A Therapist's Guide to Existential OCD and Derealization

Key takeaways:

• Existential OCD involves intrusive questioning about reality, existence, and meaning that goes beyond philosophical curiosity.

• Derealization and depersonalization are common companions to existential OCD, creating a disconnected feeling from yourself and the world.

• Living with existential OCD involves learning to sit with uncertainty rather than seeking absolute answers to life's biggest questions.

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Ever find yourself spiraling down the rabbit hole of "What if nothing is real?" or "Do I even exist?" only to realize you've been googling the meaning of consciousness for three hours straight? Yeah, no, me either…

If this resonates, I’d like to formally welcome you to the peculiar world of existential OCD, where your brain decides that pondering life's biggest mysteries isn't just a hobby—it's a full-time obsession. Literally. 

Hi, I’m Dr. Cynthia Shaw, founder of Authentically Living Psychological Services, existential therapy enthusiast, and fellow deep (sometimes too deep) thinker. I know this territory well—both from working with folks in my practice and my own personal experience—well enough to know that it’s not something you can just turn off, but you can learn how to sit with these big feelings and questions without getting derailed…most of the time, that is.

Here, we’ll be exploring what existential OCD is, what it looks like, how it’s related to derealization, and how you can start finding some relief when your mind gets stuck asking questions that would make Socrates himself need a nap.

What is existential OCD?

To effectively answer this question, we need to first understand what OCD itself is. 

OCD, according to the Diagnostic and Statistical Manual (DSM, the manual that therapists use to diagnose mental health disorders) or obsessive-compulsive disorder, is a mental health condition that consists of—you guessed it—obsessions and compulsions. “Obsessions” are intrusive, unwanted thoughts that cause distress, anxiety, and discomfort, and compulsions are behaviors, rituals, or mental acts that are executed to ease the uncomfortable feelings that obsessions cause.

While it may cause momentary relief, the reality is that indulging these obsessive thoughts may feel relieving in the moment, but it only fuels the existential merry-go-round, keeping you captive to repetition instead of free in uncertainty.

Now, let’s move on to the question at hand: what is existential OCD? Basically, it’s a particular subtype (i.e., flavor) of OCD that centers around profound questions about existence, consciousness, meaning, and the nature of reality itself.

Unlike the casual late-night thoughts we all have from time to time about life's mysteries, existential OCD turns these ponderings into relentless ruminations. You become convinced that if you can't definitively answer questions like "What is consciousness?" or "How do I know I'm real?" then you can’t rest. 

Plot twist: these questions have been stumping humans for millennia, and that's okay—even if you feel otherwise right now.

What are the symptoms of existential OCD?

Now that you’ve got the gist of existential OCD (also referred to as philosophical OCD), let’s take a deeper look at what you might actually be experiencing if you experience this.

Common “obsessions”:

• Constantly questioning whether reality is real or if you’re living in a dream

• Questioning whether you live in a simulation

• Obsessive fears about death, the afterlife, or the idea of nonexistence

• Panicking about whether life has any meaning or purpose

• Feeling stuck in unanswerable “what if” loops about the universe, consciousness, or time

• Doubting your own perception of reality (e.g., “What if nothing I see is actually real?”)

• Questioning your own existence (“Am I even real?”)

• Fear that you’ll never feel connected to life or others again

• Worrying whether you’re a fundamentally bad person

• Obsessive preoccupation with whether free will exists

• Spiraling thoughts about infinity, eternity, or the “endlessness” of existence

• Worrying about not living up to your purpose or whether you’ll look back on life with regret

  
  

Common compulsions:

• Constantly checking your own thoughts and feelings for authenticity

• Seeking reassurance from friends, family, or online forums (“Do you ever feel this way too?”)

• Excessively researching philosophy, religion, or science to “solve” existential questions

• Mentally reviewing or replaying conversations, memories, or experiences to confirm reality

• Avoiding triggering topics like death, spirituality, or space.

• Engaging in grounding rituals in a compulsive, rigid way (rather than flexible coping).

• Distracting yourself constantly to avoid intrusive thoughts

• Repeating mental “tests” (e.g., pinching yourself, checking mirrors) to confirm reality

• Overanalyzing every sensation or emotion to “prove” that life is real

• Compulsively journaling or writing out arguments to find certainty

• Obsessively monitoring your thoughts, feelings, or sense of presence to check if you’re “normal”

These symptoms create a feedback loop where the more you try to resolve these cosmic questions, the more urgent and terrifying they become. Basically, you’re trying to think your way out of thinking too much, which is clearly counterintuitive (though I recognize saying that alone isn’t enough to make the thoughts stop).

Can OCD cause derealization?

Absolutely, and it's more common than you might think. Researchers have pointed out that dissociative experiences like derealization—that eerie feeling that the world around you seems unreal, dreamlike, or detached—are commonly linked to OCD, though the “why” behind it is poorly understood.

But when you stop to think about it (not too hard, though 😉), it's not a huge leap for you to start experiencing reality as, well, questionable when you’re already questioning the fundamental nature of reality.

In my experience, I see how the constant mental gymnastics of existential questions can overwhelm your nervous system, leading to dissociative symptoms like derealization and its cousin, depersonalization (feeling disconnected from yourself).

When your nervous system feels dysregulated and its coping mechanisms (in this case, compulsions) aren’t soothing it, it totally makes sense that it would resort to its next-level tactic: going into freeze mode (i.e., dissociation). 

The good news? This disconnected feeling, while deeply unsettling, is a window into the soul, a sign that there’s something there that needs our curiosity—not a sign that you're actually losing touch with reality permanently. 

How do I get rid of derealization in OCD?

Before we dive into steps you can take to learn how to coexist with existential OCD, let me emphasize a hard truth that you might not want to hear: there's no magic button to make OCD or derealization disappear overnight. Wanting that is your way of seeking the reassurance and relief it craves, which is what fuels your OCD and dissociation symptoms in the first place.

What makes the biggest difference is learning how to embrace uncertainty and uncomfortable feelings (like derealization) and accepting that we can’t eliminate them entirely. Trying to do so only furthers the cycle of OCD that got us here in the first place.

With that in mind, let’s get into some strategies that you can start using today.

Ground yourself in the present moment

• How to do it: Engage your five senses deliberately—notice three things you can see, two you can hear, and one you can touch or smell.

• Why it works: Sensory grounding pulls your awareness back into your body and immediate environment, interrupting the dissociative drift.

• Therapist tip: Don't aim for perfect presence or start spiraling if you can’t smell anything (I see you 👀). The point is just to notice, and if you start drifting or getting more anxious, try gently redirecting your attention without judgment. 

Practice radical acceptance

• How to do it: When existential thoughts arise, respond with "Maybe I'll never know for certain, and that's okay" instead of trying to solve the unsolvable. These questions have existed for centuries, and, no offense, but you’re not going to be the one who finds the “true” answer.

• Why it works: Acceptance reduces the internal struggle that fuels both obsessions and derealization, allowing your nervous system to settle.

• Therapist tip: It’s cheesy, but it works: think of uncertainty as a river you learn to float in rather than a problem to swim against. Constantly swimming upstream is only going to tire you out unnecessarily. 

Engage in embodied activities

• How to do it: Choose activities that require physical presence—cooking, gardening, exercise, or playing an instrument—to get you out of your head.

• Why it works: Embodied activities anchor you in sensory experience and remind your system that you exist in a physical body in a real world, even if it doesn’t feel like it at first.

• Therapist tip: Pick activities you genuinely enjoy. Crazy dancing to Taylor Swift songs in your kitchen? Love it. Rolling down a grassy hill in a park like you’re five years old again? Go for it. Forcing yourself through joyless motions defeats the purpose of reconnection.

Limit philosophical rabbit holes

• How to do it: I’m going to hold your hand when I say this: Just. Say. No. (to doomscrolling, that is). If you must engage in some philosophical thinking, set specific times with a hard stop, but avoid endless Google searches that—let’s be real—never actually make you feel better.

• Why it works: Restricting compulsive research breaks the cycle of seeking certainty about inherently uncertain questions.

• Therapist tip: The problem isn't having big questions—it's the compulsive need to answer them right now, which paradoxically makes the questions feel more urgent and terrifying. You don’t need to erase your thoughts (you can’t control those anyway), but you can control how you respond to them.

Make meaning in the ambiguity

• How to do it: When uncertainty arises, consider reframing it as a possibility rather than a threat—"I don't know what consciousness is, so I get to explore it" instead of "I must figure this out, or else.”

• Why it works: You’re never going to find finite answers to these big questions, so why not try taking a new perspective? This can help you befriend (or at least tolerate) uncertainty and see it as an opportunity. Creativity, choice, and authentic meaning-making can all be born from this place of ambiguity.

• Therapist tip: This isn’t about gaslighting yourself into “just thinking positive.” You already have such a strength in considering tons of different perspectives—it can be exciting to try applying it in a whole new way.

Have a conversation with your thoughts (not an argument)

• How to do it: Instead of fighting existential thoughts, try having a conversation with them: "Oh, there's that question about reality again. Hi! What are you trying to protect me from?"

• Why it works: When you follow your instinct to “fight” or “cancel out” your stressful thoughts, that’s when the cycle of overthinking and anxiety begins. Curiosity toward intrusions can reduce their power and intensity. 

• Therapist tip: Your obsessive thoughts aren't villains—they're anxious parts of you trying to soothe you by solving the unsolvable. If it helps, try visualizing them as a parrot on your shoulder (or if birds aren’t your thing, think of something else small and cute) that’s a companion to chat with rather than a scary monster you’re trying to chase away. 

Confront finitude

• How to do it: Practice sitting with the reality of mortality and limitation by acknowledging "I am finite, and that makes this moment precious" during daily activities.

• Why it works: Existential OCD craves a certainty that just doesn’t exist. By confronting finitude directly, you can slowly learn to sit with that truth and embrace the beauty of being alive, in this moment, right now.

• Therapist tip: Anxiety around death often underlies existential OCD. It can sound like a bit of a paradox, but facing mortality head-on frees you to live more fully in the present.

Consider identity as fluid vs. fixed

• How to do it: Instead of trying to nail down definitive answers to “Who am I?” and “What is my purpose?,” consider responding with "I am someone who is becoming" rather than seeking a fixed definition.

• Why it works: Change is a natural part of the human experience—not a crisis to resolve. Learning how to roll with that instead of struggling against it can reduce the resistance that keeps you feeling stuck, stressed, and overwhelmed.

• Therapist tip: The self isn't a thing to discover but an ongoing process to participate in—you're not finding yourself, you're creating yourself.

When to consider therapy for existential OCD

If existential questioning has moved from occasional midnight musings to a daily source of distress, it might be time to consider working with a therapist. While there’s no “right” or “wrong” time to start therapy, these signs would tell me that you could benefit from some support.

Consider therapy when:

• Existential thoughts consume several hours of your day

• You avoid activities, media, or conversations due to triggering content

• Derealization or depersonalization episodes are frequent or intense

• Your sleep, appetite, or concentration suffers due to existential anxiety

• You find yourself seeking constant reassurance about reality or existence

• The thoughts feel intrusive and unwanted rather than genuinely curious

• You feel lonely and emotionally disconnected from others

Sound familiar? We’re here for you.

Final thoughts

Existential OCD might make you feel like you're losing your mind, but ironically, questioning existence is one of the most human things you can do. 

At Authentically Living Psychological Services, we understand that sometimes the biggest questions require the gentlest answers. Our therapists specialize in working with deep thinkers like you, taking a holistic, trauma-informed, relational approach to therapy that empowers you to live authentically without the burden of constantly fighting against your own mind.

Ready to explore life's mysteries without getting trapped in them? We’d love to support you. Contact us today to schedule your free consultation or click here to get matched with a therapist—we look forward to hearing from you!