ORIGINAL ARTICLES
Psychometric Properties of the Defense Style Questionnaire
(DSQ-40) in Adolescents
Titta Ruuttu, MA(Psych),*†‡ Mirjami Pelkonen, PhD,*† Matti Holi, MD, PhD,*§
Linnea Karlsson, MD, PhD,*储 Olli Kiviruusu, BSocSc,* Hannele Heilä, MD, PhD,*
Virpi Tuisku, MSocSc,* Annamari Tuulio-Henriksson, LicPhil,* and Mauri Marttunen, MD, PhD*†¶
Abstract: This study examined the psychometric properties of the
Defense Style Questionnaire (DSQ-40) in adolescents. Internal con-
sistency, factor structure, and discriminant and concurrent validity
of the DSQ-40 were studied in 211 adolescent psychiatric outpa-
tients aged 13 to 19 years and 199 age-matched and sex-matched
controls. Principal components analysis yielded four internally con-
sistent components: mature, neurotic, image-distorting, and imma-
ture defense styles. The outpatients reported more immature, image-
distorting, and neurotic styles and less mature style than did the
controls, suggesting adequate discriminant validity. As a demonstra-
tion of convergent and concurrent validity, the severity of psychi-
atric symptoms assessed by the General Health Questionnaire and
psychosocial adjustment assessed by the Global Assessment of
Functioning Scale correlated theoretically meaningfully with the
different defense styles. The DSQ-40 appears to be a reliable and
valid instrument for adolescents.
Key Words: defense mechanisms, adolescents, defense style
questionnaire, psychometrics.
(J Nerv Ment Dis 2006;194: 98 –105)
P sychological defense mechanisms can be adaptive when
maintaining emotional homeostasis or dysfunctional
when constricting mental functioning and distorting reality.
Based on clinicians’ ratings, Vaillant (1971) presented a
model of ego defenses according to which defenses can be
arranged on a continuum of ego maturity from immature to
mature. Empirical research on defenses with self-report in-
ventories assumes that although defenses primarily operate
*Department of Mental Health and Alcohol Research, National Public
Health Institute, Helsinki, Finland; †Department of Adolescent Psychi-
atry, Peijas Hospital, Hospital District of University of Helsinki, Vantaa,
Finland; ‡Department of Psychology, University of Helsinki, Helsinki,
Finland; §Department of Psychiatry, Helsinki University Central Hospi-
tal, Helsinki, Finland; 㛳Department of Psychiatry, Turku University
Central Hospital, Turku, Finland; and ¶Department of Psychiatry, Uni-
versity of Kuopio, Kuopio, Finland.
Send reprint requests to Titta Ruuttu, National Public Health Institute,
Department of Mental Health and Alcohol Research, Mannerheimintie
166, FIN-00300 Helsinki, Finland.
Copyright © 2006 by Lippincott Williams & Wilkins
ISSN: 0022-3018/06/19402-0098
DOI: 10.1097/01.nmd.0000198141.88926.2e
98 The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
unconsciously, individuals can be aware of their residuals.
Based on this premise, the first Defense Style Questionnaire
(DSQ), an 81-item measure, was created by Bond et al.
(1983). They relied on factor analysis when developing this
self-report measure and named their four factors maladaptive
action patterns (immature), image-distorting, self-sacrificing
(neurotic), and adaptive (mature) defenses. The revised 88-
item DSQ was published by Bond and Vaillant (1986) and
was later modified by Andrews et al. (1989) to make it largely
consistent with the DSM-III-R draft glossary of defense mech-
anisms. The resulting 72-item DSQ loaded on three factors,
labeled as mature, neurotic, and immature defense styles. The
DSQ-40 was derived from the 72-item version with the goal
of creating a briefer instrument (Andrews et al., 1993). Along
with the work of Bond et al. (1983), several studies with
different methods (clinical observer ratings, projective test
data, or self-report inventories) have provided empirical ev-
idence for Vaillant’s hierarchical model.
The DSQ has proved a substantially valid measure among
adults. Various versions of the DSQ have been found able to
differentiate between normal controls and, among others, psy-
chiatric populations (Spinhoven et al., 1995), subjects with
anxiety disorders (Pollock and Andrews, 1989), subjects with
personality disorders (Sammallahti and Aalberg, 1995), and
child abusing parents (Andrews et al., 1993). The DSQ has
also distinguished borderline female patients from those with
other types of personality disorders (Bond et al., 1994), and
even different groups of anxiety disorder patients (Andrews
et al., 1989). Comparable psychometric properties have been
reported for different forms of the questionnaire (Andrews
et al., 1989; 1993; Bond et al., 1989; Bonsack et al., 1998;
Muris and Merckelbach, 1996; Sammallahti et al., 1996;
Spinhoven et al., 1995). As with the 72-item scale, the
40-item DSQ has proven to be an internally reliable instru-
ment with relatively high Cronbach ␣ values, split-half reli-
ability, test-retest reliability, and item-scale correlations
(Andrews et al., 1993; Watson and Sinha, 1998). Both the
DSQ-72 and DSQ-40 have been suggested to explain psychi-
atric symptomatology (Holi et al., 1999; Watson, 2002).
Factor analysis studies of the DSQ in adults have yielded two
to five more or less theoretically coherent defense styles
depending on the version of the measure and the population
studied (Andrews et al., 1989; Bond et al., 1983; Bonsack et
The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
al., 1998; Flannery and Perry, 1990; Reister et al., 1993;
Rutherford et al., 1998; Sammallahti and Aalberg, 1995).
It is agreed that the use of defenses matures from
infancy to adulthood as a part of normal personality devel-
opment (Cramer, 1987; Evans and Seaman, 2000; Vaillant,
1971; Vaillant and Vaillant, 1990). The most primitive de-
fenses emerge in infancy as normal responses to distress
(Freud, 1948; Spitz, 1961). These immature defenses recede
during maturation and form the foundation for the more
mature and complex defenses developing in adolescence and
young adulthood (Vaillant, 1977). Furthermore, different de-
fenses emerge at different chronological periods of develop-
ment. The use of denial, for example, is predominant and
age-appropriate in the preschool years but then declines
in importance and is considered immature among adults
(Cramer, 1987; Vaillant, 1977). Neurotic and immature de-
fense styles significantly decrease in both sexes during the
transition to young adulthood, whereas mature defense style
scores do not change significantly between late adolescence
and young adulthood (Tuulio-Henriksson et al., 1997). Thus,
the standards for appropriate functioning of the defense
mechanisms in adolescence are somewhat different from
those in adulthood.
Steiner et al. (Feldman et al., 1996; Steiner and Feldman,
1995; Steiner et al., 2001) have developed adolescent ver-
sions of the DSQ. Several studies have reported theoretically
meaningful results for the adolescent versions of DSQ, using
different numbers of reworded items, different factor struc-
tures, and even different Likert scales (Erickson et al., 1996;
Evans and Seaman, 2000; Feldman et al., 1996; Muris et al.,
2003; Steiner and Feldman, 1995). In adolescent studies, both
adult and modified versions have been used. Some adoles-
cent versions have discriminated normal from pathological
(Feldman et al., 1996; Steiner and Feldman, 1995) and
delinquent youths (Feldman et al., 1996). Immature defense
style has associated with psychological symptoms (Chan,
1997; Evans and Seaman, 2000; Muris et al., 2003) in
nonclinical adolescents, and with psychosocial adjustment
both in clinical (Smith et al., 1992) and nonclinical adoles-
cents (Erickson et al., 1996). Factor analysis studies have
yielded two (Evans and Seaman, 2000), three (Feldman et al.,
1996; Muris et al., 2003), or four (Nasserbakht et al., 1996;
Steiner, 1990) DSQ factors in adolescents. Although these
earlier findings suggest that DSQ may be useful for adoles-
cents, none of these versions has been used widely or become
established. The adult DSQ-40 is a widely used and practical
DSQ version that, in the present authors’ view, has face
validity among adolescents. We are not aware, however, of
psychometric studies on the DSQ-40 in adolescent samples.
Moreover, little information is available on the general psy-
chometric properties of DSQ-40.
The aim of the present study was to analyze the psy-
chometric properties of DSQ-40 in adolescents by assessing
its factorial construct, stability of this in subgroups, and
reliability of extracted components. We also evaluated dis-
criminant validity by assessing differences in defenses by
patient status, age, and sex, and convergent validity by
determining whether defenses associated with psychiatric
© 2006 Lippincott Williams & Wilkins
DSQ-40 in Adolescents
symptoms. Finally, we aimed to assess concurrent validity by
exploring the association between defense use and psychos-
ocial adjustment.
METHODS
Subjects
This study forms part of the Adolescent Depression
Study, a longitudinal naturalistic clinical research and devel-
opment project on adolescent mood disorders in a sample of
218 consecutive adolescent psychiatric outpatients and 200
controls from the cities of Kerava and Vantaa in the greater
Helsinki area of southern Finland. The study population was
drawn from two adolescent psychiatric outpatient clinics. The
screened patients with a total sum score of ⱖ10 on the BDI
and a sum score of ⱖ5 on the General Health Questionnaire
(GHQ)–36 were interviewed for DSM-IV disorders using the
Schedule for Affective Disorders and Schizophrenia for
School-Aged Children—Present and Life-Time (Kaufman et
al., 1997). The clinical sample (N ⫽ 218) consisted of those
who met the diagnostic criteria of current depressive mood
disorder. The control group consisted of a random sample of
age-matched and sex-matched students from four schools in
the same area; 200 adolescents were assessed in a manner
identical to the outpatient group.
Based on unpublished analyses of the data, the study
population included a wide spectrum of mood disorders and
accompanying psychiatric disorders (Karlsson et al., Personal
communication). Eight subjects were excluded from the
present analyses because they did not complete the DSQ-40
(N ⫽ 7) or more than a third of answers in the questionnaire
were missed (N ⫽ 1). Thus, the final sample consisted of 410
subjects (211 outpatients, 199 controls) with a mean age of
16.4 years (SD ⫽ 1.6, range, 13–19 years): 333 females
(81%) and 77 males.
Measures
The DSQ-40 (Andrews et al., 1993) produces scores for
both defense styles and separate defenses. It comprises 40
items in a 9-point Likert format. The 40 items are used to
derive scores for 20 defense mechanisms, two items for each.
Immature, neurotic, and mature styles are usually reported.
Scores for defense mechanisms and defense styles are formed
by averaging the ratings for relevant items. The original
English version of the DSQ-72 was translated into Finnish
and satisfactorily back-translated.
Psychiatric symptomatology was measured with the
GHQ (Goldberg, 1972), a self-report instrument designed to
identify short-term changes in mental health. It is validated in
both adult and adolescent samples (Goldberg et al., 1997;
Winefield et al., 1989). The GHQ-36, a shortened version of
the GHQ-60 (Goldberg and Williams, 1988), is a state mea-
sure of how much the subject feels that their present state
“over the past few weeks” is unlike their usual state. For
items, there is a 4-point response scale for presence of a
symptom, scored bimodally as “not at all” (0); “same as
usual” (0); “rather more than usual” (1); and “much more
than usual” (1). For psychometric analyses, it is possible to
use a simple Likert scale (0-1-2-3), which was employed in
99
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this study. The total score obtained by summing the scores of TABLE 1. Four-Component Solution of the Quartimax
the individual items is a measure of severity of the illness and Rotated PCA of the DSQ-40 in a Sample of 410 Adolescentsa
can range from 0 to 108 (Goldberg and Williams, 1988).
The Global Assessment of Functioning Scale (GAF), Loadings
designed for Axis V in the DSM-IV (American Psychiatric Rotated Component Matrix 1 2 3 4
Association, 1994), was completed for every subject as part Immature defense style
of the diagnostic interview. Current overall psychological Projection .74 ⫺.21
functioning was rated on a scale of 0 to 100 according to Passive aggression .74 .21
DSM-IV Axis V definitions. Autistic fantasy .67 ⫺.19 .18
Somatization .65
Statistical Methods
Displacement .63 ⫺.13 ⫺.11
Data were analyzed with SPSS 11.0 (SPSS Inc., 2001). Acting out .54 .22
Principal components analysis (PCA) with quartimax rotation Mature defense style
was used, as Bond et al. (1983) employed in their original Humor ⫺.29 .67
study. The number of components was based on Cattell’s Sublimation .67 .18
scree test and interpretability. PCA was first carried out for Suppression ⫺.36 .59 .19
the entire sample and then separately for the outpatient and Rationalization ⫺.22 .59 .27
control groups, for males and females, and for younger Anticipation .39 .49 ⫺.26
(13–15 years) and older adolescents (16 –19 years). To obtain Image-distorting defense
defense-style scores, the average score for all the defenses style
loading on the respective factor was calculated. Because no Denial .76
previous work to our knowledge has attempted to factor the Dissociation .11 .12 .74
DSQ-40 for adolescents, exploratory rather than confirmatory Devaluation .42 .20 .52
factor analysis was used. The internal consistency of the Isolation .38 .41
scales was determined by calculating the Cronbach ␣ coeffi- Splitting .32 .33 .31
cient for the whole group. The nonparametric Mann-Whitney Neurotic defense style
U test was used to detect differences in defense styles and Reaction formation .77
defense mechanisms between clinical and control groups, Undoing .14 .70
early and late adolescents, and the sexes. Pearson correlations Idealization .17 .23 .17 .55
were used to quantify the associations between the scales, and Pseudo-altruism .27 .33 ⫺.18 .52
between defenses and both GHQ scores and GAF ratings. Eigen values 4.1 2.5 1.8 1.34
% Total variance explained 18 11 10 9.4
RESULTS a
Loadings below .10 were omitted.

Factorial Construct Validity

The principal components analysis of the 20 defense
scores carried out on the combined group revealed four
components (Table 1). The scree test and interpretability
supported the four-factor solution. The first six eigen values
were 4.1, 2.5, 1.8, 1.34, 1.1, and .93. The loadings are shown
in Table 1. Four factors explained 49% of the total variance;
we named these four components as immature, mature, im-
age-distorting, and neurotic styles. The internal consistencies
obtained for these defense subscales, as measured by Cron-
bach ␣, were .78 for immature style, .62 for mature style, .62
for image-distorting style, and .60 for neurotic style. The
immature style correlated positively with image-distorting
style (r ⫽ 0.42) and with neurotic style (r ⫽ 0.22), the mature
style correlated negatively with immature style (r ⫽ – 0.26)
and positively with neurotic style (r ⫽ 0.18), and the image-
distorting style correlated with neurotic style (r ⫽ 0.22); all p
values were ⬍0.001.
We also performed the PCA using three factors, which
enabled us to directly compare the three components of our
data with those of Andrews et al. (1993). This also yielded
two factors both containing immature defenses, plus a third
factor consisting of neurotic and mature defenses. The results
of the three-component solution in the whole group are
shown in Table 2, where the defenses are arranged according
to Andrews’ solution. Cronbach ␣ values for the defense
styles calculated using Andrews’ factors were .57 for mature,
.60 for neurotic, and .75 for immature style.
To evaluate further the stability and generalizability of
the four-factor solution, the defense structure was also eval-
uated according to treatment status, sex, and age (Table 3).
The results indicated rather slight variation in defense struc-
tures between these groups.
To facilitate comparison of different solutions, the results
of the three-factor component structure studies by Andrews et al.
(1993) and Feldman et al. (1996), the four-factor component
structure study by Bond et al. (1983), and our four-factor
component structure study are shown in Table 3.
Discriminant Construct Validity
We compared use of defenses between patients and con-
trols, between younger and older adolescents, and between the
sexes to determine whether there were differences in how these
groups used defenses (Table 4). The patients reported greater
use of immature, image-distorting, and neurotic styles than did
the controls. Of the individual defenses, patients used every
immature defense more, as well as devaluation, isolation, split-
ting, reaction formation, undoing, and pseudo-altruism. Further,
the patients used less mature defense style and, of individual

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The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006 DSQ-40 in Adolescents

mature defenses were, without exception, associated with

TABLE 2. Three-Component Solution of the Quartimax
Rotated PCA of the DSQ-40 in a Sample of 410 Adolescentsa high global adjustment, and the immature, image-distorting,
and neurotic defenses with low psychosocial adjustment. The
Loadings patterns of correlation were generally similar for patients and
Rotated Component Matrix 1 2 3 controls, although weaker for patients.
Mature defense style
Sublimation ⫺.36 .52 DISCUSSION
Humor ⴚ.60 .36 The main finding of this psychometric study was that
Anticipation .51 the adult version of DSQ-40 is a valid measure for adoles-
Suppression ⴚ.66 .18 .18 cents. It scored well for the different aspects of validity and
Neurotic defense style reasonably for internal consistency of defense styles.
Undoing .11 .50 .11
Factorial Construct Validity
Pseudo-altruism .69
This is the first study to investigate the structure and use
Idealization .56 .23
of defense mechanisms among adolescents using the DSQ-40.
Reaction formation .56 ⫺.12
The three-component structure found in adults in the original
Immature defense style
DSQ-40 study (Andrews et al., 1993) was not verified as such
Projection .72 .16 .24
in this adolescent sample. We considered a three-factor so-
Passive aggression .56 .14 .44
lution, but it was not easily interpretable: two immature
Acting out .37 .39
factors emerged with mature defenses also loading negatively
Isolation .28 .48
on the other factor, and the third factor was a mixture of the
Devaluation .15 .15 .66
neurotic and mature defenses. Instead, a more subtle, four-
Autistic fantasy .65 .21 .25
factor solution resulted. The first factor consisted of immature
Denial ⫺.15 .69
defenses: projection, passive aggression, autistic fantasy, so-
Displacement .61 .21
matization, displacement, and acting out. These defenses
Dissociation .74
describe maladaptive action patterns that very often emerge
Splitting .24 .26 .39
in object relationships, and may appear quite provocative.
Rationalization ⴚ.55 .16 .31
The individual deals with emotional conflicts by indirectly
Somatization .56 .24 .12
and often self-detrimentally expressing feelings toward some-
a
Loadings below .10 were omitted. one or something.
The second factor consisted of mature defenses: humor,
sublimation, suppression, rationalization, and anticipation.
defenses, less humor, suppression, and rationalization than did These defenses reflect constructive ways of mastering con-
the control adolescents. Females reported less use of mature and flict. The third factor, consisting of denial, dissociation,
image-distorting style than did males. Of the individual de- devaluation, isolation, and splitting, is descriptive of image-
fenses, females reported more use of somatization, displace- distorting coping. It is associated with narcissistic and bor-
ment, anticipation, and reaction formation than males, but less
derline personality patterns, and it differs from the immature
suppression, denial, and devaluation. Younger adolescents (aged
style in being image-oriented rather than action-oriented. The
13–15) reported more rationalization and splitting than did older
individual refuses to acknowledge some aspect of reality. We
ones (aged 16 –19). There were no differences in the use of
interpreted splitting to be included in the image-distorting
defense styles by age group. style, even though its loadings were equal to immature and
Convergent Construct Validity neurotic factors. The defenses that loaded on the fourth factor
To analyze the association between psychiatric symp- (reaction formation, undoing, idealization, and pseudo-altruism)
toms and defenses, correlations between the GHQ-36 and are described as neurotic defenses. These intermediate defenses
DSQ scores were calculated (Table 5). Psychiatric symptom- are more private than the immature ones and thus do not occur
atology had a strong positive association to immature defense in response to interpersonal events as immature defenses
style and a negative association to mature defense style. usually do. The rearranging of ideas and feelings is typical,
Image-distorting and neurotic styles were also positively for example, so that a person can see him/herself as exces-
correlated with GHQ-36 scores. The correlations were gen- sively kind and helpful. Our findings on the content of the
erally parallel for patients and controls. four extracted components and the correlations between the
styles support Vaillant’s (1971) view that defenses form a
Concurrent Criterion Validity continuum from immature or pathological to adaptive or
To determine concurrent criterion validity for the mature.
DSQ-40, the individual defense scores and composite factors Despite the fact that the items, number of components,
were correlated with the ratings on the GAF (Table 5). There and age of subjects differed between the studies we exam-
were significant correlations between psychosocial adjust- ined, our findings were very similar to those reported by
ment and both individual defenses and all four composite Bond et al. (1983), Andrews et al. (1993), and Feldman et al.
factors for the total study group. Specifically, 15 of the 20 (1996). In terms of the number of factors, our component
correlations for the total study group were significant; the structure differed from that in the original DSQ-40 study on

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TABLE 3. Component Structures of the Four-Component Solutions of PCA With Quartimax Rotation for the Whole
Adolescent Sample and Subgroups, and the Component Structures of Bond’s, Andrews’, and Feldman’s Studies
Group Sex Age Study
a,b
Bond 1983 Andrewsa 1993 Feldmanc 1996
Total Patients Controls Females Males 13ⴚ15 y 16ⴚ19 y DSQ-81 DSQ-40 DSQ-59
N ⴝ 410 N ⴝ 211 N ⴝ 199 N ⴝ 333 N ⴝ 77 N ⴝ 125 N ⴝ 285 N ⴝ 209 N ⴝ 712 N ⴝ 515
Projection Im Im Im Im Im Im Im Im Im Im
Passive aggression Im Im Im Im Im Im Im Im Im Im
Autistic fantasy Im Im Im Im Im Im Im — Im Im
Somatization Im Im Im Im Im Im Im Im Im Im
Displacement Im Im Im Im Im Im Im Im Im —
Acting out Im Im N Im Im Im Im Im Im Im
Humor M M ⴚIm M M M M M M M
Sublimation M M M M Im M M M M M
Suppression M M ⴚIm M M M M M M M
Rationalization M M ⴚIm M M M M — Im —
Anticipation M M M M Im Im M — M M
Denial Id Id Id Id Id Id Id N Im Im
Dissociation Id Id Id Id Id Id Id Im Im —
Devaluation Id Id Id Id Im Id Id — Im —
Isolation Id Id Id Id Im Im Id — Im —
Splitting Id N/Im/Id N Im/Id N N Im Id Im Im
Reaction formation N N M N N N N N N N
Undoing N N M N N N N — N Im
Idealization N N N N N N M Id N —
Pseudo-altruism N N M N Id N Im N N N
Im, Immature factor; M, mature factor; Id, image-distorting factor; N, neurotic factor.
a
Studies mainly on adults.
b
Bond referred to neurotic defenses as “self-sacrificing style,” which, in its final form, contained reaction formation and pseudo-altruism.
c
Feldman referred to neurotic defenses as “prosocial.”

adults by Andrews et al. (1993); in our adolescents, the
immature defenses loaded themselves on two distinct com-
ponents: immature action-oriented and immature image-dis-
torting. On the other hand, our immature factors were
very similar to those described by Bond et al. (1983) and
Sammallahti and Aalberg (1995), who also ended up with
four-factor solutions. Studies using the DSQ-40 have usually
chosen a three-factor solution without performing a factor
analysis. To our knowledge, the only exceptions are the two
adult studies conducted by Watson and Sinha (1998) and
Punamäki et al. (2002). The former resulted in a five-factor
solution, but the results were reported using three factors,
whereas the latter was reported using four factors. Here, the
emergence of two distinct immature components—action and
image distorting—may be explained by the legacy of the
different phases of development still clearly being present
during adolescence. Apart from the subjects’ age, the diver-
gent findings between the present study and the study by
Andrews et al. could reflect Finnish-Australian cultural dif-
ferences. This is supported by the similarities in our factor
structure to another Finnish study of the DSQ (Sammallahti
and Aalberg, 1995). Comparison of the present findings with
the original DSQ study (Bond et al., 1983) was complicated
by the different amounts and contents of items.
The factor structure of the whole group slightly differed
from that of the controls. Acting out, splitting, and idealiza-
tion clustered together for the control sample. The neurotic
factor did not emerge as such a coherent factor for the school
sample as it did for the whole sample and patients: the
defenses traditionally described as neurotic (pseudo-altruism,
reaction formation, and undoing) loaded on the mature factor
among the controls. Otherwise, the mature factor and the
neurotic factor were highly consistent across all groups.
Defenses that were named immature in the DSQ-40 study by
Andrews et al. (1993) divided into two distinct factors in
almost the same manner in every subgroup.
The component structure was quite similar for males
and females, but due to the low number of males, this result
must be interpreted with caution. Neither were there any
major age differences in defense structure between younger
and older adolescents. This invariability supports the stability
and generalizability of the DSQ-40 among youths.
Contrary to the theoretical coherence of the factor
structure, the internal reliabilities of the extracted defense
styles were only reasonable. The Cronbach ␣ values, how-
ever, were fully comparable to earlier ones calculated on
factors of 40-item (Andrews et al., 1993; Punamäki et al.,
2002) or even longer versions of the DSQ (Andrews et al.,
1993; Sammallahti and Aalberg, 1995). Internal reliabilities
have tended to remain modest, probably due to the heterog-
enous nature of defenses loading on one factor.

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TABLE 4. Differences,a Means, and SDs in Use of DSQ-40 Defenses by Patient Status, Age, and Sex in a Sample of 410
Adolescent Outpatients and Controls
Patient Status Age Sex
Patients Controls 13–15 y 16–19 y Females Males
N ⴝ 211 N ⴝ 199 N ⴝ 125 N ⴝ 285 N ⴝ 333 N ⴝ 77
Mean (SD) Mean (SD) P Mean (SD) Mean (SD) P Mean (SD) Mean (SD) P
Immature 5.2 (1.2) 3.6 (1.2) ⬍0.001 4.5 (1.4) 4.5 (1.4) 0.976 4.6 (1.4) 4.2 (1.5) 0.051
Projection 5.3 (1.9) 3.1 (1.8) ⬍0.001 4.3 (2.1) 4.2 (2.1) 0.611 4.3 (2.2) 4.0 (2.0) 0.401
Passive aggression 4.6 (1.9) 3.6 (1.7) ⬍0.001 4.3 (1.9) 4.1 (1.8) 0.334 4.1 (1.8) 4.2 (2.0) 0.881
Autistic fantasy 5.1 (2.3) 3.4 (2.0) ⬍0.001 4.2 (2.3) 4.3 (2.4) 0.541 4.4 (2.4) 3.9 (2.2) 0.182
Somatization 5.2 (2.0) 3.6 (1.8) ⬍0.001 4.2 (2.0) 4.6 (2.1) 0.084 4.6 (2.2) 4.0 (2.0) 0.021
Displacement 5.0 (1.9) 4.1 (1.7) ⬍0.001 4.5 (1.9) 4.6 (1.9) 0.924 4.7 (1.9) 4.0 (1.9) 0.006
Acting out 5.7 (1.9) 4.7 (1.8) ⬍0.001 5.3 (1.8) 5.2 (2.0) 0.650 5.3 (1.9) 4.9 (1.8) 0.228
Mature 4.7 (1.2) 5.4 (1.0) <0.001 5.1 (1.1) 5.0 (1.2) 0.616 5.0 (1.2) 5.3 (1.2) 0.029
Humor 5.6 (2.0) 6.9 (1.5) ⬍0.001 6.3 (1.8) 6.2 (1.9) 0.921 6.2 (1.9) 6.4 (1.8) 0.535
Sublimation 4.4 (2.0) 4.8 (1.7) 0.056 4.6 (1.9) 4.6 (1.9) 0.869 4.6 (1.9) 4.8 (1.8) 0.267
Suppression 3.7 (2.0) 5.0 (1.8) ⬍0.001 4.5 (1.9) 4.3 (2.1) 0.284 4.1 (1.9) 5.1 (2.1) ⬍0.001
Rationalization 4.5 (1.8) 5.2 (1.5) ⬍0.001 5.1 (1.7) 4.7 (1.7) 0.023 4.8 (1.6) 5.1 (1.9) 0.080
Anticipation 5.2 (1.7) 5.1 (1.6) 0.413 5.0 (1.6) 5.2 (1.7) 0.305 5.2 (1.7) 4.9 (1.6) 0.034
Image-distorting 3.9 (1.1) 3.5 (1.0) <0.001 3.8 (1.1) 3.7 (1.1) 0.103 3.7 (1.1) 4.0 (1.1) 0.044
Denial 3.1 (1.8) 2.9 (1.5) 0.573 3.1 (1.7) 3.0 (1.6) 0.398 2.9 (1.6) 3.4 (1.7) 0.008
Dissociation 3.3 (1.7) 3.1 (1.6) 0.680 3.3 (1.6) 3.1 (1.7) 0.202 3.1 (1.6) 3.5 (1.7) 0.056
Devaluation 3.9 (1.5) 3.6 (1.3) 0.018 3.8 (1.5) 3.8 (1.4) 0.848 3.7 (1.4) 4.1 (1.5) 0.036
Isolation 4.4 (2.0) 3.4 (1.9) ⬍0.001 4.0 (1.9) 3.9 (2.1) 0.807 3.9 (2.0) 4.0 (2.2) 0.924
Splitting 5.0 (1.9) 4.5 (1.9) 0.030 5.0 (2.0) 4.6 (1.9) 0.043 4.7 (1.9) 4.7 (2.0) 0.933
Neurotic 4.8 (1.3) 4.4 (1.2) 0.002 4.7 (1.3) 4.6 (1.3) 0.489 4.7 (1.2) 4.4 (1.3) 0.061
Reaction formation 4.9 (1.9) 4.4 (1.7) 0.005 4.6 (1.8) 4.7 (1.9) 0.544 4.8 (1.8) 4.3 (1.7) 0.008
Undoing 4.9 (2.0) 4.5 (1.7) 0.033 4.8 (1.8) 4.6 (1.9) 0.390 4.7 (1.8) 4.7 (1.9) 0.942
Idealization 4.4 (2.3) 4.2 (2.0) 0.360 4.6 (2.2) 4.2 (2.1) 0.074 4.3 (2.1) 4.2 (2.2) 0.832
Pseudo-altruism 5.1 (1.7) 4.7 (1.5) 0.026 4.8 (1.6) 5.0 (1.7) 0.396 5.0 (1.6) 4.6 (1.7) 0.051
a
Differences tested with Mann-Whitney U test.

Discriminant Construct Validity Convergent Construct Validity

The outpatients had more maladaptive and less adaptive
defenses than their controls. Sex differences were also found
in defense use. The defenses favored by girls (somatization,
displacement, anticipation, and reaction formation) are in line
with previous results (Feldman et al., 1996). The boys’
emphasis on suppression, denial, and devaluation also some-
what support the previous results found in adults (Watson,
2002; Watson and Sinha, 1998) and adolescents (Feldman et
al., 1996). Because of suppression, the boys scored higher on
the mature defense style than the girls; the boys also used
more image-distorting defense style. It seems that when girls
resort to immature coping, they tend to redirect their feelings
or responses toward something (somatization and displace-
ment), whereas boys fail to acknowledge some aspect of the
external reality (denial and devaluation).
Age differences were not significant for defense style
scores, but they were significant for two of the specific
defenses: rationalization and splitting were more rarely used
by older adolescents. The use of these defenses appears to
predominate in young adulthood, and both are usually in-
cluded in the immature defenses of adults (Andrews et al.,
1993). The authors are unaware of prospective studies of the
development of defenses in adolescence.
The maturity of the defense style was clearly associated
with the amount of psychiatric symptoms as measured by the
GHQ. Adolescents with greater use of mature style had fewer
psychiatric symptoms, while those preferring immature, im-
age-distorting, and neurotic styles had more psychiatric
symptomatology. These findings suggest that mature de-
fenses protect against psychological symptoms, whereas im-
mature defenses could predispose to psychopathology. This is
supported by a follow-up study showing immature defenses
in late adolescence to predict psychiatric symptoms in young
adulthood (Tuulio-Henriksson et al., 1997). The results are in
line with reports that immature defense mechanisms are
positively related to several indices of psychopathology, such
as the GHQ (Chan, 1997; Tuulio-Henriksson et al., 1997),
Symptom Checklist 90 (Bond and Perry, 2004; Holi et al.,
1999), DSM-IV Psychopathology Questionnaire for Youths
(Muris et al., 2003), and internalizing/externalizing symp-
toms on the Youth Self-Report behavior checklist (Evans and
Seaman, 2000).
Concurrent Criterion Validity
Defenses and adaptation were significantly related;
greater maturity of defense style was consistently associated

© 2006 Lippincott Williams & Wilkins 103

Ruuttu et al. The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006

TABLE 5. Pearson Correlations of Defense Mechanisms and Styles of the Defense Style Questionnaire (DSQ-40) With the
General Health Questionnaire (GHQ-36) and the Global Assessment of Functioning Scale (GAF) Among Adolescent
Outpatients and Age- and Sex-Matched Controls
GHQ-36 GAF
Total Patients Controls Total Patients Controls
(N ⴝ 410) (N ⴝ 211) (N ⴝ 199) (N ⴝ 410) (N ⴝ 211) (N ⴝ 199)
Immature 0.65*** 0.35*** 0.65*** ⴚ0.54*** ⴚ0.17* ⴚ0.40***
Projection 0.62*** 0.31*** 0.59*** ⫺0.55*** ⫺0.25*** ⫺0.38***
Passive aggression 0.36*** 0.12 0.43*** ⫺0.32*** ⫺0.14 ⫺0.25***
Autistic fantasy 0.49*** 0.25*** 0.48*** ⫺0.40*** ⫺0.13 ⫺0.27***
Somatization 0.50*** 0.25*** 0.45*** ⫺0.38*** ⫺0.08 ⫺0.20**
Displacement 0.40*** 0.25*** 0.42*** ⫺0.29*** 0.01 ⫺0.32***
Acting out 0.31*** 0.10 0.32*** ⫺0.28*** ⫺0.05 ⫺0.25***
Mature ⴚ0.45*** ⴚ0.37*** ⴚ0.34*** 0.35*** 0.17* 0.27***
Humor ⫺0.45*** ⫺0.32*** ⫺0.37*** 0.36*** 0.16* 0.24***
Sublimation ⫺0.16*** ⫺0.19** ⫺0.03 0.18*** 0.12 0.20**
Suppression ⫺0.46*** ⫺0.33*** ⫺0.39*** 0.36*** 0.15* 0.24***
Rationalization ⫺0.32*** ⫺0.23*** ⫺0.33*** 0.20*** 0.03 0.16*
Anticipation 0.02 ⫺0.10 0.11 ⫺0.03 0.06 ⫺0.04
Image-distorting 0.20*** ⴚ0.01 0.21** ⴚ0.25*** ⴚ0.12 ⴚ0.21**
Denial 0.01 ⫺0.07 0.01 ⫺0.09 ⫺0.07 ⫺0.08
Dissociation 0.02 ⫺0.01 ⫺0.02 ⫺0.06 ⫺0.08 ⫺0.01
Devaluation 0.13** ⫺0.00 0.14* ⫺0.17*** ⫺0.06 ⫺0.15*
Isolation 0.27*** 0.05 0.25*** ⫺0.30*** ⫺0.15* ⫺0.20**
Splitting 0.17*** 0.02 0.24*** ⫺0.16*** 0.01 ⫺0.20**
Neurotic 0.15** 0.05 0.08 ⴚ0.10* 0.11 ⴚ0.07
Reaction formation 0.11* 0.03 0.00 ⫺0.06 0.08 0.07
Undoing 0.15** 0.15* 0.03 ⫺0.11* 0.04 ⫺0.13
Idealization 0.04 ⫺0.07 0.10 ⫺0.04 0.11 0.06
Pseudo-altruism 0.12* 0.04 0.09 ⫺0.06 0.06 0.01
ADS, Adolescent Depression Study.
*p ⬍ 0.05; **p ⬍ 0.01; ***p ⬍ 0.001 (two-tailed test).

with better psychosocial adjustment, and greater immaturity
with lower level of functioning. The results were less clear in
outpatients due to smaller variation in the GAF scores. Our
findings confirm that self-report of defense styles correlates
with independent and reliable observer ratings of psycho-
social functioning in adolescent populations. They are also
consistent with previous findings among adolescents
(Erickson et al., 1996; Smith et al., 1992) showing matu-
rity of defense style to be associated with level of psycho-
social functioning.
Strengths and Limitations
Consecutive outpatients and age-matched and sex-
matched controls from the same area were used. Data collec-
tion was comprehensive, and little information was missing.
We used standardized and validated measures for assessing
psychiatric symptomatology and psychosocial functioning
(observer-rated measure). However, when generalizing these
findings, several limitations need to be taken into account.
First, the sample was not balanced for gender or age, since
girls and older adolescents were overrepresented. The sample
nevertheless successfully represents youths who present
themselves to clinicians. Second, due to the cross-sectional
design of the study, no causal relationships between defenses
and correlates could be established. Third, a wider spectrum
of diagnoses and also a group of adults would have been
useful for validation purposes. Fourth, our setting did not
permit evaluation of test-retest reliability, which would have
given a complete picture of the reliability of the DSQ-40.
CONCLUSION
We conclude that the adult version of DSQ-40 is
appropriate for use in adolescents. The Finnish version of
DSQ-40 showed good psychometric properties in our sample
of adolescent outpatients and controls, including factorial
structure, internal consistency, and concurrent and discrimi-
nant validity. The instrument discriminates between mature,
neurotic, image-distorting, and immature defense styles in
this age group. Defenses loaded on factors in a way that
makes clinical sense. The outpatient group differed from the
sex-matched and age-matched control group in the use of
defense styles and even in most of the individual defense
mechanisms. Defense mechanisms were related to psycho-
pathological symptoms and psychosocial adjustment. This
study reveals a heterogeneity of defenses among clinical
adolescents that parallels normal adolescents. Because de-
fenses differ in their relative maturity and in their develop-

104 © 2006 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease • Volume 194, Number 2, February 2006
mental appropriateness, age has to be considered when mea-
suring the adaptive success of defenses. Although most
previous studies have favored a three-factor solution with
only one immature factor, the different nature of the two
extracted immature defense components suggests the need to
consider a more complex four-factor structure for adoles-
cents. Longitudinal studies are needed to determine the va-
lidity of the DSQ-40 for predicting specific symptomatology
in adolescents.
ACKNOWLEDGMENTS
The authors thank research assistant Eevaliisa Orelma
for her contribution to patient recruitment and data manage-
ment and Johanna Törrönen, MD, and Kirsi Kettunen, MD,
for their contribution in the interviews. This study was finan-
cially supported by the Hospital District of University of
Helsinki, Peijas Hospital, the Yrjö Jahnsson Foundation, and
the Finnish Konkordia Fund.
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