Anxiety and Fear
A generalized expectation of danger occurs during the stressful condition known as anxiety. The anxious person experiences a state of heightened tension that Walter Cannon described in 1927 as readiness for "fight or flight." If the threat passes or is overcome, the person (or animal) returns to normal functioning. Anxiety has therefore served its purpose in alerting the person to a possible danger. Unfortunately, sometimes the alarm keeps ringing; the individual continues to behave as though in constant danger. Such prolonged stress can disrupt the person's life, distort relationships, and even produce life-threatening physical changes. Is the prospect of death the alarm that never stops ringing? Is death anxiety the source of people's most profound uneasiness? Or is death anxiety a situational or abnormal reaction that occurs when coping skills are overwhelmed?
There are numerous examples of things that people fear—cemeteries, flying, public speaking, being in a crowd, being alone, being buried alive, among others. Unlike anxiety, a fear is associated with a more specific threat. A fear is therefore less likely to disrupt a person's everyday life, and one can either learn to avoid the uncomfortable situations or learn how to relax and master them. Fears that are unreasonable and out of proportion to the actual danger are called phobias. Many fears and phobias seem to have little or nothing to do with death, but some do, such as fear of flying or of being buried alive.
Theories of Death Anxiety and Fear
Two influential theories dominated thinking about death anxiety and fear until the late twentieth century. Sigmund Freud (1856–1939) had the first say. The founder of psychoanalysis recognized that people sometimes did express fears of death. Nevertheless, thanatophobia, as he called it, was merely a disguise for a deeper source of concern. It was not death that people feared because:
Our own death is indeed quite unimaginable, and whenever we make the attempt to imagine it we . . . really survive as spectators. . . . At bottom nobody believes in his own death, or to put the same thing in a different way, in the unconscious every one of us is convinced of his own immortality. (Freud 1953, pp. 304–305)
The unconscious does not deal with the passage of time nor with negations. That one's life could and would end just does not compute. Furthermore, whatever one fears cannot be death because one has never died. People who express death-related fears, then, actually are trying to deal with unresolved childhood conflicts that they cannot bring themselves to acknowledge and discuss openly.
Freud's reduction of death concern to a neurotic cover-up did not receive a strong challenge until Ernest Becker's 1973 book, The Denial of Death . Becker's existential view turned death anxiety theory on its head. Not only is death anxiety real, but it is people's most profound source of concern. This anxiety is so intense that it generates many if not all of the specific fears and phobias people experience in everyday life. Fears of being alone or in a confined space, for example, are fears whose connections with death anxiety are relatively easy to trace, but so are the needs for bright lights and noise. It is more comfortable, more in keeping with one's self-image, to transform the underlying anxiety into a variety of smaller aversions.
According to Becker, much of people's daily behavior consists of attempts to deny death and thereby keep their basic anxiety under control. People would have a difficult time controlling their anxiety, though, if alarming realities continued to intrude and if they were exposed to brutal reminders of their vulnerability. Becker also suggested that this is where society plays its role. No function of society is more crucial than its strengthening of individual defenses against death anxiety. Becker's analysis of society convinced him that many beliefs and practices are in the service of death denial, that is, reducing the experience of anxiety. Funeral homes with their flowers and homilies, and the medical system with its evasions, are only among the more obvious societal elements that join with individuals to maintain the fiction that there is nothing to fear.
Ritualistic behavior on the part of both individuals and social institutions generally has the underlying purpose of channeling and finding employment for what otherwise would surface as disorganizing death anxiety. Schizophrenics suffer as they do because their fragile defenses fail to protect them against the terror of annihilation. "Normal" people in a "normal" society function more competently in everyday life because they have succeeded at least temporarily in denying death.
Other approaches to understanding death anxiety and fear were introduced in the late twentieth century. Terror management theory is based on studies finding that people who felt better about themselves also reported having less death-related anxiety. These data immediately suggested possibilities for preventing or reducing disturbingly high levels of death anxiety: Help people to develop strong self-esteem and they are less likely to be disabled by death anxiety. If self-esteem serves as a buffer against anxiety, might not society also be serving this function just as Becker had suggested? People seem to derive protection against death anxiety from worldview faith as well as from their own self-esteem. "Worldview faith" can be understood as religious belief or some other conviction that human life is meaningful, as well as general confidence that society is just and caring.
Another fresh approach, regret theory, was proposed in 1996 by Adrian Tomer and Grafton Eliason. Regret theory focuses on the way in which people evaluate the quality or worth of their lives. The prospect of death is likely to make people more anxious if they feel that they have not and cannot accomplish something good in life. People might torment themselves with regrets over past failures and missed opportunities or with thoughts of future accomplishments and experiences that will not be possible. Regret theory (similar in some respects to Robert Butler's life review approach) also has implications for anxiety reduction. People can reconsider their memories and expectations, for example, and also discover how to live more fully in the present moment.
Robert Kastenbaum suggests that people might not need a special theory for death anxiety and fear. Instead, they can make use of mainstream research in the field of life span development. Anxiety may have roots in people's physical being, but it is through personal experiences and social encounters that they learn what might harm them and, therefore, what they should fear. These fears also bear the marks of sociohistorical circumstances. For example, fear of the dead was salient in many preliterate societies throughout the world, while fear of being buried alive became widespread in nineteenth-century Europe and America. In modern times many people express the somewhat related fear of being sustained in a persistent vegetative state between life and death. Death-related fears, then, develop within particular social contexts and particular individual experiences. People do not have to rely upon the untested and perhaps untestable opposing views of Freud and Becker—that they are either incapable of experiencing death anxiety, or that death anxiety is the source of all fears. It is more useful to observe how their fears as well as their joys and enthusiasms are influenced by the interaction between cognitive development and social learning experiences. In this way people will be in a better position to help the next generation learn to identify actual threats to their lives while not overreacting to all possible alarms all the time.
Death Anxiety Studies
There have been many empirical studies of death anxiety, but many questions also remain because of methodological limitations and the difficulties inherent in this subject. Nevertheless, a critical review of the literature does reveal some interesting patterns:
- • Most people report that they have a low to moderate level of death-related anxiety.
- •Women tend to report somewhat higher levels of death-related anxiety.
- • There is no consistent increase in death anxiety with advancing adult age. If anything, older people in general seem to have less death anxiety.
- • People with mental and emotional disorders tend to have a higher level of death anxiety than the general population.
- • Death anxiety can spike temporarily to a higher level for people who have been exposed to traumatic situations.
Religion . The relationship between death anxiety and religious belief seems to be too complex to provide a simple pattern of findings. Death-related teachings differ, and believers may take different messages from the same basic doctrine. Historical studies also suggest that religious faith and practices seem to have sometimes reduced and sometimes increased death anxiety.
Health . The findings already mentioned come mostly from studies in which respondents in relatively good health reported on their own fears. Other studies and observations, though, give occasion for further reflection. There is evidence to suggest that people may be experiencing more anxiety than they are able to report. Even people who respond calmly to death-related words or images show agitation in breathing, heart rate, and reaction time, among other measures. Researchers Herman Feifel and B. Allen Branscomb therefore concluded in 1973 that everybody, in one way or another, is afraid of death. Presumably, people may have enough self-control to resist death-related anxiety on a conscious level but not necessarily to quell their underlying feelings of threat.
Gender . The gender differences also require a second look. Although women tend to report higher levels of death-related anxiety, it is also women who provide most of the professional and volunteer services to terminally ill people and their families, and, again, it is mostly women who enroll in death education courses. Women are more open to death-related thoughts and feelings, and men are somewhat more concerned about keeping these thoughts and feelings in check. The relatively higher level of reported death anxiety among women perhaps contributes to empathy with dying and grieving people and the desire to help them cope with their ordeals.
Age . The relationship between age and death anxiety is also rather complex. Adolescents may at the same time harbor a sense of immortality and experience a sense of vulnerability and incipient terror, but also enjoy transforming death-related anxiety into risky death-defying activities. What people fear most about death often changes with age. Young adults are often mostly concerned about dying too soon—before they have had the chance to do and experience all they have hoped for in life. Adult parents are often more likely to worry about the effect of their possible deaths upon other family members. Elderly adults often express concern about living "too long" and therefore becoming a burden on others and useless to themselves. Furthermore, the fear of dying alone or among strangers is often more intense than the fear of life coming to an end. Knowing a person's general level of anxiety, then, does not necessarily identify what it is that most disturbs a person about the prospect of death.
Anxiety levels . The fact that most people report themselves as having a low to moderate level of death anxiety does not offer support for either Freud's psychoanalytic or Becker's existential theory. Respondents do not seem to be in the grips of intense anxiety, but neither do they deny having any death-related fears. Kastenbaum's Edge theory offers a different way of looking at this finding. According to the theory, most people do not have a need to go through life either denying the reality of death or in a high state of alarm. Either of these extremes would actually interfere with one's ability both to enjoy life and cope with the possibility of danger. The everyday baseline of low to moderate anxiety keeps people alert enough to scan for potential threats to their own lives or the lives of other people. At the perceived moment of danger, people feel themselves to be on the edge between life and death, an instant away from catastrophe. The anxiety surge is part of a person's emergency response and takes priority over whatever else the person may have been doing. People are therefore not "in denial" when, in safe circumstances, they report themselves to have a low level of death anxiety. The anxiety switches on when their vigilance tells them that a life is on the edge of annihilation.
Anxiety and Comfort Near the End of Life
What of anxiety when people are nearing the end of their lives, when death is no longer a distant prospect? The emergence of hospice programs and the palliative care movement is stimulating increased attention to the emotional, social, and spiritual needs of dying people. Signs of anxiety are more likely to be recognized and measures taken to help the patient feel at ease. These signs include trembling, restlessness, sweating, rapid heartbeat, difficulty sleeping, and irritability. Health care professionals can reduce the anxiety of terminally ill people by providing accurate and reassuring information using relaxation techniques, and making use of anxiolytics or antidepressants.
Reducing the anxiety of terminally ill people requires more than technical expertise on the part of physicians and nurses. They must also face the challenge of coping with their own anxieties so that their interactions with patients and family provide comfort rather than another source of stress. Family and friends can help to relieve anxiety (including their own) by communicating well with the terminally ill person.
Becker, Ernest. The Denial of Death . New York: Free Press, 1973.
Bondeson, Jan. Buried Alive. New York: Norton, 2001.
Butler, Robert N. "Successful Aging and the Role of Life Review." Journal of the American Geriatric Society 27 (1974):529–534.
Cannon, Walter B. Bodily Changes in Pain, Hunger, Fear, and Rage. New York: Appleton-Century-Crofts, 1927.
Chandler, Emily. "Spirituality." In Inge B. Corless and Zelda Foster eds., The Hospice Heritage: Celebrating Our Future. New York: Haworth Press, 1999.
Choron, Jacques. Modern Man and Mortality. New York: Macmillan, 1964.
Chung, Man, Catherine Chung, and Yvette Easthope. "Traumatic Stress and Death Anxiety among Community Residents Exposed to an Aircraft Crash." Death Studies 24 (2000):689–704.
Feifel, Herman, and B. Allen Branscomb. "Who's Afraid of Death?" Journal of Abnormal Psychology 81 (1973):282–288.
Freud, Sigmund. "Thoughts for the Times on War and Death." The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 4. London: Hogarth Press, 1953.
Greyson, Bruce. "Reduced Death Threat in Near-Death Experiences." In Robert A. Neimeyer ed., Death Anxiety Handbook. Washington, DC: Taylor & Francis, 1994.
Hamama-Raz, Yaira, Zahava Solomon, and Avrahm Ohry. "Fear of Personal Death among Physicians." Omega: The Journal of Death and Dying 41 (2000):139–150.
Jalland, Pat. Death in the Victorian Family. Oxford: Oxford University Press, 1996.
Kastenbaum, Robert. "Death-Related Anxiety." In Larry Michelson and L. Michael Ascher eds., Anxiety and Stress Disorders. New York: Guilford Press, 1987.
Kastenbaum, Robert. The Psychology of Death, 3rd edition. New York: Springer, 2000.
Page, Andrew C. "Fear and Phobias." In David Levinson, James J. Ponzetti Jr., and Peter F. Jorgenson eds., Encyclopedia of Human Emotions. New York: Macmillan, 1999.
Pontillo, Kathleen A. "The Role of Critical Care Nurses in Providing and Managing End-of-Life Care." In J. Randall Curtis and Gordon D. Rubenfeld eds., Managing Death in the Intensive Care Unit. Oxford: Oxford University Press, 2001.
Selye, Hans. The Stress of Life. New York: McGraw-Hill, 1978.
Tomer, Adrian. "Death Anxiety in Adult Life: Theoretical Perspectives." In Robert A. Neimeyer ed., Death Anxiety Handbook. Washington, DC: Taylor & Francis, 1994.
Tomer, Adrian, and Grafton Eliason. "Toward a Comprehensive Model of Death Anxiety." Death Studies 20 (1996):343–366.