Pituitary volumes in patients with adjustment disorder.

The pituitary gland plays an important role in the stress response mechanism. Given the direct link between adjustment disorder and stress, we hypothesized that there might be changes in the pituitary gland in these patients. The study comprised a patient group of 19 individuals with adjustment disorder according to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, and 18 healthy controls. The mean pituitary gland volumes of the patient group were not statistically significantly different from those of the healthy control group (80.81 ± 1.82 mm3 in patients with adjustment disorder vs. 81.10 ± 7.04 mm3 in healthy controls, with a statistically nonsignificant difference of P > 0.05). This finding is contrary to our previous findings in anxiety-related disorders. In this regard, adjustment disorder is not similar to anxiety-related disorders in terms of pituitary gland volumes. We should also clearly state that our study is a pioneering study and that studies with large samples are needed to support our findings. The limitations of our study can be attributed to the small sample size, the utilization of a cross-sectional design, and the inclusion of patients using psychotropic drugs.

Leptin, Nesfatin-1, Orexin-A, and Total Ghrelin Levels in Drug-Naive Panic Disorder.

OBJECTIVE: This study aimed to examine the changes in serum nesfatin-1, leptin, orexin-A, and total ghrelin levels of patients diagnosed with drug-naive panic disorder (PD) before and after six weeks of the treatment and to compare the findings with the healthy subjects. METHODS: The neuropeptides were measured in venous blood samples taken from 32 patients and 32 healthy subjects. The blood samples of the patients who used paroxetine 20 mg/day plus alprazolam 0.5 mg/day were retaken again after six weeks. Measurements were performed with the Enzyme-Linked Immunosorbent Assay (ELISA) method. RESULTS: Serum nesfatin-1, leptin, orexin-A and total ghrelin levels of the patient group were found to be significantly lower than the control group (p<0.001, p<0.001, p<0.001, and p<0.001, respectively). When the serum nesfatin-1, leptin, orexin-A and total ghrelin levels of the patient group were compared before and after treatment, significant differences were found in terms of orexin-A and total ghrelin levels (p=0.046, p<0.001, respectively). However, no significant differences were found in terms of nesfatin-1and leptin levels (p=0.205, p=0.988, respectively). CONCLUSION: This study reports that PD, like other anxiety disorders, may affect serum nesfatin-1, leptin, orexin-A, and total ghrelin levels, and there may be a relationship between PD treatment and the levels of these neuropeptides. The variability of this relationship among the neuropeptides examined indicates that various factors other than treatment play a role in this process.

Evaluation of Arterial Stiffness in Depression Patients.

Background: It has been known that there is a significant correlation between depression and cardiovascular diseases. However, the reasons behind this correlation that could affect mortality and morbidity were not fully identified. The present study aimed to analyze arterial stiffness diagnosed with ultrasonography, which could be associated with cardiovascular disease risks in depression patients, and to compare the findings with those of healthy controls. Methods: The study was conducted with 35 depression patients and 35 healthy individuals. Routine complete blood and biochemistry tests were requested for all patients, and their weight and height, waist circumference, and diastolic and systolic arterial blood pressure were measured. Femoral and carotid artery intima-media thickness and other arterial stiffness parameters were determined with Doppler ultrasonography. Results: It was determined that the systolic pressure (P = .028) was higher in the patient group (P = .028). Also, the carotid elastic modulus (P = .048) was significantly higher in the patient group. A negative and significant correlation was determined between femoral compliance and chlorpromazine equivalent dose (P = .021, r = -0.389). Conclusion: It was determined that the systolic blood pressure and carotid elastic modulus arterial stiffness parameters were significantly higher in depression patients. Measurable arterial stiffness parameters should be investigated in depression patients as cardiovascular risk markers. Furthermore, the determination of the effects of psychotropic drugs employed in arterial stiffness treatment could play an important role in the determination of cardiovascular disease risk in these patients.

Cortical Thickness of the Orbitofrontal Cortex in Patients with Alcohol Use Disorder.

AIMS: In the present study, it was hypothesised that compared to healthy control subjects, significant differences in the cortical thickness of the orbitofrontal cortex (OFC) region of the brain, which is relevant to both impulsivity and decision making, would be identified. METHODS: The subject groups included in the study were composed of 15 individuals who met the criteria for alcohol use disorder, according to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM 5) diagnostic criteria based on the Structured Clinical Interview for DSM 5 (SCID), and were admitted to the Firat University School of Medicine Department of Psychiatry or were hospitalised, and 17 healthy control comparisons were made. The volumes of and cortical thickness of the OFC were measured in the subjects. RESULTS: It was found that patients with alcohol use disorder had reduced volumes of the OFC bilaterally and a thinner cortical thickness of the same region bilaterally compared to those of the healthy control comparisons. CONCLUSIONS: Consequently, it is suggested that the OFC region of the brain appears to be statistically significantly smaller in patients with alcohol use disorder, both in terms of cortical thickness and volume, compared to healthy controls. Future research should focus on the status of these relationships longitudinally and should assess the causality of the association with the treatment response.

Monocyte/HDL Cholesterol Ratios as a New Inflammatory Marker in Patients with Schizophrenia.

PURPOSE: Monocyte/HDL cholesterol ratio (MHR) is a novel inflammatory marker that is used as a prognostic factor for cardiovascular diseases and has been studied in many diseases. The aim of this study was to investigate the role of inflammatory factors in schizophrenia patients by examining MHR levels and to compare schizophrenia patients and healthy controls in terms of cardiovascular disease risk. METHOD: A total of 135 participants between the ages of 18-65, 85 diagnosed with schizophrenia, and 50 healthy individuals in the control group were included in this cross-sectional study. Venous blood samples were taken from the participants and CBC parameters and lipid profiles were analyzed. The sociodemographic and clinical data form and positive and negative symptoms scale (PANSS) were administered to all participants. RESULTS: Although monocyte levels were significantly higher in the patient group, HDL-C levels were lower at significant levels. MHR was found to be higher in the patient group compared to the control group at significant levels. When compared to the control group, total cholesterol, triglyceride, WBC, neutrophil, basophil, and platelet levels were higher in the patient group at significant levels, and RBC, hemoglobin, and hematocrit levels were significantly lower. CONCLUSION: The elevated MHR in patients with schizophrenia may contribute to our understanding that inflammation plays important roles in the pathophysiology of schizophrenia. Additionally, knowing the levels of MHR and considering the recommendations, such as diet and exercise, in the treatment approaches made us think that it might be beneficial in protecting schizophrenia patients against cardiovascular diseases and early death.

Relationship between optical coherence tomography findings and clinical variables in patients with opiate use disorder / Relação entre os achados da tomografia de coerência óptica e as variáveis clínicas em pacientes com transtorno por uso de opiáceos

ABSTRACT Purpose: This study aimed to examine optical coherence tomography findings in patients with opiate use disorder by comparing them with healthy controls. Methods: The study included 30 opiate use disorder patients and 30 controls. The participants' detailed biomicroscopic examinations, visual acuity, intraocular pressure, and both eye examinations were evaluated. A total of 120 eyes were evaluated using optical coherence tomography, measuring the central macular thickness, mean macular thickness, mean macular volume and retinal nerve fiber layer thickness. Moreover, all participants filled in the demographic data form and Barratt Impulsiveness Scale. Results: Upon examination of the optical coherence tomography findings, central macular thickness, mean macular thickness, and mean macular volume were thinner in both eyes in patients with opiate use disorder (p<0.01 in all measurements in both eyes). Similarly, the total values of the superior quadrant and retinal nerve fiber layer thickness were statistically significant in both eyes compared to that in the control group (p=0.007, p=0.002; p=0.049, p=0.007, in the right and left eyes, respectively). Only the left eye was positively correlated with retinal nerve fiber layer superior quadrant measurement and hospitalization (r=0.380, p=0.039). Conclusion: Our results revealed that the patients' central macular thickness, mean macular thickness, and mean macular volume values were thinner. Increase in the retinal nerve fiber layer thickness superior quadrant thickness and total value was also observed. Further studies with larger sampling groups that evaluate neuroimaging findings should be conducted.

RESUMO Objetivo: O objetivo foi investigar foi, os achados da tomografia de coerência óptica em pacientes com transtorno do uso de opiáceos, comparando-os com controles saudáveis. Métodos: O estudo incluiu 30 pacientes com transtorno do uso de opiáceos e 30 controles. Os exames biomicroscópicos detalhados de todos os participantes, acuidade visual, pressão intraocular e ambos os exames oculares foram avaliados com tomografia de coerência óptica. Um total de 120 olhos foram avaliados usando tomografia de coerência óptica, e a espessura macular central, espessura macular média, volume macular médio e a espessura da camada de fibra nervosa da retina dos participantes foram medidos. Além disso, todos os participantes preencheram o Formulário de Dados Demográficos e a Escala de Impulsividade Barratt (BIS-11). Resultados: Quando os achados de tomografia de coerência óptica foram examinados, espessura macular central, espessura macular média e volume macular médio eram mais finos de acordo com controles saudáveis em ambos os olhos em pacientes com transtorno do uso de opiáceos (p<0,01 em todas as medições em ambos os olhos). Da mesma forma, os valores totais do quadrante superior e espessura da camada de fibra nervosa da retina estavam mais em níveis estatisticamente significativos em ambos os olhos em comparação com o grupo controle (p=0,007, p=0,002; p=0,049, p=0,007, no olho direito e esquerdo, respectivamente). Estar internado em hospital e apenas a medida do quadrante superior da espessura da camada de fibra nervosa da retina do olho esquerdo associou-se positivamente (r=0,380, p=0,039). Conclusão: Em nossos resultados, descobrimos que os valores de espessura macular central, espessura macular média e volume macular médio dos pacientes eram mais finos. Verificamos também espessamento no quadrante superior e valor total da espessura da camada de fibra nervosa da retina. Nosso estudo deve ser apoiado por novos estudos com grupos de amostragem maiores, nos quais os achados de neuroimagem são avaliados.

Relationship between optical coherence tomography findings and clinical variables in patients with opiate use disorder.

PURPOSE: This study aimed to examine optical coherence tomography findings in patients with opiate use disorder by comparing them with healthy controls. METHODS: The study included 30 opiate use disorder patients and 30 controls. The participants' detailed biomicroscopic examinations, visual acuity, intraocular pressure, and both eye examinations were evaluated. A total of 120 eyes were evaluated using optical coherence tomography, measuring the central macular thickness, mean macular thickness, mean macular volume and retinal nerve fiber layer thickness. Moreover, all participants filled in the demographic data form and Barratt Impulsiveness Scale. RESULTS: Upon examination of the optical coherence tomography findings, central macular thickness, mean macular thickness, and mean macular volume were thinner in both eyes in patients with opiate use disorder (p<0.01 in all measurements in both eyes). Similarly, the total values of the superior quadrant and retinal nerve fiber layer thickness were statistically significant in both eyes compared to that in the control group (p=0.007, p=0.002; p=0.049, p=0.007, in the right and left eyes, respectively). Only the left eye was positively correlated with retinal nerve fiber layer superior quadrant measurement and hospitalization (r=0.380, p=0.039). CONCLUSION: Our results revealed that the patients' central macular thickness, mean macular thickness, and mean macular volume values were thinner. Increase in the retinal nerve fiber layer thickness superior quadrant thickness and total value was also observed. Further studies with larger sampling groups that evaluate neuroimaging findings should be conducted.

The relationship between defence mechanisms and clinical variables in myocardial infarction patients.

Introduction: Although patients with myocardial infarction (MI) history exhibit individual differences, several psychological problems can be observed in these patients. The present study aimed to investigate the correlation between defence mechanisms and other clinical and sociodemographic data in the early period in patients with MI history. Material and methods: Sixty patients diagnosed with MI and hospitalized in the cardiology department were included in the study. The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Defence Styles Questionnaire (DSQ) were applied. Results: It was determined that the mean BDI score of the participants was 15.9 ±11.2, and the mean BAI score was 15.98 ±10.9. There was a positive correlation between the depression and immature defence mechanism scores of the patients, and there was a negative correlation between the depression and mature defence mechanism scores of the patients (p = 0.001, r = 0.412; p = 0.005, r = -0.359). A negative correlation was determined between anxiety scores and mature defence mechanism scores (p = 0.002, r = -0. 397). Conclusions: The findings demonstrated that depressive complaints of the post-MI patients increased as the immature defence mechanism score increased, and depressive complaints decreased as the maturity defence mechanism score increased. The correlation between the defence mechanisms adopted by MI patients and depression and anxiety symptoms should not be neglected.

Stigmas and childhood traumas associated with psychological help-seeking in suicide attempted individuals.

PURPOSE: The aim was to investigate the possible associations of suicide attempt with childhood trauma, social support, psychological support seeking, stigmatizations. The study was case-control study and included 100 participants (50 suicide, 50 controls). CONCLUSION: BDI, BAI scores were higher in the patient (p < 0.001). While scores of all-subscales of Childhood-Trauma-Questionnaire were higher (p < 0.05) in the patients, scores of Perceived-Social-Support were lower (p < 0.001). Repeating suicide attempts has higher Stigma-Scale-for-Receiving-Psychological-Help scores than the patients who attempted to the first time (p = 0.045). PRACTICE IMPLICATION: Suicide is relationship with more childhood traumas, less social support. Repeating suicide attempts, individuals felt public stigma for receiving psychological help.

Health Anxiety, Health Perception, and Healthy Lifestyle Behavior Among Psychiatric Patients During the COVID-19 Pandemic.

Objective: To compare the health anxiety and healthy lifestyle behavior experienced by psychiatric patients due to the coronavirus disease 2019 (COVID-19) pandemic with that of a control group.Methods: The study included 120 outpatients (aged 18-65 years) diagnosed with a psychiatric illness (DSM-5 criteria) who presented to a psychiatry outpatient clinic between June and August 2020. The control group included 120 healthy individuals with a similar age and sex distribution as the patient group. Data were collected with a questionnaire developed by the authors to determine the participants' adherence to COVID-19 hygiene rules and associated behavioral norms. The Health Anxiety Scale-Short Form, Health Perception Scale, and Health-Promoting Lifestyle Profile were completed by all participants.Results: The mean Health Anxiety Scale score was significantly lower in the patient group compared to the control group (P < .01). Health anxiety was high in 8% of the patients and 32% of the controls. Also, the mean Health-Promoting Lifestyle Profile score was statistically significantly lower in the patient group compared to the control group (P < .01). There was no significant difference between the groups based on health perception scores and adherence to hygiene rules.Conclusions: As expected, the healthy lifestyle behavior of individuals without psychiatric illness was higher compared to those with mental disorders. However, health anxiety about COVID-19 was higher among healthy individuals compared to those with a psychiatric disorder. Thus, it could be suggested that individuals without a psychiatric illness prior to the pandemic could need psychiatric assistance after the pandemic.

Peripheral Inflammatory Parameters in Patients with Antisocial Personality Disorder.

Introduction: The aim of the study was to examine the peripheral inflammatory parameters in patients with Antisocial Personality Disorder (APD) including white blood cell levels, red cell distribution width (RDW), mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), basophil-to-lymphocyte ratio (BLR) by comparing with those of healthy controls. Methods: 48 patients diagnosed with APD and a matched healthy control group of 52 individuals were included in our study. Venous blood samples were taken from the participants in the fasting state and at approximately the same time of the day. Socio-demographic data sheet, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Barratt Impulsiveness Scale (BIS-11), Buss-Durkee Hostility Inventory (BDHI) were applied to all of the participants. Results: RDW and basophil cell levels were found significantly higher in the patients than the controls (p=0.005, p=0.038 respectively). BLR was found significantly higher in the participants with alcohol use than those without alcohol use (p=0.016). No significant difference in other laboratory parameters was found between the patient group and the control group. Scores of BDI, BAI, BIS-11, motor impulsivity subscale and physical aggression, anger, hostility and verbal aggression subscales of BDHI, and the total score of BDHI were significantly higher in patients than controls (p<0.001, p<0.001, p<0.001, p<0.001, p<0.001, p=0.003, p=0.001, p<0.001 respectively). A positive correlation was determined between the scale scores and the RDW, basophil, monocyte, lymphocyte levels among the laboratory parameters, and a negative correlation was determined between the MPV levels and the depression and impulsivity levels. Conclusion: The results of our study suggested that inflammation might play a role in the etiopathogenesis of APD. Furthermore, a significant relationship was found between the severity of symptoms and some inflammatory parameter levels such as RDW and basophil in APD patients.

Insula volumes in patients with schizoaffective disorder.

We aimed to investigate insula volumes in patients with schizoaffective disorder with the motivation that schizoaffective disorder has strong resemblance of clinical presentaion with schizophrenia and bipolar disorder and that there have been studies on insula volumes in patients with schizophrenia and bipolar disorder but not in patients with schizoaffective disorder.

Volúmenes de la ínsula en pacientescon trastorno esquizoafectivo / Insula volumes in patients with schizoaffective disorder

Nuestro objetivo era investigar los volúmenes de la ínsula en pacientes con trastorno esquizoafectivo con la motivación de que el trastorno esquizoafectivo presenta una gran similitud de manifestación clínica con la esquizofrenia y el trastorno bipolar, además de que ha habido estudios sobre los volúmenes de la ínsula en pacientes con esquizofrenia y trastorno bipolar, pero no en pacientes con trastorno esquizoafectivo. Nuestra hipótesis era que los pacientes con trastorno esquizoafectivo tendrían alteraciones similares en cuanto a los volúmenes de la ínsula. Se incluyó en el estudio a dieciocho pacientes con trastorno esquizoafectivo y a diecinueve sujetos de control sanos. Los volúmenes medios de la región de la ínsula para ambos lados fueron estadísticamente significativos en los pacientes con trastorno esquizoafectivo en comparación con los sujetos de control sanos (P<0,001). En conclusión, nuestros hallazgos sugieren que los pacientes con trastorno esquizoafectivo tenían volúmenes reducidos de la región de la ínsula. Debido a algunas limitaciones, se requiere replicar nuestros resultados actuales en este grupo de pacientes.(AU)

We aimed to investigate insula volumes in patients with schizoaffective disorder with the motivation that schizoaffective disorder has strong resemblance of clinical presentaion with schizophrenia and bipolar disorder and that there have been studies on insula volumes in patients with schizophrenia and bipolar disorder but not in patients with schizoaffective disorder. We hypothesized that patients with schizoaffective disorder would have similar alterations in regard to insula volumes. Eighteen patients with schizoaffective disorder and nineteen healthy controls were included into the study. Insula volumes were measured by using the MRI. the mean volumes of the insula region for both sides were statistically significant smaller in patients with schizoaffective disorder compared to those of healthy ones (P<0.001). In conclusion, our findings suggest that patients with schizoaffective disorder had reduced volumes of the insula region. Beacuse of some limitations, it is required to replicate our present results in this patient group.(AU)

Suicidal Ideation, Self-esteem, and Hopelessness in Patients With Pulmonary Arterial Hypertension.

Objective: To investigate the frequency of suicidal ideation and its correlation with other clinical variables in patients with pulmonary arterial hypertension.Methods: Fifty patients with pulmonary arterial hypertension who presented to the cardiology department between 2018 and 2019 and 50 healthy controls were included in the study. A sociodemographic and clinical data form was completed by both the patients and controls, and the Beck Depression Inventory (BDI), Beck Hopelessness Scale (BHS), Rosenberg Self-Esteem Scale (RSE), and Suicide Probability Scale (SPS) were administered. SPSS version 22 software was used in the statistical analysis.Results: The mean ± SD systolic pulmonary pressure of the patients was 47.48 ± 18.86 and the pulmonary artery pressure was 33.32 ± 19.69. BHS, BDI, and SPS total scores were statistically significantly higher in the patient group compared to the control group (P < .001, P = .001, P = .026, respectively). RSE scores were also higher in the patient group compared to the control group (P = .017).Conclusions: It is important to identify pulmonary arterial hypertension patients with intense feelings of hopelessness and depressive symptoms and to provide psychiatric treatment and psychotherapeutic interventions to improve their self-esteem.

Superior Temporal Gyrus Volumes in Patients With Social Anxiety Disorder.

Objective: To determine if superior temporal gyrus volumes are altered in patients with a social anxiety disorder.Methods: Magnetic resonance imaging (MRI) was utilized to determine the superior temporal gyrus volume in 21 patients with a social anxiety disorder and 20 control subjects without a social anxiety disorder. The superior temporal gyrus volumes were measured by manual tracing method. The study was conducted between September 2019 and April 2020.Results: The mean superior temporal gyrus volume for both sides was statistically significantly smaller than that of control subjects (left side: 11.38 ± 0.85 cm3 for patients and 12.73 ± 0.86 cm3 for controls, t=-5.064, P < .001; right side: 11.42 ± 0.84 mm3 for patients and 12.92 ± 0.85 cm3 for controls, t=-5.574, P < .001). Moreover, when comparing volumetric measurements for subregions, we detected that volumes of all subregions were also statistically significantly smaller than those of healthy comparisons (for both sides of the Heschl's gyrus and planum temporale).Conclusions: The study findings suggest that patients with social anxiety disorder seem to have smaller superior temporal gyrus volumes compared to healthy control subjects, although we do not know whether these results were in accordance with functional changes of the same region.

Insula volumes are altered in patients with social anxiety disorder.

OBJECTIVE: In the present study, we aimed at examining the volumes of the insula in more pure patients with a social anxiety disorder. METHODS: We examined twenty-one patients with social anxiety disorder according to DSM-IV and twenty healthy controls. All patients and controls were applied to magnetic resonance imaging (MRI). Insula volumes were measured by using the manual tracing method in accordance with the standard anatomical atlases and related previous studies on insula volumes. RESULTS: We found that the mean posterior and anterior insula volumes for both sides of patients were statistically significantly reduced compared to those of healthy control subjects. CONCLUSION: Consequently, in the present study, we found that patients with a social anxiety disorder had reduced insula volumes compared to those of healthy control subjects. However, to get strong this finding, novel studies with a larger sample size are required.

The anxiety levels, quality of sleep and life and problem-solving skills in healthcare workers employed in COVID-19 services.

OBJECTIVE: The present study aims to investigate the level of anxiety experienced by healthcare workers employed in COVID-19 services, the effects of anxiety on sleep quality and quality of life and, the relationship between these variables and problem-solving skills of the healthcare workers. MATERIAL AND METHOD: The study was conducted in two healthcare facilities which serve as pandemic hospitals. 140 healthcare workers, who were employed in the COVID-19 outpatient clinics or emergency departments, participated in the present study. All participants were submitted to the Pittsburgh Sleep Quality Index (PSQI), Problem Solving Inventory (PSI), World Health Organization Quality of Life-BREF (WHOQOL-BREF), Beck Anxiety Inventory (BAI). FINDINGS: The number of participants without anxiety was 41(29%), with mild anxiety was 53(38%). Clinically significant anxiety findings were found in only 33% of the participants. A positive correlation was found between the participants' BAI scores and PSQI, PSI scores, and a negative correlation with the WHOQOL-BREF scores. PSQI and PSI scores of nurses were statistically higher when compared to those of physicians and staff. WHOQOL-BREF scores were found to be lower. CONCLUSION: Healthcare workers might develop psychiatric symptoms such as anxiety and sleep disturbance. Such symptoms could adversely affect the problem-solving skills of healthcare workers and cause a deterioration in their quality of life.

Analysis of Childhood Traumas and Defense Styles in Patients With Tension Headache.

OBJECTIVE: Studies indicate that patients tend to develop chronic tension headache as a response to stress. The present study investigated the relationship between headache and the events that caused childhood traumas and defense styles, which could be considered as a significant source of stress in individuals with tension headache. METHODS: Fifty patients between the ages of 18 and 65 years diagnosed with tension headache were included in the present study. The control group included 50 healthy participants. All study participants completed a sociodemographic data form prepared by the researchers and the Childhood Trauma Questionnaire and Defense Style Questionnaire. RESULTS: Traumatic experiences (emotional abuse, physical abuse, emotional neglect, physical neglect, and sexual abuse) were significantly higher in the patient group compared to the control group. The total score of immature and neurotic defense styles was higher in the patient group than in the control group (P < .001, P < .001). The mature defense styles total score was significantly higher in the control group than in the patient group (P = .006). A positive correlation was found between the childhood trauma scores and immature and neurotic defense style scores. CONCLUSION: The findings indicate that traumatic experiences during childhood were more frequent in patients with tension headache compared to healthy individuals. Furthermore, these individuals had difficulty coping with stress, and inappropriate defense styles were employed as a response to stress.