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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Impact of COVID-19 on death anxiety in patients with anxiety spectrum disorders: A case–control study


1 Program Manager, Project Stree Manoraksha, NIMHANS, Central Institute of Psychiatry, Ranchi, Jharkhand, India
2 Assistant Professor, Department of Psychology, Central Institute of Psychiatry, Ranchi, Jharkhand, India
3 Associate Professor, Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
4 Professor - Director, Department of Psychiatry, Central Institute of Psychiatry, Ranchi, Jharkhand, India
5 Clinical tutor, Department of Psychology, Central Institute of Psychiatry, Ranchi, Jharkhand, India

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Date of Submission04-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication15-Apr-2022
 

  Abstract 


Background: COVID-19 pandemic has exacerbated symptoms in existing diagnosed cases of anxiety. Its impact on people with mental illness is expected to be significant, leading to an increase in relapse rates and expectedly inducing or exacerbating death anxiety.
Aims & Objectives: This study aimed to assess the impact of Covid 19 fear on general anxiety and wellbeing and death anxiety and compare people with anxiety spectrum disorders on perceived fear, autonomic anxiety symptoms, and death anxiety with those without these disorders.
Materials & Methods: We recruited 36 participants with anxiety spectrum disorder (generalized anxiety disorder (n=6), obsessive-compulsive disorder (n=17), panic disorder (n=5) and mixed anxiety and depression (n=8) and 36 individuals free from any psychiatric illness. Tools used include General Health Questionnaire, Fear of COVID-19 Scale, Perceived Stress Scale, Beck Anxiety Inventory and Multidimensional Fear of Death Scale.
Results: A statistically significant correlation was noted between many variables in both the study groups. The regression analysis showed a significant difference in general well-being and anxiety & death anxiety in the clinical group. Study outcomes indicated that the current pandemic has triggered significant fear and anxiety in anxiety patients and among healthy controls and has triggered significant death anxiety in the clinical and healthy control group.
Conclusion: The study showed that fear of covid-19 is a predictive factor for stress, death anxiety, and general well-being. These findings may be helpful to plan preventive measures, tailored intervention focusing on death anxiety and relapse plans effectively.

Keywords: Anxiety disorders, Covid 19, death anxiety, general well-being, perceived stress


How to cite this URL:
Chakraborty S, Sinha P, Pratap A, Das B, Kumar V. Impact of COVID-19 on death anxiety in patients with anxiety spectrum disorders: A case–control study. Arch Ment Health [Epub ahead of print] [cited 2022 Jun 26]. Available from: https://www.amhonline.org/preprintarticle.asp?id=343320





  Introduction Top


The world has been grappled as 2020 marked the beginning of the coronavirus disease (COVID-19), caused by the novel coronavirus SARS-CoV-2, which soon turned into a pandemic. Only when the situation was slightly seeing a positive trend, the world gets attacked by multiple mutants of the virus.[1] The pandemic, quarantine, and social distancing have led to a wide range of problems in people's mental health in general. It is expected to have precipitated feelings of fear, anger, anxiety, panic about the worst possible outcome, boredom and loneliness, guilt about not being there for family, and finally, grief for a significant loss.[2]

As the global health agencies struggle to find a solution for containment and prevention, and every media source stresses the importance of hygienic measures, its impact on mental health in the immediate or prolonged future is yet to be stressed and researched. Individuals who already have their doubts about hygiene and the compulsive need to stay clean (patients with the obsessive-compulsive disorder) or the ones who already experience breathlessness, tightening of the chest, choking feeling, or fear of death (patients with panic disorder) or the ones who have a generalized stream of anxiety are facing a renewed dilemma in the worsening situation.[3] Any anticipated attack of COVID-19 pandemic with mutant viruses, shortage of oxygen, hospital beds, lifesaving medicines, and any expected countrywide lockdown in coming days is likely to increase the new onset of anxiety spectrum disorders in the community and to cause exacerbation of symptoms in already diagnosed cases.[4],[5] Few studies indicate that people with anxiety symptoms or obsessive-compulsive disorder and panic disorder are experiencing a detrimental impact on mental health to a much greater extent than individuals without these mental health disorders since the COVID-19 pandemic onset.[6] However, on the contrary, some studies have provided data that there is no increase in anxiety symptoms during the pandemic.[7]

In general, humans have difficulty dealing with uncertainty, and COVID-19 has taken the uncertainty to a different level, causing an increased inability to tolerate the uncertainty and heightened catastrophic thinking.[8] Some studies have also explored the extent to which fear of disease and contagion with prevention and safety behaviors, such as handwashing and physical distancing, have impacted patients with OCD.[9],[10],[11]

Although it is natural for older adults to experience death anxiety, the COVID-19 pandemic has also exacerbated feelings of death anxiety in younger individuals.[12] Death anxiety is associated with adverse health consequences, such as decreased physical functions or psychological resilience, weakening of religious beliefs, life dissatisfaction, and poor immunity.[13] While many studies have explored death anxiety in older adults, studies exploring death anxiety experienced by younger people during the COVID-19 pandemic are sparse.

In this current study, we aimed to compare people with anxiety spectrum disorders on the perceived impact of the pandemic, perceived stress, physiological anxiety, and death anxiety with people without diagnosable levels of anxiety or the presence of any existing psychiatric disorders.


  Materials and Methods Top


Participants

We recruited 72 participants for the study. The first group consisted of 36 participants diagnosed with an anxiety spectrum disorder as per the International Classification of Diseases (ICD)-10 diagnostic criteria for research (DCR). These participants were taken from the outpatient, inpatient, and psychosocial unit of the institute in East India. A healthy control group of 36 individuals free from any significant physical or psychiatric illness was taken from the community. All the selected participants had a minimum of 5 years of formal education and were aged between 18 and 60 years. They belonged to both rural and urban residences. Our study was initiated after obtaining permission from the Institutional Ethics Committee. All the participants signed the informed consent form.

Procedure

The sociodemographic details of all the participants were recorded, along with additional clinical information about the patients. The sociodemographic details included gender, age, education, religion, residence, occupation, marital status, family type, and history of physical illness. ICD-10 DCR was used to diagnose mental health disorders and consisted of generalized anxiety disorder (6 cases), obsessive-compulsive disorder (17 cases), panic disorder (5 cases), and mixed anxiety and depression (8 cases). We used GHQ-12 to evaluate psychological state and measure general well-being. The seven-item Fear of COVID-19 Scale (FCV-19S) developed by Ahorsu et al.[14] was used to assess fear regarding COVID-19. The responses were recorded on a five-point Likert scale ranging from strongly disagree[1] to strongly agree.[5] The Perceived Stress Scale developed by Sheldon Cohen[15] was used to assess the degree to which situations in one's life are appraised as stressful in the given time. Beck Anxiety Inventory,[16] a 21-question multiple-choice self-report inventory, was used for measuring the severity of physiological anxiety. The Multidimensional Fear of Death Scale (MFODS),[17] a 42-item Likert scale, was used to measure fear of death through multiple domains. Each domain is represented with one of eight subscales: (a) fear of the dying process, (b) fear of the dead, (c) fear of being destroyed, (d) fear for significant others, (e) fear of the unknown, (f) fear of conscious death, (g) fear for the body after death, and (h) fear of premature death. Cronbach's alpha value ranging from 0.65 to 0.82 for eight subscales suggests MFODS as a reliable measure.

Data collected on the scales were then analyzed using IBM-Statistical Package for Social Sciences (SPSS), Version 25. Descriptive statistics in the form of numbers and percentages were calculated, and item mean scores and the overall mean score for the responses were calculated and compared based on demographic variables using a t-test for two groups. Pearson correlation analysis was done between the study variables for both groups. A multiple logistic regression analysis of fear levels with demographic variables was conducted, and 0.05 was considered the significance level.


  Results Top


No statistically significant difference was noted between the clinical (n = 36) and healthy control groups (n = 36) regarding age, gender, religion, residence, occupation, marital status, family type, and history of physical illness (t = −0.358, df = 70, P = 0.721) [Table 1]. However, we found a statistically significant difference between both the groups on education as the healthy control group had higher education levels.
Table 1: Comparison between sociodemographic variables between clinical group and healthy control group (n=72)

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Correlation analysis between outcome variables in both the groups suggested a statistically significant correlation between variables, and the highly correlated values were further analyzed using regression analysis [Table 2].
Table 2: Correlation between experimental variables in clinical and healthy control groups

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The logistic regression analysis results between experimental variables and factors are significantly associated with general well-being across the clinical and healthy control groups. There was a significant difference in the factor of general well-being and anxiety and death anxiety in the healthy control group (t = 1.621; P = 0.116 *R = 0.785, R2 = 0.617). In the clinical group, there was a significant difference between factors of general well-being and anxiety (t = − 0.201; P = 0.116; *R = 0.874, R2 = 0.764).


  Discussion Top


The present study was conducted on 36 patients with anxiety disorders and 36 healthy controls who were homogenous for all sociodemographic variables except the level of education. Pandemic is expected to develop anxiety and stress and impact mental health strongly, and the present study shows a similar finding. The study has found a significant correlation between perceived stress and anxiety and general well-being in the clinical and healthy control groups. Analysis of the psychometric properties of the Fear of COVID-19 Scale showed that the item “I am afraid of losing my life because of coronavirus-19” had the highest factor loading. This suggests that one's worry about one's own death is highly predictive of broad fears of the virus. There was a significant correlation between fear of COVID-19 and general well-being, death anxiety, and perceived stress in the clinical group. A negative correlation between multidimensional fear of death and general well-being in both groups indicates that death anxiety due to pandemics is strongly associated with a person's well-being. Fear of death is a central and universal part of the experience of being human, and there is evidence of humans experiencing death anxiety for as long as our species has recorded its history.[18] In the context of the current pandemic, death anxiety appears to be of extreme relevance. Fear of death may be related not only to anxiety related to the virus but also to play a causal role in the experience of psychological distress and eventually predict the incidence of various mental health conditions. Fears of death have also been argued to play a central role in various presentations of obsessive-compulsive disorder, as patients consciously try to prevent death by illness (in the contamination subtype), fire (in compulsive checking), and death to self or other due to acting on intrusive thoughts (as seen in aggressive obsessions).[19] One study conducted in Australia (n = 810) explored fears of death in the context of the pandemic. The findings revealed a significant positive correlation between death anxiety and anxious beliefs and behaviors related to COVID-19 (e.g., estimated likelihood of contracting the virus and estimated likelihood of wearing a mask in public). This was noted in addition to self-reported health anxiety and overall psychological distress.[20] Furthermore, participant responses showed a heightened perception and belief of a threat. For example, when participants were asked how likely they would die if they contracted COVID-19 in the next 18 months, the mean likelihood estimate was 22%, which is approximately 11 times more than the actual Australian fatality rate of <2%. Thus, death anxiety which may indeed be a natural fear and driving factor in everyday human behavior appears to be more relevant in the context of the current pandemic.

The results of logistic regression analysis [Table 3] showed that there was a significant difference in the factor of general well-being and death anxiety in the healthy control group (GHQ 12 total scores [general well-being], for control-constant B = 5.604, SD = 3.458, t = 1.621 [P = 0.116]. *R = 0.785, R2 = 0.617 [change statistical significance P = 0.000]). Studies have suggested that individuals under 40 years old have also exhibited more adverse psychological symptoms during the pandemic partly due to their caregiving role in families – financial and emotional support to children or the elderly.[21],[22] In addition to this, job loss, emotional distress due to school and college closures, cancellation of social events, lower study efficiency with remote online courses, postponements of examinations, work from home, and social isolation have also affected the younger cohorts.[23] In the clinical group, there was a significant difference between factors of general well-being and anxiety (clinical-constant B = −1.831, SD = 9.123, t = −0.201 [P = 0.116]. *R = 0.874, R2 = 0.764 [change statistical significance, P = 0.000]). Individuals with preexisting mental health diagnoses (anxiety spectrum) are already disadvantaged due to their intolerance of uncertainty and heightened catastrophic thinking. As a result, their general well-being is affected in unthinkable ways, which may be reflected in a person's experience of perceived stress, greater autonomic arousal, and fear of death.[4],[5],[8]
Table 3: Logistic regression analysis on factors significantly associated with general well-being across in clinical group and healthy control group (n=36 in each group)

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The current study found COVID-19 fear as a potential predictive factor for stress, death anxiety, and general well-being. This study effectively highlights the importance of addressing death anxiety as it is linked with the general well-being of people; however, the study has its limitations. The anxiety spectrum disorder was not equally represented, while some anxiety disorders were not included in the study. A differential analysis across the anxiety spectrum disorder could have been more conclusive.

However, the present situation has triggered and is maintaining a debilitating impact on general well-being and mental health and causing significant death anxiety among anxiety patients. Ignorance of the impact of the pandemic on patients with anxiety disorders will not only hinder any aims to prevent the further exacerbation of anxiety disorder diagnosis but will also augment already existing health inequalities and fail to serve a preventive role. Therefore, special attention should be given to the anxiety patients, and their treatment should be highly individualized when there is any indication of relapse or worsening of symptomatology linked to the intolerance of uncertainty, catastrophic thinking, and death fears.[4],[5]


  Conclusion Top


The study's findings are significant to help plan preventive intervention strategies for the general population to prevent a greater risk of mental health breakdown and increased incidence of psychological morbidity in the coming days. Additionally, the study also suggests that the existing intervention protocols for anxiety spectrum disorder may also need to be revised and uniquely target death anxiety for better treatment outcomes. The findings are not conclusive enough due to the small sample size but warrants deeper and more conscious investigation in this field.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Sampurna Chakraborty,
Project Manager, Project Stree Manoraksha, NIMHANS, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amh.amh_2_22




 
 
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