Navigating mortality: exploring the dynamic changes related to cultural worldviews and self-esteem in cancer patients

Abstract

Background

This study examines the dynamic changes between cultural worldview and self-esteem as distal defense mechanisms in cancer patients and explores the role of these mechanisms in the different psychological stages of cancer patients’ resistance to death, thereby elucidating the unique responses of cancer patients to the salience of death.

Methods

Our sample comprises 113 cancer patients and 92 dental pain patients. We measured participants’ levels of cultural worldview defenses, death thought accessibility (DTA), self-esteem, depression, and suicidal ideation in two studies.

Results

In Study 1, increased levels of cultural worldview defenses coincided with increased levels of DTA. Initial avoidance and denial inhibited cultural worldview defenses in cancer patients, which were progressively strengthened in subsequent psychological stages of death. In Study 2, there were no significant differences in explicit self-esteem among cancer patients in different psychological stages of death; however, there were differences in tests of implicit self-esteem, with the lowest scores on the depression and suicidal ideation scales in the Acceptance of Death stage, the most pronounced suicidal ideation in the Bargaining stage, and the highest scores on depression in the Avoidance of Death stage.

Conclusion

The findings of the study indicate that cancer patients exhibited dynamic shifts in their cultural worldviews and self-esteem during the psychological phases of death. Interestingly, self-esteem may be a more effective defense mechanism than cultural worldview in this context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-025-03037-9.

Introduction

Cancer is a significant cause of morbidity and mortality worldwide. According to the latest estimates from the International Agency for Research on Cancer, there will be an estimated 20 million new cancer cases and 9.7 million deaths in 2022 [1, 2]. The number of people surviving five years after cancer diagnosis is estimated to be 53.5 million. In 2020, the number of cancer deaths in China will reach 2,397,772, an increase of 21.6% compared with 2005 [3]. Cancer is a life-threatening disease that presents numerous challenges to patients and caregivers. These challenges encompass declining health, physical symptoms, and psychological distress. A cancer diagnosis and treatment can significantly disrupt various aspects of a patient’s daily life, leading to negative impacts on their self-perception, attitude toward life, and value systems. These impacts can make the continuity and consistency of life seem meaningless. All living things, including humans, are motivated by the sustenance of life. While life has a beginning, it also has an end, and self-awareness regarding an individual’s mortality is considered a uniquely human trait [4, 5].

The Terror Management Theory (TMT) posits that the realization of one’s mortality gives rise to a profound psychological conflict, which in turn gives rise to death anxiety. This anxiety is the emotional response of fear that arises from the realization of death [6–9]. While moderate death anxiety is beneficial in encouraging patients to engage in the process of finding meaning in life, abnormally high death anxiety leads to several problems, including maladjustment, anxiety, and other psychological disorders [10–12]. Some studies have indicated that cancer patients in China experience high levels of anxiety related to death [13, 14]. The fear and anxiety of death can give rise to a range of psychological distress and negative behaviors if something is not done to alleviate it [15–17].

According to Greenberg et al. [18], TMT is the most influential theoretical approach for treating death anxiety; this theory suggests that cultural worldview and self-esteem are important anxiety buffers for managing fear of death [19]. Similarly, Willis et al. [20] showed that patients with stronger distal defenses have lower death anxiety compared to patients with cancer who have no strong defenses or only one strong defense. These findings support the relevance of TMT among individuals facing a real threat of death and highlight the need for further research on TMT in these populations [20, 21]. Based on the model proposed by Pyszczynski et al. [22], individuals initially engage their proximal defenses when death-related thoughts become salient in the conscious mind. This engagement leads to a decrease in DTA, indicating the ease with which death-related thoughts are retrieved from memory [23]. The concept of death-thought accessibility (DTA) refers to the availability of thoughts related to death in one’s mind [24]. As individuals’ death-related thoughts become more accessible, their behaviour changes accordingly in response to this anxiety. In addition, threatening feelings of self-worth increase the accessibility of death thoughts [25]. DTA can help distinguish between the processing mechanisms of proximal (i.e., conscious) and distal (i.e., unconscious) defense mechanisms in the management of fear of death [7, 26] and can immediately rise in the presence of subconscious mortality salience (MS) and when buffering mechanisms are threatened [27]. When individuals face MS, their DTA levels change, reflecting their perception of death threat and activation of defence mechanisms. By measuring DTA, researchers can better understand how individuals cope with death anxiety and what factors may influence their defence strategies [22]. Notably, however, emotional responses to thoughts of death may not be immediate. Routledge et al. [28] observed that distal emotional responses, such as fear, may emerge after a delay. According to the classical assumptions of TMT, individuals turn to distal defenses when death anxiety cannot be alleviated [27, 29].

The TMT posits two principal distal defense mechanisms for coping with fear and anxiety of death: cultural worldview and self-esteem. An individual’s cultural worldview provides a certain meaning and purpose to life, and positive identification with the worldview can reduce some of the negative thoughts and emotions associated with death [30, 31]. This is because conformity to cultural values can promote individuals’ beliefs that they can achieve symbolic or literal immortality [31–33]. Particularly, positive identification with a worldview encourages the recognition of one’s contributions to a meaningful world of symbolic immortality, including adherence to social norms and values [31, 34].

Terror management theory is an experimental approach to studying the psychology of death. Its core assumption is that people desire life but also realize that death is inevitable. When facing the awareness of mortality, people have two main reactions: they attempt to maintain either their cultural worldview or their positive self-esteem (e.g., self-worth [34, 35]). TMT argues that people manage death-related anxiety through the meanings provided by their cultural worldview and self-esteem arising from the sense of personal worth. Self-esteem is defined as the feeling that one has become an important part of a world full of meaning, and it serves as a protective factor against anxiety stemming from the innate fear of death [36, 54]. Self-esteem is the general tendency to evaluate oneself positively or negatively [37]. High self-esteem inhibits the fear of death after experiencing its salience [38], reduces anxiety and worry about death [39], and serves as a defense mechanism against death anxiety. Higher self-esteem is associated with lower death anxiety [40–42]. According to Liu et al. [43], early identification of risk factors and interventions to enhance meaning in life can prevent the loss of dignity among patients with advanced cancer.

Although the core ideas of TMT are supported by a substantial body of research, there has been a paucity of research focusing on its application to real-life, life-threatening illnesses. If TMT can assist healthcare providers in comprehending the adaptive evolution of belief systems in the context of life-threatening illnesses and their role in mitigating death-related anxiety, it could provide deeper insights and guidance for optimizing communication strategies for cancer treatment and other related areas [44, 45]. The deepening of knowledge and understanding of TMT can facilitate the development of more targeted interventions designed to address the psychological and emotional challenges that terminally ill patients may experience as part of their treatment journey.

Psychologists have conducted extensive research on the threat of death and defensive behaviors to clarify various death-defensive behaviors. However, past research has primarily focused on imagined Mortality Salience (MS) and its subsequent effect. A number of studies have [46–48] shown that patients with cancer experience higher levels of death anxiety as their condition worsens and death becomes increasingly imminent. They suggested that appropriate psychological interventions should be implemented to help patients cope with anxiety. Consequently, an in-depth analysis of the interrelationship of distal defense mechanisms in the psychological stage of death of cancer patients and their differences in defense roles will not only enhance the breadth and depth of TMT but also provide crucial insights for clinical practice. Particularly, such analyses can assist in the design and implementation of more accurate psychological counseling services and psychological intervention programs for cancer patients, thereby enhancing their overall well-being and treatment outcomes.

Currently, researchers have incorporated the Kubler-Ross [49] model of the stages of death, including denial and isolation, bargaining, acceptance, and the two emotional stages of anger and depression, into the defense system of the TMT theory to explore the various proximal defense mechanisms of cancer patients against the threat of death at the level of consciousness in the three stages of the death psyche: denial and isolation, bargaining, and acceptance [50]. In this study, we further explore the role of distal defense mechanisms in different psychological stages of death in cancer patients, whether there are differences in the distal defense mechanisms in different psychological stages of death in cancer patients, and whether they modulate these defense mechanisms in the face of real death threats. We investigated whether reminders of mortality result in heightened cultural worldview defenses, such as more severe suicidal evaluations and reduced willingness to engage in helping behaviors, among patients with cancer facing a real threat of death. Additionally, we explored whether self-esteem moderates these responses to reminders of mortality among patients with cancer. We hypothesized that this effect is moderated by explicit self-esteem among patients.

Study 1: cultural worldview defense mechanisms among patients with cancer

Methods

Participants

The study population comprised two main groups: cancer patients and dental pain patients serving as controls. All cancer patients included in this study were sourced from the oncology department of a tertiary care hospital. This included both inpatients and patients receiving special outpatient services. All participants in the experimental group were aware that they had cancer. Participants were excluded from the experimental group based on the following criteria: (1) patients with recurrence or metastasis, (2) patients aged younger than 18 years, and (3) patients who had lost the ability to walk. Control group participants were recruited from the community through a community health awareness campaign. Participants were excluded from the control group based on the following criteria: (1) patients with cancer or other serious life-threatening diseases and (2) those aged younger than 18 years.

Finally, 205 eligible adults participated in this experiment (age range: 18–69 years, M = 41.04, SD = 12.53 years, 65.4% women). The experimental group included 113 patients with cancer (aged 18–68 years, M = 45.08, SD = 10.86 years, 61.9% women). The Attitudes Attitude Death Questionnaire was employed to divide patients with cancer into three distinct groups: death-acceptance group, bargaining group, and death-avoidance group; no further MS was set for the entire experimental group. A control group of 92 patients (aged 18–69 years, M = 36.08, SD = 12.71 years, 69.6% women) with dental pain was included in the MS with classical questions. The control group participants were further divided into a death-priming group and a non-death-priming group.

There was no significant difference between the control and experimental groups in terms of educational background or socioeconomic status, but there was a significant difference in age (t = 5.38, p <.001). Since age was not the main factor we explored in this study, considering that it can have an impact on the experimental results. Therefore age is the main additional variable to be controlled for in this study and in all subsequent statistical treatments age has been included in the analysis of covariates to control for its confounding effect. The results of the covariate effect of age in this experiment were as follows: f(1,185) = 0.830, p =.094, ŋ² = 0.015.

Materials

The Death Attitudes Questionnaire-Revised (DAQ-R) is a 32-item assessment tool developed by Wong et al. in 1994 [51]. It is designed to quantify five key dimensions of an individual’s attitudes toward death: convergent acceptance, fear, avoidance, avoidant acceptance, and neutral acceptance. The questionnaire was chosen because it contains three dimensions—avoidance of death, neutral acceptance of death, and fear of death—that were the focus of the experiment. In this study, participants were asked to rate each item in the questionnaire on a scale of 1 to 7, with 1 representing strong agreement and 7 representing strong disagreement. The mean ratings of the relevant items provided by the participants were used as their final scores. Lower scores indicated that an individual’s attitudes towards death on a particular dimension were closer to the typical characteristics defined for that dimension. The study identified three responses to MS: avoidance of death, neutral acceptance of death, and fear of death. The only missing concept was a measure of the bargaining stage; therefore, we use some of the survey items designed by Zhou et al. [52] for this section, including the following: (1) If God grants me one wish, I will have no regrets when I die; (2) If I change all of my bad habits, I hope that this will make me a better person; (3) In order to prolong my life, I am willing to give away the wealth I have or do more good deeds; (4) I am willing to make a promise to God in exchange for more time; and (5) I have been thinking about how I can prolong my life. Dimensions related to collective acceptance of death were excluded. In this study, the instrument had good internal consistency, with Cronbach’s alphas of 0.86 for the bargaining dimension, 0.76 for the neutral acceptance of death dimension, 0.88 for the fear of death dimension, and 0.79 for the avoidance of death dimension.

The Cultural Worldview Discrepancy Measure (CWDM) was developed by Greenberg et al. [53] to assess the degree to which individuals identify with their own culture, with identification with one’s own culture being the most prevalent cultural worldview. The CWDM comprises two parts: Cultural Worldview Material 1 and Cultural Worldview Material 2, which are essays by foreigners in praise of the United States and against the United States, with five evaluative questions about these materials accompanying each reading. The order in which the two readings appeared in the experimental test was counterbalanced to offset order errors. Three of the five items assessed impressions of the author who wrote this part of the study (whether they liked the author and if they judged the author as being intelligent and knowledgeable), and two items were used to assess participants’ impressions of the study itself. A nine-point Likert scale was used to answer each item. In this experiment, we replaced the United States with China for the CWDM materials, and both materials showed excellent internal consistency. Cronbach’s alpha for the assessment items targeting the Praise China materials was 0.91, and higher scores on this part of the test indicated stronger worldview defenses. Cronbach’s alpha for the assessment items targeting anti-China material was 0.95, with lower scores indicating a stronger worldview defense.

When cultural worldviews are threatened, individuals tend to avoid associating the self with the concept of death [54]. When self and death-related words share the same response option, this associative inhibition may impede accurate responses on the Implicit Association Test (IAT), resulting in prolonged response times and increased errors [55]. In this study, we employed the self-compiled tone version of the DTA test to assess participants’ DTA. Given that the participants were all Chinese, we utilized the pinyin version of the DTA quiz. As pinyin tones lack tone labels, the resulting characters and meanings may vary depending on the tones employed. A total of 26 pinyin sounds were included in the study. Of these, 13 could be spelled with death-related characters, while another 13 could not be spelled at all. The number of death-related characters spelled was recorded, with the DTA values ranging from a score of 0 to 13. Higher scores indicated a greater threat of death at a subconscious level [51].

The test is designed to assess the level of DTA present at different psychological stages of the participant’s life. It is hypothesized that different levels of MS will result in different DTA values. Specifically, the greater the threat of death, the smaller the DTA value; the lower the threat of death, the greater the DTA value. MS can sometimes increase DTA due to delays, but these ideas can be blocked before they occur [56]. Following the manipulation of MS, but prior to the measurement of DTA, participants were presented with the PANAS as a distraction task [18]. This entailed the utilization of the Positive and Negative Affect Scale (PANAS) as a delayed-effects manipulation task.

Results

The Death Attitude Questionnaire identified three distinct groups of patients with cancer: death acceptance (n = 31), bargaining (n = 48), and death avoidance (n = 34) groups. Patients with dental pain were categorized into the death-priming (n = 40) and non-death-priming (n = 52) groups. We reverse-scored the five question items from Cultural Worldview Material 2 and performed a one-way analysis of variance (ANOVA) on the mean scores of the two material sums before comparing the results of each group twice. The level of defense of the cultural worldview for the five groups was significant (F(4,200) = 21.35, p <.001, η² = 0.16). The Bonferroni method was used for each group. Two-by-two comparisons revealed that the cultural worldview defense level was significantly stronger in the death-acceptance group (M = 7.18, SD = 0.88) than in the death-avoidance group (M = 5.88, SD = 2.82, p <.01, 95% CI = [0.25, 2.35]) and the dental pain without death-priming group (M = 5.94, SD = 0.83, p <.01, 95% CI = [0.28, 2.20]). However, the cultural worldview defense level in the death-acceptance group was not significantly different from that in the bargaining and dental pain death-priming groups. The cultural worldview defense level in the dental pain death-priming group (M = 7.52, SD = 0.69) was significantly stronger than that in the dental pain no-death-priming group (M = 5.94, SD = 0.83, p <.001, 95% CI = [0.70, 2.48]) and significantly stronger than that in the death-avoidance group (M = 5.88, SD = 2.82, p <.001, 95% CI = [0.66, 2.63]). The means and standard deviations of all outcomes in this study are detailed in Table 1; Fig. 1.

Table 1.

Means and standard deviations of the cultural worldview defense levels and death-thought accessibility

Test items		Patients with cancer			Patients with dental pain
		Death acceptance (n = 31)	Bargaining (n = 48)	Death avoidance (n = 34)	Death priming (n = 40)	No death priming (n = 52)
Cultural worldview	M	7.18	6.68	5.88	7.52	5.94
	SD	0.88	1.50	2.82	0.69	0.83
Death-thought accessibility	M	2.06	0.52	0.56	2.90	1.17
	SD	2.16	1.50	1.08	2.85	1.20

Fig. 1.

Graph comparing cultural worldview defense levels and DTA results. Note: Death acceptance: Death-acceptance group; Bargaining: Bargaining group; Death avoidance: Death-avoidance group; Death priming: Death-priming group; No death priming: No-death-priming group. *p <.05, **p <.01, ***p <.001

Discussion

Study 1 focused on cultural worldview defense mechanisms in the distal defense of patients with cancer. The results of the control group of patients with dental pain verified prior results: that the value of DTA increased significantly after patients were subjected to MS, and the increase in DTA enhanced patients’ cultural worldview defense level.

In contrast, the cultural worldview defense level of patients with cancer in the death-avoidance stage was not significantly different from that of patients with dental pain who did not receive death priming, which indicates that the cultural worldview defense level of patients with cancer in this stage is lower, similar to that of patients with dental pain without MS. We concluded that patients with cancer were avoiding the death stage; therefore, the cultural worldview defense mechanism was suppressed at this stage. The cultural worldview defense level increased to the highest level in the acceptance-of-death groups. Although the cultural worldview defense level was not significantly higher in the bargaining phase than in the death-avoidance phase, we observed an upward trend in the mean cultural worldview defense level in the bargaining group.

The distal defense does not appear only after the proximal defense, as Greenberg [53] believed, but the distal defense mechanism is suppressed under the avoidance and denial defense stages of the proximal defense. However, as the individual’s level of rationality and unbiased cognition increases, the distal defense mechanism appears and gradually rises, even though the awareness of death is still present at the level of consciousness. Once the individual has faced death and is no longer in the avoidance or denial phase, the level of rational cognition begins to rise, and the meaning system of the cultural worldview comes into play. Among patients with cancer, we found a trend of increased cultural worldview defense levels, consistent with increased DTA levels. This patient group also showed an increase in DTA after the delayed task only in the acceptance-of-death phase and very low DTA levels in both the bargaining and avoidance-of-death phases. These results suggest that the avoidance and denial phases of the death psyche of patients with cancer inhibit the defense mechanisms of cultural values.

These results do not negate the theoretical constructs and assumptions of TMT but enrich and refine its theory. We believe that the proximal and distal defense mechanisms do not occur in a complete, alternating, and linear fashion; rather, the two defense mechanisms occur in parallel. However, distal defense will have an inhibitory stage in the avoidance and denial stages. When human beings are faced with a strong threat of death, the most primitive defense is instinctive avoidance and denial, and, at this stage, everything that is meaningful and valuable becomes meaningless. Cultural values are the cultural system constructed by human beings, and they include a whole set of meaning systems; therefore, the cultural value defense mechanism cannot defend against death psychology simultaneously in the stages of avoidance and denial. However, as the cognitive and rational levels of patients with cancer gradually rise, they begin to enter the bargaining and accepting death stages, in which the cultural worldview defense mechanism begins to work.

Study 2: self-esteem defense mechanisms among patients with cancer

Methods

Participants

Participants were identical to those in Study 1.

Materials

Rosenberg’s [57] Self-esteem Scale was used to measure explicit self-esteem. The scale consists of 10 items that measure a single dimension of overall self-esteem, with five positive and five negative items. Each item was scored on a scale of 1 to 4 (1 = “very inconsistent” to 4 = “very consistent.” Items 3, 5, and 8–10 are reverse-scored). The scale measures self-esteem levels, with higher scores indicating higher levels of self-esteem. Aprilianto et al. [58] found the scale highly reliable and valid for use with patients with cancer. In this study, the internal consistency was deemed acceptable, with a Cronbach’s alpha of 0.78.

The Beck Scale for Suicide Ideation-Chinese Version [59] was developed to quantify and assess suicidal ideation based on clinical experience and theoretical research. The questionnaire comprises 19 items, but the test was shortened to consider the fatigue and physical factors of patients with cancer participating in the experiment; therefore, only the initial five core items were selected for this study to measure suicidal ideation in cancer patients: (1) How much do you want to live? (2) How much do you want to die? (3) Do your reasons for living outweigh your reasons for dying? (4) How much do you actively want to try to kill yourself? (5) How much do you want to end your life by external forces (i.e., how much do you have a “passive desire to kill yourself”; e.g., wish to go to sleep and never wake up, die unexpectedly, etc.)? All items were rated on a scale of 1 to 3, with higher scores indicating a greater inclination toward death. Cronbach’s alpha in this study was 0.63. The questionnaire was administered only to patients with cancer and not to those with dental pain. The reasons for the slightly lower reliability of the scale in comparison to other measurement tools may be as follows: (1) The measurement is aimed at a specific group of people facing a real threat of death (cancer patients). (2) The shortened content of the test. (3) The scale is older and has not been updated to match modern understandings.

The Hospital Anxiety and Depression Scale (HADS) was developed by Zigmond and Snaith in 1983 [60]. The scale is primarily employed for screening anxiety and depression in non-psychiatric settings. Additionally, it can be used to assess the severity of depression and track patient progress in a range of contexts. The diagnostic criteria for depression in this scale removes somatic symptoms, such as insomnia, fatigue, and pessimism about the future. Zigmond and Snaith found that physical illness did not affect the scale results once emotional and somatic disorders were eliminated [60]. The scale aids in evaluating the severity and presence of depression among patients with cancer, enabling providers to make more precise and confident diagnoses. The HADS excludes depressive states owing to somatic symptoms that may be attributed to cancer and its treatment [61]. The questionnaire comprised seven items scored on a scale of 1 to 4. The depression subscale produced scores ranging from 7 to 24. Scores below 15 were classified as “non-cases,” scores between 15 and 17 were considered threshold scores, and scores of 18 or higher were indicative of possible psychological distress due to depression.

In a study conducted by Walker et al. [61], the HADS was compared with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The results indicated that, when the HADS total score was used to identify cases of major depressive disorder (MDD), the area under the participants’ operating characteristic curve (ROC) was 0.94. A critical score of ≥ 15 was optimal for screening for MDD among patients with cancer, with a 95% confidence interval of 0.70–0.95 and a specificity of 0.85 (95% confidence interval = 0.81–0.89), reducing the number of misclassifications of MDD. Walker et al. [61] confirmed that the HADS is a reliable screening tool for the screening of major depressive disorder in outpatients with mixed cancers, with an ROC curve area close to 1.0, indicating an excellent overall performance with high sensitivity and specificity. In this study, the internal consistency of the HADS was good, as indicated by a Cronbach’s alpha of 0.82.

Implicit self-esteem testing procedure

The study focuses on self-esteem. Therefore, in addition to using a questionnaire to measure explicit self-esteem, the IAT was utilized to measure implicit self-esteem. There are several reasons for using implicit tests of self-esteem. First, the social approval effect often influences explicit measures of certain psychological traits. Second, there is individual variability in the degree of introspection of implicit representations. Some individuals exhibit highly aligned and overlapping implicit and explicit psychological traits, whereas others exhibit highly dissociated implicit and explicit psychological traits [62]. Therefore, since the psychological trait of self-esteem has a certain social expectancy effect, an implicit test was added to increase measurement accuracy.

We used E-prime 2.0 software (E-prime; PST, USA) in accordance with standard IAT procedures to write the stimulus presentation and data collection program for this study. There were seven steps, and the basic task was to ask participants to follow the categorization cues on the top left and right of the screen and to categorize keystrokes for words presented one by one in the center of the screen. To counteract the sequential effect of the arrangement of compatible and incompatible tasks, two sets of procedures were designed: Procedure 1 (compatible task first) for even-numbered participants and Procedure 2 (incompatible task first) for odd-numbered participants.

The assignment of the two sets of procedures to participants was automatically performed using the program: Procedure #1: (1) Attribute word exercise: participants were asked to categorize positive and negative words by pressing “F” and “J,” respectively; (2) Target word exercise: participants were asked to categorize “self words” and “non-self words” by pressing “F” and “J,” respectively; (3) Compatible joint exercise: participants were asked to categorize conceptual words and attribute words jointly; that is, to press “F” for self words and positive words, and to press “J” for other people’s words and negative words. After responding to the first three tasks, participants were given feedback to help familiarize themselves with the experimental procedure; (4) Compatible joint test: task (3) was repeated, but multiplying the number of trials; (5) Target word flip exercise: participants had to categorize self and other words, but the key press requirement was the opposite of task (2); (6) Incompatible joint exercise: participants had to perform joint categorization of conceptual and attribute words, but had to press the “F” key for other and positive words and the “J” key for self and negative words; (7) Incompatible joint test: task (6) was repeated, but the number of trials was multiplied. No answer feedback was included for tasks (4)–(7). Repeating tasks increases data stability [41–63]. The flowchart of procedure #1 in this study is shown in Fig. 2.

Fig. 2.

Flowchart of procedure 1 for compatible and incompatible tasks

Procedure #2: The procedure was approximately the same as Procedure 1 (above), except that the incompatibility task was performed first; that is, steps (2), (3), and (4) were interchanged with steps (5), (6), and (7) to balance the sequential errors introduced by the experimental content. The flowchart of Procedure 2 in this study is shown in Fig. 3.

Fig. 3.

Flowchart of procedure 2 for compatible and incompatible tasks

Implicit self-esteem data processing procedures

In this study, the Implicit Associative Self-esteem Test was administered using an optimized algorithm relative to the traditional algorithm [42–64]; the test indicated that the new algorithm was less affected by extraneous variables than the old algorithm, better reflected the strength of the underlying associations, better assessed the relationship between the strength of the associations and the other variables, and was better able to observe the effect of the trial manipulation on the strength of the associations. Calculations were performed as follows: (1) drawing on data from the practice group (third and sixth trials) and the test group (fourth and seventh trials); (2) excluding data from trials with response times greater than 10,000 ms, and excluding all data from participants with more than 10% of the data with response times less than 300 ms; (3) not excluding the first two trials in each group; (4) not treating extreme values; (5) calculating the mean number of correct response times (M_bc) for each test group; (6) calculating the joint standard deviation (S_dp) of the responses of the practice trial group and the joint standard deviation (S_dt) of the responses of the test trial group; (7) replacing all incorrect response times with (M_bc + 600 ms); (8) not performing logarithmic transformations; (9) calculating the mean of the responses of the four trial groups separately (M_b3, M_b6, M_b4, M_b7); (10) calculating the mean of the response times of the (M_b3–M_b6) and (M_b4–M_b7); 11) calculating D_3,6 = (M_b3– M_b6) / S_dp and D_4,7 = (M_b4– M_b7) / S _dt; and 12) calculating D = (D_3,6 + D_4,7) / 2.

Results

As in Study 1, patients with cancer were categorized according to the Death Attitude Questionnaire as follows: 31 in the death-acceptance group, 48 in the bargaining group, and 34 in the death-avoidance group. There were 40 and 52 patients in the death and no-death-priming groups, respectively. A one-way ANOVA of the total Rosenberg questionnaire scores for episodic self-esteem for these five groups was significant (F(4,200) = 3.26, p <.05, η² = 0.06). Using the Bonferroni method, a two-way comparison of the groups revealed no significant difference among the three groups of patients with cancer. Additionally, no significant differences were found between the two-way comparisons of patients with dental pain, and none were observed among the three groups of patients with cancer. Similarly, no significant differences were found compared to patients with dental pain. Among participants in the dental pain group, explicit self-esteem was significantly stronger in the death-priming group (M = 30.30, SD = 3.52) compared to the no-priming group (M = 27.38, SD = 4.42, p <.01, 95% CI = [0.54,5.29]).

The result of the one-way ANOVA on the D-value of the implicit self-esteem effect size for the five groups was significant (F(4,200) = 6.11, p <.001, η² = 0.11). A two-way comparison of the groups using the Bonferroni method showed that implicit self-esteem was significantly stronger in the death-avoidance group (M = 1.41, SD = 0.42) than in the death-acceptance group (M = 0.78, SD = 0.53, p <.05, 95% CI = [0.03, 0.69]), the dental pain death-priming group (M = 0.75, SD = 0.57, p <.01, 95% CI = [0.08, 0.70]), and the dental pain no-death-priming group (M = 0.67, SD = 0.44, p <.001, 95% CI = [0.18, 0.77]). In the death-avoidance and bargaining groups, there were no significant differences regarding implicit self-esteem. There were no significant differences in implicit self-esteem between the dental pain death-priming group and the dental pain no-death-priming group.

A one-way ANOVA of the total scores on the hospital anxiety and depression questionnaires for the five groups was significant (F(4,200) = 6.47, p <.001, η² = 0.11). A Bonferroni method of two-by-two comparisons of the groups showed that the depression level was significantly higher in the death-avoidance group (M = 14.79, SD = 5.02) than in the death-acceptance group (M = 10.84, SD = 3.80, p <.001, 95% CI = [1.41, 6.50]), the dental pain death-priming group (M = 11.50, SD = 2.79, p <.01, 95% CI = [0.90, 5.69]), and the dental pain no-death-priming group (M = 11.53, SD = 2.48, p <.01, 95% CI = [ 1.00, 5.52]), with no significant differences between them and the bargaining group. There were no significant differences in depression levels between the dental pain death- and no-death-priming groups.

A one-way ANOVA on suicidal ideation among patients with cancer was significant (F(2,110) = 102.51, p <.001, η² = 0.65). A two-by-two comparison of the groups using the Bonferroni method showed that the level of suicidal ideation was significantly higher in the bargaining group (M = 9.42, SD = 1.46) than in the death-acceptance (M = 5.65, SD = 0.66, p <.001, 95% CI = [3.13, 4.41]) and death-avoidance (M = 8.24, SD = 0.99, p <.001, 95% CI = [0.56, 1.81]) groups. The level of suicidal ideation was significantly higher in the death-avoidance group (M = 8.24, SD = 0.99) than in the death-acceptance group (M = 5.65, SD = 0.66, p <.001, 95% CI = [1.88, 3.28]). Table 2 presents the means and standard deviations of all the outcomes in this study.

Table 2.

Self-esteem defense levels, depression, suicidal intent, and death-thought accessibility

Test items		Patients with cancer			Patients with dental pain
		Death acceptance (n = 31)	Bargaining (n = 48)	Death avoidance (n = 34)	Death priming (n = 40)	No death priming (n = 52)
Implicit self-esteem	M	0.78	0.93	1.14	0.75	0.67
	SD	0.53	0.40	0.42	0.57	0.44
Explicit self-esteem	M	29.35	28.75	29.12	3.030	27.38
	SD	3.49	3.62	4.62	3.52	4.42
Depression	M	10.84	12.62	14.79	11.50	11.53
	SD	3.80	3.93	5.02	2.79	2.48
Death-thought accessibility	M	2.06	0.52	0.56	2.90	1.17
	SD	2.16	1.50	1.08	2.85	1.20
Suicidal intent	M	5.65	9.42	8.24
	SD	0.66	1.46	0.99

Discussion

Study 2 focused on the self-esteem defense mechanism in the distal defense of patients with cancer and the dynamics of the relationship between self-esteem, depressed mood, and suicidal intent. Patients with cancer at different psychological stages of death did not differ significantly in explicit self-esteem tests. However, on the implicit self-esteem test, the death-avoidance group scored significantly higher than the death acceptance and even significantly higher than the dental pain groups. This finding suggests that among patients with cancer, even in the first stage of strong activation of proximal defenses, distal defenses may be activated and involved in defending against the threat of death.

This result directly challenges Greenberg’s [53] conclusion that distal defenses are not activated when proximal defenses are active. The avoidance and denial phases of the death psychology of patients with cancer in Study 2 also suppressed elevated explicit self-esteem but not implicit self-esteem defense against the threat of death. In response to this inconsistency, we suggest that this may be because several previous empirical studies by Greenberg [53] were based on the method of asking participants to imagine completed MS scenarios to exclude death thoughts from consciousness (proximal defense), and then allow death thoughts to disappear further at the unconscious level (distal defense).

Thus, generally, the distal and proximal defense systems are dissociative and non-overlapping. Among patients with cancer, the defense system becomes more complex, contradictory, repetitive, and overlapping in the face of a high-intensity threat of death. For example, when patients with cancer in the stage of death avoidance face the unchangeable end of death, on the one hand, they may think that they are small and non-significant at the conscious level; on the other hand, they will search for and enhance their own value and significance to reduce the threat of death at the unconscious level, which leads to contradictory and overlapping psychological states. Therefore, the real, imminent, and strong threat of death directly causes patients’ thoughts of death at both the conscious and unconscious levels to be at a higher level during the same period. To enhance adaptability, distal and proximal defense mechanisms not only increase in strength but also appear to overlap.

As for the lower DTA level measured in the death-avoidance phase, we believe it is partly a result of proximal defense suppression because DTA levels rise when proximal defenses are suppressed by using the alternating cognitive-load task. Moreover, this suppression is partly a result of implicit self-esteem defense. Harmon-Jones et al. [36] showed that either participants’ own tendencies to have high self-esteem or the temporary elevation of the self-esteem level induced by artificial experimental controls will reduce the impact of death-related thoughts, especially in response to things that threaten their cultural worldview. Contrastingly, the control group of patients with dental pain did not show a significant increase in implicit self-esteem after MS. Therefore, the proximal defense in the death-avoidance phase is a process of eliminating the threat of death and the meaning system, while at the unconscious level, the increase in self-esteem helps the individual to restore the meaning system.

These results support the interpretation that the defence mechanism of a sense of self-worth may be superior to the defence mechanism of a cultural worldview among the distal defence mechanisms of cancer patients. This further suggests that defence mechanisms against the threat of death through a sense of self-worth may be more effective than defence mechanisms through a sense of meaning in the external world (outside the self). Based on the results of the current data self-esteem level may be one of the key correlates of cancer patients’ ability to combat the threat of death, but its relative potency in relation to cultural worldviews needs to be interpreted with caution in relation to the cultural context.

A particularly interesting result was that the self-esteem level of patients with cancer who had accepted death dropped to its lowest value, significantly lower than in the other two stages. Research on individuals with depression has shown that their level of self-esteem is significantly lower than that of healthy individuals [65], and the low self-esteem, coupled with feelings of worthlessness and lack of purpose, is a major contributing factor to the increased risk of suicide among individuals with depression. The low self-esteem of inhibited patients with a sense of worthlessness and meaning to the self is a major reason for the high risk of suicide. However, unlike the death-seeking mentality, patients with cancer who accept death had the lowest scores on the suicidal intent scale, indicating that patients with cancer at this stage do not have a death-seeking mentality; unexpectedly, the depression scores of patients with cancer at this stage were also at the lowest level, which means that patients do not experience any other depressive mood, except for the factors related to the disease. Patients at this stage accept death but do not subjectively seek it.

Suicidal intent was most pronounced among patients with cancer in the bargaining stage, most likely mainly because patients with cancer in this stage overwhelmingly experienced bargaining failure, reduced self-control, and lowered self-esteem. However, a high level of suicidal intent is not necessarily indicative of a fear of death but, rather, an extreme fear of death [66, 67]. The great sense of anxiety and fear caused by the threat of death has reached an unbearable level in the individual’s psyche, producing a choice of death to escape the pain caused by the threat of death. However, the high risk of suicide during the bargaining phase may partly result from the concentrated experience of loss of control during this phase, but may also be the result of a synergy of biopsychosocial factors. Future follow-up designs are needed to further clarify whether self-esteem and cultural worldview are complementary or alternative mechanisms, and whether bargaining failure is a causal or concomitant phenomenon of suicide.

Conclusion

Coping with death is a fundamental existential topic for human beings and has led to the derivation and evolution of various strategies to protect against the threat of death and to ensure psychological and spiritual resilience. The TMT, as proposed by Greenberg et al. [17-], offers a valuable theoretical framework for understanding how individuals cope with anxiety and fear related to death. Consequently, psychologists have conducted extensive research on the threat of death and the utilization of defensive behaviors. However, past research has focused on imagined MS and its subsequent effect, while few studies have been conducted on real MS and subsequent defense effects. Studies 1 and 2 investigated the distal defense mechanisms of the cultural worldview and self-esteem among patients with cancer. The studies also explored the changes in these mechanisms in conjunction with the three phases of the proximal defense mechanisms to determine their interrelationships. An important conclusion drawn from this combination is that, for patients with cancer, distal defense mechanisms indicate a transition from meaningless to meaningful and a continuous process of change. When proximal defenses are performed, distal defenses are also performed, and the only variation is in the appearance of distal defenses according to individual and stage differences. Future research should consider the limitations of the sample, study design, cultural differences, and interventions.

This study examined the relationship between cultural worldview and self-esteem among Chinese patients with cancer, which could be further explored in other populations or among patients with different diseases. Future research should also examine additional psychological factors that may impact patients’ mental health and coping abilities. The current findings offer a reference for future research on the influence of cultural worldview and self-esteem on patients’ mental health and the creation of suitable interventions.

Future research could further focus on the dynamic interactions between distal defence mechanisms, cultural worldviews and self-esteem in cancer patients, with an emphasis on exploring the following directions: first, the moderating effects of cultural differences, such as the divergence of defence strategies in the context of collectivism versus individualism and cross-cultural adaptation conflicts among immigrant patients; secondly, the integration of key mediating variables, including types of social support, psychological resilience, attributional models of disease (fatalistic vs. controllable), and the use of technology; and third,, multidisciplinary methodological innovations, such as combining neuroimaging techniques to reveal the neural coding of cultural worldviews or using ecological transient assessments to capture real-time psychological fluctuations. Furthermore, ethical practices, such as the optimisation of defence resource allocation by culturally sensitive care and policy support, must be given due consideration in order to provide a scientific pathway for personalised interventions that balances cultural identity and psychological adaptation.

Electronic supplementary material

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Author contributions

Jia Zhou contributed to conceptualization, data curation, investigation, methodology, project administration, resources, software, and writing (original draft and review/editing). Furong Zhou contributed to conceptualization, investigation, methodology, project administration, software, validation, and writing (original draft and review/editing). M contributed to investigation, methodology, project administration, resources, supervision, validation, and writing (review/editing). T contributed to investigation, project administration, resource allocation, supervision, validation, and writing and editing of the manuscript. All authors read and approved the final manuscript.

Funding

General Program of the National Social Science Fund（24BSH094）and the School-level Education and Teaching Reform Project of Southwest Medical University (08/02323012), and the Sichuan Psychological Association’s project on Traditional Chinese Medicine Integrative Therapy Combined with Conformalised Psychotherapy (SCSXLXH2023040) and the project of Sichuan Psychological Association - An intervention study of self-compassionate writing on the extinction of suspenseful fear in patients with seclusion disorder in different treatment periods (SCSXLXH2023025).

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of Southwest University and the Affiliated Hospital of Southwest Medical University (no. XNYD2017268). This study was conducted in compliance with local legislation and institutional requirements. Participants provided written informed consent to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.