# Motivation and emotion/Book/2016/Death anxiety

* Multimedia presentation (3 min)

## Overview

* Case study
* Jessica is a 24 year old university student who is studying a Bachelor of Nursing. During her second year of study she was undertaking a unit which had a module on "end of life care". This module led to Jessica's increasing awareness of death's inevitability which had some negative consequences on her life including:
* Regularly called in sick to her retirement village part-time job; and eventually resigned because the elderly with whom she worked were mortality cues.
* Missing her university lectures and tutorials for her end of life unit which resulted in her failing her assessments.
* Withdrawing from her friends as she avoided leaving the house for fears of being hit by a car or catching a deadly disease.
* No longer watching television or movies as they too often have death related themes.
* Spending the majority of her time at home in her apartment researching death on the internet which is exacerbates her death anxiety.
There is only one thing in life that we can be 100% certain about - death. When this awareness dawns on us, death anxiety can kick in. Death anxiety can impact on all aspects of human existence[vague]. The effects can disrupt an individual's everyday life as seen in Jessica's case. A further challenge is the magnitude of mortality cues that we are exposed to on a day to day basis. With so many death reminders present it is nearly impossible for us to avoid thinking about death. It can therefore be very difficult for individuals to remain optimistic and continue to live happy fulfilling lives. This chapter explores death anxiety and the theories that explain how we continue to function optimally in face of our finiteness. The effects that death anxiety produce as well as treatment options available for this are also explored[vague].

## Definition

Death anxiety is a persisting, abnormal fear of dying, accompanied by feelings of worry, anxiety and dread, which disrupt the individual from their daily life. Death anxiety incorporates the emotions, cognitions and fears that are experienced when acknowledging the inevitability of death (Daradkeh & Moselhy, 2011). This fear of death is also known as Thanatophobia, as proposed by Freud (Princy & Kang, 2013). The word, Thanatophobia, is made up of the words thanatos which means death, and phobia, which means fear (McClatchey & Kin, 2015). The awareness that death is inescapable is known as mortality salience (MS) (Lewis, 2014).
There are three different types of death anxiety including:
* Predatory death anxiety: a fear of being harmed or killed.
* Predator death anxiety: a fear of the consequences that would arise upon harming or killing another
* Existential death anxiety: the personal implications that accompany the awareness of death's inevitability (Langs, 2004).

## Theoretical background

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### Freud's Thanatophobia

Psychological theory about death anxiety began with the ideas put forward by Sigmund Freud. He realised that some people were afraid of death and he termed this fear "Thanatophobia" (Princy & Kang, 2013). Freud proposed that this death-related drive had an impact upon human behavior (Sliter, Sinclair, Yuan & Mohr, 2014). However, he believed that humans did not possess the capacity to accept their own death. Therefore, he proposed that the fear of death was due to childhood conflicts which were unresolved (Furer & Walker, 2008). Freud also proposed that defense mechanisms such as denial and rationalisation work to protect humans from the reality of their eventual death (McClatchey & King, 2015).

### Generativity Theories

Erikson's theory proposes a series of eight developmental stages that a person progresses through over their lifetime. Each stage has a developmental crisis which the individual must overcome before they move on to the next stage (Princy & Kang, 2013). Erikson proposed that during middle adulthood an individual faces the crisis of generativity versus stagnation. This stage is concerned with whether the individual is making a valuable contribution to society. Those who aren't {{missing]} become stagnant members of the community and withdraw. Conversely, this stage can be overcome by participating in generative activities such as mentoring and community work (Grant & Wade-Benzoni, 2009). Support for this theory was provided by Major and colleagues (2016) who found that death awareness in older adults lead to higher levels of generativity (Major, Whelton, Schimel & Sharpe, 2016). The final developmental stage is integrity versus despair which is reached in late adulthood (McClatchey & King, 2015). Erikson proposed that during this stage humans review their lives and if they are happy and have found meaning in their existence then ego integrity is achieved (Princy & Kang, 2013). The alternative to this is that the individual experiences despair when they realise that their life had little or no meaning (McClatchey & King, 2015). Reaching ego integrity and accepting that one has had a purposeful life helps to lower death anxiety in older adults (Princy & Kang, 2013).

### Terror-Management Theory (TMT)

The most prominent and well-supported theory of death anxiety is Terror Management Theory (Iverach, Menzies & Menzies, 2014). The work of Ernest Becker, a cultural anthropologist, influenced the development of TMT: he proposed that humans share the basic survival motive with other animals (Bassett, 2007). What separates humans from these other animals is our cognitive abilities, which allow us to be aware of our eventual death (Major, Whelton & Duff, 2016). This awareness is known as mortality salience, and it can cause extreme anxiety within the individual (Lewis, 2014). This anxiety is due to the inconsistency between our evolutionary drive to survive and our awareness of death (Juhl & Routledge, 2016). To avoid being in a constant state of death anxiety our cognitive abilities, which established this dilemma originally, work to address the terror we feel (Major, Whelton & Duff, 2016). We have psychological structures which unconsciously combat the negative impacts of anxiety. Grouped together these buffering systems (see Table 1) allow an individual to perceive their existence as significant despite their fear of eventual death (Juhl & Routledge, 2016).
Table 1.
Death Anxiety Buffering Systems
| Buffering System | Description |
| Cultural Worldviews | Worldviews consist of a set of culturally appropriate morals, standards and values. If the individual adheres to these it can give their life a sense of meaning which can combat death anxiety (Maxfield, John & Pyszczynski, 2014). Upholding these values can allow one to perceive death as being able to be postponed through viewing the world as controllable, stable and safe (Bassett, 2007). Cultural worldviews give individuals a sense of meaning beyond that of their own existence which enables the possibility of symbolic immortality (Maxfield et al., 2014). This feeling that life will matter even after one's death helps to combat death anxiety (Bassett, 2007). Further, most worldviews incorporate a belief in an afterlife which gives one the hope that there is a chance of literal immortality (Maxfield et al., 2014). |
| Self-esteem | Self-esteem can be achieved through meeting the standards and upholding the values which are appropriate within ones[grammar?] culture (Maxfield et al., 2014). Self-esteem buffers against death anxiety by providing the individual with a sense of uniqueness; this allows us to separate ourselves from everyone else which gives us the hope for literal and symbolic immortality (Bassett, 2007). |
| Meaningful interpersonal relationships | When TMT was originally proposed it only had the buffering systems of cultural worldviews and self-esteem however, relationships with significant others has been since been identified as a death anxiety buffer (Lehto & Stein, 2009). Close relationships with others can give a sense of meaning and purpose to an individual's life. These relationships buffer anxiety as they symbolise eternity and promise and the lasting nature of such relationships allows one to transcend death. The realisation that one can live on through those they are close to after death helps to alleviate the dread of dying (Mikulincer, Florian & Hirschberger, 2003). |

### Other theories

* Regret theory was developed by Tomer and Grafton and concentrates on an evaluation of life. They proposed that individuals determine whether their life was meaningful and if they accomplished anything worthwhile through this evaluation. Death anxiety is observed when one's evaluation does not achieve these feelings of purpose and meaning (Princy & Kang, 2013).
* Separation theory proposes that death anxiety may be caused by successes and closeness to others. Due to this people perform destructive and self-limiting behaviours in order to reduce their intimacy levels and enable an illusion of connection (Bassett, 2007).[say what?]
* Posttraumatic growth theory (PTG) suggests that positive changes can follow life crisis' such as death of a significant other. These changes due to mortality exposure includes things such as an increased awareness and striving towards personal goals, a better appreciation for life and an increased level of commitment to intimate relationships (Furer & Walker, 2008).

## How does death anxiety affect our lives?

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### Workplace death anxiety

| Withdrawal: Stress and strain are a result of death anxiety which contribute to an individual becoming emotionally overwhelmed. This can lead to both short and long term withdrawal behaviours in the workplace, resulting in work disengagement. Short term behavioural withdrawals include poor concentration on work-related activities, arriving late to work and absenteeism. Turnover is a long term withdrawal behaviour where the individual may leave their job, often to reduce the amount of death reminders that they encounter. This is highly occurring in health professions where mortality cues are frequently encountered. | Generativity: Generative behaviours are a positive consequence of death anxiety and can occur in some situations. Generative behaviours are undertaken to assist the individual in fulfilling a meaningful life through benefiting others. Examples of generative behaviours that can occur in the workplace include: mentoring and helping others, and putting effort into work activities which will have advantages for others. TMT proposes that some individuals deal with death anxiety by ignoring mortality cues and instead concentrating on other aspects of their lives such as work. This in turn reduces withdrawal behaviours as well as the stress and strain that death anxiety causes. |
|} (Grant & Wade-Benzoni, 2009).

### Psychopathology

The buffering systems of TMT are constantly working to protect the individual from death anxiety. However, as death anxiety is a multidimensional construct it is easy for these systems to become overwhelmed. Under these conditions one can face challenges that can't be overcome which can result in negative consequences (Major, Whelton & Duff, 2016).

#### Anxiety disorders

Anxiety disorders can develop due to the frightening reality of non-existence (Major, Whelton & Duff, 2016). According to TMT when the psychological buffering systems that protect against death anxiety are not working efficiently anxiety disorders can develop. A multitude of anxiety disorders have been associated with death anxiety as demonstrated in Table 2 below (Iverach, Menzies & Menzies, 2014).
Table 2.
Death Anxiety and Anxiety Disorders
| Anxiety Disorder | Impact Of Death Anxiety |
| Phobias | The fear of death is the basis for almost all phobias. Often phobias develop from situations which either did or had the possibility to cause harm and obsessions are then developed as a way of avoiding future encounters (Iverach, Menzies & Menzies, 2014). |
| Social Anxiety | Mortality salience has been found to impact on an individuals social anxiety and related disorders. Strachan and colleagues (2007) found that reminders of death made those with high social anxiety more likely to avoid interaction with other individuals (Strachan et al., 2007). |
| Panic Disorder | Those with panic disorder also show a high level of death anxiety and in some cases it has been the prominent presenting issue of the disorder (Iverach, Menzies & Menzies, 2014). |
| Agoraphobia | The development of symptoms of agoraphobia are associated with death anxiety these include: hypochondriacal worries, fears of harm once leaving the confines of ones home and a large number of concerns regarding catastrophe's which may result in death. The development of agoraphobia itself is often due to traumatic events which increase an individuals awareness of death (Iverach, Menzies & Menzies, 2014). |
| Separation Anxiety | As death anxiety levels increase so does the fear of being separated from significant others (Iverach, Menzies & Menzies, 2014) |

#### Somatic symptom disorder

Fear of death has been identified as a central feature in somatic symptom and related disorders as individuals suffer from a preoccupation with bodily threat. They have such an intense fear that they will develop an illness or die that they undergo excessive levels of health-checking behaviour such as requesting medical tests, unnecessary doctor appointments and body scanning (Iverach, Menzies & Menzies, 2014).

#### Mood disorders

Death anxiety has also been associated with mood disorders, particularly depression. As is characteristic of those with depression, death anxiety can induce feelings of worthlessness and cause an individual to think that their life has little or no meaning. The depression may develop through a combination of consistent death thoughts and an insufficient TMT buffering system which can lead to low self-esteem (Major, Whelton & Duff, 2016). Death anxiety exacerbates the symptoms of depression as well as the feelings of hopelessness which are associated with the disorder (Iverach, Menzies & Menzies, 2014).

#### Obsessive-compulsive disorder (OCD)

The concern of mortality is evident in many obsessions and compulsions that individuals participate in to protect themselves (Iverach, Menzies & Menzies, 2014). Consider those with OCD who excessive wash their hands in order to eliminate germs and dirt to prevent illness and disease. This threat of death can cause such behaviours to develop and they are sustained through the individuals perception that they are being protected from death (Strachan et al., 2007).

#### Post-traumatic stress disorder (PTSD)

Death anxiety can also contribute to the development of PTSD. Being involved in near-death experiences or harmful situations can increase death anxiety and mortality salience which can result in PTSD. The buffering systems that operate to protect an individual from death anxiety are disrupted by PTSD and can therefore, no longer work efficiently in preventing such fears (Iverach, Menzies & menzies, 2014).

#### Eating disorders

The TMT buffering structure of cultural worldviews is also subject to challenges which can result in mental health issues. Consider the vast preoccupation that Western societies place on women to be thin. A failure to adhere to this worldview to feel desirable can result in drastic measures being taken to try and meet this standard which includes maladaptive eating (Major, Whelton & Duff, 2016). Goldenberg and colleagues (2005) found that mortality salience can impact on a womans[grammar?] motivation to be thin. This impact resulted in such women eating less to try and achieve this perceived desirable body (Goldenberg, Arndt, Hart & Brown, 2005).

### Positive consequences

While the negative affects of death anxiety are primarily concentrated on, the awareness of death can lead to positive consequences as well. Posttraumatic growth theory can explain positive personal changes when one has been exposed to mortality cues. Positive consequences such as an increased motivation to strive for personal goals, a better appreciation for life and increased commitment to close relationships are some results of personal crises such as death of a loved one (Furer & Walker, 2008). The awareness of death can also lead to generative behaviours in the workplace or outside the workplace such as volunteer work and raising children (Grant & Wade-Benzoni, 2009). Death anxiety may also inspire individuals to undertake new activities which may result in growth and learning (Lehto & Stein, 2009). A further positive consequence is seen through an individual investing more commitment into their close and romantic relationships. This is theorised to be because these insulate against the impacts of death anxiety as it is a buffer proposed by TMT (Lehto & Stein, 2009).
The significance of death anxiety is evident when we consider it from an evolutionary perspective which puts forward an adaptive benefit of fearing death. When one fears death, the survival instinct we possess can deter us from participating in risky behaviours which have the possibility to cause harm or death. Therefore, our safety and survival is maintained through our fear of death (Sliter et al., 2014).

## Treatment

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### Existential psychotherapy

Existential psychotherapy has been utilised extensively for the treatment of death anxiety and many associated psychological disorders. This framework concentrates on the existential concern of dying as a significant cause of anxiety that impacts on all aspects of life. The therapy integrates techniques such as establishing purpose and meaning, building support networks and interpersonal relationships, enhancing coping strategies, reducing maladaptive techniques for coping, addressing both conscious and unconscious issues and education on symptomology and triggers for its success (Iverach, Menzies & Menzies, 2014). There are a number of different existential-based therapies which have shown promise in the treatment of death anxiety:
* Lewis (2014) composed a TMT integrated existential therapy (TIE) to address death anxiety. The therapy exposes individuals to death anxiety and then determines which coping strategies are most effective in dealing with loss. Coping strategies which utilise the individuals cultural and psychological resources are encouraged.
* Meaning Therapy is an existential therapy which assists an individual in finding purpose and meaning in their life. The therapy is often utilised in a group setting which has found to enhance life meaning, reduce psychological issues and increase self-efficacy (Vos, Craig & Cooper, 2015).

### Acceptance and Commitment Therapy (ACT)

ACT is a behavioural therapy which attempts to confront the fear of dying. The therapy uses activities which focus on death to help the individual to find meaning in their life. Such activities include things like one writing their own eulogy and the wording that would appear on their tombstone (Iverach, Menzies & Menzies, 2014).

### Cognitive-Behavioural Therapy (CBT)

The treatment of death anxiety through the use of CBT has shown success for a number of psychological disorders (Iverach, Menzies & Menzies, 2014).
Table 3.
CBT techniques and death anxiety
| CBT Technique | Usefulness in death anxiety |
| Assistance in reducing reassurance-seeking and health checking behaviours | The therapist can enable the client to identify specific safety behaviours and then they can monitor it through a diary. This allows a baseline level to be established as well as reasons for the behaviour occurring and the impact it has on the individual afterwards. The therapist can then work with the client to reduce the target behaviour through response prevention homework. |
| Exposure | In vivo exposure can be useful when clients avoid particular situations because they may experience mortality cues. Exposure to these situations as well as other difficult death-related tasks such as writing a will should help to reduce death anxiety. Imaginal exposure can be particularly useful in confronting death anxiety as the feared situations may not have ever occurred or are uncommon. Clients are able to confront their death-related fears within a safe and facilitated environment. |
| Cognitive reappraisal | The therapist can address the clients[grammar?] view of death and try to eliminate unrealistic beliefs about dying. It can include education on death and tailors the concerns of death so that they are dealt with in an appropriate way. |
| Increasing concentration on personal goals and life satisfaction | The therapist helps the client to identify their short and long term goals which often become obstructed by death anxiety. Through redirecting the clients concentration to these goals they may participate in activities that they used to find enjoyable, which can reduce death anxiety. |
| Relapse prevention | This aspect of CBT is important because those who reduce their death anxiety often encounter challenges which hinder their progress. Clients are encouraged to face their problem with realistic expectations and address their difficulties in an appropriate way with effective coping strategies. |
(Furer & Walker, 2008).

## Suggestions based on theories and research

* The theories and treatment options can be used to give suggestions to those suffering from death anxiety, [grammar?] we revisit the case study of Jessica here:
* Make an effort to spend more time with close friends and family as TMT proposes that interpersonal relationships can buffer against death anxiety.
* Try to participate in some form of generative behaviour such as volunteer work to help her work towards a more meaningful existence which Erikson proposes will reduce death anxiety.
* Participate in CBT to confront her death anxiety through: addressing her safety-checking behaviour of researching death on the internet; exposure to death realted[spelling?] themes such as through the media or on a TV show; cognitive reappraisal to correct her unrealistic belief that she will die if she leaves her apartment; redirecting her attention back towards her goals and activities she used to find enjoyable.
* Directly confront the fear of death through ACT with an activity such as writing her own eulogy.
* Undergo existential psychotherapy to enhance coping strategies and supportive networks

## Conclusion

Whilst the thought of death strikes fear in most, there are effective ways to cope with these feelings so that one does not become overwhelmed with anxiety. As proposed by TMT, the psychological buffering systems we have available usually do this for us. However, these systems do not function optimally all of the time as they can be disrupted and therefore death anxiety must be managed in other ways as well. One such way that we have discussed is through generative behaviours which can give the individual a feeling of purpose in the world. However, not all individuals can address the fear of dying in such a positive way and this can result in numerous negative affects such as psychological issues and withdrawal behaviours. Death anxiety is very understandabl, but we must try to remember that we are privileged to be alive every day and we need to make the most of what we are offered.