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10 Articles in Volume 17, Issue #8
A Fresh Look at Opioid Antagonists in Chronic Pain Management
Addressing Chronic Pain in the United States Armed Forces
Are biosimilars as effective as their biologic counterparts?
Integrative Pain Care: When and How to Prescribe?
Lady Gaga, Fame, and Fibromyalgia
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients.
Must-Have Devices for Your Pain Practice
Obsessive-Compulsive Disorder & Chronic Pain
Theory of Motivated Information Management and Coping With Death
United Nations Says Untreated Pain Is “Inhumane and Cruel”

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.

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

Defining Related Disorders

APA’s new chapter distinguishes OCD from related disorders by identifying important differences. Some disorders are characterized by cognitive symptoms, such as perceived defects or flaws in appearance (eg, body dysmorphic disorder) or the perceived need to save possessions (ie, hoarding disorder). Others are characterized by recurrent body-focused repetitive behaviors, such as hair-pulling (eg, trichotillomania) and skin-picking (eg, excoriation).

Substance/medication-induced disorder is defined as having symptoms that are due to substance intoxication or medication withdrawal. OCD-related disorder due to another medical condition is described as involving symptoms characteristic of OCD that are the direct pathophysiological consequence of a medical disorder. Other specified/unspecified OCD consist of symptoms that do not meet criteria for a recognized disorder because of atypical presentation or uncertain etiology.1

Adding Hoarding & Excoriation to the Mix

The new chapter on OCD and related disorders reflects the increasing evidence of these disorders’ relatedness to one another and, importantly, their distinction from other anxiety disorders. Two new disorders have been added to the DSM-5 and to this chapter: hoarding disorder and excoriation.1 APA’s addition of these unique diagnoses in DSM-5 was intended to increase public awareness, improve identification of cases, and stimulate research and development of specific treatments for these conditions.1

Hoarding disorder reflects the persistent difficulty with discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Beyond the mental impact of the disorder, the accumulation of clutter can create a public health and safety issue (eg, tripping and fire hazards). Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.1

Excoriation disorder is characterized by recurrent skin-picking resulting in medical issues, such as infections, skin lesions, scarring, and physical disfigurement. This disorder has strong evidence for its diagnostic validity and clinical utility.1 Symptoms can lead to clinically significant distress or impairment in social, occupational, or other key areas of functioning.

OCD Assessment & Treatment Options

There are several OCD and related disorder assessment measures available to trained mental health professionals and healthcare practitioners. Composed of items for measuring specific and typical types of obsessions and compulsions, these assessments include the Obsessive Compulsive Inventory-Revised, the Padua Inventory-Revised, the Vancouver Obsessive-Compulsive Inventory, and the Schedule of Obsessions, Compulsions, and Pathological Impulses.

Additional measures, such as the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Dimensional Y-BOCS, serve to first identify the patient’s most salient obsessions and compulsions and then rate these symptoms using parameters of severity (eg, time occupied/frequency, interference in functioning, associated distress, degree of resistance, perceived control). Y-BOCS includes a checklist of more than 60 specific types of obsessions and compulsions that the patient indicates as “present” or “absent,” while the Dimensional Y-BOCS includes a checklist of more than 100 items.21

Scholars have suggested that OCD is the most challenging of the traditionally defined anxiety disorders to treat.22 There have been several changes noted in DSM-5, including the separation of the diagnoses of post-traumatic stress disorder (PTSD) and OCD from anxiety disorders and the creation of new sections for each.

The placement of these new chapters reflects the close relationship between these diagnoses and disorders in the surrounding chapters on anxiety disorders, OCD and related disorders, trauma- and stressor-related disorders (including PTSD), and dissociative disorders.1 The April 2017 issue of Practical Pain Management provides a more detailed description.23

Research findings suggest that even in cases with subthreshold symptoms in which OCD was not diagnosed have been associated with poorer self-reported physical health.24 The cognitive and social rigidity associated with the OCD and related disorders may influence pain behavior that may have an impact in the treatment process.9

To revisit the example given, when a person with a cleaning obsession suffers from lower back pain, they may choose to wash dishes meticulously by hand rather than bending to use a dishwasher. This behavior not only reinforces the cleaning obsession but may also lead to muscle weakness and decreased physical activity. The effect is in direct conflict with the treatment plan for chronic pain, which includes movement.

Patients with chronic pain may, therefore, require a treatment plan that encourages and supports patients to verbalize pain-related fears and disabilities.


In terms of psychotherapy, there is moderate to strong evidence for several OCD interventions, including exposure and response, cognitive therapy (CT), and acceptance and commitment therapy (ACT), according to Division 12 of the APA’s Society of Clinical Psychology.25

Exposure and response prevention is based on the premise that if fears can be confronted and their escape response discontinued, the patients’ anxiety will eventually be reduced. Exposure and response prevention instructs individuals with OCD to repeatedly confront the thoughts, images, objects, and situations that make them anxious and/or start their obsessions in a systematic fashion, without performing compulsive behaviors that typically serve to reduce anxiety. Through this process, the individual learns that there is nothing to fear, and the obsessions no longer cause distress.26

CT proposes that individuals susceptible to anxiety may develop inaccurate/unhelpful core beliefs about themselves, others, and the world, as a result of their learning histories. These beliefs can be dormant for extended periods and then activated by certain life events that carry specific meaning for that person. CT also focuses on information processing deficits, selective attention, and memory biases toward the negative. In CT, patients are taught cognitive skills so they can develop more accurate/helpful beliefs and grow more independent.27

ACT is a behavioral therapy based on the Relational Frame Theory, a theory on how human language influences experience and behavior. ACT aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided.

Acceptance and mindfulness strategies help teach patients to decrease avoidance, attachment to cognition and increase focus on the present. Patients learn to clarify their goals and values and commit to behavioral change strategies.28

The Pain Connection

There are other psychological treatments that may also be effective in treating OCD, but they have not been evaluated with the same scientific rigor as the treatments mentioned. There is some evidence that certain tricyclic antidepressants may have anti-obsessional effects, for example.29 If the experience of chronic pain does, in fact, share essential similarity with OCD, then such anti-depressants may be of particular value in treating OCD in patients with chronic pain.

If the experience of chronic pain does, in fact, share essential similarity with OCD, then such anti-depressants may be of particular value in treating OCD in patients with chronic pain.14 Providers may want to suggest a referral to a mental health professional for an accurate diagnosis and discussion of treatment options.


Despite being one of the most prevalent lifetime psychiatric disorders in the US, OCD has gained little attention in terms of chronic pain comorbidity research. This scarcity may be due to frontline practitioners not being aware of the changes made to DSM-5. This article serves to educate the frontline practitioner about the need to look into this potential comorbidity in pain management.

The American Psychiatric Association recognized obsessive-compulsive and related disorders (OCD) as a distinct class of psychological behaviors in 2013. Here’s how pain practitioners may assist patients diagnosed with OCD and chronic pain to best address their needs going forward.

Last updated on: November 3, 2017
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Theory of Motivated Information Management and Coping With Death

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