1. Types of Death Anxieties

Death anxiety is caused by the fear of pain and also the unknown, of separation from the loved ones and permanent end of existence after death. Langs (2004) has classified three forms of death anxiety: (1) Predatory death anxiety (triggered by external situations that may be physically or psychologically dangerous, and anxiety ensures the survival of the organism in the face of adversities); (2) predator death anxiety (results from an individual harming someone either physically or mentally, which is often accompanied by unconscious guilt that may compel an individual to punish oneself); and (3) existential death anxiety (emanates from the knowledge that life has an end and distinguish self from others. Usually individuals defend against death anxiety through denial, and excess use of denial tends to be detrimental). A few research scholars have discerned four types of death anxiety, namely, personal death anxiety, personal dying anxiety, anxiety toward the death of someone close, and anxiety toward the death of someone close^[1][2] .

2. Theories on Death Anxiety

Several theoretical models relevant to the study of death anxiety have appeared in the literature. Leading theories about death anxiety were developed by Sigmund Freud (Thanatophobia), Ernest Becker (Terror Management Theory), Erik Erikson (Wisdom: Ego integrity vs. despair) and Kastenbaum (Edge theory).

Thanatophobia is fear of death. Sigmund Freud was the first theorist to coin death anxiety and hypothesized that individuals express a fear of death as a response to cope with unresolved childhood conflicts. Thanatophobia is evolved from the Greek mythological figure of death, Thanatos. Ernest Becker proposed terror management theory supported existential views which turned death anxiety theories towards a new dimension. Death anxiety can generate fears of existence such as fear of being alone. Many try to deny death and to keep their anxiety under strict regulation resulting in mortality salience, i.e., become responsive to the understanding of certainty of death and instinctively try to suppress it in response to fear. This method of suppression usually links towards cultural, spiritual, and religious beliefs, and seeks external support. Erik Erikson formulated the psychosocial theory which envelops the concept that once an individual reaches the latest stages of life, they reach “ego integrity”—a state when one comes to terms with their life and accepts it when one finds meaning or purpose in their life. On the contrary, when individual views their life as a series of failed and missed opportunities, then they do not reach the ego integrity stage and exhibit death anxiety. This stage is known as Wisdom: Ego integrity vs. despair. Kastenbaum’s Edge theory postulates that death anxiety contains a survival function that evolves in perceived life-threatening situations.

Hoelter and Hoelter (1978) conceptualized death anxiety as a multidimensional concept and offered eight elements of death anxiety: (1) Fear of dying process, (2) fear of premature death, (3) fear of death of significant others, (4) phobic fear of death, (5) fear of being destroyed, (6) fear of the body after death, (7) fear of the unknown, and (8) fear of the dead. Similarly, Florian and Mikulincer (1998) have articulated three mechanisms of death anxiety: Intrapersonal, interpersonal, and transpersonal. The intrapersonal component focuses on the impact death has on one’s body and psyche. Fear of losing the body after death is prominent during this phase. An interpersonal component brings attention to how interpersonal relationships get stricken by death and therefore the transpersonal component, on the opposite hand, is said with fears about the afterlife.

Paul Wong (2008) developed the meaning management theory. It highlights that human reactions to death are complex, multifaceted, and dynamic. The theory proposes three types of death acceptances as Neutral, Approach, and Escape acceptances. Besides these, it explains different aspects of the meaning of death that eventually regulates death anxiety include finality, uncertainty, annihilation, ultimate loss, disruption of life flow, leaving the loved ones, intense pain, sense of loneliness, prematurity of death, failure of life, unfulfilled work, judgment, and retribution. The theory indicates our existence is based on two primary motivations: To survive and to find meaning and reason for survival. The pursuit of meaning in life can be the best remedy to allay death anxiety. In other words, individuals who find meaning in their existence and contribute productively to the society may not feel threatened by inevitable death ^[3].

Other theories include self-realization theories ^[4][5], personal construct theory ^[6], an illusion of control theory ^[7][8], self-concept discrepancy theory ^[9], search-for-meaning theories ^[10][11][12], theories of denial ^[13], and a two-factor theory of death ^[14].

Hossain and Gilbert (2010) postulated Death and Adjustment Hypotheses (Hossain and Gilbert 2010). It postulated two things; first, death should not be considered the end of existence, second, the belief that the immortal pattern of human existence can only be adopted in an exceedingly morally rich life with the attitude towards morality and materialism balanced mutually.

The recurrent four themes in these theories are death as self-defeating, radical transformation, a threat to the purpose of life, and a threat to the realization of life potential. Such diversity in theoretical approaches has led to varied perspectives on death anxiety; however, these theories have substantial overlapping concepts (Barnett et al. 2018). It means threats to death anxiety can be classified based on two factors: External causes, such as presence and search for meaning in life; and the internal evaluation of the self (Florian and Mikulincer 1998).

3. Psychological Effects of Death Anxiety

Researches indicate that people tend to become increasingly defensive in ways that are harmful to themselves as well as to others when death anxiety is aroused. Although people may initially embrace life more fully, over time, most people shift to a more defended action. However, as we discussed in an earlier section, these reactions vary across religiosity, age, and gender. People with death anxiety deny death to protect themselves and fail to value other relevant and meaningful influences by giving importance to insignificant issues in their lives.

In one experiment conducted by Solomon and colleagues (2015), subjects (judges) were subliminally presented with the word “death”. After these subjects strongly endorsed the worldview of their own ethnic group or nation while, at the same time, they denigrated members of other groups whose worldviews differed from their own (Solomon et al. 2015). It means that judges who were exposed to the word “death” exercised more punitive sentences than those in the control group who were not exposed. If the single word “death” introduced in an experimental setting can produce significant changes in subjects’ attitudes and actions, one can imagine the powerful effect of the word “death” in countless situations in the real world on attitude and actions.

As researches indicate a belief in religion represents the denial of death. Some individuals rationalize death, taking a more philosophical position to keep themselves away from feeling about their own mortality (Kastenbaum 2000). Others may believe that someone will ultimately save them—a relationship partner, a guru, or other (Kastenbaum 2000). Some defenses against death anxiety have beneficial side effects; for example, the symbolic immortality, finding lasting meaning in devotion to family, friends, and people at large, and attempting to leave a positive legacy generally has a good effect. Other defenses, such as living on through one’s children, have a generally negative effect (Hart and Goldenberg 2008).

4. Death Anxiety and Mental Health Conditions

Previous research has identified a connection between death anxiety, quality of life, and a range of mental health conditions (Galek et al. 2007; Sherman et al. 2010; Bahrami et al. 2013; Iverach et al. 2014; Willis et al. 2019). A recent study indicated death anxiety as a predictor of mental health conditions (Menzies et al. 2019) and numerous studies have demonstrated symptomatology of various disorders, including anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, depression, and eating disorders (Iverach et al. 2014; Le Marne and Harris 2016; Menzies and Dar-Nimrod 2017; Ongider and Eyuboglu 2013).

A few studies have explored the causal role of death anxiety in mental illnesses. These studies have revealed that death anxiety increases avoidance of stimuli that generates fear among phobics, social avoidance and attentional biases towards threats among the socially anxious, and even restricted consumption of high caloric foods amongst women, suggesting the relevance of death anxiety in eating disorders (Finch et al. 2016; Strachan et al. 2007; Iverach et al. 2014). One study examined the effect of mortality salience on compulsive handwashing in a large sample of individuals diagnosed with obsessive-compulsive disorders (Menzies and Dar-Nimrod 2017). In another recent study, participants with a panic disorder or a somatic symptom-related disorder were shown increased time checking one’s body for physical symptoms, increased perceived threat of one’s symptoms, and also increased intention to visit a medical specialist in the near future (Menzies and Menzies 2020). Therefore, these findings establish that death anxiety causes anxious behavior for those vulnerable to health-related worries (Menzies and Menzies 2020).

Implications of studies on death anxiety in Indian cotext

While much is known about death anxiety, religiosity and universality, the role of death anxiety in psychological distress and mental illness; how culture inhibits or exhibits an expression of fear of death; how it can be assessed and addressed in therapeutic processes and any interventions that can enhance well-being by addressing death anxiety is still unknown.  

1. Types

Robert Langs distinguishes three types of death anxiety:^[10][11][12]

Predatory death anxiety

Predatory death anxiety arises from the fear of being harmed.^[10][11][12] It is the oldest and most basic^[13]:615 form of death anxiety, with origins in the first unicellular organisms' set of adaptive resources. Unicellular organisms have receptors that have evolved to react to external dangers, along with self-protective, responsive mechanisms made to increase the likelihood of survival in the face of chemical and physical forms of attack or danger.^[13]:616 In humans, predatory death anxiety is evoked by a variety of dangerous situations that put one at risk or threaten one's survival.^[13]:617 Predatory death anxiety mobilizes an individual's adaptive resources and leads to a fight-or-flight response, consisting of active efforts to combat the danger or attempts to escape the threatening situation.^[13]:617

Predation or predator

Predation or predator death anxiety is a form that arises when an individual harms another, physically and/or mentally. This form of death anxiety is often accompanied by unconscious guilt.^[14][11][12] This guilt, in turn, motivates and encourages a variety of self-made decisions and actions by the perpetrator of harm to others.^[15]

Existential

Existential death anxiety stems from the basic knowledge that human life must end. Existential death anxiety is known to be the most powerful form of death anxiety.^[16] It is said that language has created the basis for existential death anxiety through communicative and behavioral changes.^[14] Other factors include an awareness of the distinction between self and others, a full sense of personal identity, and the ability to anticipate the future.^[16] The existential psychiatrist Irvin Yalom asserts that humans are prone to death anxiety because "our existence is forever shadowed by the knowledge that we will grow, blossom, and inevitably, diminish and die."^[17] Human beings are the only living things that are truly aware of their own mortality and spend time pondering the meaning of life and death.^[18] Awareness of human mortality arose some 150,000 years ago.^[19] In that extremely short span of evolutionary time, humans have fashioned a single basic mechanism through which they deal with the existential death anxieties this awareness has evoked: denial.^[19] Denial is effected through a wide range of mental mechanisms and physical actions, many of which go unrecognized.^[16] While denial can be adaptive in limited use, excessive use is more common and is emotionally costly.^[16] Denial is the root of such diverse actions as breaking rules, violating frames and boundaries, manic celebrations, directing violence against others, attempting to gain extraordinary wealth and power, and more.^[19] These pursuits are often activated by a death-related trauma, and while they may lead to constructive actions, more often than not they lead to actions that are damaging to self and others.^[19]

2. Theories

Thanatophobia

The term thanatophobia stems from the Greek representation of death, known as Thanatos. Sigmund Freud hypothesized that people express a fear of death as a disguise for a deeper source of concern. He asserted the unconscious does not deal with the passage of time or with negations, which do not calculate the amount of time left in one's life. Under the assumption people do not believe in their own deaths, Freud speculated it was not death people feared. He postulated one does not fear death itself, because one has never died. He suspected death related fears stem from unresolved childhood conflicts.^[10][20][21]

Wisdom: ego integrity vs. despair

Developmental psychologist Erik Erikson formulated the psychosocial theory that explained that people progress through a series of crises as they grow older. The theory also envelops the concept that once an individual reaches the latest stages of life, they reach the level he titled as "ego integrity". Ego integrity is when one comes to terms with their life and accepts it. It was also suggested that when a person reaches the stage of late adulthood they become involved in a thorough overview of their life to date. When one can find meaning or purpose in their life, they have reached the integrity stage. In opposition, when an individual views their life as a series of failed and missed opportunities, then they do not reach the ego integrity stage. Elders that have attained this stage of ego integrity are believed to exhibit less of an influence from death anxiety.^[10][20][21]

Terror management theory

Main page: Philosophy:Terror management theory

Ernest Becker based terror management theory (TMT) on existential views which added a new dimension to previous death anxiety theories. This theory ascertains that death anxiety is not only real, but also people's most profound source of concern. He explained the anxiety as so intense that it can generate fears and phobias of everyday life—fears of being alone or in a confined space. Based on the theory, many of people's daily behavior consist of attempts to deny death and to keep their anxiety under strict regulation.^[20][21][22] This theory suggests that as an individual develops mortality salience, or becomes more aware of the inevitability of death, they will instinctively try to suppress it out of fear. The method of suppression usually leads to mainstreaming towards cultural beliefs, leaning for external support rather than treading alone. This behavior may range from simply thinking about death to the development of severe phobias and desperate behavior.^[13]:603 Religiosity can play a role in death anxiety through the concept of fear. There are two major claims concerning the interplay of fear and religion: that fear motivates religious belief, and that religious belief mitigates fear.^[23] From these, Ernest Becker and Bronislaw Malinowski developed what is called "Terror Management Theory."^[23] According to Terror Management Theory, humans are aware of their own mortality which, in turn, produces intense existential anxiety. To cope with and ease the produced existential anxiety, humans will pursue either literal or symbolic immortality.^[23] Religion often falls under the category of literal immortality, but at times, depending on the religion, can also provide both forms of immortality.^[23] Through Terror Management Theory, and other death-focused theories, there is a distinct pattern that develops indicating that those who are either very low or very high in religiosity experience much lower levels of death anxiety, meanwhile those with a very moderate amount of religiosity experience the highest levels of death anxiety.^[23] One of the major reasons that religiosity plays such a large role in Terror Management Theory, as well as in similar theories, is the increase in existential death anxiety that people experience. Existential death anxiety is the belief that everything ceases after death; nothing continues on in any sense.^[23] Seeing how people deeply fear such an absolute elimination of the self, they begin to gravitate toward religion which offers an escape from such a fate. According to one specific meta-analysis study that was performed in 2016, it was shown that lower rates of death anxiety and general fear about dying was experienced by those who went day-to-day living their religion and abiding by its practices, compared to those who merely label themselves as a member of a given religion without living in accord to its doctrines and prescribed practices.^[23] A 2009 study on death anxiety in the context of religion showed that Christians scored lower for death anxiety than non-religious individuals, which supports the main tenets of terror management theory, that people pursue religion to avoid anxiety about death by finding comfort in the ideas about afterlife and immortality. Interestingly, the study also found that Muslims scored much higher than Christians and non-religious individuals for death anxiety. These findings do not support terror management theory, the belief in an afterlife for muslims in the study caused more anxiety than those with no belief in an afterlife. This finding highlights a need for further examination into TMT in the context of different religions/sects as well as the impact of varying beliefs about afterlife on levels of death anxiety.^[24]

Being, time and dasein

Martin Heidegger, the German philosopher, on the one hand showed death as something conclusively determined, in the sense that it is inevitable for every human being, while on the other hand, it unmasks its indeterminate nature via the truth that one never knows when or how death is going to come. Heidegger does not engage in speculation about whether being after death is possible. He argues that all human existence is embedded in time: past, present, future, and when considering the future, we encounter the notion of death. This then creates angst. Angst can create a clear understanding in one that death is a possible mode of existence, which Heidegger described as "clearing". Thus, angst can lead to a freedom about existence, but only if we can stop denying our mortality (as expressed in Heidegger's terminology as "stop denying being-for-death").^[25]

Meaning management theory

Paul T. P. Wong's work on the meaning management theory^[26] indicates that human reactions to death are complex, multifaceted and dynamic.^[25] His "Death Attitude Profile" identifies three types of death acceptance as Neutral, Approach, and Escape acceptances.^[27][28] Apart from acceptances, his work also represents different aspects of the meaning of death fear that are rooted in the bases of death anxiety. The ten meanings he proposes are finality, uncertainty, annihilation, ultimate loss, life flow disruption, leaving the loved ones, pain and loneliness, prematurity and violence of death, failure of life work completion, judgment and retribution centered.^[26]

Existential theories

The existential approach, with theorists such as Rollo May and Viktor Frankl, views an individual's personality as being governed by the continuous choices and decisions in relation to the realities of life and death.^[29] Rollo May theorized that all humans are aware of the fact that they must one day die, reminiscent of the Latin adage memento mori. However, he also theorized that humans must find meaning in life, which led to his main theory on death anxiety: that all humans face the dichotomy of finding meaning in life, but also confronting the knowledge of approaching death. May believed that this dichotomy could lead to negative anxiety that hindered life, or a positive anxiety that would lead to a life full of meaning and living to one's fullest potential and opportunities.^[30] Victor Frankl theorized that through suffering there is meaning and that if one can find meaning in their life even in suffering, they can then aim to reach existentialism. ^[31]

Other theories

Other theories on death anxiety were introduced in the late part of the twentieth century.^[32] Another approach is the regret theory which was introduced by Adrian Tomer and Grafton Eliason.^[32] The main focus of the theory is to target the way people evaluate the quality and/or worth of their lives.^[32] The possibility of death usually makes people more anxious if they feel that they have not and cannot accomplish any positive task in the life that they are living.^[32] Research has tried to unveil the factors that might influence the amount of anxiety people experience in life.^[32]

Personal meanings of death

Humans develop meanings and associate them with objects and events in their environment which can provoke certain emotions. People tend to develop personal meanings of death which could be either positive or negative. If the formed meanings about death are positive, then the consequences of those meanings can be comforting (for example, ideas of a rippling effect^[33] left on those still alive). If the formed meanings about death are negative, they can cause emotional turmoil. Depending on the certain meaning one has associated with death, positive or negative, the consequences will vary accordingly.^[34] The meaning that individuals place on death is generally specific to them; whether negative or positive, and can be difficult to understand as an outside observer. However, through a Phenomenological perspective, therapists can come to understand their individual perspective and assist them in framing that meaning of death in a healthy way.^[35]

Religiosity

A 2012 study involving Christian and Muslim college-students from the US, Turkey, and Malaysia found that their religiosity correlated positively with an increased fear of death.^[36] A 2017 review of the literature found that in the US, both the very religious and the not-at-all religious enjoy a lower level of death anxiety and that a reduction is common with old age.^[37] A 2019 study further examined the aspect of religiosity and how it relates to death and existential anxiety through the application of supernatural agency.^[38] According to this particular study, existential anxiety relates to death anxiety through a mild level of preoccupation that is experienced concerning the impact of one's own life or existence in relation to its unforeseen end.^[38]  It is mentioned how supernatural anxiety exists independently on a different dimensional plane than the individual and, as a result, is seen as something that cannot be directly controlled.^[38] Oftentimes, supernatural agency is equated with the desires of a higher power such as God or other major cosmic forces.^[39] The inability for one to control supernatural agency triggers various psychological aspects that induce intense periods of experienced death or existential anxiety.  One of the psychological effects of supernatural agency that is triggered is an increased likelihood to attribute supernatural agency toward causality when dealing with natural phenomena.^[39]  Seeing how people have their own innate form of agency, the attribution of supernatural agency to human actions and decisions can be difficult. However, when it comes to natural causes and consequences where no other form of agency exists, it becomes much easier to make a supernatural attribution of causality.

3. Death Acceptance and Death Anxiety

Researchers have also conducted surveys on how being able to accept one's inevitable death could have a positive effect on one's psychological well-being, or on one's level of individual distress. A research study conducted in 1974 attempted to set up a new type of scale to measure people's death acceptance, rather than their death anxiety. After administering a questionnaire with questions regarding the acceptance of death, the researchers found there was a low-negative correlation between acceptance of one's own death and anxiety about death; meaning that the more the participants accepted their own death, the less anxiety they felt.^[40] While those who accept the fact of their own death will still feel some anxiety about it, this acceptance could allow them to form a more positive perspective on it. A more recent longitudinal study asked cancer patients at different stages to fill out different questionnaires in order to rate their levels of death acceptance, general anxiety, demoralization, etc. The same surveys administered to the same people one year later showed that higher levels of death acceptance could predict lower levels of death anxiety in the participants.^[41]

4. Death Row Phenomenon

Main page: Medicine:Death row phenomenon

The death row phenomenon is the distress and anxiety seen in inmates awaiting execution, which can cause an increased risk for suicidal tendencies and psychotic delusions. A contributing factor to this phenomenon is solitary confinement, lack of social interaction, as well as the psychological impact as a result of their crimes. One study collected data on death row suicides from 1978 to 2010 and found the rate of death row suicides to be higher than suicides in the male prison population as well as males in society, regardless of the increase in supervision of death row inmates.^[42]

5. Children

Death anxiety typically begins in childhood.^[43] The earliest documentation of the fear of death has been found in children as young as age 5.^[44][43] Psychological measures and reaction times were used to measure fear of death in young children. Recent studies that assess fear of death in children use questionnaire rating scales.^[44] There are many tests to study this including The Death Anxiety Scale for Children (DASC) developed by Schell and Seefeldt.^[44] However the most common version of this test is the revised Fear Survey Schedule for Children (FSSC-R).^[44] The FSSC-R describes specific fearful stimuli and children are asked to rate the degree to which the scenario/item makes them anxious or fearful.^[44] The most recent version of the FSSC-R presents the scenarios in a pictorial form to children as young as 4. It is called the Koala Fear Questionnaire (KFQ).^[44] The fear studies show that children's fears can be grouped into five categories. One of these categories is death and danger.^[44] This response was found amongst children age 4 to 6 on the KFQ, and from age 7 to 10.^[44] Death is the most commonly feared item and remains the most commonly feared item throughout adolescence.^[44] A study of 90 children, aged 4–8, done by Virginia Slaughter and Maya Griffiths showed that a more mature understanding of the biological concept of death was correlated to a decreased fear of death. This may suggest that it is helpful to teach children about death (in a biological sense), in order to alleviate the fear.^[44]

6. Relationship to Adult Attachment

There has been much literature that supports the existence of a correlation between one's state of coping skills, mental health, emotions and cognitive reactions to stressful events, and one's ability to regulate affect concerning one's death anxiety. A series of tests determined that significantly high levels of death anxiety tend to occur in close relationships with an intimate partner (more so amongst females than males).^[45]

7. Sex

The connection between death anxiety and one's sex appears to be strong.^[43] Studies show that females tend to have more death anxiety than males. In 1984, Thorson and Powell did a study to investigate this connection, and they sampled men and women from 16 years of age to over 60. The Death Anxiety Scale, and other scales such as the Collett-Lester Fear of Death Scale, showed higher mean scores for women than for men.^[46] Moreover, researchers believe that age and culture could be major influences in why women score higher on death anxiety scales than men.^[47] Through the evolutionary period, a basic method was created to deal with death anxiety and also as a means of dealing with loss.^[46] Denial is used when memories or feelings are too painful to accept and are often rejected.^[48] By maintaining that the event never happened, rather than accepting it, allows an individual more time to work through the inevitable pain.^[48] When a loved one dies in a family, denial is often implemented as a means to come to grips with the reality that the person is gone.^[48] Closer families often deal with death better than when coping individually.^[48] As society and families drift apart so does the time spent bereaving those who have died, which in turn leads to negative emotion and negativity towards death.^[48] Mothers hold greater concerns about death due to their caring role within the family.^[11] It is this common role of women that leads to greater death anxiety as it emphasize the 'importance to live' for her offspring.^[11] Although it is common knowledge that all living creatures die, many people do not accept their own mortality, preferring not to accept that death is inevitable, and that they will one day die.^[11]

8. Age

Multiple studies show death anxiety peaking in the early 20s for both men and women, followed by a sharp decline.^[49] A 1996 study showed while death anxiety decreased with age, psychosocial maturity was a better predictor of death anxiety than age overall. Higher psychosocial maturity was positively correlated with lower levels of death anxiety.^[50]

9. Measuring

There are many ways to measure death anxiety and fear.^[51] In 1972, Katenbaum and Aeinsberg devised three propositions for this measurement.^[51] From this start, the ideologies about death anxiety have been able to be recorded and their attributes listed.^[51] Methods such as imagery tasks to simple questionnaires and apperception tests such as the Stroop test enable psychologists to adequately determine if a person is under stress due to death anxiety or post-traumatic stress disorder.^[51] The Lester attitude death scale was developed in 1966 but not published until 1991 until its validity was established.^[51] By measuring the general attitude towards death and also the inconsistencies with death attitudes, participants are scaled to their favorable value towards death.^[51] One systematic review of 21 self-report death anxiety measures found that many measures have problematic psychometric properties.^[52]

10. Death Anxiety and COVID-19

Millions^[53] of people around the world have died from COVID-19 during the ongoing COVID-19 pandemic. Those who fear that they are more prone to contracting and dying from COVID-19 have higher levels of death anxiety and are more susceptible to general psychological disturbances such as depression, anxiety, stress, and paranoia.^[54] Elderly individuals, who were already likely to experience death anxiety outside of a pandemic situation, now find their fear of death largely exacerbated.^[55] The fear of dying from COVID-19 has also been one of the leading factors in psychological distress among many countries during the course of the pandemic. It has particularly affected women and those with a lower level of education.^[56] During the COVID-19 pandemic, death anxiety has been a large contributor to declining mental wellbeing among those working in helping professions such as nursing and social work.^[57]