Psychoanalytic theorists have considered the possibility that certain defenses (i.e., internal or behavioral means of averting painful feelings or threatening unconscious fantasies) either may be specifically mobilized by depressive affects or may predispose individuals to the development of depressive syndromes (Brenner 1975; Jacobson 1971). Bloch et. al (1993) described three possibilities in this regard: 1) defenses may become structured in response to a chronic mood disturbance; 2) maladaptive defenses may actually lead to depression; and 3) the mood disorder and defenses may each be related to a third factor, such as underlying low self-esteem. For most theoreticians, the defenses in depressed patients are initially triggered to contend with intolerably angry fantasies or with painfully low self-esteem but actually only result in an exacerbation of depression. Thus, anger projected outward, according to Abraham (1911), ends up being directed toward the self, whereas efforts to idealize the self or others to cope with low self-esteem eventually lead only to further disappointment and devaluation (Jacobson 1971). Other defenses mentioned specifically by psychoanalytic authors as mobilized to cope with intolerable anger and sadness include denial, passive aggression, reaction formation, and identification with the aggressor.
In a more systematic study by Bloch et al. (1993), the defense mechanisms employed by patients with dysthymic disorder were compared with those of patients with panic disorder, by using the Defense Mechanism Rating Scale (DMRS) (Perry 1990). The scale, which contains criteria for operationalized assessment for the presence or absence of each defense, is scored by use of a psychodynamic interview. Two defenses, denial and repression, were found to be used frequently by both patients with panic disorder and patients with dysthymia. Compared with panic disorder patients, those with dysthymia were found to employ higher levels of devaluation, passive aggression, projection, hypochondriasis, acting out, and pro-jective identification. In the formulation by Bloch et al. (1993) from the data, depression could occur through directing anger toward the self, expressing anger passively (passive aggression), distorting perceptions of self and others (devaluation, projection), inviting retaliation from others (acting out, passive aggression), or asking for and then rejecting help (related to the DMRS formulation for hypochondriasis).
In individual patients, the clinician should be alert to the characteristic defenses that they employ, particularly to those noted above (see Chapter 10, "Defense Mechanisms in Depressed Patients," in this volume). Feedback to patients about the nature and impact of these defenses may allow them to more effectively cope with their feelings and alter their characteristic perceptions of and responses toward others. In the case of Ms. C, her initial presentation included the defenses of passive aggression, repressed anger, the projection of her anger onto others, and identification with the aggressor, via her guilty identifications with her mother's rage.
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