Parts of the Freudian Psyche

1.1 Human Behavior as a Combination of Impulse

and Control
1.1 . 1 Id
Instinctive ( biological ) urges/ drives .
Sex and aggression; desires.
Can lead to overindulgence and disregard for needs of others.
"I want . "
USMLE ® Key Concepts
1.1 .2 Ego For Step 1, you must be able to:
Logical and language- based .
Recognize the existence of
Problem solving in context of reality. defense mechanisms in self
"I think . " and others.
Understand howto
1.1 .3 Superego differentiate between
Moral conscience is based on ideals and values of society. defense mechanisms, not
Directs appropriate behavior based on social ideals . just to memorize definitions.

Can lead to deprivation, so needs are not met. Understand how to respond
appropriately.
"I should."

1.1 .4 Defenses
Ways the ego tries to solve the twin problems of:
Mediating conflict between desires of the id and restrictions of
the superego.
Keeping person connected to reality at the same time.
Important:
— All defenses are unconscious ( below the level of awareness) .
\ Important Concept

Id: impulses from self

— Defenses change with changing circumstances.
— Defenses can be both good ( coping ) and bad ( pathological ) . Ego: Problem solving
— Pathology is determined by intensity and extent. Super-Ego: Values from others

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Chapter 5 • Defense Mechanisms Behavioral Science

Specific Defense Mechanisms

2.1 Primitive Defense Mechanisms

2.1. 1 Projection
Seeing what is within self as part of the outside world, either the
general environment or a particular person.
\ Important Concept

Projection: Seeing self in others

What is in self is projected onto others the way a movie projector
puts the movie on the screen.
" Self, seen in others . "
Produces paranoia, delusions .
Examples:
Man accuses his wife of having an affair, when he is attracted
to his new work colleague .
A soldier says, "I wasn ' t scared, but everyone else was . "

2.1.2 Denial
Refusal to accept some feature of objective reality.
\ Important Concept

Expected first response to bad medical news . Denial: Refusal to accept reality

First stage of grief.

Often seen in substance- use disorders.
Examples:
"Those tests may say I have cancer, but they are wrong."
"The bank statement says I' m out of money, but that just can 't
be right ! "

2.1 .3 Splitting
The world seen in terms of extremes .
Things are seen as "all good " or " all bad . " Can rapidly shift from
\ Important Concept

Splitting: Black and white

one to the other.
without shades of gray
Key symptom for borderline personality disorder .
Any extreme evaluation is likely the result of this defense.
Examples:
"You are the best doctor in the world . My old doctor was a
malpractice nightmare. "
"That man is pure evil and must be destroyed."

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Chapter 5 • Defense Mechanisms Behavioral Science

2.2 Basic Defense Mechanisms

2.2. 1 Blocking
A momentary gap in thinking . Important Concept

Disruptive; usually followed by an embarrassed reaction.

Blocking: Gap in thinking process
Content will come to mind again, but after the moment has passed .
Examples:
A moment after a student walks out of an exam she suddenly
remembers the answer to the one question that stumped her.
The doctor cannot recall the name of the disease when trying
to tell the patient the diagnosis.
Someone talking about a sensitive subject goes blank and
forgets the subject . "I'm sorry, what were you saying ?"

2.2.2 Repression Important Concept

An idea or feeling is deleted from conscious thought .
Repression : What was conscious
An unwanted idea is pushed and held outside of the
conscious mind . is permanently pushed from
awareness
Involves " unconscious" forgetting, with retrieval essentially
impossible .
A person who was a prisoner of war cannot recall a period in
captivity.
A boy who was sexually abused cannot recall time spent with
his uncle.
Contrast with suppression and denial.

Figure 5- 2.2A Repression

2.2.3 Displacement
Redirecting emotion or behavior to a different target .
\ Important Concept

The person who has the emotion or reaction stays the same, Displacement: Redirection to a
but the target shifts (contrast with projection ) . different target

Usually impulses are redirected to a less threatening, lower

status target .
Can be redirected in inanimate objects: After husband walks out,
wife throws a plate at the wall.
Person is not aware of displaced emotion or action ( unconscious ) .
Examples:
I' m angry at you, but I yell at him .
A person who is angry at the boss yells at the spouse instead .

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Chapter 5 • Defense Mechanisms Behavioral Science

2.2.4 Regression
Returning to an earlier level of functioning.
Regression often happens when people are tired, afraid, hungry,
or in pain. Frequently seen in medical settings.
\ Important Concept

Regression : Return to earlier

Children, although young, can still regress. functioning
Examples:
•An adult acts like a child.
A previously toilet- trained child develops enuresis after his
baby brother is born.
•" Baby talk " between sweethearts .
A patient breaks down crying hysterically when told bad news .
A man, tired at the end of the day, grunts and points at
something he wants rather than asking for it verbally.

2.2. 5 Somatization
Real, objective physical symptoms produced by psychological
processes.
\ Important Concept

Somatization: Psychological
Feelings manifest as physical symptoms .
action produces physical
" Symptom replaces anxiety. " symptoms
Examples:
Woman says she is not sad about her divorce, but complains
of headaches and GI upset.
Baseball player reports that his hands shake just before he
steps up to bat.
At the extreme, produces the somatic disorders .

2.2.6 Introjection (Identification)

Taking in behaviors and emotions observed in others, and making
\ Important Concept

them part of self. Introjection: Parts of the outside

brought in to make a self
Reverse process of projection .
Psychotherapy can be seen as getting rid of bad parts of self
and replacing them with better ones, often introjected from a
therapist.
Examples:
An abused child becomes an abusive parent ( identification with
the aggressor ) .
A medical student develops a bedside manner that is very
similar to her mentor ' s .
• Being a sports fan ( " Be like Mike ! ").
When conscious, we call this imitation .

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Chapter 5 • Defense Mechanisms Behavioral Science

2.2.7 isolation of Affect

Cognitive aspects of experience are retained while emotion
is discarded .
Facts retained; feelings disposed .
A Important Concept

Isolation of affect: Cognitive

Reality engaged, emotion absent. facts retained; emotion pushed
Examples: aside
Woman who was raped discusses the events without any
emotion .
A surgeon tells a patient about negative results without
empathy or sensitivity.

2.2.8 Intellectualization
Emotion expunged and replaced by excessive cognition.
A Important Concept

Intellectualization: Emotion
Intellect accentuated to push out feelings .
pushed aside and replaced with
Not conveying useful information, but keeping up the flow of excessive cognition
cognition as a way to avoid underlying emotion .
Examples:
Academic discussions, philosophical musings, focusing on
numerical data while talking with patient.
Physician speaking to patient who has a gunshot injury
uses Latin anatomic terms and describes the physics of
bullet velocity.

2.2.9 Acting Out

Filling self with alternative feelings and sensations to push away
actual underlying feelings .
\ Important Concept

Acting out: Emotion pushed

The stronger the feeling to be covered, the more dramatic the
aside and replaced with
covering sensations need to be .
excessive sensation-producing
Key: Emotional outburst is not what the person actually feels, behaviors
but a covering up of actual feelings.
Common covering behaviors: Getting drunk, driving fast,
overeating, having sex, playing music loudly, getting into fights.
In milder form: Flumming a tune as you go in to see a patient
for the first time.
Often seen in adolescents, post - traumatic stress disorder ( PTSD ) ,
and borderline personality disorder.
Differentiate from displacement.

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Chapter 5 • Defense Mechanisms Behavioral Science

2.2.10 Reaction Formation

Transforming unacceptable or unattainable emotion into its
exact opposite.
An exact attitude reversal : Love hate, joy despair
A Important Concept

Reaction formation: Expression

Look for overreaction ( "The lady protests too much, methinks. " ) of the opposite of what is felt
Examples:
From a fable : Fox cannot get the grapes, so he says, "They are
sour anyway. "
Person who does not like children becomes a pediatrician .
Young boys show they like girls by hitting them and calling
them names.
A mother who does not want her new baby is very solicitous
and overprotective.

Manifest

T
behavior

Figure 5- 2.2B Reaction Formation

2.2.11 Undoing
An action that reverses or fixes the unacceptable or intolerable.
Focal and behavioral .
A Important Concept

Undoing: Action to fix or repair

Sense of making things right again; fixing or atoning . the unacceptable
Compulsive behaviors as seen in obsessive compulsive disorder;
repeated vomiting for bulimia nervosa.
Examples:
Superstitions: " Knocking on wood "; salt thrown over shoulder
after it is spilled.
A man makes the sign of the cross as the airplane takes off.
• Checking and checking again to make sure the doors to the
house are locked .
Contrast with reaction formation .

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Chapter 5 • Defense Mechanisms Behavioral Science

2.2.12 Rationalization
Inventing a reason why the normally unacceptable is OK .
Unconscious justification .
Not reasoning about what to do, but giving reasons why
\ Important Concept

Rationalization: Reasons why an

something is done, or deciding it is acceptable. action or reason is OK
Looks for a list of reasons, usually not just one reason.
Examples:
"Yes, we killed women and children, but we were at war."
"If the room were not so darn noisy, I would have done better
on the exam . "
" Of course I took the bribe. Everybody does it."
Differentiate from intellectualization and reaction formation .

2.2.13 Passive Aggressive

Expression of hostility by delaying action or not acting at all .
\ Important Concept

Expectation of action followed by inaction. Passive aggressive: Hostility

expressed by inaction
Examples:
A woman makes a date to meet someone at a restaurant but
does not show up.
Patients who do not keep appointments, do not follow
instructions, or show up late are being passive aggressive.
( When this happens, figure out why they are angry, fix it,
and the behavior should fade .)
A professor ignores questions from a particular student after
class but answers questions for others.

2.2.14 Dissociation
Separating oneself from difficult or unbearable experiences .
k Important Concept

Person is having an experience, but is shielded from feeling the Dissociation: Self separated
full emotional weight of events . from experience
"Third- person experience" of events affecting you .
Feeling as if in a dream - like state, floating, feeling that things are
in slow motion.
Example:
A woman who was raped says that during the rape she felt as if
she were floating on the ceiling instead of being within her own
body (depersonalization ).
In extreme form, it produces dissociative disorders . Also seen
in substance abuse and in PTSD .
Differentiate from repression.

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Chapter 5 • Defense Mechanisms Behavioral Science

Mature Defense Mechanisms

3.1 Suppression
Conscious decision to push something out of consciousness.
\ Important Concept

Suppression: Conscious
Content can be recovered from the unconscious by the right cue decision to push things into
or stimulus. unconscious
Person has the ability to access the emotion later and accept it:
A medical student forgets about his workload while at a party,
but then remembers the test he has to study for as he returns
to his room.
As the music began to play, the woman suddenly recalled a boy
she dated in high school .
Different from repression in that content can be recalled .

Figure 5-3.1 Suppression

B.2 Humor
Venting of unpleasant feelings by laughter.
Not just a covering, but a release of feelings. You feel better after
\ Important Concept

Humor: The unpleasant

a good laugh .
becomes laughter
A way to recognize and cope with an unpleasant reality without
being overwhelmed by it.
Examples:
" When you said I needed a shot, I thought it would be tequila . "
"Every time you say carcinoma, I just keep thinking of little
gnomes driving cars around a track . "

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Chapter 5 • Defense Mechanisms Behavioral Science

3.3 Altruism
Helping others without apparent return to self.
Important Concept
Person gets unconscious benefit from:
• Making the world a better place. Altruism : Doing good to feel
• Relieving guilt that we have that others do not. good
Storing up credits to balance out future bad behaviors .
Examples:
A man who lost a leg in an accident volunteers at camps for
children with physical disabilities.
A ruthless business man donates to and takes great interest in
the local orphanage.
A wealthy woman volunteers weekly at a soup kitchen for
the poor.

3.4 Sublimation
Gratification is achieved by altering a socially unacceptable desire
into one that is acceptable.
\ Important Concept

Sublimation: Acceptable means

Much of art and music comes from this . to gratify unacceptable impulse

Examples:
Professor becomes a helpful mentor for a female student to
whom he is attracted .
Becoming a nutritionist to overcome personal obesity.
•A pedophile becomes a child photographer.

Manifest
behavior

Acceptable Unacceptable
Figure 5-3.4 Sublimation

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Chapter 5 • Defense Mechanisms Behavioral Science

3.5 Transference
In transference, emotions and reactions to someone in the past are
unconsciously carried forward and applied to someone in the present.
Unconscious process, but not a defense.
\ Important Concept

People have defense

Can be positive or negative . mechanisms because they need
Example: them. In psychotherapy, doctors
do not try to strip away defense
You meet someone for the first time and like them at once
mechanisms, but remove the
( positive transference) .
need for them. As an analogy,
•You hate them on sight (negative transference ) .
therapists do not take off
For displacement, you give the reaction to one person instead of patients ' coats on a cold day,
giving it to another. For transference, you had a reaction to someone but make it warmer so patients
in the past and then in addition have the same reaction to remove the coats themselves.
someone in the present .
For behaviorists, transference represents stimulus generalization .
Patient toward doctor = transference.
Doctor to patient = countertransference.

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