Death anxiety is a common fear affecting individuals across all stages of life. But therapists can help clients confront and manage their fears about mortality.
Related articles: Assessing and Treating Anxiety, Treating Generalised Anxiety with Cognitive Behavioural Therapy, Treating Generalised Anxiety with Motivational Interviewing.
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Introduction
Anxiety is one of the most prevalent mental health concerns globally, characterised by excessive worry, fear, and tension. One specific form of anxiety that can significantly impact clients’ well-being is death anxiety, or the fear of death and dying. This article explores the clinical presentation of death anxiety and its various manifestations. It includes a practical example and intervention for each of four life stages – young children, adolescents, adults, and older adults – to assist clients struggling with this often-overlooked aspect of anxiety.
What is anxiety?
Anxiety is a natural emotional response to perceived threats and danger, designed to prepare individuals for action in the face of risk. It can range from mild to severe and, when persistent or disproportionate to the actual threat, may become an anxiety disorder. Death anxiety, also known as thanatophobia, is a subset of anxiety rooted in the fear of one’s own mortality or the process of dying. While death is a universal reality, anxiety surrounding it varies greatly among individuals, influenced by factors like personal experiences, age, and cultural or religious beliefs.
How death anxiety may present
Death anxiety can manifest in both overt and subtle ways, affecting individuals across different life stages. Common symptoms include obsessive thoughts about death, avoidance of death-related conversations or situations, physical symptoms such as heart palpitations or shortness of breath, and existential rumination. Clients may experience heightened anxiety during life transitions, traumatic events, or after the loss of loved ones.
Case example 1: Adolescence. Emma, a 16-year-old girl, presents to therapy with frequent panic attacks. Upon exploration, it becomes clear that her attacks are triggered by thoughts of death. She reports an overwhelming fear of dying in her sleep and avoids anything that reminds her of mortality, including movies, books, and conversations about death. She has begun to withdraw from social activities and her academic performance has deteriorated.
Case example 2: Older Adulthood. George, a 68-year-old widower, comes to therapy with concerns about his health. Although his recent medical check-ups indicate that he is physically healthy, he frequently visits doctors and monitors his body for signs of illness. He expresses persistent worry about the prospect of dying alone and without support, leading to insomnia and feelings of depression.
Clinical strategies and interventions
Addressing death anxiety requires a tailored approach, depending on the client’s developmental stage, cognitive capacities, and specific concerns. The following sections outline effective strategies for various populations.
Young Children
Children are often introduced to the concept of death through the loss of a pet, grandparent, or even media exposure. Clinicians working with young children can use developmentally appropriate language to explain death, emphasising that it is a natural part of life. Play therapy and creative activities, such as drawing or storytelling, can be helpful in allowing children to express their feelings and fears.
Practical example: In a session, a therapist might use puppets to facilitate a conversation about death. The therapist could say, “This puppet is feeling worried because their friend went away and won’t come back. Have you ever felt that way?”
Intervention: Cognitive Behavioural Play Therapy (CBPT) and psychoeducation are effective tools in addressing death anxiety in children. By teaching children relaxation techniques and helping them understand death within their cognitive development level, they can build resilience against these fears.
Resource tip: This video playlist, by Dr. Cirecie West-Olatunji, illustrates the use of a range of play and creative therapy interventions for young children.
Adolescents
Adolescents, like Emma in the earlier case example, are at a stage where existential questions may arise, often leading to death anxiety. Cognitive Behavioural Therapy (CBT) is a well-established intervention for treating anxiety in this population. Clinicians can help adolescents identify and challenge irrational fears related to death and provide tools to manage anxiety, such as deep breathing and mindfulness exercises.
Practical Example: During a CBT session, the therapist might ask Emma, “When you think about death, what are the thoughts that come up?” and work with her to reframe those thoughts. For example, replacing “I’m going to die any moment” with “It’s normal to be concerned about death, but it’s not happening right now.”
Intervention: Exposure therapy, where the client gradually faces death-related stimuli in a safe environment, can help reduce avoidance behaviors over time. Mindfulness-based Stress Reduction (MBSR) may also assist adolescents in managing anxiety by focusing on the present moment instead of worrying about the future.
Resource tip: This article looks at how a person with probable generalised anxiety disorder (GAD) might be treated with CBT.
Adults
In adulthood, death anxiety may be triggered by personal losses or health scares. For many, death anxiety is intertwined with existential concerns about the meaning of life. Existential therapy, which focuses on these deeper questions, can be useful for helping clients find personal meaning and confront the fear of death in a constructive way.
Practical example: A therapist working with an adult client might engage in dialogue such as: “What does dying mean to you? What would you want your legacy to be?” Encouraging clients to explore their values and create a fulfilling life can help reduce death anxiety.
Intervention: Acceptance and Commitment Therapy (ACT) is particularly effective for adults. In ACT, clients are encouraged to accept their fears rather than fight them, while committing to actions aligned with their values. For example, a client fearful of death might focus on strengthening their relationships or pursuing meaningful goals, thus shifting attention from death anxiety to life-enhancing behaviours.
Resource tip: This article explores the various ways our clients resist change, and how as therapists we can support their journey towards acceptance.
Older Adults
Older adults, like George, may face death anxiety as they near the end of life. Health concerns, social isolation, and grief can exacerbate these fears. Interventions for older adults often include life review therapy, which encourages reflection on their life experiences, accomplishments, and relationships. This can help provide a sense of closure and reduce feelings of existential distress.
Practical example: The therapist may ask George to create a “legacy book,” where he writes stories about his life, focusing on meaningful experiences. This intervention can provide him with a sense of purpose and reduce the fixation on death.
Intervention: Cognitive Behavioural Therapy for Insomnia (CBT-I) can be useful when death anxiety manifests in sleep disturbances, as it addresses both the cognitive and behavioural components of insomnia, often tied to existential fears in older clients.
Resource tip: This article explores three innovative approaches to CBT: technology-assisted CBT, culturally adapted CBT for diverse populations, and trauma-focused CBT.
Assessment tools
Assessing death anxiety is an important step in the therapeutic process. Several validated tools can be used to gauge the severity of death anxiety in clients, including:
- Death Anxiety Scale (DAS): A widely used tool to measure an individual’s anxiety about death.
- Collett-Lester Fear of Death Scale (CLFDS): This scale assesses fear of death and dying in different domains (self, others).
- Multidimensional Fear of Death Scale (MFODS): Measures different aspects of death-related anxiety.
These tools, used in conjunction with clinical interviews, provide a comprehensive understanding of the client’s concerns and guide the treatment process.
Conclusion
Death anxiety is a common yet often unspoken fear that affects individuals across all stages of life. Through appropriate assessment and tailored interventions, clinicians can help clients confront and manage their fears about mortality. Whether through play therapy for children, CBT for adolescents, existential therapy for adults, or life review therapy for older adults, mental health professionals have a range of tools to address this complex form of anxiety. By normalising discussions around death and providing clients with strategies to live a meaningful life, therapists can help reduce death anxiety’s grip on their clients.
Key takeaways
- Death anxiety is a subset of anxiety centred around the fear of death or dying.
- It manifests differently across life stages, with children, adolescents, adults, and older adults presenting unique challenges.
- Evidence-based interventions like CBT, ACT, and life review therapy can help clients manage death anxiety.
- Assessing death anxiety is crucial, with tools such as the Death Anxiety Scale (DAS) and the Collett-Lester Fear of Death Scale providing valuable insights.
References
- Arndt, J., Cook, A., & Routledge, C. (2004). The blueprint of terror management: understanding the cognitive architecture of psychological defense against the awareness of death. International Review of Psychiatry. Corpus ID: 142595459
- Iverach, L., Menzies, R. E., & Menzies, R. G. (2014). Death anxiety and its role in psychopathology: Reviewing the status of a transdiagnostic construct. Clinical Psychology Review, 34(7), 580-593, 10.1016/j.cpr.2014.09.002.
- Menzies, R. E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (2018). The effects of psychosocial interventions on death anxiety: A meta-analysis and systematic review of randomised controlled trials. Journal of Anxiety Disorders, 59, 64-73. DOI:10.1016/j.janxdis.2018.09.004 Corpus ID: 52965504
- Yalom, I. D. (2008). Staring at the sun: Overcoming the dread of death. Australia: Scribe Publications.
- Wong, P. T. P. (2020). Existential positive psychology and integrative meaning therapy, 32(7-8), 565-578. https://doi.org/10.1080/09540261.2020.1738339