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Is anything real? How therapists approach existential worry

Nov 28, 20236 min read minute read

It’s not uncommon for people to occasionally ponder the nature of reality, wondering if the world around them is real. Momentary, non-distressing thoughts about the authenticity of our world are a normal part of human contemplation. 

Certain phenomena, like déjà vu, where one feels they’ve experienced a moment before, or derealization, a sense of detachment from surroundings, can trigger contemplation about the nature of reality. Existential concerns arising from philosophical discussions or the portrayal of simulated realities in media—the Matrix series being the predominant example—may prompt similar reflections.

But while passing questions about reality are part of the human experience, similar concerns can become mental health problems when they morph into overwhelming worries, consume a lot of time, or otherwise get in the way of our lives. In such cases, these thoughts may be indicative of any one of a number of mental health disorders, including several I’ve treated during my years as a therapist, and one I specialize in helping people recover from. 

In this article, I’ll describe how some mental disorders can produce unshakable thoughts about whether anything is real, along with their respective treatment recommendations. But please know that no matter the cause of your anxiety, you don’t have to feel this way forever. I know from extensive professional experience that you can conquer your fears and live a life that isn’t dominated by existential worry.

Contemplating reality: a quintessentially human trait

The concept that our reality might be a dream or an illusion has ancient roots and has been explored in various philosophical and religious traditions. One notable early example can be found in the Upanishads, a collection of ancient Indian texts that form the core of Vedic philosophy. In particular, the Mandukya Upanishad delves into the nature of reality and consciousness and introduces the concept of “maya,” the illusory nature of the world, suggesting that what we perceive is not the ultimate reality.

In centuries since, the theme of reality’s unreliability has been a recurring trope in literature and cinema. Lewis Carroll’s “Alice’s Adventures in Wonderland” challenges conventional reality, as does Philip K. Dick’s “Ubik,” where the boundary between reality and illusion becomes blurred. For another popular example,” The Truman Show” features a phony world meticulously crafted for its protagonist. These works reflect an enduring fascination with questioning the authenticity of our perceived world.

In recent years, some popular scientists and other figures have posited that the notion of our reality being a simulation is possible. Bostrom’s simulation theory argues that advanced civilizations might create simulated worlds, blurring the lines between science fiction and scientific speculation.

Conditions that can cause people to doubt their reality

For many people, the idea that reality is not what it seems goes far beyond intriguing and becomes terrifying, even all-consuming. When this happens, any one of the following conditions—or a combination thereof—could be at play. 

Existential OCD:

Several conditions may involve doubts or fears about the nature of reality in some form or other, but these thoughts and worries are central hallmarks of a particular subtype of obsessive-compulsive disorder (OCD) known as Existential OCD.

OCD is characterized by persistent, distressing obsessions—unwanted, intrusive thoughts, worries, feelings, images, or urges—and compulsions, which are repetitive behaviors or mental rituals done to alleviate the discomfort caused by obsessions. 

Existential OCD is characterized by persistent, distressing thoughts centered around the nature of reality. These obsessions often revolve around the possibility that our existence is a simulation or a dream. Obsessive thoughts related to existential OCD include:

These intrusive thoughts can be deeply unsettling, leading people to engage in compulsions in order to reduce their anxiety, find “true” answers to their worries, or feel certain about the nature of their lives and reality.

These compulsions are likely invisible to others, and often involve prolonged rumination and cognitive efforts to answer unanswerable questions. People may also seek reassurance as a compulsion. One example could be reaching out to experts or religious leaders and inundating them with questions about the “true” nature of reality.

While these thoughts and doubts are most closely connected with Existential OCD, there are other conditions that can may involve similar symptoms:

Depersonalization/Derealization Disorder:

Depersonalization/derealization disorder leads to feelings of detachment from oneself or the surroundings, creating a surreal, dreamlike experience. The distorted perception of reality contributes to a pervasive sense of unreality.

Psychotherapy, particularly cognitive-behavioral therapy (CBT), is a treatment approach with promising results. CBT effectively addresses distorted perceptions and promotes a more grounded sense of reality. Additionally, medications such as selective serotonin reuptake inhibitors (SSRIs) may be prescribed to manage associated symptoms. 

Post-Traumatic Stress Disorder (PTSD):

PTSD distorts reality, especially during flashbacks or intrusive trauma recollections, leading to a blurred line between past and present. The intense, vivid memories contribute to a pervasive sense of unreality.

Trauma-focused therapies, such as prolonged exposure (PE) therapy, serve as common interventions for PTSD. Medications, such as SSRIs or selective norepinephrine reuptake inhibitors (SNRIs), may be prescribed to manage associated symptoms.

Major Depressive Disorder with Psychotic Features:

Severe depression with psychotic features prompts delusions or hallucinations, distorting people’s perception of reality. The interplay of depressive symptoms and psychosis contributes to a heightened sense of unreality.

Treatment involves antidepressant medications, often combined with antipsychotic drugs. There is also effective psychotherapy for depression in the form of behavioral activation (BA), which shows strong evidence as a first-line psychotherapy option. 

How can I learn to accept or overcome my doubts?

Fortunately, exposure and response prevention (ERP) therapy, a well-established and highly effective therapeutic approach for all themes of OCD, can be effectively used to address existential concerns. 

ERP works by guiding you to confront your obsessions and anxiety, learning to sit with uncomfortable feelings rather than seeking a false sense of certainty through compulsions. In the context of existential OCD, therapy exercises may include listening to lectures discussing theories about simulated reality, engaging in discussions that invite doubt about existence, or simply reciting statements like “The world may or not be real. Whatever—I’ll keep living my life.”

By changing their relationship with uncertainty, people undergoing ERP for existential OCD can greatly reduce the discomfort and anxiety associated with their obsessions. This therapeutic approach empowers people to reshape their response to intrusive thoughts and doubts, building resilience and a healthier relationship with existential concerns.

You can live with confidence, despite uncertainty

If you think your anxieties about the nature of reality might be related to existential 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 OCD treatment.

Remember, you’re taking a significant step toward reclaiming your life from OCD. With the right therapist and ERP, you can learn to engage fully in the life you want to live, even when you’re confronted with doubt and uncertainty about the universe. I’m confident that ERP therapy can help you, just as it’s helped thousands of others with similar fears and doubts. 

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