Death anxiety

– body bags, catastrophic thinking and facing the inevitable

Psychologist and researcher at the University of Sydney Rachel Menzies, who studies death anxiety.


Rachel Menzies has lost count of the number of people she has zipped into body bags.

While other people stood around watching – sipping tea and nibbling on cake, or snapping photos of their friends’ faces disappearing into the plastic – she always stayed close by, waiting for rustling or a shout from inside the bag.

“They would stay in for however long they felt comfortable – some just for 10 seconds, others for a few minutes,” says Menzies, a Sydney-based psychologist and researcher at the University of Sydney.

After the occupants of the bag – psychologists, psychiatrists, and counsellors – clambered out, they were treated to a video of decomposing human bodies: bloating, maggots swarming over flesh that then ruptures and leaks fluids, and the open grin of a skull wrapped in shrunken skin. It was deliberately shocking, but Menzies says it serves as a reality check.

“It’s important to come to terms with the fact that, at the end of the day, we are all made of flesh and bone which will eventually decay. We need to stare death in the face instead of turning away and pretending it doesn’t happen.”

Psychologist Rachel Menzies says there is growing evidence that death anxiety is a transdiagnostic construct – something that causes or worsens a range of mental health disorders

The idea of death anxiety as central to mental health has been gaining attention in clinical psychology since roughly 2014, says Menzies. So in 2019, she and her clinical psychologist father, Professor Ross Menzies, toured the country running workshops to help mental health professionals address it with patients.

“We wanted to get participants trying out exercises they might recommend as exposure tasks [for clients], with the body bags being one of the more unusual tasks.”

“I would have loved to get a coffin and carry that around Australia, but it’s much less practical than a foldable plastic body bag.”

When fear of death becomes debilitating

Being afraid of dying and having occasional thoughts about it is normal, but if it gets in the way of life – working, travelling, or seeing friends – it’s becoming a problem, Menzies says. And in this particular Covid moment, it’s hard to escape reminders of our mortality, with doom and death tolls constantly in the news.

Canadian-based clinical psychologist Patricia Furer has been working with patients on death anxiety for about 20 years.

“I have found most people who are struggling with fear of death have had difficult experiences with illness and death that have made them particularly attuned to these concerns,” says Furer, an associate professor and director of the anxiety disorders clinic at Saint Boniface Hospital in Winnipeg.

‘People who have thought about what might happen after death … often sit in a more comfortable place when facing their own death,’ says Dr Kerrie Noonan.

“For example, having experienced deaths of four close family members or loved ones in one year or perhaps a series of difficult health issues in themselves and loved ones.”

Death anxiety isn’t recognised as a disorder in the US’s Diagnostic and Statistical Manual of Mental Disorders, but fear of death can be classified as a specific phobia (thanatophobia), and Menzies says there’s growing evidence that death anxiety is a transdiagnostic construct – something that causes or worsens a range of mental health disorders.

Furer agrees, but says a lot of research is needed to understand how it works across categories used for different diagnoses.

“I think it’s probably more of a concept or attribute – like we talk about perfectionism,” Menzies says.

A 2019 study led by Menzies found a strong relationship between death anxiety and worse severity of symptoms in 12 disorders including alcohol use disorder, depression, and social anxiety.

“Death anxiety was also significantly associated with a person’s number of hospitalisations, how many medications they’re on for their mental health, and how many different disorders they’ve had across their life,” Menzies says.

The risk of death anxiety worsening mental health conditions is particularly relevant now, Menzies says.

As an example of the sort of effect this might have, Menzies refers to a study where people with obsessive compulsive disorder were asked to complete personality questionnaires.

Those whose questionnaires included two questions about death spent more than twice as long washing their hands afterwards (more than 20 seconds compared to less than 10) than those who had two questions on dental pain.

Managing catastrophic thinking

If death anxiety is at the root of a mental health disorder, many current treatments may not be as effective as we think, Menzies says.

“If that underlying causal factor of death anxiety isn’t addressed, people might just return to health services with different conditions years later. Say they get effective treatment for OCD, but later develop health anxiety or a specific phobia.”

Menzies cites the case of Anna, 34, who came to Menzies having suffered health anxiety for 15 years and had seen several psychologists.

She often asked her GP for tests for fairly benign symptoms, such as headaches or minor skin irregularities, then worried they had missed something, asking for more tests and second opinions.

“Her worries focused on death-related outcomes, such as dying of cancer, and she made catastrophic interpretations of benign symptoms, for example assuming a headache was a brain tumour,” Menzies says.

“It became apparent that Anna also avoided things: flying, for fear of plane crashes, or driving long distances in case she had an accident. When asked about her general health, Anna mentioned she avoided any exercise as she worried the change in her heartrate may be a sign of a heart attack.”

Cognitive behaviour therapy (CBT) focused on exposure is the most evidence-based treatment for death anxiety, Menzies says.

But there’s a twist.

“Standard CBT for most disorders generally won’t touch on death at all, and if it does, it’s trying to disprove the person’s estimate of the likelihood of death: for a fear of flying, you’re trying to get them to see that dying in a plane crash is very unlikely,” Menzies says.

But as life comes with a 100% likelihood of death, says Menzies, reducing someone’s fear of dying from a specific cause won’t help. Instead of trying to convince someone that planes don’t crash, Menzies would suggest exposing that person to death-related situations, like writing their own obituary or planning their funeral.

In Anna’s case, therapy included books and TV shows featuring death, and gradually reducing her GP visits each month. Over time, she returned to work, and could see sick loved ones she had avoided visiting before, Menzies says.

Or you could also have your phone remind you five times a day that you’re going to die – which is what Menzies does. She has the app WeCroak and recommends it to clients to help normalise death.

“I often find I’m stewing on something or worrying about a deadline, then the notification comes up and helps put things in perspective.”

Furer also says writing a list of death-related fears can identify exactly what people are afraid of.

“For example, some people fear the process of dying, some people fear missing out on life after they are dead, some fear leaving loved ones behind.”

Finding joyful activities can balance out the more difficult exposure tasks, she adds.

“Fear of death can result in people limiting their lives and spending all of their time focused on their worries. Shifting at least some of their energy to building positive and satisfying activities into their day-to-day lives can be helpful.”

On the positive side, Furer says patients who were already working on death anxiety are feeling “particularly well-equipped” to manage current pandemic fears because they already had coping strategies – such as managing catastrophic thinking – in place.

Are we warming up to death?

Dr Kerrie Noonan, who researches community behaviours around dying, says death-related groups and public activities have bloomed in the last decade.

“There are weddings and community events in cemeteries, Coffin Club in Tasmania where you build your own casket, festivals like We’re All Going To Die,” says Noonan, a clinical psychologist and social researcher at Western Sydney University.

But it’s too soon to know whether this will lead to death anxiety easing in individuals, Noonan says.

“All this interest could speak to the fact we’re really anxious about dying, but we’re often educating ourselves in these events and that could help our fears decrease.

“In my experience [in palliative care] people who have thought about what might happen after death – whether they’re religious, spiritual, or have no religion – often sit in a more comfortable place when facing their own death.”

While first-hand experience around death can be agonising, it does appear to help us and others.

People experiencing loss often find a “mentor” in their family or friends who have experienced bereavement before, Noonan says.

“If we can deal with our fears about death and dying, we will be better at supporting our families, our friends, those who are dying and bereaved. We all need to be better at that – for ourselves, and for each other.”

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