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Akbari M, Gholamirad Z, Bakhshinezhad Talesh Bejari K, Rezaeian M. The Role of Death Anxiety in Suicide Attempt During the Covid-19 Pandemic: A Case Report. JSP. 2021; 3 (1) :51-56
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                     Journal of Suicide Prevention
https://isssp.ir                                                                                               Vol. 3. 2021. Article ID: e20210006

Original Article                                        

The Role of Death Anxiety in Suicide Attempt During the Covid-19 Pandemic: A Case Report

Moslem Akbari1, Zeinab Gholamirad2, Khadijeh Bakhshinezhad Talesh Bejari 3, Mohsen Rezaeian4*

1- MA in Clinical Psychology, Islamic Azad University, Roudehen Branch, ORCID:  0000-0003-4061-6347
2- MA in Family Counseling, Razi University, Kermanshah, Iran, ORCID: 0000-0003-1776-9951
3- MA in General Psychology, Kooshiar High Tech Educational Institution, Rasht, Iran, ORCID: 0000-0002-3370-0789
4-  (Corresponding author) Prof., Dept. of Epidemiology and Biostatistics, Occupational Environmental Research Center, Medical School, Rafsanjan University of Medical Sciences, Rafsanjan, Iran, ORCID: 0000-0003-3070-0166,  Tel: (+9834) 31315123, Fax: (+9834) 31315123, E-mail: moeygmr2@yahoo.co.uk


Background and Objectives: The Covid-19 pandemic has caused the death anxiety to be increased. Due to the role of death anxiety in attempting suicide, the present case study aimed at investigating the effect of death anxiety caused by the Covid-19 on the suicide attempt.
Case report: The present study was a case report in which a 34-year-old man was studied after a suicide attempt. Since death anxiety is one of the main axes of the originality approach, the variables of this approach were examined. The patient’s life history was also investigated.
Conclusion: The results showed that the patient in all areas including death anxiety, loneliness, freedom, and meaning of life carries problems that he has always been unaware of their existence. Covid-19 has revealed them all to him at once. The patient carried out suicide due to the inability to cope with these anxieties. Also, a study of the patient's life history showed that he has ignored his existence from an early age and has been a victim of his parents' wishes. The patient has had a strong desire to control, anticipate, and plan for the future since childhood, and Covid-19 has taken them all away. By designing existential variables, it was confirmed that he has never had a meaning in life and always ignored himself. He also expressed a desire to become more familiar with the approach to the originality of existence and to begin to know oneself.
Death, Anxiety, Suicide, Covid-19 Pandemic
Received: 03/06/21
Revised: 17/08/21
Accepted: 21/08/21
Conflicts of interest: None
Funding: None
Cite this article as:
Akbari M, Gholamirad Z, Bakhshinezhad Talesh Bejari Kh, Rezaeian M. The Role of Death Anxiety in Suicide Attempt During the Covid-19 Pandemic: A Case Report. J Suicid Prevent. 2021 (Jun): 3: 51-56. e2019003
*This work is published under CC BY-NC-SA 3.0 licence.

On January 30, 2020, the World Health Organization (WHO) announced the outbreak of the Covid-19 and declared a state of health emergency, and on February 11 of that year, it was designated as the Covid-19 disease. Due to the speed of spread and also the cause of the virus, the best solution to fight this virus is to prevent it from knowing that it causes psychological conditions and social and economic situations on different days [1].
While the Covid-19 pandemic is spreading rapidly around the world, it has caused fear and anxiety among the general public [1]. The outbreak of Covid-19 has left many people around the world at home or in a quarantine center. Uncertainty over the progression of the epidemic and its duration causes more psychological pressure on the public. One of the possible causes of psychological problems is related to fear of infection and fear of not controlling the disease during quarantine [2]. Quarantine is often an unpleasant experience. Separation from loved ones, loss of freedom, impatience, and even anger are long-standing effects of quarantine [4]. Although most psychological studies have focused on anxiety and stress caused by Covid-19 disease, the fact is that during an epidemic of a disease such as Covid-19, in addition to anxiety and stress in general, fear of death and death anxiety also increase [5]. Death anxiety includes negative emotional and cognitive reactions including fear, grief, apprehension, worry, and unhappiness about dying [5]. Death anxiety itself includes several smaller anxieties, including: my death causes grief and mourning to my relatives and friends, my entire wills end, the process of death is painful, I am afraid what happens to me, and I am afraid of what will happen to my body after my death [6]. People with higher levels of death anxiety are more likely to experience mental disorders such as anxiety and stress [7], depression [8], and even suicide [9]. Numerous studies have shown that there is a relationship between death anxiety and suicide [10, 11]. According to the American Psychological Association (APA), suicide is any intentional harm with the intent to kill oneself [12]. People deliberately kill themselves through suicide. Suicide is often caused by frustration, which is often attributed to mental disorders such as depression, bipolar disorder, schizophrenia, love failure, alcoholism, or drug abuse. Often, stressors such as financial problems or interpersonal communication problems are involved [13]. About 800,000 people die from suicide each year, making it the tenth leading cause of death worldwide [14]. The impact of Covid-19 epidemic on suicide rates in most countries of the world, including the United States of America (USA) [15], Canada [16], Germany [17], United Kingdom (UK) [18], France [19], China [11], Japan [20], and Iran [21] have been studied. Although a correlation between suicide and mental disorders has been shown in the Covid-19 epidemic, the higher suicide death rate in patients with higher death anxiety indicates the mediating role of death anxiety in predicting the suicidal behavior [22]. To achieve relevant research, the keywords “death anxiety”, “suicide”, “mental health”, and “Covid-19” in both Persian and English in 5 international databases (Web of Knowledge, CINHAL, MedLine, PsychArticles, PsychInfo) and 3 internal databases (Scientific Information Database (SID), Magiran, Noormags) were searched. Therefore, in this study, we intended to investigate the relationship between these two variables of death anxiety and suicide in the patient with Covid-19 and show the relationship between these variables. Also, why might a person, who is anxious to die and fears death, carry out suicide, and does the Covid-19 pandemic play a role?
 Case report
The case study is a 34-year-old single man who has not been married before, has a bachelor's degree, and is self-employed. After carrying out suicide with medication and recovery, he was interviewed and followed up in the hospital. According to him, he did not have any financial problems and had the minimum necessary to be able to afford living expenses safely. He has owned a clothing store for many years and is satisfied with his income and has been able to buy a car for himself and rent a house in a relatively good place in Tehran city.
The patient's mental state before the epidemic in his own language
I have been migrating to Tehran for several years to continue my studies, and from the first year of university I worked part-time, I have always stood on my own, I did not ask anyone for help as much as possible. I have always tried to be successful and rich, and I thought I would be able to do everything by myself. I have never seen a psychologist or psychiatrist before, but since I was a teenager, I have felt that I am often not psychologically like everyone else. I had a lot of ability to plan and achieve my goals. I feel good whenever I focus and can predict and control everything. I can claim that I almost did not have a specific psychological problem before the epidemic.
The mental state of the patient in the Covid-19 pandemic in his own language
When I first heard about the Covid-19 from the media, I did not have much stress and anxiety and I did not think that the virus would reach Iran. But since the first case of this virus was reported and confirmed in Iran, and exactly one day after I entered the street and almost half of the people had been hit by masks, I felt that I should be afraid too. I went and got a mask and tried to cheer myself up.
 A few days passed like this until the number of infected people increased and the first cases of death due to the virus were reported. My anxiety increased a lot. I could not go anywhere I wanted anymore. I often ate outside; this was also being taken away from me little by little. I knew a few people in Tehran and my relationship was limited to a few from the beginning, but now I could not be with them anymore. I was also in contact with a limited number of people. I was living alone and that was good at first because I thought I was not in a relationship with anyone and I would not get infected. But after a few weeks, I became very anxious and stressed. What happens if I get sick with Covid-19? May I die? Yes, many may die. Why don't you die? If I get sick or die, not a single person will know. If I die, who will send money to the family? After a while, I thought I was dead all the time, and while I was being eaten by worms, there was no one to even bury me. Even most of my dreams were about dying; even in my sleep, I could not escape from death.
Suicide day
The thought of dying like this, and this amount of stress and anxiety was driving me crazy. So I decided that what I really needed to do was learning how to do it right. The reason for choosing the suicide method was simply the availability of a large number of different pills in the refrigerator. I had been thinking about suicide for a few days before I carried out it that day.
After taking a lot of pills, I became very ill for a while. I almost lost consciousness and fell to the ground in the hallway. Neighbors brought me to the hospital. Of course, at first they were afraid that it might be infection with Covid-19 (the patient smiles) but they called the emergency and took me to the hospital.
The patient knows the root of his problems after the pandemic, that is, he considers Covid-19 to be the cause of all anxiety, stress, and suicide. However, the patient's childhood examination shows that the patient didn’t have very favorable conditions in childhood. He was the only child of a middle-class family, and according to him, his parents expected a lot from him. He always had to act like adults. He even spent money like an adult. According to him, he tried his best to please his parents, but he always thought he should try a little harder. As a teenager, the patient had to adjust to the role provided by the parents. Despite not needing money, he spent more time working and earning encouragement from his parents and elders, but he almost never spent time with his friends. When he went to university, he felt as if he has been made just for work and money. He could not easily communicate with the academics because he did not understand their world and thought they were children. His relationship with his mother was not very good and he never received as much love and attention from her as he wanted and he could not establish an intimate and deep relationship with women except when working. He always thought he could only marry a woman who was independent and wealthy. For him, even marriage was a means to more income, more growth, and more success. Perhaps the main reason for the patient's suicide is related to death anxiety. Death anxiety is one of the pillars of philosophy and existential approach [24]. In this approach, it is assumed that each individual must deal with the underlying issues of ultimate concern, which are: death anxiety, freedom, loneliness, and meaning. Existential psychotherapy is an attitude towards human suffering and does not use any therapeutic guidelines. This treatment raises profound questions about the nature of the human species and the nature of anxiety, frustration, grief, loneliness, isolation, and abnormality. It also centrally challenges with questions about meaning, creativity, and love.
Examining the patient from an existential perspective
Death anxiety in the patient manifests itself with the onset of Covid-19 disease. The patient has never had a near-death experience or any other life-threatening experience such as an accident or fall, so the Covid-19 pandemic was the patient's first serious encounter with the issue of death anxiety. The patient has been safe from this anxiety for years and has not experienced it before and therefore, was not prepared for it at all and has faced this death anxiety with almost the least ability. Another pillar of this approach is solitude. The patient had lived alone for many years, but before Covid-19 pandemic he had been in contact with at least a few people, and at least whenever he felt the need he could make friends because of his working and financial situation. But the epidemic led him to the fact that he was doomed alone. Before the Covid-19 pandemic, he felt lonely, but he thought he could be alone whenever he wanted. Another variable in this existential approach is freedom. Usually, a lonely person has a lot of freedom. He can go wherever he wants to eat any food he wants (patient definition of freedom). But the Covid-19 pandemic completely disrupted the patient's sense of freedom. He could no longer go where he wanted to go, he could no longer go to restaurants and eat whatever food he wanted. The patient’s choices were very limited. He no longer had the ability to control, plan, and anticipate, and rely too much on them to feel good. Another variable of this approach is the meaning of life. Prior to the epidemic, the patient's goal was greater progress, success, and income. But an epidemic in this superficial sense had also taken hold. Now that he was going to die, what did high income, success, and further growth mean? Were these the means by which the patient could grasp them and endure the anxiety of death?
An examination of the existential approach shows that he has encountered problems in all four main areas of this approach. On the other hand, previous studies have shown the correlation between death anxiety [24], loneliness [25], freedom [26], and meaninglessness [27]. It also manifests itself as death anxiety through its recurring nightmares. This is often the message of accepting death anxiety. If we do not actually accept death, we will face it in our sleep [28]. But why does a patient who is suffering from death anxiety and fleeing death decide to carry out suicide? In the case of this disease, although the patient claims that he just wanted everything to end, if we examine the suicide a little deeper, we will find that the patient ends the unbearable anxiety through suicide, at least a little. Through suicide, he finds at least a little sense of control over when and how to die. Thus he finds the freedom to end life by himself and the way he chooses, not as he encounters it in his dreams. But why does the patient regret it soon after carrying out suicide and end up in the hallway? The first is that he has never encountered death up close, and the second is that suicide still does not give meaning to his life. The patient has plans for the future, so suicide draws a line at all of these plans and goals. The patient responds positively to the design of existential variables in the session and wishes to discuss these variables further with the psychologist after discharge from the hospital. At the end of the session, the patient states that he has forgotten his origin and that it is time to discover the meaning of his life.
As indicated by the results, the patient in all areas including death anxiety, loneliness, freedom, and meaning of life carries problems that he has always been unaware of their existence. Covid-19 has disclosed them all to him at once. The patient carried out suicide due to the inability to cope with these anxieties. Also, a study of the patient's life history showed that he has ignored his existence from an early age and has been a victim of his parents' wishes. The patient has had a strong desire to control, anticipate, and plan for the future since childhood, and Covid-19 has taken them all away. By designing existential variables, it was confirmed that he has never had a meaning in life and always ignored himself. He also expressed a desire to become more familiar with the approach to the originality of existence and to begin to know oneself.
Conflict of interest
The authors have declared no conflict of interest for this study.
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Type of Study: Research | Subject: Special
Received: 2021/08/24 | Accepted: 2021/03/30 | Published: 2021/03/30

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