Disorders of the Ironic Process

In past blog posts, we have explored the phenomenon of paradoxical effort as it applies to our inner experience. We have talked about how, in the external world of objects, effort produces results. If you want a table moved, you put in effort to push it–and it moves. If you want to make your car go, you move your body with intent and press the gas pedal.

Source: Roman Synkevych/Unsplash

In the inner world, effort can work backwards. The harder you try not to think something or not to feel something or not to be aware of something, the more you do. You may succeed in distracting yourself for a moment, but the thought or feeling or experience of a sensation comes back—often stronger and more bothersome. This phenomenon is called the ironic process of the mind and was explored in the pioneering research of Dan Wegner (1994).

Now we would like to address a particular set of disorders which, despite their very different presentations, hold in common what can be called the ironic process of the body. (Carl Robbins, personal communication, 2020). In these syndromes, the effort to resist, avoid, or stop the unwanted physical phenomena also works backwards. Even thinking about it can make it happen. And the harder you make efforts to intervene, the worse it gets.

While it would seem as if relaxing would be the best approach to these disorders, it turns out that direct approaches to relaxing away the symptoms backfire. It is, ironically, impossible to insist urgently on becoming calm. Every time it happens, it seems more likely to happen again.

So then, anticipatory anxiety—the anxiety one experiences in anticipation of making contact with an anxiety filled action or situation—produces a frustrating self-fulfilling prophecy. Anticipatory preoccupations can lead to checking compulsions and anxious monitoring, which then reinforce the ironic process even further.

Here is a partial list. Many of these disorders can have medical causes that should be explored, but even where there is an underlying medical condition, ironic process may well be part of the picture.

• Stuttering
• Insomnia
• Erectile dysfunction
• Anorgasmia
• Paruresis (shy bladder)
• Sweating
• Blushing
• Shy bowel
• Selective mutism
• Somatosensory OCD
• Essential tremor
• Anticipatory diarrhea

Spectatoring, judging, and goal-orientation clearly interrupt the path towards orgasm. Ask a golfer with the “yips'' whether trying to control a tremor makes it worse or better. And why is it that blushing happens precisely at those moments when it is not wanted? Notice how preoccupation with the breath or heartrate or blinking disrupts natural rhythms—and how this only subsides when you happen to forget to keep checking it.

Children who are mute at school actually can’t talk, and it is not because they are not trying. Malcolm Gladwell (2000) made the distinction between panicking and choking which involves an over-awareness under stress of those things that are generally non-conscious.

People with these disorders describe being unable to make their bodies perform, even when they are consciously reassuring themselves and trying to “let go." They commonly report that it is not that they feel panicked, but that they simply cannot will their body to do what they want it to do.

The fear that they do experience is anticipatory worry about failure or embarrassment, which leads to avoidance, distress and loss of hope. They are often anxious and sensitized before confronting the actual situation, activating the perverse forces that interfere with performance and spontaneity.

Both acute and anticipatory anxiety affect the autonomic nervous system in complex ways. For example, a surge of adrenalin due to anxiety is a rapid vasoconstrictor, which interferes with sexual arousal, especially erection which relies on vasodilation. Paruresis (commonly called shy bladder) is the fear of not urinating, and this fear causes the tensing of the very pelvic muscles that need to relax for urination to occur.

The soft tissue of the gastrointestinal tract is exquisitely sensitive to messages to and from the fear circuitry of the brain, forming a feedback loop where anxiety and GI symptoms end up reinforcing each other. A similar effect occurs in blushing which is caused by vasodilation and is outside of voluntary control. These effects are automatic; they cannot be consciously controlled.

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It is the patient’s relationship with the symptoms, the attitude of acceptance rather than struggle that is key to progress. In the same way that the panic attack that is truly greeted with willingness does not tend to happen, the way forward embraces willingness to experience discomfort and even dysfunction.

Because anticipatory anxiety is so sensitizing to the body, it is often simply not possible to prevent dysfunction or symptoms that others can see once the cycle of dread and conditioned cues get started. Until it is not an utter catastrophe not to sleep, or not a life-altering humiliation to be unable to complete sexual intercourse, or an unacceptable experience to have someone notice you are blushing or hear you urinate, the resistance to the experience will actually create it.

A caveat is needed here about self-compassion and temporary medications: In some of these disorders, the consequence of being unable to perform has medical implications (e.g., paruresis) and in others, the embarrassment of bodily dysfunction would be difficult to accept for anyone (e.g. anticipatory diarrhea).

In these cases, a very graduated exposure regimen can be accompanied by the security of a back-up plan without the implication of failure or judgment or shame (for example, knowing how to safely self-catheterize, or the temporary use of constipating medications). There are also medical interventions that have significant potential for success, such as medications for hyperhidrosis and erectile dysfunction. There are no extra points for “doing it myself" when effort works backwards.

Temporary medications to assist sleep can be invaluable if disabling insomnia is impairing the ability to learn new concepts and attitudes. Indeed, with prn medications, there is the problem of state-dependent learning, but the value of successful performance in re-programming the brain, developing confidence, and combatting hopelessness may well be more important in early treatment.

Recognizing the paradoxical effect of direct efforts to relax on these anxious disorders of the ironic process is the first step in effective treatment. It provides an alternative framework, increasing expectations of real change by indirect means. It also reduces shame by explaining why conscientious efforts of the past have not worked.