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Home Body-Focused/Sensorimotor Symptoms Sensorimotor OCD & Social Anxiety DifferentialDiagnosis: Obsessive Swallowing

Sensorimotor OCD & Social AnxietyDifferential Diagnosis: ObsessiveSwallowingPosted by Steven J. Seay, Ph.D. on Nov 1, 2011 in Body-Focused/Sensorimotor Symptoms, ERP,OCD, Social Anxiety | 23 comments

Social Anxiety & Sensorimotor OCD Differential Diagnosi... http://www.steveseay.com/sensorimotor-ocd-social-anxiety/

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Sometimes the symptoms ofsocial anxiety and OCD canoverlap. Because avoidancemaintains fear, consider highlevel exposures that involve"broadcasting" yoursymptoms in order toaddress anxiety-relatedcognitions. This is a CBTtechnique called intentionalmistake practice.

Reader Question: For the past year, I have been dealing with OCD-related sensorimotorobsessions focused on swallowing. My symptoms started during a class discussion inwhich I noticed myself swallow. Since then, whenever I am in a lecture or quiet placesurrounded by people, I become deeply focused on my own swallowing and worry thatothers will notice my swallowing and then judge me.I am practicing meditation and daily exposures in which I sit down in a quiet room andintentionally invite the swallowing in. I also purposefully invite the swallowing in throughoutthe day, even when I am in the presence of friends. I try to be mindful of my swallowingwithout doing anything to avoid it or mask it. Even though my awareness of swallowing hasnot entirely gone away, the anxiety associated with it has decreased significantly. However, Ifind myself feeling impatient and worried on the random days when my OCD-related anxietyflares up.For me, the most difficult situations continue to be one-on-one conversations, especiallywhen I notice other people swallowing after I do. This makes me worry that I am spreadingthe condition, even though I know rationally that this is not possible.Do you have any recommendations for how to deal with OCD-related swallowingobsessions when they are triggered by interactions with friends? Should I seek professionalhelp to address my sensorimotor obsessions and compulsions? I have always felt like avery 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 arenot doing anything to intentionally change the behavior (i.e., trying to swallow with less force or withless sound) or perfect the behavior.HoweverBased on your description, it is likely that you are experiencing significant symptoms of socialanxiety in addition to OCD-related symptoms. It is also possible that your symptoms might beprimarily social in nature, rather than being OCD-based. This important differential diagnosis issueshould guide treatment selection.

Social Anxiety vs. Sensorimotor OCD Obsessions/Compulsions: Treatment Implications

Unfortunately, meditation and imaginal exposure will not address the social aspects youvedescribed. You must specifically target these social situations directly in order to habituate to yourfear. Your in vivo exposures should address the mistaken belief that swallowing loudly will lead to anegative outcome that you wont be able to handle (e.g., embarrassment, shame, etc.). This willhelp you increase your confidence in your ability to handle these situations effectively regardless ofhow they play outjust as you are confident in your ability to effectively handle other areas of yourlife.

Social Anxiety & Sensorimotor OCD CBT-Based Exposure Ideas (Treatment)

For example, you might consider swallowing loudly (on purpose) in order to draw the attention ofothers. Or, if you find that its difficult to swallow loudly enough for others to notice, you mightsurreptitiously 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 authorityover you) would be ranked higher on your hierarchy than practicing in front of strangers. Also, largegroups are probably harder than small groupsProceed with your exposures according to a hierarchy and make sure you address easier situationsbefore progressing to harder ones. Your final exposure might involve swallowing loudly severaltimes while giving a public talk or presentation. If you can do this while using a microphone, all thebetter. Remember that in order for your fear to habituate, you must correct the mistaken belief thatswallowing loudly might be socially or personally dangerous. Once youve proven this to yourselfexperientially 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. Ina way, its kind of like a fear of mentally contaminating or harming other people. For thisOCD-related symptom area, 1:1 practice is key since it triggers your anxiety. Practice swallowingintentionally during 1:1 conversations (as described above) and avoid discussing the swallowing ormentioning it to your conversation partner. Dont reinforce it as an important event. For your anxietyto resolve, you will need to experience paired swallows multiple times without seekingreassurance.Remember, the problem here is not the behavior per se; we are all swallowing all the time Theproblem is the fear-related attributions you make regarding the behavior (i.e., the possibility that thebehavior might result in an unwanted outcome). Stick with your exposures and dial them up whenyou 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 anunavoidable 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 downsis an important contributor to the resolution of your symptoms. Do not treat flare-ups as truealarmsrather, stick with your exposures even when your anxiety increases. Dont let increasedanxiety result in fewer exposures as this can indirectly reinforce your OCD and social anxietysymptoms.

Social Anxiety & Sensorimotor OCD: Do I need professional help?

For OCD and social anxiety-related issues, the choice about whether or not to seek professionalhelp is up to you. Given how frustrating this situation has been, I suspect that professionalassistance would be helpful. If you go this route, definitely find a trained CBT therapist with aspecialty 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

Matt / November 24, 2011Thank you so much for sharing. I too have has ocdswallowing off and on for years. It lead toabusing alcohol. This is the first site that I have seen addresses the problem.Thanks,Reply

Steven J. Seay, Ph.D. / November 26, 2011Thanks for the comment, Matt. Im glad you found it helpful. I think many other peoplealso fall into the alcohol abuse trap because theres not a lot of quality information abouthow to effectively address these symptoms in a healthy way.Reply

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Diane / January 26, 2012I too suffer from some sort of anxiety related swallowing disorder. It has lead to agorophobiaon two occasions, and some general isolating much of the time. Ive been taking Lexapro foryears, and I have not had symptoms for quite some time. Now, suddenly they havereappeard.

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Im not sure the advice above will help me. My main problem is that I have trouble eating infront of others. Ill be eating fine, then all of a sudden the fear pops into my head. As Im tryingto swallow, food actually gets stuck which triggers more panic. People notice that Impanicking/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 Icarry 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 aboutgetting help? I cant seem to find a therapist who can help me.Reply

Steven J. Seay, Ph.D. / January 27, 2012Hi Diane,I would recommend finding a therapist who practices exposure and response prevention(ERP). The International OCD Foundation maintains a database of providers who mightbe able to help. Heres the list:http://ocfoundation.org/treatment_providers.aspxIf you scroll down the page, youll also find that the page includes questions you shouldask your potential therapist. Dont neglect this part, because even providers in thedatabase may not have much experience treating OCD.Remember, treatment needs to address your feared outcome. If youre really afraid ofchoking because of the social embarrassment it causes, the best way to get over yourfear is to practice eating in public. The more times you practice fake choking in publicand 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 ofthe embarrassment, rather than the embarrassment itself, that keeps your symptomsgoing.Also, the water bottle needs to goits a safety behavior/ritual that will prevent you frombenefiting from the exposure. Your first exposures might simply involve going placeswithout 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 thatanyone with physical symptoms consults with a medical doctor. Make sure you rule outany possibility of a swallowing disorder before you go the exposure route. If theres anunderlying medical problem, this needs to be addressed before you attempt anyexposures.Reply


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Diane / January 27, 2012Thank 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 youthink that could be a first step in my therapy?Reply

Steven J. Seay, Ph.D. / January 31, 2012Definitely! That exposure would be a great addition to your hierarchy!Reply

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terry / February 7, 2012i have the same symptoms for about 7 years im 19 now btw, i just reached a point where ialmost feel that i fixed the problem, i started out thinking this was a psychological problemthen a physical problem, but my method is relaxing your shoulders( like droop down) thenrelaxing your neck(its probably tense when you think about it) idk how long this methodworks but its what i`m currently experimenting just try to think about relaxing your muscles.Reply

Steven J. Seay, Ph.D. / February 21, 2012If there is an anxiety component to your symptoms, I would make sure that whatevertechnique you use appropriately addresses the underlying anxiety.Reply

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Gabriele / February 22, 2012Hi Steven,very informative article. I started to focus on swallowing in august 2009 (at 28, before i hadsimilar pure-obsessive problems), when i was on holiday with my girlfriend. I was in a verystressfull 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 swallowingthing stayed with me 24/7 for two months, when Sereupim (prescribed by a psychiatrist withno exerience about OCD) started to have some effect on me. By december 2009, i had animprovment of about 30%. In march 2010 i had a massive panic attack related to a switch inthe obsession (from swallowing to breathing), so i decided to get a visit from a psychiatrist inRome with a huge history in solving cases similar to mine. He changed my medications (fulldoses 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 theproblem (best period of my life), having only few relapses till last month. In the periodnovember-december 2011 i gradually stopped all medications on my own. What a stupidmistake! In few weeks, the swallowing-thing starts again, as intense as in august 2009. Mypsychiatris told me i acted like a fool and decided to give me the medications again. After amonth, 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 everysecond 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 agood job in a huge italian company as a legal consultant, have several hobbies, andbench-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, 2012Hi 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 weresymptomatic, you were still pursuing things that were meaningful to you be it in thecontext of your job, health, or life in general This is one of the most importantprinciples of recovery: continuing to move forward toward the things you want out of lifedespite (or to spite) your symptoms.Best wishes on your continued recovery!Reply

Geoffrey / June 4, 2012I must thank you, Dr, for putting the spotlight on the co-occurance of these conditions. I suffercomorbidly 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 whymost people arent susceptible?Reply

Steven J. Seay, Ph.D. / July 15, 2012Hi Geoffrey,There are some great researchers investigating some of the questions youvementioned, and Im hopeful that well eventually uncover some of the answers. In themeantime, you might want to consider attending the annual IOCDF conference. Many ofthe big names in the field will be in Chicago at the end of this month (July 2012)presenting cutting edge research findings.Reply

Katherine / June 14, 2012Hi, 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 tobeat it without any other help- However, after about a month free of OCD symptoms, I startedto get the swallowing problem.Its been really hard, and Im kinda lost. I told my parents about it, and that I desperately needsome help with it, however they say they refuse to take me to any kind of therapist orpsychiatrist.I was wondering though, can swallowing constantly, all the time, hurt your throat at all? Im asinger. My biggest fear is that Ill be stuck with it forever. Oh, and the other problem Im havingis that when my throat starts to get dry, and even hurt, I start eating compulsively to get rid ofthe pain and dryness. Any advice?Thank you so much.Reply

Steven J. Seay, Ph.D. / July 15, 2012Hi Katherine,

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With sensorimotor symptoms, its important that you talk with your doctor and rule outmedical causes. This would also give you an opportunity to ask your medical questions.Good luck!Reply

Chris / July 6, 2012I am so glad that you have posted this article because I thought for years I was the only onesuffering from this condition. I constantly think about saliva filling up in my mouth and myneed to swallow it. I obsess over this thought from the time I go to bed until the time I wakeup. When I am really anxious I notice that I often wake up in a soaking wet pillow. I have beento three different ENTs about the issue and they all agree I hypersalavate because I thinkabout it so often and have given me several medications that have been renderednoneffective. My psychiatrist has prescribed me adderall which helps a lot with my socialanxiety, however my fear is that I am becoming addicted to the medication because it hasbeen the only solution I have found to temporarily make the problem go away. This issue hasaffected every aspect of my life and I honestly am at the end of my rope. What treatmentwould you suggest I seek to get more help and should I talk to my psychiatrist about trying toween off the adderall?Reply

Steven J. Seay, Ph.D. / July 15, 2012Hi Chris,Every situation is different, and only you and your doctors should make decisions thatdirectly affect your health. Good luck.Reply

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Carmen / September 5, 2012Hola soy Carmen de Barcelona, hace 3 meses tengo problemas con el tragar, soy medico de43aos y ansiosa, pero nunca me haba sentidotan afectada.Empece a ser consciente de tragar saliva a raiz de que me atragante un poco, y desdeentonces, que estoy pendiente de mi garganta, tengo esceso de saliva, que he de tragar oescupir.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 seme 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 detranstorno.Muchas graciasAtentamenteCarmenReply

Steven J. Seay, Ph.D. / September 6, 2012Hi Carmen,Yes, if youre continuing to experience symptoms, you might consider getting the help ofa psychologist. I dont have any specific recommendations in Barcelona, but you mighttry contacting the International Obsessive-Compulsive Foundation for a referral. Theirwebsite is ocfoundation.org.Wishing you the best with this!Reply

Carmen / September 7, 2012Thanks a lot for ypur information.I suppose it is not possible to make a therapy with you or someone of your center byvideoconference, skype, or something like that, isnt it?Tank you againReply

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rafaela / March 7, 2013hello , steven my name is Rafaela Morel, i am writing to you because im at extremedesperation because of my swallowing anxiety. I do not know what to do anymore and havebecome extremly depressed because of this. I have a sensation in my throat or mouth that forsome reason produces saliva, and makes me want to swallow constantly this has beengoing 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 withthis anymore.. its like my brain programmed itself to swallow atleast 4 times in a minute andits so embarassing, please email me back i would trulyReply

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MH / March 28, 2013Hi Rafaela,I have had these OCD swallowing symptoms for almost two years. The fear andphysical/emotional distraught with regards to your obsessive-compulsive swallowingsymptoms can be overcome I have overcome it myself. To help motivate yourrecovery, I will share my personal story.My first symptoms appeared while completing my second year of my engineeringprogram at university. During one of the lectures (incidentally during my quantummechanics course, which proved daunting without the added stress of OCD) I realizedthe amount of noise that each of my swallows produced. This caused me to obsessover swallowing, although only during class. This initial obsession endured for about twoweeks, and was then forgotten for about three months.The symptoms returned after moving to a different city in order to complete one of mymandatory 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 aconversation, or even enjoy leisurely time without the constant thought of salivaaccumulating within my mouth, followed by the compulsion to dutifully swallow. It washorrific I was being tortured, and I had not the faintest idea how to combat theproblem. In fact, my attempts to eliminate my OCD symptoms actually worsened them. Itried to optimize my swallowing mechanism (remember, Im an engineer) such that Iwould 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 hadforgotten it. Hence not only did I have to manually control each individual swallow, mymouth was also perpetually uncomfortable. Shortly thereafter I began obsessing aboutthe rest position of my tongue within my mouth, and realized that regardless if itsposition, it too felt uncomfortable. Hence throughout the entire day, my mouth wasuncomfortable, I obsessed about correct tongue position, and I also obsessed abouteach individual swallow. I was deeply stressed, depressed, and unhappy. I couldntbelieve that something like this would ever happen to me, as prior to these events myfuture appeared extremely promising. I lived through this daily torture for approximatelyten months. The thought process that enabled me to continue my life was the belief thatin time would recover from these symptoms. And I was right I have regained control ofmy life, as well as the confidence to pursue all the activities that I enjoy. Recovery wasby 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 mayhave these symptoms for the remainder of my life. This was much more difficult than itsounds, and involved convincing myself that I could still perform all of my endeavorsequally well as I was able to prior to having these OCD symptoms. I forced myself tocontinue to go to the gym, to study, to have lengthy conversations, etc, even though Iwas terrified that I would i.e. not be able to lift as much weight, not be able toconcentrate or focus, and not be able to have a decent conversation. However, afterhaving tirelessly forced these endeavors, I was indeed convinced that I could stillperform them very adequately, and a large portion of my anxiety disappeared. Once Ihad achieved this initial goal, I realized that I simply did not care if other people thoughtI 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 extremelyvaluable thought process one that I have, and continue to, depend on exhaustively. Itruly 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. Whenmy OCD swallowing symptoms first arose, I believed that swallowing this often must beabnormal and unhealthy. However, over time I have realized that this is untrue (both ofmy parents are medical doctors and I have been assessed frequently and deemedperfectly healthy), that everybody swallows at different rates, and that I was onlyincreasing 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 mysymptoms that I am going to try to reduce. In order to do so, I plan on allowing myself toobsess about my mouth filling with saliva. However, I will not allow myself to conform toanxiety. That is, I will only perform a swallow once my anxiety towards not swallowinghas disappeared (this is the basis of ERP expose yourself to the obsession, yetprevent the compulsive response until your anxiety towards it has receded). Thisstrategy 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 currentposition, and if you have any questions please ask me! Remember, you are NOT alone!Cheers,MHReply

Katie / April 4, 2013Hi MH,Thank you very much for sharing your personal experience. Its really reassuringand inspiring. I too suffer from social anxiety & obsessive swallowing. My biggestfear is that when I interact with other people, they will notice my swallowing andget it too. Im so sensitive about it that whenever I interact with a person, I alwaysobserve their swallowing and drinking behaviors. I feel guilty if I notice they start toswallow too. I dont want this to ruin my life and I still want to have a normal sociallife and work life. Do you have any advice on how I can overcome my problem?Thank you very much!KatieReply

Rafaela / August 3, 2013THAnk you so much MHI 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 ican !! thanks so much for being brave enough to share your expirience . i have so muchhope that i will get better i have become agoraphobic because of this . thanks i wiol startright now with your suggestionsReply

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