Archives of

1. Introduction
An outbreak of a viral disease was reported in Wuhan, China, in December 2019 [1]. This disease is caused by a novel type of genetically mutated virus from the Coronavirus family, also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which was named COVID-19 [2,3]. Due to its fast transmission rate, this virus spread rapidly throughout the world and infected the entire world in almost no time. The main symptoms of this disease include acute respiratory problems with a mortality rate of 2%. Taking into account the outbreak and transmission rate of this disease, on February 4, 2020, the World Health Organization (WHO) declared this outbreak a public health emergency and recommended that countries minimize the person-to-person transmission of this disease by reducing people’s contact with each other, particularly special people such as the infected people and health care workers and control the global outbreak of this disease [4,5].
The pandemic state of COVID-19 has affected almost all economic and social aspects of life around the world; therefore, the psychological effects of this viral disease on the mental health of individuals in different social aspects are enormously crucial [6,7]. Tedeschi and Calhoun [8] proposed posttraumatic growth (PTG) as one of the important concepts in this regard. Jones et al [9] demonstrated that PTG can serve as an important factor in the improvement of the psychological and
Mediating Role of Coping Strategies and Defense Mechanisms in Relationship of Mental Health, Resilience, and Perceived Social Support with Posttraumatic Growth in COVID-19 Survivors
Elnaz Deldadeh Mehraban1ID, Abdolhassan Farhangi1*ID, Shahnam Abolghasemi1ID
1Department of Psychology, Tonekabon Branch, Islamic Azad University, Tonekabon, Iran
*Corresponding Author: Abdolhassan Farhangi, Email: abdolhasanfarhangi@gmail.com
Abstract
Background & Aims: Posttraumatic growth (PTG) refers to positive changes resulting from trauma. As a traumatic stressor, COVID-19 can affect various aspects of one’s life. The present study aimed to investigate the mediating role of coping strategies and defense mechanisms in the relationship of PTG and mental health, resilience, and perceived social support in COVID-19 survivors.
Materials and Methods: This study was conducted using a path analysis method from the correlation matrix. The research population included all COVID-19 recovered patients in Golestan province, Iran. Using the convenience sampling method, 300 patients who recovered from COVID-19 were selected. The participants were given questionnaires online. The research instruments included the Posttraumatic Growth Inventory (PTGI), the General Health Questionnaire (GHQ-28), the Multidimensional Scale of Perceived Social Support (MSPSS), Connor-Davidson Resilience Scale (CD-RISC), the Defense Style Questionnaire (DSQ), and the Ways of Coping Questionnaire (WOC). The data were analyzed through structural equation modeling (SEM) using SPSS and AMOS version 25.
Results: The findings of SEM revealed that the model fits the data. The relationship between problem-focused coping strategies and PTG, mental health, and perceived social support, the relationship between PTG and perceived social support, resilience, and mental health, and the relationship between mature defense mechanisms and PTG, mental health, resilience, and perceived social support were positive and significant (P < 0.01). The relationship between emotion-focused strategies and PTG, resilience, and perceived social support, the relationship between neurotic defense mechanisms and mental health, resilience, PTG, and perceived social support, and the relationship between immature defense mechanisms and mental health, resilience, and PTG were negative and significant (P < 0.01). Furthermore, the direct path analysis revealed that the relationships between mental health and emotion-focused strategies and between perceived social support and immature defense mechanisms were not significant.
Conclusion: The study results suggested that mental health, resilience, perceived social support, as well as problem-focused coping strategies played a crucial role in increasing PTG in COVID-19 patients. Therefore, they can be utilized to reduce the mental damage caused by the COVID-19 pandemic.
Keywords: Posttraumatic growth, Psychological support, Social support, Acclimatization, Resilience, Defense mechanisms, COVID-19
Received: April 22, 2022, Accepted: June 19, 2022, ePublished: March 18, 2023
https://jhygiene.muq.ac.ir
10.34172/AHS.12.1.1.395
Vol. 12, No. 1, 2023, 12-20
Original Article
Arch Hyg Sci. Volume 12, Number 1, 2023 13
Posttraumatic Growth in COVID-19 Survivors
even physical state of patients. In this situation, it is
crucial to find strategies to cope with stress to increase
psychological well-being and reduce posttraumatic stress
[10]. Individuals employ a variety of coping strategies
when they face stressful situations. Effective coping
strategies can diminish the effects of stressors and prevent
the short-term and long-term side effects of stress [11].
Coping is referred to the cognitive and behavioral efforts
to manage the internal and external demands in stressful
situations [12]. Coping strategies are divided into two
basic types: adaptive and maladaptive. Adaptive coping
strategies are generally based on problem-solving. They
aim at changing, reducing, and eliminating stressors.
However, maladaptive coping strategies, which are
emotion-focused, include stress management through
self-focus and the reduction of unpleasant emotions and
feelings [13]. Kim et al [14] revealed that social support
is one of the factors that have a positive and significant
relationship with PTG. In their study on students during
the COVID-19 pandemic, Cao et al [15] demonstrated
that 24% of students have experienced anxiety. Among
them, 9% reported symptoms of severe anxiety and the
rest reported mild symptoms.
Defense mechanisms are among other psychological
characteristics related to the COVID-19 disease [16].
Defense mechanisms refer to the subconscious and
unintentional cognitive processes that protect individuals
against anxiety, risk perception, or stressors. Such
mechanisms have three levels (i.e., developed, neurotic,
and immature). A mature defense mechanism is an
adaptive, normal, and efficient coping strategy, whereas
immature and neurotic defense mechanisms include
maladaptive and inefficient coping strategies [17].
One of the important factors to be considered in
COVID-19 survivors is their mental health [18,19].
Mental health is defined as a behavior in coordination
and harmony with society, the cognition, and acceptance
of social realities, as well as the ability to adjust to and
meet the well-balanced needs of self [20]. In addition,
it is an important factor affecting the general health of
individuals in a society [21]. Herrera et al [22] argued
that patients with chronic diseases do not have desirable
mental health, and their lower mental health is predictive
of high perceived stress, low self-efficacy, low life
expectancy, acute physical symptoms, depression, high
anxiety, and poor social performance.
Resilience is one of the indices influencing the
improvement of psychological characteristics [23].
Resilience is defined as the ability to deal with problems
and transform them into opportunities to grow [24]. It
is also an invaluable framework to interact with others
and challenging situations in life. Resilience is one of the
protective factors that play a vital role in one’s success
and survival during harsh situations. Accordingly, this
characteristic enables the individual to develop adaptive
behaviors, face problems easily, and effectively deal with
obstacles they face on the path to success [25].
Perceived social support is one of the effective factors in
reducing the negative psychological effects of COVID-19
[26]. Perceived social support includes one’s perception of
the love and support one receives from family, friends, and
relatives when facing mental pressures and accidents [27].
Perceived social support plays a crucial role in alleviating
the negative psychological effects of diseases. Moreover, it
is associated with less distress, a sense of greater control,
reduction of the effects of negative events on life, and
improvement of self-esteem and quality of life [28].
Therefore, based on the above-mentioned considerations,
the present study aimed to investigate the mediating
role of coping strategies and defense mechanisms in the
relationship of mental health, resilience, and perceived
social support with PTG in COVID-19 survivors in 2021.
2. Materials and Methods
This descriptive correlational study was performed
employing path analysis. The research population
included all COVID-19 recovered patients in Golestan
province, Iran. Using the convenience sampling method,
300 patients who recovered from COVID-19 were
selected. Online research questionnaires were designed,
uploaded to a credible website, and distributed to
participants. Inclusion criteria were as follows: history
of COVID-19, conscious agreement to participate in the
research, age range of 20 to 60 years, absence of mental
problems, and non-use of psychiatric medications.
The exclusion criterion included failure to respond to
questions. Ethical considerations were observed in this
study by obtaining informed written consent. Participants
were also offered the option to withdraw from the study.
After consulting with the research unit and getting the
necessary permissions, sampling was carried out. The
researcher analyzed the data.
2.1. Research instruments
2.1.1. Posttraumatic Growth Inventory (PTGI)
Tedeschi and Calhoun developed the PTGI in 1996 to
examine the beneficial outcomes reported by individuals
with a history of trauma. There are 21 questions in this
questionnaire. The questionnaire is graded on a 6-point
Likert scale, with scores of 0 (not at all), 1 (very low), 2
(low), 3 (medium), 4 (high), and 5 (very high). Tedeschi
and Calhoun [29] found an internal consistency of 0.90
for this questionnaire. Heidarzadeh et al [30] reported
a reliability of 0.81 for this questionnaire based on
Cronbach’s alpha coefficient. In this study, Cronbach’s
alpha coefficient was 0.84 for the questionnaire.
2.1.2. Connor-Davidson Resilience Scale (CD-RISC)
This study employed the CD-RISC [31] to measure
resilience. This scale contains 25 items, which measure
Deldadeh Mehraban et al
14 Arch Hyg Sci. Volume 12, Number 1, 2023
resilience based on the 5-point Likert scale, i.e., ranging
from zero (totally disagree) to 4 (totally agree). The
reliability of the Connor-Davidson Resilience Scale was
estimated to be 0.89 [32], and Cronbach’s alpha coefficient
was determined to be 0.85 for the scale in the present
study.
2.1.3. General Health Questionnaire (GHQ-28)
Goldberg and Hiller designed the GHQ-28 in 1979 [33].
This questionnaire has 28 items. Participants rate each
item on a four-point scale (strongly disagree to strongly
agree). The questions are rated on a scale of 1 to 4, with
the higher the score, the better the person’s mental health
[33]. The reliability of the GHQ was estimated to be 0.91
[34], and Cronbach’s alpha coefficient was determined to
be 0.87 for the questionnaire in the present study.
2.1.4. Multidimensional Scale of Perceived Social Support
(MSPSS)
Zimet et al [35] developed the MSPSS, which gives a
subjective evaluation of social support adequacy. The
scale consists of 12 questions that evaluate the participant’s
opinion of social well-being in family, friends, and other
important people using a 5-point Likert scale ranging
from completely disagree (1) to completely agree (5).
Higher scores imply higher levels of perceived social
support. The reliability of this tool was reported to be 0.89
[36]. In the present study, Cronbach’s alpha coefficient
was 0.85 for the scale.
2.1.5. Defense Style Questionnaire (DSQ)
The DSQ was developed by Andrews et al. It contains 40
questions, in which 20 defense mechanisms are evaluated
at three levels (i.e., developed, neurotic, and immature).
It is scored based on the Likert scale, ranging from 1 to
9 [37]. Jafari et al [38] reported a reliability of 0.79 for
this questionnaire based on Cronbach’s alpha coefficient.
In this study, Cronbach’s alpha coefficient was 0.83 for the
questionnaire.
2.1.6. The Ways of Coping Questionnaire (WOC)
In 1988, Lazarus and Folkman designed this questionnaire,
which consists of 66 questions that evaluate the two
primary subscales of problem-based and emotion-based
coping. This questionnaire is graded on a 5-point Likert
scale (1 to 5). The higher the score in each coping style,
the more often that style is used by participants, and
vice versa. Internal consistency ranged from 0.66 to 0.79
for each of the coping strategies, according to Lazarus.
Salmanian and Marashian [39] reported a reliability of
0.87 for this questionnaire based on Cronbach’s alpha
coefficient. In this study, Cronbach’s alpha coefficient was
0.82 for the questionnaire.
2.2. Statistical Analysis
The data was analyzed through structural equation
modeling (SEM) using SPSS and AMOS version 25. All
statistical analyses were performed at the 0.05 level of
significance.
3. Results
Findings related to demographic variables revealed that
22.33% of the participants were under 25 years old, 37.33%
were 25 to 35 years old, 27.33% were 35 to 45 years old,
and 13.01% were over 45 years old. Furthermore, 52.67%
of the participants were male, while 47.33% were female.
Additionally, 49% had a high school diploma, and 51%
had a university degree. Descriptive statistics, including
mean and standard deviation (SD), and correlation
coefficients between the study variables are presented
in Table 1. The original suggested model to describe the
relationship between the variables is shown in Figure 1.
The kurtosis and skewness of all the variables fell in
the -2 to + 2 range; therefore, the normal distribution of
the data was confirmed. All the variables had variance
inflation factor (VIF) < 10 and tolerance statistics > 0.1;
therefore, the assumption indicating non- multi-linearity
was confirmed.
The results in Table 2 demonstrate that the initial model
has to be modified based on the root-mean-square error
(RMSEA = 0.223). To correct the model, the insignificant
relationships between mental health and emotionfocused
coping, and between perceived social support
and immature defense mechanisms were removed. There
was a root-mean-square error (RMSEA = 0.017) in the
final model, indicating that the model fits well. Figure 2
shows the final modified model.
Table 3 shows the results of estimating path coefficients
Table 1. Mean (SD) and Pearson correlation coefficients of the research variables
Variables Mean ± SD Skewness Kurtosis 1 2 3 4 5 6
1- Mental health 62.16 ± 21.14 0.83 0.71 1
2- Perceived social support 29.17 ± 8.12 0.91 0.62 0.49** 1
3- Coping strategies 121.43 ± 45.17 0.36 -0.55 -0.31** 0.45** 1
4- Defense mechanisms 52.81 ± 17.34 0.23 -0.35 0.39** 0.52** 0.28** 1
5- Posttraumatic growth 44.65 ± 12.33 -0.34 -0.51 0.43** 0.29** 0.57** 0.33** 1
6- Resilience 49.22 ± 15.26 -0.16 -0.16 0.37** 0.41** 0.36** 0.51** 0.45** 1
** P < 0.01.
Arch Hyg Sci. Volume 12, Number 1, 2023 15
Posttraumatic Growth in COVID-19 Survivors
for testing direct hypotheses. The results showed that
there was a direct relationship between problemfocused
coping strategies and PTG (β = 0.43; P = 0.010),
mental health (β = 0.46; P = 0.009), and perceived social
support (β = 0.42; P = 0.011), between PTG and perceived
social support (β = 0.66; P = 0.004), resilience (β = 0.59;
P = 0.004), and mental health (β = 0.51; P = 0.001), and
between mature defense mechanisms and PTG (β = 0. 48;
Figure 1. The initial model of the study.
Figure 2. The Final Modified Model of the Study.
Deldadeh Mehraban et al
16 Arch Hyg Sci. Volume 12, Number 1, 2023
P = 0.005), mental health (β = 0.58; P = 0.011), resilience
(β = 0.51; P = 0.001), and perceived social support
(β = 0.51; P = 0.027) in COVID-19 recovered patients.
There was a negative relationship between emotionfocused
strategies and PTG (β = -0.56; P = 0.001),
resilience (β = -0.46; P = 0.007), and perceived social
support (β = -0.36; P = 0.012), between neurotic defense
mechanisms and mental health (β = -0.52; P = 0.022),
resilience (β = -0.48; P = 0.001), PTG (β = -0.37; P = 0.001),
and perceived social support (β = -0.42; P = 0.001), and
between immature defense mechanisms and mental
health (β = -0.55; P = 0.001), resilience (β = -0.37;
P = 0.001), and PTG (β = -0.43; P = 0.023) in COVID-19
recovered patients. There was no significant relationship
between mental health and emotion-focused strategies
and between perceived social support and immature
defense mechanisms in the recovered patients (Table 3).
The bootstrapping method was used to evaluate
the significance of intermediary relationships. Table 4
summarizes these findings. The results showed that there
was a significant indirect path from mental health,
resilience, and perceived social support to PTG through
the mediating role of problem-focused coping, mature
defense mechanisms, and neurotic defense mechanisms
in the COVID-19 survivors (P < 0.01). There was a
significant indirect path from resilience and perceived
social support to PTG through the mediating role of
emotion-focused coping (P < 0.01). Moreover, there was a
significant indirect path from resilience and mental health
to PTG through the mediating role of immature defense
mechanisms in COVID-19 survivors (P < 0.01) (Table 4).
4. Discussion
The present study aimed to investigate the mediating
role of coping strategies and defense mechanisms in the
relationship of mental health, resilience, and perceived
social support with PTG in recovered patients in Golestan
province in 2021. The results showed there was a direct
Table 2. Fit indicators of the initial and final models
Fit indicators χ2 df (χ2/df) IFI TLI CFI NFI RMSEA
Initial model 2.15 1 2.15 0.57 0.62 0.67 0.54 0.223
Final model 5.36 2 2.68 0.92 0.94 0.92 0.91 0.017
Note: IFI, incremental fit index; RMSEA, root mean square error of approximation; CFI, comparative fit index; NFI, normed fit index; TLI, Tucker Lewis index .
Table 3. Direct relationship between research variables in the initial and final modified models
Path Initial model Final modified model
Mental health to problem-focused coping 0.56 0.001 0.46 0.009
Mental health to emotion-focused coping -0.11 0.136 - -
Mental health to mature defense mechanisms 0.61 0.002 0.58 0.011
Mental health to immature defense mechanisms -0.59 0.001 -0.55 0.001
Mental health to neurotic defense mechanisms -065 0.013 -0.52 0.022
Mental health to PTG 0.69 0.001 0.61 0.001
Resilience to problem-focused coping 0.51 0.009 0.43 0.010
Resilience to emotion-focused coping -0.49 0.008 -0.46 0.007
Resilience to mature defense mechanisms 0.50 0.001 0.51 0.001
Resilience to immature defense mechanisms -0.47 0.001 -0.37 0.001
Resilience to neurotic defense mechanisms -0.54 0.001 -0.48 0.001
Resilience to PTG 0.63 0.001 0.59 0.004
Perceived social support to problem-focused coping 0.52 0.002 0.42 0.011
Perceived social support to emotion-focused coping -0.43 0.003 -0.36 0.012
Perceived social support to mature defense mechanisms 0.59 0.011 0.51 0.027
Perceived social support to immature defense mechanisms -0.09 0.128 - -
Perceived social support to neurotic defense mechanisms -0.52 0.001 -0.42 0.001
Perceived social support to PTG 0.68 0.002 0.66 0.004
Problem-focused coping to PTG 0.60 0.004 0.53 0.013
Emotion-focused coping to PTG -0.68 0.001 -0.56 0.001
Mature defense mechanisms to PTG 0.51 0.006 0.48 0.005
Immature defense mechanisms to PTG -0.56 0.014 -0.43 0.023
Neurotic defense mechanisms to PTG -0.47 0.001 -0.37 0.001
PTG: posttraumatic growth.
Arch Hyg Sci. Volume 12, Number 1, 2023 17
Posttraumatic Growth in COVID-19 Survivors
relationship between problem-focused coping strategies
and PTG, mental health, and perceived social support,
between PTG and perceived social support, resilience, and
mental health, and between mature defense mechanisms
and PTG, mental health, resilience, and perceived
social support in COVID-19 recovered patients. There
was a negative relationship between emotion-focused
strategies and PTG, resilience, and perceived social
support, between neurotic defense mechanisms and
mental health, resilience, PTG, and perceived social
support, and between immature defense mechanisms
and mental health, resilience, and PTG in COVID-19
recovered patients. There was no significant relationship
between mental health and emotion-focused strategies
and between perceived social support and immature
defense mechanisms in the recovered patients. Moreover,
the results showed that there was a significant indirect
path from mental health, resilience, and perceived social
support to PTG through the mediating role of problemfocused
coping, mature defense mechanisms, and
neurotic defense mechanisms. There was a significant
indirect path from resilience and perceived social support
to PTG through the mediating role of emotion-focused
coping. Moreover, there was a significant indirect path
from resilience and mental health to PTG through the
mediating role of immature defense mechanisms in the
COVID-19 survivors. This finding is consistent with the
results of previous studies [40-42].
When patients experience PTG, COVID-19 not only
does not lead to a sense of despair and hopelessness but
also becomes a turning point in their lives and enables
them to encounter new situations and experiences.
Therefore, it improves their mental perception of life
situations and, consequently, their mental health [41].
Resilience is one of the crucial factors in experiencing
and managing malignant comorbidities in COVID-19
survivors. Accordingly, COVID-19 survivors who
reported resilience, effectively participated in the
treatment since they were more prepared to accept the
natural course of the disease. Patients with higher levels
of resilience reported higher PTG [42].
Perceived social support is signified as the personal
perception regarding access to support, sufficient
assessment of support, and the quality of support when
required. It is referred to the idea that the afflicted person
has influential individuals who can potentially provide
them with assistance during distress and hopelessness.
On the other hand, perceived social support is often
prospective and indicates predicting help when necessary
[27]. The mental aspect of social support provides
effective psychological help for patients to enable them to
cope with pressures and problems in life.
In cases where COVID-19 survivors consider stress
controllable, they employ problem-focused coping.
Otherwise, they use emotion-focused coping. It might
explain why problem-focused coping is mostly used for
dealing with stressors related to work, social interactions,
and performance, whereas emotion-focused coping
is employed more for managing stressors related to
health, well-being, and moods (anxiety and depression).
However, several factors might cause the insignificance
of the relationship between mental health and emotionfocused
coping strategies [12]. For instance, if this study
was conducted at a different time and location, the
relationship between mental health and emotion-focused
coping strategies might be significant. Furthermore,
the constituents of mental health and emotion-focused
coping strategies might not be similar, or they might have
Table 4. Results of Analysis of Indirect and Intermediary Paths in the Proposed Model
Predictor variable Mediator variable Criterion variable
Proposed model Final modified model
β P β P
Mental health Problem-focused coping PTG 0.129 0.001 0.133 0.001
Resilience Problem-focused coping PTG 0.132 0.001 0.144 0.001
Perceived social support Problem-focused coping PTG 0.126 0.001 0.139 0.001
Mental health Emotion-focused coping PTG 0.113 0.216 - -
Resilience Emotion-focused coping PTG 0.127 0.006 0.138 0.006
Perceived social support Emotion-focused coping PTG 0.131 0.001 0.149 0.001
Mental health Mature defense mechanisms PTG 0.134 0.001 0.151 0.001
Resilience Mature defense mechanisms PTG 0.126 0.001 0.133 0.001
Perceived social support Mature defense mechanisms PTG 0.127 0.001 0.136 0.001
Mental health Immature defense mechanisms PTG 0.129 0.004 0.137 0.004
Resilience Immature defense mechanisms PTG 0.121 0.001 0.137 0.001
Perceived social support Immature defense mechanisms PTG 0.097 0.331 - -
Mental health Neurotic defense mechanisms PTG 0.131 0.001 0.142 0.001
Resilience Neurotic defense mechanisms PTG 0.138 0.001 0.144 0.001
Perceived social support Neurotic defense mechanisms PTG 0.126 0.012 0.137 0.012
Deldadeh Mehraban et al
18 Arch Hyg Sci. Volume 12, Number 1, 2023
emerged from two philosophically and culturally different
contexts and backgrounds.
Coping is a multidimensional and self-regulating
construct indicating the behavioral and cognitive
mechanisms used to manage the internal and external
demands in stressful situations. Emotion-focused coping
styles include all regulative efforts to diminish emotional
consequences of stressful events. However, problemfocused
styles include all active efforts to manage stressful
situations. Failure to employ emotion-focused coping
strategies increases resilience. COVID-19 survivors who
receive good social support are willing to employ more
problem-focused styles and fewer avoidant ones. Patients
who use problem-focused coping styles feel more control
over stressful situations. In addition, it can be stated that
patients who used emotion-focused coping styles faced
more problems during stressful situations. Consequently,
it resulted in lower PTG in these patients [13]. Therefore,
when individuals use the developed defense mechanisms
to face stressful situations, they experience less anxiety
than individuals who use immature defense mechanisms.
Moreover, they enjoy higher levels of general health [40].
Defense mechanisms are associated with mental and
physical outcomes. When individuals use the developed
defense mechanisms to deal with negative events, they
experience less anxiety and higher resilience than those
who use immature defense mechanisms [16]. COVID-19
survivors who enjoy higher social support mainly employ
developed defense mechanisms and rarely resort to
immature or neurotic defense mechanisms. Defense
mechanisms serve individuals in this regard and protect
them from excessive internal and external anxiety. This
type of mental force can be helpful in the short run.
There were several limitations to this study. First, it
was only conducted on recovered COVID-19 patients in
Golestan Province; therefore, generalizing the findings
to other statistical populations should be done with
caution. Second, the study results were based on scales
or questionnaires, which are prone to distortion due to
conclusions based on unconscious responses.
5. Conclusion
Following the results, the proposed model achieved a
good fit. The findings may be utilized to improve mental
and physical patterns among COVID-19 patients. Given
the significance of the post-traumatic growth pattern
in COVID-19 patients, this study may lead to future
research. In this sense, it may help investigations on stressrelated
difficulties and behavioral disorders (e.g., anxiety
and depression), and its findings may pave the way for
psychological interventions. It is also recommended
that plans be established to improve the post-traumatic
growth associated with the pandemic.
Acknowledgements
This article was extracted from a part of the PhD dissertation of
Elnaz Deldadeh Mehraban in the Department of Psychology,
Tonekabon Branch, Islamic Azad University, Tonekabon, Iran. The
researchers wish to thank all the individuals who participated in
the study.
Authors’ Contribution
Conceptualization: Elnaz Deldadeh Mehraban, Abdolhassan
Farhangi.
Methodology:Elnaz Deldadeh Mehraban, Shahnam Abolghasemi.
Validation: Abdolhassan Farhangi.
Formal Analysis: Shahnam Abolghasemi.
Investigation: Elnaz Deldadeh Mehraban, Abdolhassan Farhangi.
Resources: Elnaz Deldadeh Mehraban, Abdolhassan Farhangi.
Data Curation: Shahnam Abolghasemi.
Writing—Original Draft Preparation: Elnaz Deldadeh Mehraban.
Writing—Review and Editing: Elnaz Deldadeh Mehraban,
Abdolhassan Farhangi.
Visualization: Abdolhassan Farhangi.
Supervision: Abdolhassan Farhangi, Shahnam Abolghasemi.
Project Administration: Abdolhassan Farhangi.
Funding Acquisition: Elnaz Deldadeh Mehraban.
Competing Interests
All the authors declare that they have no conflict of interest.
Ethical Approval
The present study was approved by the Ethics Committee of
Islamic Azad University- Tonekabon Branch (code: IR.IAU.TON.
REC.1400.033).
Funding
Self-funding.
References
1. Yang J, Chen X, Deng X, Chen Z, Gong H, Yan H, et al. Disease
burden and clinical severity of the first pandemic wave of
COVID-19 in Wuhan, China. Nat Commun. 2020;11(1):5411.
doi: 10.1038/s41467-020-19238-2.
2. He F, Deng Y, Li W. Coronavirus disease 2019: What we know?
J Med Virol. 2020;92(7):719-25. doi: 10.1002/jmv.25766.
3. Pourrazi H, Modaberi S, Kabiri R. Disordered eating attitudes
during the COVID-19 pandemic: the predictive role of
physical activity, body mass index, and gender. Arch Hyg Sci.
2021;10(2):133-42. doi: 10.52547/ArchHygSci.10.2.133.
4. Cascella M, Rajnik M, Aleem A, Dulebohn SC, Di Napoli
R. Features, evaluation, and treatment of coronavirus
(COVID-19). In: StatPearls. Treasure Island, FL: StatPearls
Publishing; 2022.
5. Li H, Liu SM, Yu XH, Tang SL, Tang CK. Coronavirus disease
2019 (COVID-19): current status and future perspectives.
Int J Antimicrob Agents. 2020;55(5):105951. doi: 10.1016/j.
ijantimicag.2020.105951.
6. Vazquez C, Valiente C, García FE, Contreras A, Peinado V,
Trucharte A, et al. Post-traumatic growth and stress-related
responses during the COVID-19 pandemic in a national
representative sample: the role of positive core beliefs about
the world and others. J Happiness Stud. 2021;22(7):2915-35.
doi: 10.1007/s10902-020-00352-3.
7. Wu X, Kaminga AC, Dai W, Deng J, Wang Z, Pan X, et al.
The prevalence of moderate-to-high posttraumatic growth:
a systematic review and meta-analysis. J Affect Disord.
2019;243:408-15. doi: 10.1016/j.jad.2018.09.023.
8. Tedeschi RG, Calhoun LG. The Posttraumatic Growth
Arch Hyg Sci. Volume 12, Number 1, 2023 19
Posttraumatic Growth in COVID-19 Survivors
Inventory: measuring the positive legacy of trauma. J Trauma
Stress. 1996;9(3):455-71. doi: 10.1007/bf02103658.
9. Jones AC, Hilton R, Ely B, Gororo L, Danesh V, Sevin CM, et
al. Facilitating posttraumatic growth after critical illness. Am J
Crit Care. 2020;29(6):e108-e15. doi: 10.4037/ajcc2020149.
10. Wagner AC, Torbit L, Jenzer T, Landy MS, Pukay-Martin ND,
Macdonald A, et al. The role of posttraumatic growth in a
randomized controlled trial of cognitive-behavioral conjoint
therapy for PTSD. J Trauma Stress. 2016;29(4):379-83. doi:
10.1002/jts.22122.
11. Ogueji IA, Okoloba MM, Demoko Ceccaldi BM. Coping
strategies of individuals in the United Kingdom during the
COVID-19 pandemic. Curr Psychol. 2022;41(11):7493-9.
doi: 10.1007/s12144-020-01318-7.
12. Thai TT, Le PTV, Huynh QHN, Pham PTT, Bui HTH. Perceived
stress and coping strategies during the COVID-19 pandemic
among public health and preventive medicine students in
Vietnam. Psychol Res Behav Manag. 2021;14:795-804. doi:
10.2147/prbm.s317059.
13. Vintila M, Tudorel OI, Stefanut A, Ivanoff A, Bucur V.
Emotional distress and coping strategies in COVID-19 anxiety.
Curr Psychol. 2022:1-10. doi: 10.1007/s12144-021-02690-8.
14. Kim Y, Kim Y, Kwak Y. Factors associated with post-traumatic
growth in male patients with rectal cancer: a cross-sectional
study. Eur J Oncol Nurs. 2021;54:102028. doi: 10.1016/j.
ejon.2021.102028.
15. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The
psychological impact of the COVID-19 epidemic on college
students in China. Psychiatry Res. 2020;287:112934. doi:
10.1016/j.psychres.2020.112934.
16. Altwaijri N, Abualait T, Aljumaan M, Albaradie R, Arain Z,
Bashir S. Defense mechanism responses to COVID-19. PeerJ.
2022;10:e12811. doi: 10.7717/peerj.12811.
17. Walker G, McCabe T. Psychological defence mechanisms
during the COVID-19 pandemic: a case series. Eur J Psychiatry.
2021;35(1):41-5. doi: 10.1016/j.ejpsy.2020.10.005.
18. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al.
Impact of COVID-19 pandemic on mental health in the
general population: a systematic review. J Affect Disord.
2020;277:55-64. doi: 10.1016/j.jad.2020.08.001.
19. Tsamakis K, Tsiptsios D, Ouranidis A, Mueller C, Schizas D,
Terniotis C, et al. COVID-19 and its consequences on mental
health (Review). Exp Ther Med. 2021;21(3):244. doi: 10.3892/
etm.2021.9675.
20. Banihashemi SA. The effectiveness of creative drama on mental
health and self-esteem in aggressive gifted students. Arch Hyg
Sci. 2022;11(1):45-52. doi: 10.32598/ahs.11.1.341.1.
21. Serafini G, Parmigiani B, Amerio A, Aguglia A, Sher L, Amore
M. The psychological impact of COVID-19 on the mental
health in the general population. QJM. 2020;113(8):531-7.
doi: 10.1093/qjmed/hcaa201.
22. Herrera PA, Campos-Romero S, Szabo W, Martínez P,
Guajardo V, Rojas G. Understanding the relationship between
depression and chronic diseases such as diabetes and
hypertension: a grounded theory study. Int J Environ Res Public
Health. 2021;18(22):12130. doi: 10.3390/ijerph182212130.
23. Killgore WDS, Taylor EC, Cloonan SA, Dailey NS. Psychological
resilience during the COVID-19 lockdown. Psychiatry Res.
2020;291:113216. doi: 10.1016/j.psychres.2020.113216.
24. Amereh M, Sobhigharamalki N. Predicting impulsive
behavior based on responsibility and resilience among
Qom municipality employees, Qom city, Iran. Arch Hyg Sci.
2021;10(2):171-8. doi: 10.52547/ArchHygSci.10.2.171.
25. Traunmüller C, Stefitz R, Schneider M, Schwerdtfeger
A. Resilience moderates the relationship between the
psychological impact of COVID-19 and anxiety. Psychol Health
Med. 2021:1-12. doi: 10.1080/13548506.2021.1955137.
26. Grey I, Arora T, Thomas J, Saneh A, Tohme P, Abi-Habib R.
The role of perceived social support on depression and
sleep during the COVID-19 pandemic. Psychiatry Res.
2020;293:113452. doi: 10.1016/j.psychres.2020.113452.
27. Ferber SG, Weller A, Maor R, Feldman Y, Harel-Fisch Y,
Mikulincer M. Perceived social support in the social distancing
era: the association between circles of potential support and
COVID-19 reactive psychopathology. Anxiety Stress Coping.
2022;35(1):58-71. doi: 10.1080/10615806.2021.1987418.
28. Huang Y, Su X, Si M, Xiao W, Wang H, Wang W, et al. The
impacts of coping style and perceived social support on the
mental health of undergraduate students during the early
phases of the COVID-19 pandemic in China: a multicenter
survey. BMC Psychiatry. 2021;21(1):530. doi: 10.1186/
s12888-021-03546-y.
29. Tedeschi RG, Calhoun LG. The posttraumatic growth
inventory: measuring the positive legacy of trauma. J Trauma
Stress. 1996;9(3):455-71. doi: 10.1002/jts.2490090305.
30. Heidarzadeh M, Naseri P, Shamshiri M, Dadkhah B, Rassouli
M, Gholchin M. Evaluating the factor structure of the Persian
version of posttraumatic growth inventory in cancer patients.
Asian Nurs Res (Korean Soc Nurs Sci). 2017;11(3):180-6. doi:
10.1016/j.anr.2017.07.003.
31. Connor KM, Davidson JR. Development of a new resilience
scale: the Connor-Davidson Resilience Scale (CD-RISC).
Depress Anxiety. 2003;18(2):76-82. doi: 10.1002/da.10113.
32. Derakhshanrad SA, Piven E, Rassafiani M, Hosseini SA,
Mohammadi Shahboulaghi F. Standardization of Connor-
Davidson Resilience Scale in Iranian subjects with
cerebrovascular accident. J Rehabil Sci Res. 2014;1(4):73-7.
doi: 10.30476/jrsr.2014.41059.
33. Goldberg DP, Hillier VF. A scaled version of the General
Health Questionnaire. Psychol Med. 1979;9(1):139-45. doi:
10.1017/s0033291700021644.
34. Malakouti SK, Fatollahi P, Mirabzadeh A, Zandi T. Reliability,
validity and factor structure of the GHQ-28 used among
elderly Iranians. Int Psychogeriatr. 2007;19(4):623-34. doi:
10.1017/s1041610206004522.
35. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The
multidimensional scale of perceived social support.
J Pers Assess. 1988;52(1):30-41. doi: 10.1207/
s15327752jpa5201_2.
36. Hassani SF, Tizdast T, Zarbakhsh MR. The role of selfcompassion
and hope in the relationship between
psychological wellbeing, maladaptive schemas, resilience,
and social support in women with multiple sclerosis. J Client-
Centered Nurs Care. 2021;7(3):195-204. doi: 10.32598/
jccnc.7.3.372.1.
37. Andrews G, Singh M, Bond M. The defense style
questionnaire. J Nerv Ment Dis. 1993;181(4):246-56. doi:
10.1097/00005053-199304000-00006.
38. Jafari S, Rafiepour A, Taheri A, Sabet M. The mediating role of
psychological wellbeing in the relationship between defense
mechanisms and therapeutic alliance among therapists and
psychiatric nurses. J Client-Centered Nurs Care. 2022;8(1):33-
40. doi: 10.32598/jccnc.8.1.399.1.
39. Salmanian K, Marashian FS. Association of coping strategies
with death anxiety through mediating role of disease
perception in patients with breast cancer. Arch Breast Cancer.
Deldadeh Mehraban et al
20 Arch Hyg Sci. Volume 12, Number 1, 2023
2021;8(3):226-232. doi: 10.32768/abc.202183226-232.
40. Gori A, Topino E, Palazzeschi L, Di Fabio A. Which personality
traits can mitigate the impact of the pandemic? Assessment
of the relationship between personality traits and traumatic
events in the COVID-19 pandemic as mediated by defense
mechanisms. PLoS One. 2021;16(5):e0251984. doi: 10.1371/
journal.pone.0251984.
41. Schneider S, Rasul R, Liu B, Corry D, Lieberman-Cribbin W,
Watson A, et al. Examining posttraumatic growth and mental
health difficulties in the aftermath of Hurricane Sandy. Psychol
Trauma. 2019;11(2):127-36. doi: 10.1037/tra0000400.
42. Ebrahim MT, Alothman AA. Resilience and social support as
predictors of post-traumatic growth in mothers of children
with autism spectrum disorder in Saudi Arabia. Res Dev
Disabil. 2021;113:103943. doi: 10.1016/j.ridd.2021.103943.