Obsessive compulsive disorder - OCD treatment and therapy from NOCD

What if I’m actually dead and don’t know it? A therapist’s perspective

By Elle Warren

Oct 31, 20237 minute read

Reviewed byApril Kilduff, MA, LCPC

We have experiences that are beyond overwhelming, things we don’t have the answers for. It’s natural to have existential thoughts from time to time. Thoughts like, “What is the meaning of life?” “What is my true purpose?” or “What if I’m actually dead and just don’t know?” While part of the joy of being human is our consciousness, it can also torture us. 

For some, those existential questions become constant and bring feelings of fear, distress, anxiety, and even depression. 

When I was a kid coming to terms with the idea of death, I’d imagine myself being inside a grave. I thought about the darkness, the loneliness, the stark contrast between it and this vibrant world. 

Today, I recognize that experience as one of my earliest memories of obsessive-compulsive disorder (OCD). Years later, when I was twenty and my mother died, I was forced to confront my fears surrounding death. I was not only distressed by seeing death up close, but also by the ways in which grief made me feel dead. In my grief, depersonalization and derealization, which I’d experienced before but never to such an intense degree, led me to think that I, and the world around me, might not be real. My life became mostly about trying to prove to myself that I was, indeed, real. 

Today, more than five years after my mother’s death and my mental health crisis, I have a much less frantic relationship with death. I know how to recognize intrusive thoughts for what they are, not as facts or real threats. I spoke with Dr. Patrick McGrath, NOCD’s Chief Clinical Officer, about where this fear might come from and how to get help for it.

Why are you having this worry?

One reason this fear could be coming up for you is existential OCD. This subtype of OCD involves recurring intrusive thoughts, images, feelings, sensations, and urges surrounding philosophical, impossible-to-answer questions about life, death, and the universe. These are known as obsessions, and they cause significant distress, anxiety, and/or panic. 

In order to relieve oneself of those hard, scary feelings, you might engage in the second component of OCD: compulsions. Compulsions can be an outward action or an inward, mental process. Dr. McGrath says the most common compulsion he sees with this subtype is excessive online research. People with existential OCD are desperate to find answers, and so they find themselves falling down the many “rabbit holes” offered by the internet. Other compulsions you might experience include:

  • Mentally reviewing past scenarios to look for clues of being dead.
  • Seeking reassurance from yourself or others. Asking a loved one: “Do you think I’m really alive?” or “How would we know if we were dead?” or repeating to yourself: “My heart is beating. I must be alive.”
  • Ruminating on the topic for hours, attempting to “think yourself out of it”
  • “Checking” yourself in the mirror to make sure you’re really there or looking down at your hands to “make sure” they’re real
  • Balling up your fists to feel a sensation in your body, “proving” to yourself that you must be alive

Depersonalization and derealization, which I mentioned earlier, can be byproducts of OCD, trauma, or major depression, or can be a disorder themselves called depersonalization/derealization disorder (DPDD). 

Depersonalization indicates feelings of one’s body not being real. The sufferer feels disconnected from their body; for example, they might look down at their hands and think, “Are these really my hands? Am I really here, in this body?” 

Derealization indicates a feeling of separation between oneself and their surroundings; you feel like your surroundings are not real. You might think, “Am I really here in this room?” or “Is this room real?” 

In either case, the individual tends to have the sense they’re watching themselves from afar, living in a dream, or the feeling that they’re a robot. It differs from psychotic disorders in that one is aware of what they’re experiencing and are often afraid that they’re “losing their minds.”

Lastly, there is a very rare condition called Cotard’s syndrome, also referred to as walking corpse syndrome. It occurs when one suffers delusions that parts of their body or their entire selfhood is non-existent. In other words, they believe they are dead or that death is imminent. Because the condition is so rare, there is much left to be researched. However, one study points to its connection to other, pre-existing neurological conditions. 

The important distinction between Cotard’s syndrome and both existential OCD and depersonalization/derealization is that people with Cotard’s syndrome do not believe that their thoughts are irrational at all—they fully believe that they are dead. The sense of being dead, in this case, is a delusion, not an intrusive thought, fear, or worry. In OCD, on the other hand, you would recognize on some level that your fears are irrational (and most likely, that’s why you’re here in the first place). 

When should you get help? 

Dr. McGrath says that the main distinction between normal existential thoughts that everyone experiences versus disordered thinking is “excessive fixation, intrusive thoughts, and spending a lot of time on the thoughts and feelings you have.” 

A person who is having existential thoughts in a healthy way will briefly ponder a question, like “What if I was actually dead?”, chalk it up to a strange, quirky thought, and move on with their day. The thought will not be attached to a sense of urgency, anxiety, or panic. 

If worries about being dead are causing significant distress, impacting your mental health, or negatively affecting your life in any other way, it’s time to seek help. 

How can I get help for this?

As terrifying as the thought of being dead and not knowing it may be, there’s good news: there are treatment options that can help you to gain back a full life that’s more focused on living than dying. 

OCD is treated with a highly effective, evidence-based form of therapy: exposure response-prevention therapy (ERP). ERP consists of client and therapist working together to identify the triggers of one’s obsessions. Instead of avoiding your fears, you face them head on, ultimately diminishing the power they hold over you. Exposure exercises that you might practice in order to overcome your fear of being dead and not knowing it could include:

  • Writing down, “I am dead and don’t know it,” then reading it back to yourself over and over
  • Watching a movie that involves someone who’s dead but still lives on Earth
  • Reading a book that involves ghosts who don’t know they’re ghosts
  • Going to a hospital
  • Going to a cemetery 

To reiterate, resisting compulsions amidst these exposures is just as important, if not more so than the exposures themselves. Continuing to engage in compulsive behavior will not break the OCD cycle nor train your brain not to see intrusive thoughts as real threats.

If you resonate with what you learned about depersonalization/derealization, speak with a licensed mental health professional to get to the root of why you’re experiencing it. Treatment will vary depending on where it’s coming from. If it’s a symptom of OCD, for example, you’ll be directed to ERP and as your OCD improves, so should your depersonalization/derealization.

If it’s determined that you’re experiencing depersonalization/derealization disorder (DPDD), you might be recommended cognitive-behavioral therapy (CBT) or dialectical-behavioral therapy (DBT). CBT is a method of psychotherapy where one learns to recognize the relationship between their thoughts, feelings, and actions. When the relationship between the three is clear, the client can begin to change their thoughts and feelings to lead to healthier action. In DBT, you learn to build tolerance to difficult, intense emotions and cope with them more effectively. 

Where to go for effective OCD treatment

No matter the cause of your struggle, there is hope for getting back the richness of your life before this fear took hold. As afraid as you may feel, know that that feeling is not forever. 

If you think you may be struggling with existential OCD, I encourage you to learn more about ERP therapy at NOCD. Every NOCD Therapist receives intensive, specialized training to treat all themes of OCD, and many have additional firsthand insights from living with OCD themselves.

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