MANUAL FOR

DEATH D
ANXIETY A
sCALE S
Upinder Dhar, Savita Mehta
AND
Santosh Dhar
Prestige Institute of Management and Research,
2, Education and Health Sector, Scheme54
INDORE 452 010

SVVSvTSSHA/psy ./teoels DA cole/45

CHOLO
GICAL

ICRA

Estd. 1971 (0562) 364926

NATIONAL PSYCHOLoGICAL CORPORATION
4/230, KACHERI GHAT, AGRA 282 004 INDIA
 MANUAL
FOR

DEATH ANXIETY SCALE

INTRODUCTION
of oneS own death. It
is
Death anxiety refers to the fear and apprehension
of
self which in intense state parallels feelings
the neurotic fear of loss of the
of his own death produces
and Man's awareness
nelplessness depression.
one's individuality. According
that can only be dealt with by recognising
anxiety him the
man's awareness of death gives
to Fromm and the existential analysts,
in life. Death
is a biological, personal,
for finding meaning
responsibility death is useful to
socio-cultural and phenomenon. The biological
existential
Yet when
the of and the ending called death.
distinguish between process aging
alone, the psychological
the actual time comes, and the individual faces death
had found that in the
reactions appear to be remarkably similar. Kubler (1969)
the reactions to imminent
of personal
majority of persons, almost regardless age,
and
death five phases Denial, Anger, Bargaining, Depression
pass through
not every individual achieves the final phase). Dying
and
Acceptance (although

like other major aspects of human life, are also very important cultural and
death,
social phenomena.
event in
Even less than a century ago, death was a common and familiar
to control infection and
everyday life. There was no widespread technology
classes the
medicine could not do much for most diseases. Among the poorer
and they all died at
young died at an appalling rate, and the old died in their time,
home. Ihe average person had been in the immediate presence of dead bodies
at least half a dozen times before reaching adulthood. Against this background,

death was in former years much more a part of life than is today.
it was not a
It

matter to be shunned or a taboo to be mentioned by means of euphemisms

Manua torDeath Ariety See
Such as passed onbt was seat aith drecTy ane asuen aaboratect at the
wakE. was not unusual smal Eurapean toans of afee centunies ago for
in

someone who was dying to pass their death bed hours in the pubilic square,
and gioyng D Bstbret time ina position
gesting tiends, sayine goadbya,
of respec Under such circumstances, deh was an ccasion for
sadness but
not for shame.No one wouid
have dieamd Oiang
the yng asme ay do
in thewards of hosptals or in old agehames

The death canbe tully understood onily if itis viesaed asone af thecentrail
sanings of human existenoe. An idea of the centrality of one'soan death can
be gathered if individuals couid be made to coempiateserious)y the
of their own death (MoCarthy. 1980 As desth s the final stage of life
possibility

oycile. itcan

be approached naturally by dying individuais and their families. Deah and

dyina
can be seen as part of the le process, or they can be viewed asa dramatc
paintul, tortured experience
both for the pabents and the tamilies. Increasingly.

more research reports are being presented on the nature of death and dying
Research on exactly when death occurs, how the dying should be treated, and
how their families mightbetter copewill continue for many years (Leton, 1982)
In oid age peopie must conront the passibility of their own death as well as
the death of loved ones.Death may also be considered in statistical terms, which

supply us with significant figures and facts. Even though death most commonly
occurs in later years, may happen at any stage in ife. Accidents and suicides
it

are the major causes of death among younger persons, and continue to be so in
later years, their relatve significance declines. Oten death is associated
athough
with some special psychological stress, may be acute mourming. or an anniver
it

or self esteem. Death is sometimesdefined

sary, or some particular loss of status
as the absence of certain clinicaly detectable vital signs. A person is dead "t his
for an extended period of time, his
heart stops beating and he quits breathing
his pupils dilate, his body
blood pressure drops as low as to be unreadable,
and so forth. This clinical definition has been
temperature begins to go down,
 Manual for Death Anxiety Scale
5
deatn
used over the centuries, both by physicians and laymen. More recently
others sayy
has sometimes been difined as the lack of brain wave activity. Still
an irreversio
that death can only be defined as a bodily state which represents
be revived.
oss of vital functions and from which the individual cannot possibly
from certain
be predicted
to the concept of terminal drop, death can
ACCording demise. That is,
preceding
aramatic changes in cognitive function in the period serve as
may
and performance
Sgniicant changes both in personal adjustment
1972).
ndicators of impending death (Reigal and Reigel,
death
Even when approaching
Certain attitudes toward death are typical. This
for their suffering.
find a meaning
peOple ask, "why me ?"and wish to e
because the meaning or
terms
question cannot be answered in generalized of
1975). The act dying9
and death one ndividual to another (Kubler,
vary from the loss
self grief", grief
over
Eselt may involve a certain amount of "anticipatory
one's self. In addition,
of one's own life- that is, fearing what
it may be to lose
itself is quite
often associated with unfounded beliefs that dying
fear of dying is

one may be abandoned by everyone when dying, that death

painful, that
and "that there may be final medical procedures
involves an ultimate aloneness,
of plumbing9
that will further dehumanize oneself by being turned into a sort
1975). The fear of pain can
be relieved by the knowledge o
shop.(Holocomb,
is rarely
modern pain relieving processes. It can help to know that tough dying

it is neither as painful nor as unpleasant as is often fered. Fear of dying

pleasant,
more easily
involves not only physiological but psychological factors, too. Pain is
the patient's family visits frequently,
dealt with than loneliness. It helps if

communicates openly, and gives constant assurance that the dying person will
a
not be abondoned. About two-third of the dying are anxious about being

burden to others, and about half are anxious about separation from their loved

ones, they are concerned about how their loved ones will get along after they die.

Many also feel that life no longer has any real meaning.
6 Manual torDeath Anxiety Scale

Bischof (1976)summarized the attitudes of older adults feelings about

death They realized that they had already lasted longer than many of their earier

contemporaries. They have a strong belief that their ife should not be prolonged
artficialy.They realized that thought of ife, not asthe number of years lived, but
interms of time that remained. Finally they desired to leave this worid with

respect and dignity. In general, the older the adult, the less importanttime
becomes, so thatdeath is less formidable to the very old that it is to the young. t
is true that older people think aboutdeath most frequently, but they are less
afraid of it. Many older persons come to accept, oreven welcome, the idea of

their own death. They may feel that they are ready; or they may wish to escape
infirmity:or they may have religious convictions which convince them that their
life will continue after death (Butler,1975). Young people generally avoid thinking

about death; and when it does intrigue on their consciousness; they view it

questionnaire, the typical respondent

religious, protestant, somewhat

a
negatively. Yet even at this stage, individual views vary. In a psychology today

politically
20 to 24 years
liberal,
old, single,

college graduate
from
somewhat
a small
family had an ambivalent atttude toward death, both risking death and loving life,

and behaving in self-destructive ways: regarding death as

wanting happiness

taboo and on a new permissiveness to talk about it. Most of the

insisting

respondents recognised death and dying as aspects of living. Aimost half

believed that most people participate consciously or unconsciously in their own
death. Only 2% wanted formal funerals, and a third wanted one at all. Aimost a

third wished donate their bodies to medical schools or to science. Almost

to
of them
none of them wanted to die in youth or in the prime of life. Two-thirds
wanted to live out
would have liked to live to old age, and more men than women
the time of least fear of death in
their ful life spans. Both sexes accurately placed

the years over seventy.

 Manual for Death Anxiety ScaleZ
n a study. retarded were given a series of Piagetian tasks
nd
E nterviewed
subjects
to determine their degree of understanding
the
of death.
sures
Age was
not an understanding of death on any of
significantly related to measu
a more realistic
owEver,Piagetian cognitive levels were significantly related to
developmen
prenension of death on three measures indicating that cognitive
by the mentaily
Sreiated to an increasingly complex understanding of death
and level of aspiration
eErOed person (Elson et. al, 1 982). In a study of anxiety
diferences
the overall results showed
singificant
reaton to certainsocial factors,
vs broken)
n tne level of aspiration with regard to religion, nature of home (normal
with regard to age, patients
and age while anxiety showed significantdifferences
influence on any of the
Ome and nature of home. Locality exerts no significant
1978).
wo, level of aspiration, an.ety and personality dimensions (Husain,
of
tis not that anxiety plays
a causal role in the development
necessary
involved (Kahn
of the mechanisms
neart disease, but depends upon the nature
it

attempted to
et al, 1980; Krantz and Durel, 1983). In an article,Templer (1971)
of a
between death anxiety and health
determine the correlation depression,
between
population of The findings revealed a positive relationship
elderly.
health status and death anxiety were not
depression and death anxiety but
found to be related. Kimsey, Roberts and Logen (1972) surveyed the attitudes
toward death and dying of institutionalised and non-institutionalised subjects.

The group expressed great fear of death

and dying
findings revealed that neither

on the attitude question naires, but the

TAT revealed institutionalised group
significantlydemonstrating denial than non-institutionalised group. The
researchers concluded that aging as such did not result in psychological

regression but sickness and dependency compelled an individual to face the

dying process resulting in denial of death anxiety. Salter and Salter (1978),

however, obtained different findings on a sample of 65 college students. They

correlated the scores of students on Templer's Death Anxiety Scale with their
 8 Manualfor Death Anxiety Scale
atttudes and their behaviour towards elderly. The results could
not support the

anxiety denial hypothesis that fear of aging and death results in repression of
deas associated with aging. Kalish and Reynolds (1977) conducted interviews
on death attitudes of four ethnic groups of men and women of the age group
Oyears and found that agewas a significant factor on the attitudes toward

Oeath and dying. Older subjects accepted facts related to death more frequently
n comparison to younger subjects. Some other studies also showed relationship
between attitudes toward death and certain psycho-social variables (e.g., Kelly
and Dubek, 1977;
Howell, 1977:Wass, 1977;Myska et.al., 1978; Cappon,
1978:Sanders et. al., 1980:Mullins
and Lopez, 1982).
In a study of relationship between fear of death and
by religiosity reported
Long (1987), the results indicated that church (mosque) attendance had a
significantlynegative correltion with fear of premature death. Hyams et. al., (1982)
had investigated the relationship between locus of control and death and
anxiety
resuits indicated a significant relationship between external locus of control and
concern about death. No sex differences were found for death anxiety.
Schumaker (1988) compared reported death anxiety in Malaysian and Australian
students. Australian subjects had
University significantly higher death anxiety
scores than Malaysian subjects and in contradiction to the findings of Hyams et.
al., (1982), females had significantlyhigher death anxiety scores than malesin
both the samples. Findings were explained in terms of factors in eastern cultures

that more effectively control fear of death. It was contended that women might be

evaluating death emotionally, whereas men might be doing so cognitively. Khalek

and Omar (1988) too, have reported that women had higher mean scores than

men on death and trait anxiety but they were similar in state anxiety. The mean
death anxiety score for Kuwaitians was very close to that of Egyptians. There was

similarity in death anxiety between Kuwaitian and United States men, but not
women.Significant differences appeared on trait anxiety, showing the order from
 Manual lor Deallh
Anioty Sioale
9
low to high mean scores: United States, Kuwaitian and Eayptian
Eayptiar
univers
the scales were signiflcant.However, the corre
Correlations among
students. reliion
was higher than tnat botwoen death
between state and trait anxiety anxiety and
men and women. Deatn anxioty was associated
both state and trait anxiety for
In another cros0-Cultural study
more than with state anxiety.
closely with trait

was revealed that women scored higher

reported by McMordie et al (1984), it

and eastern 5amples

than men, subjects of different ages scored differently

scored lower than western samples

Mahabeer and Bhan (1984) in a study of Indian university and high school

students living in South Africa and representing in equal numbers the Christian,

Hindu and Muslim faith examined the influence of age, sex and religion on death

anxiety and the relationsihipbetween death anxiety and religiosity. Equal number
of male and female subjects were included each age and religious group.
in

Results showed that Muslim subjects were more death anxious than Christian or

Hindu subjects. The degree of commitment to religious practices and beliefs did

not intensifty or reduce death anxiety. Female subjects in all groups manifested
higher death anxiety than male subjects. The effect of age was not significant.

Downey (1984) in a study to determine the association between religiosity

and death anxiety indicated that experience of death or amount of contact the
subjects had with death was not related to death anxiety. The study did not

support the hypothesis that those subjects who were less religiour would exhibit
higher scores on death anxiety than would those subjects w1o were more
religious.

Further analysis had demonstrated a curvilinear relationship between

religiosity and death anxiety. The subjects who were moderately religious
demonstrated a significantiy higher fear of death than the subjects who were
either low or high in religiosity. Khanna et. al., (1988) had reported that

schizophrenics had the highest death anxiety followed by manic depressives and
 Scale
Manual for Death Anxiety e
10 a significantly higher "fear of
groups had sonal
Patient
normal subjects. also had a significantly hiether
to normals. Schizophrenics
death" compared were significantly positiue
and lingering death". There
"concern about suffering of death anxiety for
between most of the components
correlations
few for normal subjejcts.
and manic depressives but
schizophrenics
was studied by Baum et. al., (1984) in elderly
Age and death anxiety
residents who wgre
persons who were divided into three groups: community
actively involved a group membership club (affiliated subjects), community
in

and
residents who were inactive group members (community subjects)
institutionalisedsubjects. No relationship was found between age denial and
who were poorer in emotional death and felt more
death denial. Single subjects

externally controlled appeared to manifest more death anxiety. Conversely, those

subjects who were married, of sound emotional health, and who perceived
themselves as internally controlled showed iower death anxiety.

While studying death anxiety among early and advanced malignancy

cancer patients, Feroz et. al., (1987) had indicated that younger subjects (below
30 years of age) scored significantly higher on death anxiety than older subjects

(above 50years of age). Early malignancy subjects too, scored significantly

higher on death anxiety than advanced malignancy patients. Death anxiety was
least affected by financial status.In a study of heart attack patients, Kumar et. al,
(1987) found that female heart attack patients possess higher death
anxiety than
male patients. Heart attack patients
aged 46-50 indicated years somewhat
greater death anxiety than other patient age groups. Patients
consistently
indicated greater death anxiety than normals.

In an attempt to cross-validate the results

with cancer survivors and to test
its to
sensitivity illness related variables, Cella and Tross (1987) administeredd
death anxiety
questionnaire with measures of general anxiety,
depression,
somatization and
global psychological distress to
Hodgkin's disease survivors
Norms
Norms for the scale are available on a sample of Subjects
belonging to the
the
age range of 25-55 years (Table 2). These norms should be regarded as

reterence points for interpreting the Death Anxiety scores. However, norms are

based on the sample drawn from Rohtak and Delhi. The users of this scale
would
be well advised to develop their own norms based on their own samples

An individual with a very high score i.e., above (M + 10), may be considered
to have very high level of death anxiety, symptomatic of such
high state that is

likely to have a disruptive and interfering infiuence on his performance, especialy

on complex activities and individual concerned may be in need of
counselling or

psychotherapy.The low score i.e., below (M 1o), would indicate people who
have very low level of death anxiety. The scores lying within (M +1a) would
represent especially "normal" individuals with moderately good drive to stimulate

performance without any interference of the kind of

anxiety under focus.

USE OF THE SCALE

Like other psychometric tests of this nature, its
primary and proper utility

work on large groups, whether for research,

lies with
survey purposes, or for

comparison of populations. The scale can be successfully used for

screening out
individuals who suffer from alarmingly high degree of death
anxiety which has a
disruptive, or interfering influence on the
inhibiting day-to-day life and
performance.The scale is likely to be a useful tool in the armoury of a
psychologist. It
give a quick measure of death anxiety for experimental, clinical

and counselling purposes when subject can spare only halt an hour or so. It is
self- administering and does not require the services of a highly trained tester. t
is
eminently suitable for group administration as well as for individual testing.
 Manual for Death
Anxiety Scale 13

Instructions for Administration and Scoring

1 The instructions printed on the response sheet are sufficient to take care of 15
the questions that are asked. is

2 No time limit should be given for completing the scale. However, most of
should finish it in about seven to eight minutes, though is
the respondents
there may always be a few individuals who would take much longer time.

3. Before administering the scale, is advisable to emphasize orally that

it

as possible, and sincere

responses should be checked as quickly
should be told that
cooperation is required for the same. The respondents
the results of the scale would help in self- knowledge and that responses
would always remain strictly confidential.

4. It should also be emphasized that there is no right or wrong answer to the

statements. The statements are designed to have differences in individual's
reactions to various situations. The scale is meant to know the difference

between individuals and is not meant to rank them as good or bad, right or
wrong, desirable or undersirable.
5. It should be duly emphasized that all the statements have to be responded
in either positive or negative and no statement is to be left unanswered.

6. It is not desirable to tell the subjects the exact purpose for which the test is

used. If the subject is of 'inquisitive type' vague answers like "the test
measures personality, "it assesses the reactions of individuals in varying
situations", etc. should be given.
7
7. Though the scale is self-administering, it has been fould useful to read out
the instructions printed on the response sheet to the
subjects.
8. Manual scoring is done conveniently. No scoring key or stencil is provided.
9. Each item or statement which is checked as "Yes"or
"No"should be
awarded the score of "1"or "0"respectively. The sum of scores of all the
ten items is the
DA score.
14Manual forDeath Anviety Scale

Limitations and Cautions

In all testsofthis nature, the subjects do manage to
get some
insightinto
hat ts purpose is.As such there is alwaysthe factor of 'social
desiratilty ae
aking', The scale is purported to death anxiety of
measure which the
subject n
areand is ready to respond regarding it. It
should not be

nscious or such symptoms of death

aniety of which the
expected to tan
p
subject hinself has ha
no self-knowledge. It should not be used as a tool for individual
diagnosis uniese
euDDorted by other evidence. Ihough it is a useful clinical
instrument for
rina death anxiety, it cannot be a substtute for the sound judgement of the
clinician.The scale is not considered a suficient
substitute for direct
clinical
of the individual
observation

2stly. since the subject is to get

likely some "insight as to what
the scale
ries to assess, it should be used with very great caution,
especially where any
areat advantage occurs to the individual for
making a high or low score

The Psychological Consequences of Hansen's

Disease at
Discrete Age Levels

The results of astudy conducted by Mehta

(1992) are as under
Hansen's disease promotes death anxiety.

2 Age promotes death anxiety in both, patients as well as normals.

3 Hansen's disease and age do not interact to afect death anxiety.

Age promotes death anxiety in normal population.

5. The correlation between learned helplessness and death anxiety is low in

the young population (= 0'24).

6. The correlation between learned helplessness and death anxiety is

moderately high in the middle aged population (r 0

= 69).
 The correlation
Manual for Death
Anxiety Scale
between learned helplessness and death anxiety
| 15
is
moderately high in the patients of Hansen's disease (r = 0'63).
8 The correlation between learned helplessness and death anxiety is

moderate in normal population (r

= 0'53).
Acknowledgement
The cooperation and help rendered by a latge number of persons including
the is gratefullyacknowledged.
experts/judges
TABLE 1 A
Showing the List of Final Items Constituting the Scale (Hindi Version')

2
3.

5.

7.

8.

9.

10.

It was developed from the list of original items in consultation with 50

judges/experts.
 keal kr Dealh Anviey Seale
TABLEIB
hewng the Liat ofFnal Iema Conatituting the Soale
(English
Version*)

co not ikeold age

Tam afraid of taking medicine given by a quack

3 get panicky on having even milcd chest pain.

4 Iget terified on seeing a criminal being hanged.

5 Icannot see anybodydying

6. I cdread suffocating surroundings.

7. Iget nervous on hearing aboutsomeone's sudden death.

8. Irealise the importance
ofdestiny on seeing an accident.

9. I do not want to die a miserable death.

10. I
get frightened on looking into a wel.

It was developed from Hindi Version in consultation with ten

judges/experts

TABLE 2
Norms for
Interpretation of the Raw Scores

Mean (M)
542
Standard Deviation () 1'62
Normal Range (M 1a) 380-704
High

Low
705 and above
3'79and below