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.
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.
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?
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?
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.
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
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 🙂
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!