Question 1

What are best practices for dealing with obsessive thoughts about one's own death? What are best practices for dealing with obsessive thoughts about the death of loved ones?

Rachel Menzies · Accepted Answer

Meta-analytic findings have shown that CBT is the most evidence-based treatment for reducing death anxiety. Meta-analysis found that exposure therapy is most effective at reducing fears of death. Given this, treatments for death anxiety should aim to gradually expose the client to reminders of death, and should be tailored to their own specific fears. For example, exposure therapy could involve imaginal exposure to the death of a loved one, or their funeral, or vividly imagining one’s own death. This can be done in a similar way to writing an “illness story”, as suggested by Furer, Walker, & Stein as a treatment for health anxiety. Other exposure tasks could involve planning one’s own funeral, writing one’s own obituary or eulogy, or discussing end-of-life preferences with others. The same approaches can be used for addressing fears about the death of loved ones. Watching films or reading books about death can be effective at beginning to normalise death, and cultivate acceptance of it.

Whilst exposure therapy is the most evidence-based approach for death anxiety at present, cognitive treatments should also not be overlooked. These include identifying the particular beliefs which are underlying the fear, and examining how helpful or realistic these beliefs are. For example, beliefs such as “dying will be painful” or “I wouldn’t cope with the death of a loved one” can be targeted through examining evidence, such as the fact that most people do not die in severe pain, and that most people do manage to cope with the death of someone close to them. Helping clients come to more realistic and helpful beliefs about death are key here.

Whether the thoughts are about the death of oneself or a loved one, cultivating a sense of gratitude for existence can also be valuable. As Richard Dawkins puts it: “we are going to die and that makes us the lucky ones”, because most people are never going to be born (https://www.brainpickings.org/2014/11/05/richard-dawkins-death-unweaving-the-rainbow/). Understanding that there was an infinitesimal chance of your unique string of DNA ever coming into existence in the first place, can help reduce the sense of injustice felt towards death, and create a sense of awe for the unlikelihood of existence.

Cultivating ‘neutral acceptance’ of death is also an important goal of therapy. Neutral acceptance is the idea of accepting death because it is neither good nor bad, and because it is outside of our control. Neutral acceptance of death has been shown to be associated with reduced death anxiety, and better psychological wellbeing (see chapter 6, https://www.amazon.com/Death-Anxiety-Handbook-Instrumentation-Application-ebook/dp/B019P2L12O). The concept of neutral acceptance overlaps heavily with the ideas of the ancient stoic philosophers. Stoic philosophers wrote a lot about death. They argued that we should not worry about death, given that it is outside of our control, and therefore worrying about it is futile (https://www.bookdepository.com/Mortals-Rachel-Menzies/9781760879167).  The stoics also wrote about the idea that death is not something to be feared, because we have experienced non-existence for thousands of years, before we were born, and it did not trouble us then. Many stoic authors encourage us to focus on using the time we have, however long or short it may be, rather than fixating on our inevitable death. Reading about stoic philosophy can often be very valuable when targeting death anxiety specifically, or anxiety more broadly (https://medium.com/stoicism-philosophy-as-a-way-of-life/the-five-most-popular-books-on-stoicism-e450e03fccb).

Question 2

What does it feel like to have death anxiety?

Rachel Menzies · Accepted Answer

People’s subjective experience of death anxiety can be very variable. For many people, they may not be aware of their fears of death on a regular basis, as they are able to keep thoughts of death at bay through distraction, or through adaptive coping strategies, such as focusing attention on relationships or personal achievements. They may only notice an increase of thoughts about death and mild anxiety symptoms following some kind of external reminder of death (e.g., hearing about a fatal accident on the news).

However, research from Terror Management Theory shows that even if people do not consciously report any anxiety when thinking about death, their behaviour changes dramatically after being prompted to think about death (https://journals.sagepub.com/doi/10.1177/1088868309352321). For example, after being subtly reminded of death in the laboratory, people become more interested in having children, are more interested in purchasing luxury products, and even become more hostile towards people with different religious and political ideologies. These experiments show that death anxiety is not something that people are always consciously aware of.

For some people, their death anxiety may be having a more direct and explicit impact on their day-to-day life.  They may experience more frequent fight and flight symptoms at the thought of death itself, or the thought of anything that could bring their death about, such as illness, climate change, accidents, or natural disasters. They may find that their mind is often filled with thoughts of their own death or the death of loved ones. They may find themselves going to greater lengths to ward off death, such as visiting their doctor at the slightest sign of poor health, excessively exercising or using vitamins, or avoiding situations which have a chance of bringing about their death, such as flying or driving.

For some people, they may not experience anxiety about death, or engage in anxiety-related behaviours. Instead, their dread of death may manifest in feelings of sadness or pointlessness. They may experience thoughts about the meaninglessness of life given it is all going to end one day, and may find themselves withdrawing more and more from day-to-day events or activities (https://www.bookdepository.com/Mortals-Rachel-Menzies/9781760879167).

Question 3

How does fear of death develop in a person? And why would fear of death just suddenly appear in one's mind? Thank you very much.

Rachel Menzies · Accepted Answer

People often assume that fears of death develop in adulthood. In fact, fears of death can begin in early childhood, as children begin to develop their awareness of death (See chapter 2, https://www.amazon.com/Curing-Dread-Death-Research-Practice/dp/1925644111). Research shows that children acquire an understanding of death in stages, between the ages of 4 to 10. By the age of 10, children understand that death is irreversible and that it applies to all living things, including the self. Alongside this awareness, comes the potential for fear. In fact, items tapping into fears of death remain the most commonly endorsed items on measures of anxiety in children and adolescents.

Regarding why death might suddenly appear in one’s mind, we are often surrounded by reminders of death in our daily lives; from news articles describing fatal accidents, wars, or natural disasters, to films or books which depict fictional deaths.  These external events may trigger thoughts of death, which people might manage through either helpful or unhelpful ways. Helpful, adaptive strategies for managing fears of death may include extending the self via cultivating relationships with others, or focusing on creating achievements or projects which will outlast us (https://www.bookdepository.com/Mortals-Rachel-Menzies-Ross-Menzies/9781760879167). Unhelpful strategies may include denial or excessive attempts to ward off death, such as through the behaviours we often see in clinical practice (e.g., compulsive handwashing or excessive attention to physical health or illness). According to Terror Management Theory, these defense mechanisms work to keep the fear of death at bay for many people. However, if these defenses are not working effectively, someone may be more likely to experience higher death anxiety.

There are other factors which may make someone more likely to experience higher levels of death anxiety. Research by Florian and Mikulincer has shown that insecure attachment styles are associated with higher levels of fears of death. Uncertainty about religious beliefs (i.e., being neither firmly committed to one’s religion nor firmly atheistic) is also associated with more death anxiety, as is low self-esteem, in line with Terror Management Theory. Of course, life events such as a period of illness, an accident, or loss of some kind, may also trigger a more pronounced awareness of mortality.

Question 4

How can CBT help with patients who know that they are dying (e.g., end stages of cancer)? How about other approaches such as ACT? Is there a common concept among these different approaches?

Rachel Menzies · Accepted Answer

CBT approaches to death anxiety for patients who are terminally ill are not dissimilar to the approaches used for those who are not at the end of life. Treatment should still seek to assess the patient’s beliefs about death which appear to be driving the fear (e.g., “My family will not cope without me”, “It will be awful to never experience anything again”, “Life is pointless if it is going to end so soon), and help the patient work towards more adaptive or realistic beliefs. Given that exposure therapy is the most evidence-based treatment for death anxiety, this should also be considered for those facing imminent death. Exposure therapy for this population may also involve discussing funeral or burial preferences with loved ones, particularly if this is something that the patient appears to be avoiding. As with other populations, treatment should focus on cultivating neutral acceptance of death and helping the patient to focus solely on what is within their control. The concept of “rippling” put forward by Irvin Yalom in Staring at the Sun is also worth discussing in treatment. That is, while death may physically destroy us, parts of ourselves will “ripple on” to those around us. In ways we may not even be aware of, our beliefs, values, thoughts and mannerisms, will linger on when we are gone, based on our interactions and behaviours while we were alive.

There is indeed some overlap between ACT approaches and CBT for death anxiety. Exercises such as writing your own eulogy or tombstone inscription were popularised by ACT, and may serve a dual purpose as exposure tasks, whilst simultaneously prompting a reflection on what the patient most values. Encouraging values-based living is of particular relevance to patients who are imminently facing death. Both ACT and CBT approaches encourage active reflection on death, and using the awareness of death as a motivator to live in a meaningful, purpose-driven way in the present moment.

Question 5

How are thanatophobia and OCD related? What are some of the typical compulsions for people with thanatophobia?

Rachel Menzies · Accepted Answer

Although thanatophobia is not officially a recognised disorder, fears of death play a role in many different presentations of OCD.  Both research and discussions with clients suggest that many obsessions in OCD centre on death. These may include  intrusive images or thoughts of harming oneself or loved ones, worries about the house burning down, falling ill through contamination with germs, and so forth. Many compulsions are therefore either direct or indirect attempts to prevent death or physical harm in some way. For example, compulsively checking stovetops or electrical outlets can be seen as a way of trying to prevent death by fire or electrocution. Compulsively checking locks on the front door or windows are often done to prevent household invasion, which may potentially result in death. Individuals who compulsively wash often say that they do so to prevent catching some kind of serious illness, which may threaten their own life or that of their loved ones.

For some people with OCD, their fears of death may manifest in worries that they will "snap" and harm someone, or that they have already harmed someone without realising it. These individuals may compulsively "check" whether or not they have committed harm (e.g., by mentally reviewing their day, or physically retracing routes to check whether they have accidentally run someone over), or by avoiding being in situations in which they could harm others (e.g., handling knives, or standing next to strangers on a train platform or busy intersection, for fear of pushing them into the vehicle's way).

Superstitious rituals are often a more "magical" way of preventing death in some form. For example, when asked, individuals with OCD may say that they repeat certain phrases, carry "lucky" objects, or count or tap, to  ward off death or prevent a dangerous outcome.

Whilst many of the above examples are largely based on clinical observation, recent laboratory research suggests that fears of death often underlie common presentations of OCD. In 2017 we published experimental research showing that fears of death drive compulsive washing in OCD. In this study, we had a large sample of people diagnosed with OCD. We asked half of this sample to contemplate death, while the other half contemplated a different topic. We found that people with the washing type of OCD who had been reminded of death spent twice as long washing their hands, compared to people who had not been reminded of death. Importantly, there was no difference in self-reported anxiety between the two conditions. This suggests that it was contemplating death itself (rather than any resulting conscious change in emotion) that produced this significant increase in washing behaviour. This study suggests that death anxiety plays a significant role in driving the compulsive handwashing seen in OCD.

In research we published in 2020, we found that death anxiety was significantly associated with each symptom cluster of OCD that we measured. This included hoarding, checking, obsessions, contamination, indecisiveness, and "just right". These relationships remained significant after controlling for neuroticism, suggesting that fears of death appear to play a unique role in predicting the severity of OCD symptoms.  However, this research is just correlational, so we will need to do further research to see whether death anxiety plays a casual role in these other presentations, such as in hoarding disorder.

Outside of OCD, people who are highly death anxious may engage in a range of behaviours to manage this. This may include excessive checking of their body for symptoms of illness (such as in health anxiety, and monitoring heartrate or "scanning" one's body in panic disorder), frequent reassurance seeking from loved ones, or frequent requests for tests from medical professionals, or avoidance of any situation or object which is seen as having the potential to cause death (e.g., flying, driving, heights, spiders, and so forth). This may even include compensatory behaviours that many of us probably engage in, such as exercise or vitamin use - such behaviours can range from being adaptive to maladaptive, depending on the frequency and consequences of the behaviour. In this way, people can engage in a multitude of different behaviours to try and prevent death in some way.

Death Anxiety