What is obsessive-compulsive disorder (OCD)? Often, it is misconstrued or misrepresented as that friend who is always cleaning and needs everything to be neat and tidy. Perhaps images come to mind of highly frequent or unnecessary showering or handwashing. While these are not incorrect portrayals of one’s possible experience with OCD, they are by no means a complete picture of the broad scope of this disorder. In reality, the subject of the intrusive thoughts that plague individuals with OCD are not one-size-fits-all and span across a wide variety of topics.
With existential OCD, intrusive thoughts revolve around questions that are impossible to answer. These thoughts are often philosophical, and wouldn’t necessarily be out of character for someone without OCD: “What is my purpose?” or, “Is there a God?” or, “Is there life after death?” While these questions can be frustrating or even frightening to anyone, they are not usually all-consuming. For most, leaving these thoughts unanswered and moving onto other thoughts does not pose a challenge. However, for individuals with existential OCD, it is not quite as simple. People with this subtype of OCD may spend hours contemplating these questions and thoughts over and over again, the weight of which can cause a great deal of distress, anxiety and depression. Individuals with existential OCD may experience the following stream of thought:
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“What if I am not really here? Would I know if I was not really here? How would I know? What if my whole life has been a simulation and no one and nothing around me are actually real? If I am not actually here, then why does anything I do matter? What is the point of my life or anyone’s life if none of us are actually real?”
“What if life has no meaning? What if we’re just an accident? What if our lives are lived for no purpose and when we die we just go away? What if we are just a speck of dust and one of one trillion particles after all is said and done.”
As with other manifestations of OCD, these intrusive thoughts are typically followed by the urge to perform compulsive acts. These compulsions are intended to eliminate the doubt that ensues from lack of answers to existential thoughts and questions and reduce distress. As with other types of obsessive thoughts, the compulsions related to existential OCD are numerous and varied. These compulsions can take many forms but frequently include time-consuming behaviors such as spending hours thinking about or researching these thoughts and questions in order to find answers. Other common compulsions related to existential OCD involve seeking reassurance from others that you are real or that they are real, evaluating past experiences for information to prove or disprove an obsessive thought or engaging in actions that may offer physical clues of existence, such as checking for your reflection in the mirror. The problem with all of these compulsive behaviors is that their aim is to find concrete answers to questions that do not have any. This leaves individuals constantly searching for answers that they may accept for a brief period of time — only to begin doubting them again and searching for new ones.
As discussed earlier, existential thoughts and questions are quite common. Because of how commonplace these thoughts and questions are, individuals with existential OCD may delay seeking treatment. But even once they do seek treatment, getting a diagnosis of existential OCD can be difficult. Because existential OCD often involves an evaluation of life and its meaning, it may be confused with depression. It is also possible for existential OCD to be inaccurately interpreted as general worry and existential fear or even misdiagnosed as Generalized Anxiety Disorder.
Although it may be difficult to identify at first, the only real difference between existential OCD and any other form of the disorder is the nature of the intrusive thoughts. As such, the recommended treatment for existential related OCD remains the same as for any other variety of OCD: exposure and response prevention (ERP) therapy, a type of cognitive behavioral therapy (CBT) that has been referred to as the gold standard approach for treating OCD. ERP therapy requires clients to lean into uncomfortable thoughts without engaging in compulsions to learn to tolerate uncertainty. The goal is that through repeated exposure to the feared thoughts or stimuli the individual will begin to develop a tolerance toward the negative feelings associated with those thoughts (e.g., anxiety). It’s important to note that while the work of ERP can be uncomfortable, every step of the process is a fully agreed upon collaboration between therapist and patient. ERP never starts with the most intrusive thoughts but rather a patient starts with thoughts that land in the middle to the lower end of the hierarchy and as a patient gets more comfortable they work to tackle more difficult thoughts.
It is also common for individuals in ERP treatment to receive homework assignments. For someone with existential OCD, these assignments may involve reading articles or watching videos that validate or trigger the obsessive thoughts, repeatedly writing notes about the feared thoughts or creating and replaying audio recordings that confirm the thoughts. This intentional exposure to one’s obsessive thoughts can be extremely challenging and frightening, and should always be done with the help of a licensed and trained therapist. However, the “response prevention” part of ERP requires that individuals not turn to their usual compulsions such as analyzing, questioning, seeking reassurance or avoidance. Rather, the individual is gradually exposed to the feared existential thoughts through different means such as articles, books and videos. Over time, the more the individual is confronted with their feared existential thoughts while withholding from engaging in compulsive responses, the less feared those thoughts may become.
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If you or someone you know is experiencing existential OCD, help is available. You can schedule a free 15-minute call with an NOCD therapist today. All NOCD therapists are trained to provide ERP therapy. NOCD also offers video therapy for those who need it and is available in all 50 states.