This post is adapted from an article, I wrote with my colleague, Monica A. Frank, Ph.D., and originally appeared in the OCD Foundation newsletter. It can also be found on Dr. Frank's website, excelatlife.com.
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 socially anxious 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 also has social anxiety disorder. Janine is not alone; researchers estimate that 24% of individuals diagnosed with OCD receive an additional diagnosis of social anxiety disorder (1). In fact, this study found that social anxiety disorder 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 anxiety disorder, explain how it can complicate treatment, and call your attention to three key issues in dealing with the combination of OCD and social anxiety.
WHAT IS SOCIAL ANXIETY DISORDER?
Social anxiety disorder is 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 anxiety disorder 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.
HOW DO I KNOW IF I HAVE SOCIAL ANXIETY DISORDER?
A mental health professional who specializes with anxiety disorders should be able to help you assess whether or not you have social anxiety disorder 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 anxiety disorder.
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 self or someone else.
For someone with social anxiety disorder 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 also 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 anxiety. If the social anxiety diagnosis is missed, it may wreak havoc with the treatment plan.
CAN’T I DEAL WITH THE SOCIAL ANXIETY LATER?
You may wonder why diagnosing and addressing social anxiety is important to your treatment. Why can’t the treatment of OCD and social anxiety be separate processes? In our experience, social anxiety 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 anxiety disorder 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.
It appears that the most severe cases of OCD are in combination with social anxiety disorder. 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 anxiety disorder may believe that she truly will be rejected by others if she isn’t perfect.
These issues are more than philosophical questions for discussion. Social anxiety disorder is a critical factor to be addressed because the treatment for an individual with both these disorders 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 anxiety 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 ANXIETY DISORDER
Given the above inferences, we will now present three treatment issues that you and your therapist may need to consider in dealing with the combination of OCD and social anxiety disorder. 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 anxiety, 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 anxiety. 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) 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 anxiety disorder.
3) 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, which describes common pitfalls in conducting social exposures (2). 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.
If you think you may have social anxiety disorder 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.
*Here are the symptoms of Obsessive-Compulsive Disorder.
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.
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I am the co-author of Dying of Embarrassment, Painfully Shy, and Nurturing the Shy Child. Dying of Embarrassment: Help for Social Anxiety & Phobia was found to be one of the most useful and scientifically grounded self-help books in a research study published in Professional Psychology, Research and Practice.
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