Steve, a 26 year-old computer programmer: “I can’t stop thinking about why we’re all here and whether there’s any purpose to life. I keep going over it in my mind all day long. I have continual thoughts of how one day I’ll be dead and no one will remember me. It will be as if I never existed. Then I ask myself, what is the use of doing anything if we’re all going to die anyway?”
Kristin, a 34 year-old homemaker: “I can’t get the idea out of my head that everything I see isn’t real. How do I know I’m not really in a coma, or else dreaming, and that my whole life is imaginary? I start to wonder if my husband and children are real and it frightens me terribly.”
Marty, a 19 year-old college student: “Every day I spend hours looking at myself in the mirror and I wonder - Is this really me? How do I know? What makes me, me, and how do I know I am who I think I am? How do I know the things I feel are my own real feelings, or that my thoughts are my own real thoughts? I also keep thinking about how vast the universe is and how we’re all just tiny specks that are meaningless. I keep thinking that because we are so insignificant, nothing we do matters, so why not give up on everything?”
What do all these people have in common? A type of OCD some refer to as “Existential Obsessions,” or in some places, as “Philosophical Obsessions.” This involves repetitive persistent questions which cannot possibly answered, and which may be philosophical or frightening, or both. The questions usually revolve around the meaning, purpose, or reality of life, the universe, existence, etc. These same questions might come up in a philosophy or physics class, however, most people can leave such classes or read about these topics and move on to other thoughts. As is the case with other forms of OCD, these people can’t drop their ideas. It is often a difficult type of OCD to recognize, as it might resemble the questions many of us sometimes wonder about and then move on from with a shrug of the shoulders. It might also be confused with the kind of ruminations people experience when they are depressed, where they keep going over negative thoughts about the seeming meaninglessness of life. As a type of OCD, it is way beyond these things.
Sufferers typically spend hour going over and over these questions and ideas and may become extremely anxious and depressed. Sometimes, others simply label them as worries or existential fears, or diagnose them as suffering from Generalized Anxiety Disorder. When a person suffers ongoing, intrusive, repetitive, persistent, anxiety-producing, doubtful thoughts, it is most likely OCD.
Many people out there have a very stereotyped image of what OCD is all about. They generally see sufferers as people who either wash their hands too frequently, or who are super-organized and perfectionistic. While these may represent two specific types of OCD, they by no means represent the OCD population as a whole. There are literally dozens of forms that OCD may take. People’s obsessions would only seem to be limited by the imagination. Why individuals come up with their own particular types of OCD is anyone’s guess. We have no real answers to this question. Many sufferers also spend hours analyzing why they are having their particular thoughts and questioning exactly what they may mean. This activity is just another type of compulsion that accompanies their obsessive thoughts, and never leads to any true answers. If anything, it only leads to more obsessive questions. Sufferers just seem to get what they get.
Obsessive doubts cannot be argued with, reasoned out, analyzed, or questioned. They do not seem to come from the place where real thoughts come from. There are never any lasting answers to obsessive questions. Whatever answers they do come up with may only last a few minutes, but then quickly slip away in the face of newer doubts. The doubts may vary a bit, but are mostly variations on a theme. OCD is insidious, as it seems to have a way of finding out what will bother someone the most.
Most sufferers wear themselves out trying to find answers, or try to get the thoughts out of their heads, but these are the worst ways to deal with OCD. As mentioned previously, there are no answers to existential or any other obsessive questions. So what to do? Research tells us that cognitive/behavioral therapy (CBT) and medication are the best approaches to dealing with OCD. Those with mild OCD may not need medication, but the majority of suffers will always benefit from CBT. Some people go for the quick fix of relying only on medication, but it cannot change longstanding habits or your philosophy of how to deal with the things that scare you. The true purpose of medication in OCD treatment is that it makes it easier for you to do the therapy. The therapy, however, is ultimately what changes you.
Those in therapy learn to do the opposite of what their instincts tell them. Our intuition tells us to avoid or escape from things that make us anxious. Unfortunately, there is no escape from the things we fear, and there is definitely no escape from your own thoughts. You take your thoughts with you wherever you go. It is a paradox – the more you tell yourself to not think something, the more you then think of what you are not supposed to think about. Another feature is that the thoughts mostly seem to revolve around uncertainty, and we humans don’t like uncertainty. In therapy, sufferers learn to face their thoughts and to build up a tolerance to them – the anxiety they produce and the uncertainty that goes along with them. In order to do this, they have to go against their instincts even agree with the thoughts and also try to think them more, rather than less. As we like to say, “If you want to think about it less, think about it more.” This is what is included in CBT, in particular the type known as Exposure & Response Prevention. In the Exposure part, sufferers deliberately and gradually expose themselves to the feared thoughts and images, and even learn to agree with them. They learn to do this daily in a variety of ways that can include reading articles or books, watching videos, listening to home-made therapy recordings, writing feared words or sentences, actively agreeing with the thought of the moment, etc. As they do this, the thought gradually loses its impact, and even boredom can result. You can’t stay anxious where nothing ever happens to you. I have always told my patients that you cannot be bored and scared at the same time. In the Response Prevention part, the goal is to not escape or avoid, so patients are taught to agree with the thoughts, and to not try to analyze, question, or argue with them. They are also discouraged from seeking reassurance from others or even themselves, as this is another form of escape. Over time, avoidance can become an overlearned habit that becomes very automatic. You can avoid seemingly without even thinking about it. Also, avoidance simply leads to more avoidance. How can you build up your tolerance to something you never come in contact with?
Some typical Exposure homework assignments might include:
Making a series of gradually more challenging 2-minute recordings on your phone that tell you the fearful thought is true and listening to them several times daily
Posting signs or notes around your house stating the feared idea
Agreeing with the thoughts as much as possible whenever they occur, and also agreeing that there will be bad consequences because they are true
Going to places and doing activities that bring on the thoughts
Reading articles that seem to agree with the feared thoughts
Watching videos or movies that bring on the thoughts
Writing feared sentences 25x per day until you get bored with them (then write new ones)
Some typical Response Prevention homework assignments might include:
Not arguing with, questioning, or analyzing the thoughts in any way
Not seeking reassurance from yourself or anyone else
Resisting looking up articles that disprove the thoughts or tell you they don’t matter
Not trying to discuss the topics with others
Acceptance is another very important piece of therapy. There are several things that need to be accepted:
That you have OCD
That there is no real explanation for why you have the particular thoughts you have
That there are no real answers to your questions and doubts
That the solutions you have previously come up with haven’t worked, aren’t working now, and will not work in the future, and therefore must be abandoned because there really is no escape
That you can have thoughts of the type you experience, that they will not simply go away on their own, and that they can be lived with
That your anxiety and uncertainty can ultimately be overcome but only by confronting them and building up your tolerance to them
That it will take hard work, time, and practice to overcome your fears and the habits you have built up by avoiding
Most importantly, based upon what we now know about treating OCD, you do not have to suffer as you do on a daily basis. There is effective treatment out there and you would do well to find some. Every day you are not getting help is another day you have to suffer.
Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.
If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).