Symptoms of psychopathology and their association with psychological immunity in medical students

Introduction

University students represent a vulnerable group in terms of experiencing stress. Compared to the general population, they are exposed to intense stressors and often have mental problems such as depression and anxiety (Larcombe, 2016). Problems in the field of psychological life make their academic functioning much more difficult and, in addition to performance, have a negative impact on their family, colleagues and teachers at universities (Tosevski et al., 2010). A high degree of experienced stress is closely connected with manifestations of psychopathology. The attitude towards oneself also plays an important role in the relationship between stress and psychopathology. On a set of Czech students, Kotera et al. (2021, 2022) showed that the relationship between stress and psychopathology (depression, anxiety) is mediated by self-criticism, as well as that self-compassion predicts well-being.

Regarding specialization of study, it is documented that medical students experience higher levels of stress than the general population (Dahlin et al., 2005) and higher levels of stress and academic burnout than students of other fields (Dyrbye, 2008, Salam et al., 2013). The main source of stress for them is the academic sphere, such as exams and a large amount of coursework (Salam et al., 2013). Stressors can also be factors resulting from professional stress, such as a high level of responsibility, emotional exhaustion, exposure to taboo topics, insufficient attention to one's own unresolved problems, and the like (Gazdíková, 2017).

The very nature of the university environment, which is unstructured and offers a significant amount of immediate rewards, can also be stressful. At the university, high demands are placed on independence in functioning. It is necessary to have developed planning and organizing skills. That is why adaptation stress can be experienced especially by those students who have difficulties in self-regulation (Fleming, & McMahon, 2012). Most university students are in the developmental-transitive period of early adulthood. This is a challenging period in terms of creating one's own identity, both in the work and personal spheres (Arnett, 2000). Findings show that the prefrontal cortex does not mature until around the age of 25, which means that by this age the regulation of executive functions is underdeveloped, the ability to estimate the long-term consequences of one's behavior is reduced, and there is a risk of impulsive action (Arain et al, 2013). The period of early adulthood is also a high-risk time for the development of several mental disorders (Auerbach, 2016).

In summary, we can conclude that university students from medical fields are exposed to various stressors and that in order to successfully manage the demands of the school, they should have skills that will enable them to overcome difficulties adaptively.

Individual characteristics and an individual's level of resilience are related to the occurrence and intensity of stress-induced symptoms (Lee et al., 2019). In recent years, various protective variables have been intensively investigated to protect the individual from the negative consequences of stress. As part of the effort to establish criteria for effective personality functioning in the context of dealing with stress, a comprehensive model of the psychological immune system of psychology professor Attila Oláh (2021) was also presented. The model presents three load resistance criteria. The first criterion is the tendency to actively and optimistically approach the environment and one's own self-actualization (in the model called the cognitive-approximation subsystem). Approaching assumes such cognitive dispositional abilities as optimism, internal locus of control, sense of coherence, or self-development. The second criterion is adequate monitoring, creative, mobilizing and executive abilities for finding alternative solutions and activating one's own resources (called the monitoring-creative-executive subsystem in the model). These are competencies such as self-efficacy, goal and challenge orientation, creative potential, ability to solve problems, build groups, mobilize and monitor social resources. The last criterion is that these processes must be controlled and stabilized by well-functioning self-regulatory abilities. According to the model, effective approach is stabilized through control of impulsivity and emotions, monitoring through presence of mind, and mobilization through control of irritability and impulsivity (called a self-regulatory subsystem in the model).

The model of psychological immunity extends the well-known transactional model of stress management by Lazarus and Folkman (1966, 1984). It systematizes several already established protective constructs of positive psychology such as optimism, self-efficacy, sense of coherence, internal locus of control and self-actualization. The model comprehensively captures the personality, cognitive, motivational and behavioral dimensions that lead to adaptive overcoming of the demands of everyday life (Oláh, 2021). Therefore, it is a useful theoretical framework for understanding the individual in the context of clinical symptoms of psychopathology.

Considering the risk of psychopathological manifestations in medical students, we decided to examine the relationship between the occurrence of selected symptoms of psychopathology (depression, anxiety and insecurity in social contact) and the criteria of optimal personality functioning in the context of the theoretical model of psychological immunity in this group. We hypothesized that the currently perceived burden resulting from individual symptoms of psychopathology will be negatively correlated with the level of psychological immunity as well as its subsystems.

File and Methods

The research group consisted of undergraduate students of the Slovak Medical University, namely nursing, midwifery, physiotherapy, public health, emergency medical care and radiological technology in the first and third year of study. A total of 210 students between the ages of 19 and 35 (M = 21.18; SD = 2.81) participated in the research, with 161 women, 38 men, and 11 participants who did not state their gender.

A test battery consisting of a questionnaire for mapping basic demographic data, the Psychological Immune Competence Inventory (Oláh, 2021) and the SCL-90®-S (Pulkrabková, 2020) was used for data collection. The data were scanned based on the official instructions for the used methodologies and subsequently processed using the statistical program IBM SPSS Statistics, ver. 23.

The Psychological Immunity Inventory (Oláh, 2021) was designed to measure an individual's mental resilience and coping capacity. It consists of 80 items that saturate 16 factors: positive thinking, sense of coherence, sense of control, sense of self-development, orientation to changes and challenges, social monitoring, goal orientation, creative self-concept, problem solving, self-efficacy, capacity for social mobilization, capacity for group building, presence of mind, impulsivity control, emotional control, and irritability control. The factors are divided into three subsystems: cognitive-approximation, monitoring-creative-executive and self-regulatory.

SCL-90®-S (Pulkrabková, 2020) is designed to assess perceived psychological stress. It provides a basic diagnosis within nine scales: aggression/hostility, anxiety, depression, paranoid thinking, phobic anxiety, psychoticism, somatization, insecurity in social contact and compulsivity, in addition to measuring three global indices to capture overall psychological distress, number and intensity of perceived symptoms. As part of the work, we focused on four scales: depression, anxiety, uncertainty in social contact and the overall intensity of mental stress.

Results

Table 1 shows the results of descriptive statistics of perceived physical and psychological symptoms measured using the SCL-90®-S. The data is also divided by gender, as the tool has different standards for men and women. For the purposes of processing data from the point of view of gender, we excluded 11 respondents who did not state their gender from the statistical file.

Table 1. Average score of selected scales of the SCL-90®-S questionnaire among students of medical fields

N = total number of participants; n1 = total number of men; n2 = total number of women; GSI = index of general psychological burden; ANX = anxiety; DEP = depression; INT = insecurity in social contact; SD = standard deviation; M = diameter

Table 2 shows the number and percentage representation of students according to the severity of the perceived symptoms. Students are placed into one of 5 categories based on their T-score (normal T-score, mild, moderate, severely elevated T-score, and very severely elevated T-score) as measured by the SCL-90®-S inventory. If the T-score is greater than 60, we are talking about a clinically significant burden. The total clinically significant burden was measured in up to 170 participants (80.95%). In the case of anxiety, a clinically significant burden was detected in 128 participants (60.95%), in the case of depression in 138 participants (65.71%) and in the case of uncertainty in social contact in 148 participants (70.48%).

Table 2. Number and percentage representation of students according to the severity of perceived symptoms measured by SCL-90®-S

N = total number of participants; n1 = total number of men; n2 = total number of women; GSI = index of general psychological burden; ANX = anxiety; DEP = depression; INT = insecurity in social contact

Regarding the relationship between psychological immunity and its subsystems and psychopathological symptoms, the data showed significant negative relationships. We present the results in Table 3.

Table 3. Results of the Spearman correlation of psychological immunity and its three subsystems with selected scales of the SCL-90®-S questionnaire

**. The correlation is significant at the 0.01 level (two-sided). GSI = index of general psychological burden; ANX = anxiety; DEP = depression; INT = insecurity in social contact; PI = psychological immunity; KAS = cognitive-approximation subsystem; MKES = monitoring-creative-executive subsystem; SRS = self-regulatory subsystem

Discussion

Our results pointed to a high level of perceived psychological burden of university students of health professions. Of the three scales monitored by us (depression, anxiety and uncertainty in social contact), the respondents achieved the highest values ​​in the scale uncertainty in social contact. It is a scale that focuses on mapping the experience of one's own inadequacy compared to others, which is manifested by lowering one's own value, acute uncertainty and negative expectations in connection with contact with other people (Pulkrabková, 2020). On this scale, up to 70.48% of the respondents we monitored felt a clinically significant burden. Uncertainty in social contact can also arise as a result of the confrontation of one's own performance and the performance of others, which manifests itself as perfectionism and the need for high performance, which have been demonstrated for example by Eley et al., (2022) among health professionals. In a meta-analysis focusing on the link between parental expectations and perfectionism, it was found that the level of parental expectations and criticism of students' academic performance increases over time, which is directly related to maladaptive perfectionism, competitiveness, and individualism in college students (Curran & Hill, 2022). In a study comparing adaptive and neurotic perfectionism in academically successful medical students, it was found that maladaptive (neurotic) perfectionism manifests itself as achieving good academic results in order to compensate for personal problems, while these students also have unrealistic demands on themselves and others (Baranskaya et al., 2022). Another explanation for the high insecurity in social contact can be the focus on learning of these students (Salam et al., 2013), which can result in a less intense social life, social isolation and experiencing loneliness.

Rates of depressive and anxiety symptoms were surprisingly high in our study population. In Slovakia, a longitudinal study of experienced stress and depression during the second and third waves of the coronavirus pandemic was carried out on a representative sample, which found that in December 2021, 27.8% of people experienced depression and 20.5% experienced stress for much of the time (Urban & Lášticová, 2022). A longitudinal study by Hajdúk et al., (2022) also found that during the second wave of the coronavirus pandemic, the prevalence of moderate to severe depression was 34.3% and anxiety 20.1% among Slovak university students, while this prevalence increased significantly compared to the measurements from 2018. The level of depression and anxiety found by us exceeds these values and together with the results of other authors (Kotera et al. 2022; Larcombe, 2016) confirms the vulnerability of this group of students.

Another part of our research was focused on finding the relationship between psychological immunity and psychopathological symptoms. The psychological immune system represents such protective and resource variables that enable adaptive management of psychological stress and contribute to the development and maintenance of mental health (Oláh, 2021). The results of our research support this assumption. They show a statistically significant negative correlation between psychological immunity, including its three subsystems, and currently perceived psychopathological symptoms of frequent clinical manifestations. Our findings support the conclusions of foreign studies. Although we have not encountered any study to date that examines psychological immunity in the context of clinically significant symptoms of psychopathology expressed by the SCL-90®-S inventory, there are several studies confirming this association. Zábó et al., (2022) found that there is a significant negative relationship between subsystems of psychological immunity and negative emotional states, experiencing loneliness and maladaptive cognitive schemas. A negative relationship between immune subsystems and depression was demonstrated by Voitkâne (2007) and between immune subsystems and burnout syndrome by Gombor (2009). On the contrary, the positive relationship between psychological immunity and mental and physical health was confirmed by Oláh (2021). In research, psychological immunity was also positively correlated with life satisfaction (Bóna 2014; Gombor, 2009), life aspirations (Voitkâne, 2004), meaning in life and experiencing positive emotions (Zábó, Oláh, & Vargha, 2022). The psychological immune system proves to be a useful model that describes a system of psychological defense and proactive coping with various stresses. Its advantage is the possibility to apply it in practice, for example, to create individualized recommendations based on the unique immunity profile of the individual, which, in addition to strengths, also detects a set of weakened functions.

Our findings should be interpreted with some caution. A limitation is that the research set was not representative and at the same time not balanced in terms of gender. Other limitations result from the very nature of the self-assessment tools that were used in the research, as well as from the cross-sectional nature of the study. Overall, however, the research work offers useful insight into the investigated issue in our conditions.

Conclusion

The article focused on the issue of mental health of medical students. The use of the SCL-90®-S tool enabled us to perform a detailed screening of the respondents' psychological difficulties, which we investigated in connection with psychological immunity. Our results pointed to the frequent experience of mental stress by university students of health fields. At the same time, a statistically significant negative correlation was shown between psychological immunity and perceived psychological burden. These findings support the validity of the psychological immune system model. At the same time, they point out the importance of supporting the mental health of students of health professions.

Authors: PhDr. Kristina Široká ORCID: 0000-0002-9908-8107 Mgr. et Mgr. Annamária Antalová, PhD. ORCID: 0000-0001-5642-7941 *** doc. PhDr. Daniela Čechová, PhD.*** ORCID: 0009-0001-5695-1310

Acknowledgment: The contribution was created thanks to the APVV project: "Analysis of psychoneuroimmunological parameters of health in selected groups of the Slovak population" Project registration number: APVV-22-0160. Heartfelt thanks to all students of the Slovak Health University who participated in the research, as well as to the management of the Faculty of Medicine of the SZU for making this research possible.

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