The fear of coughing or choking on your own saliva can be effectively treated through exposure and response prevention (ERP). However, treatment will fail if it does not target your specific feared outcomes.

Question: I have sensorimotor OCD, and I’m suffering from conscious swallowing. My main fear is that I’ll choke or swallow my own saliva whenever I’m speaking or singing. Any tips for how to tackle this fear via exposure and response prevention (ERP)?

Great question. Consistent with general exposure and response prevention (ERP) principles, your exposures need to address your specific feared outcomes. Feared outcomes can vary greatly for individuals with the same presenting problem. I discuss this idea in a different context here: feared outcomes in OCD. For people with a fear of swallowing or drinking saliva, there are several possibilities.

Fear of Potential Embarrassment: Social Anxiety

If you are afraid of potential embarrassment due to coughing or choking while speaking, your symptoms might actually reflect underlying social anxiety (rather than somatosensory OCD). However, it’s also possible for social phobia symptoms to coexist with sensorimotor OCD. I touched on the intersection of OCD and social anxiety in my post about the fear of cursing/swearing/blurting out obscenities. I also discussed it more extensively in my post on compulsive swallowing.

Those posts describe somewhat different OCD symptom domains, but the social fears sound quite similar to what you’re describing. Social anxiety fears can be targeted via behavioral exposures that do not actually involve saliva swallowing. You might practice stuttering on purpose, tripping over your words, or “freezing up” intentionally so that it looks like you don’t know what to say. These examples of intentional mistake practice can help you become less frightened of the potential social consequences of getting interrupted while speaking or singing. Such exposures would also be appropriate for targeting perfectionism-related OCD obsessions.

OCD Fear of Swallowing Saliva: Coughing/Choking

OCD fears based on saliva swallowing itself can also be tackled directly through non-avoidance and exposure exercises. For example, you might practice having conversations and/or singing with spit in your mouth. Your goal should be to resist rituals (i.e., compulsions) that involve clearing your mouth of excess saliva.

During these exposures, don’t let your fear of coughing/choking cut your interactions short. Coughing and choking can be uncomfortable but these symptoms are not dangerous. When you do cough, it is critical that you continue with the conversation. If you stop your exposure upon choking or coughing, you run the risk of inadvertently strengthening your fear. Always continue the exposure until your anxiety has decreased significantly. Other creative OCD exposures might involve placing a small amount of honey in your mouth and then immediately having a conversation.

Fear of Saliva: Disgust or Danger

If you are afraid of swallowing saliva because you fear that it’s disgusting and/or dangerous, you should practice actual saliva swallowing. You could spit into a cup and then practice drinking it. Alternatively, you could spit into a cup of water, swirl it around, and then drink it. For many people (even those without OCD), this type of exposure can be challenging. However, your disgust response will decrease with practice.

OCD or Tics?

Based on your description, it’s also possible that your swallowing behaviors reflect tics rather than OCD. Is your swallowing volitional? Are you choosing to swallow in order to prevent phlegm from changing your vocal tone or in response to an urge to swallow? If it’s volitional, what happens if you resist the urge? What might happen if you don’t swallow?

If the behavior isn’t fully volitional, it might reflect a tic. Tics are more likely to occur when we’re anxious (performing in front of others) than when we’re not (practicing when alone). If tics are a possibility, you should schedule an individual consultation with a psychologist or neurologist in order to establish a proper diagnosis.

If tics are ruled out and you begin exposure and response prevention (ERP) for OCD, keep in mind that you will likely have to engage in many exposure repetitions. Stick with it, and your efforts will pay off. As always, I recommend working with a therapist who specializes in OCD, as this will help you avoid any potential pitfalls associated with exposure.

South Florida residents (and those visiting Palm Beach County, FL – Palm Beach Gardens, Jupiter, West Palm Beach, etc.) are welcome to see me for individual therapy to work on these issues. If there’s sufficient interest and we’re able to identify enough people with overlapping symptoms, I would also love to start up a Sensorimotor OCD Treatment Group.

Best of luck with this!

Questions? Comments? Experience with swallowing- or choking-related fears? Share below…