Journal of Abnormal Psychology © 2017 American Psychological Association

2017, Vol. 126, No. 4, 367–377 0021-843X/17/$12.00 http://dx.doi.org/10.1037/abn0000263

Death Anxiety and Its Relationship With Obsessive-Compulsive Disorder

Rachel E. Menzies and Ilan Dar-Nimrod
The University of Sydney

The studies presented in this article explored the relevance of death fears to Obsessive Compulsive
Disorder (OCD). In Study 1, the relationships between death anxiety and a variety of markers of
psychopathology were examined in 171 treatment-seeking participants with OCD. Moderate to large
correlations between Collett-Lester Fear of Death scale scores, taken at initial assessment, and clinical
ratings of OCD severity, number of hospitalizations, number of medications, and total number of lifetime
anxiety-related diagnoses identified in structured diagnostic interviews were obtained. Study 2 used the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

mortality salience (MS) paradigm to examine whether experimentally manipulated death cognitions
This document is copyrighted by the American Psychological Association or one of its allied publishers.

exacerbate compulsive cleaning behaviors among OCD washers. Treatment-seeking participants with
OCD (66 washers and 66 nonwashers) were randomly allocated to either a MS or dental pain priming
condition. Following priming, participants completed a series of distraction tasks involving skin con-
ductance recording, before being offered an opportunity to wash conductive gel off their hands. As
hypothesized, washers went to greater efforts in cleaning (as measured by washing duration and soap and
paper towel use) than nonwashers. Similarly, participants in the MS condition showed greater cleaning
than those in the dental pain salience condition. However, these main effects were qualified by significant
interactions for both washing duration and soap use. As expected, simple effect contrasts revealed that
the effect of MS on cleaning behaviors was significant for washers but not for nonwashers. Clinical
implications and directions for future research are discussed.

General Scientific Summary

These studies suggest that death anxiety is positively associated with severity of symptoms and
distress among individuals with obsessive-compulsive disorder, and that thoughts of death may
increase cleaning behaviors among compulsive washers.

Keywords: obsessive-compulsive disorder, mortality salience, death anxiety, terror management theory,
washing

The fear of death has appeared throughout recorded human Iverach, Menzies, and Menzies (2014) have recently proposed
history, frequently serving as the subject of literature, art, and that the dread of death should be viewed as a transdiagnostic
cultural and religious practices (Becker, 1973). The conscious construct with the potential to underpin a range of mental disor-
awareness of our own mortality, arguably a capacity unique to ders. For example, fear of death appears to lie at the heart of the
humans, was famously described by William James as “the worm somatoform disorders, with body scanning, palpating of lymph
at the core” of our existence (James, 1985/1902, p. 119). Yalom nodes, and requests for repeated medical tests featured heavily
(2008, p. 1) proposes the fear of death to be central to the struggles (Iverach et al.). Similarly, those with panic disorder frequently
of many individuals, stating that humans are “forever shadowed by attend emergency services and request repeated consultations with
the knowledge that we will grow, blossom, and inevitably, dimin- cardiologists due to stated fears of sudden cardiac arrest (Fleet &
ish and die.” Notably, while death anxiety may be associated with Beitman, 1998). Many adults with a related disorder, agoraphobia,
the emergence of positive coping mechanisms (e.g., pursuing report that avoidance of unfamiliar places and refusal to travel
meaningful achievements or extending the self through personal without security figures (e.g., a partner or a close friend) is
relationships), it can also lead to the development of crippling intended to prevent death from sudden misadventure or collapse
terror and maladaptive coping strategies (e.g., Menzies, 2012; (Foa, Steketee, & Young, 1984). Further, Marks (1987) notes that
Mikulincer, Florian, & Hirschberger, 2003; Stolorow, 1979). the majority, if not all, of the specific phobias are associated with
objects or situations that could result in death (e.g., heights, snakes,
spiders, blood, water). Even the anxiety disorders of the young
appear to involve fears of death. For instance, separation anxiety
disorder involves persistent worry about losing major attachment
This article was published Online First March 9, 2017.
Rachel E. Menzies and Ilan Dar-Nimrod, School of Psychology, The
figures, including loss through death (APA, 2013). In addition,
University of Sydney. social anxiety disorder, although lacking any obvious connection
Correspondence concerning this article should be addressed to Rachel E. with concerns about mortality, may potentially be similarly driven
Menzies, School of Psychology, The University of Sydney, Griffith Taylor by death anxiety. For example, individuals with high levels of
Building (A19), NSW 2006, Australia. E-mail: [email protected] social anxiety have been found to demonstrate significantly higher

367
 368 MENZIES AND DAR-NIMROD

levels of social avoidance when reminded of their own death which has garnered support from hundreds of studies to date (e.g.,
(Strachan et al., 2007). However, unique features of social anxiety Arndt, Greenberg, Solomon, Pyszczynski, & Simon 1997; Dar-
disorder that seem devoid of any clear connections with death Nimrod, 2012; Greenberg et al., 1992), proposes that divergent
preclude us from making any strong theoretical claim about the outcomes arise from conscious and nonconscious death cognitions.
role of death anxiety in this specific disorder. According to the dual process model (Pyszczynski, Greenberg, &
Along similar lines, Menzies, Menzies, and Iverach (2015) have Solomon, 1999), conscious thoughts of death trigger proximal
argued that death anxiety plays a central role in many presentations defense mechanisms, involving suppression of death-related
of Obsessive Compulsive Disorder (OCD), the most prevalent thoughts and denial of one’s vulnerability. In contrast, when fears
forms of which are dominated by washing and checking behaviors, of death are unconscious, distal defenses are activated to mitigate
respectively (Krochmalik & Menzies, 2003). Many compulsive such fears, including bolstering of self-esteem or defense of cul-
washers explicitly associate their behavioral responses with anxi- tural worldviews. Thus, the effects of death anxiety may differ
ety about fatal diseases, toxins, poisons, and bodily fluids, stating depending on whether or not thoughts of death are the focus of
that these may cause contamination and death (St. Clare, Menzies,
current attention.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

& Jones, 2008; Jones & Krochmalik, 2003). Disgust sensitivity,

Given that TMT posits that nonconscious death thoughts give
This document is copyrighted by the American Psychological Association or one of its allied publishers.

which is associated with contamination-based symptoms of OCD

rise to paralyzing fear, Strachan et al. (2007) argued that individ-
(Berle & Phillips, 2006), also appears to be associated with fear of
uals who employ ineffective strategies to manage anxiety will
death (Haidt, McCauley, & Rozin, 1994). Similarly, compulsive
increase the manifestation of such strategies following reminders
checkers may repeatedly inspect electrical outlets, cooktops, heat-
ers, and door and window locks in a reported attempt to prevent of their own mortality. To test this assertion, Strachan et al. used
potentially fatal fire, electrocution, or home invasions (Vaccaro, the mortality salience (MS) paradigm (e.g., Arndt et al., 1997;
Jones, Menzies, & St. Clare, 2010). Some patients appear to fear Rosenblatt et al., 1989), a manipulation designed to activate death
that their intrusive death thoughts by themselves could magically cognitions, to explore the impact of priming participants with
cause the death of loved ones. Such individuals may use any reminders of their death on cleaning behaviors among students
means, including superstitious tapping, blinking, or counting ritu- with varying sensitivity to contamination. Specifically, the study
als, to prevent death (Einstein & Menzies, 2003). Even among included 23 students with high contamination sensitivity [termed
OCD sufferers with pure obsessions, in which behavioral mani- high washer (HW) group] and 23 students with low contamination
festations are largely absent, themes of death are common. For sensitivity [termed low washer (LW) group] on the measure. These
example, some individuals with aggressive obsessions fear that participants were randomly allocated to a MS condition or a social
they may inadvertently, in an altered state of awareness, take their exclusion salience condition. Following the manipulation and the
own life or the life of a loved one (Einstein & Menzies). necessary distractor task (Pyszczynski et al., 1999), the experi-
Laboratory studies on compulsive washing are consistent with menter explained that they would then be connected to a physi-
the aforementioned verbal reports of OCD sufferers. In one study ograph machine. They were told that the purpose was to provide
(Jones & Menzies, 1997a), OCD washers placed their hands into a initial testing of some new laboratory equipment. After two min-
compound mixture of soil, food scraps, raw meat, and animal hair, utes of apparent monitoring of the incoming data, the experimenter
submerging them for as long as possible, up to a maximum of 5 removed the sensors and gave them access to a basin, a liquid soap
min. At 1-min intervals during the hand immersion task, partici- dispenser, and paper towels to wash off the conductive gel. In
pants were asked to assess the severity of any potential illness, addition to main effects for washer-status and salience conditions,
ranging from “no noticeable symptoms” to “death certain” (p. MS increased the duration of hand washing only among the HW
846). Compared to non-OCD controls, participants with OCD participants. No effects were found for supplementary analyses on
perceived increased severity. Moreover, the severity of illness paper towel or soap usage, though trends in the expected direction
rating was strongly associated with various aspects of OCD symp- were observed.
tomatology (e.g., urge to wash ratings, and time spent washing
Thus, Strachan et al. (2007) found that people who are worried
after the task). That is, consistent with other models of OCD
about contamination engaged in exaggerated cleaning when death
symptomology (e.g., Tolin, Worhunsky, & Maltby, 2006), partic-
is nonconsciously activated. However, it may be premature to
ipants’ avoidance of perceived contamination was congruent with
draw inferences from this study to clinical populations for a
their overestimation of the likelihood of contracting a severe
number of reasons. First, the sample in that study was taken from
illness. Most notably, when scores on the single item severity of
illness or death certainty scale were held constant, no other pre- a normative, student population rather than a clinical one, limiting
dictor, including perfectionism, inflated perceived responsibility, our ability to draw conclusions about individuals with actual
and self-efficacy, remained significantly associated with any OCD anxiety-related disorders. Second, a control condition with similar
measure. levels of anxiety or with other compulsive tendencies was not
The last three decades have seen much attention directed toward employed, limiting the ability to establish whether it was washing
better understanding the implications of existential anxiety among tendencies or general obsessional tendencies of the experimental
nonclinical populations. Terror Management Theory (TMT) is the group that made participants vulnerable to the MS effect. Third,
central theoretical approach guiding this research (see Greenberg, with 23 participants per condition, the study may have been
2012, for a review). TMT broadly argues that self-preservation underpowered; in order to detect a medium-sized main effect (d ⫽
instincts, coupled with the knowledge that one’s demise is certain, 0.5), 132 participants would have been required to obtain power to
have the power to produce crippling fear of death (Rosenblatt, the level of 0.8. The failure to obtain effects on paper towel and
Greenberg, Solomon, Pyszczynski, & Lyon, 1989). The theory, soap usage may reflect the relatively modest power of that study.
 DEATH ANXIETY AND OCD 369

Overview of Current Studies (12 items), Hoarding (7 items), Just Right (12 items), and Indeci-
siveness (6 items), and each item is rated on a 5-point response
Despite theoretical accounts (Iverach et al., 2014; Menzies et al., scale. The VOCI has shown good psychometric properties (Thor-
2015), to the best of our knowledge, no research has empirically darson et al.).
examined the relationship between fear of death and symptoms of The Collett-Lester Fear of Death Scale (CLFD; Collett &
anxiety-related disorders in clinical populations to date. Thus, Lester, 1969). A 36-item measure with four subscales: Death of
given suggestive evidence of the role of death-related fears in Self (9 items), Death of Others (10 items), Dying of Self (6 items),
OCD (e.g., Jones & Menzies, 1997a; Strachan et al., 2007), as well and Dying of Others (11 items). Items are rated on 6-point re-
as the aforementioned verbal reports of individuals diagnosed with sponse scales. The CLFD subscales have shown good psychomet-
OCD, we conducted two studies to address this important area of ric properties (Rigdon & Epting, 1985).
research in relation to this disorder. In the first study, we explored The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1965).
the relationship between fear of death and multiple manifestations The RSES was administered to participants, but was not included
of OCD severity and mental health history. In the second study, we in analyses for the present study.
manipulated distal death cognitions to examine actual experimen-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Big Five Inventory (BFI; John & Srivastava, 1999). A 44-

tal effects among OCD patients.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

item self-report measure of personality, the BFI has shown good

psychometric properties (Denissen, Geenen, van Aken, Gosling, &
Study 1 Potter, 2008; John & Srivastava, 1999), and includes eight items
assessing the personality domain of neuroticism. This measure was
In Study 1, the relationship between subscale scores on the completed at a later time point, by a subsample of participants
Collett-Lester Fear of Death Scale and OCD severity was exam- from the present sample who met criteria to participate in Study 2
ined. It was hypothesized that (a) OCD severity would be posi- (see further below).
tively correlated with all fear of death subscales. In addition, a first
test was conducted of Iverach et al.’s (2014) proposition that Results
individuals with a complex (i.e., different diagnoses at different
times) and severe mental health history may simply be displaying Characteristics of the sample are reported in Table 1. The
chronic, high-level fear of death that is attaching to relevant stimuli participants, on average, had experienced extensive mental health
across the life span. Consistent with this proposal, it was hypoth- difficulties across the lifetime, with an average of three diagnoses
esized that (b) fear of death scale scores would be positively on the ADIS-5L, high levels of medication use, and an average
related to the total number of anxiety and mood-related psychiatric OCD duration of 13 years.
diagnoses across the lifetime, number of prior hospitalizations, As hypothesized, positive correlations were found between all
number of medications used, and clinician ratings of overall clin- four CLFD subscales and ratings of overall OCD severity, as
ical impairment. measured by the VOCI and the ADIS-5L OCD severity score (see
Table 2). Further, as hypothesized, all CLFD subscale scores were
positively correlated with both objective (e.g., the number of prior
Method hospitalizations) and subjective (the clinician’s ADIS-5L rating of
Participants. At a large group psychology practice in Sydney, overall distress and impairment) measures of lifetime pathology.
Australia, 183 patients identified with OCD at their first interview Many of these correlations were quite substantial (over 70% of
were offered inclusion in the study by assessing clinicians; 175 them eclipsed r ⫽ .40).
agreed to participate. These individuals completed the Anxiety and In addition, to assess whether these results could be explained
Related Disorders Interview Schedule for DSM–5, Lifetime Ver- by a third variable, neuroticism, analyses were conducted in a
sion (ADIS-5L; Brown & Barlow, 2014), and a battery of addi-
tional measures (see below). Four individuals failed to satisfy Table 1
criteria for a current diagnosis of OCD on the ADIS-5L, leaving Summary of Study 1 OCD Sample Characteristics (N ⫽ 171)
171 participants (76 female). The study was approved by the
University of Sydney Human Research Ethics Committee. Measure M SD
Procedure. At an initial testing session, all participants com- VOCI total score 77.68 36.25
pleted the following measures: ADIS-5L OCD severity 6.06 1.36
The ADIS-5L (Brown & Barlow, 2014). This structured clin- ADIS-5L distress/impairment 6.24 1.45
ical interview is designed to establish current and lifetime diagno- Total no. of medications 1.86 1.76
No. of hospitalizations .31 .61
ses for anxiety, mood, obsessive-compulsive, and related disor- Total ADIS-5L diagnoses 3.22 1.84
ders. It uses the criteria of The Diagnostic and Statistical Manual OCD duration (years) 13.11 7.36
of Mental Disorders, Fifth Edition (DSM–5; APA, 2013). Previous RSES 24.65 5.55
editions of the ADIS have been shown to have good interrater CLFD death of self 8.07 10.48
CLFD death of others 6.39 10.14
agreement and reliability for the majority of DSM–IV disorders CLFD dying of self 5.06 6.61
(Brown, Di Nardo, Lehman, & Campbell, 2001). CLFD dying of others .16 11.55
The Vancouver Obsessive Compulsive Inventory (VOCI;
Note. ADIS-5L ⫽ Anxiety and Related Disorders Interview Schedule for
Thordarson et al., 2004). This widely used self-report instru- DSM-5—Lifetime Version; CLFD ⫽ Collett-Lester Fear of Death Scale;
ment measures obsessive-compulsive behavior using six sub- OCD ⫽ obsessive-compulsive disorder; RSES ⫽ Rosenberg Self-Esteem
scales: Contamination (12 items), Checking (6 items), Obsessions Scale; VOCI ⫽ Vancouver Obsessive Compulsive Inventory.
 370 MENZIES AND DAR-NIMROD

Table 2 ipants in a MS condition would show greater washing behavior

Summary of Pearson Correlations Among CLFD Subscales and than those in a control condition, and (c) an interaction between
Markers of Clinical Severity salience condition and OCD type would emerge; specifically, the
increase in cleaning associated with death priming, would be
Death Death of Dying Dying of greater for OCD washers than for OCD nonwashers.
Measure of self others of self others

VOCI total .46ⴱⴱ .56ⴱⴱ .41ⴱⴱ .33ⴱⴱ

ADIS-5L OCD severity .56ⴱⴱ .58ⴱⴱ .48ⴱⴱ .41ⴱⴱ Method
ADIS-5L total diagnoses .56ⴱⴱ .38ⴱⴱ .49ⴱⴱ .43ⴱⴱ
Participants. From the 171 participants who completed Study
ADIS-5L distress/impairment .64ⴱⴱ .56ⴱⴱ .58ⴱⴱ .51ⴱⴱ
No. of hospitalizations .34ⴱⴱ .25ⴱ .38ⴱⴱ .32ⴱⴱ 1, equal groups of OCD washers and nonwashers were sought. For
Total no. of medications .48ⴱⴱ .36ⴱⴱ .43ⴱⴱ .40ⴱⴱ inclusion in the washer group, a twofold decision rule was used.
First, on the ADIS-5L participants had to receive a 6 (i.e., “fre-
Note. ADIS-5L ⫽ Anxiety and Related Disorders Interview Schedule for
DSM-5—Lifetime Version; CLFD ⫽ Collett-Lester Fear of Death Scale; quently”) or higher on the 8-point clinician rating scale for the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

OCD ⫽ obsessive-compulsive disorder; VOCI ⫽ Vancouver Obsessive “current washing” item. Second, as the VOCI has been shown to
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Compulsive Inventory. discriminate between washer and nonwasher groups (Thordarson

ⴱ
p ⬍ .01. ⴱⴱ p ⬍ .001. et al., 2004), participants had to score a minimum of 14 on the
contamination scale (one standard deviation below the mean iden-
tified for “washer-cleaners”: Thordarson et al.). For inclusion in
subsample of 130 participants, using data made available through
the nonwasher group, participants had to receive a score of 2 (i.e.,
Study 2 (see further below). Regression analyses revealed that
“rarely”) or lower on the ADIS-5L’s “current washing” rating
CLFD scores significantly predicted all of the aforementioned
scale as well as score 11 or lower on the contamination scale of the
markers of severity above and beyond the effects of neuroticism
VOCI. Applying these inclusion criteria led to 39 participants
(all ⌬R2’s ⬎ .163, p’s ⬍ .0001).
being excluded, leaving 132 participants (56 female) in the final
sample. The study was approved by the University of Sydney
Discussion Human Research Ethics Committee.
Consistent with the first hypothesis, moderate to large positive Design. OCD washer (n ⫽ 66) and OCD nonwasher (n ⫽ 66)
correlations were found between OCD severity and CLFD scores. participants were randomly allocated to either the MS (n ⫽ 66) or
That is, greater fear of death was associated with more severe dental pain salience (n ⫽ 66) conditions, yielding a 2 (OCD type:
manifestations of OCD, whether measured by self-report or clini- washer vs. nonwasher) ⫻ 2 (Salience condition: mortality vs.
cian ratings. Further, all subscales of the CLFD were positively dental pain) factorial design. The dependent variables were time
related to OCD severity. This is consistent with clinical observa- spent washing, number of paper towels used, and the amount of
tions that many OCD sufferers fear causing harm to others as much soap used.
as death to themselves (Salkovskis, 1985). Finally, as expected, Materials.
each CLFD subscale was also positively associated with (a) total Salience questionnaire. Participants in the MS condition were
number of lifetime ADIS-5L diagnoses, (b) total number of hos- asked two open-ended questions extensively used in TMT research
pitalizations, (c) total number of medications used, and d) clinician to prime death thoughts: (a) “Please briefly describe the emotions
ratings of ADIS-5L overall distress and impairment, supporting that the thought of your own death arouses in you,” and (b) “Jot
Iverach et al.’s (2014) suggestion that greater fears of death and down, as specifically as you can, what you think will happen to
dying are associated with more severe and complex lifetime men- you as you physically die and once you are physically dead” (e.g.,
tal health problems. Arndt, Greenberg, Simon, Pyszczynski, & Solomon, 1998, p.
A significant limitation of a correlational design is the ability to 1218). In the second condition, which employed commonly used
draw causal inferences. It is possible, for example, that developing control stimuli, participants were asked two similar questions
OCD may later increase fear of death as individuals seek out more about dental pain (e.g., Long & Greenwood, 2013). The dental
information over time about possible threats in the environment. pain questions mirrored the aversive nature of the MS questions,
Alternatively, a third variable may be the central driver of both while not being inherently death-related.
death fears and the mental health problems of the participants. As Big Five Inventory (BFI; John & Srivastava, 1999). A 44-
such, fear of death may in fact be a surface-level symptom for item, self-report measure of personality, the BFI was primarily
some individuals, rather than the true underlying cause of other used in Study 2 as a filler measure to disguise the importance of
mental health difficulties. In order to explore the causal effects of the salience questionnaire by making it part of a larger package.
death cognitions in OCD, Study 2 utilized an experimental design. Positive and Negative Affect Scales—Expanded Form
(PANAS-X; Watson & Clark, 1994). A 60-item, self-report
measure that assesses the individual’s current positive and nega-
Study 2
tive affect, the PANAS-X was included to assess the affect of the
Study 2 was an extension of the work of Strachan et al. (2007), participants following the experimental salience manipulations.
addressing the methodological and generalizability issues raised This ensured that any effect on time spent washing could be
and extending its scope. It is the first study to incorporate the MS attributed to the MS induction, and not to a differential change in
paradigm with a community sample of OCD patients. It was mood between the two conditions.
hypothesized that: (a) OCD washers would expend greater efforts Comfort and cleanliness scales. Adapted from Strachan et al.
in cleaning after contamination than OCD nonwashers, (b) partic- (2007), two final questions were administered to participants: (a)
 DEATH ANXIETY AND OCD 371

“How comfortable did you feel being connected to the physi- audio recording was to allow a precise, covert recording of the
ograph machine?” and (b) “How clean did you find the experi- washing duration that was to follow. The data displayed on
mental room and sink area to be?” Both questions were rated on the iPad was left facing the participants for 10 s to enhance believ-
9-point response scales, with higher ratings reflecting more posi- ability that the study was about physiological reactions to perfor-
tive responses. These were included to ensure that potential dif- mance conditions. After this time, the screen was turned away to
ferences between the groups could not be explained by varying minimize any confounding differences between conditions.
perceptions of comfort or cleanliness in the laboratory or during After five minutes, the experimenter terminated the GSR testing
the procedure. session, disconnected the sensors, and informed participants that
Procedure. At the initial assessment, as detailed in Study 1, the gel could be washed off in the neighboring room. The sink area
all participants completed a number of self-report measures. Indi- was washed and wiped clean between experimental sessions. One
viduals who met the inclusion criteria for the washer and non- full roll of disposable paper towels sat beside the sink and an open
washer groups took part in Study 2 two to three weeks after the plastic bin stood next to the sink with three used paper towels in
initial assessment. view. The soap dispenser was nontransparent, and always filled
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

After providing consent, participants learned that the experiment with between 235 and 245 ml of clear, unscented liquid soap. It
This document is copyrighted by the American Psychological Association or one of its allied publishers.

involved two phases. The experimenter explained that the first had been weighed prior to each participant so that the amount of
phase consisted of a series of personality questionnaires, whereas soap used could be calculated after each individual was tested. The
the second involved a test of the effects of a performance task on experimenter then left the room to allow the participant privacy to
arousal among individuals with OCD. Participants were informed clean his or her hands.
that during the second phase their physical arousal would be The time spent washing was recorded from the moment the tap
measured with a galvanic skin response (GSR) sensor, as they was turned on until it was turned off. The number of paper towels
completed a word search performance task. The word search task and amount of soap used were recorded also. After hand washing
was included to allow sufficient time for any effects of the MS was completed, each participant was given the cleanliness and
induction to be outside of conscious awareness in line with the comfort measures to assess comfort during the GSR task and
theoretical foundation and experimental practices of TMT (e.g., perceived cleanliness of the experimental room. All participants
Norenzayan, Dar-Nimrod, Hansen, & Proulx, 2009). were then probed as to the aim of the study, in order to exclude any
Participants were then instructed to work through the packet of participant who identified the dependent variables of interest (i.e.,
questionnaires in order, and the experimenter left the room to cleaning behaviors). None of the participants showed any suspi-
allow privacy. The questionnaires came in a set order: (a) Salience cion regarding the death manipulation or the cleanliness measures.
prime, (b) Big Five Inventory, and (c) PANAS-X. Recent meth- Finally, participants were fully debriefed and thanked.
odological discourse has amplified the emphasis on the need to
blind to reduce the researchers’ bias in experimental designs (e.g.,
Forbes, 2013). As such, an administrative officer placed the ques- Results
tionnaire pack (i.e., with MS or dental pain salience included) in a
sealed envelope prior to each testing session, based on a stratified Primary Analyses.
block (for OCD type: washers vs. nonwashers) random allocation OCD group characteristics. Table 3 presents severity and
table. Thus, the experimenter was blind to both OCD group mem- washing-related summary data for the two OCD groups, whereas
bership (i.e., washer and nonwasher) and salience group member- Table 4 presents the distribution of the additional diagnoses of the
ship (i.e., MS and dental pain conditions). The participants were overall sample. Analyses were conducted in order to confirm that
instructed to put the questionnaires back into the envelope once the twofold decision rules for group membership did indeed pro-
they were completed, and to alert the experimenter in the attached duce two distinct groups of participants with OCD (i.e., washers
room that they were ready for the second phase of the study. and nonwashers). A univariate ANOVA revealed a significant
Once these were completed, participants were introduced to the difference between the groups in the VOCI washing subscale
GSR machine. The setup included a mobile sensor to measure the scores, F (1, 130) ⫽ 232.65, p ⬍ .001, ␩2 ⫽ .642, 90% CI [.56,
participant’s GSR during the experimental session. Two electrodes .70]. Similarly, a significant difference was found in the ADIS-5L
on the fingertips were connected to an iPad Air 2, supported with “current washing” scores of the washer and nonwasher groups, F
a Native Union Gripster stand in full view of the participant, which (1, 130) ⫽ 1,389.17, p ⬍ .001, ␩2 ⫽ .914, 90% CI [.89, .93].
displayed the data using the eSense Skin Response application. Further analyses were conducted in order to determine if the two
The experimenter rubbed a small amount of conductive gel on the OCD groups differed on a potential confound, namely, overall
index and middle fingertips of the participant’s nondominant hand disorder severity. No significant differences (all p’s ⬎ .05) were
before attaching the two electrodes. The experimenter explained found between the two OCD groups for any of the following:
that this gel would help to increase the accuracy and sensitivity of ADIS overall distress and impairment, total VOCI score, total
the electrodes, and the recorded physiological data. In actuality, OCD ADIS-5L severity, total number of medications, number of
the entire GSR component was used in order to give participants a hospitalizations, duration of OCD illness, total number of
reason to wash the gel off their hands at the end of the protocol. ADIS-5L lifetime diagnoses, and current number of ADIS-5L
Participants were instructed that they had five minutes in which lifetime diagnoses. Importantly, there were no significant differ-
to work on the word search task, and that they must call out each ences between the groups on the CLFD subscales (all F’s ⬍ 0.2,
word as it was found to enable audio recording of their perfor- p’s ⬎ .65). Thus, by and large, the two groups appear to be
mance. They were told that the recording was to allow GSR levels comparable in terms of OCD severity, general dread of death, and
to be charted for each word identified. The actual purpose of the clinical levels of impairment.
 372 MENZIES AND DAR-NIMROD

Table 3 125) ⫽ 7.3, p ⬍ .001, Wilks’ ␭ ⫽ .849, ␩2 ⫽ .15, and OCD type,
Summary of Characteristics of the OCD Groups F (1, 125) ⫽ 11.63, p ⬍ .001, Wilks’ ␭ ⫽ .779, ␩2 ⫽ .22, as well
as a significant interaction effect, F (1, 125) ⫽ 3.96, p ⫽ .01,
OCD group Wilks’ ␭ ⫽ .912, ␩2 ⫽ .088. Given the significance of the overall
Washers Non-washers test, the univariate main effects were examined. Three 2 (OCD
(n ⫽ 66) (n ⫽ 66) type) ⫻ 2 (salience condition) univariate ANOVAs were per-
Measure M SD M SD formed on time spent washing, the amount of soap used, and the
ⴱ ⴱ number of paper towels used.
VOCI washing score 23.29 7.40 4.53 6.71
ADIS-5L current washing 6.68ⴱ .75 .74ⴱ 1.06 As expected, main effects were found for OCD type, such that,
VOCI total score 74.86 37.00 78.68 39.18 compared to OCD nonwashers, OCD washers spent more time
ADIS-5L OCD severity 6.11 1.31 5.95 1.47 washing their hands, F (1, 127) ⫽ 30.52, p ⬍ .001, ␩2 ⫽ .194,
ADIS-5L distress/impairment 6.24 1.45 6.23 1.61 90% CI [.10, .29], used more soap, F (1, 128) ⫽ 28.74, p ⬍ .001,
Total no. of medications 1.59 1.60 1.91 1.77
No. of hospitalizations .23 .49 .42 .68 ␩2 ⫽ .183, 90% CI [.09, .28], and used a greater number of paper
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Total ADIS-5L diagnoses 3.11 1.95 3.05 1.91 towels, F (1, 126) ⫽ 18.45, p ⬍ .001, ␩2 ⫽ .138, 90% CI [.05,
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Current ADIS-5L diagnoses 2.18 1.19 2.24 1.31 .22]. Similarly, main effects of the salience condition were found,
OCD duration (years) 13.27 6.81 13.58 7.30 such that those in the MS condition had greater washing duration,
RSES 25.12 6.06 24.32 5.25
F (1, 127) ⫽ 20.18, p ⬍ .001, ␩2 ⫽ .137, 90% CI [.06, .23], used
CLFD death of self 8.44 10.33 7.85 11.78
CLFD death of others 6.82 9.93 7.50 10.00 more soap, F (1, 128) ⫽ 17.69, p ⬍ .001, ␩2 ⫽ .121, 90% CI [.06,
CLFD dying of self 4.65 6.70 4.91 6.70 .21], and used more paper towels, F (1, 126) ⫽ 14.05, p ⬍ .001,
CLFD dying of others ⫺1.12 10.79 ⫺.30 12.20 ␩2 ⫽ .113, 90% CI [.05, .18], than those in the dental pain
Note. ADIS-5L ⫽ Anxiety and Related Disorders Interview Schedule for condition. Lastly, as expected, these effects were qualified by Type
DSM-5 – Lifetime Version; CLFD ⫽ Collett-Lester Fear of Death Scale; x Salience interactions, such that the effects of the MS prime on
OCD ⫽ Obsessive-Compulsive Disorder; RSES ⫽ Rosenberg Self-Esteem washing duration, F (1, 127) ⫽ 12.60, p ⬍ .001, ␩2 ⫽ .09, 90% CI
Scale; VOCI ⫽ Vancouver Obsessive Compulsive Inventory. Group means
[.05, .16], and soap usage, F (1, 128) ⫽ 7.91, p ⫽ .006, ␩2 ⫽ .058,
marked with an asterisk (ⴱ) were significantly different at p ⬍ .01.
90% CI [.03, .11], were more pronounced for washers than for
nonwashers. However, the Type x Salience interaction failed to
Analyses of cleaning behavior. Prior to analysis, the data reach significance for paper towel usage, F (1, 126) ⫽ 3.16, p ⫽
were examined for outliers. Three data points that had Z-scores .08, ␩2 ⫽ .039, 90% CI [.01, .05] (see Figure 1, Figure 2, and
greater than 3.29 were considered to be outliers and were removed Figure 3).
(in line with recommendations by Tabachnick & Fidell, 2001). The When significant interactions were identified, analyses of sim-
application of this decision rule preceded all analyses. ple effects were conducted using the Bonferroni procedure to
A two-way MANOVA analyzing cleaning behaviors revealed a control familywise error rate at .05. Analyses showed that the
significant multivariate main effect for both prime condition, F (1, effect of MS on washing duration was significant for OCD wash-

Table 4
Summary of Study 2 Sample Characteristics: Prior and Current Diagnoses Additional to OCD

Diagnostic criteria met (ADIS-5L)

Currently Previously Never
DSM-5 Diagnosis n % n % n %

Agoraphobia 4 3.0 6 4.5 122 92.4

Alcohol Use Disorder 7 5.3 6 4.5 119 90.2
Bipolar Disorder 8 6.1 0 0 124 93.9
Body Dysmorphia 3 2.3 1 .8 128 97.0
Cyclothymic Disorder 1 .8 0 0 131 99.2
Generalized Anxiety Disorder 19 14.4 5 3.8 108 81.8
Illness Anxiety Disorder 23 17.4 7 5.3 102 77.3
Major Depressive Disorder 29 22.0 8 6.1 95 72.0
Panic Disorder 19 14.4 14 10.6 99 75.0
Persistent Depressive Disorder 9 6.8 6 4.5 117 88.6
Posttraumatic Stress Disorder 3 2.3 1 .8 128 97.0
Separation Anxiety Disorder 0 0 25 18.9 107 81.1
Social Anxiety Disorder 17 12.9 5 3.8 110 83.3
Somatic Symptom Disorder 4 3.0 3 2.3 125 94.7
Specific Phobia 12 9.1 25 18.9 95 72.0
Substance Use Disorder 1 .8 0 0 131 99.2
No additional diagnoses 55 41.7 40 30.3 40 30.3
Note. ADIS-5L ⫽ Anxiety and Related Disorders Interview Schedule for DSM-5 — Lifetime Version;
DSM-5 ⫽ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; OCD ⫽ obsessive-compulsive
disorder.
 DEATH ANXIETY AND OCD 373

25 4.5

4
20
3.5
Mean Washing Duration (secs)

Mean Paper Towels Used

3
15
2.5

2
10
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

1.5
This document is copyrighted by the American Psychological Association or one of its allied publishers.

5 1

0.5

0 0
Washer Non-washer Washer Non-washer

Figure 1. Mean washing duration (s) for OCD washers and nonwashers, Figure 3. Mean number of paper towels used for OCD washers and
as a function of salience condition (mortality vs. dental pain). Error bars nonwashers, as a function of salience condition (mortality vs. dental pain).
represent standard errors of the mean. Error bars represent standard errors of the mean.

90% CI [.07, .26], but not for nonwashers, F (1, 128) ⫽ .971, p ⫽
ers, F (1, 127) ⫽ 32.05, p ⬍ .001, ␩2 ⫽ .202, 90% CI [.11, .30],
.33, ␩2 ⫽ .008, 90% CI [.00, .05]. Notably, for participants in the
but not for OCD nonwashers, F (1, 127) ⫽ .45, p ⫽ .50, ␩2 ⫽ .004,
dental pain salience condition, there were no significant differ-
90% CI [.00, .04]. Similarly, analyses revealed that MS increased
ences in washing duration, F (1, 127) ⫽ 1.97, p ⫽ .16, ␩2 ⫽ .015,
soap usage for washers, F (1, 128) ⫽ 24.64, p ⬍ .001, ␩2 ⫽ .161,
90% CI [.00, .07], or soap usage, F (1, 128) ⫽ 3.25, p ⫽ .07, ␩2 ⫽
.025, 90% CI [.00, .08], as a function of OCD type.
Secondary Analyses.
Positive and negative affect. A two-way MANOVA revealed
1.6 no significant differences in General Negative and Positive Affect
for OCD type, F (1, 128) ⫽ .672, p ⫽ .513, Wilks’ ␭ ⫽ .99, ␩2 ⫽
.01. Similarly, no significant differences were found for prime
1.4 condition, F (1, 128) ⫽ .683, p ⫽ .507, Wilks’ ␭ ⫽ .989, ␩2 ⫽ .01,
consistent with most TMT studies (e.g., Arndt et al., 1998; Green-
1.2 berg, Solomon, & Pyszczynski, 1997). Further, no significant Type
Mean Soap Used (grams)

x Salience interaction was found for General Negative and Positive

1 Affect, F (1, 128) ⫽ .614, p ⫽ .543, Wilks’ ␭ ⫽ .99, ␩2 ⫽ .01.
Measures of cleanliness and comfort. Potential differences in
perceptions of cleanliness and comfort during the procedure were
0.8
examined through 2 (OCD type) ⫻ 2 (salience condition) univar-
iate ANOVAs on these variables. Consistent with the findings of
0.6 Strachan et al. (2007), there were no significant differences in
cleanliness ratings between washers (M ⫽ 7.18, SD ⫽ 1.08) and
0.4 nonwashers (M ⫽ 7.18, SD ⫽ 1.29), F (1, 128) ⫽ .000, p ⫽ 1.0,
␩2 ⫽ .00, 90% CI [.00, .00], or any significant differences in
0.2 comfort ratings between washers (M ⫽ 6.59, SD ⫽ 1.72) and
nonwashers (M ⫽ 6.42, SD ⫽ 1.52), F (1, 128) ⫽ .351, p ⫽ .56,
␩2 ⫽ .003, 90% CI [.00, .04]. Similarly, ratings of cleanliness did
0
Washer Non-washer not significantly differ between those in the MS condition (M ⫽
7.18, SD ⫽ 1.23) and those in the dental pain condition (M ⫽ 7.18,
Figure 2. Mean soap used (g) for OCD washers and nonwashers, as a SD ⫽ 1.15), F (1, 128) ⫽ .000, p ⫽ 1.0, ␩2 ⫽ .00, 90% CI [.00,
function of salience condition (mortality vs. dental pain). Error bars rep- .00], nor did ratings of comfort differ between the MS condition
resent standard errors of the mean. (M ⫽ 6.67, SD ⫽ 1.63) and the dental pain condition (M ⫽ 6.35,
 374 MENZIES AND DAR-NIMROD

SD ⫽ 1.60), F (1, 128) ⫽ 1.28, p ⫽ .26, ␩2 ⫽ .01, 90% CI [.00, Analyses of simple effects further clarified the nature of the
.06]. Finally, no interactions were observed for cleanliness, F (1, obtained interactions. Compared to dental pain priming, MS prim-
128) ⫽ 3.12, p ⫽ .08, ␩2 ⫽ .024. 90% CI [.00, .08], or comfort ing was associated with greater washing duration and soap use
ratings, F (1, 128) ⫽ 1.53, p ⫽ .21, ␩2 ⫽ .012, 90% CI [.00, .06]. among OCD washers, but not among nonwashers. That is, as
Neuroticism. Regression analyses were performed in order to expected, reminders of mortality selectively increased cleaning
explore the potential role of neuroticism in moderating the effect behaviors among OCD washers. This effect is unlikely to be due
of the prime on cleaning behaviors, using participants’ responses to differences in severity or disability between the two obsessional
on the BFI. Neuroticism was not found to significantly predict groups; analyses showed no differences in baseline severity or fear
washing duration, b ⫽ .042, t (126) ⫽ .166, p ⫽ .87, soap, b ⫽ .22, of death, or positive and negative affect during the experimental
t (127) ⫽ .869, p ⫽ .39, or paper towels, b ⫽ .211, t (125) ⫽ .812, session. Finally, the selective exacerbation of MS priming among
p ⫽ .42. Further, neuroticism also did not appear to significantly washers does not appear to be due to differences between groups
interact with the prime to predict washing duration, b ⫽ .055, t in comfort with the GSR recording or in their general perceptions
(126) ⫽ .216, p ⫽ .83, soap, b ⫽ ⫺.2, t (127) ⫽ ⫺.772, p ⫽ .44, of cleanliness, as no differences between OCD washers and non-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

or paper towels, b ⫽ ⫺.176, t (125) ⫽ ⫺.675, p ⫽ .50. Impor- washers on these measures were detected.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

tantly, mean neuroticism did not significantly differ as a function The findings therefore support the notion that the behavioral
of the prime, F (1, 126) ⫽ 1.31, p ⫽ .25, ␩2 ⫽ .01, or OCD type, response of individuals with OCD to reminders of mortality de-
F (1, 126) ⫽ 1.14, p ⫽ .29, ␩2 ⫽ .009, suggesting minimal (if any) pends on their own particular pattern of compulsions. The present
effect of the prime on neuroticism. procedure provided an opportunity for washing behaviors to be
Fear of death. In addition, regression analyses were per- activated, and these behaviors may simply have been irrelevant to
formed to assess whether conscious fears of death affected the OCD nonwashers. An alternative hypothesis is that MS priming is
effects of the prime on cleaning behaviors. The Dying of Self limited to the washer subtype in OCD. Further research is needed
subscale of the CLFD explained a significant proportion of vari- to explore whether the alternative compulsions of individuals with
ance in washing duration, ⌬R2 ⫽ .053, F (4, 123) ⫽ 10.86, p ⬍ different types of OCD can be similarly exacerbated, given that the
.001, and significantly predicted washing duration above and be- generality of the MS effect in OCD remains to be seen.
yond salience condition and OCD type, b ⫽ 1.57, t (123) ⫽ 2.3, Some comment should be made about the size of the MS
p ⫽ .023. However, it did not significantly predict soap or paper priming effect on OCD washers. Not only did MS priming lead to
towel use, nor did it moderate the effects of OCD type or salience a statistically significant increase in cleaning among washers, it
condition on washing duration in one of the two-way or three-way also appears to have produced a clinically meaningful change in
interactions (all p’s ⬎ .068). Scores on the remaining three CLFD behavior. Whereas OCD washers primed with dental pain aver-
subscales did not significantly predict washing duration, soap, or aged a washing duration of less than 10 s, when primed with MS
paper towel usage, above and beyond the effects of OCD type and this average more than doubled, representing an increase in wash-
ing duration of more than two standard deviations. The magnitude
salience condition, nor did they significantly interact with these
of this change is particularly notable given that the participants
variables to predict cleaning behavior (all ⌬R2’s ⬍ .054, p’s ⬎
were exposed to an inert conductive gel, rather than a typical
.062).
contaminant. The similar comfort with the procedure among the
two groups, along with no increase in PANAS-X General Negative
General Discussion Affect scores and no differences in perceptions of the sink area’s
cleanliness, suggests that washers did not consciously perceive a
Studies 1 and 2 collectively aimed to explore the relationship greater threat in the experimental procedure. The data therefore
between fears of death and severity of clinical symptoms, using present a challenge to expectancy models of anxiety-based disor-
correlational and experimental designs, respectively. In Study 2, as ders. These disorders, and anxiety more generally, have been
in Study 1, support was found for each of the hypotheses. First, broadly regarded as being mediated by expectancies of proximal
OCD washers expended greater efforts in cleaning after contact threats (Beck & Emery, 1985). Such expectancy accounts are
with an inert conductive gel than OCD nonwashers. Second, based largely on the observation in first-order fear conditioning
participants in the MS condition showed greater washing behavior that individuals display anxiety and avoidance on the first trial in
than those in the dental pain salience condition. Third, interactions which they can articulate the association between the conditioned
between salience condition and OCD group were apparent for stimulus and unconditioned stimulus (Chan & Lovibond, 1996).
hand washing duration and soap use. As with Strachan et al. However, in the present study, OCD washers primed with MS
(2007), no significant interaction was observed for paper towel appeared to display avoidance or escape behaviors without any
use. However, a trend in the expected direction was apparent on apparent evidence of increased threat perception, in line with TMT
this measure. This may suggest that the effect of MS priming on theoretical focus on nonconscious processes rather than expectan-
hand towel use is a small one, and therefore difficult to detect with cies (e.g., Pyszczynski et al., 1999).
the present sample size. Alternatively, hand towel use may be a Further supporting TMT’s focus on nonconscious processes, the
poorer indicator of contamination fears than the other behavioral current sample reported significantly high levels of death anxiety,
variables in the study; to note, lengthy hand washing and excessive with mean scores on the various CLFD subscales being more than
soap use are highlighted in the major chapters and manuals ex- double those obtained in community samples using this instrument
ploring contamination fears (Jones & Krochmalik, 2003; St. Clare, (e.g., Dickstein, 1978; Vargo, 1980). However, the lack of evi-
Menzies, & Jones, 2008), whereas excessive hand towel use is dence for moderation suggests that a high level of conscious death
generally not. anxiety was not the reason why reminders of mortality directly
 DEATH ANXIETY AND OCD 375

increased cleaning behavior. That is, the salience condition did not ported similarly higher rates of lifetime disorders compared with
appear to have a differential effect for those with varying levels of the individual’s current diagnosis (e.g., Brown, Campbell, Leh-
conscious fears of death. Despite this, the high CLFD scores in the man, Grisham, & Mancill, 2001).
current clinical sample should be considered, and the results from Iverach et al. (2014) suggested that it may be necessary to
nonclinical samples with lower death anxiety may differ. directly address death anxiety to stop a lifetime of mental health
Limitations of the current studies should be considered. First, difficulties among individuals with excessive death fears. In this
diagnostic interviews used to classify groups and determine symp- regard, they recommend exploring components of transdiagnostic
tom severity were conducted by a single clinical psychologist. As treatments such as Existential Psychotherapy, Acceptance and
such, no indication of diagnostic reliability is available. However, Commitment Therapy (ACT), Dignity Therapy, and Meaning-
all participants were interviewed by the same clinician, whose Centered Therapy (Barrera & Spiegel, 2014). ACT, for instance,
judgment of both their overall distress and OCD severity was employs tasks such as writing one’s own tombstone inscription or
significantly correlated with the self-report severity ratings of eulogy (e.g., Hayes & Smith, 2005), which may prove beneficial in
participants. Second, given that participants in Study 2 completed addressing pervasive existential fear (Menzies et al., 2015). Of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the BFI immediately after the salience induction, it is plausible that course, these claims are speculative, and the importance of the
This document is copyrighted by the American Psychological Association or one of its allied publishers.

the results regarding neuroticism were affected by the prime. present data in the growing call for existential treatments should
Importantly, however, there were no significant differences in not be overstated. Controlled studies are needed in order to deter-
neuroticism between participants in the mortality salience and mine the efficacy of procedures targeting death anxiety, and
control conditions. Third, cognitive features significantly associ- whether they improve the long-term outcomes of sufferers when
ated with OCD (e.g., perfectionism, inflated perceived responsi- offered as an adjunct to established CBT programs.
bility), were not assessed. Future research may benefit from ex-
ploring the potential role of such features as moderators of the Concluding Comments
effect of death fears on both symptom severity and behavior.
Despite the vast body of research investigating the dread of
Finally, given the high levels of death fears found in the present
death through the MS experimental paradigm, few studies have
sample, future research may benefit from utilizing more recent
targeted clinical participants. The present research included the
measures, such as the Death Attitudes Profile-Revised (Wong,
first report to target a treatment-seeking community sample of
Reker, & Gesser, 1994), which may provide a more detailed
individuals with OCD using a mortality activation design. In fact,
picture of the precise concerns related to mortality found among
to the best of the authors’ knowledge, Study 2 is the first MS
clinical populations.
priming study to use any treatment-seeking sample of diagnosed
Taken together, the results of the two studies offer some support
psychiatric patients. Under tight experimental conditions, MS
for Iverach et al.’s (2014) call for innovative approaches to treating
priming was found to selectively produce a clinically significant
the dread of death. Cognitive behavioral therapy (CBT) for OCD
increase in cleaning behavior among OCD washers, despite no
may address elements of death anxiety through existing techniques
increase in fear or apparent perception of threat. In addition, in
including imaginal exposure, such as by encouraging clients to
Study 1, moderate to large positive correlations have been reported
imagine dying as a result of failing to perform a ritual (Williams,
between death anxiety, OCD severity, and lifelong markers of
Powers, & Foa, 2012). Similar exposure-based interventions ap-
mental health. Thus, the present research not only contributes to
pear in implosive therapy (Stampfl & Levis, 1967), in which
the existing TMT literature, but also to broader discussions about
clients with fears of injury may be instructed to imagine scenes of
the role of death fears in psychopathology. These two studies have
bodily mutilation and death. In addition, recent CBT treatment
provided an important step forward in highlighting the potential
approaches to illness anxiety disorder have featured in vivo expo-
role of death fears in a crippling and disabling mental health
sure to death-related material (e.g., newspaper obituaries) and
disorder. Future research is needed to (a) explore the extent to
cognitive reappraisal of unrealistic beliefs about death (Furer &
which intruding death cognitions are involved in cleaning behavior
Walker, 2008). However, Iverach et al. argue that contemporary
among OCD washers outside of the laboratory, (b) establish
CBT typically focuses on reducing expectancies of proximal
whether MS priming influences the behavior of individuals with
threats, but may do little to address long-term existential issues.
other OCD subtypes, (c) assess the specificity of MS priming in
For example, exposure for phobias, behavioral experiments for
relation to its effect on other psychiatric conditions, and (d) iden-
panic, and psychoeducation programs about disease and illness
tify potentially effective ways in which to reduce fears of death
(e.g., the DIRT program of Jones & Menzies, 1997b), frequently
through innovative therapies.
seek to demonstrate that the individual’s current threat expectan-
cies are erroneous (Menzies et al., 2015). These CBT techniques References
produce rapid improvements in functioning and have become the
gold standard in psychotherapy (Öst, Havnen, Hansen, & Kvale, American Psychological Association. (2013). Diagnostic and statistical
2015). However, Iverach et al. have argued that such programs, in manual of mental disorders (5th ed.; DSM–5). Washington, DC: Amer-
failing to address core fears of death, will not stop the “revolving ican Psychiatric Association.
Arndt, J., Greenberg, J., Simon, L., Pyszczynski, T., & Solomon, S. (1998).
door” of mental health problems (p. 590). That is, it is not rare for
Terror management and self-awareness: Evidence that mortality salience
children and adolescents to be treated successfully for one anxiety- provokes avoidance of the self-focused state. Personality and Social
based condition, only to return with another in adulthood (Menzies Psychology Bulletin, 24, 1216 –1227. http://dx.doi.org/10.1177/
et al.). Consistent with this, Simon et al. (2007) found that rates of 01461672982411008
comorbid anxiety-related lifetime diagnoses were around double Arndt, J., Greenberg, J., Solomon, S., Pyszczynski, T., & Simon, L. (1997).
those of current comorbid disorders, and other studies have re- Suppression, accessibility of death-related thoughts, and cultural world-
 376 MENZIES AND DAR-NIMROD

view defense: Exploring the psychodynamics of terror management. Washington, DC: American Psychological Association. http://dx.doi
Journal of Personality and Social Psychology, 73, 5–18. http://dx.doi .org/10.1037/13748-001
.org/10.1037/0022-3514.73.1.5 Greenberg, J., Solomon, S., & Pyszczynski, T. (1997). Terror management
Barrera, I., & Spiegel, D. (2014). Review of psychotherapeutic interven- theory of self-esteem and cultural worldviews: Empirical assessments
tions on depression in cancer patients and their impact on disease and conceptual refinements. In M. P. Zanna (Ed.), Advances in experi-
progression. International Review of Psychiatry, 26, 31– 43. http://dx.doi mental social psychology (Vol. 29, pp. 61–139). San Diego, CA: Aca-
.org/10.3109/09540261.2013.864259 demic Press. http://dx.doi.org/10.1016/S0065-2601(08)60016-7
Beck, A. T., & Emery, G. (1985). Anxiety disorders and phobias: A Greenberg, J., Solomon, S., Pyszczynski, T., Rosenblatt, A., Burling, J.,
cognitive perspective. New York, NY: Basic Books. Lyon, D., . . . Pinel, E. (1992). Why do people need self-esteem?
Becker, E. (1973). The denial of death. New York, NY: Free Press. Converging evidence of an anxiety-buffering function. Journal of Per-
Berle, D., & Phillips, E. S. (2006). Disgust and obsessive-compulsive sonality and Social Psychology, 63, 913–922. http://dx.doi.org/10.1037/
disorder: An update. Psychiatry, 69, 228 –238. http://dx.doi.org/10.1521/ 0022-3514.63.6.913
psyc.2006.69.3.228 Haidt, J., McCauley, C., & Rozin, P. (1994). Individual differences in
Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related Disorders sensitivity to disgust: A scale sampling seven domains of disgust elici-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Interview Schedule for DSM–5: Lifetime Version. New York, NY: tors. Personality and Individual Differences, 16, 701–713. http://dx.doi
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Oxford University Press. .org/10.1016/0191-8869(94)90212-7

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, Hayes, S. C., & Smith, S. (2005). Get Out of Your Mind and Into Your Life:
R. B. (2001). Current and lifetime comorbidity of the DSM–IV anxiety The New Acceptance and Commitment Therapy. Oakland, CA: New
and mood disorders in a large clinical sample. Journal of Abnormal Harbinger Publications, Inc.
Psychology, 110, 585–599. http://dx.doi.org/10.1037/0021-843X.110.4 Iverach, L., Menzies, R. G., & Menzies, R. E. (2014). Death anxiety and
.585 its role in psychopathology: Reviewing the status of a transdiagnostic
Brown, T. A., Di Nardo, P. A., Lehman, C. L., & Campbell, L. A. (2001). construct. Clinical Psychology Review, 34, 580 –593. http://dx.doi.org/
Reliability of DSM–IV anxiety and mood disorders: Implications for the 10.1016/j.cpr.2014.09.002
classification of emotional disorders. Journal of Abnormal Psychology, James, W. (1985). The varieties of religious experience. Cambridge, MA:
110, 49 –58. http://dx.doi.org/10.1037/0021-843X.110.1.49 Harvard University Press. (Original work published 1902)
Chan, C. K. Y., & Lovibond, P. F. (1996). Expectancy bias in trait anxiety. John, O. P., & Srivastava, S. (1999). The Big-Five trait taxonomy: History,
Journal of Abnormal Psychology, 105, 637– 647. http://dx.doi.org/10 measurement, and theoretical perspectives. In L. A. Pervin & O. P. John
.1037/0021-843X.105.4.637 (Eds.), Handbook of personality: Theory and research (Vol. 2, pp.
Collett, L., & Lester, D. (1969). The fear of death and dying. Journal of 102–138). New York, NY: Guilford Press.
Psychology, 72, 179 –181. Jones, M. K., & Krochmalik, A. (2003). Obsessive-compulsive washing. In
Dar-Nimrod, I. (2012). Viewing death on television increases the appeal of R. G. Menzies & P. de Silva (Eds.), Obsessive-compulsive disorder:
advertised products. The Journal of Social Psychology, 152, 199 –211. Theory, research and treatment (pp. 121–137). West Sussex, UK: John
http://dx.doi.org/10.1080/00224545.2011.588273 Wiley & Sons.
Denissen, J. J., Geenen, R., van Aken, M. A., Gosling, S. D., & Potter, J. Jones, M. K., & Menzies, R. G. (1997a). The cognitive mediation of
(2008). Development and validation of a Dutch translation of the Big obsessive-compulsive handwashing. Behaviour Research and Therapy,
Five Inventory (BFI). Journal of Personality Assessment, 90, 152–157. 35, 843– 850. http://dx.doi.org/10.1016/S0005-7967(97)00035-1
http://dx.doi.org/10.1080/00223890701845229 Jones, M. K., & Menzies, R. G. (1997b). Danger ideation reduction therapy
Dickstein, L. S. (1978). Attitudes toward death, anxiety, and social desir- (DIRT): Preliminary findings with three obsessive-compulsive washers.
ability. Omega: Journal of Death and Dying, 8, 369 –378. Behaviour Research and Therapy, 35, 955–960. http://dx.doi.org/10
Doron, G., Sar-El, D., & Mikulincer, M. (2012). Threats to moral self- .1016/S0005-7967(97)00042-9
perceptions trigger obsessive compulsive contamination⫺related behav- Krochmalik, A., & Menzies, R. G. (2003). The Classification and Diag-
ioral tendencies. Journal of Behavior Therapy and Experimental Psy- nosis of OCD. In R. G. Menzies & P. de Silva (Eds.). (2003), Obsessive-
chiatry, 43, 884 – 890. http://dx.doi.org/10.1016/j.jbtep.2012.01.002 compulsive disorder: Theory, research and treatment (pp. 3–20). Chich-
Einstein, D., & Menzies, R. (2003). Atypical presentations. In R. G. ester, UK: John Wiley & Sons.
Menzies & P. de Silva (Eds.), Obsessive-compulsive disorder: Theory, Long, C. R., & Greenwood, D. N. (2013). Joking in the face of death: A
research and treatment (pp. 209 –220). Chichester, UK: John Wiley & terror management approach to humor production. Humor: International
Sons. Journal of Humor Research, 26, 493–509. http://dx.doi.org/10.1515/
Fleet, R. P., & Beitman, B. D. (1998). Cardiovascular death from panic humor-2013-0012
disorder and panic-like anxiety: A critical review of the literature. Marks, I. (1987). Fears, phobias, and rituals: Panic, anxiety, and their
Journal of Psychosomatic Research, 44, 71– 80. http://dx.doi.org/10 disorders. New York, NY: Oxford University Press.
.1016/S0022-3999(97)00135-9 Menzies, R. G. (2012, 2012). The dread of death and its role in psycho-
Foa, E. B., Steketee, G., & Young, M. C. (1984). Agoraphobia: Phenom- pathology. Keynote Address, 35th National Conference of the Australian
enological aspects, associated characteristics, and theoretical consider- Association for Cognitive and Behaviour Therapy, Queensland, Austra-
ations. Clinical Psychology Review, 4, 431– 457. http://dx.doi.org/10 lia.
.1016/0272-7358(84)90020-5 Menzies, R. G., Menzies, R. E., & Iverach, L. (2015). The role of death
Forbes, D. (2013). Blinding: An essential component in decreasing risk of fears in obsessive-compulsive disorder. Australian Clinical Psycholo-
bias in experimental designs. Evidence-Based Nursing, 16, 70 –71. gist, 1, 6 –11.
http://dx.doi.org/10.1136/eb-2013-101382 Mikulincer, M., Florian, V., & Hirschberger, G. (2003). The existential
Furer, P., & Walker, J. R. (2008). Death anxiety: A cognitive– behavioral function of close relationships: Introducing death into the science of
approach. Journal of Cognitive Psychotherapy, 22, 167–182. love. Personality and Social Psychology Review, 7, 20 – 40. http://dx.doi
Greenberg, J. (2012). Terror management theory: From genesis to revela- .org/10.1207/S15327957PSPR0701_2
tions. In P. R. Shaver & M. Mikulincer (Eds.), Meaning, mortality, and Norenzayan, A., Dar-Nimrod, I., Hansen, G., & Proulx, T. (2009). Mor-
choice: The social psychology of existential concerns (pp. 17–35). tality salience and religion: Divergent effects on the defense of cultural
 DEATH ANXIETY AND OCD 377

worldviews for the religious and the non-religious. European Journal of Strachan, E., Schimel, J., Arndt, J., Williams, T., Solomon, S., Pyszczyn-
Social Psychology, 39, 101–113. http://dx.doi.org/10.1002/ejsp.482 ski, T., & Greenberg, J. (2007). Terror mismanagement: Evidence that
Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive mortality salience exacerbates phobic and compulsive behaviors. Per-
behavioral treatments of obsessive-compulsive disorder: A systematic sonality and Social Psychology Bulletin, 33, 1137–1151. http://dx.doi
review and meta-analysis of studies published 1993–2014. Clinical .org/10.1177/0146167207303018
Psychology Review, 40, 156 –169. http://dx.doi.org/10.1016/j.cpr.2015 Tabachnick, B. G., & Fidell, L. S. (2001). Using multivariate statistics (4th
.06.003 ed.). Boston, MA: Allyn & Bacon.
Pyszczynski, T., Greenberg, J., & Solomon, S. (1999). A dual-process Thordarson, D. S., Radomsky, A. S., Rachman, S., Shafran, R., Sawchuk,
model of defense against conscious and unconscious death-related C. N., & Ralph Hakstian, A. (2004). The Vancouver Obsessional Com-
thoughts: An extension of terror management theory. Psychological pulsive Inventory (VOCI). Behaviour Research and Therapy, 42, 1289 –
Review, 106, 835– 845. http://dx.doi.org/10.1037/0033-295X.106.4.835 1314. http://dx.doi.org/10.1016/j.brat.2003.08.007
Rigdon, M. A., & Epting, F. R. (1985). Reduction in death threat as a basis Tolin, D. F., Worhunsky, P., & Maltby, N. (2006). Are “obsessive” beliefs
for optimal functioning. Death Studies, 9, 427– 448. http://dx.doi.org/10 specific to OCD? A comparison across anxiety disorders. Behaviour
.1080/07481188508252535 Research and Therapy, 44, 469 – 480. http://dx.doi.org/10.1016/j.brat
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Rosenberg, M. (1965). Society and the adolescent self-image. Prince- .2005.03.007

ton, NJ: Princeton University Press. http://dx.doi.org/10.1515/ Vaccaro, L., Jones, M., Menzies, R., & St. Clare, T. (2010). Danger
This document is copyrighted by the American Psychological Association or one of its allied publishers.

9781400876136 Ideation Reduction Therapy (DIRT) for obsessive-compulsive checkers:

Rosenblatt, A., Greenberg, J., Solomon, S., Pyszczynski, T., & Lyon, D. A comprehensive guide to treatment. Bowen Hills, Queensland, Austra-
(1989). Evidence for terror management theory: I. The effects of mor- lia: Australian Academic Press.
tality salience on reactions to those who violate or uphold cultural Vargo, M. (1980). The relationship between the Templer Death Anxiety
values. Journal of Personality and Social Psychology, 57, 681– 690. Scale and the Collett-Lester Fear of Death Scale. Psychological Reports,
http://dx.doi.org/10.1037/0022-3514.57.4.681 46, 561–562.
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive- Watson, D., & Clark, L. A. (1994). The PANAS-X: Manual for the Positive
behavioural analysis. Behaviour Research and Therapy, 23, 571–583. and Negative Affect Schedule-Expanded Form. Ames, IA: The Univer-
http://dx.doi.org/10.1016/0005-7967(85)90105-6 sity of Iowa.
Simon, N. M., Zalta, A. K., Otto, M. W., Ostacher, M. J., Fischmann, D., Williams, M. T., Powers, M. B., & Foa, E. B. (2012). Psychological
Chow, C. W., . . . Pollack, M. H. (2007). The association of comorbid treatments for obsessive-compulsive disorder. In P. Sturney & M.
anxiety disorders with suicide attempts and suicidal ideation in outpa- Hersen (Eds.), Handbook of evidence-based practice in clinical psychol-
tients with bipolar disorder. Journal of Psychiatric Research, 41, 255– ogy: Vol. 2 (pp. 313–335). Hoboken, NJ: Wiley. http://dx.doi.org/10
264. http://dx.doi.org/10.1016/j.jpsychires.2006.08.004 .1002/9781118156391.ebcp002013
Stampfl, T. G., & Levis, D. J. (1967). Essentials of implosive therapy: A Wong, P. T. P., Reker, G. T., & Gesser, G. (1994). Death Attitude
learning-theory-based psychodynamic behavioral therapy. Journal of Profile-Revised. In R. A. Neimeyer (Ed.), Death anxiety handbook:
Abnormal Psychology, 72, 496 –503. http://dx.doi.org/10.1037/ Research, instrumentation, and application (pp. 121–148). Philadelphia,
h0025238 PA: Taylor & Francis.
St. Clare, T., Menzies, R. G., & Jones, M. K. (2008). Danger Ideation Yalom, I. D. (2008). Staring at the sun: Overcoming the terror of death.
Reduction Therapy (DIRT) for obsessive-compulsive washers: A com- San Francisco, CA: Jossey-Bass.
prehensive guide to treatment. Bowen Hills, Queensland, Australia:
Australian Academic Press.
Stolorow, R. D. (1979). Defensive and arrested developmental aspects of Received June 29, 2016
death anxiety, hypochondriasis and depersonalization. The International Revision received January 26, 2017
Journal of Psychoanalysis, 60, 201–213. Accepted January 27, 2017 䡲