munity, killing 11 residents), the El Al Boeing 747-F air disaster (in. 1992, an .... were exposed happened in December 1994, when a Boeing 737-. 2D6C was ...
Death Studies, 24: 689–704, 2000 Copyright Ó 2000 Taylor & Francis 0748-1187 / 00 $12.00 1 .00
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TRAUMA TIC STRESS A ND DEATH ANXIETY A MONG COMMUNITY RESIDENTS EXPOSED TO A N A IRCRA FT CRASH `
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MA N CHEUNG CHUNG University of Sheffield, Sheffield, England CA THERINE CHUNG University of Sheffield, Sheffield, England YVETTE EA STHOPE University of Wolverhampton, Wolverhampton, England
T his article examined the relationship between traumatic stress and death anxiety among community residents who lived near woodlands in which an aircraft had crashed in Coventry, England. T he hypothesis was that there would be a high level of impact of the crash experienced by residents and that the residents would experience psycholog ical distress. It was also hypothesized that the impact of the crash and distress were associated with death anxiety. Eig hty-two residents were interviewed for the study. T hey were asked to complete the Impact of Event Scale, the General Health Questionnaire ( GHQ) , and the D eath Anxiety Scale. T he results showed that Coventry residents were f ound to experience intrusive thoug hts and display avoidance behavior. T he residents’ intrusive thoughts and avoidance behavior were sig nicantly more severe than one g roup of Horowitz’s standardized samples ( i.e., the medical students) , but not signi cantly diå erent f rom another g roup ( i.e., the stress clinic samples) . Fifty-seven percent scored at or above the GHQ cutoå point, which meant that they were considered to be psychiatric cases. Community residents scored sig ni cantly lower in death anxiety than the standardized high-death anxiety patients but no diå erently from the standardized control patients. Correlations were found between the impact of the event, psycholog ical distress, and death anxiety.
Received 16 September 1999 ; accepted 26 January 2000. Address correspondence to Man Cheung Chung, University of Sheffield, Institute of General Practice and Primary Care, Community Sciences Centre, Northern General Hospital, Herries Road, Sheffield S5 7AU, England.
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Traumatic psychological reactions of people who have been exposed to aircraft disasters have been reported in several studies, focusing on such disasters as the Lockerbie air disaster ( in 1988, Pan Am Flight 103 exploded in mid-air, killing all on board—its wreckage and burning aviation fuel fell onto the Lockerbie community, killing 11 residents) , the El Al Boeing 747-F air disaster ( in 1992, an aircraft crashed into two apartment buildings in Bijlmermeer, Amsterdam, killing 43 people and causing 260 people to lose their homes) , and the Gander aircrash ( in 1985, a chartered airliner crashed on take-oå , following a refuelling stop, killing 248 U.S. Army soldiers) . Because of the often 100% mortality rates of such disasters, these studies do not focus on people who were on board. Rather, they focus on people such as community residents or disaster helpers. In the studies on community residents exposed to the Lockerbie and the El Al Boeing 747-F air disaster, the ndings on the whole showed that people could consequently manifest post-traumatic stress disorder ( PTSD) or partial PTSD, panic and anxiety disorder, and depression ( Brooks & McKinlay, 1992 ; Carlier & Gersons, 1995 ; Gersons & Carlier, 1993 ; Livingston, Livingston, Brooks, & McKinlay, 1992) . Some of these victims still su å ered from PTSD after 6 months ( Carlier & Gersons, 1997) . Research has also shown that various types of helpers can su å er from psychological distress by being involved in disaster rescue operations ( e.g., Hodgkinson & Shepherd, 1994 ; McCarroll, Ursano, Wright, & Fullerton, 1993 ; Paton, 1989 ; Stuhlmiller, 1994) , including aircraft disaster operations. For example, as a result of involvement in the Mount Erebus aircrash ( in which the 257 people on board died) rescue operation, Taylor and Frazer ( 1982) pointed out that, in 3 months, 53% of the personnel reported moderate severity in symptoms such as intrusive thoughts, bad dreams, sleep disturbance, wanting to be alone, tension, depression, somatization, obsessive and compulsive problems, interpersonal sensitivity, and anxiety. Similarly, the Gander aircrash in 1985 put helpers and others ( e.g., grieving families, commanders of the lost troops and soldiers who arrived safely on other ights, service providers who worked closely with bereaved families, chaplains, mental health workers and mortuary workers, school personnel, and some members of social organizations or authorities) at great risk of becoming sec-
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ondary victims ( Wright & Bartone, 1994 ; Wright, Ursano, Bartone, & Ingraham, 1990) . Six months later, many assistance officers who were involved with helping families a å ected by the Gander aircrash reported symptoms such as headaches, nervousness or tenseness, sleep disturbance, general aches and pains, common colds, depressed moods, and feeling tired/ lacking energy. One year later, on the whole, all of the above symptoms had almost doubled in severity ( Bartone, Ursano, Wright, & Ingraham, 1989) . Ursano and McCarroll ( 1990) reported that helpers such as police officers and re personnel had been traumatized through viewing, smelling, and touching dead bodies. One might speculate that disasters such as the above would likely generate a great deal of anxiety concerning death for the community residents or the helpers involved. Indeed, awareness of their own death might be heightened as a result. Research has shown that death anxiety has been found to be associated with exposure to traumatic or life-threatening events, such as the civil disturbance in Northern Ireland. People were found to be characterized by their concern about shortness of life, the viewing of a corpse, and contracting cancer ( Lonetto, Fleming, & Mercer, 1979 ; Lonetto, Mercer, Fleming, Bunting, & Clare, 1980) . Victims of the Bu å alo Creek ood disaster were found to manifest death anxiety related to memories and images of the disaster. They had fears that were constituted of inner terror and their dreams were related to their own death ( Lifton & Olson, 1976) . Several studies have revealed a signi cant relationship between death anxiety and psychological distress. Death despair, death loneliness, death dread, death sadness, death depression, and death nality were correlated positively with death anxiety, general depression, and general anxiety ( Templer, Lavoie, Chalgujlan & Thomas-Dobson, 1990) . Death anxiety or death depression was found to be associated with people who were su å ering from illnesses. One study showed that, as expected, people terminally ill with cancer tended to have signi cantly higher death anxiety scores than orthopedically ill patients ( Sinha & Nigan, 1993) . HIV victims were also found to manifest signi cant correlations between death anxiety or depression and state-trait anxiety and clinical depression ( Hintze, Templer, Cappelletty, & Frederick, 1994) . Florian, Mikulincer, and Green ( 1993) also found associations
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between fear of personal death factors and psychological distress of paranoia, psychasthenia, and schizophrenia. However, such seemingly straightforward positive correlations between death anxiety and traumatic events or life-threatening experiences may be considered somewhat controversial. Some studies have suggested that on the whole, after having experienced near-death experiences, people tended to become less fearful of death ( Gallup & Proctor, 1982) . For example, Noyes ( 1980) reported that 41% of survivors of life-threatening accidents or illnesses claimed that their fear of death had reduced since the accident or illness. Resignation to death, which survivors described as a remarkable aspect of their experience, often brought a sense of peace and tranquillity. As a result of these accidents and illnesses, many survivors claimed that they had obtained a greater awareness of death and felt that their near-death experiences brought them closer to death. They could now integrate it more fully into their lives. Similarly, we conducted a study examining the traumatic experience of the survivors of a 1989 boat-sinking disaster in the river Thames in London, in which 51 people died. Some of the descriptions of the survivors revealed unexpected results. Some explained that when they gave up struggling under the water, they felt calm and were curious about what death was like ( Thompson, Chung, & Rosser, 1995) . Several pieces of research have demonstrated that patients with terminal cancer had lower Death Anxiety Scale scores than those who did not have cancer ( Dougherty, Templer, & Brown, 1986 ; Gibbs & Achterberg-Lawlis, 1978) . People who had experienced a life-threatening cardiac arrest were found to lose much of their fear of dying immediately after the event, as opposed to those who did not have such a near-death experience. A 6-month follow up study also showed that those who had the near-death experience scored signi cantly lower on both the Death Anxiety Scale and the Death Concern Scale than those who had not had such an experience ( Sabom, 1982) . Ring ( 1980) reported that among 49 people who had had near-death experiences, 80% claimed that their fear of death had decreased or vanished entirely, as opposed to 29% of a control sample of non-near-death experience participants. Flynn ( 1986) reported that of 21 people who had near-death experiences, all claimed that their fear of death had decreased. On the other
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hand, of 12 survivors who did not have near-death experiences, 42% claimed their fear of death had decreased, 25% reported it had not changed, and 33% claimed it had increased. Focusing on the relationship between near-death experiences and the feeling of life or death threat, Neimeyer, Dingemans, and Epting ( 1977) reported that previous closeness to dying was not signi cantly associated with Threat Index scores. In a post-hoc analysis, Rigdon and Epting ( 1985) found that participants reporting a previous close brush with death tended to have lower Threat Index scores than those who did not report having been close to death, although that di å erence was not signi cant. Greyson ( 1994) reported that near-death experience participants showed signi cantly less death threat than non-near-death experience participants or participants who had never been near to death. Among the near-death experience group, deeper near-death experiences were associated with less death threat. It is clear from the foregoing research ndings on traumatic stress that people ( e.g., community residents or helping professionals) exposed to disasters ( e.g., aircraft disasters) could consequently develop traumatic stress responses. These responses could be manifested in diå erent forms. However, the relationship between death anxiety and traumatic events remains unclear, with particular reference to aircraft disasters. In this study, we set out, rstly, to clarify further the traumatic responses of community residents exposed to traumatic events, in this case, an aircraft crash ( see later descriptions) . In particular, we wished to focus on the extent to which residents thought about or avoided thinking about the crash. Secondly, we aimed to focus on the psychological health of these community residents after the crash. Finally, we aimed to clarify the association between death anxiety and the traumatic eå ect of the crash. We hypothesized that residents experienced a high level of impact of the event, measured in terms of intrusive thoughts and avoidance behavior, and experienced some degree of psychological distress. We also hypothesized that the impact of the crash and distress were associated with death anxiety. The aircraft crash to which the present community residents were exposed happened in December 1994, when a Boeing 7372D6C was returning to Coventry, England from the Netherlands, having exported a cargo of live animals. On board were two pilots,
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a maintenance engineer, and two stock handlers. At approximately 0952 hours, the left wing of the aircraft accidentally struck a 132 kV, 86 ft high pylon at a distance of approximately 1.1 miles from the runway of Coventry airport. Consequently, the aircraft lost control and rolled uncontrollably to the left. At this stage, the aircraft was immediately above a complex of housing estates. It banked slightly beyond the vertical and the left wingtip struck the gable ends of two houses. The aircraft passed over the end houses, still rolling to the left and descending. Finally, almost fully inverted, it hit a lamp-post on a street and crashed into an area of woodland close to the edge of a large housing estate. Multiple res started and spread progressively a short time after the crash, growing into an intense re. Although hundreds of residents had escaped death, all 5 people on board died ( HMSO, 1996) . Method Participants Eighty-two local residents ( 29 men, 53 women) were selected for the study. Ninety-eight percent ( n 5 80) were Caucasian and the rest ( n 5 2) were Afro Caribbean. The average age was 50.48 ( SD 5 18.37) , ranging between 14 and 81. Over half were married ( n 5 44 ; 55% ) , and the rest were single ( n 5 18 ; 22% ) , widowed ( n 5 12 ; 15% ) , divorced ( n 5 7 ; 9% ) , or separated ( n 5 1 ; 1% ) . Almost one third ( n 5 30 ; 38% ) were retired ; 12 ( 15% ) were unemployed ; 26 ( 32% ) were employed ( e.g., building laborers, mechanics, engineers, factory workers, nurses, cleaners, waitresses, security guards, social servants, and shop assistants) ; and 14 ( 18% ) were housewives. Their average length of residence was 16 years, ranging from 1 to 40 years. Procedure The study commenced approximately 6 months after the disaster. We approached 150 households who lived between 100 and 300 meters from the crash. In other words, the sample was a convenience sample. Letters explaining the purpose of the research were
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distributed. The letter also informed residents that the research team would be visiting them for interviews. Nine people refused to participate in the study. Two were not relevant because they had moved there after the crash. The rst household, whose gable end had been struck by the aircraft, had moved. Fifty-six residents were not at home when visited and the remaining 82 were interviewed. They were interviewed using a semi-structured questionnaire that aimed to collect information on their experience and knowledge of the accident. The results of this questionnaire have been reported elsewhere ( Chung, Easthope, Eaton, & McHugh, 1999) . Participants were then asked to ll in the Impact of Event Scale, the General Health Questionnaire, and the Death Anxiety Scale. Measures The Impact of Event Scale ( IES ; Horowitz, Wilner, & Alvarez, 1979) is a 15-item, four-point scale ( 0 5 not at all, 1 5 rarely, 3 5 sometimes, 5 5 often) , self-report instrument that measures intrusive recollection phenomena related to the traumatic event and consequent avoidance behavior. The questionnaire was tested on two samples: stress clinic patients ( n 5 66) and medical students ( n 5 110) who had recently begun dissection of a cadaver. The stress clinic patients had stress response syndrome due to having experienced bereavement, accident, violence, illness, or surgery. There was a high internal consistency of the two subscales ( intrusion 5 0.78, avoidance 5 0.82) . There was also a high test– retest reliability of 0.89 for intrusion and 0.79 for avoidance. The General Health Questionnaire 28 ( GHQ-28 ; Goldberg & Hillier, 1979) was designed as a screening instrument that attempts to estimate the likelihood of participants being assessed as psychiatric cases at interview. There are four subscales to this questionnaire: Somatic, Anxiety, Social Dysfunction, and Depression. As the total GHQ score exceeds the recommended cutoå point of 4, the probability of psychiatric caseness increases. Thus, the GHQ-28 was used as a screening test using a simple scoring method ( 0–0–1–1) . The Death Anxiety Scale ( DAS ; Templer, 1970) is a 15-item, two-point scale ( true or false) , self-report instrument that measures
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death anxiety. The scoring system is 1 5 true and 0 5 false for questions 1, 4, and 8–14. The rest of the questions are scored 0 5 true and 1 5 false. The questionnaire has a test–retest reliability of 0.83 and an internal consistency coefficient of 0.73. Results Table 1 shows the mean scores of the two IES subscales of the Coventry residents and Horowitz’s medical students and Stress Clinic samples. We pooled together the means and standard deviations of males and females in both of Horowitz’s samples and subsequently arrived at new means and standard deviations for comparison purposes. T tests showed that the Coventry residents were signi cantly higher in both intrusion ( t 5 13.32, df 5 184, p = .001) and avoidance ( t 5 9.77, df 5 184, p = .001) than the medical students. However, the Coventry residents scored slightly lower than the Stress Clinic sample but there were no signi cant diå erences between them ( intrusion t 5 0.95, df 5 140, ns ; avoidance t 5 0.29, df 5 140, ns) . The IES results showed that with regard to intrusive thoughts, over 40% often had waves of strong feeling about the disaster ( 45% ) , and found that any reminders could bring back feelings about it ( 41% ) . Over 30% found that other things kept making them think about the disaster ( 38% ) and had trouble falling or staying asleep ( 36% ) . Thirty-three percent often had pictures of the disaster popping into their minds and 25% often thought about it when they did not mean to. Most ( 70% ) did not have, or rarely had, dreams about it. In terms of avoidance behavior, over 30% often tried to consciously remove the disaster from memory and not think about it. TA BLE 1 Mean Scores and Standard Deviations of Coventry Residents and Horowitz’s Medical Student and Stress Clinic Samples I ES subscales Intrusion Avoidance
Coventry residents
Medical students
Stress clinic
18.53 ( 10.69) 17.56 ( 11.26)
3.64 ( 3.87) 5.1 ( 5.88)
21.35 ( 9.65) 19.02 ( 11.46)
N ote. Standard deviations in parentheses.
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Over 20% often found themselves consciously trying to stay away from reminders, avoided letting themselves get upset and tried not to talk about it. Twenty-seven percent experienced feelings of numbness. Less than 20% often felt that they had lots of feelings that they had not dealt with or felt that the disaster was not real. The total score of the GHQ was 7.65 ( SD 5 7.90) , which was well above the cutoå point of 4. This meant that these residents were thought to be psychiatric cases. The results also showed that 57% scored at or above the cutoå point of 4. Table 2 showed the percentages of residents who responded to the individual items of the DAS. The results were mixed in that, on the one hand, the majority ( 70% ) of the residents were not very much afraid to die. Sixty percent said that the thought of death never bothered them. Just over half said that the thought of death seldom entered into their minds and that they were not at all afraid to die. A large majority ( 80% ) of residents said that the subject of life after death did not trouble them greatly and 60% said that the future held nothing for them to fear. Over 60% also said that they were not particularly afraid of getting cancer and that the sight of a dead body was not horrifying to them. On the other hand, a large majority of the residents ( 80% ) were fearful of dying a painful death and over 70% said that they often thought about how short life really was. Over 60% said that it did TA BLE 2 Percentages of True and False Items of the Death Anxiety Scale Death anxiety items
True (% )
False (% )
I am very much afraid to die The thought of death seldom enters my mind It doesn’t make me nervous when people talk about death I dread to think about having to have an operation I am not at all afraid to die I am not particularly afraid of getting cancer The thought of death never bothers me I am often distressed by the way times ýies so very rapidly I fear dying a painful death The subject of life after death troubles me greatly I am really scared of having a heart attack I often think about how short life really is I shudder when I hear people talking about a World War III The sight of a dead body is horrifying to me I feel that the future holds nothing for me to fear
29 53 36 41 52 60 60 62 80 20 57 74 54 35 60
71 47 64 59 48 40 40 38 20 80 43 26 46 65 40
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TA BLE 3 Correlations Between Death Anxiety and the General Health and the Impact of Event Death Anxiety Items I am very much afraid to die The thought of death seldom enters my mind It doesn’t make me nervous when people talk about death I dread to think about having to have an operation I am not at all afraid to die I am not particularly afraid of getting cancer The thought of death never bothers me I am often distressed by the way times ýies so very rapidly I fear dying a painful death The subject of life after death troubles me greatly I am really scared of having a heart attack I often think about how short life really is I shudder when I hear people talking about a World War III The sight of a dead body is horrifying to me I feel that the future holds nothing for me to fear
GHQ total
]
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0.14 0.11 0.01 0.13 0.13 0.26* 0.05 0.05 0.09 0.01 0.01 0.11 0.14 0.28* 0.16
IES total
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]
0.25* 0.13 0.13 0.16 0.23* 0.14 0.07 0.08 0.13 0.01 0.13 0.14 0.23* 0.37* * 0.12
N ote. * Correlation was signiücant at the 0.05 level. * * Correlation was signiücant at the 0.01 level.
make them feel nervous when people talked about death and that they were often distressed by the way time ies so very rapidly. Over 50% said that they were really scared of having a heart attack and that they shuddered when they heard people talking about a World War III. About 40% said that they dreaded to think about having to have an operation. We compared the mean scores of the total death scores ( M 5 7.25, SD 5 2.28) with those of Templer’s high death anxiety patients ( M 5 11.62, SD 5 2.45) and control patients ( M 5 6.77, SD 5 2.58) . The results showed that the community residents scored signi cantly less ( t 5 ] 7.54, df 5 93, p = .001) in death anxiety than the high death anxiety patients. However, there was no signi cant di å erence between the community residents and Templer’s control patients ( t 5 0.81, df 5 93, ns) . Correlation coefficients were computed to identify the relationships between the impact of the event, the general health, and death anxiety. The results showed that ‘‘I am very much afraid to die,’’ ‘‘I am not at all afraid to die,’’ ‘‘I shudder when I hear people talking about a World War III,’’ and ‘‘The sight of a dead body is horrifying to me’’ were correlated with the IES total. ‘‘I am not particularly afraid of getting cancer’’ and ‘‘The sight of a
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dead body is horrifying to me’’ were correlated with the GHQ total ( see Table 3) . Further analyses showed that the death anxiety total was not associated with the two subscales of the IES ( Intrusion : r 5 0.05, ns ; Avoidance : r 5 0.14, ns) . Neither was it associated with the four subscales of the GHQ ( Somatization : r 5 0.021, ns ; Anxiety : r 5 ] 0.022, ns ; Social dysfunction : r 5 0.120, ns ; Depression : r 5 ] 0.029, ns) . Discussion The results seemed to support the hypothesis that at the time of the study, the residents still experienced a high level of impact of the crash. That is, the level was higher than that of Horowitz’s medical students but no di å erent from patients who received specialized treatment of stress response syndromes. This implied that the Coventry residents could be comparable to people who have been referred for psychological treatment of their traumatic stress. To accompany the high impact of the crash, we considered over half of the subjects to be psychiatric cases, which con rmed the hypothesis that the residents experienced psychological distress. Anxiety ( 45% scored at 4 or above) was particularly problematic, probably due to the fact that residents still felt anxious about what could happen to them. That is, aircrafts were still ying low on a daily basis, so a similar incident could happen again, even though most of the residents interviewed did say that, rationally speaking, the chance was very low. Nevertheless, such rational thinking did not necessarily eradicate the anxiety of what they might experience. Somaticism was less of a problem in that 34% scored 4 or above. One family experienced the direct impact of the disaster in that the mother, who was upstairs at the time, heard a loud and frightening aircraft ying past and a loud ‘‘bang’’ downstairs. She then ran downstairs and found wreckage of the aircraft and of the house next door ( the roof of which had been clipped by the plane) , in the living room. The wreckage went through the glass of the front door and barely missed the children playing in the living room. Since then, she had developed clear signs of somatic problems in that, as aircraft ew by at night, her mouth became dry and she developed
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a dry cough. Also, she developed what she called ‘‘red skin’’—a rash had appeared on her skin. The ndings revealed some amount of death anxiety but not as much as the patients with high death anxiety. The hypothesis that the impact of the crash, and distress were correlated with death anxiety was supported. There were more correlations between the impact of the crash and death anxiety. It was plausible that the crash had created an idea in the minds of many residents that they were very lucky to be alive. In other words, their awareness of death might have increased as a result. The subject of death was probably enhanced by the fact that ve people had died in the disaster and that the area devoid of trees was a reminder of death. In addition, the ‘‘anxiety’’ aspect of death might have been a å ected by the fact that a large majority were still anxious about their safety as they could still hear aircrafts ying overhead. Seemingly, a large majority of the residents could cope with death on an intellectual level. That is, they could discuss death and did not particularly feel nervous about it. As a result of the intellectual treatment of the subject of death, the residents could distance themselves emotionally from it. This perhaps explains why 71% reported that they were not very much afraid to die. However, when they were asked to respond to the statement ‘‘I am not at all afraid to die,’’ 48% said that it was false. That is, although a large majority were not ‘‘very much’’ afraid to die, just over half reported a degree of anxiety about death. A large majority of the residents were concerned about the stress and pain involved in death. This was probably connected with their concern about death by heart attack, cancer, and war. Although one might argue that it was only human to be afraid of dying a painful death, one could suggest that such fear was possibly heightened by the aircraft crash, in the fact that people died in a ‘‘painful’’ air disaster. A disaster could possibly make people become more aware of how fragile and indeed, short, life can be. A large majority ( over 60% ) of the residents were aware of time ying by quickly and of the fact that life was rather short. Only a minority of residents were afraid of seeing a dead body. In the light of the aircraft crash, although no one interviewed had actually seen any dead or mutilated bodies from the crash, many could imagine how horrifying it could be to have to collect human
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remains from the crash. Nevertheless, on the whole, most people interviewed did not seem to nd the death of the ve crew members disturbing because they were more occupied by the fact that aircrafts continued ying past. Of course, not all residents were bothered to a signi cant degree by death anxiety. For example, one couple explained that this disaster did not make them worry about death, the reason being that they had been exposed to even worse ‘‘life-threatening events’’ in the world wars. As a result, to them, the aircraft crash was a lot less traumatic. Focusing on depression, the present nding has contradicted previous ndings, for example, Templer et al.’s ( 1990) correlation between the six factors of the Death Depression Scale and death anxiety, in addition to general depression and anxiety ( Templer et al., 1990) and Hintze et al.’s ( 1994) correlations between death anxiety, death depression, and depression, in addition to state anxiety, trait anxiety, and other variables. The lack of association between death anxiety and depression in the present study could be accounted for by the fact that the GHQ subscale of depression consisted of speci c items on suicidal intent. Indeed, most residents did not nd them appropriate. For example, 88% did not think that ‘‘life was not worth living’’ ; 86% did not think they would ‘‘make away with themselves’’ ; 93% did not ‘‘wish to be dead’’ ; and 89% did not have thoughts about ‘‘the idea of taking their own lives.’’ Perhaps, a more general measure on depression needs to be used to identify, if any, the depressive features of the present residents and their association with death anxiety. To close the study, it is worth making two remarks. One concerns further studies and the other concerns some clinical implications of the present study. First, although the present study has revealed a glimpse of the relationship between death anxiety and traumatic stress, we feel that death anxiety, measured solely by the DAS, was somewhat limited. Consequently, the foregoing relationship might be underexplored. To further investigate that relationship in future studies, one would need to supplement the DAS with other instruments. For example, the Multidimensional Fear of Death Scale ( Neimeyer & Moore, 1994) could be used to explore di å erent dimensions of fear of death. The combination of death
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anxiety and the fear of death should give us much richer data on the notion of death. An attempt can then be made to see if traumatic stress, resulting from a ‘‘life-threatening and death-related event’’ or a ‘‘near-death’’ experience, such as the aircraft crash in the present study, is correlated with the above data. This is one possible way of enhancing our understanding of the relationship between death and traumatic stress. Secondly, one important implication from the present study is that to help people who su å er from death anxiety one might need to explore any past traumatic events that they might have experienced. In other words, our death anxiety might actually be a manifestation of some past traumatic event, the eå ects of which have not been properly dealt with. By the same token, to help people who su å er from traumatic stress responses we need to explore the possibility of death anxiety and fear of death constituting part of these responses, even though death anxiety and fear of death might not be apparent to many clinicians. One reason for this is that they are inclined to put emphasis on the well-recognized traumatic stress symptoms of intrusive thoughts, avoidance behavior, general anxiety, and the like.
References Bartone, P. T., Ursano, R. J., Wright, K. M., & Ingraham, L. H. ( 1989) . The impact of a military air disaster on the health of assistance workers : a prospective study. J ournal of N ervous and M ental D isease, 177, 317–328. Brooks, N., & McKinlay, W. ( 1992) . Mental health consequences of the Lockerbie disaster. J ournal of T raumatic Stress, 5, 527–543. Carlier, I . V. E., & Gersons, B. P. R. ( 1995) . Partial posttraumatic stress disorder ( PTSD) : The issue of psychological scars and the occurrence of PTSD symptoms. J ournal of N ervous and M ental D isease, 183, 107–109. Carlier, I. V. E., & Gersons, E. P. R. ( 1997) . Stress reactions in disaster victims following the Bijlmermeer plane crash. J ournal of T raumatic Stress, 10, 329–335. Chung, M. C., Easthope, Y., Eaton, B., & McHugh, C. ( 1999) . Describing traumatic responses and distress of community residents directly and indirectly exposed to an aircraft crash. Psychiatry : Interpersonal and Biolog ical Processes, 62, 125–137. Dougherty, K., Templer, D. I., & Brown, R. ( 1986) . Psychological states in terminal cancer patients as measured over time. J ournal of Consulting Psycholog y, 33, 357–359.
T raumatic Stress and Death A nxiety
703
Florian, V., Mikulincer, M., & Green, E. ( 1993) . Fear of personal death and the MMPI pro le of middle-age men : The moderating impact of personal losses. Omega, 28, 151–164. Flynn, C. P. ( 1986) . A fter the beyond : Human transf ormation and the near-death experience. Englewood Cli å s, NJ : Prentice-Hall. Gallup, G., & Proctor, W. ( 1982) . A dventures in immortality : A look beyond the threshold of death. New York : McGraw-Hill. Gersons, B. P. R., & Carlier, I . V. E. ( 1993) . Plane crash crisis intervention : A preliminary report from the Bijlmermeer, Amsterdam. Crisis, 14, 109–116. Gibbs, H. W., & Achterberg-Lawlis, J. ( 1978) . Spiritual values and death anxiety : Implications for counseling with terminal cancer patients. J ournal of Counseling Psycholog y, 25, 563–569. Goldberg, D. P., & Hillier, V. F. ( 1979) . A scaled version of the General Health Questionnaire. Psycholog ical M edicine, 9, 139–145. Greyson, B. ( 1994) . Reduced death threat in near-death experiencers. In R. A. Neimeyer ( Ed.) , Death anxiety handbook ( pp. 169–179) . Washington, DC : Taylor & Francis. Hintze, J., Templer, D. I ., Cappelletty, G. G., & Frederick, W. ( 1994) . Death depression and death anxiety in HI V-infected males. In R. A. Neimeyer ( Ed.) , D eath anxiety handbook. Washington, DC : Taylor & Francis. Her Majesty’s Stationery Office. ( 1996) . Report on the accident to Boeing 737-2D 6C, 7T -VEE at Willenhall, Coventry, Warwickshire on 21 D ecember 1994. London : HMSO. Hodgkinson, P. E., & Shepherd, M. A. ( 1994) . The impact of disaster support work. J ournal of T raumatic Stress, 7, 587–600. Horowitz, M., Wilner, N., & Alvarez, W. ( 1979) . I mpact of Events Scale : A measure of subjective stress. Psychosomatic M edicine, 41, 209–218. Lifton, R. J., & Olson, E. ( 1976) . The human meaning of total disaster: The Bu å alo Creek experience. Psychiatry, 39, 1–18. Livingston, H. M., Livingston, M. G., Brooks, D. N., & McKinlay, W. W. ( 1992) . Elderly survivors of the Lockerbie air disaster. International J ournal of Geriatric Psychiatry, 7, 725–729. Lonetto, R., Fleming, S., & Mercer, G. W. ( 1979) . The structure of death anxiety : A factor analytic study. J ournal of Personality Assessment, 43, 388–392. Lonetto, R., Mercer, G. W., Fleming, S., Bunting, B., & Clare, M. ( 1980) . Death anxiety among university students in Northern Ireland and Canada. J ournal of Psycholog y, 104, 75–82. McCarroll, J. E., Ursano, R. J ., Wright, K. M., & Fullerton, C. S. ( 1993) . Handling bodies after violent death : Strategies for coping. A merican J ournal of Orthopsychiatry, 63, 209–214. Neimeyer, R. A., Dingemans, P. M. A. J., & Epting, F. R. ( 1977) . Convergent validity, situational stability and meaningfulness of the Threat Index. Omega, 8, 251–265. Neimeyer, R. A., & Moore, M. K. ( 1994) . Validity and reliability of the multidimensional fear of death scale. In R. A. Neimeyer ( Ed.) , D eath anxiety handbook ( pp. 103–119) . Washington, DC : Taylor & Francis.
704
M . C. Chung et al.
Noyes, R. ( 1980) . Attitude change following near-death experiences. Psychiatry, 43, 234–242. Paton, D. ( 1989) . Disaster and helpers: Psychological dynamics and implications for counselling. Counselling Psycholog y Quarterly, 2, 303–321. Rigdon, M. A., & Epting, F. R. ( 1985) . Reduction in death threat as a basis for optimal functioning. D eath Studies, 9, 427–448. Ring, K. ( 1980) . Life at death: A scientic investigation of the near-death experience. New York : Coward, McCann & Geoghegan. Sabom, M. B. ( 1982) . Recollections of death: A medical investigation. New York : Harper & Row. Sinha, S. P., & Nigan, M. ( 1993) . Stress and death anxiety. Indian J ournal of Clinical Psycholog y, 20, 78–81. Stuhlmiller, C. M. ( 1994) . Occupational meanings and coping practices of rescue workers in an earthquake disaster. Western J ournal of N ursing Research, 16, 268– 287. Taylor, A. J. W., & Frazer, A. G. ( 1982) . The stress of post-disaster body handling and victim identi cation work. J ournal of Human Stress, 8, 4–12. Templer, D. I. ( 1970) . The construction and validation of a Death Anxiety Scale. J ournal of General Psycholog y, 82, 165–177. Templer, D. I ., Lavoie, M., Chalgujlan, H., & Thomas-Dobson, S. ( 1990) . The measurement of death depression. J ournal of Clinical Psycholog y, 46, 834–839. Thompson, J . A., Chung, M. C., & Rosser R. ( 1995) . Psychological eå ects of the Marchioness disaster on survivors and relatives. European J ournal of Psychiatry, 9, 197–208. Ursano, R. J ., & McCarroll, J. E. ( 1990) . The nature of a traumatic stressor : Handling dead bodies. J ournal of N ervous and Mental D isease, 178, 396–398. Wright, K. M., & Bartone, P. T. ( 1994) . Community responses to disaster: The Gander plane crash. In R. J . Ursano, B. G. McCaughey, & C. S. Fullerton ( Eds.) , Individual and community responses to trauma and disaster ( pp. 267–284) . Cambridge, England : Cambridge University Press. Wright, K. M., Ursano, R. J ., Bartone, P. T., & Ingraham, L. H. ( 1990) . The shared experience of catastrophe : An expanded classi cation of the disaster community. American J ournal of Orthopsychiatry, 60, 35–42.
