Death Anxiety and Suicidal Behavior

In Joiner’s Interpersonal Theory of Suicide, those who are planning to die by suicide have to overcome their fear of death in addition to acquiring the capacity for self-harm. The present study sought to examine this proposal in a sample of 1,145 university students in China. Those who had planned to dye by suicide in the past had less death anxiety than non-suicidal students and those who had suicidal ideation or made attempts at suicide in the past. The implications of this result were discussed.

There has been interest in whether those who are suicidal have a reduced fear of death or lower death anxiety than non-suicidal people. In a recent review of research on this topic, Sims MA, et al. [1] found only four studies to include in their meta-analysis of the research, and only one study in the 21st century. They concluded that there was a weak association between death anxiety and suicidal intent, and they said that it was imperative that more research is carried out on this topic. The one study that they identified on the topic after the year 2000 was by Bonnewyn A, et al. [2] on a sample of elderly hospitalized patients. Bronnewyn A, et al. [2] found that both religiousness and death attitudes predicted suicidal ideation in these patients. In particular, the fear of death subscale in the measure of death attitudes predicted suicidal ideation in a multiple logistic regression.

In older research on this topic, Goldney RD [3] compared 103 young adult women who had attempted suicide with nonsuicidal women and found no differences in death anxiety. For the attempted suicides, higher current suicidal intent was associated with less death anxiety. Tarter RE, et al. [4] found no differences in death anxiety and the lethality of suicide attempts in 50 attempted suicides, nor between first-time attempters and multiple attempters. In contrast, D’Attilio JP, et al. [5] studied 62 adolescents aged 16-20 found that higher death anxiety was associated with higher scores on a suicide probability scale. There may be sex differences in these associations. In a sample of Iranian university students, Naderi F, et al. [6] found that the men had higher scores on a measure of suicidal ideation along with lower scores on a measure of death anxiety. However, the researchers did not correlate scores on these two measures.

Death anxiety is theoretically associated with past and current suicidal behavior in Joiner’s TE, et al. [7]. Interpersonal Theory of Suicide. This theory proposes that the occurrence of suicide depends on two psychological dimensions: thwarted belongingness and perceived burdensomeness. Those who think that they are a burden to their significant others and also have their interpersonal relationships disrupted are more likely to contemplate, plan and attempt suicide, even successfully. However, a third factor must be present, the acquired capability to engage in self-harm. This capability is dependent on previous experiences of pain and risk-taking and also a reduced fear of death, and Joiner and his colleagues devised a scale to measure this reduced Fear of Death (ACSS-FAD).

This scale has produced mixed results for its reliability and validity. In a sample of undergraduate students, Rimkeviciene J, et al. [8] found that the 7 items of the ACSS-FAD scale did not fit a one-factor model, nor did the scores differentiate between students who had a history of attempted suicide and those who did not, although it did differentiate those with and without a history of non-suicidal self-harm. In samples of undergraduates, Ribeiro JD, et al. [9] found that the seven items “largely” fitted a one factor model, and the reliability was “adequate to good.” However, scores were not associated with current suicidal ideation.

In a sample of military veterans, Gutierrez PM, et al. [10] used a 5-item version of the ACSS-FAD and found that only 4 items loaded on one factor. The internal consistency of the scale was good (omega = 0.74), but scores did not differentiate between veterans who had attempted suicide and those who had not. Wachtel S, et al. [11] also used a 5-item version of the ACSS-FAD and found that 4 of the items loaded on one factor, but the Cronbach alpha was excellent (0.90).

Almost all of the research on death anxiety and suicidal behavior has been conducted on Western samples, and one purpose of the present study was to examine this association in respondents who are resident in mainland China. Because of the importance of Joiner’s theory of suicide, the present study used his 7-item version of the ACSS-FAD was used, even though better scales to measure the fear of death may exist, as well as a validated measure of suicidality (the SBQ-R).

Participants

The participants were 1,145 students at Shandong University in Shandong, Jinan Province, China. The mean age of the students was 20.2 (SD = 1.1; range 18-24), and 51.3% were female.

Measures

ACSS-FAD: The ACSS-FAD (Ribeiro JD, et al. 2014) has seven items assessing anxiety about dying and death, answered on a scale ranging from not at all like me (0) to very much like me (4). A typical item is “I am very much afraid to die.” For the present sample, Cronbach alpha was 0.51, and item-total correlations ranged from 0.54 to 0.75. Examination of the items using a Principal Components factor analysis and a Varimax rotation identified two factors, one with 4 items reflecting no death anxiety and one with 3 items reflecting death anxiety (Table 1). The Cronbach alphas for these two sets of items were 0.75 and 0.77, respectively, better than the total ACSS-FAD score. Accordingly, the data analysis examined correlations for the total ACSS score and for the two separate scores based on these two sets of items.

SBQ-R: The Suicide Behaviors Questionnaire-Revised [12] consists of four items assessing prior suicidal behavior (ideation, threat, planning and attempt), recent suicidal ideation (in past year), prior communication of suicidal intent to others, and estimate of the likelihood of a future suicide attempt. Each item has 5-7 response options. Osman, et al. reported excellent reliability and validity for the total score on the SBQ-R. Cronbach alpha for the present sample was 0.76, and item-total correlations ranged from 0.63 to 0.89.

DASS-21: The Depression Anxiety Stress Scales, short version (DASS-21) consists of 21 items measuring depression, anxiety and stress, scored ranging from did not apply to at all (0) to applied to me very much or most of the time (3). Szabó M. [13] reported excellent reliability and validity for the three scales. For the present sample, the Cronbach alphas were depression (0.87), anxiety (0.84) and stress (0.86).

The mean scores for the scales are shown in table 2.

The data were collected from enrolled students from November 2017 to April 2018. Stratified cluster sampling was used to obtain students from a variety of departments and year of study/ Classes from each cluster (department-by-year) were then randomly selected. All students in the classes chosen were briefed about the purpose of the study which took about 30 minutes to complete (12 scales with 210 items). Participants were informed that they could stop their participation at any time if they desired, and information on crisis hotlines was provided in the questionnaire. No reward was offered for participation, which was voluntary and with anonymity. Students were given the paper-and-pencil questionnaire to complete in class.

Approval for the study was given by the university’s institutional Research Board.

Question 2 on the SBQ asks about suicidal ideation in the past year. Recent suicidal ideation was positively correlated with the total ACSS score (Pearson r = 0.084, two-tailed p < 0.01) and with scores on the four items measuring low death anxiety (r = 0.122, p < .001), but not with scores on the three items measuring high death anxiety (r = -0.002, ns). A history of recent suicidal ideation was, therefore, weakly associated with less death anxiety. The significant associations remained statistically significant after controlling for DASS anxiety using partial correlation coefficients (partial r’s = 0.120 and 0.152, p < .001). In a backward linear regression to predict recent suicidal ideation, both death anxiety and depression (along with sex) were significant predictors (p < .001): low death anxiety (beta = 0.131), depression (beta = 0.275), and sex (beta = 0.084), with a multiple = 0.305.

Question 1 on the SBQ asks whether the person has thought about suicide, planned suicide, attempted suicide or never been suicidal in the past. The results are shown in table 3. It can be seen that those who have attempted suicide and those who have never been suicidal have the highest scores for death anxiety. Those who have planned suicide but not carried out their plan had the least death anxiety.

The results of the present study indicate that the ACSS-FAD requires modification. As in other fear of death scales, the inclusion of items worded positively and negatively reduces the internal consistency of the scale. The reliabilities of the two subscales (for the positively worded and negatively worded items separately) were higher than that for the 7-items scale as a whole, despite the smaller number of items in each subscale. However, the results also indicate that the ACSS-FAD scale can be used in a Chinese population.

The results of the present study lend some support to Joiner’s [7] Interpersonal Theory of Suicide which proposes that a reduced fear of death is critical in the decision to die by suicide. Since this theory cannot be tested on those who die by suicide, the scales to measure the variables in Joiner’s theory have to be given to those with suicidal ideation, who have planned suicide or who have attempted suicide. In the present study, the results indicated that students with a history of suicidal ideation and attempts had higher death anxiety scores than those who had planned suicide (but not yet attempted suicide). It appears that, in the planning stage for suicidal behavior, individuals may suppress their normal death anxiety. However, after attempting suicide (but surviving), the death anxiety returns to the level found in nonsuicidal students. Since the association of death anxiety and planning suicide has not been examined in previous research, this association needs to be examined in new samples, both clinical and non-clinical.

Since the fear of death is an important variable in suicidal individuals, those counseling suicidal individuals should consider how death attitudes are relevant to their client, as well as the other variables in Joiner’s theory (thwarted belongingness, perceived burdensomeness and the acquired capacity for self-harm). The administration of scales to assess death attitudes is not necessary, but this variable can be brought out for discussion during the counseling sessions.

The present study had several limitations. There were very few students who had a history of attempted suicide (only 23 out of 1,145:2.0%), but 328 (29%) of the students reported suicidal ideation, a much larger proportion. The sample was a non-clinical sample, limited in age and educational status. More research is needed using individuals whose suicidal behavior is more recent and who have made suicide attempts. The study was also limited by the lack of homogeneity in the death anxiety scale, and the results should be replicated using a death anxiety scale with better psychometric properties and more previous research on its validity, such as Templer’s Death Anxiety Scale [14] or the Collett-Lester Fear of Death Scale [15]. Incidentally, Lester found that negatively worded items in the Collett-Lester Fear of Death Scale impaired the internal consistency of the scale, and the final version had items all keyed (scored) in the same direction (indicating a great fear of death and dying).

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