Journal of Hospital & Medical Management

Keywords

Death anxiety; PTSD; Fear of death; Combat exposure; Types of trauma; Trauma treatment; Depression; Anxiety.

Introduction

Background of the problem

According to the U.S. Department of Veteran Affairs (2007) [1,2], Post traumatic Stress Disorder (PTSD) is thought to occur in 11-20% of Iraq and Afghanistan war veterans and only 7-8% of the general population by comparison. Soldiers are among the most likely to develop PTSD because of the risk soldiers are asked to take during their time serving in the military. Most importantly, the rates are the highest when a veteran has military combat exposure (American Psychiatric Association, 2013) [3]. Individuals with PTSD are also 80% more likely to develop symptoms consistent with another mental disorder (APA, 2013). Commonly, individuals with PTSD suffer from depression, anxiety, and cognitive difficulties [4]. This means that when military individuals are exposed to combat, the risk of PTSD greatly increases and when PTSD develops, the individual has significant risk of developing depression or anxiety in relation to the traumatic stress experienced.

In the past few decades, most PTSD treatments have been Cognitive/Behavioral in nature, and focused on exposure therapy and symptom treatment, which has been only partially effective [5-7]. Recently, researchers have begun to recognize the possibility that some of the current treatments in use may actually re-traumatize the individual or exacerbate the trauma [8]. Given the recent research, current treatments are moving away from the focus on exposure therapy.

From a Psychodynamic and/or Humanistic/Existential theoretical perspective, these Cognitive/Behavioral treatments for soldiers suffering from post-combat trauma are not taking into account nor assisting in the treatment of the central and important construct of death anxiety. Death anxiety has been defined as the fear of one’s own death in a physically healthy individual [9]. McCarthy’s research posits that when individuals are being treated for PTSD, the treatment is focusing on the symptoms that manifest and not the true impact of the trauma. Non-CBT theorists and practitioners would argue that treatment for PTSD is focused on relief of current symptoms, which can be seen as a short-term solution. Ernest Becker [10] stated that death anxiety is a true fear and that it underlies many different types of anxiety. The DSM-5 recognized that PTSD must begin with, “exposure to actual or threatened death, serious injury, or sexual violence,” and lists specific diagnostic criterion, which are the current focus of treatment (APA). Yet the treatment for PTSD as it stands currently does not take into account the complex nature of traumatic experiences in relation to death anxiety.

Although current treatments may show some effectiveness in treating specific symptoms, longitudinal research has shown PTSD is usually a chronic disorder that often lasts for decades and is marked with remissions and relapses [11]. Without development of more effective treatment strategies, the focus of treatment will be on the immediate display of symptoms and not on the underlying issues such as death anxiety. Treatment for PTSD needs to be further studied in relation to underlying issues to provide a more comprehensive treatment plan that will inform longer-term treatment and increase treatment outcomes. Developing a better understanding of the relationship between death anxiety and PTSD would allow for more effective assessment, diagnosis, and treatment of PTSD.

Death anxiety and PTSD

Death anxiety is a potentially paralyzing fear of one’s own death upon which an individual’s conscious mind is unceasingly focused. According to [1], death anxiety, both distressing and unavoidable to mortal humans, is a normal human experience, and is at the core of anxiety itself. In building upon the ideas of fear and death by Becker, Routledge and Juhl stated that all humans have the innate capacity to not only understand but to interpret the implications of their own inevitable death in addition to their instinct for survival [12]. The experience of death anxiety has been deemed normal, yet there is a point when it becomes too much – even unconsciously. Langs suggested the normality of death anxiety, yet also concluded that “excessive conscious death anxiety is likely to seriously disrupt adaptive functioning” [13]. Manifestations of excessive death anxiety can lead to generalized anxiety and depression. Death anxiety will become more conscious and can become excessive in the face of death or death experiences. For soldiers, the most common form of this is exposure to war.

The impact of death anxiety on an individual’s daily life is transformed by the traumatic event that has been experienced. Research indicated that death anxiety can be influenced by many events throughout an individual’s lifetime, but death or neardeath experiences (trauma) are profound indicators for how a person feels about death [14-16]. For soldiers, being placed into combat situations is the moderating variable that can lead to the development of PTSD. When in combat, soldiers are exposed to the actual harm and fear of death, and the fear becomes heightened because it is no longer just the anticipation of a lifethreatening situation or event, this leads to a change in death anxiety overall. In determining the correlation between death anxiety and PTSD, treatment could become deeper and more individualized to treat the root of the problem and not just the symptoms.

This study aimed to provide information about the relationship between death anxiety and post-combat trauma, especially as expressed via symptoms associated with PTSD. The impact of death anxiety is an overlooked, yet potentially important component for finding a treatment that focuses on core difficulties and not just the current manifestation of symptoms. This study surveyed all those within the military selected from U.S. military sources across the United States. Individuals were given measures for death anxiety and PTSD symptoms to determine the direction and strength of the relationship between death anxiety and traumatic stress due to combat exposure, the results of which could be used to develop a more comprehensive treatment plan for veterans with PTSD. The following research questions were explored within this study.

Primary Research Question #1: Is there a significant relationship (if any) between traumatic stress related to combat exposure and death anxiety?

Primary Research Question #2: Is there a significant relationship between reported death anxiety and reported depression in military members who have seen combat?

Primary Research Question #3: Is there a significant relationship between death anxiety and the amount of reported generalized anxiety in those who have seen combat?

Secondary Research Question #1: Is there a significant relationship between active status in the U.S. military and the reported levels of death anxiety?

Secondary Research Question #2: Is there a significant relationship between time served in the U.S. military and amount of time served in combat and reported death anxiety?

Post hoc analyses sought to determine if there are any other significant factors that will increase the understanding of the complex relationship between traumatic stress and death anxiety.

Methods

Participants

Participants for this study consisted of 42 individuals serving in four military branches. To qualify for this study, participants needed to be currently serving or have previously served in the United States military. Of the 42 participants, only 2 met the cutoff (scores of 35 or higher) for the PTSD Checklist for the Military (PCL-M) to be indicative of severe enough symptoms for a Posttraumatic Stress Disorder (PTSD) diagnosis and were excluded from the study per the agreement with the IRB board at (edited out for blind review).

The study contained a male-to-female ratio of 1.33:1 (24 male, 18 female). The ages of participants ranged from 20 to over 40 years old; this included: 20-25 (7.1%), 26-30 (40.5%), 31-35 (19%), 36- 40 (9.5%), and >40 (23.8%). The majority of participants identified as White/Non-Hispanic (36 participants), totaling 85.7% of all those in the study. Remaining participants included three African Americans and one each of Hispanic, Asian-Pacific Islander, and Native American. Of those who completed the study, 66.7% were married with an additional 14.3% reporting being in a serious relationship (14.3% single, 4.8% divorced). Although the majority of participants reported being in the Army (73.8%), participants also consisted of Marine Corps (9%), Navy (5%), and Air Force (12%).

Participants were also asked to report current status in the U.S. Military. Status reported as follows: 14 active duty (33.3%), 7 reserve/individual ready reserve (16.7%), 8 Army National Guard (19.0%), 1 Air National Guard (2.4%), and 12 retired/discharged (28.6%). Of the 42 participants, 9 served between 1 and 5 years (21.4%), 12 served between 6 and 10 years (28.6%), and 21 participants served more than 10 years in the military (50.0%). Reported time spent in combat varied; 35.7% of participants reported spending 6-12 months in combat, only 14.3% reported being in combat for less than six months, whereas the other 50% reported being in combat situations for more than 12 months.

Procedure

This study was approved by the IRB board at (edited out for blind review). Participants were recruited using snowball sampling. All data collection for this study was conducted online using the survey tool Survey Monkey. Participants were presented a page including a brief description of the study and informed consent. To maintain confidentiality, this research did not ask for names on the informed consent or any of the measures. Participants were then asked to fill out a brief demographics questionnaire to record age, gender, religious affiliation, and information related to the individual’s military experiences. Next, participants were given the instruments that were used to measure the reported levels of death anxiety, combat-related stress, depression, and anxiety. After each section of the study, participants were then asked to rate their feelings of distress to check for levels of distress. Any participants who reported distress that was higher than 6 on a scale of 0-10 were rerouted to a page with recommendations for assistance and were excluded from the study results. The rating of distress served as a checkpoint to minimize the chances of retraumatization for participants of this study.

Measures

Demographic survey: The demographic survey was created to address the information relevant to this study. Demographic questions were not used as exclusion criteria; questions were instead used for further examination in correlation with both death anxiety and with PTSD.

Death Anxiety Scale – Extended (DAS-E): The Death Anxiety Scale – Extended (DAS-E) was used for this study to assess the level of reported death anxiety for each participant. The DAS-E defined death anxiety as an “unpleasant response centered on death and dying of the self or significant others” [17]. The DAS-E is a 51- item self-report measure consisting of true/false questions. With regard to its psychometric properties, the DAS-E linked with its predecessor, the DAS, with a correlation of 0.81 [18]. This was used to determine if the DAS-E was as accurate as the DAS after the addition of new questions.

PTSD Checklist for Military (PCL-M): Next, the PTSD Checklist for Military (PCL-M) was used to assess the impact and importance of combat-related stress for each individual’s experience. The PCL-M is a 17-item self-report measure that uses questions in relation to the DSM-IV symptoms of PTSD. The military version of the PCL specifically asks about symptoms that are a reaction to “stressful military experiences” and is frequently used for active military to determine status changes and to clarify possible PTSD diagnoses (U.S. Department of Veteran Affairs, 2007). The suggested cut off for symptoms strong enough to be indicative of a potential PTSD diagnosis is a total severity score of at least 35. To determine reliability and validity, the PCL was correlated with the Clinician Administered PTSD Scale (CAPS). The correlation with the CAPS has an alpha of 0.929 and a diagnostic efficiency of 0.900 [19,20].

Depression Anxiety Stress Scales (DASS): The Depression Anxiety Stress Scales (DASS) was used to assess self-reported levels of both depression and anxiety. The DASS contains three scales that measure the negative emotional states of depression, anxiety, and stress (Psychology Foundation of Australia) [21]. Each of the scales contains 14 items and within each scale, there are subscales that contain 2-5 items each. While the DASS was developed in Australia, research has been completed in the U.S. to inform the validity results [22]. In comparison to the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI), the DASS showed strong psychometric properties [23]. The DASS anxiety scale correlated 0.81 with the BAI, and the DASS Depression scale correlated 0.74 with the BDI. Overall, the function of the DASS was to assess the severity of the core symptoms of depression, anxiety, and stress.

Data Analysis

The study sought to find whether there was a significant relationship between death anxiety and combat-related stress, depression, and anxiety by using a matrix of Pearson product (r) correlations on SPSS. Correlations were run to check for a significant positive relationship between traumatic stress, as measured by the total score of the responses to the PTSD Checklist for Military (PCL-M), and death anxiety, as measured by the total score of the self-reported responses to the Death Anxiety Scale-Extended (DAS-E). Correlations were also run to compare the relationships between death anxiety and mental health distress symptoms measure by the Depression Anxiety Stress Scales (DASS). Correlations were also run to compare demographics that were collected including items such as time in military, military status, gender, etc.

Results

In comparing the variables of death anxiety and generalized anxiety, a significant positive correlation was found between the results of the DAS-E and the Anxiety subscale of the DASS (r (42) = .373, p<.05). The significant relationship suggests that individuals who report high levels of death anxiety also report high levels of feelings of generalized anxiety. Another significant relationship to note is the one found between death anxiety and overall feelings of distress, as found through using the DASS total symptom score. A strong positive correlation was found between participants’ scores on the DAS and the DASS (r (42) = .324, p<.05). This suggests a positive relationship between distress feelings and specific feelings of death anxiety.

A positive correlation was found between participants’ scores on the DAS-E with their scores on the PCL-M (r (42) = .276, p>.05) as well at the Depression subscale of the DASS (r(42) = .303, p>.05). The relationships were not statistically significant but showed a positive trend between death anxiety and both combat-related stress and depression. This speaks to the need to conduct further study on this topic with a larger sample size to analyze findings.

Correlations were also run to compare each of the measures with demographic and military information reported during this study. Death anxiety was compared with current status in military, total time served, and total time spent in combat. A slight relationship trend was found between the DAS-E total and the current status in the military (r (42) = .109, p>.05). There was also a slight relationship found between the DAS-E total and the total time spent in combat (r (42) = -.048, p>.05). However, a strong and significant relationship was found when comparing the DAS-E total with the total time served in the military (r (42) = -.319, p<.05). These results are indicative of a significant negative relationship between decreased feelings of death anxiety in relation to longer amount of time spent in the military. These analyses were included as preliminary data that demonstrates the importance of further study.

Post hoc analyses were run with other variables to test for relationships of significance and to check the validity of the results by comparing the data to results expected based on past research. Analyses were run for this study to compare levels of PTSD symptoms with depression and anxiety. In this study, a strong positive correlation was found between the PCL-M and the Depression subscale of the DASS (r 42) = .862, p<.01). The strong relationship found among this study’s sample is consistent with past research [1] that indicated depression is related with symptoms found in veterans reporting combat-related stress. A strong positive correlation was also found between combatrelated stress and anxiety. Data analyzed showed a significant relationship between the PCL-M and the Anxiety subscale of the DASS (r (42) = .857, p<.01). When considering overall reported symptoms, the comparison is found to show an even stronger positive relationship. A significant relationship was found between the PCL-M and the DASS total score (r (42) = .903, p<.01). The strong relationship found suggests the data results in this study are consistent with past experiences of participants from other studies that included combat-related stress in relation to depression and anxiety.

Discussion

As previously stated, individuals with death anxiety likely use coping mechanisms that suppress the overwhelming anxiety surrounding death [16]. This only increases the importance of assessing for death anxiety among those with psychological distress [24]. Symptoms of death anxiety could be correlated with or exacerbating symptoms of PTSD. The primary hypotheses of this study focused on the relationship of death anxiety with PTSD, depression, and anxiety. Of the outcomes expected, two showed positive relationships while the third indicated a statistically significant positive relationship to death anxiety. The impact of death anxiety is far-reaching and multi-layered regarding individuals in the military.

Death anxiety and PTSD

Past studies on death anxiety have not focused on the concept that death anxiety could be a predisposition for PTSD and have mentioned death anxiety as no more than just an unfortunate outcome from trauma [16]. Past theories suggested an elevated fear of death may be an important factor in the development of PTSD symptomatology. Reported elevated fear of death is shown during reported symptoms of PTSD, particularly in those who reported more time exposed to combat and more time served. For those in the military, awareness of death occurs more often than in civilians due to the nature of what they do. For the same reason, those with military experience are also more likely to be suffering from PTSD [25]. There is a suggested relationship in regards to the similarities between DSM criteria for PTSD and death anxiety. The relationship is important to note because past theories have suggested death anxiety is the result of traumatic experiences, such as those experienced by people in the military (Hoelterhoff & Chung, 2013) [15]. This study suspected the relationship between death anxiety and PTSD is further complicated when individuals are in the military and is not addressed with current treatments for PTSD.

Death anxiety and depression

Although not significant, this study found a positive relationship between death anxiety and depression. This is important to note as this study is only a preliminary study to encourage future studies on this topic. Death anxiety will often become more conscious and can become excessive in the face of death or death experiences. For soldiers, the most common form of this is exposure to war. For this study, the relationship shown between PTSD and depression provided confirmation of the connection between military experiences and reported depressive symptoms. Following Langs’ (2008) [13] theory, this may indicate a manifestation of death anxiety through reported symptoms of depression. For this study, people in the military acknowledged a positive relationship between death anxiety and depression but intensity may have been underplayed due to mental health stigma and the mindset of being in the military.

Death anxiety and generalized anxiety

There was a significant positive relationship found between death anxiety and generalized anxiety. Becker argued that when constantly faced with death, soldiers are better able to adapt to thoughts of their own mortality [10]. It is likely the severity of death anxiety is downplayed in the military culture. This is adaptive because it assists in survival during combat and other anxietyprovoking situations. People in the military likely rationalize or desensitize themselves to death anxiety as a protective instinct. It is hard to know the causality, but it is interesting to note that, in this study, people in the military who experienced high levels of combat also reported low levels of both anxiety and death anxiety. This speaks to a resiliency after combat and could explain why the participants in the current study do not report symptoms significant enough to be considered to be suffering from PTSD.

Death anxiety and distress

A significant relationship was found between death anxiety and the results from the death anxiety stress scales (DASS). Overall feelings of distress were analyzed to include individuals who reported distress but did not report specific depressive or anxious symptoms. This relationship is indicative of the participants in this study having past experiences, either in combat or other military events that have been defined as stressful to the individual. General symptoms of distress may be easier for people in the military to report because there is not as much of a stigma associated with distress as there is with PTSD, depression, and anxiety symptoms [25-28]. This significance could also be due to the chosen participants for this current study. In order to be eligible for this study, participants could not be currently receiving treatment for PTSD. This likely narrowed the participant pool to only include individuals who are not experiencing as much distress as an individual suffering from PTSD due to combat-related stress.

Affective military service

Length of time in the military or in combat seemingly has some bearing on the impact and depth of death anxiety. There was a significant negative correlation between death anxiety and amount of time served. Participants who were retired may have found a way to move on from their past, and are not as likely to report symptoms of death anxiety. As hypothesized, military individuals could become desensitized due to repeated exposure which could have led to lowered death anxiety. Further research would be needed to explore prolonged exposure and death anxiety.

Conclusions/Implications

Treatment protocols for PTSD have largely failed to assess and utilize the importance of death anxiety to help individuals overcome a traumatic experience [15]. Most treatments for PTSD that have recognized the importance of death anxiety tend to view death anxiety as a result of the trauma experienced and not a cause, despite the fact that an encounter with death or the threat of death is the primary DSM criterion of the PTSD diagnosis. Nonetheless, past theories have identified a strong correlation between death anxiety and trauma [1]. Without the development of more effective treatment strategies, the focus of treatment will always be on the immediate display of symptoms and not on the underlying issues such as death anxiety.

As indicated above, the results of this study were consistent with past research which found significant relationships between PTSD, depression, and anxiety. The depth of death anxiety as described in the literature review is not captured fully by the data. Rather, the literature describing death anxiety offered the idea of the relationship between death anxiety and PTSD with military populations. Consequently, this study shows signs of high validity. The correlations found between death anxiety and both anxiety and depression are important to note. Finally, the relationship found between death anxiety and PTSD agreed with past theories that suggested death anxiety is the root of all anxiety and that past experiences with death can lead to the development of PTSD. This preliminary study showed the importance of further study that is needed in order to better understand and treat the anxieties associated with traumatic stress.

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