Interesting defence mechanisms of healthcare workers in COVID era, a case series.

COVID-19 has had a negative effect on mental health across the world's population. Healthcare workers, in particular, have experienced increased levels of psychological distress, depression, and anxiety. Any perceived stress to an individual can provoke psychological defence mechanisms. A study published in European journal of psychiatry assessed the various aspects of defence mechanisms used by healthcare workers to deal with COVID-19 pandemic state.

For healthcare workers, an observational cross-sectional study identified psychological distress in 37.4% of participants. At least moderate anxiety was identified in 30.7% and depression in 30.0% of study participants. Any perceived stress to an individual can provoke psychological defence mechanisms which is described as an unconscious psychological strategy, with or without resulting behaviour, which aims to reduce or eliminate anxiety arising from unacceptable or potentially harmful stimuli.

Vaillant proposed that response to stress can be viewed from two vantage points --- pathological or coping. A defence mechanism can become pathological when its persistent use leads to maladaptive behaviour, resulting in an adverse effect on an individual's social functioning, physical or mental health.

Coping responses to stress can be divided into three broad categories. These are (a) voluntarily eliciting help from appropriate others (e.g. by seeking social support), (b) voluntary strategizing (e.g. by gathering information, anticipating danger, and rehearsing responses to danger) and/or (c) involuntary defences (similar to fever and leucocytosis in physical health) which involve unconscious homeostatic mechanisms that reduce the disorganizing effects of sudden stress.

4 categories of defence mechanisms include:

1. Psychotic defences allow the individual to reconstruct external experiences and eliminate the need to cope with reality.

2. Immature defences lessen distress and anxiety produced by a perceived threat or an uncomfortable reality.

3. Neurotic defences allow an individual to avoid feelings of guilt and anxiety, particularly in relation to aggressive tendencies and sexual desires.

4. Mature defences are more conscious processes which enhance pleasure and feelings of control.

The present study aimed to describe a range of psychological defence mechanisms encountered within healthcare workers in relation to the COVID-19 pandemic.

Clinical vignettes from the study were:

(1)Denial --- As the frequency of news reports on the virus spreading across the world, a consultant psychiatrist did not want to accept the reality of this. The reality of the situation was too threatening and anxiety provoking. Therefore, it was easier from a cognitive perspective to deny the virus being a real threat.

(2) Hypochondriasis --- A psychiatry trainee started to think more and more about the impact of catching 'the virus'. They had a diagnosis of asthma and several elderly family members in residential care. They recurrently asked their peers about how to minimise the risk of catching the virus, and checked up on daily guidelines multiple times a day. Despite peers offering advice and support, the psychiatry trainee did not accept this advice. It was perceived by the trainee that their colleagues were not being affected as much by COVID-19 as the trainee themselves, and therefore their advice was deemed not good enough.

(3) Altruism --- A psychiatry trainee took it on themselves to take on multiple extra shifts to cover for colleagues who were self-isolating. He gained satisfaction knowing that he was able to help out others by working during the outbreak and combatting the virus.

(4) Sublimation --- A psychiatry trainee felt irritated at the fact that he had to go into work to do excessive hours whilst his partner has been placed on furlough and was getting paid to sit at home. Instead of letting this bring his spirit down however, he volunteered to create the new rota for trainees during COVID-19 to cover for staff shortages. This converted some of his negative energy into more positive thoughts as he felt he was making a difference to others.

(5) Humour --- A member of nursing staff donned full personal protective equipment to demonstrate the current guidelines to other members of staff. She had an unusual appearance, and when walking down the corridor did a dancing motion. Whilst the reasons for wearing this equipment were very serious, some laughter enhanced the mood in what could have been otherwise a very sombre occasion.

These defences are proposed to be dynamic and reversible. They are not necessarily negative to an individual, and can be adaptive or creative, but can also be harmful and pathological.

It has been proposed that defence mechanisms associated with the COVID-19 pandemic could be more typically immature, in that anxiety over the viral outbreak can be temporarily alleviated by alteration of painful mental contents and/or radical distortion of external reality. Excessive use of immature defences is a risk factor for the development of psychopathology. Despite this, defence mechanisms, have also played an important role as protective factors against psychological distress during the COVID-19 pandemic. Utilisation of defence mechanisms can promote mental resilience.

In conclusion acknowledgement of psychological defence mechanisms and their implications on day to day practice should be encouraged. Whilst defence mechanisms can have a number of negative consequences, they also have an important role, particularly in the case of mature defence mechanisms, as protective factors against psychological distress and symptom formation.

Source: European Journal of psychiatry: https://doi.org/10.1016/j.ejpsy.2020.10.005