The Role of Defense Mechanisms in Borderline and Antisocial Personalities

Transcription

1 Journal of Personality Assessment, 92(2), , 2010 Copyright C Taylor & Francis Group, LLC ISSN: print / online DOI: / The Role of Defense Mechanisms in Borderline and Antisocial Personalities MICHELLE D. PRESNIAK, 1 TREVOR R. OLSON, 1 AND MICHAEL WM.MACGREGOR 2 1 Institute of Community and Family Psychiatry at SMBD Jewish General Hospital, Department of Psychiatry, McGill University, Montreal, Quebec, Canada 2 Department of Psychology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada We examined whether borderline personality disorder (BPD) and antisocial personality disorder (APD) could be differentiated based on defense mechanisms as measured by observer (Defense-Q; MacGregor, Olson, Presniak, & Davidson, 2008) and self-report (Defense Style Questionnaire; Andrews, Singh, & Bond, 1993) measures. We conducted 2 studies whereby nonclinical participants were divided into borderline and antisocial groups based on scores from the Personality Assessment Inventory (Morey, 1991). Multivariate analysis of variance results revealed significant overall group differences in defense use. Univariate analyses further showed group differences on several individual defenses (e.g., acting out, denial, and turning against self). Together, the findings suggest that in BPD, the defenses may emphasize interpersonal dependency and a tendency to direct aggression toward the self; whereas in APD, the defenses may emphasize egocentricity, interpersonal exploitation, and a tendency to direct aggression toward others. Overall, this study demonstrates important differences in defense use between borderline and antisocial personality groups across both observer and self-report measures. Recently, there has been a renewed interest in the empirical study of defense mechanisms and the role they play in many aspects of psychosocial functioning (e.g., Hilsenroth, Hibbard, Nash, & Handler, 1993; MacGregor, Davidson, Barksdale, Black, & MacLean, 2003). Defenses are now included in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM IV TR]; American Psychiatric Association, 2000) as a diagnostic axis for further study. Empirical evidence has emerged demonstrating the role of defenses in childhood and adolescent development (Cramer, 1997), adult social functioning (Vaillant, 1977), physical health (MacGregor et al., 2003), and psychopathology (Andrews, Singh, & Bond, 1993). Defenses may also be helpful in differentiating between similar mental disorders (Spinhoven & Kooiman, 1997). Cluster B personality disorders are some of the most difficult disorders to differentiate, with literature having shown overlapping criteria, high comorbidity, and low discriminant validity (e.g., Becker, Grilo, Edell, & McGlashan, 2000). One of the highest comorbidity rates within this cluster is between borderline personality disorder (BPD) and antisocial personality disorder (APD; Becker et al., 2000; Zanarini et al., 2004). The goal of these studies was to investigate the utility of defenses in differentiating borderline and antisocial personalities. CONCEPTUALIZATION AND ASSESSMENT OF DEFENSE MECHANISMS Conceptualization Current psychodynamic authors have defined defenses as unconscious mental operations that function to defend against ex- Received February 1, 2009; Revised October 21, Address correspondence to Michelle D. Presniak, Institute of Community and Family Psychiatry at SMBD Jewish General Hospital, Department of Psychiatry, McGill University, 4333 Chemin de la cote Ste-Catherine, Montreal, Quebec, H3T 1E4, Canada. michelle.presniak@usask.ca 137 cessive anxiety (e.g., Vaillant, 1994). Defenses are viewed as both protectors against unconscious feelings and as cognitive and relational behaviors that protect the self (Cooper, 1998). At present, there is no consensus on the number of defenses that exist. Anna Freud (1936/1986) discussed 10 defenses in The Ego and the Mechanisms of Defense, and there has since been an expansion of recognized defenses. For example, Vaillant (1977) included 18 in his original hierarchy of defenses, whereas the DSM IV TR (American Psychiatric Association, 2000) includes a list of 31 defenses. Despite disagreement in the number of defenses that exist, most authors agree on the role of defenses. Defense mechanisms work to alter internal psychological states (e.g., emotions, thoughts). They alter meaning or significance of perceived threats, create the perception of control, reduce or eliminate the experience of conscious anxiety, and thus protect and enhance the self (Ihilevich & Gleser, 1995). Assessment of Defense Mechanisms One area of debate in defense mechanism literature centers on how best to assess defenses. For example, theorists who see defenses predominantly as intrapsychic processes have argued against the use of self-report measures to assess defenses, whereas others argue that self-report assessment has some utility (Bond, Gardener, Christian, & Sigal, 1983; Cooper, 1998). Self-report defense measures require individuals to report on their thoughts, feelings, and behaviors, which are believed to represent aspects of various defenses (Cramer, 2006). Advantages of this method are that it limits researcher bias and allows timely collection of data in large samples. A criticism, however, is that individuals must consciously report on their unconscious behavior (Shedler, Mayman, & Manis, 1993). Because selfreport assessment requires an awareness of thoughts, feelings, and behaviors, these measures are problematic for assessment of individuals with limited self-awareness or who frequently use defenses that distort self-evaluation (e.g., denial; Shedler et al.,

2 138 PRESNIAK, OLSON, MACGREGOR 1993). As such, most self-report defense measures use items intended to assess conscious derivatives of defenses (Bond, 2004). Other researchers have focused on objective observational assessment of defenses (e.g., MacGregor, Olson, Presniak, & Davidson, 2008; Perry, 1990). This usually involves the use of coding manuals to assist trained observers in the identification and assessment of the defenses. These measures allow for use of some inference by coders, which facilitates the assessment of unconscious material. One limitation of this approach, however, is that it is often labor intensive and makes data collection in large samples difficult. Additionally, although good interrater reliability can often be achieved for overall defensive functioning or defense levels, it can be difficult to achieve good reliability at the individual defense level. Assessing defenses with more than one method of measurement can provide additional information regarding an individual s defense use. However, problems may arise when trying to compare results from different measures. One common difficulty is differences in the conceptualization of a particular defense mechanism between the measures. For example, devaluation, as assessed by some measures (e.g., Defense Style Questionnaire [DSQ]; Andrews et al., 1993), combines both the devaluation of self and the devaluation of others, whereas other measures only include one direction of devaluation, such as devaluating others (e.g., Defense-Q; MacGregor et al., 2008). Additionally, the behaviors an individual can or will self-report in the context of privately filling out a questionnaire may differ from behaviors evident to an external observer viewing a video-recorded interview (Bond, 1990). In turn, these behaviors may differentially relate to various aspects of psychopathology or personality to which the defense scores are compared. Because of these conceptualization, measurement, or contextual differences, it is difficult to generalize results across measures. As such, it is important to utilize multiple methods of assessing defenses in any study (Davidson & MacGregor, 1998). DIFFERENTIATING BPD AND APD BASED ON DEFENSE MECHANISMS Since the introduction of personality disorders into the DSM III (American Psychiatric Association, 1980), there have been many criticisms of the diagnoses, especially of those disorders within Cluster B (e.g., Herkov & Blashfield, 1995; Widiger, 1993). One major criticism is the high comorbidity and poor discriminant validity between the Cluster B personality disorders due to their overlapping criteria (Blais & Norman, 1997). BPD has one of the highest comorbidity rates with other personality disorders, especially with APD (e.g., 26%: Becker et al., 2000; Herkov & Blashfield, 1995). Theoretical Role of Defenses in BPD and APD According to psychodynamic theory, BPD and APD share many similarities in personality structure. Both disorders fall within Kernberg s (1984) borderline personality organization, thus sharing primary use of primitive defenses, a lack of an integrated identity, and maintained reality testing. The primitive defenses are thought to protect the ego by separating contradictory experiences of self and others, thus preventing anxiety related to these conflicts (Kernberg, 1984). Despite the similarities in psychodynamics (e.g., identity disintegration) of BPD and APD, many argue that these groups differ in the expression of the underlying dynamics. For example, Perry and Cooper (1986) suggested that BPD is expressed through interpersonal dependency, whereas APD is expressed through interpersonal exploitation and antisocial behaviors (e.g., stealing). Also, although both disorders are characterized by manipulative behavior, in BPD, it is used in interpersonal relationships to gain concern from others; whereas in APD, it is used to establish and gain material goods and power (American Psychiatric Association, 2000). Finally, although both disorders are characterized by aggression, Gacono, Meloy, and Berg (1992) suggested that the aggression may be more strongly directed toward the self in BPD and toward others in APD. Although individuals with BPD and APD both exhibit primitive defense use (e.g., splitting, denial, devaluation), many authors have also stated that these groups will differ in their relative use of some defenses. For example, BPD is considered more severe than APD within borderline personality organization and should therefore be associated with higher reliance on maladaptive defenses (Cramer, 1999). Perry and Cooper (1986), however, proposed that two dimensions of primitive defenses exist. The first dimension includes splitting of self, splitting of others, and projective identification and would be more associated with BPD because it leads to interpersonal instability and dependency. The second dimension includes omnipotence, primitive idealization, and devaluation and would be more associated with APD because it protects the self from low self-esteem and feelings of anger. Gacono et al. (1992) suggested some differences in the way these defenses relate to BPD and APD. First, Gacono et al. suggested that projection may be more characteristic of APD because the primary way these individuals can relate to others is through a projection of themselves. Second, unlike Perry and Cooper (1986), Gacono et al. argued that many of the broader conceptualized defenses will be associated with both BPD and APD such as splitting and devaluation. However, Gacono et al. suggested that the way in which the defense is utilized differs between groups. For example, although both groups use splitting, those with BPD tend to alternate between idealization of others and devaluation. The devaluation, however, is predominantly turned inward with negative self-thoughts, feelings, and behaviors (i.e., devaluation of self, turning against self). Although at times aggression in BPD can be directed toward others, this often results in an exacerbated view of the self as damaged. In those with APD, splitting is evident through a poorly integrated identity in which they present with an overt grandiosity of the self and tendency to devalue others. Splitting, therefore, occurs between a grandiose and devalued self, but this latter portion is defended against through grandiosity and devaluation of others. Gacono and Meloy (1988) also argued that denial is an especially integral defense for individuals with APD because it prevents them from thinking about the consequences of their antisocial behaviors. They additionally note that, in its more developmentally advanced form, denial may develop into rationalization. This occurs as the individuals mature and, rather than deny their behaviors, they will justify them through distorted explanations. Empirical Evidence of Defense Use in BPD and APD Research has supported Kernberg s (1984) hypotheses that BPD is positively associated with primitive defenses (e.g.,

3 DEFENSE MECHANISMS AND PERSONALITY 139 denial, devaluation, idealization, projective identification, splitting; Berg, 1990; Hilsenroth et al., 1993). Studies have also shown a positive association between APD and primitive defense use (e.g., devaluation, projective identification, splitting; Chabrol & Leichsenring, 2006; Leichsenring, Kunst, & Hoyer, 2003). Although both disorders are associated with primitive defenses, some findings have supported that BPD may demonstrate higher levels of maladaptive defenses, such as acting out and passive aggression, compared to other personality disorder groups (Bond, 1990; Perry & Cooper, 1986). Few studies have examined the association of defenses with BPD and APD concurrently (e.g., Cramer, 1999; Gacono et al., 1992). The results of these studies have shown that BPD is positively associated with acting out, denial, principalization, reversal, and turning against self (TAS), and APD is positively associated with acting out, denial, intellectualization, principalization, projection, and turning against object (Berman & McCann, 1995; Cramer, 1999; Lingiardi et al., 1999; Perry & Cooper, 1986). In addition, Perry and Cooper (1986) tested their hypothesis that two dimensions of primitive defenses existed. They found that the first dimension (i.e., splitting of self, splitting of others, and projective identification) was associated with BPD symptoms (r =.36), whereas the second (i.e., omnipotence, primitive idealization, and devaluation) was associated with APD symptoms (r =.23). Perry and Cooper (1986) also found that the action defense level (most maladaptive level) was associated with BPD symptoms (r =.26), and the disavowal defense level (e.g., denial) was associated with APD symptoms (r =.22). Despite different patterns of defense use emerging in these correlational studies, only two studies have statistically compared the mean differences in defense use between BPD and APD groups. Perry and Cooper (1986) compared defenses between 10 patients with BPD and 8 patients with APD. Defenses were assessed with an early version of the Defense Mechanism Rating Scales (DMRS; Perry, 1990). Results from a canonical discriminant function analysis revealed no significant differences between groups. In 1992, Gacono et al. examined the results of previous studies that used the Lerner Defense Scales (Lerner & Lerner, 1980) to assess defenses. One-way analyses of variance (ANOVAs) revealed no significant differences between BPD (n = 18) and APD (n = 21) groups, although there was a trend toward higher primitive idealization scores in the BPD group. Together, the results of these two studies suggest that these disorders could not be differentiated based on defenses. CURRENT RESEARCH STUDIES Most studies that have investigated defenses and personality disorders have examined correlations between disorders and defenses. To date, however, only Gacono et al. (1992) and Perry and Cooper (1986) have statistically explored differences in defense use between BPD and APD groups. Although no significant results were found in either study, both studies had very small samples sizes. Additionally, the chosen analyses may have restricted potential findings. For example, Perry and Cooper (1986) compared the groups on five defense styles rather than individual defenses, whereas many argue that differences between the groups will be seen on individual defenses and not on broad defense styles (e.g., Gacono et al., 1992). Only Gacono et al. (1992) previously examined differences in individual defense mean scores between BPD and APD groups. In their study, however, Gacono et al. acknowledged that they were limited by the defense measure used, the Lerner Defense Scales, because the measure requires human responses on the Rorschach. Gacono et al. (1992) noted that too few scores were produced to analyze these indices meaningfully (p. 41). In these studies, we examined mean differences in individual defense mechanisms between BPD and APD groups. In Study 1, we assessed defenses using a self-report measure, the DSQ; and in Study 2, the DSQ and an observer report measure, the Defense-Q, were used. In both studies, mean defense scores were compared between BPD and APD groups using multivariate ANOVA (MANOVA) analyses. To avoid the small sample limitation of previous studies, we used a self-report personality measure in two large samples to identify potential participants that might approximate participants diagnosed with BPD or APD. The Personality Assessment Inventory (PAI; Morey, 1991) was chosen based on its good overall validity and reliability indexes as well as its demonstrated validity at assessing BPD pathology in nonclinical samples (Boone, 1998; Kurtz, Morey, & Tomarken, 1993; Trull, 1995). Group membership was assigned based on clinical cutoff scores from the PAI. Defense use comparisons between groups were conducted to extend previous research, which has primarily examined the correlations between many defenses and personality disorders. Hypotheses Based on the theoretical and empirical literature described previously, 12 hypothesized defense use differences were tested between the BPD and APD groups. Five defenses were proposed to be higher in the BPD group (acting out, idealization, passive aggression, splitting, and TAS), and seven defenses were proposed to be higher in the APD group (denial, devaluation of other, grandiosity, intellectualization, projection, rationalization, and turning against others [TAO]). STUDY 1 Method Participants. A total of 674 undergraduate students from a Canadian university participated in this study. All students were enrolled in an introductory psychology class and received partial course credit for participation. All participants provided informed consent, and the study was approved by the Research Ethics Board of the University of Saskatchewan. The mean age of the sample was 19.4 years (range = 17 40; SD = 3.0). The sample was 71.0% female, and 87.1% of the participants were Caucasian. Measures PAI (Morey, 1991). The PAI is a 344-item self-report measure of mental health and personality functioning, which includes four Validity scales, 11 Clinical scales, five Treatment scales, and two Interpersonal scales (Morey, 1991). The Borderline Features (BOR) and Antisocial Features (ANT) Clinical scales were used in this study. The PAI has demonstrated good reliability and validity in census, college, and clinical samples (e.g., Boyle & Lennon, 1994; Kurtz et al., 1993; Morey, 1991; Walters, Duncan & Geyer, 2003). The ANT and BOR

4 140 PRESNIAK, OLSON, MACGREGOR TABLE 1. Study 1 means and standard deviations for the Defense Style Questionnaire. Defense BPD M (SD) a APD M (SD) b F p d Reliability (No. of Items) c Acting Out (8.07) (6.12) (6) Denial 5.82 (2.84) 7.92 (3.32) (2) Idealization (4.72) (4.82) (3) Passive Aggression (9.13) (7.59) (8) Projection (9.17) (10.84) (10) Rationalization 4.20 (2.25) 5.34 (2.35) (1) Splitting (4.78) (4.98) (3) Note. BPD = borderline personality disorder group; APD = antisocial personality disorder group. a n = 34. b n = 38. c Reliability calculated using Cronbach s alpha. Reliability for rationalization is not calculated because it consists of one item. scales have demonstrated good concurrent validity. For example, the BOR scale correlated with borderline scales from other self-report measures (e.g., Minnesota Multiphasic Personality Inventory [Hathaway & McKinley, 1943]; Kurtz et al., 1993), and the ANT scale correlated with the Psychopathy Checklist Revised (Hare, 1991) total scale, Factor 1 (Affective and Interpersonal Features), and Factor 2 (Behavioral Features; Walters et al., 2003). Finally, the PAI has demonstrated good validity in nonclinical samples (Boone, 1998; Kurtz et al., 1993; Trull, 1995). For example, nonclinical participants who scored 70t on the BOR scale demonstrated more interpersonal problems, maladaptive coping methods, academic difficulties, and psychopathology in general compared to those scoring <70t (Trull, 1995; Trull, Useda, Conforti, & Doan, 1997). DSQ (Andrews et al., 1993). The DSQ is a 72-item selfreport questionnaire that assesses the use of 20 defense mechanisms categorized into three defense styles: mature, neurotic, and immature (Andrews et al., 1993). Participants rate their agreement of each item on a scale ranging from 1 (no agreement) to9(strong agreement). Only the hypothesized defenses of acting out, denial, idealization, passive aggression, projection, rationalization, and splitting were used in analyses. Devaluation was not included because the DSQ combines both devaluation toward others and toward the self; therefore, the directional differences proposed by Gacono et al. (1992) could not be tested. Other defenses hypothesized to be related to BOR and ANT (e.g., TAS) are not assessed by the DSQ. Internal consistency for individual defenses has ranged from.07 to.82 (Andrews et al., 1993). Concurrent validity of the DSQ is evidenced by differences in individual defense use between individuals with clinical disorders and healthy controls (Andrews et al., 1993). Procedure We asked participants to complete the PAI and the DSQ. Participants who did not complete both measures were not included, resulting in a sample of 446 participants. These participants were screened using PAI scores. Invalid profiles were identified according to Morey (1991). We removed any profiles that evidenced inconsistent (Inconsistency scale; t score > 73), careless (Infrequency scale; t score > 74), exaggerated negative (Negative Impression Management scale; t score > 91), or exaggerated positive responding (Positive Impression Management scale; t score > 68), resulting in a sample of 428. Second, we divided participants into BPD and APD groups based on the following criteria: 34 participants met criteria for the BPD group (i.e., scored 70t on the PAI BOR scale and < 70t on the ANT scale), and 38 participants met criteria for the APD group (i.e., score 70t on the ANT scale and < 70t on the BOR scale). We excluded participants who had scores 70t on both the ANT and BOR scales. The mean t score for BOR in the BPD group was 74.1 (SD = 4.0), and in the APD group it was 58.4 (SD = 7.3). The mean t score for ANT in the APD group was 76.1 (SD = 5.3); and in the BPD group, it was 56.5 (SD = 7.4). The mean age of the grouped sample was 20.0 years (range = 18 33; SD = 3.0), and 93.2% were Caucasian, with no significant age or racial differences between groups, t(58) = 1.62, p =.11 and χ 2 (2, N = 72) = 2.31, p =.32, respectively. There were significant differences in percentage of each sex between groups, χ 2 (1, N = 72) = 17.51, p<.001, with more women in the BPD group (85.3%) compared to the APD group (36.8%). Many of the participants in each group had elevations on other scales on the PAI. The most common concurrent elevations in the BPD group were on the Suicide (38.2%) and Depression scales (47.1%); and in the APD group, the most common elevations were on the Alcohol Problems (31.6%) and Aggression (15.8%) scales. Results MANOVA results. Due to the significant differences in sex between the two groups, we conducted a preliminary factorial ANOVA whereby the interaction between sex and defenses was tested. There was no significant interaction, F (7, 62) = 0.22, p =.98; therefore, the MANOVA was conducted with men and women combined. We conducted a MANOVA between the APD and BPD groups on the following defenses: Acting Out, Denial, Idealization, Passive Aggression, Projection, Rationalization, and Splitting. The mean and standard deviation for each defense mechanism is presented in Table 1. 1 Wilks Lambda indicates there was an overall significant difference between the BPD and APD groups on defenses, F (7, 64) = 5.01, p<.001. This effect accounted for 35.4% (η 2 ) of the variance. The univariate results revealed that Acting Out and Passive Aggression were significantly higher in the BPD group, and Denial and Rationalization were significantly higher in the APD group. Acting Out accounted for the most variance (partial ω 2 = 15.9%) followed by Passive Aggression (13.7%), Denial (10.5%), and Rationalization (5.9%). 1 After examining the variables for normal distribution, one variable (Projection) was significantly skewed (z >3.33).Weconductedasquareroottransformation, which resulted in a normal distribution. Because the results with the transformed score confirmed the results with the nontransformed score, the latter results were reported.

5 DEFENSE MECHANISMS AND PERSONALITY 141 TABLE 2. Study 1 correlations between seven Defense Style Questionnaire defenses and the Borderline Features and Antisocial Features scales from the Personality Assessment Inventory. Defense Borderline Features Antisocial Features z p Acting Out <.001 Denial <.001 Idealization Passive Aggression <.001 Projection <.001 Rationalization Splitting Note. N = 428. z scores indicate differences in magnitude of correlations according to Meng, Rosenthal, and Rubin (1992). p<.05. p<.001. Correlation results. Because a larger sample of participants had completed both the PAI and DSQ (of whom many did not meet inclusion criteria), we also conducted correlation analyses between the individual defenses with the BOR and ANT scales of the PAI in this larger sample (n = 428). The results of the Pearson correlations are reported in Table 2. 2 Results indicated four defenses were positively correlated with the BOR scale: Acting Out, Passive Aggression, Projection, and Splitting. Six defenses were positively correlated with the ANT scale: Acting Out, Denial, Passive Aggression, Projection, Rationalization, and Splitting. One defense, Idealization, was negatively correlated with the ANT scale. STUDY 2 Method Participants. A total of 1,539 undergraduate students from a Canadian university participated in this study. All participants provided informed consent, and the study was approved by the Research Ethics Board of the University of Saskatchewan. The mean age of the participants was 19.7 years (range = 17 40; SD = 2.7); 68.0% were female, and 87.0% were Caucasian. All participants received partial course credit for their participation. Measures The PAI and DSQ as described in Study 1 were used in Study 2. Defense-Q (MacGregor et al., 2008). The Defense-Q is an observational measure used to assess the relative use of 25 defense mechanisms (MacGregor & Davidson, 1998; MacGregor et al., 2008). It is a Q-sort instrument based on a system of rank ordering: one defense is identified as most characteristic, twoasquite characteristic, five as somewhat characteristic, nine as neither uncharacteristic nor characteristic, five as somewhat uncharacteristic, twoas quite uncharacteristic, and one as most uncharacteristic. The categorization results in a seminormal distribution representing a participant s overall pattern (or profile) of defense use. The Defense-Q allows for the examination of individual defense use as well as provides a profile 2 Three variables (denial, projection, and splitting) were significantly skewed (z >3.33) and we conducted transformations, resulting in a normal distribution. Because the results with the transformed scores confirmed the results with the nontransformed scores, the latter results were reported. TABLE 3. Study 2 means and standard deviations for the Defense-Q. BPD M APD M Defense (SD) a (SD) b F p d Reliability c Acting Out 2.84 (0.83) 3.27 (1.05) Devaluation 3.86 (0.80) 4.32 (0.91) Grandiosity 3.94 (0.76) 4.33 (0.81) Idealization 3.82 (0.68) 3.84 (0.48) Intellectualization 3.07 (1.23) 3.55 (1.54) Neurotic Denial 4.18 (1.14) 4.63 (1.22) Passive Aggression 4.18 (0.86) 4.18 (0.77) Projection 4.31 (0.57) 4.01 (0.55) Rationalization 5.41 (0.86) 5.26 (0.84) Splitting 3.39 (0.84) 3.19 (0.69) Turning Against Others 4.66 (0.77) 4.36 (0.79) Turning Against Self 4.62 (0.97) 4.12 (0.99) Note. BPD = borderline personality disorder group; APD = antisocial personality disorder group. a n = 34. b n = 49. c Defense-Q reliability calculated using one-way random effects model intraclass correlation coefficients. of overall defense use. The individual defense scores from the Defense-Q coders were averaged together to produce a mean score for each of the 12 defenses used in this study. We used the defenses of Acting Out, Devaluation, Grandiosity, Idealization, Intellectualization, Neurotic Denial, Passive Aggression, Projection, Rationalization, Splitting, TAO, and TAS in this study. The Defense-Q has demonstrated good convergent and concurrent validity (see MacGregor & Olson, 2005). Interrater reliability for the Defense-Q has been shown to range from poor to excellent for individual defenses and excellent for profile comparisons (MacGregor & Olson, 2005). The interrater reliability for each defense from this study are reported in Table 3. Procedure Participants completed the PAI in the initial meeting. Of the 1,539 participants, we called back 171 for this study. We contacted participants if they had elevated scores on BOR or ANT. We asked participants to return to complete the DSQ and the Expanded Structured Interview (ESI; Hall, Davidson, MacGregor, & MacLean, 1998). The ESI is a 12 to 15 min semistructured interview designed to elicit information related to stress, anxiety, and coping (Hall et al., 1998). Participants are asked questions related to school and work and how they react in certain stressful situations. The ESI is based on a Type A interview (used to assess hostility, competitiveness, time urgency, etc.) adapted for use with a university population and modified to assess defense use and emotional expression. Defenses have been assessed using the ESI in previous research on defenses, personality, and health (e.g., MacGregor et al., 2003). The entire interview is viewed separately by each coder, providing them with a sample of responses and behaviors from which they observationally assess defenses using the Defense-Q. Of the 171 participants who were called back, 92 participants returned to complete the ESI and DSQ. The most common reasons for not returning were a failure to respond to repeated contact attempts or a response that they had already reached their maximum allotted research credits. Once we removed participants for incomplete data or invalid PAI profiles (see Study 1 for criteria), the resulting sample was 83 participants, of which 34 met criteria for the BPD group (i.e., scored 70t on the PAI

6 142 PRESNIAK, OLSON, MACGREGOR TABLE 4. Study 2 means and standard deviations for the Defense Style Questionnaire. Defense BPD M (SD) a APD M (SD) b F p d Reliability (No. of Items) c Acting Out (7.27) (7.09) (6) Denial 5.97 (3.08) 6.84 (3.09) (2) Idealization (4.57) (4.26) (3) Passive Aggression (7.92) (6.44) (8) Projection (12.24) (12.71) (10) Rationalization 5.06 (2.51) 5.45 (2.07) (1) Splitting (4.47) (5.05) (3) Note. BPD = borderline personality disorder group; APD = antisocial personality disorder group. a n = 34. b n = 49. c Reliability calculated using Cronbach s alpha. Reliability for rationalization is not calculated because it consists of one item. BOR scale and < 70t on the ANT scale), and 49 met criteria for the APD group (i.e., score 70t on the ANT scale and < 70t on the BOR scale). All variables were normally distributed with no outliers. Of the total sample, 93.4% were Caucasian, and the mean age was 19.5 years (range = 18 26; SD = 1.6), with no significant age, t(59) = 0.04, p =.97, or racial differences, χ 2 (3, N = 61) = 3.88, p =.28 between the groups. There were significant differences in the sex of participants between groups, χ 2 (1, N = 61) = 8.15, p =.006, with more women in the BPD group (84.6%) compared to the APD group (48.4%). Many of the participants in each group had elevations on other scales on the PAI. The most common concurrent elevations in the BPD group were on the Suicide (26.5%) and Depression scales (38.2%); and in the APD group, the most common elevations were on the Alcohol Problems (34.7%) and Drug Problems (26.5%) scales. Defense coder training. Data were collected over 4 consecutive years. Each year s participant interviews were coded by three Defense-Q coders, some of whom coded multiple years. The coders from the initial 2 years had additionally coded defense mechanism data for another published manuscript (Olson, Presniak, & MacGregor, 2009). All coders were senior undergraduate students who received standard training for the Defense Q. This included a minimum of 20 hr of training, which involved a discussion of theory, how to rate each defense mechanism (i.e., definition, examples of its manifestation, how to look for evidence of its presence or absence), and observation of trainers (current authors) coding defenses from video-recorded interviews as well as coders independently practicing coding and then reviewing their assessment in a group meeting (see Davidson & MacGregor, 1996, or MacGregor & Olson, 2005, for a more detailed discussion of training procedure). After coding defenses for this data began, coders met together with trainers weekly to discuss coding and maintain reliability. Results DSQ results. Due to the significant differences in sex between the two groups, we conducted a preliminary factorial ANOVA whereby we tested the interaction between sex and defenses. There was no significant interaction for the DSQ analyses, F (7, 47) = 0.58, p =.77; therefore, we conducted the MANOVA with men and women combined. The mean and standard deviation for each defense in the analysis is presented in Table 4. Results of the Wilks Lambda multivariate test indicated a significant overall difference between the BPD and APD groups on defenses, F (7, 75) = 2.68, p =.016. This effect accounted for 18.8% (η 2 ) of the variance. Univariate results revealed that Acting Out and Passive Aggression were higher in the BPD group compared to the APD group. Passive Aggression accounted for 10.6% (partial ω 2 ) of the variance, and Acting Out accounted for 8.9%. Defense-Q results. Due to the significant differences in sex between the two groups, we conducted a preliminary factorial ANOVA whereby we tested the interaction between sex and defenses. There was no significant interaction for the Defense- Q analyses, F (12, 42) = 0.58, p =.85; therefore, we conducted the MANOVA with men and women combined. The mean and standard deviation for each defense mechanism used in the Defense-Q analysis is presented in Table 3. There was an overall significant difference between the BPD and APD groups on defenses, F (12, 70) = 3.08, p =.002. This effect accounted for 34.5% (η 2 ) of the variance. Results from univariate analyses revealed that Projection and TAS were higher in the BPD group, and Devaluation and Grandiosity were significantly higher in the APD group. Devaluation accounted for the most variance (partial ω 2 = 6.6%), followed by TAS (6.2%), Grandiosity (5.7%), and Projection (1.5%). DISCUSSION Overall group differences were demonstrated across the two studies. Of the five defenses hypothesized to be higher in the BPD group, two were supported (passive aggression and TAS), one was inconsistently supported (acting out), and two were not supported (idealization and splitting). Of the seven defenses hypothesized to be higher in the APD group, two were supported (devaluation of others and grandiosity), one was partially supported (denial; all effects in the right direction, but only one of three was significant), one was inconsistently supported (rationalization), and three were not supported (intellectualization, TAO, and projection). Consistent with our hypothesis and previous theory and research (e.g., Bond, 1990; Cramer, 1999), we found partial support that the BPD group would use the maladaptive defenses, acting out, and passive aggression more than the APD group. These results, however, were not consistent across measurement type. 3 The Defense-Q results indicated no difference in Passive Aggression scores and showed a moderate effect size for lower Acting Out scores in the BPD group. One explanation for this discrepancy could be the differences in the measurement 3 For a correlation table of the convergence between the DSQ and Defense-Q defenses from this study, please contact M. D. Presniak.

7 DEFENSE MECHANISMS AND PERSONALITY 143 of these defenses between the DSQ and Defense-Q. For example, the DSQ s Acting Out predominantly assesses impulsivity and limited aggression, which may be more likely to be selfreported by individuals with BPD. In comparison, APD groups may be less likely to admit exploitative and criminal acts on self-report measures, but their acting out behaviors may be observed by coders. As such, it would be valuable to further assess the types of acting out and passive aggressive behaviors used by each group and to examine whether these differences are reflected in measurement type or differentially related to each group. Contrary to our hypothesis, splitting was not used significantly more by the BPD group. Our results, however, were consistent with researchers who previously have found no difference in splitting use between BPD and APD groups (Gacono et al., 1992). Another explanation for the unsupported hypothesis could be related to the low reliability of Splitting scores. In Study 2, interrater reliability of Splitting on the Defense-Q was poor (.28), therefore likely affecting the validity of these results. The hypotheses, however, were not supported with the DSQ either. The construct validity of assessing splitting through self-report may have impacted the findings. For example, the DSQ asks participants to report the extent to which they view things as polar opposites (e.g., Sometimes I think I m an angel and other times I think I m a devil ). Accurate self-report of this behavior may be challenging for individuals who rely heavily on splitting because it requires a self-awareness of an inability to integrate that is inherently problematic for them. Gacono et al. (1992) also proposed an alternate theory of splitting in BPD and APD, and our results provide support for this conceptualization. First, Grandiosity scores were higher in the APD group, supporting the notion that this group splits their identity into a grandiose and devalued self, of which only the grandiose self is evident. Second, our findings also partially supported Gacono et al. s (1992) suggestion that the direction aggression is aimed will differ between groups. TAS was significantly higher in the BPD group compared to the APD group. This finding was consistent with previous findings showing that BPD is positively associated with TAS (Berman & McCann, 1995). In addition, devaluation of others was used significantly more by the APD group. Lingiardi et al. (1999) had previously found no correlation between APD scores and devaluation on the DMRS, although this research was conducted using a previous version of the DMRS that combined the constructs of devaluation of self and others, thus obscuring the directional relationships. Although a large portion of Gacono et al. s (1992) theory on splitting was supported (i.e., use of devaluation, grandiosity, and TAS), our results did not show support for significant differences between the groups for use of idealization or TAO. The results for TAO, which showed no significant differences but a small to medium effect size indicating a lower score in the APD group, were contrary to previous theory and research. Using the self-report Defense Mechanisms Inventory (DMI; Ihilevich & Gleser, 1986), Berman and McCann (1995) previously found APD was positively associated with the individual defense Turning Against Object. The DMI, however, uses a forced-choice self-report format in which participants are required to choose between five reactions to multiple situations. Each reaction represents a defense, and as such, participants are unable to have elevated scores on all five defenses. It may be that blaming others is characteristic of both BPD and APD, but that when required to choose one s most likely reaction to situations, participants with APD are more likely to choose TAO. Our results also did not support our hypothesis that idealization would be used more by the BPD group. However, a moderate effect size emerged indicating idealization scores on the DSQ were higher in the BPD group and, in addition, there was a significant negative correlation between Idealization on the DSQ and the ANT scale of the PAI. This latter finding supports Gacono et al. s (1992) suggestions that individuals with APD are incapable of idealizing others. Therefore, there is partial evidence that idealization may not be characteristic of APD and may be used more by the BPD group. The findings are consistent with the results of Gacono et al. (1992), but additional research is needed to further understand whether differences in the use of idealization exist between BPD and APD groups. We hypothesized that denial would be used more by the APD group based on Gacono and Meloy (1988) who suggested that denial is an important defense for APD. Gacono and Meloy explained that intrinsic to APD is a shut-off mechanism that allows the exclusion of personality aspects that could diminish their grandiose self-view or lead to a recognition of their exploitative and criminal behaviors. Denial is a key component of this proposed mechanism. In our studies here, Denial and Neurotic Denial scores were higher, with small to medium effect sizes, in the APD group compared to the BPD group, although the difference was statistically significant in only one of the three tests. These findings provide partial support for the hypothesis and are consistent with previous findings showing APD to be associated with disavowal level defenses including denial (Perry & Cooper, 1986). We also hypothesized that the APD group would use more rationalization. Gacono and Meloy (1988) suggested that, in its developmentally advanced form, denial would develop into rationalization. This occurs when individuals become more aware of their antisocial behaviors but justify them through distorted self-serving explanations. The results supported this hypothesis in Study 1 but not in Study 2. The Defense-Q results showed that both groups were rated by observers as using the defense above average (M >4). It has been noted by many that college students tend to rationalize maladaptive behaviors (e.g., cheating on tests, violence; McCabe, 1992; Pezza & Bellotti, 1995). It may be that elevated use of rationalization in this university sample obscured our ability to examine this hypothesis. Lingiardi et al. (1999) also suggested that intellectualization can capture the tendency to minimize negative experiences. Lingiardi et al. previously found that use of intellectualization positively correlated with APD in a sample of clinical outpatients. Based on this finding, we expected intellectualization on the Defense-Q to be higher in the APD group; however, the hypothesis was not supported. Further research is needed to explore the use of intellectualization and rationalization in APD. Finally, the hypothesis that projection would be used more by the APD group was not supported. This result is also inconsistent with the theory proposed by Gacono et al. (1992) that, in APD, the world is seen through a projected view of themselves as well as inconsistent with the results of Cramer (1999) who found that projection was a predictor of APD but not BPD. Our results are consistent, however, with the theory and findings of Perry and Cooper (1986), who suggested that projective identification, which is a more primitive form of projection, was associated

8 144 PRESNIAK, OLSON, MACGREGOR with BPD. Therefore, additional research is needed to examine the role of projection in both of these groups. Overall, although all hypotheses were not supported, the findings support the conceptualization of BPD and APD as having separate and diverse defensive profiles. Supporting Perry and Cooper s (1986) proposition, the defenses in BPD appear to emphasize interpersonal relatedness or dependency. These include defenses that lead to difficulties expressing one s needs and wishes to others (passive aggression), projecting internal selves onto others (projection), and the splitting of the ego, which involves predominantly a devaluation of the self (TAS). Supporting many of Gacono et al. s (1992) and Gacano and Meloy s (1988) theoretical work, the defensive profile in APD, on the other hand, appears to emphasize egocentricity, interpersonal exploitation, and the expression of aggression toward others. Specifically, the defenses contribute to a splitting of the ego, which results in a grandiose view of the self (grandiosity); the tendency to minimize, distort, or avoid the consequences of their behavior (denial and rationalization); and a tendency to protect the self by devaluing others (devaluation). Strengths and Limitations One limitation to these studies is the weaknesses in reliability and validity that is characteristic of some defense measures, which may have decreased the likelihood of finding significant results. For example, the interrater reliability for Splitting on the Defense-Q was poor for Study 2, and the Acting Out items and behaviors measured by the DSQ and Defense-Q may capture different aspects of acting out. Additionally, some of the group comparisons made using the DSQ may have been attenuated by the low internal consistency observed for several of these scales. These difficulties capturing defenses can compromise our ability to accurately assess defenses and their relation to personality disorders, which complicates the comparison of results across studies. To mitigate this problem, we used both observer and self-report measures of defenses in this study to get a more complete and detailed defense assessment. However, further measurement development is still needed to improve the assessment of defenses. Another limitation to these studies is the use of a nonclinical sample for the BPD and APD groups. Nonclinical samples may not display the degree of symptom severity and behaviors that would be found in a clinical group. Although it will be important to replicate these results in a clinical sample, our findings suggest that in BPD, the defenses may emphasize interpersonal relatedness or dependency, whereas in APD, the defenses may emphasize egocentricity and interpersonal exploitation. ACKNOWLEDGMENT This study was conducted with the support of a Canada Graduate Scholarship awarded to M. D. Presniak by the Social Sciences and Humanities Research Council of Canada. REFERENCES American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Andrews, G., Singh, M., & Bond, M. (1993). The Defense Style Questionnaire. The Journal of Nervous and Mental Disease, 181, Becker, D. F., Grilo, C. M., Edell, W. S., & McGlashan, T. H. (2000). Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults. American Journal of Psychiatry, 157, Berg, J. L. (1990). Differentiating ego functions of borderline and narcissistic personalities. Journal of Personality Assessment, 55, Berman, S. M., & McCann, J. T. (1995). Defense mechanisms and personality disorders: An empirical test of Millon s theory. Journal of Personality Assessment, 64, Blais, M. A., & Norman, D. (1997). A psychometric evaluation of the DSM IV personality disorder criteria sets. Journal of Personality Disorders, 11, Bond, M. (1990). Are borderline defenses specific for borderline personality disorders? Journal of Personality Disorders, 4, Bond, M. (2004). Empirical studies of defense style: Relationships with psychopathology and change. Harvard Review Psychiatry, 12, Bond, M., Gardener, S. T., Christian, J., & Sigal, J. J. (1983). Empirical study of self-rated defense styles. Archives of General Psychiatry, 40, Boone, D. (1998). Internal consistency reliability of the Personality Assessment Inventory with psychiatric patients. Journal of Clinical Psychology, 54, Boyle, G. J., & Lennon, T. J. (1994). Examination of the reliability and validity of the Personality Assessment Inventory. Journal of Psychopathology and Behavioral Assessment, 16, Chabrol, H., & Leichsenring, F. (2006). Borderline personality organization and psychopathic traits in nonclinical adolescents: Relationships of identity diffusion, primitive defense mechanisms and reality testing with callousness and impulsivity traits. Bulletin of the Menninger Clinic, 70, Cooper, S. H. (1998). Changing notions of defense within psychoanalytic theory. Journal of Personality, 66, Cramer, P. (1997). Evidence for change in children s use of defense mechanisms. Journal of Personality, 65, Cramer, P. (1999). Personality, personality disorders, and defense mechanisms. Journal of Personality, 67, Cramer, P. (2006). Protecting the self: Defense mechanisms in action. New York: Guildford. Davidson, K., & MacGregor, M. Wm. (1996). The reliability of the Defense-Q. Journal of Personality Assessment, 66, Davidson, K., & MacGregor, M. Wm. (1998). A critical appraisal of self-report defense mechanism measures. Journal of Personality, 66, Freud, A. (1986). The ego and the mechanisms of defense. In J. D. Sutherland (Ed. & Trans.), The writings of Anna Freud (Vol. 2). London, England: Hogarth Press. (Original work published 1936) Gacono, C. B., & Meloy, J. R. (1988). The relationship between cognitive style and defensive process in the psychopath. Criminal Justice and Behavior, 15, Gacono, C. B., Meloy, J. R., & Berg, J. L. (1992). Object relations, defensive operations, and affective states in narcissistic, borderline, and antisocial personality disorder. Journal of Personality Assessment, 59, Hall, P., Davidson, K., MacGregor, M. Wm., & MacLean, D. (1998). Expanded Structured Interview administration training manual (Tech. Rep. No. 1). Halifax, Nova Scotia, Canada: Heart Health of Nova Scotia. Hare, R. D. (1991). The Hare Psychopathy Checklist Revised. North Tonawanda, NY: Multi-Health Systems. Hathaway, S. R., & McKinley, J. C. (1943). The Minnesota Multiphasic Personality Inventory. Minneapolis, MN: University of Minnesota Press. Herkov, M. J., & Blashfield, R. K. (1995). Clinician diagnoses of personality disorders: Evidence of a hierarchical structure. Journal of Personality Assessment, 65, Hilsenroth, M. J., Hibbard, S. R., Nash, M. R., & Handler, L. (1993). A Rorschach study of narcissism, defense, and aggression in borderline, narcissistic, and cluster c personality disorders. Journal of Personality Assessment, 60, Ihilevich, D., & Gleser, G. C. (1986). Defense mechanisms: Their classification, correlates, and measurement with the Defense Mechanism Inventory. Owosso, MI: DMI associates.