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Year : 2019  |  Volume : 40  |  Issue : 1  |  Page : 41-47

Defense style and dissociative phenomena in patients with borderline personality disorder

Department of Psychiatry, Faculty of Medicine, Minia University, Minia, Egypt

Date of Submission08-Nov-2018
Date of Acceptance02-Dec-2018
Date of Web Publication9-May-2019

Correspondence Address:
Nashaat A.M Abdel-Fadeel
Department of Psychiatry, Faculty of Medicine, Minia University, Minia, 61111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejpsy.ejpsy_35_18

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Introduction Patients with borderline personality disorder (BPD) are unique and diverse in their pathology, defense style, and clinical presentations. Many of these patients have other personality disorders as well. They tend to display a wide range of other psychiatric disorders, including dissociative phenomena and experiences.
Patients and methods A total of 60 female patients were diagnosed with BPD using the Diagnostic and Statistical Manual of Mental Disorders, IV ed. Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Severity of illness and emotional and behavioral aspects of patients were assessed using Borderline Evaluation of Severity over Time. Defense style of patients was assessed using the Defense Style Questionnaire. Dissociative phenomena were studied using the Dissociative Experience Scale (DES).
Results The most commonly used defenses by the study patients were undoing, idealization, somatization, and splitting. Patients with absent criteria 4 (impulsivity) and 7 (feeling of emptiness) of BPD significantly displayed more mature defenses, whereas patients having criterion 9 (paranoid ideation and severe dissociation) of BPD significantly displayed neurotic type of defenses. Mature defenses were significantly negatively correlated with the absorption and depersonalization factors of DES. Neurotic defenses were significantly correlated with the total score of DES, absorption, and depersonalization factors. Immature defenses were significantly correlated only with the depersonalization factor of DES.
Conclusion Patients with BPD have a specific pattern of defense style that might be linked to their specific illness criteria. Displaying certain phenomena of dissociation might be related to the particular pattern of the dominant defense mechanisms in these patients.

Keywords: borderline personality, defense style, dissociative phenomena

How to cite this article:
Abdelhameed MA, Seddik MT, Abdel-Fadeel NA. Defense style and dissociative phenomena in patients with borderline personality disorder. Egypt J Psychiatr 2019;40:41-7

How to cite this URL:
Abdelhameed MA, Seddik MT, Abdel-Fadeel NA. Defense style and dissociative phenomena in patients with borderline personality disorder. Egypt J Psychiatr [serial online] 2019 [cited 2023 Dec 10];40:41-7. Available from: https://new.ejpsy.eg.net//text.asp?2019/40/1/41/257850

  Introduction Top

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines the main features of borderline personality disorder (BPD) as a pervasive pattern of instability in interpersonal relationships, self-image, and affects, as well as impulsive behavior (American Psychiatric Association, 2013). Suggestions for other names include emotional regulation disorder or emotional dysregulation disorder and interpersonal regulatory disorder (Gunderson and Hoffman-Perry, 2005)

The lifetime prevalence of BPD in the general population is estimated to be 1–2% (Coid et al., 2003). Comorbidity with other personality disorders (PDs) is expected in approximately two-thirds of patients with BPD (Grant et al., 2008).

Kernberg (1967) described the borderline psychopathology and its core features. Among these features, he listed five defense mechanisms: devaluation, omnipotence, primitive idealization, projective identification, and splitting. These defenses have progressively become strongly associated with the borderline diagnosis (Kernberg, 1967).

Bond et al. (1994) administered the Defense Style Questionnaire (DSQ) to 78 patients with BPD, and another 72 patients with other PDs. They found that borderline patients had significantly higher scores on the scales measuring maladaptive action and image distorting/borderline defenses and a significantly lower score on the scales measuring adaptive defenses.

Koenigsberg et al. (2001) studied the relationship between the BPD traits of affective instability and impulsive aggression and the DSQ scores for 20 defense mechanisms. Scores on affective instability were found to be significantly correlated with scores on six defense mechanisms: undoing, acting out, passive aggression, projection, schizoid fantasy, and splitting.

The term dissociation describes a spectrum of experiences ranging from mild detachment from immediate surroundings to marked detachment from experience (whether physical or emotional). The dissociative phenomena involve a detachment from reality, excluding loss of reality as in psychosis (Dell, 2006).

Dissociative symptoms and disorders are common and represent one of the nine criteria in the DSM-IV for BPD: ‘transient, stress-related paranoid ideation or severe dissociative symptoms’ (Spitzer et al., 2006).

Ross (2007) found that 59% of patients with BPD met the criteria for a DSM-IV-TR dissociative disorder. In addition, Korzekwa et al. (2009) concluded that more than 60% of patients with BPD do have dissociative symptoms.

In a study done by Zanarini et al. (2008), Dissociative Experience Scale (DES) scores classified patients with BPD (according to dissociative experiences) into the following: low dissociators (32%) (DES scores, 0–10), moderate dissociators (42%) (DES scores, 10–29), and severe dissociators (26%) (DES scores, ≥30).

  Patients and methods Top

This study design had a cross-sectional and retrospective questionnaire-based format. Participants completed a series of self-report and semistructured questionnaires and interviews.

Our sample included 60 patients diagnosed with BPD with or without dissociation. The sample was recruited from those attending or referred to the psychiatry outpatient clinic in Minia University Hospital.

Inclusion criteria

The inclusion criteria were as follows: DSM-IV diagnostic for BPD age 18–50 years, and female patients only.

Exclusion criteria

The following were the exclusion criteria: current active depressive disorder (DSM-IV criteria for depressive disorder), current active psychotic illness, serious somatic disease (e.g. cancer, severe rheumatic disease, and severely painful medical conditions), and substance use disorders (recreational use was not excluded).

Ethical considerations

Written consents have been collected from all participants after informing them about the purpose and procedures of the study. Participants were informed of their rights as research patients and the measures taken to protect their confidentiality.

Procedures of the study

Patients had been diagnosed clinically by their referring psychiatrists as having BPD with or without dissociative manifestations.

Diagnosis of BPD was confirmed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) (First et al., 1997), which was done by two approaches. First, all participants were assessed by using all the 119 questions that correspond to the diagnostic criteria for the 10 different PDs in addition to passive aggressive and depressive PDs. Following this, the SCID-II interview items were pursued for those disorders where full DSM-IV criteria were met.


  1. SCID-II((Firstet al., 1997).
    • The SCID-II is an efficient, standardized, and reliable tool for accurate diagnoses of the 10 DSM-IV Axis II PDs as well as depressive PD, passive aggressive PD, and PD not otherwise specified. It has good reliability (Lobbestael et al., 2011) and convergent validity (Skodol et al., 1991).
  2. Borderline Evaluation of Severity Over Time (BEST).
    • The BEST is a 15-item measure used to test for borderline personality symptoms. It is a self-report questionnaire to measure the severity of and change in borderline personality symptoms over the course of treatment.
    • It consists of three subscales: the first two subscales (A and B) are based on the DSM-IV criteria for BPD. Subscale A (eight items) addresses problematic thoughts and feelings that are characteristic of BPD (including suicidal thoughts), whereas subscale B (four items) addresses problematic or negative behaviors (i.e. problems with impulsive behavior). The third subscale of BEST, subscale C, consists of three items that assess the use of positive behaviors. These items are rated based on frequency over the course of a week (Pfohl et al., 2009).
    • The BEST is scored in three steps. Adding the scores of the individual items in subscales A and B derives subscale scores. The total frequency of behaviors in subscale C is then calculated and subtracted from the summed scores for subscales A and B, giving the total scale score.
  3. DSQ-40.
    • The DSQ-40 is a 40-item self-reported questionnaire that measures 20 individual defense mechanisms grouped into three factors: immature, neurotic, and mature (Andrews et al., 1993). The DSQ-40 was reported to be the most frequently used self-reported tool for defense mechanisms (Chabrol et al., 2005). The Arabic version was used in our study (Soliman, 1996).
    • The immature factor includes the defenses of projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalization, and somatization. The neurotic factor includes the defenses of undoing, pseudo-altruism, idealization, and reaction formation. The mature factor includes the defenses of sublimation, humor, anticipation, and suppression.
  4. The DES.
    • Bernstein and Putnam (1986) developed the DES. It is a screening tool for dissociative disorders. It is easy to understand and simple to interpret. It is scored on a continuum from 0 to 100, where a score of 30 or higher is considered suggestive of severe or pathological dissociation. It is generally considered to have good reliability and validity (Yargic et al., 1995).

Items from the DES for each of the three main factors of dissociation.
  1. Amnesia factor:
    • This factor measures dissociative memory loss or disturbance.
  2. Depersonalization/derealization factor.
    • Depersonalization means the recurrent experience of a sense of unreality of the self, or feeling detached from one’s self and mental processes. On the contrary, derealization is the sense of a loss of reality of the surrounding environment.
  3. Absorption factor.
    • This factor includes being intensely preoccupied or absorbed by something to the degree of being distracted from what is happening around.

  Results Top

As shown in [Table 1], our sample included 60 female patients, with the mean age of 26.17 years. Approximately half of them were single (51.7%) and unemployed (48.3%).
Table 1 Demographic data of the total sample (N=60)

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As shown in [Table 2], five (8.3%) patients had only five SCID-II borderline criteria (minimum number essential for diagnosis), 10 (16.75%) patients had six borderline criteria, 20 (33.3%) patients had seven borderline criteria, 18 (30%) patients had eight borderline criteria, and seven (11.7%) patients had the all nine borderline criteria.
Table 2 Borderline personality disorder severity according to the number of borderline criteria as measured by Structured Clinical Interview for DSM-IV Axis II Personality Disorders

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As shown in [Table 3], according to BEST, problematic thoughts and feelings (subscale A) scores showed a range of 16–40, with a mean of 27.2±5.94; problematic or negative behavior (subscale B) scores showed a range of 8–20, with a mean of 13.7±2.64; positive behavior (subscale C) scores showed a range of 4–12, with a mean of 8.2±1.8; and the total BEST score (A+B−C+15) showed a range of 27–65, with a mean of 47.3±8.7.
Table 3 Severity of borderline personality as measured by Borderline Evaluation of Severity over Time

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As shown in [Table 4], immature and neurotic defense mechanisms are those used substantially, whereas mature defenses are those least to be used in patients with BPD. The main immature defenses used are acting out, splitting, and somatization, whereas the main neurotic defenses used are idealization, undoing, and pseudo-altruism.
Table 4 Individual defense mechanisms as measured by the Defense Style Questionnaire

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[Table 5] shows that mature defenses used by borderline patients had higher mean and SD in patients who had absent criteria (1, 2, 4, 5, 6, 7, and 9) and lower in patients who had absent criteria (3 and 8), but all these differences were not statistically significant, except with criteria 4 and 7.
Table 5 Comparison between types of defense mechanisms as measured by Defense Style Questionnaire in relation to individual borderline personality criteria

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However, neurotic defenses had higher mean and SD in borderline patients with absent criteria (1, 2, 4, 5, and 6), whereas the mean and SD of such defenses were higher in patients with criteria (3, 7, 8, and 9), but all these differences were not statistically significant except with criterion 9. Regarding immature defenses, they had lower mean and SD in patients who had absence of all criteria, but these differences were not statistically significant.

[Table 6] shows that mature defenses were negatively correlated with scores of subscales A (problematic thoughts) and B (negative behaviors), whereas positively correlated with scores of subscale C (positive behaviors), and all of these correlations were statistically significant. Neurotic defenses were positively correlated with scores of subscales A (problematic thoughts), B (negative behaviors), and C (positive behaviors), but none of these correlations were statistically significant. Immature defenses were significantly positively correlated with scores of subscales A (problematic thoughts) and B (negative behaviors) whereas nonsignificantly negatively correlated with scores of subscale C (positive behaviors).
Table 6 Correlation between scores of groups of defenses of patients with borderline personality disorder as measured by Defense Style Questionnaire and borderline severity as measured by Borderline Evaluation of Severity over Time

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[Table 7] shows that mature defenses were associated with less dissociative phenomena, where mature defenses were significantly negatively correlated with amnesia, whereas the higher the scores of neurotic and immature defenses, the higher the scores for dissociative experiences, as neurotic defenses were significantly positively correlated with absorption, depersonalization, and DES total score while immature defenses were significantly positively correlated with depersonalization.
Table 7 Correlation between dissociation (as measured by Dissociative Experience Scale) and defense style (as measured by Defense Style Questionnaire) in borderline personality disorder

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  Discussion Top

It is difficult to find reasonably reliable methods for assessing the presence of defenses mechanisms or at least, their conscious products of behavior and responses (Zanarini et al., 2009). Defense mechanisms used by patients with borderline disorder have been studied to determine if these defenses discriminate patients with borderline from those with other diagnoses (Zanarini et al., 2009).

The DSQ, which is a self-report measure designed to study the conscious outcome of unconscious mechanisms of defense developed by Bond et al. (1983), was used repeatedly to study the defense mechanisms in patients diagnosed with BPD (Bond, 1990; Bond et al., 1994; Paris et al., 1996; Koenigsberg et al., 2001).

In the current study, we used DSQ-40 to assess defenses. We found that neurotic defenses were the most commonly used defenses by patients with BPD, followed by immature and finally mature defenses. These findings are consistent with the findings of Zanarini et al. (2009) who found that patients with BPD tended to use primitive defenses, such as splitting, acting out, projection, projective identification, passive aggression, and autistic fantasy more than mature mechanisms (suppression, humor, and sublimation).

In addition, we found that patients with BPD had a particular style of defenses assessed by DSQ. The ten most frequently used defenses were acting out, splitting, somatization, idealization, undoing, pesudo-altruism, devaluation, rationalization, autistic fantasy, and displacement. Zanarini et al. (2013) compared 290 patients with borderline disorder with a sample of 72 patients with other PDs. They reported their patients with borderline disorder to score significantly higher on undoing, acting out, emotional hypochondriasis, passive aggression, projection, projective identification, in addition to splitting.

Three defenses seem to be reported significantly both in their study and in the current one (acting out, splitting, and undoing). However, the difference in the rest of reported defenses may be related to the comparative nature of their study and the fact that they included both male and female patients, whereas ours included females only.

On the contrary, comparing the findings of the current study with the hypothesized borderline organization (Kernberg, 1967), it was found that three of the previous mostly used defenses by BPD in the current study (idealization, devaluation, and splitting) are among the five most strongly used defenses by BPD according to Kernberg (1967), which were devaluation, omnipotence, primitive idealization, projective identification, and splitting. However, as noticed, the hierarchical arrangement of defenses is different among the two studies, which might be explained by the fact that all our patients were female borderline, whereas Kernberg was referring to an organization that extends to both sexes including other PDs, such as antisocial and narcissistic PDs.

In comparison with other studies, Perry and Cooper (1986) assessed the defensive profile of 73 patients meeting DSM-III criteria for BPD. They were able to identify two groups of defenses in their patients with BPD: action defenses (acting out, hypochondriasis, and passive aggression) and image distorting/borderline defenses (projective identification and splitting). Borderline psychopathology was significantly correlated with these two sets of defenses. They did not find devaluation or primitive idealization to be strongly associated with borderline illness, which seems to be different from the results reported in the current study. However, they assessed the presence and magnitude of defense in their patients by semistructured interview and not by a self-report tool as in our study, which may partially explain the difference in the reported assessment.It could be suggested that using more than one method of defense assessment might be useful in adding more information on the defense style of different patients. However, comparison of the results of these different methods of assessment may carry additional research difficulties as well (Presniak et al., 2010).

The relationship between type of defenses used by BPD and individual BPD criteria according to DSM-IV (either absent or present) showed that mature defenses were negatively associated with the presence of BPD criteria, but this relationship was statistically significant regarding criteria 4 (impulsivity) and 7 (feeling of emptiness) only. On the contrary, the use of neurotic and immature defenses by BPD was not particularly related to any BPD criteria (either present or absent), except the positive significant association between neurotic defenses and the presence of criterion 9 (paranoid ideation and severe dissociation). It is worth mentioning here that this criterion includes the occasional episodes of severe dissociation, which is the issue of this study.

The current study results were in agreement with what was found in a study done by Koenigsberg et al. (2001) (a sample including 41 patients meeting DSM-III-R criteria for BPD). Their measures of affective instability were significantly correlated with scores on six defense mechanisms: undoing, acting out, passive aggression, projection, schizoid fantasy, and splitting (mostly immature defenses). Bowins (2010) suggested that patients with BPD have an extremely defective regulation of defensive strategy application, leading to intense emotional distress and marked overuse of immature defenses.

Regarding correlation between groups of defenses of patients with BPD diagnosed by DSQ and their scores of BEST measuring borderline illness severity, it was found that mature defenses were negatively correlated with total score, subscale A (problematic thoughts), and subscale B (negative behaviors) of BEST, and positively correlated with subscale C of BEST (measuring a range of positive behaviors), and all of these correlation were statistically significant. These results indicate an association between the use of mature defense mechanisms and displaying positive and adaptive behaviors by patients with BPD. Bond et al. (1994) suggested that severe and long-term use of immature defenses contributes to the development of BPD. We could argue that those patients with more mature defenses could have less intensely developed borderline personality pathology, with the chance of having relatively more positive and adaptive behaviors.

On the contrary, immature and neurotic defenses were positively and significantly correlated with scores of subscale A (problematic thoughts) and B (negative behaviors) and the total score of BEST, and negatively correlated with subscale C (positive behaviors) of BEST (statistically insignificant). This could be interpreted as an association between the use of more primitive and less adaptive defense style and the presence of a more pathological thinking and behavioral profile in patients with BPD of our study.

The current study results were in line with the results reported earlier in a study by Simeon et al. (2003). They administered the DES and DSQ on 20 patients with BPD and 24 healthy comparison patients of similar age and sex, and they found that within the BPD group, dissociation was associated with the use of immature defenses. Their study was, however, a preliminary one with a small sample size, yet it shed light on the importance of studying the correlations between defense style and dissociation in BPD.[30]

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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