ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 15, 2025

THE THEORETICAL, CLINICAL, AND METHODOLOGICAL ASPECTS OF DEATH ANXIETY: A NARRATIVE REVIEW

Andrada-Elena STAN (1), Camelia POPA (2)
Keywords: anxiety, death, theory, clinical meaning, instruments.

DOI: https://doi.org/10.26758/15.1.3

(1) PhD student, School of Advanced Studies of The Romanian Academy, The “Constantin Rădulescu – Motru” Institute of Philosophy and Psychology, The Romanian Academy, Romania

(2) The “Constantin Rădulescu – Motru” Institute of Philosophy and Psychology, The Romanian Academy, Romania, UNATC “I. L. Caragiale” Bucharest; e-mail: popa_zaizon@yahoo.com

Corresponding address: Andrada-Elena STAN, The “Ana Aslan” National Institute of Gerontology and Geriatrics, Central Headquarters, 9 Căldărușani street, 1st district, Bucharest, Romania. Phone: +40-728-044-553; E-mail: andrada.stan@yahoo.com

Abstract

Objective. The present paper aims to offer an overview of the concept of anxiety in the death research literature by considering the concept’s theoretical, clinical and methodological perspectives, an overview that is susceptible to open a new path for the exploratory research in this area of high scientific interest.

Materials and methods. The Google Scholar search engine was used to access the to-be-reviewed research articles. After a first selection, the relevant articles’ reference lists were analysed for a second selection phase. The inclusion criteria were linked to the three to-be-described perspectives – studies describing the theoretical, clinical, and methodological aspects of death anxiety. Those studies that did not focus on these topics were excluded.

Discussions. Two complementary theories were chosen for the theoretical perspective, because these offered comprehensive explanations for the concept of death anxiety. The clinical perspective described the psychological domains affected by death anxiety – the cognitive, emotional, and behavioural domains, as well as the associated psychosomatic symptoms. The methodological perspective presented the psychometric advantages and disadvantages of 13 of the existing scales measuring death anxiety and/or similar constructs, that are considered to be used the most in this area of research.

Conclusions. Despite the researchers’ increased interest for the investigation of death anxiety, the existing studies and instruments require an adaptation to the recent societal changes. Terror Management Theory and Existential Psychology offer complementary and comprehensive perspectives in order to ensure a better understanding of both the concept and the directions that future scientific efforts can approach. Since death anxiety has negative effects on all psychological domains, and it causes significant psychosomatic symptoms with a strong impact on people’s quality of life, updating the research literature with new studies is necessary.

Keywords: anxiety, death, theory, clinical meaning, instruments.

Suggested citation (APA)

Stan, A.E., & Popa, C. (2025). The theoretical, clinical, and methodological aspects of death anxiety: A narrative review. Anthropological Researches and Studies, 15, 43-63. https://doi.org/10.26758/15.1.3

Introduction

Survival represents humans’ primary goal, while death is the first danger they encounter throughout their lives. Even though Psychology researchers have shown an increased interest in death anxiety in the last 50 years, this concept is not yet fully understood. Death anxiety can even be underestimated in a clinical context, because, – as opposed to other fear-based psychopathologies, – it can be considered natural since death is a certain event. The specialized research literature focusing on this topic consists of relatively old studies that tend to differ from a methodological and conceptual standpoint. These differences in approaching and interpreting the concept of death anxiety can only contribute to its rather unclear image that present-day researchers are attempting to decipher. The present paper aims to critically describe the theoretical, clinical and methodological aspects of death anxiety in the form of a narrative review in order to offer a starting point for future scientific efforts directed at an in-depth investigation of this construct.

According to Green, Johnson, and Adams (2006), narrative reviews are useful, because they are a summarisation of many papers which can help the researchers who are interested in investigating a specific subject save time and effort. Narrative reviews represent a starting point for researching areas that have been insufficiently and/or variably studied, because they describe different perspectives in a single paper. As a result, the death anxiety literature could benefit from a narrative review that focuses on the theoretical and clinical implications of the concept, as well as on the in-depth description of the instruments presently used for measuring it.

Defining death anxiety in a precise manner is a difficult task. Anxiety is considered to be a type of fear that lacks a feared object, one that is generated by the idea of what may or may not happen (Strang, 2014). Some authors are placing death anxiety at the core of any anxiety disorder, even if this is not made obvious by the manner in which the disorder manifests itself (Iverach, Menzies & Menzies, 2014). Moreover, death anxiety can take diffused shapes and it can generate different psychopathologies, sometimes even at the same time. According to recent research, death anxiety can be defined as a transdiagnostic construct rather than a standalone diagnostic profile, because it is a common denominator for many psychopathologies, such as generalised anxiety disorder, psychosomatic disorders, hypochondriasis, specific phobias, depressive disorders, post-traumatic stress disorders, obsessive-compulsive disorder and many others (Gürbüz & Yorulmaz, 2024). Iverach et al. (2014) insist on the importance of understanding transdiagnostic concepts, as well as their symptomatic correlates during the evaluation and intervention processes, because they can lead to a reduction in the overall psychopathology, regardless of comorbidities; if, however, these concepts are not considered by the professionals, then they can pose significant challenges during the intervention process. Therefore, the conceptual delimitations of death anxiety deserve clinical consideration, especially during interventions.

Given that death anxiety is omnipresent in psychopathology, its conceptual delimitation from the existing categorical diagnoses is based on the person’s level of awareness of the anxiety-generating object, and on the different shapes this anxiety takes. For example, a person suffering from a panic disorder will often times be anxious about his own dying by a heart attack. In this context, the person is aware of their death anxiety, while the shape it takes is the one of a cardiovascular disease. On the other hand, someone who has arachnophobia does not reach the basis of their anxiety with the same ease as someone with a panic disorder, while the spider is the shape taken by death anxiety (Iverach, 2018; Strachan et al., 2007).

Regarding the relationship between death anxiety and phobias, a real challenge in conceptually delimitating them is posed by thanatophobia. Some researchers consider death anxiety and thanatophobia to be the same concept (e.g., Daradkeh & Fouad Moselhy, 2011; Balaji, Ramya, & Maiti, 2024), but the two are, in fact, different. One of the main characteristics of phobias is that the phobic person does everything they can in order to avoid thinking about the feared object, since even thinking about it causes the same intense negative effects as if it were present (American Psychological Association, 2016). Although a certain level of avoidance and denial is also manifested by those with high levels of death anxiety (Menzies & Menzies, 2020), Furer and Walker (2008) offer evidence of the ruminative characteristic death anxiety presents – the patient from their case study could not think of anything else. Therefore, even though thanatophobia and death anxiety are often times considered synonyms, a closer analysis indicates that they do not overlap entirely.

Death anxiety can be then defined as a psychopathological result of a maladaptive management of one’s survival instinct, which can manifest itself either directly, or indirectly by taking the shape of different psychopathologies. To gain a better understanding of death anxiety and its characteristics, this narrative review used the scientific databases to summarise the theories, clinical information and measuring instruments that have been used in the investigation of death anxiety from 1970 to June 2024. Two complementary theories were selected to explain the construct (Terror Management Theory, TMT; Greenberg, Pyszczynski, & Solomon, 1986, and Existential Psychology theory; Yalom, 1980). The psychological domains affected by death anxiety were described based on the existing studies, while 13 measuring instruments were analysed based on their psychometric advantages and disadvantages.

Materials and methods

A first selection of scientific articles discussing the theoretical, clinical, and/or scaling aspects of death anxiety was done using the Google Scholar search engine. The search keywords were: “death anxiety theory”, “death anxiety clinic*”, “death AND anxiety AND cognitive AND/OR affective AND/OR behaviour* AND/OR psychosom*”, “death anxiety scal*”. After a first selection, the reference lists of the chosen articles were analysed, and any new, relevant papers were accessed using Google Scholar for further investigation.

The year 1970 was chosen as a lower limit for the publishing year, while the upper limit was set to June 2024. Since narrative reviews are more flexible than systematic literature reviews and meta-analyses (Green et al., 2006), aiming to offer an overview of the existing understanding of a specific concept, the inclusion/exclusion criteria were not strict, and were limited to the categories set by the three perspectives. The selected papers were analysed in full-text, and were centralised for the write-up of the narrative review.

Discussions

After a thorough analysis of the selected scientific articles, two theories – TMT and Existential Psychology theory – were chosen for the theoretical perspective, in an attempt to conceptually delineate death anxiety from other psychopathologies. For the clinical perspective, the research literature showed that all three psychological domains – cognitive, affective, and behavioural – are negatively impacted by death anxiety, which can even elicit psychosomatic symptoms. Thirteen instruments measuring death anxiety or a related construct which were identified as being often used in this area of research are presented in the methodological perspective.

The theoretical perspective

TMT

Following the work of Becker (1973), Greenberg et al. (1986) offered a unique explanation for the human behaviour – which is that humans act throughout their lives in a way that is meant to protect them from the elevated anxiety they feel due to their awareness of their imminent death. Their theory posits that humans are the only beings that are aware of their own mortality, knowledge that generates and maintains increased levels of anxiety. To decrease these anxiety levels, people subscribe to cultural worldviews and engage in activities meant to boost their self-esteem in order to create a sense of immortality (Jonas & Fischer, 2006; Curșeu & Pop-Curșeu, 2011; Harmon-Jones, Simon, Pyszczynski, Solomon, & McGregor, 1997).

Immortality, as it is understood in the process of reducing death anxiety levels, can be literal or symbolic (Pyszczynski, Greenberg, & Solomon, 1999; Curșeu & Pop-Curșeu, 2011; Harmon-Jones et al., 1997). The former is defined as a strong belief in the afterlife, which means that the person will continue to live forever, even though this will take place in the absence of a corporeal body. Symbolic immortality is referring to the continuation of one’s life through the legacy one leaves behind – children, achievements, beloved objects.

Achieving the sense of immortality through cultural worldviews and self-esteem is considered a distal defence against death anxiety, while proximal defences refer to the behaviours of avoiding the subject of death, denying one’s own mortality, and engaging in activities meant to maintain one’s physical health (Abeyta, Juhl, & Routledge, 2014; Pyszczynski et al., 1999).

The Dual-Process Model of Defence against death-related thoughts proposed by TMT (Pyszczynski et al., 1999) is presented in Figure 1.

Promoting one’s personal and cultural worldviews to gain protection against death anxiety represents a key element in understanding the drivers of human behaviour (Maxfield, John, & Pyszczynski, 2014). Past studies have shown that when people are reminded of their impending death and are forced to access these thoughts of their own mortality, they will strongly protect their worldviews and their values, and, sometimes, they will even act aggressively to reduce their death anxiety levels (McGregor et al., 1998). This is because any cultural worldview that is opposing their own is a threat to their capacity to achieve immortality, therefore they will behave harshly towards those considered to be in opposition (McGregor et al., 1998). Thus, this theory explains not only people’s behavioural choices, but also the fact that death anxiety is at the core of people’s way of perceiving the world.

An interesting aspect shown by Fairlamb, Stan and Lovas (2023) is that those people whose personal and not necessarily cultural values focus on the protection of the environment and of animals are somewhat more inclined to sacrifice their own wellbeing and their sense of immortality in order to protect the objects of their values. In other words, there are instances in which people’s personal values – meant to be used as a protective factor in the presence of death-related stimuli – will be protected even though it results in a negative consequence for one’s wellbeing, and in the possible maintenance of death anxiety. What Fairlamb et al. (2023) did not include however is a measure of the cost of such an action. Given that death anxiety is a transdiagnostic construct, the long-term impact of the contradictory behaviours regarding its reduction on people’s psychological wellbeing is uncertain. Moreover, the amount of overall anxiety that people feel when engaging in such behaviours is also uncertain.

One conclusion of Fairlamb et al.’s (2023) study is that the manner in which people perceive the world they live in can influence their capacity to face death anxiety. This conclusion is also supported by Curșeu and Pop-Curșeu (2011), who thematically analysed the messages written on the crosses from the Merry Cemetery from Săpânța, a famous Romanian cemetery. These researchers explained how the inhabitants of Săpânța design their own crosses in the preparation of their death.

Each message is rhymed and humorous, while the chosen paint has vibrant colours. It can be thus assumed that these villagers embrace the imminence of their death, and they do not perceive it as a negative event, belief that is also supported by the Orthodox religion. They achieve both literal (through their religious beliefs) and symbolic immortality (through decorating their own crosses and graves, which will be visited by their loved ones and by tourists alike).

There are many cultures of the world that have unique and cheerful ways of organising the funerals of the community members. For example, in New Orleans people organise the so-called “jazz funerals”, during which they march around the city while singing and dancing to this genre, with the aim of supporting each other in the healing process (New Orleans, 2024). In Ghana, community members sculpt and decorate what they call “fantasy coffins”, based on what the deceased loved the most – some coffins are sculpted in the shape of airplanes, hens, crabs, etc. (Dini-Osman, 2022). In Mexico, people design altars for the deceased in order to keep their memory alive, while also respecting the religious practices in order to aid the deceased in their journey to the afterlife (Ever loved, 2023). Moreover, they organise the annual celebration of the “Day of the Dead”, a holiday dedicated to the dead, during which people wear colourful clothes and skeleton-like make-up, and they decorate altars and symbols to represent the ones who died (National Geographic Kids, 2024). All these cultures emphasise the role the meaning of life and death is playing in reducing death anxiety, aspect that is explained in detail by the Existential Psychology theory (Yalom, 1980).

Existential Psychology

The approaches proposed by Existential Psychology are compatible with TMT, since their message can be associated with the idea of strengthening the distal defences (Chochinov et al., 2004; Lewis, 2014). According to this branch of Psychology, people tend to worry most about five main elements: death, isolation, identity, freedom, and the meaning of life (Pyszczynski, Greenberg & Koole, 2004; Koole, Greenberg & Pyszczynski, 2006).

Koole et al. (2006) explained that worrying about these elements occurs after certain traumatic experiences take place – even if these happened directly to the person, indirectly, to their loved ones, or on a global level. The questions arising with regards to the five pillars are mostly originating from fear: the fear of dying, the fear of being alone and isolated, the fear of losing one’s freedom, and, nevertheless, the fear generated by people’s confusion of who they are and what their meaning in the world is.

According to Koole et al.’s (2006) explanations, the first four pillars are the ones creating the context for the fifth. This is due to the fact that in a world where nothing from the first four pillars is guaranteed, the meaning is missing. As a result, one can infer that death anxiety and the meaning of life and/or of death are interdependent, inference which is supported by the research literature (Lyke, 2013; Zhang et al., 2019).

Jin, Zeng, Cong, An and Zheng (2023) analysed the effects that the death anxiety caused by the Covid-19 pandemic had on a Chinese sample’s mental health, and the mediating influence that meaning of life had on the relationship between the two variables. Following the TMT research methods, the researchers created two groups – an experimental one, in which participants were reminded of their own mortality, and a control one, where participants were asked to write about their reading impressions and experiences. The results showed that the experimental group had an increased level of death anxiety, a lower level of mental health, and an increased score on the meaning of life scale, when compared to the control group. These results were all statistically significant.

Figure 1

The Dual-Process Model of defence against death-related thoughts, as described by Pyszczynski et al. (1999). (to see Figure 1, please click here )

The results of the mediation analysis showed that death anxiety was negatively correlated with mental health when this was the only variable in the model, as well as after introducing meaning of life. Death anxiety was positively correlated with meaning of life, which was positively correlated with participants’ mental health levels (Jin et al., 2023).

Therefore, even though death anxiety has a strong enough influence on mental health which can generate negative effects, meaning of life can become a protective factor, if it is supported through interventions. A limitation of the previous study is the fact that it introduced meaning of life only as a mediator, when it would make more sense to be analysed as a moderator, given the theoretical explanations and the results of similar research studies.

Although meaning of life is an important pillar proposed by Existential Psychology, it is possible that when death anxiety levels are high, and one’s defence system against it does not function optimally (Iverach, 2018), one’s meaning of life might not mediate the relationship between death anxiety and mental health. It is more likely that this variable will influence the relationship between the other two by optimising the person’s defence system. Thus, meaning of life should also be analysed as a moderator, and, if its effects are considered beneficial, then it can be integrated in targeted interventions.

A possible explanation for the results published by Jin et al. (2023) and for the increased level of meaning of life shown by the experimental group is that the manipulation determined the participants to engage in proximal defences. In other words, the results can be explained by an overestimation of the meaning of life felt by the participants, out of the increased effort to deny their mortality. Once the effect of the death-related stimuli wore off, and the person did not engage in proximal defences anymore, it is possible that the level of meaning of life reverted to a lower-level baseline, which could have placed the person at a risk of feeling more anxious about their own death. If one’s meaning of life is strengthened through targeted interventions, then it can become a protective and a preventive factor.

The clinical perspective

The existing nosology, represented by the DSM-5 (American Psychological Association, 2016), and, respectively, by the ICD-10 (World Health Organization, 2016) does not include death anxiety as a standalone diagnostic construct. Death anxiety is presently described as a symptom that the person seeking professional help might feel. The mental disorder classification manuals are widely used and referenced in the diagnosing of psychopathology, but, at the moment, they focus on the categorical classification of psychopathology (Coiffait, 2003; Krueger & Markon, 2011). Given the high number of comorbidities and of transdiagnostic constructs that are found in clinical practice, the need for redefining these classifications based on dimensional elements is becoming more and more evident (Krueger & Markon, 2011).

The death anxiety research literature is showing evidence that this construct can represent the core of different mental disorders, when it is not approached in an adaptive manner (Gürbüz & Yorulmaz, 2024).

Prevalence

Past studies showed a higher prevalence of death anxiety among females, younger people, and among those with lower educational and financial levels (Neimeyer, 1994; Kastenbaum, 2000; MacLeod, Crandall, Wilson, & Austin, 2016). Moreover, religiosity did not seem to correlate with death anxiety (Kastenbaum, 2000). However, a global, recent prevalence has not yet been calculated.

The reported results can be explained by methodological limitations. Death anxiety literature consists of studies that were conducted more than 10 years ago and most of these studies had samples where women represented the majority – the women-to-men ratio is generally approximately 2:1 in the existing studies (Mohammadzadeh, Ashouri, Vahedi, & Asgharipour, 2018; Kızılgeçit & Yıldırım, 2023). Moreover, there is a high chance that death anxiety has become more prevalent among the elderly as a result of the Covid-19 pandemic.

The pandemic had a significant impact on people’s quality of life and wellbeing on a global level, but it had an even higher impact on the elderly. This population segment was strictly protected due to their high vulnerability to developing life-threatening conditions after being infected with the virus (Duru, 2020). This vulnerability is likely to have increased the elderly’s levels of death anxiety, especially since the negative health consequences caused by the virus were strongly promoted in the media (Giritli Nygren, Klinga, Olofsson, & Öhman, 2021). Any form of social interaction – which was already reduced with aging – was further reduced due to the obligation to socially isolate, while the support received from relatives was kept at a minimum and changed to a virtual setting. These parameters placed the elderly at a high risk of developing different types of anxiety disorders (in which death anxiety could have had a crucial role; Menzies & Menzies, 2020). Thus, the existing data on death anxiety prevalence based on age has likely changed, even more so given the 25% increase in the prevalence of anxiety and depression as a result of the pandemic (World Health Organization, 2022).

Regarding the religiosity levels, the existing literature showed contradictory results, with some studies concluding that these do not correlate with death anxiety, while others indicated the opposite (e.g., Iverach et al., 2014). The degree of participants’ bias, the perceived level of death anxiety, and the level of engaging in worldview defence can all account for the non-significant results. In other words, participants could have overestimated their faith, if their system of defence against their death anxiety was triggered.

Spirituality seems to be the one associated with protecting the participants when facing death anxiety (Yalom, 1980), and some people consider religion and spirituality to be different, the latter being associated more with a focus on faith, rather than on practices. Future studies must then introduce an assessment of faith with more precise instruments, placed before the presentation of the death-related stimuli.

Another discussion concerning the death anxiety prevalence is that the known data was collected from Western, developed and strongly individualised countries, while the prevalence in Eastern countries is not well-known (Menzies, Sharpe, & Dar-Nimrod, 2022; Zana, Szabó, & Hegedűs, 2009). Both the research literature, and the classification manuals consider the importance of the cultural context during the diagnosing process. The cultural practices can offer potential risk and/or protective factors when it comes to death anxiety. Fighting for survival is a biological instinct all people have, and the effects of the Covid-19 pandemic have been seen globally, however these two aspects can only offer a basis for the manifestation of death anxiety, which can take different shapes based on the cultural context. An in-depth study of the construct, while considering the different shapes it can take based on the culture in which it is studied, is thus required.

The cognitive domain

Research linking death anxiety with the cognitive processes are missing. There are, however, studies that look at the effects that anxiety (especially excessive worrying and panic) has on cognition. These effects can be considered both adaptive, and maladaptive (Robinson, Vytal, Cornwell, & Grillon, 2013). Thus, anxious people’s attention is mainly directed towards any potential threats, which on the one hand can be helpful in keeping them grounded in their environment, but, on the other hand, it can generate an increased sensitivity towards negative stimuli (Abado, Richter, & Okon-Singer, 2020). Moreover, their cognitive distortions, and their increased focus on their physiological states places them at risk of developing a panic disorder, by exaggerating natural biological symptoms (Ehlers, 1993). Anxious people’s intrusive thoughts, their increased level of attention directed towards potential environmental threats, and towards their physiological states causes concentration difficulties during task completion (Eysenck & Calvo, 1992; Maloney, Sattizahn, & Beilock, 2014).

The anxiety generated attention deficits lead, automatically, to memory deficits. Given that anxious people are making a higher effort to maintain focus while completing tasks compared to low-anxiety individuals, the working-memory is also negatively affected (Robinson et al., 2013). As a result, the encoding and recollecting processes are impacted, which causes negative effects on long-term memory (Unsworth, Brewer, & Spillers, 2013). Moreover, according to Herrera, Montorio, Cabrera and Botella (2017), it seems that anxious people’s long-term memory consists of mainly negative information and events, while the presence of positive memories is undermined or overlooked.

There is, also, research looking at the effects of long-term elevated anxiety on people’s memory function and on their brain overall. Although longitudinal studies are costly, there are some papers published in this area. Aggarwal, Williams, Tromp, Pine and Kalin (2022) studied the effects of anxiety on white matter volume in a sample consisting of 182 girls aged between 9 and 11 years old, that were followed over a period of 3 years. The results showed that those with higher levels of anxiety had lower levels of white matter over time; this was how the researchers explained the participants’ cognitive difficulties.

In a different study, Cannizzaro, Patru and Hanganu (2023) showed that patients diagnosed with Parkinson’s disease who also suffered from anxiety exhibited a faster cognitive decline with time when compared with those diagnosed with Parkinson’s disease, but who did not suffer from anxiety. Additionally, over time, the anxious patients with Parkinson’s disease showed a more pronounced decline of their temporal, frontal and parietal lobes when compared to their non-anxious counterparts (Cannizzaro et al., 2023).

Anxiety is comorbid with both biological afflictions, as well as with some psychological disorders. DeLuca et al. (2005) compared elderly patients diagnosed with major depressive disorder without any comorbidities to elderly patients who had a comorbid anxiety disorder. Those with both an anxiety disorder and a major depressive disorder diagnosis had a significantly more pronounced cognitive decline compared to the elderly who only had a major depressive disorder diagnosis. This study concluded that a comorbid anxiety disorder, present over a longer period of time can cause memory and attention deficits, and it can alter the brain’s morphology (DeLuca et al., 2005).

Other researchers (Ferreira & Monteiro, 2018; Tohill & Holyoak, 2000) reported even executive function difficulties in anxious participants. Although their planning ability was retained (Robinson et al., 2013), the anxious people tended to make safer decisions than their low-anxiety counterparts, and they showed difficulties in terms of their capacity to integrate information (Tohill & Holyoak, 2000), and in terms of their spatial navigation abilities (Robinson et al., 2013).

The emotional domain

Anxiety is in and of itself a negatively perceived emotion, and it is characterised by excessive worrying, fear, terror, and by a feeling that danger is imminent (Mallorquí-Bagué, Bulbena, Pailhez, Garfinkel & Critchley, 2016; American Psychological Association, 2016).

Positive emotions and feelings are minimised, while the negative ones are emphasised, especially through the cognitive distortions exhibited by those with high levels of anxiety (Hofmann, Sawyer, Fang, & Asnaani, 2012).

Hofmann et al. (2012) studied the role played by emotional dysregulation in generating and maintaining anxiety disorders. These authors explained that life events can elicit higher or lower levels of affect, which can be positive and/or negative (depending on the situation, and on the person involved). When there is a lack of flexibility between the two types of affect, and the negative one is overly emphasised, the person will feel increased levels of anxiety. This then starts a vicious cycle, because if in the beginning, the person felt the negative emotions disproportionately, which led to increased anxiety, then this anxiety will now increase the level of attention directed towards negative emotions which will continue to increase the person’s anxiety levels (Hofmann et al., 2012). Also, an increased level of emotional dysregulation has been found to be linked to peritraumatic symptoms caused by the Covid-19 pandemic (Siegel, Mor, & Lahav, 2021).

Having a complex image of the self, and of one’s emotions, which allows for a detachment from and for a blockage of the changes caused by life events seems to be a protective factor from the negative consequences of anxiety. Bodner, Shrira, Bergman and Cohen-Fridel (2015) studied the effects that complex emotionality had on death anxiety and on aging anxiety. Their sample consisted of 188 adults, and it was gender-balanced. The results showed that complex emotionality had the capacity to moderate the relationship between death anxiety (and, respectively, aging anxiety), and the perceived psychological distress. In other words, the psychological distress was elevated by death anxiety and by aging anxiety when participants did not have increased levels of complex emotionality (Bodner et al., 2015).

Death anxiety can indeed cause strong negative emotions that remain elevated every day. Furer and Walker (2008) exemplified this through a case study of a patient that felt so anxious about the imminence of her death, that she could not get emotionally involved in celebrating her children’s anniversaries and in recollecting their childhood events, because any indicator of the passage of time made her feel pure terror. Moreover, she was worrying excessively and she felt helpless when thinking about what would happen when she died – what would happen to her, as well as to her loved ones (Furer & Walker, 2008). These kinds of intense, and dysfunctional negative emotions can become debilitating, and they can have significant impacts on someone’s behaviour.

The behavioural domain  

The case study presented by Furer and Walker (2008) offered a good example of how death anxiety can impact people’s behaviours. The patient weighed herself every day to make sure that she did not lose or gain weight, she refused to go through photo albums, so that she would not see how quickly time passed, going to happy family events was very difficult, while going to funerals was completely out of the question. Additionally, her daily activities were limited to her duty she had towards her job and her children, while keeping socialising at a minimum level. Although she used to like to exercise and to meet her friends, she avoided these types of activities ever since her death anxiety levels increased.

Since the patient in this case study was a mother, it is important to note that mothers’ behaviours affect the children’s emotional stability. Creswell, Apetroaia, Murray and Cooper (2012) showed that the anxiety felt by mothers was a good predictor of their children’s anxiety levels, and of their children’s responsiveness to treatment. The researchers had a sample of 88 anxious children aged between 7 and 12 years old. Their mothers were also included in the study, 44 of which had a clinical diagnosis of an anxiety disorder. The results showed that mothers’ anxiety levels, especially during stressful conditions had, on the one hand, a negative impact on the quality of their relationship with their children, while on the other hand, it had a maintenance effect of the children’s anxiety levels (Creswell et al., 2012). Therefore, one’s felt anxiety, and the behaviour it generates can have a negative impact on children’s development.

Children’s development is not the only behavioural area which is affected by anxiety. Grecucci et al. (2013) revealed that anxious people tend to accept unfair financial offers. This can be explained by the fact that anxious people do not want to risk being involved in a conflict with others, and/or they do not want to be in a situation that can cause them to have a panic attack. Either way, their social and financial behaviours were negatively influenced by their high levels of anxiety (Grecucci et al., 2013).

Moreover, TMT explains that those who come into contact with death reminders can become mentally inflexible and even aggressive towards those with opposing worldviews (Landau, Solomon, Pyszczynski, & Greenberg, 2007). McGregor et al. (1998) studied a sample consisting of liberal and conservative participants. Half of the participants were in the death-reminder group, while the other half were in the control group. Participants then read a text that expressed a worldview that was either in agreement with or in opposition to their worldviews, and the experimenters explained that the text was written by another participant. After the experimental manipulation, the participants were asked how much hot sauce they would give the author of the text, and they were assured that this participant would be obliged to eat the offered quantity. The results showed that those in the death-reminder group who read the text with the opposing worldviews gave twice as much hot sauce to the author of the text compared to those in the same group who got a text presenting the same worldviews (McGregor et al., 1998).

In other words, according to TMT studies, participants with high levels of death anxiety can behave in an aggressive manner towards those who have different worldviews and/or ways of thinking. This aspect is highly relevant, because it emphasises the importance of treating death anxiety at a societal level, and not just at a personal level. Moreover, the psychotherapeutic interventions aimed at this psychopathology need to adapt this information to their patients in order to be effective.

The associated psychosomatic symptoms

Anxiety can cause different physiological symptoms, most times misunderstood from a biological perspective, but which can sometimes be measured with medical devices (Mallorquí-Bagué et al., 2016; McLeod, Hoehn-Saric, & Stefan, 1986). These symptoms can be: tachycardia (Mallorquí-Bagué et al., 2016), excessive sweating and heart palpitations (McLeod et al., 1986), sleeping difficulties, headaches, gastrointestinal symptoms, fatigue, stomach aches (Carlehed, Katz, & Nordin, 2017) and others.

The Hamilton Anxiety Questionnaire (MDCalc, 2024; for the original version, see Hamilton, 1959) divides the scores in two domains: psychosomatic anxiety and mental anxiety. Psychosomatic anxiety is measured through seven categories of symptoms that this pathology can generate (MDCalc, 2024; Hamilton, 1959):

  • muscular symptoms: muscle aches, muscle stiffness, myoclonic jerks, twitching, teeth grinding, unsteady voice;
  • sensory symptoms: tinnitus, blurry vision, hot-and-cold flushes, feeling weak, feelings of pricking;
  • cardiovascular symptoms: tachycardia, heart palpitations, thoracic pain, feeling that the veins are throbbing, feeling faint, irregular pulse;
  • respiratory symptoms: feeling of thoracic pressure or constriction, feeling like one cannot breathe, sighing, difficulties in breathing;
  • gastrointestinal symptoms: swallowing with difficulty, feeling flatulent, indigestion, burning sensations, feeling too full, feeling nauseous;
  • genito-urinary symptoms: frequent micturition, urinary incontinence, amenorrhea, menorrhagia, frigidity, premature ejaculation, loss of erection, impotence;
  • autonomic symptoms: dry mouth, blushing, being pale, sweating, dizziness, migraines, piloerection.

Although the questionnaire was developed in 1959, its clinical utility is still relevant (Shear et al., 2001), as it is a good representation of the psychosomatic effects that anxiety, and by extrapolation, death anxiety can have on the human body. Death anxiety is not as studied from a psychosomatic standpoint, and, although there are research studies offering favourable results for its definition as a transdiagnostic construct (e.g., Gürbüz & Yorulmaz, 2024), further research is required to gain a better understanding of its psychosomatic effects.

Psychotherapeutic approaches

Given the negative impact of death anxiety on all psychological domains, there are several works explaining the potential psychotherapeutic methods aimed at reducing it. Cognitive Behavioural Therapy (CBT) offers effective protocols in this process, as it is focused on the client’s beliefs, emotions and behaviours (Lam, 2004). Menzies (2018) explained that involving the client in exposure exercises and reducing the number of their dysfunctional behaviours (such as avoiding the subject of death and the constant verification of one’s health levels), while increasing the number of functional behaviours is effective in treating death anxiety. Additionally, Menzies (2018) emphasised the importance of helping clients to accept the reality of death and dying. This latter idea which acknowledges the importance of acceptance can also be found in a third-wave CBT approach called Acceptance and Commitment Therapy (ACT; Hayes, Luoma, Bond, Masuda, & Lillis, 2006) that has been effective in treating different psychopathologies.

In a different approach, Nozari, Mo’tamedi, Eskandari, and Ahmadivand (2019) organised group narrative exposure therapy sessions in order to reduce death anxiety in a geriatric population. Although narrative exposure therapy is a form of cognitive restructuring in CBT terms, working in a group while revisiting one’s life story was shown to facilitate learning and to increase the level of received social support which is key in reducing death anxiety according to theoretical explanations.

Lewis (2014) proposed that TMT and Existential Psychology should be combined to form a basis for a specific death anxiety psychotherapeutic approach. However, several obstacles arise. Death anxiety literature is still in its infancy, as it consists of varied studies that do not easily offer a basis for a concrete conceptualisation necessary for a psychotherapeutic approach. Additionally, further research can offer new insights for the underlying mechanisms of death anxiety that need special attention in therapy. This can be done by investigating the theories’ application in clinical practice, by conducting experimental studies with instruments that have good psychometric properties, and, after replicating the results, by integrating the obtained knowledge in a psychotherapeutic protocol that is specific to death anxiety. Therefore, although some therapeutic approaches are in place, one cannot be certain that they will work in all cases and in the long run without a clear understanding of the concept, and this understanding can be provided only by future research.

The methodological perspective

The research literature has offered a series of instruments measuring death anxiety, in both clinical and non-clinical settings. Table 1 is depicting some of the mostly used scales, as well as their descriptions. Given the characteristics of the presently used instruments, developing new, multidimensional, and culturally adapted scales is required in order to support future scientific efforts aiming at investigating death anxiety (Zuccala, Menzies, Hunt, & Abbott, 2019; Menzies et al., 2022).

The majority of the mostly used scales were developed 10 or more years ago (e.g., Templer 1970; Dickstein, 1972; Templer et al., 2006), in Western countries, and were based mainly on university samples (Mohammadzadeh et al., 2018; Zuccala et al., 2019). The psychometric properties of the instruments change from one study to another, which negatively impacts the possibility to replicate the results.

One of the most used scales is the Death Anxiety Scale (DAS; Templer, 1970). The instrument has an oscillating Cronbach’s alpha coefficient: Jin et al. (2023) reported a coefficient of 0.57, while Mohammadzadeh et al. (2018) reported a score of 0.77, and Kızılgeçit and Yıldırım (2023) had a Cronbach’s alpha of 0.91. Although the internal consistency coefficient is dependent on participants’ responses, the oscillation from an unacceptable level to an excellent level indicates psychometric limitations. Even though translating the scales can impact the internal consistency levels (e.g., Chang, Chau, & Holroyd, 1999), the other scales that were translated in the studies reporting a low Cronbach’s alpha for DAS did not have psychometric issues. This suggests that the instrument proposed by Templer (1970) was the one generating the lower levels of internal consistency, and not the studies’ methodological choices.

Another criticism related to the psychometric properties of the existing scales (Iverach et al., 2014) refers to the multidimensional character of death anxiety, which cannot be measured through a simple summing of the questionnaires’ items, or through the numerical estimate of the factors that express fear.

Menzies et al. (2022) showed that death anxiety had impacted different dimensions of one’s mind – beliefs, emotions, and behaviours. As a result, the severity of death anxiety’s effects should be considered in each area, and not overall.

The Death Anxiety Beliefs and Behaviours Scale (DABBS), developed by Menzies et al. (2022) is the most recent instrument that measures death anxiety on a multidimensional level. It has good to excellent levels of internal consistency (Cronbach’s alpha of 0.90 for the entire scale, 0.94 for the affect subscale, 0.83 for the belief subscale, and 0.87 for the behaviours subscale), and good levels of discriminant validity (AUC = 0.90). Any DABBS score over 55 indicates that death anxiety has clinical significance. Therefore, this instrument can discriminate between clinical and non-clinical populations and it overcomes many of the older scales’ limitations.

The instrument offers good support for the scientific efforts aimed at investigating the mechanisms through which death anxiety generates different psychopathologies. On the other hand, the argument related to the necessity of testing and modifying the scale based on the cultural context in which it will be applied stands for this instrument as well. The Romanian population’s perceptions, and even more so, the Romanian elderly population’s perceptions differ from the ones observed in Australia and the U.K., therefore changes are required in order to ensure an accurate measurement of Romanians’ death anxiety.

Limitations

The present narrative review has the advantage of summarising a large number of studies focusing on different death anxiety characteristics, which were published over a long timeframe, by considering both the theoretical and the clinical aspects, as well as the instruments often used in death anxiety research. Narrative reviews have, however, two essential points of criticism. One such point is the fact that a narrative review does not have a rigorous methodological structure, and it can be affected by the researchers’ levels of bias. The second point of criticism is that this type of reviews does not aim towards the centralisation of an exhaustive database of published studies on a subject of choice. A systematic literature review or a meta-analytic review can offer details that are more precise and objective with regards to death anxiety, and the research literature can definitely benefit from scientific efforts directed towards these types of formats. The goal of this paper was to offer an overview of the present understanding of death anxiety as a starting point, from general to specific, for future studies.

Table 1

Descriptions of the death anxiety scales used often in the research literature. (to see Table 1, please click here)

Conclusion

When considering the two presented theories, as well as the existing studies, it can be concluded that death anxiety is at the core of many psychopathologies (e.g., Cikrikcili & Altıntaş, 2024), without it being the same as these. Even if it can take different shapes, from arachnophobia to social phobia (Iverach, 2018), death anxiety is both a common denominator, and the most relevant aspect to be approached to prevent relapses and comorbidities in its associated pathologies (Gürbüz & Yorulmaz, 2024). Thus, even though it does not exist in a standalone manner in the present nosologies – and even though its conceptual delimitations can seem diffused –, death anxiety is a challenging concept, that attracts the researchers’ interest. How does this type of anxiety work? In which way finding or losing one’s sources of meaning of life correlate with the fluctuations in death anxiety’s intensity levels? How can the quality of life of those suffering from different pathologies benefit from treating their death anxiety? What are the resilience factors and the most effective cognitive and emotional coping strategies when facing death anxiety? How can death anxiety be measured effectively and precisely? All these questions remain to be answered by future scientific efforts.

Competing interests

The authors declare no competing interests.

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