Introduction
As a prevalent chronic disease, cancer is one of the major health issues in the world which ranks as the second leading cause of mortality after heart disease (Götze et al., 2020) and is predicted to become the leading cause of mortality by 2060 (Mattiuzzi & Lippi, 2019; Ren et al., 2024). Technological advances have extended the life expectancy of cancer patients (Lu et al., 2023; Hampton et al., 2024); however, the challenges associated with this disease have not been fully re-solved (Cho et al., 2020) and patients often struggle with feelings such as anxiety, fear, and chronic pain (Li et al., 2024; Besharat et al., 2020; Götze et al., 2020; Vehling et al., 2017).
In 2019, a total of 1.8 million people were diagnosed with cancer in the United States. Cancer is expected to be the main cause of 70% of deaths by 2030 (Siegel et al., 2019; Mardani, 2023). In 2020, cancer affected 131 191 people in Iran and led to the death of 79136 patients (The Global Cancer Observatory, 2021). Cancer is recognized as a significant health problem of the century (Stagl et al., 2015) and its development has resulted in negative complications (El-Sayed et al., 2023; Firouzi, 2022).
Individuals diagnosed with cancer are forced to think of and confront the end of their lives. These patients are struggling with death anxiety, characterized by an unusual fear of dying, as well as feelings of panic and presentiment (Lu et al., 2024). Death anxiety has been reported to affect 91% of cancer patients, making it one of the most prevalent types of anxiety in this population. This type of anxiety is persistent and abnormal, defined as an intense fear of death, accompanied by panic and worry about the death process and events thereafter (Shakeri et al., 2022). Death anxiety culminates in helplessness, physical changes, loss of control, and loss of people around (Coutts-Bain et al., 2023; Bastani et al., 2016). The fear and anxiety of death are among the most significant concerns in cancer treatment, leading to profound distress in the patient (Togluk & Budak, 2024). This anxiety accompanies long-term dysfunctions (Gulbahar Eren et al., 2023). Attention to psychotherapy in cancer patients in general and intervention on death anxiety in particular has been suggested in numerous studies (Blunt & Trigg, 2024; Spitz et al., 2023; Togluk & Budak, 2024; Lu et al., 2024; Gulbahar Eren et al., 2023; Babanejad Derikande et al., 2023; Mina et al., 2023; Bajelan et al., 2022). 
Women suffer from mental illness almost twice as often as men (Yu, 2018). They are more vulnerable to stress and fear-related disorders (Maeng et al., 2015). Past research has strongly supported differences in the prevalence and severity of mental disorders between men and women (van de Venne et al, 2019). Women experience markedly greater levels of anxiety disorders than men. In a study of more than 20000 individuals, the collaborative psychiatric epidemiology surveys found higher rates of lifetime diagnosis for nearly all anxiety disorders among women in the United States (Alegria et al., 2024). Core features of anxiety disorders include subjective anxiety or fear experience, physiologic reactivity, and often, avoidance behaviors. Anxiety disorders are characterized by anxious apprehension or fear in response to a perceived threat. Anxiety or anxious apprehension is a future-oriented state in which one is concerned about potential threats, whereas fear occurs in response to an immediate threat. Finally, women may be more physiologically responsive to stressors, leading to an increased risk of anxiety or other neuropsychiatric disorders (Hantsoo et al, 2017). Considering the importance of women’s role as one of the main pillars in the family (Beck, 1988) and that women are more vulnerable than men to anxiety and fear-related disorders (Maeng et al., 2015), this research focused on wom-en’s society.
Conventional psychological interventions have provided varying degrees of improvement but have often neglected to deal with the intricate perspective re-sulting from cancer.
A therapeutic intervention that is considered very effective among psychotherapy methods is paradoxical psychotherapy which views anxiety and pain as cata-lysts for psychological improvements (Browning & Hull, 2021). Besharat (2019) has developed a paradox therapy model (paradox + timetable=cure [PTC]) that makes this therapy more effective. PTC is a new and comprehensive approach to the treatment of a broad spectrum of psychological disorders, such as obses-sive-compulsive disorder (Besharat, 2020). This method has been effective on a couple of issues (Besharat, 2020), illness anxiety (Peimanpak et al., 2023), social anxiety (Besharat, 2019; Maba, 2017; Babaie et al., 2023), body dysmorphic disorder (Ataoglu et al., 2003; Besharat, 2020), binge eating disorder (Ghadimi Nouran et al., 2020), insomnia (Zhang et al., 2016), rumination (Mohammadi et al., 2020), anger rumination in people suffering from anxiety caused by COVID-19 (Eatesamipour et al., 2023), ego-strength and self-knowledge (Tahernejad et al., 2022), emotion regulation in couples (Chitgarzadeh et al., 2023), grief (Jahanpanah et al., 2023), relationship obsession (Dehaqin et al., 2023), and self-esteem (Hashemizadeh et al., 2023). Two substantial items in PTC ac-celerate healing. The first item is a paradox, meaning the prescription of a disease symptom. The patients reconstruct the same symptoms and behaviors they have experienced based on the prescribed order. The second item is timetable which dictates when and how long the patient reconstructs the symptoms. There are four effective mechanisms in PTC, including formalization/artificialization, disconnection of the symptom and anxiety, changing the meaning of the symptom, and finally ego-strength. The primary and ultimate goal of treating psychological disorders in this approach is to enhance the consistency and power of ego strength. Simultaneously with removing anxiety related to the disease symptoms, the ego-strength process commences and evolves in parallel with performing tasks in the form of artificial mechanisms, disconnection of the symptom and anxiety, and changing the meaning of the symptom (Besharat, 2023).
Numerous interventions have been introduced to manage and control psychological and behavioral complications stemming from death anxiety, such as cogni-tive behavioral therapy (Togluk & Budak, 2024), semantic therapy (Babanejad Derikande et al., 2023), unity-oriented therapy (Bajelan et al., 2022), and ac-ceptance and commitment therapy (Mina et al., 2023). While these interventions have achieved favorable results as expected, there is still a significant need for experimental studies to assess the effectiveness of psychological interventions on individuals with cancer.  
Considering the significance of the mentioned features of PTC and the lack of a study to assess the effectiveness of PTC on death anxiety in cancer patients, the current study investigates the effectiveness of PTC on death anxiety of women with cancer. Based on this, we hypothesize that PTC is effective on death anxiety in women with cancer and that its effectiveness is sustained over time.

Materials and Methods
This was a quasi-experimental study with a pre-test-post-test design and a control group. The statistical population consisted of all female cancer patients referring to Dr. Vosoughi Cancer Treatment Center in Ahvaz Province, Iran, from January 21 to February 19, 2023.  The sample size was estimated using the statistical method outlined by G*Power soft-ware (Farahani & Roshan Chesli, 2023). The effect size was set at 0.35, with a statistical power of 0.08 and a significance level of 0.05. Considering potential attrition, four additional subjects were included, resulting in a final sample size of 52. The subjects were first recruited based on inclusion criteria and then were assigned into intervention (n=26) and control (n=26) groups by simple randomization. The inclusion criteria were consent to participate in the study, women with various types of cancer, aged 18 years and above, being in all stages of treatment except the final stage, being in either active treatment or follow-up stages, no history of psychiatric illness, no comorbid physical illness, no drug abuse, being literate in reading and writing, being fluent in Persian language, and having full consciousness. Meanwhile, the exclusion criteria were missing more than two treatment sessions, and using complementary and alternative medicine. Psychotherapy sessions were held on even days. Each patient had a session once a week. The time of each session was 45 min. The sessions were conducted face-to-face and individually at the cancer treatment center in Ahvaz Province, Iran. The first author of the article (Maryam Mardani) was responsible for conducting these sessions. She has attended courses in cognitive behavioral therapy, acceptance and commitment therapy, mindfulness, and schema therapy. Also, as a PhD student at Tehran University, Iran, she has taken up the course of PTC under the supervision of Dr. Besharat (the developer of the PTC model). The treatment con-sisted of 6 sessions, which were implemented individually; however, the number of sessions could vary from 4 to 6 based on the patient’s characteristics (every patient has a different ego and the goal of paradox therapy is to strengthen the ego. Once the ego strength is achieved, both the patient and the therapist will know that the sessions are terminated). After the end of the study, each member of the control group received an in-person meditation session. 

The paradox therapy
Besharat (2019) developed a new model of paradox therapy for the treatment of psychological disorders, called PTC (paradox + timetable = cure). In this research, this model was used to treat the selected samples. The PTC sessions implemented in the present research are summarized in Table 1.



Study tools
The demographic information questionnaire: The demographic information included the level of education, marital status, age, job status, type of cancer, duration of illness, and ethnicity. 

The death anxiety scale
The death anxiety scale, compiled by Templer (1970), consists of 15 questions used to assess the subjects’ attitudes toward death. Each question requires a “yes/no” answer. A score of 1 is assigned to the “yes” answers, and a score of zero is assigned to the “no” answers. As a result, scores on this scale can range from 0 (no death anxiety) to 15 (very high death anxiety) (0 to 6=low death anxiety and 7 to 15=high death anxiety). A score between 6 and 7 was considered the cut-off point. Saggino and Kline (1996) reported the Cronbach α coefficients for the three factors obtained through the factor analysis method and revision of the Italian version of this scale as 0.68, 0.49, and 0.6, respectively. Templer (1970) obtained the scale’s test re-test coefficient to be 0.83. Rajabi and Bahrani (2002) assessed the reliability and validity of the Persian version of this questionnaire. They reported a split-half reliability coefficient of 0.6 and an internal consistency coefficient of 0.73. In addition, in Ghasempour et al.’s study (2012) in Iran, the scale’s reliability was reported as 0.65 using Cronbach α. In the present research, the reliability coefficient of the death anxiety scale was calculated using Cronbach α, which was 0.76, indicating the desirable reliability coefficient for the scale.

Data analysis
The Mean±SD, and demographic characteristics for the experimental and control groups were first reported separately. A comparison of sociodemographic characteristics between the experimental and control groups was conducted by chi-square test and independent t-test. The results of the research hypothesis were presented using the mixed analysis of variance method in the SPSS software, version 25. Additionally, the Shapiro-Wilk test and Mauchly test of sphericity were employed to verify the assumptions of repeated measures analysis of variance. The Bonferroni test was used for within-group pairwise comparisons of death anxiety. The significance level was set at P<0.05.

Results

Descriptive findings of the research variables
Description and comparison of demographic variables are shown in Table 2. 
Table 2 demonstrates that the groups are homogeneous with respect to all demographic variables.



The descriptive findings related to the research variable in both groups are presented separately for the pre-test, post-test, and follow-up phases (Table 3).



The mean scores of death anxiety in both groups, across the pre-test, post-test, and follow-up stages, are visually represented in Figure 1.



In the present study, mixed variance analysis was used to test the research hypothesis. Before analyzing the data related to the hypothesis, they were examined to ensure that the data met the underlying assumptions of the statistical analysis. For this purpose, the assumptions of normality, Mauchly sphericity, and homogeneity of variances were investigated.  
To check the normality of the distribution of the variable in the pre-test, post-test, and follow-up stages, the Shapiro-Wilk test was used and the results showed that the significance level of the statistical values obtained for the distribution of the variable scores in the three-time points is higher than 0.05, which shows that the variable scores of the current research, have a normal distribution. Therefore, the assumption of normality for the dependent variable is maintained in both experimental and control groups.  
To check the assumptions of using mixed analysis of variance, the Levene test was used to check the homogeneity of variances in the two groups, and the Mauchly sphericity test was conducted to check the variance of the difference between all the combinations of the variance-covariance matrix in the groups. The results of the Levene test for the death anxiety variable showed that the F value obtained regarding the difference in the variances of the two groups in the pre-test (P=0.96), post-test (P=0.42), and follow-up (P=0.82) stages are not statistically significant; therefore, the assumption of homogeneity of variances is confirmed. Mauchly test was used to check the assumption of sphericity (Table 4).


 
According to Table 4, the obtained chi-square value is not significant at the level of (P<0.05), and due to the homogeneity of the matrix, the sphericity coefficient should be used. 
The results of the analysis of intragroup and intergroup effects are reported in Table 5 using an analysis of variance with repeated measures.



As the results of Table 5 show, the effect of time on death anxiety scores is significant (F=169.77, P=0.0001). As a result, there is a significant difference between the meam scores of death anxiety in the pre-test, post-test, and follow-up stages. Also, the interaction effect of time and treatment group is significant (F=153.58, P=0.0001). In other words, the difference in the mean death anxiety score at different times according to the paradox therapy group and the control is significant and indicates the effect of the treatment on the dependent variable. According to the above results, the hypothesis is confirmed.
The pairwise comparisons regarding within-group and between-group differences were performed using the Bonferroni test. This test shows the change process from pre-test to post-test from pre-test to follow-up and from post-test to follow-up. The results are reported in Table 6.



According to Table 6, death anxiety in the experimental group decreased significantly (P<0.0001) in the post-test compared to the pre-test. In addition, death anxiety had a significant decrease in the follow-up phase compared to the pre-test (P<0.0001); also, death anxiety decreased in the follow-up phase compared to the post-test, but this amount was not significant (P=0.8).

Discussion 
Cancer diagnosis can be very stressful for the patient physically and mentally. After exposure to a cancer diagnosis, patients experience severe psychological reactions. Among the feelings that appear after a cancer diagnosis is a sense of closeness to death to the extent that nowadays death anxiety is expressed as one of the crucial psychological components in cancer patients (Moraes et al., 2021; Kiyak & Türkben, 2022). Due to its ambiguous nature, death manifests for many individuals as a threat. Death is a reality that has always existed, and each individual may have a unique reaction and perception towards it. There are high levels of death anxiety in many people with cancer, which can be caused by insufficient education of these patients and their ignorance of how to deal with it (Curran et al., 2020).
The present research determined the effectiveness of PTC on the death anxiety of women with cancer. Based on the research results, the strong effect size, and the improved death anxiety symptoms, PTC can be considered a very effective intervention that maintains its reducing effect on death anxiety over time. In PTC, the individual is required to think about their intrusive automatic thoughts and feelings at a specified and predetermined time, and in essence, they reconstruct and re-experience the symptoms of their disorder. In exposure to these symptoms, and during the ego-strengthening processes, the conflicts between the patient’s id and superego that lead to morbid symptoms gradually end without tension (Besharat, 2019). Different psychotherapeutic approaches have investigated this variable in various studies and suggested that the life of a patient with this anxiety is unbearable and destructive (Blunt & Trigg, 2024; Togluk & Budak, 2024; Gulbahar Eren et al., 2023; Babanejad Derikande et al., 2023). According to the results of this research, PTC is very effective in the reduction of death anxiety in female cancer patients. The results of the current study are consistent with other studies regarding the effectiveness of PTC on different diseases, including a broad spectrum of neuropsychiatric disorders, such as various types of anxiety disorders (Maba, 2017; Peimanpak et al., 2023), self-esteem (Hashemizadeh et al., 2023), body dysmorphic disorder (Ataoglu et al., 2003), insomnia (Zhang et al., 2016), and relationship obsession (Dehaqin et al., 2023).
The specific advantages of the paradoxical therapy model are its simplicity and efficiency (short duration to achieve therapeutic goals). These factors lead to a reduced likelihood of treatment dropout, lower treatment costs for patients, a high certainty of achieving therapeutic goals, and a significant reduction in the likelihood of relapse (Besharat, 2020). Based on the effectiveness mechanisms of paradox therapy, the patient reconstructs and re-experiences disease symptoms according to the pattern taught by the therapist in the first session. Unlike the compulsory and involuntary nature of morbid symptoms, these are voluntary with two characteristics, including formalization (according to the therapist’s instructions) and artificialization (self-produced by the patient and not spontaneous). Due to their imposed, compulsory, annoying, and undesirable nature, the morbid symptoms disappear. Decreasing anxiety, results in mitigating or eliminating the connection between the patient’s intra-psychic stress, consequently reducing involuntary thoughts in the patient (Besharat, 2023). Parallel to the formalization and artificialization of morbid symptoms and the constant repetition of timetable exercises, the patient’s thoughts and actions are gradually and quickly separated from anxiety and a state of symptoms free from anxiety and negative emotions is created. Consequently, when an anxiety-free symptom appears, it is no longer considered a psychological disorder and a morbid symptom of a neuropsychiatric disease, but a source of tension and distress for the patient. Alongside the optionality and artificialization of morbid symptoms and also the removal of the connection between anxiety and these morbid symptoms, the meaning of these symptoms and psychological disorders will quickly change for the patient with death anxiety (Besharat, 2023).

Conclusion
In short, cancer patients often find themselves in a cycle of anxieties. The more they try to resist or cope with these anxieties and pains, the more obvious they become. PTC which often comprises asking patients to accept or even exaggerate their anxieties and fears, can break this cycle and make them more controllable by disclosing the contradictory nature of these anxieties and fears. Considering the physical and mental challenges faced by cancer patients at present due to the disease diagnosis and treatment, long-term psychotherapy may be challenging. Although PTC is a short-term psychotherapy, its impact can be long-lasting. By training patients to cope with their anxiety using this new approach, this method provides tools that can be used beyond therapy sessions and ensures the long-term sustainability of its effects. PTC, while structured, offers flexibility and can be adjusted according to the patient’s needs, making it a versatile tool in the hands of psychotherapists. Moreover, PTC can help uncover and address deeper and often unexpressed beliefs that patients may have about their illness, prognosis, or treatment, making the therapeutic intervention deeper and more comprehensive. Therefore, the importance and necessity of PTC in cancer care cannot be ignored. Since cancer patients are struggling with numerous challenges, offering a beneficial and short-term psychotherapeutic tool to manage their anxiety can be extremely helpful in their life process. Despite the availability of various psychological interventions to support cancer patients, there was a gap in understanding how paradox therapy could specifically impact death anxiety. This research provided perspectives denoting that patients benefited from PTC and this method allowed for more personalized and influential psychological care. PTC has not been assessed in psycho-oncology as much as in other psychotherapeutic approaches. This research provided an experimental assessment of its effectiveness, which was necessary for its validation and potential acceptance. By evaluating the effectiveness of PTC, this study could indicate a cost-effective approach to improve mental health in cancer patients, which is particularly valuable in healthcare systems with limited resources. Reducing the psychological burden of cancer can remarkably improve patients’ lives, resulting in better overall health outcomes and potentially affecting the survival rate. Perceiving the long-term effects of this treatment can help develop future care plans and provide long-term support for cancer survivors. This research can offer valuable insights into psychosocial oncology and steer future studies and clinical practices to better support cancer patients.

Study limitations
The research population in this study was Iranian women with cancer over 18 years of age. Therefore, it is necessary to consider this issue in generalizing the results. In addition, the results cannot be generalized to men with cancer. Carrying out this intervention in samples with different ethnicities and cultures can help to further confirm its effect. Since this research was conducted in a cancer treatment center where patients had frequent interactions with the treatment team for their visits and treatments, they felt more comfortable participating in psychotherapy sessions, and the recommendations of their specialist doctor to participate in this psychotherapy led them to better trust and adherence. Furthermore, addressing the mental well-being of these patients and providing them with an opportunity to express themselves, viewed by some as a last resort, brought them a sense of satisfaction. Thus, it is recommended that officials from the Ministry of Health and Medical Education consider incorporating PTC by psychologists and psychiatric nurses as part of the treatment process for cancer patients in similar cancer treatment centers.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by Iranian National Ethics System in Biomedical Research, Ministry of Science, Research and Technology, Tehran, Iran (Code: IR.UT.PSYEDU.REC.1403.001). Also, all ethical considerations including providing explanations about the research objectives, ensuring confidentiality of information, respecting voluntary participation in the research, and obtaining informed consent from the participants, were adhered to in this research.

Funding
This study was extracted from the PhD dissertation of Maryam Mardani, approved by the Department of Psychology, School of Psychology and Educational Sciences, University of Tehran, Tehran, Iran. This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization: Maryam Mardani, and Mohammad Ali Besharat; Initial draft preparation: Maryam Mardani, Mohammad Ali Besharat, and  Manijeh Firoozi; Study design, data interpretation, review, editing, and final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors thank all the women with cancer referred to the specialized blood and cancer treatment center in Ahvaz Province for their assistance and support.




References

Alegria, M., 2024. Collaborative Psychiatric Epidemiology Surveys (CPES), 2001-2003 [United States] (ICPSR 20240). Inter-university Consortium for Political and Social Research. [DOI:10.3886/ICPSR20240.v9]

Ataoglu, A., 2003. Paradoxical therapy in conversion reaction. Journal of Korean Medical Science, 18(4), pp. 581-4.  [DOI:110.3346/jkms.2003.18.4.581] [PMID] 

Bababnejad Darikandeh, S., Norozi, A. & Bagheri, H., 2023. [The effectiveness of logotherapy based on rumi’s thoughts in death anxiety and depression among women with breast cancer (Persian)]. Community Health Journal, 17(1), pp. 76-86. [Link] 

Babaie, V., Abolmaali Alhosseini, K. & Hobbi, M. B., 2023. [Investigating the efficacy of paradoxical time table therapy on anxiety sensitivity and focused-attention in people with social anxiety disorder (Persian)]. Journal of Psychological Science, 22(125), pp. 967-83. [Link] 

Bajelan, M., Zadeh Mohammadi, A. & Ghorban Jahromi, R., 2022. [Determining the effectiveness of unity-oriented treatment on death anxiety and resiliency in cancer patients (Persian)]. Applied Psychology, 16(3), pp. 112-93. [DOI:10.52547/apsy.2021.222982.1097]

Bastani, F., Farnood, F. & Haqhani, H., 2016. Evaluation of death anxiety in elderly patients with cancer undergoing chemotherapy. Journal of Client-Centered Nursing Care, 2(3), pp. 153-60. [DOI:10.32598/jccnc.2.3.153]

Beck, A, T., 1989. Love is never enough: How couples can overcome misunderstandings, resolve conflicts, and solve relationship problems through cognitive therapy. New York: HarperPerennial, HarperCollinsPublishers. [Link]

Besharat, M., 2020. [The application of paradox therapy for the treatment of body dysmorphic disorder: A case report (Persian)]. Journal of Psychological Science, 19(95), pp. 1371-87. [Link]

Besharat, M. A., 2019. [Evaluating the effectiveness of paradox therapy for the treatment of obsessive-compulsive disorder: A case study (Persian)]. Journal of Psychological Studies, 14(4), pp. 7-36.  [DOI:10.22051/psy.2019.23631.1801]

Besharat, M. A., 2019. [Evaluating the effectiveness of paradox therapy for the treatment of social anxiety disorder: A case study (Persian)]. Journal of Psychological Science, 18(76), pp. 383-96. [Link]

Besharat, M. A., 2023. Paradoxical psychotherapy: A practitioner’s guide. Berlin: Springer Nature. [DOI:10.1007/978-3-031-27717-7]

Blunt, J. & Trigg, J., 2024. Psycho‐oncological counselling for mental health in south australians with cancer. Advances in Public Health, 2024(1), pp. 2131827. [DOI:10.1155/2024/2131827]

Browning, S. & Hull, R., 2021. Reframing paradox. Professional Psychology: Research and Practice, 52(4), pp. 360 -7. [DOI:10.1037/pro0000384]

Chitgarzadeh, M. J., et al., 2023. [Investigating the effectiveness of paradoxical couple therapy (PTC) on marital conflicts and emotion regulation in conflicting couples (Persian)]. Rooyesh-e-Ravanshenasi Journal (RRJ), 12(2), pp. 39-50.‏ [Link]

Cho, Y. U., Lee, B. G. & Kim, S. H., 2020. Coping style at diagnosis and its association with subsequent health-related quality of life in women with breast cancer: A 3-year follow-up study. European Journal of Oncology Nursing, 45, pp. 101726.  [DOI:10.1016/j.ejon.2020.101726] [PMID]

Coutts-Bain, D., Sharpe, L. & Russell, H., 2023. Death anxiety predicts fear of Cancer recurrence and progression in ovarian Cancer patients over and above other cognitive factors. Journal of Behavioral Medicine, 46(6), pp. 1023–31.  [DOI:10.1007/s10865-023-00422-w] [PMID] 

Curran, L., et al., 2020. Testing a model of fear of cancer recurrence or progression: The central role of intrusions, death anxiety and threat appraisal. Journal of Behavioral Medicine, 43(2), pp. 225 -36. [DOI:10.1007/s10865-019-00129-x] [PMID]

Dehaqin, V., et al., 2023. The effectiveness of paradoxical therapy on relational practical obsessive-compulsive symptoms. Journal of Adolescent and Youth Psychological Studies, 4(4), pp. 118-33. [DOI:10.61838/kman.jayps.4.4.12]

Eatesamipour, R. & Ramazanzade Moghadam, K., 2023. [The effectiveness of paradox therapy on anger rumination in people with anxiety caused by corona Disease (Persian)].Journal of Clinical Psychology and Personality, 21(2), pp. 105-16. [DOI:10.22070/cpap.2023.17770.1370]

El-Sayed, M. M., et al., 2023. Association of health anxiety, fatalism and medication adherence among geriatric clients: An exploratory study. Geriatric Nursing (New York, N.Y.), 54, pp. 8–15. [DOI:10.1016/j.gerinurse.2023.08.020] [PMID]

Farahani, H. & Roshan Chesli, R., 2023. [Calculation and justification of sample size in psychological science research: Application of G*Power Software (Persian)]. Journal of Clinical Psychology & Personality, 20(2), pp. 221-34. [Link]

Firouzi, M., 2023. [A new model of mindfulness-based couple therapy for improving the sense of coherence and marital satisfaction in caregivers and patients with prostate cancer (Persian)]. Journal of Family Research, 18(4), pp. 641-56. [DOI:10.48308/JFR.18.4.641]

Ghadimi Nouran, M., et al., 2020. Develop a therapy protocol based on the paradoxical timetabling model and its effectiveness on binge eating disorder among women. Journal of Research in Psychological Health, 14(2), pp. 81-94. [Link]

Ghasempour, A., Sooreh, J. & Seid Tazeh Kand, M. T., 2012. [Predicting death anxiety on the basis of emotion cognitive regulation strategies (Persian)]. Knowledge & Research in Applied Psychology, 13(2), pp. 63-70. [Link]

Götze, H., et al., 2020. Depression and anxiety in long-term survivors 5 and 10 years after cancer diagnosis. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 28(1), pp. 211–20.  [DOI:10.1007/s00520-019-04805-1] [PMID]

Gulbahar Eren, M., Üçgül, K. & Sert, H., 2023. Effectiveness of interventions on death anxiety and fear in adults with chronic disease: A systematic review and meta-analysis of randomized controlled trials. Omega, 302228231167725. Advance online publication. [DOI:10.1177/00302228231167725] [PMID]

Hampton, J., et al., 2024. Fear of cancer recurrence in differentiated thyroid cancer survivors: A systematic review. Thyroid, 34(5), pp. 541-58. [DOI:10.1089/thy.2023.0642] [PMID]

Hantsoo, L. & Epperson, C. N., 2017. Anxiety disorders among women: A female lifespan approach. Focus, 15(2), pp. 162-72. [DOI:10.1176/appi.focus.20160042] [PMID] 

Hashemizadeh, F.S., Atashpour, S. H. & Farhadi, H., 2023. Comparison of the Effectiveness of Paradoxical Timetable Cure (PTC), Acceptance and Commitment Therapy Matrix (ACTM), and Emotion-Focused Therapy (EFT) on self-esteem and marital boredom in women with marital conflict. Psychology of Woman Journal, 4(4), pp. 27-38. [DOI:10.61838/kman.pwj.4.4.4]

Jahanpanah, M., Besharat, M. A. & Asayesh, M. H., 2023. [Effectiveness of paradox therapy on complex grief symptoms of bereaved women (Persian)]. Paper presented at: 9th Scientific Research Conference on Development and Promotion of Educational Sciences and Psychology in Iran, Tehran, Iran, 6 September 2023. [Link]

Kiyak, S. & Türkben Polat, H., 2024. The relationship between death anxiety and COVID -19 fear and anxiety in women with breast cancer. Omega, 89(3), pp. 1128–41. [DOI:10.1177/00302228221086056] [PMID] 

Li, Y., et al., 2024. Correlates of death anxiety for patients with cancer: A systematic review and meta‐analysis. Journal of Clinical Nursing, 33(5), pp. 1933-47.‏ [DOI:10.1111/jocn.17021] [PMID]

Lu, J., et al., 2024. Effects of different psychosocial interventions on death anxiety in patients: a network meta-analysis of randomized controlled trials. Frontiers in Psychology, 15, pp. 1362127.  [DOI:10.3389/fpsyg.2024.1362127] [PMID]

Lu, X., et al., 2023. Relationship between social support and fear of cancer recurrence among Chinese cancer patients: A systematic review and meta-analysis. Frontiers in Psychiatry, 14, pp. 1136013. [DOI:10.3389/fpsyt.2023.1136013] [PMID] 

Maba, A. P., 2017. Paradoxical intervention dalam bimbingan dan konseling untuk mengatasi kecemasan. Counsellia: Jurnal Bimbingan Dan Konseling, 7(2), pp. 99-109. [DOI:10.25273/counsellia.v7i2.1852]

Maeng, L. Y. & Milad, M. R., 2015. Sex differences in anxiety disorders: Interactions between fear, stress, and gonadal hormones. Hormones and Behavior, 76, pp. 106–17. [DOI:10.1016/j.yhbeh.2015.04.002] [PMID] 

Mardani, M., 2023. [Investigation of fear of relapse in cancer patients, a systematic review article (Persian)]. Paper presented at: The 12th International Educational Conference of Psychology, Educational Sciences and Lifestyle, Tbilisi, Georgia, 18 September 2023. [Link]

Mattiuzzi, C. & Lippi, G., 2019. Current cancer epidemiology. Journal of Epidemiology and Global Health, 9(4), pp. 217–22. [DOI:10.2991/jegh.k.191008.001] [PMID] 

Mina, F., et al., 2023. [The effectiveness of acceptance and commitment based therapy on death anxiety in women with breast cancer in Shiraz (Persian)]. Iran University of Medical Sciences, 30(7), pp. 1-12.  [DOI:10.47176/rjms.30.154]

Mohammadi, Z., et al., 2020. The effects of paradoxical time table therapy on worry, rumination, thought-action fusion and symptoms in patients with obsessivecompulsive disorder.‏ Journal of Disability Studies, 10, pp. 70. [Link]

Moraes, R. F., et al., 2021. Resistance training, fatigue, quality of life, anxiety in breast cancer survivors. Journal of Strength & Conditioning Research, 35(5), pp. 1350 -6. [DOI:10.1519/JSC.0000000000003817] [PMID]

Peimanpak, F., Pourshahriari, M. & Abdollahi, A., 2023. [Comparison of the effectiveness of paradoxical timetable therapy and cognitive behavioral therapy on reducing symptoms in women with generalized anxiety disorder (Persian)]. Women and Family Studies, 16(59), pp. 47-63.‏ [DOI:10.30495/jwsf.2022.1952517.1656]

Rajabi, Gh. R. & Bohrani, M., 2002. [Item factor analysis of the death anxiety scale (Persian)]. ‏ Journal of Psychology, 5(4), pp. 331-44. [Link] 

Ren, H., et al., 2024. Prediction of high-level fear of cancer recurrence in breast cancer survivors: An integrative approach utilizing random forest algorithm and visual nomogram. European Journal of Oncology Nursing, 70, pp. 102579.  [PMID]

Saggino, R. & Kline, P., 1996. Item factor analysis of the Italian version of the Death Anxiety Scale. Journal of Clinical Psychology, 52(3), pp. 329-33. [PMID]

Shakeri, B., 2022. A systematic review and meta-analysis of death anxiety among iranian patients with cancer. Omega, 89(1), pp. 247–58.  [DOI:10.1177/00302228211070400] [PMID]

Siegel, R. L., Miller, K. D. & Jemal, A., 2019. Cancer statistics, 2019. CA: A Cancer Journal for Clinicians, 69(1), pp. 7-34.  [DOI:10.3322/caac.21551] [PMID]

Spitz, N. A., Kivlighan III, D. M. & Aburizik, A., 2023. Psychotherapy alone versus collaborative psychotherapy and psychiatric care in the treatment of depression and anxiety in patients with cancer: A naturalistic, observational study. Journal of Clinical Psychology, 79(10), pp. 2193-206. [DOI:10.1002/jclp.23531] [PMID]

Stagl, J. M., et al., 2015. Randomized controlled trial of cognitive behavioral stress management in breast cancer: a brief report of effects on 5-year depressive symptoms. Health psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 34(2), pp. 176-80. [DOI:10.1037/hea0000125] [PMID] 

Tahernejad, J. Z., et al., 2022. [Evaluating and comparing the effectiveness of paradox therapy and reality therapy on ego strength and integrative self-knowledge in 20-40 years old women with spinal cord injury (Persian)]. Journal of Disability Studies, 12, pp. 214. [Link]

Templer, D. I., 1970. The construction and validation of a Death Anxiety scale. The Journal of General Psychology, 82(2d Half), pp. 165–77. [DOI:10.1080/00221309.1970.9920634] [PMID]

The Global Cancer Observatory., 2021. Islamic Republic of Iran. International Agency for Research on Cancer. Geneva: WHO.   

Togluk, S. & Budak, F. K., 2024. The effect of cognitive behavioral therapy-based psychoeducation on anger management and death anxiety in individuals receiving chemotherapy: A Randomized Controlled Trial. Omega. [DOI:10.1177/00302228241237279] [PMID]

van de Venne, J., et al., 2019. Sex differences in mental health outcomes of suicide exposure. Archives of Suicide Research, 24(2), pp. 158-85. [DOI:10.1080/13811118.2019.1612800] [PMID]

Vehling, S., et al., 2017. The association of demoralization with mental disorders and suicidal ideation in patients with cancer. Cancer, 123(17), pp. 3394-401.‏  [DOI:10.1002/cncr.30749] [PMID]

Yu, S., 2018. Uncovering the hidden impacts of inequality on mental health: A global study. Translational Psychiatry, 8(1), pp.  98. [DOI:10.1038/s41398-018-0148-0] [PMID] 

Zhang, R. X., Yu, Y., Li, L., Zhao, W. & Guo, S. J., 2016. Analysis of the intervention effect of paradoxical intention therapy in patients with community chronic insomnia. Modern Preventive Medicine, 15.‏ [Link]