رابطه سبکهای دفاعی، آلکسی تایمیا و شخصیت در بیماران وابسته به الکل

In the present study, the defense styles were assessed in alcohol-dependent patients to verify whether they used less adaptive defense mechanisms compared with healthy controls and to evaluate if immature defense styles (IDSs) are related with alexithymia, while controlling the effect of age, temperament, and character on this relationship in male alcohol-dependent inpatients. Participants were consecutively admitted 118 male alcohol-dependent inpatients and 60 healthy controls. Patients were investigated with the Defense Style Questionnaire, the Toronto Alexithymia Scale, and the Temperament and Character Inventory. The alcohol-dependent patients were using neurotic defense style, some IDSs (projection, acting out, splitting, and somatization) more, and the mature defense style humor less than the control group. Together with higher age, IDS discriminated alcohol dependents from the control group (higher age, acting out, and splitting and lower humor in the second regression model). Immature defense style was positively correlated with novelty seeking, harm avoidance, self-transcendence, difficulty in identifying feelings (DIF), difficulty in describing feelings, external oriented thinking, and total alexithymia score in the present study, whereas it was negatively correlated with self-directedness and cooperativeness. Mean scores of neurotic and IDS were higher in the alexithymic group than the nonalexithymic group, and alexithymia was correlated with some IDSs. Higher difficulty in describing feelings predicted mature defense style, higher harm avoidance and DIF predicted neurotic defense style, and lower cooperativeness and self-transcendence and higher DIF predicted IDS. These suggest that alcohol dependents are using maladaptive IDS more, which can be taken into account in the development of therapeutic programs for these patients. In addition, IDS seems to be related with alexithymia, particularly DIF factor, whereas low cooperativeness and high self-transcendence are significant covariants. Thus, these results could indicate the use of specific strategies in the clinical and psychotherapeutic management of patients with alexithymic feature and IDS.

Defense mechanisms, a psychoanalytical concept, have been defined as indicative of how individuals deal with conflict [1]. The concept has been recognized as one of the most important contributions in bringing together psychoanalytic theory and empirical research. The defense style has turned into the first psychoanalytical concept recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) [2] as an axis for future studies [3]. Defense mechanisms are defined in the DSM-IV as “automatic psychological processes that protect the individual against anxiety and from the awareness of internal and external stressors” [2]. Defense mechanisms are involuntary cognitive operations that occur on an unconscious level to minimize sudden changes in internal and external environments by modifying the conscious experience of thought, feeling, and emotion [4] and [5]. The function of ego defenses is considered as to maintain homeostasis and prevent inordinate anxiety forcing its way into consciousness, whether the anxiety arises from conflict within the person or between the person and the environment [6]. Self-report questionnaires, such as the Defense Style Questionnaire (DSQ) [7] and [8], assess groups of defenses, called defensive styles, which could be arranged according to the Vaillant continuum ranging from being immature or maladaptive to being mature or adaptive [4] and [9]. The DSQ has been used in a wide variety of clinical areas, including eating, anxiety, depressive [10], and personality disorders and alexithymia [11]; it has also been used to assess the relationship of defense styles with psychopathology and change [12]. The use of a self-report questionnaire to assess defensive behaviors seems to be in contrast to the classic psychoanalytic concept of defenses as unconscious processes and, therefore, inaccessible to the ego [13]. The theoretical basis underlying the development of a self-report inventory such as DSQ was the integration of concepts like defense and coping into one instrument, which partially helped to overcome this contradiction [13]. In the DSM-IV, defense mechanisms are considered almost equivalent to coping mechanisms [2] and [9]. Some studies found a relationship between adaptive coping strategies and mature defenses, as well as between maladaptive coping strategies and immature defenses [14]. Although coping mechanisms are studied frequently among substance dependents, there are no studies considering defense styles in these populations. Nevertheless, according to early reports, substance-dependent individuals use rationalization, projection, denial, and suppression defenses more than healthy individuals [15] and [16]. In Turkish substance dependents, sublimation, pseudoaltruism, acting out, isolation, and autistic fantasy were found as predictors of patient group [17]. In this study, using immature defenses was related with severity of dependency, dissociative experiences, and childhood trauma experiences [17], which may suggest that these groups of patients are psychologically more problematic. For individuals unable to achieve satisfactory or acceptable outcomes to stressful situation, drinking may become a predominant way of coping [18]. In this regard, the use of “avoidant” coping styles has been found to be associated with greater levels of alcohol consumption [19], adverse consequences [20], and relapse [21]. Substance-dependent patients who are using more immature defense styles may need substance as a way of coping with the anxiety caused by their conflicts, thus resulting in higher severity of dependence [17]. Nevertheless, in panic disorder, for example, studies have demonstrated that the immature defenses are associated with the severity of the disorder [22] and [23], with a worse response to cognitive behavioral [22] and pharmacological treatment [24], and achieving less full remission rates in panic disorder patients [25]. Alexithymia is a multifaceted personality construct defined as the inability to distinguish one's feelings from the accompanying bodily sensations, the inability to communicate feelings to others, and an externally oriented cognitive style reflecting an absence of inner thoughts and fantasies [26]. The prevalence of alexithymia among Turkish alcoholic patients has been reported to range from 42% to 43% in several studies [27] and [28]. Much of the previous research with clinical and nonclinical populations suggests strong associations between alexithymia and immature or maladaptive defense styles [10], [29], [30], [31] and [32]. The Temperament and Character Inventory (TCI) is an instrument to measure personality dimensionally, and it evaluates 4 basic temperament and 3 basic character dimensions [33]. The psychobiological model assumes interactions between temperament and character scales, eliciting secondary emotions, which are important in the development of personality [34]. Individual differences in personality structure and development have a strong influence on the risk of all forms of psychopathology, including alcohol abuse [35]. The defense style is considered to be an important dimension of the individual's structure of personality [1]. Ego mechanisms of defense are conceptually linked to psychological development, personality traits, and psychopathology [36] and [37]. There have been few studies where the relationship of alexithymia with temperament and character was evaluated. Among psychiatric inpatients and outpatients [38] and in a healthy college student sample [39], high harm avoidance (HA), low self-directedness (SD), and low reward dependence (RD) were found to be related with alexithymia. Thus, alexithymia was related with both temperament and character dimensions of personality, indicating that both genetic and environmental factors might contribute to alexithymia development. Finally, in a recent study among alcohol dependents, high HA and self-transcendence (ST) and low SD were the predictors of alexithymia, suggesting that alexithymia can be explained by specific dimensions within Cloninger's psychobiological model of personality in this population [28].