What Is Death Anxiety And What Keeps It Going?

Worries about dying or losing a loved one are a normal part of life, but if thoughts about death or dying are extremely distressing, time-consuming, or stop someone from doing important things, they might be experiencing death anxiety. Death anxiety, or thanatophobia, is a common fear that anyone can experience. Research suggests that up to 10% of people experience death anxiety, and around 3% have an intense fear of death. These concerns might relate to one’s own death, someone else’s death (like a parent or child dying), the process of dying, or what happens after death.

What is death anxiety?

Like all other animals, humans strive to survive. However, what makes humans unique is knowing that one day their lives will end at some point. For this reason, it is only humans who fear death and the process of dying.

Fearing death is a normal part of life that shapes how people think and behave in subtle ways. These concerns usually lie on a continuum – while a small proportion of people seem indifferent or comfortable with dying, an equally small proportion of people are terrified or “phobic” of death. Most people exist somewhere in the middle of this spectrum: they feel a bit anxious about the prospect of dying and do their best to cope with this awareness.

In some ways, fearing death is helpful: knowing that we will die can prompt us to be cautious and protect ourselves from danger. It can also help us savor the limited time that we have. This doesn’t mean that being aware of death is easy. Quite the opposite – most people are unable to fully accept their life will end one day.

When does fear of death become clinically significant, and how might it present in therapy?

People are said to struggle with death anxiety when concerns about death and dying are extremely distressing, time-consuming, or get in the way of doing things. While death anxiety is not a psychiatric diagnosis, it can lead to serious problems.

People experience death anxiety in different ways. They might worry about the process of dying (e.g., “Dying will be extremely painful”), what happens after dying (e.g., “What if I suffer after I die?”), the consequences of dying (e.g., “My death will destroy my family”), or other people dying (e.g., “I wouldn’t be able cope if my parents died”). Key signs of death anxiety include:

• Feeling extremely distressed about death and dying.

• Spending lots of time dwelling on one’s death or other people dying.

• Having unwanted and distressing images related to death.

• Avoiding places, activities, or topics related to death or dying.

• Going to extreme lengths to prevent or minimize the risk of dying.

Death anxiety can be an isolated issue or part of another mental health difficulty. Death-related concerns can appear across presentations, including health anxiety (e.g., “I’m terrified of dying from an aggressive illness”), obsessive compulsive disorder (e.g., “If I don’t check my oven, my family might die in a fire”), post-traumatic stress disorder (e.g., “My accident shows how horrific death can be”), and several others.

What keeps death anxiety going?

Cognitive behavioral models of death anxiety focus on what might keep this fear going. These maintenance factors may include trying (and failing) to feel more certain about death, thinking negatively about death, avoiding reminders of death, and coping with anxiety in unhelpful ways.

1. Trying and failing to be certain about death

There are lots of uncertainties surrounding death: when it will happen, how it will feel, and what happens afterward. If someone has death anxiety, these unknowns can be very anxiety-provoking and difficult to tolerate. One way people try to feel more in control and prepared is by worrying about death, or by trying to reduce uncertainty by making life as safe and predictable as possible. Unfortunately, worry makes people feel more anxious, and trying to reduce uncertainty can make it even harder to tolerate the inevitable uncertainties around death.

2. Thinking negatively about death

The way people think has a powerful effect on how they feel. People with death anxiety often experience negative automatic thoughts and expectations about dying that make them fearful. These may include scary thoughts about their own or someone else’s death, the consequences of dying, or needing to prevent death. Some people also experience intrusive and distressing images related to death which contribute to their anxiety. The opposite can also be true – fear can affect the way people think (sometimes called “emotional reasoning”). For example, someone might assume that feeling anxious means a threat is present, which can then make them feel even more anxious about death or dying.

3. Avoiding reminders of death

Avoidance is a natural response to things that scare people, including death. People with death anxiety may try to protect themselves by avoiding things that remind them of death, including places, activities, objects, or thoughts that make them feel uncomfortable. While avoidance might relieve fear in the short term, it tends to worsen death anxiety over time. This happens for a few reasons. First, avoidance stops people from learning that their worst fears either do not come true, or that they can cope with them if they do. Second, they lose an opportunity to find out that anxiety is tolerable and will pass if it is given enough time. Third, avoidance stops people from doing the things that matter to them - not only does this stop them from enjoying life, but it gives them more time to worry about death.

4. Coping with fear in unhelpful ways

If someone cannot avoid their fear of death, they might do things to cope with it. These safety behaviors might include checking that they or other people are safe, gathering information about death and dying, or asking for reassurance. The main problem with these actions is that they prevent people from learning what would happen if they did not do them. A second problem is that they sometimes backfire: the more people check things, the less confident and reassured they feel. Finally, safety behaviors undermine confidence in how well someone thinks they can tolerate death anxiety. Like avoidance, safety behaviors reinforce death anxiety in the long term.

Summary

Death anxiety is a normal human concern that can become extremely distressing and debilitating. While it is sometimes an isolated issue, it can also be a feature of another mental health difficulties, such as health anxiety, OCD, or depression. Fortunately, effective treatments are available for death anxiety (Menzies et al., 2018), including CBT (e.g., Furer & Walker, 2008; Menzies, 2018). For CBT therapists, key tasks in therapy include identifying the content of a client’s death-related fears, understanding what is keeping these fears going (such as avoidance), and addressing these maintenance factors.

Further Reading

• Furer, P., & Walker, J. R. (2008). Death anxiety: A cognitive-behavioral approach. Journal of Cognitive Psychotherapy, 22, 167–182. DOI: 10.1891/0889-8391.22.2.167.

• Iverach, L., Menzies, R. G., & Menzies, R. E. (2014). Death anxiety and its role in psychopathology: Reviewing the status of a transdiagnostic construct. Clinical Psychology Review, 34, 580–593. DOI: 10.1016/j.cpr.2014.09.002.

• Menzies, R. E., & Veale, D. (2022). Free yourself from death anxiety: A CBT self-help guide for a fear of death and dying. Jessica Kingsley Publishers.

• 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 randomized controlled trials. Journal of Anxiety Disorders, 59, 64–73. DOI: 10.1016/j.janxdis.2018.09.004.

• Pyszczynski, T., Solomon, S., & Greenberg, J. (2015). Thirty years of terror management theory: From genesis to revelation. Advances in Experimental Social Psychology, 52, 1-70. DOI: /10.1016/ bs.aesp.2015.03.001.

• Yalom, I. D. (2008).Staring at the sun: Overcoming the terror of death. Jossey-Bass.