Posttraumatic obsessive-compulsive disorder: a three-factor model

Treating trauma-driven OCD with narrative exposure therapy alongside cognitive behavioural therapy

When post-traumatic stress disorder (PTSD) co-occurs with obsessive compulsive disorder (OCD), symptoms of the former can interfere with evidence-based treatment of the latter. As a result, exposure-based treatments are recommended for both OCD and PTSD, potentially facilitating a concurrent treatment approach. This case study describes the application of concurrent cognitive behaviour therapy (CBT including exposure and response prevention; ERP) for OCD and narrative exposure therapy to treat a patient whose PTSD symptoms of intrusive images of memories and hyperarousal were interfering with standard CBT (including ERP) treatment for OCD. Following this concurrent approach, the patient’s symptoms of OCD reduced to non-clinical levels and showed reliable improvement in PTSD symptoms. Whilst further methodologically robust research is required, this case study highlights that this approach may be beneficial to the treatment of OCD where PTSD symptoms are impacting on treatment.

Key learning aims

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Sexual Trauma, Cognitive Appraisals, and Sexual Intrusive Thoughts and Their Subtypes: A Moderated Mediation Analysis

The relationships between sexual trauma, cognitive appraisals, and subtypes of sexual intrusive thoughts have not been adequately examined in the context of obsessive-compulsive concerns. We employed variations of a moderated mediation model to test these relationships, situating sexual trauma as the predictor, sexual intrusive thoughts as the outcome, cognitive appraisals of these thoughts as the mediator, and subtypes of sexual intrusive thoughts as the moderator of the predictor-mediator link. Based on the continuum perspective, 180 individuals (159 females, 21 males) with or without a history of sexual trauma were recruited to complete measures assessing their most distressing sexual intrusion, cognitive appraisals, and severity of sexual intrusive thoughts. The results indicated that individuals with a history of sexual trauma reported more intrusions with sexual harm content, greater distress with sexual intrusions, more dysfunctional appraisals, and more severe sexual intrusions. The trauma-sexual intrusions link was also separately mediated by responsibility and importance/control appraisals (and when combined), with medium-to-large effect sizes, although this model was not moderated by whether intrusions contained sexual harm content or not. These findings shed light on the posttraumatic effects of sexual violence on sexual intrusions, their appraisals, and level of distress and functional impairment associated with sexual intrusive thoughts, with key clinical and research implications.

Interaction between PGRN gene and the early trauma on clinical characteristics in patients with obsessive-compulsive disorder

BACKGROUND

Emerging evidence suggests that obsessive-compulsive disorder (OCD) is caused by a combination of genetic predisposition and environmental factors. In this regard, abnormity of progranulin (PGRN, a key regulator of brain inflammation) and a history of childhood trauma have both been linked to an increased risk of developing OCD. This study is aimed to investigate the association between PGRN and childhood trauma in the development of OCD.

METHODS

We genotyped four single nucleotide polymorphisms (SNPs) covering PGRN in 484 OCD patients and 368 healthy controls. Among the OCD patients, 335 of them accepted clinical assessments in details. Generalized multifactor dimensionality reduction (GDMR) analysis and a general linear model were used to identify gene-environment interactions. The Braineac expression Quantitative Trait Loci (eQTL) dataset was used to analyze the differences in PGRN expression in various brain regions among different genotypes.

RESULTS

Our linkage disequilibrium analysis revealed that rs3859268-rs2879096-rs3785817 combined OCD and control groups constructed one haplotype block. The haplotype analysis suggested that TCA haplotype frequency was associated with the risk of developing OCD (Padj=0.03). The Braineac eQTL database revealed that rs2879096 and rs3785817 might be associated with PGRN expression in the hippocampus (Padj=0.00085, Padj=0.007). Emotional abuse was positively correlated with the obsession subscale and Y-BOCS total scores. Except for common trauma, physical abuse, emotional abuse and sexual trauma were all positively correlated with the BAI and BDI-II scores of OCD patients (all P<0.05). The interaction between emotional abuse and PGRN haplotype was associated with the development of depression symptoms in OCD patients corrected by age (Padj=0.043).

CONCLUSIONS

The PGRN gene and childhood trauma may be closely related to the incidence of OCD, and OCD patients who have experienced more childhood trauma may exhibit a more severe clinical symptom. The interaction between PGRN and the early trauma may play a critical role in the development of depression symptom in OCD patients.

Association Between Childhood Maltreatment and Symptoms of Obsessive-Compulsive Disorder: A Meta-Analysis

Background: Previous studies have indicated that childhood maltreatment (CM) may potentially influence the clinical symptomatology of obsessive-compulsive disorder (OCD). Here, we aimed to quantify the relationship between CM and obsessive-compulsive symptoms (OCS) and depressive symptoms in OCD through a meta-analysis. Method: We searched PubMed, Embase, Cochrane Library, and PsycARTICLES databases for articles reporting the association between CM and OCD on April 15, 2020. Random-effect models were used to quantify the relationship between CM and the severity of OCS and depressive symptoms in OCD. Results: Ten records with 1,611 OCD patients were included in the meta-analysis. The results revealed that CM is positively correlated with the severity of OCS [r = 0.10, 95%Confidence Interval (CI): 0.01-0.19, P = 0.04] as well as depressive symptoms in OCD (r = 0.15, 95%CI: 0.07-0.24, P = 0.0002). For the subtypes of CM, childhood emotional abuse (CEA) and childhood sexual abuse (CSA) was related with the severity of OCS (r = 0.11, 95%CI: 0.03-0.19, P = 0.009) and obsession (r = 0.13, 95%CI: 0.03-0.23, P = 0.01), respectively. Conclusion: Our meta-analysis indicates that OCD patients who suffered more CM may exhibit more severe OCS and depressive symptoms.

Relationship between childhood trauma and suicide probability in obsessive-compulsive disorder

The aim of this study is to assess the relationship between childhood trauma with the probability of suicide in obsessive compulsive disorders. Sixty-seven patients who were diagnosed with OCD were included in the study out of the patients who were admitted to Malatya Training and Research Hospital psychiatry outpatient clinic. The research data were collected using Yale Brawn Obsessive Compulsive Scale (YBOCS), Beck Depression (BDS) and Beck Anxiety Scales (BAS), Childhood Trauma Questionnaire-28 (CTQ-28), and Suicide Probability Scale (SPS). CTQ was detected as ≥ 35 in 36 of 67 patients who were included in the study. Aggression (p = 0.003), sexual (p = 0.007) and religious (p = 0.023) obsessions and rituelistic (p = 0.000) compulsions were significantly higher in the group with CTQ ≥ 35. Mild correlation was detected between the SPS score and the scores of CTQ. Correlation remained even when the effect of BAS and BDS scores were excluded. At the end of our study, childhood traumas were found to be associated with obsessive symptoms. In the group with childhood trauma, increased suicide probability was detected independently from depression and anxiety.

Acute obsessive compulsive disorder (OCD) in veterans with posttraumatic stress disorder (PTSD)

OBJECTIVES

Posttraumatic obsessions have been reported in a few studies and case series. However, as the patients described were chronic, and the onset of their posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) symptoms was dated some time previously, this hampers interpretation of the temporal, biological and psychological relationship of OCD following traumatic events. In the current paper we describe the emergence of posttraumatic obsessions a short time following the exposure to a traumatic event.

METHODS

The emergence of posttraumatic obsessions, a few months after exposure to trauma, is described for five veterans. All the veterans participated in combat during the summer of 2006 (in the Second Lebanon War).

RESULTS

For all cases, OCD symptoms were initially related to the trauma but later became generalized and independent.

CONCLUSIONS

The course of the symptoms suggests a potential environmental role in the development of OCD following an exposure to a traumatic event. These observations suggest a biological linkage between exposure to trauma and OCD.

High prevalence of obsessive-compulsive disorder among posttraumatic stress disorder patients

Posttraumatic obsessions have been reported in a few studies and case series. However, the magnitude of this phenomenon is still unknown. In the current study we systematically evaluated the prevalence of OCD in a sample of combat and terror related PTSD patients. Out of 44 referrals, 43% of the participants had PTSD with no OCD and 41% were diagnosed also with OCD. Six percent had sub-threshold OC symptoms. No difference was found between PTSD and PTSD-OCD participants' characteristics (including demographics, trauma-related factors, and other psychiatric co-morbidity). The surprisingly high number of OCD found in the current study suggests that PTSD-OCD might be underdiagnosed, signifies the importance of direct assessment of OCD in patients with PTSD, and raise questions regarding the underlying mechanism of post-traumatic OCD.

Restraint stress-induced reduction in prepulse inhibition in Brown Norway rats: role of the CRF2 receptor

Stress plays a role in many psychiatric disorders that are characterized by deficits in prepulse inhibition (PPI), a form of sensorimotor gating. Corticotropin-releasing factor (CRF) is one of the most important neurotransmitters involved in behavioral components of the stress response. Central infusion of CRF reduces PPI in both rats and mice. In mice, it has been shown that CRF(1) receptor activation mediates the effect of exogenous CRF on PPI. However, the roles of the two CRF receptors in a stress-induced reduction in PPI are not known. We sought to determine whether CRF(1) and/or CRF(2) receptor blockade attenuates a stress-induced reduction of PPI in rats. In separate experiments, we assessed PPI in Brown Norway rats after exposure to 5 days of 2-h restraint, and after pretreatment with the CRF(1) receptor antagonist, CP-154,526 (20.0 mg/kg), or the CRF(2) receptor antagonist, antisauvagine-30 (10.0 μg). Repeated, but not acute, restraint decreased PPI and attenuated the increase in PPI caused by repeated PPI testing. Blockade of the CRF(1) receptor did not attenuate the effect of repeated restraint on PPI or grooming behavior. While CRF(2) receptor blockade did attenuate the effect of repeated restraint on PPI, repeated ICV infusion of the selective CRF(2) receptor agonist urocortin III, did not affect PPI. These findings demonstrate the effect of stress on sensorimotor gating and suggest that the CRF(2) receptor mediates this effect in rats.

The effect of restraint stress on prepulse inhibition and on corticotropin-releasing factor (CRF) and CRF receptor gene expression in Wistar-Kyoto and Brown Norway rats

Stress plays a role in many psychiatric disorders that are characterized by deficits in prepulse inhibition (PPI), a form of sensorimotor gating. Corticotropin-releasing factor (CRF) is one of the most important neurotransmitters involved in behavioral components of the stress response, and central infusion of CRF decreases PPI in rodents. We recently demonstrated that restraint stress decreases PPI and attenuates the increase in PPI caused by repeated testing. To broaden our investigation into how restraint affects PPI, we subjected Wistar-Kyoto (WKY) and Brown Norway (BN) rats to 10 consecutive days of 2-hour restraint, or to brief handling, prior to assessing PPI. We next examined the effects of 1 or 10days of 2-hour restraint on plasma corticosterone levels in order to determine whether the endocrine response to stress parallels the behavioral effect of stress. Finally, we examined the effects of 1 or 10days of 2-hour restraint on CRF and CRF receptor gene expression in the amygdala, hippocampus, frontal cortex, and hypothalamus in order to determine whether a temporal pattern of gene expression parallels the change in the behavioral response to stress. The major findings of the present study are that 1) restraint stress attenuates the increase in PPI caused by repeated testing in both WKY and BN rats, and BN rats are more sensitive to the effects of restraint on PPI than WKY rats, 2) restraint-induced increases in corticosterone levels mirror the effect of restraint on PPI in WKY rats but not in BN rats, 3) laterality effects on gene expression were observed for the amygdala, whereby restraint increases CRF gene expression in the left, but not right, amygdala, and 4) some restraint-induced changes in CRF and CRF receptor gene expression precede changes in PPI while other changes coincide with altered PPI in a rat strain- and brain region-dependent manner.

Do traumatic events influence the clinical expression of compulsive hoarding?

Traumatic experiences have been posited as one potential catalyst for the abrupt onset of obsessive-compulsive symptoms including compulsive hoarding. To determine whether traumatic life events (TLEs) might influence the expression of compulsive hoarding in obsessive-compulsive disorder (OCD), interview responses to the Posttraumatic Stress Disorder module of the Structured Clinical Interview for DSM-IV (SCID) were examined in 180 individuals with OCD. Compared to individuals with OCD who did not meet criteria for hoarding, participants classified as hoarders (24% of the sample) were significantly more likely to have reported at least one TLE in their lifetime. Patients who met criteria for hoarding and who had also experienced TLEs had significantly greater hoarding symptom severity than those hoarders not exposed to trauma. This association was found to be robust. That is, the relationship between TLEs and hoarding symptom severity was not better accounted for by age, age of OCD onset, depressive symptoms, general OCD symptomatology, or mood and anxiety comorbidity. Closer examination revealed that the clutter factor of compulsive hoarding (and not difficulty discarding or acquisitioning) was most strongly associated with having experienced a traumatic event.

Posttraumatic obsessive-compulsive disorder: a case series

This report documents emerging posttraumatic obsessive-compulsive disorder in 13 Israeli military veterans diagnosed with both obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD), for whom the onset of OCD was clearly associated with the trauma. Data presented include four detailed case reports that delineate relations between symptomatology in the two disorders. Clinical and theoretical implications of these data are discussed.

Obsessive-compulsive symptomatology: a goal-directed response to anticipated traumatization?

Through the use of case material, this article traces the evolution of one individual's potentially adaptive response to traumatic stressors into obsessive-compulsive illness. The following discussion offers a conceptualization of trauma-induced obsessive-compulsive symptomatology that presents the phenomena as a predictable pattern of traumatic antecedents, anticipatory arousal, and a subsequent goal-directed motivational state to prevent anticipated traumatization. However, this hypothesis depends upon an expansion of our diagnostic understanding of traumatization to include interpersonal threat and how it might be symbolized by the individual seeking relief.