Death anxiety: the worm at the core of mental health

Rachel E. Menzies and Associate Professor Ross G. Menzies MAPS

For as long as humans have been recording their history, death anxiety has been a pervasive theme. From
Gilgamesh’s 4000-year-old laments over his own mortality, to recent attempts to preserve one’s body using
cryogenics (an effort not dissimilar in its goal to the ancient Egyptian practice of mummification), our species
has grappled with our own impermanence in myriad ways. Themes of mortality and the dread of death have
appeared throughout art, literature, myth, ritual and philosophy across the ages. William James famously
referred to our knowledge of our own mortality as “the worm at the core” of human existence, and, more
recently, Yalom (2008) proposed that death anxiety may underlie much of human distress, casting a shadow
over our daily life.

“Fears of death feature heavily within illness anxiety and the somatoform disorders, with body checking,
frequent medical appointments and reassurance seeking, and requests for medical testing being key behaviours
in these conditions”

Thoughts of death have the ability to create a sense of powerlessness, loneliness, and meaninglessness, and for
some individuals, may seriously undermine their experience of happiness or peace. Although people may
develop helpful methods of managing their fears of death, such as building relationships and working towards
meaningful goals, they may equally engage in maladaptive coping strategies, such as avoidance. As a result,
death anxiety has been argued to be a transdiagnostic construct, contributing to the development and
maintenance of numerous mental health conditions (Iverach, Menzies, & Menzies, 2014).

For example, fears of death feature heavily within illness anxiety and the somatoform disorders, with body
checking, frequent medical appointments and reassurance seeking, and requests for medical testing being key
behaviours in these conditions. In a similar vein, individuals with panic disorder may frequently worry that they
are having a heart attack, and consult with cardiologists in order to keep such fears of death at bay. Most, if not
all, of the common specific phobias can similarly be seen as having death anxiety at the root, with flying, water,
spiders, snakes, and enclosed and high places all having the potential to occasion death. In obsessive
compulsive disorder, patients often explicitly describe their compulsive washing as an attempt to protect
themselves and their family from germs and fatal illnesses, while others ascribe their compulsive checking of
stovetops, power points and locks to a means of preventing household fires, electrocutions, and invasion.

Further, exposure to life-threatening events such as the loss of a loved one or physical threats to the self often
precede the onset of both agoraphobia and post-traumatic stress disorder. Within the depressive disorders,
existential concerns such as meaninglessness and death anxiety have been argued to play a significant role.
Even disorders for which the relevance of death anxiety appears less clear, such as social anxiety disorder or
eating disorders, there appears preliminary evidence suggesting death fears may be at the root. For instance,
reminders of death have been shown to increase social avoidance among participants high in social anxiety
(Strachan et al., 2007), and lead to restricted consumption of high-calorie food (Goldenberg, Arndt, Hart, &
Brown, 2005).
If death anxiety is truly at the centre of so many of these disorders, this may explain the ‘revolving door’ often
seen in clinical practice. That is, it is commonplace for an individual to present for treatment in childhood with
one disorder, such as separation anxiety, only to return in adolescence, and later in adulthood, with conditions
that appear on the surface fundamentally different, such as OCD or panic disorder. This clinical observation is
also supported by the literature, with estimates of lifetime diagnoses rates around double the number of current
diagnoses in presenting clients.

If this ‘revolving door’ is driven by underlying fears of death, the implication is that until such fears are directly
addressed, psychopathology will continue to return, albeit manifested in a superficially different presentation.
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While crippling death anxiety may have once led an individual to attend his local emergency department several
times each month, after an apparently successful course of exposure therapy for panic disorder he may now
resort instead to washing his hands for several hours each day in an effort to ward off death, resulting in the
apparent need for exposure and response prevention with a focus on contamination concerns.

If treatments focus on the symptoms on the surface – such as the avoidance of spiders, the checking of locks, or
the repeated requests for brain scans – rather than the existential concerns that lie at the root, are they failing to
ensure long-term wellbeing? Particularly when the numbers suggest that clients are likely to return to treatment
with a different disorder?

Cultivating death acceptance

At present, standard treatments do not usually address death anxiety directly. Some argue that this failure to
address death fears may in fact be due to the death anxiety of clinicians and researchers themselves. How can
we begin to work with clients’ concerns about death and dying if we ourselves avoid the subject in our own
life? In order to overcome the dread of death, one must start to cultivate some form of acceptance of mortality.
But in what way should we accept death? Three discrete types of death acceptance have been proposed (Gesser,
Wong, & Reker, 1988):
 Escape acceptance  – embracing death as a welcome escape from the suffering and pain of one’s life 
 Approach acceptance – accepting death due to one’s beliefs about the existence of a desirable afterlife 
 Neutral acceptance  – accepting death as a natural part of life, and something outside of one’s control.
Although all three types of death acceptance are associated with reduced levels of death fears, neutral
acceptance appears to produce the lowest levels of death anxiety. Neutral acceptance of death can be seen as
similar to the Stoic approach in Greek philosophy, in the sense that death, like many of life’s hardships, is
something to neither mourn nor celebrate. Rather, given that it is outside of one’s control, it is viewed with
relative indifference. This attitude is summed up nicely in the words of the Stoic philosopher Epictetus: “Death
is necessary and cannot be avoided. I mean, where am I going to go to get away from it?” Given that it is
neutral acceptance that leads to the lowest levels of death anxiety, treatments which seek to reduce death fears
will likely benefit from cultivating this type of acceptance. What might such treatments look like?

Treatment approaches
A number of cognitive and behavioural therapy (CBT) techniques have been proposed to address the dread of
death (for a thorough overview, see Furer, Walker, & Stein, 2007). First, it is important to acknowledge that all
of us are likely to hold a number of different beliefs related to death and dying, some of which will be more
helpful and realistic than others. As with any other anxiety condition, maladaptive or unrealistic beliefs about
death and dying (e.g., “death is unfair, and I shouldn’t have to experience it”) are likely to maintain death
anxiety, produce distress and may interfere with functioning. Assessing such beliefs and concerns prior to
treatment is therefore a crucial step before cognitive reappraisal can be used in order to challenge or correct
such attitudes. For example, beliefs such as “My death will destroy my children’s lives forever” can be
substituted with “My children will be understandably upset, but most children cope with the loss of their
parents”, or something similar. Providing patients with corrective information drawn from medical research or
palliative care can also help challenge unrealistic beliefs, such as those concerning the pain of the dying
process.

Behavioural experiments can also prove useful, by giving clients the chance to ‘test out’ their various death-
related beliefs, particularly regarding the ‘cost’ of death. For example, the belief “If I die, my partner wouldn’t
cope, and my children might be removed from their care” could be directly tested by asking the patient to
survey and assess their family’s coping strategies in the event of their death. Of course, behavioural experiments
have long been used to challenge beliefs surrounding the probability of dying across a range of mental health
conditions, such as “If I let go of the railing, I’ll fall to my death” in acrophobia or “if my heartrate increases,
I’ll have a heart attack” in panic disorder. However, is challenging the probability of death in a particular
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situation likely to reduce long-term anxiety if the certainty of death from one cause or another remains
guaranteed? If anything, targeting these proximal threats of death may be yet another way of failing to address
the underlying fear of the inevitability of death. If this is the case, we may need different treatment approaches,
such as exposure therapy, in order to cultivate acceptance of the certainty of death, rather than challenging the
likelihood of dying from one cause or another.

As in any anxiety-related condition, avoidance is one of the most prevalent strategies employed to manage
death anxiety. It is not uncommon for people to completely avoid thinking about mortality, and instead, to live
as though they were not going to die. Given this, exposure therapy may play a central role in the treatment of
death anxiety by allowing clients to gradually face their fears. As with any good intervention, exposure should
be individualised, and driven by the client’s unique formulation, with first priority given to situations (e.g., the
grave of a loved one) or themes (e.g., cancer) towards which they have shown systematic patterns of avoidance.

Exposure to death-related situations or themes can be done via imaginal or in vivo exposure tasks. For instance,
clients may write vivid stories imagining their own death or the death of a loved one, with a particular focus on
their own specific fears, such as the moment of diagnosis with a terminal illness, or the grieving family they
will leave behind. Options for in vivo exposure tasks are extensive and may include visiting hospitals,
cemeteries or funeral homes, talking to someone with a terminal illness, preparing a will, reading obituaries, or
discussing one’s end of life preferences with a loved one. Fortunately, the universality of death themes means
that there are ample opportunities for creative and accessible exposure tasks. Songs (e.g., George Harrison’s All
Things Must Pass), films (e.g., Beaches, Coco, and Death at a Funeral), television shows (e.g., Six Feet Under),
and both fiction (e.g., Tolstoy’s The Death of Ivan Ilyich) and non-fiction (e.g., Atul Gawande’s Being Mortal,
Mitch Albom’s memoir Tuesdays with Morrie) books may all serve as valuable and engaging exposure tasks.
Technology may also prove useful in this regard, with an increasing number of apps allowing you to plan your
own funeral, or remind you periodically throughout the day; “Remember, you will die” (WeCroak).

Of course, techniques which address a client’s fears of deaths are not found solely within CBT. Within
existential psychotherapy, Yalom encourages clients to vividly visualise their own death. He also suggests
similar tasks likely to cultivate neutral acceptance, such as drawing a line on paper, with one end symbolising
your birth and the other symbolising your death, and marking where on that line you believe you sit currently.
Yalom also encourages integrating techniques drawn from philosophy with clients who fear the notion of their
own non-existence, by introducing Epicurus’ ‘symmetry argument’: “After death, I will be in the same state of
nonbeing as before birth”. Writing one’s own eulogy or tombstone inscription, a task popularised by acceptance
and commitment therapy (ACT), may be a similarly powerful exercise for clients struggling with death
acceptance. This task may also prove valuable as it indirectly addresses another existential concern – meaning –
as it encourages clients to reflect on what is important to them, and what they would like to be remembered for.
In this way, traditional CBT approaches may benefit from incorporating similar components in the pursuit of
reducing death anxiety, such as ACT’s focus on identifying personal values and creating a meaningful life.

Evidence for treating death anxiety

Unfortunately, rigorous studies of the effect of treatments on death anxiety, particularly among those with
mental health conditions, are few and far between. However, some findings have emerged from related areas,
such as psycho-oncology. One relevant systematic review explored the effects of various therapies on attitudes
towards death among adults with advanced cancer (Grossman, Brooker, Michael & Kissane, 2018). The
findings suggested that interventions which focused on creating meaning (e.g., dignity therapy, meaning-
centered therapy) were the most effective at ameliorating attitudes towards death and improving general
wellbeing.

Outside of psycho-oncology, a recent meta-analysis examined the effects of 15 randomised controlled trials
(RCTs) on death anxiety, and found that CBT interventions, typically involving group systematic
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desensitisation, produced significant reductions in death fears relative to other treatment types and control
conditions (Menzies, Zuccala, Sharpe, & Dar-Nimrod, in press). However, the majority of the included studies
used a non-clinical sample, limiting the generalisability of these findings to individuals with mental health
conditions. Further, both reviews concluded that the methodological quality of many of the included studies was
low, highlighting a clear need for further RCTs using rigorous methodologies. In particular, there is an
unfortunate dearth of research using samples with a mental health diagnosis, meaning that only guarded
conclusions can be drawn regarding the efficacy of such interventions on death anxiety among individuals with
mental health difficulties.

Looking to the future

Death anxiety is unique to our experience of being human, and our awareness of mortality is a central part of
our existence. Increasing evidence suggests that fears of death may be at the root of numerous mental health
conditions, and it has been argued that they need to be addressed in order for satisfactory long-term treatment
outcomes. Despite this, many standard treatment approaches, such as CBT, do not typically target death fears,
potentially contributing to a ‘revolving door’ of mental health problems.
However, treatment opportunities for death fears are numerous, and may involve cognitive reappraisal and
exposure, including the creative use of film, literature, and philosophy. Drawing from existential and meaning-
centered therapies may also prove useful. However, rigorous research testing the impact of death-focused
interventions is lacking. More high-quality research is essential to explore whether treatments targeting death
anxiety produce reductions in symptoms above and beyond the effects of standard treatments.

References
 Furer, P., Walker, J. R., & Stein, M. B. (2007).  Treating health anxiety and fear of death: A
practitioner’s guide.  Springer Science & Business Media.
 
 Gesser, G., Wong, P. T. P., & Reker, G. T. (1988).  Death attitudes across the life span.  The
development and validation of the Death Attitude Profile (DAP). Omega, 2, 113-128.
 
 Goldenberg, J. L., Arndt, J., Hart, J., Brown, M. (2005). Dying to be thin: The effects of mortality
salience and body mass index on restricted eating among women. Personality and Social Psychology
Bulletin, 31,  1400-1412.
 
 Grossman, C. H., Brooker, J., Michael, N., & Kissane, D. (2018). Death anxiety interventions in patients
with advanced cancer: A systematic review. Palliative Medicine, 32, 172-184.
 
 Iverach, L., Menzies, R. G., & Menzies, R. E. (2014). Death anxiety and its role in psychopathology:
Reviewing the status of a transdiagnostic construct. Clinical Psychology Review, 34, 580-593.
 
 Menzies, R. E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (in press). The effects of psychosocial
interventions on death anxiety: A meta-analysis and systematic review of randomised controlled
trials. Journal of Anxiety Disorders.
 
 Strachan, E., Schimel, J., Arndt, J., Williams, T., Solomon, S., Pyszczynski, T., & Greenberg, J. (2007).
Terror mismanagement: Evidence that mortality salience exacerbates phobic and compulsive
behaviors. Personality and Social Psychology Bulletin, 33, 1137-1151.
 
 Yalom, I. D. (2008).  Staring at the sun: Overcoming the terror of death. San Francisco, CA: Jossey-
Bass.

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