Title:
Ego Defense Mechanisms in Pakistani Medical Students: A cross sectional
analysis
Authors:
Maria Babar Afridi1, Hina Majeed2, Tuba Rashid Khan2, Anum Bilal Khan2,
Salman Khalid2, Nadia Mansoor Khwaja2, Roha Khalid2, Mohammad Awais
Khan2, Ibrahim M. Rizqui2, Imtiaz Jehan3
1
Department of Biological & Biomedical Sciences, Aga Khan University,
Karachi, Pakistan
2
3
Medical College, Aga Khan University, Karachi, Pakistan
Department of Community Health Sciences, Aga Khan University, Karachi,
Pakistan
Email addresses:
[email protected]; [email protected]; [email protected];
[email protected]; [email protected];
[email protected]; [email protected]; [email protected];
[email protected];
Corresponding author:
Maria Babar Afridi
Department of Biological & Biomedical Sciences
The Aga Khan University
Karachi, Pakistan
[email protected]
Word Count: 2380
ABSTRACT
Background: Ego defense mechanisms, defined by Sigmund Freud as unconscious
resources used by the ego to reduce conflict between the id and superego, are a reflection
of how an individual deals with conflict and stress. This study assesses the prevalence of
various ego defense mechanisms employed by medical students of Karachi.
Methods: A questionnaire based cross-sectional study was conducted on 687 students
from five medical colleges of Karachi in November 2006. Ego defense mechanisms were
assessed using the Bond style Defense Style Questionnaire (DSQ-40)
Results: Neurotic factors had a higher mean score (5.62) than Mature (5.60) and
Immature (4.78) mechanisms. Immature mechanisms were found to be higher in males
whereas Neurotic mechanisms were more prevalent in females. Neurotic and Immature
factors were significantly more prevalent in the Preclinical group. Mature mechanisms
were significantly higher in Government colleges than Private institutions (p<0.05).
Conclusion: Neurotic mechanisms are prevalent among medical students of Karachi and
this reflects greater stress levels than the general population. Female gender, enrollment
in a private medical college, and preclinical students constituted greater risk.
Keywords: Defense mechanisms, coping styles, medical students, Sigmund Freud,
psychoanalytic theory
INTRODUCTION:
Ego defense mechanisms were defined for the first time by Freud as unconscious
resources used by the ego to reduce the conflict between the id, and superego. They
provide a reflection of how an individual deals with conflict and stress, and thus, have
been turned into the first psychoanalytical concept recognized by the DSM-IV as axes for
future studies. [1]
Andrew et al classified the 20 defense mechanisms in accordance with the DSM-III-R
into: (a) four mature: sublimation, humor, anticipation and suppression; (b) four
neurotic: undoing, pseudo-altruism, idealization, reaction formation; (c) twelve
immature: projection, passive aggression, acting out, isolation, devaluation, autistic
fantasy, denial, displacement, dissociation, splitting, rationalization and somatisation
Perceived medical school stress has been linked to clinically significant mental distress,
which subsequently leads to mental health concerns such as anxiety and depression [11].
A number of studies have been conducted to asses the level of stress and depression in
medical students. A study conducted in Karachi, Pakistan on a similar population of
medical students indicated that more than 90% of the students admit to being stressed at
one time or another, boys showing a greater tendency than girls [13]. Another study
conducted in Zimbabwe [14] found the level of stress in Year 1 medical students to be
significantly high. They concluded that such a state of psychological and emotional
distress in the subsequent years of medical training and during the professional years may
lead to serious social consequences; Hence the need of a system of identifying students
with low stress threshold early in their training as a means of helping them to deal with
the stress and its causes. One particular study [15] seems to asses the level of distress in
medical students in a pre exam and normal school setting. The preliminary data support
the view that, upon entering medical school, students' emotional status resembles that of
the general population. However, the rise in depression scores and their persistence over
time suggest that emotional distress during medical school is chronic and persistent rather
than episodic.
Our study aims to identify the prevalence of various defense mechanisms employed by
medical students of Karachi. The data collected would aid in identifying the subset of
medical students more likely to employ immature and neurotic defense mechanism.
Moreover, as the anxiety level varies through out the five years of medical education, our
study also aims to identify the different ego defense mechanisms utilized by students
enrolled in different years of the medical curriculum
METHODS:
This study was a cross-sectional questionnaire-based analysis, conducted in November
2006.
Subjects:
Sample size was calculated to be 634, using EpiInfo. A representative sample was
randomly selected from 5 government and private institutions to incorporate a larger
sample size as well as to choose a more representative sample for Karachi. Medical
students enrolled through Years 1 to 5 in the 5 major medical colleges of Karachi were
included, irrespective of their age, sex, ethnicity, religion, or comorbids. Only those
giving written consent were included in the study.
The questionnaire was administered by interviewers who were trained during
administration of pilot questionnaire for uniformity and avoidance of possible interviewer
bias.
Methods of Measurement:
Research on ego defense mechanisms has exponentially increased in recent years with the
development of different tools for measuring defense mechanisms. The DSQ-40 is a
reliable tool for assessing defense mechanisms [14]. Bond et al initially developed the
DSQ as a 67-item self-reported questionnaire to assess conscious derivatives of defense
mechanisms [15]. The aim of this instrument is to identify the characteristic style of how
people – conscious or unconscious – deal with conflict, based on the idea that people can
accurately comment on their behavior. Andrews et al reorganized the instrument into
forty questions in 1993 to make it short and manageable.[16].
We employed the 40-item DSQ-40 to assess conscious derivatives of defense
mechanisms. This instrument has been translated and validated into Finnish, French,
Japanese, and Brazilian-Portuguese with similar results to the 67-item original
questionnaire developed by Bond et al. The DSQ-40, which has also been employed in
other cultures, comprises 40 items in a 9-point Likert format. The 40 items are used to
derive scores on 20 defense mechanisms, two items for each defense mechanism. E.g.
The defense mechanism “projection” is evaluated with two items—“People tend to
mistreat me” and “I am sure to get a raw deal from life”). The mechanisms are grouped in
three factors: mature, neurotic, and immature style.
Data Analysis:
The groups were compared according to gender and year of medical education, 1st and
2nd year students being considered in the preclinical group while 3rd, 4th and 5th year
students were a part of the clinical students group. The students were also compared in
relation to type of college they belonged to, by dividing them into two broad categories,
i.e. private and government medical colleges.
The DSQ-40 was analyzed in 2 ways: (a) as originally suggested by Andrews et al.
(1993), by pairing 2 items together under the label of a defense mechanism; and (b) as
suggested by Andrews et al. (1993) by grouping the defense mechanisms into mature,
neurotic, and immature defenses.
Ethical Approval, Informed Consent and Patient Confidentiality:
This study complied with the Declaration of Helsinki. Patients who agreed to participate
were explained the nature and the objectives of the study, and informed consent was
formally obtained. The study was approved by the Ethical Review Committees of all
participating medical institutes. No reference to the patient’s identity was made at any
stage during data analysis or in the paper.
RESULTS:
Our study sample constituted 236 males (34.6%) and 446 females (65.4%). A comparable
proportion was sampled from government (N=418, 60.8%) and private (N=269, 39.2%)
medical colleges of Karachi, as was from preclinical (N=366, 54.5%) and clinical
(N=306, 45.5%) groups of students. The mean age of our population was 20.18 years
(Range = 16-26 years). Only 39 students (5.7%) of the total sample had previous
knowledge of the psychological defense mechanisms.
Figure 1: Prevalence of Ego Defense Mechanisms in Medical Students of Karachi
According to our study, the mean score of neurotic ego defense mechanisms was slightly
higher than that of mature and immature. The most common ego defense mechanisms
employed by medical students were Rationalization (Mean = 6.43), Anticipation (Mean =
6.34), and Undoing (5.93). The least commonly employed mechanisms were Devaluation
(Mean = 3.62), Displacement (Mean = 3.94), and Denial (Mean = 4.14). (Table 1)
Gender Differences:
There was no significant difference in the means of Mature defense mechanisms in males
as compared to females. Neurotic mechanisms were found to be higher in females (p
value = 0.013) whereas immature mechanisms were more prevalent in males (p value =
0.055).
When comparing the individual defense mechanisms, we found that Undoing (p = 0.01),
Idealization (p =0.011), and Somatization (p = 0.024) were more commonly found in
females as compared to males. A higher prevalence of Isolation (p = 0.038), Devaluation
(p = 0.000), Denial (p =0.000), and Dissociation (p = 0.000) was found in males. (Table
2)
Year of Medical Education:
As mentioned above students were classified into 2 groups based on the year of their
medical education: (a) Preclinical – Years 1 and 2; and (b) Clinical – Years 3, 4 and 5.
While comparing the two groups, Mature factors failed to reach a statistical significance,
whereas Neurotic defense mechanisms were significantly found to be more prevalent in
the Preclinical group (p=0.000) as were Immature ego defenses (p=0.015).
Individual analysis of the ego defense mechanisms showed that Idealization (p=0.011),
Reaction formation (p=0.002), Splitting (p=0.000) and Rationalization (p=0.023) were
more commonly found in the preclinical students group while Undoing was the only
defense mechanism significantly more prevalent (p=0.003) amongst the clinical group.
Medical Institutions:
Mature defense mechanisms were found to be significantly higher in Government
medical colleges (p= 0.057) as compared to Private medical colleges. No difference was
found in the means of Neurotic and Immature defense mechanisms between the two
groups.
Anticipation (p=0.000), Idealization (p=0.056) and Rationalization (p=0.049) were more
commonly found in the Government colleges while Devaluation (p=0.010) and
Displacement (p=0.055) ego defense mechanisms were more prevalent in Private
institutions.
DISCUSSION:
As our data was collected from five different medical colleges all over Karachi, it would
be safe to say that our results can be generalized to represent the entire medical student
population of Karachi, if not Pakistan. Female students were overrepresented as have
been in other studies published on the use of ego defense mechanisms using convenient
sampling indicating that a large proportion of the future physicians of Pakistan might be
females; hence increasing the importance of identifying the differences in psychological
defense mechanisms used amongst the two gender groups.
We were only able to find two major studies published using DSQ-40, on a similar topic,
one by Watson and Sinha [24], using Australian and Canadian groups of university
students and the other by Peter La Cour [20] on first year medical students of Denmark.
To our knowledge this is the first study conducted to identify the prevalence of different
ego defense mechanisms on Pakistani medical students. We hence found it to be an
interesting task to discuss the possible differences in findings found by us on Pakistani
students as compared to those made by Peter La Cour on Danish Medical students.
The three main themes representing the characteristics of our student population were:
1. Rationalization
Rationalization was found to be the most common defense mechanism among the
medical students. This observation has also been made by La Cour in his study conducted
in Denmark in 2002 [20]. We found rationalization to be significantly more common
among students in preclinical years as compared to students in clinical years. Another
study done on ego defense mechanisms indicates that defense mechanisms tend to
become mature with advancement of age in adolescents and young adults [21]. In our
study it makes sense that as students mature when they enter their clinical years,
rationalization becomes less common.
2. Anticipation
Anticipation was found to be the second most common ego defense mechanism; similar
observation has been reported be La Cour [20] in Danish Medical students. It was found
to be so independently of gender difference and year of education. However, there was
significant difference between private and government institutions, with more
anticipation in government college students. Generally in Pakistan, the socioeconomic
status of students is lower in government colleges. We may suggest that these students
may be forced to face the harsh realities of life sooner than their rich and spoilt
counterparts.
3. Undoing
Undoing is an improbable finding, but was the third most common defense mechanism
used, and more commonly by female students of the clinical group. In the questionnaire,
it deals with undoing of aggressive behavior. This can be related to the hierarchical
nature of medical professional life. It has been seen that competition is very strong
among medical students [22]. “Undoing could be seen as a submissive, but adaptive,
strategy in the field of competition. The “fight for rights” is not a suitable attitude in an
authoritarian environment.” La Cour [20] aptly explains his finding which is very similar
to ours.
Clinical vs. Preclinical
In our study we found that immature and neurotic factors are more common in preclinical
years. We can infer that defense mechanisms tend to become more mature with age and
with more responsibility in clinical years. Among neurotic factors undoing, reaction
formation and idealization were significantly more common in preclinical years. Among
immature factors, splitting and rationalization were significantly greater in preclinical
years. These results could have been obtained due to the fact that pre-clinical Pakistani
students are teenagers aged 17 to 19. They are at a point where their personalities are
being molded and various life events tend to leave a very strong impression on them.
These impressions are either completely positive or negative because the teenagers view
things as black and white. With time as they mature they learn to see the grayer shades of
life as well.
Gender Differences
Neurotic Factors were found to be more common among females and Immature Defenses
were more common among males. This was explained by Levit’s [23] study that showed
that males tend to use introversion using projection and aggression and girls are likely to
use introversion by turning against the self. In our study, Isolation was found to be
significantly greater in males than females. This is consistent with findings made by
Watson and Sinha [24] as well as La Cour [20]. This could be due to the fact that females
are generally more emotionally labile as compared to their male counterparts who are
better at splitting emotional components from their thoughts, as shown by higher means
for isolation in men in our study. [23]
Somatization was also found to be a significantly common defense mechanism used by
females which has also been reported by La Cour but not by Watson and Sinha. Females
are generally more psychologically aware of their bodily functions and reactions, which
might explain the defense mechanisms higher prevalence rates. Gender variations were
also found in undoing, devaluation and idealization defense mechanisms however these
variations were inconsistent with those reported in other studies.
Andrew et al [16] did not find any differences in the ego defense mechanism between
genders. Studies by Watson, Sinha and La Cour, along with our own results do not
support his findings. Our study supports the suggestion made by Watson and Sinha in
relation to the fact that specific norms of the DSQ-40 need to be reconstructed with
regard to gender. (Table 2)
The first psychoanalytical concept based on Ego Defense Mechanisms, described by
Freud, provide a reflection of how an individual deals with conflict and stress. In this
article, the authors describe the higher prevalence of neurotic mechanisms among
medical students of Karachi, which reflects greater stress levels than the general
population. Female gender, enrollment in a private medical college, and preclinical
students were found to be significant risk factors. The findings of this study may suggest
a need for further research and understanding of the complex effects of motives and
personality on becoming a physician. Future studies are recommended to assess the effect
of the defense mechanisms employed by individuals on their quality of life.
Competing interests: The authors have declared that no competing interests exist.
Authors’ Contributions: MBA and HM participated in the design of the study,
performed the statistical analysis, and wrote the final manuscript. TRK, ABK, NMK and
RK conceived of the study, and participated in its design and coordination and helped to
draft the manuscript. SK, MAK, IJ and IMR revised the manuscript for important
intellectual content. All authors participated in data collection, read and approved the
final manuscript.
Acknowledgements: The authors wish to thank Dr Naim Siddiqui for his constant
supervision and support, Dr Saman Iqbal and Dr Riffat Moazam-Zaman for their valuable
feedback. We acknowledge the continuous administrative support of Mr Shakeel Damani
and Mr Dominic D’Souza (senior administrative assistant)
Funding: This research was partially supported by research funds from the Department
of Community Health Sciences, Aga Khan University.
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Table 1: Prevalence of different Ego Defense Mechanisms, Full Sample
Medical students (N=690)
Defense Mechanism
Mean
Mature
5.6017
Sublimation
5.08
Humor
5.74
Anticipation
6.34
Suppression
5.24
Neurotic
5.6192
Undoing
5.93
Pseudoaltruism
5.82
Idealisation
5.45
Reaction Formation
5.11
Immature
4.7761
Projection
4.68
Passive-aggression
4.4
Acting out
5.36
Isolation
5.12
Devaluation
3.62
Autistic fantasy
4.58
Denial
4.16
Displacement
3.94
Dissociation
4.71
Splitting
5.32
Rationalization
6.43
Somatization
4.95
Table 2: Gender Differences in the Prevalence of EDM using Independent Sample T-test
Females
Males
Defense Mechanism
Mean (SD)
Mean (SD)
p value
Mature
Sublimation
Humor
Anticipation
Suppression
Neurotic
Undoing
Pseudoaltruism
Idealisation
Reaction Formation
Immature
Projection
Passive-aggression
Acting out
Isolation
Devaluation
Autistic fantasy
Denial
Displacement
Dissociation
Splitting
Rationalization
Somatization
5.6398
5.1399
5.7698
6.4101
5.1602
5.7180
6.1365
5.8792
5.6378
5.1025
4.7216
4.6413
4.2968
5.4203
4.9988
3.4368
4.5516
3.9467
3.8971
4.4831
5.4299
6.5092
5.0973
5.5294
4.9498
5.6769
6.2039
5.4204
5.4441
5.5649
5.7203
5.1272
5.1542
4.8885
4.7733
4.5943
5.2788
5.3717
4.0022
4.6542
4.5939
4.0582
5.1681
5.1169
6.2783
4.6775
.296
.256
.598
.187
.134
.013*
.001*
.318
.011*
.743
.055*
.400
.087
.403
.038*
.000*
.612
.000*
.373
.000*
.092
.125
.024*
* Statistically Significant
Figure 1
Additional files provided with this submission:
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25K
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Additional file 2: appendix ii - dsq 40.doc, 26K
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