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

This literature review and hypothesis paper (2019) proposes that the enduring improvements in well-being following psychedelic therapy are mediated by a reduction in death anxiety. It integrates existential psychology with psychedelic science to suggest that addressing this fundamental anxiety is central to the therapeutic process.

Authors

Arena, A. F.
Menzies, R. E.
Moreton, S. G.

Published

November 29, 2019

Psychopharmacology

meta Study

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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.

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

Introduction

The paper opens by situating recent psychedelic research within an existential-humanistic framework, arguing that conventional psychopharmacology has paid insufficient attention to fundamental human needs and existential concerns such as meaning, isolation, freedom, and fears of death. Psychedelic substances—principally serotonergic compounds such as psilocybin, LSD, DMT and mescaline—are presented as pharmacological tools that can reliably produce enduring changes in connectedness, meaning and attitudes to death, changes that coincide with improvements in psychological well‑being. Despite accumulating evidence for long‑lasting benefits after psychedelic experiences, the psychological mechanisms that drive these benefits remain uncertain. Moreton and colleagues set out to integrate extant empirical and theoretical literature from psychedelic science and existential psychology to propose a novel hypothesis: reductions in death anxiety may be a key, potentially transdiagnostic, mediator of the therapeutic effects of psychedelics. The paper aims to (a) review evidence that psychedelics reduce death anxiety, (b) summarise research linking death anxiety to diverse psychopathology, and (c) outline plausible mechanisms—both direct and indirect—by which psychedelic experiences might mitigate death anxiety and thereby contribute to clinical improvement.

Methods

The extracted text does not include a dedicated Methods section or report a formal, systematic review protocol. Instead, the paper is a narrative, integrative review and theoretical argument that draws on multiple lines of empirical work (clinical trials, observational studies, experimental priming studies, and neurobiological models) and on existential and terror management theory frameworks. The investigators synthesise evidence from early clinical work with LSD, contemporary trials and observational studies of psilocybin and other psychedelics, experimental studies probing death‑related cognition, and theoretical accounts from existential psychotherapy and terror management theory. They then articulate a set of candidate mechanisms (for example, ego dissolution, exposure to death‑like experiences, increased connectedness and meaning, and shifts in metaphysical belief) that could explain how psychedelics reduce death anxiety. Where available, the review cites empirical findings (including clinical samples and longitudinal follow‑ups) to illustrate each mechanism, and it recommends that future empirical studies employ mediation analyses to test the hypothesis that reductions in death anxiety mediate therapeutic outcomes.

Results

Rather than new empirical results, the paper presents a synthesis of existing findings, organised around three core propositions: (1) psychedelics commonly produce sustained reductions in death anxiety; (2) death anxiety is implicated transdiagnostically across many forms of psychopathology; and (3) there are multiple plausible psychological and neurophenomenological mechanisms linking psychedelic experiences to reduced death anxiety. Across historical and recent literature, the authors report that both early LSD work and modern studies with psilocybin, LSD and ayahuasca document enduring decreases in fear of death and existential distress, including in samples with life‑threatening illness. A noted systematic review concluded that psychedelics show promise for reducing distress in terminally ill patients. The review also references studies in general and clinical populations that find significant associations between death anxiety and a broad range of symptoms and disorders; one treatment‑seeking sample of 200 individuals reportedly showed large correlations between fears of death and measures of impairment, medication use, lifetime diagnoses, depression, anxiety and stress, with these associations remaining after controlling for neuroticism. Experimental priming studies are summarised as further supporting causal links: mortality reminders increase avoidance and threat perception in specific phobias, elevate social avoidance and attentional bias in social anxiety paradigms, and exacerbate compulsive washing in participants with OCD. In trauma‑related disorders, the authors cite the anxiety buffer disruption theory of PTSD and studies that show disrupted terror‑management responses among those with high PTSD symptomatology. To explain how psychedelics might reduce death anxiety, the paper lays out several interrelated mechanisms supported by different empirical strands. One is exposure to a death‑like experience: high‑dose psychedelic sessions often produce ego dissolution or ‘‘ego death’’ phenomenology that resembles near‑death experiences and may function like a form of flooding exposure, with evidence that depth of perceived dying in near‑death episodes predicts attitude change. A second mechanism is reduction in self‑focus, or the ‘‘small self’’, linked to decreased default mode network activity and to feelings of awe and humility that buffer death anxiety. Third, psychedelics can foster death transcendence by shifting metaphysical beliefs toward views of consciousness that endure beyond physical death; some longitudinal work found increases on measures of death transcendence persisting at 1 and 14 months after psilocybin. Fourth, psychedelic experiences can amplify preexisting religiosity or faith maturity, which are known to attenuate reactions to mortality salience. Finally, indirect pathways include increased connectedness to others, nature and cosmos, and heightened meaning‑in‑life; both connectedness and meaning have empirical links to reduced death anxiety and are frequently reported as outcomes of psychedelic therapy. The authors also note risks and boundary conditions reported in the literature: set and setting strongly influence outcomes; vulnerable individuals (for example those at risk for psychosis) are commonly screened out of trials; and some individuals exposed to intense death‑like experiences (including non‑drug near‑death events) have developed subsequent psychopathology. The paper emphasises heterogeneity in effects and the likely moderating role of individual differences such as preexisting religious belief and personality traits (for example openness and neuroticism).

Discussion

The discussion frames reduced death anxiety as a plausible mediating mechanism that could help explain many of the enduring therapeutic effects observed after psychedelic experiences. Moreton and colleagues position this account alongside other proposed mediators—such as connectedness, awe, and ego‑dissolution—rather than as a replacement, arguing that death anxiety reduction may operate both directly and indirectly via increases in meaning and social or natural connectedness. The authors argue that treating death anxiety as a transdiagnostic construct has clinical implications: psychedelics might be particularly beneficial for disorders closely linked to concerns about bodily integrity and mortality (for example panic disorder, somatic symptom disorders and trauma‑related conditions), but may also contribute to improvements across a wider range of diagnoses by alleviating an underlying existential vulnerability. They recommend that future empirical work explicitly test death anxiety as a mediator, using prospective designs and mediation analyses, to disentangle the relative contribution of death anxiety versus other psychological mechanisms. Limitations acknowledged by the authors include the predominance of correlational evidence in the literature, the lack of direct mediation tests to date, and the variable quality and contexts of historical studies. They emphasise potential harms: confronting mortality can be overwhelming for some individuals and may exacerbate psychopathology if not managed within appropriate set and setting; screening and supportive therapeutic context are therefore crucial. Finally, the authors note that individual differences (for example religiosity, personality, and prior psychological structure) likely moderate both the extent of death anxiety reduction and downstream clinical effects, and they call for research to map these moderators and to clarify when psychedelic interventions are most likely to be helpful or harmful.

Conclusion

Moreton and colleagues conclude that psychedelics can surface and often help resolve concerns about mortality, and that this capacity may constitute an important mechanism underlying many of the therapeutic benefits observed after psychedelic experiences. Testing death anxiety as a mediator could both advance understanding of how psychedelic therapies work and clarify the role of death anxiety as a transdiagnostic factor in mental illness. The authors advocate for targeted empirical work—particularly mediation studies conducted within well‑controlled therapeutic contexts—to evaluate this hypothesis and to inform clinical application while emphasising careful attention to individual and contextual risk factors.

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SECTION

"If I take death into my life, acknowledge it, and face it squarely, I will free myself of the anxiety of death and the pettiness of life-and only then will I be free to become myself.Although our understanding of the neurobiological correlates of mental illness has grown substantially over the past decades, much is still not known regarding the specific mechanisms through which modern psychiatric medications reduce psychological distress). On their own, common psychiatric medications such as selective serotonin reuptake inhibitors often do not provide a permanent solution to the underlying causes of psychopathology, and, thus, discontinuation can lead to withdrawal symptoms and relapse (see. Arguably, what has been lacking from medical approaches to psychopathology is an appropriate consideration of the fact that-while, of course, informed and mediated by biological systems-the development and maintenance of psychopathology is strongly influenced by the (dis)satisfaction of fundamental human needs (ala. A more promising pharmacological paradigm for the treatment of many common forms of psychopathology (e.g. anxiety and mood-related disorders) would involve lowered 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. This shift would help provide a firmer theoretical grounding for modern psychiatry through a returned focus on existential-humanistic approaches to psychopathology. Such existential approaches emphasize the need to confront the "givens" of human existence-including isolation, meaninglessness, freedom, and fears of death-in order for people to flourish. Emerging research suggests that one specific class of drug, serotonergic psychedelics, can facilitate such existential confrontations and help people resolve these fundamental human concerns. As an existential-humanistic perspective would predict, effects of psychedelics on connectedness, meaning, and death transcendence have been found to coincide with improvements in psychological wellbeing (e.g.. Although rigorous research into their clinical utility is still in its infancy, psychedelics are largely unique amongst drugs in their ability to reliably produce salutary effects that persist long after the user has stopped taking the drug. Nevertheless, it has been noted in the literature that significant uncertainty still exists regarding the psychological mechanisms responsible for these enduring positive effects. A number of potential mechanisms have recently been put forward such as increased feelings of connectedness, heightened perception of life as meaningful, and the emotion of awe. The present article contributes to this growing literature by linking extant research on psychedelics and existential psychology to present a hypothesis that the ability of psychedelics to reduce death anxiety may be another key mechanism contributing to many of their therapeutic effects.

THE THERAPEUTIC POTENTIAL OF PSYCHEDELICS

Implying an ability of these substances to reveal aspects of the mind, the term psychedelics comes from the Greek "psyche" (mind) and "delos" (clear or brought to light). Typically included in this class of drugs are lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), mescaline, and psilocybin-the active ingredient in "magic mushrooms." Although there is some divergence in the pharmacology and resulting phenomenology of these substances, these drugs all act as agonists of the 5-HT 2A serotonin receptor. The crucial role played by this receptor is supported by recent research that has found that delivery of a 5-HT 2A antagonist can block the subjective effects of psychedelics. Although researchers are yet to unite behind a single unifying theory explaining the effects of psychedelics, there is a broad consensus that psychedelics disrupt the functioning of the neural mechanisms that normally constrain cognition, perception, and emotion. Psychedelics have been suggested to induce an entropic brain state (Carhart-Harris 2018) involving reduced within-network connectivity but increased connectivity between typically unrelated brain networks (otherwise termed "disintegration" and "desegregation";). For instance, psychedelics reduce activity in the default mode network (DMN)-a key network involved in self-referential, metacognitive processes-while increasing activity between the DMN and networks involved in processing information about the external world). These changes in functional connectivity induced by psychedelics result in the myriad changes in perception and cognition that are welldocumented in popular culture, such as hallucinations) and the sense of becoming "one with everything". The discovery of the psychotropic effects of LSD in the 1940s led to substantial early research-although often of questionable quality-into the therapeutic potential of psychedelics. Unfortunately, this research came to a stand-still due to the souring of public sentiment in the late 1960s. Following this was a veritable dark age for research into psychedelic therapies with sanctioned empirical research halted for the next several decades. However, since the turn of this century, there has been a revival of research into the therapeutic potential of psychedelics. The majority of recent psychedelic research has investigated the effects of psilocybin, in part because it does not have the same cultural baggage as LSD. Psilocybin has been found to induce experiences of "substantial and sustained personal meaning and spiritual significance" to quote the title of a seminal paper by. Positive effects of psilocybin persisting beyond the duration of the drug experience have now been found by other research groups (e.g., and similar effects have been found for other psychedelics such as LSDand ayahuasca. In sum, the emerging evidence suggests that the clinical use of psychedelics has the potential to bring about enduring improvements in psychological well-being. As such, psychedelic therapy has been hailed by some as representing a new paradigm for the treatment of mental illness, and preliminary research suggests that psychedelics may aid in the treatment of a number of psychological disorders (see dos). An enduring line of inquiry has involved the use of psychedelics to treat distress associated with life-threatening illness. An early advocate for the use of psychedelics in reducing existential distress was the author Aldous Huxley who reportedly used LSD in his final hours to aid the process of dying). Huxley's belief that psychedelics could aid the dying process was supported by a number of early studies showing reduced fear of death in terminally ill patients treated with LSD (e.g., withnoting that many subjects "displayed a peculiar disregard for the gravity of their situation and talked freely about their impending death with an affect considered inappropriate in our western civilization but most beneficial to their own psychic states" (p.291). The ability of psychedelics to engender enduring reductions in death anxiety has also been evidenced in the recent wave of psychedelic research with a recent systematic review byconcluding that psychedelics represent a promising treatment option for distress associated with terminal illness. The emerging evidence suggests that psychedelics often have profound, long-lasting effects on both psychological well-being and death anxiety. However, the relationship between these outcomes has yet to be thoroughly explored in the literature, and we argue here that the therapeutic effects of psychedelics may be partially mediated by reductions in underlying death anxiety. To our best knowledge, this hypothesis is novel. Although it has been suggested that reduced death anxiety from psychedelics may be beneficial to those suffering from severe illness, psychedelic researchers have yet to engage with a growing literature suggesting a role for death anxiety in psychopathologies of the physically healthy. Before discussing mechanisms through which psychedelic therapies may reduce death anxiety, we next introduce the concept of death anxiety as a transdiagnostic construct and clarify its relevance across various manifestations of psychopathology.

DEATH ANXIETY AS A TRANSDIAGNOSTIC CONSTRUCT

Due to significant comorbidity between psychological disorders, the last decade has seen a growing focus on the role played by transdiagnostic constructs in the development and maintenance of psychopathology (see. As the name suggests, transdiagnostic constructs are explanatory variables that underpin multiple mental health diagnoses. Recent evidence suggests that treatments that target transdiagnostic constructs can reduce the severity and progression of mental illness, and a growing number of theorists have suggested that death anxiety may be a transdiagnostic construct implicated in many psychological disorders (e.g.. Key to this approach is the idea that death anxiety is not only correlated with psychological distress but may indeed be the "worm at the core" of many manifestations of psychological dysfunction, contributing to the maintenance and development of mental health conditions. The idea of death anxiety as a transdiagnostic construct builds on the work of existential psychotherapists such as Irvinand Rollo, as well as theorists working within the theoretical framework of terror management theory (TMT;: an evolutionary, socio-motivational theory informed by the work of Ernest. TMT suggests that individuals employ defense mechanisms to deal with the terror that emerges from the uniquely human awareness of our own mortality. Importantly, TMT suggests that death anxiety often influences cognition and behavior, even when this fear lies outside of conscious awareness. The mortality salience hypothesis suggests that, when people are reminded of their mortality, they will increase their reliance on psychological structures that serve to buffer death anxiety. Along these lines, the majority of TMT research has investigated the effects of unconscious death anxiety in activating defensive responding such as defending one's worldview and striving for self-esteem. However, TMT theorists have also suggested that insufficiently developed terror management defenses can lead to psychopathology. Arguing from a TMT perspective,suggest that four components play key roles in the etiology of many forms of psychological dysfunction: "(a) specific life problems; (b) the needs for meaning, self-esteem, and relatedness that are often disrupted by life problems; (c) the loss of protection from existential anxiety that occurs when these structures are undermined; and (d) the maladaptive ways in which people attempt to cope with the resulting anxiety." In short, this framework suggests that psychopathology can emerge when insufficiently buffered death anxiety gives rise to dysfunctional coping mechanisms. This suggestion that observed anxieties can represent ostensibly unrelated underlying tensions is not new; for instance,believed that neuroses were often manifestations of unresolved unconscious conflict. However, as opposed to the Freudian perspective that ostensible death anxiety is usually a surrogate for other repressed fears (e.g., a TMT perspective conversely suggests that anxieties seemingly unrelated to death are often surrogates for death anxiety.

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. In particular, death anxiety has been argued to underlie most, if not all, of the anxiety disorders. For instance, almost a century ago, death anxiety was proposed to lie at the heart of all phobias, with the feared targets of the most common phobias (e.g. spiders, snakes, heights, dogs, and water) all having the potential to directly result in death. Within panic disorder, patients frequently report concerns about having a heart attack and often repeatedly visit cardiac specialists to allay these fears. Indeed, common symptoms of panic attacks include fear of imminent death) and an increased focus on ostensibly life-threatening bodily sensations. Similarly, among the somatoform disorders, patients are excessively concerned with the potential of serious health problems and may repeatedly check their body for signs of illness, seek medical advice, and interpret benign bodily symptoms as life-threatening. Death anxiety has also been argued to play a central role in obsessive-compulsive disorder (OCD), with many related behaviors (e.g. compulsive handwashing or checking of stoves, locks, or electrical powerpoints) being directly linked to fears of death (i.e. contamination and disease or household fire, invasion, or electrocution, respectively; see further,. Increasing empirical evidence supports these clinical observations and the conceptualization of death anxiety as a transdiagnostic construct. For example, significant associations have been found between death anxiety and symptoms of a number of disorders, including separation anxiety, hypochondriasis, OCD, and disordered eating behavior (Le Marne and Harris 2016). Further, the results of one recent study revealed large to very large correlations between fears of death and psychopathology (i.e. impairment, number of medications, lifetime number of diagnoses, depression, anxiety, and stress scores) among a treatment-seeking sample consisting of 200 individuals with a number of different mental health diagnoses). In addition, large correlations were found between death anxiety and the symptom severity of 12 disorders, including generalized anxiety disorder, social anxiety disorder, alcohol use disorder, and depressive disorders. Importantly, these results remained significant after controlling for neuroticism, suggesting the potentially unique role of death anxiety in explaining psychopathology. While much of the research exploring death anxiety and psychopathology is correlational in nature, precluding assumptions of causality, a growing number of experimental studies add further support to the argument that fears of death play a causal role in psychopathology. Among individuals with a spider phobia, reminders of death have been shown to increase avoidance and threat perception of photos of spiders. There is also evidence that death anxiety contributes to social anxiety as research has found that priming mortality salience can increase both social avoidance) and attentional bias towards threatening social cues. Supporting a hypothesized role of death anxiety in OCD,found that priming mortality led participants diagnosed with OCD to spend twice as much time washing their hands. In sum, there is emerging evidence that death anxiety plays a significant role in driving a diverse range of anxiety-related behaviors, across a range of diagnostic categories. Specific theoretical accounts have also been proposed in relation to the role of death anxiety in trauma-related disorders.have proposed the anxiety buffer disruption theory of post-traumatic stress disorder (PTSD), which suggests that PTSD emerges when traumatic events disrupt terror management defenses, leaving the individual exposed to anxiety. The inclusion of suffering "exposure to death or threatened death" in the diagnostic criteria for PTSD further emphasizes the central role that death anxiety may play in the condition (American Psychiatric Association 2013). Consistent with this, death anxiety has been found to correlate with the severity of PTSD symptoms in a number of studiesandfound that high levels of PTSD symptomology predicted increased death thought accessibility following mortality salience. Further,found that individuals with PTSD who were primed with mortality salience did not engage in worldview defense, which ordinarily functions to reduce death anxiety. These findings all indicate that PTSD involves a disruption in the normal functioning of the death anxiety buffering system and that, when this system is disrupted, people will experience persistent issues with trauma-related anxiety. In a similar vein, fears of death and lack of meaning have been argued to play a significant role in the depressive disorders, and ineffective existential anxiety buffers (e.g. inability to bolster self-esteem or reduced endorsement of cultural worldviews) have been linked with depression. Depression is associated with increased morbid thoughts of death, and death anxiety has been found to be significantly correlated with depressive symptomology among a clinical sample. Experimental findings further support this, as depressed individuals have been found to exhibit higher levels of worldview defense following mortality salience, suggesting that depressed people may have a heightened need for defenses against death. In summary, emerging evidence supports the proposition that death anxiety contributes to many manifestations of psychological dysfunction, and may cut across a number of diagnostic categories (e.g. anxiety disorders, mood disorders, obsessive-compulsive disorders, trauma-related disorders, and somatic symptom disorders). This has led a number of theorists to suggest that addressing underlying death anxiety may be necessary in order to observe long-term improvements in mental health conditions. If treatments fail to address the underlying fears of death, they may in fact be contributing to the "revolving door" of mental health, in which it is not uncommon for individuals to simply shift from one disorder to another across their lifespan). In the following section, we outline a number of mechanisms through which psychedelics may help mitigate death anxiety.

WHY DO PSYCHEDELICS REDUCE DEATH ANXIETY?

Although it appears clear that psychedelics do often reduce death anxiety, it is less clear exactly why they have this effect, although intimations have been made in the literature (e.g.. A number of researchers have suggested that mystical or ego death experiences may be key to the therapeutic effects of psychedelics (e.g., and previous research has found the intensity of psychedelic-induced mystical experiences to correlate with increased feelings of death transcendence). Although it is likely that mystical experiences play a role, little research has addressed the specific mechanisms through which psychedelics may reduce death anxiety. We believe that psychedelics may typically reduce death anxiety through varied combinations of the following related factors: (a) forcing confrontations with one's mortality involving exposure to, and processing of, typically unconscious fears of death; (b) generally reducing focus on the self and its concerns; (c) shifting meta-physical beliefs regarding the nature of human consciousness; (d) amplifying religious faith; and (e) increasing feelings of connectedness and perceptions of the meaningfulness of life. The exact contribution of these factors may depend on the preexisting psychological structures of the individual (e.g. religious beliefs). Thus, the magnitude of the effects of psychedelics on death anxiety should also be expected to vary as a function of these individual differences. Below we lay out the evidence for this account.

EXPOSURE TO A DEATH-LIKE EXPERIENCE

Many existential psychotherapists have long maintained the need to confront death in order for people to live meaningful lives. Cognitive-behavioral approaches to treating death anxiety also involve exposing patients to thoughts of death)-a strategy that dovetails with the consensus that exposure to the feared stimuli is one of the most effective ways to treat anxiety. Supporting this hypothesis, the findings of a recent metaanalysis revealed that cognitive-behavioral treatments focusing on graded exposure produced significant reductions in death anxiety, relative to other therapies and control groups. In this vein,suggest that exposure to death cognitions may unintuitively allow compromised defenses against existential anxiety to be restored, therefore reducing psychopathology in which death anxiety is implicated. Pertinently, psychedelic experiences frequently involve thoughts of death and deep confrontations with one's mortality). Indeed, one common outcome of the administration of a high-dose psychedelic is a phenomenon that has been termed ego dissolutionor ego death, whereby the normal sense of self dissolves or "dies." Recent empirical evidence supports earlier contentions (e.g.) that the phenomenology of a psychedelic experience is often highly comparable with that of a near-death experience. Unlike typical cognitive-behavioral approaches to death anxiety, which rely on systematic desensitization through gradually exposing people to thoughts of death), a single psychedelic experience can lead people to believe the self is dying or, indeed, has died. These effects can be likened to flooding techniques, whereby people are exposed to their fear in its most extreme manifestation (see. If people are exposed to an in vivo experience of "dying" through experiencing ego death, this may lessen their fears of their inevitable physical death. In fact, in studies of near-death experiences, the depth of the experience and the extent to which people believe or accept that they are dying has been associated with larger attitude changes and decreases in fear of death. A similar degree of receptivity or surrender to the ego death or mystical experience may be crucial for the reduction of death anxiety in psychedelic-assisted psychotherapy. This suggestion dovetails with previous research suggesting that surrendering to the experience may play a key role in the therapeutic effects of the psychedelic experience (e.g.).

THE SMALL SELF

The ego death experience also involves a decreased focus on the concerns of the self)-a claim supported by evidence of decreased activity in the default mode network. Indeed, psychedelics have been referred to as "humility agonists" and "narcissilytic". This is not surprising as psychedelics commonly induce the emotion of awe, which has been shown to induce a state previously referred to as the small self, which involves feelings of humility) and reduced self-focussed attention. Self-awareness is a necessary precondition for the experience of anxiety about one's personal death, and humility has been shown to reduce death anxiety and buffer against the effects of induced mortality awareness. It is thus plausible that psychedelics 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, ego death experiences involve degradation of the subject-object dichotomy to such an extent that there is little to no demarcation between the self and external world. Although it is now a cliché, psychedelics often make people feel as though they are becoming one with everything and experience, in the words of, an "undifferentiated unity." This sense of unity is a core component of mystical experiences, and can provide a form of death transcendence. If one sees the boundaries of their ego dissolve, while experience itself continues on, then there may be room for the notion that the death of the physical body is not an absolute end of experience. Along these lines,suggests that psychedelics often lead to a change in people's beliefs regarding the nature of consciousness towards a philosophy of mind whereby the brain acts as "a filter of consciousness which transmits part of the Vaster Consciousness of Reality, like a partially opaque glass allowing through a few rays of a super solar blaze" (p.16). He suggests that this can lead people to believe that, even when the physical brain dies, this larger consciousness does not cease to exist and, in this sense, an aspect of their consciousness may transcend death. Emerging empirical evidence provides support for Pahnke's early speculations. For instance, in a general population sample,found significant increases i n the Religious subscale of t he Death Transcendence Scale, which persisted at 1 and 14 months following treatment with psilocybin. This subscale measures agreement with statements such as "death is a transition to something even greater than this life" and "death is never just an ending, but a part of a process," suggesting that psychedelics foster beliefs that death may not be the ultimate end of the self. Long-term effects of psilocybin on death transcendence have now also been documented in a number of studies using samples from the general public) and people with life-threatening diseases.suggests that one method for reducing death anxiety involves viewing death as a merger with a force larger than the self, and this appears to be what psychedelics facilitate-even for people who are not aligned with any specific religion.

AMPLIFYING RELIGIOUS FAITH

Nevertheless, it is also possible that psychedelics may reduce death anxiety through amplifying people's preexisting faiths. As psychedelics can induce mystical experiences that are phenomenologically comparable with traditional non-psychedelic mystical experiences, it is not surprising that psychedelics have been found to increase religiosity (e.g.). Indeed, one of the earliest demonstrations of the intense psychotropic effects of psychedelics was the Good Friday Experiment, whereby a majority of divinity students who ingested psilocybin in Boston University's Marsh Chapel reported having intense religious experiences. Recent findings bysimilarly suggest that psychedelic experiences can involve encounters with "God," and that using psychedelics can turn people away from hardline atheism. Further,found that participants who took psilocybin had enduring increases in "faith maturity": the extent to which an individual "embodies the priorities, commitments and perspective characteristic of vibrant and life-transforming faith". Supporting the contention ofthat a major function of religion is to reduce death anxiety, research has found that intrinsic religiosity and beliefs in a literal afterlife can reduce the effects of mortality salience. These findings suggest that the ability of psychedelic experiences to amplify religiosity may play a significant role in why they often reduce death anxiety.

CONNECTEDNESS AND MEANING

The potential mechanisms we have discussed thus far can be considered direct, insofar as they involve a direct confrontation with, or solution to, the problem of death. However, psychedelics may also indirectly reduce death anxiety as a byproduct of increased feelings of connectedness and meaning. Inspired by early theorists such as, research suggests that close attachment relationships provide a symbolic shield against death anxiety, and recent studies have found that social ostracism can increase unconscious awareness of death. As psychedelic experiences often involve increased feelings of interpersonal connectedness), these feelings may help buffer individuals from death anxiety. In addition to often amplifying bonds with close others, psychedelics can also lead to a broadening of people's perspective in which they see themselves as deeply connected with nature and the cosmos at large. Such a perspective does not necessarily imply the continuation of consciousness beyond death but is nonetheless transcendental as it positions the self as inseparable from a greater, eternal entity-even if only in terms of the physical substance of one's body. Along these lines,suggests one way in which people can achieve symbolic immortality is by feeling part of a universe that transcends the self. Similarly,suggest that feeling connected to nature can help embed "us more deeply into the existence of life beyond the course of our single lifetime" (p.381) and thus help resolve death anxiety. Recent research supports earlier contentions (e.g Masters and Houston 1966) that psychedelics can increase people's feelings of connectedness to nature, and it is plausible that these broader feelings of connectedness also help shield the individual from death anxiety. Often coinciding with increased connectedness, the ability of psychedelics to generate meaningful experiences is a related mechanism that may also buffer death anxiety. Many theorists have suggested that people have a fundamental need for meaning-in-life.suggest that deficits in meaning-in-life are linked to psychopathology because meaning acts as a buffer to death anxiety, and meaning in life has indeed been found to be negatively associated with death anxiety. Experimental research has also found that viewing life as meaningful can buffer against the effects of mortality salience. Williamnoted that one feature of mystical experiences was their "noetic quality": the sense that one has gained access to some higher plane of profound, indisputable knowledge (also see). The psychedelic experience is often accompanied by this sense of revelatory clarity about even mundane aspects of existence. For instance, Aldouswrote of his experience with mescaline that a bunch of flowers were "all but quivering under the pressure of significance by which they were charged" (p.5).similarly suggests that psychedelics facilitate a "reenchanted experience of the world" (p.3) and can increase the significance of both internal mental phenomena and the external world. Indeed, research suggests that a majority of people who take psychedelics in supportive settings rate the experience as one of the most meaningful of their lives. This ability of psychedelics to increase meaning-in-life may be another mechanism through which they may reduce death anxietya possibility previously touched on bywho suggested that a heightened appreciation of beauty and meaningful sensory experiences in terminal patients treated with LSD may have played a role in the observed reduction in death anxiety in their subjects.

INTEGRATING EXISTENTIAL PSYCHOLOGY INTO CLINICAL PSYCHEDELIC RESEARCH

In summary, there are multiple mechanisms through which psychedelics may potentially reduce death anxiety, and further research is needed to clarify the relative contribution of these mechanisms. Regardless of the mechanisms at play, the fact that psychedelics appear to typically reduce death anxiety when used in a supportive context has clear implications for future research into the therapeutic utility of these substances.note that significant uncertainty still exists regarding the psychological mechanisms underlying the therapeutic effects of psychedelics, and they suggest that future work may employ mediation analyses to help unravel the mechanisms at play. They suggest several plausible mediators of the therapeutic benefits of psychedelics, including ego-dissolution, awe, and connectedness. As death anxiety is a transdiagnostic construct implicated in a large variety of psychological disorders, reduced death anxiety must be considered as a plausible addition to this list of potential mediators. This possibility is touched upon bywho suggest that "The observed decreases in psychological distress and anxiety about death may relate to recent epidemiological findings that lifetime psilocybin use was associated with significantly reduced odds of past month psychological distress and suicidality." Yet this sentence sits alone with no extrapolation nor supporting theoretical framework, and, to date, publications investigating the effects of psychedelics on death anxiety and mental health outcomes have not given due consideration to the possibility of death anxiety as a significant causal variable. We believe that testing death anxiety as a mediator of the therapeutic benefits of psychedelics would have twin benefits insofar as it would provide further clarification regarding (a) the psychological mechanisms underpinning the therapeutic effects of psychedelics and (b) the role played by death anxiety in the etiology of mental illness. Thus, the testing of this hypothesis should be of interest to both psychedelic scientists and mental health clinicians. This hypothesis may also be used to inform the targets of future interventions involving psychedelics. Although death anxiety appears to influence many forms of psychopathology, theoretical knowledge and clinical observation suggest that fears of death are more directly relevant to certain disorders (such as those with a clear focus on physical health, e.g. panic disorder and the somatic symptom disorders). Thus, ceteris paribus, drugs which reduce death anxiety are more likely to reduce symptomology of these disorders, compared with disorders which appear to have a less direct relationship with death anxiety. Of course, there are numerous psychological and neural mechanisms through which psychedelics may engender therapeutic effects. As such, psychedelic therapy may aid the treatment of specific forms of psychopathology unrelated to death anxiety. Although we have suggested that meaning-in-life and connectedness both serve a function of buffering death anxiety, we do not mean to imply that the therapeutic contributions of these constructs can be reduced to this function. Connectedness and meaning are fundamental human needs (seeand, as such, likely play their own unique roles in the therapeutic effects of psychedelics. Thus, the perspective put forward in this article is intended to complement, rather than replace, recent accounts suggesting these constructs as unique mechanisms underlying the effects of psychedelics (e.g.. Nevertheless, an awareness of the varying magnitude of the role played by death anxiety across distinct forms of psychopathology may help provide further theoretical justification for the direction of future clinical interventions involving psychedelics. For instance, the relevance of death anxiety to PTSD suggests that psychedelic therapy may be beneficial for sufferers of this disorder, although no published research has investigated this possibility. Nevertheless, it is important to note that the use of psychedelics is not without risk. Although the tone of this article has been positive about the clinical potential for psychedelics, we are not suggesting that they will necessarily always produce beneficial effects. One important feature of psychedelics is that their effects can vary drastically depending on "set" (the mindset one brings to the psychedelic experience) and "setting" (the environment in which the experience takes place;. Psychedelic research is commonly conducted in supportive environments and participants are often screened for a predisposition towards certain psychological disorders (e.g. schizophrenia). For certain at-risk populations, the ego death experience could have potentially harmful effects. Pertinently,found that, although near-death experiences led to increased positivity and personal growth for many individuals, some developed psychopathology as a result of their brush with death. Similarly, the confrontation with mortality provoked by psychedelics could be overwhelming for certain individuals and provoke or exacerbate psychopathology. We stress that we are not suggesting psychedelics as a blanket treatment for death anxiety; characteristics of the individual and environment should be expected to modulate their effects on death anxiety. However, we draw attention to the fact that psychedelics have been used safely in numerous studies involving people with lifethreatening diseases (see, who would presumably be more sensitive to confrontations with death. On the whole, the emerging evidence suggests that psychedelics generally tend to reduce death anxiety when used in positive contexts. Nevertheless, it is important that psychedelic research continues to develop a greater understanding of the role that individual difference variables may play in determining the effects of psychedelics on death anxiety. It is interesting to note that althoughfound neuroticism (a personality domain comprised of temperamental negative affectivity) to predict many facets of challenging psychedelic experiences, it did not predict feeling like one was dying during the psychedelic experience. Rather, their first study found that this facet was related to increased openness to experience: a personality domain associated with long term personal growth. Although this data was cross-sectional, we note this finding specifically because it is consistent with the notion that confrontations with death may often have positive benefits. Although we have suggested that reduced death anxiety may contribute to the salutary effects of psychedelics, we feel that our account is not complete without acknowledging that the confrontation with death may also contribute to the benefits of psychedelics above and beyond its ability to reduce death anxiety.dual-existential systems model posits that, while abstract death awareness can lead to defensive responding, deep, personalized processing of mortality can often lead to a growth-oriented motivational state. This suggestion aligns with the clinical observations of psychotherapists such as, as well as research into post-traumatic growth (e.g.. As such, the deep confrontation with death posed by 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). The picture we paint is complex: We have suggested that death anxiety may be reduced by psychedelics in part via increased connectedness and meaning, but it may also be that the confrontation with death may conversely play a role in why psychedelics can lead to sustained increases in these constructs.

CONCLUSION

As a solution to a perceived stagnation in the development of novel psychotherapies, Rollo May once suggested that psychotherapists should return their focus towards making the unconscious conscious. In an allusion toclaim that dreams are a "royal road" to the unconscious, psychedelics have previously been suggested to be a "superhighway". We suggest that psychedelics can bring concerns around mortality to the fore while, at the same time, often providing the opportunity to resolve these concerns. This suggestion is not new and echoes the claims of many early psychedelic researchers such as Walterwho wrote that, "[under psychedelics]…problems concerning death can be dealt with rather than escaped from" (p.17). As evidence has emerged suggesting that psychopathology can emerge from maladaptive attempts to deal with underlying death anxiety, we suggest that the ability of psychedelics to help resolve mortality concerns may be a significant mechanism involved in many of their therapeutic effects, even in individuals without life-threatening illness. The testing of this hypothesis has the potential to inform our understanding of the psychological mechanisms underpinning the therapeutic effects of psychedelics as well as providing further clarity to the concept of death anxiety as a transdiagnostic construct.