The Relationship Between Death Anxiety and Alexithymia in Emergency Medical Technicians

Abstract

Introduction: When confronted with traumatic accidents and events that result in death, people are at risk of developing death anxiety. Due to their stressful job, emergency medical technicians (EMTs) will develop alexithymia and be unable to express and manage their emotions over time. Studies show that alexithymia causes physical and mental disorders in many people. The present study aimed to determine the relationship between death anxiety and alexithymia in EMTs.Methods: The convenience sampling method was used to select 400 EMTs in southeastern Iran who met the inclusion criteria for this descriptive-analytical study. The Templer Death Anxiety Scale and the Toronto Alexithymia Scale were used to collect data. SPSS version 20 was used to analyze the data, which included descriptive and analytical statistics (Independent t test, ANOVA, Pearson correlation, and regression). Results: The results of the study showed that the mean score of death anxiety in EMTs was 10.26 ± 3.69. It was revealed that 46.7% of the EMTs experienced severe death anxiety. Furthermore, the total mean score of alexithymia in EMTs was 59.65 ± 8.28, indicating the possibility of alexithymia. The Pearson correlation test showed a direct moderate relationship between death anxiety and alexithymia scores (r = .351, p < .001).Conclusion: According to the results, there is a direct significant relationship between death anxiety and alexithymia in EMTs. Therefore, it is suggested that EMTs be continuously taught effective methods to deal with death anxiety and reduce the physical and mental disorders caused by this problem.

Keywords

death anxiety alexithymia emergency medical technician

Introduction

The services of Emergency Medical Technicians (EMTs) are one of the most important health services in many countries. EMTs are the first responders in emergencies, from major traffic accidents to natural disasters, minor injuries, and illnesses. They are subjected to various physical and emotional stresses in order to stabilize the patients’ condition, calm the patients and their anxious relatives, and ensure the continuity of care until the patient’s admission to treatment centers (Cheraghi et al., 2019). The nature of EMTs’ jobs is stressful, resulting in emotional and anxiety disorders. EMTs are more likely to encounter scenes of sudden death and sometimes terrifying scenes other people. (Ducar et al., 2020).

Saberi et al., (2009) in Iran showed that mental trauma was severe in about one third of EMTs, which is at a higher level compared to other countries . The results of other studies show that 62.9 to 75.5% of EMTs have experienced moderate to high stress levels (Froutan et al., 2018).

They are worried because they have a lot of contact with the dying patients. Some people talk about death, but many people avoid it and suffer from death anxiety (Arab et al., 2019; Asadi et al., 2020). An important reason may be confrontation with the finiteness of life. Mortality cues may remind EMTs of their own mortality and the vulnerability of the human body. Such confrontations could induce a fear of death (Beiramijam et al., 2018).

Sadeghi et al. (2018) examined death anxiety in EMTs and showed a significant relationship between resuscitation operations and death anxiety, indicating that the greater the engagement in resuscitation operations, the greater the death anxiety. More exposure of EMTs to dying patients may increase their fear and anxiety about death, as well as remind them of death and dying (Sadeghi et al., 2018).

Death anxiety is a multidimensional concept with emotional, cognitive, and empirical characteristics and it is the fear of the end of one’s existence, dying process, the unknown after death or death of other important family members (Draper et al., 2019). Death anxiety is related to one’s occupation (Roodbandi et al., 2018). It can have an impact on the quality of care provided for dying patients, as well as 0 job satisfaction and mental health (Aghajani, Valiee, & Tol, 2010). Death anxiety can lead to distancing in order to protect oneself from the recognition that the fate of another person could be one’s own. For example, confrontation with critically ill people triggers thoughts about death, leading to avoidance of engagement with them or avoidance of conversations about patients’ values and preferences. EMTs may use avoidance coping mechanisms to suppress death-related thoughts and deny their vulnerability (Beiramijam et al., 2018).

The term “alexithymia” was originally defined as the inability to recognize and express one’s emotions.

Alexithymia is a broad term to describe problems with feeling emotions a lack of positive emotions, with a high prevalence of negative emotions (Nekouei et al., 2014). Since the actions of EMTs on the scenes are very important and stressful, they require adequate information and the ability to control emotions. One of the main professional characteristics of EMTs that can expose them to severe emotional disorders is the ability to make decisions in ambiguous situations and deal with traumatic events (Bayrami et al., 2017). In many cases, they cannot express their emotions and suffer from alexithymia (Duquette, 2020). Studies have shown that the prevalence of psychological disorders among EMTs has been more than 40% ( Masoudzade, Masoudzade, Setare, Mohamadpour, & Kurdi, 2008; Sadeghi et al., 2018).

As a result, there is unresolved emotional and physical excitements. The cost of unresolved emotional disorders is borne first by patients and the injured, and then by the individual. There are also issues such as high absenteeism, drug abuse, apathy at work, and low work motivation. (Sadeghpoor et al., 2018)

Alexithymia is a cognitive-emotional disorder that interferes with the emotion adjustment, concentration, processing, and evaluation of cognitive-emotional information. Therefore, individuals with alexithymia fail to manage their cognitive-emotional system and cope with stressful situations. This strengthens the feelings of inadequacy and insufficiency in this group and intensifies negative emotions such as anxiety and depression (Nekouei et al., 2014).

As in many other countries, the services and capabilities of this organization expanded gradually in Iran as people’s need for services increased, as well as due to population growth, urbanization, increased road accidents, more heart diseases, increased natural and industrial accidents, as well as increase in social disorders and other factors. . Now nearly 1900 prehospital emergency stations with nearly 3000 ambulances, 112 bus ambulance, air ambulance, and motorlance are operational throughout the country and emergency stations completed over two million missions in 2010 (Beiramijam et al., 2018).

Therefore, considering the sensitive nature of EMTs’ jobs, examining their mental health and emotions that can affect their professional competence, is critical. One way to promote mental health is to conduct various studies and identify the factors affecting it, which, in addition to scientific advancement, increases awareness and knowledge in this field. Social and cultural issues are among the factors influencing death anxiety and alexithymia.

Therefore, this study aimed to investigate the relationship between death anxiety and alexithymia in EMTs in southeastern Iran in 2020, in order to take a small step toward improving their mental health.

Methods

Sample and setting

This is a cross-sectional descriptive-analytical study (March–May 2020). Convenience sampling was done among EMTs affiliated to Kerman University of Medical Sciences, Southeast Iran. Inclusion criteria include: no history of known psychiatric disorders (depression, anxiety disorders,…), no use of psychiatric medications. The failure to complete more than two-thirds of the questionnaire was a criterion for exclusion. An online survey was conducted using social media (WhatsApp) and personal contacts. Participants were given a brief written description of the study and its objectives. According to pilot study and correlation coefficient, 476 participants were considered as the sample size, with 95% confidence, and 90% test power. Finally, 76 participants were excluded from the study. (Figure 1)

Figure 1.

Number of samples studied and number of samples attrition.

Measures

Data were collected using a three-part questionnaire consisted of demographic information, death anxiety scale, and alexithymia scale.

Background information questionnaire, which included demographic information such as age, gender, etc.), as well as information about occupational conditions (employment status, organization level, number of CRR in the last month, number of shifts per month, etc.).

Death Anxiety Scale: This questionnaire was first introduced by Templer in 1970. It consists of 15 True/False items, with a score of one for nine true responses and six false responses. The total score of the questionnaire ranges from 1 to 15, with higher scores indicating higher levels of death anxiety. Accordingly, anxiety is classified into three levels: mild (0–6), moderate (7–9), and severe (10–15). Templer (1970) reported the 0.83 coefficient for test-retest reliability and 0.76 for internal consistency (Templer, 1970). In the current study, the content validity index was determined to be .91. The reliability (internal consistency) of this questionnaire was also confirmed by a Cronbach’s alpha coefficient of .89.

The Toronto Alexithymia Scale-20 (TAS-20): It was developed by Bagby in 1994 (Bagby et al., 1994). This scale measures individual differences at three emotional dimensions: difficulty in identifying emotions (seven questions), difficulty in expressing emotions (five questions), and externally oriented thinking (eight questions). The questions are scored based on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree), with the total score of 20–100. The highest score for each dimension indicates the highest level of alexithymia.

The TAS-20 demonstrated acceptable internal consistency (Cronbach’s alpha = .81) with the derivation sample, as did each of the three dimensions of difficulty in identifying emotions, difficulty in expressing emotions, and externally oriented thinking, which were .78, .75, and .66, respectively, indicating good internal consistency of the scale. The test-retest reliability of the TAS-20 was investigated using a separate sample of 72 students who were asked to complete the scale at the beginning of class on two occasions. The difference after 3 weeks was .77 (Bagby et al., 1994). In the current study, the content validity index was determined to be 0.93 by faculty members. Cronbach’s alpha coefficient was calculated to be .97 after participants completed this questionnaire to confirm its reliability (internal consistency).

SPSS 20 was used for data analysis. Frequency, Percentage, Mean, t-test, ANOVA, and Pearson correlation and regression analysis were used for the analysis. The significance level was considered .05.

Results

Participants Characteristics

The results of the present study showed that most of the participants (92.2%) were male. More than 48.3% of the participants had a bachelor’s degree. In terms of marital status, 72.3% of them were married. Also, 72% of the participants had an income between 3 and 5 million tomans per month. The mean age of the EMTs was 33.76 ± 7.1 years.

In terms of employment status, 29.2% of the participants Annually contracted with payment less than hired nurses. Seventy-six percent of them had 24-hour shifts and more than half of them (68%) were senior technicians. In terms of the number of cardiopulmonary resuscitation (CPR) in the last month, 46.7% of EMTs did not have any CPR during the past month. Most of them (73.5%) reported 3–5 deaths per month. The mean work experience of EMTs was 7.92 ± 5 years and the mean clinical work experience of personnel was 8.1 ± 5.3 years.

Table 1 shows demographic details of the research samples, as well as results of independent t test and ANOVA that examined differences between demographic factors, the death anxiety and alexithymia. This table includes mean and SD of death anxiety and alexithymia and demographic factors, including gender, marital status, education level, monthly income, and type of shift, number of CPR in the last month, number of deaths observed in the last month and number of shifts per month.

Table 1.

Demographic Characteristics of Study Sample and Their Associations with Death Anxiety and Alexithymia.

Variable	Alexithymia		Statistic test	p value	Death anxiety		Statistic test	p value
Variable	Mean	Standard Deviation	Statistic test	p value	Mean	Standard Deviation	Statistic test	p value
Gender
Man	59.70	8.4	t = .359	0.8	10.17	3.72	t = 1.73	.08
Woman	59.19	6.8	t = .359	0.8	11.2	3.32	t = 1.73	.08
Marital status
Married	59.90	8.61	t = .865	0.39	10.37	3.76	t = .689	.49
Single	59.09	7.32	t = .865	0.39	10.02	3.51	t = .689	.49
Education
Associate degree	58.88	8.5	F = 8.22	.06	10.22	3.77	F = 3.82	.28
Bachelor	60.58	8.03			10.39	3.53
Master	58.62	8.47			9.12	4.37
PhD	50.50	4.95			11.5	3.53
Monthly income (tomans)
<3 milion	59.54	8.42	F = .03	.95	11.29	3.3	F = 3.38	.18
3–5 milion	59.75	7.71			10.37	3.73
>5 milion	50.5	4.95			10.13	3.73
Type of shift
Day	60.12	6.65	F = .85	.84	10.12	3.38	F = .547	.76
Night	56.88	6.15			12.38	2.97
Rotation	59.27	7.37			10.41	3.98
Rotation of 24 hour	59.74	8.63			10.18	3.66
Number of CPR in the last month
0	59.43	8.41	F = .156	.92	10	3.82	F = .631	.72
1–3	59.09	8.52			10.18	3.57
4–6	59.99	6.01			10.21	3.62
>7	60.21	4.6			10.55	3.71
Number of deaths seen in the last month
1–2	59.17	7.7	F = 6.9	.03	9.92	3.65	F = 12.5	.002
3–5	59.95	9.35			10.94	3.75
>6	64	9.36			12.04	3.29
Number of shifts per month
Duty	59.34	8.24	t = .393	.69	10.20	3.44	t = .822	.41
Overtime	59.77	8.28	t = .393	.69	10.60	3.75	t = .822	.41

t = Independent t test.

F = Analysis of variance (ANOVA).

The results of the present study showed that observing more deaths per month resulted in a statistically significant difference in death anxiety and alexithymia. People who observed more than six deaths a month had higher levels of death anxiety and alexithymia (Table 1).

The mean score of death anxiety in EMTs was 10.26 ± 3.69; 46.7% (187 N) of EMTs had severe, 32.3% (129 N) had moderate, and 21% (84 N) had mild death anxiety. (Table 2)

Table 2.

Mean Score of Death Anxiety and Frequency of its Dimensions in EMTs.

Group variable	Mean	Standard Deviation
Death anxiety	10.26	3.69
Group variable	Frequency	Percentage (%)
Mild anxiety (0–6)	84	21
Moderate anxiety (7–9)	129	32.3
Severe anxiety (10–15)	187	46.7

The mean total score of alexithymia in EMTs was 59.65 ± 8.28. According to the cut-off point of the alexithymia scale (score = 61), EMTs may have alexithymia. In addition, the highest score of alexithymia was related to the dimension of difficulty in identifying emotions (22.70 ± 3.60) when compared to other dimensions (Table 3).

Table 3.

The Mean Score of Alexithymia and Its Dimensions in EMTs.

Group Variable	Mean	Standard Deviation
Difficulty in identifying emotions	22.70	3.60
Difficulty in expressing emotions	14.95	2.42
Externally oriented thinking	22	2.26
Total score of alexithymia	59.65	8.28

The results of Pearson correlation showed a direct moderate relationship between scores of death anxiety and alexithymia (r = .351, p < .001). In other words, as the death anxiety score rises, so does alexithymia in EMTs. Death anxiety was also directly related to all dimensions of the alexithymia scale. Death anxiety had a direct and moderate relationship with difficulty in expressing emotions (r = .452, p < .001) and difficulty in identifying emotions (r = .335, p < .001).

The multivariate logistic regression with enter method was used for further analysis. The results showed that demographic variables were not significantly associated with death anxiety (Table 4).

Table 4.

The Logistic Model of Associations of Important Variables With Death Anxiety.

Variable	Multi variate logistic regression
Variable	Unstandardized β	Standardized Coefficients β	t	p value
Age	000	.008	.055	.956
Gender	.033	.012	.2	.841
Marital status	−.097	−.068	−1.237	.217
Educational level	−.007	−.007	−.138	.890
Monthly income	−.065	−.050	−.860	.390
Type of shift	−.057	−.054	−.924	.356
Number of CPR in the last month	.019	.041	.740	.460
Number of deaths seen in the last month	.029	.106	1.88	.06
Number of shifts per month	−.066	−.034	−.594	.553

The multivariate logistic regression with enter method was conducted for further analysis. The results showed that demographic variables were not significantly associated with alexithymia. (Table 5)

Table 5.

The Logistic Model of Associations of Important Variables With Alexithymia.

Variable	Multi variate logistic regression
Variable	Unstandardized β	Standardized Coefficients β	t	p value
Age	−.027	−.023	−.310	.757
Gender	−1.008	−.034	−.562	.574
Marital status	.168	.011	.198	.843
Educational level	.481	.048	.880	.380
Monthly income	−.123	−.009	−.152	.879
Type of shift	−.094	−.008	−.140	.889
Number of CPR in the last month	.133	−.027	−.484	.629
Number of deaths observed in the last month	.172	.059	1.037	.301
Number of shifts per month	.296	.014	.245	.806

The results of logistic regression showed that demographic variables did not predict the scores of death anxiety and alexithymia.

Discussion

The results of the present study showed that the mean scores of death anxiety in EMTs were in the severe range. Furthermore, 46.7% of the EMTs had severe death anxiety, 32.2% had moderate death anxiety, and 21% had mild death anxiety. The results of some studies have also shown that EMTs can experience more vivid moments of death, such as the death of family members, and more traumatic events compared to others, putting them at risk of death. Since emergency nurses and paramedics experience sudden and traumatic death, observation of death scenes makes them more anxious than other professionals, and death is viewed negatively by some people as a deprivation of life, happiness, goals, past achievements, and future events, making it a destructive concept that can induce anxiety (Routledge & Juhl, 2010; Nyatanga, 2005). In addition, the results of a study showed that the rate of death anxiety in emergency nurses was 32.4%, which is higher than the rate in general ward nurses because they are more exposed to death than others (Adriaenssens, De Gucht, & Maes, 2012).

Sliter et al. (2014) also showed that nurses working in the intensive care unit (ICU) and emergency department had higher levels of death anxiety than nurses who had experienced traumatic events for a long time. There have been also several studies on the level of death anxiety in nurses in ICU and general wards which reported severe death anxiety in nurses (Black, 2007; Payne, Dean, & Kalus, 1998; Sadeghi, Hoseinzade, Mehrabi, Bahrami, & Frouzan, 2018).

According to these studies, death anxiety is higher in wards with a higher number of critical or dying patients. A high rate of death anxiety was reported among emergency medical technicians in current study.

However, the results of some studies contradict with the results of the present study. Sadeghi et al. (2018) showed that the average death anxiety in EMTs was mild; the difference in results could be attributed to the use of a small sample size and convenience sampling. (Sadeghi, Hoseinzade, et al., 2018). In addition, a study found that the level of death anxiety in nurses in different wards of the hospital was significantly different. Death anxiety in operating room and ICU nurses was higher than in emergency ward nurses; this difference in results could be attributed to the selection of a small sample size of emergency nurses compared to those in other wards, as well as the selection of single-sex samples (Naderi, Bakhtiar, & Shokouhi, 2010).

Furthermore, the results of the present study showed that the mean total score of alexithymia in EMTs was 59.65 ± 8.28. According to the cut-off point of the alexithymia scale (score = 61), EMTs may have alexithymia. Moreover, the highest score of alexithymia was related to the dimension of difficulty in identifying emotions when compared to other dimensions.

One study found high levels of alexithymia among emergency nurses (Deng et al., 2018), which is consistent with the results of the present study. Saeidi et al. (2020) showed that the level of alexithymia in nurses was 56.78 ± 8.64 (Saeidi et al., 2020), indicating the possibility of alexithymia, which is consistent with the results of the present study.

Various studies on the level of alexithymia in nurses in the ICU and general wards have been conducted, indicating that the level of alexithymia in nurses and EMT has been possible or in the range of or severe (Karami, Zakiei, & Amirpoor, 2014; Dehghanpour, & Seraj Khorami, 2017).

According to the current study, people working in critical wards in Iran have alexithymia because daily observation of heartbreaking and fatal scenes does not allow them to express negative emotions.

The results of the present study also showed a direct moderate relationship between death anxiety and alexithymia. In other words, as alexithymia score rises, so does the level of death anxiety in EMTs. Death anxiety was also directly related to all dimensions of the alexithymia scale. As a result, death anxiety had a direct moderate relationship with dimensions of difficulty in expressing emotions and difficulty in identifying emotions but a direct insignificant relationship with dimension of the externally oriented thinking. Various studies have shown that people with alexithymia have significantly higher levels of anxiety, depression, and psychological distress. These people are prone to physical-functional symptoms as well as emotional distress symptoms due to their poor mental health. Alexithymia is also a risk factor for many psychological disorders, as people with alexithymia are under severe pressure from unresolved psychosomatic correlations. This failure hinders the regulation of emotions and makes adjustment difficult (Lundh, Johnsson, Sundqvist, & Olsson, 2002; Taylor, 2000).

In a systematic review titled “Alexithymia as a Prognostic Risk Factor for Health Problems”, Kojima (2012) found that alexithymia had negative effects on the individuals’ health in half of the reviewed articles, including depression, anxiety, chest pain, sudden cardiac arrest, back pain, and post-traumatic stress disorder (PTSD). In this review, half of the articles assessed the effects of alexithymia on the non-clinical population and the other half assessed the clinical staff (Kojima, 2012). A person with alexithymia may also experience physical problems and symptoms as a result of prolonged or increased physiological stimulation. Alexithymia can cause physiological aspects of emotions to be triggered, which can eventually lead to negative mood states such as stress, anxiety, and depression (Lumley, Neely, & Burger, 2007). In a systematic review titled “The Impact of Alexithymia on Anxiety Disorders,” Berardis et al. (2008) found that people with generalized anxiety disorder had difficulty identifying problems and describing emotions. The scores of Toronto’s alexithymia scale have been reported to be higher in this group of people. The results of this study showed that they had difficulty understanding and managing emotional experiences (Berardis et al., 2008).

As most studies have reported a direct relationship between alexithymia and anxiety, it can be concluded that the direct relationship between alexithymia and death anxiety is partially justifiable in EMTs. Most of the EMTs experience death anxiety due to a lack of emotion regulation during crises and unpredictable and high-risk events, which is consistent with the results of the present study.

Due to a lack of personnel, emergency medical technicians in Iran work long and consecutive shifts, witnessing more deaths and heartbreaking scenes. Furthermore, when selecting an emergency medical job, various factors such as personality traits, values, interests, skills, family circumstances, and community conditions should be taken into account for each individual. One of the most important of these factors is personality traits, which can result in various attitudes toward the current situation. Unfortunately, in Iran, people enter this profession only through scientific tests, and no personality tests are administered to them. People who enter this profession may face psychological problems when confronted with heartbreaking scenes. Increased death anxiety or alexithymia in this group can be attributed to how these people enter the field of medical emergencies or to cultural differences between individuals.

Furthermore, the results of the present study showed that the score of death anxiety was higher in women, married people, people with a doctorate, people with less than 3-million-toman income, people who worked night shifts, EMT with higher CPR, and people who worked more shifts per month, but these differences were not statistically significant.

In some studies, women had higher rates of death anxiety than men, and this difference between men and women was significant (Masoudzade et al., 2008; Buzzanga, Miller, Perne, Sander, & Davis, 1989; Peters et al., 2013). In the present study, the difference between the means of death anxiety in the two groups did not show a significant difference, which could be due to the fact that the number of women in prehospital emergency was less than men.

In the present study, married people had a higher mean score for death anxiety than single people. According to Sadeghi et al. (2018) and Aghajani, Valiee, & Tol (2010), death anxiety was higher in single people than in married people, which may be due to the fact that most of technician students are single (Sadeghi et al., 2018; Aghajani et al., 2010).

Death anxiety research has suggested that marital roles, particularly the male’s role as the family provider, influence the sex differences in death attitudes.Cole (1979) investigated the effect of marital roles on death anxiety scores by comparing sex differences in married people with and without children, as well as single people. Death anxiety among older adults is not well understood. Although existing research is somewhat inconsistent, most evidence suggests that death anxiety is greater in younger age groups and declines with age (Thorson & Powell, 2000).

Death anxiety was statistically significant with the number of deaths observed in patients last month. So that death anxiety has increased by observing more deaths per month. In one of the study showed that the number of critically ill and dying patients and the number of deaths per month are related to the level of death anxiety and in these people death anxiety is higher. While the study of Sadeghi et al. (2018) and Korte (1985) showed that there is no relationship between the number of death and the observation of the last death with death anxiety (Sadeghi et al., 2018; Korte, 1985).

The results of the present study showed that the score of alexithymia was higher in men, married people, individuals with a doctorate, people with less than 3-million-toman incomes, people who worked in day shifts, EMTs with a higher number of CPR. More shifts per month than Routine shifts, but these differences were not statistically significant.

Alexithymia was statistically significant in terms of the number of deaths observed in patients in the last month.

According to Kokkonen et al. (2001), alexithymia is structurally gender-dependent, with men having a slightly higher rate than women. Karagöl (2017) stated that the rate of alexithymia in women was higher than men, which may be due to the fact that the difference between this study and the present study was the assessment of alexithymia only in physicians and a small number of samples (83 N) (Karagöl, 2017).

Kokkonen et al. (2001) and Karagöl (2017) showed that married people had a higher rate of alexithymia than single people (Kokkonen et al. 2001, Karagöl, 2017). However, Mansouri et al. (2014) found that the rate of alexithymia in single people was higher (Mansouri et al., 2014). The reason may be that alexithymia was studied in students and the number of single people was more than that of married people. Other studies have also shown that alexithymia is associated with male gender, low socioeconomic status and fewer years of education, which is consistent with the present study (Lane et al., 1998, kikkonen et al., 2001). One study found a high score of alexithymia in people with more than 11 years of work experience, being inhigher positions such as nurse managers, working >45 hours per week, having extra shifts per month and having more rotating shifts (Saeidi et al., 2020).

One of the limitations of this study was that the study was conducted during the Covid-19 pandemic, which may be effective in the study results.

Conclusion

According to the results of this study, EMTs have a high level of death anxiety and alexithymia, which can lead to disease. There was also a strong and significant relationship between alexithymia and death anxiety in EMTs. Due to their high level of alexithymia, they are more likely to experience death anxiety, followed by psychological disorders, anxiety, and physical and psychological problems in this occupational group. Therefore, improving communication skills and their ability to express emotions may help prevent or reduce alexithymia among them.

Footnotes

Acknowledgments

The authors would like to gratitude all the participants in this study and the officials of the Emergency Medical Center of Southeastern Iran who helped us to perform this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics approval and consent to participate

The Ethics Committee of Kerman University of Medical Science approved this study with No. and the code of ethics No. IR. KMU.REC.1399.059. All methods were carried out in accordance with applicable guidelines and regulations. Participation in this study volunteered to take part. All participants were informed about the objectives and process of the study and their informed consent was obtained.

ORCID iD

Fatemeh Salmani

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