DEPRESSION AND ANXIETY 25:69–71 (2008)

Brief Report
TRAUMA AND POSTTRAUMATIC STRESS DISORDER
IN TREATMENT-RESISTANT
OBSESSIVE-COMPULSIVE DISORDER
Beth S. Gershuny, Ph.D.,1 Lee Baer, Ph.D.,2 Holly Parker, Ph.D.,3 Emily L. Gentes, B.A.,1 Alison L. Infield, B.A.,1
and Michael A. Jenike, M.D.2

Prior research has indicated a seemingly unique relation between obsessive-

compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) that
appears to relate to negative treatment outcome for OCD. However, to date, the
prevalence of trauma and PTSD in individuals seeking treatment for OCD is
unclear. To begin to address this gap, this study assessed history of traumatic
experiences and current PTSD in individuals seeking treatment for treatment-
resistant OCD. Trauma predictors of PTSD severity also were examined in this
sample. Participants included 104 individuals diagnosed with treatment-
resistant OCD who sought treatment over the course of 1 year from OCD
specialty treatment facilities. Data were collected via naturalistic retrospective
chart reviews of pre-treatment clinical intake files. Findings revealed that 82%
of participants reported a history of trauma. Over 39% of the overall sample met
criteria for PTSD, whereas almost 50% of individuals with a trauma history
met criteria for PTSD. Interpersonal traumas and greater frequency of
traumas were most predictive of PTSD severity, and individuals diagnosed with
OCD and additional major depressive disorder (MDD) or borderline personality
disorder (BPD) appeared at particular risk for a comorbid PTSD diagnosis.
PTSD may be relatively common in individuals diagnosed with treatment-
resistant OCD; and interpersonal traumas, MDD, and BPD may play a
relatively strong predictive role in PTSD diagnosis and severity in such OCD
patients. 25:69–71, 2008. & 2007 Wiley-Liss, Inc.

Key words: obsessive-compulsive disorder; posttraumatic stress disorder;

prevalence; treatment-resistant

INTRODUCTION
R ecent research has examined various types of
relations among obsessive-compulsive disorder
(OCD), trauma history, and posttraumatic stress
disorder (PTSD) [e.g., Huppert et al., 2005]. Findings
suggest a unique relation among these constructs that
may have implications for assessment, diagnosis, and
treatment [de Silva and Marks, 1999; Gershuny et al.,
2003]. Though childhood trauma has been implicated
in the development of OCD [Lochner et al., 2002], no
study to date has assessed the prevalence of both
childhood and adulthood trauma and current PTSD in
OCD. Several case studies have documented the
possible development of treatment-resistant OCD after
various types of traumas [e.g., Gershuny et al., 2003;
1
Department of Psychology, Skidmore College, Saratoga
Springs, New York
2
Department of Psychiatry, Harvard Medical School and
Massachusetts General Hospital, Boston, Massachusetts
3
Department of Health Care Policy, Harvard Medical School,
Boston, Massachusetts
Contract grant sponsor: Obsessive Compulsive Foundation
Correspondence to: Beth S. Gershuny, Department of Psychol-
ogy, Skidmore College, 815 N. Broadway, Saratoga Springs, NY
12866. E-mail: gershuny@skidmore.edu
Received for publication 26 April 2006; Revised 17 October 2006;
Accepted 1 November 2006
DOI 10.1002/da.20284
Published online 22 February 2007 in Wiley InterScience
(www.interscience.wiley.com).

r 2007 Wiley-Liss, Inc.

70 Gershuny et al.
Pitman, 1993]. Case studies also have suggested that
individuals with co-occurring OCD and PTSD may be
particularly difficult to treat successfully (i.e., be
‘‘treatment-resistant’’) [de Silva and Marks, 1999;
Gershuny et al., 2003; Pitman, 1993]. Furthermore, a
recent empirical study demonstrated that a diagnosis
of comorbid PTSD in individuals seeking treatment
for resistant OCD led to poorer treatment outcome
(i.e., no change or a worsening of symptoms) than for
individuals without comorbid PTSD [Gershuny et al.,
2002]. However, the following question still remains:
what proportion of treatment-resistant OCD indivi-
duals have experienced trauma and meet criteria for
current PTSD? We addressed this question by asses-
sing prevalence of traumas and PTSD, and trauma
predictors of PTSD severity, in individuals seeking
treatment for resistant OCD.
METHODS
Participants included 104 individuals (54 females,
50 males; mean age 5 32 years; age range 5 16–76
years, with most [95%] falling between the ages of 18
and 52 years) who met criteria for OCD (and whose
OCD was believed to represent their primary diag-
nosis) and sought treatment from the Harvard Medical
School, Massachusetts General Hospital OCD Clinic
or Institute. Chart reviews were conducted for all
participants who sought treatment over the course of 1
year. All of these participants were labeled ‘‘treatment-
resistant’’ due to failure of at least one adequate prior
treatment trial (e.g., psychodynamic therapy, cognitive
behavior therapy, or at least two types of medication
trials). Note: We did not pre-select for treatment-
resistant participants; these were the individuals who
sought treatment and thus represented a naturalistic
sample of treatment-resistant OCD. In addition,
almost all of the patients (97%) arrived at the Clinic
or Institute already on medications, the most common
of which were selective serotonin reuptake inhibitors
(68%) and benzodiazepines (45%), with 29% of
patients taking both types of medications simulta-
neously. Information was gathered from self-report
questionnaires (Traumatic Events Scale-Lifetime
[TES-L]; Gershuny [1999]; Posttraumatic Diagnostic
Scale [PDS]; Foa et al. [1997]) and a semi-structured
diagnostic interview (based on DSM-IV-TR criteria)
that had been administered to individuals as part of
routine clinical intake procedures before and during,
respectively, their initial meeting with a psychologist
or psychiatrist. Note: The TES-L evaluates lifetime
history of traumas based on DSM-IV-TR criteria that
require the possibility of death or serious injury and
the subjective experience of fear, helplessness, and/or
horror. Natural disaster, major accident, combat,
robbery/mugging, adulthood sexual assault, adulthood
rape, childhood physical abuse, childhood sexual abuse,
and witnessing of violence were assessed.
Depression and Anxiety DOI 10.1002/da
RESULTS
Descriptive analyses revealed that most of the total
sample (82%) reported a history of at least one trauma;
an average of 2.7 (SD 5 2.5) types of traumatic events,
and 5.9 (SD 5 7.5) incidences of trauma overall
regardless of type, were experienced. Specifically,
participants reported witnessing violence (48.1%), a
major life-threatening accident (46.5%), robbery/mug-
ging (24.8%), physical assault in adulthood (25.7%),
physical abuse in childhood (28.7%), sexual abuse in
childhood (26%), natural disaster (23.8%), adulthood
sexual violation (i.e., rape or sexual assault) (16.3%),
and combat (2%). The overall proportion of partici-
pants who met criteria for PTSD based on diagnostic
interview was 39.4%; of the participants who reported
experiencing at least one trauma, 49.4% met criteria
for PTSD. As a validity check, the PDS also was used
to determine diagnosis: based on self-report, 46.6%
of participants met criteria for PTSD, and 58% of
participants who experienced at least one trauma met
criteria for PTSD. On the basis of interview data,
w2 analyses further revealed that a diagnosis of PTSD
was higher in individuals who also met criteria for
major depressive disorder (MDD) [50%; w2(1) 5 6.14,
Po.01] or borderline personality disorder (BPD)
[100%; w2(1) 5 8.07, Po.01]. No additional DSM-IV-
TR disorders revealed significant findings. Further-
more, hierarchical linear regression analyses with all
assessed traumas entered simultaneously (with PTSD
severity as the criterion variable) indicated that
incestuous childhood sexual abuse (b 5 .32), witnessing
family violence (b 5 .30), witnessing non-family vio-
lence (b 5 .25), and experiencing a natural disaster
(b 5 .19) were the greatest predictors of PTSD severity
in our sample [F(12, 90) 5 5.67, Po.001, R 5 .67].
In addition, the greater the number of traumas endured
(b 5 .63), the higher the level of PTSD severity
experienced [F(1, 100) 5 65.49, Po.001].
DISCUSSION
The majority of individuals seeking treatment for
resistant OCD reported a history of traumatic experi-
ences (similar to community samples; Elliott [1997]).
The highest proportions reported a history of adult-
hood interpersonal violence (i.e., witnessing violence,
robbery, physical assault) and childhood interpersonal
violence (i.e., physical abuse, sexual abuse) that appears
higher than those found in prior studies [Lochner et al.,
2002]. In addition, incestuous childhood sexual
abuse and witnessing violence, and greater frequency
of traumatic experiences overall, were particularly
predictive of higher levels of PTSD severity.
Almost 40% of our overall sample met criteria for
PTSD, which appears higher than the approximately
9% [Breslau et al., 1991] and 28% [McFarlane et al.,
2001] found in community and general psychiatric
populations respectively, and similar to the 43% found
 Brief Report: Trauma, PTSD, and OCD
in a sample of ‘‘severe mental illness’’ [Mueser et al.,
1998]. Furthermore, about half of the individuals who
reported a history of trauma in our sample met criteria
for PTSD, which appears higher than the approximate
third who met criteria for PTSD in other clinical
samples [e.g., Rothbaum et al., 1992]. In addition,
PTSD prevalence appeared highest in individuals
who had an additional comorbid diagnosis of BPD or
MDD. BPD has been described as highly related to a
history of trauma and PTSD [e.g., Herman, 1997],
and individuals diagnosed with anxiety disorders may
be particularly vulnerable to MDD if they have a
history of trauma [Zlotnick et al., 1997]. Though
research has indicated that comorbid MDD and
personality disorders may individually predict poorer
treatment outcome for OCD [Steketee et al., 2001],
future research may wish to assess whether or not
MDD and BPD predict poorer treatment outcome for
OCD above and beyond the negative prediction
afforded by PTSD [Gershuny et al., 2002].
This study is not without limitations, and future
research is suggested. We relied on a non-random
sample of OCD treatment seekers, all of whom were
deemed treatment-resistant. Therefore, it is unclear
whether or not our findings would generalize to less
severe OCD (e.g., OCD that is amenable to treatment
success after one treatment trial) or to other anxiety
disorders, and we recommend that this be assessed in
future prevalence and comparative studies. However,
the constellation of our sample also may be conceptua-
lized as a strength in that it represents a naturalistic
group of individuals seeking treatment. Indeed, of all
the anxiety disorders (not including PTSD), OCD may
be considered the most potentially debilitating, and
treatment-resistant OCD is considered very common
[Hollander et al., 2002]. Because of our cross-sectional
methodological approach, causality of symptoms can-
not be inferred. For example, though some have argued
that a history of trauma and untreated PTSD may lead
to the development of treatment-resistant OCD [e.g.,
Gershuny et al., 2003; Pitman, 1993] or to treatment
resistance in OCD, others might argue that symptoms
of OCD could render someone particularly vulnerable
to developing PTSD after experiencing a trauma. We
recommend that future research assess the development
of symptoms prospectively to begin to disentangle this
question of causality.
Acknowledgments. Data gathering was supported
in part by a grant awarded to Dr. Gershuny from the
Obsessive Compulsive Foundation.
71
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