Obsessive Compulsive Disorder and Social Phobiaby 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.
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 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.
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.
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.
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 Relationshi 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.
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.
Butler, G. (1985). Exposure as a treatment for social phobia: some instructive difficulties. Behavior Research and Therapy, 23, 651-657.