ERP Therapy Stories: Existential OCD
I created this “ERP Therapy Stories” series to share a glimpse of how the application of ERP therapy could look within the context of different OCD subtypes. I hope to provide some examples of ERP therapy while channeling my creative and imaginative side. The stories and characters that I write about are fictional, but the ERP strategies depicted are ones that I teach and use in treatment with my clients. This particular post focuses on illustrating Existential OCD symptoms, including common Existential OCD obsessions and compulsions. As an OCD therapist who enjoys storytelling, I hope these vignettes can help you feel less alone and see hope in ERP therapy.
Joel is a 28-year-old Engineer living in downtown San Jose. When he is not working, he is enjoying music. Specifically, alternative 90’s rock music. Joel is the drummer for the rock cover band that he and his college buddies formed a few years ago. They meet several times weekly at a South Bay studio that they lease. This is where they rehearse and unwind from their demanding Silicon Valley jobs. They occasionally play at local venues and community events. Preparing for these gigs is always fun.
Recently, Joel noticed OCD symptoms.
This is something he hadn’t dealt with since late high school. Back then, he believed these symptoms to be general anxiety due to upcoming graduation. What he was experiencing during that time were symptoms of Relationship OCD (ROCD) around his friendships. He couldn’t stop questioning whether his friends still liked him. He engaged in mental compulsions and sought frequent reassurance from them. Joel’s friends thought it was unusual and excessive behavior, but they went along. They reassured him that he was still liked and that everything was good between them. After enduring these symptoms all summer, Joel sought help from the student health center at UC Berkeley. He was diagnosed with OCD during his freshman year of college. Joel was referred to an OCD therapist who could provide ERP therapy in Berkeley. However, Joel’s symptoms subsided as the year progressed and he never followed through.
Joel’s current symptoms are similar.
He’s having “sticky” thoughts that are hard to move from.
But they are about something different this time. It started one night when he was watching The Matrix, a movie that had been on his watch list for a while. He usually enjoys these kinds of Sci-Fi movies, but this one left him questioning reality. “What if life is just a simulation? What if this reality I’ve accepted, is all fake?” his mind asked. “I’m a software engineer just like Keanu Reeve’s character, this must be a sign to help me discover the truth.” Joel realized these thoughts were a little out there, but the more he thought about them, the more stuck he got. The idea that everyone and everything he cared about not being real freaked him out. Rather than going to bed, he did online research for several hours. It started with Nick Bostrom's simulation hypothesis. Then it moved to binge-reading “Glitch in the Matrix” Reddit threads. It was hard to focus on work the next day, those questions kept creeping up.
The obsessions consume his mind for the next several days and weeks. Since then he’s been on an endless quest to answer his mind’s questions about existence and reality. “How do I know I’m not living in an alternate universe? What if I’m not real? What if none of us are real?” These thoughts are disturbing and cause him to engage in compulsions. He finds himself mentally reviewing past events for indications that they were “real”, checking for “real” feelings throughout the day, pinching his hand to experience a “real” sensation, and avoiding activities that may trigger these obsessions (movies, music, etc.). These symptoms are similar to when he experienced ROCD. They hook on to something specific, have a bit of an illogical feel to them, and cause him to feel like he needs to settle the internal doubt with urgency.
Joel suspects that this is an OCD flare-up and gets evaluated by an OCD therapist in San Jose.
His suspicions are confirmed and he starts ERP therapy to treat his Existential OCD symptoms.
Joel begins OCD treatment by re-engaging in enjoyable activities that he has been avoiding while learning how to resist his compulsions. He starts by saying triggering words, watching trailers of movies around the theme of existentialism, listening to songs with “glitchy” instrumentals, and playing with his VR system. One day he’s rehearsing with his bandmates and they are deciding on a song list for their next gig. Joel is mostly quiet as the group agrees to the RHCP song “Parallel Universe” and some “glitchy” sounding songs from Radiohead and The Gorillaz. Joel says very little for most of the conversation as his chest tightens and his hands get sweaty. The group is excited and he nods in agreement as he feels his drumsticks slipping from his hands.
That week Joel starts avoiding band rehearsals, something he has never done before. He’s embarrassed to tell his friends that playing a song about a parallel universe and hearing glitchy songs trigger his Existential OCD obsessions. Instead, he tells his friends that he has COVID. Joel feels so disillusioned. His OCD symptoms have caused him to miss out on his music and time with friends, something so meaningful to him. He tells his therapist about this and they begin working on exposures to help him ease his way back to rehearsals. They gradually work through the triggering songs on that playlist. They read the lyrics out loud, write them down, listen to songs, watch the music videos, and then Joel plays them. While doing this, Joel practices accepting that he may never have the answers to these questions.
He allows the fear and distress to co-exist with the pleasure he derives from his favorite activities.
After a few weeks of exposure work, Joel returns to rehearsals feeling anxious but determined. He walks up North 4th Street towards the studio for band rehearsal. He’s greeted by his longtime friends who started to worry about him. They quickly catch him up before getting down to business. Joel has a lot of anticipatory anxiety. They get through the “glitchy” sounding songs and it goes better than expected. “Parallel Universe” is up and Joel starts to get that sinking feeling in his stomach. He’s so nervous about having Existential OCD obsessions triggered during the song. The phrase “You could die but you’re never dead” triggered OCD symptoms in therapy sessions. While manageable in that controlled environment, performing live feels more threatening.
The song starts and as they get through the first part of the song, Joel does have a few Existential OCD obsessions pop up. However, it was not enough to rob the joy out of this performance. His mind tries with “You might be in an alternate universe and not know it. Pinch yourself, bite your lip, do something to see if this is real!”
Joel does not attach significance to these thoughts.
He responds with a statement of uncertainty “Maybe I am, maybe I’m not. But I’m still going to enjoy this performance.” Joel feels proud by the end of rehearsals. He’s mostly glad he trusted himself and invested the last few weeks of ERP treatment focusing on re-engaging in his passion. He feels ready to perform at the next gig. OCD won’t be stopping him.
