Stress and Coping Styles are Associated with

Severe Fatigue in Medical Students

Masaaki Tanaka, MD, PhD; Sanae Fukuda, PhD; Kei Mizuno, PhD; Hirohiko Kuratsune, MD, PhD;
Yasuyoshi Watanabe, MD, PhD

Fatigue is a common complaint among medical students and researchers

consider it to be related to poor academic outcomes. The authors’ goal in
the present study was to determine whether stress and coping strategies were
associated with fatigue in medical students. The study group consisted of
73 second-year healthy students attending the Osaka City University Gradu-
ate School of Medicine. Participants completed a questionnaire about fatigue
(Japanese version of Chalder Fatigue Scale), stress, stress coping (Japanese
version of the Coping Inventory for Stressful Situations), overwork, and
nocturnal sleeping hours. On univariate and multivariate logistic regression
analyses adjusted for age and gender, stress was positively associated with
fatigue. In addition, after adjustment for age, gender, and emotion- and task-
oriented stress coping activities, avoidance-oriented stress coping activity
was associated with fatigue. The results suggest that stress and the coping
style are correlated with fatigue in medical students.
Index Terms: coping, fatigue, medical students, overwork, stress

Dr Tanaka is with the Departments of Physiology and of Biomarker
and Molecular Biophysics at Osaka City University Graduate
School of Medicine in Japan as well as with the 21st Century COE
Program Base to Overcome Fatigue (from the Ministry of Educa-
tion, Culture, Sports, Science and Technology of the Japanese
Government). Dr Fukuda and Dr Mizuno are with the Depart-
ment of Physiology at Osaka City University Graduate School of
Medicine in Japan as well as with the Japan Science and Technol-
ogy Corporation/Research Institute of Science and Technology
for Society. Dr Kuratsune is with the 21st Century COE Program
Base to Overcome Fatigue as well as with the Department of
Health Science, Faculty of Health Science for Welfare, at Kansai
University of Welfare Sciences in Japan. Dr Watanabe is with
the Department of Physiology at Osaka City University Graduate
School of Medicine in Japan, the 21st Century COE Program Base
to Overcome Fatigue, the Japan Science and Technology Corpo-
ration/Research Institute of Science and Technology for Society,
and the RIKEN Center for Molecular Imaging Science in Japan.
Copyright © 2009 Heldref Publications
In addition to depression,1–3 on the basis of our observa-
tion, fatigue is a common complaint among medical stu-
dents. Because severe fatigue is related to poor academic
attainment, such as impaired academic performance and
absenteeism,4–6 the impact of severe fatigue on medical
students should be addressed.7
The association between stress and fatigue has been
noted in healthy participants.8,9 Stress might, in some cases,
trigger chronic fatigue syndrome (CFS).10,11 Researchers
have found serious life events12–15 and other stressful situa-
tions16–20 to be related to the development of illness. Coping
refers to the cognitive or behavioral efforts used to manage,
reduce, or control stress. Patients with CFS utilize more
avoidance-oriented21 or escape-avoiding22 coping strategies
compared with healthy participants or primary care patients
without chronic fatigue.23 In addition, another study reported

87
STRESS AND COPING STYLES ARE ASSOCIATED WITH SEVERE FATIGUE IN MEDICAL STUDENTS
that twins with chronic fatigue or CFS used more avoidance-
oriented stress coping strategies than did their nonfatigued
counterparts; those with chronic fatigue also used more
avoidance-oriented strategies, as opposed to a problem-
focused coping style, than did their co-twins.24 CFS is char-
acterized by profound disabling fatigue that persists for at
least 6 months without relief and is not lessened by ordinary
rest.25 Patients with CFS have substantial impairment of
functional status, resulting in significant personal and eco-
nomic morbidity. Thus, stress and the coping style used to
deal with it seem to be associated with severe fatigue.
Medical school is considered to be a stressful environment
that often has a negative effect on the academic performance,
physical health, and psychological well-being of the
students.26 Therefore, our aim in the present study was to
determine the relationships among stress, particular coping
strategies, and severe fatigue in medical students.
METHODS
Two groups of participants were enrolled. The healthy group
included all 2nd-year students who attended an advanced course
lecture at the Osaka City University Graduate School of Medi-
cine (55 males, 26 females; M age ⫽ 20.8 years, SD ⫽ 2.0 years).
Eight sparticipants with medical illness, such as depression,
chronic nephritis, atopic dermatitis, and seasonal allergic rhini-
tis, were excluded from the analyses. The severe fatigue group
consisted of 52 patients with CFS (30 males, 22 females; M
age ⫽ 44.7 years, SD ⫽ 17.7 years) who were consecutively
admitted to the Osaka City University Hospital for the first time
between January 13, 2005, and May 26, 2005. CFS was diag-
nosed according to the criteria for CFS given by the US Centers
for Disease Control and Prevention.25,27 CFS is an illness char-
acterized by a profound, disabling, and unexplained sensation
of fatigue lasting at least 6 months, which severely impairs daily
functioning and is accompanied by a combination of nonspecific
symptoms. The definition requires at least 6 months of persistent
or relapsing fatigue that substantially reduces occupational,
social, educational, and personal activities and is not substan-
tially alleviated by ordinary rest. In addition, 4 or more of the
following symptoms must be present for more than 6 months:
impaired memory or concentration, sore throat, tender cervical
or axillary lymph nodes, muscle pain, pain in several joints, new
onset headaches, unrefreshing sleep, or malaise after exertion.
Medical conditions that are associated with fatigue and many
psychiatric disorders are listed among the exclusion criteria.
Exclusionary conditions were ascertained by detailed clinical
and laboratory examinations of a physician specialized in CFS
and of a psychiatrist. The Ethics Committee of Osaka City Uni-
versity approved the present study, and all participants provided
written informed consent prior to participating in the study.
88
Paper-and-pencil questionnaires were distributed to the
participants. The questionnaire completed by each par-
ticipant asked about fatigue, stress, stress coping, over-
work, and nocturnal sleeping hours during school days.
We measured the severity of fatigue using the Chalder
Fatigue Scale,28 which was previously used in Japanese.29
Permission to use the fatigue scale was obtained from Dr.
Chalder. The fatigue scale consists of 11 questions using a
2-level0–1 general health questionnaire-type scale in which
responses can be 0 (less than usual or no more than usual)
or 1 (more than usual or much more than usual during the
past several weeks). The total score for the 11-item fatigue
scale ranges from 0 to 11, with higher scores indicating a
greater degree of fatigue. We assessed coping activity that
reflects preferred characteristics or typical manners of cop-
ing with stress by using the Coping Inventory for Stressful
Situations (CISS),30 which was previously translated into
Japanese.31 The CISS consists of 48 questions (including 16
ones about task-, emotion-, and avoidance-oriented coping)
and responses are given on a 5-point Likert-type scale with
the following range: 1 (always), 2 (almost), 3 (sometimes),
4 (rarely), and 5 (never). The total score for each oriented
stress coping scale ranges from 16 to 80, with higher scores
indicating a greater degree of coping activity. The item
about stress was “Are you stressed?” Participants selected an
answer from the following choices: no more than usual, more
than usual, and much more than usual. The item about over-
work was “In your daily life, is your rest time sacrificed for
the sake of your work?” Participants selected an answer from
the same set of answers as that of the item related to stress.
Relative operating characteristics (ROC) and discrimi-
nant analyses were used to determine a cutoff score value
for the fatigue scale. Univariate and multivariate logistic
regression analyses were performed to identify factors
associated with the prevalence of severe fatigue. The 95%
confidence interval (CI) was calculated for each odds ratio
(OR). The number of cases in the analyses varied because
of incidental missing values. All p values were 2-tailed;
p values less than .05 were considered statistically signifi-
cant. Statistical analyses were performed using the SPSS
14.0 software package (SPSS, Chicago, IL).
RESULTS
ROC (see Table 1) and discriminant analyses were used
to determine a cutoff score value for severe fatigue on the
Chalder Fatigue Scale by comparing the fatigue scale scores
of the healthy participants with those of the patients with
CFS. The results suggest that the optimum cutoff score
value of the fatigue scale was 7, with a sensitivity of 73.1%,
a specificity of 73.9%, and an area under the ROC curve of
Behavioral Medicine
 TANAKA ET AL

logistic regression analyses using the healthy participants’

TABLE 1. Sensitivity and Specificity of the Chalder
Fatigue Scale Score for Healthy Participants and
data (see Table 2). On univariate logistic regression analy-
Patients with Chronic Fatigue Syndrome sis, stress (no more than usual vs much more than usual:
OR ⫽ 19.50, 95% CI ⫽ 1.78–213.89, p ⫽ .015) and over-
VCutoff Sensitivity Specificity work (no more than usual vs more than usual: OR ⫽ 13.99,
95% CI ⫽ 2.79–70.25, p ⫽ .001; no more than usual vs
0/1 98.1 11.6
1/2 96.2 24.6 much more than usual: OR ⫽ 23.32, 95% CI ⫽ 2.95–184.04,
2/3 96.2 31.9 p ⫽ .003) were positively associated with severe fatigue.
3/4 92.3 43.5 On a multivariate logistic regression analysis adjusted for
4/5 90.4 53.6 age and gender, stress (no more than usual vs much more
5/6 88.5 66.7
6/7 73.1 73.9 than usual: OR ⫽ 25.91, 95% CI ⫽ 2.03–330.73; p ⫽ .012)
7/8 61.5 79.7 and overwork (no more than usual vs more than usual:
8/9 51.9 84.1 OR ⫽ 14.99, 95% CI ⫽ 2.83–79.56, p ⫽ 0.001; no more
9/10 42.3 92.8 than usual vs much more than usual: OR ⫽ 31.29, 95%
10/11 17.3 95.7
CI ⫽ 3.54–276.85, p ⫽ .002) were positively associated
with severe fatigue. Nocturnal sleeping hours during school
days was not associated with severe fatigue.
0.805. Therefore, severe fatigue was defined as a score of To identify factors associated with the prevalence of
equal to or greater than 7 on the Chalder Fatigue Scale. The severe fatigue in relation to the CISS score, we performed
prevalence of severe fatigue among the healthy participants univariate and multivariate logistic regression analyses
was 25.3%. using the healthy participants’ data (see Table 3). In the
To identify the factors associated with the prevalence of univariate logistic regression analysis, the avoidance-
severe fatigue in relation to stress, overwork, and nocturnal oriented stress coping score (Tertile 1 vs Tertile 3: OR ⫽
sleeping hours, we performed univariate and multivariate 5.36, 95% CI ⫽ 1.25–23.02, p ⫽ .024) was positively

TABLE 2. Univariate and Multivariate Logistic Regression Analyses of the Prevalence of Severe Fatigue in Relation to Stress,
Overwork, and Nocturnal Sleeping Hours

Variable Crude OR 95% CI OR 95% CI†

Age 1.02 0.78–1.33 —
Female Gender 1.69 0.57–5.06 —
Stress
No more than usual 1.00 Reference 1.00 Reference
More than usual 3.97 0.47–33.86 5.26 0.54–50.93
Much more than usual 19.50 1.78–213.89* 25.91 2.03–330.73*
p .026 .024
Overwork
No more than usual 1.00 Reference 1.00 Reference
More than usual 13.99 2.79–70.25** 14.99 2.83–79.56**
Much more than usual 23.32 2.95–184.04** 31.29 3.54–276.85**
p .003 .002
Nocturnal sleeping hours
Tertile 1 (4.0–5.5 h) 1.00 Reference 1.00 Reference
Tertile 2 (6.0–6.0 h) 0.84 0.22–3.25 0.79 0.20–3.11
Tertile 3 (6.6–10 h) 0.69 0.17–2.73 0.60 0.14–2.50
p .864 .778

Note. CI ⫽ confidence interval; OR ⫽ odds ratio.

*
p ⬍ .05. **p ⬍ .01.
†
adjusted for age and gender.

Vol 35, Fall 2009 89

STRESS AND COPING STYLES ARE ASSOCIATED WITH SEVERE FATIGUE IN MEDICAL STUDENTS

TABLE 3. Univariate and Multivariate Logistic Regression Analyses of the Prevalence of Severe Fatigue in Relation to the
CISS Score

Crude OR 95% CI OR 95% CI†

CISS score (task oriented)

Tertile 1 1.00 Reference 1.00 Reference
Tertile 2 1.14 0.33–4.01 1.25 0.33–4.80
Tertile 3 0.27 0.06–1.23 0.31 0.06–1.51
p .140 .169
CISS score (emotion oriented)
Tertile 1 1.00 Reference 1.00 Reference
Tertile 2 0.91 0.25–3.30 0.74 0.18–2.98
Tertile 3 0.71 0.19–2.70 0.67 0.17–2.59
p .881 .831
CISS score (avoidance oriented)
Tertile 1 1.00 Reference 1.00 Reference
Tertile 2 1.41 0.28–7.18 1.65 0.30–8.97
Tertile 3 5.36 1.25–23.02* 6.33 1.34–29.85*
p .035 .032

Note. CISS ⫽ Coping Inventory for Stressful Situations; CI ⫽ confidence interval; OR ⫽ odds ration.
*
p ⬍ .05.
†
adjusted for age and gender.

associated with severe fatigue. In a multivariate logistic associated with severe fatigue in medical students. These
regression analysis adjusted for age and gender, the findings were independent of age and gender. In addition,
avoidance-oriented stress coping score (Tertile 1 vs Tertile the avoidance-oriented coping strategy was related to severe
3: OR ⫽ 6.33, 95% CI ⫽ 1.34–29.85; p ⫽ .020) was also fatigue even after adjustment for age, gender, and other
associated with severe fatigue. Task- or emotion-oriented stress coping strategies. However, nocturnal sleeping hours
stress coping scores were not associated with severe during school days was not correlated with severe fatigue
fatigue. Furthermore, in a multivariate logistic regression in these participants.
analysis adjusted for age, gender, dietary habit (skipping Previous studies have demonstrated the relationship
breakfast), and exercise habit, the avoidance-oriented between stress and severe fatigue.8–20 Researchers have
stress coping score (Tertile 1 vs Tertile 3: OR ⫽ 7.21, reported that the prevalence of CFS is related to the use of
95% CI ⫽ 1.46–35.57, p ⫽ .015) was also associated with
severe fatigue (data not shown). TABLE 4. Multivariate logistic regression analysis
Finally, to determine whether the prevalence of severe of the prevalence of severe fatigue in relation to the
fatigue was associated with the avoidance-oriented stress avoidance-oriented CISS score
coping score after adjustment by the task- or emotion-
oriented stress coping scores, a follow-up multivariate Avoidance-oriented CISS score OR 95% CI†
logistic regression analysis was performed (see Table 4). In
a multivariate logistic regression analysis adjusted for age, Tertile 1 1.00 Reference
gender, task-, and emotion-oriented stress coping scores, Tertile 2 1.35 0.23–8.09
Tertile 3 7.61 1.43–40.36*
the avoidance-oriented stress coping score (Tertile 1 vs p .019
Tertile 3: OR ⫽ 7.61, 95% CI ⫽ 1.43–40.36, p ⫽ .019) was
positively associated with severe fatigue. Note. CISS ⫽ Coping Inventory for Stressful Situations;
CI ⫽ confidence interval; OR ⫽ odds ratio.
COMMENT *
p ⬍ .05.
†
adjusted for age, gender, and task- and emotion-
These cross-sectional data show that stress and a par- oriented CISS scores.
ticular coping style (avoidance-oriented coping style) were

90 Behavioral Medicine

an avoidance-oriented stress coping strategy rather than a
problem-focused coping style.21–24 These reports are con-
sistent with the present results (see Tables 2–4). However,
in post-stroke fatigue, it was found that emotion-oriented
stress coping was negatively associated with fatigue level,
whereas task-oriented coping was positively associated; the
emotion-oriented style of coping was the most important
correlate of fatigue.32 Thus, the association between each
stress coping style and fatigue may differ depending on the
cause of fatigue. To the best of our knowledge, the pres-
ent study is the first cross-sectional study to examine the
relationship between stress coping style and severe fatigue
in medical students. Because avoidance-oriented coping
style is associated with poorer outcomes in patients with
CFS,33 maladaptive stress coping strategies may contribute
to the development of severe fatigue in medical students.
Another possibility is that severe fatigue engenders avoid-
ance strategies.
The mechanism by which the stress is associated with
a higher prevalence of severe fatigue in medical students
remains to be determined. At present, stress-associated
neural,34 immune-cytokine,35 and hormonal36 changes are
thought to be related to the pathophysiology of CFS. There-
fore, a plausible mechanism by which stress causes severe
fatigue may be, at least in part, based on stress-associated
neural, immune, and hormonal perturbations in medical
students.
There are several potential limitations to our study. First,
this study had a limited number of participants. The large
CIs around the ORs are likely due to the small sample size
and indicate imprecise estimates. To generalize our results,
studies involving a large number of participants are essen-
tial. Second, one cannot draw conclusions about cause-and-
effect relationships because of the cross-sectional nature of
the data. Last, the levels of stress, overwork, and fatigue
were evaluated using a paper-and-pencil questionnaire,
and measurement of stress and overwork by 1 question is
not sufficient. The development of objective, quantitative
scales to measure the levels of stress, overwork, and fatigue
would allow the reliability and validity of our results to
be determined.
In conclusion, the present results provide evidence that
stress and coping style are significantly correlated with
severe fatigue among medical students similar to that in
patients with CFS.37 The mechanisms by which stress and
coping strategies are associated with severe fatigue remain
to be elucidated. However, further efforts to develop educa-
tional training programs that reduce stress and help guide
individuals to develop efficient stress coping styles would
contribute to a lower incidence of severe fatigue, a higher
Vol 35, Fall 2009
TANAKA ET AL
rate of recovery from severe fatigue, and even more favor-
able academic outcomes among medical students.
ACKNOWLEDGMENTS
This work was supported by the 21st Century COE
program Base to Overcome Fatigue from the Ministry of
Education, Culture, Sports, Science and Technology, and
the Japan Science and Technology Corporation/Research
Institute of Science and Technology for Society, the
Japanese Government. The authors thank Dr. Luba Wolchuk
for editorial assistance.
NOTE
For comments and further information, address correspon-
dence to Dr Masaaki Tanaka, Department of Physiology,
Osaka City University Graduate School of Medicine, 1-4-3
Asahimachi, Abeno-ku, Osaka City, Osaka 545-8585, Japan
(e-mail: masa-t@msic.med.osaka-cu.ac.jp).
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