Defense Mechanisms

sub-future doctors, this episode is actually made by myself, so I'll just let the intro play out. Please enjoy. Hello future doctors, you are tuning into spoon full of sugar, the podcast made for medical students by med students where we break down complex medical topics into bite size pieces for your success. I'm your host Bill Aldrana, a third year med student at Western Union, and today we are talking about a comparatively lighter topic for the Steppen complex, defense mechanisms. So, right off the bat, let me ask you all a question, what are defense mechanisms? You won't need to know the exact definition for the purposes of examinations, but what they are are a balance between the super ego which controls morality versus the id, which controls desires, and they reconcile them through the ego. And they do so either unconsciously, and these would be known as immature defense mechanisms, or consciously, what we would call mature defense mechanisms. In this episode we will be covering 17 immature aka unconscious defense mechanisms, as well as four mature aka conscious defense mechanisms, nine of the immature defense mechanisms and two of the mature defense mechanisms are higher yield, while the other eight and two respectively are lower yield. In between, I'll be sure to mention something about transference and counter transference, which are technically not considered defense mechanisms, but they show up on your exam, so I figured I'd mention them here. I will forego questions this time to keep this episode as simple as can be, but do go ahead and check our Instagram for a few practice questions about this topic. So I have structured this episode, such that we are comparing defense mechanisms that are similar to one another, aka those that often get placed as differentials on a multiple choice. This way we can be more confident about these questions going forward. Now I've mentioned this in one of the first few episodes I've made for this spoonful sugar podcast, but studying for the step in complex is a stressful experience, and it culminates in a lengthy eight hour exam. It's not fun. So being able to guarantee that we can get correct answers on some of the simpler topics, such as defense mechanisms, can at least provide some reassurance step. Things will be okay. I hope this episode provides such reassurance. To keep this episode short, again, like I mentioned, we'll skip the practice questions, but we will maintain the Q&A format. Another thing I should mention, since the vast majority of the defense mechanisms are immature, aka unconscious, I'll only make a point to mention which four are mature defense mechanisms. And I'll actually ask you this now so you're prepared when you hear them. What are the four mature defense mechanisms? So the four mature defense mechanisms are suppression, sublimation, altruism, and humor. Now let's begin our discussion of the different defense mechanisms. And the first two we have are displacement, and I would like for us to compare this with projection. So first of all, what is displacement? So displacement is when feelings are taken out on a third party. Compare this to projection. What is projection? So projection is the attributing of internal feelings to somebody else. So I'll give an example here. So imagine if two co-workers are arguing and then they're yelling at each other. And then one of them comes home and yells at their significant other, right? This is a displacement of feelings. It doesn't have to be physical. As in this case, it's done verbally, but sometimes when we think of displacement, it has to be an action. It doesn't necessarily have to be that physical versus projection. So one example of projection would be somebody who is just not in the best state of health, not doing well in life, and then goes over to tell their friend that they're not in the best state of health and they're not doing well in life. So that's their personal feeling that they're assuming that somebody else has, despite the fact that they don't actually have it, that would be projection. Next is isolation of affect. Pretty self-explanatory from the name, but could you think about what that could be? So isolation of affect, we need into what affect means affect refers to emotion. So isolation of affect is essentially an isolation or a separation of emotions from what, from the ideas that you have in your head. An example of this would be if somebody has a very blank, expressionless face when discussing a recent trauma, for example, a loss of a loved one as opposed to a typical response, which would be sadness. Next let's compare rationalization versus intellectualization. They sound similar but they're actually very different. First off, what is rationalization? To give an easy way of explaining it, rationalization is essentially excuse making. So an example of this would be a student who gets a 230 on their step 2 and then says something like, oh, board scores aren't relevant in the grand scheme of things relative to publications despite the fact that they are applying the plastics. So they're trying to justify their competitiveness as an application with their publications, despite the fact that a competitive specialty like plastics demands a step high step 2 score, whether you like it or not. Compare this to intellectualization, can you tell me what that is? So intellectualization is focusing on the non-emotional aspects of something. And so one easy example would be somebody who gets a diagnosis of cancer. And rather than spending time worrying about it emotionally, what they like to do is they perform research. They do research on their diagnosis, on the different treatment methods and lifestyle modifications that they can do. Essentially intellectualizing the problem, making it theirs, studying about it so that they're not as worried about it. They say you fear what you don't understand, so if you can understand it, then you would be doing a lot better. That's what intellectualization is. Next we have reaction formation versus sublimation. Now recall that of the four matured defense mechanisms, one of them is sublimation. And although this is a matured defense mechanism, it can sometimes be confused with reaction formation. So just as before, let's first start with the definitions. What is reaction formation? So reaction formation is when you feel one way, but then your actions say otherwise. An example of this is, let's say you absolutely despise your racist uncle, you don't want anything to do with them, but then when they get sick, you're looking out for them. So your thoughts say I don't want to do anything with that person, but then your actions are doing the exact opposite. So in short, reaction formation is when your actions are not in line with your thoughts and feelings. Compare this to sublimation. What would that be? So sublimation is about channeling negative energy and turning it into something positive. One example would be if you have anger, and rather than taking your anger out on somebody else, you take it out on sports. For example, martial arts, basketball, swimming, whatever. Essentially, it's about finding a healthy outlet for expression. Notice how this is different from reaction formation, which is when your actions are just not in line with your thoughts and feelings at all, sublimation is about channeling that energy into something positive and something socially acceptable. Now we are actually going to compare three different defense mechanisms. We're going to compare repression versus suppression versus denial. So what is repression? So repression is the involuntary withholding of information. For example, if you have a traumatic thought that's so bad in your mind on its own, blocks out the thought as if the thought isn't ever there. That is repression versus suppression, recall that this is one of the mature defense mechanisms. This is a voluntary withholding of information that you accept as reality. And so this would be the, oh, I'm just not going to think about it. Like I know I got a bad grade on my test, but you know, it is what it is. That's an example of suppression. For those of you, this is just a brief aside, if any of you are listening who are legal legends, players, you probably know the champion's war rick in Malzahar, they use suppression with their ultimates. You have to press the ultimate button voluntarily in order to make that happen. So that's one way I remember that suppression is voluntary. It is an action. In the case of war rick, you know, he's going to miss, but that's beside the point. The other way you can remember this is that suppression being voluntary, and naturally that's going to be a lot more mature than something that's involuntary. The hallmark of something mature is your ability to control it oftentimes. And this is a really terrible way of remembering things, but if it helps, great. So the letter S comes after the letter R in the alphabet. And the way I remember this is that the 19th letter is more mature than the 18th letter. Very silly stuff, I know sucks, but if it helps, it helps. And then the last one we have is denial. This is a little bit different than repression. What is denial? So denial is the avoidance of accepting reality, whereas repression is involuntarily withholding information, as if the thought's not even there. And denial is, you know the thought is there, but you just don't want to acknowledge that it's real. For example, the denying of passing of a loved one, or if you receive a certain diagnosis that you're not okay with, and you just say, nope, nope, that can't be me, I can't have cancer, I'm 45, I'm too healthy, just can't be for me. That's denial. Alright, and next on the list is splitting. What is splitting? It's when you see things as 100% good and 100% bad. And this is seen in what psychiatric disorder? Borderline personality disorder. Extremely high yield, you are very likely going to get a question on this. Alright, let's take a little break from defense mechanisms to talk about two concepts that aren't actually defense mechanisms, even though they sound like it. So they are transference and counter transference. This usually pertains to the doctor, patient relationship. So transference and I'll just briefly just talk about it. It's when patients attribute feelings about important people in their lives to the physician. This is best understood with an example. So here's an example, you have a patient who dislikes their dad. Their doctor reminds them of their dad. Therefore the patient dislikes the doctor, that's transference. And counter transference is literally the same thing but the other way around. This time the doctor is doing this. So for example, doctor dislikes his dad, patient reminds him of the dad, so the doctor dislikes the patient. There you go, transference and counter transfer is done. Now let's move on to the lower yield defense mechanisms. So the first of the low yield defense mechanisms is acting out. It's pretty much exactly what it sounds like. It's a temper tantrum, essentially. It's not the same thing as displacement, there's a third party, there's a clear target acting out as pretty reckless. You'll see this a lot in kids. I just explained that right out the gate because it's a pretty self-explanatory. The next one is dissociation. So this one's a little bit more detailed and the discussion surrounding dissociation tends to go a little bit away from defense mechanisms and more towards specific psychiatric conditions. So with that said, let's go over this a little bit slowly. What is dissociation? So dissociation is a drastic change in behavior, consciousness, personality, something that is very uncharacteristic and which identity disorder would you see this in? Yeah, it's in the name, dissociative identity disorder. Now for the purposes of board examinations, you're going to want to be able to distinguish what dissociative identity disorder is as opposed to purely knowing the defense mechanism. So in case they ask, let's go over the different dissociations. We have four, we have dissociative identity disorder, dissociative fugue spelled F-U-G-U-E, dissociative amnesia as well as depersonalization and de-realization. So that's technically five, but I kind of grouped the last two together. So because this is possibly a little bit nuanced for the purposes of this discussion, I'll go ahead and just list them out. So when you're thinking of dissociative identity disorder, you want to think of multiple identities. When you think of dissociative fugue, you want to think of an abrupt change in personality or identity, usually following a trauma. And usually it's one personality, not multiple. And one characteristic feature is you see people who have dissociative fugue, they tend to wander and travel away outside wherever they live. So for example, somebody would dissociative fugue one second there on Ohio and then within a day they're in Minnesota. Why they don't know, they couldn't tell you. Then you have dissociative amnesia. So this is when you straight up forget everything, post trauma kind of sounds very similar to repression where you involuntarily withhold information because of a trauma. And then the last one would be depersonalization and de-realization. And the difference between the two is that depersonalization involves an out-of-body experiencing, involving oneself. Like you can kind of see yourself from outside and de-realization is when you feel dissociated from your environment. Okay, now moving on to actual defense mechanisms, we're going to compare regression versus fixation. So what is regression? So regression is when you are regressing to previous developmental stages. This usually happens after a trauma. So for an example, a 17-year-old experiences a stressful event and now has a desire to sleep in and with a sleep in it in his parents' room. Maybe he even wets the bed. Now wanting to sleep with your parents at night and wedding the bed, this is pretty characteristic of people who are a lot younger, not characteristic of a 17-year-old. They weren't doing this before, but the stress kind of triggered them to do so. Compare this to fixation. What is fixation? So fixation is never getting past that developmental stage to begin with. So for example, a 17-year-old who's been wanting to sleep with his parents since childhood and never stopped. That's fixation. So regression happens with trauma, takes you back at a developmental stage. regression is when you never progress from that developmental stage. The next one is fantasy, as is literally what it sounds like. It's basically when you create an imaginary situation to avoid a real one. So nothing else to say about that. Next is identification. What is identification? So identification is when you imitate good or bad behavior from a more powerful person. So one example would be if you have a kid who's growing up in a rough neighborhood and they want to seek protection from bullying, they join a gang and become the bully. They're imitating that bad behavior as it means to protect themselves. So that would be identification. Then you have idealization. What is idealization? So this one is actually really common in our society. So this is one positive thoughts are expressed predominantly ignoring the negative thoughts. This is kind of the folks who will say, you know, stay positive, good vibes, live laugh, love, whatever. Super common stuff, but you know, they don't deal with their negative thoughts and then eventually those are going to build up. You can see where this is problematic, hence why it's an immature defense mechanism. All right, and we have three more to go. So this next one is passive aggression. What is that? So passive aggression is demonstrating hostility without direct confrontation. So an example would be leaving your friend on red because they told your jokes louder at a party and received credit for them rather than kindly letting them know, hey, don't steal the spotlight from me next time. And now finishing off with the last two, we actually have two mature defense mechanisms left. This first one is altruism. Now what is altruism? So the short and sweet explanation for altruism is when somebody gives charity to alleviate guilt. So an example of this would be somebody who feels really bad for bullying someone on Instagram and then they go on to decide, hey, I'm going to donate to a cyber bullying fund. That would be altruism. And then lastly, you have humor. There really isn't much to say about this. Humors essentially making jokes. For example, you've probably seen a bunch of those medical school memes about people receiving three out of five evils despite working really hard. That would be an example of humor just joking about the situation. All right, and we've reached the end. Let's do a quick rundown of everything. So we have displacement, which is taking feelings out on the third party versus projection, which is attributing internal feelings to somebody else. Isolation of affect is when you separate your emotions from your thoughts. Rationalization is essentially excuse making and intellectualization is seeking to understand something as a ways of making yourself feel better. Reaction formation is when you feel one way, but your actions say otherwise, whereas sublimation is channeling your negative energy into something positive and socially acceptable. Reaction is the involuntary withholding of information. This is due to trauma. You don't have any control over this. This happens involuntarily compared that to suppression, where you voluntarily withhold the information. Remember S after R, 19th letter, more matured, and 18th letter, suppression is mature, repression is not. And then denial, which is you understand that there is a reality, but you're trying to avoid it entirely. And then you have splitting. This is when you see things as either 100% good or bad and you see this in borderline personality disorder. Transference is when the patient attributes feelings about people to a physician and counter transference is the other way around, when the doctor does it. Then for the lower, lower yield ones, excuse me, you have acting out, which is exactly what it sounds like. It's a tantrum dissociation, which is a drastic change in behavior that is uncharacteristic. Remember, there are four different types, dissociative identity disorder, which involves multiple identities, dissociative fugue, which is an abrupt change usually after trauma. You see people who have dissociative fugue, often wander and travel to places other than where they actually live. The dissociative amnesia, where you straight up forget everything, post trauma, kind of like repression. And then depersonalization is when you're having that out of body experience, whereas de-realization is when you're having the inability to feel in touch with your surroundings. Transference is when you're agress to a previous development stage, compared that to fixation where you never get past that stage to begin with. Fantasy, literally what it sounds like, you create an imaginary circumstance to avoid a real one. Identification is the imitation of good and bad behavior patterns of a more powerful person. Idealization, stay positive, good vibes, all that stuff. Passive aggression is indirectly confronting someone, while you're also demonstrating hostility. And lastly, you have altruism, which is charity to alleviate guilt, and humor, which is jokes. And that's it. Alright, I am very grateful that you are listening. Thank you for tuning in to Spoonful of Sugar and stomaching some of my terrible demonics. If you have any questions, comments, or concerns, please visit our website at spoonfulofsugar.org and post them under the link for this episode. You can also contact us through our website if you are interested in making an episode on a topic that hasn't been covered yet. Anywho? The setting? And remember that if you ever have an SOS moment while studying, spoonfulofsugar is always here to help the medicine go down.