Note: All parts of the guide have been updated as of Sep 2022 after much discussion from those suffering from SOCD and my own experience. In particular I have considerably adjusted the ERP approach, as I now believe that is better to simply avoid doing any explicit rituals, rather than trying to literally do nothing, which seems to have been causing some issues for people.
This begins Module 2, which is about applying Exposure and Response Prevention (ERP) to SOCD. To see all units in the guide, click here.
What is ERP?
As I’ve mentioned, all this consciousness of bodily sensations is actually a form of Obsessive Compulsive Disorder (OCD). The best practice treatment for OCD, after some psycho-education (which we did in Module 1), is Exposure and Response Prevention (ERP). With OCD, there is some kind of trigger/obsession which elicits anxiety, and you do some kind of ritual (often called a response or compulsion) to reduce the anxiety. This might sometimes work in the short time, but very soon the anxiety is back, and you feel like you need to the compulsion again. As you keep repeating the pattern, the anxiety often gets worse and worse. This is the OCD cycle as below:1
The only way to really get rid of the anxiety is to keep exposing yourself to the trigger/obsession and NOT do the ritual/compulsion, which is what is called response prevention. This is essentially breaking the OCD cycle. This will often increase anxiety in the short term, but in the long run it will reduce it. What happens is that your brain realises there’s actually nothing to fear from the trigger and the anxiety thus dissipates, which is called habituation.
An Example with Classical OCD: Handwashing
This is easily understood when it comes to classical kinds of OCD. For example, let’s say someone has OCD with always washing their hands. She might feel unclean every time she touches the couch, and she feels anxiety and gets a compulsion that she has to wash her hands with soap. However after she washes her hands, it still doesn’t feel ‘right’, and so she washes her hands again, and again til it feels ‘right’. The next time she touches a couch, she might feel like she has to wash her hands even more times. And so it goes on, and such people often spend hours washing their hands.
To treat this person, the first step would be psycho-education. We’d talk to her about how there probably isn’t really anything dirty on the couch, and even if there is, there’s no need to wash her hands. Even after she agrees with this and knows it rationally though, she will still get a compulsion to wash her hands and feel extreme anxiety if she doesn’t. This is because these beliefs held in the sub-conscious and can’t just be removed by thinking alone. We have to do ERP and break the cycle; she has to stop doing the ritual (hand washing) in response to exposure to the trigger (touching a couch). This will be very difficult at first, but this is what will ultimately work in getting rid of the anxiety and reaching habituation. What’s happening deep inside her brain is that those sub-conscious beliefs are changing. Each exposure, the brain is learning that touching the couch is not dangerous, because nothing bad happened when she was exposed to it and did not do the ritual. Your brain can’t learn this if you keep doing the ritual. It’s exposure to the trigger WITHOUT doing the ritual that does the trick.
How does ERP work with sensorimotor OCD?
So how does this work with sensorimotor OCD? Your trigger is being aware of the bodily sensation or the thought of being aware, whatever the specific obsession might be. You feel discomfort and/or anxiety. You do something to try to get rid of it: controlling your breath in some way, perhaps blinking to a certain pattern, monitoring your saliva, or something else. The point is, you’re doing something to try to quell the anxiety. This is your ritual. This is what you need to learn to stop doing; just expose yourself to the trigger without actually doing that ritual. The idea is you get used to doing nothing in particular when the awareness comes.
For many people with SOCD, it’s not at first clear that they were even doing some kind of ritual; it just seemed like the awareness was always there by itself causing all the anxiety. But I can almost guarantee you are doing some kind of ritual, and that’s what is keeping the anxiety there. If you weren’t, your brain would have habituated to it and the anxiety would have decreased. It’s impossible to keep being anxious about something if you’re exposed to it continuously without doing any kind of response/ritual.
Doing ERP can be quite difficult unfortunately. But there’s no other way but through. You have to hang in there and ride it out. There’s a few ways to practice exposure, which we’ll get to in the next unit. But the first step is to work out what your triggers are and crucially, what your rituals are that you need to stop doing.
Exercise: Work out and write your triggers and existing rituals for them in the table below. Your triggers will be thoughts like being awareness of itches, blinking, breathing, swallowing etc. Ideally already in Module 1 you identified some problematic thoughts you had about these and corrected them. Your rituals will be what you do currently when you get those triggers. These are often things like doing things to a certain pattern, monitoring them consciously or checking something about them. Sometimes it’s more subtle, like researching online trying to answer some question like how often the ‘normal rate’ of breathing or blinking is, or mental rituals where you think through it in your head repeatedly. It’s important to identify your rituals so you don’t do them when you practice exposures. I have filled an example table below.
Note some of these may be related to avoidance (e.g avoiding certain situations) while others might be more something you do repeatedly, such as research or monitoring.
Feel free to post your answers and any questions below. If you honestly feel like you can’t work out your rituals, that’s okay for now, at least list your triggers. You might discover them when we get to exposures in the next unit.
Continue to 2.2 ERP: Three Kinds of Exposures
At the moment I can only identify my trigger as blinking and just being aware of it so when I am I try see it in a relaxed way now and just focus on whatever I was doing before I came aware of it.
I think that’s pretty much the right approach. The only thing I’d be wary of is trying to ‘not think’ of it and trying to force focus on what you’re meant to be doing (I’m not saying you’re doing this, just a warning!). It’s more like you just accept the awareness and learn to carry on with your activities with it there. It’s a subtle difference but I think an important one.
I have been suffering this type of OCD for many years but all of a sudden it has jumped to songs, one song in particular going around and around all day long and I mean all day long. It is the first thing I remember when I wake and I am still humming it at night. It has been with me for 14 days solid and I dont know what to do or how to handle it.
Hey Lesley,
That would be a kind of hyperawareness OCD I think; I’ve seen the term earworm being used. I think the principles for dealing with it would be similar. Presumably the more you are worried about a certain song, the more it can get stuck with you.
The idea would be to learn to accept the earworm, and just learn to get on with your life, so you’re able to operate whether it’s there or not. ERP in this case would be reminding yourself of the earmworm every so often while you carry on with your daily life.
I am hyper aware of my fingers. Or mouth and tongue. The trigger is usually a situation where I feel like I need to perform. The ritual is then probably rumination about what could have been if I haven’t had this condition. Don’t know about many other rituals tho. Perhaps trying to feel comfort whenever I feel it.
Thanks so much for the guide tho! It’s a life saver so far. May God bless you.
I’m really happy to hear it’s useful for you :). God help you.
What do you mean by when you need to perform? Is there anything you do physically when you feel the awareness?
By the way is it possible when I try to feel the sensation for that to be the ritual?
Or when I try to remind myself it’s just an OCD?
Should I really just leave it completely and embrace the anxiety?
I have this breathing and heart rate consciousness for last 6 years.It normally arises when i m deep in something like my studies.When this arises i am scared of and think of heart ailments.Thanks to you that i m finally accepting it and viewing at it from different perspectives such as these 6 years have been the most productive years for me and i have learnt many things due to this obsession.
Now I don’t know how to stop it and do ERP.Because it pops up everytime i concentrate on anything and it frightens me even when i listen to some bad news related to heart attacks and all.Most of the time I devise some kind of mechanisms such as law of attraction or mindfulness.But those work for a limited time.
So , kindly guide me through this ERP.
That sounds like a common manifestation of sensorimotor OCD where it’s related to health.
You might need a professional therapist/psychologist to guide you through ERP as it can be tricky. It sounds like you should be exposing yourself to your triggers where here sounds like news/articles related to heart attacks etc. So you could maybe on purpose research that stuff (maybe beginning just be reading about anatomy of heart, and slowly get into more scary stuff). Along with that, practicing breathing ‘incorrectly’, in a way that triggers your fears.
CBT is also important. You should be clear that conscious breathing or consciousness of heart rate does not lead to any heart problems. Then you can do exposures.
But as I said, this can be tricky, so ideally you want a professional to guide you through the process.
Actually I am not exposing myself to that area.I am just concentrating on something like studies or discussions or office related pressures and that too not extremely.Just regular stuffs.
I have gone through a lot so I have learned a lot e.g. LOA, Mindfulness etc.So my problem doesn’t bother me much as before but when it does it makes my life hell.So when I came across your website and read this I have understood it clinically that it is called SOCD.
And I genuinely feel that I will conquer this with your help.
Thank you.
How can I stop constant rubbing of tongue against teeth, feeling of crowded edges makes me anxious. As soon as I wake up I start and it doesnt go away until sleep. I have Mianserin for anxiety – no help really 🙁
That’s what this blog is all about 🙂
Ultimately you want to be able to get used to and accept the feeling of the rubbing of your tongue against teeth, or whatever it is. When you accept it and do ERP to expose yourself to it, over time the anxiety will diminish, and you won’t care if the awareness is there or not.
Hang in there and all the best, I know it can be very difficult.
I do not fully understand this. There are probably good and bad rituals. Bad things like blinking more / more violently if I first become aware of how I blink. but good rituals such as reassuring oneself that it is okay to be aware, there is nothing dangerous in the attention, it is my reaction to it, and there is nothing dangerous. It’s my new “ritual” after Reading Your guide. Is this okay? Also I must say it is a balance between trying to be neutral and not reacting e.g. by blinking more often, and at the same time not starting to think “you must not blink” – do you have any tips here? I can quickly come to think of what I should not do and it aggravates my anxiety. in addition, I have read elsewhere that you have to take ownership and do / think about what you are afraid of and what triggers the anxiety, so for example you have to blink more, to find out that this is not dangerous and that you are in control. but this can also quickly become a ritual I think. what do you think?
Thanks for this thoughtful comment. Sorry I seemed to have missed replying to it earlier, and it looks like it was in response to an earlier version of the guide.
However I think what you touch on is really important. It is impossible to do ‘nothing’. My main focus is on not doing the harmful rituals which are keeping the OCD there. It is true that almost anything could become a ritual, but you can hopefully identify for yourself which ones are the problematic ones. For instance someone can make reassurance mentally (repeating certain thoughts to themselves) a ritual, but it won’t be for most people by default. But it could be if you make it something you do to manage the anxiety/awareness each time, going through a set of thoughts or thinking process or something like that.
And yes, its about NOT doing the ritual as opposed to doing anything, like not blinking at all.
I do agree that you should exposure yourself to the fears. The idea behind ERP is to expose yourself to the fear (the awarenesss + the results of the awareness (like how it feels) and then NOT doing the ritual.
For me, awareness of breathing changes the breathing pattern. The more I expose myself to the trigger the more it changes the breathing pattern. It is like I have to manually breathe. Is this a ritual? I try to expose myself without controlling the breath but I am unable to. How do I go back to the normal breathing?
hello! did you manage to turn it around? I’m having the exact same thought. it’s not like other ocd themes where I could just notice it and get on with my life. noticing our breathing requires us to control it even if we don’t want to. I’m so stuck here!
This is what makes SOCD so tricky; the fact that awareness actually changes the situation. Other kinds of hyperawareness OCD don’t actually change your experience of the sensation.
The idea is to learn to accept having some ‘control’ over your breathing and get on with your life, without running away from that control. You can breathe in a certain way, or you can not, but you are no longer running away from being given that control. You get used to doing things in your life with awareness (and sometimes control) of your breath. The thing is once the anxiety diminishes and you focus less on it, it becomes less and less of a deal. But it is something to learn, to do these activities while having the awareness as well as control there.
I am “relieved” to see this as I feel exactly the same. It is difficult to judge what is the right thing to do. Awareness, and for me that can be just the thought of breathing, makes me focus directly on my. breathing pattern which might change my breathing pattern. I also feel like I have to breathe manually, but when I don’t try to this it feels like.holding my breath which also doesn’t help. I don’t quite know how to handle it.
I’d reiterate what I said above. You are absolutely right in that it makes it tricky and you can’t just ‘do nothing’ when you have complete control over your breath. But this is what you need to learn to accept, it’s okay if you have some control, and it’s okay if it’s not ‘normal’.
So difficult to accept though, feels it consumes the whole day, day in day out
Yes :/ It is a slow process, but just hang on. I recommend tracking your anxiety levels ea day on a scale of 1-10…you will notice progress by the weeks usually, not days
Hi,
This is a brilliant website. I am suffering from compulsive swallowing throughout the day. My confusion is beyond 10 mins of erp, what about the rest of the day. Do i continue compulsive swallowing during rest of the day?
I dont arrive to identify my ritual/compulsion.
My hiperawareness Is related also to a sensation that i cant control, a sensation of emptyness, its going with thé hiperawareness AT same Time, i cannot really separate one from thé other, because IS not a phisical ritual.
Another thing for example i sleep a lot because when i sleep i dont have any hiperawareness that bring me to sleep a lot during thé day.
Also i pass a lot of Time on internet researching info about sensorimotor,that bring me also to have 8 sensorimotor obsessions instead of 5 that i generate by my self.
Seeking réassurance also Can bé a ritual or compulsion, read internet also?
Avoiding making sport and dance ( because one of my obsessions is body movement) Can bé another ritual?
You are absolutely right that seeking reassurance on the internet and researching can be a compulsion. In fact, I personally think ‘figuring it out’ and researching is one of the most common rituals which people do not realise. You don’t want to spend time consciously doing anything related to it.
yes I would say avoiding anything like sport/dance for these reasons is problematic. You want to actually expose yourself to those situations.
I have the above listed swallowing ritual number 2, constantly trying to figure out how to manage the swallowing. It’s not as simple as just “be aware and don’t engage” because if I don’t swallow that is avoidance and increases the anxiety and tension and if I manually swallow I’m always trying to control when. It’s like a no win situation. Please any tips?
And I am fully aware it’s my fear of it but that does not help me with the minute by minute management.
Hey Bonnie. Sorry I didn’t see this comment earlier. I responded to your other comment which I hope helps.
Specifically on this, it’s neither that you avoid swallowing altogether (consciously stopping it) nor that you try do it to a certain pattern. It’s neither. You have no particular strategy is my view like I said; it’s okay if it’s sometimes conscious because you feel like doing it (that’s how it is for normal people) and okay if it’s not either. It’s just about not having something you are trying to do in particular once you have the awareness of it.
Aadil,
Thank you very much for your reply, and for this site. I have suffered with this on and off for many years, not knowing that it was OCD or specifically sensorimotor. I thought I was the only person to have this and because it seemed so embarrassing, so bizarre, this added to my fear and made me feel incurable. In the last 2 months I discovered your site as well as the “OCD Recovery” channel; finding out that this is a real disorder, and many people suffer from it has been HUGE. Being able to talk about it has begun to lessen the stigma for me, which was a big part of it. Although I still have the hyperawareness, the fear is starting to subside as I practice the tools and tips I have learned from you as well as the other channel I just mentioned. I also reread the book “Hope and help for your nerves” by Dr. Claire Weekes, which my mother gave me 30 years ago. I am very appreciate of your help and hope I can reach out with more questions as time progresses.
I had been advised in the past by a doctor to be aware with disinterest, with no emotion, then return to the present moment. This did not help me before (was told this 5 years ago) but for some reason I understand it better now and am able to put it into practice, now that I have discovered these new groups. I really think it is largely just discovering that I am not so unusual, that others have this, and it is not just something my mind concocted to torture me, that has instigated my recovery. LOL
Have you found this with other people? Is my experience common?
Thank you again
Bonnie
Hi Bonnie,
Sorry for the late reply, I’ve been on the road. It’s wonderful to hear you are doing better! I think what you say is a big part of it; understanding it for what it is, seeing that it’s not so uncommon, and breaking out of that bubble where you’re suffering alone and it’s just weird. But I still say knowing the treatment goal (getting okay with it running than forgetting about it) and ERP are the most important 🙂
Hello,
Ty for this Site. It helps much in understanding thst it is the fear and not the breathing that let mee fell horible. im haveing the brathing for a week i had it formmer somtimes but only for 1 hour or so but now it is here for a Week. I dont know if i do Rituals or not , can it be a Ritual if i notice i take a deep breath and try to breath normally or should i accrpt the deep breaths i take AT the Moment im cofused if the derp breath or the normal breathing is the Ritual. Sry for my bad englisch i hope you underdstand what i mean
I think it can be a ritual if you are trying to ‘breathe normally’, and consciously observing it trying to make it to a certain pattern. Just accept the breathing however it happens, whether it’s happening consciously or not, or is big or small. It doesn’t matter how it is happening. The ritual is ‘trying’ to do something to fix it, rather than just letting it go and not worrying how it happens.
Hope that is helpful!
Hello, thank you for the website. it’s very interesting. my problem is on swallowing. during the exhibition I concentrate on my saliva and my swallowing. I don’t have anxiety coming up. can you detail what we have to do during the exhibition? (sorry for my English, I’m French..)
Hi Marc,
Thank you for the comment.
During the exposure, there’s no need to concentrate on your saliva as such. It’s just about inviting the awareness and not doing any specific ritual (e.g. monitoring the amount of saliva). It should be quite straight forward, there’s no need to over think it.
Hope that helps!
Thanks 😊
I really like the site and your objectives with it. I just wanted to clarify something in your opinion, and it’s about adding nuance to the method of erp. For most people with sensorimotor, unlike other forms of ocd, they are constantly ‘exposed’ already to their obsession. For this reason, quite a few therapists – including those who run ocd recovery and dr Greenberg – put more focus on response prevention rather than forcing exposures (which can result in over attending). You also run the risk of thinking ‘I’m doing exposure, why haven’t I habituated, and why hasn’t the sensation gone now!’
For me, having been through it too, it’s definitely about switching up the goals. Fundamentally, being able to experience the sensation for what it is and just accepting it and that it won’t ruin your life – no matter how long you experience awareness
Great point. I think that’s right. I definitely think shifting the goal and accepting it is the most important thing. I think the ERP thing is just to go from ‘avoiding’ it to facing it head on, but after some point it’s probably not required.
It’s more in my view as opposed to consciously thinking about it, more so just encouraging it in your life, at least the initial stages.
Thanks for commenting, and would love to hear any further insights on what has been helpful for you.
one thing i’m having a hard time with is this rapid blink/looking the other way when i do that has become “my ritual” since about 2 days ago while worrying about blinking. which i think was after i read this. the thing is idk how to stop doing it so how would i do the erp if it feels automatic as of now? thanks!
Hi Macy. I’ll reply via the email you sent me 🙂
okay i read this wrong. i became aware of my blinking and started doing it so i tried to stopped blinking and became hyper aware. now my vision gets blurry every so often and i blink. what is the compulsion here? and how do i stop? stop to keep asking questions i just think i’m doing ERP wrong. before i use to worry about blinking without ever having to do a ritual or anything. now i am in a pattern after reading this
I have suffered from many types of OCD, especially sensorimotor OCD but my Scariest OCD is that I question every single thought and when I try to make myself calm my mind my answers are negative. Not being able to control my thoughts without any negative response from my mind makes me stressed. when you are in this situation anything could be annoying and scary. I am scared of my thoughts. for example, I felt I was going crazy and I thought it was like my mind was haunted because of negative responses, and at the same time, it said look you are getting insane. every single try that I feel I am trying to respond positively comes back with a more scary reaction from my mind and this is an endless process. I feel my thoughts will ruin every good thoughts wanna make me better. That increases my anxiety. so I think these good thoughts generally should make me feel better but my second thoughts are going to ruin every single one even those that work very well or those that helped me before. This is like all helpful thoughts are gonna get blocked with these second negative thoughts. so when you cannot help yourself self what can do that? it is like you don’t have any other solution. so what do I think happens? the worst case scenario is that I am scared of my thoughts and I don’t have any helpful responses to make it satisfied and it is scaring me with negative responses all the time. so it annoys me during the day and night all the time I am not happy anymore. I can’t have a good relationship. I can’t progress in my professional life. I will lose my partner. . when I am at this level ocd and anxiety I am scared a lot of being lonely in my room far from my family which gives me anxiety and loneliness and i don’t want to back to my house.
Hi Reza,
Sorry hear about your situation. That sounds really difficult.
It sounds like you have a kind of pure-O OCD, where it’s all about certain thoughts and refuting those thoughts. It sounds like you might be trying to refute certain thoughts with other ones. This is a never ending game. The solution as I understand it, tends to be to accept the thoughts without trying to fight or refute them. Just because they are there, it doesn’t mean they are true or your believe them. It’s more about acceptance (this is where ACT comes in) rather than CBT.
https://www.verywellmind.com/pure-o-primarily-obsessional-ocd-4159144 See here for more
Best
Aadil
so doing nothing
Is doing nothing a ritual or telling yourself you’re not going to react?
What exactly am I supposed to say to myself or what do I do?
Awareness of breathing and I don’t want to create other rituals or do the same rituals
I would really appreciate anyone’s help on this
Hi Hamzah,
What I mean is to stop doing the thing you might have been doing to reduce anxiety or ‘solve’ the problem. For some people, it is actually telling themselves something, for others it is doing online research. Don’t stress about being perfect with not doing rituals, it should be obvious if you have been doing something.
it doesn’t matter how you breathe too much, whether you control or do it to a pattern or whatever. as long as you have stopped trying to figure it out or run away from the awareness or sensations.
Hey Aadil,
One quick question about this!
I’m currently struggling with breathing OCD. I’ve found it helpful to try and let my body breathe how it wants to and have no control of it. So the main thing I’m doing is not manually breathing or taking control of my breathing process, knowing that it can do it, itself.
But I’m worried that could be a ritual?
And instead would it be better to have no strategy, which would mean sometimes I would manually breathe and other times I would let my body do it, itself?
Thanks,
Chris
Hi Chris,
Superb question. I would say yes, having no strategy is the way to go. It doesn’t really matter what you do. You can let the body do its thing, or take control if you want. The point is to not be fixated on something to try to solve it, whether it is breathing to a fixed pattern or trying to not control it at all 🙂
Thanks very much for the quick reply, that’s really helpful
Hello Aadil . I have Pure-O (harm, sexual thoughts) and I’m also dealing with a sleep obsession for so many years, and I was wondering if it could fit into the Sensorimotor OCD subtype. It’s been getting worse and worse over the years.
I have the biggest fear of never being able to sleep “correctly” again. So I keep having insomnia because everytime I notice that I’m falling asleep, it brings me back to my awareness of my body letting go. I also contract my muscles and stop breathing when I feel myself going into relaxed sleep. It’s really about that hyperawareness of letting go but I don’t know how to get out of it since they are almost no resource on that.
I also always find external triggers that will disturb my sleep and I focus on them to not let go into sleep either.
How could I do my ERP ? Only benzodiapines help with it but I can’t have lots because it’s addictive. I’m getting really desperate as I’m exhausted every day and it’s impacting my work and mental health a lot. For the moment in therapy we are working with the other themes and don’t have time for this one.
Thanks so much for reading
Hi Fiona,
Sorry to hear about what you are going through, that sounds really tough :/ . Glad to hear you are seeing a therapist.
I would say yes, it all sounds like OCD, and I think this is sensorimotor OCD. In this case, the root fear is about sleeping correctly (not sure if that’s for health or for other reasons, but sleep fears are quite common). In this case, I would look at what you might be doing and stop those behaviours and accept whatever you are scared of feeling; sounds like for you it’s contracting muscles or focusing on external triggers.
Hard to say more with hearing more detail, but usually we are repeating some kind of behaviour for the anxiety to remain there. So the ERP would be going to sleep without doing those things…it might be more anxiety inducing at first, but it should get better after a couple of weeks…
Thanks a lot for the reply. I’ll try to do that!
Hello, I have an awareness of breathing. Whenever I try to visualize some physical phenomenon, like how actually are the waves creating and spreading along the cord, the thought of the awareness of breathing comes and I cannot properly visualize the phenomenon. Then I am trying to do this multiple times and still cannot properly visualize it. I think that I should control the breathing at this moment. Instead focusing on the visualization, I focus on my breathing instead. So, how to do exposures with it if I cannot even properly do the task with the awareness of breathing