Death anxiety refers to the feelings of dread, fear, and apprehension related to the anticipation, and awareness, of death and dying.
Despite the uncomfortable feelings of dread and trepidation that are part of death anxiety, death anxiety is not a formal mental disorder, although it is thought to play a role in many different mental disorders. Death anxiety is often brought about by a negative life event which threatens one’s self-esteem or reminds one of death, such as serious illness, rejection, accident, or tragedy (Pyszczynski et al. 2015). Psychologists have begun to conceptualize death anxiety as a transdiagnostic concept, meaning that death anxiety occurs over a range of mental disorders across multiple categories; it increases vulnerability to the development of these mental disorders and contributes to their maintenance (Iverach et al. 2014). Death anxiety is thought to be present within all human beings at one time or another. However, it is important to note that death anxiety is not always pathological. In fact, death anxiety is thought to be a primary motivating factor underlying much of human behavior, and humans have developed many efficient coping strategies to mitigate the anxiety that occurs in response to death reminders.
Terror management theory (TMT) is a primary framework in which death anxiety is addressed and conceptualized. This theory is rooted in social psychology and is used to understand much of human behavior. TMT posits that while the evolutionary adaptations which separate us from other animals, such as abstract thought and capacity for symbolic communication (language), have given us many advantages, they have also caused human beings to have awareness of their eventual, inevitable death. Human beings understand not only that death is inevitable, but that it is also unpredictable, which then causes an intense primal fear, referred to as terror by TMT theorists (Pyszczynski et al. 2015). TMT posits that anxiety is created from the conflict between self-preservation and the knowledge of one’s own mortality (Greenberg et al. 1986; Solomon et al. 1991). Additionally, TMT suggests that even though awareness of our finite existence is largely unconscious, it still has a profound effect on our thoughts, feelings, and behaviors (Pyszczynski et al. 2015). Most prominently, the awareness of inevitable death increases one’s need for self-esteem and the structure and meaning provided by their personal worldview (Lykins et al. 2007). Death anxiety often causes people to hold more strongly to the views and beliefs held by their in-group and more aggressively reject people or views they view as belonging to an out-group.
Key Research Findings
Present research on death anxiety has primarily focused on testing the hypotheses within TMT, specifically the anxiety-buffer hypothesis, the mortality salience hypothesis, and the death-thought accessibility hypothesis. The anxiety-buffer hypothesis states that self-esteem buffers the effects of death anxiety, and therefore threats to self-esteem will increase death anxiety. Through empirical studies, it has been shown that threats to self-esteem do in fact increase death anxiety and that when given a self-esteem boost, people are less responsive to death reminders that would normally induce death anxiety (Pyszczynski et al. 2015). The mortality salience hypothesis states that reminders of death increase the need to protect one’s worldview. This means that when people encounter a death reminder that increases their death anxiety, they cling more strongly to the views and beliefs that align with their worldview. Studies have repeatedly found this hypothesis to be supported. Furthermore, along with increasing one’s commitment to their own beliefs, studies have shown that when people are confronted with death reminders, they become more aggressive and defensive toward those who do not share their beliefs (Pyszczynski et al. 2015). Finally, the death-thought accessibility hypothesis states that when people encounter more threats to the things protecting them from death anxiety, such as their self-esteem, worldview, and close attachments, they think about death more often and feel more death anxiety. Studies have confirmed this hypothesis with word-stem completion tasks, in which people who experienced a threat to one of those stated protective factors completed more word stems with words related to death and dying (Pyszczynski et al. 2015).
Death anxiety becomes problematic and can contribute to the development of psychopathology (See “Psychopathology”) and mental disorders when it is excessive and causes people to act in ways which are maladaptive and harmful. Death anxiety has been found to contribute to the development and maintenance of a diverse array of mental disorders, including somatic symptom disorders, anxiety disorders, depressive disorders, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and eating disorders. Death anxiety is thought to be a central feature of somatic symptom disorders, such as hypochondriasis and illness anxiety disorder, as these disorders are characterized by a pathological fear of death, in that people with these disorders are overly concerned about their health failing or misinterpret normal bodily sensations as being problematic, which they fear could lead to death (Furer and Walker 2008). Anxiety disorders in particular are thought to develop due to an insufficient anxiety-buffering system, which is an important protective factor for death anxiety. In particular, specific phobias are characterized by an excessive fear that the focus of the phobia has the potential to kill the person (Strachan et al. 2001, 2007), and panic disorder is characterized by bodily sensations that are interpreted as being life-threatening (Furer and Walker 2008).
Depressive disorders are also thought be associated with death anxiety, as they impact a person’s ability to cultivate meaning and self-esteem and to establish meaningful relationships (Maxfield et al. 2014). These are all essential factors which protect against death anxiety, and therefore depression can increase a person’s feelings of death anxiety. OCD also often has links to death anxiety, as the obsessive thoughts and compulsions involved in OCD are sometimes concerned with mortality of the self or loved ones (Menzies and Dar-Nimrod 2017). An essential feature of PTSD is exposure to a trauma in which a person believes their own life, or the life of someone they care for, is in imminent danger. Exposure to an event of this nature increases death anxiety, which then leads to PTSD symptoms, such as hypervigilance and avoidance (Cheung et al. 2005). Other research has suggested that PTSD also disrupts the anxiety-buffering systems protecting people from death anxiety (Maxfield et al. 2014). Finally, eating disorders are thought to be driven by existential concerns, such as finding a partner and having children, which may drive the desire to be thin (Goldenberg et al. 2005). These existential concerns are considered to be part of death anxiety, as reproduction allows people to pass on their genes and reduces death anxiety by giving them a sense of symbolic immortality.
In contrast, several factors have been identified as protective against the negative consequences of death anxiety, the first of which is religion. Religiosity has been found to have an inverse relationship with death anxiety, such that high religiosity is associated with less fear of death (Wink and Scott 2005; French et al. 2017). This is thought to be true for a number of reasons. First, in many religions, there exists the concept of an afterlife. This belief, specifically, has been shown to be protective for death anxiety (Henrie and Patrick 2014). This is thought to be the case because a belief in an afterlife makes death feel less final, and the concept of an afterlife is often pleasant (i.e., heaven, reincarnation). Therefore, belief in an afterlife provides a buffer against the terror that the thought of death often evokes in human beings. Furthermore, religion provides for people a group identity which will continue on after one has passed, offering a kind of symbolic immortality.
In addition to religion, a strong sense of group identity that is supportive of the person and his or her ideas is also protective against death anxiety. This can come in the form of clubs, political parties, geographic location, race, and culture, among countless others. Other protective factors include stoicism and feelings of power. For example, research has demonstrated that people who tend to be more stoic (e.g., endure pain or hardship without complaint) have lower levels of death anxiety. This is thought to be due to a pattern of low arousal in response to distressing information or events. Feelings of increased power have also been associated with lower rates of death anxiety, possibly due to a false sense of control over one’s own mortality (Belmi and Pfeffer 2016).
Finally, old age is a known protective factor against death anxiety (Chopik 2017), although precise reasons for this are currently unclear (See “Terror Management Theory and its Implications for Aging”). Some researchers suggest that older adults are in denial about their mortality as a defense mechanism in response to being closer to death (Baum and Boxley 1984). Others suggest that people who live longer have more time to come to terms with the inevitable mortality; therefore, the thought of death no longer evokes as much terror for an older person. Some researchers who favor the reproductive mortality viewpoint believe that older people who have passed reproductive age have done what they can to pass on their genes and therefore are not as threatened by the thought of death (Russac et al. 2007). Furthermore, research has shown that older adults tend to focus on and prioritize meaningful social and family connections, which is a protective factor for death anxiety (Chopik et al. 2013; Knee et al. 2008).
A related line of research has examined factors shown to increase a person’s risk for developing pathological death anxiety. First, jobs with exposure to mortality can be a risk factor for death anxiety, with workers sometimes experiencing elevated distress and anxiety (Grant and Wade-Benzoni 2009; Lee and King 2014; Melo and Oliver 2011; Sliter et al. 2014; Stein and Cropanzano 2011). As previously stated, because reminders of death are the primary cause of increased death anxiety, those who regularly deal with death such as first responders, doctors, and military members are at greater risk of experiencing death anxiety. Additionally, certain personality factors can increase a person’s likelihood of experiencing death anxiety. Specifically, people who are more neurotic, have more type A personality traits, and have more difficulty with emotion regulation tend to experience more distressing death anxiety. Neuroticism refers to the disposition of having a greater inclination toward negative emotions such as anxiety, depression, anger, or guilt, as well as increased arousal in response to these emotions. Type A characteristics include being more ambitious, prone to stress, and competitive. Both of these personality traits have been found to be highly correlated with death anxiety (Frazier and Foss-Goodman 1988). These characteristics also tend to represent higher emotionality (Frazier and Foss-Goodman 1988). As such, it is understandable that they are associated with higher death anxiety.
Multiple measures have been created to assess the presence and severity of death anxiety in a person. The most frequently used measures are the Death Anxiety Scale (Abdel-Khalek and Neimeyer 2017) and the Collett-Lester Fear of Death Scale (Durlak 1982; Furer and Walker 2008; Iverach et al. 2014). The Death Anxiety Scale is a self-report measure in true/false format, which consists of statements concerning anxiety about death and dying. It is one of the most commonly used scales for assessing death anxiety due to having a substantial body of research which suggest sound psychometric properties. It has also been translated into 15 different languages, for use with more diverse populations (Abdel-Khalek and Neimeyer 2017). The Collett-Lester Fear of Death Scale also has good psychometric properties and has been validated across many studies (Lester 1990). This measure includes subscales to help clinicians differentiate between the types of death anxiety, including death of self, dying of self, death of others, and dying of others (Lester 1990). When assessing for death anxiety in a clinical interview, Furer and Walker (2008) suggest beginning with a broad question about whether the client worries about death or dying. If the client responds that she does worry about this topic, Furer and Walker (2008) suggest that clinicians ask follow-up questions to get a better sense of the client’s worries. These researchers also highlight the importance of assessing suicidality among clients, stating that although it is not common in those with death anxiety, some endorse suicidality to avoid the uncertainty and anxiety of death. Some other commonly used measures for assessing death anxiety are the Death Anxiety Inventory (Tomas-Sabado and Gomez-Benito 2005), the Death Anxiety Questionnaire (Conte et al. 1982), and the Multidimensional Fear of Death Scale (Hoelter 1979).
Examples of Application
One common approach for treating death anxiety is through the use of existential psychotherapy. Existential therapy is recommended for treatment of death anxiety because death and the power that it has to cause anxiety and impact multiple domains of life is a major thrust of the existential approach (Iverach et al. 2014; Yalom 1980). Another essential focus of existential therapy is meaning making and a focus on what a person wants to leave behind, both of which can help relieve death anxiety. Furthermore, existential therapy has empirical support for the treatment of many of the comorbidities commonly associated with death anxiety, such as depressive disorders, anxiety disorders, and eating disorders (Schneider and Krug 2017). Another common treatment for death anxiety is cognitive behavioral therapy (CBT; Menzies et al. 2018). CBT is one of the most frequently used and most effective treatments for other anxiety disorders, and many of the techniques used in CBT are applicable to the treatment of death anxiety. Exposure, cognitive reappraisal, and the reduction of checking behaviors, reassurance seeking, and other safety behaviors are some of the main methods of CBT in treating death anxiety (Furer and Walker 2008).
A recent comprehensive review by Menzies et al. (2018) identified the primary treatments for death anxiety focused on either psychoeducation about death or therapeutic treatments, such as CBT, relaxation training, life review workshops, support groups, implosive therapy, visualization, logotherapy, and discussing end-of-life choices. Results from this meta-analysis revealed that treatments were effective in reducing death anxiety across 15 studies (Menzies et al. 2018). Comparing the effectiveness of psychoeducation and therapeutic interventions, this review found that therapeutic interventions were more effective in reducing death anxiety than psychoeducation alone. Furthermore, CBT-type interventions were found to be the most effective treatment for death anxiety, when compared to the other treatments listed above. Overall, results from this meta-analysis revealed that psychosocial interventions are effective in reducing death anxiety, especially interventions using CBT techniques, and that death education alone did not produce a significant reduction in death anxiety. However, it is important to note that many of the non-CBT therapeutic interventions had only one or two studies evaluating their effectiveness. As such, it is possible their effectiveness was overshadowed by the larger number of studies demonstrating the effectiveness of CBT.
Even with treatment, some death anxiety will likely persist, as this is thought to be an essential part of the human experience (Yalom 2008), though it appears that treatments can help lessen arousal in response to death anxiety and decrease its negative effects.
The research on death anxiety, specifically that which has come out of TMT studies, offers several important insights into human behavior and psychopathology. For example, TMT studies have offered another reason for prejudice and discrimination aside from simply hatred of the other. Rather, studies suggest that racism and prejudice are responses to death anxiety, causing people to reject and degrade those with differing worldviews (Pyszczynski et al. 2015). Empathetic understanding of the reasons for a person’s actions is important in taking steps to change their actions or their beliefs. The application of this research then seems to be leading people to a richer understanding of the underlying reasons for people’s actions, and how responses to death reminders can be adjusted to be more adaptive and helpful to society at large.
Future Directions of Research
There have been a large number of empirical studies concerning death anxiety and its impact on human behavior; however, it appears that death anxiety research is lacking in clinical application (Furer and Walker 2008). Moving forward, research on death anxiety will likely begin to focus more on clinical applications of research findings as well as increased focus on the treatment of death anxiety. Specifically, clinical trials are needed to evaluate the most effective treatment modalities for death anxiety, as well as a focus on the response to treatment for people with severe death anxiety (Iverach et al. 2014). Although there have been some studies examining the effects of therapeutic interventions and psychoeducation on the reduction of death anxiety, more research is needed to evaluate the effectiveness of these interventions, especially non-CBT treatments for death anxiety. It is expected that research will continue to focus on evaluating the effectiveness of different death anxiety treatments and identifying aspects of treatment that are most effective.
Death anxiety is a uniquely human experience which almost all people will experience at some point in their lives. Death anxiety can be positive or negative, depending primarily on how the person reacts to it. Death anxiety can often motivate people and move them into action phases. However, death anxiety can also be debilitating if the person lacks appropriate and effective coping skills to help them deal with the anxiety that the realization of inevitable death can bring up. TMT is the primary theory in which death anxiety is conceptualized and normalized as a human experience that will occur for everyone. Death anxiety is thought to be an underlying factor for many different mental disorders, with those people who have more anxiety surrounding thoughts of death being at a greater risk for developing a mental disorder. Treatments such as existential psychotherapy and CBT are effective ways for coping with extreme death anxiety and the disorders to which it contributes.
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