Humor is a universal entity, widely cherished. Sense of Humor and Its Association with Psychological Disturbances Among Dental Students in India

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1 Sense of Humor and Its Association with Psychological Disturbances Among Dental Students in India Balasubramanian Madhan, M.D.S., P.G.D.H.M., M.Sc., M.A.; Ashish Kumar Barik, M.D.S., D.N.B.; Rajesh Patil, M.D.S.; Haritheertham Gayathri, M.D.S.; Mora Sathi Rami Reddy, M.D.S. Abstract: Although the health benefits of humor and the potential advantages of having a good Sense of Humor (SoH) have been long recognized, they have not been investigated in dental students. The aim of this study was to assess the extent and demographic correlates of SoH in dental students and its association with their self-reported level of psychological disturbances. Six hundred and five students (age 20.3±1.83 years, 250 males, 355 females) from two dental schools in India anonymously completed the Multidimensional Sense of Humor Scale (MSHS) and the Depression Anxiety Stress Scales-21. Independent samples t-test and one-way ANOVA were used to analyze the intergroup differences based on gender and year of study, respectively. The association between SoH and each of the three negative affective states was evaluated with multiple linear regressions. The mean MSHS score of the sample was 59.65± Male students showed a marginally higher SoH than females (60.78 vs , p<0.05). The level of SoH steadily improved along the course duration, with statistically significant increases in the third and fifth years of study. SoH was negatively associated with all three negative affective states and explained nearly 3 to 5 percent of their variance. These results warrant further inquiry on the correlates of SoH in dental students, the psychosocial roles of humor, and their application in improving the psychological climate in dental schools. Dr. Madhan is Additional Professor, Faculty of Dentistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India; Dr. Barik is Professor, Orthodontics and Dentofacial Orthopedics, Institute of Dental Sciences, Bhubaneswar, Orissa, India; Dr. Patil is Professor, Orthodontics and Dentofacial Orthopedics, MGM Dental College and Hospital, Navi Mumbai, Maharashtra, India; Dr. Gayathri is Senior Lecturer, Periodontics and Oral Implantology, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India; and Dr. Reddy is Professor, Orthodontics and Dentofacial Orthopedics, Jodhpur Dental College, Jodhpur, Rajasthan, India. Direct correspondence and requests for reprints to Dr. Balasubramanian Madhan, Faculty of Dentistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthri Nagar, Puducherry , India; madhanb@hotmail.com. Keywords: sense of humor, depression, anxiety, stress, dental students, India Submitted for publication 6/29/12; accepted 10/26/12 Humor is a universal entity, widely cherished for its potential physical and psychological benefits. The word humor can denote a stimulus (humorous video), a mental process (perception of amusing incongruities), or a response (laughter, exhilaration). 1,2 While humor is a psychosocial construct, Sense of Humor (SoH) is a multidimensional personality construct that refers to the habitual individual differences in all sorts of behaviors, experiences, affects, attitudes, and abilities relating to humor. 1,3,4 People with high SoH are more likely to perceive less stress, cope well, use positive reappraisal, and adopt better problem-solving strategies. 5-7 They exhibit better interpersonal relations and higher motivational levels, are more socially competent, and report less worry than those with low SoH SoH is positively associated with intelligence, creativity, cheerfulness, optimism, self-esteem, and hope and negatively with neuroticism, depression, anxiety, and stress Thus, a good SoH is often recognized as a desirable trait positively linked to mental health. Age and gender are two demographic variables known to affect humor dimensions. Age influences both the level of SoH and the way in which it is construed. As compared to young adults, lower but more diverse SoH has been reported for older individuals. 7 The overall SoH does not appear to differ between genders, 13,14 but males score higher on aggressive and self-defeating types of humor. 4 There is a growing consensus that the dental school environment is highly taxing on the mental resources of students, often resulting in suboptimal psychological health. Newbury-Birch et al. 15 found pathological levels of depression and anxiety in 14 and 67 percent of final-year dental students, respectively. Seventy-two percent of them also experienced a considerable degree of psychological stress. The 1338 Journal of Dental Education Volume 77, Number 10

2 extent of negative affective states in dental students was comparable or higher than in medical students, at times corresponding to levels seen in general medical patients diagnosed psychiatrically ill The effect of gender on anxiety and stress levels in dental students is not conclusive, but a clear female preponderance, similar to that in the general population, has been noted for depression. 15 The transition to clinical training seems to be the most turbulent time in the dental curriculum, with a noticeable spike in the levels of depression, anxiety, and stress. 19,20 Age, marriage, living at home, family, social support, and career choice are a few factors evaluated for their effect on the sequelae of this unfavorable environment Most of the available reports on the mental health of dental students are restricted to the prevalence of psychological disturbances and the effect of dental climate. The role of psychological factors and personality characteristics of students has not received due attention. In a multinational survey by Pau et al., 23 emotional intelligence emerged as the most important predictor of perceived stress in dental students. Perfectionism and impostor feelings (chronic feelings of self-doubt and fear of being discovered as an intellectual fraud) were found to be stronger predictors of psychological adjustment in health professions students than most of the demographic variables. 24 Sense of humor is one such variable that can potentially be related to psychological health in the student population. Studies on undergraduate students have found SoH to be positively associated with better mental health and negatively with worry. 8,25 Kuiper et al. 26 observed that students with high coping humor appraised examinations as more of a positive challenge and adjusted their performance expectations on the basis of performance in the previous exam. Humor was negatively related to both perceived stress and dysfunctional standards for self-evaluation in these students. There is an absolute dearth of information related to the extent and demographic correlates of SoH in students of dentistry. Also, its relation to psychological health has not been investigated in dental students. Given the rigorous nature of the dental climate and a higher incidence of psychological disturbances in dental students, elucidation of the association between them would have potential implications in improving their mental health and the academic climate of the dental schools. Hence, the current study was undertaken to assess the Sense of Humor in two groups of dental students; analyze the influence of gender and the year of study on this construct; and evaluate the association, if any, between SoH and depression, anxiety, and stress in these students. Methods The target sample of the study was a convenience sample of 800 students pursuing the Bachelor of Dental Surgery program at two private dental schools in India: Institute of Dental Sciences, Bhubaneswar and Mahatma Gandhi Missions Dental College and Hospital, Navi Mumbai. After approval from the schools Institutional Ethics Committees, the Multidimensional Sense of Humor Scale (MSHS) and Depression Anxiety Stress Scales-21 (DASS- 21) were administered to the students in a year-wise setting. The details collected from them included age (in years), gender (male/female), and year of study. The students were asked for the history of any systemic disease, prolonged systemic medication, or major life event they had experienced in the past six months, and those who responded positively were excluded from the study. Participation in the study was anonymous and voluntary; returning completed questionnaires implied consent. The timing of data collection (December 2011 to February 2012) corresponded to the middle of the academic year and was at least three weeks away from any important academic event like internal assessment, project submission, etc. The Multidimensional Sense of Humor Scale of Thorson and Powell 3,7 is a twenty-four item instrument that captures four dimensions of humor: humor production, coping with humor, humor appreciation, and attitudes toward humor. Each statement is rated on a five-point Likert scale from strongly agree to strongly disagree (score of 0 to 4). Six items are negatively phrased and hence reversed during scoring. The scale score ranges from 0 to 96, and higher scores indicate a greater sense of humor. The scale has demonstrated excellent reliability (alphas of 0.89 or higher) in diverse demographic samples. 3,7,27 The Cronbach s alpha for the MSHS in our study was MSHS scores have been shown to be related positively to factors associated with psychological health (optimism, self-esteem, extraversion, cheerfulness) and negatively with signs of mental distress (depression, anxiety). 3,7 The Depression Anxiety Stress Scales-21 described by Lovibond and Lovibond 28,29 has seven items for each of three scales. Respondents rate the extent to which they have experienced the symptoms October 2013 Journal of Dental Education 1339

3 over the previous week on a four-point Likert scale. The sum of the scores for the seven items in each scale is multiplied by 2 to assess the scale severity. The structure of the DASS is akin to the tripartite model of Clark and Watson, 30 which conceptualizes depression and anxiety as having unique distinguishing features and some common symptoms as well. During factor analysis, a third factor emerged that referred to symptoms like difficulty in relaxing, nervous tension, irritability, and agitation. Due to their similarity with the symptoms of tension or stress, this factor was labeled stress. The instrument has shown excellent reliability (alphas of 0.91 to 0.97 for depression, 0.81 to 0.92 for anxiety, and 0.88 to 0.95 for stress scales), good convergent validity, and acceptable to good discriminant validity. 28,29,31,32 The Cronbach s alphas for depression, anxiety, and stress scales in our study were 0.90, 0.84, and 0.90, respectively. Data from the completed forms were tabulated and independently cross-verified by two operators. Summary statistics were calculated for the whole sample and the grouped data based on the demographic variables. An independent samples t-test was used to evaluate the differences between male and female students. Comparisons based on year of study were done with one-way ANOVA followed by Tukey s HSD post hoc tests. Multiple linear regressions (Enter method) were carried out to evaluate the association between SoH and the three negative affective states. Age, gender, and year of study at the dental school have been reported to have a significant influence on the mental health of students Hence, they were included as independent variables in the regression model along with the MSHS score. The DASS-21 score for the three scales was presented as the dependent variable. The semi-partial r-square values obtained from the models were used to assess the individual contribution of the independent variables towards the variance in the extent of negative affective states. All the tests were two-tailed with alpha set at p<0.05. PASW 18 for Windows (SPSS Inc., Somers, NY, USA) was used for data management. Results A total of 619 usable forms were returned for data evaluation. Fourteen of them were excluded because of a positive response for the history of any systemic disease, prolonged systemic medication, or major life event in the past six months, leaving an effective sample size of 605 (response rate of 75.6 percent). The age of the students ranged from seventeen to twenty-eight years, with a mean age of 20.3±1.83 years. Demographic details of the sample are shown in Table 1. Fifteen percent of the students had MSHS scores less than 48, the median score of the instrument. The summary statistics and group-wise comparisons for the MSHS and DASS-21 are shown in Table 2. The mean MSHS score for males was marginally higher than for females, and the difference was statistically significant (60.78 vs , p<0.05). The results of ANOVA (F 4,600 =30.591, p<0.001) for comparisons based on the year of study revealed that the sense of humor was the least for the firstyear students (53.62±14.16) and increased steadily during the period of the course with the differences achieving statistical significance at the third- and fifth-year points. The multiple linear regressions demonstrated a significant negative association between SoH and Depression (F 4,600 =14.634, p<0.001), Anxiety (F 4,600 =8.969, p<0.001), and Stress (F 4,600 =11.339, p<0.001). Data from the regression analysis are shown in Table 3. While gender and year of study showed a significant influence on DASS-21 scores, age of the students failed to make any appreciable contribution. Overall, the regression models explained a modest 5.6 to 8.9 percent of the variance in the extent of negative affective states, with SoH being the main contributor in all (3 to 5 percent). Discussion There is a global concurrence on the suboptimal nature of the academic climate in dental schools. The surge of associated reports in the contemporary dental education literature is a positive indication of both concern for this unfavorable environment and efforts to improve it. However, most investigations of the mental health of dental students have focused only on the environmental influence and have largely overlooked the equally important variable: the psychological constitution of the student. Sense of Humor is one such personality construct that has been described to be positively associated with good mental health in student populations. The dearth of related data for dental students caused us to evaluate the SoH and its association with mental health in dental students Journal of Dental Education Volume 77, Number 10

4 The mean MSHS score of our sample was 59.6±11.7. Non-availability of normative data for the Indian population has precluded any populationbased comparison. If the median score of 48 (on a possible score of 0-96) could be considered the cutoff to represent a satisfactory extent of SoH, the 15 percent of the students who had MSHS scores lower than that indicate unfavorable levels of SoH. The only available report for SoH in dental students is that of Dumitrescu et al., 13 who evaluated the relationship between humor and oral health of first-year dental students in Romania. The mean MSHS score of (calculated from their data) indicated a higher sense of humor in those students. There is a wide variation in the level of SoH described for students from other disciplines. The reported SoH of 140 undergraduate students from a Southwestern university in the United States was considerably higher (88±16.5) than both the dental student samples. 8 However, the data of Ho Table 1. Demographic details of the sample (n=605) Variable Group N Percentage Gender Male % Female % Year of study I % II % III % IV % V % Table 2. Summary statistics and group-wise comparisons for MSHS and DASS-21 Gender Year of Study Mean (SD) Mean (SD) Overall Scale Mean (SD) Male Female I II III IV V MSHS * III, IV, V > I** (11.77) (12.08) (11.49) (14.16) (12.09) (9.21) (8.82) (7.59) III, IV, V > II** V > III* Depression * III, V > I* (6.70) (6.27) (7.21) (5.84) (7.04) (6.29) (6.54) (7.38) Anxiety NS NS (6.64) (6.49) (6.75) (6.16) (6.42) (6.52) (7.20) (6.88) Stress NS III, V > II* (7.72) (7.23) (8.05) (8.12) (6.63) (7.45) (8.05) (8.09) Note: Gender analyzed with independent samples t-test; year of study analyzed with ANOVA and Tukey HSD post hoc tests. *p<0.05, **p<0.001, NS=nonsignificant Table 3. Multiple linear regressions for each negative affective state Criterion Variable Predictor Variables R Square Semi-Partial R Square Beta (standardized) Sig. Depression MSHS <0.001 Age Gender Year of study <0.001 Anxiety MSHS <0.001 Age Gender Year of study Stress MSHS <0.001 Age Gender Year of study <0.001 Note: Gender coded as Female=1, Male=2. October 2013 Journal of Dental Education 1341

5 et al. 27 for students of two Hong Kong universities showed only a marginally higher SoH (63.78±10.70) than reported for our sample. Variation in the SoH among individuals is generally ascribed to a combination of genetic and non-shared environmental factors. 33 Sociocultural, geographic, and linguistic factors have a profound effect on the way humor is construed and are important environmental variables influencing the SoH. 27,33-35 Together, these factors might explain the wide variation in MSHS scores noted in those studies. In our study, males had a marginally higher MSHS score than females. In contrast, Dumitrescu et al. 13 observed no significant gender difference in SoH of first-year dental students. Similar findings have also been reported by Boyle and Joss-Reid for Australian students. 14 While the influence of gender on overall SoH is not clear, noteworthy differences exist in the various dimensions of humor. Males fare better in humor production and the social uses of humor, while the reverse is true for the use of humor as a coping mechanism. 7,36,37 Edwards and Martin 4 observed no difference between men and women in their ability to generate humor, but the former scored higher when it came to aggressive type of humor. Studies that have noted significant gender-based differences in SoH have often attributed them to variations in gender role stereotyping and socialization. Scrutinizing the humor literature over the past fifty years, Kotthoff 38 summarized the issue as gender still influences humor, sometimes overtly, sometimes covertly. In our study, analysis of changes in the SoH across the years of study revealed a steady increase in MSHS scores for the five years, with a sharp increase at the third year. Previous investigations on perceived stress levels in dental students have reported an analogous trend, with a conspicuous spike at the transition between the preclinical and clinical phases of dental education. 19,20 Considering the similar pattern of increase in stress and humor levels, one can speculate that the increase in MSHS scores along the duration of the course could have resulted from the use of humor as a stress-coping mechanism by these students. Significant negative associations were found between SoH and all three affective states, albeit this construct explained only 3-5 percent of their variance. Edwards and Martin 4 found a negative correlation between healthy humor styles and depression, anxiety, and stress in 215 psychology students. Thorson et al. 7 showed that SoH was positively related to factors of psychological health such as optimism and self-esteem and negatively to signs of distress such as loneliness, depression, and stress. Students with high SoH were found to perceive less stress, report less anxiety, and were more likely to use positive reappraisal strategies than those with low SoH. 8 They also tended to cope better by dealing with the situation in a more direct fashion (problem-solving approach), at the same time emotionally distancing themselves to a greater extent. 26 The potential mechanisms through which humor affects positive health have been summarized by Martin 39 in four major categories: 1) physiological changes in various systems of the body that accompany laughter (muscle relaxation, improved respiration and circulation, immune stimulation, etc.); 2) positive emotional states accompanying humor and laughter; 3) moderation of the adverse effects of psychosocial stress; and 4) indirectly by increasing one s level of social support. Limitations and Recommendations The results of our study reflect the extent and demographic correlates of the Sense of Humor in dental students at two academic institutions in India. Considerable cross-cultural differences exist in the way humor is perceived and used in a social setting Hence, these findings cannot be generalized to students from other cultural backgrounds. The use of a cross-sectional approach to evaluate the influence of the dental environment on the SoH is another limitation of this study. Though adept in eliciting associations, such a design is inadequate for causal implications. Further, the evolving body of research supports the contention that the relationship between humor and mental health depends on the type of humor. While adaptive styles of humor (affiliative and self-enhancing) facilitate physical and mental well-being, maladaptive forms of humor (aggressive and self-defeating) appear to be detrimental to psychological health. 4,11 Extending the investigation in this direction could yield more interesting and productive results. The psychosocial roles of humor and ways to tap them in a dental school can be described broadly under two settings. In the classroom environment, humor can increase the attention span of students; improve their comprehension, motivation, and attendance; and boost their academic performance. It can also reduce their boredom, stress, and anxiety 1342 Journal of Dental Education Volume 77, Number 10

6 and make them feel more comfortable Berk 46 lists ten systematic strategies of using humor as a teaching tool. Opening jokes, spontaneous humor, humorous questions, and examples are a few that can be routinely practiced in the classroom. However, for humor to be effective in these ways, it needs to be relevant to the subject under consideration, of the right type, and in the right amount. 47 Self-defeating, sarcastic, offensive, and student-targeted types of humor are to be avoided. Also, too much humor may induce a feeling of lack of substance and may become counterproductive. In the clinical setting, humor can reduce stress and burnout in students, promote cordial relationships between colleagues, and increase job satisfaction. Appropriate use of humor with patients can reduce their pain, anxiety, and stress, increase their treatment satisfaction, and build a good doctor-patient relationship. 42,43 Establishing good rapport and sensitivity to their SoH are essential prerequisites for use of humor in patient care. Special attention should be paid to avoiding the use of gender, ethnicity, politics, or disease-related symptoms as areas of humor with patients. 47 Conclusion The results of our study warrant further investigations on the demographic and psychosocial correlates of sense of humor in dental students. Given its potential benefits to physical and mental health, we recommend that dental educators promote a climate in which humor is a welcome entity. It could help students cope with the demands of dental school and improve their psychological health. REFERENCES 1. Martin RA. Humor, laughter, and physical health: methodological issues and research findings. 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