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Coping responses to stress can be divided into three broad categories. The first coping category involves voluntarily mobilizing social supports. The second category involves voluntary coping strategies like rehearsing responses to danger. The third coping category, like fever and leukocytosis, is involuntary. It entails deploying unconscious homeostatic mechanisms that reduce the disorganizing effects of sudden stress, DSM-5 offers a tentative hierarchy of defenses, from psychotic to immature to mature. The 70-year prospective Study of Development at Harvard provides a clinical validation of this hierarchy Maturity of coping predicted psychosocial adjustment to aging 25 years later, and was associated with not developing symptoms of post-traumatic stress disorder after very severe WWII combat.
Les stratégies d'adaptation au stress peuvent être divisées en trois grandes catégories. La première comprend des supports sociaux à mobilisation volontaire. La deuxième comprend des stratégies d'adaptation volontaires comme la préparation des réponses au danger. La troisième catégorie, comme la fièvre et la leucocytose, est involontaire. Elle suppose le déploiement de mécanismes homéostatiques inconscients qui réduis effets désorganisateurs d'un stress soudain. Le DSM-V présente une hiérarchie de la tentative des défenses allant de psychotique à immature à mature. L'étude prospective de 70 ans du Développement conduite à Harvard apporte une validation clinique de cette hiérarchie. Ainsi, la maturité de la stratégie d'adaptation a permis de prédire l'ajustement aux effets de l'âge 25 ans plus tard, et était associée à une absence de développement de l'état de stress post-traumatique après des combats très sévères durant la seconde guerre mondiale.
Resilience can be defined as the capacity to recover following stress or trauma by adopting healthy strategies for coping with trauma and stress. Psychopatho logical response to stress may be considered from two perspectives. The first, perspective emphasizes pathological consequences of stress, such as impaired brain function, post-traumatic stress disorder (PTSD), hippocampal shrinkage, or elevations in scrum Cortisol levels.
The second perspective focuses on how an individual's integrated central nervous system alters and copes with the stressor. In this case, the result, of stress is seen not as nonspecific depression and anxiety, but, as a set of differentiated creative but involuntary behaviors that may range from elaborate delusional systems to Beethoven warding off suicidal depression by inserting Schiller's Ode to Joy into his Ninth Symphony. This second perspective is the orientation of this report. A fever is a coping response, not a sign of illness.
If response to stress can be viewed from two vantage points - pathological or coping, coping responses to stress can be divided into three broad categories. The first coping category involves voluntarily eliciting help from appropriate others, for example, by mobilizing social supports. The second coping category involves voluntary strategies like information gathering, anticipating danger, and rehearsing responses to danger.1 The third coping category, like fever and leukocytosis, is involuntary. It entails deploying unconscious homeostatic mechanisms that, reduce the disorganizing effects of sudden stress.
Such coping mechanisms (shortened to defenses for this paper) have more to do with adaptation to life than with Freud's “psychoanalysis.” Despite the emerging dialogue between neuroscience and dynamic psychiatry, the chemical processes and neuronal assemblies underlying involuntary defenses have not been identified.
Not long ago at an amusement park, I watched my grandson ride the loop-the-loop roller coaster with astonishment. As he hung suspended upside down 30 meters above the ground, I saw that for him the experience was one of joy, release, and exhilaration. I imagined that for myself the ride might produce panic. By what, alchemy had the chemistry of his brain, hardwired to feel lasting fear at dangerous heights, left, him without residual distress? Who is sane and who is crazy - the excited teen or the phobic grandfather?
Choice of defense is involuntary, but so-called “mature defenses” (eg, sublimation and humor) rather than “immature defenses” (eg, projection and hypochondriasis) can make an enormous difference in mental health. But even the most, “pathologic” defenses serve to calm. Early 19th-century medical phenomenologists viewed pus, fever, and coughing as evidence of disease; late 19th century pathophysiologists learned to regard these symptoms as evidence of the body's healthy efforts to cope with infectious insult. Similarly, immature defense mechanisms like imaginary friends (fantasy), temper tantrums (acting out), and self-mutilation (passive aggression) produce behaviors that appear annoying and/or pathological to others but. in fact, reflect the brain's homeostatic effort to cope with sudden changes in the brain's internal and external environment. In both deafness and traumatic brain injury, the usually maladaptive defense of projection helps to provide subjective order to a disordered brain. The difficulty is that, often, as with hypnosis, defenses like my grandson's denial of danger compromise other facets of cognition. Perhaps Freud's most, original contribution to human psychology was his inductive postulation in 1894 that, unconscious “defense mechanisms” protect, the individual from painful emotions, ideas, and realities.2 Freud observed that not only could emotion be “dislocated or transposed” from ideas (by the mechanism Freud would later call isolation) but, also that emotion could be “reattached” to other ideas (by displacement) and that the idea accompanying the emotion could be “forgotten” by repression. Consider, for example the different responses of different people to the immediate aftermath of 9/11.
Defenses have six important properties3:
Clinicians must learn to perceive a patient's often irritating, even disgusting, defenses as lifesaving, as the Viennese hematologist Julius Cohnheim learned to perceive disgusting pus as “laudable.” For example, hypochondriacal help-rejecting complaints often seen in inarticulate trauma victims lead to anger and unwitting retaliation on the part of the clinician. Like understanding a foreign language, the discovery of past trauma not, in the chart permits the clinician to be empathie towards the patient's unconsciously angry demands.
Although in every effort to produce a comprehensive list of defenses, there will be enormous semantic disagreement,4 over the last 30 years several longitudinal studies at Berkeley5 and at Harvard6 have clarified our understanding. Empirical studies reviewed by Cramer7 and Skodol and Perry8 finally organized defenses into a consensual hierarchy of relative psychopathology. By offering a tentative hierarchy and glossary of consensually validated definitions, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV),9 hardly a psychoanalytic document, has included a Defensive Functioning Scale (pp 751-753) adapted from Vaillant, 1971 ,10 as a proposed diagnostic axis.
The hierarchy has four levels. At the first level are psychotic defenses (common in PTSD): delusional projection, psychotic denial, and psychotic distortion. These mechanisms are common in young children, in our dreams, and in psychosis. To breach them requires altering the brain by neuroleptics or waking the dreamer.
At the second level are immature defenses (also common in PTSD): acting out (eg, My Lai Massacre); passive aggression (cutting oneself); autistic fantasy; dissociation (out-of-body experience during torture, multiple personalities common after childhood abuse); and projection (paranoia). The relatively maladaptive defenses found in the second level are common in adolescents, in substance abusers, in personality disorders, and in brain injury. Defenses in this category rarely respond to verbal interpretation alone.
The third level arc intermediate (neurotic) defenses. Defensive functioning at. this level keeps potentially threatening ideas, feelings, memories, wishes, or fears out. of awareness. Examples are: displacement (kicking the dog instead of the boss), isolation (a surgeon thinking the Whipple operation for pancreatic cancer is interesting) repression, the opposite of isolation - feeling without thinking. These intermediate defenses are manifested clinically by phobias, compulsions, somatizations, and amnesias. In contrast to the immature defenses, intermediate defenses usually make the user more uncomfortable than the observer. They can often be breached with psychotherapy.
At the fourth level are mature defenses. If immature defenses are most, common in adolescents, mature defenses increase with age11 just as PTSD decreases with age. These defenses usually maximize gratification and allow relatively more conscious awareness of feelings, ideas, and their consequences. Examples of defenses at this level are: altruism, sublimation, suppression, and humor. For example, although humor appears to reflect denial and dissociation, humor, like meditation, helps shift the body's autonomic sympathetic agitation to parasympathetic calm. Black humor on the battlefield and in the operating theater reflect such examples of transformation of terror into relaxation. Thus, not only do defenses lie along a continuum of relative psychopathology; they also lie along a continuum of personality maturation.11 With the passage of decades and the continuing myclinization of frontal lobe connections to the limbic system,12 the defense of adolescent acting out. (eg, temporarily comforting shoplifting) could evolve into reaction formation (becoming a strict policeman) and finally into the altruism of a parole officer.
Immature defenses can be breached in three ways. First, by confrontation - often by a group of supportive peers - or by videotaped empathie but. focused psychotherapy.13 Second, immature defenses can be breached by improving intrapsychic competence by rendering the individual less anxious and lonely through empathy, or less tired and hungry through food and rest. Third, improving brain function, (for example, sobriety or relieving normal-pressure hydrocephalus). At. present few evidence -based treatment results are available, except for a small body of literature on change in defenses over treatment and time.3,14
At present we have only clinical evidence to support, the importance and the clinical utility of the concept, of a hierarchy of defenses. The Study of Adult Development at Harvard University offers one such experimental clinical setting. The Study consists of three cohorts of adolescents followed for a lifetime: The College cohort (Harvard sophomores selected for mental health in 1940),6 The Core City cohort, (socioeconomically deprived, but nondelinquent, inner city adolescents selected in 1940)16 and the Terman cohort, (California grammar school girls with high IQs selected for longitudinal study in 1922).16,17 Evidence of involuntary coping was obtained by 2-hour interviews with the subjects between 45 and 80. Independent raters, blind to the future, using the rating of theoretical “maturity” and adaptiveness outlined earlier, achieved labeling of coping mechanisms. Rater reliability was adequate.18
For all three samples the maturity of each subject's coping choice was assessed along a 9-point scale: 1 equaled men and women only using mature defenses, and 9 equaled individuals only using immature defenses. Table I illustrates that, analogous to blood clotting mechanisms, defense choice is relatively unaffected by parental social class, IQ, and education.11 Table II illustrates that, maturity of defense mechanism predicts successful aging and income for the College sample and Core City sample.19 (Only objective physical deterioration after age 50 seemed independent of mature coping).6
In order to assess the relevance of maturity of defenses to symptoms of PTSD, the Study took advantage of the fact that, most, of the College sample (studied prospectively from 1938 to 2011) served in World War II.20,21 and had been extensively studied in college before the war. Immediately after serving overseas in World War II, they were extensively debriefed on their combat, experiences, their physical symptoms during combat, and their persisting symptoms of stress. Forty years later, 107 surviving men filled out. questionnaires reflecting persisting symptoms of PTSD. Men with high combat exposure continued to report, increased symptoms of PTSD. Combat, exposure and number of physiological symptoms during combat, - but, not during civilian stress - predicted symptoms of PTSD in 1946 and 1988.
Men with high combat, exposure reported 20 times as many symptoms of PTSD as those with low exposure. Sixteen men had very high combat, exposure but no reported PTSD symptoms either in 1946 or 40 years later. When contrasted with men who experienced PTSD symptoms after similar combat, exposure, these 16 resilient, men did not manifest less neuroticism or less severe combat; but, they did as young adults manifest, more “mature” defenses. The 16 men with high combat, exposure and mature defenses (age 20 to 47) reported only an eighth as many PTSD symptoms as the 18 men with similarly high combat, exposure and less mature defenses (F 9.5, P=.000 two-tailed, df=33). However this example does not exclude the possibility that brains altered by PTSD, like brains altered by traumatic brain injury (eg,Phineas Gage) or alcohol, subsequently manifest less mature mechanisms.
At. present many imaging studies have illuminated the brain circuits underlying PTSD,22,23 social anxiety, and phobia.24 Only a few25-27 have begun tentatively to understand how the brain adapts (downregulates) the effects of conflict. À study by Westen et al28 helped clarify the brain pathways by which partisan voters altered unwelcome facts. The brain “reward” neurons in the striatum and nucleus accumbens appeared to be involved, providing a basis for reinforcing specific mechanism choices for downregulation. A recent study by Nili and colleagues29 illuminates a putative pathway leading to downregulation of (or dissociation from) fear. Hopefully, the next. 10 years of neuroimaging will bring increasing clarity to the field.
The concept of involuntary coping mechanisms, (the “politically correct” renaming of the now outmoded (?) term, “ego mechanisms of defense”), is too valuable to be discarded by neuroscience because of its association with Sigmund Freud and psychoanalysis. The diagnostic and prognostic validity of such “mechanisms” in longitudinal studies more than make up for their unreliability and difficulty in rating. The task of neuroscience is to continue to use neuroimaging to identify and to understand the neural connections of such mechanisms.