Death Anxiety and Obsessional Death among University Palestinian Students

Aim: The aim of this study was to determine the perception and relationship between death anxiety and death obsession among Palestinians university students. The sample consisted of 216 Palestinian university students enrolled in two universities in Gaza Strip (Al-Al-Azhar and Islamic University of Gaza) and one university in West Bank (Al Quds university of Jerusalem). Eighty-seven of the students (40.3%) were males and 129 (59.7%) were females. Age ranged from 17 to 30 years. Mean age was 20.4 years (SD=1.8). The researcher used three questionnaires; a predesigned sociodemographic sheet, death anxiety, obsessive about death scale. The study showed that mean death anxiety score was 60.39. The study showed that female student, and those live in Gaza Strip reported more death anxiety. Mean scores on the death obsession was more in students from Gaza. Mean scores of death dominance, death idea repetition, and death ruminations were higher in female’s students than males. There was a positive association between death anxiety and death obsession, death dominance, death idea repetition, and death ruminations. Clinical implications: Our findings that university students had high scores of death anxiety, and obsessive anxiety could be the continuous conflict in the area and repeated exposure to war trauma in the area. Such findings highlight the need for establishing counselling centers in the universities to help students on overcoming their death anxiety and obsession. Also, there is needed for training courses for students in causes and ways of intervention with such problems. *Corresponding author: Abdelaziz M Thabet, Emeritus Professor of Psychiatry, School of PublicConsultant Psychiatrist at Child and Family Training and Counseling Center, Al-Quds University, Gaza, Palestine, Tel: + 00970599604400; E-mail: abdelazizt@hotmail.com Received: January 03, 2018; Accepted: January 10, 2018; Published: January 17, 2018 Citation: Thabet AM, Abdalla T (2018) Death Anxiety and Obsessional Death among University Palestinian Students. Clin Exp Psychol 4: 178. doi: 10.4172/24712701.1000178 Copyright: © 2018 Thabet AM, et al. This is an open-access article distributed under he terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
In this study we used the Tomer and Eliason's [1] definition death anxiety, they defined death anxiety as a negative emotional reaction provoked by the anticipation of a state in which the self does not exist" (p. 4). Others included in the "anticipation" is dying, which is considered to be part of death anxiety [2]. Templer [3] approached death anxiety as a subjective painful experience common to everyone and originally developed the 15-item self-report Death Anxiety Scale (DAS), which has been widely used and was translated to variety of languages. Abdel-Khalek et al. [4] in study sample of (N =601) of Palestinians living in the city of Beit Jala, the village of Al-Khader, and the Aida refugee camp in the Bethlehem area. They live in war conditions; the houses of half of them have been demolished. They showed tha Palestinian men and women attained significantly lower DOS mean scores than participants from 4 Arab countries: Egypt, Kuwait, Syria, and Lebanon in 7 out of 8 comparisons. However, Palestinian women had significantly higher DOS mean score than their Spanish, American and British counterparts, whereas Palestinian men had significantly higher mean DOS score than Spanish peers. Such findings were congruent with previous investigations on Kuwaiti and Lebanese participants, but contradicted the non-significant gender differences on the death obsession among Egyptian [5], Syrian [6], American [7], samples. Another review of articles concluded that the most previous studies reported gender differences, with women consistently reporting greater death anxiety than men. Similarly, Kirshenbaum [8] reported higher self-reported death anxiety for women than men. Moreover, Abdel-Khalek [9] reported that female students obtained significantly high scores for the following three items of the scale: fear of hell and doomsday, fear of vague and unknown issues, and torture of the grave. Moreover, Iverach et al. [10] have recently proposed that the dread of death should be viewed as a transdiagnostic construct with the potential to underpin a range of mental disorders. Another study showed that female nurses achieved significantly higher scores on only two items of the scale, particularly, grieving over what they would leave behind (wealth and valuables) and over the loss of self or identity, than female non-nurses Dadfar et al. [11]. Furthermore Asadpour et al. [12] found that the occurrence of death fear was significantly high in the young female nurses in Iran with low work experience, no experience in the intensive care unit (ICU) ward, and no history of death education.
Similarly, Dadfar et al. [13] in study a total of 106 Iranian volunteer nurses were selected from different wards of two hospitals in Tehran, Iran revealed that the mean score of reasons for fear of death among nurses was moderately high. The means for 15 items of the RDFS (0.83%) were above midpoint, i.e., 3.
Another component of death distress is death obsession [5], which he defined it as ''repetitive thoughts or ruminations, persistent ideas, or intrusive images that are centered around death of the self or significant others'' (p. 160). At the extreme pole of the death obsession continuum, the individuals become obsessed with the notion of death. The Death Obsessive Scale (DOS) was developed by Abdel-Khalek [5] as a measure of the third element of the triadic death distress construct that encompasses death anxiety and death depression [14][15][16]. The factorial structure of the DOS has since been determined in a number of studies using different samples in diverse milieus. All the studies used exploratory factor analysis (EFA), and did so using either principal component (PCA) or principal axis (PA) factoring. Most followed that by oblique rotation of the factors, based on the assumption that the DOS measures a single characteristic, and therefore, its factors are correlated. Finally, a three-factor model was obtained by Abdel Khalek [5] among Egyptian students, Abdel-Khalek et al. [4] among Palestinian refugees [17] using Spanish students, and Mashegoane and Moripe [18] among African students. Only two studies [18] obtained common factors (Death Rumination, Death Dominance and Death Idea Repetition), with completely matching item loadings. Maltby and Day [15] stated that Abdel-Khalek's "Death Obsession Scale was developed to complement research areas, which have investigated death anxiety and death depression and is thought to provide a third element (of which death anxiety and death depression are the other two) to a general concept of death distress" (p. 696).
The relationship between death obsession and anxiety, and other indicators of worry, rumination, and distress from a central personality trait perspective of anxiety or neuroticism. Among seven Egyptian samples, scores on death obsession were significantly higher in anxiety disorder patients than the other clinical groups [9]. Abdel-Khalek [9] in seven Egyptian samples, found that scores on death obsession were significantly higher in anxiety disorder patients than the other clinical groups. Similarly, Maltby and Day [16] used the DOS with two U.K. samples and found statistically significant positive relationships between death obsession and anxiety, depression, and neuroticism. Among American and Arabic undergraduates, death obsession shared a statistically significant positive correlation with anxiety, obsessioncompulsion and ego-grasping orientation, and suicidal ideation [7]. Furthermore, in study South African university students Mashegoane and Moripe [18] compared male and female students' DOS average scores to determine if there were any significant differences. It turned out that there were score differences, with female students scoring comparatively higher mean values on nine of the Death Obsessive Scale items.
Another study found contradictory findings, in study aimed to establish and explore the relationship between gender differences and death obsession to understand increasing suicide statistics, and discuss the impact of marital status, religion and political instability found in Pakistan on death obsession. A convenience sample of 125 participants was selected and Death Obsession Scale (DOS) was administered [5]. The results found significant gender differences in death obsession, with males obtaining a higher mean score (t= -1.625, p<0.019, M=0.47) than females (M=0.39) [19]. Others, Menzies et al. [20] have argued that death anxiety plays a central role in many presentations of Obsessive Compulsive Disorder (OCD), the most prevalent forms of which are dominated by washing and checking behaviors, respectively. Menzies and Dar-Nimrod [21] in study of the relationships between death anxiety and a variety of markers of psychopathology in 171 treatment-seeking participants with Obsessive Compulsive Disorder. Moderate to large correlations between Collett-Lester Fear of Death scale scores, taken at initial assessment, and clinical ratings of OCD severity, number of hospitalizations, number of medications, and total number of lifetime anxiety-related diagnoses identified in structured diagnostic interviews were obtained.
To the best of our knowledge, no research has empirically examined the perception of death anxiety and death obsessive and the relationship between them in Palestinian students to date. Thus, given suggestive evidence of the role of death-related fears in death obsessive we conducted this to address this important area of research in relation to this problem. The first aim of the study was we explored the prevalence of death anxiety and death obsession. The second aim was to find the relationship between death anxiety and death obsession. In the third aim we investigated the socio demographic variables differences in both death anxiety and obsession among Palestinians university students.

Participants
The study sample selected was 216 Palestinian university students enrolled in to two universities in Gaza Strip (Al-Al-Azhar and Islamic University of Gaza) and one university from West Bank (Al Quds university of Jerusalem). Eighty-seven of the participants (40.3%) were males and 129 (59.7%) were females.

Measures A predesigned socio-demographic sheet
This questionnaire included; gender, age, name of the university, place of residence, and marital status.

The Arabic scale of death anxiety (ASDA)
The ASDA [14] consists of 20 statements. The scale used a five-point response format, particularly, (1) strongly disagree, (2) disagree, (3) neutral, (4) agree and (5) strongly agree. The score can range from 20 to 100 Alpha reliabilities ranged from 0.88 to 0.93, and item-remainder correlations ranged between 0.27 and 0.74; the 1-week test-retest reliability was 0.90, denoting high internal consistency and temporal stability. In this study the internal consistency using Chronbach's alpha was 0.90 and split half was 0.84

Data collection procedures
The researcher implemented structured questionnaires to collect data directly from universities students. The permission was received from the three universities mentioned before. The researcher collected data by trained field workers through coordinated the public relation offices, to the students in the three universities. The students were interviewed in classroom settings in two weeks period in the second semester of the Academic year 2004/2005.

Statistical analysis
Data analyses were performed using SPSS Version 20 (SPSS, Inc. Chicago, United States). The frequencies of categorical data are presented. Differences in mean scores for death anxiety and death obsession and socio demographic variables were tested using independent t test for two groups and One-way ANOVA for more than three groups. The relationship between death anxiety and death obsession was investigated using the Pearson correlation test. The level of significance was set at p<0.05.

Socio-demographic of the study sample
The results showed that 216 Palestinian university students enrolled in two universities in Gaza Strip (Al-Al-Azhar and Islamic University) and one university from West Bank (Al Quds university of Jerusalem) had been interviewed. Eighty-seven of them (40.3%) were males and 129 (59.7%) were females. Age ranged from 17 to 30 years, mean age was 20.4 years (SD=1.8) ( Table 1).

Frequency of death anxiety
The results showed that 59.5% said they had fears of the torture in their grave, 51.9% said they had fears of having cancer, 50.5% said they are worried that death will take someone they love. While the least common items were: Walking in cemetery frightening them (11%), upset when seeing funnel (10.4%), and afraid visiting the cemetery (9.1%) ( Table 2).

Means and standard deviation of death anxiety
The study showed that mean death anxiety scores was 60.39 (SD=17.57).

Sociodemographic differences in death anxiety:
The results showed that mean death anxiety in male students was 37.4 (SD=20) compared to female mean=44.9 (SD=18.5). Female students significantly reported more death anxiety than male students (t (216)=-3.82, p=0.001). Regard place of residence, the results showed that death anxiety in students from Gaza Strip was 62.9 (SD=16.73) compared to 58.10 (SD=18.06) from West Bank. There were statistically significant differences in death anxiety toward students from Gaza Strip (t (214)=2.04, p=0.04). Regard to university, One Way ANOVA tests using Tukey post hoc test showed that students from Al Azhar university had significantly more than the other two universities (Islamic and AL Quds university) in total scores of death anxiety (F(213/2)=11.14, p<0.001).

Frequency of death obsession
The results showed that students commonly reported the following: 45.4% said some questions about death come to their mind which they were unable to answer, 44.5% had a feeling that he will die suddenly, 36.61% were compelled to think about death, 33.4% recalled alarming and painful aspects of death (Table 3).

Means and standard deviation of death obsession scale (DOS)
Total scores on the DOS was 38.09 (SD=16.24).
Regard site of the study, the results showed that death obsession in students from Gaza Strip was 37.54 (SD=14.49) compared to 38.59 (SD

Relationships between death anxiety and the death obsession
Pearson's Correlation Coefficient was used to study the relationship between death anxiety and the death obsession. The results showed that there was a positive association between death anxiety and the death obsession (r=0.48, p>0.001), death dominance (r=0.45, p>0.001), death idea repetition (r=0.62, p>0.001), and death ruminations (r=0.43 p>0.001) ( Table 5).

Discussion
Our study aimed to determine the perception and relationship between death anxiety and death obsession among Palestinians university students The study showed that mean death anxiety score was 60.39 (SD=17.57). Our findings of rate of death anxiety were higher than found in Iranian nurses (mean total score was (57.51 ± 14.15) [13]. Our study showed that mean death anxiety in males was 37.4 compared to female mean=44.9. Gender differences in death anxiety was toward female students. Such gender differences findings were consistent with study of Abdel-Khalek [22] who reported that Egyptian female students obtained significantly high scores for the following three items of the scale: fear of hell and doomsday, fear of vague and unknown issues, and torture of the grave. Also, Abdel-Khalek [9], in study of Kuwaiti sample of undergraduates (N =215), showed that females had significant tendency to attain higher mean scores on death anxiety, death depression, general anxiety, and general depression in comparison to their male counterparts. Similarly, the study of Iranian older adults found that Iranian women older adults showed higher death distress than men older adults. Tomas-Sabado and Gomez-Benito [23] reported death anxiety and death depression is related together, but they are distinct aspects of human reactions to the death phenomenon. Moreover, in study of a sample of 2,978 undergraduates took part in the study. Four samples from Arab countries were recruited: Egypt (n=418), Kuwait (n=509), Syria (n=709) [24][25][26][27][28][29] along with three samples from Western countries: Spain (n=659), the United Kingdom (n=205), and the United States (n=232). All the Arab samples had significantly higher mean scores than their Western peers. The effect sizes ranged from small (Lebanon, Spain; Syria, Spain and the United Kingdom) to large effect size (Egypt and Kuwait vs. Spain, the United Kingdom and the United States) [29].
Our study findings were consistent with study of Asadpour et al. [12] which showed that the occurrence of death fear was significantly high in the young female nurses with low work experience, no experience in the intensive care unit (ICU) ward, and no history of death education. Death escape scores were significantly high among the subjects aged 31-35 years. Women with higher education, older than 46 years, and have over 20 years of work experience have a superior approach toward death. Thus, these researchers concluded that their findings could be attributed to religious beliefs and looking at death from a bridge to the afterlife. Similarly, Ayyad [30] found that the nurses who deal with critical cases and work in high-stress wards, such as the ICU, obtained higher mean scores on death distress than the nurses who work in low-stress wards, such as the internal medicine department. Similarly, Thabet et al. [31] in study of Palestinians in Gaza Strip showed that mean death anxiety in males was 37.4 compared to female mean=44.9. Another study showed that female nurses achieved significantly higher scores on only two items of the scale, particularly, grieving over what they would leave behind (wealth and valuables) and over the loss of self or identity, than female non-nurses. Moreover, Abdel-Khalek [9] reported that female students obtained significantly high scores for the following three items of the scale: fear of hell and doomsday, fear of   vague and unknown issues, and torture of the grave. Abdel-Khalek [27] in study of a sample of 245 volunteer Kuwaiti college students, found gender differences on love of life were not significant. However, women had significantly higher mean scores for the four death distress scales than did their male counterparts.
The study showed that total scores on the DOS were 38.09. Abdel-Khalk et al. [4] in study of Palestinian residents of the West Bank showed that death obsession was lower in total sample and were significantly higher in women (M=28.7) than men (M=23.3). Our findings of mean of Death Obsession were higher than finding of death obsession among Kuwait (n=271) and United Kingdom sample (n=205) (Mean=30.75 vs. 26.40) [28]. Moreover, our findings of mean of death obsession were higher than found in Iranian nurses (mean total score was=30.74) [32,33]. Gender differences in total DOS and all subscales (death dominance, death idea repetition, and death ruminations) were higher in female students than males. Our findings of gender differences were consistent with study of 1,853 volunteer undergraduates from four Arab countries (Egypt, Kuwait, Lebanon, and Syria) with 791 from three Western countries, i.e., Britain, Spain, and the USA. Comparable Arabic, Spanish, and English versions of the Death Obsession showed that all women samples had higher mean scores than men in the same country, except the British sample; means are nearly identical. The only statistically significant sex differences were found in the Kuwaiti and Lebanese samples. The least difference between men and women was noted for the Syrian sample.

Clinical Implications
Our findings that university students had high scores of death anxiety, and obsessive anxiety could be the continuous conflict in the area and repeated exposure to war trauma in the area. This study can be generalized on to the current study where Palestine is at constant risk and death-thought primes are easily accessible in the environment in terms of continuous bombardment, sudden violent Israelis strikes, and other political violence faced by people of Palestine on a daily basis.

Conclusion
In conclusion, the current study emphasizes the importance of meaning in life and to accept the inevitability of death as a reality. Therefore, to have a holistic life it becomes imperative to accept ones mortality and by doing so achieving an authentic and self-fulfilling life. This death acceptance can be achieved by having healthier religious views, increasing companionship and intimacy -thus, providing meaning to life even in adverse conditions. Such findings highlight the need for establishing counselling centers in the universities to help students on overcoming their death anxiety and obsession. Also, there is needed for training courses for students in causes and ways of intervention with such problems.