Embedding existential psychology within psychedelic science: reduced death anxiety as a mediator of the therapeutic effects of psychedelics

The hypothesis paper (2019) reviewed the psychological mechanisms through which psychedelics can improve psychological well-being and proposes that reducing death anxiety is a key mechanism. The review called for linking existential psychology with psychedelic science so that an awareness of the role of death anxiety in psychopathology can help guide more research into psychedelic therapies in the future.

Abstract

“Psychedelic therapies can engender enduring improvements in psychological well-being. However, relatively little is known about the psychological mechanisms through which the salutary effects of psychedelics emerge. Through integrating extant research on psychedelics with contemporary existential psychology, we present a novel hypothesis that reduced death anxiety may be a key mechanism underpinning the therapeutic effects of psychedelics. In developing this hypothesis, we also provide a complimentary review of mechanisms through which psychedelics may reduce death anxiety. We conclude that an awareness of the role of death anxiety in psychopathology has the potential to guide future research into psychedelic therapies.“

Authors: Sam G. Moreton, Luke Szalla, Rachel E. Menzies & Andrew F. Arena

Summary

Psychedelic therapies can improve psychological well-being. A new hypothesis proposes that psychedelics reduce death anxiety, which may be a key mechanism underpinning the therapeutic effects of psychedelics.

Although much is known about the neurobiological correlates of mental illness, it is still not known how modern psychiatric medications reduce psychological distress. A more promising pharmacological paradigm would involve lowering the reliance on medications that aim to correct a vaguely defined “chemical imbalance” and instead turning towards substances that assist in the satisfaction of fundamental human needs.

Emerging research suggests that psychedelics can help people resolve existential concerns by increasing feelings of connectedness, meaning, and death transcendence. This article presents a hypothesis that psychedelics’ ability to reduce death anxiety may be another key mechanism contributing to their therapeutic effects.

The therapeutic potential of psychedelics

Psychedelics are drugs that act as agonists of the 5-HT2A serotonin receptor. These drugs can reveal aspects of the mind and can be blocked by delivery of a5-HT2A antagonist. Researchers are yet to unite behind a single unifying theory explaining the effects of psychedelics, but there is a broad consensus that psychedelics induce an entropic brain state involving reduced within-network connectivity but increased connectivity between typically unrelated brain networks.

Since the 1940s, there has been a revival of research into the therapeutic potential of psychedelics. Psilocybin has been found to induce experiences of “substantial and sustained personal meaning and spiritual significance”, and similar effects have been found for LSD and ayahuasca. The emerging evidence suggests that the clinical use of psychedelics may improve psychological well-being and aid in the treatment of a number of psychological disorders.

Psychedelics have been used to treat distress associated with life-threatening illness, with Aldous Huxley using LSD in his final hours to aid the process of dying. Recent studies have shown that psychedelics can reduce fear of death in terminally ill patients.

The emerging evidence suggests that psychedelics may have profound effects on both psychological well-being and death anxiety, and that these effects may be partially mediated by reductions in underlying death anxiety.

Death anxiety as a transdiagnostic construct

The last decade has seen a growing focus on the role played by transdiagnostic constructs in the development and maintenance of psychopathology. Death anxiety may be a key transdiagnostic construct contributing to the development of many psychological disorders.

Death anxiety is a transdiagnostic construct that builds on the work of existential psychotherapists and terror management theory. It suggests that individuals employ defense mechanisms to deal with the terror that emerges from the uniquely human awareness of our own mortality.

Psychopathology can emerge when insufficiently buffered death anxiety gives rise to dysfunctional coping mechanisms. This is because the anxiety can be a surrogate for other repressed fears, such as anxiety about losing one’s job or being rejected.

Evidence for the role of death anxiety in psychopathology

Clinical observation and theoretical understanding appear consistent with the central role of death anxiety in much of psychopathology, including most if not all of the anxiety disorders, panic disorder, somatoform disorders, and obsessive-compulsive disorder.

Increasing empirical evidence suggests that death anxiety may be a transdiagnostic construct, and that it may explain the symptoms of a number of disorders, including separation anxiety, hypochondriasis, OCD, and disordered eating behavior.

Research suggests that death anxiety plays a causal role in psychopathology, including spider phobia, social anxiety, OCD, and attentional bias towards threatening social cues.

Specific theoretical accounts have been proposed in relation to the role of death anxiety in trauma-related disorders, including post-traumatic stress disorder (PTSD). These accounts suggest that a disruption in the normal functioning of the death anxiety buffering system may be responsible for PTSD.

Depressive disorders are associated with increased morbid thoughts of death and a reduced endorsement of cultural worldviews, suggesting that depressed people may have a heightened need for defenses against death.

Death anxiety may contribute to a number of mental health conditions, including anxiety disorders, mood disorders, obsessive-compulsive disorders, trauma-related disorders, and somatic symptom disorders. Psychedelics may be able to help mitigate death anxiety.

Why do psychedelics reduce death anxiety?

Although it is clear that psychedelics reduce death anxiety, it is less clear exactly how they do this. We believe that a combination of factors, including forcing confrontations with one’s mortality, reducing focus on the self, shifting meta-physical beliefs, amplifying religious faith, and increasing feelings of connectedness and perceptions of the meaningfulness of life, contribute to this effect.

Exposure to a death-like experience

Existential psychotherapists have long maintained that people must confront death in order to live meaningful lives. Cognitive-behavioral treatments that involve graded exposure to thoughts of death have been found to be effective in treating death anxiety.

Psychedelic experiences frequently involve thoughts of death and deep confrontations with one’s mortality. The normal sense of self dissolves or “dies” during a high-dose psychedelic experience.

In psychedelic-assisted psychotherapy, people are exposed to thoughts of death through a single psychedelic experience, which can lead them to believe the self is dying or has died. This can reduce their fears of their inevitable physical death.

The small self

Psychedelics induce a state previously referred to as the small self, which involves feelings of humility and reduced self-focussed attention. This state may reduce death anxiety through a generalized reduced sense of the importance of the self and its concerns, including its inevitable demise.

Death transcendence

According to Richards (1978), ego death experiences involve degradation of the subject – object dichotomy to the point where there is little to no demarcation between the self and external world. This sense of unity may lead to a belief that the death of the physical body is not an absolute end of experience.

Emerging empirical evidence suggests that psychedelics can foster beliefs that death is not the end of the self. This belief is also supported by studies using samples from the general population and people with life-threatening diseases.

Amplifying religious faith

Nevertheless, it is possible that psychedelics reduce death anxiety through amplifying people’s preexisting faiths. Indeed, psychedelics have been found to increase religiosity, and can turn people away from hardline atheism.

Research suggests that intrinsic religiosity and beliefs in a literal afterlife reduce death anxiety, and that psychedelic experiences may amplify these beliefs.

Connectedness and meaning

Psychedelics may reduce death anxiety through direct mechanisms such as increased feelings of connectedness and meaning, but they may also reduce death anxiety indirectly through increased feelings of social ostracism and close attachment relationships.

Psychedelics can increase people’s feelings of connectedness to nature, which can help resolve death anxiety. This feeling is transcendental, as it positions the self as inseparable from a greater, eternal entity.

Psychedelics can generate meaningful experiences, which can buffer death anxiety. Meaning in life is linked to psychopathology, and viewing life as meaningful can buffer against the effects of mortality salience.

William James (2003) noted that a feature of mystical experiences was their “noetic quality”; a psychedelic experience is often accompanied by this sense of revelatory clarity about even mundane aspects of existence. This may be another mechanism through which psychedelics reduce death anxiety.

Integrating existential psychology into clinical psychedelic research

Psychedelics may reduce death anxiety through multiple mechanisms, and further research is needed to clarify the relative contribution of these mechanisms. Regardless of the mechanisms at play, the fact that psychedelics reduce death anxiety when used in a supportive context has clear implications for future research.

Griffiths et al. (2016) suggest that lifetime psilocybin use was associated with significantly reduced odds of past month psychological distress and suicidality. However, no extrapolation nor supporting theoretical framework has been given to death anxiety as a significant causal variable.

Although death anxiety may influence many forms of psychopathology, specific forms of psychopathology seem to be more directly related to death anxiety, such as panic disorder and the somatic symptom disorders. Although we have suggested that meaning-in-life and connectedness buffer death anxiety, we do not mean to imply that these constructs can be reduced to this function. Instead, we are suggesting that these constructs may play their own unique roles in the therapeutic effects of psychedelics.

Psychedelics can have positive effects for some people, but they can also have harmful effects for others. The confrontation with mortality provoked by psychedelics can be overwhelming for some people and provoke or exacerbate psychopathology. Psychedelics have been used safely in numerous studies involving people with life-threatening diseases, and the emerging evidence suggests that they generally tend to reduce death anxiety when used in positive contexts.

Barrett et al. (2017) found that neuroticism was related to increased openness to experience, not feeling like one was dying. This finding is consistent with the notion that confrontations with death may often have positive benefits. The dual-existential systems model posits that deep, personalized processing of mortality can lead to a growth-oriented motivational state, and that psychedelics may reduce psychopathology not only through reducing death anxiety but also through facilitating growth-related outcomes such as heightened gratitude, personal meaning, and authenticity.

Conclusion

Rollo May once suggested that psychotherapists should return their focus towards making the unconscious conscious. We suggest that psychedelics can help resolve concerns around mortality, and that this may be a significant mechanism involved in many of their therapeutic effects, even in individuals without life-threatening illness.