Co-occurring PTSD in intensive OCD treatment: Impact on treatment trajectory vs. response

BACKGROUND

Obsessive-compulsive disorder (OCD) and co-occurring posttraumatic stress disorder (PTSD) is associated with more severe and chronic OCD. However, findings regarding treatment effectiveness of cognitive behavioral treatment (CBT) with exposure and response prevention (ERP) with this comorbidity are mixed. Research aimed at understanding the precise barriers to OCD treatment effectiveness for individuals with co-occurring PTSD may help elucidate unique treatment needs.

METHODS

The current study used linear regression and latent growth curve analysis comparing treatment response and trajectory from patients with OCD (n = 3083, 94.2 %) and OCD + PTSD (n = 191, 5.2 %) who received CBT with ERP in two major intensive OCD treatment programs.

RESULTS

Although patients with OCD + PTSD evidenced similar trajectories of overall severity change, patients at one site required nearly 11 additional treatment days to achieve comparable reduction in OCD severity. Further, at the dimensional level, those with OCD + PTSD had poorer treatment response for unacceptable thoughts and symmetry symptoms. The moderate effect for unacceptable thoughts, indicating the widest gap in treatment response, suggests these symptoms may be particularly relevant to PTSD.

LIMITATIONS

Findings are limited by a naturalistic treatment sample with variation in treatment provision.

CONCLUSIONS

Findings emphasize caution in using a one-size-fits-all approach for patients with co-occurring OCD + PTSD within intensive OCD treatment programs, as broadly defined outcomes (e.g., reduction in overall severity) may not translate to reduction in the nuanced symptom dimensions likely to intersect with trauma. Unacceptable thoughts and symmetry symptoms, when co-occurring with PTSD, may require a trauma-focused treatment approach within intensive OCD treatment.

The clinical presentation of major depressive disorder in youth with co-occurring obsessive-compulsive disorder

BACKGROUND

Major depressive disorder (MDD) is common in youth and among the most frequent comorbid disorders in pediatric obsessive-compulsive disorder (OCD), but it is unclear whether the presence of OCD affects the symptom presentation of MDD in youth.

METHODS

A sample of youth with OCD and MDD (n = 124) and a sample of youth with MDD but no OCD (n = 673) completed the Patient Health Questionnaire for Adolescents (PHQ-A). The overall and symptom-level presentation of MDD were examined using group comparisons and network analysis.

RESULTS

Youth with MDD and OCD, compared to those with MDD and no OCD, had more severe MDD (Cohen's d = 0.39) and more reported moderate to severe depression (75 % vs 61 %). When accounting for demographic variables and the overall severity of MDD, those with comorbid OCD reported lower levels of anhedonia and more severe difficulties with psychomotor retardation/agitation. No significant differences in the interconnections among symptoms emerged.

LIMITATIONS

Data were cross-sectional and self-reported, gold standard diagnostic tools were not used to assess OCD, and the sample size for the group with MDD and OCD was relatively small yielding low statistical power for network analysis.

CONCLUSIONS

Youth with MDD and OCD have more severe MDD than those with MDD and no OCD and they experience more psychomotor issues and less anhedonia, which may relate to the behavioral activation characteristic of OCD.

Disclosure of traumatic details and obsessive-compulsive contamination symptoms in sexual assault survivors

OBJECTIVE

Contamination concerns are common following sexual victimization and are associated with increased attentional bias and difficulty disengaging from contamination cues. While most survivors of sexual trauma disclose their experience to others, it is unclear whether disclosure increases feelings of contamination or whether, consistent with the fever model of disclosure, existing contamination-related distress increases the amount of content shared during disclosure, indicative of attentional bias toward contamination-inducing aspects of the trauma memory.

METHOD

Accordingly, the current study examined the directionality and relationships between contamination symptoms and content shared during sexual assault disclosure in 106 sexual assault survivors (76.4% women). Forced decision regression with subsequent independence test (RESIT) was used to identify directionality of relationships, and multivariate and linear regressions examined these proposed effects in the presence of assault and demographic characteristics.

RESULTS

More severe contamination symptoms predicted greater sharing of details during sexual assault disclosure yet had no impact on sharing of emotions, cognitions, and beliefs during disclosures. Although RESIT suggested that contrary to other content domains, disclosure of social experiences may directionally predict contamination symptoms, this relationship did not retain statistical significance in a linear regression model.

CONCLUSIONS

Findings support the fever model of disclosure and attentional bias theories regarding contamination-related stimuli, and suggest that survivors experiencing postassault contamination symptoms may be more likely fixate on the contamination-invoking details of the trauma memory when disclosing. Such fixation has the potential to interfere with typical treatment-related processes (e.g., habituation) and should be thoughtfully addressed to maximize treatment gains. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Assessment of Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are commonly comorbid and share prominent features (e.g., intrusions, safety behaviors, and avoidance). Excellent self-report and clinician-administered assessments exist for OCD and PTSD individually, but few assess both disorders, and even fewer provide instruction on differential diagnosis or detection of comorbid OCD and PTSD. To address this gap in the literature, the current paper aims to (1) highlight diagnostic and functional similarities and differences between OCD and PTSD to inform differential diagnosis, (2) outline assessment recommendations for individuals with suspected comorbid OCD and PTSD, OCD with a significant trauma history or posttraumatic symptoms, or PTSD with significant obsessive-compulsive symptoms, and (3) explore future directions to evaluate and improve methods for assessing co-occurring OCD and PTSD.

Common rituals in obsessive-compulsive disorder and implications for treatment: A mixed-methods study

Obsessive-compulsive disorder (OCD) is characterized by engagement in rituals that serve to obtain certainty and prevent feared outcomes. Exposure and response prevention is most effective when rituals are resisted, yet existing self-report measures of OCD limit identification of the full range of possible rituals, and little is known about how rituals might cluster together and predict worsened severity and poorer treatment outcomes. In a retrospective sample of 641 adult patients who received intensive OCD treatment, the present study used a mixed-methods approach to (a) identify and validate treatment provider-identified rituals using the Yale-Brown Obsessive-Compulsive Scale, (b) identify clustering patterns of rituals, and (c) examine the impact of these clusters on severity and treatment outcomes. Sixty-two discrete rituals clustered into eight higher order ritual clusters: avoidance, reassurance, checking, cleaning/handwashing, just right, rumination, self-assurance, and all other rituals. At admission, reassurance predicted greater intolerance of uncertainty (IU) and rumination predicted less OCD severity. Only one ritual cluster-just right-predicted treatment outcomes; patients with just right rituals had worse IU at discharge and significantly longer length of treatment (average 7.0 days longer). Clinical observation can identify more nuanced and individualized rituals than self-report assessment alone. Patients presenting with just right rituals may benefit less from treatment focused on harm avoidance and habituation; instead, treatment should be tailored to the idiosyncrasies of incompleteness and not just the right experiences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Causal attributions and OCD treatment response: A linguistic analysis of OCD patients' self-reported etiological explanations in intensive residential treatment

In the present study, 43 obsessive-compulsive disorder (OCD) patients receiving cognitive-behavior therapy (CBT)/exposure and response prevention (ERP) in an intensive residential treatment program responded to an open-ended question about causal attributions (i.e., personal explanations for the etiology of their OCD) at baseline and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) at baseline and treatment discharge. Baseline self-reported responses about causal attributions were qualitatively coded to derive predictors (biological/genetic, environmental, psychological, and interactional attributions). Predictors were entered into a binary logistic regression with Y-BOCS responder status (at least partial response [≥25% pre-post reduction] vs. no response) as the outcome. After controlling for length of stay and number of comorbid psychiatric diagnoses, only biological/genetic attributions uniquely predicted increased odds of treatment response, odds ratio = 10.04, p = 0.03. Biological/genetic attributions may reduce self-blame for symptoms or increase expectancy violation likelihood during treatment, thereby improving odds of response. Clinicians should assess OCD patients' causal attributions as part of routine clinical care to hopefully optimize treatment outcomes.

Symptom severity and presentation in comorbid OCD and PTSD: A clinical replication

Individuals with comorbid obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) experience more severe OCD symptoms and poorer treatment response. Despite some evidence linking OCD symptom domains to trauma, only one study to date has examined typical OCD and PTSD presentations in individuals with OCD+PTSD, and findings were based on a nonclinical sample. The current study sought to replicate findings in a clinical sample of 1,014 patients diagnosed with OCD (n = 928), PTSD (n = 40), and OCD+PTSD (n = 46) in specialty OCD and anxiety treatment programs. Consistent with previous research, patients with OCD+PTSD reported more severe OCD yet similar severity PTSD symptoms and did not evidence a unique phenotypic presentation once symptom overlap and comorbid mood and personality disorders were considered. OCD+PTSD is equally as heterogeneous as OCD and PTSD alone. Implications for the research and treatment of OCD+PTSD are discussed, and assessment and treatment recommendations are provided.

Introduction to the Special Issue: Conceptualization, Assessment, and Treatment of Obsessive-Compulsive Disorder and Co-Occurring Conditions

Obsessive-compulsive disorder (OCD) has a lifetime prevalence of 1%-2% and typically presents as a chronic condition with significant functional impairment. Comorbidity with OCD is the norm, with 90% of individuals with OCD also meeting diagnostic criteria for a co-occurring condition. Co-occurring conditions can complicate the conceptualization, assessment, and treatment of OCD, such as by intensifying existing symptoms, obscuring differential diagnosis of phenotypically and functionally similar symptoms, and interfering with cognitive behavioral treatment. This two-part special issue reviews extant literature and provides expert advice on conceptualizing, assessing, treating, and researching OCD with co-occurring conditions of depression, posttraumatic stress disorder, eating disorders, schizophrenia, hoarding disorder, panic disorder, obsessive-compulsive personality disorder, and illness anxiety disorder.

Call to Action: Recommendations for Justice-Based Treatment of Obsessive-Compulsive Disorder With Sexual Orientation and Gender Themes

Gender and sexual minorities are subjected to minority stress in the form of discrimination and violence that leads to vigilance; identity concealment and discomfort; and internalized homophobia, biphobia, and transphobia. These experiences are related to increased susceptibility to mental health concerns in this population. Historically, the behavioral treatment of sexual orientation (SO) and gender-themed obsessive-compulsive disorder (OCD) has inadvertently reinforced anti-lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) stigma and contributed to minority stress in clients, treatment providers, and society at large. We present updated recommendations for treatment of SO- and gender-themed OCD through a more equitable, justice-based lens, primarily through eliminating exposures that contribute to minority stress and replacing them with psychoeducation about LGBTQ+ identities, and exposures to neutral and positive stimuli, uncertainty, and core fears. We also present recommendations for equitable research on SO- and gender-themed OCD.

Efficacy of intensive CBT telehealth for obsessive-compulsive disorder during the COVID-19 pandemic

Despite evidence for the effectiveness of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD), many individuals with OCD lack access to needed behavioral health treatment. Although some literature suggests that virtual modes of treatment for OCD are effective, it remains unclear whether intensive programs like partial hospitalization and intensive outpatient programs (PHP and IOPs) can be delivered effectively over telehealth (TH) and within the context of a global pandemic. Limited extant research suggests that clinicians perceive attenuated treatment response during the pandemic. The trajectory and outcomes of two matched samples were compared using linear mixed modeling: a pre-COVID in-person (IP) sample (n = 239) and COVID TH sample (n = 239). Findings suggested that both modalities are effective at treating OCD and depressive symptoms, although the pandemic TH group required an additional 2.6 treatment days. The current study provides evidence that PHP and IOP treatment delivered via TH during the COVID-19 pandemic is approximately as effective as pre-pandemic IP treatment and provides promising findings for the future that individuals with complicated OCD who do not have access to IP treatment can still experience significant improvement in symptoms through TH PHP and IOP treatment during and potentially after the pandemic.

Does a unique co-occurring OCD and PTSD factor structure exist?: Examination of overlapping OCD and PTSD symptom clusters

OCD and PTSD share many commonalities, including phenotypic and functional overlap in symptoms. Specifically, both disorders are characterized by unwanted, intrusive, anxiety/distress-eliciting intrusive thoughts and evoking behaviors intended to control, neutralize, suppress, or outright avoid intrusive thoughts and associated anxiety/distress. Extant factor analytic research supports a model of PTSD at odds with current DSM-5 criteria, and no examination of the factor structure of comorbid OCD+PTSD currently exists despite the noted overlap in symptomatology and high rates of comorbidity. Using a sample of 4073 patients diagnosed with OCD and/or PTSD enrolled in intensive treatment programs for OCD or PTSD, multigroup confirmatory factor analysis (MGCFA) and measurement invariance tests were run to determine the best fitting model of OCD and PTSD symptoms in patients with OCD+PTSD. Four models were compared across patients with OCD, PTSD, and OCD+PTSD: DSM-5 and 7-factor hybrid PTSD models with OCD symptoms structured as either combined or comorbid constructs. The comorbid hybrid model proved the best fit, and both hybrid models evidenced better fit than DSM-5 models. The current study lends additional support for the hybrid model of PTSD and suggests that there is no existence of a unique factor structure of OCD and PTSD symptoms in individuals with the comorbid conditions.

Reappraisal Bias and Sexual Victimization: Testing the Utility of a Computerized Intervention for Negative Post-Assault Support Experiences

Women are at notable risk for negative reactions from others following sexual victimization which serve to intensify negative post-traumatic outcomes. The current study tested the effectiveness of cognitive bias modification-appraisal (CBM-App) training targeting post-traumatic cognitions theorized to be impacted by positive and negative social support with 45 female undergraduates, grouped by experiencing overall positive or negative post-assault support. Whereas all participants experienced improvements in post-traumatic cognitions at 1-week follow-up, a crossover effect for intrusion symptoms was found; CBM-App training reduced intrusions in participants with negative support experiences yet increased intrusions in participants with positive support experiences. While findings highlight the need for careful selection of post-trauma interventions, the study is the first to integrate findings from CBM-App, sexual assault, and social support literature. Socially relevant post-traumatic cognitions appear to be malleable and may be an important focus of treatment for survivors who experienced negative post-assault support.

The Influence of Sexual Assault Resistance on Reporting Tendencies and Law Enforcement Response: Findings From the National Crime Victimization Survey

Despite its prevalence, sexual assault remains a vastly underreported crime. Previous research suggests that engagement in certain types of resistance during an assault affects the way in which both victims and others perceive the attack; such perceptions influence victims' likelihood of reporting the assault to law enforcement as well as the criminal justice system response to reported allegations. Using a fight/flight/freeze theoretical framework, the current study sought to examine how forceful, nonforceful, and freeze responding influenced victim reporting and the extent to which reported assaults were pursued and investigated by law enforcement. Using data from the National Crime Victimization Survey between 2010 and 2016, logistic regression analysis indicated that victims are significantly less likely to report to law enforcement if they froze during the attack. Interestingly, although engagement in forceful resistance increases victims' likelihood of reporting to law enforcement, it has no bearing on law enforcement response beyond the effect of physical injury. Rather, physical injury (e.g., bruises, cuts, broken bones) is the only predictor of law enforcement response to sexual assault allegations. Findings suggest that whereas fight and freeze responses to sexual victimization influence victims' willingness to report to law enforcement, resistance is not uniquely predictive of law enforcement response once physical injury is considered.

OCD in the time of COVID-19: A global pandemic's impact on mental health patients and their treatment providers

Individuals with obsessive-compulsive disorder (OCD) have evidenced resilience against large-scale crises, although emerging research on the impact of COVID-19 is mixed. Little is known about the impact of COVID-19 on mental health providers. Items from an instrument evaluating the impact of the September 11, 2001, terrorist attack were adapted to measure the impact of COVID-19 on emotions, cognitions, and behaviors. Using a sample of 65 patients with primary OCD diagnoses and OCD treatment providers in intensive programs for OCD and anxiety, the authors found that COVID-19 evidenced a less significant overall impact on patients than providers. Specifically, providers reported more significant impact on the amount of time spent worrying about COVID-19, taking additional cleaning and sanitization precautions, and time spent socializing with loved ones. Findings support previous literature indicating that individuals with OCD demonstrate resilience to large-scale crises, and offer insights into the specific struggles of providers who treat OCD.

Intolerance of uncertainty and obsessive-compulsive disorder dimensions

Intolerance of uncertainty (IU), which can include prospective (i.e., desire for predictability) and inhibitory (i.e., uncertainty paralysis) IU, is widely understood to be a central underlying component of obsessive-compulsive disorder (OCD). IU has several treatment implications, yet research on the differences in IU underlying OCD dimensions is limited and does not account for covarying effects of overlapping symptoms, shared variance in IU, demographic variables, and comorbid psychiatric conditions like generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). A sample of 974 patients with diagnosed OCD enrolled in residential, partial hospitalization, and intensive outpatient treatment programs for OCD and anxiety completed self-report measures of OCD symptoms and IU at admission. Structural equation modeling included prospective. inhibitory IU, and common IU and covariates (i.e., race, ethnicity, level of care, and comorbid GAD and PTSD) as predictors of four common OCD dimensions found that contamination and unacceptable thoughts symptoms evidenced a unique relationship with IU. Specifically, whereas a common IU factor predicted all four OCD symptom dimensions, inhibitory IU uniquely predicted contamination and unacceptable thoughts symptoms over and above covarying effects. Individuals with contamination and unacceptable thoughts symptoms may be more likely to feel "paralyzed" by uncertainty due to overreliance on overt immediate rituals, outright avoidance, rumination, or difficulties with emotion regulation, and may benefit from additional psychoeducation, problem-solving, and accountability. Broadly, individuals with OCD may benefit from explicit discussions about IU-related expectancies and disconfirmation of fears.

Psychometric Properties of the Institutional Betrayal Questionnaire, Version 2: Evidence for a Two-Factor Model

Institutional betrayal reflects the failings of a trusted institution to prevent or respond appropriately to negative experiences. Following sexual assault, survivors who encounter institutional betrayal may experience greater distress and poorer functioning. The current study sought to assess the construct validity of the Institutional Betrayal Questionnaire, Version 2 (IBQ.2) and evaluate its factor structure. Survivors of sexual assault (N = 426) were recruited via Amazon Mechanical Turk and completed various questionnaires related to mental health, disclosure and assault characteristics, world beliefs, and rape myth adherence. The IBQ.2 demonstrated convergent validity with disclosure to formal support providers, assault severity, turning against reactions, and beliefs about self-control, and evidenced discriminant validity with disclosure timing, rape myth adherence, and beliefs about randomness and controllability of outcomes. Notably, the IBQ.2 was unrelated to measures of distress, including symptoms of stress, depression, anxiety, and posttraumatic stress disorder, providing mixed evidence for the IBQ.2's construct validity. Confirmatory factor analyses failed to replicate the single-factor model of institutional betrayal found in a previous study, and, instead, suggested a two-factor structure of the IBQ.2 that delineates between the promotion of and response to sexual victimization. Post hoc analyses revealed that only one of the two factors (Response to Sexual Victimization) evidenced convergent and discriminant validity largely consistent with the single-factor model. The novelty of these relationships and factor structure of the IBQ.2 found in the current study warrants replication in future research.

Institutional Betrayal: Who Is Most Vulnerable?

Institutional betrayal occurs when, following sexual victimization, institutions create hostile environments which normalize sexual violence, make it difficult to report the experience, mishandle the complaint, attempt to cover up the experience, or retaliate against survivors. These responses are not uncommon and have been linked to adverse survivor outcomes such as dissociation, anxiety, sexual dysfunction, poorer physical health, and depression, yet little is known about which survivors are most at risk for experiencing institutional betrayal. Using a sample of 404 sexual assault survivors recruited from Amazon Mechanical Turk, the current study employed logistic regression to identify risk factors for institutional betrayal. The findings indicate that institutional betrayal is more likely to be reported by survivors who identify as heterosexual, were older at the time of the assault, and endorse more severe PTSD symptoms yet, unexpectedly, less severe distress severity. Gender, race, assault characteristics, and disclosure tendencies did not significantly predict institutional betrayal risk. Although some relationships may be bidirectional, the results suggest that survivors already at risk for some negative post-assault outcomes may be particularly at risk for institutional betrayal.

Understanding Gender Differences in Rape Victim Blaming: The Power of Social Influence and Just World Beliefs

Victims of sexual violence are frequently blamed by friends, family, or legal personnel in the aftermath of an attack, with men attributing greater blame on average than women. Victims' experiences of being blamed may generate a vicious cycle in which they are more likely to be blamed in the future. Moreover, just world beliefs (JWB) have been studied extensively as an underlying cognitive mechanism that predicts greater blame. Studies examining the influence of social support on blame have yet to examine the unique role of JWB on these attributions. The current study examined blame attribution of a fictional rape victim who received either positive, negative, or neutral support from friends and family in a sample of 383 undergraduate men and women. Individually, social support and JWB were both significant predictors of blame, and women were more influenced by social support than men; specifically, gender was a more salient predictor of blame toward the positively supported victim, suggesting that positive support received by friends and family may evoke a domino effect of support from other women. Conditional effects revealed that JWB were most influential on blame when responding to the positively supported victim. Implications and suggestions for future research are discussed.

It Won't Happen to Me: An Examination of the Effectiveness of Defensive Attribution in Rape Victim Blaming

Defensive attribution posits that victim blame results from one's underlying perception of vulnerability. The resulting blame is believed to reduce perceived similarity to the victim and vulnerability to victimization, though extant research has neglected to examine its effectiveness in men and women. The current study employed multigroup analysis structural equation modeling with 618 male and female undergraduates exposed to fictional police reports of a reported rape. The theory was partially supported; among women, defensive attribution of blame effectively reduced perceived vulnerability to sexual victimization, whereas among men, blame had no effect on perceived similarity or vulnerability. Recommendations for interventions to target perceived vulnerability are discussed.

Reliability and Findings From an Instrument Examining Sexual Assault Disclosure Content and Context: The Sexual Assault Inventory of Disclosure

Compared to the depth of research examining the impact of sexual assault disclosure and related responses from others, little is known about the content shared during disclosures. Categorizing survivors as disclosers or nondisclosers disregards the nuanced and complex nature of disclosure. To address this gap, the current studies examined the reliability and preliminary results of the Sexual Assault Inventory of Disclosure (SAID), an inventory of content shared during disclosures and the context in which it was shared. The SAID proved reliable and preliminary findings suggest that perceptions of disclosures as positive or negative are predicted by differences in content and context, above and beyond disclosure recipients' response. The current study also explored gender differences in disclosure. Additional findings, implications, and suggestions for future studies using the SAID are discussed.

Re-Examining the Relationship Between Avoidance and Post-Traumatic Stress Symptoms in Rape Survivors Enrolled in Self-Defense Training: The Protective Effect of Activities Self-Efficacy

Although many women do not report sexual victimization as motivation for seeking self-defense training, differences in self-efficacy suggest that self-efficacy deficits may influence survivors' desire to seek training. Lower self-efficacy, thought to negatively influence perceived confidence in one's ability to engage in everyday activities, may relate to avoidance of mundane activities and cause exacerbation of post-traumatic stress symptoms (PTSS). The current study examined a three-way interaction modeling the relationships between history of rape, activities self-efficacy, activities avoidance, and PTSS in a diverse sample of 233 women enrolled in self-defense training. Results suggest that survivors who avoid everyday activities experience increased PTSS, but this effect is mitigated by perceived self-efficacy to engage in these activities. Activities self-efficacy may promote resilience in rape survivors regardless of whether they actually engage in such activities. Training that targets self-efficacy, rather than actual engagement in activities, may be sufficient to reduce PTSS in rape survivors.

Barriers to self-compassion for female survivors of childhood maltreatment: The roles of fear of self-compassion and psychological inflexibility

Preliminary evidence has demonstrated the benefits of targeting self-compassion in the treatment of posttraumatic stress disorder (PTSD). However, survivors of childhood maltreatment may present with unique challenges that compromise the effectiveness of these and other PTSD treatments. Specifically, childhood maltreatment victims often exhibit a marked fear and active resistance of self-kindness and warmth (i.e., fear of self-compassion). Victims may also attempt to control distressing internal experiences in a way that hinders engagement in value-based actions (i.e., psychological inflexibility). Research suggests that psychological inflexibility exacerbates the negative effects of fear of self-compassion. The present study expanded on previous research by examining the relations among childhood maltreatment, fear of self-compassion, psychological inflexibility, and PTSD symptom severity in 288 college women. As expected, moderate to severe levels of childhood maltreatment were associated with greater fear of self-compassion, psychological inflexibility, and PTSD symptom severity compared to minimal or no childhood maltreatment. A mediation analysis showed that childhood maltreatment had a significant indirect effect on PTSD symptom severity via fear of self-compassion, although a conditional process analysis did not support psychological inflexibility as a moderator of this indirect effect. A post hoc multiple mediator analysis showed a significant indirect effect of childhood maltreatment on PTSD symptom severity via psychological inflexibility, but not fear of self-compassion. These findings highlight the importance of addressing fear of self-compassion and psychological inflexibility as barriers to treatment for female survivors of childhood maltreatment.