Austin J Psychiatry Behav Sci. 2017; 4(1): 1061.
Dadfar M¹* and Lester D²
¹School of Behavioral Sciences and Mental Health-Tehran Institute of Psychiatry, International Campus, Iran University of Medical Sciences, Iran
²Psychology Program, Stockton University, USA
*Corresponding author: Mahboubeh Dadfar, School of Behavioral Sciences and Mental Health-Tehran Institute of Psychiatry, International Campus, Iran University of Medical Sciences, Tehran, Iran
Received: March 20, 2017; Accepted: June 27, 2017; Published: July 05, 2017
Death anxiety is a complicated construct. It is experienced with variable severity during one’s life. Individuals react and cope with death anxiety in their own way. There are many theories about concepts and terms of death, and dying anxiety. Some studies have developed, and validated different instruments for measuring of anxieties and attitudes toward death and dying. Many studies have focused on the various aspects, components, clinical correlates, and issues related to death and dying in Western, Eastern, Arab and Asian countries. The most of studies showed that death anxiety is influenced by a variety of factors such as religiosity, spirituality, health, gender, age, and culture. The article has reviewed the religiosity/spirituality as one of correlates of death anxiety in 93 studies published by a host of American, European, Arab, and Iranian psychologists and psychiatrists.
Keywords: Death anxiety; Religiosity; Spirituality; Mental health
Death anxiety/fear is defined as the dread of death, the horror of physical and mental deterioration, the essential feeling of aloneness, the ultimate feeling of aloneness, the ultimate feeling of separation anxiety, sadness about the eventual loss of self and extremes of anger and despair about a situation over which people have no control . According to another definition death anxiety means a set of negative emotional reactions with variable severity due to thoughts indicating the loss of one’s existence. In this definition, addition to the emotions, emphasis is on the cognitive view [2-3]. Death anxiety defined as an eccentric and a great fear of death associated with feelings of dread of death or apprehension when thinking about dying process or the things that happen after death . It is also referred to as thanatophobia (fear of death) and necrophobia (fear of death or the dead) . The Association for Death Education and Counseling (ADEC)-The Thantology Association (2015) stated that anxiety is the preeminent emotion in acute grief and can manifest in a number of ways. It can be a leading indicator of complicated mourning; yet often, grief professionals focus their attention and interventions on other emotions. This is unfortunate, since anxiety after a loved one’s loss is often a significant concern and can create many problematic reactions .
There are many theories about concepts and terms of death anxiety. Three of the leading theories about death and death fear/ anxiety were developed by Sigmund Freud, Ernest Becker, and Mohammad Samir Hossain. Theories about these concepts include Thanatophobia; Theory of Ernest Becker; Edge theory; Wisdom: Ego integrity vs. despair; Terror Management Theory (TMT); Separation Theory; Death and Adjustment Hypotheses (DAH); Being, time, and Dasein; Meaning management theory; the existential approach; the regret theory; Personal meanings of death and so on . Previous studies have developed, and validated different tools for measuring of death anxiety and attitudes toward death and dying [8-13].
Many studies on death anxiety have focused on gender differences, religious and spiritual influences, and aging . Agras, Sylvester, and Oliveau (1969) reported that 16% of people had fear of death . Kastebbaum (2000) reviewed studies on fear of death in general population and showed that fear of death is common in general population, women had higher fear of death than men, in cross sectional studies elders had no higher fear of death than youths, higher educational economic social levels were associated with lower fear of death, high level of religious beliefs and participation in religious activities were not associated with low level of fear of death .
Pierce, Cohen, Chamber, and Meader (2007) reported that women high school and college students had higher fear of death than men . Duff and Hong (1995) revealed that persons with motivation of internal religious had lower death anxiety, and stronger belief to afterlife live was associated with lower death anxiety. Caring for the dying may trigger negative emotions such as unstable emotional equilibrium, emotional distress, grief and anguish, stress and anxiety .
Death anxiety influencing factors include demographic variables, such as age and gender, religiosity/spirituality, psychological factors, culture, environmental events, personal and professional experience, attitudes towards caring for the dying, and education [19-24].
Studies showed that females typically report higher death anxiety than males; higher education and socioeconomic status are moderately associated with lower death anxiety; older people do not typically report higher death anxiety than younger people; higher religious beliefs and practices are not necessarily associated with lower death anxiety; good physical health is associated with lower death anxiety; and more psychological problems are associated with higher levels of death anxiety [25,26].
Although there are exceptions, it is possible to summarize the association between death anxiety and several demographic and experiential factors [27-31]. Nienaber and Goedereis (2015) investigated the association between level of education and selfreported levels of anxiety regarding death of self and others among college students. On the Multidimensional Fear of Death Scale
(MFODS) and the Revised Death Anxiety Scale (RDAS), results showed that undergraduate students and graduate students did not differ on Fear of Being Destroyed, but graduate students reported lower levels of death anxiety on all remaining measures .
The thought of death causes a different degree of anxiety for different individuals, depending on many factors including education, religion, health, gender, age, culture, and psychosocial variables. Mortality salience increases death anxiety for individuals who lack meaning in life , and for individuals low in personal need for structure . Failure causes fear and self-esteem threat effects on death-anxiety [35-37]. Abeyta, Juhl, and Routledge (2014) explored the effects of self-esteem and mortality salience on proximal and distally-measured death anxiety . Juhl and Routledge (2014) showed effects of trait self-esteem and death cognitions on worldview defence and search for meaning . Tavan, Jahani, and Hekmatpour (2014) found that the academicians’ views about death concept were originated from their belief in resurrection, positive, spiritual, and death was considered as a stage in the evolution of mankind . McLennan, Bates, Johnson et al (1993), and McLennan, Sewart, Pollard et al (1997) used metaphors to assess anticipatory perceptions of personal death [41-42]. Lester (2015) reported that on the Collett- Lester Fear of Death Scale (CLFDS), fear of death was no affected by self-construing in priming students .
The great Allah (God) has mentioned about death, its realization and impossibility of escape from death in many verses of the Holy Quran (Sura Al-Imran, Verse 168; Sura Malak, Verse 2; Sura Baqarah, Verses 19, 73, 243, 258-259; Sura Jasieh, Verses 23-24; Sura Ahzab, Verses 16 & 19; Sura Enfal, Verses 5-6; Sura Al-Ankabut, Verse 57; Sura Al-Nisa, Verse 78; Sura Jumuah, Verse 8; Sura Al-Zumar, Verse 13; Sura Al-Hashr, Verse 18; Sura Al-Mu’minoon, Verse 115; Sura Yunus, Verses 4, & 56). Imani Far, Bostani, Dodman, and Raeisi (2011) compared views of Holy Quran and psychology about confront with death. They found that both of views emphasize in the willingness for immanent and the fear of death and agree with emotional reactions of individuals in the face with death and its acceptance depend on their behavior, personality, and coping mechanisms to deal with the past problems during the time of life. The most important difference between two views was the belief or non-belief in life after death that causes different operational definitions of quality of death, therapy targets and way of encounter with death .
The relationship between death anxiety and religious belief seems to be too complex to provide a simple pattern of findings. Chaggaris and Lester (1989) reported that scores on the four fear subscales of the CLFDS were not related to belief in God, an afterlife, or the subject would go to heaven, to church attendance, or whether the subject considered himself to be a religious person. Fear of one’s own of death was related to a fear of hell. There was no evidence for a strong association between fears of death and religious belief . Roshdieh, Templer, Cannon et al (1998-1999) showed a relationship of death anxiety and death depression with religion and civilian warrelated experiences in Iranians . Alvarado, Templer, Bresler and Thomas-Dobson (1992, 1995) found that religious variables related to death depression and death anxiety [47,48].
Death-related teachings are 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 in death education . Kastenbaum (2007) reported that there are difficulties in interpreting death anxiety scales: It cannot interpret death anxiety out of context of religious, cultural, and personal beliefs, low scores do not mean low death anxiety or denial, no a normal score for death anxiety, level of death anxiety which is most adaptive and productive, participants’ responses do not reflect the general population, a one-time sample of an individual’s thoughts do not give an adequate indication of death anxiety, and researchers assume that individuals would behave in a way that is consistent with their attitudes towards death anxiety .
On the Arabic Scale of Death Anxiety (ASDA), Lester, and Abdel- Khalek (2008) found that religiosity in a Muslim context and death anxiety were not associated . Abdel-Khalek and Lester (2009) reported that there were not significantly correlated between death anxiety and intrinsic religious motivation, or religiosity and strength of religious belief . Religion was the predominant predictor in the understanding of death acceptance or attitude, but the influence of racial socialization and world view were also significant contributors. World view and religion were dominant predictors in the understanding of death anxiety and racial socialization was a significant contributor . The studies on death have been performed based on the metaphysical and psychological meaning from the philosophical, cultural and religious aspects. It was also true that they were treated independently in each area with the direction of analyzing the meaning of death from the medical and social aspects [54,55].
Dennis Yoshikawa, a Shin Buddhist, explained that according to Shin Buddhist teaching, “to solve the problem of death, one must first solve the problem of life, living life. If one is able to do that, to live a truly human life, then there’s nothing to be feared by the experience of death, because the experience of death is a natural part of life [56,57]. It has been shown through results of various studies that a strong sense of religion in a person’s life can be related to a lower sense of anxiety towards the death. Although there has been no association discovered between religiosity and death anxiety, it has also been shown that death anxiety tends to be lower in individuals who regularly attend religious meetings or gatherings. On a recent study, one hundred and sixty-five church participants have been asked to fill out the “Intrinsic Religious Motivation Scale, the RDAS” and the results were analyzed using factor analyses, Pearson correlation, and linear and quadratic regression. All found an inverse relationship between intrinsic religious motivation and death anxiety. In short, the more religious you are, the less anxious you are about death because you may associate death with another beginning that is promised through many religions. The study also found that gender did not have an effect on religiosity and total death anxiety . Religiosity/spirituality is one of the dimensions of human health .
There are mechanisms that indicate religiosity and spirituality effect on mental health. Relationship between religious spiritual wellbeing and mental health was been shown in some studies [60-64]. Some studies have reported that religious attitudes toward death can be considered as a threat to mental health . Ellis, Wahab, and Ratnasingan (2013) found that religiosity is positively correlated with increase of death fear and meaning and more religious persons showed more fear from the death in the US, Turkey, and Malaysia .
Religiosity was not connected with the levels of fear of death. It seems that age is more important factor than religiosity. The thought of death causes a different degree of anxiety for different individuals; depending on many factors for example religion [66,67]. Religious attitudes are a preventive agent to reduce of problems related to death and dying issues. Religion is one of the spiritual intelligence domains that can reduce death anxiety in elders . Findings have shown that faith and believe to life after death is related to less fear of death. Persons, who were more religious, reported more less fear of death. In fact religious attitudes make persons overcome to their fear, feel more comfortable in their life and more cope with fact of death fear [69-71].
There is a relationship between religious orientation and issues related to death. Wen (2010) reported that there was a positive relationship between intrinsic religious motivation and frequency of religious service attendance and strength of belief. There was a linear and a quadratic relationship between death anxiety and intrinsic religious motivation . Ali Akbari Dehkordi, Oraki, and BarghiIrani (2011) reported that there was a negative correlation between internal religious orientations and death anxiety, and a significant positive solidarity between external religious orientations and death anxiety . There was a relationship between existential and religious variables to death depression , and between religious orientation and death obsession .
A negative association between having a Taoist orientation to life and death anxiety was found for American students but not in a Turkish students . Ben Park, Zeyrek, and Lester (2007) showed associations for a measure of having a Taoist orientation to life with death anxiety and the perception that one’s self is unified (versus fragmented) in Korean high school and Korean university students . Zeyrek and Lester (2009) found Taoist orientation was not consistently associated with fear of death and dying .
Beshai (2012) reviewed a handbook review of Abdel-Khalek’s (2005) Arabic Handbook on “Death and Dying” which presented an Islamic ontology on death anxiety. He found the Islamic ontology of death to be similar to the Judeo-Christian one. Islam provided believers with assurance of God’s mercy regardless of human vulnerability to evil. Death anxiety could be relieved by exercising moderation in relations with others . Quoting from the Qur’an, Abdel-Khalek (2005) made the claim that there was a judicious path to follow between daily distress and achieving social goals. The Arabic term to describe this path is Surat-Mustakeem, and the Farsi term is straight way. It came close to happiness. Death anxiety was neither negative nor positive in connotation. It was the ethical pursuit of a dialectic of truth and virtue. Death anxiety research showed a convergence between ontology and empirical research .
Some studies focused on relationship between religiosity and death anxiety for example [80-82]. Naderi and Roushani (2010) indicated that on the CLFDS, there was a significant correlation between spiritual intelligence and death anxiety. Spiritual intelligence was the only predicting variable for death anxiety . Mahboubi, Ghahramani, Shamohammadi, and Parazdeh (2014) reported that on the CLFDS, significant relationship between fear of death and spirituality in hemodialysis patients. There was no significant correlation between fear of death and spiritual needs .
Ali Akbari Dehkordi, Oraki, Barghi Irani, and Kimia Kiarad (2011) reported that there was a negative correlation between the internal religious orientation and death anxiety and a positive and significant correlation between the external religious orientation and death anxiety . Mansurnejad and Kajbaf (2012) showed that main effects of religious orientation on death anxiety were significant. The individuals with intrinsic religious orientation significantly reported lower levels of death anxiety than individuals with extrinsic religious orientation. Internal religious orientation seems to decrease death anxiety and is an important factor in mental health . In study of Campbell (2013), one of reason for fearing death was a non-existent or a terrible afterlife. Religious individuals may fear death more because they are afraid of the afterlife and the judgment that will be made about the way they lived their life .
Beshai and Lester (2013) found that scores on a scale to measure the belief in a Day of Judgment were associated with scores on a traditional religiosity scale, but not with fears of death and dying . On the Reasons for Death Fear Scale (RDFS), Aflakseir (2014) reported that there was positive relationship between religiosity with reasons for death fear (Fear of Pain and Punishment, and Religious Transgression and Failures) in Iranian college students . Azaiza, Ron, Shoham, and Tinsky-Roimi (2011) reported that religiosity was not related to death and dying anxiety . Ziapour, Dusti, and Abbasi Asfajir (2014) showed that there was no significant correlation between religious orientation and death anxiety in health personnel of Zare hospital staff of Iran . Amjad and Bokharey (2014) reported that three dimensions of spiritual wellness include concept of hereafter, mystery, and meaning significantly negative predicted generalized anxiety disorder symptoms . Khezri, Bahreyni, Ravanipour, and Mirzaee (2015) found that there was a significant negative relationship between spiritual wellbeing and the death anxiety; between religious dimension of spiritual wellbeing and death anxiety; and between the mean score existential dimension of spiritual wellbeing and death anxiety in patient with cancer. With increasing spiritual wellbeing, death anxiety reduced in the patients . Overall, death anxiety is influenced by a variety of factors such as religiosity, and spirituality, which can effect on mental health. Using religious spiritual approaches can reduce death anxiety and improve mental health.
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