Comparison of Ego Strength, Aggression, and Fear of Loss in Three Groups with Anxiety Symptoms, Depression Symptoms, and Normal Individuals

Introduction

Anxiety disorder, as defined in the DSM-5, is a mental state characterized by intense arousal, with its primary features being excessive fear, doubt, and worry (Rapee et al., 2023). Cognitive processing in anxiety disorder mirrors that observed in trait anxiety; therefore, understanding the cognitive processes and mechanisms underlying this disorder enhances our general understanding of vulnerability to anxiety (Thom et al., 2023).

In addition to anxiety, all individuals experience depression at some point in their lives. Depression is the most common mental disorder, and its prevalence has been increasing recently (Daly et al., 2021). Depression is generally recognized as sadness and can occur following any unpleasant event (Harsányi et al., 2022). Depression is a disorder primarily characterized by mood alterations, which are accompanied by distinct changes in behavior, attitude, thinking, efficiency, and physiological functions. As a symptom, depression may be present in various psychological and physical disorders, constituting a secondary component of the clinical presentation (Heul et al., 2021).

Furthermore, depression can be a natural emotion, characterized by mourning and grief. The illness of depression affects the entire organism and impacts all areas of an individual’s life (Reynaud et al., 2021). This effect is evident in feelings, energy, motivation, thinking, physical actions, personality, and interests. Depression is an emotional challenge that can be distressing for both the individual and those close to them, often manifesting as persistent boredom (Moncrieff et al., 2023). This condition persists for most of the day and may last for several weeks or longer. The presence of depression can lead to stress, affecting work or social performance. Boredom is often accompanied by sadness or a sense of emptiness (Cunningham et al., 2021).

Various approaches in psychology have examined how individuals respond to unpleasant psychological conditions, with one of the most profound being the psychoanalytic approach (Toprak et al., 2022). According to this approach, personality consists of three components: the id, ego, and superego. Since the ego is responsible for managing the psychic system, psychological problems arise when the ego fails to fulfill its duties (Sadafi et al., 2020). Ego strength refers to the ability to maintain one’s identity despite psychological stress, suffering, and the conflict between internal needs and external demands. In other words, it is the ability to preserve ego stability based on a relatively stable set of personality traits, which reflects in maintaining mental health (Aldahadha & Mohammid, 2023). Ego strength essentially indicates an individual’s capacity to endure stress without experiencing debilitating anxiety (Mehrdadi et al., 2021). In their study, Brody and Carson concluded that ego strength could enhance flexibility in using defense mechanisms (Toprak et al.); therefore, it can be said that the strength and resilience of the ego, as well as how defense mechanisms are employed in the face of events and during the experience of unpleasant emotions, are among the factors related to self-injurious behavior (Hoffer, 2020).

One variable that appears to influence depression and anxiety disorders is aggression. Aggression is behavior intended to harm another (Kravik & Beuschman, 2021). Aggressive behaviors manifest in various forms, with the most prominent being physical and verbal aggression. Physical aggression includes activities such as hitting, pushing, shoving, throwing objects, and threatening to perform these actions, all intended to harm others (Fala et al., 2023). Physical aggression, like verbal aggression, is observable through its manifestations and is therefore considered a direct expression of aggression (Wei et al., 2023).

Another component that seems to be present in individuals with depression and anxiety disorders is the fear of missing out (FoMO). FoMO, added as a new term to the dictionary in 2013, is characterized by a pervasive fear that others may be having valuable experiences from which one is absent. This fear is marked by a desire to stay connected with what others are doing, constantly checking social networks, and fearing missing out on events (Ching & Wei, 2023). Additionally, studies have shown that FoMO is a psychological construct defined by the fear of not being present in rewarding experiences that others are having, coupled with the desire for continuous connection with others' experiences (Rudmowski et al., 2022). This phenomenon, prevalent among most people, can cause significant stress and lead to harmful outcomes (Weiss et al., 2019). Recent studies have linked internet and social media addiction to psychological factors, including increased stress levels, anxiety, depression, lower self-esteem, reduced relationship quality, poor sleep quality, and heightened suicidal thoughts and behaviors, along with reduced life satisfaction among young people (Wei et al., 2022). On the other hand, problematic social media use and its connection with rumination, repetitive thoughts, negative feelings, and loneliness have been observed (Kelly & Radomsky, 2020). Based on the aforementioned points, the present study aims to compare ego strength, aggression, and fear of loss in individuals with anxiety symptoms, depression symptoms, and normal individuals.

Methods and Materials

Study Design and Participants

The present study employed a causal-comparative design. The statistical population consisted of all women aged 20-40 years who referred to counseling centers in Qom province, and their anxiety and depression symptoms were assessed using the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory-II (BDI-II). They were categorized into three groups: those with anxiety symptoms, those with depression symptoms, and normal individuals. The research sample comprised 105 women aged 20-40 years who visited counseling centers in Qom province. They were assessed using the BAI and BDI-II and categorized into three groups: those with anxiety symptoms, those with depression symptoms, and normal individuals. According to Delavar (2012), the minimum sample size in each group for causal-comparative studies is 30 individuals. In this study, using Cohen’s formula, considering the number of variables under investigation, an effect size of 1, a test power of 0.8, and a confidence level of 95%, it was estimated that 35 participants per group (35 in the anxiety disorder group, 35 in the depression group, and 35 in the normal group) were required, resulting in a total of 105 participants. The sampling method used in this study was convenience sampling. Inclusion criteria included informed consent to participate in the study, complete filling out of the questionnaires, age between 20 and 40 years, at least elementary education, no substance abuse, willingness to participate in the study, no use of antidepressant or anti-anxiety medications, and no depression or anxiety symptoms for normal individuals. Exclusion criteria included psychosis, the presence of other psychological disorders based on DSM-5-TR, alcohol and substance abuse, incomplete questionnaires, and the use of antidepressant and anti-anxiety medications.

After obtaining the necessary approvals and identifying the participants through convenience sampling at counseling centers in Qom, individuals were screened for anxiety and depression symptoms using the Beck Anxiety Inventory and Beck Depression Inventory-II. For the depression group, individuals with the highest scores on the Beck Depression Inventory-II were selected, and for the anxiety group, those with the highest scores on the Beck Anxiety Inventory were chosen. For the normal group, individuals with normal scores on both inventories were selected. The three groups—individuals with anxiety symptoms, depression symptoms, and normal individuals in Qom—completed the questionnaires. Participants were instructed to ask the researcher for clarification if they encountered any ambiguities while completing the questionnaires. At the end, participants were thanked for their cooperation. Before the study began, ethical approval was obtained from the university’s ethics committee and relevant authorities at the research site. Participants were provided with written information about the study, assured of the confidentiality of their information, informed that the data would be used solely for research purposes, and assured that their participation was voluntary. Their names and personal information were not recorded to protect their privacy, and written informed consent was obtained from all participants.

Measures

Depression

The Beck Depression Inventory was designed and developed by Beck to measure the severity of depression in adults diagnosed with depressive disorders. The inventory consists of 21 items, rated on a four-point Likert scale, with items such as “I feel that there is no hope for the future and that things will only get worse.” The inventory is self-rated. In this study, depression is defined by the score obtained by respondents on the 21-item Beck Depression Inventory. The inventory is unidimensional, and a cut-off score of 18 can correctly identify up to 92% of patients with major depressive disorder. The following ranges indicate the severity of depression: 0 to 13: minimal or no depression; 14 to 19: mild depression; 20 to 28: moderate depression; and 29 to 63: severe depression. The Cronbach’s alpha coefficient reported in the study by Taheri Tanjani (2014) for this inventory was above 0.7. The reliability of this inventory, using Cronbach’s alpha, was reported as 0.79.

Fear of Missing Out

To measure the Fear of Missing Out (FoMO), the questionnaire developed by Przybylski (2013) was used. It consists of 10 items rated on a five-point Likert scale (not at all true, slightly true, moderately true, mostly true, extremely true). Scores range from 1 (not at all true) to 5 (extremely true), with total scores ranging from 10 to 50. A score above 20 indicates a higher level of FoMO. This questionnaire was translated into Persian and validated by Bayrami and colleagues in 2019, with a Cronbach’s alpha of 0.87. The reliability of this questionnaire, using Cronbach’s alpha, was reported as 0.79.

Aggression

The Buss-Perry Aggression Questionnaire, a revised version of the earlier Hostility Questionnaire, was developed by Buss and Perry (1992). It is a self-report tool comprising 29 items and four subscales: physical aggression (PA), verbal aggression (VA), anger (A), and hostility (H). Respondents rate each item on a five-point scale from “very much like me” (5) to “not at all like me” (1). Items 9 and 16 are reverse-scored. The total aggression score is obtained by summing the subscale scores. The questionnaire has demonstrated acceptable validity and reliability, with test-retest coefficients for the four subscales (over a 9-week interval) ranging from 0.72 to 0.80, and intercorrelations among the subscales ranging from 0.38 to 0.49. Internal consistency, as measured by Cronbach’s alpha, was 0.82 for physical aggression, 0.81 for verbal aggression, 0.83 for anger, and 0.80 for hostility. The reliability of this questionnaire, using Cronbach’s alpha, was reported as 0.79, 0.77, 0.78, and 0.76, respectively.

Anxiety

Assessing anxiety symptoms is crucial in diagnosis and treatment. Although various scales have been developed based on different perspectives (e.g., Costello, 1967; Endler, 1991; Zung, 1965), these scales have been criticized for theoretical conceptualization and methodological issues (Dobson, 1985; Mendels et al., 1972). To address these issues, Aaron Beck and his colleagues (1990) developed the Beck Anxiety Inventory (BAI), specifically designed to measure the severity of clinical anxiety symptoms in individuals. The BAI is a self-report questionnaire for measuring anxiety severity in adolescents and adults. The total score ranges from 0 to 63. The internal consistency (alpha coefficient) of the BAI is 0.92, its one-week test-retest reliability is 0.75, and the item-total correlations range from 0.30 to 0.76. Five types of validity—content, concurrent, construct, diagnostic, and complete—have been assessed, all indicating the BAI’s high efficacy in measuring anxiety severity (Beck et al., 1988). Kaviani and Mousavi (2008) reported a validity coefficient of approximately 0.72, a one-month test-retest reliability of 0.83, and a Cronbach’s alpha of 0.92 for the BAI in the Iranian population.

Psychological Ego Strength

This inventory was developed by Markstrom, Sabino, Turner, and Berman in 1997 to assess ego strength. It consists of 64 items and 8 subscales: ego strength, hope, will, purpose, competence, fidelity, love, care, and wisdom. The inventory uses a five-point Likert scale (not at all like me, somewhat unlike me, no opinion, somewhat like me, very much like me), with scores of 1-2-3-4-5 assigned accordingly. The score for each subscale is obtained by summing the scores of the relevant items. The highest possible score is 320, and the lowest is 64. A score close to 320 indicates a high level of ego strength, while a score close to 64 indicates low ego strength. Markstrom and colleagues (1997) confirmed the face, content, and construct validity of the inventory. They reported a Cronbach’s alpha of 0.68 for reliability. Altafi (2009) reported a Cronbach’s alpha of 0.91 and a split-half reliability of 0.77 for the inventory in an Iranian sample. The reliability of this inventory, using Cronbach’s alpha, was reported as 0.76.

Data analysis

For data analysis in this study, the following statistical methods were used: descriptive statistics, including mean, standard deviation, skewness, and kurtosis. For inferential statistics, univariate and multivariate analysis of variance (ANOVA) was used, and data analysis was conducted using SPSS version 26.

Findings and Results

The demographic characteristics of the study sample are presented with frequency and percentage. As shown, each of the three studied groups consisted of 35 participants, representing 33.33% of the total sample for each group.

Table 1 shows the descriptive statistics for the studied groups based on the variables under investigation, including mean and standard deviation for each group. The normal group had a higher ego strength score than the other groups. Additionally, the anxiety group scored higher on ego strength compared to the depression group. The depression group had a higher fear of loss score compared to the anxiety group. Aggression was higher in the anxiety group. Data from all 105 observations were analyzed, with no missing or lost data found. Univariate outliers were identified using frequency tables and box plots, with no outliers observed. Therefore, all 105 observations were ready for analysis. The box plot below illustrates the overall variables of the study.

The results also indicated that for all variables and their subscales, the skewness and kurtosis divided by the standard error fell within the range of -2 to +2, suggesting that the distribution of scores in the three groups was not non-normal, meaning this assumption was met. Box's M test examines the null hypothesis that the observed covariance matrices of the dependent variables are equal across groups. Since the value of F (1.224) is not significant at the given error level (p = .259), the null hypothesis is not rejected. This means that the observed covariance matrices between the different groups are equal.

Table 2 reports the results of Pillai's Trace, Wilks' Lambda, Hotelling's Trace, and Roy's Largest Root tests. All four tests are used to assess the significance of multivariate analysis of variance (MANOVA). As noted, Wilks' Lambda is the most commonly reported test, while Pillai's Trace is considered the most robust when assumptions are violated. When all conditions are met and sample sizes are equal, the results of all four tests tend to be similar. The results of the Pillai's Trace test (Sig = .000), Wilks' Lambda test (Sig = .000), Hotelling's Trace test (Sig = .000), and Roy's Largest Root test (Sig = .000), all with p-values less than .05, indicate that there is a significant difference between the three groups in at least one of the variables or components examined.

Table 3 presents the final results of the analysis of variance (ANOVA). To test the hypotheses and examine the differences in means between the groups, the significance level of the test should be referred to. The results indicate significant differences between the three groups in ego strength, fear of loss, and aggression.

As the p-value for the Bonferroni post hoc test was estimated to be less than .05, it can be concluded that there is a significant difference between the three groups for each of the variables: ego strength, fear of loss, and aggression (Table 4).

Discussion and Conclusion

Based on the results obtained, it is evident that the normal group had higher ego strength compared to the depression and anxiety groups. The depression group exhibited a higher mean fear of loss compared to the anxiety and normal groups. There is a significant difference in aggression among the normal, anxiety, and depression groups. Comparing the three groups showed that the aggression variable score was lower in the normal group compared to the anxiety and depression groups, and higher in the anxiety group compared to the depression group. These findings are consistent with studies by Bahmani Nia & Sohrabi Shekafi (2024), Zanjanchi Nikoo & Farahani (2024), Modarresi & Shomali Eskouei (2023), Nikoo Safat et al. (2020), Malhotra et al. (2023), and Tao et al. (2023).

In explaining these findings, it can be said that the ego strives to balance external reality and internal pressures. Ego strength is a strong predictor of success in facing life’s difficult situations, and weakness in the ego leads to resorting to ineffective strategies. From a mental health perspective, ego strength is the ability of individuals to maintain identity and a sense of self when confronted with pain, distress, and conflicts. A strong ego has the capacity to develop new defense mechanisms and coping strategies. Ego strength is related to our core sense of self and is a part of our psychological, social, emotional, and cultural growth, indicating the ability to adapt and be flexible in responding to life’s challenging situations. This ability influences an individual’s capacity to regulate difficult emotions, accept and endure stress, discomfort, and disappointment without losing emotional control. On the other hand, a deficiency in ego strength can lead to poor judgment, difficulty in reality assessment, and interpersonal problems (Tao et al., 2023). Low ego strength is associated with depression symptoms such as guilt and the lack of impact on the environment. Choi Tin (2023) has shown in their research that a lack of ego strength leads to decreased self-esteem, as observed in depression. Therefore, a strong ego allows individuals to exhibit fewer psychological distress symptoms and to show more tolerance and resilience in the face of life’s hardships.

Another variable with a significant difference among the three groups is aggression. Comparing the three groups revealed that the aggression variable score was lower in the normal group compared to the anxiety and depression groups, and higher in the anxiety group compared to the depression group. Aggression is an antisocial behavior characterized by harming others directly or indirectly (Edavi et al., 2017). Uncontrolled aggressive behavior not only leads to interpersonal problems and violations of others’ rights but may also be internalized, causing various physical-psychological problems. Research indicates that mental rumination or revisiting events significantly increases anger and aggression, which may manifest not only in physical but also in verbal behaviors (Kinnerad, Hart, & Lambert, 2022).

In explaining this finding, it can be said that aggression differs among individuals with anxiety, depression, and normal symptoms. Individuals with anxiety symptoms may seek experiences that demonstrate stress and worry. They may react more strongly than others to stressful situations and struggle to control their aggression. In individuals with depression, aggression may be used as a way to alleviate pain and suffering. They may harm themselves and others to mask their pain and suffering. These individuals need professional support to manage their problems and find more constructive ways to cope with negative emotions. Finally, in normal individuals, aggression may naturally occur in response to stressful situations. However, if aggression leads to physical or psychological harm, professional counseling and support are needed. Therefore, the treatment and management of aggression in individuals with anxiety, depression, and normal symptoms require different and specialized approaches. This involves a thorough understanding of the individual’s history, analysis of symptoms, and identification of triggers and underlying causes of aggression to determine the best therapeutic strategies for each person.

On the other hand, the fear of loss was greater in the depression group compared to the anxiety and normal groups. Fear of loss is manifested by a strong desire to be aware of what others are doing. Some describe fear of loss as the fear of regret, leading to intense worry about missing out on social interactions, unique experiences, profitable investments, or other pleasurable events. Fear of loss can be defined from the perspective of self-determination theory as a state of poor self-monitoring, which forms due to a prolonged lack of real connection or difficulty in fulfilling psychological needs. In other words, fear of loss can be seen as intense anxiety about not being connected to social events, experiences, and interactions.

This finding can also be explained by stating that anxiety and depression crises can lead to fear of loss in individuals. Anxiety symptoms include constant worry, nervous tension, excessive anxiety, fear of unpleasant events occurring, and even physical symptoms. Depression symptoms include feelings of sadness and loss of appetite, self-disgust and dislike for others, decreased energy and interest in daily activities, and even suicidal thoughts. Treating fear of loss in individuals with anxiety and depression symptoms requires different approaches (Soheili Pour et al., 2023). For individuals with anxiety symptoms, stress management techniques, breathing exercises, physical exercises, and even psychological counseling can be effective. For individuals with depression symptoms, psychological counseling, antidepressant medications, and even psychotherapy may be necessary. In any case, accurate diagnosis and timely treatment can help reduce fear of loss. Therefore, it is important for individuals with anxiety or depression symptoms to consult specialists and receive appropriate treatment.

Limitations & Suggestions

Despite the valuable results and new insights provided by this study, there are several limitations. The non-random sampling and use of convenience sampling methods may limit the generalizability of the results to a broader population. The use of self-report tools for data collection may involve response biases. Environmental factors, such as the setting for completing questionnaires and the daily stress and concerns of participants, may lead to changes in responses and affect the study results, compromising accuracy. Random sampling methods should be employed to enhance generalizability. Longitudinal methods for examining causal relationships between variables could be useful. To reduce response biases, combining self-report tools with more objective methods, such as semi-structured interviews or direct observation, is recommended. Intervention programs aimed at reducing fear of loss in individuals with anxiety and depression symptoms could significantly improve their quality of life. These programs could include psychological counseling and cognitive-behavioral therapies. Educating families and the community about the importance of recognizing and managing anxiety and depression symptoms could help reduce the psychological burden on these individuals. Workshops and educational courses for individuals with anxiety and depression symptoms and their families could be beneficial. Developing and using apps and online platforms to provide psychological counseling and support could increase access to psychological services and help reduce fear of loss. Further research into the relationship between fear of loss and other psychological factors could help identify new ways to reduce this fear.

Acknowledgments

We would like to express our appreciation and gratitude to all those who cooperated in carrying out this study.

Declaration of Interest

The authors of this article declared no conflict of interest.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.

Transparency of Data

In accordance with the principles of transparency and open research, we declare that all data and materials used in this study are available upon request.

Funding

This research was carried out independently with personal funding and without the financial support of any governmental or private institution or organization.

Authors’ Contributions

All authors equally contributed in this article.