BEHAVIOUR

RESEARCH AND
THERAPY
PERGAMON Behaviour Research and Therapy 37 (1999) 941±951
www.elsevier.com/locate/brat

The role of traumatic experiences in the genesis of

obsessive±compulsive disorder
Padmal de Silva *, Melanie Marks
Department of Psychology, Institute of Psychiatry, University of London, De Crespigny Park, London SE5 8AF, UK
Accepted 1 October 1998

Abstract

This paper discusses the role of traumatic stress in the genesis of obsessive±compulsive disorder.
While the early classical conditioning theory of the onset of obsessive±compulsive disorder has only
limited empirical support, authorities have always recognised the role of stress in precipitating this
disorder, and in triggering relapse in those who have been successfully treated. Here, clinical cases are
cited that show a causal link between severe trauma and the onset of obsessive±compulsive disorder.
The nature of the traumatic reaction and the possible mechanisms by which it leads to frank obsessive±
compulsive disorder are discussed. The apparent links between this and posttraumatic stress disorder are
also explored. Finally, implications for therapy are considered. # 1999 Elsevier Science Ltd. All rights
reserved.

1. Introduction

The role of stressful events in the genesis of obsessive±compulsive disorder (OCD) has been
recognised for a long time (Rachman & Hodgson, 1980; de Silva & Rachman, 1998). The early
learning theory view was that a traumatic learning experience caused, via classical
conditioning, certain stimuli to become anxiety-arousing, and that the behaviours which
provided relief from this anxiety were strengthened and maintained, becoming compulsions
(Eysenck & Rachman, 1965). While there is much evidence showing that compulsive
behaviours may be maintained by their anxiety-reducing e€ects (e.g. Rachman et al. 1976),
evidence is limited on there being a clear traumatic conditioning experience triggering the OCD
in the ®rst place (e.g. Grimshaw, 1965; Pollitt, 1969; Jones & Menzies, 1998; for review, see de
Silva, 1992). On the other hand, there is evidence that in many cases OCD originates in the

* Corresponding author.

0005-7967/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 0 5 - 7 9 6 7 ( 9 8 ) 0 0 1 8 5 - 5
942 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951

wake of a stressful life event, and that stresses can lead to relapses in this disorder (e.g.
Metzner, 1963; Marks, 1987). There is also a great deal of evidence that exposure to stress
increases the incidence of unwanted intrusive thoughts (e.g. Horowitz, 1975; Rachman & de
Silva, 1978), and intrusive thoughts ``are after all the raw material for full obsessions''
(Rachman, 1997, p. 797). Rachman (1997) has provided an analysis of the paths from stress to
obsessions.
The recognition that a severely stressful or traumatic experience might lead to the onset of
OCD is independent of the theoretical position postulating a classical conditioning model of
the acquisition of the disorder. Indeed, Janet, an early theorist on obsessive±compulsive
problems, considered that in some cases the OCD was caused by emotional shock (Janet, 1903;
Pitman, 1984, 1987). He cited the case of a 59-year old woman who developed obsessions after
seeing the charred body of her daughter who had perished in a ®re. Pitman (1993) in a recent
paper has provided a brief but valuable discussion of this issue, and also given a detailed case
study of a combat-exposed Vietnam war veteran who developed OCD, along with
posttraumatic stress disorder (PTSD), which persisted for two decades. It is also worth noting
that, in a general population epidemiological survey, it was found that the risk of OCD was 10
times greater in those with PTSD than in others (Helzer et al., 1987). In a study of psychiatric
morbidity in Vietnam War veterans, it was found that those who had had high-war-zone
experience had a current prevalence of OCD of 5.2%, a ®gure far higher than in any other
population (Jordan et al., 1991). Solomon's work on combat-exposed Israeli veterans in the
Lebanon war showed elevated scores on obsessive±compulsive symptoms on the Symptom
Checklist-90, when compared to control subjects (Solomon, 1993). Despite such relevant data,
the issue of the possible role of trauma in the genesis of OCD has received little attention in
the empirical literature (cf. Pitman, 1993).
In this paper, we explore this issue with the aid of clinical material. Our work with a series
of patients with traumatic experiences of a variety of kinds (e.g. plane crashes, sea disasters,
industrial accidents, serious road trac accidents, personal violence, sexual assault, combat
exposure) has led us to a reconsideration of this topic. We have come across a small number of
cases that appear to ®t a traumatic origin model of OCD and are similar in presentation to the
case examples of Janet (1903) and Pitman (1993). We shall present some of these cases below.
We shall then discuss the theoretical and therapeutic issues that are relevant.

2. Case examples

2.1. Case 1

Mr K, a 50-year old company director, was subjected to a vicious knife attack near his oce
one morning. He survived his serious physical injuries, but was left with some physical
handicaps as a result. Over the weeks and months after the event, Mr K developed a range of
psychological symptoms. These included: frequent intrusive cognitions about the event,
recurrent dreams and nightmares, avoidance of various settings and stimuli, poor
concentration, loss of interest in previously enjoyed activities, exaggerated startle reactions and
hypervigilance. The hypervigilance took the form, among others, of checking for signs of
 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951 943

intruders both when at home and when he was out. The checking was extensive and ritualistic.
Doors and windows had to be checked a certain number of times to ensure that they were
properly secured. He had recurrent doubts about their security. Mr K also began constantly to
ask for reassurance from his wife about the safety of the house and of himself and the family.
At the time he was seen, he satis®ed the diagnostic criteria of PTSD as well as those of OCD.
His own doctor had diagnosed the PTSD, but the OCD had not been recognised. We found
him to su€er from both disorders with equal severity. Mr K did not have a previous history of
OCD or any other psychiatric disorder.

2.2. Case 2

Mrs D, a mother of two in her late thirties, was referred with various psychological
diculties following a road trac accident. She was not in any way responsible for the
accident, but was injured and seriously shocked. She developed anxiety about driving and
began to avoid the area where the accident had taken place. She also had ¯ashbacks of the
accident, loss of interest in leisure activities, diculty in relating to others, poor sleep, impaired
concentration and hypervigilance. She clearly had PTSD at the time she was referred. She also
reported that, within a matter of weeks after the accident, she developed extensive rituals of
cleaning and tidying the house. She did this several times a day, with great energy. She said
that she `had to do it'. She recognised that the repetitive cleaning and tidying rituals were
unnecessary and irrational, but she could not resist the compulsion to engage in them. So she
would wake up very early in the morning and carry out her rituals. She did this again in the
afternoon and ®nally late into the night. Mrs D also demanded that her husband and children
follow strict instructions from her about cleanliness, orderliness and tidiness. For example,
certain things could be put only in certain places; and certain areas of the house were not to be
entered except in her presence and in the manner directed by her. At the time she was seen,
while she was still clearly handicapped by her anxiety about driving and related posttraumatic
symptoms, Mrs D was also signi®cantly handicapped by her compulsive behaviours. The
compulsive behaviours had also begun to a€ect the marital relationship. Mrs D clearly satis®ed
the diagnostic criteria for OCD, as well as PTSD. As for her previous history, she had always
been someone who was proud of keeping a neat and tidy house. This, however, had never got
out of control and she had not had any obsessions or compulsions that ®tted the diagnostic
criteria of OCD. When seen by us, it was clear that she was in need of speci®c help for her
compulsive behaviours.

2.3. Case 3

Miss M, a 24-year old single woman, was referred with a history of a serious sexual assault
whilst on holiday abroad. Immediately after the traumatic event, she felt `quite dirty', and
spent a long time washing herself and everything she had with her at the time. After her return
home, she continued to feel dirty and said that she could not stop or resist the urge to wash
repeatedly. She washed both her person and her clothes and other things in her ¯at; she would
spend hours doing this. She also su€ered many symptoms of PTSD, including ¯ashback
experiences, numbing, nightmares, poor sleep and hypervigilance. She had in fact had full-
944 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951

blown PTSD for some time after the attack, for which she had received some professional
counselling. By the time she was seen by us, the main complaint was OCD, and she had a clear
diagnosis of the disorder. She had obsessional thoughts about being dirty and unclean (``I am
dirty'', ``I am ®lthy'', ``everything is unclean'', etc.), which were linked to the washing
compulsions. Miss M agreed that her washing was excessive and irrational, yet, despite her
attempts to resist the compulsive urges, she continued to engage in these rituals. It was this
problem that she speci®cally sought help for.

2.4. Case 4

Mr X, a 28-year old professional man, came with a history of a major accident in which he
sustained physical injury, from which he recovered over a period of time. He also developed
psychological diculties typical of posttraumatic stress reactions. At the time he was referred,
Mr X reported clear obsessional thoughts and images. These were in addition to speci®c
intrusions about the accident itself, and were not directly related to the event content-wise.
These came repeatedly and continually, and he was unable to dismiss them easily. Mr X also
engaged in mental rituals, aimed at countering and neutralizing the obsessions. At the time he
was seen, he satis®ed the diagnostic criteria of both OCD and PTSD.

2.5. Case 5

Mrs Y, a 26-year old woman, was tied up and raped. During the attack her assailant
threatened to scar her body and to kill her with a large knife. He videotaped the rape and
played it back to her which she found deeply humiliating. She developed numerous symptoms
of PTSD including intrusive thoughts and images, ¯ashbacks, nightmares, exaggerated startle
responses and hypervigilance. She also developed OCD. She felt unclean and washed her
hands, body and home repetitively and in a ritualistic manner. In addition, she felt compelled
to make sure that objects in her house were correctly positioned. When she presented for
treatment she met the diagnostic criteria for both PTSD and OCD and required treatment for
both conditions. She had not had any obsessive±compulsive problems prior to being raped.

2.6. Case 6

Miss B, a 20-year old woman who presented with OCD, reported a number of traumatic
events which related thematically to the content of her OCD. Some years prior to onset she
was enjoying a picnic with her family, watching an air show, when a plane which appeared to
be making an emergency landing approached them. The pilot, seeing them at the last moment,
swerved to avoid them and crash-landed elsewhere, killing himself. Miss B felt upset and guilty
about having survived and `causing' the pilot's death but did not develop full-blown PTSD or
symptoms of OCD at the time. A few years later, she was driving when an ambulance
appeared behind her in an emergency. It took a few minutes for the trac to clear before she
could get out of the way. She developed the idea that by causing a delay and `again' being `in
the way', she might have harmed, if not caused the death of, the person needing medical help.
She developed obsessional ideas about harming people, particularly bumping into them, and
 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951 945

constantly checked behind her. She had immense diculty going through swing doors in case
she caused them to bump into people and when driving developed various checking rituals. She
eventually stopped driving altogether. Around this time a close friend of hers was murdered in
a mistaken identity stabbing. She found hearing about the violent details of his death very
distressing and began to experience vivid intrusive images about his death. She then began to
®nd that red meat reminded her of his death and when she ate it she had obsessional ideas
about eating ¯esh. She developed checking rituals to ensure that the food she ate was not
human ¯esh and that any powdery or crumbly food did not contain human ashes. She
recognised the absurdity of her symptoms but could not control them. She also found having
menstrual periods very distressing and had obsessional ideas about her menstrual blood being
the blood of someone she might have killed. This made her think of her friend. Though she
did not develop full blown PTSD, her obsessional thoughts and images were directly linked to
her feeling responsible for the pilot's death and to her friend's violent death.

2.7. Case 7

Ms J, an 18-year old woman, presented for treatment of OCD. Her symptoms followed her
being held at knife point during a robbery at home shortly after her father had disappeared,
permanently leaving the country without warning or informing her family of his whereabouts
for some months. During the robbery she feared she would be killed but managed to escape
unharmed. Her mother was also in the house at the time. Ms J developed intrusive thoughts
and images, nightmares and hypervigilance which lasted for some months after the event. She
also developed OCD symptoms which worsened over time, though the symptoms of PTSD
resolved. She felt compelled to pray in a ritualistic manner so as to avoid further harm to
herself or her mother. She also felt compelled to `concentrate fully' when praying and had to
repeat the prayer if any doubts about her concentration appeared during prayer. She developed
washing, counting and touching rituals. As a child she had been very particular about how she
liked her room arranged but she had not shown full blown OCD symptoms, or indeed any
de®nite obsessional traits, prior to the robbery and her father's disappearance.

2.8. Case 8

Mrs T, a 46-year old woman, was seen with several symptoms of PTSD and full-blown
OCD. She was witness to the shooting of her brother several years ago. This unfortunate
incident caused many symptoms, including recurrent, vivid images of the shooting, with a
particularly clear image of her brother, covered in blood in the face and chest, collapsing. After
some time, she began to respond to this distressing image by conjuring up a counter-image of
her brother, at a younger age and looking well. This was carried out compulsively, and it
always led to a transient reduction of her distress and anxiety. Over months and years, Mrs T
developed a wider pattern of cognitive compulsions: any distressing or unpleasant thought or
image had to be countered or neutralised with a comforting image. The image of her dying
brother still remained a powerful intrusion, but it had now become one of many distressing
cognitions. Mrs T also began to make silent verbal utterances along with the neutralizing
images, which she had to struggle to conjure up. She sought help as many new traumatic
946 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951

symptoms had emerged ¯oridly, as the result of being exposed to another distressing event
(seeing someone perishing in a ®re accident). On presentation, it became clear that Mrs T's
most handicapping problem was OCD, characterised by cognitive compulsions, not the
symptoms caused by the distressing recent trauma which prompted the referral. Her
functioning had been severely a€ected by the OCD for years.

3. Discussion

The cases detailed above are all illustrative of the links between a severe traumatic
experience and the genesis of OCD. In each of these, the onset of the disorder was preceded by
trauma. With one exception, the obsessive±compulsive symptoms started either in the
immediate aftermath of the event, or within a number of weeks. The full-blown OCD appears
to have developed in the course of time. In all of the cases, the OCD co-existed with full-blown
PTSD or with signi®cant PTSD symptoms at least for some of the time.
With regard to the content of the OCD, it is clear from these cases that the nature of the
trauma may or may not provide the main concerns on which the obsessions and/or
compulsions are built. In the case of Miss M (case 3), the main content of the OCD was
directly determined by the nature of the trauma: sexual assault, followed by the feeling of
`being dirty' leading to concerns about dirt and contamination and the associated urges to
wash and clean. In Mrs Y (case 5), there is a similar link between the experience of rape and
feeling unclean, leading to washing compulsions. In Mr K (case 1), again the main content of
the OCD was governed and de®ned by the nature of the trauma he had su€ered. He became
concerned about danger and safety, and his checking, doubting and reassurance seeking were
almost exclusively related to this. His diagnosis of OCD was due to the clearly compulsive
nature of his behaviour (e.g. compulsive urge to check, checking a certain number of times,
temporary relief from anxiety after checking, relief from receiving reassurance). If he only had
hypervigilance along with nonritualised and nonrepetitive checking, one might have understood
this behaviour as entirely falling within the realm of PTSD symptomatology. The nature of Mr
K's checking, however, was typical of OCD, and he satis®ed the diagnostic criteria for the
disorder.
Mr K's case is in some ways similar to that of BA, the Vietnam war veteran described in
detail by Pitman (1993) in his illuminating paper. BA developed numerous symptoms; one of
these was extensive and highly ritualised checking, associated with doubt. To quote: ``After he
chambered a round in his ri¯e, BA found himself doubting whether he had really done so,
which led him to chamber another; he went through hundreds of rounds in this manner. He
worried that a kink in the ammunition belt could cause his machine gun to jam. In the evening
while the other guys stood around drinking beer, he returned to his helicopter and ran the
ammunition through his hands, checking for kinks. Having run through it all once, as he was
walking back to his tent he would be overcome by doubt that he had done it properly and
would need to return to check again'' (Pitman, 1993, p. 103). Like Mr K, BA also developed
counting rituals. After returning home from the war, BA's compulsions persisted. ``He patrols
his property daily for signs of intruders and dreads the arrival of even the mailman. . . He
 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951 947

checks the stove and the locks on the doors, at times driving home 7 or 8 miles to do so . . .''
(Pitman, 1993, p. 104). Like Mr K, BA also su€ered from PTSD concurrent with the OCD.
In Ms J (case 7), the OCD symptoms showed some link with the trauma experienced. Her
compulsive praying rituals were aimed at warding o€ further harm to her mother and herself;
they had been `harmed' in the traumatic event that preceded the symptoms.
In the case of Miss B (case 6), there is a rather complex and indirect link between the
traumatic events she experienced and the presentation of her OCD. Guilt and responsibility
appear to be the themes that linked the nature of her traumas and her later obsessions (cf.
Rachman, 1993).
In the case of Mrs T (case 8), the OCD took the form of a pattern of cognitive compulsions,
aimed at countering various distressing and/or aversive intrusions. These remained linked to
the original trauma, and the image of the brother was still a distressing intrusion which needed
to be countered. It had generalised to numerous aversive intrusions, developing into a wider
theme of countering distressing subjective experiences in a compulsive manner.
In the other two cases cited above, Mrs D (case 2) and Mr X (case 4), the symptoms of the
OCD had no apparent link with the nature of the traumatic event experienced prior to its
onset. The relationship between the trauma and the OCD, in these cases, was a temporal and
historical one. This is not unusual, as the clinical literature has numerous references to the
onset of OCD, in many cases, in the period following Ð or during Ð a stressful life event,
such as family illness, marital disharmony or personal illness (Rachman & Hodgson, 1980;
Marks, 1987). In a recent study in Australia, it was found that, in a sample of 23 patients with
obsessive±compulsive washing, three (13%) had an onset ``following an unrelated traumatic
experience'' (Jones & Menzies, 1998, p. 278). There has been some theoretical speculation in
the literature on this issue. Pitman (1991) has postulated the view that OCD symptoms
constitute latent response tendencies in humans which may be activated by several factors,
including extreme stress. The experimental animal literature also suggests stereotyped
behavioural responses in relation to unrelated and/or nonspeci®c aversive situations (Pitman,
1987; see also de Silva, 1992). Data emerging from recent epidemiological studies point in the
same direction, albeit only suggestively. The high incidence of OCD in combat-exposed soldiers
(e.g. Jordan et al., 1991) can be understood as showing that extremely stressful experiences
may lead to the development of OCD in individuals who would not otherwise have developed
the disorder.
Another possible explanation of cases like Mrs D and Mr X comes from the views of
Rheaume et al. (1998). These authors suggest that certain critical experiences Ð such as
accidents, very unusual events, serious mistakes Ð may lead to faulty assumptions which in
turn contribute to the development of OCD. These experiences can be chronologically distant
or proximal to the advent of the disorder. Rheaume et al. (1998) have described 13 case
examples that appear to provide evidence of this phenomenon, which they call `bad-luck'
experiences. It appears that their analysis may also provide a plausible account of the
complicated way in which Miss B's problems developed.
The question arises as to whether premorbid tendencies have a role in the development of
OCD in those who get the disorder following severe trauma. The overall issue of the links
between obsessional personality and OCD is a much discussed topic (e.g. Lewis, 1965; Pollak,
1979; Rachman & Hodgson, 1980) and does not need to be gone into in any detail here. In the
948 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951

examples we have cited above, only one out of eight cases had a premorbid tendency that
appeared to have any link with the OCD which later manifested: Mrs D, who had always been
somewhat concerned about cleanliness and tidiness. This appears to have in¯uenced the
content of the OCD in her when she developed it following her traumatic experience, but we
do not take the view that it was a causal or contributory factor in the actual genesis of the
disorder.
General vulnerability of the individual may well be a relevant factor. It may be that those
who develop OCD after extreme stress are those who are particularly vulnerable. Pitman
(1993) comments on elements of BA's past history, including his mother's depressive illness
and his dropping out of high school. Can one de®ne vulnerability more precisely in this
context? Rachman (1997), in his recent analysis of the genesis of obsessions, has postulated
four vulnerability factors. These are: elevated moral standards, including striving for moral
perfectionism; particular cognitive biases, such as thought action fusion and elevated sense of
responsibility; depressed mood (cf. Riccardi & McNally, 1995); and anxiety-proneness. It is too
early to attempt to evaluate the role of each of these in relation to trauma-related OCD, but it
is clear that some of these factors may have played a part in generating obsessional cognitions,
and subsequently other symptoms of OCD, in the cases we have cited. For example, elevated
Ð and irrational Ð responsibility was a major factor in Miss B. It is also clear that in some of
the cases cited here dysphoric mood following the traumatising experience was a key factor
during the time the obsessions, and the full-blown OCD, emerged. It is likely that in some
cases several vulnerability factors operate jointly and contribute to the development of a
clinically signi®cant obsessive±compulsive problem.
The need at this point is to consider some of the theoretical aspects of the links that we and
others, notably Pitman (1993), have observed between trauma and OCD. What mechanisms
might be involved? In the case of those whose subsequent obsessive±compulsive symptoms
re¯ect the content of the traumatic experience, including BA (Pitman, 1993), it is tempting to
speculate that the posttraumatic reaction, including frank PTSD, may over a period of time
give way to OCD. In the example of Miss M, this may well be what happened. Her immediate
posttraumatic responses included excessive washing, but the major diculties in the early
months were those characteristic of PTSD. The full-blown OCD developed and got established
later, and by the time she was seen by us, she no longer met the diagnostic criteria for PTSD.
Ms J also presents a similar picture. It is possible that, over the course of time, trauma-related
intrusions gave way to, or turned into, true obsessions. After all, the two phenomena share
many formal properties (intrusive, unwanted, distressing, repetitive, hard to dismiss or control).
It is worth noting here the view of Rachman (1997) that frank obsessions are caused by
catastrophic misinterpretations of the signi®cance of one's intrusive cognitions. It is possible
that in some, the common posttrauma intrusions lead to such catastrophizing. This is
especially likely, in our view, when the intrusions persist. The persistence of the intrusion may
lead to the secondary e€ect of the person developing catastrophic interpretations (e.g. `I am
losing control', `I am going insane', `I am doomed to su€er or I can never put this behind
me'). This may be at least one of the pathways in which a traumatic event leads to a frank
obsessive±compulsive problem. The model presented by Rheaume et al. (1998), brie¯y noted in
a previous paragraph, suggests another Ð not dissimilar Ð pathway. Similarly, it is possible
that trauma-related reparative activities (e.g. washing to clean herself in the case of Miss M;
 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951 949

conjuring up neutralizing mental images to counter a distressing intrusive image in the case of
Mrs T) become, with time, stereotyped rituals. The same would apply to trauma-related
avoidant, vigilant and preventative activities, such as the checking for signs of danger by Mr
K. The co-existence of PTSD and OCD in some of these cases for a period of time re¯ects the
fact that, in this transformation, there may be an overlap period, sometimes even a prolonged
one, before the OCD became the sole psychiatric disorder.
It is entirely possible that many cases of OCD seen and reported in the era prior to the full
recognition of PTSD did have a history of PTSD, or even concurrent PTSD. Clinical
descriptions and anecdotes sometimes suggest this. Janet (1903) certainly recognised this, as
noted above. The extensive observations of Kardiner (1941) on the psychological sequelae of
war also included the recognition that some of those a‚icted by war-induced traumatic
neurosis had what he called `defensive ceremonials'. It is also well known that imagery
occurring in OCD sometimes re¯ects a psychologically signi®cant past event or events (cf. de
Silva, 1986). The overlap between ¯ashback experiences of past traumatic events and true
obsessional imagery has also been commented on by Lipinski and Pope (1994).
As Rachman (1980) has shown in his paper on emotional processing, stressful or traumatic
experiences not fully processed and absorbed by the individual can leave him/her with residual
e€ects, including frank psychological disorder. The most patent manifestation of such e€ects is
of course PTSD, which by de®nition is trauma-related. But, as Rachman (1980) rightly stresses,
the unresolved or unprocessed experiences can also lead to obsessions and other symptoms and
syndromes. The framework provided by Rachman's notion of emotional processing can, in our
view, partly accommodate the phenomena of traumatic experiences leading to OCD, either
with or without an intermediate and/or overlapping phase of PTSD. This theory cannot
explain, however, why some patients with PTSD develop OCD and others do not, and more
research is needed to identify factors associated with the onset of OCD after a traumatic event.
The vulnerability factors identi®ed by Rachman (1997) in his more recent paper, noted in an
earlier paragraph, highlight some individual di€erences that may be relevant. The nature of the
traumatic event is also likely to be a relevant factor here.
We would also like to make the point that the study of the comorbidity between OCD and
PTSD would be a fruitful exercise. In proposing a psychological approach to the study of
comorbidity of psychological/psychiatric disorders, Rachman (1991) has drawn attention to the
value of exploring the connectedness of the two disorders, not simply determining their co-
occurrence. He makes a distinction between a static connection that may exist between two
conditions and a dynamic connection that may be present. The determination whether the
reported co-occurrence is a static connection or a dynamic one ``would provide the basis for
making accurate prognoses (e.g. if problem A is treated successfully, will problem B disappear,
or persist?)'' (Rachman, 1991, p. 462). Our view, as it should be clear from what we have said
so far in this communication, is that there is a dynamic connection between PTSD and OCD,
not simply a static one. As we have shown above, there is, in a proportion of cases of OCD, a
history of traumatic experience which has an aetiological role. This latter experience may also
have caused, in some of the cases, the development of PTSD. The commonest and the most
likely scenario is for the trauma to lead to PTSD ®rst and later to OCD. In our experience,
there is often a period of time when the two conditions co-exist, and may do so for a long time
if untreated.
950 P. de Silva, M. Marks / Behaviour Research and Therapy 37 (1999) 941±951

Regarding the clinical implications of links between PTSD and OCD, we recommend that
clinicians routinely enquire about traumatic events when assessing patients with OCD and be
prepared for the need to treat both conditions. The treatment may be carried out concurrently
or consecutively as needed, depending on the presentation and the relative severity of the
disorders. As yet we do not have any ®rm data to indicate whether dealing ®rst with the initial
traumatic event and associated PTSD leads to any spontaneous improvement in obsessive±
compulsive symptoms, whether both conditions always require treatment in their own right
and whether OCD which arises in the wake of a traumatic event is more resistant to change
when compared to OCD which has no such aetiology. In case 5 discussed above, the symptoms
of PTSD were treated ®rst as these were causing the greatest distress. This did not lead to any
improvement in the OCD which was treated later on. In case 6 the presenting symptoms of
OCD were treated alongside tackling the underlying the trauma-related guilty thoughts about
always being responsible for bad things happening to other people. The occurrence of
traumatic events prior to the onset of OCD may also in¯uence the choice of treatment
strategy. For example, washing rituals related to feeling dirty following sexual assault, may
require a more cognitive approach than washing rituals unrelated to such an event which may
respond to purely behavioural approach. These issues clearly need further exploration, and
systematic investigation is needed before ®rm guidelines for practice can be formulated.

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