Structural Analysis of the Relationship Between Death Anxiety, Health Anxiety, and Attachment Styles in Patients With Cancer With Emphasis on the Mediating Role of Mindfulness
Keywords:
Death anxiety, Health anxiety, Attachment styles, Mindfulness, Cancer, Structural equation modelingAbstract
Objective: The present study aimed to investigate the structural relationship between death anxiety, health anxiety, and attachment styles in patients with cancer with emphasis on the mediating role of mindfulness.
Methodology: This study employed a descriptive-correlational design using structural equation modeling. The statistical population included all patients with cancer referred to specialized oncology centers and hospitals in Tehran during 2026, from whom 320 participants were selected through convenience sampling. The research instruments included the Templer Death Anxiety Scale, the Salkovskis and Warwick Health Anxiety Questionnaire, the Hazan and Shaver Attachment Styles Questionnaire, and the Five Facet Mindfulness Questionnaire developed by Baer and colleagues. After data collection, analyses were conducted using SPSS-27 and AMOS-26 software. Descriptive statistics, Pearson correlation coefficients, structural equation modeling, and bootstrapping procedures were applied for data analysis.
Findings: The results indicated that death anxiety had a significant positive relationship with health anxiety. Secure attachment style demonstrated a significant negative association with health anxiety, whereas avoidant and anxious attachment styles showed significant positive relationships with health anxiety. Mindfulness was negatively associated with both death anxiety and health anxiety. Model fit indices demonstrated satisfactory fitness of the proposed structural model. Structural equation modeling revealed that death anxiety had a direct positive effect on health anxiety and that mindfulness played a significant mediating role in the relationship between death anxiety and health anxiety. Furthermore, mindfulness significantly mediated the relationship between attachment styles and health anxiety.
Conclusion: The findings demonstrated that death anxiety and attachment styles are important psychological factors associated with health anxiety among patients with cancer, and mindfulness can function as a protective factor in reducing psychological distress in this population. Therefore, implementing mindfulness-based interventions and considering patients’ attachment characteristics may contribute to improving mental health and reducing illness-related anxiety among individuals with cancer.
Downloads
References
Abadian, K., & Tavassoli, A. (2025). The Impact of Death Anxiety on the Quality of Life of Iranian Women With Breast Cancer, Mediated by Life Expectancy. Illness Crisis & Loss. https://doi.org/10.1177/10541373251330009
Al‐Ghabeesh, S. H., Alnaeem, M. M., & Soub, R. (2024). How Does Perceived Social Support, Mindfulness, and Coping Strategies Influencing Death Anxiety Among Patients With Tuberculosis. OMEGA - Journal of Death and Dying. https://doi.org/10.1177/00302228241243241
Alavi, F., Tafti, S. H. A., Alaeddini, F., Ebrahimyan, Z., Ebrahimyan, A., & Mansourian, M. (2022). The Effect of Group Logotherapy on Spirituality and Preoperative Anxiety in Patients Seeking Open Heart Surgery Referring to Tehran Heart Center in 2020. Journal of education and health promotion, 11(1), 233. https://doi.org/10.4103/jehp.jehp_917_21
Andersen, B. L., Arrato, N. A., Conley, C. C., & Blevins, T. R. (2025). Psychological and Behavioral Interventions for Patients With Cancer. 357-376. https://doi.org/10.1037/0000395-016
Anghel, T., Melania, B. L., Costea, I., Albai, O., Marinca, A., Levai, C. M., & Hogea, L. (2025). Review of Psychological Interventions in Oncology: Current Trends and Future Directions. Medicina, 61(2), 279. https://doi.org/10.3390/medicina61020279
Carreno, D. F., & Eisenbeck, N. (2022). Existential Insights in Cancer: Meaning in Life Adaptability. Medicina, 58(4), 461. https://doi.org/10.3390/medicina58040461
Chen, L., Ren, T., Tan, Y., & Li, H. (2022). Global Trends of Research on Depression in Breast Cancer: A Bibliometric Study Based on VOSviewer. Frontiers in psychology, 13. https://doi.org/10.3389/fpsyg.2022.969679
Deng, X., Hu, Y., Xiong, Y., Mao, N., Hong, B., & He, G. (2025). Correlation of Anxiety and Depression With Mindfulness in Esophageal Cancer Patients Undergoing Esophagectomy and Analysis of Risk Factors. World journal of psychiatry, 15(9). https://doi.org/10.5498/wjp.v15.i9.104813
Emanuel, L. L. (2023). Existential Matters and Quality of Dying: A Model of Maturation Processes. Journal of Palliative Medicine, 26(12), 1604-1609. https://doi.org/10.1089/jpm.2023.0546
Fink, M., Pasche, S., Schmidt, K., Tewes, M., Schüler, M., Mülley, B. W., Schadendorf, D., Scherbaum, N., Kowalski, A., Skoda, E. M., & Teufel, M. (2023). Neurofeedback Treatment Affects Affective Symptoms, but Not Perceived Cognitive Impairment in Cancer Patients: Results of an Explorative Randomized Controlled Trial. Integrative Cancer Therapies, 22. https://doi.org/10.1177/15347354221149950
Grassi, L., Caruso, R., Riba, M. B., Lloyd‐Williams, M., Kissane, D. W., Rodin, G., McFarland, D. C., Campos-Ródenas, R., Zachariae, R., Santini, D., & Ripamonti, C. (2023). Anxiety and Depression in Adult Cancer Patients: ESMO Clinical Practice Guideline. Esmo Open, 8(2), 101155. https://doi.org/10.1016/j.esmoop.2023.101155
Hussain, M. (2022). Role of Peace of Mind for Mental Health Outcomes in Cancer Patients. Journal of Development and Social Sciences, 3(II). https://doi.org/10.47205/jdss.2022(3-ii)61
Krutchan, N., Skulphan, S., Thapinta, D., Thungjaroenkul, P., & Saengthong, S. (2024). Factors Predicting Self-Compassion Among Patients With Breast Cancer Undergoing Chemotherapy in Thailand: A Cross-Sectional Study. Belitung Nursing Journal, 10(3), 341-350. https://doi.org/10.33546/bnj.3359
LaPorte, M. R. C., Emanuel, L. L., Solomon, S., Poffo, C. V., Joshi, I., Yao, Y., & Wilkie, D. J. (2025). Measuring American Adults’ Perceptions About Human Existence: A Cross-Sectional Study. Palliative & Supportive Care, 23. https://doi.org/10.1017/s1478951525100497
Luo, X., Miao, X., Ding, N., Fu, Z., Wang, X., & Li, Y. (2025). Application of the End-of-Life Demands Card Game and Mindfulness-Based Cancer Recovery Program for Reducing Negative Emotion in Patients With Advanced Lung Cancer: A Randomized Controlled Trial. Frontiers in psychology, 16. https://doi.org/10.3389/fpsyg.2025.1476207
Marano, G., & Mazza, M. (2024). Impact of Gynecological Cancers on Women’s Mental Health. World journal of psychiatry, 14(9), 1294-1300. https://doi.org/10.5498/wjp.v14.i9.1294
Marchand, L., Lewin, D., & Kozak, L. (2021). Addressing Symptom Clusters With Complementary and Integrative Health Therapies in Palliative Care Populations: A Narrative Review. Obm Integrative and Complementary Medicine, 06(01), 1-16. https://doi.org/10.21926/obm.icm.2101007
Marinovic, D. A., & Hunter, R. (2022). Examining the Interrelationships Between Mindfulness‐based Interventions, Depression, Inflammation, and Cancer Survival. Ca a Cancer Journal for Clinicians, 72(5), 490-502. https://doi.org/10.3322/caac.21733
Marmarosh, C. L., Vo, D., Abraham, M. B., & Rajput, A. (2024). The Psychological Vital Signs of Incurable Cancer: Implications for Training and Practice. Academia Oncology, 1(1). https://doi.org/10.20935/acadonco6259
Mastnak, W., & Mao, Q. (2021). Chinese Arts-Based Psycho-Oncology: A Translational Systemic Meta-Synthetic Perspective. Biomedical and Translational Science, 1(1). https://doi.org/10.33425/2768-4911.1003
Mirmahmoodi, M., Mangalian, P., Ahmadi, A., & Dehghan, M. (2020). The Effect of Mindfulness-Based Stress Reduction Group Counseling on Psychological and Inflammatory Responses of the Women With Breast Cancer. Integrative Cancer Therapies, 19. https://doi.org/10.1177/1534735420946819
Penberthy, J. K., Russell, G., Phillips, J., Banaji, M., Mann, N. P., & Dameron, E. (2020). Medical Stress and Fear of Death and Dying in a Medical Patient Population. OMEGA - Journal of Death and Dying, 86(1), 255-270. https://doi.org/10.1177/0030222820966926
Qiu, J., & Xu, X. (2025). On the Effectiveness of Buddhist View of Life and Death in Regulating Mortality Salience. Frontiers in psychology, 15. https://doi.org/10.3389/fpsyg.2024.1523125
Rezapour, M., & Ferraro, F. R. (2023). The Associations Between Death Anxiety, Supernatural Beliefs, Caring for Loved Ones and Attachments. OMEGA - Journal of Death and Dying, 91(4), 2103-2118. https://doi.org/10.1177/00302228231169541
Ruano, A., García‐Torres, F., Gálvez‐Lara, M., & Moriana, J. A. (2022). Psychological and Non-Pharmacologic Treatments for Pain in Cancer Patients: A Systematic Review and Meta-Analysis. Journal of Pain and Symptom Management, 63(5), e505-e520. https://doi.org/10.1016/j.jpainsymman.2021.12.021
Safaie, N., Zeinali, H., Ghahramanfard, F., Mirmohammadkhani, M., & Moonesan, M. (2022). Anxiety and Depression Among New Cancer Patients. Journal of Family Medicine and Primary Care, 11(8), 4146-4150. https://doi.org/10.4103/jfmpc.jfmpc_1984_21
Straker, N. (2020). The Treatment of Cancer Patients Who Die. Psychodynamic Psychiatry, 48(1), 1-25. https://doi.org/10.1521/pdps.2020.48.1.1
Teigen, A. (2023). Mindfulness for Depression Management in Men With Prostate Cancer. Jaapa, 36(3), 28-31. https://doi.org/10.1097/01.jaa.0000911220.25098.91
Tung, Y. Z., Ng, D.-L.-C., Lai, N. Z., Ang, C. M., Lim, P. K., Zainuddin, S. I., Lam, C. L., Loh, E. C., Chai, C.-S., & Tan, S.-B. (2025). Symptom Reduction in Advanced Cancer From Multi-Session Mindful Breathing: Randomised Controlled Study. BMJ Supportive & Palliative Care, spcare-2024-005086. https://doi.org/10.1136/spcare-2024-005086
Vincenzo, F. D., Quinto, R. M., Iani, L., Durante, S., Scalpelli, C., & Lombardo, L. (2025). Peaceful Acceptance and Struggle With Terminal Cancer: The Role of Mindfulness, Self-Compassion, and Body Image Distress. Palliative & Supportive Care, 23. https://doi.org/10.1017/s1478951525000094
Wang, K., Sun, Z., Hou, Y., & Yuan, M. (2023). Coping With Mortality Salience: The Role of Connection Thinking and Afterlife Beliefs in Chinese Context. Frontiers in psychology, 14. https://doi.org/10.3389/fpsyg.2023.1190906
Wang, S., Zhang, C., & Xu, W. (2023). Mindfulness, Mortality, Disability Rates, Physical and Mental Health Among the Oldest Old. Health Psychology. https://doi.org/10.1037/hea0001315
Wei, M., Marzuki, M. A., Zhang, X., & Hu, Q. (2025). Effectiveness of Mindfulness‐Based Couple Interventions on Psychological Distress in Patients With Cancer and Their Partners: A Critical Review. Journal of clinical nursing, 34(12), 4989-5001. https://doi.org/10.1111/jocn.17822
Yıldırım, D., Yıldız, C. Ç., Ozdemir, F. A., Özdoğan, M. H., & Can, G. (2022). Effects of a Mindfulness-Based Stress Reduction Program on Stress, Depression, and Psychological Well-Being in Patients With Cancer. Cancer Nursing, 47(2), E84-E92. https://doi.org/10.1097/ncc.0000000000001173
Zhang, Z., Mohammad Farris Iman Leong Bin, A., Shari, N. I., & Lu, P. (2022). Acceptance and Commitment Therapy Versus Mindfulness-Based Stress Reduction for Newly Diagnosed Head and Neck Cancer Patients: A Randomized Controlled Trial Assessing Efficacy for Positive Psychology, Depression, Anxiety, and Quality of Life. PLoS One, 17(5), e0267887. https://doi.org/10.1371/journal.pone.0267887
Downloads
Publication Timeline
- Submitted
- Revised
- Accepted
Issue
Section
License
Copyright (c) 2025 Masoumeh Foroughameri (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
