The Relationship Between Anxiety/OCD and Pain
by Samantha Levy, Ph.D.
Over my 25 years of treating youth with pain, I have rarely met a client without some form of anxiety. This anxiety may be generalized (meaning, it applies to many areas of their lives) or social. It may be test anxiety, perfectionism, panic attacks, phobias, trauma-based, concern about identity, and so on.
There are endless factors that may contribute to anxiety, panic, or phobias.
Sometimes there are learning differences or uneven IQ’s (some areas of significant relative weaknesses compared to other areas) that have not been discovered or addressed. This can lead to academic stress and make the young person feel confused and demoralized.
Sometimes there are other neurodivergent issues, such as autism, dysgraphia, or ADD that lead to anxiety if they are not adequately addressed. Other times, family strife (such as marital discord), leads to anxiety in the child, or a child is worried about a parent with medical or psychiatric issues.
Obsessive-Compulsive Disorder (OCD)
A significant number of my clients suffer from undiagnosed Obsessive-Compulsive Disorder (OCD). This disorder has become part of the common lexicon, and unfortunately, it is often used incorrectly. In the media, we often hear the term OCD to describe someone who is a perfectionist, likes things to be “just so,” or is a “neat freak.” While that can be true of some people with OCD, that is not the common symptom, and this use of the term really minimizes its destructive impact on people’s lives.
OCD can be a significantly debilitating disorder and is not a choice. Having OCD means that you feel you have to do something or have to refrain from doing something. This is in contrast to wanting to do or not do something. The obsessions are thoughts or feelings that are very uncomfortable, and the compulsions are actions taken (or not taken) to relieve the obsessions.
Unfortunately, the relief is temporary. Think of it as having an itch and scratching it to relieve it, only to have it start itching all over again. These compulsions or avoidances can take significant time away from normal activity or thoughts, and often affect normal functioning.
Another aspect of OCD that is less understood by lay people, as well as those who suffer from it, is intrusive thoughts. These are thoughts or images -- sometimes even “videos” -- that pop up in the person’s mind. These thoughts are typically gruesome, violent, or sexual. They are deeply disturbing to the individual who suffers from them, often leaving the victim feeling like a bad person for having these thoughts.
Even worse, the intrusive thoughts are usually about whatever would be most upsetting to that particular individual. For example, a child in a religious family may have intrusive thoughts that are blasphemous. While these feelings are common to all people who have intrusive thoughts, you can imagine that they are even more disturbing for a child.
Jacob came to me in the middle of 8th grade. He had traditional OCD symptoms, but he was most disturbed by his intrusive thoughts. They started after a classmate showed him a violent pornographic scene on the classmate’s phone. The images had disturbed him, but then he started having intrusive thoughts with similar images involving family members. The thoughts would always be about whomever was most vulnerable in the family at the time, making it feel even more perverted. Aside from feeling like a perverse person, he feared he would never have a normal sex life when he became an adult.
What Do Anxiety and OCD Have To Do With Chronic Pain?
From my experience, anxiety and/or OCD are often intertwined with chronic pain. Sometimes, clients will tell me that they are not anxious -- that they just have pain and that the pain is their only source of anxiety. In this situation, we often discover that there are anxieties or stressors, but the feelings are felt in the body instead of cognitively or emotionally.
Even during a panic attack, some people will say that they have no anxiety -- just that they can’t breathe, their hearts are racing, and they feel like they are choking. Even if it is not temporally related, there is always a source of stress or anxiety that has not been discovered, acknowledged, or treated.
As we have discussed in other blogs and stories, chronic pain occurs when pain signaling (sometimes from an acute injury or illness) keeps firing, even after the acute injury or illness has healed. The pain has become part of the central nervous system. This “switch” that gets turned on becomes a feedback loop between emotions and body sensations. In order to decrease the firing of the pain signals, we need to calm down the body’s nervous system. It is essential to decrease the “fight or flight” mode that the body is in.
In order to release emotions that are bottled up, part of what is required is to help provide strategies for whatever is causing the nervous system to be heightened. These underlying causes may be internal (e.g., questioning sexual orientation or dealing with OCD), biological (e.g., a learning disability or autism), or systemic (e.g., marital discord in the family or a bad teacher at school). It’s usually all three.
That is why we employ the biopsychosocial model to address all areas of concern. As I have mentioned in other blogs, when the difficult, unexpressed feelings pile up in the body, it is like a bottle getting filled with goop -- eventually it will explode. That is the chronic pain, fatigue, POTS, dizziness, and so on. Once we begin to poke holes in the jar by addressing emotional needs, there is a release of the pressure.
Kids are anxious, which leads to pain, which then leads to anxiety because of the physical symptoms, school absences, parental stress, financial stress, isolation, and so on that the pain causes. All of these issues then lead to more pain. The vicious cycle of anxiety and body symptoms has to be broken somewhere.
Breaking the Cycle
We have to approach each situation like a puzzle with many pieces, which we start putting into place one at a time until the whole picture comes into view. We need to look at all of the fears, worries, and stressors that the child is dealing with. Sometimes I help a client to resolve her pain, and then the deeper psychological issues are revealed. At other times, we work on the obvious emotional issue, and then the pain resolves.
Justine was a 14-year-old who came to me with chronic abdominal pain and headaches. It was clear early on that she was perfectionistic, very bright, very sensitive, and well-behaved. She got good grades, and was both athletic and artistic. Over time, it became clear that she was questioning her sexual orientation and gender identity. She was also engaging in self-harm. As we worked on her worries, fears, and OCD, she made steady progress in all areas -- both physical and emotional -- and greatly reduced her incidence of self-harm.
However, she continued to have occasional relapses in her physical symptoms. Eventually, after I knew her very well, she admitted to having scary and mortifying intrusive thoughts. The times when she did still engage in self-harm were when she felt she was a horrible person for having these thoughts. After education about intrusive thoughts and intensive OCD treatment at a day treatment program, she finally found relief.
She had made progress in reducing her pain issues by working on her more behavioral OCD symptoms, along with her worries, fears, and stressors. However, once she freed herself of the impact of the intrusive thoughts, her physical symptoms resolved. She was then able to attend school, go back to art classes, and begin seeing friends again.
Anxiety/OCD and chronic pain are often intertwined. It takes time to untangle everything and address each strand of the braid. Each time we resolve one problem, it helps make the entire chain easier to untangle. Just like with a tangled chain, sometimes you have to start with the easiest issue to access and address, and then the others become clearer.