The January BABCP Article of the Month is from Behavioural and Cognitive Psychotherapy (BCP) and is entitled “OCD, death anxiety, and attachment: what’s love got to do with it?” by Rachel E. Verin, Rachel E. Menzies and Ross G. Menzies

The awareness of our own mortality is a central aspect of the human experience (Becker, 1973; Menzies & Menzies, 2021). Whilst death anxiety may be relevant to all of us, it appears particularly prevalent among people with mental health conditions. We have suggested that death anxiety plays a role in various mental illnesses (Iverach et al., 2014). For example, scores on questionnaires measuring death anxiety predict the severity of 12 different mental disorders (Menzies et al., 2019). These and other studies (e.g., Menzies et al., 2021, Strachan et al., 2007), suggest that fears of death may in fact be at the root of many mental illnesses.

Obsessive-Compulsive Disorder, or OCD, is one disorder which seems particularly closely linked to death anxiety (Menzies et al., 2020). The most common types of OCD can be seen as attempts to prevent death in some form. For example, compulsive handwashing can be seen as a way of preventing death by illness, whereas the checking of stovetops, electrical outlets and locks may be a means of preventing death by fire, electrocution, or home invasion. Other people with OCD may be troubled by distressing images of themselves or loved ones dying, fearing that these thoughts may magically cause these deaths to happen (Menzies et al., 2015). One study found that when we gave people with OCD a subtle reminder of death, they spent twice as long washing their hands compared to OCD sufferers who had not been made to think about death (Menzies & Dar-Nimrod, 2017).

One thing that appears to help protect many people from death anxiety is a secure attachment style; that is, a sense of trust in close relationships, as well as a feeling of confidence in being independent. People with secure attachment styles report lower fears of death on questionnaires, compared to people without a secure attachment style (i.e., those who feel uncomfortable in close relationships, or who feel anxious when separated from them; Mikulincer & Florian, 2000). However, these studies have only been conducted in the general community. We wanted to find out whether attachment styles might help buffer death anxiety among people with a mental illness; specifically, OCD. 

We conducted a study with 48 people who had been diagnosed with OCD. We gave them questionnaires which measured their fears of death, their OCD symptoms, and their attachment styles. As we expected, higher levels of death anxiety were associated with worse OCD symptoms. However, unexpectedly, attachment styles did not influence this relationship. We suspect that this is because secure attachments are not a strong enough buffer in the face of severe fears of death. It is also possible that close relationships are another source of worry among people with OCD, with many sufferers’ fears centering on the idea of losing loved ones.

We hope that clinicians reading this paper will consider the relevance of death anxiety when working with OCD. We also believe that we need more research to see whether treatments which specifically target fears of death (e.g., Menzies et al., 2021) help to improve the symptoms of OCD.

References:

Becker, E. (1973). The denial of death. NY: Free Press.

Iverach, L., Menzies, R.G., & Menzies, R.E. (2014). Death anxiety and its role in psychopathology: Reviewing the status of a transdiagnostic construct. Clinical Psychology Review, 34(7), 580-593. https://doi.org/10.1016/j.cpr.2014.09.002

Menzies, R.E., & Dar-Nimrod, I. (2017). Death anxiety and its relationship with obsessive-compulsive disorder. Journal of Abnormal Psychology, 126, 367-377.

Menzies, R.E., & Menzies, R.G. (2021). Mortals: How the Fear of Death Shaped Human Society. Sydney: Allen & Unwin.

Menzies, R.G., Menzies, R.E., & Iverach, L. (2015). The role of death fears in obsessive–compulsive disorder. Australian Clinical Psychologist, 1(1), 6-11.        

Menzies, R.E., Sharpe, L., Helgadóttir, F.D., & Dar-Nimrod, I. (2021). Overcome Death Anxiety:  The development of an online CBT program for fears of death. Behaviour Change.

Menzies, R.E., Sharpe, L., & Dar-Nimrod, I. (2019). The relationship between death anxiety and severity of mental illnesses. British Journal of Clinical Psychology, 58, 452-467.

Menzies, R.E., Sharpe, L., & Dar-Nimrod, I. (2021). The effect of mortality salience on bodily scanning behaviors in anxiety-related disorders. Journal of Abnormal Psychology, 2(999).

Menzies, R.E., Zuccala, M., Sharpe, L., & Dar-Nimrod, I. (2020). Subtypes of obsessive-compulsive disorder and their relationship to death anxiety. Journal of Obsessive-Compulsive and Related Disorders, 27, 100572.

Mikulincer, M., & Florian, V. (2000). Exploring individual differences in reactions to mortality salience: Does attachment style regulate terror management mechanisms? Journal of Personality and Social Psychology, 79(2), 260-273. https://doi.org/10.1037/0022-3514.79.2.260

Strachan, E., Schimel, J., Arndt, J., Williams, T., Solomon, S., Pyszczynski, T., & Greenberg, J. (2007). Terror mismanagement: Evidence that mortality salience exacerbates phobic and compulsive behaviors. Personality and Social Psychology Bulletin, 33(8), 1137-1151. https://doi.org/10.1177/0146167207303018

From Paul Salkovskis, the Editor-in-Chief of BCP: Why I chose this article:

Therapists working with anxiety problems focus on threat, along the lines of “when you felt anxious, at that time what did you think was the worst thing that could mean”. Death, and responsibility for it, is typically top of any list, and in this month’s featured article the authors offer some important clues as to the role beliefs about (and fears of) death may play in OCD. Another feature of this important article is the way in which findings noted in healthy community samples, linking insecure attachment to fear of death, do not generalise to those with diagnosable OCD.  Once a problem such as OCD has established the kind of vicious circles involved in its maintenance, it can be that factors which may have been involved in the original inception of the problem are overshadowed.

The researchers in this article have provided a clear indication of the importance of the association between threat and responsibility perceptions and the severity of OCD symptoms. Helping people we try to help give voice to their fears of death is likely to make a significant contribution to reducing anxiety. Future research will clarify the extent to which this is specific to OCD or is a trans-diagnostic factor.

Author Bio:

Dr Rachel E. Menzies is a Clinical Psychologist and Postdoctoral Research

Fellow at The University of Sydney, Australia. Her research on the role of death anxiety in mental health conditions has won multiple awards. She has delivered workshops on treating death anxiety across 7 cities, hosted by the Australian Association for Cognitive and Behaviour Therapy (AACBT). She is the author of several books on the topic of death anxiety, and most recently co-authored Mortals: How the Fear of Death Shaped Human Society.