The other day, a 27 year-old named Aaron came to see me in a very anxious state. He was an IT software engineer. He related that he was fearful of going out in public and being seen by other people. He added that his previous therapist diagnosed his problem as social anxiety, but had been unable to help him after 8 months of treatment, even with recommended cognitive/behavioral therapy approaches for that disorder. He described how when he was out in the street, he could not stop thinking about the way his legs moved when he walked, which ironically caused him to walk in an awkward way. His thoughts questioned whether he was walking normally, suggested that he wasn’t, and that he looked weird. He further feared that people would notice this and think there was something wrong with him, and end up judging him badly. The thoughts focused on such things as which foot to put forward first, how rapidly to move them, and even wondered how he even knew how to walk at all. The thoughts were doubtful, repetitive, and intrusive, and were becoming worse, as they sometimes even occurred when he was home alone. His anxiety was also becoming increasingly unmanageable, which was no surprise. Things were now so bad, that he avoided going out in public as much as possible and even had difficulty walking around the office at his job, only walking the halls after first checking that no one else was around. After talking to him further and obtaining more information about his life and his symptoms, I concluded that the diagnosis was actually Obsessive-Compulsive Disorder (OCD), and given this, it was no wonder that he hadn’t been able to improve in therapy designed to treat social anxiety.
A number of years ago, I previously wrote an article about people with fears of staring inappropriately at, and excessively noticing other people (“Here’s Looking At You, Kid” – Summer Issue, 2010). After seeing this person, it occurred to me that I had never really discussed people who focus on and pay too much attention to themselves. I have come to refer to this behavior as ‘compulsive over-focusing.’ Symptoms of this problem tend to involve studying the way different parts of one’s body work or may not work correctly. People may typically focus on such things as:
the way they walk
how often, or the way they do involuntary acts (breathing, blinking, swallowing, etc.)
the pitch of their voice, how rapidly they speak, how they laugh, etc.
how their mouths move when they talk
the way their head turns or how their limbs move
whether or not their facial expressions are appropriate
the way they gesture
whether or not they are making eye contact at any given time
if they are correctly processing and understanding what others are saying to them
This list is by no means complete, and only seems limited by a person’s imagination. It is by no means a minor problem. Aaron had developed severe difficulties at his job, getting around in public, and in social situations to the point where he was isolating himself and had become nearly housebound. He feared losing his job. What differentiated the problem from Social Anxiety Disorder was the presence of relentless negative and doubtful intrusive thoughts about his body, and his attempts to eliminate or avoid the doubtful thoughts by compulsively studying and analyzing himself and the way his legs worked so that he could perfectly control them. His thinking was that if he could be in total control of his movements at all times, he would be able to rid himself of the doubt the thoughts caused, and therefore his anxiety.
Of course, attempts to eliminate the thoughts and doubts, such as Aaron was doing can never work. This is because:
it is futile to simply tell yourself to not think about something because you first must think about whatever it is you are not supposed to think about.
OCD can be very relentless in the way it can constantly bombard you with thoughts. This is not something that you can directly control. They cannot simply be shut off.
the doubtful nature of OCD makes it impossible to really hold onto whatever reassurance you think you can get from checking yourself, because as soon as you think you have achieved certainty, it vanishes
you cannot totally focus on a single aspect of your own behavior at all times, meaning that no matter how careful you are, you will still not be completely certain of what your body is doing
Needless to say, Aaron was not very happy to discover he had been treated for the wrong problem. I explained to him that he would never be able to succeed in his attempts to achieve perfect control due to the above reasons. I explained that in order to succeed, he would need to:
Surrender his need for certainty and control over what his legs were doing
Increase his ability to accept and tolerate his negative and doubtful thoughts by letting them be there, and by not trying to deliberately eliminate or cancel them in any way
Do away with any kind of reassurance
Allow himself to go places and do things that would cause him to feel the anxiety, but to not try to escape it, to further increase his tolerance for it
I like to explain to my patients that there really is no escape from anxiety or any other Inner experience, and that the only way to overcome a fear is to face it. I further explained that this would not be easy and would take time to do successfully. In addition, I could not promise to eliminate the thoughts, but told him we could teach him to no longer do compulsions and to be able to handle whatever anxiety or doubt OCD threw at him.
We began a program of homework for Aaron designed to accomplish the above goals. Some of his assignments included:
Agreeing with any thoughts about his legs moving awkwardly
Agreeing with any thoughts of others viewing him critically
Not avoiding walking when and where others could see him
Deliberately taking walks in increasingly crowded public places
Listening to recordings about how badly he was walking, while on some of his public walks, and of all the bad consequences that would result from it
Watching videos of other people walking strangely and agreeing that he looked just like them
Watching videos of himself walking with a voice-over saying how strange he looked
Writing repetitive daily sentences 25 times, that said such things as “Other people can see how weird I walk.”
Conducting experiments where he would walk oddly in public and then observe other people’s reactions to it
These were very challenging for Aaron to do at first. He stated that “I don’t know if I am up to doing this.” He really had to push himself to carry many of them out. He felt very anxious at the beginning, but he began to observe that the more he did the assignments, the less anxious he felt, and the less he felt controlled by his intrusive thoughts. Doing the experiments had a very big effect on him. He was shocked that when he walked strangely on purpose, no one even seemed to notice or to make remarks to him. “I can’t believe nobody cares,” he said. Part of the way through the treatment, he decided to give medication a try to “See if I can cut down on the noise in my head.” He tried an SSRI-type antidepressant which did reduce the thoughts themselves and made it easier for him to face his feared situations. Improvement did not happen immediately, but as the weeks went by, he found himself thinking less about his walking and even forgetting to think about it at times. It seemed to take more work to bring on his anxiety, and what there was, he was able to push through. This is not to say that everything went flawlessly. Some weeks were harder than others, and he would occasionally forget himself and caught himself trying to control his steps. At this point, however, he was able to catch himself more quickly and get back to following his treatment guidelines. A few times, he thought he might even quit, but then he realized that if he did, it would guarantee that things wouldn’t get any better. “I guess you never promised me that it would be easy,” he told me. “Sometimes when I’m feeling down, I remind myself that even though treatment could be hard, having OCD every day was a lot harder.”
Eventually, as happens when people persistently stick to their treatment, we got to the point where it appeared that we were running out of assignments. Most of the things we were doing no longer made him anxious. It was becoming increasingly difficult to bring up the old feelings of strong anxiety. He was able to say ‘I may still not like the thoughts, but I can stand them. They’re more annoying now than anything else.” We moved on to talk about maintenance, since getting well was only half of the job. The other half, of course was staying that way. He learned that to keep what he had gained, he would need to be vigilant, and to still agree with thoughts when they did occur, and to be sure to resist doing any compulsions. If he did slip, he would have to act immediately to challenge himself until the thoughts and the anxiety subsided. At the end, he told me half-jokingly, “Now I can tell my symptoms to take a walk.”
He felt as if he had gotten his life back, and could resume working on his career and reestablishing a social life. This, too, was challenging, but in a different way. I told him, “Now you’re free to have the same problems as everyone else.” He agreed.
Fred Penzel, Ph.D., is a licensed psychologist who has specialized in the treatment of OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services in Huntington, Long Island, New York, a private treatment group specializing in OCD and related disorders. He has written numerous articles that have been featured in many issues of the International OCD Foundation Newsletter.
If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well (2nd edition)," (Oxford University Press, 2016).