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Psychological defence mechanisms during the COVID-19 pandemic: A case series

Psychological defence mechanisms during the COVID-19 pandemic: A case series KEYWORDS Background and objectives: COVID-19 has had a negative effect on mental health across the COVID-19; world’s population. Healthcare workers in particular have experienced increased levels of Defence mechanisms; psychological distress, depression and anxiety. Any perceived stress to an individual can pro- Psychoanalytic; voke psychological defence mechanisms. Using psychoanalytic theory, a defence mechanism is Stress; described as an unconscious psychological strategy, with or without resulting behaviour, which Emotions aims to reduce or eliminate anxiety arising from unacceptable or potentially harmful stimuli. This paper aims to describe a range of psychological defence mechanisms encountered within colleagues in relation to the COVID-19 pandemic. Methods: Using the methodology of a case series, specific defence mechanisms are explored with reference to further literature in the field. Results: The author has encountered varying psychological defence mechanisms, both within himself and in other members of the multidisciplinary team. These have been illustrated in the attached clinical vignettes, relating to the specific psychological coping mechanisms of; denial, hypochondriasis, altruism, sublimation and humour. Conclusion: We encourage acknowledgement of psychological defence mechanisms and their implications on day to day practice. Whilst defence mechanisms can have a number of negative consequences as described in this article, they also have an important role, particularly in the case of mature defence mechanisms, as protective factors against psychological distress and symptom formation. Deeper understanding of the gold-standard hierarchical organisation of defence mechanisms could help increase utilisation of specific therapeutic interventions for enhancing changes from immature to mature defensive responses to stressful experiences as the COVID-19 pandemic progresses. © 2020 Asociacion ´ Universitaria de Zaragoza para el Progreso de la Psiquiatr´ ıa y la Salud Mental. Published by Elsevier Espana, ˜ S.L.U. All rights reserved. Corresponding author. E-mail address: graham.walker@forensicare.vic.gov.au (G. Walker). https://doi.org/10.1016/j.ejpsy.2020.10.005 ´ ´ ˜ 0213-6163/© 2020 Asociacion Universitaria de Zaragoza para el Progreso de la Psiquiatrıa y la Salud Mental. Published by Elsevier Espana, S.L.U. All rights reserved. 42 G. Walker, T. McCabe an adverse effect on an individual’s social functioning, physi- Introduction cal or mental health. Defence mechanisms protect the mind, self and/or ego from perceived negative consequences, and On the 11th of March 2020, The World Health Organisa- provide protection from a situation with which one cannot tion declared that the coronavirus disease 2019 (COVID-19) currently cope. caused by severe acute respiratory syndrome coronavirus Vaillant proposed that response to stress can be viewed 2 (SARS-CoV-2) was at a pandemic level across the world. from two vantage points --- pathological or coping. Patholog- This has been an unusual time, in that most of the world ical responses to stress include impairment of brain function population has been affected by an outbreak of disease via chemical or structural changes, possibly leading to diag- simultaneously. nosable conditions such as post-traumatic stress disorder. Social distancing has been one of the primary miti- Coping responses to stress can be more within control of the gation strategies used across the World to control the experiencing individual, being divided into three broad cate- spread of COVID-19. Twitter analysis (an American based gories. These are voluntarily eliciting help from appropriate microblogging and social networking service) has shown others (e.g. by seeking social support), voluntary strategiz- that posts related to implementation and negative emo- ing (e.g. by gathering information, anticipating danger, and tions around social distancing largely dominated their media rehearsing responses to danger) and/or involuntary defences platform, in combination with topics of social disruption (similar to fever and leucocytosis in physical health) which and adaptation. Analysis of Weibo posts (a Chinese based involve unconscious homeostatic mechanisms that reduce microblogging website) suggested that negative emotions the disorganizing effects of sudden stress. (for example anxiety, depression and indignation) and sen- Vaillant discusses the properties of involuntary sitivity to social risks increased, while the scores of positive defenses. They are generally not conscious; with the emotions (for example Oxford happiness) and life satis- exception of some mature responses as described below. faction decreased. Those affected were concerned more They reduce distressing effects of both emotional and cog- about their health and family, while less about leisure and nitive dissonance and can be defined discreetly from one friends. another, in four different categories. Psychotic defences More specifically to healthcare workers, a recent obser- allow the individual to reconstruct external experiences and vational cross-sectional study was conducted amongst eliminate the need to cope with reality. Immature defences anaesthesiologists and nursing staff at a tertiary academic lessen distress and anxiety produced by a perceived threat medical centre in Singapore. Appropriate screening tools or an uncomfortable reality. Neurotic defences allow an identified psychological distress in 37.4% of participants. At individual to avoid feelings of guilt and anxiety, particularly least moderate anxiety was identified in 30.7% and depres- in relation to aggressive tendencies and sexual desires. sion in 30.0% of study participants. Psychological distress This can facilitate short-term advantages in coping with was significantly associated with the presence of multi- stress, but longer term implementation can lead to issues ple co-morbidities in staff, direct involvement in COVID-19 within both intimate and more formal relationships. Mature patient care, receiving a quarantine order, and redeploy- defences are more conscious processes which enhance ment outside normal professional boundaries. Perceived pleasure and feelings of control. These defences are risks of infection (83.6%) and infecting family members proposed to be dynamic and reversible. They are not (78.0%) were the top two concerns identified. necessarily negative to an individual, and can be adaptive Further studies have shown similar negative impacts on 4,5 or creative, but can also be harmful and pathological. To the mental health of healthcare workers. Both the individ- the unaware individual, defences can be unnoticeable, but ual and wider working team, can experience psychological to the observer they can appear odd or even irritating. stress and react to that perceived threat in different ways Following on from Vaillant’s seminal findings, Perry from one another, depending on a variety of factors including developed a 7-level hierarchical organisation of defence psychological reserve and supervision support. mechanisms known as the Defence Mechanisms Rating Any perceived stress to an individual can provoke psycho- Scales. This was inspired by Vaillant’s work but used empir- logical defence mechanisms. Using psychoanalytic theory, ical validation and benefited from research perspective and a defence mechanism is described as an unconscious psy- consensus for definitions, functions and examples of specific chological strategy, with or without resulting behaviour, defences and thus is considered the gold standard theory for which aims to reduce or eliminate anxiety arising from the assessment of defence mechanisms. unacceptable or potentially harmful stimuli. In life, these It has been proposed that defence mechanisms associ- can result in healthy or unhealthy consequences depend- ated with the COVID-19 pandemic could be more typically ing on the circumstances and frequency with which the immature, in that anxiety over the viral outbreak can be mechanism is used. The construct of defence mechanisms temporarily alleviated by alteration of painful mental con- initiated in the psychoanalytic field, but in recent years tents and/or radical distortion of external reality. Anxiety has been used increasingly in various psychological and can reduce levels of work and functioning, and much of psychiatric approaches. They are defined in the American the population have stopped working in their regular jobs, Psychiatric Association’s Diagnostic and Statistical Manual of therefore going back to a more immature level of exis- Mental Disorders, 5th Edition as ‘Mechanisms that mediate tence. The extent of psychological symptoms presenting in the individual’s reaction to emotional conflict and external individuals seem to be proportionally related to the extent stressors’. This would support the argument that defence of employed defence mechanisms. Psychological health is mechanisms are not only a psychoanalytic concept. closely related to the ability to appropriately use a variety A defence mechanism can become pathological when its of defences in challenging contexts, and excessive use of persistent use leads to maladaptive behaviour, resulting in Psychological defence mechanisms during the COVID-19 pandemic: A case series 43 immature defences is a risk factor for the development of (1) Denial --- As the frequency of news reports on the 12,13 psychopathology. virus spreading across the world from Wuhan, China Despite these described negative impacts of defence increased, a consultant psychiatrist did not want to mechanisms, they have also played an important role as accept the reality of this. The reality of the situation protective factors against psychological distress during the was too threatening and anxiety provoking. Therefore COVID-19 pandemic. Utilisation of defence mechanisms can it was easier from a cognitive perspective to deny the promote mental resilience. Higher overall defensive func- virus being a real threat. This caused the consultant to tioning was associated with lower levels of depression and speak out to fellow staff about precautions being unnec- post-traumatic stress symptoms in an Italian cohort. essary. This caused frustration and upset, amongst other As a psychiatry trainee, I was involved in co-ordinating members of the team, who could not understand why the ‘on-call’ rota for a large teaching hospital in Scotland. their colleagues were not taking this threat as seriously I worked together with members of staff across the multi- when starting to implement precautionary action. disciplinary team, including senior and junior medical staff, (2) Hypochondriasis --- A psychiatry trainee started to think nursing staff, and administration support staff. It has been more and more about the impact of catching ‘the virus’. a challenging time, with staff being redeployed to roles and They had a had a diagnosis of asthma and several elderly departments they may not be routinely familiar with. This family members in residential care. They recurrently has included staff being redeployed to roles where they have asked their peers about how to minimise the risk of to deal with acute medical issues, something that a number catching the virus, and checked up on daily guide- of staff members may not encountered on a consistent basis lines multiple times a day. Despite peers offering advice for a number of years. Further challenges have presented and support, the psychiatry trainee did not accept this by way of staff having to change their on call hours at short advice. It was perceived by the trainee that their col- notice and an anecdotal higher rate of staff sickness and leagues were not being affected as much by COVID-19 as isolation --- disrupting regular routines and requiring flexibil- the trainee themselves, and therefore their advice was ity. This has caused both concerns for colleague’s physical deemed not good enough. The trainee did not follow health, and also increased working hours for those having to advice given to them by colleagues, despite repeatedly cover for those colleagues. asking for this. Eventually, the stress levels became too high for the trainee to cope and they signed themselves off work with stress. Objectives (3) Altruism --- A psychiatry trainee took it on themselves to take on multiple extra shifts to cover for colleagues Using the methodology of a case series, this paper aims who were self-isolating. His planned holiday to Europe to describe a range of psychological defence mechanisms had been cancelled so he had time to allocate to work encountered within colleagues in relation to the COVID-19 and did not over-exert himself. He gained satisfaction pandemic. These defence mechanisms are then explored knowing that he was able to help out others by working within the discussion section of the paper. during the outbreak and combatting the virus. (4) Sublimation --- A psychiatry trainee felt irritated at the fact that he had to go into work to do excessive hours Methods whilst his partner has been placed on furlough and was getting paid to sit at home and play computer games. The author has encountered varying psychological defence Instead of letting this bring his spirit down however, he mechanisms, both within himself and in other members of volunteered to create the new rota for trainees during the multidisciplinary team. These have been illustrated in COVID-19 to cover for staff shortages. This converted the attached clinical vignettes, which have been modified some of his negative energy into more positive thoughts slightly to protect anonymity. Case series are uncontrolled as he felt he was making a difference to others. study designs which have an increased risk of bias. Despite (5) Humour --- A member of nursing staff donned full per- this, they have an important influence on the medical lit- sonal protective equipment to demonstrate the current erature, and can form the foundations for more in depth, guidelines to other members of staff. She had an unusual focused studies. These clinical vignettes were recalled appearance, and when walking down the corridor did several weeks after the author had witnessed the events of a dancing motion. Whilst the reasons for wearing this them. A number of events were not directly witnessed by the equipment were very serious, some laughter enhanced author, nor were focused interviews or further qualitative the mood in what could have been otherwise a very research carried following these encounters. The clinical sombre occasion. vignettes are given more to illustrate examples and promote further thinking in the reader of similar encounters they may have within their own practice. It is acknowledged that the Discussion description of the cases may be influenced by the authors internal bias and own interpretation of events. When the virus was in its initial stages of spreading in Wuhan, China, there was widespread denial of the virus being a threat to life in the Western world. Denial can be defined as Results a refusal to accept external reality because it is too threat- ening, which can reduce anxiety. Simultaneously, denial can Clinical vignettes: also involve lack of acceptance of internal reality. It felt eas- 44 G. Walker, T. McCabe ier for some individuals to refuse to accept the virus was a Conclusion threat, despite objective evidence to the contrary or indeed ignorance. We present a partial range of psychological defence mech- There has also been evidence of hypochondriasis, in anisms associated with the recent pandemic. It is likely which an individual repetitively voices a complaint or series that readers will be able to think of other defence mech- of complaints, apparently to seek help. Despite this, covert anisms that they have encountered in their own practice, or feelings of, hostility or resentment towards a potential within teams they have been involved with. The author has help provider are expressed simultaneously by the subject’s aimed to highlight that whilst these defence mechanisms rejection of the suggestions, advice, or other offerings. The are discussed in many texts as something to be learned for complaints may consist of either somatic concerns or life examinations, it is important to acknowledge their existence problems. Despite the individual being offered a potential and consider their implications on day to day practice. helpful response from those they are seeking it from, they Whilst defence mechanisms can have a number of nega- will reject this. tive consequences as described in this article, they also have Many health professionals and their family members have an important role, particularly in the case of mature defence become unwell with COVID-19. This has ranged from minor mechanisms, as protective factors against psychological dis- symptoms that can be managed at home in isolation, to tress and symptom formation. There is a requirement for more serious and potentially life threatening symptoms that deeper knowledge of the gold-standard hierarchical organi- require hospital admission. Some individuals have perceived sation of defence mechanisms, which considers all defences symptoms consistent with COVID-19 and therefore have in a continuum that goes from immature to mature defensive 8,14 had to take time off work to isolate as per government strategies. This could help increase utilisation of specific guidelines. Whilst repeatedly seeking reassurance from col- therapeutic interventions for enhancing changes from imma- leagues regarding physical health and recovery from the ture to mature defensive responses to stressful experiences resulting illness, some individuals have harboured resent- as the COVID-19 pandemic progresses. ment towards those who have not fallen ill personally, or do not have vulnerable relatives who are more likely to become Ethical considerations seriously ill. Therefore, these individuals may reject advice from those they resent on recovering from COVID-19, not fol- Ethical approval was not required for this research article low guidelines with regard to reducing spread of the virus, and any discussion is fully anonymised. or behave in a more hostile manner towards an intended helpful responder. Hypochondriasis is positively correlated Funding with development of depression and anxiety symptoms. Development of features of hypochondriasis has specifically predicted COVID-19 pandemic-related psychopathology in There was no funding for this work. adults. There has also been evidence of defence mechanisms Conflict of interest during the COVID-19 pandemic that have provided more ben- efit to the local service. Staff members have channelled The authors have no conflict of interest to declare. their energy in altruism or sublimation, where they have focused their energy on getting involved in stretching their References skills and physical resources in face of challenge. This has included getting involved in additional services such as per- 1. Kwon J, Grady C, Feliciano JT, Fodeh SJ. Defining facets of sonal protective equipment mask fitting, or working extra social distancing during the covid-19 pandemic: Twitter anal- on call shifts to cover for colleagues who are off sick. ysis. medRxiv. 2020. Humour has also been implemented during working hours 2. Li S, Wang Y, Xue J, Zhao N, Zhu T. The impact of COVID- to help mentally deal with the very stressful and challeng- 19 epidemic declaration on psychological consequences: a ing environment of day to day work. Altruism, sublimination study on active Weibo users. Int J Environ Res Public Health. and humour are examples of high adaptive defences. These 2020;17:2032. defences usually maximise gratification and allow more con- 3. Lee MC, Thampi S, Chan HP, Khoo D, Chin BZ, Foo DP, et al. Psychological distress during the COVID-19 pandemic amongst scious awareness of feelings, ideas, and their consequences. anaesthesiologists and nurses. Br J Anaesth. 2020;125:e384---6. In a population of cancer patients, implementation of these 4. Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Man- defences correlated positively with physical and emotional 18 aging mental health challenges faced by healthcare workers functioning and reduced levels of anxiety and depression. during covid-19 pandemic. BMJ. 2020:368. Defence mechanisms can be penetrated in many ways, 5. Kang L, Li Y, Hu S, Chen M, Yang C, Yang BX, et al. The mental including by confrontation and highlighting of them. This health of medical workers in Wuhan, China dealing with the is particularly true for psychotic, immature and neurotic 2019 novel coronavirus. Lancet Psychiatry. 2020;7:e14. defences, where the mechanisms are less conscious. This 6. Vaillant GE. Involuntary coping mechanisms: a psychodynamic can be a wide variety of psychological therapy methods, perspective. Dialogues Clin Neurosci. 2011;13:366. including psychodynamic psychotherapy. Recent research 7. American Psychiatric Association. Diagnostic and statistical has also shown a role for medication in managing defence manual of mental disorders (DSM-5 ). American Psychiatric Pub; 2013. mechanisms, in combination with psychotherapy. Psychological defence mechanisms during the COVID-19 pandemic: A case series 45 8. Perry JC. Defence mechanism rating scale. Cambridge, MA: Har- Italians during the first week of lockdown. Front Psychiatry. vard School of Medicine; 1990. 2020;11:1022. 9. Di Giuseppe M, Perry JC, Lucchesi M, Michelini M, Vitiello S, 15. Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological qual- Piantanida A, et al. Preliminary reliability and validity of the ity and synthesis of case series and case reports. BMJ Evid-Based DMRS-SR-30, a novel self-report measure based on the defence Med. 2018;23:60---3. mechanisms rating scales. Front Psychiatry. 2020;11:870. 16. Wheaton MG, Abramowitz JS, Berman NC, Fabricant LE, Olatunji 10. Marˇ cinko D, Jakovljevi´ c M, Jakˇ si´ c N, Bjedov S, Mindoljevi´ c BO. Psychological predictors of anxiety in response to the H1N1 Drakuli´ c A. The importance of psychodynamic approach during (swine flu) pandemic. Cognit Therapy Res. 2012;36:210---8. COVID-19 pandemic. Psychiatria Danubina. 2020;32:15---21. 17. Lee SA, Crunk EA. Fear and psychopathology during the COVID- 11. Santana MRM, Zatti C, Spader ML, Malgarim BG, Salle E, Piltcher 19 crisis: neuroticism, hypochondriasis, reassurance-seeking, R, et al. Acute stress disorder and defence mechanisms: a study and coronaphobia as fear factors. OMEGA-J Death Dying. 2020, of physical trauma patients admitted to an emergency hospital. p.0030222820949350. Trends Psychiatry Psychother. 2017;39:247---56. 18. Di Giuseppe M, Ciacchini R, Micheloni T, Bertolucci I, Marchi 12. Bond M, Perry JC. Long-term changes in defence styles with L, Conversano C. Defence mechanisms in cancer patients: a psychodynamic psychotherapy for depressive, anxiety, and per- systematic review. J Psychosom Res. 2018;115:76---86. sonality disorders. Am J Psychiatry. 2004;161:1665---71. 19. Perry JC, Banon E, Bond M. Change in defence mechanisms and 13. Zanarini MC, Weingeroff JL, Frankenburg FR. Defence mech- depression in a pilot study of antidepressive medications plus anisms associated with borderline personality disorder. J 20 sessions of psychotherapy for recurrent major depression. J Personal Disord. 2009;23:113---21. Nerv Ment Dis. 2020;208:261---8. 14. Di Giuseppe M, Zilcha-Mano S, Prout TA, Perry JC, Orrù G, Conversano C. Psychological impact of COVID-19 among http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Psychiatry Pubmed Central

Psychological defence mechanisms during the COVID-19 pandemic: A case series

Walker, G.; McCabe, T.
The European Journal of Psychiatry , Volume 35 (1) – Nov 7, 2020
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© 2020 Asociación Universitaria de Zaragoza para el Progreso de la Psiquiatría y la Salud Mental. Published by Elsevier España, S.L.U. All rights reserved.
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Abstract

KEYWORDS Background and objectives: COVID-19 has had a negative effect on mental health across the COVID-19; world’s population. Healthcare workers in particular have experienced increased levels of Defence mechanisms; psychological distress, depression and anxiety. Any perceived stress to an individual can pro- Psychoanalytic; voke psychological defence mechanisms. Using psychoanalytic theory, a defence mechanism is Stress; described as an unconscious psychological strategy, with or without resulting behaviour, which Emotions aims to reduce or eliminate anxiety arising from unacceptable or potentially harmful stimuli. This paper aims to describe a range of psychological defence mechanisms encountered within colleagues in relation to the COVID-19 pandemic. Methods: Using the methodology of a case series, specific defence mechanisms are explored with reference to further literature in the field. Results: The author has encountered varying psychological defence mechanisms, both within himself and in other members of the multidisciplinary team. These have been illustrated in the attached clinical vignettes, relating to the specific psychological coping mechanisms of; denial, hypochondriasis, altruism, sublimation and humour. Conclusion: We encourage acknowledgement of psychological defence mechanisms and their implications on day to day practice. Whilst defence mechanisms can have a number of negative consequences as described in this article, they also have an important role, particularly in the case of mature defence mechanisms, as protective factors against psychological distress and symptom formation. Deeper understanding of the gold-standard hierarchical organisation of defence mechanisms could help increase utilisation of specific therapeutic interventions for enhancing changes from immature to mature defensive responses to stressful experiences as the COVID-19 pandemic progresses. © 2020 Asociacion ´ Universitaria de Zaragoza para el Progreso de la Psiquiatr´ ıa y la Salud Mental. Published by Elsevier Espana, ˜ S.L.U. All rights reserved. Corresponding author. E-mail address: graham.walker@forensicare.vic.gov.au (G. Walker). https://doi.org/10.1016/j.ejpsy.2020.10.005 ´ ´ ˜ 0213-6163/© 2020 Asociacion Universitaria de Zaragoza para el Progreso de la Psiquiatrıa y la Salud Mental. Published by Elsevier Espana, S.L.U. All rights reserved. 42 G. Walker, T. McCabe an adverse effect on an individual’s social functioning, physi- Introduction cal or mental health. Defence mechanisms protect the mind, self and/or ego from perceived negative consequences, and On the 11th of March 2020, The World Health Organisa- provide protection from a situation with which one cannot tion declared that the coronavirus disease 2019 (COVID-19) currently cope. caused by severe acute respiratory syndrome coronavirus Vaillant proposed that response to stress can be viewed 2 (SARS-CoV-2) was at a pandemic level across the world. from two vantage points --- pathological or coping. Patholog- This has been an unusual time, in that most of the world ical responses to stress include impairment of brain function population has been affected by an outbreak of disease via chemical or structural changes, possibly leading to diag- simultaneously. nosable conditions such as post-traumatic stress disorder. Social distancing has been one of the primary miti- Coping responses to stress can be more within control of the gation strategies used across the World to control the experiencing individual, being divided into three broad cate- spread of COVID-19. Twitter analysis (an American based gories. These are voluntarily eliciting help from appropriate microblogging and social networking service) has shown others (e.g. by seeking social support), voluntary strategiz- that posts related to implementation and negative emo- ing (e.g. by gathering information, anticipating danger, and tions around social distancing largely dominated their media rehearsing responses to danger) and/or involuntary defences platform, in combination with topics of social disruption (similar to fever and leucocytosis in physical health) which and adaptation. Analysis of Weibo posts (a Chinese based involve unconscious homeostatic mechanisms that reduce microblogging website) suggested that negative emotions the disorganizing effects of sudden stress. (for example anxiety, depression and indignation) and sen- Vaillant discusses the properties of involuntary sitivity to social risks increased, while the scores of positive defenses. They are generally not conscious; with the emotions (for example Oxford happiness) and life satis- exception of some mature responses as described below. faction decreased. Those affected were concerned more They reduce distressing effects of both emotional and cog- about their health and family, while less about leisure and nitive dissonance and can be defined discreetly from one friends. another, in four different categories. Psychotic defences More specifically to healthcare workers, a recent obser- allow the individual to reconstruct external experiences and vational cross-sectional study was conducted amongst eliminate the need to cope with reality. Immature defences anaesthesiologists and nursing staff at a tertiary academic lessen distress and anxiety produced by a perceived threat medical centre in Singapore. Appropriate screening tools or an uncomfortable reality. Neurotic defences allow an identified psychological distress in 37.4% of participants. At individual to avoid feelings of guilt and anxiety, particularly least moderate anxiety was identified in 30.7% and depres- in relation to aggressive tendencies and sexual desires. sion in 30.0% of study participants. Psychological distress This can facilitate short-term advantages in coping with was significantly associated with the presence of multi- stress, but longer term implementation can lead to issues ple co-morbidities in staff, direct involvement in COVID-19 within both intimate and more formal relationships. Mature patient care, receiving a quarantine order, and redeploy- defences are more conscious processes which enhance ment outside normal professional boundaries. Perceived pleasure and feelings of control. These defences are risks of infection (83.6%) and infecting family members proposed to be dynamic and reversible. They are not (78.0%) were the top two concerns identified. necessarily negative to an individual, and can be adaptive Further studies have shown similar negative impacts on 4,5 or creative, but can also be harmful and pathological. To the mental health of healthcare workers. Both the individ- the unaware individual, defences can be unnoticeable, but ual and wider working team, can experience psychological to the observer they can appear odd or even irritating. stress and react to that perceived threat in different ways Following on from Vaillant’s seminal findings, Perry from one another, depending on a variety of factors including developed a 7-level hierarchical organisation of defence psychological reserve and supervision support. mechanisms known as the Defence Mechanisms Rating Any perceived stress to an individual can provoke psycho- Scales. This was inspired by Vaillant’s work but used empir- logical defence mechanisms. Using psychoanalytic theory, ical validation and benefited from research perspective and a defence mechanism is described as an unconscious psy- consensus for definitions, functions and examples of specific chological strategy, with or without resulting behaviour, defences and thus is considered the gold standard theory for which aims to reduce or eliminate anxiety arising from the assessment of defence mechanisms. unacceptable or potentially harmful stimuli. In life, these It has been proposed that defence mechanisms associ- can result in healthy or unhealthy consequences depend- ated with the COVID-19 pandemic could be more typically ing on the circumstances and frequency with which the immature, in that anxiety over the viral outbreak can be mechanism is used. The construct of defence mechanisms temporarily alleviated by alteration of painful mental con- initiated in the psychoanalytic field, but in recent years tents and/or radical distortion of external reality. Anxiety has been used increasingly in various psychological and can reduce levels of work and functioning, and much of psychiatric approaches. They are defined in the American the population have stopped working in their regular jobs, Psychiatric Association’s Diagnostic and Statistical Manual of therefore going back to a more immature level of exis- Mental Disorders, 5th Edition as ‘Mechanisms that mediate tence. The extent of psychological symptoms presenting in the individual’s reaction to emotional conflict and external individuals seem to be proportionally related to the extent stressors’. This would support the argument that defence of employed defence mechanisms. Psychological health is mechanisms are not only a psychoanalytic concept. closely related to the ability to appropriately use a variety A defence mechanism can become pathological when its of defences in challenging contexts, and excessive use of persistent use leads to maladaptive behaviour, resulting in Psychological defence mechanisms during the COVID-19 pandemic: A case series 43 immature defences is a risk factor for the development of (1) Denial --- As the frequency of news reports on the 12,13 psychopathology. virus spreading across the world from Wuhan, China Despite these described negative impacts of defence increased, a consultant psychiatrist did not want to mechanisms, they have also played an important role as accept the reality of this. The reality of the situation protective factors against psychological distress during the was too threatening and anxiety provoking. Therefore COVID-19 pandemic. Utilisation of defence mechanisms can it was easier from a cognitive perspective to deny the promote mental resilience. Higher overall defensive func- virus being a real threat. This caused the consultant to tioning was associated with lower levels of depression and speak out to fellow staff about precautions being unnec- post-traumatic stress symptoms in an Italian cohort. essary. This caused frustration and upset, amongst other As a psychiatry trainee, I was involved in co-ordinating members of the team, who could not understand why the ‘on-call’ rota for a large teaching hospital in Scotland. their colleagues were not taking this threat as seriously I worked together with members of staff across the multi- when starting to implement precautionary action. disciplinary team, including senior and junior medical staff, (2) Hypochondriasis --- A psychiatry trainee started to think nursing staff, and administration support staff. It has been more and more about the impact of catching ‘the virus’. a challenging time, with staff being redeployed to roles and They had a had a diagnosis of asthma and several elderly departments they may not be routinely familiar with. This family members in residential care. They recurrently has included staff being redeployed to roles where they have asked their peers about how to minimise the risk of to deal with acute medical issues, something that a number catching the virus, and checked up on daily guide- of staff members may not encountered on a consistent basis lines multiple times a day. Despite peers offering advice for a number of years. Further challenges have presented and support, the psychiatry trainee did not accept this by way of staff having to change their on call hours at short advice. It was perceived by the trainee that their col- notice and an anecdotal higher rate of staff sickness and leagues were not being affected as much by COVID-19 as isolation --- disrupting regular routines and requiring flexibil- the trainee themselves, and therefore their advice was ity. This has caused both concerns for colleague’s physical deemed not good enough. The trainee did not follow health, and also increased working hours for those having to advice given to them by colleagues, despite repeatedly cover for those colleagues. asking for this. Eventually, the stress levels became too high for the trainee to cope and they signed themselves off work with stress. Objectives (3) Altruism --- A psychiatry trainee took it on themselves to take on multiple extra shifts to cover for colleagues Using the methodology of a case series, this paper aims who were self-isolating. His planned holiday to Europe to describe a range of psychological defence mechanisms had been cancelled so he had time to allocate to work encountered within colleagues in relation to the COVID-19 and did not over-exert himself. He gained satisfaction pandemic. These defence mechanisms are then explored knowing that he was able to help out others by working within the discussion section of the paper. during the outbreak and combatting the virus. (4) Sublimation --- A psychiatry trainee felt irritated at the fact that he had to go into work to do excessive hours Methods whilst his partner has been placed on furlough and was getting paid to sit at home and play computer games. The author has encountered varying psychological defence Instead of letting this bring his spirit down however, he mechanisms, both within himself and in other members of volunteered to create the new rota for trainees during the multidisciplinary team. These have been illustrated in COVID-19 to cover for staff shortages. This converted the attached clinical vignettes, which have been modified some of his negative energy into more positive thoughts slightly to protect anonymity. Case series are uncontrolled as he felt he was making a difference to others. study designs which have an increased risk of bias. Despite (5) Humour --- A member of nursing staff donned full per- this, they have an important influence on the medical lit- sonal protective equipment to demonstrate the current erature, and can form the foundations for more in depth, guidelines to other members of staff. She had an unusual focused studies. These clinical vignettes were recalled appearance, and when walking down the corridor did several weeks after the author had witnessed the events of a dancing motion. Whilst the reasons for wearing this them. A number of events were not directly witnessed by the equipment were very serious, some laughter enhanced author, nor were focused interviews or further qualitative the mood in what could have been otherwise a very research carried following these encounters. The clinical sombre occasion. vignettes are given more to illustrate examples and promote further thinking in the reader of similar encounters they may have within their own practice. It is acknowledged that the Discussion description of the cases may be influenced by the authors internal bias and own interpretation of events. When the virus was in its initial stages of spreading in Wuhan, China, there was widespread denial of the virus being a threat to life in the Western world. Denial can be defined as Results a refusal to accept external reality because it is too threat- ening, which can reduce anxiety. Simultaneously, denial can Clinical vignettes: also involve lack of acceptance of internal reality. It felt eas- 44 G. Walker, T. McCabe ier for some individuals to refuse to accept the virus was a Conclusion threat, despite objective evidence to the contrary or indeed ignorance. We present a partial range of psychological defence mech- There has also been evidence of hypochondriasis, in anisms associated with the recent pandemic. It is likely which an individual repetitively voices a complaint or series that readers will be able to think of other defence mech- of complaints, apparently to seek help. Despite this, covert anisms that they have encountered in their own practice, or feelings of, hostility or resentment towards a potential within teams they have been involved with. The author has help provider are expressed simultaneously by the subject’s aimed to highlight that whilst these defence mechanisms rejection of the suggestions, advice, or other offerings. The are discussed in many texts as something to be learned for complaints may consist of either somatic concerns or life examinations, it is important to acknowledge their existence problems. Despite the individual being offered a potential and consider their implications on day to day practice. helpful response from those they are seeking it from, they Whilst defence mechanisms can have a number of nega- will reject this. tive consequences as described in this article, they also have Many health professionals and their family members have an important role, particularly in the case of mature defence become unwell with COVID-19. This has ranged from minor mechanisms, as protective factors against psychological dis- symptoms that can be managed at home in isolation, to tress and symptom formation. There is a requirement for more serious and potentially life threatening symptoms that deeper knowledge of the gold-standard hierarchical organi- require hospital admission. Some individuals have perceived sation of defence mechanisms, which considers all defences symptoms consistent with COVID-19 and therefore have in a continuum that goes from immature to mature defensive 8,14 had to take time off work to isolate as per government strategies. This could help increase utilisation of specific guidelines. Whilst repeatedly seeking reassurance from col- therapeutic interventions for enhancing changes from imma- leagues regarding physical health and recovery from the ture to mature defensive responses to stressful experiences resulting illness, some individuals have harboured resent- as the COVID-19 pandemic progresses. ment towards those who have not fallen ill personally, or do not have vulnerable relatives who are more likely to become Ethical considerations seriously ill. Therefore, these individuals may reject advice from those they resent on recovering from COVID-19, not fol- Ethical approval was not required for this research article low guidelines with regard to reducing spread of the virus, and any discussion is fully anonymised. or behave in a more hostile manner towards an intended helpful responder. Hypochondriasis is positively correlated Funding with development of depression and anxiety symptoms. Development of features of hypochondriasis has specifically predicted COVID-19 pandemic-related psychopathology in There was no funding for this work. adults. There has also been evidence of defence mechanisms Conflict of interest during the COVID-19 pandemic that have provided more ben- efit to the local service. Staff members have channelled The authors have no conflict of interest to declare. their energy in altruism or sublimation, where they have focused their energy on getting involved in stretching their References skills and physical resources in face of challenge. This has included getting involved in additional services such as per- 1. Kwon J, Grady C, Feliciano JT, Fodeh SJ. Defining facets of sonal protective equipment mask fitting, or working extra social distancing during the covid-19 pandemic: Twitter anal- on call shifts to cover for colleagues who are off sick. ysis. medRxiv. 2020. Humour has also been implemented during working hours 2. Li S, Wang Y, Xue J, Zhao N, Zhu T. The impact of COVID- to help mentally deal with the very stressful and challeng- 19 epidemic declaration on psychological consequences: a ing environment of day to day work. Altruism, sublimination study on active Weibo users. Int J Environ Res Public Health. and humour are examples of high adaptive defences. 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Psychological impact of COVID-19 among

Journal

The European Journal of Psychiatry – Pubmed Central

Published: Nov 7, 2020

References

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  • The impact of COVID-19 epidemic declaration on psychological consequences: a study on active Weibo users
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  • Managing mental health challenges faced by healthcare workers during covid-19 pandemic
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  • The importance of psychodynamic approach during COVID-19 pandemic
  • Acute stress disorder and defence mechanisms: a study of physical trauma patients admitted to an emergency hospital
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  • Fear and psychopathology during the COVID-19 crisis: neuroticism, hypochondriasis, reassurance-seeking, and coronaphobia as fear factors
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  • Change in defence mechanisms and depression in a pilot study of antidepressive medications plus 20 sessions of psychotherapy for recurrent major depression