Motivation and emotion/Book/2019/Death anxiety stages

Overview
Death anxiety has been described as a mental defence mechanism against the universal danger all living creatures face. Death anxiety has adaptive functioning for survival. The awareness of death can enhance adaptive responses to improve chances of survival (Langs & Giovacchini, 1997). Kubler-Ross (1969) developed a model of death and grief stages, consisting of Denial and isolation, Anger, Bargaining, Depression and finally Acceptance. Whilst this is the theoretical model that will be focused on most, frameworks such as the Death Anxiety Scale, fight and flight response, Terror Management Theory and Thanatophobia will also be discussed. Influencing factors, such as developmental stage and religious and cultural experiences, will be examined in reference to the stages of death anxiety and its impact on the dying experience.

As death anxiety is an anxiety-disorder, it can be clinically treated using similar techniques to other anxiety-related illnesses. This chapter delves into Cognitive Behaviour Treatment (CBT), existential psychology and exposure therapy referencing clinical research on these treatment options. Finally, the dying experience will be discussed, with particular attention to Kubler-Ross's stages of dying. We can use motivation and emotion theories, and research to expand our understanding of death anxiety. With an accumulating knowledge base of each stage of death anxiety and the influencing factors, clinicians can work closely with patients experiencing death anxiety to choose the right treatment path for them.


 * Focus questions:
 * 1) What is death anxiety?
 * 2) What treatments are available for death anxiety?
 * 3) How can psychological theories increase our understanding of death and dying?

Stages of death anxiety
The stages of death anxiety are those developed by Kubler-Ross (1969) (See Figure 1.); they can also be referred to as the 'grief cycle'. Beginning with denial and isolation, followed by anger, then bargaining, death anxiety and the experience of grief can lead to feelings of depression and finally acceptance. Each of these stages will be discussed in further detail below.

Denial and isolation


The first stage of death anxiety is 'denial and isolation'. People use this stage as a buffer from harsh reality, almost like an escape from the hurtful situations of life. Denial can be verbal (e.g. 'this cannot be happening to me'), cognitive (e.g. believing the doctors mixed up test results with another, much sicker, patient), or physical (e.g. going to multiple different medical professionals hoping for a more reassuring answer). Kubler-Ross (1969) describes denial as a process of shock and as a coming-and-going response.

The second part of this stage, isolation, can occur with the first. Isolation may come about when people live in a state of denial and perhaps hold out that 'things will get better' despite a quick, terminal diagnosis. Towards the end of life, some people may want to be isolated so they are not a 'hassle' or 'burden' to their close family and friends, preferring to be left alone. Denial can be seen as a temporary defence that may lead to partial acceptance (Kubler-Ross, 1969).

Anger
Following on from denial and isolation, anger changes the statement 'it cannot be me' to 'why me?'. Feelings of anger can develop from fear of an impeding death of yourself or someone close to you. People may feel as if they are being tricked into believing some horrible false reality, as if some higher power has played a trick on them. (Grof, Halifax, & Kubler-Ross, 1978).

Bargaining
Bargaining in the face of death could be seen as a last ditch attempt at being saved. Some might make extravagant promises to god or another higher power in hopes of more time (Copp, 1998). In countries that still practice capital punishment, people facing the possibility of the death penalty could more willingly accept a plea bargain out of fear of death (Ehrhard, 2008).

Death row phenomenon:

The death row phenomenon occurs in countries that still utilise capital punishment. It is the experiences and emotions felt by inmates on death row. Recently, a microscope has been placed over the harsh emotional and physical conditions of death row which has been likened to inhumane treatment (Hudson, 2000). Studies have shown people on death row experience heightened depression and anxiety (Vogelman, Lewis & Segal, 1994).

Depression
Depression may arise from a great sense of loss that occurs when someone has a terminal diagnosis or is aware of a loved ones mortality. The impeding death and sadness that accompanies it can bring about early feelings of helplessness. People who have strong religious beliefs may develop feelings of depression nearing the end of their life. They may feel that there is a god who has control over all things, including themselves, and that they are not caring for them (Edmondson, Park, Chaudoir, & Wortmann, 2008). This depression may be a personal experience for the dying, however it can also extend to loved ones around them.

Acceptance
Acceptance of death doesn't necessarily mean you're absent of anxiety about death. As death is inevitable, out of all the stages of death anxiety, acceptance would be the easiest approach to take (Ray, & Najman, 1975). Wong and associates (as cited in Wong, 2007, p.3) discuss three different types of death acceptance:


 * 1) Neutral death acceptance - accepting death as what it is... a natural inevitable process.
 * 2) Approach acceptance - viewing death as a step towards a better afterlife.
 * 3) Escape acceptance -  escaping from a painful life or condition through the choice of death.

Viewing death with a neutral perspective involves the acceptance that theres nothing more to death than a simple switch between living and not; or a more positive view that death means completing a legacy or life mission.

People with strong religious and/or spiritual beliefs may be the most inclined to engage with approach acceptance of death. Their beliefs could be the reason they believe there is an afterlife, and that it is a positive experience.

Probably the least positive view on death acceptance is escape acceptance, based on the idea that life is too hard, sad or unfulfilling to live. Escape acceptance could be used to describe the acceptance approach to death of people who attempt, commit or engage in suicide and assisted dying.

Theoretical frameworks
Theoretical frameworks are used to help us understand situations and interactions in society. Theorists create frameworks to increase our understanding and imply meaning to aspects of life. The following frameworks and theories are in direct relevance to death anxiety and the experience of it.

Death anxiety scale
The Death Anxiety Scale (DAS) was initially developed by Templer in 1970, and consisted of 15 statements, on a 5-point likert scale (Abdel-Khalek & Neimeyer, 2017). The statements consisted of 'I fear dying a painful death' and 'I am very much afraid of dying' (Templer et al., 2006). Although the DAS is a widely used and accepted scale, questions on the dependability and accuracy have been raised. Despite the concerns raised, the DAS has been shown to have .83 test-retest reliability and an internal consistency coefficient of .76 (using the Kuder-Richardson Formula 20 Psychometric).

Fight or flight response
The fight or flight response term originally coined in 1929, is a physiological response of the body to perceived harm. This response has been noted as 'survival instincts' taking over to drive us away from potential harm or death (Frey, Savage, & Torgler, 2010). Frey et al. (2010) suggests this survival response played a part in the different survival trends during the sinking of the Titanic and the Lusitania. Suggesting in such situations, self-preservation overtakes social cohesion, that we engage in a savage-like fight response to save our lives. As the Lusitania sunk in 18 minutes, a stronger survival competition was found compared to the Titanic (which sank in 2 hours, 40 minutes); signifying that under extreme stress (shortened time limit) our fight or flight response is greatly increased, as we scramble to save ourselves first from potential death.

Bracha (2004) suggests the addition of fright, freeze and faint to the classic 'fight or flight' stress response phenomenon. 'Fright' is a necessary addition to the fight or flight response, as it differs from freeze because it incorporates very slow movements. However both fright and freeze are natural reactions to acute stress. Adding that fainting is a biological response that occurs in most medical phobias (blood, needles, injuries) and so is also relevant. In partial agreeance, Bracha, Ralston, Matsukawa, Williams, & Bracha (2004) comment on the fact the term 'fight or flight' hasn't been updated since 1929-when it was first coined and therefore is due for an update.

Terror Management Theory
Terror Management Theory explains the human experience of distracting ourselves with meaningful societal contributions to avoid the awareness of our own mortality and the anxiety that comes with that. Humans are motivated to believe they make significantly important contributions to an appreciative world as a defence mechanism against the awareness of their own mortality. Terror Management Theory is largely based on Ernest Becker's social science theories (Greenberg et al., 1990). Becker suggested the awareness of our own mortality creates internal feelings of terror concerning the experiences leading eventually to death which can manifest into phobias that affect everyday life i.e. claustrophobia or the fear of being alone. Pyszczynski, Greenberg and Solomon (1999) describe Terror Management Theory as the motivation behind people maintaining positive self-images and faith in their cultural worldviews, because of the protection they provide from anxiety that resides deep in our unconscious about our mortality.

In a study investigating the fear of death in adults aged 60-100 years old, Cicirelli (1999) found a stronger sense of death anxiety was linked to weaker religious ties, less social support and higher externality. These links support Terror Management Theory, which states the distraction social engagement provides, lessens our death anxiety. Research on Terror Management Theory shows that it isn't the direct experience of terror and anxiety that drive thoughts and behaviours, but it is the accessibility of thoughts related to death that are the Terror Management defences Becker discusses (Pyszczynski, Greenberg & Solomon, 1999).

Thanatophobia
The fear of death, or 'Thanatophobia', stems from the Greek god of nonviolent death Thanatos and Phobos meaning fear (Milosevic & McCabe, 2015). Sigmund Freud conceived the first theory of death phobia with regards to anxiety. He discussed Thanatophobia as developing from unresolved childhood conflicts that feeds on our inability to accept our own mortality. Milosevic and McCabe (2015) discuss the fact death is a fear held by many organisms, however Thanatophobia occurs when there is an intense and persistent fear surrounding death.

Quiz
Choose the correct answers and click "Submit": {When was the term 'Fight or flight response' coined? - 2004 - 1901 - 1965 + 1929
 * type=""}

{The Death Anxiety Scale consists of how many statements? + 15 - 16 - 5 - 10
 * type=""}

{Who was behind the idea of Thanatophobia? - Erik Erikson + Sigmund Freud - Ernest Becker - Einstein
 * type=""}

{Terror Management Theory states humans use which of the following as a defence mechanism? - Gym work out - Movie marathon + Meaningful societal contribution - Regression
 * type=""}

Factors influencing death anxiety
Death anxiety is a universal experience to people who come close to, or experience the death of, someone close in their life, and eventually at the end of their own lives. Factors which may affect the way we experience death anxiety include our life stage, cultural experience, religious experience and medical diagnoses.The following paragraphs discuss these factors.

Infancy
Some research suggests inquisitive behaviour around death begins as early as 6 months old. Maurer, (as cited in Kastenbaum & Costa, 1977, p.230) proposes a young infants fascination with games such as 'peek-a-boo' are testaments to their interest in the ideas of being and nonbeing, dark and light. Bowlby's attachment theory pays great relevance in this aspect, almost if developing the infants understanding of separation and reunion is essential to the perception of death finality (Kastenbaum & Costa, 1977).

Childhood
Nagy (as cited in Kastenbaum & Costa, 1977, p.230) investigated the understanding of death from over 300 Hungarian children through their words and drawings. Nagy came across 3 stages of understanding.


 * 1) Death is not final - death can be 'reversed'. Children have this ideal until around age 5.
 * 2) Finality of death - whilst death is understood as final, it is not inevitable and can be avoided. This stage is present between ages 6-8.
 * 3) Inevitable death - death is inevitable and final. True comprehension of our mortality shows around age 9.

Adolescence
Following on from childhood understanding, understanding the finality of death develops further as people progress through adolescence. This can be sped up if someone experiences death close to them (Noppe & Noppe, 2004). It is suggested that while adolescent understanding has progressed from infancy and childhood, it is not of the same level as that of adults. This due to the lack of social, physical, cognitive and emotional development between adolescence and adulthood. The riskiness of adolescent activities is attributed to an attempt of defying death, acknowledging the inevitability of our mortality while trying to 'trick death' out of it (Noppe & Noppe, 2004).

Adult life
Russac, Gatliff, Reece, & Spottswood, (2007) investigated age and gender effects on death anxiety. In the first of two studies 304 participants between ages 18 and 87 years completed the Collett-Lester Fear of Death scale (Neimeyer, 2015). They found that death anxiety was at its highest for both males and females during their 20s followed by a significant decline. However, women's death anxiety peaked again during their 50s. The second study consisted of 113 women aged between 18 and 85 years who completed the Templer Death Anxiety Scale (see Theoretical Frameworks - Death Anxiety Scale for more information). The second study gave similar results, with a peak of death anxiety experienced during early adulthood, a significant decline followed by another peak for women during their 50s.

Later life
Erik Erikson has mentioned the influence of later life on death anxiety through his life stage Ego integrity vs Despair. The idea is that as we approach the end of our lives we engage in life review. Ego integrity meaning the ability to accept our past experiences, and despair being the stress or concern nearing the end of ones life. The more frequent and in depth life review, the lower feelings of anxiety around death (Fishman, 1992). Erikson suggested that as we progress through life, we accept and come to terms with our life.

Fishman (1992) conducted a study looking at the connections between life review, ego integrity and death anxiety in older adults. They put forward three hypotheses:


 * 1) Greater engagement in life review means having higher ego integrity.
 * 2) More life review, the lower anxiety surrounding death.
 * 3) Lower death anxiety is linked to higher ego integrity.

To summarise, Fishman proposed that the higher life review, meant having higher ego integrity which then meant experiencing lower death anxiety. After completing the Life Review Questionnaire, Adult Ego Development Scale, DAS, Death Preparation Scale and a personal information sheet results showed life review was negatively correlated with death anxiety. Meaning the less life review, the higher death anxiety felt. Life review has been attributed to lowered feelings of guilt or stress about past negative events as older adults work through their feelings about the past (Fishman, 1992).

Cultural experience


The western society experience of death is surrounded generally with a lot of sad, negative emotion. However, other cultures experience death in a vastly different way, with some even celebrating it.

Each year coming up to November 2nd, streets throughout Mexico are lined with decorative skulls, and people dress up in colourful vibrant costumes to celebrate the Day of the Dead (see Figure 2.). The bright and colourful skulls represent the respect and love felt for deceased family and friends (Ward, 2017).

Religious experience
Research from Templer and Dotson (1970) resulted in no significant correlation between religiosity and death anxiety. Surveys from the DAS on 213 college student participants gave this puzzling result. Researchers attributed the contradictory result to the limited affect religion has on the attitudes and behaviour of the majority of college students.

Harding, Flannelly, Weaver, and Costa (2005) conducted a survey on 130 parishioners of an episcopal New York City church to investigate the correlations between religiosity, death anxiety and death acceptance. Contradicting the previous research from Templer and Dotson (1970). Four types of religiosity were examined, ritual (engaging in praying and attendance of religious services), experiential (confidence in degree of religiousness felt), consequential (amount of influence religion has on daily life), and theological religiosity (belief in god and the afterlife). Of the four, theological religiosity was the only one with a significant effect on death acceptance and death anxiety. Negatively correlated with death anxiety was both belief in gods existence and belief in the afterlife. Both were positively correlated with death acceptance. Meaning, a stronger belief in god and the afterlife is linked to lower anxiety around death.

Medical diagnosis
Accepting a terminal diagnosis can be a hard process, affecting not only the individual but their family and friends. The following studies accepted participants on the basis of their terminal medical diagnosis.

Adelbratt & Strang (2000) conducted a study looking at the death anxiety felt by 20 terminally ill patients and their next of kin (generally their spouse). They found six common emotions and behaviours experienced by the patients and their next of kin.


 * 1) Anxious feelings related to death anxiety.
 * 2) Questioning the meaning of their life and/or life in general.
 * 3) Contradictions.
 * 4) Trigger situations.
 * 5) Similar ways of managing death anxiety.
 * 6) New outlook and meaning for their life.

Results showed that the patients and their next of kin did think about the meaning of life and experience death anxiety quite often.

Another study assessing death anxiety among people diagnosed with terminal cancer used a modified DAS and found 83% of the terminally ill patients experienced death anxiety at a moderate level, whereas 17% experienced severe death anxiety (Kavitha, 2013). The higher instance of death anxiety among terminally ill patients and their families could be due to the approaching inevitability of death, perhaps earlier than was originally thought and accepted. Research into this area could look at the implications of death anxiety for people in their final moments and therapeutic measures that could make these moments easier.

Death anxiety treatment
Along with generalised anxiety and other forms of mental illnesses, people suffering from death anxiety can seek treatment from various health professionals. The most common treatment models for death anxiety are CBT, existential psychotherapy and exposure therapy.

Cognitive Behavioural Therapy
The core concept of CBT is to challenge negative cognition's. CBT is utilised for many other anxiety diagnoses and so has been applied in the treatment of death anxiety (Furer & Walker, 2008). Furer and Walker (2008) describe the use of the Attention Training Procedure (ATT). The ATT involves selective attention, attention switching and divided attention (Papageorgiou & Wells,1998 as cited in Furer & Walker, 2008). The ATT 'switches off' the persistent thoughts associated with anxiety. In the study, all participants exposed to ATT had positive responses, lowering their death anxiety (Furer & Walker, 2008). Through refocusing cognition's, CBT is an effective treatment for death anxiety.

Existential psychotherapy
The website Psychology Today defines existential psychotherapy as focusing on free will, self-determination and the search for meaning. Self-awareness is a powerful tool we can use to our advantage. Existential psychotherapy looks at experiences universal to humans including freedom, death, responsibility and the meaning of life (Wong, 2010). Existential psychotherapy views human experiences of anxiety and depression as natural progressions along the path of human development. In this way, death anxiety becomes more acceptable and meaningful as stepping stone in a persons life journey.

Exposure therapy
Exposure therapy can be used to overcome phobias. It is based on classical conditioning theory, where gradual exposure to a feared stimulus leads to extinction of the anxiety attached to the stimulus. Exposure therapy allows patients to be guided through their fears and phobias in a safe way. There is three types of exposure used in therapy for death anxiety (Furer & Walker, 2008):


 * Imaginal exposure - people cognitively engage in memories and thoughts surrounding death and dying.
 * In vivo - physically enacting parts of the phobia such as attending avoided situations and, places such as funerals and cemetery's.
 * Interoceptive - experiencing bodily sensations relating to specific death fear (e.g. increased heart rate associated with a heart attack).

Repeated exposure to themes of death gradually leads to weakened or extinguished phobia of death and lessened death anxiety.


 * Case Study

Emma is a 23-year-old who works full time in the city. She used to fear driving her car to work, because she felt very anxious in the car, fearing she would die from a horrific crash.

She suffered from death anxiety and sought treatment from a Psychologist who suggested exposure therapy. During exposure therapy, the Psychologist guided Emma through imaginative scenarios where Emma first sat in her car, then turned the car on, and eventually imagined she drove to work. Guided imaginative exposure allowed Emma to face her fear in a productive and safe manner.

The dying experience


A persons dying experience is influenced by their understanding of death. Noppe and Noppe (2004) suggest death is comprised of 5 core concepts:


 * 1) Universality - all living things eventually die.
 * 2) Irreversibility - once dead, a physical body cannot come back to life.
 * 3) Non-functionality - the body is absorbed of all physiological functioning.
 * 4) Causality - the reasons for death.
 * 5) Non-corporeal continuation - existence after physical body dies.

Most infants and children have not yet grasped these concepts of death. By age 9, Nagy (as cited in Kastenbaum & Costa, 1977, p.230) suggests children do understand the universality, irreversibility and non-functionality of death. However they still dont understand the reasons why everything eventually must die or the potential for life after death.

The understanding of causality comes as we progress further through life, understanding the biological, social and psychological factors surrounding death. People have different ideas of what non-corporeal continuation could be. Some people may experience this as the feeling of carrying someone in your heart and thoughts after their passing and others may believe in life after death. Some religions believe in a figure such as the Grim Reaper, an entity to guide souls to their next destination following death (See Figure 3.).

Conclusion
Death anxiety is a coping mechanism people may use as protection against the thought of death. There are a variety of treatments available for death anxiety, including CBT, existential psychotherapy and exposure therapy. Each therapy model is effective at reducing death anxiety levels, through altering cognition and classical conditioning. Theoretical frameworks such as the DAS allow us to research the facets of death anxiety. Terror Management Theory gives meaning to why people experience death anxiety, and Thanotophobia theory also improves our understanding of death anxiety but also provides researchers with a name for the phobia of death. The stages of death anxiety begin with denial and isolation, followed by anger, bargaining, then depression and finally acceptance. The higher the stage of death anxiety and deeper understanding of death a person has allows their death experience to be more smooth and simple. Generally, the older people get, the deeper their understanding of death and dying is. From the research surrounding death anxiety, social facilitation, life review and an understanding of the 5 core concepts of death lessen the likelihood of experiencing death anxiety.