Sensorimotor OCD & Social Anxiety Differential Diagnosis: “Obsessive Swallowing”

Social Anxiety & OCD Symptoms: CBT Treatment

Sometimes the symptoms of social anxiety and OCD can overlap. Because avoidance maintains fear, consider high level exposures that involve "broadcasting" your symptoms in order to address anxiety-related cognitions. This is a CBT technique called intentional mistake practice.

Reader Question: For the past year, I have been dealing with OCD-related sensorimotor obsessions focused on swallowing. My symptoms started during a class discussion in which I noticed myself swallow. Since then, whenever I am in a lecture or quiet place surrounded by people, I become deeply focused on my own swallowing and worry that others will notice my swallowing and then judge me.

I am practicing meditation and daily exposures in which I sit down in a quiet room and intentionally invite the swallowing in. I also purposefully invite the swallowing in throughout the day, even when I am in the presence of friends. I try to be mindful of my swallowing without doing anything to avoid it or mask it. Even though my awareness of swallowing has not entirely gone away, the anxiety associated with it has decreased significantly. However, I find myself feeling impatient and worried on the random days when my OCD-related anxiety flares up.

For me, the most difficult situations continue to be one-on-one conversations, especially when I notice other people swallowing after I do. This makes me worry that I am spreading the condition, even though I know rationally that this is not possible.

Do you have any recommendations for how to deal with OCD-related swallowing obsessions when they are triggered by interactions with friends? Should I seek professional help to address my sensorimotor obsessions and compulsions? I have always felt like a very confident and outgoing person, but this frustrating obsession has kept me from being my normal self.

Your general approach of allowing yourself to focus on the swallowing is sound as long as you are not doing anything to intentionally change the behavior (i.e., trying to swallow with less force or with less sound) or “perfect” the behavior.

However…

Based on your description, it is likely that you are experiencing significant symptoms of social anxiety in addition to OCD-related symptoms. It is also possible that your symptoms might be primarily social in nature, rather than being OCD-based. This important differential diagnosis issue should guide treatment selection.

Social Anxiety vs. Sensorimotor OCD Obsessions/Compulsions: Treatment Implications

Unfortunately, meditation and imaginal exposure will not address the social aspects you’ve described. You must specifically target these social situations directly in order to habituate to your fear. Your in vivo exposures should address the mistaken belief that swallowing loudly will lead to a negative outcome that you won’t be able to handle (e.g., embarrassment, shame, etc.). This will help you increase your confidence in your ability to handle these situations effectively regardless of how they play out…just as you are confident in your ability to effectively handle other areas of your life.

Social Anxiety & Sensorimotor OCD CBT-Based Exposure Ideas (Treatment)

For example, you might consider swallowing loudly (on purpose) in order to draw the attention of others. Or, if you find that it’s difficult to swallow loudly enough for others to notice, you might surreptitiously play a recording of a swallowing sound. You could do this in elevators, on buses, etc. I suspect practicing in front of people you know (e.g., peers, people who have evaluative authority over you) would be ranked higher on your hierarchy than practicing in front of strangers. Also, large groups are probably harder than small groups

Proceed with your exposures according to a hierarchy and make sure you address easier situations before progressing to harder ones. Your final exposure might involve swallowing loudly several times while giving a public talk or presentation. If you can do this while using a microphone, all the better. Remember that in order for your fear to habituate, you must correct the mistaken belief that swallowing loudly might be socially or personally “dangerous.” Once you’ve proven this to yourself experientially through repeated practice, you’ll find that your triggers will lose their potency.

As for the “paired swallowing”, I think this is one of the more OCD-ish aspects of your symptoms. In a way, it’s kind of like a fear of “mentally contaminating” or harming other people. For this OCD-related symptom area, 1:1 practice is key since it triggers your anxiety. Practice swallowing intentionally during 1:1 conversations (as described above) and avoid discussing the swallowing or mentioning it to your conversation partner. Don’t reinforce it as an important event. For your anxiety to resolve, you will need to experience “paired swallows” multiple times without seeking reassurance.

Remember, the problem here is not the behavior per se; we are all swallowing all the time… The problem is the fear-related attributions you make regarding the behavior (i.e., the possibility that the behavior might result in an unwanted outcome). Stick with your exposures and dial them up when you can.

Social Anxiety & Sensorimotor OCD Treatment Course

Your impatience is understandable, but it’s important to recognize that ups and downs are an unavoidable part of the recovery process. Stress and other events can sometimes sensitize you, and sometimes you’ll have flare-ups for no apparent reason. How you handle these ups and downs is an important contributor to the resolution of your symptoms. Do not treat flare-ups as “true alarms”…rather, stick with your exposures even when your anxiety increases. Don’t let increased anxiety result in fewer exposures as this can indirectly reinforce your OCD and social anxiety symptoms.

Social Anxiety & Sensorimotor OCD: Do I need professional help?

For OCD and social anxiety-related issues, the choice about whether or not to seek professional help is up to you. Given how frustrating this situation has been, I suspect that professional assistance would be helpful. If you go this route, definitely find a trained CBT therapist with a specialty in anxiety issues.

Wishing you the best with this!

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