will acknowledge the existence of a stressor, will agree that the problem belongs to them, and will be able to integrate the associated affect and cognition. Such persons may respond to stressors with self-deprecating humor, by sublimating it (in created artworks, for instance), or by noting anxiety and suppressing it until it is more convenient to deal with it effectively "Suppression is the 747 of defenses. It carries the most people," Dr. Beresford said.

In Dr. Beresford's view, analysis of ego defense mechanisms provides an alternative to focusing narrowly on phenomenology or on medical issues while performing a differential diagnosis. Focusing solely on the DSM-IV, he said, is "the Chinese restaurant approach to diagnosis, where you have two [symptoms], one from Column A and one from Column B, and then you have your diagnosis." Focusing on ego defense mechanisms, on the other hand, comes from the schools of depth psychology and psychoanalysis, and the goal is to determine what exactly is going on with a patient.
Ego Defense Mechanism Categories

 Primitive Immature

Age Appropriate Early childhood Adolescence

Adult Pathology Psychosis Character

Response to Stress Does not exist Someone
 else's problem

Defense Types Denial (concrete) Acting out
 Avoidance- Passive
 distortion aggression
 Projection Schizoid fantasy
 (concrete) Hypochondriasis

 Neurotic Mature

Age Appropriate Early adulthood Adulthood

Adult Pathology Adjustment None

Response to Stress Affective-cognitive Affective-cognitive
 disjunction integration

Defense Types Repression Anticipation
 Isolation of affect Humor
 Dissociation Sublimation
 Displacement Suppression
 Reaction Altruism

Source: Dr. Thomas P. Beresford
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Author:Finn, Robert
Publication:Clinical Psychiatry News
Article Type:Brief Article
Geographic Code:1USA
Date:Feb 1, 2002
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