In Barbie, Margot Robbie’s pretty and pink “Stereotypical Barbie” is in crisis. She has cellulite — and she can’t stop thinking about death.
That existential concern is what drives much of the drama in the blockbuster film. And though it never quite reaches the level of full-blown pathology for Robbie’s Barbie or America Ferrara’s Gloria, who also struggles with “irrepressible thoughts of death,” it certainly raises a question: When does the fear of death — actually called thanatophobia, but also known as a preoccupation with death, having intrusive thoughts of death and “death anxiety” — constitute a mental-health crisis?
“There are many terms which people use to talk about this fear, and often they are used interchangeably,” explains Rachel Menzies, psychologist, prominent death-anxiety researcher and director of the Sydney, Australia-based Menzies Anxiety Centre, for the “psychological treatment of death-anxiety and related conditions.”
“There is currently no formal diagnosis for death anxiety, although some people consider it a type of specific phobia,” she tells Yahoo Life. “However, you can think of death anxiety as a normal and universal part of being human, in that all of us have to grapple with our awareness of death and the discomfort that can come with this. When the anxiety becomes more severe, this is when it is particularly important to seek help.”
Menzies stresses that “all of us can likely benefit from facing our mortality and normalizing death,” which is partly why she so appreciated Barbie, which she recently watched. “I thought it did an excellent job at depicting and normalizing death anxiety … I’ve already had a few conversations with patients about it and it seems to have really struck a chord with people.”
Death anxiety, in general, she explains, “refers to any negative feeling people may have about death or dying. This can include feelings of fear, dread or sadness. It is completely normal to think about death, and death anxiety exists on a spectrum, such that some people will experience only mild discomfort about death and dying, whereas others may experience intense distress.”
It can also, when harnessed correctly, be a positive force in our lives, according to psychologist David Rosmarin, founder of Center for Anxiety in New York and Boston and Harvard Medical School associate professor. “On one hand, it’s a good thing, because death is inevitable, and being aware of our mortality can have positive effects: It can make us more humble, it can make us think twice before we do certain things, it can make us more cautious, it can make us think about issues of greater meaning and purpose and why we’re here,” he tells Yahoo Life. “So, it’s a double-edged sword.”
Here’s what to know about death anxiety.
Take note if anxiety over death disrupts your daily existence
“When it becomes invasive and disrupts your normal functioning, or interferes with your quality of life, then it’s problematic,” Elaine Eshbaugh, professor of gerontology at the University of Northern Iowa who has researched death anxiety, tells Yahoo Life.
Other red flags are if it impacts your relationships or work life, adds Menzies, who says, “If people are finding that they are routinely troubled by thoughts of their own death or that of others, or that it is impacting their mood, or leading to unhelpful coping behaviors, this is usually a sign that they could benefit from getting professional support.”
Rosmarin says that having severe enough death anxiety to warrant treatment is a rarity, noting, “We see more than 1,000 patients a year, but if we see one or two with death anxiety, that would be a lot.” Similarly, he says, thanatophobia is a “rare phobia — it’s not like, snakes, heights, planes, death.”
Anxiety around death is typically not the only symptom at play
“For people with severe death anxiety, it would be unlikely that they’d only be anxious about that,” notes Eshbaugh, who explains that it’s “related to generalized anxiety disorder [GAD], so it’s rare to have an overwhelming fear of death and no other anxieties.”
Rosmarin adds that, with GAD, “people have multiple worries, and often they pertain to death, but typically it’s not about them but their kids or their loved ones — did their flight land? Do they have a disease?”
While death anxiety is not a mental health diagnosis in and of itself, it would typically present itself as part of a “constellation of symptoms,” says Eshbaugh — not only of GAD but also possibly part depression, post-traumatic stress disorder (PTSD) or obsessive-compulsive disorder (OCD), which would bring with it a “more irrational death anxiety, such as, ‘if I don’t [tap the table] 47 times I’m going to die,’” she says.
Menzies, in fact, found in one study that, “Across 12 different disorders, death anxiety significantly predicted symptom severity.”
There are factors that can make some more susceptible than others
Barbie may or may not find comfort in one of Eshbaugh’s findings, which is there’s “a higher rate of death anxiety among females.” Also seen in women, and a contributing factor, is “a higher rate of ruminative thought, meaning you can’t let go of something, and that you tend to ruminate or perseverate on an issue, no matter what that is,” she says.
Another factor, says Eshbaugh, is the level of interactions and familiarity with older adults — and that the lower the level, the higher the possibility of having death anxiety seems to be. Similarly, “in general, the more exposure you have had to death, the less death anxiety you have.” For individuals who actually are closer to death, either through age or illness, she adds, “it either goes up or it goes down — some of death anxiety is fear of the unknown, and when you’re in hospice, for example, you have a little less fear of the unknown. So sometimes you find the death anxiety is actually going to decrease.”
Approaches to treatment
A therapist’s approach will largely depend on the related diagnosis, says Eshbaugh, so if a patient is dealing with PTSD, for example, then trauma-therapy approaches such as EMDR can be effective. If the anxiety over death is a manifestation of clinical depression, then one would treat the depression, using therapy and maybe medication, “because when we’re talking about obsessive and ruminating thoughts, sometimes medication is really helpful.”
But generally speaking, says Menzies, who coauthored Free Yourself from Death Anxiety: A CBT Self-Help Guide for Fear of Death and Dying, it’s CBT (Cognitive Behavior Therapy), which is “the most evidence-based treatment for death anxiety. This involves addressing unhelpful beliefs which may underlie the anxiety, as well as managing behaviors which we know drive anxiety, such as avoidance behaviors, reassurance seeking, and so forth.”
The clinicians at Rosmarin’s center all work with CBT, which he says is “focused on change,” as well as DBT (Dialectical Behavior Therapy), which is “a broader approach, but balances change with acceptance, because sometimes you can’t make those changes and you have to learn to sit with the fact that we’re imperfect.”
It’s something Barbie (spoiler alert!) decided she’s ready to sit with, choosing life — with all of its imperfections and promise of death — over her bright pink fantasy world.
“Death anxiety can make life harder, but it can also make life better, and if we use it to have a better sense of meaning, of purpose, and to avoid impulsive, dangerous things, all of that is actually very positive,” Rosmarin says. “Barbie decides it’s better to be a human and have the uncertainty.”