The Profound Challenge of Existential Anxiety

The COVID pandemic has likely contributed to an uptick in existential anxiety.

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For the past few years, likely due to the COVID pandemic, I have encountered more people suffering from existential anxiety than at any time I can remember. Existential anxiety is the term used to describe a chronic state of discomfort and fear about issues related to one's existence, like aging, dying, and the uncertainty about what happens to us when we die.

Though not a formal DSM-5 diagnosis, existential anxiety is one of four types of anxiety that mental health professionals informally distinguish between when considering where an individual's anxiety originates. Other forms of anxiety, including situational (the consequence of a temporary, external event), biological (related to an imbalance of neurotransmitters or hormones), and psychological (the result of problematic mental schemas and thinking patterns), overlap with numerous diagnoses in the DSM-5 and they are more successfully treated with traditional approaches. Existential anxiety, however, much like existential depression, requires a different set of tools than what psychology and psychiatry typically offer.

Accordingly, those who suffer from existential anxiety are often at a loss, not knowing why the usual array of anti-anxiety medications don't seem to make them feel better or why therapy techniques that have worked in the past are ineffective this time around. For this reason, a number of people who read my previous post on four types of anxiety emailed me to express feelings of relief and validation that there was a name for what they were experiencing and that they were not alone.

The reason why existential anxiety can be so difficult to treat is that it's deeply rooted in the familial, cultural, and religious belief systems that transcend one's personal psychology and biology. It's grounded in our schemas about life, death, and aging that we've sublimated into a series of unconscious coping mechanisms: coping mechanisms that were successful in staving off our anxiety about death, dying, and aging for years... until they mysteriously and abruptly stopped working.

What happens to us when we die?

Will there be karmic consequences for my actions in this life (e.g., will I be punished for the bad things I've done)?

Will aging mean that I'll lose my mind, my memory, and control of my body?

Will my family leave me to die alone, or worse, in a nursing home?

These can be scary questions at any stage in life, but especially during middle age as we begin to see our abilities and our power in the world decline. And it can be especially terrifying after we see close friends or family members suffer death and disease.

Terror Management Theory and Existential Anxiety

According to cultural anthropologist Ernest Becker (1973), the ability of humans to acknowledge and anticipate our eventual death is not only unique to our species, it's the driving force behind our entire psychology and culture. In this way, existential anxiety can be thought of as the mother of all other anxieties.

In the years since Becker's seminal book, The Denial of Death (1973), social psychologists Sheldon Solomon, Jeff Greenberg, and Tom Pyszczynski (2015) codified Becker's work into a formal theory called terror management theory (TMT). Nearly 50 years of research on TMT has demonstrated that the more conscious we are of our own death, even by someone simply showing us the word "death," the more likely we are to alter our decisions in myriad, though often conflicting, ways.

In some contexts, reminders of death have led judges to mete out harsher punishments; in other cases, it has led to people hardening their cultural beliefs and becoming more tribalistic; and yet, in others, it has contributed to people increasing behaviors that boost their self-esteem, like buying a sports car or protecting themselves with sunscreen (Solomon et al., 2015; Morris et al., 2014). From the perspective of TMT, the incessant images and discussions of death that we've all been forced to incur—in real life and on our screens—since the beginning of the COVID pandemic have made all of us vulnerable to the prospects and consequences of existential anxiety.

The drumbeat of our own mortality gets louder by the day, and taking Xanax or Prozac won't make it go away. Similarly, traditional psychotherapy has few answers for existential anxiety because the fear of no longer existing or of relinquishing one's consciousness is neither "irrational" nor the result of a cognitive error. This doesn't mean, however, that all is hopeless.

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Treating Existential Anxiety

In my experience, existential anxiety requires a combination of strategies integrated over a long period of time. Although cognitive behavioral therapy (CBT) is very effective for treating situational and psychological anxiety, when it comes to existential anxiety, I have found that ongoing treatment with a therapist who is insight-oriented (perhaps from a psychodynamic/psychoanalytic orientation) is a good place to start. Therapy should not be pushed at a pace faster than the patient is willing to go, and it may seem that progress is not being made, even after years in therapy.

Below are a few recommendations for treating existential anxiety:

1. Explore as many belief systems as possible.

Existential anxiety often comes at a time when issues related to aging and the prospect of death become salient—sometimes after the death of a peer—and this often pushes people to reflect on the religious lessons they were taught as a child. For most people, however, their existential, religious, and spiritual beliefs were not chosen, they were bequeathed to them at birth, and the belief system we were born into may not be the one that best fits our adult worldview.

As such, I recommend reading books about different belief systems and discovering what similarities and differences those belief systems have with your own. Interview spiritual leaders from different traditions. Talk to people who have survived life challenges that were more significant than your own and ask them how they feel about the things that trigger your existential anxiety. You may also want to check out the recent Netflix documentary series Surviving Death, which covers some of these topics in greater depth.

2. Expand your world.

I often tell patients, "If your world isn't expanding, it's contracting, and if it's contracting, you need to reverse the process." Many of us have friends or family members whose moderate anxiety symptoms progressed to the point of agoraphobia—a fear of being away from one's safe space—until they eventually refused to leave their homes. This fate can become a reality for any of us if we're not mindful.

Although it may be difficult to make new friends and try new things when you're feeling anxious, during periods when you're feeling well, this is the time to start taking steps outside your comfort zone. There's no need to do anything extreme, like joining an improv troupe; you simply need to find small ways to expand your existing activities and your existing social network. Here are some suggestions:

• If you play cards or table games with friends, consider asking your friends to invite a new friend or family member to the group.
• Among friends with whom you already feel comfortable, try a new activity, like a book club, a movie club, or a writing group.
• Try a different vacation spot than where you typically go.
• Explore in-person meetup groups or online chat rooms on sites like Reddit, where you can link up with people with common interests, even around your favorite TV shows.

3. Consider psychedelic therapy.

The past two decades have been a renaissance for established research and informal experimentation into the use of psychedelic drugs—like LSD, psilocybin, and ketamine—to treat myriad psychological disorders, including anxiety, depression, and PTSD (Tupper et al., 2015), and Yale University researchers have even published a manual for psilocybin-assisted therapy. Two studies, in particular, specifically examined the efficacy of psychedelic therapy on individuals with clinical anxiety suffering from terminal illnesses. These studies reported significant anxiety reductions for psilocybin (Grob et al., 2011) and LSD (Gasser et al., 2014) for patients with terminal illnesses, with the latter's effects remaining significant at a one-year follow-up. Increased legalization of psychedelics offers both promise and risk, as the New York Times noted recently. The promise is that these drugs work very differently than established pharmaceuticals and often show long-term efficacy after only a few microdose treatments.

For those who are curious to learn more, there are a few Netflix documentaries that offer insight and information, including Michael Pollan's How to Change Your Mind and Fantastic Fungi.

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