The Effect of Trait Anxiety on Medical Freshmen's Post-Traumatic Growth: The Mediating Role of Resilience

Trait anxiety is a risk factor for post-traumatic growth when medical freshmen are experiencing stressful events. However, little is known about whether resilience has the mediating role between trait anxiety and post-traumatic growth. The current study surveyed the Post Traumatic Growth Inventory (PTGI), Self-rating Depression Scale (SDS), the State-Trait Anxiety Inventory (STAI) and the Connor-Davidson Resilience Scale (CD-RISC) in a sample of 295 medical freshmen. The results founded that posttraumatic growth was negatively correlated with trait anxiety, with correlation coecients of -0.609( p < 0.01), and positively correlated with resilience, with correlation coecient of 0.635 ( p < 0.01). Moreover, resilience could mediate the relationship between trait anxiety and post-traumatic growth. These ndings provide theoretical implications to promote medical freshmen’s resilience to adapt to their life of college.


Introduction
It is widely known that trait anxiety is a risk factor for the development of anxiety-related psychopathology [1,2]. Individuals with high trait anxiety are more susceptible to heighten subjective estimates or feelings towards uncertainty about a potential threat. Previous studies reported that medical students are faced with multiple challenges such as academic pressure and interpersonal distress [3,4]. These challenges bring about much higher prevalence of emotional problems and somatic symptoms compared to their peers [5]. Especially for the rst-year medical students with trait anxiety are quite vulnerable to stress-related mental problems, because the maladjusted environment and overburdened study-related tasks make them at greater risk of experiencing anxiety [6].
Although, the negative effect of trait anxiety on medical freshmen warrants greater attention to its signi cant implications, the students' potentials to deal with di culties should also be taken into account. Actually, most people that face stressful events do not present any mental disorder but show much growth [7], who may nd many bene ts and experience growth from these stressful events. Posttraumatic growth (PTG) is known as an important concept in positive psychology. It is theorized to be facilitated by engagement in cognitive processing, emotional coping and disclosure, resulting in bene cial changes in self-perception, external relationships, and philosophy on life [8]. The positive changes after experiencing stress events, including increasing personal strength, identifying new possibilities, increasing enjoyment of life, improving interpersonal relationships and positive mental changes, and these changes could be consistently found across different types of trauma [9,10]. It should be noted that PTG is not a return to baseline following trauma exposure, but rather it could create an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life [11].
When in a new circumstance, medical freshmen may experience anxiety because of uncertainty, but it is also worth noted that Kalin pointed out the positive accent of anxiety, in which its higher level may bring about a higher possibility of revealing a person's potential goal [12]. Substantial evidence suggests that resilience has protective effects on mental health. Resilience is con rmed as a crucial mediator of the relationship of clinical practice-related stress with depression and anxiety in nurse students [13,14].
Resilient students with greater positivity could view situations in a better light to struggle with adversity successfully, and nally get the growth after stress [15]. However, it is still unclear how resilience plays a role in trait anxiety and PTG of medical freshmen.
Based on the literature discussed above, the present study aimed to assess the relationships of trait anxiety, resilience and PTG of the medical freshmen, and examine the mediating role of resilience between trait anxiety and PTG. A more thorough understanding of the mechanism of PTG in medical students has important implications for intervention to improve mental health. is rated from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis), with high total score indicating high level of growth after stress. This inventory has been proved to possess good psychometric properties in populations in many countries [17,18]. In this study, the internal consistency of the scale was 0.907.

State-Trait Anxiety
The State-Trait Anxiety Inventory (STAI) is conducted to assess individuals' state and trait anxiety [19].
The scale consists of 40 items, divided into 20 items that refer to state anxiety (STAI-S) and 20 items that refer to trait anxiety (STAI-T). In this study, we only focus on the STAI-T. The STAI-T is administered to evaluate stable and longstanding anxiety, and each item is scored on a 4-point Likert ranging from 1(almost never) to (almost always). The higher the score indicates greater trait anxiety. The internal consistency coe cient of STAI-T was 0.798 in this study.

Resilience
The Connor-Davidson Resilience Scale (CD-RISC) is used to evaluate individuals' ability to successfully cope with adversity or di culties [20]. The scale includes 25 items, and respondents endorsed each item on a 5-point Likert from 0 (not true at all) to 4(true nearly all of the time). The total score of the scale range from 0 to 100, with higher score re ecting better resilience. Due to the translation and revision of Yu and Zhang [21], the Chinese version of the scale is well documented and demonstrated good reliability and validity. In this study, the internal consistency coe cient of the scale was 0.904. SPSS 22.0 and PROCESS 3.3 were carried out to perform statistical analysis on the data. Pearson correlation analysis and multiple regression analysis were applied to examine the effects of each variable on PTG. The PROCESS version 3.3(Model 4) developed by Hayes [22] was used for to examine the mediating role of resilience between anxiety and PTG. 5000 bootstrap samples with retraction were drawn to obtain a 95% con dence interval of the mediating effect value. If the upper and lower limits of the interval do not include 0, the mediating effect reaches statistical signi cance [23].

2 Mediating effect of resilience in the relationship of trait anxiety and PTG
The mediating analysis of resilience on the association between trait anxiety and PTG is illustrated in Fig. 1. Trait anxiety was negatively associated with resilience (a =-0.609, p < 0.01) (a path). Resilience was positively associated with PTG (b=0.562, p<0.01). The result indicated that with the mediator (c path), trait anxiety was negatively associated with PTG (c' =-0.120, p < 0.01). Because the a and b paths were signi cant, the mediation analysis was performed using bootstrapping methods with bias-corrected con dence estimates. In the present study, the 95% CI of the indirect effect was obtained through 5000 bootstrap resampling to re ne the mediating effects and provides higher accuracy power [24,25]. The indirect effect was ab = -0.343; 95% CI = [-0.434, -0.261]. Empirical 95% CI didn't consist of zero, indicating that resilience was the path through which trait anxiety could in uence PTG when controlling for age (see Table 2). The direct effect size was -0.120, and the mediation effect was -0.343, accounting for 25.92% and 74.08% of the total effect, respectively. Altogether, the model accounted for 74.24% of the total variance of PTG.

Discussion
The current study examined whether resilience acted as a mediator in the association between trait anxiety and PTG of medical freshmen. The results demonstrated that resilience had mediating effects between trait anxiety and PTG.
Medical education is considered to be one of the most stressful training programs out of any profession, especially in the rst year [26]. Stressful events such as interpersonal relationship and overloaded academics could cause negative effects on the students' psychological well-being [27]. Individuals with high trait anxiety are more susceptible to stress [28]. However, in our study we found medical students with trait anxiety had different degree of PTG. Most of the freshmen began to show resilience, which is the adaptive ability to maintain mental health despite adversity and stressful events. More importantly, they believed that the academy life had made them obtain comprehensive growth how they are affected by moderate anxiety. Moreover, in this study gender differences were observed in PTG. Compared to the female medical fresh students, the males' PTG is signi cantly higher than females'. The results are consistent with previous studies that females were experiencing more severe stress and anxiety symptoms, while males showed better resilience to stress [29,30].
Our study also found PTG was negatively related with trait anxiety and positively with resilience, and the association between anxiety and PTG was mediated by resilience. That is, PTG was not directly in uenced by trait anxiety, but indirectly through resilience. This was in line with the mixed model of PTG proposed by Tedeschi and Calhoun [31], indicating that an individual's temperamental vulnerability such as trait anxiety combined with pretrauma characterisitics, the nature of the traumatic event (e.g., prolonged exposure to the trauma), and coping processes in uence the development of PTG. Although trait anxiety was a risk factor for PTG [32], but according to Connor and Davidson, resilience is de ned as a constellation of personal characteristics (i.e., optimism, hardiness, strong self-esteem, and positive affects) and cognitive characteristics to reframe the stressor to emphasize positives of the situation as a coping strategy being positively associated with PTG [33,34]. The current result suggested that resilience had a mediating role between trait anxiety and PTG. The possible explanation is that anxious medical freshmen with high resilience can reconstruct the meaning of adversity and give it a new and positive value. As an individual's ability to deal with frustration and stress and recover mental health, the higher the level of resilience, the better it is to adjust negative emotions, and could adopt cognitive reappraisal strategy to make them get more growth after encountering stressful events [35].
Several limitations of the present study need to be mentioned. First, the pertinent variables (trait anxiety, resilience, and PTG) were measured with self-report questionnaires. The relations among the three constructs might have been impacted by common method variance [36]. Second, other unmeasured variables (e.g., social support, coping style) that likely affect PTG were not included in the current study. Therefore, future studies should consider these variables to verify whether these dimensions in uence on trait anxiety and PTG. Finally, the study relied on cross-sectional self-report data with Chinese medical freshmen, which limited our capacity to make causal statements and the generalizability of the results.
Notwithstanding these limitations, the current study contribute to our knowledge concerning the linkages among trait anxiety, resilience and PTG. Speci cally, the nding of the mediating role of resilience between trait anxiety and PTG suggests that resilience may be considered as a useful intervening target for psychological service providers to enhance medical freshmen's PTG in a stressful context. Further studies are required to determine the e cacy of resilience-building interventions in medical freshmen. Mediation model examining the indirect relationship between trait anxiety and PTG through resilience. **p < 0.01.