I recommend reading Awareness, Attention, Distraction, and Rumination before reading this article, since the concepts discussed there are foundational to the approach outlined below.
Sensorimotor OCD (also known as Somatically Focused OCD) refers to cases in which people become hyper attentive to their bodily sensations, such as breathing, swallowing, or heartbeat. While this might not sound so bad to someone who hasn’t experienced it, it can be profoundly distressing.
As with ‘Pure O’, the key to treating sensorimotor OCD typically engages in three different mental processes that perpetuate the problem:
1. They try not to notice the sensation (they try to push it out of awareness)
2. They check/monitor whether they are noticing the sensation (they direct attention towards it)
3. They try to figure out how to stop noticing the sensation (they analyze)
Let’s take these one at a time.
1. They Try Not to Notice the Sensation
Trouble distinguishing between awareness and attention is at the center of sensorimotor OCD. The following two resources are intended to help with this:
- Awareness, Attention, Distraction, and Rumination provides a theoretical discussion of the difference.
- How to Stop Paying Attention provides an exercise to help people experience the difference.
2. They Check/Monitor Whether They Are Noticing the Sensation
Checking and monitoring involve directing attention toward the sensation. Needless to say, directing attention toward something is not a good strategy for someone who is trying to stop noticing it. As explained in the above resources, directing attention toward the sensation is an essential part of treating sensorimotor OCD.
3. They Try to Figure Out How to Stop Noticing the Sensation
The person with sensorimotor OCD is constantly trying to figure out how to stop noticing the sensation, why they are noticing the sensation, how to navigate life with this problem, etc. In other words, they are constantly trying to solve the problem, and this constant analysis keeps them thinking about the sensation all the time. As explained in How to Stop Ruminating, this analysis is also controllable, and refraining from it is another essential part of treatment.
In summary, treating sensorimotor OCD requires:
- Refraining from checking and monitoring (i.e., from actively directing attention toward) the sensation
- Refraining from trying to solve the problem (i.e., from analyzing it)
- Not trying to prevent the sensation from entering awareness, and when it does enter awareness, not trying to push it out
Here are some additional things to keep in mind:
- Awareness, attention, and analysis are technically separate phenomena. However, they don’t initially feel separate to someone with sensorimotor OCD, because as soon as the person becomes aware of the sensation, they immediately start directing attention towards it and trying to figure out how to stop noticing it. It takes practice to distinguish among these phenomena and to allow something to enter awareness but not engage with it any way.
- While it is crucial to understand the conceptual distinction between awareness and attention, in practice it is not always possible to distinguish between them precisely. For example, when someone notices something, where exactly is the line between awareness and attention? Trying to separate out these phenomena too exactly just leads to directing additional attention toward one’s mental activity, which is obviously counterproductive. It is therefore essential to hold the distinction lightly and to allow the boundary between awareness and attention to sometimes be blurry.
- Learning to allow something to remain in awareness without directing attention towards it can take practice, and therefore time, so it is necessary to be patient and allow this to be a process. When it comes to rumination proper, I believe that stricter is better, but when it comes to differentiating between awareness and attention, I believe a lighter touch is necessary.
- Sometimes a person with sensorimotor OCD is monitoring their body because they are afraid of missing a medical problem. When the person things that monitoring is important for this or any other reason, it’s important to identify, evaluate, and potentially challenge this justification. Does monitoring actually accomplish anything? If it does, is there another way to accomplish the same goal without monitoring all the time? Until a person lets go of this justification, they will not get better, because they’re trying to monitor and to stop monitoring at the same time, and they can’t do both.
- Many people who are in the process of working on their sensorimotor OCD feel upset when the sensation enters their awareness again. It’s important to keep the following in mind:
- You’ve been thinking about this bodily sensation for a long time, so of course you’re not just going to forget about it, and of course it will come to mind from time to time.
- The goal isn’t to stop this from happening. It’s to learn that you don’t have to get stuck when it does. As you learn that you can become aware of the sensation without getting stuck, awareness of the sensation will become progressively less threatening, which will make it easier not to engage with the sensation at all. That will make you progressively less aware of it, and less aware of when you’re aware of it. Eventually you won’t notice that you’ve noticed.
- The fact that the sensation has entered your awareness again is cause for celebration. Hear me out: If the sensation has entered your awareness again, that means it must have left, which means you successfully disengaged from it. Congratulations! Now do the same thing again.
Does Exposure Have a Role to Play?
As stated above, the key to this treatment is response prevention. There are only two types of exposures I use in treating sensorimotor OCD:
- Doing anything that has been avoided because of the symptoms.
- Setting reminders of the sensation. This allows one to practice not engaging with the sensation even when it comes into awareness. This exposure also underscores that awareness of the sensation is not the problem and does not need to be avoided.
Deliberately sustaining attention to the sensation (which is unfortunately the most common intervention that therapists try) is not an effective exposure. In fact, it is just asking the patient to do a compulsion (directing attention toward the sensation) on purpose. Mindfulness is also not an effective intervention, because it does not distinguish between awareness and attention.
Sensorimotor as a Paradigm
Although this presentation of OCD is called ‘sensorimotor’ or ‘somatic,’ with both names implying a focus on the body, someone can have the same presentation of OCD without the focus being their body. That kind of case may also benefit from the approach to treatment outlined above.
For example, sometimes the person’s focus is on certain thoughts being present. These cases differ from typical ‘Pure O’ cases because the person is distressed by the very presence of the thought, as opposed to being distressed by some question that they are desperately trying to answer.
Cases like these are more similar to how people used to think about ‘Pure O’ in general (and how some people unfortunately still do).
The sensorimotor paradigm can also be applied to some cases of tinnitus and depersonalization-derealization (DPDR). This is not to say that all such cases involve hyperattention, nor that applying this treatment can completely resolve those symptoms. It’s just to say that in some such cases hyperattention may play a role, and that in those cases the treatment outlined in this article may be helpful.
Sensorimotor as Type 3
Based on my clinical experience, I believe that sensorimotor cases – both those that are focused on the body and those that are not – are generally the third type of OCD case discussed here. This has implications for addressing the emotional dynamics underlying symptoms.
On a cognitive-behavioral level, the treatment for sensorimotor is very straightforward. The key is distinguishing between awareness and attention. If you stop fighting the mental processes you can’t control and start fighting the ones you can, you will start to feel better soon.