1. Background
Throughout their educational years, medical students are subjected to increasing levels of external and internal stress, as they should develop their characters in both personal and professional aspects, which are influenced by their presence at institutional clinics and hospitals and interactions with patients and fellow students (1). Nonetheless, many universities have only focused on raising professional aptitude without investing in the education of psychosocial skills and raising self-awareness in students that would substantially aid them with better management of stress and anxiety (2). The method by which medical students might approach stress is determined by several factors, including, but not limited to, psychological health (3).
Anxiety is a physiologic/psychologic process characterized by various cognitive, physical, emotional, and behavioral manifestations. Anxiety is, in fact, the collection of symptoms that might arise due to inappropriate adaptation of individuals to stress. These symptoms might include fear of losing control and instability, fear of death, inability to remain calm, shortness of breath, palpitations, sweating, flushing, numbness, restlessness, dizziness, chills, tremors, and dyspepsia. Fear of malevolent occurrences or anticipatory anxiety is perhaps the most common (4).
According to both the International Classification of Diseases, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are specific differences between generalized anxiety disorder (GAD) and other types of anxiety, and even depression, as GAD, compared with depression, leaves a more profound negative impact on an individual's quality of life (2). With annual incidence rates of 12% and 2% in Europe and the world, respectively, anxiety disorders are adults' most common psychological disorders (5). A meta-analysis by Dyrbye et al. on the prevalence of psychological disorders among American and Canadian students indicated an overall higher prevalence of anxiety and depression among medical students (6). A more recent investigation on medical students reported a prevalence of 14.3% for moderate to severe depression and a higher prevalence of suicidal ideation among senior students than in juniors (7).
There is no precedent that certain psychosocial traits, such as alexithymia, might affect how students interact with their perceived stress. Alexithymia, or “no words for emotion,” is a condition in which individuals cannot describe their mood with words. The term was coined in 1973 to describe a series of emotional and cognitive traits among patients with psychosomatic disorders (8). In 2017, Messedi et al. reported a prevalence of 16.5% for alexithymia in American medical students at the University of Michigan (9). Another investigation on French medical students in 2018 suggested that alexithymia might negatively affect empathy and resilience (10).
Defense mechanisms constitute another critical aspect of personality and behavior that help individuals deal with their stress. These mechanisms are subconsciously mediated to minimize the negative effect of potentially threatening environmental alterations (11). Defense mechanisms can be categorized into three major classes: Mature, neurotic, and immature. The mature mechanism aids individuals with adapting to external stressors (12) and is associated with better grades in students (13). These mechanisms might act in different ways, rendering medical students caring physicians or egoistic individuals (11), and thus, a good understanding of defense mechanisms can contribute to the efforts made to improve the psychological well-being of medical students (14).
2. Objectives
Since there is little information on the epidemiology of GAD among medical students in northeastern Iran, the present study aimed to study the prevalence of GAD, alexithymia, and types of defense mechanisms among medical students.
3. Methods
The present investigation was a cross-sectional study on a population consisting of 14 groups of medical students at a major university in northeastern Iran in 2020. Our sampling method was a census of all medical students at Mashhad University of Medical Sciences, who were 1,800 people. The sample size for the study was calculated using the test of two means related to a quantitative variable in two communities and values provided in the "Ego defense mechanisms in Pakistani medical students: A cross-sectional analysis" study (15). The sample size obtained a total of 193 (β = 0.2, α = 0.05, mean (SD) = 5.62(3.01) and 4.78 (2.7), respectively). Considering 20% dropout, the sample size in the present study was considered 231.
Information was collected from the participants using online questionnaires on Telegram, a popular messenger among students in Iran, through automated bots specific to this platform. The idea of using automated Telegram bots was adopted to reduce expenditures. Demographic information of the subjects, including age, sex, and the number of years spent as a medical student, was also recorded.
We used three questionnaires to collect information from the participants:
3.1. Generalized Anxiety Disorder-7 (GAD-7)
It is a self-reporting questionnaire consisting of seven items, each with a minimum and maximum score of 0 and 3, respectively. Based on GAD-7, a cumulative score of 0 - 4 indicates negligible anxiety. Accordingly, scores falling within the 5 - 9, 10 - 14, and 15 - 21 ranges denote mild, moderate, and severe anxiety, respectively. The reliability and validity of this questionnaire were conducted in the original (16) and Persian versions (17). This study determined internal consistency by Cronbach's alpha of 0.876. Also, construct validity was evaluated via confirmatory factor analysis (CFA). The results obtained by the unidimensionality test were: CFI = 0.99, GFI = 0.97, RMSEA = 0.068, and SRMR = 0.031. All seven standardized factors were in the expected direction (with factor loading from 0.58 to 0.80), and loadings were statistically significant (17).
3.2. Toronto Alexithymia Scale-20 (TAS-20, Farsi Version)
It is a 20-item self-reporting questionnaire in three categories: (1) difficulty identifying feelings, (2) difficulty describing feelings, and (3) externally oriented thinking. Participants can select their answers from five choices ranging from strongly disagree (1 point) to strongly agree (5 points) (18). The cumulative sum of points is then calculated as an indicator of alexithymia. The validity and reliability of Toronto Alexithymia Scale-20 (TAS-20) of the Farsi version have also been confirmed (19). In the Besharat study, the three-factor structure met the criteria for adequate fit to the data (GFI = 0.91, AGFI = 39, NNFI = 0.93, CFI = 0.92, and RMSEA = 0.05) for construct validity. All parameter estimates met the criteria for "goodness-of-fit." The correlations were 0.76 between factors 1 and 2 (P < 0.05), 0.44 between factors 1 and 3 (P < 0.05), and 0.55 between factors 2 and 3 (P < 0.05). Its Cronbach's alpha coefficient was 0.85 for internal consistency. Test-retest was conducted for the reliability of the questionnaire. Subscale coefficients of the test-retest ranged from 0.80 to 37 (19).
3.3. Defense Style Questionnaire-40 (DSQ-40, Farsi Version)
This 40-item self-reporting questionnaire was introduced in 1993 to evaluate defense mechanisms in three major categories, including mature, neurotic, and immature. Each question has a maximum score of 9. Mature defense mechanisms include sublimation, humor, anticipation, and suppression. Neurotic defense mechanisms include undoing, pseudo-altruism, idealization, and reaction formation. Immature defense mechanisms comprise projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalization, and somatization (20). An iteration of the Farsi language was developed in 2001 (21). Cronbach's alpha for all items of Defense Style Questionnaire-40 (DSQ-40) was calculated as 0.716 for reliability. Item defense correlations for mature, neurotic, and immature factors were 0.614 to 0.863, 0.773 to 0.849, and 0.709 to 0.901, respectively. Item defense correlations for mature, neurotic, and immature factors included 0.220 to 0.645, 0.189 to 0.642, and 0.097 to 0.601, respectively (21).
The participants provided their information anonymously via specific bots on Telegram. The only exclusion criterion was the incomplete answers to the three questionnaires initially, 300 subjects were enrolled bot and filled out questionnaires however 20% of them, were filled out incomplete and excluded from our study. The final study population size was N = 232.
The collected information was then imported into a spreadsheet in Microsoft Excel. Statistical analyses were conducted with IBM SPSS 22.0. Correlations between variables were evaluated with a bivariate correlation test. The chi-square test was used to analyze the differences between the groups. Linear regression was used for the analysis of estimated effects. A P-value of < 0.05 was considered statistically significant.
The study was conducted following the STROBE checklist (EQUATOR guidelines). The strengthening the reporting of observational studies in epidemiology (STROBE) was used to ascertain high-quality reporting of this observational study.
4. Results
Three hundred students answered the questionnaires on social media, giving an approximate response rate of 17%. Among them, 232 questionnaires were completed and included in our study, representing approximately 12% of all medical students of Mashhad University of Medical Sciences. Occupation with work and study, lack of internet access, or dissatisfaction with answering were the reasons for not filling out the questionnaires.
A total of 232 medical students studying at a major university in northeastern Iran were enrolled in the present investigation, which aimed to evaluate the prevalence of GAD, alexithymia, and adaptation of defense mechanisms. Among them, 136 (60%) participants were female, and the remaining 96 (40%) were male. Moderate and severe anxieties were reported by 87 (37.5%) participants, who were suggested to be further followed up by specialists. A total of 38 (16.3%) subjects reported negligible levels of anxiety. Alexithymia was detected in 49 (21.1%) subjects, and the most frequent complaints were difficulty identifying and describing feelings. Of the three significant categories of defense mechanisms, mature mechanisms had the highest prevalence among students, as 121 (52.1%) participants confirmed to have adopted these mechanisms. From the mature defense mechanisms, anticipation was the most commonly used, with a prevalence of 85.3% (Table 1).
Table 1.Demographic Information of Participants and Prevalence of Anxiety, Alexithymia, and Defense Mechanisms
| Variables | Patients (No = 232); No. (%) |
|---|---|
| Sex | 232 (100) |
| Male | 96 (60) |
| Female | 136 (40) |
| Educational level (years of training) | 232 (100) |
| Basic medical sciences (2) | 80 (34.5) |
| Pre-clerkship (1) | 24 (10.3) |
| Clerkship (2) | 63 (27.2) |
| Internship (2) | 65 (28) |
| Anxiety | 232 (100) |
| None | 38 (16.4) |
| Mild | 107 (46.1) |
| Moderate | 58 (25) |
| Severe | 29 (12.5) |
| Alexithymia | 49 (21.1) |
| Difficulty identifying feelings | 70 (30.2) |
| Difficulty describing feelings | 108 (46.6) |
| Externally oriented thinking | 23 (9.9) |
| Defense mechanisms | |
| Mature | 131 (56.5) |
| Neurotic | 121 (52.2) |
| Immature | 54 (23.3) |
| Mature defense mechanisms | |
| Anticipation | 198 (85.3) |
| Humor | 151 (65.1) |
| Suppression | 100 (43.1) |
| Sublimation | 84 (36.2) |
| Neurotic defense mechanisms | |
| Pseudo-altruism | 204 (87.9) |
| Undoing | 126 (54.3) |
| Idealization | 105 (45.3) |
| Reaction formation | 83 (35.8) |
| Immature defense mechanisms | |
| Rationalization | 178 (76.7) |
| Autistic fantasy | 152 (65.5) |
| Dissociation | 140 (60.3) |
| Devaluation | 128 (55.2) |
| Somatization | 112 (48.3) |
| Isolation | 107 (46.1) |
| Acting out | 97 (41.8) |
| Displacement | 84 (36.2) |
| Passive aggression | 80 (34.5) |
| Denial | 62 (26.7) |
| Splitting | 53 (22.8) |
| Projection | 52 (22.4) |
Concerning individual defense mechanisms, the mean scores of sublimations, devaluation, displacement, splitting, and somatization were found to be statistically significantly different between the two genders (P-value: 0.008, < 0.001, 0.04, 0.03, and 0.01, respectively) (Figure 1).
Figure 1.
Gender differences in defense mechanism mean scores (using independent sample t-test)
There was no statistically significant difference in the mean scores of neurotics, mature, and immature mechanisms, GAD, and alexithymia between the two genders. However, the mean scores of neurotic mechanism GAD and alexithymia were higher in females than males (Table 2).
Table 2.Relationship Between Gender and Defense Mechanisms
| Variables | Male (N = 90); Mean ± SD | Female (N = 130); Mean ± SD | P-Value a |
|---|---|---|---|
| Neurotic | 39.4 (8.83) | 40.42 (10.19) | 0.44 |
| Mature | 41.14 (9.33) | 40.85 (10.19) | 0.83 |
| Immature | 108.3 (20.83) | 106.25 (21.16) | 0.47 |
| GAD | 8.29 (4.2) | 9.3 (4.54) | 0.09 |
| Alexithymia | 50.22 (9.36) | 51.02 (11.06) | 0.57 |
Abbreviation: GAD, generalized anxiety disorder.
a Independent sample t-test.
We classified the students based on medical education training years into two groups: Pre-clinical (years 1 and 2 and 3) and clinical (years 4, 5, 6, and 7) levels. Mature, immature, and neurotic mechanisms were more prevalent in the clinical-level students than in pre-clinical students, but there were no statistically significant differences in those mechanisms between the two groups. Concerning individual defense mechanisms, only the splitting mechanism was statistically different between the two groups of students (Table 3).
Table 3.Association Between Defense Mechanisms and Students' Levels
| Defense Mechanism | Adoption, No. (%) | Non-adoption, No. (%) | P-Value a |
|---|---|---|---|
| Mature | 0.73 | ||
| Pre-clinical | 60 (55.7) | 44 (55.5) | |
| Clinical | 71 (55.5) | 57 (44.5) | |
| Sublimation | 0.2 | ||
| Pre-clinical | 33 (31.7) | 71(68.3) | |
| Clinical | 51 (39.8) | 77 (60.2) | |
| Humor | 0.23 | ||
| Pre-clinical | 72 (69.2) | 32 (30.8) | |
| Clinical | 79 (61.7) | 49 (38.3) | |
| Anticipation | 0.77 | ||
| Pre-clinical | 88 (84.6) | 16 (15.4) | |
| Clinical | 110 (85.9) | 18 (14.1) | |
| Suppression | 0.56 | ||
| Pre-clinical | 47 (45.2) | 57 (54.8) | |
| Clinical | 53 (41.4) | 75 (58.6) | |
| Neurotic | 0.46 | ||
| Pre-clinical | 57 (54.8) | 47(45.2) | |
| Clinical | 64 (50) | 64 (50) | |
| Undoing | 0.89 | ||
| Pre-clinical | 56 (53.8) | 48 (46.2) | |
| Clinical | 70 (54.7) | 58 (45.3) | |
| Pseudo altruism | 0.55 | ||
| Pre-clinical | 90 (86.5) | 14 (13.5) | |
| Clinical | 114 (89.1) | 14 (10.9) | |
| Idealization | 0.06 | ||
| Pre-clinical | 54 (51.9) | 50 (48.1) | |
| Clinical | 51 (39.8) | 77 (60.2) | |
| Reaction formation | 0.95 | ||
| Pre-clinical | 37 (35.6) | 67 (64.4) | |
| Clinical | 46 (35.9) | 82 (64.1) | |
| Immature | 0.8 | ||
| Pre-clinical | 25 (24) | 79 (76) | |
| Clinical | 29 (22.7) | 99 (77.3) | |
| Projection | 0.82 | ||
| Pre-clinical | 24 (23.1) | 80 (76.9) | |
| Clinical | 28 (21.9) | 100 (78.1) | |
| Passive-aggression | 0.25 | ||
| Pre-clinical | 40 (38.5) | 64 (61.5) | |
| Clinical | 40 (31.3) | 88 (68.8) | |
| Acting out | 0.5 | ||
| Pre-clinical | 46 (44.2) | 58 (55.8) | |
| Clinical | 51 (39.8) | 77 (60.2) | |
| Isolation | 0.78 | ||
| Pre-clinical | 49 (47.1) | 55 (52.9) | |
| Clinical | 58 (45.3) | 70 (54.7) | |
| Devaluation | 0.86 | ||
| Pre-clinical | 58 (55.8) | 46 (44.2) | |
| Clinical | 70 (54.7) | 58 (45.3) | |
| Autistic fantasy | 0.81 | ||
| Pre-clinical | 69 (66.3) | 35 (33.7) | |
| Clinical | 83 (64.8) | 45 (35.2) | |
| Denial | 0.51 | ||
| Pre-clinical | 30 (28.8) | 74 (71.2) | |
| Clinical | 32 (25) | 96 (75) | |
| Displacement | 0.2 | ||
| Pre-clinical | 33 (31.7) | 71 (68.3) | |
| Clinical | 51 (39.8) | 77 (60.2) | |
| Dissociation | 0.31 | ||
| Pre-clinical | 59 (56.7) | 45 (43.3) | |
| Clinical | 81 (63.3) | 47 (36.7) | |
| Splitting | 0.02 | ||
| Pre-clinical | 31 (29.8) | 73 (70.2) | |
| Clinical | 22 (17.2) | 106 (82.8) | |
| Rationalization | 0.94 | ||
| Pre-clinical | 80 (76.9) | 24 (23.1) | |
| Clinical | 98 (76.6) | 30 (23.4) | |
| Somatization | |||
| Pre-clinical | 44 (42.3) | 60 (57.7) | 0.1 |
| Clinical | 68 (53.1) | 60 (46.9) |
a Chi-square tests
The mature mechanism significantly correlated positively with neurotic and alexithymia, and negatively correlated with GAD. The immature mechanism positively correlated with neurotic mechanism, alexithymia, and GAD. The neurotic mechanism positively correlated with immature mechanism, mature mechanism, and GAD. Alexithymia had significant positive correlations with the immature mechanism and GAD, and a negative correlation with the mature mechanism. Also, GAD was positively correlated with immature and neurotic defense mechanisms and alexithymia. On the contrary, a negative correlation was noted between alexithymia and mature defense mechanisms (Table 4).
Table 4.Correlation Among Generalized Anxiety Disorder, Alexithymia, and Three Major Defense Mechanisms
| Variables | Mature | Neurotic | Immature | GAD | Alexithymia |
|---|---|---|---|---|---|
| Mature | |||||
| Correlation coefficient | 1 | 0.27 a | 0.09 | -0.38 a | 0.24 a |
| P-value b | < 0.001 | 0.13 | < 0.001 | < 0.001 | |
| Neurotic | |||||
| Correlation coefficient | 0.27 | 1 | 0.29 a | 0.15 b | 0.11 |
| P-value b | < 0.001 | < 0.001 | 0.01 | 0.07 | |
| Immature | |||||
| Correlation coefficient | 0.09 | 0.29 a | 1 | 0.39 a | 0.42 |
| P-value b | 0.13 | < 0.001 | < 0.001 | < 0.001 | |
| GAD | |||||
| Correlation coefficient | -0.38 a | 0.15 b | 0.39 a | 1 | 0.35 a |
| P-value b | < 0.001 | 0.01 | < 0.001 | < 0.001 | |
| Alexithymia | |||||
| Correlation coefficient | -0.24 a | 0.11 a | 0.42 a | 0.35 a | 1 |
| P-value b | < 0.001 | 0.07 | < 0.001 | < 0.001 |
a P-value < 0.01.
b Pearson correlation test, P-value < 0.05.
In linear regression analysis, GAD and alexithymia were dependent, and defense mechanisms were independent variables. Linear regression assumptions were a linear relationship between variables, independency between samples, homogeneity of variances, and normality of dependent variables.
Linear regression analysis revealed a statistically significant negative association between some defense mechanisms (Table 5). Mature defense mechanisms (suppression and humor) had a negative correlation with GAD (P-value < 0.05). On the other hand, none of the neurotic mechanisms had a statistical correlation with alexithymia. Humor and rationalization were the negative predictors of alexithymia (Table 5).
Table 5.Linear Regression Analysis Results for Generalized Anxiety Disorder, Alexithymia, and Defense Mechanisms
| Variables | Unstandardized B | SE | Standardized B | t | P-Value |
|---|---|---|---|---|---|
| GAD | |||||
| Suppression | -0.172 | 0.066 | -0.156 | -2.624 | 0.009 |
| Sublimation | 0.133 | 0.062 | 0.116 | 2.167 | 0.031 |
| Humor | -0.315 | 0.06 | -0.3 | -5.256 | < 0.001 |
| Pseudo altruism | 0.214 | 0.07 | 0.154 | 2.862 | 0.005 |
| Acting out | 0.149 | 0.067 | 0.126 | 2.21 | 0.028 |
| Autistic fantasy | 0.134 | 0.056 | 0.137 | 2.39 | 0.018 |
| Passive-aggression | 0.191 | 0.067 | 0.164 | 2.845 | 0.005 |
| Displacement | 0.154 | 0.059 | 0.138 | 2.624 | 0.009 |
| Somatization | 0.137 | 0.055 | 0.135 | 2.487 | 0.01 |
| Alexithymia | |||||
| Humor | -0.335 | 0.157 | -0.135 | -2.132 | 0.034 |
| Autistic fantasy | 0.335 | 0.147 | 0.146 | 2.289 | 0.023 |
| Splitting | 0.406 | 0.17 | 0.149 | 2.386 | 0.018 |
| Rationalization | -0.573 | 0.217 | -0.173 | -2.639 | 0.009 |
Abbreviation: GAD, generalized anxiety disorder.
5. Discussion
A total of 232 medical students participated in this investigation. Of them, 87 (37.5%) participants passed the threshold score for GAD and, thus, were more extensively assayed. An investigation by Ahmed et al. on anxiety in 2009 indicated a prevalence of 28% for GAD among medical students studying in Dubai (5), confirming the theory that anxiety is not a rare condition in medical students. Consistent with our findings, the Labbafinejad and Bossaghzade study of Iranian medical students reported prevalence rates of 36.2% and 4.3% for moderate and severe anxiety, respectively (3).
5.1. Gender Differences
We found that neurotic mechanisms were more commonly employed by females, similar to the Parekh et al. study (15). Also, male students employed projection and passive aggression more (but not statistically significant). The ascertain of gender differences in defense mechanisms based on classical psychoanalytic theory (22) has generally been confirmed, which declares that women tend to employ internalizing defenses such as introversion, and men are more likely to use externalizing ones (23) such as projection and aggression (24-26).
We observed that female students employed somatization more commonly than male students, similar to the La Cour study (27). Women's greater psychological awareness of their bodily functions and reactions may explain these higher prevalence rates. Gender variations were also found in sublimation, pseudo-altruism, reaction formation, isolation, autistic fantasy, displacement, and rationalization defense mechanisms; however, these differences were inconsistent with those reported in prior investigations (15). There were no differences in the defense mechanisms employed by the two genders in Andrews et al. study (20). These findings may suggest that specific norms of the DSQ-40 need to be revised about gender.
5.2. Level of Students
Only was splitting statistically significant between the two clinical-level groups, consistent with the findings of Parekh et al. (15). The mature mechanism was more prevalent in the clinical-level students than in pre-clinical students. Increased levels of stress and the overall psychological maturity mechanisms utility (because of high levels of chronic stress) in senior medical students may be explained by these differences in prevalence.
Among individual neurotic ego defense mechanisms, undoing and pseudo-altruism were more prevalent among pre-clinical years students in our study. In Parekh et al. study, the mean scores of undoing, reaction formation, and idealization were significantly higher in pre-clinical students (15).
In our study, autistic fantasy and rationalization were the most prevalent immature defenses in the pre-clinical group, whereas splitting and rationalization were the most prevalent immature defenses in this group in the Parekh et al. study (15). These findings may be explained by the fact that early-year medical students are teenagers whose personalities are being formed, and various life events strongly influence their personalities.
5.3. Predictors of Anxiety in Medical Students
We found that autistic fantasy and displacement somatization were positively associated with anxiety scores, whereas suppression was negatively associated, consistent with the Waqas et al. study (13). Mature defense mechanisms promote mental health since they allow an individual to view his environment positively, although slightly distorted, increasing his self-esteem and protecting him against anxiety. In contrast, adaptation with immature defense mechanisms is more likely associated with psychiatric manifestations.
5.4. Conclusions
Alexithymia was detected in 21.1% of subjects in our study, and the most frequent complaints were difficulty identifying and describing feelings. Like any other human being, medical students are susceptible to the negative impact of external stress, which could manifest as dissatisfaction and isolation. Also, our study indicated that 37.5% of medical students in northeastern Iran had symptoms of generalized anxiety disorder, indicating the overwhelming burden that can be superimposed on their lives. The type of defense mechanism through which an individual approaches their anxiety determines the level of their anxiety, as sublimation and humor, two examples of mature defense mechanisms, can negatively regulate the level of anxiety. A good understanding of the interaction between defense mechanisms and the development of GAD and alexithymia is highly likely to help institutions develop awareness-raising programs to help students deal with their anxiety. Implementing programs in medical education to identify the defense mechanisms of medical students and promote adaptive mechanisms by strategies designed for this purpose (for instance, behavioral therapy and meditation) would improve the performance and mental health of medical students.
The lack of knowledge in this field due to the small number of studies conducted in Iran regarding the subject of study, the importance of mental health, and the high health and economic burden of these disorders in societies, including medical students, were the strengths of our study. The present investigation is limited in terms of population size and ethnicity of participants, and a more solid conclusion should be verified by prospective studies.
