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.