How does fear of COVID-19 differ from depression and generalized anxiety in the interplay of death anxiety and emotion regulation?

Year 2025, Volume: 9 Issue: 2, 163 - 173, 25.08.2025

Bilge Nur Özdemir , Talat Demirsöz

https://doi.org/10.57127/kpd.26024438.1599031

Abstract

The COVID-19 pandemic had a significant impact on the mental health of medical students. Symptoms of depression and generalized anxiety intensified, and a new type of fear, the fear of COVID-19, emerged. These changes are potentially induced by increased death anxiety, and variability in psychological outcomes are potentially explained by emotion regulation differences. Terror Management Theory and Gross’s Emotion Regulation Model informed this research, and the goal of the study is to examine whether emotion regulation mediates the effect of death anxiety on depression, generalized anxiety, and the fear of COVID-19. Data from 192 medical students were gathered through online surveys, which included sociodemographic questions, the Beck Depression Inventory, Generalized Anxiety Disorder-7, Difficulties in Emotion Regulation Scale–Brief Form, Fear of COVID-19 Scale, and Death Anxiety Scale. Mediation analyses revealed that emotion regulation difficulties fully mediated the relationship between death anxiety and depression and between death anxiety and generalized anxiety. However, the mediation effect did not take place between death anxiety and COVID-19-related fear. The findings suggest that the COVID-19-related fear could be different from other psychological conditions. The study highlights the differential psychological impact of the pandemic and the vulnerability of medical students. Clinical and educational implications are discussed in the light of the relevant literature.

Keywords

fear of COVID-19 , death anxiety , depression , generalized anxiety , emotion regulation , medical students

Ethical Statement

This study was approved by the Ethics Committee of Hacettepe University under approval number 2021/10-42.

Supporting Institution

No fund was obtained for this study.

Thanks

Conflict of Interest: The authors of this article certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, know-ledge or beliefs) in the subject matter or materials discussed in this manuscript. Informed consent: Informed consent was obtained from all participants included in the study. Project/Funding: No fund was obtained for this study. Data Sharing/Availability: Data is available upon reasonable request. Authors’ Contributions: All authors contributed to the study's conception, design, and data collection. TD conducted the analyses. BNO drafted the manuscript. All authors read and approved the final manuscript.

Ölüm kaygısı ve duygu düzenlemesi etkileşiminde COVİD-19 korkusu, depresyon ve yaygın kaygı bozukluğundan nasıl ayrışır?

Abstract

COVİD-19 pandemisi, tıp fakültesi öğrencilerinin ruh sağlığını önemli ölçüde etkilemiştir. Depresyon ve yaygın anksiyete belirtileri artmış, buna ek olarak yeni bir korku türü olan COVİD-19 korkusu ortaya çıkmıştır. Bu değişimlerin, artan ölüm kaygısından kaynaklanabileceği ve psikolojik sonuçlardaki bireysel farklılıkların duygu düzenleme biçimleriyle açıklanabileceği düşünülmektedir. Bu çalışmanın kuramsal çerçevesini Terör Yönetimi Kuramı ve Gross’un Duygu Düzenleme Modeli oluşturmaktadır. Araştırmanın amacı, ölüm kaygısının depresyon, yaygın anksiyete ve COVİD-19 korkusu üzerindeki etkisinde duygu düzenleme güçlüklerinin aracı bir rol oynayıp oynamadığını incelemektir. Çalışma kapsamında, 192 tıp öğrencisinden çevrim içi anketlerle veri toplanmıştır. Anketler, sosyodemografik bilgilerin yanı sıra Beck Depresyon Ölçeği, Yaygın Anksiyete Bozukluğu-7, Kısa Duygu Düzenleme Güçlüğü Ölçeği, COVİD-19 Korkusu Ölçeği ve Ölüm Kaygısı Ölçeğini içermektedir. Aracılık analizleri, duygu düzenleme güçlüklerinin ölüm kaygısı ile depresyon ve yaygın anksiyete arasındaki ilişkide aracı rol oynuyor olduğuna işaret etmiştir. Ancak, ölüm kaygısı ile COVİD-19 korkusu arasındaki ilişkide aracılık etkisi bulunmamıştır. Bulgular, COVİD-19’a özgü korkunun diğer psikolojik durumlardan farklı bir yapıya sahip olabileceğini düşündürmektedir. Bu çalışma, pandeminin farklı psikolojik etkilerini ve tıp öğrencilerinin kırılganlıklarını ortaya koymaktadır. Klinik ve eğitim alanlarına yönelik çıkarımlar ilgili alanyazın ışığında tartışılmıştır.

Keywords

COVİD-19 korkusu , ölüm kaygısı , depresyon , yaygın kaygı , duygu düzenleme , tıp öğrencileri

Ethical Statement

This study was approved by the Ethics Committee of Hacettepe University under approval number 2021/10-42.

Supporting Institution

No fund was obtained for this study.

Thanks

Conflict of Interest: The authors of this article certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, know-ledge or beliefs) in the subject matter or materials discussed in this manuscript. Informed consent: Informed consent was obtained from all participants included in the study. Project/Funding: No fund was obtained for this study. Data Sharing/Availability: Data is available upon reasonable request. Authors’ Contributions: All authors contributed to the study's conception, design, and data collection. TD conducted the analyses. BNO drafted the manuscript. All authors read and approved the final manuscript.

References

• Ahorsu, D. K., Lin, C. Y., Imani, V., Saffari, M., Griffiths, M. D., & Pakpour, A. H. (2022). The Fear of COVID-19 Scale: Development and Initial Validation. International Journal of Mental Health and Addiction, 20(3), 1537-1545.
• Bakioglu, F., Korkmaz, O., & Ercan, H. (2021). Fear of COVID-19 and positivity: Mediating role of intolerance of uncertainty, depression, anxiety, and stress. International Journal of Mental Health and Addiction, 19(6), 2369-2382.
• Balaratnasingam, S., & Janca, A. (2006). Mass hysteria revisited. Current Opinion in Psychiatry, 19(2), 171-174.
• Baron, R., & Kenny, D. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173-1182.
• Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4(6), 561-571.
• Becker, E. (1973). The denial of death. Free Press.
• Bjureberg, J., Ljótsson, B., Tull, M. T., Hedman, E., Sahlin, H., Lundh, L.-G., Bjärehed, J., DiLillo, D., Messman-Moore, T., Gumpert, C. H., & Gratz, K. L. (2016). Development and validation of a Brief Version of the Difficulties in Emotion Regulation Scale: The DERS-16. Journal of Psychopathology and Behavioral Assessment, 38(2), 284-296.
• Brimstone, R., Thistlethwaite, J., & Quirk, F. (2007). Behaviour of medical students in seeking mental and physical health care: Exploration and comparison with psychology students. Medical Education, 41(1), 74-83.
• Christophers, B., Nieblas-Bedolla, E., Gordon-Elliott, J. S., Kang, Y., Holcomb, K., & Frey, M. K. (2021). Mental health of US medical students during the COVID-19 pandemic. Journal of General Internal Medicine, 36(10), 3295-3297.
• Cisler, J. M., Olatunji, B. O., Feldner, M. T., & Forsyth, J. P. (2010). Emotion regulation and the anxiety disorders: An integrative review. Journal of Psychopathology and Behavioral Assessment, 32(1), 68-82.
• Cucinotta, D., & Vanelli, M. (2020). WHO declares COVID-19 a pandemic. Acta Bio-medica, 91(1), 157-160.
• Daros, A. R., Haefner, S. A., Asadi, S., Kazi, S., Rodak, T., & Quilty, L. C. (2021). A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety. Nature Human Behaviour, 5(10), 1443-1457.
• Doulougeri, K., Panagopoulou, E., & Montgomery, A. (2016). (How) do medical students regulate their emotions? BMC Medical Education, 16(1), 312.
• Dyrbye, L. N., Thomas, M. R., & Shanafelt, T. D. (2006). Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Academic Medicine, 81(4), 354-373.
• Essangri, H., Sabir, M., Benkabbou, A., Majbar, M. A., Amrani, L., Ghannam, A., Lekehal, B., Mohsine, R., & Souadka, A. (2021). Predictive factors for impaired mental health among medical students during the early stage of the COVID-19 pandemic in Morocco. The American Journal of Tropical Medicine and Hygiene, 104(1), 95-102.
• Eysenck, M., Derakshan, N., Santos, R., & Calvo, M. (2007). Anxiety and cognitive performance: Attentional control theory. Emotion, 7(2), 336-353.
• Ganjari, M., Khanmohammadzadeh, Z., Nobakht, H., & Kenarsari, H. (2020). The role of cognitive emotion regulation strategies, cognitive flexibility, and distress tolerance in death anxiety among women with hypertension: A descriptive correlation study. Jundishapur Journal of Chronic Disease Care, 9(4), e104117.
• Givens, J. L., & Tjia, J. (2002). Depressed medical students' use of mental health services and barriers to use. Academic Medicine, 77(9), 918-921.
• Gold, J. A., Johnson, B., Leydon, G., Rohrbaugh, R. M., & Wilkins, K. M. (2015). Mental health self-care in medical students: A comprehensive look at help-seeking. Acad Psychiatry, 39(1), 37-46.
• Gratz, K., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41-54.
• Gross, J. J. (2015). Emotion regulation: Current status and future prospects. Psychological Inquiry, 26(1), 1-26.
• Halperin, S. J., Henderson, M. N., Prenner, S., & Grauer, J. N. (2021). Prevalence of anxiety and depression among medical students during the Covid-19 pandemic: A cross-sectional study. Journal of Medical Education and Curricular Development, 8, 2382120521991150.
• Han, Y., Millar, K. M., & Bayly, M. J. (2021). COVID-19 as a mass death event. Ethics & International Affairs, 35(1), 5-17.
• Hartley, C. A., & Phelps, E. A. (2010). Changing fear: The neurocircuitry of emotion regulation. Neuropsychopharmacology, 35(1), 136-146.
• Hisli, N. (1989). Beck Depresyon Envanterinin üniversite öğrencileri için geçerliği, güvenirliği. Psikoloji Dergisi, 7(23), 3-13.
• Holman, E. A., Thompson, R. R., Garfin, D. R., & Silver, R. C. (2020). The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health in the United States. Science Advances, 6(42), eabd5390.
• Jia, Q., Qu, Y., Sun, H., Huo, H., Yin, H., & You, D. (2022). Mental health among medical students during COVID-19: A systematic review and meta-analysis. Frontiers in Psychology, 13, 846789.
• Joormann, J., & Gotlib, I. H. (2010). Emotion regulation in depression: Relation to cognitive inhibition. Cognition & Emotion, 24(2), 281-298.
• Kashdan, T. B., Barrios, V., Forsyth, J. P., & Steger, M. F. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies. Behaviour Research and Therapy, 44(9), 1301-1320.
• Konkan, R., Şenormancı, Ö., Güçlü, O., Aydın, E., & Sungur, M. Z. (2013). Validity and reliability study for the Turkish adaptation of the Generalized Anxiety Disorder-7 (GAD-7) Scale. Nöropsikiyatri Arşivi, 50(1), 53-59.
• Lasheras, I., Gracia-Garcia, P., Lipnicki, D. M., Bueno-Notivol, J., Lopez-Anton, R., de la Camara, C., Lobo, A., & Santabarbara, J. (2020). Prevalence of anxiety in medical students during the COVID-19 pandemic: A rapid systematic review with meta-analysis. International Journal of Environmental Research and Public Health, 17(18), 6603.
• Lawrence, S., Troth, A., Jordan, P. J., & Collins, A. (2011). A review of emotion regulation and development of a framework for emotion regulation in the workplace. In P. L. Perrewé and D. C. Ganster (Eds.), The role of individual differences in occupational stress and well being (Research in occupational stress and well being, Vol. 9) (pp. 197-263). Emerald Group Publishing Limited.
• Lin, Y. K., Saragih, I. D., Lin, C. J., Liu, H. L., Chen, C. W., & Yeh, Y. S. (2024). Global prevalence of anxiety and depression among medical students during the COVID-19 pandemic: A systematic review and meta-analysis. BMC Psychology, 12(1), 338.
• Mahat-Shamir, M., Pitcho-Prelorentzos, S., Kagan, M., Kestler-Peleg, M., & Lavenda, O. (2023). Adjustment disorder in the face of COVID-19 outbreak: The impact of death anxiety, media exposure, fear of contagion and hypochondriasis symptoms. Omega (Westport), 87(4), 1189-1206.
• Menzies, R. E., & Menzies, R. G. (2020). Death anxiety in the time of COVID-19: Theoretical explanations and clinical implications. Cognitive Behaviour Therapist, 13, e19.
• Metin, A., Erbiçer, E. S., Şen, S., & Çetinkaya, A. (2022). Gender and COVID-19 related fear and anxiety: A meta-analysis. Journal of Affective Disorders, 310, 384-395.
• Nguyen, H. T., Do, B. N., Pham, K. M., Kim, G. B., Dam, H. T. B., Nguyen, T. T., Nguyen, T. T. P., Nguyen, Y. H., Sørensen, K., Pleasant, A., & Duong, T. V. (2020). Fear of COVID-19 Scale-Associations of its scores with health literacy and health-related behaviors among medical students. International Journal of Environmental Research and Public Health, 17(11), 4164.
• Nyatanga, B., & de Vocht, H. (2006). Towards a definition of death anxiety. International Journal of Palliative Nursing, 12(9), 410-413.
• O'Byrne, L., Gavin, B., & McNicholas, F. (2020). Medical students and COVID-19: The need for pandemic preparedness. Journal of Medical Ethics, 46(9), 623-626.
• Özgüç, S., Kaplan Serin, E., & Tanriverdi, D. (2024). Death anxiety associated with coronavirus (COVID-19) disease: A systematic review and meta-analysis. Omega (Westport), 88(3), 823-856.
• Panayiotou, G. (2022). The role of emotion regulation during the Covid-19 pandemic and beyond. European Journal of Psychology Open, 81(2), 35-37.
• Pappas, G., Kiriaze, I. J., Giannakis, P., & Falagas, M. E. (2009). Psychosocial consequences of infectious diseases. Clinical Microbiology and Infection: The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases, 15(8), 743-747.
• Paredes, M. R., Apaolaza, V., Fernandez-Robin, C., Hartmann, P., & Yañez-Martinez, D. (2021). The impact of the COVID-19 pandemic on subjective mental well-being: The interplay of perceived threat, future anxiety and resilience. Personality and Individual Differences, 170, 110455.
• Pradhan, M., Alisha, C., & Maheshwari, S. (2022). Fear of death in the shadow of COVID-19: The mediating role of perceived stress in the relationship between neuroticism and death anxiety. Death Studies, 46(5), 1106-1110.
• Pyszczynski, T., Solomon, S., & Greenberg, J. (2015). Chapter one - Thirty years of Terror Management Theory: From genesis to revelation. In J. M. Olson & M. P. Zanna (Eds.), Advances in experimental social psychology (Vol. 52, pp. 1-70). Academic Press.
• Rossi, R., Socci, V., Talevi, D., Mensi, S., Niolu, C., Pacitti, F., Di Marco, A., Rossi, A., Siracusano, A., & Di Lorenzo, G. (2020). COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy. Frontiers in Psychiatry, 11, 790.
• Rufino, K. A., Babb, S. J., & Johnson, R. M. (2022). Moderating effects of emotion regulation difficulties and resilience on students’ mental health and well-being during the COVID-19 pandemic. Journal of Adult and Continuing Education, 28(2), 397-413.
• Russac, R. J., Colleen, G., Mimi, R., & Spottswood, D. (2007). Death anxiety across the adult years: An examination of age and gender effects. Death Studies, 31(6), 549-561.
• Saladino, V., Algeri, D., & Auriemma, V. (2020). The psychological and social impact of Covid-19: New perspectives of well-being. Frontiers in Psychology, 11, 577684.
• Sarıkaya, Y., & Baloğlu, M. (2016). The development and psychometric properties of the Turkish Death Anxiety Scale (TDAS). Death Studies, 40(7), 419-431.
• Siegel, A., Mor, I., & Lahav, Y. (2021). Profiles in COVID-19: Peritraumatic stress symptoms and their relation with death anxiety, anxiety sensitivity, and emotion dysregulation. European Journal of Psychotraumatology, 12(1), 1968597.
• Søvold, L., Naslund, J., Kousoulis, A., Saxena, S., Qoronfleh, M. W., Grobler, C., & Münter, L. (2021). Prioritizing the mental health and well-being of healthcare workers: An urgent global public health priority. Frontiers in Public Health, 9, 679397.
• Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092-1097.
• Thiemann, P., Quince, T., Benson, J., Wood, D., & Barclay, S. (2015). Medical students' death anxiety: Severity and association with psychological health and attitudes toward palliative care. Journal of Pain and Symptom Management, 50(3), 335-342.
• Tian-Ci Quek, T., Wai-San Tam, W., X. Tran, B., Zhang, M., Zhang, Z., Su-Hui Ho, C., & Chun-Man Ho, R. (2019). The global prevalence of anxiety among medical students: A meta-Analysis. International Journal of Environmental Research and Public Health, 16(15), 2735.
• Turhan, E. H. (2021). Ölüm sosyolojisi ekseninde ölüm kaygısı ve koronavirüs. Habitus Toplumbilim Dergisi, 2(2), 85-101.
• WHO. (2022). Wake-up call to all countries to step up mental health services and support. World Health Organization. https://www.who.int/news/item/02-03-2022-covid -19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide
• WHO. (2024). WHO COVID-19 dashboard. https://data. who.int/dashboards/covid19/variants
• Xiong, J., Lipsitz, O., Nasri, F., Lui, L. M. W., Gill, H., Phan, L., Chen-Li, D., Iacobucci, M., Ho, R., Majeed, A., & McIntyre, R. S. (2020). Impact of COVID-19 pandemic on mental health in the general population: A systematic review. Journal of Affective Disorders, 277, 55-64.
• Yiğit, İ., & Guzey Yiğit, M. (2019). Psychometric properties of Turkish version of Difficulties in Emotion Regulation Scale-Brief Form (DERS-16). Current Psychology, 38(6), 1503-1511.