How can I tell if I’m going insane? Advice from a therapist

Rare is the person who has never had cause to momentarily question their sanity. This highly distressing phenomenon can happen for several reasons: 

Just a few consecutive nights of tossing and turning can turn our world blurry, making us question whether what we call reality is some bizarre, interminable dream. Juggling work deadlines, family obligations, and social commitments can create a mental cacophony that can likewise leave us briefly wondering whether we’re on the verge of a mental meltdown.

Could it be a mental health issue?

For most of us, the feeling that we’ve lost our ability to navigate the world is short-lived. However, several quite common mental disorders can cause protracted or recurrent episodes of feeling as though one has gone insane or may soon go insane. As a therapist, I’ve seen most of them in my patients. In this article, I’ll detail a handful of these conditions and how they’re treated including one I specialize in treating.  

Panic Disorder:

People with panic disorder often experience sudden, intense bouts of fear or discomfort, accompanied by physical sensations like heart palpitations, trembling, and a sense of impending doom. This intense surge of anxiety can lead to a pervasive fear of losing control or going insane. The unpredictable nature of panic attacks can create a profound sense of vulnerability, making people question their mental stability. The fear of the next attack can amplify these concerns.

First-line treatments typically involve cognitive-behavioral therapy (CBT), specifically panic-focused CBT and medications like selective serotonin reuptake inhibitors (SSRIs). CBT has shown significant efficacy in reducing panic attacks and the associated fear of psychosis or going insane. 

Illness Anxiety Disorder:

Formerly known as hypochondriasis, illness anxiety disorder involves excessive worry about having a serious medical condition, even with little or no medical evidence. While historically dominated by fears of physical ailments, there exists a subset—almost a “mental illness anxiety disorder.” This involves the misinterpretation of normative, albeit bizarre, mental phenomena as signs of impending insanity. I actually had a roommate in graduate school who published a paper on this called “psycho-hypochondriasis.” He proposed criteria for DSM that looked at normative, albeit bizarre, mental phenomena that would be misinterpreted as an indication that you’re going crazy.

Cognitive-behavioral therapy can be effective in challenging maladaptive health beliefs. Medications such as SSRIs may also be prescribed, but, as mentioned above, drugs may quell the symptoms but won’t address the underlying cause. 

Schizophrenia:

Distorted thinking, hallucinations, delusions, and impaired social functioning characterize schizophrenia. The disconnection from reality can prompt people to question the stability of their mental state. The presence of hallucinations and delusions creates an alternate perception of reality, making it challenging for people to discern what is real and what is not. It’s not hard to see why this confusion can contribute to doubts about sanity.

Antipsychotic medications are the mainstay of treatment, though individual responses vary. These medications are often combined with psychosocial interventions like cognitive therapy and family support, which can play a crucial role in improving functional outcomes and minimizing relapses.

Borderline Personality Disorder (BPD):

BPD is characterized by pervasive patterns of instability in interpersonal relationships, self-image, and emotions. People with BPD may experience intense and sudden mood swings, along with difficulties in forming stable identities and maintaining relationships.

The emotional volatility and shifting self-perceptions in BPD can lead people to question the stability of their emotions and identity. Episodes of intense anger, fear of abandonment, and distorted self-image contribute to this internal turmoil.

Dialectical behavior therapy (DBT) is a primary treatment for BPD. Medications, such as mood stabilizers or antidepressants, may be used to address specific symptoms.

Post-Traumatic Stress Disorder (PTSD):

PTSD can develop after exposure to a traumatic event, leading to intrusive memories, avoidance behaviors, adverse changes in mood and cognition, and heightened arousal. People with PTSD may struggle with recurrent distressing memories that blur the lines between past and present.

The intrusion of traumatic memories and the associated emotional dysregulation can create a sense of being haunted by the past. This can lead people to question their ability to maintain a coherent and stable sense of self.

Trauma-focused, specialized therapies, such as prolonged exposure (PE) therapy—which we offer at NOCD—are commonly used for PTSD. 

Obsessive-Compulsive Disorder (OCD):

As a therapist who specializes in OCD, the question of how one can discern if they are going insane is highly familiar terrain for me. Before we get into why that is, let’s get a little more familiar with this disorder.  

OCD is a serious and misunderstood mental health condition marked by persistent, intrusive thoughts (obsessions) and repetitive behaviors or mental rituals (compulsions). Globally, it affects approximately 2.5% of the population. Onset often occurs in childhood, adolescence, or early adulthood, with men and women affected equally. 

People often off-handedly say they are a “little OCD” due to a preference for cleanliness or order. The reality is that people must meet several criteria to be correctly diagnosed with the condition. These include the presence of obsessions and compulsions that take up time, are distressing, and/or negatively affect usual functioning.

Known as “the doubting disease,” OCD can cause people to question their sanity due to the relentless nature of their intrusive thoughts. Patients may doubt their moral integrity or question their identity.

It’s exceedingly common, for example, for people with OCD to grapple with constant doubts about whether they had accidentally caused harm—say, hitting someone with their car—leading to exhaustive rituals of checking and seeking reassurance. Others struggle with intrusive thoughts challenging their sexual orientation, causing immense distress and prompting similar rituals for validation. 

These intrusive, unwanted thoughts, particularly those of taboo themes, can trigger a secondary fear in people with OCD, where the mere presence of such thoughts is seen as an indication of losing control or sanity.

For people with OCD, this fear leads to compulsions—attempts to reassure themselves that they are indeed sane or in an attempt to regain their sanity. This could manifest as hours spent googling, asking friends and family whether they think they’ve “gone mad,” or even seeking psychiatric evaluations, hopping from one mental health professional to another in a quest for an impossible degree of certainty about their mental state. 

These compulsions often reduce anxiety for a short while, but anxiety is practically guaranteed to flare up the moment something triggers it again, leading to more compulsions and a strengthening of OCD’s vicious cycle. That’s why OCD tends to get worse without treatment. Luckily, there’s a tailor-made therapeutic approach that’s evidence-based, highly effective, and more accessible than ever before. It’s called exposure and response prevention therapy (ERP). 

Exposure and Response Prevention (ERP)

In ERP, a specialized therapist works closely with you to identify your main fears and the things that trigger them, whether rooted in physiological sensations or intrusive thoughts that preempt your doubts about your sanity. This systematic and collaborative approach ensures that exposures are tailored to your unique experiences, fostering a sense of agency in confronting your fears.

During a typical ERP session, a therapist will guide you to confront your triggers and sit with the anxiety you feel, rather than resorting to compulsive responses. This process will, over time, empower you to tolerate the anxiety associated with your fears, challenging the ingrained patterns of avoidance and compulsions.

Research consistently underscores the effectiveness of ERP in treating OCD, with significant reductions in symptoms and improved overall quality of life. ERP offers freedom from the shackles of obsessive thoughts and compulsive behaviors—including doubts about one’s sanity—fostering resilience and allowing you to live life on your own terms.

Start getting better today

If you think you might have OCD and are interested in learning how it’s treated with ERP, I encourage you to learn more about NOCD’s evidence-based, accessible approach to treatment.

Like myself, all of our therapists specialize in OCD and receive ERP-specific training. You can also get 24/7 access to personalized self-management tools built by people who have been through OCD and successfully recovered.

Remember, you’re taking a significant step toward reclaiming your life from OCD. With the right therapist and ERP, you’re setting yourself on a path toward meaningful progress and improved well-being. You’re not alone in this journey; there is hope for positive change.