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To cite this article: J. Christopher Perry M.P.H., M.D.,, Michelle D. Presniak Ph.D. & Trevor R. Olson Ph.D.
(2013) Defense Mechanisms in Schizotypal, Borderline, Antisocial, and Narcissistic Personality Disorders,
Psychiatry: Interpersonal and Biological Processes, 76:1, 32-52
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Psychiatry 76(1) Spring 2013 32
Defense Mechanisms
Perry et al.
Numerous authors have theorized that defense mechanisms play a role in per-
sonality disorders. We reviewed theoretical writings and empirical studies about
defenses in schizotypal, borderline, antisocial, and narcissistic personality disor-
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Studies have demonstrated that per- 2000), and greater treatment use (Bender et
sonality disorders (PD) are associated with a al., 2006) compared to those without per-
chronic, symptomatic course (Skodol et al., sonality disorders. While there is consistent
2005), high numbers of co-occurring axis evidence for the efficacy of existing psycho-
I and other II disorders (McGlashan et al., therapeutic treatments for PDs (Leichsenring
J. Christopher Perry, M.P.H., M.D., Michelle D. Presniak, Ph.D., and Trevor R. Olson, Ph.D., are all affiliated with
the Department of Psychiatry at McGill University.
Michelle D. Presniak and Trevor R. Olson are also with the FIT for Active Living Program at Saskatoon City
Hospital.
Some data from the present manuscript were the basis for separate analyses in previous reports (Perry & Cooper
1985; 1986; Perry & Perry, 2004). Data collection was underwritten by a grant from the National Institute of Mental
Health RO1 MH34123. The authors would like to thank The Cambridge Hospital, Cambridge, Massachusetts, at
which the original data collection took place.
Address correspondence to J. Christopher Perry, Institute of Community and Family Psychiatry, SMBD Jewish
General Hospital, Montreal, QC H3T 1E4. E-mail: jchristopher.perry@McGill.ca.
& Leibing, 2003; Perry, Banon, & Ianni, be maintained by the persistent use of specific
1999), long treatment durations are the rule defenses that serve to avoid awareness of as-
(Perry, Bond, & Roy, 2007; Zanarini, Fran- pects of stress and conflict. Avoidance keeps
kenburg, Hennen, & Silk, 2004), and the the personality traits ego-syntonic, making it
likelihood of full return to health is yet to be unlikely that the patient would see that their
established. At this point, the need for fur- own actions engender some aversive life ex-
ther study of important potentially modifi- periences. It also makes these traits resistant
able risk factors is clear, to develop a firmer to the suppressive effects of punishment or
scientific basis for the design, conduct, and the competing effects of new operant learn-
ascertainment of long-term success for treat- ing. Further, any gratification resulting from
ments. One such area is the study of poten- the defensive actions reinforces their use,
tial mechanisms that promote or maintain such as the pleasure obtained when passive
the presence of pathological and adaptive aggression discomforts one’s oppressor or
personality functioning (Kazdin, 2007). The superior. To the extent that these theoreti-
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present report examines the association be- cal points are true, then understanding the
tween specific defense mechanisms and four specific defenses underlying PD types should
PD types and considers their potential role in have heuristic value.
personality functioning. Personality disorders are generally hy-
Defense mechanisms are the automatic pothesized to rely heavily on so-called imma-
psychological responses that individuals use ture defenses—those 12 on the lower part of
in response to anxiety and internal or exter- the hierarchy of adaptation, from omnipo-
nal stress and conflict (American Psychiatric tence down through help-rejecting complain-
Association, 1994). Previous research has ing noted in Table 1 (Perry & Bond, 2005).
demonstrated differential relationships be- We do not posit a one-to-one causal cor-
tween specific defenses, or levels or groups of respondence between PD type and specific
defenses, and PD types (Perry & Bond, 2005; defenses, because there are undoubtedly ad-
Presniak, Olson, & MacGregor, 2010; Vail- ditional causal factors operating to produce
lant & Drake, 1985). surface traits, such as temperament (Perry &
Körner, 2011). In addition, certain PD types
Defenses May Make Surface Traits may share some underling dynamics while
Resistant to Change others do not. From a dynamic perspective,
other factors contribute to character types,
such as persistent motives, conflicts, and pat-
There is a theoretical reason to study terns of object relations based on develop-
PDs and defenses together. Personality dis- mental experiences. Rather, we hypothesize
orders are defined on the basis of phenom- that there is some meaningful overlap be-
ena measurable with low inference. These tween PD type and specific defense mecha-
include surface traits (e.g., impulsiveness), nisms as reviewed and reported below.
specific behaviors (e.g., self-mutilation), self- We began by reviewing the concep-
reported experiences (e.g., feelings of empti- tual and empirical literature and devised
ness), and beliefs or cognitions (e.g., grandi- the hypotheses below about the relationship
ose sense of self-importance). It is puzzling between individual defenses and PD diagno-
why individuals do not perceive that these ses. Our conceptual review includes those
traits are often maladaptive and then strive writing on character or personality types
to supplant them with more adaptive traits. in the psychoanalytic and psychodynamic
The avoidance function of defenses may sup- literature, several antedating the PD types
ply one answer to this puzzle. From a dy- described in the Diagnostic and Statistical
namic point of view, personality traits may Manual of Mental Disorders, third edition
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34
TABLE 1. Summary of Theoretical Reports and Empirical Studies Relating Defenses to Individual Personality Disorders
SPD BPD ASP NPD
Defense Theory Empirical Theory Empirical Theory Empirical Theory Empirical
Obsessional
Isolation
Intell. Lingiardi et al., Perry & Perry, 2004
1999 (OR)
Undoing Millon, 1986 Zanarini et al.,
2009 (SR)
Other Neurotic
Repression Not present: Not present: Kernberg, Not present: Kernberg, Not present: Kern- -rs: Clemence et al.,
Kernberg, 1984; Alternates be- 1984 berg, 1984 2009 (OR); Perry &
1984 tween present and not, Perry, 2004 (OR)
Reich 1925/1975;
Dissociationa Vaillant, 1994 Gacono & Meloy, 1988; Vaillant & Drake, Vaillant, 1994 Vaillant & Drake,
Vaillant, 1994 1985 (OR; same 1985 (OR; same
data also published data also published
in Vaillant, 1994) in Vaillant, 1994)
Reaction Mostly not present
Formation Reich, 1925/1975
Displacement
Minor Image-
Distorting
Omnipotence/ Kernberg, Higgitt & Fonagy, Gacono et al., 1992; Presniak et al., Gacono et al., Berg, 1990 (Ror);
Grandiosity 1984 1992; Kernberg, 1984 Kernberg, 1984; Perry & 2010 (OR) 1992; Kernberg Clemence et al.,
Cooper, 1986 1970; 1984; Perry 2009 (OR); Perry &
& Perry, 2004 Perry, 2004 (OR)
Idealization Kernberg, Gacono et al., 1992; Gacono et al., Kernberg, 1984; Perry & Kernberg, 1970; Clemence et al.,
1984 Kernberg, 1984 1992 (Ror) Cooper, 1986Not pres- 1984; Perry & 2009 (OR); Gacono
ent: Gacono et al., 1992 Perry, 2004 et al., 1992 (Ror)
Devaluation Kernberg, Gacono et al., 1992; Blais et al., Gacono & Meloy, 1988; Presniak et al., Kernberg, 1984; Clemence et al.,
1984 Higgitt & Fonagy, 1999 (Ror) Kernberg, 1984; Perry & 2010 (OR) Perry & Perry, 2009 (OR); Perry &
1992; Kernberg, Cooper, 1986; Vaillant, 2004; Vaillant, Perry, 2004
1984;Vaillant, 1994; 1994 1994
Reich, 1925/1975
Disavowal
Denial Kernberg, Kernberg, 1984 Cramer, 1999 Cramer, 1999; Gacono Cramer, 1999 Cramer, 1999: Cramer, 1999 (TAT)
1984 & Meloy, 1988; Kern- (TAT); Presniak et Kernberg, 1970;
berg, 1984 al., 2010 (SR) 1984
Defense Mechanisms
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Projection Kernberg, Kernberg, 1984 Presniak et Cramer, 1999; Kernberg, Cramer, 1999 Kernberg, 1984 Cramer, 1999
1984; Vail- al., 2010 (SR); 1984 (TAT); Lingiardi (TAT); Perry &
lant, 1994 Zanarini et al., et al., 1999 (OR); Perry, 2004
2009 (SR) Presniak et al.,
2010 (SR)
Rationalization Reich, 1925/1975 Gacono & Meloy, 1988 Presniak et al., Cramer, 1999; Mil- Clemence et al.,
2010 (SR) lon, 1986; Perry & 2009 (OR)
Perry, 2004
Fantasy Vaillant, 1994 Cramer, 1999; Perry Perry & Perry, 2004
& Perry, 2004 (OR)
Major Image distorting
Splitting Kernberg, Kernberg, 1984; Hig- Berg, 1990 Gacono & Meloy, 1988; Presniak et al., Kernberg, 1970; Blais et al., 1999
1984 gitt & Fonagy, 1992; (Ror); Blais Kernberg, 1984; Perry & 2010 (SR) 1984; Vaillant, (Ror)
Perry & Cooper, 1986; et al., 1999 Cooper, 1986; Vaillant, 1994
Vaillant, 1994; Reich, (Ror); Hilsen- 1994
1925/1975 roth et al.,
1993 (Ror);
Presniak et
al., 2010 (SR);
Zanarini et al.,
2009 (SR)
Projective Kernberg, Higgitt & Fonagy, Hilsenroth, Gacono & Meloy, 1988; Kernberg, 1970; Clemence et al.,
Identification 1984 1992; Kernberg, 1984; et al., 1993 Kernberg, 1984 2009 (OR)
Perry & Cooper, 1986; (Ror); Zanarini
Reich, 1925/1975 et al., 2009
(SR)
Action
Acting Out Vaillant, 1994; Reich, Lingiardi et al., Gacono & Meloy, 1988; Lingiardi et al., Vaillant, 1994 Lingiardi et al.,
1925/1975 1999 (OR); Millon, 1986; Vaillant, 1999 (OR); Presn- 1999 (OR); Perry &
Presniak et 1994 iak et al., 2010 Perry, 2004 (OR);
al., 2010 (SR); (SR); Vaillant & Vaillant & Drake,
Zanarini et al., Drake, 1985 (OR: 1985 (OR; same
2009 (SR) same data also pub- data also published
lished in Vaillant, in Vaillant, 1994)
1994)
Passive Aggression Reich, 1925;1975 Presniak et Presniak et al.,
al., 2010 (SR); 2010 (SR)
Zanarini et al.,
2009 (SR)
Help-Rejecting Zanarini et al.,
Complaining 2009 (SR)
Note. SPD = Schizotypal Personality Disorder; BPD = Borderline Personality Disorder; ASP = Antisocial Personality Disorder; NPD = Narcissistic Personality Disorder; SR = Self-report; OR
Perry et al. 35
= observer report; Ror = Rorschach Inkblot Test; TAT = Thematic Apperception Test. aAlthough there are multiple studies examining the broader construct of dissociation and its association
with personality disorders, we only included empirical studies which specifically examined dissociation as a defense mechanism.
36 Defense Mechanisms
intellectualization, dissociation, projection, (Perry, O’Connell, & Drake, 1984) and NPD
projective identification, and acting out, as (Perry & Perry, 1996).
well as negatively associated with repression. Initially, 124 participants entered the
Of these 14 defenses, empirical studies have study, 91 from the first recruitment phase be-
shown support for 12, excepting sublimation tween 1980 and 1983, and 33 from the sec-
& intellectualization. As such, we tested the ond recruitment phase from 1985 to 1988.
hypotheses that 13 of these 14 defenses are The second recruitment phase explicitly in-
associated with NPD. Because the majority cluded participants with SPD, as well as all
of the present study sample was rated for de- other study diagnoses. Of 124 participants
fenses with an earlier version of the DMRS who entered the study, 107 agreed to the vid-
that did not include the adaptive defense eotaping of a 50-minute dynamic interview,
sublimation, this 14th hypothesis could not which served as the raw data for this study.
be tested. Participant collection and diagnoses
We examined these hypotheses com- were reported in detail elsewhere (Perry &
bining two recruitment phases from the same Perry 1996). All participants were collected
overall study. While we previously reported from ambulatory settings as well as a local
some data on two PD diagnoses (BPD, ASP) district probation department and advertise-
and defenses (Perry & Cooper, 1986) in the ments in the local newspaper for symptom-
first sample, and a report on another diag- atic volunteers. Exclusion criteria included
nosis, NPD, on the combined sample (Perry DSM-III schizophrenia, evidence of current
& Perry, 2004), the present report differs in alcohol dependence, or an IQ less than 80.
five important ways. First, we now include The prevalence of concurrent axis I major
participants from both recruitment phases depressive disorder and dysthymic disorder
1 and 2. Second, we examine SPD, which was high, and many participants met more
had not previously been reported on. Third, than one study diagnosis. For the current
we examine the individual defenses instead report, 107 participants with complete data
of only the summary defense levels. Fourth, ranged in age from 18–45 (M = 28.9 ± 5.5),
we use the proportional scoring system with with slightly more females (55%).
improved distributional characteristics de-
scribed below. Fifth, we employ multivariate Procedures
analytic methods. Thus, the present report
meaningfully advances our knowledge in this
area. Professionals conducted semi-struc-
tured diagnostic interviews lasting more than
38 Defense Mechanisms
two hours using the Guided Clinical Inter- about 50 minutes and were videotaped. The
view (GCI), which involved taking a history dynamic interviews were not structured,
and using semi-structured checklists to ascer- although there was a list of ten topic areas
tain coverage of study diagnostic symptoms. considered important (e.g., family of origin,
BPD was diagnosed if the subject met both work, intimate relationships; Perry, Fowler,
DSM-III or III-R criteria and the Borderline & Greif, 2008). Compared to other types of
Personality Disorder Scale cut-off of 28. The interviews, dynamic interviews most resem-
BPD Scale is a quantitative assessment of ble psychotherapy sessions (Beck & Perry,
borderline psychopathology (Perry & Coo- 2008), allowing patient’s defenses to emerge.
per, 1986). ASP and SPD were diagnosed
according to DSM-III criteria, and rescored Defense Ratings. Defenses were rated from
for DSM-III-R criteria when they became the intake videotaped interviews using the
available. Bipolar type II was diagnosed ac- Defense Mechanisms Rating Scales, fourth
cording to the Research Diagnostic Criteria edition (DMRS; Perry, 1986). The scales,
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(Spitzer & Endicott, 1978). Videotaped in- rating method, and reliability are described
terviews from participants collected during in detail elsewhere (Perry, 1988; Perry &
the first phase were reviewed and rated for Cooper, 1989). Briefly, groups of three bac-
the DSM-III-R criteria for NPD (Perry & calaureate-level raters viewed each interview
Perry, 1996), and rediagnosis for DSM-III-R and, after making individual ratings, formed
SPD was also done at that time, while in the a consensus rating of 22 defenses. The eight
second phase, all PD diagnoses were made mature defense scales were not available ex-
from intake interviews. cept for the 31 participants in the second re-
Weighted kappa inter-rater reliabilities cruitment phase, and we therefore omitted
for the intake interview diagnoses were as them from these analyses, along with two
follows: SPD = .77, NPD = .71, ASP = 1.00, alternate forms of denial, bringing the total
and BPD = .83 (n = 13). The BPD diagnosis to 20 defenses. Based on the whole inter-
made by the BPD Scale had a reliability of view, each defense was initially rated quali-
Kw = .80, while the continuous BPD Scale tatively as 0 = absent, 1 = probably present,
score had an intraclass R(IR) = .91, and or 2 = definitely present. Conceptually and
the continuous SPD and ASP scores had IR empirically correlated defenses were previ-
values of .82 and .92, respectively. The reli- ously grouped into summary scales called
ability of the NPD diagnosis made from the defense levels (median reliability IR = .74),
videotapes was Kw = .47, while the reliabil- representing each of 7 defense levels. These
ity for the continuous scale was IR = .56 (n include the levels 1–6 in Table 1, and high
= 25; Perry & Perry, 1996). On the phase II adaptive level 7 (mature) defenses, available
subsample, agreement between the GCI diag- only in phase II subjects.
nostic interview and the videotaped method
was Kw = .52 (n = .31) for NPD. This level Proportional Defense Scoring. Because par-
of agreement between the two methods for ticipants varied in how many defenses they
diagnosing NPD is twice the magnitude of used, we corrected for this as follows. The
the median of studies of agreement between raw score for each defense (0, 1, or 2) was
any two structured instruments for PD diag- divided by the total sum of all defense scores,
noses available in the same era (Perry, 1992), to yield a proportional score. This is inter-
indicating good concurrent validity of our pretable as the proportion of all of an indi-
method. vidual’s defensive functioning (without ma-
After intake, the dynamic interview ture defenses) attributable to the defense in
was conducted by experienced clinicians, question. This scoring method approximates
most of whom were psychoanalysts, blind the more recent and preferred quantitative
to diagnostic data. The interviews lasted assessment of participants’ defensive func-
Perry et al. 39
TABLE 2. Percentage Using the Defense and Mean (M) Percentage Score by Diagnostic Group
Defense SPD BPD ASP NPD
% use1 M% % use1 M% % use1 M% % use1 M%
N/n = 39/19 41/8 33/9 7/0
Affiliation 5.3 1.0 12.5 1.7 0.0 0.0 — —
Altruism 0.0 0.0 0.0 0.0 0.0 0.0 — —
Anticipation 0.0 0.0 0.0 0.0 0.0 0.0 — —
Humor 0.0 0.0 0.0 0.0 0.0 0.0 — —
Self-Assertion 0.0 0.0 0.0 0.0 0.0 0.0 — —
Self-Observation 0.0 1.1 0.0 2.0 0.0 0.0 — —
Sublimation 0.0 0.5 0.0 0.6 0.0 0.0 — —
Suppression 0.0 0.3 0.0 0.6 0.0 0.0 — —
Isolation 53.8 6.5 39.0 5.5 54.5 6.7 14.3 3.4
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tioning, and it has better distributional char- teria for BPD, we used the BPD Scale because
acteristics compared to our previous reports. the latter is a more precisely quantitative
The resulting proportional scores of all 20 scale (Perry & Cooper, 1985). We tested the
defenses then add up to 100%. relationships between hypothesized defenses
and each continuous diagnostic variable in
Data Analysis question by using stepwise multiple linear re-
gression. We did not enter non-hypothesized
variables into the models to decrease the
Because PD comorbidity resulted in likelihood of Type I errors (i.e., false posi-
reduced samples of pure PD types, for mul- tives). This enabled us to detect whether the
tivariate analyses, we employed continuous hypothesized defenses shared unique vari-
rather than categorical diagnostic variables, ance with each diagnostic variable. How-
consisting of the sum of the DSM-III-R scores ever, because the defense scores are semi-
for each type. In lieu of the sum of DSM cri-
40 Defense Mechanisms
TABLE 3. Defenses and Defense Levels Predict SPD Symptoms in Multiple Linear Regression Models
Partial Cumulative
df B R2 R2 F p
Model 1: Hypothesized Defenses
Defenses Only 1, 104 4.14 .008
1 Displacement 11.86 .040 .040 5.37 .022
2 Undoing -11.87 .041 .081 5.46 .021
3 Omnipotence -8.80 .026 .107 3.03 .085
Model 2: Hypothesized Defenses
Controlling Sex, Age 5, 102 4.36 .001
0 Sex 0.80 4.43 .038
Age 0.09 .077 6.67 .011
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quantitative, they may under-represent the major findings on individual defenses. For
true variation in defense scores. As a result, this model, after entering the above forced
we selected a probability of .10 for reten- variables, the defense levels were entered
tion of variables in the model to minimize stepwise.
type II (false negative) errors. For each di-
agnostic continuous variable, we proceeded
RESULTS
as follows. The first model allowed only hy-
pothesized defense variables to enter into the
model. The second model forced any associ-
ated demographic (i.e., age, sex) or diagnos- The total study group (n = 125) had a
tic variables into the model, followed step- mean age of 28.9 years (SD = 5.5) and 50%
wise by the hypothesized defense variables. were female. The diagnostic breakdown in-
Whenever a forced variable became insignifi- cluded SPD 44 (35%), BPD 59 by DSM-III-R
cant in the full model, the model was rerun criteria (48%), or 46 (37%) by BPD Scale
without it. Finally, the third model examined criteria, ASP 41 (33%), NPD 10 (8%), bipo-
the defense levels and autistic fantasy (not a lar type II 74 (60%) or 22 (18%) with bipo-
member of any level), rather than the indi- lar II but without any PD. Pairwise compari-
vidual defenses. Because each level reflects son of diagnostic groups revealed only one
the broader functional aim of its constituent significant association, that between ASP
defenses, the level’s occurrence and functions and NPD, χ2 (2, n = 125) = 14.3, p < .001.
may be more readily perceived by clinicians. Similarly, intercorrelations of all continuous
These findings were expected to mirror the diagnostic scales were nonsignificant, except
Perry et al. 41
TABLE 4. Defenses and Defense Levels Predict BPD Symptoms in Multiple Linear Regression Models
Partial Cumulative
df B R2 R2 F p
Model 1: Hypothesized Defenses
Defenses only 5, 102 12.47 < .001
1 Splitting Self-Images 58.31 .146 .146 13.68 < .001
2 Omnipotence -54.02 .081 .228 12.29 < .001
3 Dissociation 62.06 .071 .298 13.78 < .001
4 Acting Out 37.83 .050 .348 8.99 .003
5 Splitting Others-Images 37.71 .032 .379 5.18 .025
Model 2: Hypothesized Defenses
Controlling Sex, Age 7, 100 9.16 <.001
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between ASP and NPD, rs (123) = .35, p < tioning attributable to that defense). The
.001). There were no significant associations percentage of those with SPD definitely us-
between diagnostic group and age, although ing each of the 20 defenses ranged from 13%
there were with percent female: SPD 64%, χ2 (undoing & dissociation) to 74% (projec-
(1, n = 125) = 5.07, p = .02; BPD 64% χ2 (2, tion). The most prevalent defenses are those
n = 125) = 13.43, p = .001; ASP 37%, χ2 (1, with scores for the percentage of all defen-
n = 125) = 4.41, p = .04, NPD 20%, χ2 (2, n sive functioning that were 5% or higher,
= 125) = 14.17, p < .001. as 5% represents the expected score if all
were equally prevalent (100%/20 defenses
Schizotypal Personality = 5%). For SPD this included 11 defenses,
Disorder (SPD) six of which were hypothesized (italicized)
in descending order: projection, passive-ag-
gression, devaluation, rationalization, isola-
Table 2 displays two descriptive statis- tion, splitting of others-images, splitting of
tics for each diagnostic group: the percent- self-images, intellectualization, acting out,
age of those scored as definitely using each repression, and denial, although repression
defense, followed by the mean proportional was hypothesized to be absent (it was not),
score (i.e., percentage of all defensive func-
42 Defense Mechanisms
but it was less prevalent than splitting. SPD ting of self-images, dissociation, acting out
had an overall mean proportion of immature and splitting of others-images were positive
defenses = 65.6% (SD = 11.6%). predictors of BPD symptoms, while omnip-
otence was negative in direction. Model 2
Table 3 displays the results of the mul- forced sex and age into the model before the
tiple regression analyses. In the first model, 3 same five defenses entered stepwise, yield-
of the 11 hypothesized defenses entered the ing a cumulative R2 = .391. Dissociation and
model, yielding a cumulative R2 = .107. Dis- omnipotence traded their step at entry, while
placement was a positive predictor of SPD omnipotence remained negative in direction.
symptoms, while undoing and omnipotence Finally, model 3 examined the defense levels
were negative in direction. Model 2 forced after forcing in sex. Three defense levels were
sex and age into the model, then three de- positive predictors of BPD symptoms, major-
fenses were entered stepwise, yielding a cu- image distorting, hysterical and action de-
mulative R2 = .176. Displacement and autis- fense levels, yielding a cumulative R2 = .317.
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TABLE 5. Defenses and Defense Levels Predict ASP Symptoms in Multiple Linear Regression Models
Partial Cumulative
df B R2 R2 F p
Model 1: Hypothesized Defenses
Defenses Only 3, 104 8.71 < .001
1 Omnipotence 52.88 .152 .152 19.05 < .001
2 Devaluation 28.69 .030 .179 3.44 .038
3 Denial 20.03 .022 .201 2.80 .097
Model 2: Hypothesized Defenses
Controlling NPD, Age 4, 103 8.44 < .001
0 NPD score 0.28 4.23 .042
Age -0.19 .136 5.73 .019
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TABLE 6. Defenses and Defense Levels Predict NPD Symptoms in Multiple Linear Regression Models
Partial Cumulative
df B R2 R2 F p
Model 1: Hypothesized Defenses
Defenses Only 2, 105 12.31 < .001
1 Omnipotence 36.74 .160 .160 20.28 < .001
2 Devaluation 17.99 .030 .190 3.83 .053
Model 2: Hypothesized Defenses
Controlling ASP, Sex 5, 102 8.83 < .001
0 ASP score 0.15 5.56 .020
Sex -2.18 .186 10.83 .001
dictor. Finally, model 3 examined the defense In examining the association between
levels after forcing in the ASP score and sex. PD type and defense usage, Table 2 paradox-
Two defense levels, both minor and major ically indicated that almost every defense is
image-distorting defenses, and autistic fan- definitely used by at least a small proportion
tasy were positive predictors of ASP symp- of individuals with each PD type. Within
toms, cumulative R2 = .309. each PD type, a number of non-hypothesized
defenses were also prominent, such as intel-
lectualization, isolation of affect, and ra-
DISCUSSION
tionalization. Considered alone, prevalence
confounds those defenses differentially as-
sociated with the disorder in question, with
The present report serves two pur- those present for general reasons that cut
poses. First, our review brings together both across disorders. This partly explains why
theoretical description and empirical findings some authors might posit or find an asso-
about defenses in four PD types. We consid- ciation that is there by chance, or because of
ered these results as a series of hypotheses. some other co-occurring neurotic process—
Second, we examined these hypotheses using such as learning to distance oneself from
systematic, reliable, and validated methods distressing affect—rather than as a reflection
for assessing both diagnosis and defenses. of a fundamental mechanism for a disorder.
Together, both aims allowed us to advance Our use of multiple regression mitigated this
our understanding of one fundamental psy- problem by identifying only those defenses
chodynamic component of these disorders.
Perry et al. 45
which explained some unique variance for 1974; Fairbairn, 1954), SPD is a more re-
each disorder in question. The resulting de- cent addition derived from family studies of
fenses are those most closely related to the schizophrenia (e.g., Kendler, Gruenberg &
underlying dynamics of the disorder. Iden- Strauss, 1981), emphasizing description of
tifying the most characteristic defenses does mild psychotic-like symptoms and schizoid
not imply that the other defenses are not traits. The diagnosis has been largely consis-
also used sometimes, just that they are less tent from DSM-III onward. Individuals with
specific to the disorder itself. A limitation of SPD used as high a proportion of immature
this statistical technique is that it may miss defenses as the individuals with other PD
defenses that do not share unique variance types. Several highly prevalent defenses were
with the disorder, and contrariwise is neither consistent with the inclusion of SPD within
immune to false positives nor to be equat- Kernberg’s BPO construct: projection, deval-
ed with an actual test of a model. Together, uation, splitting of others-images, splitting of
prevalence and unique associations provide self-images and denial. Most other prevalent
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complementary information. A related prob- defenses were either action (i.e., passive-ag-
lem devolves from the choice of comparison gression & acting out), disavowal (rational-
groups. By design, the study compared BPD ization), or obsessional defenses (i.e., isola-
to “near-neighbor disorders,” which should tion & intellectualization). Repression was
yield fewer differentiating defenses than also prevalent, contrary to the hypothesis,
comparisons to highly dissimilar groups, albeit with a lower mean prevalence than
for example comparing PDs to non-ill par- splitting, consistent with the predominance
ticipants. As a result, we have more confi- of the latter.
dence about what the regression models did Defenses predicted a lower proportion
find than what they did not. The likelihood of variance in SPD than the other PDs. This
of false negatives must be considered. To the may reflect a difference from other personal-
degree that defenses reflect the psychody- ity types in the degree to which SPD has a dy-
namic contribution to disorders, these PDs namically rooted origin or dynamic factors
vary in how dynamically determined they that maintain it. The sparse literature on psy-
may be. One proxy for this is the cumulative chodynamic treatment of individuals with
variance that defenses predict. By this metric, SPD relies largely on the more well-developed
BPD was the most dynamically determined literature on schizoid personality (Gabbard,
disorder, with 37.9% variance by individual 2005, p. 413), with a treatment focus on af-
defenses and 31.7% by defense levels, fol- fective experience that is frozen and relation-
lowed by NPD, then ASP. SPD was the least, ships avoided. For individuals with schizoid
with only 10.7% of the variance explained personality, therapy works by developing a
by individual defenses and15.5% by defense safe, tolerant, and meaningful bond more
levels. These figures vary from medium to than by the analysis of neurotic level con-
large effect sizes (Cohen, 1992), and they flicts (Stone, 1985). In SPD, the therapy must
are clinically meaningful as discussed be- deal with defenses related to the fragility of
low. However, all four PDs have a similarly experiencing disturbances in relationships
high proportion of defenses within the broad with important objects, such as projective
group of immature defenses. identification and fantasy, when they come
into play (Stone, 1985). Our regression anal-
Schizotypal Personality yses indicated several defenses most specific
Disorder (SPD) to SPD. The reliance on displacement and
fantasy are consistent with a preference for
dealing with people indirectly by expressing
While schizoid personality has a tra- interest in symbolic connections, and with a
dition in the dynamic literature (Appel, penchant to express inhibited motives more
46 Defense Mechanisms
by fantasy (i.e., autistic fantasy) than in real authors may be less than apparent when one
relationships. Autistic fantasy may be more considers the relationship between the trau-
prevalent than we found, because a single matic origins of BPD (see Herman, Perry, &
dynamic interview may under-represent the van der Kolk, 1989; Zanarini et al., 2002)
individual’s reliance upon it, unlike therapy and fluctuations between different states
sessions once trust has developed. The nega- of mind over time. Splitting may be a very
tive association with undoing suggests a lack useful defense when a child is subjected to
of ambivalence about objects, something trauma at the hands of an adult upon whom
more characteristic of other PD types and he or she is very dependent and insecurely
neurotic individuals. Finally, the lack of di- attached. However, in later life, splitting
rect need-satisfying engagement with others re-emerges in situations that connote some
is consistent with the defense level analysis. threat to the individual, reminiscent of early
Along with autistic fantasy, individuals with traumatic situations, which then re-engages
SPD rely on the group of action defenses the split-off object representations. Other-
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(i.e., passive-aggression, help-rejecting com- wise, the early traumatic memories remain
plaining, & acting out), similar to those with repressed while the only evidence of their
BPD. Overall, many of the most prevalent presence is revealed in dissociative symp-
defenses in SPD are those within Kernberg’s toms or states of mind that may lead to self-
broad categorization of BPO, although the destructive episodes (van der Kolk, Perry, &
defenses most uniquely related to SPD are Herman, 1991) or other problems with im-
not related to BPO. While SPD had a high pulses (Perry & Körner, 2011) or poor func-
proportion of immature defenses, it is clearly tioning (Gunderson et al., 2006). Thus, both
dynamically distinguishable from the other splitting and repression set the individual up
PD types. for episodic use of action and hysterical de-
fenses, in alternation with defenses against
Borderline Personality these same impulses, such as rationalization,
Disorder (BPD) denial, and reaction formation. However, ad-
ditional research is needed, first, to replicate
and, second, to understand the interplay of
The most prevalent defenses in BPD these defenses. One unexpected finding was
were largely those noted in the literature and the high prevalence of obsessional defenses
supported by previous empirical work. Our of intellectualization and isolation. How-
findings clearly place BPD as a core disorder ever, this was a universal finding across all
within BPO (Kernberg, 1975) and, histori- the PD types, possibly an artifact of the press
cally prior to that, as an impulsive character of the dynamic interview to generalize about
(Reich, 1925/1975). Kernberg posited that one’s life. However, contrary to one hypoth-
splitting is the core defensive operation in the esis, undoing was not prevalent, suggesting a
ego, keeping object representations of oppo- relative absence of true ambivalence. This is
site affective valences apart. We found that consistent with our reading of possible con-
both forms of splitting (self and others’ im- founding between undoing and acting out in
ages) were highly prevalent. However, con- the self-report assessment used in the study
trary to Kernberg’s assertion that repression in which this hypothesis arose (Zanarini,
would be relatively absent, we found repres- Weingeroff, & Frankenburg, 2009).
sion to be almost as prevalent as splitting. BPD had the strongest relationship of
This finding is more consistent with Reich’s the four PD types between defenses and per-
(1925/1975) observation that repression is sonality pathology. This further reinforces
both absent at times when the individual is the above discussion about the centrality of
most impulsive and strikingly active on other the major image-distorting defenses, primar-
occasions. The different views of these two ily splitting of self and others’ images, and
Perry et al. 47
the hysterical level defenses, dissociation and the disorder declines. The findings still sup-
repression. Omnipotence was a negative pre- port Kernberg’s (1970) clinical description of
dictor, which may partly reflect its higher lev- NPD as one of splitting off self-images and
els in comparison disorders NPD and ASP. holding onto a grandiose or omnipotent self-
While all four PDs fall within the concept view. Further, individuals with NPD tend to
of BPO, the regression analyses highlighted devalue others, primarily as a defense against
their differences. BPD was most strongly as- their own fear of being mediocre or ordi-
sociated with major image-distorting defens- nary, or disappointing to others. Although
es, while both NPD and ASP were more asso- both splitting of others and self is evident in
ciated with minor image-distorting defenses. Table 2, the finding that only splitting of self-
Although action defenses were prevalent in predicted NPD is consistent with Kernberg’s
all four PD types, they were most uniquely assertion that the most salient form of split-
characteristic of BPD, and to a lesser extent ting in individuals with NPD is their own
SPD. The association of BPD with hysterical split image. Although no previous study has
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defenses has been found elsewhere (Kramer, shown splitting of self to be associated with
de Roten, Perry, & Despland, 2013) and NPD, this defense is typically only seen when
was previously alluded to by Zetzel (1968), the level of self-esteem has been altered in
distinguishing hysterical individuals from some way (e.g., narcissistic injury). Although
“so-called good hysteric” individuals, who Table 2 indicates that the disavowal level
initially present in a neurotic state of mind, defenses are utilized in NPD, the regression
prior to regressing and presenting as border- analyses did not find that denial, rationaliza-
line. tion, or projection alone were unique predic-
tors. In fact, finding that rationalization was
Narcissistic Personality a negative predictor of NPD is a paradoxical
Disorder (NPD) result, but one that is a likely confound due
to its high prevalence in ASP. Although Table
2 indicates that both the ASP and NPD had a
From Table 2, we can see that defen- high prevalence of rationalization, those not
sive functioning in this sample of individu- using rationalization contributed to differen-
als with NPD is relatively consistent with tiating NPD from ASP. However, given the
previous theory and research. Conceptually, high comorbidity between ASP and NPD in
individuals with NPD split their self-images, this sample, it is difficult to make any defini-
whereby the negative ones are denied and tive conclusions about these disavowal level
the positive ones are transformed into an in- defenses without further study in larger and
tegrated omnipotent or grandiose self-view less co-morbid samples. Finally, without rat-
(Kernberg, 1970). This self-view is main- ing mature defenses in everyone, we could
tained through the use of disavowal level not test the hypothesis about sublimation.
defenses, whereby their negative self-image
or any potential attack on their image (e.g., Antisocial Personality
perceived failure, disapproval) is disavowed Disorder (APD)
through either denying the problem (i.e., de-
nial), covering it up (i.e., rationalization), or
misattributing their own experiences onto The results in Tables 2 and 5 are high-
others (i.e., projection) (Clemence, Perry, & ly consistent with previous theoretical de-
Plakun, 2009; Cramer, 1999; Perry & Perry, scriptions of ASP. Gacono, Meloy, and Berg
2004). However, frequent use of devaluing (1992) proposed that individuals with ASP
others’ images remains a marker of the nega- and/or psychopathy, have a split-off self-
tive self-image. In the regression analyses, the image, as in NPD, wherein the negative im-
number of defenses that significantly predict age is denied. They strongly fear their true
48 Defense Mechanisms
of NPD. Clinically, these disorders can look (dissociation in NPD) to 8.9% (projection
quite similar in their grandiose self-presenta- in NPD). By contrast, a quantitative scor-
tion and their tendency to dismiss others as ing of interviews of a sample of women in
inferior. At times, they may display their neg- the community yielded mean defense scores
ative self-view, say after a failure, but these that ranged from a low of 0.0% (projec-
are quickly defended against by disavowal tive identification) to a high of 17.0% (self-
level defenses. The most striking difference assertion; data supplied by the first author).
between these two groups is that individu- One consequence is that the current method
als with NPD engage in more “pseudosub- is more likely to miss findings compared to
limatory behaviours” to earn the adoration the full quantitative method, hence, replica-
of others and defend against their negative tions using the latter method are likely to de-
self-image (Cramer, 1999; Kernberg, 1970), tect some findings that we missed. Another
whereas individuals with ASP resort to direct limitation is that the data source was a single
aggression towards others through acting- dynamic interview, which with some partici-
out behaviors (e.g., threats, violence, and pants may provide an unstable estimate. Per-
stealing). This overall view of ASP was par- ry and colleagues (2008) found significant
tially supported in the regression analyses. variation among individuals with BPD or
In model 1, omnipotence, devaluation, and major depression in the quality of dynamic
denial were significant predictors. Even after interviews on different occasions, which in
controlling for NPD, omnipotence remained turn might be associated with differences
a significant predictor, although devalua- in defensive functioning. Countering this
tion and denial dropped out of the analysis. is that our sample size was large enough
Model 3 confirmed the theory most strongly. to smooth out some of these differences. A
The predictors of ASP were the minor im- third limitation is that we did not have rat-
age-distorting defenses (i.e., omnipotence, ings of the high adaptive level (mature) de-
devaluation, and idealization) and disavowal fenses for the whole sample. However, in the
defenses (i.e., denial, rationalization, and 31 participants where mature level defenses
projection). This concurs with the clinical ratings were available, only 5 (16.1%) used
observation that ASP individuals have a dis- any, suggesting that this omission would not
torted view of themselves and others, which distort most PD defense profiles. A fourth
is maintained by disavowal and image-dis- limitation is that DSM-III-R diagnoses were
tortion directed at anything that threatens used. However, due to the great similarity of
their omnipotent self-view. the criteria between DSM-III-R and DSM-
IV, this is likely to have had minimal effect
on the results of the regression analyses, as
Perry et al. 49
the continuous diagnostic criteria scores we ry et al., 2009), and that change in defenses
used are likely robust to slight alterations in may in fact mediate improvement in symp-
criteria. As a result of these limitations, we toms (Kramer, Despland, Michel, Drapeua,
consider our results as tentative confirmation & de Roten, 2010). In addition, there is
of some of the hypotheses derived from the some evidence that addressing or interpret-
literature, not fully validating. ing defenses improves defensive functioning
within and across sessions (Perry, Petraglia,
Future Directions Olson, Presniak, & Metzger, 2012; Winston,
Winston, Samstag, & Muran, 1994). As a
result, the study of psychotherapy process
Additional studies should replicate/ presents unique opportunities to examine
validate and expand our findings by the use the effect of therapeutic processes on pat-
of quantitative assessment techniques, iden- terns of change in defensive functioning and
tifying each defense as it occurs on multiple overall outcome. From our above findings,
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data sources for more precise estimates. We we would posit that improvement in the core
already have evidence that successful treat- immature defenses in each of the above dis-
ment improves defensive functioning (Her- orders would presage overall improvement
soug, Sexton, & Hoglend, 2002; Perry, Beck, in the symptoms, cognitions, behaviors, and
Constantinides, & Foley, 2009; Roy, Perry, & overall functioning of the PD itself. Such
Banon, 2009), that different diagnoses may findings would further establish a central
show some different patterns of change (Per- role for defenses in personality disorders.
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