Ego defense mechanisms among pediatric dental postgraduate students in India: A descriptive cross-sectional study

Sharath Asokan; PR Geetha Priya; Sudhandra Viswanath; Thendral Mathiazhagan

doi:10.4103/jisppd.jisppd_302_21



ORIGINAL ARTICLE

Year : 2021 \| Volume : 39 \| Issue : 3 \| Page : 257-261

Ego defense mechanisms among pediatric dental postgraduate students in India: A descriptive cross-sectional study

Sharath Asokan, PR Geetha Priya, Sudhandra Viswanath, Thendral Mathiazhagan
Department of Pediatric and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Tamil Nadu, India

Date of Submission	13-Jun-2021
Date of Decision	25-Aug-2021
Date of Acceptance	22-Sep-2021
Date of Web Publication	22-Nov-2021

Correspondence Address:
Dr. Sharath Asokan
Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode - 637 215, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jisppd.jisppd_302_21

Abstract

Background: Ego defense mechanisms (EDMs) act as a major factor for overcoming stressful situations in life. Aims: The study aimed to assess the various patterns and factors of EDMs employed by pediatric dental postgraduate students in India. Settings and Design: Cross-sectional design, web-based questionnaire survey. Methods: A cross-sectional questionnaire study on EDM was conducted among 246 pediatric dental postgraduates in India from July to October 2019. The modified form of the Defense Style Questionnaire-20 included 10 EDMs under three major patterns– Mature, Immature, and Neurotic. The questionnaire was sent to all pediatric dental postgraduates enrolled in the Indian Society of Pedodontics and Preventive Dentistry and reminders were sent every week for 6 weeks. Results: Among the 1041 pediatric dental postgraduates who received the E-mail, two hundred and forty-six students responded to the same. The respondents included 89 males and 157 females. The mature pattern was found to be the most commonly employed EDM (males-47.20%; females-51.60%). Sublimation (72.76%), a mature type of defense was found to be the most common EDM factor employed by the majority of the students. The immature pattern was higher among males when compared to females (males-14.60%; females-5.70%). Conclusion: Most pediatric dental postgraduates exhibited a mature pattern, followed by a neurotic and immature pattern of EDM. The mature pattern of EDM was displayed more by the female students than the male students. Sublimation was found to be the maximum expressed factor followed by acting out.

Keywords: Coping mechanism, dental postgraduates, depression, ego defense, stress

How to cite this article:
Asokan S, Geetha Priya P R, Viswanath S, Mathiazhagan T. Ego defense mechanisms among pediatric dental postgraduate students in India: A descriptive cross-sectional study. J Indian Soc Pedod Prev Dent 2021;39:257-61

How to cite this URL:
Asokan S, Geetha Priya P R, Viswanath S, Mathiazhagan T. Ego defense mechanisms among pediatric dental postgraduate students in India: A descriptive cross-sectional study. J Indian Soc Pedod Prev Dent [serial online] 2021 [cited 2021 Dec 7];39:257-61. Available from: https://www.jisppd.com/text.asp?2021/39/3/257/330707

Introduction

Stress is defined as an adverse emotional state occurring as a result of events, perceived as demanding or exceeding a person's resources or ability to cope.^[1] The term “stress” describes external demands (physical or mental) on an individual's physical and psychological wellbeing.^[2] Early stress researchers believed that any changes that are required to adjust the behavior and lifestyle of a person would cause stress.^[3] Health-care workers are subjected to high levels of stress, mostly due to the high expectations placed on them and the responsibilities they have towards human life.^[4] Young adults are exposed to excessive academic stress because of the pressure placed upon them by environmental influences. Depression, anxiety, behavioral problems, and irritability are some of the problems commonly encountered by students with high academic professions.^[5]

Dentistry is one of the stressful professions because of its nature and working conditions.^[6] Practising pediatric dentistry in a general practice setup is time-consuming and requires more experience. Young general practitioners and students find it challenging to manage uncooperative children because they do not feel confident in treating.^[7] Excessive stress can also lead to depression, anxiety, substance misuse, absenteeism, diminished work efficiency, and burnout.^[8] Dentistry-related education is viewed as a complex, demanding, and pedagogical learning experience.^[9] Two studies have assessed the levels of stress and depression in dental students in India. It has been reported that the academic life of dental students seems to be hindered due to various potential stressors such as lacking the confidence to be a successful student, the amount of assigned work, competition with peers, examination, and grades, and fear of facing parents after failure.^[8],[10] To overcome these stresses and protect themselves from distress, students need to develop coping strategies. Ego defense mechanism (EDM) is one primary coping strategy used by students.^[11]

EDM is a psychoanalytical concept which reflects how individual deals with conflict and stress.^[12] EDM is categorized under three major categories: Mature, immature, and neurotic. Mature defense mechanisms are associated with adaptive functioning, whereas immature defenses and neurotic defense mechanisms are associated with high anxiety levels. These defenses represent an individual's effort to maintain psychological homeostasis in response to a stressful environment.^[13] It is relatively a rare concept to be employed in the field of medicine with minimal research. Parekh et al. and Waqas et al. studied EDM among Pakistani medical students.^[14],[15] Lovko analyzed the EDM among medical staff members of the University of Zagreb, Croatia.^[16] They reported that the extreme exposure of medical staff in the oncology department to stressful events favored the development of inadequate defensive mechanisms. Borges et al. compared the defense mechanisms and quality of life of medical students in Brazil.^[17] Tangade reported that dental education induces a considerable amount of stress and anxiety among Indian dental students.^[8] The present study, the first of its kind, was planned to investigate the prevalence of EDM employed by pediatric dental postgraduate students in India. It can hence help the teaching faculty to identify the coping strategies used by the students and provide reasonable solutions to reduce their stress levels. This could ultimately help the students have a better quality of life during their postgraduation period.

Methods

The cross-sectional study design and protocol were analyzed and approved by the Institutional Review Board and the Institutional Ethical Committee.

The sample size estimation was done using G* Power version 3.1.9.2 software with the significance level set at 5% and the power of the test at 80%. The estimated sample size was 220 students. This study planned to include all the pediatric dental postgraduate students who had enrolled in the Indian Society of Pediatric and Preventive Dentistry (ISPPD) as a student members. This questionnaire study was conducted between July 2019 and October 2019.

Defense Style Questionnaire

It is the most widely used self-report instrument for defense measurement that has been validated in numerous languages such as Chinese, Dutch, Arabic, Finnish, French, German, Italian, Japanese, and Norwegian.^[18] This method has also been included in the American Psychiatric Association's Handbook of Psychiatric Measures (APA, 2000).

Bond initially developed the Defense Style Questionnaire (DSQ) as an 88-item self-reported questionnaire to assess conscious derivatives of defense mechanisms, based on the idea that people themselves can accurately comment on their behavior.^[19] Andrews reorganized Valliants' DSQ-67 into DSQ-40 with forty questions to make it short and manageable.^[20] DSQ-40 included 20 defense mechanisms under three main categories: Mature, immature, neurotic.

A panel of six pediatric dentists and four psychologists evaluated the DSQ-40 and modified it through focus group discussions to suit the Indian population. The final questionnaire (DSQ-20) formulated included 10 EDM with 20 items applicable to the existing Indian scenario. It was categorized under three patterns: (1) Mature pattern (2)-(a) Sublimation (b) Suppression; (2) Immature pattern (6)-(a) Acting out (b) Denial (c) Displacement (d) Dissociation (e) Rationalization (f) Somatization; (3) Neurotic pattern (2)-(a) Idealization (b) Reaction formation [Appendix 1]. A detailed description of each EDM is given in [Appendix 2]. A pilot trial was conducted among 20 pediatric dental postgraduates to evaluate the face validity of DSQ-20. It was well accepted, and the students were able to comprehend the questions without any difficulties. The validated questionnaire, DSQ-20, was used in the main study and the results of the pilot trial were not included in it.

A Google survey link with the DSQ-20 was E-mailed to all the 1041 pediatric dental postgraduate students enrolled in ISPPD. Reminders to fill the questionnaire were sent every week for 6 weeks. Informed consent was obtained from the participants who were willing to take part in the study.

Scoring criteria

The DSQ consists of two statements about personal attitudes pertaining to each type of EDM. For each statement, options range from “strongly disagree” to “strongly agree” (scores from 1 to 5). The mean score was calculated for each EDM and each pattern. The highest mean score among the three patterns determines the defense style pattern commonly exhibited by the student. An individual may exhibit one or more ego defense patterns. When an individual has the same mean score for two patterns, they are considered to exhibit a combination pattern-mature immature; immature neurotic, and neurotic mature.^[21] The mean scores between 4 and 5 have been clubbed together, and the total number of students in this “high score values” category for each EDM was calculated. The EDM with the maximum number of students in this category was considered as the maximally expressed defense factor.

Statistical analysis

Data analysis was peformed using descriptive statistics (percentage, frequency) and the difference between the defense pattern exhibited by males and females was found using the Chi-square test. A significant level of P ≤ 0.05 was adopted.

Results

Two hundred and forty-six students (23.63%) responded to the DSQ-20 questionnaire, of which 89 (36.1%) students were male, and 157 (63.9%) were female. Out of 246 students, 123 (50%) expressed a mature pattern of defense, 22 (8.90%) exhibited an immature pattern, and 74 (30.10%) showed a neurotic pattern of defense mechanism. In the mature pattern, category 42 (47.20%) were male, and 81 (51.60%) were female. In the immature pattern category, 13 (14.60) were male, and 9 (5.70%) were female. Twenty-four (27%) males and 50 (31.8%) females expressed neurotic defense patterns. The majority of the students exhibited a mature defense mechanism followed by neurotic, and immature patterns. Among the combinations, 24 (9.80%) students showed a mature-neurotic pattern, two (0.80%) students expressed a mature-immature pattern, and one (0.60%) student exhibited an immature-neurotic pattern. Mature patterns and neurotic patterns were found to be more common among females than males, but there was no statistically significant difference in the pattern of EDM based on gender (P = 0.08) [Table 1].

Table 1: Distribution of various patterns of ego defense mechanisms exhibited by postgraduate students

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Sublimation (72.76%) was found to be the maximum expressed factor among the mature pattern. Among immature patterns, acting out (56.9%) followed by somatization (48.78%) were commonly expressed. Idealization (23.57%) was mostly expressed among the neurotic pattern. Among all the ten factors irrespective of the patterns, sublimation was maximally exhibited by the postgraduate students [Table 2].

Table 2: Distribution of mean score values in different ego defense mechanisms

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Discussion

Everyone experiences an ongoing daily battle among the three warring personality processes, namely the id, ego, and superego.^[22] The ego must be reliable, flexible, and resourceful enough to mediate conflicts between the demands of the id and the moral authority of the superego. When the demands of the id or superego threaten to overwhelm the ego, anxiety results. Whenever a realistic solution or compromise is not possible, the ego temporarily reduces anxiety by distorting the thoughts or perceptions of reality through a mental process called EDMs. By resorting to this unconscious self-deception, the ego can provide a more acceptable and realistic solution to reduce stress and anxiety.^[22],[23] EDM is employed in clinical psychology as a diagnostic template for understanding the distress of a person.^[24] Dentistry, being the most stressful profession among the health-care professions, leads to many frustrations.^[25] Knowledge of EDM and its application in dentistry could be an alternative approach to alleviate stress among students.

In the present study, sublimation was the most commonly employed defense mechanism, followed by acting out and somatization. The results were contradictory to the findings of Parekh et al. and Waqas et al. where rationalization was found to be the commonly employed EDM among medical students.^[14],[15] In India, postgraduate students reduce their stress and anxiety in their dental schools by behaving more sublimely in a mature manner (with faculty members). They also act out by showing their aggression to friends and family members. Students may develop the habit of smoking or drinking alcohol as a means of reducing stress. The other escape mechanism employed is absenteeism due to fabricated or psychological illness.^[8] The study by Borges et al. showed that medical students with immature EDM factors were associated with more depressive symptoms and poor psychological quality of life.^[17] Neurotic defenses are considered highly protective when compared to immature defenses.^[14] Among the neurotic defenses, idealization was more commonly employed than reaction formation. Adapting to mature defense mechanisms might help the students overcome their stressful situations by separating themselves from unpleasant events, thoughts, or actions and thus yield a better quality of life. These strategies can also help students avoid unwanted threats or feelings. Understanding the students' defense mechanisms might help the faculty members/student counselors to guide them righteously.^[26]

There exists a wide range of differences in gender concerning EDM. Differences in the socialization process may result in a difference between gender coping patterns.^[27] In this study, both male and female postgraduates predominantly expressed mature patterns of EDM followed by neurotic and immature patterns. Nevertheless, within the immature pattern of EDM, more males expressed it more compared to the female postgraduate students. Waqas et al. showed that female medical students had significantly higher scores for neurotic defense mechanisms.^[15] However, there was no significant difference in the mature and immature defense mechanisms between the genders. Parekh et al. reported that there was no statistically significant difference in EDM among males and females.^[14] However, females expressed higher neurotic factors which maybe because stress levels are more among males than females, because of the financial concerns and the added responsibilities placed upon them.^[8] Women are more mature than men of the same age, and this could be a significant reason for the difference in the ego defenses employed by them and might mostly make them act out in a situation rather than moving in a sublimed manner.^[28] Females, on the other hand, resort to a more mature pattern of defense mechanisms because of their awareness of the external environment. Cramer also reported that most women use internalizing defenses such as introversion, and men are more likely to employ externalizing defenses, such as acting out.^[29] Developing a mature pattern of coping strategy might help people to be better not only in their professional life but also in their day-to-day activities which, in turn, can help them have a better quality of life.

Limitations

Information bias and low response rate, typical of all E-mail surveys, could be considered as the limitations of this study. Six reminders were given during the study period to increase the participants' response rate. The association between the stress level and the EDM employed by the students was not assessed, as it was beyond the scope of the study.

Conclusion

The pediatric dental postgraduate students in India exhibited a mature pattern of EDM, followed by neurotic and immature patterns. Sublimation was the most commonly employed individual EDM among the students. The mature pattern of EDM was displayed more by the female students than the male students. Understanding the defense mechanisms can help students reduce their stress levels and have a better quality of life during their postgraduation period.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Appendixes

Appendix 1:

Modified Defense Style Questionnaire

1. Mature factor

Sublimation

I will overcome my anxiousness with some hobbies like painting.

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree E) Strongly agree

I believe my hobbies relieve me from my worries or anxiety.

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree E) Strongly agree

Suppression

I am able to keep a problem out of my mind until I have time to deal with it.

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree E) Strongly agree

I believe my emotions could be a hindrance to actions which is why I always keep them under control (without expressing).

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree. (E) strongly Agree

2. Immature factor

Acting out

I often get emotional (react without thinking) when something affects me.

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree. (E) Strongly 'agree

I get aggressive only when I feel hurt.

(A) Strongly disagree. (B) Disagree. (C) Neither agree nor disagree. (D) Agree. (E) Strongly agree

Denial

People claim that I walk away from undesirable truths as if nothing happened.