Comparison of the life events＇social support and defense mechanisms between patients with social phobia and normal controls in China

Di Ying DONG，Guang Yan ZHOU

Comparison of the life events＇social support and defense mechanisms between patients with social phobia and normal controls in China

Di Ying DONG*，Guang Yan ZHOU

Background：It is uncertain how stressful life events，social support networks and psychological defense mechanisms interact with each other to ameliorate or exacerbate the impairment in social functioning experienced by patients with a diagnosis of social phobia.

Objective：Compare the relationship of stress，social support and defense mechanisms between patients with social phobia and normal control subjects.

Methods：38 newly diagnosed patients with social phobia seen at the Zi Lang Hospital in Nantong between October 2009 and August 2010 were administered a Life Event Scale，the Social Support Rating Scale and the Defense Style Questionnaire.The results were compared with those for 38 normal controls.

Results：There were no differences in the in the numbers of positive and negative life events between the two groups but the psychological impact of both positive and negative life events on the social phobia group were significantly greater than on the control group.Based on the results of the Social Support Rating Scale the mean(SD) scores of objective support，subjective support，total support and utilization of social support in the social phobia group were all significantly lower than those in the control group.Results of the Defense Style Questionnaire showed that compared to the control group the total score for immature defenses was significantly higher(i.e.，respondents were more likely to report using these defenses)and the total score for the mature defenses was significantly lower in the social phobia group.The social phobia group was significantly more likely to report using the neurotic defenses of repression，avoidance，isolation，and increased social association but significantly less likely to report using the neurotic defenses of reaction formation，denial，and anticipation.

Conclusion：Differential patterns of life events do not appear to be important in the etiology of social phobia.Compared to normal control subjects，patients with social phobia have a less developed social support network，are less likely to use available social support and are more likely to employ immature defense mechanisms.

Life events;Social Support;Psychological Defense Mechanism;Social Phobia

1 Introduction

The development of disabling social phobias has been attributed to the complex interplay of a wide range of factors：genetics，temperament［1］，parental influences［2-4］，early traumatic events［5，6］and cognitive biases［7-11］.Individuals'psychological and physiological responses to events in their social world affects the maturation and functioning of their nervous system and，thus，play a crucial role in the etiology of social phobia［7］.Studies about social phobia conducted in other countries have simultaneously focused on social and psychological factors［12］，but studies in China tend to focus on either psychological or social factors［13，14］.Identifying the life events that precipitate social phobia and understanding the role of social support networks and psychological defense mechanisms in mitigating or exacerbating the negative effects of these traumatic life experiences is a reasonable approach to understanding the etiology，prevention and treatment of this condition［15，16］.The current study aims to compare these factors between persons with social phobia and normal control subjects.

2 Methods

2.1 Study population

Enrolled subjects were consecutive patients seen from October 2009 to August 2010 at thepsychology department of the Nantong Zi Lang Hospital who met the following inclusion and exclusion criteria：1)over 18 years of age，2)had finished elementary school，3)meet diagnostic criteria of Social Phobia as described in the third edition of the Chinese Classification of Mental Disorders

(CCMD-3)［17］，4)had no co-morbid psychiatric disorders，5)had no serious medical conditions，and 6)provided written informed consent to participate in the study.The control subjects were employees working at the hospital at the time of patient recruitment who underwent a through physical and psychological evaluation to ensure that they meet the same inclusion and exclusion criteria as the patients except that they had no mental illness and that they reported no mental illness in their first-degree relatives.The study was approved by the institutional review board of Zi Long Hospital.

2.2 Instruments

2.2.1 General demographic form

This instrument，compiled by the authors，recorded subjects'sex，age，occupation，years of education，marital status，and(in patients)the age of onset and duration of the social phobia.

2.2.2 Life Events Scale

The Life Event Scale(LES)used in this study is a 48-item，self-completionscaledevelopedby Zhang and Yang［18］that includes 28 items about family life，13 items about work and school，and 7 items about other life events.The scale has both positive and negative life events and differentiates single events(for which the frequency of occurrence is recorded)from persistent events(those that last longer than 6 months are considered 2 separate events).The severity of the psychological impact of each life event is coded on a 5-point scale (0=none to 4=extremely severe)and the duration of the psychological impact is categorized on a 4-point scale(1=less than 3 months，2=3-6 months，3=6-12 months，4=over 12 months).The cumulative psychological‘impact'of each life event is the product of the frequency，severity and duration scores for the event.This scale has been widely used in China［18］and has an acceptable test-retest reliability(Kappa=0.611-0.742［19］)though its validity has not been thoroughly assessed.

2.2.3 Social Support Rating Scale

The 10-item self-completion Social Support Rating Scale(SSRS)developed by Xiao［20］assesses objective support，subjective support and utilization of social support.Objective support includes items such as‘Do you live with your family，friends，or colleagues'，and‘When you need economic support，do you have the support of your spouse，relatives，religious groups，governmental agencies，or yourworkplace？'Subjectivesupportincludes questions such as‘How many friends do you have who can support you when you need help？'and‘How much aid do you think your neighbors would give you？'Utilization of social support involves questions such as‘How often do you participate in religious and social groups，or political party gatherings？'and‘When you have problems，do you ask for help or always try to solve the problem yourself？'This scale has also been widely used in China.The scale has a test/retest reliability of 0.92［20，21］，but studies of its validity have yet to be conducted.

2.2.4 Defense Style Questionnaire

The Defense Style Questionnaire(DSQ)is an 88-item self-completion scale［22，23］that was translated from English and revised by Lu and colleagues［24］.Each item is a nine-point Likert scale (from strongly disagree to strongly agree).As shown in Table 3，the questionnaire assesses four classes of psychological defenses：Factor I)immature defenses including projection，passive-aggression，acting out，complaining，autistic fantasy，dissociation，regression and somatization;Factor II)mature defenses including sublimation，suppression，and humor;Factor III)neurotic defenses including reaction formation，undoing，repression，avoidance，idealization，pseudo-altruism，omnipotence/devaluation，isolation，identification，denial，anticipation，increased social association，and increased consumption;and Factor IV)concealing(i.e.，purposely concealing the truth).Changes to the original questionnaire by Bond and colleagues include the deletion of some items(e.g.，help-rejecting)，the addition of anticipation as one of the neurotic defenses and the inclusion of the fourth factor.This scale has been widely used in China and has good reliability and validity［25，26］.

2.3 Statistical methods

SPSS 13.0 software was used for statistical analysis.Chi squared tests were used to compare categorical variables between the two groups，ttests were used to compare normally distributed continuous variables，and the rank sum test was used to compare continuous variables that were not normally distributed(e.g.，the number of positive life events).

3 Results

3.1 Socio-demographic characteristics

Figure 1 shows the enrollment of patients and controls for the study.Among the 38 enrolled patients，there were 17 males and 21 females;their mean(SD)age was 28.4(9.0)years(range，18-40);their mean duration of schooling was 13.0(3.6)years(range，9-19);27 were married，8 were single，and 3 were divorced;the mean age of onset of the social phobia was 27.1(8.2);and the median(IQR)duration of illness was 22.0(12.0-34.0)months(range，4-50).Among the 38 em ployees who completed the evaluation，there were 19 males and 19 females;their mean(SD)age was 29.1(9.2)years(range，20-39);they had com-pleted a mean of 13.1(3.4)years of schooling (range，6-16);and 26 were married，10 were single and 2 were divorced.There were no statistically significant differences in the sex ratio(χ2=0.21，P=0.180)，age(t=0.34，P=0.731)，years of schooling(t=0.12，P=0.902)，or marital status (χ2=1.43，P=0.794)between the two groups.

3.2 Comparison of Life Event Scale scores

There were no significant differences in the number of negative life events，positive life events or total life events experienced by subjects in the social phobia and normal control groups.However the cumulative psychological impact of both negative and positive life events was significantly greater in the social phobia group(Table 1).

3.3 Comparison of Social Support Rating Scale scores

The Cronbach α values for the subscales of the Social Support Rating Scale(using all 76 respondents' results)were all above 0.75，indicating that the scale and its subscales had good internal consistency.The total scores for social support，subjective support，objective support and utilization of social support were all significantly lower in the social phobia group than in the control group(Table 2).

3.4 Comparison of Defense Style Questionnaire results

As shown in Table 3，The Cronbach α values for the factor scores and specific defense mechanism scores in the Defense Style Questionnaire (using all 76 respondents'results)ranged from 0.626 to 0.823，indicating that the internal consistency of the items for each defense mechanism is fair to good.The overall factor score for immature defense mechanisms was significantly higher in the social phobia group and the factor score for mature defense mechanisms was significantly lower in the social phobia group，but the overall factor scores for neurotic defense mechanisms and for the concealing defense mechanism factor were not significantly different between the two groups.Among the immature defense mechanisms，projection，complaining，autistic fantasy，regression and somatization were significantly higher in the social phobia group.The mature defense mechanism of suppression was significantly higher in the normal control subjects.Results for the neurotic defense mechanisms were mixed：compared to normal controls patients with social phobia were more likely toreport using repression，avoidance，isolation，denial and(surprisingly)increased social association but less likely to use reaction formation，denial and anticipation.

4 Discussion

4.1 Main Findings

Our findings with Chinese patients who have social phobia confirm earlier work by Holmes and Rahe［13，27，28］and other researchers［14］that report no direct relationship between the type and number of stressful life events and the subsequent development of mental illness.We did，however，find that the cumulative psychological impact of both positive and negative life events was much higher in the patient group，suggesting that their reaction to routine life events was much stronger than that of normal control subjects.

Two factors that might help explain this increased sensitivity to life events are the individual's social support network and his or her personality style.Our study confirms the early work of Andrews and colleagues［29］which found that social support has a direct impact on the development of anxiety，independent of life events.We found that both objective and subjective social support and，importantly，the utilization of social support were much lower in social phobia patients than in normal controls.This suggests that insecurity and distrust of close associates initiates a vicious cycle that magnifies avoidance of social situations.The person with social phobia is thus never able to lay the foundation for future support from others;even when they do have social support，they may not trust this support to be there in times of need［30］. These findings are concordant with psychodynamic theories about the etiology of anxiety which posit that at the earliest stage of development social support systems are essential to the stabilization of object relations.The quality of the first social relationship(i.e.，the mother-child attachment)will exert a strong influence on a child's sense of trust in other people;uncertainty about their mother's love［10］resultsinanxietythatsubconsciouslyremains throughout one's life and can lead to the development ofanxietydisorders［2］.Degnanandcolleagues［31］propose a psychodynamic explanation for social phobia which states that insecure attachment relationships contributed to the formation of social phobia.

We also found that patients with social phobia were more likely to use immature and neurotic defense mechanisms than healthy controls.This result confirms the work of other researchers［14，32］and supports psychodynamic theories about the etiology of anxiety disorders［2］which suggest that individuals with pathological levels of anxiety will be more likely to use the defense mechanisms of displacement and avoidance.The patients in this study were more likely than control subjects to employ avoidance and projection—a form of displacement of negative emotions about oneself.We also found more frequent use of fantasy，regression，somatization and isolation in subjects with social phobia. This suggests that if the fear of social situations is great enough the patient with social phobia would turn to fantasy，regression，somatization or isolation to escape their inner conflicts and fears.As expected，subjects in the normal control group were more likely to employ the mature defense mechanism of suppression，which allows the person to continue to function despite their internal struggles.

There were，however，some unexpected findings.Normal controls reported using more reaction formation and anticipation—which are not usually considered mature defense mechanisms—than patients with social phobia.Reaction formation involves the taking of the opposite emotion in the face of a conflict;it is possible that this defense mechanism is more‘effective'and mature in Chinese culture.Some theorists consider anticipation a mature defense mechanism［33］;a contention that is supported by these findings.Perhaps the most surprising result was the more frequent use of increase social association in the social phobia group;if confirmed in other studies this finding could suggest that persons with social phobia want to affiliate with others more but are so fearful that they are unable to do so.

4.2 Limitations

This is a cross-sectional study in a relatively small number of subjects so the results must be considered preliminary.The control subjects were similar to the patient group on basic demographic parameters but they were not randomly selected and many eligible control subjects did not complete the questionnaires so there may be unrecognized biases.We did not assess the relationship of social support to the use of defense mechanisms，an analysis that may have clarified interactions between these factors in the etiology of social phobia. No causal relationships can be inferred from this analysis：it is equally possible that social phobia leads to or is caused by reduced social support and to the use of certain defense mechanisms.Larger longitudinal studies(preferably starting in childhood)are needed to confirm the causal direction of these relationships and to clarify the complex interaction between life events，social support and defense mechanisms.

4.3 Implications

Patients with social phobia are prone to use certain defense mechanisms，have less social support and are less likely to use available social support than normal control subjects.Further prospective research is needed to confirm the etiological role of these factors but these tendencies typically develop in childhood or early adult life so the resulting social phobia is often a chronically disabling condition that is difficult to treat.

Funding

1. Jiang KD.Textbook of advanced psychiatry.Beijing：People's Military Medical Press，2009：186.(in Chinese)

2. Liu DT，Li XJ.Developmental psychopathology of social anxiety disorder(review).Chin Mental Health J，2008，22(5)：376-381.(in Chinese)

3. Ayoub CC，O'connor E，Rappolt-Schlichtmann G，Fischer KW，Rogosch FA，Robinson A，et al.Cognitive and emotional differences in young maltreated children：a translational application of dynamic skill theory.Dev Psychopathol，2006，18：679-706.

4. Gabbard GO.Psychodynamics of panic disorder and social phobia.Bull Menninger Clin，1992，56(2)：A3-A13.

5. Cohen RA，Grieve S，Hoth KF，Paul RH，Sweet L，Tate D，et al. Early life stress and morphometry of the adult anterior cingulate cortex and caudate nuclei.Biol Psychiatry，2006，59 (10)：975-982.

6. Bandelow B，Torrente A，Wedekind D，Broocks A Hajak G，Ruther E.Early traumatic life events，parental rearing styles，family history of mental disorders，and birth risk factors in patients with social anxiety disorder.Eur Arch Psychiatry Clin Neurosci，2004 Dec，254(6)：397-405.

7. Gabbard GO.Psychodynamic psychiatry in the"decade of the brain".Am J Psychiatry，1992，149(8)：991-998.

8. Wells A，Papageorgiou C.Social phobic interoception：effects of bodily information on anxiety，beliefs and self-processing. Behav Res Ther，2001，39：1-11.

9. Mansell W，Clark DM，Ehlers A.Internal versus external attention in social anxiety：an investigation using a novel paradigm.Behav Res Ther，2003，41：555-572.

10. Ollendick TH，Hirshfeld-Becker DR.The developmental psychopathology of social anxiety disorder.Biol Psychiatry，2002，51(1)：44-58.

11. Cicchetti D.Gene-environment interaction.Dev Psychopathol，2007，19(4)：957-959.

12. Clark DM，McManus F.Information processing in social phobia.Biol Psychiatry，2002，51(1)：92-100.

13. Wu C，Du LY，Fu ZC.Analysis on 16PF test and comparative study on rearing styles of parents of patients with social phobia.Shanghai Arch Psychiatry，2009，21(2)：86-88.(in Chinese)

14. Wang LY，Yang YP，Lin T.Defense and Coping Style in patients with social anxiety disorder(SAD).Chin J Clinical Psychology，2006，14(2)：180-182.(in Chinese)

15. Marteinsdottir I，Svensson A，Svedberg M，Anderberg UM，von Knorring L.The role of life events in social phobia.Nord J Psychiatry，2007，61(3)：207-212.

16. Spinhoven P，Elzinga BM，Hovens JG，Roelofs K，Zitman FG，van Oppen P，et al.The specificity of childhood adversities and negative life events across the life span to anxiety and depressive disorders.J Affect Disord，2010，126(1-2)：103-112.

17. Chinese Medical Association，Psychiatric Division.Chinese Classification of Mental Disorders，3rd Ed.Jinan：Shandong Science and Technology Press，2001：104-105.(in Chinese)

18. Zhang YL，Yang DS.Life Event Scale(LES).Chin Mental Health J，1999(Supplement)：101-106.(in Chinese)

19. Xu YJ，Zhang MY，Li RB.Comparison between applications of two Life Event Scales.Chin Mental Health J，1996，10(5)：202-204.(in Chinese)

20. Xiao SY.Social Support Rating Scale(SSRS).Chin Mental Health J，1999，(Supplement)：127-131.(in Chinese)

21. Xiao SY.The basis and research applications of the Social Support Rating Scale.J of Clinical Psychiatry，1994，7(2)：98-100.(in Chinese)

22. Vaillant GE，Bond M，Vaillant CO.An empirically validated hierarchy of defense mechanisms.J Nerv Ment Disease，1993，181：246-56.

23. Pollock C，Andrews G.Defense styles associated with specific anxiety disorders，1989，146：1500-1502.

24. Lu DY，Zhang LJ，Zhao R，He MT.Report on preliminary application of Defense Style Questionnaire.Chin Mental Health J，1993，7(2)：54-56.(in Chinese)

25. Liu GH，Meng XZ.Study of the Reliability and Validity of Defense Style Questionnaire(DSQ).Chinese Journal of Clinical Psychology，2004，12(4)：352-353.(in Chinese)

26. Chen GM，Liu ZH，Zhu X.Study on the validity of Defense Style Questionnaire.Journal of the Fourth Military Medical University，2003，24(19)：1821-1823.(in Chinese)

27. Rahe RH.Psychosocial stressors and adjustment disorder：van Gogh's life chart illustrates stress and disease.J Clin Psychiatry，1990，51(Suppl.)：13-19.

28. Wyler AR，Masuda M，Holmes TH.Magnitude of life events and seriousness of illness.1971，33(2)：115-122.

29. Andrews G，Tennant C，Hewson DM，Vaillant GE.Life event stress，social support，coping style and risk of psychological impairment.J Nerv Ment Dis，1978，166(5)：307-316.

30. Torgrud LJ，Walker JR，Murray L，Cox BJ，Chartier M，Kjernisted KD.Deficits in perceived social support associated with generalized social phobia.Cogn Behav Ther，2004，33(2)：87-96.

31. Degnan KA，Fox NA.Behavioral inhibition and anxiety disorders：multiple levels of a resilience process.Dev psychopathol，2007，19(3)：729-746.

32. Pollock C，Andrews G.Defense styles associated with specific anxiety disorders.Am J Psychiatry，1989，146(11)：1500-1502.

33. Saul LJ，Warner SL.Mobilizing ego strengths.Int J Psychoanal Psychother，1975，4：358-386.

(received date：2010-10-09;accepted date：2011-05-04)

社交恐懼癥患者與正常對照的生活事件、社會支持和防御機制的比較

董帝英 周光燕

作者單位：江蘇省南通市紫瑯醫院226006。通信作者：董帝英，電子信箱dongdy0820@sina.com

背景生活事件、社會支持網絡和心理防御機制的相互作用如何減輕或加重了社交恐懼癥患者的社會功能，目前尚不清楚。

目的比較社交恐懼癥患者和正常對照之間的應激狀態、社會支持與防御機制的關系。

方法對2009年10月-2010年8月南通市紫瑯醫院診斷的38例社交恐懼癥患者，采用生活事件量表、社會支持評定量表和防御方式問卷進行測查，并與38名正常對照的測查結果進行比較。

結果 兩組患者的正性與負性生活事件數的差異無統計學意義，但是社交恐懼癥患者心理狀況受負性事件和正性事件的影響程度比對照組嚴重。根據社會支持評定量表的評定結果，社交恐懼癥組的平均（標準差）客觀支持分、主觀支持分、社會支持總分、支持利用度分均顯著低于對照組。防御方式問卷的結果顯示，與對照組相比，社交恐懼癥組不成熟防御機制的得分明顯較高（也就是說，他們更可能報告使用了這樣的防御），成熟防御機制的得分明顯降低。社交恐懼癥組更可能報告使用了神經癥型防御機制，如潛抑、回避、情感隔離、社會傾向增加，但較不可能報告使用了反向形成、否認和期望的防御機制。

結論區別生活事件的類型似乎對社交恐懼癥的病因不那么重要。與正常對照相比，社交恐懼癥患者的社會支持網絡較差，較少運用社會支持，更可能使用不成熟的防御機制。

生活事件 社會支持 心理防御機制 社交恐懼癥

rs

no external funding for this study.

10.3969/j.issn.1002-0829.2011.04.004 Zi Lang Hospital，Nantong，226006，China

*Correspondence：dongdy0820@sina.com