What psychological defense mechanism is usually prominently used by patients suffering from a paranoid personality disorder?

Summary

Psychotherapy is the use of psychological methods to help patients modify undesirable emotions, attitudes, and behaviors. The most common types of psychotherapy are psychoanalysis, behavioral therapy, cognitive therapy, cognitive behavioral therapy, dialectical behavioral therapy, motivational interviewing, group therapy, couples therapy, family therapy, and schema therapy. Psychoanalytic theory has its origin in Freud's topographic and structural theories. According to Freud, defense mechanisms help individuals to mediate their reactions to internal emotional conflicts triggered by external stressors. Defense mechanisms are categorized into four levels: pathological, immature, neurotic, and mature defenses. This article examines mature defense mechanisms, which manifest in healthy adults, as well as pathological, neurotic, and immature defense mechanisms, all of which are associated with psychiatric disorders.

Overview of psychotherapies

Overview of common psychotherapies [1]
Psychotherapy	Indications	Typical duration	Description	Techniques
Psychoanalysis	Personality disorders Anxiety disorders Sexual disorders Depressive disorders Healthy individuals under stress Somatic symptom disorders	3–5 times per week for years	Focuses on creating awareness of repressed feelings and experiences Aims to resolve conflicts in the subconscious	Transference Free association Dream interpretation
Psychodynamic psychotherapy	Anxiety disorders Depressive disorders Personality disorders Anorexia nervosa	Once weekly for 6 months to years	Focuses on developing insight (e.g., by uncovering past unresolved conflicts, unconscious patterns of interpersonal relationships) Aims to change current behaviors, feelings, and thoughts	Patient education Thorough history taking Promotion of a strong therapeutic alliance
Supportive psychotherapy	Anxiety disorders Depressive disorders Coping with a crisis or transient problem	Days to years (open-ended) The weekly frequency is flexible and determined by the severity of symptoms and/or disease and the patient's progress.	Focuses on identifying maladaptive behavioral patterns and problematic interpersonal relationships Aims to help the patient improve negative thinking and/or cope with stressors and life challenges	Patient counseling Promotion of a strong therapeutic alliance
Interpersonal therapy	Depressive disorders Eating disorders	Once weekly for 12–16 weeks [2]	Focuses on identifying and analyzing problematic interpersonal relationships Aims to improve communication skills and self-control	Medical model Identification of connections between the disease manifestation and life events
Behavioral therapy	Phobias Bipolar disorder Borderline personality disorder (BPD) Obsessive compulsive disorder (OCD) Panic disorders PTSD Psychosis	Brief	Focuses on helping the patient to identify, reflect on, and change maladaptive behavior that is triggered by specific stimuli Aims to teach the patient possible alternatives to maladaptive behavior Usually combined with cognitive therapy as cognitive behavioral therapy	Conditioning Classical conditioning Operant conditioning Extinction (psychology) Deconditioning Systemic desensitization Flooding Implosion Biofeedback Token economy Aversion therapy
Cognitive therapy	Major depressive disorder Anxiety disorders Paranoid personality disorder OCD Somatic symptom disorders Eating disorders	Focuses on identifying and correcting faulty assumptions and negative thoughts Aims to improve patient awareness of emotions and thoughts Usually combined with cognitive therapy as cognitive behavioral therapy	Guided questioning Journaling (psychiatry) Cognitive restructuring
Cognitive behavioral therapy (CBT)	OCD Phobias Substance use disorders Depressive disorders Anxiety disorders Trauma-related disorders Eating disorders Schizophrenia	Usually for approx. 16 weeks Twice weekly for the first 4 weeks Once weekly for the remaining 12 weeks	Focuses on changing distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns Aims to help the patient identify unhelpful and distorted thoughts and behavior patterns A combination of cognitive therapy and behavioral therapy	Combines techniques from cognitive therapy and behavioral therapy Journaling (psychiatry) Cognitive restructuring Systemic desensitization Stress management
Dialectical behavioral therapy (DBT)	BPD Eating disorders Trauma-related disorders Depressive disorders associated with suicidal thoughts	Once weekly for approx. 16 months	Focuses on teaching new skills (e.g., relaxation techniques) Aims to change severe unhealthy behavior (typically emotional regulation)	Mindfulness Emotional regulation Distress tolerance Interpersonal effectiveness
Motivational interviewing	Substance use disorders Lifestyle changes (e.g., weight loss) Depressive disorders	Approx. 2–4 sessions	Focuses on enabling behavioral change Aims to resolve ambivalence about changing behavior	Patient-centered approach Showing empathy and support Revealing discrepancies Reflective listening Avoiding arguments Accepting resistance Supporting optimism and self-efficacy
Group therapy	Personality disorders Substance use disorders Family and group disorders Chronic or life-threatening conditions Bereavement	Once weekly for months to years	Focuses on direct interaction Aims to form a support network for individuals with similar diseases or difficulties	Psychoeducation Supportive techniques Cognitive techniques
Family therapy	Schizophrenia Eating disorders Depressive disorder Bereavement	Once weekly for months to years	Focuses on identifying family dysfunctions and individual problems that affect the entire family Aims to reduce conflict	Psychoeducation Addressing boundaries Cognitive behavioral techniques
Couples therapy	Sexual disorders Motivated couples not suffering from a severe mental illness	Weeks to years	Focuses on improving communication between couples Aims to reduce conflicts	Conjoint therapy Concurrent therapy Collaborative therapy Four-way therapy
Schema therapy	BPD Posttraumatic stress disorder Substance use disorders Eating disorders	Long-term treatment: twice weekly for up to three years	Focuses on improving the patient's sense of self worth Aims to diffuse harmful potential of maladaptive schemas	Combines techniques of different psychotherapies (e.g., CBT, psychodynamic therapy)

Details of psychotherapies

Psychoanalysis [3]

Indications
Duration: 3–5 times per week for years
Description
- Focuses on improving awareness of repressed feelings and experiences
- Aims to resolve conflicts in the subconscious (e.g., by studying dreams)
- A strong therapeutic alliance (i.e., the bond between therapist and patient) is important for successful psychoanalysis therapy.
- Countertransference: a complication in which the therapist projects unconscious feelings onto the patient (e.g., the therapist sees the patient as a sibling)
Techniques
- Transference: The patient projects unconscious feelings about significant persons in their childhood onto the therapist (e.g., the therapist is treated as a parental figure). The therapist can gain insight into personal conflicts by interpreting these feelings.
- Free association: The patient describes all thoughts that spontaneously occur during the therapy session.
- Dream interpretation: identifying representations of the patient's urges and fears in their dreams to gain insight into subconscious conflicts

Interpersonal therapy [2]

Indications
- Depressive disorders
- Eating disorders
Duration: weekly sessions for 12–16 weeks
Description
- Focuses on identifying and analyzing problematic interpersonal relationships (e.g., unresolved grief or conflicts) and/or life situations (e.g., change in jobs, geographical move)
- Aims to improve communication skills and control over mood and behavior
Techniques
- Medical model: The disease the patient suffers from (e.g., depressive disorder) is a clinical syndrome distinct from the patient's personality and should be explained similarly to other medical conditions (e.g., diabetes).
- Identifying connections between the disease manifestation and life events (e.g., the connection between the death of a loved one and the development of an eating disorder)

Behavioral therapy

Indications
- Phobias
- Bipolar disorder
- Borderline personality disorder (BPD)
- Obsessive compulsive disorder (OCD)
- Panic disorders
- PTSD
- Psychosis
Duration: brief (5–20 sessions) [8]
Description
- Focuses on helping the patient to identify, reflect, and change maladaptive behavior that is triggered by specific stimuli (e.g., fear of spiders)
- Aims to teach the patient possible alternatives to maladaptive behavior
- Usually combined with cognitive therapy as cognitive behavioral therapy
Techniques
- Conditioning
  - A biologically potent unconditioned stimulus (e.g., the smell of food) leads to a natural, unconditioned response (e.g., salivation).
  - Classical conditioning: designed to produce an involuntary response
  - Operant conditioning: designed to produce a voluntary response (see the “Skinner operant conditioning quadrants” table below)
  - Extinction (psychology): the loss (unlearning) of a learned behavior due to discontinuation of a reward (in classical conditioning) or reinforcement (in operant conditioning)
- Deconditioning
  - Systemic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing progressive muscle relaxation
  - Flooding: exposing the patient to real stimuli until they achieve complete relaxation in that situation
  - Implosion: exposing the patient to an imaginary anxiety-provoking stimulus until they become more comfortable with it
  - Biofeedback: using information on involuntary physiological processes to help the patient monitor and control their response to stimuli
  - Token economy: reinforcing positive behaviors by providing tangible rewards
  - Aversion therapy: using a nonrewarding stimulus to discourage negative behaviors

Cognitive therapy [1]

Indications
Duration: brief (5–10 sessions)
Description
- Focuses on identifying and correcting faulty assumptions; and negative thoughts
- Aims to improve patient awareness of emotions and thoughts
- Usually combined with behavioral therapy as cognitive behavioral therapy
Techniques: relies mainly on thought exercises
- Guided questioning: directing the patient's behavior and thought process toward a therapeutic goal by asking a series of graded questions
- Journaling (psychiatry): The patient writes down their thoughts, feelings, and internal experiences to better understand their own ideas and emotions.
  - Self-monitoring by journaling behaviors, thoughts, and feelings (e.g., treatment for an eating disorder includes monitoring food intake by writing down every meal and the emotions/thoughts attached to eating)
  - Enables identification of triggers and problematic chains of behavior (e.g., stress-induced binge eating)
- Cognitive restructuring: The patient identifies negative automatic thoughts (i.e., dysfunctional/negative view of the self, future, or world) in order to dispute them and eventually replace them with healthy thought processes.

Cognitive behavioral therapy (CBT) [9]

Indications
- OCD
- Phobias
- Substance use disorders
- Depressive disorders
- Anxiety disorders
- Trauma-related disorders
- Eating disorders
- Schizophrenia
Duration
- Usually for approx. 16 weeks
- Twice weekly for the first 4 weeks
- Once weekly for the remaining 12 weeks
Description
- Focuses on changing distorted, harmful, irrational, or ineffective beliefs, attitudes, and behavior patterns that lead to dysfunctional behaviors
- Helps the patient to identify unhelpful and distorted thoughts
- Helps the patient develop skills and strategies to alter abnormal behaviors and develop healthy coping mechanisms
- Aims to improve the patient's control over their emotions and ability to deal with distress
Techniques: combines techniques from cognitive therapy and behavioral therapy

Dialectical behavioral therapy (DBT) [10]

Indications
- BPD
- Eating disorders
- Trauma-related disorders
- Depressive disorder associated with suicidal thoughts
Duration: once weekly for approx. 16 weeks
Description
- Focuses on teaching new skills (e.g., relaxation techniques)
- Aims to reduce unhealthy and self-destructive behavior
Techniques
- Mindfulness: a complex field that revolves around being fully present and aware of one's thoughts, feelings, and actions (e.g., practicing guided breathing, yoga asanas, meditation)
- Emotional regulation: The patient is taught to become aware of their emotions and to assess them rationally.
- Distress tolerance: The patient learns to better handle crises and stressful situations.
- Interpersonal effectiveness: The patient is trained to recognize and assert their needs without coming into conflict with others.

MEDI: Mindfulness, Emotional regulation, Distress tolerance, and Interpersonal effectiveness are techniques of DBT.

Motivational interviewing [11]

Indications
- Substance use disorders
- Depressive disorders
- Lifestyle changes (e.g., weight loss)
Duration: approx. 2–4 sessions
Description
- Motivational interviewing is a patient-centered counseling approach that focuses on enabling behavior change.
- Aims to explore and resolve ambivalence about changing behavior
- The patient is encouraged to identify their own reasons for wanting to change.
Techniques

DEARS: Determine Discrepancy, Express Empathy, Avoid Arguments, Roll with Resistance, and Support Self-efficacy are techniques of motivational interviewing.

OARS: Open-ended questions, Affirmation, Reflections, and Summaries are communication skills for motivational interviewing.

Psychoanalytic theory

Jungian archetypes

Some of the most important archetypes Carl Jung proposed include:

Defense mechanisms

Overview [21]

Definition
- Primary tools of the ego used to cope with external stressors to avoid or reduce anxiety, restrict impulses, and avoid unpleasant feelings
- Mostly unconscious
Classification

Pathological defenses [22][23]

Overview of pathological defenses
Mechanism	Description	Examples
Splitting (psychiatry)	An all or nothing view about a subject or person Affected individuals are unable to integrate positive and negative images into a cohesive whole. Can affect both the sense of self and others Can manifest in extreme prejudice/stereotyping Associated with BPD	A boy dislikes his mother's best friend, who is a teacher, just because he despises all teachers. A woman is convinced that all student counselors are good people based on their choice of profession alone.
Projection (psychiatry)	Attributing one's undesired feelings or thoughts to another person In patients with paranoid personality disorder, may include paranoid delusions, and acting on these perceptions Projection is a form of externalization. Distinct from displacement Projection: The affected individual extends emotions/thoughts about themselves to another person. Displacement: The affected individual shifts emotions/thoughts about one person to a less threatening person or object. Projective identification: When the individual onto whom emotions/thoughts are being projected internalizes these qualities and believes them to be true.	A clinician believes that a patient dislikes him when in reality he dislikes the patient. A man fears that his wife is cheating on him while he himself feels attracted to other women.
Denial (psychiatry)	Avoiding anxiety-provoking thoughts by not accepting reality Common early response to bad news Associated with substance use disorder	An elderly woman refuses to acknowledge a cancer diagnosis by planning a vacation despite imminent chemotherapy appointments.
Distortion (psychiatry)	Altered perception of external reality (e.g., hallucinations, wish-fulfilling delusions) to suit inner needs to sustain superiority/entitlement	A woman tells a story about how she was abandoned by her family when she actually ran away from home.

Immature defenses [24]

Overview of immature defenses
Mechanism	Description	Examples
Acting out (psychiatry)	Expressing unacceptable or extreme feelings and thoughts through action Associated with borderline and antisocial personality disorders	An employee yells and throws things from his desk in response to the news of being fired from his job.
Regression (psychiatry)	Involuntary return to a childlike state or prior maturational stage to avoid the stress evoked at the present level of development Associated with dependent personality disorder Common in individuals who are feeling ill, tired, or uncomfortable (compare with fixation)	A previously toilet-trained child begins to wet the bed again after the birth of a new sibling. A child who stopped sucking their thumb begins to do so again after being hospitalized for an upcoming surgery.
Primitive idealization (psychiatry)	Imposing more positive qualities on an external object or person than they actually have while ignoring their negative features Common in individuals with personality disorders	A woman believes that her new boyfriend is absolutely flawless.
Blocking (psychiatry)	Temporarily or transiently inhibited thinking when feeling increased levels of stress Commonly manifests when the affected individual is experiencing embarrassment	An individual is unable to answer a question during an exam but immediately recalls it once the exam is over.
Hypochondriasis (psychiatry)	Exaggerating or overemphasizing an illness to avoid responsibility or guilt associated with loneliness, bereavement, or aggressive impulses Common in individuals with anxiety disorders and/or a history of traumatic clinical experiences [25]	A woman with mild abdominal cramps claims to be bedridden when nobody calls her on her birthday.
Identification (psychiatry)	The unconscious modeling of one's behavior, characteristics, qualities, or traits, whether good or bad, on those of another person May be associated with anxiety disorders	A young girl begins to dress more and more like her revered older cousin, without realizing it. A boy who was abused by his father becomes an abusive parent.
Passive aggression (psychiatry)	Expressing aggression toward others indirectly in a nonconfrontational way Common in children and individuals with BPD	An employee appears to accept critique to their work but later reacts by procrastinating and avoiding work-related messages.
Somatization (psychiatry)	Converting psychological problems into real bodily symptoms May be associated with somatic symptom disorders	A medical student develops headaches during a stressful board exam.
Undoing (psychiatry)	Trying to avoid guilt about negative thoughts or actions by engaging in the opposite behavior Common in individuals with OCD	After a man thinks about harming another person, he becomes overly accommodating to them. An individual with OCD has frequent and distressing thoughts about germ contamination and washes their hands until they're raw or bleeding.
Fixation (psychiatry)	The cessation of development of personality at one of the childhood stages such as oral, anal, or phallic (compare with regression) May be associated with anxiety disorders	An individual fixated at the oral stage of development bites their nails, chews on a pen, or sucks their thumb in response to a stressful situation.
Fantasy (psychiatry)	Withdrawal into fantasy to resolve inner and/or outer conflicts May be associated with stressful situations and personal crises	An elderly man in a wheelchair repeatedly suggests to his grandson that they race one another on foot.

Neurotic defenses [26]

Overview of neurotic defenses
Mechanism	Description	Examples
Controlling (psychiatry)	Excessively attempting to manage or regulate the environment (i.e., objects or people) to minimize anxiety May be associated with OCD or anxiety disorders	A mother does not let her child attend a friend's birthday party unless she can influence who else will attend it.
Displacement (psychiatry)	Shifting an emotion to a less threatening or neutral object or person Distinct from projection Projection: The affected individual extends emotions/thoughts about themselves to another person. Displacement: The affected individual shifts emotions/thoughts about one person to a less threatening person or object. Common response to acute anxiety	A man punches a wall after an argument with a colleague rather than confronting them. A mother demonstrates feelings of anger towards her child instead of her husband, who is the actual source of her frustration.
Intellectualization (psychiatry)	Using abstract, rational, and/or logical reasoning to avoid affective expression and distance oneself from stress Common response to emotional stress	A woman reacts to the diagnosis of a terminal illness with excessive investigation into the pathophysiology of and treatment modalities for the disease.
Isolation of affect (psychiatry)	Separating or repressing an idea from the associated effect or idea Accepting reality without the accompanying emotional response Common response to emotional stress or a traumatic event	A young man recalls traumatic events without showing any emotions.
Rationalization (psychiatry)	Offering excuses or feasible explanations in an attempt to justify behaviors, attitudes, or beliefs to avoid self-blame Common in OCD	A student claims that she failed a grade because all her teachers dislike her, instead of admitting that she has not studied all year.
Reaction formation (psychiatry)	Complete denial and/or rejection of an unacceptable impulse by acting in a diametrically opposite mannerto avoid anxiety-provoking thoughts Associated with anxiety disorders (compare with sublimation)	A homosexual individual is highly critical of same-sex couples.
Repression (psychiatry)	Thoughts are unconsciously removed from conscious awareness. Certain facts that were known and accepted at some point in life become absent from memory (compare with suppression).	An adult suffers a drowning experience as a child and develops an intense fear of swimming later in life, with no memory of the childhood experience.
Externalization (psychiatry)	Perceiving one's own personality in the external world and in external elements (including instinctual impulses, conflicts, moods, attitudes, and styles of thinking) Blaming others for the way one treats themself May be associated with ADHD or substance use disorders	A man perceives his partner as aggressive and himself as peaceful, although he is the aggressor. A mother blames her son for preventing her from having friendships, although she chooses to spend all her time with her son.
Dissociation (psychiatry)	Temporarily modifying personal identity, memory, consciousness, or motor activity in an extreme manner to avoid emotional distress The affected individual usually has partial/no recollection of the traumatic incident. See “Dissociative disorders.”	An individual who was abused as a child feels detached from their own body when they come into contact with their abuser.
Sexualization (psychiatry)	Endowing an object, person, or function with sexual significance Sexualization of a person is usually linked to sexual objectification of that individual.	A woman evaluates her partner based on their sexual significance only, excluding other characteristics.
Inhibition (psychiatry)	Consciously limiting ego functions, alone or in combination, to avoid anxiety arising out of conflict May be associated with anxiety disorders	A parent is unable to discipline a disobedient child out of fear of making them angry.

Mature defenses [27]

Overview of mature defenses
Mechanism	Description	Examples
Sublimation (psychiatry)	Shifting focus of unacceptable or unattainable impulses toward goal-directed activities Typically directing impulses in a more socially acceptable direction (compare with reaction formation)	An athlete uses their feeling of anger to motivate their training for a marathon.
Altruism (psychiatry)	Serving others constructively to experience a personal vicarious experience and to cope with difficult stressors Resolving guilty feelings by meeting the needs of others (compare with reaction formation)	A rich woman gives a homeless man her lunch.
Suppression (psychiatry)	Consciously postponing attention to an anxiety-provoking thought A temporary reaction that is easily recalled with the right stimulus(compare with repression)	A resident suppresses her fear of blood during surgery to provide necessary patient care.
Humor (psychiatry)	Using comedy to express feelings and thoughts to lessen personal discomfort and avoid emotional distress without producing an unpleasant effect on others	A new employee expresses a serious situation in the form of a joke.
Anticipation (psychiatry)	Realistic planning or premature worrying about future discomforts Associated with goal-directed behavior	An A-student goes over course notes in preparation for a lecture the following morning.

“SASHA is a mature adult”: Sublimation, Altruism, Suppression, Humor, Anticipation are mature defenses.

Coping strategies

What type of therapy is used for paranoid personality disorder?

Cognitive-behavioral therapy (CBT) can help someone with paranoid personality disorder recognize their destructive beliefs and thought patterns. By changing how these beliefs influence their behavior, CBT can help reduce paranoia and improve how well your loved one interacts with others.

What is the most common defense mechanism in psychology?

Denial is one of the most common defense mechanisms. It occurs when you refuse to accept reality or facts. People in denial may block external events or circumstances from the mind so that they don't have to deal with the emotional impact. In other words, they avoid painful feelings or events.

What is the most prominent feature of paranoid personality disorder?

The core feature of paranoid personality disorder is a pervasive distrust and suspiciousness of others. Afflicted individuals are reluctant to confide in others; they assume that most people will harm or exploit them in some manner.

Which defense mechanism is most characteristic of the patient with paranoid schizophrenia?

The results indicate that schizophrenic patients in comparison to healthy persons use the specific defense mechanisms (rationalization and negation) more often and have higher level of egocentrism. On the other hand both groups can be characterised by a low level of ability to change "ego".