|
OBSESSIVE COMPULSIVE DISORDER
AND SOCIAL PHOBIA
By Monica A. Frank, Ph.D. and Barbara G. Markway, Ph.D.
Janine is a 38-year-old
married woman with two young children. She obsesses
continuously about whether her house is neat and clean enough.
She frequently stays up until three in the morning scrubbing and
straightening. In addition, Janine is painfully shy and has
few friends. She worries about what other people think of
her and is terribly afraid of rejection. Some of her
neighbors get together with their children to play in a nearby park or each
other’s homes, but Janine never joins them.
You may easily recognize
that Janine has obsessive-compulsive disorder (OCD). What
you may not recognize is that she has an additional anxiety disorder called
social phobia. Janine is not alone; recent research (1)
estimates that 24% of individuals diagnosed with OCD receive an additional
diagnosis of social phobia. In fact, this study found that
social phobia is the most common additional anxiety disorder diagnosis made for
those individuals with OCD. *
Having both of these
anxiety disorders together can make your recovery more difficult.
In this article, we will describe social phobia, explain how it can
complicate treatment, and call your attention to four key issues in dealing with
the combination of OCD and social phobia.
WHAT IS SOCIAL PHOBIA?
Social phobia is an
anxiety disorder characterized by a persistent fear of criticism or negative
evaluation from others. It is essentially a fear of
disapproval. Once thought, like OCD, to be relatively rare, current research
shows that social phobia significantly impairs the lives of 2-3% of the general
U.S. population. Another 20% experience social anxiety,
which is less severe, only because they are able to avoid the social situations
they dread.
Some people have what is
known as a specific social phobia, in which they fear one or a limited number of
situations such as eating or drinking in public, writing in public, or public
speaking. Others have a generalized form of the disorder and
fear many, if not all, social situations. Complete avoidance
of the feared social situations is common, although some people engage in subtle
forms of avoidance or endure social situations with great discomfort.
While the prevailing
clinical lore has suggested that social phobia is a relatively mild disorder,
this is frequently not the case. People suffering with
social phobia are often times quite disabled, unable to maintain jobs or
long-term relationships, for example.
HOW DO I KNOW IF I HAVE
SOCIAL PHOBIA?
A mental health
professional who specializes with anxiety disorders should be able to help you
assess whether or not you have social phobia in addition to OCD.
One way to do this is to
trace the path of your irrational thoughts. If the path
leads to a fear of rejection, of social isolation, of judgment by others, or of
ostracism that is not based in the reality of the situation, then some degree of
social evaluative anxiety is present. Depending on the
extent that this anxiety influences your behavior, it may be social phobia.
Tracing the path of the
irrational thoughts refers to a process in which you ask yourself, or a
therapist asks you, "What would happen then?" in response to the report of fear.
For example, if an individual with OCD states, "I am afraid of being
contaminated," the interviewer then asks, "What would happen then?"
The individual may
respond, "I'm afraid I'll get sick."
"What would happen
then?"
"I might die."
At this point the interviewer has uncovered the innermost fear and the
questioning terminates. The deepest fears of people with OCD
are typically of death, rejection, loss of control, or harm to oneself or
someone else.
For someone with social
phobia in addition to OCD, the above scenario might be played out differently.
The individual may still state, "I am afraid of being contaminated," but
may respond, "I'm afraid I won't be perfect," to the inquiry.
"What would happen
then?"
"Other people won't
approve of me."
"What would happen
then?"
"They would reject me
and I'll be alone."
As you can see, the
surface fear may be very similar, but the underlying fear is different.
In such a case, even the surface behavior may be similar.
For instance, both individuals may avoid contaminated items and engage in
extensive cleaning or washing rituals. As a result, the OCD
may easily be diagnosed. However, the OC behavior and
avoidance may hide the social phobia. In our experience, if
the social phobia diagnosis is missed, it may wreak havoc with the treatment
plan.
CAN’T I DEAL WITH THE
SOCIAL PHOBIA LATER?
You may wonder why
diagnosing and addressing social phobia is important to your treatment.
Why can’t the treatment of OCD and social phobia be separate processes?
In our experience, social phobia appears to interact with OCD in a manner
that necessitates attention to both disorders simultaneously.
One way that this
interaction occurs is that obsessions and compulsions may protect the individual
from more threatening social fears. As unpleasant and
frustrating as the obsessions and compulsions may be, having to face a high
anxiety-producing social situation may be even worse.
For example, a woman
with these two disorders may be invited to attend a social function.
Even though she may want to attend, she is very fearful of the situation
and the potential for rejection. Her obsessions about the
fear of harming someone cause her to avoid the situation, and thus, protect her
from experiencing the social anxiety.
You may wonder if OCD
causes the social fears and isolation because of the bizarreness of the behavior
and the concern about what others may think. Perhaps if the
OCD is treated, the social fears and isolation will disappear.
While this may be the case in some situations, research shows that social
phobia tends to develop, on average, at an earlier age than OCD.
Additionally, most of the people we have treated report that their social
fears occurred prior to the development of OCD. This
corroborates our opinion that the obsessions and compulsions may develop in
response to social evaluative anxiety.
From our experience, the
most severe cases of OCD are in combination with social phobia.
Our perspective may be due to some uniqueness in the populations we
treat. For instance, we tend to be referred severely
disabled individuals who have not benefited from treatment numerous times
previously. We have observed that the severity of the OCD
appears to increase with the degree of perfectionism. For
those with the combination of these two disorders, the perfectionism tends to be
overvalued. In other words, the individual accepts the
perfectionistic beliefs as normal and rational. For example,
as described above, the woman with social phobia may believe that she truly will
be rejected by others if she isn’t perfect.
These issues are more
than philosophical questions for discussion. We believe that
social phobia is a critical factor to be addressed because the treatment for an
individual with OCD and social phobia may need to vary from the standard
cognitive-behavioral treatment approach to OCD. In any
psychotherapy, it is the underlying fear that needs to be addressed in order for
substantial changes to occur. Therefore, for some
individuals, it is the social phobia that establishes the direction for
treatment. If this direction is not pursued, the therapist
and client may arrive at the premature and/or erroneous conclusion that
cognitive-behavioral therapy is not effective.
KEY ISSUES TO CONSIDER IN
DEALING WITH THE COMBINATION OF OCD AND SOCIAL PHOBIA
Given the above
inferences, we will now present four treatment issues that you and your
therapist may need to consider in dealing with the combination of OCD and social
phobia. The following points are to be considered in
addition to the standard cognitive-behavioral treatment for OCD.
1) RECOGNIZE THE IMPORTANCE OF
THE THERAPEUTIC RELATIONSHIP
If you have social phobia,
you desire relationships with other people, but are very fearful of possible
rejection or disapproval. This is true even in your
relationship with your therapist. Before you can make
progress in treatment, you need to feel comfortable enough in the relationship
that you know your therapist will not reject you for making a mistake or for
getting angry, for example. The development of this
therapeutic relationship can be a slow process for many people, but especially
for those with intense social fears.
This is a critical
point, as sometimes therapists will tell clients who are not completing their
behavioral assignments that they are not ready for treatment and end treatment.
Such a stance can be devastating for a client with social phobia.
If the client feels rejected by the therapist, he or she may become even
more sensitized to the fear of rejection and avoid further treatment
opportunities. The therapist needs to recognize that
although an individual may not be ready for behavioral assignments, he or she
may still need therapy to address irrational beliefs regarding social
situations. As these beliefs are challenged and the
individual becomes more comfortable in the therapeutic situation, then he or she
may be able to engage in the tasks addressing the obsessions and compulsions
and/or social avoidance.
2) BE FLEXIBLE WITH THE LEVEL
OF INTENSITY OF TREATMENT
If you have social phobia
and OCD, you may have difficulty initially tolerating the intense treatment that
is sometimes recommended. We define intensity on a continuum
with the least intense treatment being once per week outpatient sessions and the
most intense being hospitalization or full-time day treatment.
At Behavioral Consultants, P.C., we have designed our day treatment to be
flexible enough to adjust the intensity of treatment. For
example, an individual with both OCD and social phobia was frightened of
treatment after having been in an intense inpatient program several years
previously. To allow him to become comfortable with the
process of treatment, we recommended three half-days per week primarily focused
on coping with his social anxiety. Eventually, he was able
to increase the intensity of treatment and focus more on the exposures with
response prevention.
Of course, decreasing
the intensity of treatment may increase the length of treatment.
It is important that the client understands that it is necessary to
proceed more slowly so as to allow significant progress.
Cognitive therapy can assist in addressing the perfectionistic belief that
therapy must proceed quickly in order to be considered successful.
3) PAY ATTENTION TO SOCIAL
SKILLS
Many of our clients who
have been isolating themselves because of social evaluative anxiety have not had
much experience with social interactions. Therefore, they
may have skills deficits particularly in the areas of communication, assertion,
and conflict resolution. If this is the case for you, it
will be important that these deficits be identified and that you learn the
necessary skills as a part of your treatment. Although many
individuals with OCD alone may also need skills training, the deficits appear to
be more severe when OCD occurs together with social phobia.
4) FOCUS ON SOCIAL EXPOSURES
In addition to the
exposures related to your obsessions, your treatment will also need to include
plenty of exposures targeting your social fears. Such
exposures may range from simply talking to a staff member to taking a walk in a
mall to deliberately making a mistake in public.
The interested reader may
want to refer to an insightful article by Butler (2), which describes common
pitfalls in conducting social exposures. For example, there
are characteristics inherent in many social situations (for example, they can be
brief, unpredictable, and difficult to repeat) that can make conducting typical
graduated exposure therapy challenging.
In conclusion, we
recognize the limitations of our inferences as there has been no research
published in the area of the treatment of the combination of OCD and social
phobia. However, the above considerations have been
effective in our practices and we hope to stimulate more research in this area.
If you think you may have
social phobia in addition to OCD, be sure and bring this issue up with your
mental health professional. There’s every reason to believe
that with careful attention to these treatment issues outlined that you can not
only recover from your OCD, but from your social fears, as well.
* A disorder believed to be
related to OCD, Body Dysmorphic Disorder, may also share an overlap with social
phobia. Although we have not seen any research on this
specifically, we have observed such an overlap in our practices.
The comments we make in this article may also pertain to those
individuals with BDD and social phobia.
REFERENCES
1. Brown,
T.A. & Barlow, D.H. (1992). Comorbidity among anxiety
disorders: implications for treatment and DSM-IV. Journal of
Consulting and Clinical Psychology, 835-844.
2. Butler,
G. (1985). Exposure as a treatment for social phobia: some
instructive difficulties. Behavior Research and Therapy, 23,
651-657.
Copyright ©
2000 by www.excelatlife.com.
Permission to reprint this article is granted if it includes this entire
copyright and link.
|
