Sensorimotor OCD and Social Anxiety

Social Anxiety & Sensorimotor OCD Differential Diagnosi...
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Diagnosis: Obsessive Swallowing
Sensorimotor OCD & Social Anxiety

Differential Diagnosis: Obsessive
Swallowing
Posted by Steven J. Seay, Ph.D. on Nov 1, 2011 in Body-Focused/Sensorimotor Symptoms, ERP,
OCD, Social Anxiety | 23 comments
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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
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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 youve
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 wont 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 outjust 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 its 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 youve proven this to yourself
experientially through repeated practice, youll 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, its 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. Dont 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.
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Social Anxiety & Sensorimotor OCD Treatment Course
Your impatience is understandable, but its 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 youll 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
alarmsrather, stick with your exposures even when your anxiety increases. Dont 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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23 Comments
1.
Matt / November 24, 2011

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,
Reply
Steven J. Seay, Ph.D. / November 26, 2011

Thanks for the comment, Matt. Im glad you found it helpful. I think many other people
also fall into the alcohol abuse trap because theres not a lot of quality information about
how to effectively address these symptoms in a healthy way.
Reply
2.
Diane / January 26, 2012

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. Ive been taking Lexapro for
years, and I have not had symptoms for quite some time. Now, suddenly they have
reappeard.
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Im not sure the advice above will help me. My main problem is that I have trouble eating in
front of others. Ill be eating fine, then all of a sudden the fear pops into my head. As Im trying
to swallow, food actually gets stuck which triggers more panic. People notice that Im
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 cant treat me online, but could you make recommendations on how to go about
getting help? I cant seem to find a therapist who can help me.
Reply
Steven J. Seay, Ph.D. / January 27, 2012

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. Heres the list:
http://ocfoundation.org/treatment_providers.aspx
If you scroll down the page, youll also find that the page includes questions you should
ask your potential therapist. Dont 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 youre 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 dont have to be afraid of it. Its the fear of
the embarrassment, rather than the embarrassment itself, that keeps your symptoms
going.
Also, the water bottle needs to goits 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, youll 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 theres an
underlying medical problem, this needs to be addressed before you attempt any
exposures.
Reply
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3.
Diane / January 27, 2012

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?
Reply
Steven J. Seay, Ph.D. / January 31, 2012

Definitely! That exposure would be a great addition to your hierarchy!
Reply
4.
terry / February 7, 2012

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(its 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.
Reply
Steven J. Seay, Ph.D. / February 21, 2012

If there is an anxiety component to your symptoms, I would make sure that whatever
technique you use appropriately addresses the underlying anxiety.
Reply
5.
Gabriele / February 22, 2012

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 im gonna keep thinking about swallowing
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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 dont 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 its 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 its 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.
DONT GIVE UP GUYS!
Reply
Steven J. Seay, Ph.D. / March 2, 2012

Hi Gabriele,
Thanks for sharing your story! Many people with sensorimotor symptoms feel hopeless,
and youve done an excellent job illustrating that even when symptoms are extreme,
theres 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!
Reply
6.
Geoffrey / June 4, 2012

I must thank you, Dr, for putting the spotlight on the co-occurance of these conditions. I suffer
comorbidly with them and its devastating. I feel that this needs far more attention from the
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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 arent susceptible?
Reply
Steven J. Seay, Ph.D. / July 15, 2012

Hi Geoffrey,
There are some great researchers investigating some of the questions youve
mentioned, and Im hopeful that well 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.
Reply
7.
Katherine / June 14, 2012

Hi, this is a great and very very useful article. Thank you so much for posting it. I do however,
have a few questions.
Ive been through Pure O OCD, and Ive had it since I was 11. (Im 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.
Its been really hard, and Im 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? Im a
singer. My biggest fear is that Ill be stuck with it forever. Oh, and the other problem Im 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.
Reply

Hi Katherine,
22/10/2013 15:23
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With sensorimotor symptoms, its 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!
Reply
8.
Chris / July 6, 2012

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 ENTs 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?
Reply

Hi Chris,
Every situation is different, and only you and your doctors should make decisions that
directly affect your health. Good luck.
Reply
9.
Carmen / September 5, 2012

Hola soy Carmen de Barcelona, hace 3 meses tengo problemas con el tragar, soy medico de
43aos y ansiosa, pero nunca me haba 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 recet sertralina 50 mg/d y diazepam por la noche, y con esto, estoy ms
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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
Reply
Steven J. Seay, Ph.D. / September 6, 2012

Hi Carmen,
Yes, if youre continuing to experience symptoms, you might consider getting the help of
a psychologist. I dont 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!
Reply
10.
Carmen / September 7, 2012

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, isnt it?
Tank you again
Reply
11.
rafaela / March 7, 2013

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
Reply
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MH / March 28, 2013

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, Im 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 couldnt
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
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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
Reply
Katie / April 4, 2013

Hi MH,
Thank you very much for sharing your personal experience. Its 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. Im 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 dont 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
Reply
12.
Rafaela / August 3, 2013

THAnk you so much MH
I am still suffering grom this anxiety thank you for sharing your story i will defenetly perform
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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
Reply
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Dr. Steven Seay is a licensed psychologist in Florida & Missouri. He is the Director of the Center for
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Sensorimotor OCD and Social Anxiety

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Social Anxiety & Sensorimotor OCD Differential Diagnosi...

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Sensorimotor OCD & Social Anxiety

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