Defense Mechanisms and Duration of Untreated Psychosis in First-Episode Psychosis: Insights into Psychological Pathways to Care

Background: Duration of untreated psychosis (DUP) is an important predictor of outcome in first-episode psychosis (FEP). Although several clinical and service-related determinants of DUP have been identified, the contribution of psychological processes remains poorly understood. This exploratory study examined associations between specific ego defense mechanisms and DUP in individuals with FEP. Methods: Forty-three individuals with FEP receiving care at an Early Intervention in Psychosis Unit were assessed approximately one month after first clinical contact, following initial clinical stabilization. DUP was estimated using the Symptom Onset in Schizophrenia Inventory, defense mechanisms were assessed with the Greek version of the Plutchik Life Style Index, and symptom severity was assessed with the Positive and Negative Syndrome Scale. Primary analyses included Pearson correlations and multiple linear regression adjusted for demographic characteristics and overall symptom severity. False-discovery-rate correction, rank-based correlations, log-transformed DUP analyses, and bootstrap confidence intervals were used to examine the robustness of the findings. Results: The defensive profile of the sample was characterized by the highest mean scores for Projection, followed by Intellectualization and Compensation. In primary Pearson analyses, higher Denial, Projection, and Reaction Formation scores were associated with shorter DUP; after false-discovery-rate correction across the eight defense mechanisms, only Projection remained significant. In the primary multivariable model, higher Denial (β = −0.315, p = 0.035) and Projection (β = −0.339, p = 0.038) scores were negatively associated with DUP, whereas higher PANSS Total scores were positively associated with DUP (β = 0.375, p = 0.014). However, the associations of Denial and Projection with DUP were less pronounced and no longer statistically significant in sensitivity analyses using rank-based correlations, log-transformed DUP, and bootstrap confidence intervals. Conclusions: Specific defense mechanisms may represent an underexplored psychological dimension in relation to DUP in FEP. Projection showed the strongest signal in the primary analyses, although this association was not statistically significant in the sensitivity analyses. These findings raise a working hypothesis that the ways in which emerging psychotic experiences are psychologically managed may influence their interpersonal visibility and recognition by others, thereby potentially shaping pathways to care; this proposed pathway was not directly evaluated in the present study. Larger prospective studies are needed to test this hypothesis.