DEFENSE MECHANISMS AND QUALITY OF LIFE IN MILITARY PERSONNEL WITH BURNOUT SYNDROME

Introduction. Professional military personnel are exposed to a number of stressors during the war as well as in peacetime conditions that can cause some hidden or manifest disorders, especially anxiety and depression, but also the development of burnout syndrome. The aim of our investigation was to determine the defense mechanisms and subjective assessment of quality of life and anxiety in professional military personnel of the Serbian Armed Forces with the burnout syndrome.


Introduction
Professional military personnel are exposed to a number of stressors during the war but also in peacetime conditions.Those stressors can cause some hidden or manifest disorders, especially anxiety and depression, but also the development of burnout syndrome.
Burnout in military personnel is a construct delineating the psychological state resulting from non-effective strategies for coping with livable stress in military environment.Long-term stress and frustration caused by effort in daily life, but also role conflict and role ambiguity, promote or exacerbate burnout, indicating that the military person's whole life world is involved (1,2,3).
In military environment there are some risk factors for burnout among different work places and duties, among military flying personnel, among soldiers and officers in the zone of operational actions and among medical staff, particularly among intensive care nurses and the nurses in the department of psychiatry (4,5,6,7,8,9).It exists in people who do some jobs connected with communications with other people.Persons who aspire to perfectionism have a particular tendency to this syndrome, as those with unreal expectations and estimations connected with themselves and their own job.Some conflicts connected with professional roles result in emotional exhaustion and ambivalent attitude to their job, low protection of coworkers and reduce working potential and create a sense of low accomplishment and low confidence (10,11,12,13).
Persons with high burnout manifest depression, anxiety that is reflected in their quality of life.Some investigations show that there is a negative correlation between subjective assessment of quality of life and burnout.That negative correlation can have serious consequences on the health of military personnel, but also on their productivity in the workplace (14,15).
Additionally, many studies have confirmed that the defense mechanisms and the quality of life are connected.It is clear that defense mechanisms constitute an important component of a person's adaptation (16).The two central experiences in this regard are external stress and threat to the person's self.The focus on anxiety and on intrapsychic conflict is too narrow, although it is premature to dismiss anxiety as the active component in all conditions that produce defense.The type of coping mechanisms used in person's adaptation to military environment that are associated with lower burnout and psychological vulnerability is not enough investigated.
In the concept of quality of life, the defense mechanisms and object relations are associated with quality of life (16,17).Bell indicate that the normal profile of object relations discloses the presence of the capability for healthy (mature) relationships while pathological object relations point out the failure of such ability (18).With respect to that perceptions and relationships are essence elements of the concept of quality of life, one might assume that object relations and ego defense mechanisms are associated with a person's quality of life and with the burnout syndrome, as well.
Few studies have so far dealt with the study of defense mechanisms present in the burnout syndrome (19).What has been proven in many studies is that mature defense mechanisms ensure better mechanisms for coping with everyday stress by reducing the probability of significant anxiety and burnout syndrome (20,21).
The aim of our investigation was to determine the defense mechanisms and subjective assessment of quality of life in professional military personnel of the Serbian Armed Forces with the burnout syndrome.

Methods
Cross-sectional study was conducted in the three barracks of infantry units of the Serbian Armed Forces, in September 2016.
In this study were included a total of 55 randomly selected professional military personnel (officers, non-commissioned officers and contract soldiers) which were at higher professional load (duty service, guard, overtime, inability to use the days off).In investigation were included only those without current mental problem, who had volunteered to take part.Written informed consent was obtained from all participants prior to participation in the study.All participants were assured anonymity and that only grouplevel findings would be reported.The sample for the pilot study was formed with about 15% of the main study, and it made 47 respondents.After that, another 10% respondents were added, due to the possibility if they did not fully respond to the questionnaire.In that way, it was formed a sample of 55 patients, with the decision to be in error alpha level of 0.05, a beta error of 0.1 on the border, which gave strength studies of 90%.
This study was conducted with approval by the Ethics Committee of the Faculty of Medicine, Kragujevac.The study was approved by the General Staff of the Serbian Armed Forces too.Confidentiality of the response was assured.A special permit for the research in the units of the Serbian Armed Forces was obtained from the Ministry of Defence.
The study is a pilot study within the doctoral thesis that is being done at the Medical Faculty in Kragujevac.

Psychological instruments
Sociodemographic questionaire included questions of age, gender, education, marital, proffesional and health status.
Psychometric assessments of the burnout, defense mechanisms, quality of life and anxiety were made using: Maslach Burnout Inventory (MBI) 22 , Defense Style Questionnaire (DSQ-40) 23 , World Health Organization Abbreviated Instrument for Quality of Life Assessment (WHOQOL-BREF) 24 and Beck Anxiety Inventory (BAI) 25 .
Maslach Burnout Inventory (MBI) is the most commonly used instrument to assess burnout.The MBI consists of 22 items.According to the MBI manual, it contains three subscales, which measure 3 components of burnout: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA).The 9-item EE subscale assesses feelings of being emotionally overextended by one's work.The 5-item DP subscale measures having an unfeeling and impersonal response toward recipients of one's services.The 8-item PA subscale assesses feelings of competence and successful achievement.Each item could be answered on a 7-point Likert scale ranging from "never" (=0) to "daily" (=6).Burnout is indicated by high scores on emotional exhaustion and depersonalization and low scores on personal accomplishment (22).(completely agree).The average scores for the two items are used to determine individual defense mechanism (23).In our investigation, we compared our results with results of Serbian authors (Cabarkapa, Dedić, 2002) (26).

World Health Organization Abbreviated Instrument for Quality of Life
Assessment (WHOQOL-BREF) is a self-report quality of life inventory.It consists of 26 items, rated on a 5-point scale that measures the following four broad domains: physical health, psychological health, social relationships and environment.The physical health domain includes questions about daily activities, dependence on medication and treatment, energy and exhaustion, mobility, pain and discomfort, sleep and rest, and capacity to work.
The psychological health domain consists of questions about positive and negative feelings, self-esteem, body image and external image, personal beliefs and attention.The social relationship domain consists of questions about relationships with others, social support and sex life.The environmental domain of the scale consists of questions about the home environment, physical security and safety, financial resources, availability of health services, leisure activities, physical environment and transportation.This shortened instrument has been validated in various international field trials.It is considered appropriate to measure the quality of life of well populations and of ill population too (24).

Statistical analyses
Statistical analysis included parametric and non-parametric descriptive statistics, depending on the nature of data.Data analysis was carried out using IBM SPSS (Statistical Package for the Social Sciences) software version 20.0.
For the normal distribution of all numerical parameters and scores, we used the Kolmogorov-Smirnov test.We got the results showing that in all monitored and calculated parameters and scores there was normal distribution (z was less than 1.96, and p<0.05), so that it was possible to apply parametric methods in further analysis.
The subjects, according to the values of the scores MBI (Emotional exhaustion, Depersonalization and Personal accomplishment) were divided into 3 groups, with the high, mediate and low burnout, within which the values of defensive mechanisms, anxiety and quality of life are compared.

Results
Professional military personnel were aged from 25 to 55 years old (74,5% were older than 30 years).Number of male subjects was significantly higher than female (87,3% of males; χ2 = 6.047; p < 0.01).There were significantly more subjects with secondary school and university (50.9%) in relation to other categories of education completed (30.9%; χ2 = 7.449; p < 0.01).There were significantly more military personnel who were married (65.5%) compared to single (unmarried; 10.9%) and other (widowed/divorced; 23.6%) categories of marital status (χ2 = 7.267; p<0.01).The presence of the somatic diseases (hypertension, diabetes) were registered in a relatively small number of subjects (7.3%) compare to those who were healthy (92.7%; χ2 = 10.119;p < 0.01).The socio-demographic variables showed that there were statistically significant difference by all observed features (Table 1).
Based on the results obtained by the MBI on the EE subscale is observed that 49/55 (89.1%) of subjects were with low level of burnout, 6 (10.9%) of moderate level, but none with high level of burnout.
On the DP subscale in 48/55 (87.3%) of subjects is observed a low level of burnout, 7 (12.7%) a moderate level, but none with high level of burnout.
On the PA subscale in 36/55 (65.5%) of subjects is observed a low level of burnout, 7 (12.7%) a moderate level, and in 12 (21.8%)a high level of burnout.DSQ-40 questionnaire shows that there were no statistically significant differences in the average score of a group of mature, immature and neurotic defense mechanisms in subjects with low and moderate levels of burnout.
Table 2 shows defense mechanisms, quality of life and anxiety in military personnel with burnout syndrome.In the group of immature defense mechanisms, there was a statistically significant difference in subjects with moderate and low burnout in acting out (p < 0.01) compared to the depersonalization scale, with values lower in low burnout and higher at moderate level of burnout.There were also a statistically significant differences in rationalization and devaluation in relation to the personal accomplishment subscale (p < 0.05), with the lowest levels of rationalization at low level of burnout, a little more higher at high level of burnout, and the highest in moderate burnout, while the devaluation is the lowest in moderate burnout, a little more higher in high burnout and the highest at low level of burnout.The overall average values of immature defense mechanisms were higher in those with low burnout.
In the group of mature defense mechanisms, humor was significantly higher in the subjects with a moderate level of burnout on the DP subscale (p < 0.05).On the PA subscale, humor was significantly lower in subjects with a moderate level of burnout compared to those with low and high levels of burnout (p < 0.01).The overall average values of mature defense mechanisms did not differ in those with low and moderate levels of burnout on EE and DP scales, as well as low, moderate and high levels on PA scale.
In the group of neurotic defense mechanisms, there was no statistically significant difference between the average score of neurotic defense mechanisms in people with low and moderate levels of burnout.However, on the PA subscale altruism was higher in subjects with low level of burnout, and lower scores in those with moderate and high levels of burnout (p < 0.05).
BAI questionnaire registers a low level of anxiety (0 do 21) in 46 (83.6%) of subjects, a moderate level (22 do 35) in 1 (1.8%) subject, and a mild level (more than 36) in 8 (14.5%) subjects.BAI questionnaire score decreases with increasing level of education of the subjects, so that the highest average values are observed in the subjects with the lowest education, and the lowest those with the highest level of education.
Comparing the average scores of the results obtained on a scale of anxiety (BAI questionnaire) and burnout (MBI), it was observed that the subjects with a moderate level of (p < 0.01) burnout had significantly higher BAI questionnaire scores on a scale of emotional exhaustion (p < 0.05) and depersonalization of a moderate level of (p < 0.01) burnout.
Comparing the average values of the results obtained on a scale of anxiety (BAI questionnaire) and DSQ 40 questionnaires, it was evident that there were statistically significant differences in regard to the humor, rationalization and denial (p < 0.05) in the subjects with a minimal and mild anxiety (p < 0.05).
Comparing the average values of the results obtained on a scale of anxiety (BAI questionnaire) and WHOQOL-BREF, it is observed that the subjects with lower values of psychological and physical health (p < 0.01) and satisfaction with social relations (p < 0.05) had significantly higher scores on BAI questionnaire.
BREF questionnaire shows that there was a statistically significant positive correlation between quality of life and moderate level of burnout on the subscales of emotional exhaustion (EE) (p < 0.05) and depersonalization (DP) (p < 0.01), but not on the subscale of personal accomplishment (PA).
Mutual comparison of BREF questionnaire and MBI, DSQ-40 and BAI indicates that there was a negative correlation with all of the above scores, which means that higher values on BREF scores were correlated with the BAI questionnaire lower scores (Graph 1), on the emotional exhaustion (EE) (Graph 2) and depersonalization (DP) scales on the Maslach questionnaire, as well as with the overall average score of a group of immature defense mechanisms on DSQ 40, and vice versa.
There was a statistically significant correlation between the values of the BAI total score and all three subscales of Maslach questionnaire.Thereby, they had a positive correlation with the subscales of emotional exhaustion (EE) (Graph 3) and depersonalization (DP) and the negative with the subscale of personal accomplishment (PA) (Graph 4).Certainly, the higher the value of the BAI score was, the higher values of emotional exhaustion (EE) and personal accomplishment (PA) subscales at the MBI were, and vice versa.
By analyzing the correlation of the scores obtained in the BREF, BEK, Maslach and DSQ-40 questionnaires, it is evident that there was a statistically significant negative correlation of the BREF questionnaire score with the BAI questionnaire score, with the subscales of emotional exhaustion (EE) and depersonalization (DP) in MBI questionnaire and the average score of the immature defense mechanisms in DSQ-40.
Comparison of the average values of the MBI and BAI scores shows that the subjects with a moderate level of burnout had significantly higher scores on the scales of emotional exhaustion (EE) and depersonalization (DP), while their average values on the physical health score were lower in the subjects with a low level of burnout.Other scores were not significantly different compared to the level of burnout on the subscale of emotional exhaustion.

Discussion
Burnout is the result of prolonged stress in the workplace (27).Inability to cope efficiently with workplace stressors can lead to negative psychosocial and physical outcomes.Job satisfaction level is an important factor influencing the health of military personnel.Military personnel are confronted with stress in the workplace that indicates the current, but transient, maladaptation process.Their burnout was result of their psychological state resulting from maladaptive strategies for coping with enduring stress in interpersonal communication in military environment.It is accompanied by physical and psychological symptoms and occurs when the adaptive capabilities of the employee are at odds with the demands of the working environment.Burnout, on the other hand, can be considered as the last stage in the process of maladaptation, when the phase of resistance gives way to collapse (28).
Burnout is promoted by role conflict and role ambiguity, or prolonged job stress and frustration caused by strain in daily life.Burnout is indicator that military personnel had impossible expectations of themselves in all social roles they have.They are emotionally exhausted, depersonalized, and with low personal accomplishment.In addition, burnout may be caused by the mismatch between the nature of the work and personality.Coping with burnout syndrome intensifies the so-called resilience representing permanent strengths or aspects of personality that help a person to rise above life's misfortunes and build an effective style of struggle with problems, leading to the actualization of human capacities (individual, group and community) aimed at purposeful confrontation with stressful circumstances in an emotionally and physically healthy way.Whether there will be a burnout or not, depends on many factors, with personality structure as particularly significant and its reflection of practical manifestation ranging from powerless and weak with low frustration tolerance, to stable and strong personalities with high frustration tolerance (27,29).
There are some investigations in military environment where authors examined a relationship among depression, anxiety and job stress, work performance, perceptions about supervisors in military personnel.The occurrence of burnout in the military environment was first observed in pilots and flight crew (30).A survey carried out in the Wilford Hall U.S. Air Force Medical Center Mental Health Clinic showed that 60% of employees had workplace stress, and in 52% of these it was caused by emotional problems (31).Research in the FE Warren Air Force Base (United States), showed that military personnel in relation to the civil personnel had stress in the workplace more frequently, with more than a quarter to a significant degree, while 15% said that stress was caused by significant emotional problems (32).
Our investigation showed that more than 10% of military personnel had a moderate level of burnout, but without high level observed.In comparison with investigations in other armies, burnout in the Serbian Armed Forces is less observed than in other armies.
In our investigation job satisfaction and job burnout appeared closely linked inversely.Military personnel showed that job burnout is present when job satisfaction decreased because of the financial and social effects of job dissatisfaction and the damaging physical/psychological impacts of burnout (33).
Negative way of dealing with the stressor is associated with anxiety.Burnout syndrome was associated with anxiety, as confirmed by the results of our research, where in over 16% of subjects the presence of anxiety in moderate and high level was found.Our research showed that the level of anxiety is positively correlated with the level of burnout on the subscale EE (p < 0.05), as shown with DP subscale (p < 0.01).Negative reaction involves emotional focus, slow or weak reaction or absence of any attempt at solving the problem.However, despite numerous studies that have been carried out, the relationship between these two disorders is not clear.Anxiety is defined as the feeling of floating fear, embarrassment and uneasiness.It is a normal reaction to a stressful situation, however, if it lasts longer and if the person cannot control it, it is anxiety disorder.
Facing the stressor, the individual activates a positive or negative ways of coping with the stressful situation (34).Use of defense mechanisms alters individual perception of both internal and external reality (35).In our investigation we found that in the professional military personnel mature defense mechanisms are associated with a lower level of burnout syndrome, less anxiety and better perception of quality of life.
As shown by the results of our research, mature defense mechanisms were associated with a good attitude to stress and good mental and physical health, while in immature defense mechanisms better perception of quality of life is followed by a lower level of anxiety, lower level of burnout syndrome and less use.
In addition to the above, many studies have confirmed that mature defense mechanisms are associated with a higher level of quality of life (36,37).Recent Integrative models of defense and coping income a more differentiated picture with consideration to these issues: coping includes unconscious and conscious strains, defense and coping serve very similar functions, adaptiveness can be determinated in quantitative (coping) and qualitative (defenses) terms and the question of stability of coping and defenses needs to be more completely explored empirically.Moreover, the nature of the underlying fear can be theoretically differentiated and related to the difference between defense and coping (16,17).
People who develop mature mechanisms are generally happier and have better mental health than individuals who use immature mechanisms.According to DSM-IV, mature level of defensive functioning "results in optimal adaptation in the handling of stressors," whereas these defenses strive to "maximize gratification and allow the conscious awareness of ideas, feelings, and their consequences, promoting an optimum balance among conflicting motives" (29,38).
Using of altruism and humor as a "mature" defense mechanisms helped military personnel to cope with tense or stressful situations (36).In our research we obtained results that it showed, with the greatest impact on the protection of burnout on the subscales of depersonalization.The most impact on the level of anxiety had humor, while the most protective influence had humor and altruism on the scale of personal satisfaction.
Using humor, they make fun of uncomfortable situations or express unpleasant thoughts in a humorous way, allowing the military personnel to tolerate uncomfortable situations and to openly express feelings and thoughts without personal discomfort or immobilization and without producing an incommodious effect on others.Looking for a funny facet in military environment in which they lack control can help them to bear it, and it can even be an altruistic act in helping others to better cope as well.
The presence of altruism could be explained by personal satisfaction for a successful professional functioning.Military personnel undergo a vicarious experience using constructive and instinctually gratifying service to others.Altruistic behavior, an act of goodwill to another person, can be used as a way of diffusing a potentially anxious situation.Altruism may be used as a defense mechanism, by being especially helpful to a person who they feel might dislike them or neutralizing an argument with positivity and kind words.Appreciation therefore plays a unique role in social contacts.They feel thankful when they have benefited from someone's costly, intentional, voluntary effort on their behalf (39).
In addition, in our research immature defense mechanisms, primarily acting out proved to be a defense mechanism that used more persons with moderate levels of burnout in the subscale DP, which is in accordance with the results of numerous studies in which this defense mechanism is associated with maladjustment behavior (40).Rationalization and devaluation have significant influence on the development of burnout subscales measured by the subscale PA.Some researches show that immature defense mechanisms are significantly more likely used in anxiety and depressive disorders, and that devaluation and projections are significantly higher in depressive disorders compared to anxiety disorders.Since the components of all three disorders intertwined, we can say that the more investigations are needed to differentiate defense mechanisms important for the development of burnout (41).
Mutual comparison of BREF questionnaire and MBI, DSQ-40 and BAI indicates that there was a negative correlation with all of the above scores.That means that higher values on BREF scores are correlated with the lower scores of BAI questionnaire, on the emotional exhaustion (EE) and depersonalization (DP) scales on the Maslach questionnaire, as well as with the overall average score of a group of immature defense mechanisms on DSQ 40, and vice versa.
There was a statistically significant correlation between the values of the BAI total score and all three subscales of burnout, which is consistent with the results of other studies (42,43).Since, on the basis of our study, learning the adequate mechanisms of overcoming everyday stress significantly influenced on the reduction of the appearance of burnout, need further investigations in this area in order to become aware of mechanisms that act protectively.

Limitation
Our investigation of burnout was conducted as a pilot study on a relatively small sample of the Serbian Armed Forces.Further investigation should be focused on a much larger sample size of professional military personnel of the Serbian Armed Forces (300 military personnel), which would allow insight into the presence of burnout among different categories of military personnel (officers, non-commissioned officers and contract soldiers).In addition to further investigations, this issue could indicate differences in the occurrence of burnout, depending on the type of job position, years of service, age and gender of the subjects.

Conclusion
The results suggested that professional military personnel with a lower level of burnout at work were less anxious, use mature defense mechanisms and have a perception Questionnaire (DSQ-40) is a 40-item self-report questionnaire.It is one of the most widely used psychometric instruments for assessing ego defense mechanisms.According to the manual, it broadly categorizes 20 defense mechanisms into three hierarchies: mature, neurotic and immature defense mechanisms, similar to Vaillant's hierarchy of ego defense mechanisms.The defense mechanisms are classified into: (a) four mature: sublimation, humor, anticipation, and suppression; (b) four neurotic: undoing, pseudo-altruism, idealization, and reaction formation; and (c) twelve immature: projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalization and somatization.Each of the defense mechanism is covered by 2 items, that are rated on a nine-point scale from 1 (completely disagree) to 9 of a better quality of life.When burnout is diagnosed, psychological interventions requires training through the adoption of mechanisms for overcoming everyday stress, which may affect the reduction of anxiety and the improvement of the quality of life.Professional assistance, including psychotherapy is required in severe cases.Anxiety Inventory) MBI (Maslach Burnout Inventory) PA (personal accomplishment)

Table 1
Sociodemographic characteristics of military personnel

Table 2
Defense mechanisms, quality of life and anxiety in military personnel with burnout syndrome