Tag Archives: Thanatos

Anorexia Nervosa And The Eating Disorders – A Tragedy of Faulty Mirrors, Control Or the Lack of It, And A Walk Back To The Abyss

I was in a gym last week and noticed an emaciated women running on a treadmill, who was so thin that individual muscles and bones were visible in her exposed flesh around her gym clothes. I wondered if, wearing my clinical hat, I should speak with the gym staff about her, given it was clear she either had a chronic disease that caused profound secondary weight loss, or she had an eating disorder, most likely anorexia nervosa. I have noted with concern when watching cycling races how thin elite professional cyclists are during long stage races, and was interested when reading the autobiography of one of the world’s best cyclists that they believed that both themselves and several of their cycling colleagues would probably satisfy the criteria for a full-blown eating disorder diagnosis, and that they had battled with food ingestion both during their career, and even after they had stopped being competitive. As a teenager I was sent to boarding school, and didn’t settle well into the strong routine and rules based environment that boarding schools require in order to function, and I stopped eating as a ‘silent protest’ to get attention to my dislike for my environment. I eventually cut my weight to almost zero body fat, and folk wondered if I had a bone fide eating disorder, though fortunately when my parents accepted that I could not continue at the boarding school in my state of refusing to eat and resultant massive weight loss, they took me out and put me into a day school, and almost immediately I started eating again, my weight normalized, and the problem was pretty much resolved for me. Seeing the lady on the treadmill, reading the book on the eating travails of the elite cyclist, and reflecting on my own weight reduction story of my youth, got me thinking about anorexia nervosa, what causes it, and why some folk both start to refuse to eat food, and continue to do so, even if it causes them to literally starve themselves to death in an environment of plenty, and with so many of their loved ones around them willing them to eat normally, put on weight, and live a ‘normal’ life as they apparently used to do.

The symptoms and signs of anorexia nervosa were first described in medical texts as early as in the 1600’s, and was termed anorexia nervosa in the late 1800’s. The term is Greek in origin, with ‘an’ describing negation and ‘orexis’ describing appetite – so literally a psychological negation of appetite. Its classical symptom is obviously food restriction resulting in rapid weight loss, and it can be accompanied by compulsive behavior such as excessive exercise (in order to use up calories and thereby lose weight), a paradoxical preoccupation with food, recipes, or cooking food for others which is not consumed by themselves, food rituals such as cutting food into small pieces and not eating it, refusing to eat around others or hiding and discarding food, and purging themselves with laxatives, diet pills, or self-induced vomiting in order to attenuate the effect of eating any food whatsoever, no matter how small the portion (to note these purging actions also occur in its ‘cousin’ disorder, bulimia nervosa, but there is usually not the marked food restriction in bulimia nervosa, and weight loss may not be evident in folk suffering from bulimia nervosa). There are a number of other signs which are diagnostic of anorexia nervosa, including low body mass index for one’s height or weight, amenorrhea in females, the development of lanugo (fine, soft hair growing over the face and body), intolerance to cold, halitosis (bad breath), orthostatic hypotension (low blood pressure when lying down), chronic fatigue, and changes in heart rate (either slowing down or speeding up). But, most of these may be related to the chronic and extreme weight loss, rather than to anorexia nervosa per se. Clinicians have to be very cautious before diagnosing anorexia nervosa to be sure to exclude a wide variety of clinical disorders that can lead to profound weight loss, including cancer, type 1 diabetes, thyroid hormone disorders, and a host of other clinical conditions. Anorexia nervosa is thought to occur in approximately 1-4 percent of females, and 0.5 percent of males, and often begins during the teenage or young adulthood years.

There is much debate still about what causes anorexia nervosa. There has been an increased incidence of the diagnosis of anorexia nervosa in the last 50 or so years, and this increase has been correlated with increase in social pressures, particularly on females, but more recently on males too, for the ‘ultimate body’, with most cultures increasingly favouring a slender shape and the ‘size zero’ model, where clothes and fashion are displayed on waif-like models. This is theorized to put pressure on most folk to be thinner than what is possible for the vast majority of people. But, correlation is not causation, and the counter-argument to this social theory would be that 96% of women and 99.5% of men see similar fashion images and models and do not develop anorexia nervosa. There is a strong familial link to it, with twins and first degree relatives of someone diagnosed with anorexia nervosa having a significantly higher chance of developing the disorder. It has also been suggested that the prevalence of anorexia nervosa is higher in athletes doing sports that require weight control, such as gymnasts, runners and cyclists, and in those folk whose careers similarly require weight regulation, such as ballet dancers and jockeys. It has also been suggested that folk with gastrointestinal disorders such as inflammatory bowel disorder and coeliac disease may have a higher prevalence of anorexia nervosa, due to the increased requirement to be ‘aware’ of what food types are ingested if suffering from other of these challenging gastro-intestinal disorders, and indeed eating any food whatsoever may initiate their symptoms. There has been an increase in interest in ‘extreme’ diets such as the keto, carnivore, and vegan diets, amongst others, and it has been suggested that engaging with such diets may precipitate the development of anorexia nervosa, or indeed be a ‘mask’ for those with eating disorders to ‘hide’ behind as a label that would allow them to explain their weight loss and extreme thinness in a way that was more socially acceptable than telling those around them that they have anorexia nervosa, or allows folk suffering from the disorder to feel part of a group of similar food conscious folk.

Anorexia nervosa would be easy to diagnose, treat and manage if the disorder was as simple as that described in the paragraphs above. But, a major confounding issue is that a high percentage of folk who suffer from it deny having anything wrong with themselves, deny having an eating disorder, and some resist being treated to the point of requiring to be restrained and force-fed to keep them alive. It sounds terrible that folk have to be force fed against their wishes (and some doctors have an ethical problem doing so), but unfortunately anorexia nervosa has the highest mortality rate of any psychiatric or psychological disorder, around 10-12 times that of the general population, with the risk of committing suicide being 50 times higher. Anorexia nervosa sufferers literally starve themselves to death, or commit suicide while doing so, and there is a high recidivism rate, with only half of the folk who have it ‘recovering’ (if they ever do), with the rest relapsing or becoming chronic and a permanent ‘way of life’ until death intervenes. So something is clearly desperately ‘wrong’ in these folk, who either know about it and acknowledge it, know about it and don’t acknowledge it, or not know that they have the disorder and perceive themselves to be well – clearly the latter group being the most challenging to treat, though all three groups require major psychological assistance and intervention. Anorexia nervosa is classified under Feeding and Eating Disorders in the ‘bible’ / official manual of Psychological disorders (known as the Diagnostic and Statistical Manual of Mental Disorders – DSM5), but there is a high prevalence of other associated psychological disorders, including obsessive-compulsive disorder and obsessive compulsive personality disorder, anxiety disorder, and depression. An array of other psychological disorders have also been linked to anorexia nervosa, including borderline personality disorder, attention deficit hyperactivity disorder, autism spectrum disorders, and body dysmorphic disorders, and while some of these linked disorders require further research to understand their prevalence and linkage to anorexia disorder, it is thought that having these comorbidities worsens the prognosis for folk suffering with florid anorexia nervosa.

With all these challenging psychopathology and comorbidity factors, three key issues appear to be fundamental to anorexia nervosa. The first is precipitatory factors, the second loss of interoceptive (body state) awareness, and the third perception of loss of control in folk with the disorder. It is thought that a stressful incident in one’s past life, or a change in circumstances for an individual already predisposed to develop the disorder, or by being in a sport which requires weight regulation, can precipitate the development of anorexia nervosa in a susceptible individual. Sadly, a number of folk who develop anorexia nervosa have a history of childhood trauma, including abuse, parental divorce, or a conflict-filled environment, and a study published last year found there was a twenty five percent incidence of sexual abuse during childhood reported as occurring before the onset of anorexia nervosa. Equally, a change of environment that is challenging, such as moving geographically, or going to boarding school, or the death of a parent or sibling or loved one, or being teased about one’s body shape in childhood or adolescence, may also be precipitatory factors. While difficult to prove direct linkage as a response to these psychologically ‘shattering’ events, what appears to happen as a result of these traumatic challenges is that a process of ‘disembodiment’ occurs (also described as ‘interoceptive loss’) where one’s body image is altered, or one does no longer ‘recognize’ one’s current body image, perhaps as a way of ‘denying’ the trauma that was done to it as would have occurred as a result of being sexually abused for instance. It has also been suggested that folk with anorexia nervosa undergoes a ‘loss of emotional self’, where one no longer recognizes ones emotions and feelings, in a similar way, and for similar reasons described above, as why one no longer recognizes one’s physical body. Lonnie Athens, one of my most admired Psychology researchers, has suggested that one cannot have too weak a sense of self, as one would not be able to have a stable sense of self-identity if so. However, he suggested that with a profound change, such as being the victim of a violent episode, divorce, loss of a job, or some other profound experience, for which the individual has no prior frames of reference or experience of, and which their current self-identity system (whatever this is) cannot provide interpretation of or makes sense of, resulting in changes to the sense of self similar to that found in folk with anorexia nervosa. In his model, the factors which set the sense of self in the brain become confused in a crisis for which there are no previous precedents to benchmark the current experience against. Because of this, the sense of self become fragmented, and replaced by a different sense of self, if the individual is able to make sense of what happened to them and ‘move on’ from what happened, but if not, remains permanently fragmented, and folk develop into a permanent state of sense of self ‘flux’, in which the individual is to a degree unrecognizable to themselves in a manner which becomes habituated.

The underpinning issue of all of these factors, and the ‘unfinished’ response to them, is a sense of loss of control. The individual who has suffered life trauma, and the resultant ‘shattering’ of their sense of self, no longer feels in control of their life and situation. One thing that can be controlled is their food intake, and in the case of folk who develop anorexia nervosa, they stop eating due to the desire either to control one factor in their existence which they can have complete control over, or actually do want to starve themselves to death, as a compensation or ‘way out’ of their current psychological ‘fragmentation’, and they stop eating as a way of enacting a prolonged suicide. For this reason (amongst several other reasons), folk with anorexia nervosa do not believe that they have an eating disorder, as by limiting their food intake, they feel that they are for the first time since whatever precipitated the development of the condition of anorexia nervosa, and are ‘controlling’ something in their own body, and it would be too psychologically draining for them to ‘lose’ what becomes in effect a control ‘mechanism’ that they feel completely ‘in control of’. At the same time, the individual may deny or ‘forget’ that they ever had any abuse or traumatic episode happen to them, as it is too threatening to their already damaged psyche to admit such, and as a mechanism of psychological denial, they ‘remove’ it from the conscious self to the nether world of their subconscious, where it continues to ‘trip them up’ and damage their lives until they confront it. So paradoxically, folk with anorexia nervosa can be all of completely out of control (from the context that they have been ‘ripped up’ psychologically by prior damaging events), in control (from the context of what they choose not to eat), and in some folk not aware of (due to protective psychological denial processes) their current physical state, sense of self, or underlying psychopathology. The distortions of body image, and dread of adding on even a pound of weight, are a result of these three ‘issues’ (amongst others) at play in their deep psyche and if this ‘lack of awareness’ is not addressed, the person with anorexia nervosa will literally starve themselves to death, as a method of maintaining control, or of negating the damage caused to them of whatever lead to the development of their condition. Therefore, in many cases, folk forget that anorexia nervosa can be a symptom of some deeper psychopathology, which may or not be ‘hidden’ from view, apart from it being a psychopathology in itself.

All of these ‘entangled issues’ make anorexia nervosa extremely difficult to treat. If folk deny that they are sick, it becomes very difficult to treat them, as whatever one does, they will not ‘stick with’ the treatment offered. Admitting that they are sick, or that they have a mental illness, requires them to acknowledge the psychological damage underpinning their anorexia nervosa (with anorexia nervosa being a symptom itself), and that they have no control over their life, and indeed that their own ‘treatment’ they have chosen to ‘cure’ their underlying psychopathology such as sexual abuse or other issue, namely not eating, or controlling their eating patterns to an extreme degree, has been wrong. A large number of folk with anorexia nervosa want to be left alone, and find it difficult to cope with being diagnosed as having anorexia nervosa due to the requirement this would make on them to confront their underlying psychopathology, and indeed, sadly, being diagnosed as suffering with anorexia nervosa creates a stigma of its own, and may ‘label’ and define them for life as such, and this is yet another psychological challenge to accept in their challenged state (that they have both an eating disorder and also underlying psychopathology) for the folk suffering from it. Treatment of the disorder involves trying to restore the person to a functional weight, treating the underlying psychological disorders that led to the development of anorexia nervosa, and reducing behaviors and activities that result from the disorder becoming habituated (such as not eating in front of other folk, hiding food, as well as of course not eating at all most of the time). Psychotherapy, cognitive behavioral therapy and family-based therapy have all been used with varying degrees of success to treat folk with the disorder. However, given that eating is a basic requirement of life, each day is an ordeal from the context that eating is required to happen in order for life to continue, and at each meal there is thus a conflict and habitual cycle of negation that is very difficult to alter or attenuate. Force feeding has been used in extreme conditions, but there are of course ethical issues associated with this, such as the individual’s rights, though of course the debate is whether folk with anorexia nervosa are in a ‘right’ state of mind and / or can make decisions that are good for themselves, rather than being damaging for themselves (similar issues of treatment occur in folk with alcoholism or who self-harm, amongst others). In the end, as described above, it is a disorder that is extremely challenging to manage, with a high level of chronic morbidity and mortality, very much as if the folk with the disorder ‘want to die’, as challenging as it is to describe it as such, or as a clinician to understand it as such.

Anorexia nervosa, for the reasons described above, is one of the most challenging disorders clinicians, friends and families of people that have the disorder have to manage and live with. To all of us watching the lady in the gym last week it was clearly obvious that she had a severe case of anorexia nervosa, yet she appeared oblivious to this, and was indeed working hard in the gym to ‘maintain fitness’ (thought of course in this case the exercise may be both a symptom and vehicle of psychopathology itself). In many ways society advocates restrictive eating and thinness, and from this perspective, the lady in this example would be congratulated for doing this to such extremes. Yet, paradoxically, someone like this who appears to be so in control, is actually completely out of control, and even more strangely, in many cases is not aware of it. The ‘mirror’ / self-image assessment function in their brains, however it works in both health and disease, appears to warp and become convex, and to the anorexic, their body image is usually so ‘fragmented’ that they see big where they are indeed thin. Even more sadly, as a clinician seeing folk like this makes one wonder what traumatic event the individual has gone through to trigger their anorexia nervosa, and whether they hopefully are in counselling to try and help them get to terms with whatever issue is causing their ongoing self-harm. Sadly thought, this is so difficult to do, as control mechanisms are involved which have become extreme, and make them unable to ‘move on’ from a life spent in the shadows to one in the light. Sigmund Freud suggested that folk have both a life instinct (Eros) and a death instinct (Thanatos), and one’s Thanatos instinct compels us humans to engage in risky and destructive behaviours that can lead to our own personal death. Clearly, in folk suffering from anorexia nervosa, a trigger has changed their ‘behavioral setting’ from Eros to Thanatos, and once changed, the God of Death appears to be fairly resistant to change. Much research is needed in the field to help us understand the psychopathology underlying anorexia nervosa better, and how to treat, or at least manage the condition. Mirror, mirror, on the wall, am I the thinnest person of them all may be the mantra of this disorder, but sadly the mirror is telling a lie. Each time I put in the two spoons of sugar which I enjoy my tea, I thank my parents for removing me from boarding school, before a fast of defiance became overwhelmed by Thanatos, the God of Death, and before I too went down to the place where everything which seems real is not, and where once one is over the edge of the abyss, there is very little chance of ever coming back. Dying by starving oneself to death may paradoxically represent a victory to the individual that pushes themselves to their own death, but the fight between Eros and Thanatos in a loved one, when Thanatos wins, is surely one of the most tragic things a clinician, family member or loved one can ever watch from a distance and understand, or even begin to comprehend, without wanting to smash the distorted mirror, and by doing so rebuild the fragmented spirit underneath it, no matter how impossible in real life this is.

Death and Our Own Dying – Death Related Anxiety And The Understanding Of Its Certainty Patterns Our Daily Life

In the last few weeks our family has had to come to terms with the fact that the health of our wonderful dog, Grauzer the Schnauzer, who whose been our faithful companion of eleven years, and has travelled with us from Cape Town in South Africa to Newcastle upon Tyne in the UK, and then back to Bloemfontein in South Africa, is failing, and as much as we don’t want it to happen and hope he lives on for a few years more, it is very likely in the next few weeks he will be taking the journey to the next world of unlimited lamp-posts and cats and ferrets that do not move as quickly as they do in this one. My old friend and world leading Sport and Exercise Scientist, Professor Andy Jones, last week retweeted some fascinating data of what folk die from during their lifetimes at different ages, and it was fascinating to see this and understand that one had got ‘safely past’ some of the childhood and early adult related cause of death, but that equally, now being well into middle-age, a whole host of nasty causes of death could potentially be one’s fate at any time from now into the future. My great brother, John, heard the unfortunate news that one of his school classmates had passed away of natural causes at the age of forty seven, and we soberly reflected over the Christmas period that ‘there by the grace of god went we’, and we resolved to pay more attention to our health and fitness, in the chance that this would make a difference and prolong for as long as possible into the future the inevitable fate which awaits all of us. All these got me thinking about death and dying, the biggest mystery of life, and perhaps the biggest factor at play in our lives and consideration of our future.

Death is defined as the final cessation of vital functions in an individual or organism which results in the ending of life. One’s death can be a result of a number of different phenomena, from senescence (biological ageing, or in more common terms, old age), disease, violence and murder, predation by wild animals, accidents, suicide, and any number of other mechanisms that potentially can cause one to die. While how exactly to define and diagnose the occurrence of death is still debated in medical circles, generally most folk would accept that someone has died when their heart and respiratory organs stop working and cannot be sustained without external artificial assistance, along with evidence of brain death as evidenced by a ‘flat-line’ EEG (which monitors the presence of rhythmical brain waves) and a lack of cortical function or primitive brain reflexes. When this happens, the body of any person or organism starts decaying and decomposing shortly after the onset of death. Interestingly, not all ‘living’ organisms die (the definition of what constitutes a ‘living’ organism is still hotly debated), with exceptions being the hydra and jellyfish species, which appear to be immortal and never die, and can maintain their existence ‘forever’ unless they are physically torn asunder. Similarly, organisms which reproduce asexually, and unicellular organisms, also appear to ‘live’ eternally. So one can postulate that death is a ‘by-product’ of a complex cellular structure, where somatic (body) cells are created in a complex arrangement by a combination of some ‘plan’ and some energy form, which allows the occurrence of ‘life’ as we know it, but decays with time and eventually deteriorates functionally to a degree that ‘death’ occurs.

What happens to us around the time and ‘after’ death is of course still a matter of conjecture. A fair bit of research has been done on folk who have had a near-death experience where they have been clinically ‘brought back from the dead’ after either a heart attack, or a near drowning, or accident related trauma, all which lead to hypoxia (shortage of oxygen supply) to and of the brain. Most describe a feeling that they are ‘blacking out’ for what to them is an unknown and unpredictable period of time, and an awareness that one is dying, until by chance / good medical practice they are ‘brought back to life’ by resuscitation and other clinical interventions. A lot of these folk also describe a sense of ‘being dead’, a sense of peace and wellbeing and painlessness, an out-of-body experience as if they were ‘floating’ above and ‘watching’ their physical self, a ‘tunnel experience’ of entering darkness via a tunnel of light, reviewing their life in a manner often described as ‘seeing their life history flashing before their eyes’, or seeing ‘beings of light’, all before the absolute darkness / nothingness of unconsciousness (‘death’) occurs, or they ‘return’ to their body as they are resuscitated. Of course all this is first person / qualitative descriptive information, and is impossible scientifically to replicate, but it is interesting that so many folk describe similar experiences as they ‘die’. We also do not know at all what then occurs after this phase, as all these folk are ‘brought back to life’, so we are not aware what happens ‘next’ as part of the death process. Into this knowledge void folk put their own interpretation of what happens, or will happen to them, when they do die – religious folk would describe and I guess hope for some type of ‘heaven’ as the ‘next phase’, or some transcendence or continuation of one’s ‘spirit’ or ‘soul’ into another body or as an entity which exists and ‘drifts’ through the ether eternally – while secular folk would either say they are not sure of what happens, or believe that there is nothing ‘after’ death, and everything just switches off and a blankness / nothingness occurs similar to when one is in a deep sleep. Of course all of these are pure conjecture, and it is for each of us to experience and understand what is ‘ahead’ for us after own deaths only when it happens, when all shall be made clear, or we will disappear into the eternity of nothingness, and know nothing about it or anything further of our life, past, current or future.

What is for sure is that for most folk, the thought of one’s own imminent or potential mortality causes anxiety (and I have never heard anyone say with any sincerity that they really are totally not scared of death and dying, and in those that do, it is almost always manifestly evident bravado), often to a morbid degree, where it is known as thanatophobia. Thanatophobia, or death anxiety, is defined as a feeling of dread, apprehension or anxiety when one thinks of the process of dying, or the totality of death, and its impact on one’s own ‘life’ which is all that we know and ‘have’. Death anxiety can be related to the fear of being harmed and the way one will die, or to existential fear that nothing may exist after we die, or to the fear of leaving behind loved ones and things and processes we believe are reliant on us for their continuation. It has been suggested that folk ‘defend’ themselves against the anxiety they feel about their own death and dying (or that of loved ones) by ‘denial’, which results in a lot of transference, acting out, or ‘covering up’ behaviour either consciously or subconsciously, such as attempting to acquire excessive wealth or power, or committing violence against others, or breaking rules and life boundaries, or celebrating / living life in a manic way, all of which have an emotional cost, and do not usually attenuate the underlying death anxiety. Interestingly, a century and more ago, most folk used to die in a more ‘open’ way than what currently occurs, usually in the comfort (or discomfort) of their homes, surrounded by their loved ones. In contrast, today a greater proportion of folk die in hospitals or hospices, ‘away’ from the ‘visible’ world, and it is usual for most folk never to see someone actually die in their lifetime until their own death is imminent. It has been postulated that this ‘hiding’ of death from us may have paradoxically created a greater fear of death because of us never ‘seeing’ or being involved with death, and therefore death is an ‘unknown’ entity or occurrence which causes an exacerbated fear due to the fear of the unknown nature of death, rather than just a fear of death itself. It has been suggested that folk with more physical problems, more psychological problems or a ‘lower ego integrity’ (lower self-confidence) suffer from greater death anxiety. Folk like Viktor Frankl have suggested that having some life ‘meaning’, or a sense of peace from achieving life goals, or paradoxically letting go of life goals, may attenuate the feelings of death anxiety. Supporting this, death anxiety is apparently greatest during the ages of 35-65 (and is felt by children as young as five years old), but after 65, again paradoxically, death anxiety appears to decrease, perhaps because after retirement one ‘lets go’ of earthly goals and desires, or reaches a sense of peace regarding one’s life and achievements. Of course there has to be a relationship between goals / desires and death anxiety for this to be true, and it is not clear if such a relationship clearly exists, even if it does seem to be logical ‘link’.

Folk that ‘give their life away’, whether in combat as part of a perception of national duty, or to save a family member, or in a life-threatening emergency where they react to such a situation and are prepared to die to save others, are challenging to understand in relation to the death anxiety and fear of death issues described above which most folk would admit to having. Clearly having a ‘higher cause’ must be valenced by these folk to be more important than their own life, or their lives must be perceived to be meaningless enough to ‘give it away’ in such instances. It is difficult to tell which of these (a perception of a higher cause or a meaningless life) is most germane in these different examples, and indeed whether these folk have a fear of death or anxiety about it, but continue with their course of action despite feeling such, or whether some cognitive process or learned way of thinking removes this fear / anxiety before they perform their last act of sacrifice or wilful death. Sigmund Freud suggested that there is a death drive in all folk, which opposes the ‘Eros’ drive (lust for life / breeding / survival), and that when folk want to die, or risk their life doing for example extreme sports like parachuting or mountain climbing where there is a high chance of death occurring, it is part of some primordial desire to ‘go back’ to some pre-life state, though of course a theory like this is difficult to prove or disprove as we cannot yet measure ‘drives’ in a direct way.

So how does knowledge of this anxiety related to the awareness of death as the final life process we will go through, and indeed of death itself, both affect and assist us with how we live our life? We do seem to either consciously or unconsciously create a ‘scaffold’ or pattern of our life plans and life stages related to the relative perceived imminence of death. For example in our twenties we explore ‘life’ with mostly a freedom from the fear of death (though paradoxically this exploratory behaviour often can end in accidental death), perhaps because one believes that one has many years of life ahead of one, and death will occur at a time far in the distance ahead. As one enters one’s thirties, one is for some reason to a greater degree confronted by an understanding of one’s mortality, perhaps due to early signs of physical deterioration such as not being able to compete as well as one used to at sport, or hair loss / developing baldness, or experiencing the death of one’s parents which ‘brings’ awareness of both the reality and finality of death to oneself, amongst many other potential reasons. Because of this one therefore starts ‘planning’ the life left ahead of one based on average mortality figures (most folk believe and hope they will live to between 70-80 years if things go well for them) – for example buying a house that will be paid off before one ‘retires’, having children at a young enough age to see them grow up to adulthood, or writing a will for the first time. The concept of retirement is interesting related to death and dying, and is surely based on a ‘calculation’ of a death age beyond the retirement age, thereby allowing one to have a little ‘down time’ / a time of peace before shuffling off this mortal coil, even though paradoxically health reasons often do not allow folk as much enjoyment of this time as they would if they rather planned a work ‘gap period’ in their forties or early fifties where they took time out from work to relax or travel, and subsequently worked on until death occurred, rather than waiting until being ‘old’ to enjoy retirement with the time left before their death. So a lot of our life appears to be patterned and planned out based on an understanding that a finite amount of years are available to us. This is perhaps why when one has a health scare, or a cancer diagnosis, or when a young person goes to war where the chance of death is manifestly increased at this ‘incorrect’ time of the person’s life, fear of death, death anxiety and denial mechanisms come into play, that can be very difficult to attenuate or ‘put out’ of one’s mind.

As much as one would like to, as the main character in the film ‘Lawless’ concluded after his much revered brother, who he thought was immortal, died at the end of the film, no-one leaves this world alive. Understanding this creates a sense of anxiety in us (unless we perhaps have strong religious beliefs), both for what we will lose, and for what we will leave behind. But, paradoxically, the thought of death perhaps also creates a sense of wonder each day we wake up that we are indeed alive for another day, and makes the grass seem greener, the sun shine brighter, and the water seem wetter, given we know that one day we will no longer ‘have’ all these things around us. Once in my youth I capsized when paddling down a river in my kayak and was pinned under a rock for a period of time, and had that ‘out of body’ feeling described above, and my whole life to that point played out in a fast sequential ‘movie’ in front of my eyes, and then I felt everything go black and remembered nothing more. Fortunately I was ‘let go’ / washed out from under the rock, and when I regained my senses everything did indeed seem much sweeter, lusher, brighter, and more brilliant, and does still to this day. I am of the age when according to the statistics I should most fear death, and indeed, with a young family, each day I do fear that I will not see my son and daughter grow up if I die suddenly. I held my wonderful dog Grauzer in my arms as I brought him home from the vet this morning with the news that I might not be able to hold him such for much longer, and a feeling of immense sadness and impending loss almost overwhelmed me. But then I thought about the good times we have had together, and understood that the circle of life, which for him is nearly complete, was and is a full and happy one, and I understood also that part of my sadness for him is my fear for my own mortality and the sense of permanence that accompanies his impending death. I took note of the fact that, as described above, at the end of one’s life the fear of death is usually paradoxically attenuated and lessens, and hoped that dogs get to that similar point of peace at the end of their time too. And yes, his fur does feel softer, his wagging tail and uplifted ‘happy’ face each time he sees me seems even ‘sweeter’, given I know that soon he will go forever into the great unknown, and will be with us no more. Death and dying is still the greatest mystery life has for us, and a challenge we all have to go through on our own, and we will only gain the knowledge of what death is ‘about’ when we go through the dying process ourselves. When eventually facing one’s own imminent death, perhaps the best one can do is try and find the courage to meet it ‘head on’, as suggested in the wonderful words of the Nick Glennie-Smith song, ‘Sgt. Mackenzie’, written in homage to his grandfather who died in the first Great war – ‘Lay me down in the cold, cold ground, where before many men have gone. When they come, I will stand my ground, and not be afraid’ – though of course we all hope that the need to do this will occur many years from now, with all our loved ones around us, and with the contentment of a life well lived in our final moments. But we can be sure of one thing, and that is we will never get out of this world alive, unless we are an amoeba or jellyfish. And maybe, just maybe, the world is a better place because of this, or at least it feels such in those moments when we ponder on the glory of life, with the aching awareness that at some future point in time we no longer will be ‘in it’, and will go off on our own journey, alone, into the great big, wide, unknown.

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