Sensorimotor OCD: Body-Focused Obsessions & Compulsions
by Steven J. Seay, Ph.D.
September 2011; Retrieved 1/18/2012

As I have mentioned previously, one particularly distressing symptom of obsessive-compulsive disorder (OCD) can be hyperawareness of particular bodily sensations.Body-focused obsessions (also called sensorimotor obsessions (Keuler, 2011) or somatosensory obsessions) often feel intolerable and typically involve getting your attention “stuck” on thinking about or analyzing particular autonomic processes. Thoughts may become fixated on one’s breathing rate, heart rate, swallowing, blinking, eye “floaters”, or flickering of the visual field (Keuler, 2011). Sufferers frequently label the problem as conscious breathing/conscious swallowing/conscious blinking, obsessive breathing/obsessive swallowing/obsessive blinking, or compulsive breathing/compulsive swallowing/compulsive blinking. Although for most individuals these processes occur automatically below conscious awareness, individuals with this form of OCD find themselves acutely and frustratingly aware of their own bodily sensations.

People with these obsessive-compulsive symptoms attend to how often and how “completely” these processes have occurred. For example, individuals with respiration/breathing-related symptoms often try to consciously control their breathing rates, as well as how “fully” each breath is inhaled and exhaled. Obsessions and compulsions involving breathing, swallowing, and blinking are quite common in this form of OCD. However, other individuals may over-attend to fullness and other sensations in the bladder, stomach, or digestive system. Still others find their attention gets overly focused on the urge to burp or belch. Another different, distressing symptom involves analyzing the amount and frequency of eye contact with other people (Keuler, 2011). Doubt and uncertainty about how often and how intensely to make eye contact can lead to avoidance of other people, which may disrupt performance in work, school, and social settings. Additional examples of body-focused obsessions and compulsions include paying excess attention to how your tongue moves when eating or speaking, the timing of your speech, the amount of saliva in your mouth, the sound you hear when swallowing or chewing, how your teeth feel when your mouth is closed, or how your skin feels as it brushes against your clothing.

Although compulsions associated with these symptoms often involve consciously controlling these processes, mental rituals occur as well. These include repeating certain words or phrases in one’s head, counting, intentionally thinking “positive thoughts” to counteract “negative thoughts”, or engaging in “figuring out” rituals. In this way, sensorimotor OCD is similar to Pure-O OCD. Because these types of symptoms differ from “classic” OCD symptoms, diagnosis is often delayed because many individuals (and their therapists) do not understand that these symptoms reflect underlying OCD.

Understandably, individuals suffering from body-focused, sensorimotor OCD become desperate to redirect attention away from these processes (Keuler, 2011). However, attempts to forcefully distract or redirect attention are often ineffective. Most individuals find that the more they try to actively push their awareness onto something else, the more their awareness becomes locked on their symptoms. This can result in extreme anxiety, distress, and panic. Life may come to feel upsetting, intolerable, and out-of-control..

In clinical terminology, obsessive-compulsive disorder is a heterogeneous disorder. This means that different people have different combinations of OCD symptoms. Despite this variability, many individuals with body-focused, sensorimotor OCD share common fears related to their symptoms.

OCD worry about having the symptoms last forever (Keuler, 2011).

  • What if my symptoms never go away, and I have to live the rest of my life like this?
  • What if life is never satisfying again?
  • What if I can never engage in [insert specific activity] without thinking about this? (Common examples include sleeping, eating, speaking, reading, or writing.)
  • What if I lose my job (or fail out of school) because of this?
  • What if I can never focus again?
  • What if I can never sleep again?
  • What if my mind is never “at peace” again?

OCD worry about the underlying cause of the symptoms.

  • Why am I having these symptoms? There must be something seriously wrong with me.
  • What if I have a brain tumor that is causing these symptoms?
  • What if I have schizophrenia or another type of severe mental illness?
  • What if I have brain damage in the parts of my brain that control these processes (e.g., the medulla oblongata or cerebellum)?

OCD worry about specific feared outcomes.

  • What if I choke and die because I didn’t chew my food enough?
  • What if my heart stops beating?
  • What if my heart is beating at the wrong rate?
  • What if there’s something wrong with my heart?
  • What if I stop breathing?
  • What if I’m breathing at the wrong rate?
  • What if there’s something wrong with my lungs?
  • What if I’m damaging my eye muscles because I’m blinking too quickly (or slowly)?
  • What if toxic levels of carbon dioxide are accumulating in my lungs because I’m not exhaling enough CO2?
  • What if I embarrass myself because I’m so stuck in my head that I miss what other people are saying to me?
  • What if I can’t enunciate properly or trip over my words because I’m paying too much attention to my tongue?
  • I wouldn’t be paying attention to this if there wasn’t something to worry about.
  • If other people find out I’m thinking about this, they’ll think I’m crazy.

Interestingly, although common to sensorimotor OCD, this last cluster of fears can sometimes be used to differentiate body-focused OCD from more classic OCD presentations and other anxiety disorders. Sensorimotor OCD tends to be primarily associated with perceiving bodily processes, sensations, and urges, rather than specific feared outcomes. To take swallowing as an example, some individuals may fear choking and/or potential death. Others may fear the potential embarrassment of needing to be rescued by the Heimlich maneuver. Still others worry their attention will be permanently stuck on perceiving the urge to swallow. These last individuals are highly attuned to how their mouths and throats feel physically and often obsess about how often or how completely they have swallowed. They may also spit frequently and avoid wearing clothing that touches or constricts the neck (e.g., jewelry, turtlenecks, dress shirts).

Although all of the preceding examples may be consistent with OCD, the last example (i.e., hyperawareness of the urge to swallow) most clearly represents a body-focused, sensorimotor obsession. Fear of choking and/or fear of needing the Heimlich maneuver involve bodily processes, but the primary fear is death and/or embarrassment rather than being stuck with what feels like an inescapable urge. Although this distinction is fairly subtle, it is critical when selecting an appropriate treatment. Exposure with response prevention (ERP) therapy should always target a specific core OCD fear. In addition to OCD, other potential rule-out diagnoses for the first two fears might include phagophobia or social anxiety (social phobia), respectively. As will be discussed in a subsequent post, medical causes for these symptoms (e.g., neurological conditions) must also be assessed and ruled out before attributing these symptoms to OCD.

In the next installment of this series, I will discuss treatment strategies for body-focused sensorimotor obsessions and compulsions. Sadly, many individuals live with these symptoms for a long time before finding effective treatment. Due to the intolerable nature of these symptoms, it is not uncommon for people with sensorimotor obsessions and compulsions to feel frustrated and hopeless to the extent that they contemplate suicide as the only possible way of freeing themselves from their symptoms. Fortunately, effective treatment for this type of OCD is available. As I’ll discuss next time, therapy will be most effective if it’s based on the principles of exposure and response prevention (ERP), an evidence-based treatment for OCD...

Read more (part 3)

Dr. Steven Seay is a licensed psychologist in Florida & Missouri. He is the Director of the Center for Psychological & Behavioral Science and provides treatment & therapy throughout South Florida, including Palm Beach Gardens, Jupiter, West Palm Beach, Boca Raton, Boynton Beach, Fort Lauderdale, & Miami.