Name That Defense Mechanism

defendedHere's a quick quiz that should help you lock down your ease with defense mechanism. What are defense mechanisms? Wikipedia wants to tell you:

A defense mechanism is an unconscious psychological mechanism that reduces anxiety arising from unacceptable or potentially harmful stimuli. Defense mechanisms are not to be confused with conscious coping strategies. Sigmund Freud was one of the first proponents of this construct.

Okay, but which defense mechanism is which? Here's a short list of examples, courtesy of Simply Psychology. You provide the name of the defense mechanism. Good luck!

1. A young man has no conscious awareness of his desire to hurt his father.

2. A smoker refuses to admit to herself that smoking is bad for one's health.

3. A person comes to believe that their anger toward a rival started with the rival's misbehavior toward them.

4. A person frustrated by their boss, goes home and kicks their dog.

5. An angry person feels relief from working long hours.

How'd you do? Answers are in comments.

There are more defense mechanisms where these came from. Read up on the sites linked above and also here:

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Good luck on the exam!

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Generalized Anxiety Disorder and the Social Work Exam

coffee (38861808_s)The theme lately has been anxiety disorders. Let's continue now with generalized anxiety disorder (GAD). Criteria for GAD are pretty straightforward:

A. Excessive anxiety and worry occurring more days than not for at least six months, about a number of events or activities.

B. The worry is difficult to control.

C. The worry comes with three or more of these (or just one in children):

   1. Restlessness, feeling keyed up or on edge.

   2. Being easily fatigued.

   3. Difficulty concentrating or mind going blank.

   4. Irritability.

   5. Muscle tension.

   6. Sleep problems.

Plus the usual...

D. Symptoms cause clinically significant distress or impairment.

E. Not substance induced

F. Not better explained by another condition (e.g., panic, OCD, PTSD, anorexia, somatic symptom disorder, body dysmorphic disorder, illness anxiety disorder, schizophrenia, or delusional disorder).

That is, lots of anxiety, lots of the time. Which is simple enough as far as the social work licensing exam goes, until you get to the "e.g." in letter F. All those rule outs. To be able to identify GAD, you have to be able to identify what it isn't. That means you have to have a pretty good idea what all of those other anxiety and related disorders look like. Suddenly, learning GAD for the exam becomes a little more complicated than expected.

On the test, you might see GAD as a frequent distractor (an appealing answer that isn't the correct answer). It's a catch-all for anxiety-related symptoms. How to ready yourself to tell when GAD's a distractor and when it's the answer? Piecing together your own practice question might help. It could go something like this:

A client tells a social worker he's been an "anxious mess" ever since dropping out of college, worrying about a variety of things "all of the time." He reports difficulty falling asleep even though he's usually exhausted early in the day. He has trouble with self-care like reading or meditating--"my mind just keeps going."

If you leave it there, you've got GAD. Worry for more days than not, significant distress, three of the six offered symptoms. But here's a quiz. Imagine there's an added line. What's the MOST likely diagnosis then?

The client reports everything is easier when he drinks fewer than four cups of coffee in a day.


The client reports he is "obsessed" with how much he weighs. His MD wants him to put on 20 additional pounds--"but he's a quack."


The client reports he witnessed a suicide in his college dorm room--"I've never been the same since."

Etc. Now you're into something that may not be GAD. Four cups of coffee--sounds like the symptoms may be "attributable to the physiological effects of a substance." Weigh obsession and weight loss--sounds like anorexia nervosa. Witnessed a suicide--sounds like the client's symptoms might be better explained by PTSD.

And so on. You get the idea.

For more reading about generalized anxiety disorder, check out:

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Panic Disorder and the Social Work Exam

panic (3633778_s)Your client reports occasional "freak outs" during which she experiences:

1. Palpitations

2. Sweating

3. Trembling

4. Shortness of breath

5. Choking feelings

6. Chest pain

7. Nausea

8. Dizziness

9. Chills

10. Numbness

11. Feelings of unreality

12. Fear of going crazy

13. Fear of dying

What's she experiencing? That's a panic attack. What's the diagnosis? It's very likely panic disorder. This imaginary client is symptoms in every one of the thirteen categories of symptoms that make up a panic attack. (She only needed to have four to meet initial criteria for a panic disorder diagnosis.) It's as if she entered your office to help you prepare for the ASWB exam. Thanks, client!

In order to fully meet panic disorder criteria, a panic attack needs to be follow by a month or more of either 1) persistent worry about additional panic attacks or 2) significant maladaptive change in behavior related to the attacks (avoidance bx, that is). Also, as with every last diagnosis, panic disorder can only be diagnosed if it's not better explained by substance use or a medical condition. So watch out for an exam question like this:

A client reports a series of panic attacks during which he experiences an accelerated heart rate, shaking, a sensation of being smothered, and heat sensations. He worries "all the time" about future panic attacks and has stopped dating for fear of a panic attack occurring in the middle of a date. What should the social worker do FIRST to help this client?

Before looking at the answers, think of what yours would be. That's generally a good approach to studying, unless you're pressed for time (e.g., in timed mode on a practice exam). What answers might you expect to see as A-D? Maybe these:

A) Diagnose the client with panic disorder

B) Provide psychoeducation about panic attacks

C) Refer client for a medical evaluation

D) Introduce cognitive behavioral techniques for reducing panic.

What do you say? We're in a diagnostic blog post, so the diagnostic answer is tempting. But it's premature to diagnose the client. First things first: rule out an underlying medical condition that may be causing the client's panic-attacky symptoms (the client's symptoms are just about all the ones left of the DSM list of thirteen above) . The client saying he's having panic attacks doesn't mean that's necessarily what's really going on. He should get a clean bill of health, then receive the diagnosis, then the psychoed and CBT. This simple order of operations--rule outs first!--will help get you through many a social work exam item.

Before moving on to helpful links, there's one more thing to note for the diagnosis: Culture-specific symptoms are sometimes seen. The DSM-5 lists tinnitus, headaches, and "uncontrollable screaming or crying" among them. They count too.

Okay, now some helpful links:

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Social Anxiety Disorder and the Social Work Exam

judgement (34043230_s)Social anxiety disorder aka SAD aka social phobia is one of those diagnoses, like OCD or PTSD, that many people use casually to describe non-clinical symptoms (eg, "I really don't want to go to that party, my social phobia's kicking in.") But having some anxiety about party-going or spending time in groups of people isn't a disorder. It's just, for many, life--normal, non-clinical worry. Take a look at these (abridged) criteria for SAD:

A. Fear of scrutiny in social situations.

B. Fear of anxiety showing and being negatively evaluated.

C. The social situations almost always provoke anxiety.

D. The social situations are avoided and endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed.

F. Symptoms are persistent, lasting for 6 months or more.

G. Symptoms cause clinically significant distress or impairment.

H Symptoms are not attributable to the effects of a substance or

I. ...another disorder or...

J. ...a medical condition.

The focus in social anxiety disorder is a fear of scrutiny and negative evaluation. What will people say about me? On the social work licensing exam, look for phrases like that. As soon as you see,  people think I'm a loser, start thinking social anxiety disorder. Then look for the six month duration, intensity, impairment, lack of exceptions, and the absence of other explanations, and you've got your dx!

SAD was by far the most popular choice for the last free practice question. And why not? "A social worker sees a client, an MSW student, who reports feeling anxious in social situations, especially in classes. She says she gets clammy hands, shortness of breath, and can't bring herself to speak at all when called upon." That sounds a lot like social anxiety disorder. The trick there was the client's inability to speak. That's not a SAD symptom. That's selective mutism. Selective mutism was the best primary diagnosis in that case. The client in the vignette may qualify for both diagnoses. So it's sort of a trick question--the kind that will probably not be used for scoring--a tester which will be discarded before appearing as a scored item on the ASWB exam.

Hope this clears things up some. For additional reading about social anxiety disorder, try these:

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The Patient Self-Determination Act and the Social Work Exam

The Patient Self-Determination Act of 1990 directly affects social work clients and social work practice (and social work paperwork). Among other things, it made advance directives a required part of health care. summarizes:

The 1990 Patient Self-Determination Act (PSDA) encourages everyone to decide now about the types and extent of medical care they want to accept or refuse if they become unable to make those decisions due to illness. The PSDA requires all health care agencies to recognize the living will and durable power of attorney for health care. The Act applies to hospitals, long-term care facilities, and home health agencies that get Medicare and Medicaid reimbursement. Under the PSDA, health care agencies must ask you whether you have an advance directive. They also must give you information about your rights under state law.

Without knowing the history leading up to the bill, you can more-or-less figure it out based on its provisions. Wikipedia spells them out at greater length:

The requirements of the PSDA are as follows:

-Patients are given written notice upon admission to the health care facility of their decision-making rights, and policies regarding advance health care directives in their state and in the institution to which they have been admitted. Patient rights include:

  • The right to facilitate their own health care decisions

  • The right to accept or refuse medical treatment

  • The right to make an advance health care directive

-Facilities must inquire as to whether the patient already has an advance health care directive, and make note of this in their medical records.

-Facilities must provide education to their staff and affiliates about advance health care directives.

-Health care providers are not allowed to discriminately admit or treat patients based on whether or not they have an advance health care directive.

Once you've read this--or lived it as a social worker, health care receiver, caretaker, or planner--you're likely well prepared for a social work licensing exam question on the topic. You may see something as simple as this:

Which of the following requires health care facilities to discuss patient decision-making rights upon admission?

What goes in the list is up to the exam writer. The Civil Rights Act of 1964. Advance Directives. The Patient Decision-Making Rights Act of 1990 (made up). You know the correct answer. The PSDA, of course!

Find more about the PSDA here:

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