Mental health and overcoming death anxiety
University of Sydney. August 22, 2022.
Four thousand years ago, in ancient Mesopotamia, the Epic of Gilgamesh was inscribed into clay tablets. Today, these tablets represent humanity’s oldest surviving work of literature. The tale centres on the King Gilgamesh, who witnesses the death of his closest friend, Enkidu. Lamenting the death of his friend, and in horror at his sudden realisation of his own inevitable fate, Gilgamesh begins a lengthy quest to find the secret of eternal life. At the conclusion of the poem, the young king is forced to accept the futility of his efforts, having lost all hope of immortality.
“My friend, whom I loved so dear…
The doom of mortals overtook him.
Six days I wept for him and seven nights.
I did not surrender his body for burial,
Until a maggot dropped from his nostril.
Then I was afraid that I too would die,
I grew fearful of death, and so wander the wild.
What became of my friend was too much to bear…
My friend, Enkidu, whom I loved, has turned to clay.
Shall I not be like him, and also lie down,
Never to rise again, through all eternity?
...Sorrow has entered my heart! I am afraid of death.”- The Epic of Gilgamesh, 2100 BC
Gilgamesh was far from alone in his struggle to accept death. As we outline in our book Mortals: How the Fear of Death Shaped Human Society, a cursory glance across our species’ history reveals death to be, as William James famously put it, “the worm at the core” of our existence.
In ancient times, the Greeks placed a coin on the eyes or in the mouth of their dead, to pay the mythological ferryman Charon and ensure safe passage to the underworld. Egyptian pharaohs demanded grand, ambitious pyramids to serve as their tombs, establishing a legacy so large they ensured they have not been forgotten. Around 70 million Egyptians were mummified, in a complicated process which took more than two months, to ensure the corpse would not decay.
Not content with being mummified by others, hundreds of Buddhist monks have attempted to mummify themselves, by enduring years of starvation, consuming poison-laced tea, and eventually being buried alive in a tomb. For the handful of monks who successfully self-mummified, they were worshipped as a sokushinbutsu, or a ‘living Buddha’.
Shinnyokai Shonin, one of around twenty Buddhist monks who successfully self-mummified (“sokushinbutsu”). Hundreds of monks made similar efforts to defy decomposition and be eternally preserved, but were unsuccessful.
In Indonesia, it is common for the Torajan people to live at home with the corpses of their loved ones, often for several years. They lovingly talk to, groom, and prepare food for the corpse, and may even share a bed with them. From India to Brazil to Borneo, various populations have eaten their dead, as a way of keeping their loved one’s spirit alive within them. The Fore of Papua New Guinea were nearly wiped out by kuru, a disease caused by ingesting the flesh of their dead loved ones.
In many Western cultures, we do our best to keep death at as much of a distance as possible. Most corpses in the United States will be embalmed, a practice which serves no real benefit other than making a dead body look as alive as possible. Rather than accept and bear witness to the natural process of paling skin and other signs of death, the face will be rouged and lips tinted, the body will be injected with chemicals, and displayed for viewing on plush fabrics inside a casket. In the words of comedian Jerry Seinfeld: “We don’t understand death. And the proof of this is that we give dead people a pillow.”
And yet, humans actually come to understand death at a surprisingly early age. By the end of the first decade of life, children understand where they are ultimately heading: The grave (Menzies & Menzies, 2018). How then do we cope with this sword of Damocles hanging over the rest of our lives?
The Denial of Death and Terror Management Theory
In 1973, Ernest Becker published his Pulitzer Prize-winning masterpiece, The Denial of Death. Becker was a cultural anthropologist who argued that we humans create grand and elaborate cultural belief systems to allow us to cope with death. In the words of Solomon, Greenberg and Psyzczynski (1997), humans ‘could not function with equanimity if they believed that they were not more significant and enduring than apes, lizards, or lima beans.” Culture offers a solution. We seek accomplishments in line with the values of our culture, strive to build a legacy, and aspire to live the kind of life for which we will be remembered fondly after our death.
A decade after The Denial of Death, Greenberg, Solomon and Psyzczynski developed Becker’s ideas into a testable scientific theory, which they named Terror Management Theory. Hundreds of studies have shown support for Terror Management Theory (e.g., Burke et al., 2010). For example, when people are reminded of death (a procedure known as ‘mortality salience’ priming), they seek to buy more products, and are more willing to pay for luxury goods, in line with their culture’s emphasis on material possessions as a sign of status (Dar-Nimrod, 2012, Chopik & Edelstein, 2014). Reminders of death also lead people to defend their own cultural beliefs more fiercely (McGregor et al., 1989), and even to want more children (Wisman & Goldenberg, 2005), as a way of extending the self through passing on one’s own genetic material. These and other studies show that most of us are unconsciously dealing with our fears of death by clinging onto the values and beliefs of our culture and attempting to gain what Becker called “symbolic immortality”.
But what happens when these strategies, for one reason or another, fail to keep fears of death at bay?
Death anxiety and mental health
Whilst I was learning about Terror Management Theory in my undergraduate psychology degree, I began to discuss it with my father, Ross Menzies, who is also a clinical psychologist. We began to talk about how so many of the problems he was seeing in his clinic seemed to have fears of death at the root.
Death and Life (1915), by Gustav Klimt, housed at the Leopold Museum in Vienna.
For example, all of the common phobias involve things which could directly result in a person’s death, including heights, flying, and spiders. In obsessive-compulsive disorder (OCD), people seemed to be going to extreme lengths to prevent death, such as by compulsively washing to prevent illness, checking stoves and electrical outlets to prevent death by fire and electrocution, or completing tapping or counting rituals to keep loved ones safe. In panic disorder, benign symptoms such as chest pain or shortness of breath are interpreted as signs of impending doom or collapse. People with panic disorder may visit cardiologists, convinced that their symptoms indicate a fatal flaw in the structure of their heart. In illness anxiety and somatic symptom disorders, people will similarly seek out medical tests, terrified that the headache or bruise they have noticed indicates a brain tumour or fatal illness.
Alongside our colleague Lisa Iverach, we argued that death anxiety might be transdiagnostic; that is, that it may underlie many of the common mental health conditions we see in clinical practice. (Iverach et al., 2014). Transdiagnostic constructs which underpin mental health conditions have achieved much attention in clinical psychology. They are particularly important if a construct is actually causing a disorder, because they open up promising targets for treatments which can be used across multiple disorders. Those who work in clinical settings may have observed people presenting with one mental health condition, receiving apparently successful treatment for this, only to return at a later timepoint with a different disorder. We referred to this phenomenon as the “revolving door” of mental illness (Iverach et al., 2014, p. 590).
If death anxiety underlies many of these conditions, as we had theorised, then could untreated fears of death be contributing to this revolving door?
Before we could explore this, we first needed to know whether death anxiety is associated with signs and symptoms of different mental illnesses. Among 200 people seeking treatment for various mental health conditions, we found that death anxiety predicted each and every marker of psychopathology that we measured (Menzies et al., 2019). These included the number of medications an individual is on for their mental health, the number of disorders they’ve had across their life, and their overall impairment. What’s more, death anxiety was associated with the severity of twelve different mental illnesses, including depression, social anxiety disorder, generalised anxiety disorder, alcohol use disorder, and more.
However, because this was a correlational study, we couldn’t conclude that death anxiety was actually causing these mental health difficulties. Only a handful of experiments had been conducted to test whether reminders of death worsen clinically relevant in the laboratory (e.g., Strachan et al., 2007; Goldenberg et al., 2005). These studies used a mortality salience design, in which one group of participants are given a subtle reminder of death, and another group are reminded of a different unpleasant topic such as dental pain. Although the results of these studies had been promising, not one study had used a treatment-seeking clinical sample. It was impossible to be certain that these prior studies, typically conducted with groups of university students, would truly generalise to people seeking treatment with significant mental health problems.
Data from Menzies & Dar-Nimrod (2017) reveals that reminders of death led people with the washing subtype of OCD to spend twice as long washing their hands.
So, alongside my supervisor Ilan Dar-Nimrod, I carried out a study which aimed to see whether fears of death might be driving one of the common behaviours in OCD (Menzies & Dar-Nimrod, 2017). We recruited a large group of patients who had been diagnosed with OCD. Half of these patients were diagnosed with the washing subtype, dominated by concerns about contamination and compulsive cleaning. The other half had other subtypes of OCD, such as compulsive checking behaviours, hoarding, or other obsessions which did not involve cleaning.
First, we gave all of them a packet of questionnaires to complete; half of them received two questions about death (the mortality salience prime), while the other half received two similar questions about dental pain. Next, we told them that we were measuring their body’s stress response while they completed a problem-solving exercise. We applied a medical gel to two of their fingertips, and attached two electrodes, as they worked through a difficult word search task. After five minutes, we removed the electrodes, and asked them to wash the gel off their fingers at a nearby and return for the final set of questionnaires.
Unbeknownst to the participants, we were covertly timing how long they spent washing their hands, as well as how much soap and paper towels they used, by weighing the soap dispenser before and afterward, and counting the squares of paper towels disposed of in the bin. The medical gel, electrodes, and word search were all a ruse, to give us an opportunity to measure the number of seconds they spent washing at the sink.
What did we find? First, for people with the washing type of OCD, being subtly reminded of death led them to spend twice as long washing their hands, use twice as much soap, and even to use more paper towels. This was a fascinating finding, particularly because these participants showed no difference in their conscious reports of how anxious or contaminated they were feeling at the time. And yet, their behaviour at the sink showed that the fear of death was dramatically worsening their anxious behaviour—due to an apparently unconscious anxiety.
As we expected, for people with other types of OCD, their behaviour at the sink was not impacted by whether or not they had been reminded of death. Compulsively scrubbing their hands was not their main strategy for coping with death, and so they didn’t attempt to allay their fears this way when given the opportunity.
In subsequent studies, we discovered that not only does death anxiety predict symptoms of the washing type of OCD, it also predicts symptoms of nearly every manifestation of OCD, including hoarding, aggressive obsessions, checking, and the need for symmetry (Chawla et al., 2021, Menzies et al., 2020).
But what about other disorders? We later explored whether reminders of death drive the behaviours common to three other disorders: Panic disorder, illness anxiety, and somatic symptom disorder (Menzies et al., 2021). Worries about physical health, and scanning one’s body for symptoms, are at the heart of each of these conditions.
Upper: An example of the task used in Menzies et al., (2021) to measure how long people check scanning their body for symptoms, and how they perceive their own body.
Lower: Data from Menzies et al., (2021) found that for people with a scanning disorder (i.e., panic disorder, illness anxiety disorder, or somatic symptom disorder), being reminded of death led them to spend more time scanning their body for physical symptoms. People with a non-scanning disorder (depression) showed no difference when reminded of death.
We recruited a large group of people diagnosed with these three “body scanning disorders”, and compared them to individuals diagnosed with depression, which we recruited as our “non-scanning” comparison group. Half of each of the two groups were chosen at random to be given a reminder of death, whereas the other half received the dental pain prime.
Next, they were shown photos of different body parts presented on a spectrum, which were reportedly associated with particular health traits. For example, one page told participants that tongue colour can predict the likelihood of having hayfever, before asking participants to check their own body using a mirror and choose which photo of a tongue best matched their own.
We covertly timed how many seconds they spent on each page, as a measure of how long they spent checking their body. We also looked at which photo they picked from the spectrum, to see if being reminded of death actually changed how people perceive their own body. Lastly, we asked them how often they thought they would visit a GP in the next two months, compared to the previous two months.
Just like in our earlier study with OCD, we found that reminders of death worsened the behaviours which characterise scanning disorders. That is, when they had been primed with death, people with a scanning disorder spent much more time checking their body for symptoms. Additionally, reminders of death also changed what image people selected as resembling their own body. For example, if having a pale tongue colour was presented as a sign of a worse metabolism, then people were more likely to select a pale tongue as being similar to their own after they had been made to think of death. After having been reminded of death, the scanning disorder sample were also four times more likely to say that they planned to visit a doctor in the near future. Our study showed that behaviours such as being vigilant to one’s symptoms and seeking reassurance from a doctor seem to be driven by fears of death.
Overcoming fears of death
Growing numbers of studies now reveal the important role that death anxiety plays in mental health. This raises a vital question: What can we do to address this fear?
Clockwise from bottom left: Phobia of heights; OCD checking behavior; Free Yourself from Death Anxiety: A CBT Self-Help Guide for a Fear of Death and Dying (Menzies & Veale, 2022).
In 2018, we conducted a meta-analysis to investigate whether psychological treatments could alleviate death anxiety (Menzies et al., 2018). We analysed data from 15 randomised controlled trials, using various treatment styles, all of which measured death anxiety before and after the treatment. This revealed that cognitive behavioural therapy (CBT) was able to significantly reduce death anxiety, and further, that it outperformed the other treatments we examined. Specifically, the CBT interventions that produced this improvement focused on graded exposure therapy; that is, systematically facing feared death-related places or situations, such as cemeteries, funeral homes, and films about death. This is a reassuring finding – it appears that fears of death are not unchanging but can in fact be ameliorated with the right intervention.
This led us to develop two different evidence-based treatment resources: the first ever self-help book for death anxiety (Free Yourself from Death Anxiety: A CBT Self-Help Guide for a Fear of Death and Dying, Menzies & Veale, 2022) and the first online, individualised intervention for fears of death: Overcome Death Anxiety (Menzies et al., 2021). Across seven modules, the online program guides the user through identifying and challenging their unhelpful thoughts about death, creates exposure therapy exercises for them to complete, and uses various other strategies to encourage death acceptance. In our first trial of the program, 90% of those who completed the program showed an improvement in at least one facet of death anxiety, and 60% improved in their overall death anxiety score (Menzies et al., 2022). Whilst we need more research using larger controlled trials to further explore the benefits of the program, these are promising findings.
“Study death always, so that you’ll fear it never”
As research on death anxiety builds, we will learn more and more about how to improve existing treatments. In my view, treatments which are most effective will likely share one crucial component: Cultivating acceptance of death.
Two thousand years ago, the Stoic philosophers of Greece and Rome had already identified this as the key to living well. As the above quote from the philosopher Seneca highlights, the Stoics emphasised the value in reminding oneself of the inevitability of death as often as possible. Embracing death, they believed, was the key to living more deliberately in the here-and-now.
Left; Bust of Seneca, stoic philosopher. Right: Mortals (2021), by Rachel Menzies and Ross Menzies.
In a recent article, we encouraged delving into Stoic philosophy to cultivate acceptance of death (Menzies & Whittle, 2022). In fact, a construct known as ‘neutral death acceptance’ (i.e., accepting death because it is unavoidable and natural), captured by questionnaire items such as “I would neither welcome death nor fear it”, overlaps heavily with Stoic attitudes to death. Interestingly, neutral death acceptance has been shown to predict better psychological wellbeing and reduced death anxiety compared with other types of death acceptance, including escape acceptance (i.e., accepting death as an escape from present suffering) and approach acceptance (i.e., accepting death as a gateway to an afterlife). Accepting death as inevitable and natural is correlated with a greater sense of meaning in life (Tomer & Eliason, 2000), and reduced depression (Wong et al., 1994) and anger (Esnaashari & Kargar, 2018).
In Mortals (p. 374), we encourage the reader to accept that: “You are a mortal ape and, soon enough, you will be dead. You will not be remembered.” This need not be terrifying; in fact, embracing this truth can be liberating. For when we accept death, and understand the motives which drive our choices, we are free to live in a more deliberate, and authentic way. We can stop going to desperate lengths to prevent the inevitable. We are free to build a life that is authentically ours, not one which is controlled by the spectre of death.
As we write in the closing passage of Mortals (p. 375): “Right now, you have your five senses and a body that can move them anywhere you wish. You can dive into oceans, climb mountains and let your eyes gaze on the beauty of nature. You can smell and taste flavours from all over the globe, love and embrace others, and listen to the melodies from Beethoven to Beyoncé. Don’t waste your life living in fear of the fact that it ends. Accept your mortality, enjoy each moment that you have, and learn to embrace the reaper. He isn’t grim but comes to give you rest and make room for another. Everyone has their time in the sun.”
Dr. Rachel Menzies is a National Health and Medical Research Council (NHMRC) Research Fellow at the University of Sydney. Dr Menzies’ research is focused on the intersection between existential and clinical psychology. Her research has explored the impact of death anxiety on mental health, in addition to examining the assessment and treatment of the fear of death. She has published dozens of peer-reviewed research articles on the fear of death and psychopathology, and five books on existential issues, including Free Yourself from Death Anxiety: A CBT Self-Help Guide for a Fear of Death and Dying and Mortals: How the Fear of Death Shaped Human Society. Her research has been awarded various awards, and her book Mortals was awarded the Nib People’s Choice Literary Award. Dr Menzies has edited a special issue on existential psychology in the journal Clinical Psychologist, and is also a member of the Editorial Board of the peer-reviewed journal Death Studies. In addition to her academic work, Dr Menzies is a clinical psychologist and director of the Menzies Anxiety Centre,