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Ethics code: IR.IAU.YASOOJ.REC.1402.005
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Received: 2025/01/11 | Accepted: 2025/02/23 | Published: 2025/02/28
Received: 2025/01/11 | Accepted: 2025/02/23 | Published: 2025/02/28
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Zarei Z, Maredpour A, Kharamin S. Effect of Dialectical Behavior Therapy on Death Anxiety in Patients with HIV. 3 2025; 6 (1) :17-23
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1- Department of Psychology, Yasuj Branch, Islamic Azad University, Yasuj, Iran
2- Department of Psychology, Faculty of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
2- Department of Psychology, Faculty of Medicine, Yasuj University of Medical Sciences, Yasuj, Iran
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Introduction
Immunodeficiency is one of the most devastating diseases and is highly prevalent in society [1]. Upon entering the body, the HIV virus attacks CD4 cells, a type of T-helper cell [2]. Once inside these cells, the virus replicates and eventually destroys the cell. The virus and its replicated forms exit the cell and similarly enter the next cells. Over time, this process leads to the destruction of most CD4 cells in the immune system, resulting in a decline in immune function [3]. According to global statistics, by 2023, approximately 39.9 million people worldwide will be living with HIV, with 1.3 million new infections and 630,000 deaths due to AIDS [4]. In Iran, in 2023, about 43,000 individuals (ranging from 30,000 to 77,000) will be living with the virus, of which 24,000 are registered and 19,000 are not diagnosed or registered by health centers. Deaths from this virus in 2023 are estimated to be around 1,900 [5]. AIDS is the fifth leading cause of death in adults worldwide. Several factors contribute to these deaths, including late diagnosis and treatment, the occurrence of opportunistic infections, and non-AIDS-related causes of death in these patients, such as cardiovascular disease, cancer, kidney disease, liver disease, osteopenia and osteoporosis, cognitive-neurological disorders, and toxic side effects of antiviral drugs [6]. By destroying the immune system, AIDS leads to opportunistic infections, such as tuberculosis, herpes, fungal diseases, and cancer, as well as an increase in comorbidities and even death. These physical problems can result in feelings of anger, confusion, hopelessness, and fear of death [7]. Death anxiety is one of the most common psychological issues faced by patients with AIDS [8].
Death anxiety is often defined as the fear of dying and the events that follow death. It is characterized by an intense feeling of fear, dread, or worry when contemplating the process of dying, losing touch with the world, or what will happen after death [9, 10]. Death anxiety can manifest as a conscious or unconscious psychological state that acts as a defense mechanism in response to a life-threatening event [11]. Sources of death anxiety include fear of personal death, concerns about the pain and suffering associated with dying, mental proximity to death, fears related to death, and anxious thoughts about death [12]. Fear of death negatively impacts a person’s ability to cope with illness, environmental stress, and overall quality of life [7]. Because acquired immunodeficiency inserts its genetic material into the DNA of cells, it becomes a lifelong disease, and neither the immune system nor any drug (despite extensive efforts by scientists) can eliminate human immunodeficiency from the body [13]. However, medical care, including the use of antiretroviral drugs, can prevent the progression of acquired immunodeficiency in the body [14]. Onu et al. stated that various therapeutic approaches, including dialectical behavior therapy (DBT), have demonstrated effectiveness in addressing death anxiety [15].
DBT emphasizes behavior change and emotion management. It incorporates the principles of cognitive-behavioral therapy (CBT) along with mindfulness, acceptance, and dialectics; however, it also has some differences from cognitive-behavioral therapy [16]. The skills taught in DBT include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness, all of which directly target the management of an individual’s emotional experiences and teach skills to improve relationships [17]. This therapeutic approach helps individuals develop problem-solving skills by promoting positive thinking and reducing negative emotions, enhancing distress tolerance and self-acceptance, fostering emotional self-regulation, supporting healthy personality development, and encouraging mindfulness. These elements can help reduce anxiety by alleviating fear [18, 19]. The goal is to create a balance between change and acceptance, empowering individuals not only to survive but also to value life [20].
According to Khodabakhshi-Koolaee et al., DBT regulates emotions and reduces death anxiety in elderly women aged 60-75 years [21]. The results of the study conducted by Badrkhani et al. showed that commitment therapy and DBT improve death obsession in female patients with COVID-19, with no difference observed between the two treatments [22]. Additionally, Roza et al. found that CBT is effective in improving death anxiety in patients with AIDS [7].
The multidimensional and comprehensive focus of this approach on improving the emotional, cognitive, and communication systems of various patients is the main factor that supports the expectation of its effectiveness in reducing death anxiety in patients with immune system deficiencies. However, no study was found in this regard. Therefore, considering the prevalence of fear of death in patients with AIDS and the resulting consequences, the present study aimed to determine the effect of DBT on death anxiety in patients with human immunodeficiency virus.
Materials and Methods
Research Design
The present semi-experimental study utilized a two-group (experimental and control) and three-stage (pre-test, post-test, and follow-up) design and was conducted in 2024. The statistical population consisted of all patients with HIV who were referred to behavioral disease counseling centers in Yasuj city, as well as health and treatment centers in Yasuj, Gachsaran, and Dehdasht in Kohgiluyeh and Boyer Ahmad provinces in 2024.
According to the study by Lotfalizadeh et al. [23], and considering α=0.05, power=0.90, d=1.05, μ1=109.80, μ2=140.02, σ1=5.14, and σ2=5.70, using G*Power software version 3.1.9.7, the total sample size was determined to be 34 individuals. Taking into account a 15% probability of sample dropout, a total of 40 individuals were included, with 20 assigned to each group.
Convenience sampling was used to select the sample. For this purpose, 40 patients with AIDS who were referred to behavioral disease counseling centers and health centers in Kohgiluyeh and Boyer Ahmad provinces were selected through convenience sampling and randomly assigned to two intervention groups (20 individuals) and control groups (20 individuals) using a table of random numbers.
Inclusion criteria included obtaining a score of more than one standard deviation above the mean on the death anxiety questionnaire, being aged between 26 and 50 years, having at least a third-grade education, achieving scores of more than one standard deviation above the mean on the research questionnaires, and completing and signing the informed consent form. Exclusion criteria included the presence of a psychotic disorder or related features based on the patient’s medical record, the use of psychotropic medications, and failure to meet the inclusion criteria.
Data collection tools
The Templer Death Anxiety Scale (DAS) was used to collect data. This questionnaire was designed by Templer in 1970 [24] and translated and standardized in Iran by Rajabi and Bahrani [25]. It consists of 15 questions and five subscales: fear of death (questions 1, 12, and 14), fear of pain and illness (questions 2, 4, 6, and 13), thoughts about death (questions 5, 9, and 11), time passing and short life (questions 3, 7, and 10), and fear of the future (questions 8 and 15). For scoring, one point is awarded for each correct answer, and zero points for each incorrect answer. This scoring method is reversed for questions 10, 11, 12, 13, 14, and 15 (correct: zero points and incorrect: one point). A “yes” answer indicates the presence of anxiety in the individual. The range of scores on this scale is from zero to 15, with a high score (above the average, i.e., a score of eight) indicating a high degree of death anxiety. Thus, the scores on this scale vary between 0 and 15, with a higher score indicating greater anxiety about death. Templer reported the reliability of this scale using the test-retest method to be higher than 0.83 and also confirmed its construct validity. In Iran, Rajabi and Bahrani reported the reliability of this scale using Cronbach’s alpha method to be between 0.78 and 0.85, and they also confirmed its face and content validity [25].
Questionnaires were completed by patients in both the intervention and control groups before the intervention (week zero), at the end of the intervention (week eight) as a post-test, and four weeks after the end of the intervention (week 12) as a follow-up.
Intervention
The intervention used was DBT. Patients in the intervention group participated in DBT sessions conducted in groups by the researcher for eight weekly 60-minute sessions (8 weeks) (Table 1). The researcher was a clinical psychologist who had completed a DBT workshop. Seven patients in the intervention group lived in Yasuj, and one lived in Dehdasht; all eight of their intervention sessions were conducted individually and in person at the counseling clinic. Twelve patients lived in Gachsaran, and their eight intervention sessions were conducted virtually via telephone (lasting 45 minutes to 1 hour). The control group did not receive any intervention during the study but remained on a waiting list and were offered the intervention after the study concluded.
Table 1. Content of dialectical behavior therapy sessions
The primary outcome was death anxiety, while the secondary outcomes included its subscales: fear of death, fear of pain and illness, thoughts about death, fleeting time and short life, and fear of the future.
Data analysis
Statistical indicators used at the descriptive statistics level included frequency, mean, and standard deviation. At the inferential statistics level, the Kolmogorov-Smirnov test was used to determine the data distribution, which was found to be normal. To analyze the hypotheses, the analysis of covariance (ANOVA and MANCOVA) and the Bonferroni post hoc test were used for pairwise comparisons. The collected data were analyzed using SPSS version 26 software. The acceptable significance level was set at 0.05.
Findings
Twenty people were in the control group and twenty people were in the experimental group, and none withdrew from the study. In the experimental group, 8 individuals (20%) were male and 12 individuals (30%) were female. In the control group, 11 individuals (27.5%) were male and 9 individuals (22.5%) were female. In total, 47.5% of the participants were male and 52.5% were female. The average age for the experimental group was 44.95±7.12 years, for the control group it was 46.75±7.61 years, and the average age of all participants was 45.85 years.
The results of the repeated measures ANOVA showed that the effects of group, time, and the interaction of group and time on death anxiety and its subscales—including fear of death, fear of pain and illness, thoughts about death, fleeting time and short life, and fear of the future—were significant (p<0.05). The intervention group demonstrated an improvement in anxiety compared to the control group post-intervention, and the significance levels of time indicated a difference in the trend of changes in death anxiety scores between the control and intervention groups during the measurement periods (Table 2).
Table 2. Comparing mean scores of the two groups regarding death anxiety and its subscales between measurement times
The mean death anxiety score in the DBT group was significantly different among the three time stages of the study, including the pretest, post-test, and follow-up (p<0.01). To determine which pairs of time this effect pertained to, the Bonferroni test was used. Pairwise comparisons showed that mean death anxiety scores in the post-test and follow-up stages decreased significantly compared to the pre-test stage. However, the difference between the post-test scores and the follow-up scores was not significant (p>0.05). In the control group, the differences between the pre-test scores and both the post-test and follow-up scores, as well as the difference between the post-test scores and the follow-up scores, were not significant (p>0.05; Table 3).
Table 3. Comparing the mean score of death anxiety and its subscales between measurement times
Discussion
The present study was conducted to determine the effect of DBT on death anxiety in patients with AIDS. Death anxiety is one of the most common emotional-cognitive stresses experienced by patients with immune system deficiencies, particularly those with AIDS [8]. Given the lack of studies investigating the effect of DBT on death anxiety in patients with human immunodeficiency, this study appears to be the first of its kind. The results indicated that DBT significantly reduced death anxiety and its subscales, including fear of death, fear of pain and illness, thoughts about death, the passage of time and the shortness of life, and fear of the future.
Similar to our results, Roza et al. found that CBT improves death anxiety in patients with AIDS. Patients with AIDS experience fear of death, pain, and illness, thoughts related to death, fear of the passing of time and the shortness of life, and fear of the future [7]. The DBT also helped reduce patients’ death anxiety by addressing these fears. In a study by Faraji in Iran, DBT has improved distress and increased life expectancy in cancer patients [26]. Although the outcomes in the mentioned study were different from ours, it similarly has caused an improvement in life expectancy; here, DBT was also able to reduce death anxiety. According to Liang et al., group DBT has improved stress and anxiety in medical students during the COVID-19 pandemic [27]. Although the nature of the disease and the outcomes measured in the aforementioned studies differ, during the COVID-19 pandemic, the fear of contracting COVID-19 and the anxiety about dying from this disease have been comparable to the anxiety experienced by patients with AIDS. However, in both studies, DBT has a positive effect. In DBT, the emphasis is on the dialectic of acceptance and change, meaning that the therapist accepts the patient as they are and validates their thoughts, emotions, and behaviors while also acknowledging the need for change and providing the conditions for learning new skills to address problems and achieve personal goals. Dialectical behavior therapy skills include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness, which directly target the management of an individual’s emotional experiences and the teaching of skills to improve relationships [17].
According to Navarro-Haro et al., the combination of mindfulness with virtual DBT improves social anxiety disorders in patients with AIDS more effectively than mindfulness alone. Providing DBT virtually for patients with AIDS can be beneficial because AIDS is considered a social stigma, and virtual education, which does not require the patient’s physical presence, increases the acceptance of behavioral therapy programs among patients. Additionally, a combination of behavioral therapies, such as CBT and mindfulness, may further reduce death anxiety in patients with AIDS [28].
In the study by Hemmati Sabet et al., although DBT has an effect on temperament, personality dimensions, and emotional regulation strategies in patients with AIDS, the effect of schema therapy on these parameters is greater [29]. Furthermore, in the study by Afshari & Hasani, while DBT reduces anxiety and depression in patients with generalized anxiety disorder, this reduction is greater with CBT interventions than with DBT. However, the effect of DBT on executive function is greater than that of CBT interventions [30]. Although anxiety is different from death anxiety, as noted in the present study, the intervention reduced general anxiety in both studies. In these two studies, DBT has been less effective than schema therapy and CBT interventions, indicating the need for more comparative studies involving other behavioral therapy interventions.
According to Montaser et al., DBT reduces anxiety symptoms and emotional regulation problems among addicted patients [31]. Their study has used different participants, and DBT has been administered in more sessions; however, the outcome measured is anxiety, which differs from death anxiety and is assessed using a different questionnaire. The reduction in general anxiety observed in that study may show similarities with the present study. In contrast, the study by Malas & Gómez-Domenech found that DBT does not affect fear of COVID-19 and anxiety in patients with COVID-19. Although the outcome of this study focuses on general anxiety and does not measure death anxiety, it contradicts our results and those of the aforementioned studies, which indicated that DBT improved either death anxiety or general anxiety. This difference between the results of the mentioned studies and the study by Malas & Gómez-Domenech could be attributed to variations in measurement tools, the number of sessions, and sample sizes [31]. According to a systematic review, DBT can help reduce social anxiety disorder by enhancing interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance. While CBT has been the most effective, DBT has a moderate effect, as 51% of patients continue to show symptoms of social anxiety after treatment [32].
Although the outcome of our study was death anxiety in patients with AIDS, DBT was effective in helping to reduce it. These differences could be attributed to the type of anxiety, the nature of the participants’ problems, the quality of the DBT method, and the varying sample sizes in the studies. DBT focuses on improving individuals’ ability to regulate emotions, which leads to the alleviation of destructive emotions, particularly death anxiety. DBT emphasizes behavior change and emotion management. It incorporates the principles of CBT along with mindfulness, acceptance, and dialectics; however, it also differs in some respects from CBT [16]. The relationship between the individual and the therapist is one of the most fundamental aspects of the DBT approach, playing an effective role in reducing death anxiety among participants, both directly and indirectly, through the provision of understanding and psychological support. During therapy sessions, participants learned to express their emotions, cognitions, and perceptual beliefs honestly, including their death anxiety and the tensions associated with it, and to vent without fear of judgment. When the therapist explained death anxiety and its scientific basis to the participants, they became more open to understanding and accepting it. Throughout this treatment process, the negative thoughts and false cognitions underlying death anxiety were identified on a case-by-case basis with the support of the therapist. The extent to which these beliefs corresponded to reality was assessed, allowing participants to engage in a documentation process to question these destructive and ineffective beliefs and replace them with more constructive beliefs related to their physical illness and death anxiety. Participants were able to gain insight into their beliefs and cognitions about AIDS and death anxiety. By recognizing these beliefs and evaluating their alignment with reality through the cognitive restructuring process, participants found sufficient motivation to change them. With the therapist’s support, they were able to dismantle these beliefs and subsequently replace them with healthier alternatives.
This study also had limitations. The number of eligible samples was small due to the difficulty in obtaining patient consent to participate in the study, and the follow-up period was also short. The present study was quasi-experimental, which did not allow for control of all confounding parameters, potentially affecting the internal validity of the results.
The findings can be recommended to therapists working in centers with clients who have AIDS-related immune system deficiencies. In addition to medical treatments, including pharmacological interventions, therapists should incorporate psychological approaches such as DBT to address associated psychological problems, particularly death anxiety. It is suggested that this study be repeated with a larger sample size and a longer follow-up period using a randomized controlled clinical trial design. Additionally, it is recommended that a study based on DBT interventions be designed to be conducted virtually and in combination with other behavioral therapy methods.
Conclusion
DBT improves death anxiety and its subscales in patients with AIDS-related immunodeficiency.
Acknowledgments: This article is the result of Zohreh Zarei’s doctoral thesis in psychology at Islamic Azad University, Yasouj Branch. The authors would like to thank all the staff of Islamic Azad University, Yasouj Branch, as well as the Health Vice-Chancellor of Yasouj University of Medical Sciences and the Behavioral Diseases and Immunodeficiency Patients Counseling Center, who assisted the researchers in conducting this study.
Ethical Permissions: This study was approved by the Research Ethics Committee of the Islamic Azad University of Yasouj (IR.IAU.YASOOJ.REC.1402.005). Informed consent to participate in the study was obtained from the patients. The researcher is committed to ethical and humane principles to avoid any unethical means in achieving the intended goals of the research and refrain from any improper use that could harm the participants. The ethical principles of the Hellenic Declaration were adhered to throughout the research process. Confidentiality of information, anonymity of questionnaires, and patient privacy were maintained.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Zohreh Zarei (first author), principal investigator/methodologist/introductory writer/discussion writer/methodologist (40%); Alireza Maredpour (second author), assistant investigator/introductory writer/methodologist/discussion writer/statistical analyst (40%); Shirali Khoramin (third author), methodologist/assistant investigator/introductory writer (20%)
Funding/Support: This article was funded by the researchers.
Immunodeficiency is one of the most devastating diseases and is highly prevalent in society [1]. Upon entering the body, the HIV virus attacks CD4 cells, a type of T-helper cell [2]. Once inside these cells, the virus replicates and eventually destroys the cell. The virus and its replicated forms exit the cell and similarly enter the next cells. Over time, this process leads to the destruction of most CD4 cells in the immune system, resulting in a decline in immune function [3]. According to global statistics, by 2023, approximately 39.9 million people worldwide will be living with HIV, with 1.3 million new infections and 630,000 deaths due to AIDS [4]. In Iran, in 2023, about 43,000 individuals (ranging from 30,000 to 77,000) will be living with the virus, of which 24,000 are registered and 19,000 are not diagnosed or registered by health centers. Deaths from this virus in 2023 are estimated to be around 1,900 [5]. AIDS is the fifth leading cause of death in adults worldwide. Several factors contribute to these deaths, including late diagnosis and treatment, the occurrence of opportunistic infections, and non-AIDS-related causes of death in these patients, such as cardiovascular disease, cancer, kidney disease, liver disease, osteopenia and osteoporosis, cognitive-neurological disorders, and toxic side effects of antiviral drugs [6]. By destroying the immune system, AIDS leads to opportunistic infections, such as tuberculosis, herpes, fungal diseases, and cancer, as well as an increase in comorbidities and even death. These physical problems can result in feelings of anger, confusion, hopelessness, and fear of death [7]. Death anxiety is one of the most common psychological issues faced by patients with AIDS [8].
Death anxiety is often defined as the fear of dying and the events that follow death. It is characterized by an intense feeling of fear, dread, or worry when contemplating the process of dying, losing touch with the world, or what will happen after death [9, 10]. Death anxiety can manifest as a conscious or unconscious psychological state that acts as a defense mechanism in response to a life-threatening event [11]. Sources of death anxiety include fear of personal death, concerns about the pain and suffering associated with dying, mental proximity to death, fears related to death, and anxious thoughts about death [12]. Fear of death negatively impacts a person’s ability to cope with illness, environmental stress, and overall quality of life [7]. Because acquired immunodeficiency inserts its genetic material into the DNA of cells, it becomes a lifelong disease, and neither the immune system nor any drug (despite extensive efforts by scientists) can eliminate human immunodeficiency from the body [13]. However, medical care, including the use of antiretroviral drugs, can prevent the progression of acquired immunodeficiency in the body [14]. Onu et al. stated that various therapeutic approaches, including dialectical behavior therapy (DBT), have demonstrated effectiveness in addressing death anxiety [15].
DBT emphasizes behavior change and emotion management. It incorporates the principles of cognitive-behavioral therapy (CBT) along with mindfulness, acceptance, and dialectics; however, it also has some differences from cognitive-behavioral therapy [16]. The skills taught in DBT include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness, all of which directly target the management of an individual’s emotional experiences and teach skills to improve relationships [17]. This therapeutic approach helps individuals develop problem-solving skills by promoting positive thinking and reducing negative emotions, enhancing distress tolerance and self-acceptance, fostering emotional self-regulation, supporting healthy personality development, and encouraging mindfulness. These elements can help reduce anxiety by alleviating fear [18, 19]. The goal is to create a balance between change and acceptance, empowering individuals not only to survive but also to value life [20].
According to Khodabakhshi-Koolaee et al., DBT regulates emotions and reduces death anxiety in elderly women aged 60-75 years [21]. The results of the study conducted by Badrkhani et al. showed that commitment therapy and DBT improve death obsession in female patients with COVID-19, with no difference observed between the two treatments [22]. Additionally, Roza et al. found that CBT is effective in improving death anxiety in patients with AIDS [7].
The multidimensional and comprehensive focus of this approach on improving the emotional, cognitive, and communication systems of various patients is the main factor that supports the expectation of its effectiveness in reducing death anxiety in patients with immune system deficiencies. However, no study was found in this regard. Therefore, considering the prevalence of fear of death in patients with AIDS and the resulting consequences, the present study aimed to determine the effect of DBT on death anxiety in patients with human immunodeficiency virus.
Materials and Methods
Research Design
The present semi-experimental study utilized a two-group (experimental and control) and three-stage (pre-test, post-test, and follow-up) design and was conducted in 2024. The statistical population consisted of all patients with HIV who were referred to behavioral disease counseling centers in Yasuj city, as well as health and treatment centers in Yasuj, Gachsaran, and Dehdasht in Kohgiluyeh and Boyer Ahmad provinces in 2024.
According to the study by Lotfalizadeh et al. [23], and considering α=0.05, power=0.90, d=1.05, μ1=109.80, μ2=140.02, σ1=5.14, and σ2=5.70, using G*Power software version 3.1.9.7, the total sample size was determined to be 34 individuals. Taking into account a 15% probability of sample dropout, a total of 40 individuals were included, with 20 assigned to each group.
Convenience sampling was used to select the sample. For this purpose, 40 patients with AIDS who were referred to behavioral disease counseling centers and health centers in Kohgiluyeh and Boyer Ahmad provinces were selected through convenience sampling and randomly assigned to two intervention groups (20 individuals) and control groups (20 individuals) using a table of random numbers.
Inclusion criteria included obtaining a score of more than one standard deviation above the mean on the death anxiety questionnaire, being aged between 26 and 50 years, having at least a third-grade education, achieving scores of more than one standard deviation above the mean on the research questionnaires, and completing and signing the informed consent form. Exclusion criteria included the presence of a psychotic disorder or related features based on the patient’s medical record, the use of psychotropic medications, and failure to meet the inclusion criteria.
Data collection tools
The Templer Death Anxiety Scale (DAS) was used to collect data. This questionnaire was designed by Templer in 1970 [24] and translated and standardized in Iran by Rajabi and Bahrani [25]. It consists of 15 questions and five subscales: fear of death (questions 1, 12, and 14), fear of pain and illness (questions 2, 4, 6, and 13), thoughts about death (questions 5, 9, and 11), time passing and short life (questions 3, 7, and 10), and fear of the future (questions 8 and 15). For scoring, one point is awarded for each correct answer, and zero points for each incorrect answer. This scoring method is reversed for questions 10, 11, 12, 13, 14, and 15 (correct: zero points and incorrect: one point). A “yes” answer indicates the presence of anxiety in the individual. The range of scores on this scale is from zero to 15, with a high score (above the average, i.e., a score of eight) indicating a high degree of death anxiety. Thus, the scores on this scale vary between 0 and 15, with a higher score indicating greater anxiety about death. Templer reported the reliability of this scale using the test-retest method to be higher than 0.83 and also confirmed its construct validity. In Iran, Rajabi and Bahrani reported the reliability of this scale using Cronbach’s alpha method to be between 0.78 and 0.85, and they also confirmed its face and content validity [25].
Questionnaires were completed by patients in both the intervention and control groups before the intervention (week zero), at the end of the intervention (week eight) as a post-test, and four weeks after the end of the intervention (week 12) as a follow-up.
Intervention
The intervention used was DBT. Patients in the intervention group participated in DBT sessions conducted in groups by the researcher for eight weekly 60-minute sessions (8 weeks) (Table 1). The researcher was a clinical psychologist who had completed a DBT workshop. Seven patients in the intervention group lived in Yasuj, and one lived in Dehdasht; all eight of their intervention sessions were conducted individually and in person at the counseling clinic. Twelve patients lived in Gachsaran, and their eight intervention sessions were conducted virtually via telephone (lasting 45 minutes to 1 hour). The control group did not receive any intervention during the study but remained on a waiting list and were offered the intervention after the study concluded.
Table 1. Content of dialectical behavior therapy sessions
The primary outcome was death anxiety, while the secondary outcomes included its subscales: fear of death, fear of pain and illness, thoughts about death, fleeting time and short life, and fear of the future.
Data analysis
Statistical indicators used at the descriptive statistics level included frequency, mean, and standard deviation. At the inferential statistics level, the Kolmogorov-Smirnov test was used to determine the data distribution, which was found to be normal. To analyze the hypotheses, the analysis of covariance (ANOVA and MANCOVA) and the Bonferroni post hoc test were used for pairwise comparisons. The collected data were analyzed using SPSS version 26 software. The acceptable significance level was set at 0.05.
Findings
Twenty people were in the control group and twenty people were in the experimental group, and none withdrew from the study. In the experimental group, 8 individuals (20%) were male and 12 individuals (30%) were female. In the control group, 11 individuals (27.5%) were male and 9 individuals (22.5%) were female. In total, 47.5% of the participants were male and 52.5% were female. The average age for the experimental group was 44.95±7.12 years, for the control group it was 46.75±7.61 years, and the average age of all participants was 45.85 years.
The results of the repeated measures ANOVA showed that the effects of group, time, and the interaction of group and time on death anxiety and its subscales—including fear of death, fear of pain and illness, thoughts about death, fleeting time and short life, and fear of the future—were significant (p<0.05). The intervention group demonstrated an improvement in anxiety compared to the control group post-intervention, and the significance levels of time indicated a difference in the trend of changes in death anxiety scores between the control and intervention groups during the measurement periods (Table 2).
Table 2. Comparing mean scores of the two groups regarding death anxiety and its subscales between measurement times
The mean death anxiety score in the DBT group was significantly different among the three time stages of the study, including the pretest, post-test, and follow-up (p<0.01). To determine which pairs of time this effect pertained to, the Bonferroni test was used. Pairwise comparisons showed that mean death anxiety scores in the post-test and follow-up stages decreased significantly compared to the pre-test stage. However, the difference between the post-test scores and the follow-up scores was not significant (p>0.05). In the control group, the differences between the pre-test scores and both the post-test and follow-up scores, as well as the difference between the post-test scores and the follow-up scores, were not significant (p>0.05; Table 3).
Table 3. Comparing the mean score of death anxiety and its subscales between measurement times
Discussion
The present study was conducted to determine the effect of DBT on death anxiety in patients with AIDS. Death anxiety is one of the most common emotional-cognitive stresses experienced by patients with immune system deficiencies, particularly those with AIDS [8]. Given the lack of studies investigating the effect of DBT on death anxiety in patients with human immunodeficiency, this study appears to be the first of its kind. The results indicated that DBT significantly reduced death anxiety and its subscales, including fear of death, fear of pain and illness, thoughts about death, the passage of time and the shortness of life, and fear of the future.
Similar to our results, Roza et al. found that CBT improves death anxiety in patients with AIDS. Patients with AIDS experience fear of death, pain, and illness, thoughts related to death, fear of the passing of time and the shortness of life, and fear of the future [7]. The DBT also helped reduce patients’ death anxiety by addressing these fears. In a study by Faraji in Iran, DBT has improved distress and increased life expectancy in cancer patients [26]. Although the outcomes in the mentioned study were different from ours, it similarly has caused an improvement in life expectancy; here, DBT was also able to reduce death anxiety. According to Liang et al., group DBT has improved stress and anxiety in medical students during the COVID-19 pandemic [27]. Although the nature of the disease and the outcomes measured in the aforementioned studies differ, during the COVID-19 pandemic, the fear of contracting COVID-19 and the anxiety about dying from this disease have been comparable to the anxiety experienced by patients with AIDS. However, in both studies, DBT has a positive effect. In DBT, the emphasis is on the dialectic of acceptance and change, meaning that the therapist accepts the patient as they are and validates their thoughts, emotions, and behaviors while also acknowledging the need for change and providing the conditions for learning new skills to address problems and achieve personal goals. Dialectical behavior therapy skills include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness, which directly target the management of an individual’s emotional experiences and the teaching of skills to improve relationships [17].
According to Navarro-Haro et al., the combination of mindfulness with virtual DBT improves social anxiety disorders in patients with AIDS more effectively than mindfulness alone. Providing DBT virtually for patients with AIDS can be beneficial because AIDS is considered a social stigma, and virtual education, which does not require the patient’s physical presence, increases the acceptance of behavioral therapy programs among patients. Additionally, a combination of behavioral therapies, such as CBT and mindfulness, may further reduce death anxiety in patients with AIDS [28].
In the study by Hemmati Sabet et al., although DBT has an effect on temperament, personality dimensions, and emotional regulation strategies in patients with AIDS, the effect of schema therapy on these parameters is greater [29]. Furthermore, in the study by Afshari & Hasani, while DBT reduces anxiety and depression in patients with generalized anxiety disorder, this reduction is greater with CBT interventions than with DBT. However, the effect of DBT on executive function is greater than that of CBT interventions [30]. Although anxiety is different from death anxiety, as noted in the present study, the intervention reduced general anxiety in both studies. In these two studies, DBT has been less effective than schema therapy and CBT interventions, indicating the need for more comparative studies involving other behavioral therapy interventions.
According to Montaser et al., DBT reduces anxiety symptoms and emotional regulation problems among addicted patients [31]. Their study has used different participants, and DBT has been administered in more sessions; however, the outcome measured is anxiety, which differs from death anxiety and is assessed using a different questionnaire. The reduction in general anxiety observed in that study may show similarities with the present study. In contrast, the study by Malas & Gómez-Domenech found that DBT does not affect fear of COVID-19 and anxiety in patients with COVID-19. Although the outcome of this study focuses on general anxiety and does not measure death anxiety, it contradicts our results and those of the aforementioned studies, which indicated that DBT improved either death anxiety or general anxiety. This difference between the results of the mentioned studies and the study by Malas & Gómez-Domenech could be attributed to variations in measurement tools, the number of sessions, and sample sizes [31]. According to a systematic review, DBT can help reduce social anxiety disorder by enhancing interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance. While CBT has been the most effective, DBT has a moderate effect, as 51% of patients continue to show symptoms of social anxiety after treatment [32].
Although the outcome of our study was death anxiety in patients with AIDS, DBT was effective in helping to reduce it. These differences could be attributed to the type of anxiety, the nature of the participants’ problems, the quality of the DBT method, and the varying sample sizes in the studies. DBT focuses on improving individuals’ ability to regulate emotions, which leads to the alleviation of destructive emotions, particularly death anxiety. DBT emphasizes behavior change and emotion management. It incorporates the principles of CBT along with mindfulness, acceptance, and dialectics; however, it also differs in some respects from CBT [16]. The relationship between the individual and the therapist is one of the most fundamental aspects of the DBT approach, playing an effective role in reducing death anxiety among participants, both directly and indirectly, through the provision of understanding and psychological support. During therapy sessions, participants learned to express their emotions, cognitions, and perceptual beliefs honestly, including their death anxiety and the tensions associated with it, and to vent without fear of judgment. When the therapist explained death anxiety and its scientific basis to the participants, they became more open to understanding and accepting it. Throughout this treatment process, the negative thoughts and false cognitions underlying death anxiety were identified on a case-by-case basis with the support of the therapist. The extent to which these beliefs corresponded to reality was assessed, allowing participants to engage in a documentation process to question these destructive and ineffective beliefs and replace them with more constructive beliefs related to their physical illness and death anxiety. Participants were able to gain insight into their beliefs and cognitions about AIDS and death anxiety. By recognizing these beliefs and evaluating their alignment with reality through the cognitive restructuring process, participants found sufficient motivation to change them. With the therapist’s support, they were able to dismantle these beliefs and subsequently replace them with healthier alternatives.
This study also had limitations. The number of eligible samples was small due to the difficulty in obtaining patient consent to participate in the study, and the follow-up period was also short. The present study was quasi-experimental, which did not allow for control of all confounding parameters, potentially affecting the internal validity of the results.
The findings can be recommended to therapists working in centers with clients who have AIDS-related immune system deficiencies. In addition to medical treatments, including pharmacological interventions, therapists should incorporate psychological approaches such as DBT to address associated psychological problems, particularly death anxiety. It is suggested that this study be repeated with a larger sample size and a longer follow-up period using a randomized controlled clinical trial design. Additionally, it is recommended that a study based on DBT interventions be designed to be conducted virtually and in combination with other behavioral therapy methods.
Conclusion
DBT improves death anxiety and its subscales in patients with AIDS-related immunodeficiency.
Acknowledgments: This article is the result of Zohreh Zarei’s doctoral thesis in psychology at Islamic Azad University, Yasouj Branch. The authors would like to thank all the staff of Islamic Azad University, Yasouj Branch, as well as the Health Vice-Chancellor of Yasouj University of Medical Sciences and the Behavioral Diseases and Immunodeficiency Patients Counseling Center, who assisted the researchers in conducting this study.
Ethical Permissions: This study was approved by the Research Ethics Committee of the Islamic Azad University of Yasouj (IR.IAU.YASOOJ.REC.1402.005). Informed consent to participate in the study was obtained from the patients. The researcher is committed to ethical and humane principles to avoid any unethical means in achieving the intended goals of the research and refrain from any improper use that could harm the participants. The ethical principles of the Hellenic Declaration were adhered to throughout the research process. Confidentiality of information, anonymity of questionnaires, and patient privacy were maintained.
Conflicts of Interests: The authors declared no conflicts of interests.
Authors’ Contribution: Zohreh Zarei (first author), principal investigator/methodologist/introductory writer/discussion writer/methodologist (40%); Alireza Maredpour (second author), assistant investigator/introductory writer/methodologist/discussion writer/statistical analyst (40%); Shirali Khoramin (third author), methodologist/assistant investigator/introductory writer (20%)
Funding/Support: This article was funded by the researchers.