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Defense Mechanisms in Severe Adolescent Anorexia Nervosa
Defense Mechanisms in Severe Adolescent Anorexia Nervosa DORON GOTHELF, B.Sc., ALAN APTER, M.D., GIDI RATZONI, M.D., ISRAEL ORBACH, PH.D., RONIT WEIZMAN, M.D., S A M TYANO, M.D., AND CYNTHIA PFEFFER, M.D.
ABSTRACT Objective: To compare ego defense mechanisms in adolescents with anorexia nervosa and other major psychiatric disorders, to defenses in healthy adolescents. Method: Thirty-seven patients with anorexia nervosa, 30 with major depressive disorder, 20 with obsessive-compulsive disorder, 53 with borderline personality disorder, 60 with schizophrenia, and 81 healthy controls were assessed with Pfeffer’s Ego Defense Scale. Results: Regression, denial, projection, repression, introjection, and total defenses were common to all psychiatric patients and distinguished them from normal adolescents. In addition to these defenses, anorectic patients also used intellectualization more frequently than normal adolescents and psychiatric patients. They used sublimation more than other psychiatric patients. Patients with disorders, apart from obsessive-compulsive disorder, that are considered to be often comorbid with anorexia did not have different defenses than schizophrenic patients. Conclusions: Anorectic adolescents overutilize relatively more mature defenses than do psychiatrically ill adolescents, and they overutilize immature defenses compared with normal adolescents. This combination of mature and immature defenses may be related to the uniquely heterogeneous ego functioning seen in anorectic patients, and it may provide insight into the nature of the psychopathology of anorexia nervosa. It also could have important psychotherapeutic and prognostic value. J. Am. Acad. Child Adolesc. fsychiatry, 1995, 34, 12:1648-1654. Key Words: adolescents, defense mechanisms, anorexia nervosa.
Defense mechanisms are unconscious means by which the ego wards off and controls impulses, affects, and instincts (Freud, 1936). Defenses protect the individual’s psychological integrity, stability, and individualized patterns. They also indicate a person’s level of maturity (Vaillant, 1977). Defense mechanisms may have an important role in psychopathology and in the shaping of the various psychiatric disorders (Freud, 1926). There is a rich psychodynamic and clinical literature on the nature of anorexia nervosa (AN). Most theoreticians take into account the role of defense mechanisms
Accepted April 19, 1995. Mr. Gotheyis a medicalstudent at the Sackkr School ofMedicine, University of Tel Auiv, Israel. Drs. Apter, Ratzoni, and ijano are with the Department of Child and Adolescent Psychiaty, Geha Psychiatric Hospital, Beilinson Medical Center and Sackler School of Medicine, University of Tel Auiu. Dr. Orbach is with the Department of Psychology, Bar Ilan University, Ramat Gan, Israel. Dr. Weizman is with the Tel Aviv Mental Health Center, Sackler School of Medicine, University of Tel Auiu. Dr. Pjffer is with the Department of Child and Adolescent Psychiaty, The New York Hospital-Cornell Medical Center. Reprint requests to Dr. Apter, Geha Hospital, P.O. Box 102, Petah Tikva, 49100, Israel; fa: 972-3-9241041. 0890-8567/95/3412-1648$03.00/001995 by the American Academy of Child and Adolescent Psychiatry.
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in the psychopathology of this condition. Bruch (1973, 1982) and Sours (1974, 1980) see the origin o f A N in an overcontrolled, overprotective, and overconforming childhood, leaving the adolescent unable to complete the task of separation-individuation. Both Bruch and Sours as well as Crisp (1980) and Vitousek et al. (199 1) believe that denial is a central defense mechanism of anorectic patients. These patients deny thinness and body shape so that there is a consequent distortion of body image. They also deny their illness and their need for treatment. According to Bruch (1982), this denial is a result of maternal overcontrol, which forces the anorectic subject to deny impulses, feelings, and wishes. As a result of the lack of self-differentiation resulting from an unsuccessful separation-individuation, the anorectic patients can see themselves only through the images they project onto the world (Bruch, 1982; Sours, 1980). Furthermore, the inability to meet the challenges of adolescence and independence are thought to lead to libidinal and ego regression expressed by the reversal of the pubertal process, and the precipitation of the patients’ families back into biological, psychological, and social childhood (Briksted-Breen, 1989; Crisp, 1980; Sours, 1974, 1980). Cramer (1991)
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as well as Heilbron and Harris (1986) have emphasized repression of the wish for separation, as well as repression of aggressive feelings toward the overcontrolling mother. Other authors have remarked on the introjection of hostile and ambivalent attitudes of their families toward them (Strober and Humphrey, 1987). Failure to negotiate separation-individuation leaves the anorectic individual feeling worthless (Bruch, 1982; Sours, 1980). This failure is compensated for by strict control of the body and self and overinvolvement in activities that carry a high social premium. Some clinicians have interpreted the anorexic individual’s excellence and ambition at school as representing sublimation and intellectualization, although Sours (1980) has described these attempts at mastery as being superficial, empty, and not sublimatory. Bruch (1982) and Cramer (1991) also describe individuals with AN as having a primitive (concrete operational) style of thinking, incompatible with the abstract thought required for intellectualization. Until recently there had not been much empirical research on defense mechanisms despite wide acceptance of the concept of defenses and their undoubted heuristic value for clinical practice. The development over the last decade of a variety of valid and reliable instruments for the detection and quantification of defense mechanisms has, however, done much to further such studies (Bond et al., 1983; Cooper and Kline, 1986; Pfeffer, 1986; Vaillant, 1986). Vaillant’s pioneering work was based on the hypothesis that defense mechanisms, especially those characterized by immaturity, were an indicator of generalized psychopathology (Vaillant, 1976, 1986). This hypothesis has been supported by empirical studies, such as those of Plutchik et al. (1979), Steiger et al. (1990), and Steiner (1990). More specifically, there has also been some interest in the application of empirical methods to the study of defense mechanisms in AN in the hope of gaining some insight into the psychopathology of this enigmatic condition. Steiner (1990) compared defense styles of normal adults and adolescents to adolescents with restrictive and bulimic AN, bulimia, and depression, using Bond and colleagues’ (1983) Defense Style Questionnaire (DSQ). Steiner found that all the patient groups showed more immature defenses than did the normal controls. Normal adults had the highest ratio of mature to immature defenses followed in descending order by the normal
adolescents (NADOL), the subjects with AN, the bulimic adolescents, and the depressed adolescents. Using the Beck Depression Inventory, Steiner showed that the patients with eating disorders and depression had less mature defenses than the eating disorder subjects without depression. In a replication study (Smith et al., 1992), it was shown that level of maturity of defenses correlated with level of adaptation. However, Steiger et al. (1990) found no difference between defense styles, as measured by the DSQ, of eating disorder subjects and a small group of psychiatric patients with other conditions. The same group of authors (Steiger et al., 1989) did show that patients with eating disorders had more immature and less mature defenses than normal controls and that there is a positive correlation between defense styles, on the DSQ, and recollections of parental bonding. Subjects with less mature defenses felt that their parents had been unempathic and overprotective. Steiger et al. concluded that eating disorders may be related to borderline personality disorder (BPD) on the object relations level. One limitation of these studies has been their emphasis on groups of defense styles. As far as we were able to ascertain, there have as yet been no systematic studies of the individual defenses in anorectic patients mentioned in the classic literature. A confounding factor in any study of the psychopathology of AN is the remarkable comorbidity between this condition and other psychiatric disorders. The most frequent comorbid illnesses are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and BPD (Harrison and Hudson, 1989; Hsu et al., 1979; Rothenberg, 1988). Thus any study of AN, in addition to using healthy controls, should try to differentiate between AN and these illnesses, as well as between AN and disorders less likely to be associated with AN. The relationship between AN and defense mechanisms can be discussed from the vantage point of many different theoretical positions. However, most theories seem to correlate defenses with difficulties in the separation-individuation process. The present study attempts to examine these hypotheses and thus to clarify the relation between AN and defense mechanisms. The following hypotheses were tested: 1. Anorectic adolescents can be distinguished from NADOL by elevated use of the following defenses:
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denial, projection, regression, repression, introjection, compensation, sublimation, intellectualization, and total defenses (the sum of all the 11 defense scores). 2. Anorectic adolescents use different specific defenses more than adolescents with other major psychiatric disorders. 3 . The adolescents with psychiatric disorders that are often comorbid with AN (MDD, OCD, and BPD) will have several specific defense mechanisms in common differentiating them from schizophrenia (SZ), a major psychiatric disorder that is less likely to be comorbid with AN (Pope and Hudson, 1989). 4. Major psychiatric patients as a group have elevated use of several defense mechanisms in common, distinguishing them from NADOL. O n the basis of our understanding- of the literature we felt unable to formulate specific assumptions regarding individual defenses for hypotheses 2, 3, and 4. METHOD Subjects All patients admitted to the adolescent unit ofthe Geha Psychiatric Hospital during a 24-month period who received the diagnosis of AN ( n = 37) or M D D ( n = 30) or O C D ( n = 20) or BPD ( n = 53) or SZ ( n = 60) were accepted into the study. This unit has a large catchment area and accepts a wide range of socioeconomic classes of patients. All the anorectic cases were pure anorexia, that is, none of them were a mixture of anorexia/bulimia. Exclusion criteria were actual comorbidity with another condition, mental retardation, and lack of knowledge of Hebrew. The following patients were excluded because they had been given more than one diagnosis: BPDtMDD, 8; AN+MDD, 6 (11.8% of the anorectic patients): ANtBPD, 5 (9.8% of the anorectic patients); BPD+OCD, 3; AN+OCD, 2 (3.9% of the anorectic patients); OCD+SZ, 2 AN+SZ, 1 (2.0% of the anorectic patients); and OCD+MDD, 1. Other known comorbid disorders, such as other anxiety disorders apart from O C D or other mood disorders besides MDD, were not found in this study. The fact that the anorectic individuals in our study were all inpatients might have biased the comorbid disorders toward the more severe ones. The assessments were part of the normal intake procedure of the unit. None of the patients refused to cooperate in the study. All patients were between 12 and 18 years of age. There were 74 boys and 126 girls. The control group consisted of 81 NADOL who were recruited by a polling company from schools in the same areas served by the hospital. They were contacted by telephone and asked to participate in the survey on a voluntary basis. The exclusion criterion for the NADOL group was a history of psychiatric care. All subjects in all six groups were Jewish, and the groups were matched for age and socioeconomic status but not for sex, because preliminary analysis of defense mechanisms use showed only little
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sex differences (see “Results”). Parents of all patients signed informed-consent forms
Measures Diagnoses were made according to DSM-//I-R criteria using the Hebrew translation of the Schedule for Affective Disorders and Schizophrenia for School-Age Children. The reliability and validity of this instrument with regard to our population have been reported previously and have been shown to be satisfactory (Apter et al., 1989). Ego defense mechanisms were measured by the Ego Defenses Scale (EDS), which is one of the nine scales of the Child Suicide Potential Scales (CSPS) (Pfeffer, 1986; Pfeffer et al., 1979, 1980, 1984). The CSPS is a semistructured interview, ranging over a wide area of psychopathology, and is a very practical and “userfriendly” instrument, suitable for routine clinical use. The CSPS has been translated into Hebrew and adapted for use with adolescent psychiatric inpatients. It is now used as a standard intake procedure on the unit. The EDS is a semistructured interview given to the adolescent, his or her parents, and his or her therapists. Interviews are done by child psychiatry fellows who have been trained to satisfactory reliability with the unit director (A.A.). Scores are based on an overall impression without actually coding the score for each respondent. They are also based on actual observations of the adolescent’s behavior. Scores for each individual item ranged from 1 to 3. The final score is a composite of all interviews and observations regarding the adolescents. In a study of a subset of 50 adolescent inpatients, two child psychiatry fellows attained the following interjudge reliabilities for the 1 1 defenses measured (the parentheses indicate the reliabilities reported by Pfeffer et al., 1984): intellectualization, r = .93 (.96); regression, r = .90 (.87); undoing, r = .88 (.85); reaction formation, r = .85 ( 3 2 ) ; compensation, r = .78 (.74); repression, r = .79 (.74); denial, r = .80 (.72); projection, r = .72 (.69): introjection, r= .67 (.57); sublimation, r = .70 (.57); displacement, r = .57 (.52). In addition to the above-mentioned 11 defenses, the EDS includes a 12th measure, total defenses, which is the sum of all the 11 defenses. Although total defenses is not a psychoanalytic concept, nonspecific overuse of defense mechanisms has been found empirically to be a measure that distinguishes psychiatric inpatients from normal controls (Pfeffer et al; 1984; Plutchik et al., 1979). Nevertheless, how to reconcile these empirical findings with the traditional psychoanalytic thinking remains a challenge. It has been difficult to establish the validity of the scale, since there is no objective measure of defense mechanisms. However, Pfeffer et al. (1984), using the EDS, demonstrated that introjection, as an ego defense, was used significantly more in suicidal than in nonsuicidal children. Similarly, it has been found that the EDS distinguishes suicidal from nonsuicidal Israeli adolescent inpatients (Shachor, 1994). We chose to use the EDS in our study because the way it is conducted is very similar to routine clinical practice. The EDS reflects the clinician’s impression based on interviews with the adolescent and his or her parents and therapists. The child psychiatry fellows were instructed to focus on several aspects of the adolescent’s behaviors, habits, and patterns of thinking. After relatively short training, and without the need for extensive psychodynamic knowledge and experience, clinicians can reliably assess the use of defense mechanisms. The DSM-IV (American Psychiatric Association, 1994) has recently acknowledged the relevance of defense mechanism assessment, as a potentially helpful tool for diagnosis and
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DEFENSE MECHANISMS I N ANOREXIA NERVOSA treatment planning. This acknowledgment was expressed, by the inclusion in DSM-IV, of a “Defensive Functioning Scale” in the appendix of optional axes. Thus, since our goal is to combine the defense mechanisms’ assessment in our routine clinical practice, we found the EDS, which is one of the few defense mechanisms’ scales constructed especially for children and adolescents, most suitable and practical for this purpose.
Procedure All patients were interviewed by child psychiatrists within the first 2 weeks of admission. T h e initial interview was with the adolescent followed by interview with the parent and then with the therapist. As stated above, the interviews were done as part of the intake procedure. T h e interviewers were unaware of the purpose of the study and of the patients’ diagnoses (although in some cases, especially in the anorectic cases, the diagnosis may have been obvious). T h e nonpatients and their parents were interviewed in their homes by a qualified clinical psychologist who had been trained to satisfactory reliability with the unit director (A.A.). They were given the assurance that their replies would be completely anonymous. All interviews took from 30 to 60 minutes.
Data Analysis One-way analysis of variance with multiple comparisons ( ttests) with a Bonferroni correction for multiple comparisons was used to analyze the data. T h e predictor variables were the five patient groups and the NADOL group. T h e outcome variables were mean grades of each defense mechanism.
RESULTS
A t test comparison between defense scores for males and females found significant differences for compensation in NADOL ( p = .04, males > females) and sublimation ( p = .03, females > males) in the patient groups. No other sex differences were noted, and we felt that comparisons between the research groups could be made without controlling for sex. Table 1 shows the means and standard deviations for all defenses in all the research groups. O n analysis of variance all the defense scores, apart from compensation, significantly distinguished between the study groups at the p < .05 (or better) levels. There seems to be a great deal of support for our hypothesis regarding the elevated use of several defense mechanisms in all the patient groups in comparison with NADOL. O n painvise comparisons, regression, projection, denial, repression, and total defenses were all significantly ( p < .05) higher in the patient groups than in the NADOL group. Introjection scores were also higher in all the patient groups than in the NADOL but only AN, O C D , and BPD reached statistical significance ( p < .05).
In addition to the above-mentioned defenses (i.e., regression, projection, denial, introjection, repression, and total defenses), the anorectic group of patients used intellectualization significantly more frequently ( p < .05) than the NADOL group. In comparison with the other group of patients, anorectic patients exhibited higher use ( p < .01) of sublimation. Moreover, the anorectic girls showed significantly more sublimation than girls with other psychiatric conditions ( p < .01). The anorectic patients also had the highest scores on intellectualization, and their intellectualization scores were significantly higher ( p < .05) than those of the schizophrenic group of patients. Thus two defense mechanisms, sublimation and intellectualization, distinguished the anorectic group from all the other groups of patients. The third hypothesis of this study was rejected. None of the defense mechanisms measured distinguished AN and its comorbid disorder from SZ. It is interesting that reaction formation and undoing scores were significantly higher ( p < .05) in the OCD group than in all the other study groups. In addition, The OCD group had the highest total defense scores, and their total defense scores were significantly higher than those of the SZ and MDD groups ( p < .05).
DISCUSSION
The most significant differences found in this study were between the groups of psychiatric patients and the normal adolescents. The results indicate that major psychiatric disorders have many defense mechanisms in common (regression, projection, denial, introjection, repression, and total defenses) and the strength of this result may explain the rejection of our third hypothesis. It is possible that all the major psychiatric disorders share a common psychpathogenesis, characterized by ego deficits or faulty ego development, causing a lack of maturation in defense mechanisms (Steiner, 1990). In addition, we cannot rule out the possibility that this finding may be related to the “well control artefact” described by Schwartz and Link (1989). Psychiatric studies tend to apply more severe exclusion criteria to control groups than to case groups. For this reason only adolescents without history or evidence of psychopathology were included in our NADOL group. Thus
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TABLE 1 Comparison of Groups' Means (Standard Deviations) on Ego Defenses Scale Defense Mechanism
n Age Regression Projection Denial Introjection Reaction formation Undoing Displacement Intellectualization Compensation Sublimation Repression Total defenses
NADOL
81 15.36 (1.78) 1.26" (0.44) 1.46" (0.59) 1.51" (0.57) 1.51" (0.63) 2.01" (0.70) 1.64" (0.64) 1.53",' (0.59) 1.68" (0.59) 1.82 (0.76) 2.16" (0.70) 1.62" (0.68) 18.20" (3.19)
F Value
AN
sz
37 16.24 (2.13) 2.00' (0.67) 2.22' (0.75) 2.08' (0.76) 2.05' (0.71) 2.05" (0.88) 1.70" (0.78) 1.42" (0.50) 2.22' (0.79) 1.78 (0.64) 2.06" (0.62) 2.14' (0.75) 2 1.72', ' (2.65)
60 16.68 (1.77) 2.17' (0.7 1) 2.37' (0.69) 2.28' (0.72) 1.78", (0.70) 1.75" (0.71) 1.59" (0.68) 1.78". (0.67) 1.73" (0.72) 1.66 (0.73) 1.56' (0.63) 1.90'' (0.61) 20.57' (3.05)
'
MDD
OCD
BPD
30 16.34 (1.66) 2.1 3' (0.73) 2.23' (0.73) 2.00h (0.87) 1.87' (0.73) 1.83" (0.70) 1.83" (0.79) 1.70", (0.75) 1.80". (0.81) 1.80" (0.81) 1.56' (0.63) 2.07' (0.65) 20.82' (3.70)
20 16.17 (2.10) 2.15' (0.37) 2.15' (0.67) 2.10' (0.72) 2.15b (0.49) 2.70' (0.47) 2.50' (0.69) 1.85", (0.59) 2.05"' (0.89) 2.1 0". (0.79) 1.GO' (0.50) 2.30' (0.57) 23.65' (2.94)
53 16.07 (2.13) 2.08' (0.70) 2.23' (0.75) 2.15' (0.74) 1.94' (0.67) 1.85" (0.77) 1.62" (0.74) 1.87' (0.74) 1.78". (0.82) 1.96"' (0.79) 1.63b (0.56) 2.12' (0.52) 21.23',' (3.25)
'
'
' '
'
(df= 5;275)
21.87** 16.25** 10.32** 5.81** 5.79** 5.86** 3.51* 3.35' 1.47 10.17** 7.19** 14.75**
Note: Means with different superscript letters arc different at p < .05. NADOL = normal adolescents; AN = anorexia nervosa; SZ = schizophrenia; M D D = major depressive disorder; O C D = obsessive-compulsive disorder; BPD = borderline personality disorder. * p < .05; **p< .0001.
the differences between defenses in patients and controls may be related to the stress of hospitalization or of being ill and not to the actual identity of the disorder. With the exception of compensation and sublimation, anorectic patients, in comparison with NADOL, exhibited all the defense mechanisms hypothesized to characterize AN. This finding gives some empirical support to the classic literature which, as described above, has found these defenses to be common among patients with AN and, together with the findings of Steiger et al., may indicate that theories that relate AN to failure .of separation-individuation have some empirical validity. For example, the anorectic patients' resistance against eating probably represents their intense struggle with their parents regarding control and autonomy, which is fought out on the battleground of their body.
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Vitousek et al. (Vitousek and Hollon, 1990; Vitousek et al., 1991) proposed that patients with AN utilize all these defenses only in relation to their eating behavior and body image. They claim that the anorectic patients use the defense mechanisms mainly to shield their symptomatology from outside influence. Thus they conclude that anorectic patients do not have distinctive cognitive structures that are independent of eating and body image. Our findings contradict this concept and show that anorectic patients have distinctive defense mechanisms that are part of their regular functioning and not only in relation to their eating disorder. Most of the defense mechanisms that distinguish anorectic patients from normal adolescents are common to all the psychiatric patients. However, sublimation and intellectualization distinguish patients with AN
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from adolescents with other psychiatric disorders. The finding that elevated use of intellectualization and sublimation are unique to anorectic patients might explain the seeming paradox between the severity of the psychopathology of these patients and their ability to function successfully in school and in other activities. For instance, our experience is that these patients almost always assume leadership positions on the unit and take responsibility for many of the everyday milieu activities. The coexistence of relatively adaptive defenses and severe disturbance poses a challenge for accepted theories of ego defenses and ego psychology. It is possible that massive use of these defenses may account for the apparent encapsulation of psychopathology or “false self,” often described in anorectic patients. A possible explanation for the increased use of sublimation is that this defense is most commonly used in girls. However, we found that anorectic girls show significantly more sublimation than girls with other psychiatric conditions ( p < .O1). Therefore, this high use of sublimation does seem to be specific to AN. Sours (1980) and Bruch (1982) have claimed that the anorectic patients’ seemingly sublimatory activities do not represent real sublimation, but stem from the patients’ overcompliance with their parents’ expectations. These authors claim that the anorectic patients do not really enjoy their schoolwork and hobbies. T o judge whether the elevated use of sublimation found in our study is not a misjudgment in the way that Sours and Bruch have claimed, we must elaborate on how sublimation is evaluated by the EDS. The EDS defines sublimation as: “Under the influence of the ego, unacceptable feelings are changed into a socially useful modality without blocking an adequate discharge” (Pfeffer, 1986, p. 288). In addition, the EDS gives specific, typical examples that represent expressions of sublimation. The interviewers are trained to evaluate the use of sublimation (as well as the other defense mechanisms) based on the definition and the prototypic examples. The specific examples of sublimation given by the EDS are as follows: (1) the adolescent enjoys his hobbies (e.g., playing a piano, collecting, painting, dancing, etc.); (2) the adolescent expresses his aggressive feelings by participating in sporting activities; (3) the adolescent finds interest in school lessons. As mentioned previously, the interviewers’ impressions were based on several sources: interviews with the adolescents, their parents, and their therapists, and
actual observations of the adolescents’ behavior. In the process of evaluating adolescents’ use of sublimation, the interviewers also observed them at school and while participating in sports. The examples given by the EDS for the assessment of sublimation stress that an adolescent who is rated high on sublimation enjoys his or her hobbies and finds interest in his or her school lessons. According to the EDS, the high use of sublimation in anorectic patients found in our study was apparently real and not “superficial and empty,” as Sours and Bruch have claimed. Yet, naturally, concepts such as “real enjoyment” are difficult to evaluate and only a more intensive inquiry can finally settle this issue. This study found that anorectic patients do use many defenses. Some are specific, i.e., intellectualization and sublimation. Some are the result of nonspecific regression and ego deficits. It is interesting that the specific defenses are those regarded as being relatively more mature, while except for repression the “common” defenses are those described as being more immature (Vaillant, 1986). In this regard it should be noted that all the patients in our study are inpatients, i.e., treatment failures from other centers, and are severely disturbed. Therefore, it is very plausible that these patients are characterized by a higher level of psychopathology and thus also by immature defenses. The presence of these immature defenses in AN have been reported previously by Steiner (1990) and by Steiger et al. (1990), and their presence in most major psychiatric conditions was reported by Bond et al. (1983) and Vaillant (1986). The combination of relatively mature and immature defenses seen in AN in this study is, as far as we have been able to ascertain, the first empirical report of its kind in the literature. This combination is puzzling since by psychoanalytic definition the use of relatively mature defenses is, for the most part, not possible when the immature defenses are as active as they are in AN. However, the uneven use of mature and immature ego defenses might reflect the uniquely heterogeneous ego functioning of the anorectic group of patients (Norring et al., 1989; Sours, 1980; Strober, 1983). In addition, as clinicians treating AN, we have been impressed by the mature behavior these patients exhibit in many other areas not related to food and body shape.
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Clinical Implications
In this study we focused on AN patients and found an interesting combination of relatively mature and immature defenses. If these findings could be replicated in further studies it may deepen our understanding of the psychopathogenesis of AN and its dynamic subtypes. Thus, EDS evaluation could have important psychotherapeutic and prognostic implications. The research findings consolidate the psychoanalytic theory, which relates AN to failure in the separation-individuation process. In terms of psychotherapy, the study indicates that the anorectic subjects have some specific ego strength, i.e., their tendency to use sublimation and intellectualization. Yet, the study also found that the anorectic patients also have some nonspecific ego deficits, namely their overuse of immature ego defenses such as denial and regression. Anorexia nervosa has a heterogeneous clinical course. At one end of the spectrum are a group of mild, transient cases that remit readily and sometimes even spontaneously. At the other end are those malignant cases that run a chronic course well into adulthood or cases that end in suicide (Herzog et al., 1988). Sours (1980) claimed that persistent denial of illness is associated with poor outcome in anorectic patients. Possibly those anorectic patients characterized by use of more mature ego defenses have a better prognosis, while those characterized by immature ego defenses have a worse prognosis. We hope that the knowledge of the general defensive pattern used by anorectic individuals could be helpful in treating these highly talented, but severely tormented, young people.
REFERENCES American Psychiatric Association (1994), Appendix B: Criteria sets and axes provided for further study. In: Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-Iv. Washington, DC: American Psychiatric Association, pp 751-757 Apter A, Orvaschel H, Laseg M, Moses T, Tyano S (1989), Psychometric properties of the K-SADS-P in an Israeli adolescent inpatient population. / A m Acad Child Adolesc Psychiatry 28:61-65 Bond M, Gardner ST, Christian J, Sigal JJ (1983), Empirical study of self- rated defense styles. Arch Gen Psychiatry 40:333-338 Briksted-Breen 11 (1989), Working with anorexic patient. I n t / Psychoanal 170:29-40 Bruch H (1973), Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books Bruch H (1982), Anorexia nervosa: therapy and theory. Am / Psychiaq 139: 1531-1 538 Cooper C , Kline I’ (1986), An evaluation of the Defense Mechanism Test. Br / Psychol 77: 19-3 1 Cramer P (1991), Anger and the use of defense mechanisms in college students. / Pers 59:39-55
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Crisp AH ( 1 980), Anorexia Nervosa: Let Me He. New York: Grune & Stratton Freud A (19361, The Ego and the Mechanisms of Defpnse. New York: International Universities Press, 1966 Freud S (1926), Inhibitions, symptoms and anxiety. In: The Standard Edition of the Complete Psychological Works of Sigmund Freud Vol 20, Strachey J. ed. London: Hogarth, pp 87-174 Harrison GP, Hudson JI (1989), Are eating disorders associated with borderline personality disorder? A critical review. Int/ Eat Disord8:1-9 Heilbron AB, Harris A (1986), Psychological defenses in females at risk for anorexia nervosa: an explanation for excessive stress found in anorexic patients. I n t / Eat Disord 5:503-516 Herzog DB, Keller MB, Lavori P W (1988), Outcome in anorexia nervosa and bulimia nervosa: a review of the literature. / Nerv Ment Dis 176: 131-143 Hsu LKG, Crisp AH, Harding B (1979), Outcome of anorexia nervosa. Lancet 1:61-65 Norring C , Sohlberg S, Rosmark B, Humble K, Holmgren S, Nordqvist C (1989), Ego functioning in eating disorders: description and relation to diagnostic classification. Znt / Eat Disord 8:607-621 Pfeffer C R (19861, The Suicidal Child. New York: Guilford Press I’feffer CR, Conte HR, Plutchik R, Jerrett I (1979), Suicidal behavior in latency-age children: an empirical study. / A m Acad Child Psychiatry 18:679-692 Pfeffer CR, Conte HR, I’lutchik R, Jerrett I (1980), Suicidal behavior in latency-age children: an empirical study: an outpatient population. / Am Acad Child Psychiaq 19:703-710 Pfeffer CR, Zuckerman S, Plutchik R, Mizruchi MS (1984), Suicidal behavior in normal school children: a comparison with child psychiatric inpatients. J Am Acad Child Psychiatry 23:416-423 I’lutchik R, Kellerman H, Conte HR (1979), A structural theory of ego defenses and emotions. In: Emotions in Personality and Pyhopathology, hard CE, ed. New York: Plenum Publishing Corporation, pp 229-257 Pope HG, Hudson JI (1989), Eating disorders. In: Comprehensive Textbook of Psychiatry, Kaplan HI, Sadock BJ, eds. Baltimore: Williams & Wilkins, p 1860 Rothenberg A (1988), Differential diagnosis of anorexia nervosa and depressive illness: 3 review of l l studies. Compr Psychiatry 29:427-432 Schwartz S , Link BG (1989), The “well control” artefact in caselcontrol studies of specific Psychiatric disorders. Psychol Med 19:737-742 Shachor I (1 994), Defense mechanisms in suicidal adolescents. Dissertation for Doctor of Medicine, Sackler School of Medicine, Tel Aviv University Smith C, Thienemann M, Steiner H (1992), Defense style and adaptation in adolescents with depressions and eating disorders. Acta Paedopsychiatr 55:185-186 Sours JA (1974), T h e anorexia nervosa syndrome. Int / Psychoanal 55:567-576 Sours JA (1980), Starving to Death in a Sea of Objects. New York: Aronson Steiger H, Goldstein C, Mongrain M, Van der Feen J (1990), Description of eating-disordered, psychiatric, and normal women along cognitive and psychodynamic dimensions. Znt / Eat Disord 9:129-140 Steiger H , Van der Feen J, Goldstein C, Leichner P (1989), Defense style and parental bonding in eating-disordered women. Int / Eat Disord 8: 131- 140 Steiner H (1990), Defense styles in eating disorders. Znt / Eat Disord 9: 141-1 5 1 Strober M (1983), An empirically derived typology of anorexia nervosa. In: Anorexia Nervosa: Recent Developments in Research, Garfinkel P, Garner D, Coscina D, eds. New York: Alan R. Liss, pp 185-195 Strober M, Humphrey LL (1987), Familial contributions to the etiology and course of anorexia nervosa and bulimia nervosa. / Consult Clin I’sychol55:654-659 Vaillant GE (1976), Natural history of male psychological health: the relation of choice of ego mechanisms of defense to adult adjustment, Arch Gen Psychiatry 33:535-545 Vaillant G E (19771, Adaptation to L$. New York: Little Brown Vaillant GE (1986), Empirical Studies of Ego Mechanisms of Defense. Washington, DC: American Psychiatric Press Vitousek KB, Daly J, Heiser C (1991), Reconstructing the internal world of the eating-disordered individual: overcoming denial and distortion in self-report. Znt / Eat Disord 10:647-666 Vitousek KB, Hollon SD (1990), The investigation of schematic content and processing in the eating disorders. Cognit Ther Res 14:191-214 (special issue: Selthood Processes and Emotional Disorders)
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ABSTRACT Objective: To compare ego defense mechanisms in adolescents with anorexia nervosa and other major psychiatric disorders, to defenses in healthy adolescents. Method: Thirty-seven patients with anorexia nervosa, 30 with major depressive disorder, 20 with obsessive-compulsive disorder, 53 with borderline personality disorder, 60 with schizophrenia, and 81 healthy controls were assessed with Pfeffer’s Ego Defense Scale. Results: Regression, denial, projection, repression, introjection, and total defenses were common to all psychiatric patients and distinguished them from normal adolescents. In addition to these defenses, anorectic patients also used intellectualization more frequently than normal adolescents and psychiatric patients. They used sublimation more than other psychiatric patients. Patients with disorders, apart from obsessive-compulsive disorder, that are considered to be often comorbid with anorexia did not have different defenses than schizophrenic patients. Conclusions: Anorectic adolescents overutilize relatively more mature defenses than do psychiatrically ill adolescents, and they overutilize immature defenses compared with normal adolescents. This combination of mature and immature defenses may be related to the uniquely heterogeneous ego functioning seen in anorectic patients, and it may provide insight into the nature of the psychopathology of anorexia nervosa. It also could have important psychotherapeutic and prognostic value. J. Am. Acad. Child Adolesc. fsychiatry, 1995, 34, 12:1648-1654. Key Words: adolescents, defense mechanisms, anorexia nervosa.
Defense mechanisms are unconscious means by which the ego wards off and controls impulses, affects, and instincts (Freud, 1936). Defenses protect the individual’s psychological integrity, stability, and individualized patterns. They also indicate a person’s level of maturity (Vaillant, 1977). Defense mechanisms may have an important role in psychopathology and in the shaping of the various psychiatric disorders (Freud, 1926). There is a rich psychodynamic and clinical literature on the nature of anorexia nervosa (AN). Most theoreticians take into account the role of defense mechanisms
Accepted April 19, 1995. Mr. Gotheyis a medicalstudent at the Sackkr School ofMedicine, University of Tel Auiv, Israel. Drs. Apter, Ratzoni, and ijano are with the Department of Child and Adolescent Psychiaty, Geha Psychiatric Hospital, Beilinson Medical Center and Sackler School of Medicine, University of Tel Auiu. Dr. Orbach is with the Department of Psychology, Bar Ilan University, Ramat Gan, Israel. Dr. Weizman is with the Tel Aviv Mental Health Center, Sackler School of Medicine, University of Tel Auiu. Dr. Pjffer is with the Department of Child and Adolescent Psychiaty, The New York Hospital-Cornell Medical Center. Reprint requests to Dr. Apter, Geha Hospital, P.O. Box 102, Petah Tikva, 49100, Israel; fa: 972-3-9241041. 0890-8567/95/3412-1648$03.00/001995 by the American Academy of Child and Adolescent Psychiatry.
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in the psychopathology of this condition. Bruch (1973, 1982) and Sours (1974, 1980) see the origin o f A N in an overcontrolled, overprotective, and overconforming childhood, leaving the adolescent unable to complete the task of separation-individuation. Both Bruch and Sours as well as Crisp (1980) and Vitousek et al. (199 1) believe that denial is a central defense mechanism of anorectic patients. These patients deny thinness and body shape so that there is a consequent distortion of body image. They also deny their illness and their need for treatment. According to Bruch (1982), this denial is a result of maternal overcontrol, which forces the anorectic subject to deny impulses, feelings, and wishes. As a result of the lack of self-differentiation resulting from an unsuccessful separation-individuation, the anorectic patients can see themselves only through the images they project onto the world (Bruch, 1982; Sours, 1980). Furthermore, the inability to meet the challenges of adolescence and independence are thought to lead to libidinal and ego regression expressed by the reversal of the pubertal process, and the precipitation of the patients’ families back into biological, psychological, and social childhood (Briksted-Breen, 1989; Crisp, 1980; Sours, 1974, 1980). Cramer (1991)
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as well as Heilbron and Harris (1986) have emphasized repression of the wish for separation, as well as repression of aggressive feelings toward the overcontrolling mother. Other authors have remarked on the introjection of hostile and ambivalent attitudes of their families toward them (Strober and Humphrey, 1987). Failure to negotiate separation-individuation leaves the anorectic individual feeling worthless (Bruch, 1982; Sours, 1980). This failure is compensated for by strict control of the body and self and overinvolvement in activities that carry a high social premium. Some clinicians have interpreted the anorexic individual’s excellence and ambition at school as representing sublimation and intellectualization, although Sours (1980) has described these attempts at mastery as being superficial, empty, and not sublimatory. Bruch (1982) and Cramer (1991) also describe individuals with AN as having a primitive (concrete operational) style of thinking, incompatible with the abstract thought required for intellectualization. Until recently there had not been much empirical research on defense mechanisms despite wide acceptance of the concept of defenses and their undoubted heuristic value for clinical practice. The development over the last decade of a variety of valid and reliable instruments for the detection and quantification of defense mechanisms has, however, done much to further such studies (Bond et al., 1983; Cooper and Kline, 1986; Pfeffer, 1986; Vaillant, 1986). Vaillant’s pioneering work was based on the hypothesis that defense mechanisms, especially those characterized by immaturity, were an indicator of generalized psychopathology (Vaillant, 1976, 1986). This hypothesis has been supported by empirical studies, such as those of Plutchik et al. (1979), Steiger et al. (1990), and Steiner (1990). More specifically, there has also been some interest in the application of empirical methods to the study of defense mechanisms in AN in the hope of gaining some insight into the psychopathology of this enigmatic condition. Steiner (1990) compared defense styles of normal adults and adolescents to adolescents with restrictive and bulimic AN, bulimia, and depression, using Bond and colleagues’ (1983) Defense Style Questionnaire (DSQ). Steiner found that all the patient groups showed more immature defenses than did the normal controls. Normal adults had the highest ratio of mature to immature defenses followed in descending order by the normal
adolescents (NADOL), the subjects with AN, the bulimic adolescents, and the depressed adolescents. Using the Beck Depression Inventory, Steiner showed that the patients with eating disorders and depression had less mature defenses than the eating disorder subjects without depression. In a replication study (Smith et al., 1992), it was shown that level of maturity of defenses correlated with level of adaptation. However, Steiger et al. (1990) found no difference between defense styles, as measured by the DSQ, of eating disorder subjects and a small group of psychiatric patients with other conditions. The same group of authors (Steiger et al., 1989) did show that patients with eating disorders had more immature and less mature defenses than normal controls and that there is a positive correlation between defense styles, on the DSQ, and recollections of parental bonding. Subjects with less mature defenses felt that their parents had been unempathic and overprotective. Steiger et al. concluded that eating disorders may be related to borderline personality disorder (BPD) on the object relations level. One limitation of these studies has been their emphasis on groups of defense styles. As far as we were able to ascertain, there have as yet been no systematic studies of the individual defenses in anorectic patients mentioned in the classic literature. A confounding factor in any study of the psychopathology of AN is the remarkable comorbidity between this condition and other psychiatric disorders. The most frequent comorbid illnesses are major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and BPD (Harrison and Hudson, 1989; Hsu et al., 1979; Rothenberg, 1988). Thus any study of AN, in addition to using healthy controls, should try to differentiate between AN and these illnesses, as well as between AN and disorders less likely to be associated with AN. The relationship between AN and defense mechanisms can be discussed from the vantage point of many different theoretical positions. However, most theories seem to correlate defenses with difficulties in the separation-individuation process. The present study attempts to examine these hypotheses and thus to clarify the relation between AN and defense mechanisms. The following hypotheses were tested: 1. Anorectic adolescents can be distinguished from NADOL by elevated use of the following defenses:
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G O T H E L F E T AL
denial, projection, regression, repression, introjection, compensation, sublimation, intellectualization, and total defenses (the sum of all the 11 defense scores). 2. Anorectic adolescents use different specific defenses more than adolescents with other major psychiatric disorders. 3 . The adolescents with psychiatric disorders that are often comorbid with AN (MDD, OCD, and BPD) will have several specific defense mechanisms in common differentiating them from schizophrenia (SZ), a major psychiatric disorder that is less likely to be comorbid with AN (Pope and Hudson, 1989). 4. Major psychiatric patients as a group have elevated use of several defense mechanisms in common, distinguishing them from NADOL. O n the basis of our understanding- of the literature we felt unable to formulate specific assumptions regarding individual defenses for hypotheses 2, 3, and 4. METHOD Subjects All patients admitted to the adolescent unit ofthe Geha Psychiatric Hospital during a 24-month period who received the diagnosis of AN ( n = 37) or M D D ( n = 30) or O C D ( n = 20) or BPD ( n = 53) or SZ ( n = 60) were accepted into the study. This unit has a large catchment area and accepts a wide range of socioeconomic classes of patients. All the anorectic cases were pure anorexia, that is, none of them were a mixture of anorexia/bulimia. Exclusion criteria were actual comorbidity with another condition, mental retardation, and lack of knowledge of Hebrew. The following patients were excluded because they had been given more than one diagnosis: BPDtMDD, 8; AN+MDD, 6 (11.8% of the anorectic patients): ANtBPD, 5 (9.8% of the anorectic patients); BPD+OCD, 3; AN+OCD, 2 (3.9% of the anorectic patients); OCD+SZ, 2 AN+SZ, 1 (2.0% of the anorectic patients); and OCD+MDD, 1. Other known comorbid disorders, such as other anxiety disorders apart from O C D or other mood disorders besides MDD, were not found in this study. The fact that the anorectic individuals in our study were all inpatients might have biased the comorbid disorders toward the more severe ones. The assessments were part of the normal intake procedure of the unit. None of the patients refused to cooperate in the study. All patients were between 12 and 18 years of age. There were 74 boys and 126 girls. The control group consisted of 81 NADOL who were recruited by a polling company from schools in the same areas served by the hospital. They were contacted by telephone and asked to participate in the survey on a voluntary basis. The exclusion criterion for the NADOL group was a history of psychiatric care. All subjects in all six groups were Jewish, and the groups were matched for age and socioeconomic status but not for sex, because preliminary analysis of defense mechanisms use showed only little
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sex differences (see “Results”). Parents of all patients signed informed-consent forms
Measures Diagnoses were made according to DSM-//I-R criteria using the Hebrew translation of the Schedule for Affective Disorders and Schizophrenia for School-Age Children. The reliability and validity of this instrument with regard to our population have been reported previously and have been shown to be satisfactory (Apter et al., 1989). Ego defense mechanisms were measured by the Ego Defenses Scale (EDS), which is one of the nine scales of the Child Suicide Potential Scales (CSPS) (Pfeffer, 1986; Pfeffer et al., 1979, 1980, 1984). The CSPS is a semistructured interview, ranging over a wide area of psychopathology, and is a very practical and “userfriendly” instrument, suitable for routine clinical use. The CSPS has been translated into Hebrew and adapted for use with adolescent psychiatric inpatients. It is now used as a standard intake procedure on the unit. The EDS is a semistructured interview given to the adolescent, his or her parents, and his or her therapists. Interviews are done by child psychiatry fellows who have been trained to satisfactory reliability with the unit director (A.A.). Scores are based on an overall impression without actually coding the score for each respondent. They are also based on actual observations of the adolescent’s behavior. Scores for each individual item ranged from 1 to 3. The final score is a composite of all interviews and observations regarding the adolescents. In a study of a subset of 50 adolescent inpatients, two child psychiatry fellows attained the following interjudge reliabilities for the 1 1 defenses measured (the parentheses indicate the reliabilities reported by Pfeffer et al., 1984): intellectualization, r = .93 (.96); regression, r = .90 (.87); undoing, r = .88 (.85); reaction formation, r = .85 ( 3 2 ) ; compensation, r = .78 (.74); repression, r = .79 (.74); denial, r = .80 (.72); projection, r = .72 (.69): introjection, r= .67 (.57); sublimation, r = .70 (.57); displacement, r = .57 (.52). In addition to the above-mentioned 11 defenses, the EDS includes a 12th measure, total defenses, which is the sum of all the 11 defenses. Although total defenses is not a psychoanalytic concept, nonspecific overuse of defense mechanisms has been found empirically to be a measure that distinguishes psychiatric inpatients from normal controls (Pfeffer et al; 1984; Plutchik et al., 1979). Nevertheless, how to reconcile these empirical findings with the traditional psychoanalytic thinking remains a challenge. It has been difficult to establish the validity of the scale, since there is no objective measure of defense mechanisms. However, Pfeffer et al. (1984), using the EDS, demonstrated that introjection, as an ego defense, was used significantly more in suicidal than in nonsuicidal children. Similarly, it has been found that the EDS distinguishes suicidal from nonsuicidal Israeli adolescent inpatients (Shachor, 1994). We chose to use the EDS in our study because the way it is conducted is very similar to routine clinical practice. The EDS reflects the clinician’s impression based on interviews with the adolescent and his or her parents and therapists. The child psychiatry fellows were instructed to focus on several aspects of the adolescent’s behaviors, habits, and patterns of thinking. After relatively short training, and without the need for extensive psychodynamic knowledge and experience, clinicians can reliably assess the use of defense mechanisms. The DSM-IV (American Psychiatric Association, 1994) has recently acknowledged the relevance of defense mechanism assessment, as a potentially helpful tool for diagnosis and
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DEFENSE MECHANISMS I N ANOREXIA NERVOSA treatment planning. This acknowledgment was expressed, by the inclusion in DSM-IV, of a “Defensive Functioning Scale” in the appendix of optional axes. Thus, since our goal is to combine the defense mechanisms’ assessment in our routine clinical practice, we found the EDS, which is one of the few defense mechanisms’ scales constructed especially for children and adolescents, most suitable and practical for this purpose.
Procedure All patients were interviewed by child psychiatrists within the first 2 weeks of admission. T h e initial interview was with the adolescent followed by interview with the parent and then with the therapist. As stated above, the interviews were done as part of the intake procedure. T h e interviewers were unaware of the purpose of the study and of the patients’ diagnoses (although in some cases, especially in the anorectic cases, the diagnosis may have been obvious). T h e nonpatients and their parents were interviewed in their homes by a qualified clinical psychologist who had been trained to satisfactory reliability with the unit director (A.A.). They were given the assurance that their replies would be completely anonymous. All interviews took from 30 to 60 minutes.
Data Analysis One-way analysis of variance with multiple comparisons ( ttests) with a Bonferroni correction for multiple comparisons was used to analyze the data. T h e predictor variables were the five patient groups and the NADOL group. T h e outcome variables were mean grades of each defense mechanism.
RESULTS
A t test comparison between defense scores for males and females found significant differences for compensation in NADOL ( p = .04, males > females) and sublimation ( p = .03, females > males) in the patient groups. No other sex differences were noted, and we felt that comparisons between the research groups could be made without controlling for sex. Table 1 shows the means and standard deviations for all defenses in all the research groups. O n analysis of variance all the defense scores, apart from compensation, significantly distinguished between the study groups at the p < .05 (or better) levels. There seems to be a great deal of support for our hypothesis regarding the elevated use of several defense mechanisms in all the patient groups in comparison with NADOL. O n painvise comparisons, regression, projection, denial, repression, and total defenses were all significantly ( p < .05) higher in the patient groups than in the NADOL group. Introjection scores were also higher in all the patient groups than in the NADOL but only AN, O C D , and BPD reached statistical significance ( p < .05).
In addition to the above-mentioned defenses (i.e., regression, projection, denial, introjection, repression, and total defenses), the anorectic group of patients used intellectualization significantly more frequently ( p < .05) than the NADOL group. In comparison with the other group of patients, anorectic patients exhibited higher use ( p < .01) of sublimation. Moreover, the anorectic girls showed significantly more sublimation than girls with other psychiatric conditions ( p < .01). The anorectic patients also had the highest scores on intellectualization, and their intellectualization scores were significantly higher ( p < .05) than those of the schizophrenic group of patients. Thus two defense mechanisms, sublimation and intellectualization, distinguished the anorectic group from all the other groups of patients. The third hypothesis of this study was rejected. None of the defense mechanisms measured distinguished AN and its comorbid disorder from SZ. It is interesting that reaction formation and undoing scores were significantly higher ( p < .05) in the OCD group than in all the other study groups. In addition, The OCD group had the highest total defense scores, and their total defense scores were significantly higher than those of the SZ and MDD groups ( p < .05).
DISCUSSION
The most significant differences found in this study were between the groups of psychiatric patients and the normal adolescents. The results indicate that major psychiatric disorders have many defense mechanisms in common (regression, projection, denial, introjection, repression, and total defenses) and the strength of this result may explain the rejection of our third hypothesis. It is possible that all the major psychiatric disorders share a common psychpathogenesis, characterized by ego deficits or faulty ego development, causing a lack of maturation in defense mechanisms (Steiner, 1990). In addition, we cannot rule out the possibility that this finding may be related to the “well control artefact” described by Schwartz and Link (1989). Psychiatric studies tend to apply more severe exclusion criteria to control groups than to case groups. For this reason only adolescents without history or evidence of psychopathology were included in our NADOL group. Thus
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G O T H E L F E T AL.
TABLE 1 Comparison of Groups' Means (Standard Deviations) on Ego Defenses Scale Defense Mechanism
n Age Regression Projection Denial Introjection Reaction formation Undoing Displacement Intellectualization Compensation Sublimation Repression Total defenses
NADOL
81 15.36 (1.78) 1.26" (0.44) 1.46" (0.59) 1.51" (0.57) 1.51" (0.63) 2.01" (0.70) 1.64" (0.64) 1.53",' (0.59) 1.68" (0.59) 1.82 (0.76) 2.16" (0.70) 1.62" (0.68) 18.20" (3.19)
F Value
AN
sz
37 16.24 (2.13) 2.00' (0.67) 2.22' (0.75) 2.08' (0.76) 2.05' (0.71) 2.05" (0.88) 1.70" (0.78) 1.42" (0.50) 2.22' (0.79) 1.78 (0.64) 2.06" (0.62) 2.14' (0.75) 2 1.72', ' (2.65)
60 16.68 (1.77) 2.17' (0.7 1) 2.37' (0.69) 2.28' (0.72) 1.78", (0.70) 1.75" (0.71) 1.59" (0.68) 1.78". (0.67) 1.73" (0.72) 1.66 (0.73) 1.56' (0.63) 1.90'' (0.61) 20.57' (3.05)
'
MDD
OCD
BPD
30 16.34 (1.66) 2.1 3' (0.73) 2.23' (0.73) 2.00h (0.87) 1.87' (0.73) 1.83" (0.70) 1.83" (0.79) 1.70", (0.75) 1.80". (0.81) 1.80" (0.81) 1.56' (0.63) 2.07' (0.65) 20.82' (3.70)
20 16.17 (2.10) 2.15' (0.37) 2.15' (0.67) 2.10' (0.72) 2.15b (0.49) 2.70' (0.47) 2.50' (0.69) 1.85", (0.59) 2.05"' (0.89) 2.1 0". (0.79) 1.GO' (0.50) 2.30' (0.57) 23.65' (2.94)
53 16.07 (2.13) 2.08' (0.70) 2.23' (0.75) 2.15' (0.74) 1.94' (0.67) 1.85" (0.77) 1.62" (0.74) 1.87' (0.74) 1.78". (0.82) 1.96"' (0.79) 1.63b (0.56) 2.12' (0.52) 21.23',' (3.25)
'
'
' '
'
(df= 5;275)
21.87** 16.25** 10.32** 5.81** 5.79** 5.86** 3.51* 3.35' 1.47 10.17** 7.19** 14.75**
Note: Means with different superscript letters arc different at p < .05. NADOL = normal adolescents; AN = anorexia nervosa; SZ = schizophrenia; M D D = major depressive disorder; O C D = obsessive-compulsive disorder; BPD = borderline personality disorder. * p < .05; **p< .0001.
the differences between defenses in patients and controls may be related to the stress of hospitalization or of being ill and not to the actual identity of the disorder. With the exception of compensation and sublimation, anorectic patients, in comparison with NADOL, exhibited all the defense mechanisms hypothesized to characterize AN. This finding gives some empirical support to the classic literature which, as described above, has found these defenses to be common among patients with AN and, together with the findings of Steiger et al., may indicate that theories that relate AN to failure .of separation-individuation have some empirical validity. For example, the anorectic patients' resistance against eating probably represents their intense struggle with their parents regarding control and autonomy, which is fought out on the battleground of their body.
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Vitousek et al. (Vitousek and Hollon, 1990; Vitousek et al., 1991) proposed that patients with AN utilize all these defenses only in relation to their eating behavior and body image. They claim that the anorectic patients use the defense mechanisms mainly to shield their symptomatology from outside influence. Thus they conclude that anorectic patients do not have distinctive cognitive structures that are independent of eating and body image. Our findings contradict this concept and show that anorectic patients have distinctive defense mechanisms that are part of their regular functioning and not only in relation to their eating disorder. Most of the defense mechanisms that distinguish anorectic patients from normal adolescents are common to all the psychiatric patients. However, sublimation and intellectualization distinguish patients with AN
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DEFENSE MECHANISMS I N ANOREXIA NERVOSA
from adolescents with other psychiatric disorders. The finding that elevated use of intellectualization and sublimation are unique to anorectic patients might explain the seeming paradox between the severity of the psychopathology of these patients and their ability to function successfully in school and in other activities. For instance, our experience is that these patients almost always assume leadership positions on the unit and take responsibility for many of the everyday milieu activities. The coexistence of relatively adaptive defenses and severe disturbance poses a challenge for accepted theories of ego defenses and ego psychology. It is possible that massive use of these defenses may account for the apparent encapsulation of psychopathology or “false self,” often described in anorectic patients. A possible explanation for the increased use of sublimation is that this defense is most commonly used in girls. However, we found that anorectic girls show significantly more sublimation than girls with other psychiatric conditions ( p < .O1). Therefore, this high use of sublimation does seem to be specific to AN. Sours (1980) and Bruch (1982) have claimed that the anorectic patients’ seemingly sublimatory activities do not represent real sublimation, but stem from the patients’ overcompliance with their parents’ expectations. These authors claim that the anorectic patients do not really enjoy their schoolwork and hobbies. T o judge whether the elevated use of sublimation found in our study is not a misjudgment in the way that Sours and Bruch have claimed, we must elaborate on how sublimation is evaluated by the EDS. The EDS defines sublimation as: “Under the influence of the ego, unacceptable feelings are changed into a socially useful modality without blocking an adequate discharge” (Pfeffer, 1986, p. 288). In addition, the EDS gives specific, typical examples that represent expressions of sublimation. The interviewers are trained to evaluate the use of sublimation (as well as the other defense mechanisms) based on the definition and the prototypic examples. The specific examples of sublimation given by the EDS are as follows: (1) the adolescent enjoys his hobbies (e.g., playing a piano, collecting, painting, dancing, etc.); (2) the adolescent expresses his aggressive feelings by participating in sporting activities; (3) the adolescent finds interest in school lessons. As mentioned previously, the interviewers’ impressions were based on several sources: interviews with the adolescents, their parents, and their therapists, and
actual observations of the adolescents’ behavior. In the process of evaluating adolescents’ use of sublimation, the interviewers also observed them at school and while participating in sports. The examples given by the EDS for the assessment of sublimation stress that an adolescent who is rated high on sublimation enjoys his or her hobbies and finds interest in his or her school lessons. According to the EDS, the high use of sublimation in anorectic patients found in our study was apparently real and not “superficial and empty,” as Sours and Bruch have claimed. Yet, naturally, concepts such as “real enjoyment” are difficult to evaluate and only a more intensive inquiry can finally settle this issue. This study found that anorectic patients do use many defenses. Some are specific, i.e., intellectualization and sublimation. Some are the result of nonspecific regression and ego deficits. It is interesting that the specific defenses are those regarded as being relatively more mature, while except for repression the “common” defenses are those described as being more immature (Vaillant, 1986). In this regard it should be noted that all the patients in our study are inpatients, i.e., treatment failures from other centers, and are severely disturbed. Therefore, it is very plausible that these patients are characterized by a higher level of psychopathology and thus also by immature defenses. The presence of these immature defenses in AN have been reported previously by Steiner (1990) and by Steiger et al. (1990), and their presence in most major psychiatric conditions was reported by Bond et al. (1983) and Vaillant (1986). The combination of relatively mature and immature defenses seen in AN in this study is, as far as we have been able to ascertain, the first empirical report of its kind in the literature. This combination is puzzling since by psychoanalytic definition the use of relatively mature defenses is, for the most part, not possible when the immature defenses are as active as they are in AN. However, the uneven use of mature and immature ego defenses might reflect the uniquely heterogeneous ego functioning of the anorectic group of patients (Norring et al., 1989; Sours, 1980; Strober, 1983). In addition, as clinicians treating AN, we have been impressed by the mature behavior these patients exhibit in many other areas not related to food and body shape.
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Clinical Implications
In this study we focused on AN patients and found an interesting combination of relatively mature and immature defenses. If these findings could be replicated in further studies it may deepen our understanding of the psychopathogenesis of AN and its dynamic subtypes. Thus, EDS evaluation could have important psychotherapeutic and prognostic implications. The research findings consolidate the psychoanalytic theory, which relates AN to failure in the separation-individuation process. In terms of psychotherapy, the study indicates that the anorectic subjects have some specific ego strength, i.e., their tendency to use sublimation and intellectualization. Yet, the study also found that the anorectic patients also have some nonspecific ego deficits, namely their overuse of immature ego defenses such as denial and regression. Anorexia nervosa has a heterogeneous clinical course. At one end of the spectrum are a group of mild, transient cases that remit readily and sometimes even spontaneously. At the other end are those malignant cases that run a chronic course well into adulthood or cases that end in suicide (Herzog et al., 1988). Sours (1980) claimed that persistent denial of illness is associated with poor outcome in anorectic patients. Possibly those anorectic patients characterized by use of more mature ego defenses have a better prognosis, while those characterized by immature ego defenses have a worse prognosis. We hope that the knowledge of the general defensive pattern used by anorectic individuals could be helpful in treating these highly talented, but severely tormented, young people.
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