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Obsessive-Compulsive Disorder & Chronic Pain

APA recognized OCD and related disorders (OCD) as a distinct class of psychological behaviors. Here’s how pain practitioners can assist patients with OCD and chronic pain.
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Until a few years ago, obsessive-compulsive disorder (OCD) was grouped into anxiety disorders by the American Psychiatric Association (APA). In 2013, the organization added a chapter specifically on OCD and related disorders to its Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Today,  practitioners continue to work through this new and distinct classification. Despite a scarcity of research linking OCD and related disorders to pain, it is important to be aware of this potential comorbidity.

OCD is characterized by the American Psychiatric Association (APA) by the presence of obsessions, defined as recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted; and/or com­pulsions, defined as repetitive behav­iors or mental acts that an individual feels driven to perform in response to an obsession.1

OCD is distinguished from devel­opmentally normative preoccupa­tions and rituals by an excessiveness or persistence beyond developmentally appropriate periods. While the spe­cific content of obsessions and com­pulsions vary among individuals, certain symptoms frequently occur in OCD, including those of cleaning, symme­try, forbidden or taboo thoughts, and self-harm. The addition of a chapter on OCD and related disorders in the APA Diagnostic and Statistical Manual of Mental Disorders (DSM-5) reflects the increasing evidence of these disor­ders’ relatedness to one another.1 In creating a new chapter on OCD, this change reflects recognition by the APA of OCD is its own disorder, while still maintaining a close relationship with anxiety disorders.

Prevalence of OCD

The DSM-5 chapter on OCD includes obsessive-compulsive, body dysmor­phic, hoarding, trichotillomania (hair-pulling), excoriation (skin-pick­ing), substance/medication-induced OCD and related disorder, OCD and related disorder due to another medical condition, and other specified/unspec­ified OCD disorders.1 The 12-month prevalence of these descriptive condi­tions among the United States adult population are presented in Table 1.2-6

OCD is estimated to be the fourth most prevalent lifetime psychiatric disor­der, but has garnered scant attention in chronic pain comorbidity research.7 The prevalence of OCD among treatment-seeking patients with mixed chronic pain conditions is about 1.1%.8 The prevalence of 12-month and lifetime OCD among patients with chronic pain is about 2% (with onset before pain) and 2%, respectively.9 Among patients with chronic low back pain, the prevalence of OCD ranges from 2.0% to 8.2%, with a lifetime prevalence of 13.4%.10,11 The prevalence of OCD among patients with chronic, musculoskeletal pain was 0.0%, whereas the lifetime prevalence of OCD in treatment-seeking multiple sclerosis patients was estimated to be 8.6%.12,13 OCD typically has an onset in early adulthood.

Symptom Suppression

Initially, the notion among research scholars was that OCD and related disorders were especially rare in pain patients, but there was no clear reason why this should be the case.14 What appears to be more likely upon research is that a significant number of patients experience chronic pain that is com­posed of obsessions and compulsions that they try to suppress or neutralize. The obsessions may take the form of persistent, intrusive thoughts or images of pain. Although catastrophizing is not the same as intrusive thoughts, engagement in this behavior in patients with chronic pain may provide some insight and support for this assertion.15 A number of case reports have detailed patients who overvalue their pain experience to the point of it being an obsession.16 Patients with complex regional pain syndrome, for example, may reveal bizarre perceptions, similar to a body dysmorphia, about a part of their body that they wish to amputate despite the prospect of further pain and functional loss.17 Patients with chronic pain receiving adequate relief with opioids also may hoard their medication, for example, to ensure a continuous supply by stockpiling reserves for a future need.18

Patients with OCD may also require treatment for pain conditions.

The compulsions consist of repetitive behaviors, such as rubbing, limping, guarding, or groaning, performed in response to the obsessive thoughts and images.1 Trichotillomania and excoriation, or skin-picking, are not perceived by the patient as self-harm but rather self-soothing behaviors. Both conditions fall under the body-focused repetitive behavior category, which is an umbrella term for impulse control behaviors that involve compulsively damaging one’s physical appearance or causing physical injury and, at times, added pain. Despite similarities, these cognitions and repetitive behaviors do not have the senseless or unrealistic quality of classic OCD symptoms. However, the psychological functions that these pain behaviors serve may be the same as those served by OCD.

Patients who struggle to control obsessions may take comfort in the ability to contain some component of aversive stimuli, such as exposure to physical pain.19 In other words, individuals with OCD might be willing to endure physical pain as a distraction from emotional distress, an expression of negative self-worth, or as a means to gain control over some aspect of suffering.19

This action, in turn, may lead to fear-avoidance behaviors. For example, a person with a cleaning obsession may suffer from lower back pain and avoid bending to place dishes into the dishwasher and instead wash them meticulously by hand. In addition, the kitchen sink may be low depending on the height of the individual, which would require the patient to hunch over, causing other pain and difficulties. Pain-anticipation and fear-avoidance beliefs can significantly influence the behavior of patients with chronic pain in that they motivate avoidance behavior.20

Providers must be aware of the powerful effects of these cognitive processes. There are different reasons why individuals may be averse to internal sensations. Unfortunately, a comprehensive model explaining the importance of hiding or expressing emotions is still lacking.

The lack of a common nomenclature for internal states and experiences is a barrier to better understanding this phenomenon, and there is much still to be learned about how people make sense of their internal worlds.19

Last updated on: November 3, 2017
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