Can Obsessive-Compulsive Disorder (OCD) cause chest pain?

OCD Can Cause Chest Pain as a Psychosomatic Symptom

Yes, Obsessive-Compulsive Disorder (OCD) can cause chest pain through psychological mechanisms, particularly as a manifestation of anxiety that commonly accompanies OCD. According to clinical guidelines, psychological syndromes such as anxiety, panic attacks, depression, and somatoform disorders are strongly associated with noncardiac chest pain 1.

Mechanism of Chest Pain in OCD

OCD-related chest pain typically occurs through several mechanisms:

• Anxiety-related physiological responses: The anxiety that accompanies OCD can trigger autonomic nervous system activation, leading to:

  • Muscle tension in the chest wall
  • Hyperventilation
  • Increased heart rate and blood pressure
  • Sympathetic activation 1

• Central nervous system-visceral interactions: Guidelines recognize that psychological factors can influence pain perception through altered central nervous system processing 1

• Hyperbody vigilance: People with OCD may have heightened awareness of normal bodily sensations, interpreting them as threatening 1

Clinical Presentation

Chest pain in patients with OCD and other anxiety disorders typically presents as:

• Atypical compared to cardiac chest pain
• Recurrent episodes
• Often associated with other anxiety symptoms like dizziness, hot flushes, or fear of dying 2
• May be described as squeezing or burning, potentially mimicking cardiac pain 1

Epidemiology and Comorbidity

Research shows significant overlap between anxiety disorders and noncardiac chest pain:

• In patients with generalized anxiety disorder, 48% report a history of chest pain 3
• Among low-risk chest pain patients evaluated in emergency settings, approximately 30% have anxiety disorders 4
• Depression (34%), anxiety (30%), and gastroesophageal reflux disease (44%) frequently coexist in patients with noncardiac chest pain 4

Diagnostic Considerations

When evaluating chest pain in a patient with OCD:

1. Rule out cardiac causes first: This is essential before attributing chest pain to psychological factors 5

2. Look for these patterns suggesting psychological origin:

   • Recurrent, similar presentations with previous negative cardiac workups
   • Atypical pain characteristics
   • Presence of other anxiety symptoms
   • Pain that correlates with anxiety or stress levels 1, 2

3. Consider the bidirectional relationship: While anxiety can cause chest pain, chest pain (especially in those with coronary heart disease) can also increase anxiety and depression 6

Management Approach

For patients with OCD-related chest pain:

1. Cognitive-behavioral therapy (CBT): The American College of Cardiology/American Heart Association guidelines recommend CBT for patients with recurrent chest pain who have had negative cardiac evaluations (Class 2a, Level B-R recommendation) 1, 5

   • CBT has been shown to reduce chest pain frequency by 32% over a 3-month period 1

2. Pharmacological options:

   • Tricyclic antidepressants (e.g., imipramine) may be beneficial 5
   • Antidepressants and anxiolytics show mixed evidence for efficacy 1

Common Pitfalls

• Repeated cardiac testing: Patients with noncardiac chest pain often undergo extensive and repetitive cardiac testing, leading to high costs and unnecessary radiation exposure 1

• Under-recognition of psychological factors: Less than 10% of clinicians inquire about psychological factors in chest pain patients with self-reported anxiety 1, 5

• Failure to refer for appropriate treatment: There is often a missed opportunity for effective cognitive-behavioral therapy 1

By recognizing the relationship between OCD and chest pain, clinicians can provide appropriate reassurance and effective treatment, reducing unnecessary medical testing while addressing the underlying psychological factors contributing to the patient's symptoms.