Existential OCD: Obsessing About the Anything and the Everything

What happens after we die?  What is consciousness?  Is anything real?  Who am I?  What is a self?  These and many other questions will not be answered in this exploration of Existential OCD.

One could argue that all OCD is fundamentally existential.  Drill down to the core fear of any obsession and you will find a concern with identity, authenticity, reality, or legacy.  For example, a fear of having contaminated hands may connect to a fear of being negligent with hygiene, connecting to a fear of causing illness to others, connecting to a question of moral integrity, connecting to a question of overall worth as a human being.  And you thought it was just about being a neat freak.  Existential OCD is a term used to identify a subtype of the disorder in which the primary obsessive thought, not just the core fear, is one of profound philosophical woe – what is it all about?

Obsessive-compulsive disorder is characterized by two distinct symptoms: obsessions and compulsions.  Obsessions are thought, images, or urges that are perceived as intrusive, unwanted, or in some way burdensome in a repetitive and disturbing way.  Compulsions are behaviors (physical or mental acts) designed to neutralize distress around these obsessions, typically by forcing a sense of certainty that the offending thought has been resolved.

Existential obsessions:

• What if I’m not real and this is a simulation?

• What if I am the only thing that is real?  (solipsism)

• What is the universe?  How can it have a beginning?  How can it not?

• How can I matter if I am but one organism on one planet in one galaxy?

• What if failure to understand what happens after death drives me mad?

• What if I can never relax because I don’t know what the meaning of life is?

• What if there is no purpose to existence and this leads to chaos (e.g. me harming myself or others for no reason)?

• What if every decision I make changes the course of my life dramatically?  Or what if no decision I make has any effect at all?

• What is a self?  What if there is no self?  How will I know if I am being an authentic self?

As you can see above, many existential obsessions share territory with other common subtypes of OCD (e.g. fear of causing harm, mental health anxiety, identity-related obsessions).  Moral scrupulosity OCD is similar in this regard because, like existential obsessions, the core fear is fundamentally philosophical.  In other words, a decision not to go back and check that the stove is off multiple times can come down to a question of one’s moral right to make that decision.  In existential OCD, the decision to resist compulsions is subject to the question – does it ultimately matter at all?  Does anything?  

Compulsions common to existential OCD include:

• Excessive rumination about existential matters, such as why we are all here and what is real (note: this is distinct from enjoyable or even challenging philosophical inquiry, but is perceived as impairing and necessary to the point of being distressing when seeking “the answer”)

• Excessive reassurance-seeking about existential matters (from loved ones, treatment providers, those viewed as philosophical authorities, research on the internet, books, podcasts, etc.)

• Excessive rationalizing and self-reassurance (e.g. repeatedly assessing and explaining your intentions and motivations for behavior)

• Excessive checking for feelings or mental states to see if existential concerns are still there, still bothersome, or totally resolved

• Visual checking of environment for evidence of what is real or illusory

• Excessive avoidance of potential triggers of existential thoughts (books, movies, valued religious practices or institutions, or discussions that may raise unanswerable questions)

Diagnosis of Existential OCD

It’s important to remember that no subtype of OCD is truly a separate diagnosis from any other subtype.  In other words, diagnosing existential OCD means diagnosing OCD.  So there must be the presence of obsessions and compulsions, and it should be something that can be scored on a validated scale like the Yale Brown Obsessive Compulsive Scale (YBOCS) or Dimensional Obsessive Compulsive Scale (DOCS).  The engagement with obsessions and compulsion, even if exclusive only to existential themes, should be significantly time consuming, cause some level of avoidance in daily life, be distressing, as well as impairing, and have some kind of negative impact on one’s sense of control.  Specific to the issue of control, what makes these experiences qualify as disordered is the subjective sense that there is something getting in the way of just saying “that’s OCD” and dropping the subject.  Still, there are other conditions that can look very much like existential OCD and it may be important to rule them in or out.  For example, major depressive disorder (MDD) can include a symptom called depressive rumination, which might look very much like thinking all day about the meaning and value of one’s life.  Some forms of depression can also include agitation, which can look very much like the anxiety that many people with OCD experience.  Further, the effects of some substances on the brain when used excessively or in an unhealthy manner can trigger symptoms of psychosis, delusion, confusion, or other changes in thought processing that might lead a susceptible person to feel trapped in existential concerns, so the role of a substance use disorder (SUD) may be important to consider in the diagnostic process.  Many people with existential OCD are also misdiagnosed as having generalized anxiety disorder (GAD) because mental rituals are being misunderstood as simple worry.

Treatment of Existential OCD

Once an OCD diagnosis has been established, engaging with the right treatment makes a tremendous difference.  The most effective and best-understood first-line approach to any form of OCD is cognitive behavioral therapy (CBT) with an emphasis on exposure and response prevention (ERP).  There can be a lot of variation in how the cognitive and behavioral aspects are approached, and it’s important that those suffering from existential OCD work collaboratively with their provider(s).  Some forms of cognitive therapy (that is, challenging the thought process that leads to more compulsive behavior) can lead to even more mental ritualizing whereas other approaches my help the OCD sufferer disengage from distorted thought patterns.  On the behavioral front, at the heart of all ERP is generating the urge to engage in compulsive behavior (including mental rituals) and practicing doing otherwise, resulting in a de-pairing of the obsession from the compulsion.  This may involve learning how to better cope with the distress this brings on (remember, in this form of OCD the brain has become convinced that the existential concerns are necessary to figure out).  

How ERP is implemented can also vary, as long as these fundamentals are in place, and may include direct exposure to triggering concepts, writing out and reading materials that are triggering, intentionally responding to thoughts in a triggering or non-reassuring way, or other strategies.  Alongside all of the above, the development of mindfulness skills can be a tremendous asset in treatment, improving attentional control, and helping to increase awareness of when one is getting carried off into OCD stories.  However, it is worth noting that for some with existential OCD, meditation and other mindfulness practices may also be a form of exposure!

Treating the Whole Person

Specialists in OCD are sometimes viewed as technicians, the way you might understand an HVAC specialist, or someone who specializes in the maintenance of one specific type of car.  While it is fair to say that well-trained OCD specialists focus more on the here-and-now than on theoretical root cause of the content of your obsessions, good therapy always addresses the person in their context.  This means taking a meaningful look at how this person views themselves within their family of origin or current family system, what their values are and how OCD may be interfering in connecting with those values, and how a person might find themselves arriving at a particular sensitivity to a particular OCD theme.  For those with existential OCD, a theme that literally involves contemplation of our entire existence, it would be valuable to work in therapy on stabilizing and strengthening one’s sense of self, in addition to, and even as a part of the ERP work.  In conclusion, existential OCD is a real and treatable presentation of obsessive-compulsive disorder.  With the right treatment, someone suffering from this condition can re-learn how to spend more time living their life than lost in thought about it.