Before we begin discussing cognitive behavioral treatment for body-focused obsessions and compulsions, it is important to note that there are many non-psychological causes of physiological symptoms. Consequently, it is essential to be evaluated thoroughly by a medical doctor in order to rule out any possible physiological causes for your symptoms. If a medical disease is responsible for your issues with swallowing, breathing, blinking, or moving, the techniques I will be discussing below are inappropriate and may prevent you from getting the medical help you need. There are a variety of serious neurological conditions that can cause these types of symptoms, and it’s important that you rule these out prior to seeking a psychotherapy-based solution. In some cases, specialty medical providers might also be consulted to rule out health-related problems. For example, in the case of swallowing issues, it might be useful to consult with a physician who specializes in ENT (ear, nose, and throat) issues, a gastroenterologist, or a neurologist.
Assuming that your healthcare providers have ruled out medical causes for your symptoms, you should establish a relationship with a psychologist to make sure that your symptoms fit the diagnostic profile for OCD. A trained anxiety specialist can help you differentiate between specific phobias, panic, obsessive-compulsive disorder (OCD), and other anxiety-related conditions. In comparison to some of these other conditions, OCD is more likely to be associated with generalized and pervasive fears, fears that span multiple domains, fears that jump from domain to domain over time, and (in the case of body-focused OCD) the specific fear of being unable to redirect your attention away from physiological processes. Moreover, in almost all cases, OCD will be associated with both obsessions (e.g., intrusive thoughts, impulses, or images) and compulsions (attempts to reduce the anxiety associated with your obsessions). A simple way to distinguish an obsession from a compulsion is by asking yourself the following two questions:
What increases my anxiety? (These are your obsessions.)
What do I do to try to relieve this anxiety? (These are your compulsions.)
Compulsions may be observable behaviors or mental acts. Someone who is afraid of choking might avoid chewy foods, live on a mostly liquid diet, and count the number of times he or she chews before swallowing. Obsessions and compulsions also exist for individuals who get “stuck” on physiological processes like breathing, blinking, or swallowing. The compulsion (or ritual) in this case involves the strategies that the individual uses to reduce his/her anxiety. These strategies might involve exercising control over the sensation (attempting to blink, breathe, or swallow at the “proper rate”), analyzing the symptom to determine if it’s “normal”, or trying to forcefully distract oneself from thinking about the symptom. Although these strategies may work for a short time in terms of reducing anxiety, ultimately they are doomed to fail and can actually strengthen your symptoms.
I have talked a lot about exposure and response prevention (ERP) in earlier blog posts, but it’s worth revisiting briefly in the context of body-focused obsessions and compulsions because many individuals with these types of symptoms have no idea they are experiencing symptoms of OCD. As a consequence, they never learn about this evidence-based treatment. ERP is a strategy that allows you to break the anxiety cycle that is maintaining your symptoms. Only by short-circuiting this anxiety cycle will your symptoms ultimately decrease.
As is pretty obvious from the name, exposure and ritual prevention involves two essential components: 1) exposure, and 2) ritual prevention. Exposure involves intentionally confronting situations that you know are likely to increase your fear and anxiety. Ritual prevention involves choosing to sit with your anxiety (without resisting it) and letting go of the unhelpful strategies (rituals) that are maintaining the cycle. When you do this, you will naturally feel more anxious at first. However, with time, repetition, and practice, your fear will decrease. Because fear is what maintains your symptoms and causes your attention to lock onto your physiology, decreases in fear will lead to decreases in your symptoms.
Your ERP should involve several discrete steps.
1. Setting a Target Goal
2. Identifying Anxiety Triggers
3. Systematically Confronting Anxiety Triggers Without Avoiding
Let’s walk through a hypothetical example of an individual whose attention gets stuck on his breathing behaviors. This individual reports that he cannot stop thinking about breathing. He feels that he is constantly aware of his breath and often is exerting voluntary control over when to breathe and how deeply to breathe. He also perceives a strong, near-constant urge to breathe, which he responds to by taking a breath. This is followed by attempts to fully exhale all the air from his lungs. In addition to being hyper-focused on breathing, he worries that he is not breathing at the proper rate which might have medical consequences (i.e., hypoxia resulting in brain damage). He states that his life is falling apart and that he cannot function at work due to the fact that nearly all of his day is spent analyzing and controlling his breath.
ERP often involves switching up your goals. Many individuals come to therapy with the immediate goal of reducing the attention they pay to their symptoms and/or reducing the symptoms themselves. Although these goals are understandable, they are unattainable at this juncture and will only lead to frustration. Early in your recovery, such goals are unrealistic. Remember, it is fear that maintains your attentional hyper-focus on your symptoms.
Here’s a more appropriate initial goal for this hypothetical case: feeling less distressed when you notice your breathing. Think of how much better it would feel if your hyper-focus was not accompanied by worry and distress. If you adopt something like this as your goal and work on it through ERP, eventually you’ll also reap the benefit of reduced attention to your symptoms.
In order to be effective, ERP needs to target your specific obsessional triggers. What is it that “sets off” your symptoms? For some individuals, triggers are external events or situations. For example, for people whose symptoms focus on swallowing, symptoms may be triggered by swallowing events like eating, drinking, or getting ready to speak. In the case of breathing, symptoms may be triggered by high intensity (e.g., exercise) or low intensity (e.g., lying in bed getting ready for sleep) activities. It is during these times that your attention is more likely to get stuck on your symptoms. If you can’t immediately identify your external triggers, track your symptoms over the course of a day. Identify when your symptoms occurred, where you were, and what you were doing. Never assume that you lack external triggers. If you fail to identify and address important external triggers, you are likely to have a suboptimal response to treatment.
Not all triggers are external. Sometimes thoughts just pop into our heads for no apparent reason. In these cases, the thoughts themselves are considered internal triggers. It’s still a good idea to track your symptoms over the course of a day and notice the characteristics of situations that are likely to be associated with internal triggers.
In our hypothetical case, external triggers involved walking up flights of stairs, getting ready for bed, situations involving frustration (in which the person would strongly exhale), and quiet places. Internal triggers were also quite common throughout the day, especially when the individual was at work.
This is the step that actually involves ERP. Now that you have identified your internal and external triggers, you want to begin systematically facing these triggers without engaging in any rituals or escape behaviors. You should confront the easiest (least scary) trigger first and then gradually work on more challenging triggers. Your goal in all of these situations is to purposefully direct your attention to your symptoms and keep it there as long as it takes for your anxiety to decrease (“habituate”).
Remember, at this stage of treatment, your goal is to work on being less distressed by your symptoms, not to decrease the symptoms themselves. Purposefully directing your attention to your symptoms might be challenging at first, but it will get easier with practice. Make sure that you leave adequate time for your anxiety to decrease. Don’t attempt these practices when you’re busy with other things, multi-tasking, or having to interact with other people. Ideally, you should set aside time to be alone in a quiet place and work on feeling less afraid of your symptoms. To help keep you from getting distracted so that you can maximize your exposure time, it’s often helpful to have a looped recording playing in the background (“I am paying attention to my _______. The symptoms I am noticing are ________, __________, and ___________.”)
Habituation can be quick (within minutes), or it may take several hours. The key is to stick with the exposure until you have noticed some measurable decrease in your anxiety. A good rule of thumb is to stick with the exposure until your anxiety has decreased by half. At this stage, your anxiety is unlikely to decrease entirely, but repetition of the same exposure on different days will help it decrease even further. Never discontinue an exposure when your anxiety is increasing. In order to be successful with ERP, you must be more stubborn than your anxiety and stick with the exposure until you have noticed at least a small decrease in your fear.
For example, someone who is triggered by physical sensations in their throats might consider wearing a scarf to help direct attention to the throat area while listening to a loop tape to keep their attention focused on their symptoms. If this person is also triggered around mealtimes, he or she might consider purposefully eating sticky, dry foods like peanut butter without an accompanying drink. All exposures should be conducted mindfully-you should purposefully pay attention to all the physical sensations you experience rather than trying to ignore or suppress them. Internal triggers can also be addressed through exposure. In the case of a stubborn thought that keeps reoccurring, you might consider recording it and listening to it on a loop tape.
As discussed previously, somatic obsessions are also associated with very different feared outcomes. Someone who is worried that s/he might choke should approach exposure differently vs. someone who is worried that swallowing might be the sign of a serious illness (e.g., Lou Gehrig’s disease) vs. someone who is worried that they will have to live the rest of their lives noticing every swallow. One’s specific fears need to be targeted via imaginal and in vivo exposures.
The person in our hypothetical case might benefit from the following exposures:
1. Breathing the “wrong way” on purpose for an extended period of time.
2. Breathing through a straw or coffee stirrer.
3. Performing an extended handstand.
4. Going snorkeling.
5. Sleeping while wearing a stethoscope.
6. Wearing a girdle.
7. Hyperventilating on purpose.
8. Going for an extended run.
9. Exercising on a Stairmaster.
Loop tapes might accompany any or all of these activities. For treatment to be effective, this person must also abstain from any rituals used to prematurely “escape” from their anxiety (distraction, over-controlling breath, counting breaths, analyzing breaths, etc.). The overarching goal of all of these exposures is to become better at tolerating variability in breath, to be less afraid of changes in breathing, and to develop more confidence in the automatic, biological regulation systems that our bodies use to maintain homeostasis.
Due to the complex and often-changing nature of this form of OCD, I strongly encourage individuals with these symptoms to work closely with a therapist who specializes in OCD treatment. Treatment works, but it can be very tough to do it alone without professional guidance.
Questions? Comments? Tips for using ERP to combat your body-focused obsessions and compulsions? Share below.