Elsevier

Psychiatry Research

Volume 245, 30 November 2016, Pages 379-386
Psychiatry Research

The link between death anxiety and post-traumatic symptomatology during terror: Direct links and possible moderators

https://doi.org/10.1016/j.psychres.2016.08.059Get rights and content

Highlights

  • Little is known about the link between death anxiety and PTSD symptomatology.

  • Death anxiety and symptomatology were examined following exposure to terror.

  • Death anxiety was a significant predictor of posttraumatic symptom severity.

  • Personality traits were found to moderate this association.

Abstract

The current wave of terrorism which is taking place in Israel is characterized by increased arbitrary attacks by individual terrorists, acting independently, with reduced ability to anticipate when and where the next attack will take place. This situation creates an atmosphere of fear and insecurity in the lives of many citizens. Accordingly, the current study aims to establish a connection between death anxiety and PTSD symptom severity, as well as to examine whether major personality characteristics may moderate this connection. Using an online survey, 429 adult participants were recruited, and filled out death anxiety and PTSD symptomatology scales, as well as a short version of the Big Five personality scale. Findings revealed that death anxiety was a significant predictor of posttraumatic symptom severity, as were personality characteristics. Moreover, two personality traits, emotional stability and conscientiousness, moderated the association between death anxiety and PTSD symptomatology. The importance of death anxiety as a factor which is associated with PTSD symptomatology is discussed.

Introduction

Early into the 21st century, the Second intifada (also known as the Al Aqsa Intifada) erupted in Israel. This period of conflict, lasting close to five years, introduced a new escalation in the regional conflict between Israelis and Palestinians, in which high numbers of civilians were repeatedly exposed to bombings and terror attacks. While the Intifada gradually subsided, Israel and its population has continued to be subjected to periodic terror attacks perpetrated in public places, most often in its towns and cities. A few months ago, however, at mid-September 2015, there was an additional escalation in the Israeli–Palestinian conflict that sprouted a wave of terror, different from the previous ones experienced in Israel. This particular wave of terror was not confined to a specific area within Israel (such as the West Bank or secluded settlements). Rather, it is more widespread, and is characterized by individual attacks (rather than planned attacks on behalf of terrorist organizations), which wreak havoc on Israelis' sense of security by acts of stabbing and premeditated car accidents. These attacks, in which terrorists deliberately run over civilians with motor vehicles, and assault them with knives and axes, occur almost on a daily basis. Moreover, due to the individualistic nature of these acts, there is virtually no ability to anticipate when and where the next attack will take place. Not surprisingly, this state of affairs creates an atmosphere of fear and insecurity in the lives of many Israelis, and daily life disruptions are experienced. According to Magen David Adom, the Israeli equivalent of the Red Cross, there have been (as of the beginning of March 2016) 372 terrorist attacks, which resulted in 34 casualties and 338 wounded individuals (www.mdais.org).

Studies conducted among immediate victims of national terror attacks, i.e., survivors, witnesses and close relatives of those who were killed during terror attacks, confirm that such individuals are at high risk for developing distress as a reaction to the traumatic event, as well as generalized fear and anxiety, repeated thoughts regarding the terror attack, depression and problems in daily functioning (Schuster et al., 2001, Thalji et al., 2002, Tracy et al., 2008, Johnson et al., 2009, Gelkopf et al., 2013, Ron and Shamai, 2014). Among the most investigated reaction is posttraumatic stress disorder (PTSD; Bleich et al., 2006, Hobfoll et al., 2008, Neria et al., 2008) which suggests heterogeneous trajectories of PTSD symptoms following a traumatic event. Common trajectories of PTSD symptoms include resistance or resilience (i.e. minimal to no symptoms over time); subsyndromal (i.e. mild to moderate symptoms over time); chronic (i.e. chronically elevated symptoms over time); delayed dysfunction (i.e. increasing symptoms over time); and recovery (i.e. declining symptoms over time) (e.g., Norris et al., 2009, deRoon-Cassini et al., 2010).

Numerous studies have evaluated risk factors for the development of posttraumatic symptomatology following single traumatic events (Brewin et al., 2000, Ozer et al., 2003, Rosenberg et al., 2008), or in the course of continuous traumatic exposure (e.g., Gelkopf et al., 2013). However, little is known regarding the role of death anxiety as a predictor of PTSD symptomatology in the face of national terrorism. Death anxiety and Terror Management Theory (TMT) The connection between death anxiety and PTSD symptomatology can be further understood through the prism of Terror Management Theory (TMT), one of the most influential theoretical approaches for understanding how individuals respond to the threat of death (Greenberg et al., 1986, Greenberg, 2012). According to TMT, humankind has created certain psychological mechanisms which are designed to ward off the awareness regarding mortality. These mechanisms, which include the attempt to validate one's cultural worldview and enhance personal self-esteem are thought to serve an important anxiety-buffering function in order to manage existential fear of death (Pyszczynski et al., 1999). However, as suggested by Maxfield et al. (2014), normal anxiety-buffering functions associated with TMT may be hindered by continuous exposure to trauma or to other powerful stressors. Moreover, the powerful link between personality structures and self-esteem (see review by Robins et al., 2001) may also indicate that certain personality structures may limit the individual's ability to enhance self-esteem when faced with continuous reminders of human mortality, and may consequently contribute to increased death anxiety and post-traumatic symptomatology.

Death anxiety appears to be a basic fear which may be a core element for a range of mental disorders, including hypochondriasis, panic disorder, and anxiety and depressive disorders (Iverach et al., 2014). Successful management of death anxiety seems to be necessary for effective human functioning, and scholars have long posited a link between mismanaged death anxiety and psychological disorders. For example, Noyes et al. (2002) investigated the link between death anxiety and hypochondriasis among a group of general medical outpatients, and found death anxiety to be highly correlated with hypochondriac symptoms. Death anxiety has also been associated with higher levels of depression among patients with depressive disorder (Ongider and Eyuboglu, 2013), and according to Randall's (2001) case study, fear of death may be the presenting issue for many panic disorder patients. Likewise, death anxiety might play a role in the development and maintenance of PTSD, since exposure to life-threatening events is thought to increase death anxiety, which in turn, may lead to the development of PTSD symptoms and increased death anxiety (Cheung et al., 2005). It has also been argued that PTSD may involve a disruption in the anxiety buffering mechanisms that usually protect individuals against anxiety (Kesebir et al., 2011, Maxfield et al., 2014). According to the anxiety buffer disruption theory (ABDT; Pyszczynski and Kesebir, 2011), PTSD results from a disruption in one's anxiety-buffering mechanisms, which normally provide protection against anxiety in general and death anxiety in particular. The disruption of these mechanisms leaves the individual defenseless in the face of overwhelming anxiety, which leads to the major symptom clusters of PTSD: re-experiencing, hyper-arousal, and avoidance. Nevertheless, while the link between fear for one's life and the severity of posttraumatic manifestations seems plausible, if not likely, only a handful of studies examined death anxiety as a predictor of posttraumatic symptomatology concerning terror acts. More specifically, the disruption of anxiety buffering responses found to be associated with increased PTSD symptom severity in specific populations such as earthquake survivors (Abdollahi et al., 2011), HIV patients (Gershuny and Hendriksen, 2003; Safren et al., 2003), veterans and civilians with spinal cord injuries (Martz, 2004), university students who reported experiencing a past traumatic event (Hoelterhoff and Chung, 2013), technological disasters (Chung et al., 2000, Chung et al., 2002) and victims of domestic violence (Kesebir et al., 2011). However, in cases of armed conflicts or terrorism, we found only a few studies pertaining to the associations between death anxiety and PTSD symptoms (Chatard et al., 2012, Ron, 2015). In one such research, Chatard et al. (2012) investigated the anxiety buffering function among individuals with PTSD following a civil war in Africa. Their findings indicated a link between PTSD and death-related cognitions, as individuals with high PTSD symptoms reported increased immediate death-related thought accessibility following mortality salience induction, whereas individuals with low PTSD symptoms showed suppression of priming effects following mortality salience induction. In addition, mortality salience resulted in increased trauma symptoms for individuals with high exposure to the war, but not for those with low exposure. In another study, Ron (2015) examined Philippine migrant workers in Israel, who were exposed to various military operations while they were employed as caregivers for older adults in Israel. Results revealed that death anxiety added 40.4% to the explained variance of the PTSD levels. While this finding is relevant and important, it should be noted that migrant workers may experience ongoing military operations quite differently from Israeli citizens, whose whole lives and families are based in Israel, and do not have the option of relocating, either within Israel or abroad.

Advances in the field of personality have put more emphasis on the interface between personality and psychopathology, including PTSD (Jakšić et al., 2012). It is assumed that there are individual differences in personality structure regarding vulnerability or resilience to mental distress, or post-traumatic symptoms in the current context. Accordingly, several studies examined the relationship between PTSD symptoms and personality traits regarding the Five-factor model of personality: extraversion, emotional stability, agreeableness, conscientiousness and openness to experience (Costa and McCrae, 1992). For example, in a prospective study, Lawrence and Fauerbach (2003) found that emotional stability was the most important personality dimension in predicting PTSD. Additionally, other researchers have indicated that low emotional stability contributes to one's vulnerability to PTSD symptoms (Jakšić et al., 2012, Knezevic et al., 2005, Perrin et al., 2014, Guo et al., 2015), whereas the remaining four of the Big Five personality dimensions – agreeableness, conscientiousness openness and extraversion – yield inconsistent results, which may be due to differences in the instruments used to assess personality (Knezevic et al., 2005). Nevertheless, Jakšić et al. (2012) found that PTSD symptoms were negatively associated with extraversion and conscientiousness, although other studies failed in reporting on such link (e. g., Chung et al., 2007).

An additional issue which merits examination is the possibility that personality factors may provide a moderating effect on the connection between death anxiety and post-traumatic symptomatology. According to Conservation of Resource Theory (COR; Hobfoll and Lilly, 1993) an individual who has experienced resource loss because of trauma, might became vulnerable to further loss due to difficulties in restoring the ones that are lost. Accordingly, it is possible that personality traits like emotional stability will became part of those difficulties. In light of this, we cannot rule out that due to the documented linkage between emotional stability and PTSD, personal traits may found to be moderators regarding the connection between death anxiety and PTSD symptomatology.

In light of the aforementioned literature exploring the relationship between death anxiety and mental disorders/symptoms, the aims of this study were threefold: First, to assess whether death anxiety may predict the development of PTSD symptomatology following continuous traumatic exposure to terrorism; Second, to examine the relationship between the Big Five personality traits and PTSD symptomatology and, Third: to evaluate whether the Big Five personality traits moderate the link between death anxiety and PTSD symptomatology. The following hypotheses were posited: (H1) death anxiety will found to be a significant positive predictor of PTSD symptomatology, (H2) In line with the consistent connection between emotional stability and PTSD, reduced emotional stability will be associated with increased PTSD symptomatology and, (H3) personality traits would moderate the link between death anxiety and PTSD symptomatology. More specifically, in line with previous findings which delineate the importance of emotional stability in reduced symptomatology, we expected to find a more pronounced connection between death anxiety and PTSD symptomatology among individuals with low levels of emotional stability.

Section snippets

Procedure and sample

The study was conducted amidst a terror wave in Israel (2.11.15–10.11.15), and aimed at procuring a convenience sample of adult Jewish Israelis. We used an online survey, which was advertised through various means such as social media (mainly Facebook) and smartphone applications (e.g., Whatsapp). The link led to a designated site where participants provided informed consent. The survey was anonymous and no personal information could be identified. The cohort consisted of 429 participants,

Results

As can be seen in Table 1, significant correlations were found between PTSD symptomatology and death anxiety, r(429)=0.45, p<0.001, as well as between symptomatology and both conscientiousness, r(429)=0.11, p<0.05), and emotional stability, r(429)=−0.33, p<0.001.

In accordance with the first hypothesis, the hierarchical regression demonstrated that high death anxiety was a significant predictor for increased symptom severity (B=0.23, β=0.32, t=6.72, p<0.001). Moreover, in line with the second

Discussion

In line with the first hypothesis, death anxiety was a significant predictor of posttraumatic symptom severity. Additionally, in accordance with the second hypothesis PTSD symptomatology was predicted by reduced emotional ability and additional main effects were found for increased agreeableness and reduced openness. With regards to the third hypothesis, personality traits contributed to the explained variance of PTSD symptomatology and were found to moderate the association between death

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