DEATH ANXIETY

Although humans have always thought about death, empirical research on death
anxiety did not begin in earnest until the late 1950s. Over one thousand articles
have now appeared on the topic, and death anxiety remains an important issue in
thanatology (the study of psychological and social aspects of death and dying).

What is death anxiety?

There have been substantial changes in the way Western scientists have
interpreted or understood the concept of death anxiety. Early writings, which were
heavily influenced by psychodynamic theory, stressed that fear and anxiety about
death were universal, and, in an attempt to deal with their neurotic concerns about
death, most individuals repressed or denied their true, negative feelings. In other
words, everyone feared or was anxious about death, no matter what they said or
how they acted. As death research matured, however, investigators discovered not
only that some people actually had little or no anxiety about death, but also that the
term death anxiety was really a misnomer for a variety of related negative reactions
to death. These reactions include elements of fear, anxiety, concern, threat, worry,
and confusion, and they can be focused on different death-related issues. For
instance, distinctions should be made regarding anxiety about one's own death or
the deaths of others, reactions to a painful dying process, uncertainties about when
and how one will die, and concerns about an afterlife.

Another major transformation that occurred in thanatological theory and research

involved the recognition that individuals can also have positive views and feelings
about death. Death is not always viewed completely negatively. For instance, death
can give life meaning and can accentuate a positive philosophy of life. People can
view death positively, for instance, if it brings relief of pain and suffering, gives
loved ones a chance to come together and express their care and concern for each
other, or if death and dying helps to refocus attention on important personal values
and needs. Finally, dealing with death can reveal strengths in terminally ill
individuals, their family members and friends, and health care professionals. In sum,
attitudes and feelings about death are multidimensional, and people can
simultaneously have both positive and negative sentiments about a broad array of
death-related phenomena.

Correlates of death anxiety

Although there are exceptions, it is possible to summarize the association between
death anxiety and several demographic and experiential factors. For instance, both
gender and age are often related to death anxiety. Females tend to report higher
death anxiety than males, and a negative relationship is often seen between age
and death anxiety. Younger populations (primarily high school and college age
students) tend to report higher levels of death anxiety than elderly persons. The
reasons for these differences are not clear.

The effect of contact or experience with death is not straightforward. On the one
hand, some workers, such as firefighters and police, whose duties places them at
heightened risk for injury and death may have heightened concerns or thoughts
about death, which is realistic given their jobs. On the other hand, those working
directly with dying or bereaved individuals, such as physicians, nurses, funeral
directors, or hospice and AIDS volunteers, do not, as a rule, demonstrate
heightened death anxiety and may, in fact, show greater sensitivity and acceptance
of death than other groups. Bereavement does not seem to have any direct impact
one way or another on feelings about death.

As one might expect, religion and death have often been studied together. Belief in
an afterlife or having a religious affiliation seems to have no specific effect on death
anxiety, however, though one's religious orientation is important. Individuals whose
religious and spiritual beliefs have been internalized, and therefore have an
influence on their general behavior, values, and personal world view (a construct
often identified as intrinsic religiosity ) tend to report less death anxiety, while those
whose religion serves a more social than ideological function (called extrinsic
religiosity ) report greater death anxiety.

Assessing and changing death anxiety

The most common method used to assess death anxiety is the self-report
questionnaire, which has been employed in over 95 percent of all studies. Several of
the more carefully validated measures, including those assessing positive feelings
about death are reviewed in Robert Neimeyer's Death Anxiety Handbook (1994).
Projective instruments (e.g., the Rorschach inkblot test or Thematic Apperception
Test), which were once popular assessment methods, are no longer in favor due to
the inability of researchers to document the reliability and validity of projective
techniques.

Feelings about death can be modified, although there is still much to learn about
causal factors. There is information about two types of events: near-death
experiences and death-education programs. Near-death experiences are situations
in which individuals feel their death is imminent as a result of an accident, a near-
accident, a medical condition, or some other event. Near-death experiences often
have a salutary effect by reducing negative feelings and increasing positive feelings
about death.

Death education can also influence death anxieties, but it depends on the type of
program. Experiential death education refers to classes or workshops that help
participants examine and discuss their personal views and feelings about death.
This is usually achieved through a combination of readings, movies, videos,
experiential exercises, and frank discussions. In contrast, didactic death education
is primarily educational in nature and tends to include lectures and readings, but
little or no exploration and disclosure of personal feelings. Whereas experiential
death education significantly reduces death anxiety, didactic programs have no
significant impact.

Death anxiety and behavior

The few studies relating death anxiety and behavior suggest that caregivers who
are comfortable with death are more likely to interact positively with the terminally
ill, to speak directly and honestly about death, and to be emotionally comforting
and supportive to others in need. In contrast, high levels of death anxiety may
influence people to avoid seeking needed medical attention or to plan appropriately
for their own and others' medical care (e.g., by refusing to consider or
execute advanced directives, which are documents such as living wills or a Durable
Power of Attorney for Health Care that provide a person some control about how
terminal features of their medical care should be handled). High death anxiety can
also create missed opportunities to help others, such as someone who is bereaved
and needs to speak about their feelings or children struggling to understand and
cope with death-related experiences.