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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!

Questions? Comments? Experience with social anxiety and/or sensorimotor OCD symptoms? Please share below.




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28 Comments

  1. Thank you so much for sharing. I too have has ocdswallowing off and on for years. It lead to abusing alcohol. This is the first site that I have seen addresses the problem.

    Thanks,

    • Thanks for the comment, Matt. I’m glad you found it helpful. I think many other people also fall into the alcohol abuse trap because there’s not a lot of quality information about how to effectively address these symptoms in a healthy way.

  2. I too suffer from some sort of anxiety related swallowing disorder. It has lead to agorophobia on two occasions, and some general isolating much of the time. I’ve been taking Lexapro for years, and I have not had symptoms for quite some time. Now, suddenly they have reappeard.

    I’m not sure the advice above will help me. My main problem is that I have trouble eating in front of others. I’ll be eating fine, then all of a sudden the fear pops into my head. As I’m trying to swallow, food actually gets stuck which triggers more panic. People notice that I’m panicking/choking and try to intervene which is really embarrassing.

    I have several other issues with swallowing in other situations as well, and because of this I carry a bottle of water with me everywhere I go. I panic if I forget it somewhere.

    I know you can’t treat me online, but could you make recommendations on how to go about getting help? I can’t seem to find a therapist who can help me.

    • Hi Diane,

      I would recommend finding a therapist who practices exposure and response prevention (ERP). The International OCD Foundation maintains a database of providers who might be able to help. Here’s the list:

      http://ocfoundation.org/treatment_providers.aspx

      If you scroll down the page, you’ll also find that the page includes questions you should ask your potential therapist. Don’t neglect this part, because even providers in the database may not have much experience treating OCD.

      Remember, treatment needs to address your feared outcome. If you’re really afraid of choking because of the social embarrassment it causes, the best way to get over your fear is to practice eating in public. The more times you practice “fake choking” in public and dealing with whatever happens next, the more quickly your symptoms will improve. For example, when I treat people with this type of fear, we visit mall food courts, restaurants, etc., and practice fake choking.

      Embarrassment feels uncomfortable, but we don’t have to be afraid of it. It’s the fear of the embarrassment, rather than the embarrassment itself, that keeps your symptoms going.

      Also, the water bottle needs to go…it’s a safety behavior/ritual that will prevent you from benefiting from the exposure. Your first exposures might simply involve going places without the water bottle. You would then work up to the fake choking exposures.

      If you read my posts on sensorimotor OCD, you’ll also see that I recommend that anyone with physical symptoms consults with a medical doctor. Make sure you rule out any possibility of a swallowing disorder before you go the exposure route. If there’s an underlying medical problem, this needs to be addressed before you attempt any exposures.

  3. Thank you so much! The idea of giving up my water bottle both terrifies and thrills me.

    One more hitch though. I am also afraid to get the tests to rule out a physical problem. Do you think that could be a first step in my therapy?

  4. i have the same symptoms for about 7 years im 19 now btw, i just reached a point where i almost feel that i “fixed” the problem, i started out thinking this was a psychological problem then a physical problem, but my method is relaxing your shoulders( like droop down) then relaxing your neck(it’s probably tense when you think about it) idk how long this method works but its what i`m currently experimenting just try to think about relaxing your muscles.

    • If there is an anxiety component to your symptoms, I would make sure that whatever technique you use appropriately addresses the underlying anxiety.

  5. Hi Steven,
    very informative article. I started to focus on swallowing in august 2009 (at 28, before i had similar pure-obsessive problems), when i was on holiday with my girlfriend. I was in a very stressfull situation and i just started thinking “what if i’m gonna keep thinking about swallowing forever?”. I held on for 3 days in a foreign country, then i came back to Italy. The swallowing thing stayed with me 24/7 for two months, when Sereupim (prescribed by a psychiatrist with no exerience about OCD) started to have some effect on me. By december 2009, i had an improvment of about 30%. In march 2010 i had a massive panic attack related to a switch in the obsession (from swallowing to breathing), so i decided to get a visit from a psychiatrist in Rome with a huge history in solving cases similar to mine. He changed my medications (full doses after a month: citalopram 80mg, anafranil 25mg and 100mg tegretol) and, in 3 months, my life turned to normal for a year and an half. I experienced an almost total remission of the problem (best period of my life), having only few relapses till last month. In the period november-december 2011 i gradually stopped all medications on my own. What a stupid mistake! In few weeks, the swallowing-thing starts again, as intense as in august 2009. My psychiatris told me i acted like a fool and decided to give me the medications again. After a month, i see the light in the end of the tunnel, but i don’t want to take medications forever, so, toghether with my psychiatris, i decided to start ERP in combination with drugs.
    Few advices for people who have my problem:
    1- I know how you feel, like suicide it’s the only way out. Well,you wrong.
    2- Try to focus on your work and family. The swallowing will be there, i know, but every second you steal from the obsessive-thinking it’s a step forward.
    3- Find a psychiatrist experienced in pure-obsession treatment.
    One more thing. Even with my brain involved 24/7 in the swallowing-thing, i was able to get a good job in a huge italian company as a legal consultant, have several hobbies, and bench-press 250 punds.
    Thanks again to Steven for the article. Best on the web.
    DON’T GIVE UP GUYS!

    • Hi Gabriele,

      Thanks for sharing your story! Many people with sensorimotor symptoms feel hopeless, and you’ve done an excellent job illustrating that even when symptoms are extreme, there’s light at the end of the tunnel. I love the fact that even though you were symptomatic, you were still pursuing things that were meaningful to you — be it in the context of your job, health, or life in general… This is one of the most important principles of recovery: continuing to move forward toward the things you want out of life despite (or to spite) your symptoms.

      Best wishes on your continued recovery!

    • I have breathing obsession.Did the medication solved your problem.

    • Exactly my symptoms, but reverse. I began with obsessive breathing, finally became comfortable with that, so my body became fixated on the saliva build up and swallowing. Ive yet to get any relief from this.

  6. I must thank you, Dr, for putting the spotlight on the co-occurance of these conditions. I suffer comorbidly with them and it’s devastating. I feel that this needs far more attention from the money-obsessed medical community. But will there be active research into this subject — answers as to exactly why some people get attacked by the “White Bear Syndrome” and why most people aren’t susceptible?

    • Hi Geoffrey,

      There are some great researchers investigating some of the questions you’ve mentioned, and I’m hopeful that we’ll eventually uncover some of the answers. In the meantime, you might want to consider attending the annual IOCDF conference. Many of the “big names” in the field will be in Chicago at the end of this month (July 2012) presenting cutting edge research findings.

  7. Hi, this is a great and very very useful article. Thank you so much for posting it. I do however, have a few questions.

    I’ve been through Pure O’ OCD, and I’ve had it since I was 11. (I’m 13 now.)
    I was able to resolve that on my own bye learning about exposure therapy, and I was able to beat it without any other help- However, after about a month free of OCD symptoms, I started to get the swallowing problem.

    It’s been really hard, and I’m kinda lost. I told my parents about it, and that I desperately need some help with it, however they say they refuse to take me to any kind of therapist or psychiatrist.

    I was wondering though, can swallowing constantly, all the time, hurt your throat at all? I’m a singer. My biggest fear is that I’ll be stuck with it forever. Oh, and the other problem I’m having is that when my throat starts to get dry, and even hurt, I start eating compulsively to get rid of the pain and dryness. Any advice?

    Thank you so much.

    • Hi Katherine,

      With sensorimotor symptoms, it’s important that you talk with your doctor and rule out medical causes. This would also give you an opportunity to ask your medical questions. Good luck!

  8. I am so glad that you have posted this article because I thought for years I was the only one suffering from this condition. I constantly think about saliva filling up in my mouth and my need to swallow it. I obsess over this thought from the time I go to bed until the time I wake up. When I am really anxious I notice that I often wake up in a soaking wet pillow. I have been to three different ENT’s about the issue and they all agree I hypersalavate because I think about it so often and have given me several medications that have been rendered noneffective. My psychiatrist has prescribed me adderall which helps a lot with my social anxiety, however my fear is that I am becoming addicted to the medication because it has been the only solution I have found to temporarily make the problem go away. This issue has affected every aspect of my life and I honestly am at the end of my rope. What treatment would you suggest I seek to get more help and should I talk to my psychiatrist about trying to ween off the adderall?

    • Hi Chris,

      Every situation is different, and only you and your doctors should make decisions that directly affect your health. Good luck.

  9. Hola soy Carmen de Barcelona, hace 3 meses tengo problemas con el tragar, soy medico de 43años y ansiosa, pero nunca me había sentido
    tan afectada.
    Empece a ser consciente de tragar saliva a raiz de que me atragante un poco, y desde entonces, que estoy pendiente de mi garganta, tengo esceso de saliva, que he de tragar o escupir.
    A la hora de comer, es un alivio, comer o beber.
    Lo cierto es que me afecta la vida social pues me veo incapaz de estar hablando sin que se me llene la boca de saliva, y a veces la ansiedad provoca en mi que trague, con o sin salida.
    Mi psiquiatra me recetó sertralina 50 mg/d y diazepam por la noche, y con esto, estoy más animada pero el sintoma sigue.
    Debo acudir a un psicologo experto, verdad? aqui no se si hay especializados en este tipo de transtorno.
    Muchas gracias
    Atentamente
    Carmen

    • Hi Carmen,

      Yes, if you’re continuing to experience symptoms, you might consider getting the help of a psychologist. I don’t have any specific recommendations in Barcelona, but you might try contacting the International Obsessive-Compulsive Foundation for a referral. Their website is ocfoundation.org.

      Wishing you the best with this!

  10. Thanks a lot for ypur information.
    I suppose it is not possible to make a therapy with you or someone of your center by videoconference, skype, or something like that, isn´t it?

    Tank you again

  11. hello , steven my name is Rafaela Morel, i am writing to you because im at extreme desperation because of my swallowing anxiety. I do not know what to do anymore and have become extremly depressed because of this. I have a sensation in my throat or mouth that for some reason produces saliva, and makes me want to swallow constantly… this has been going on for over a year now ..and its at the point where i cant enjoy my life because of this :( i would really want some advice on how i can cure myself because i literally cant deal with this anymore.. its like my brain programmed itself to swallow atleast 4 times in a minute and its so embarassing, please email me back i would truly

    • Hi Rafaela,

      I have had these OCD swallowing symptoms for almost two years. The fear and physical/emotional distraught with regards to your obsessive-compulsive swallowing symptoms can be overcome – I have overcome it myself. To help motivate your recovery, I will share my personal story.
      My first symptoms appeared while completing my second year of my engineering program at university. During one of the lectures (incidentally during my quantum mechanics course, which proved daunting without the added stress of OCD) I realized the amount of noise that each of my swallows produced. This caused me to obsess over swallowing, although only during class. This initial obsession endured for about two weeks, and was then forgotten for about three months.
      The symptoms returned after moving to a different city in order to complete one of my mandatory coop (internship) terms. I have forgotten the trigger, or root, of its recurrence, but it returned with a vengeance. I was unable to concentrate/focus, have a conversation, or even enjoy leisurely time without the constant thought of saliva accumulating within my mouth, followed by the compulsion to dutifully swallow. It was horrific – I was being tortured, and I had not the faintest idea how to combat the problem. In fact, my attempts to eliminate my OCD symptoms actually worsened them. I tried to “optimize” my swallowing mechanism (remember, I’m an engineer) such that I would swallow less frequently. This involved changing my natural swallowing pattern. Later on when I tried to regain my initial swallow pattern, I was unable to, as I had forgotten it. Hence not only did I have to manually control each individual swallow, my mouth was also perpetually uncomfortable. Shortly thereafter I began obsessing about the rest position of my tongue within my mouth, and realized that regardless if its position, it too felt uncomfortable. Hence throughout the entire day, my mouth was uncomfortable, I obsessed about correct tongue position, and I also obsessed about each individual swallow. I was deeply stressed, depressed, and unhappy. I couldn’t believe that something like this would ever happen to me, as prior to these events my future appeared extremely promising. I lived through this daily torture for approximately ten months. The thought process that enabled me to continue my life was the belief that in time would recover from these symptoms. And I was right – I have regained control of my life, as well as the confidence to pursue all the activities that I enjoy. Recovery was by no means an easy process; it required a tremendous amount of perseverance, especially in my darkest moments. However, recovery is also very possible.
      The first step in my recovery process was the realization AND acceptance that I may have these symptoms for the remainder of my life. This was much more difficult than it sounds, and involved convincing myself that I could still perform all of my endeavors equally well as I was able to prior to having these OCD symptoms. I forced myself to continue to go to the gym, to study, to have lengthy conversations, etc, even though I was terrified that I would i.e. not be able to lift as much weight, not be able to concentrate or focus, and not be able to have a decent conversation. However, after having tirelessly forced these endeavors, I was indeed convinced that I could still perform them very adequately, and a large portion of my anxiety disappeared. Once I had achieved this initial goal, I realized that I simply did not care if other people thought I was swallowing loudly (i.e during class). I had survived torture and had recovered substantially, and hence I was entitled to swallow loudly. This proved to be an extremely valuable thought process – one that I have, and continue to, depend on exhaustively. I truly believe that this battle has greatly increased my mental endurance and, overall, has made me stronger.
      Regarding your specific case, I have to perform AT LEAST 8 swallows/minute. When my OCD swallowing symptoms first arose, I believed that swallowing this often must be abnormal and unhealthy. However, over time I have realized that this is untrue (both of my parents are medical doctors and I have been assessed frequently and deemed perfectly healthy), that everybody swallows at different rates, and that I was only increasing my anxiety by believing so. It is not abnormal to swallow as often as you do.
      Periodic swallowing and the compulsion to swallow are in fact the next aspects of my symptoms that I am going to try to reduce. In order to do so, I plan on allowing myself to obsess about my mouth filling with saliva. However, I will not allow myself to conform to anxiety. That is, I will only perform a swallow once my anxiety towards not swallowing has disappeared (this is the basis of ERP – expose yourself to the obsession, yet prevent the compulsive response until your anxiety towards it has receded). This strategy has proved extremely valuable in the past, and hence I will continue it.
      I sincerely hope this story has helped you, I wish you the best of luck in your current position, and if you have any questions please ask me! Remember, you are NOT alone!

      Cheers,
      MH

      • Hi MH,

        Thank you very much for sharing your personal experience. It’s really reassuring and inspiring. I too suffer from social anxiety & obsessive swallowing. My biggest fear is that when I interact with other people, they will notice my swallowing and get it too. I’m so sensitive about it that whenever I interact with a person, I always observe their swallowing and drinking behaviors. I feel guilty if I notice they start to swallow too. I don’t want this to ruin my life and I still want to have a normal social life and work life. Do you have any advice on how I can overcome my problem? Thank you very much!

        Katie

  12. THAnk you so much MH

    I am still suffering grom this anxiety … thank you for sharing your story i will defenetly perform ERP the way u suggested it i havent lost hope and i pray so much that ican recover i know i can !! thanks so much for being brave enough to share your expirience …. i have so much hope that i will get better i have become agoraphobic because of this …. thanks i wiol start right now with your suggestions

  13. sir i want to ask you one thing please reply—m facing the problem of starring peoples not their genitals or whatever but only peoples through my corner vision and even objects though my pheripheral vision..and i have seen many phyciatrist and even a phyclogist for it but this problem never gone..now m convinced to take a session of cbt this is my last hope..i know this is rediculuous u know this is ocd thought which has no meaning but this stupid and irrational thought really impacts on my social life the most …i know erp can make me better but i want to know what exposure they will give me i really can’t imagine..sir please read about this on google if u don’t know this ocd type…ur reply is very very important to me please sir

  14. I have the same issue here!!! i was always extremely sociable but uni (i go to cambridge) has really put me in a bad place! im being as strong as i can, go running, eat healthy, force myself to socialise. I find the symptoms tend to disappear when im by myself (and not reading about it). When i socialise they come especially due to fear i will be judged or pass the behaviour on. So im wondering, is this mainly social anxiety? or OCD mixed with it? And i wonder what are your thoughts on alternative methods, such as meditation and taking rodhiola rosea (which i am atm). Exposure too. The only problem with it is that if other people get it too it becomes a vicious circle!! do u think maybe by letting the thought go when it comes and not paying attention to it or give it special consideration will make it better? im gonna be doing lots of yoga and meditation so i will keep u guys updated on whether things get better. I wanna reclaim my life and, more importantly my ability to be close to people. this problem has seriously affected my being comfortable with being one on one. I think we need more people talking about this. It affects more ppl than we realise i think, but is kept more hidden than, say, the usual OCD. I see a lot more people suffering from it now that i got it, so i know im not alone. I really pray that neuroscience might discover a way to really help people suffering with OCD. It’s not easy living with it.

  15. Hi,

    I have for the last 5 years been having a problem with as odd as it may sound, seeing my nose when reading or conversing with someone and it is driving me “nuts” I wasn’t aware that sensorimotor ocd even existed until I stumbled upon your site.
    What would you suggest I do on my own to help relieve myself of this great nuisance?
    Any feedback would be greatly appreciated.
    Thank you so much in advance!

    Johnny

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