2.1 ERP: Your Triggers And Compulsions

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 quell 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

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 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, or swallowing every time it feels uncomfortable, or something else. The point is, you’re doing something (often almost subconsciously) 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 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 is 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 a blink every few seconds, monitoring sensations or checking something about them. Sometimes these are quite subtle like moving your hands to your eyes or mental rituals where you are trying to ‘figure out’ if it’s normal or repeating certain thoughts to yourself. It’s really important to identify your rituals so you don’t do them when you practice exposures. I have filled an example table below.

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

Footnotes

  1. https://www.souletherapy.com/single-post/how-to-tell-if-you-have-ocd-and-what-to-do-about-it
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Leah

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.

Lesley Brooks

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.

Pavel Pek

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.

Pavel Pek

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?

Vipin Yadav

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.

Vipin Yadav

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.

Evie

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 🙁

Emilie

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?

Jeenet

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?

Rohan

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?