Obsessive–compulsive disorder and trauma-related distress:
OCD is a neuropsychological disorder characterized by intrusive and uncontrollable obsessions and compulsions that cause significant distress to the individual
Obsessions are thoughts, urges, or images that the individuals experience as unwelcome and invasive. These obsessions cause discomfort to the individual with OCD by being anxiety provoking, guilt inducing, and/or disgust-laden.
Depending on the nature of the obsession. The individual with OCD will actively try to avoid, subdue, or neutralize the obsession by engaging in avoidant behaviour or compulsions (APA, 2013). OCD is a highly individualized disorder.
Obsessions may seem extremely illogical, counterintuitive, and disconnected, and yet themes of obsessions have been found across the population.
The obsessional themes into the following categories:
(a) contamination;
(b) guilt and responsibility for harm (to self or others);
(c) uncertainty;
(d) taboo thoughts about sex, violence, and blasphemy; and
(e) the need for order and symmetry”
With OCD, the compulsions that follow obsessional thoughts, images, or urges play the specific role of decreasing discomfort for the client, but do not appear to be logically connected to the obsession (APA, 2013). For example, if an individual with OCD experiences an obsessional thought, such as “my family and friends are going to get hurt”, he or she may neutralize this obsession by feeling the compulsive need to turn the light switch on and off eight times before leaving the house. When this compulsion reduces the anxiety the client feels, the obsessional thought may then morph into the thought that “my family and friends will get hurt if I don't turn the light switch on and off eight times”.
The majority of people recognize that their obsessions and compulsions are unreasonable; nevertheless, there is a small portion of clients (approximately 4%) who have “absent insight/delusional beliefs” about their obsessions and compulsions (APA, 2013, p. 237).
Trauma-related distress has been defined as psychological distress as a direct result of experiencing a stressful event (APA, 2013). The psychological distress typically manifests as intrusive thoughts (e.g. flashbacks, nightmares, and hypervigilance), which are typically about the traumatic event experienced.
The symptoms that an individual may experience are variable and situationally dependent.
At times, the symptoms are clearly anxiety or fear oriented. At other times, the clinical picture includes depressive symptoms, anger and aggression, or dissociation. Any combination of these symptoms may be present after the exposure to an aversive or distressing event (APA, 2013).
Conceptually, the overlap between OCD and trauma-related distress can be found in the way the individual thinks about and reacts to the intrusive thoughts inherent in the two situations.
Several theories of understanding OCD have been suggested over the years. The author will draw on PTSD research for understanding various models of trauma-related distress.1.2.1. Cognitive-behavioural models of OCDPsychological models suggest that OCD develops out of a unique relationship between an individual's psychological functioning and his/her environment.
Cognitive-behavioural models are the most widely accepted theories in explaining and understanding OCD (Craighead et al., 2013). Beck theorized in 1976 that dysfunctional adaptation is not a result of specific events, but rather an individual's inability to process and make sense of a said event (as cited in Craighead et al., 2013). Intrusive thoughts are experienced by roughly 80–90% of the general population (Briggs & Price, 2009).
Despite the common occurrence of intrusive thoughts, the majority of people do not develop OCD.
Normal intrusive thoughts transition into clinical obsessions when the individual takes on personal significance or responsibility for the thought.
For example, an individual on vacation may experience the intrusive thought that someone is breaking into his/her home while he/she is away. The majority of the population would dismiss this thought as being insignificant and would relatively quickly assume that he/she has locked the door and all is well. A small portion of the population, however, would not be able to dismiss this thought and it may turn into a clinical obsession. The individual would then take on personal responsibility for events related to the thought (i.e. “if I think about it, it is sure to happen” or “I must take extra precaution to ensure it does not happen”).
These thoughts would then become so intrusive that the individual would need to complete some action (i.e. refusing to go on holidays, replacing the negative thought with a positive thought, or checking that the door is locked a certain number of times before leaving) in order to reduce the distress he/she is feeling (Craighead et al., 2013).
Salkovskis, in 1985, was one of the first to develop a comprehensive cognitive-behavioural understanding of OCD. Previously, the most widely accepted theory was a behavioural model, which ignored the obvious link between cognition and psychopathology. Salkovskis (1985) combined the largely accepted behavioural theory with the relatively new cognitive theory. He believed that by combining behavioural and cognitive theories and treatments, clinicians would be able to use new approaches to intervene on treatment-resistant OCD.
According to Salkovskis (1985), each person encounters potentially triggering stimuli at many points throughout any given day. Individuals who struggle with obsessional thinking, however, will actively avoid encountering potentially triggering stimuli.
Salkovskis (1985) defines these intrusive thoughts as inherently ego dystonic (“the content is inconsistent with the individual's belief system, and is perceived as objectively irrational”, p. 578), and thus, the individual's reaction is determined by how impacting the intrusive thought is for the individual person. When the intrusive thought is viewed as being important and the individual places meaning on it, the person's belief system is shifted.
The person takes on ownership, responsibility, or blame for the intrusive thoughts, which become automatic thoughts that are ego syntonic and result in affective disturbances (Salkovskis, 1985).In Salkovskis’ (1985) model, next the individual may engage in neutralizing behaviour in order to reduce distress, which, if successful, reinforces the neutralizing behaviour. Even if the neutralizing behaviour does not reduce the anxiety, the unwanted event may not happen.
For many, this is also a strong reinforcer and may also encourage more neutralizing behaviour in the future. If neither of the previous scenarios takes place, the neutralizing behaviour may become a powerful and unavoidable trigger in and of itself. Admittedly, Salkovskis (1985) identified a few challenges associated with his cognitive-behavioural model of OCD.
Nevertheless, his theory created the groundwork for more advancement of the cognitive-behavioural understanding of OCD.In 1997, Rachman proposed a cognitive theory of obsessions, which was developed out of the aforementioned cognitive theory of OCD from Salkovskis (1985). In this theory, Rachman (1997) suggests, “obsessions are caused by catastrophic misinterpretations of the significance of one's intrusive thoughts” (p. 793).
As noted previously, most people experience intrusive thoughts, but Rachman (1997) identifies some differences between typically intrusive thoughts and atypical obsessional thoughts.
Obsessions last longer, are more intense, more persistent, cause more distress, and create more lasting impact on the individual (Rachman, 1997, p. 793) and yet the content of typical and atypical intrusive thoughts are quite similar. Additionally, Rachman (1997) identified the key element that differentiates typical obsessions with problematic obsessions; namely, meaning.
The meaning that an individual places on an intrusive thought, whether it be interpreting these thoughts as being “very important, personally significant, revealing, threatening, or catastrophic” (Rachman, 1997, p. 794), can shift a universally experienced and dismissed thought to an unavoidable obsession. Rachman's (1997) theory also suggests obsessions are more likely to occur when an individual is exposed to stressful situations and that external cues often trigger obsessional thoughts.
The more stressful the external cues, the greater the frequency of intrusive/obsessional thoughts, the greater the distress the individual will likely feel (Rachman, 2002).
These stressful situations may be traumatic and/or aversive, which may provide evidence for the link between trauma and OCD. In 2002, Rachman suggested a similar theory for compulsions (specifically, compulsive checking).
He suggested that compulsions occur when an individual believes he/she has a special responsibility to prevent unwanted events from occurring. Again, this theory can be applied to an understanding of trauma-related distress. If an individual feels responsible to prevent the traumatic event from reoccurring, he/she may respond with compulsions (as in OCD) or hypervigilance (in PTSD) or some other attempt to neutralize the anxiety experienced (Rachman, 1998).1.2.2. Cognitive-behavioural models of PTSDTraumatic events result in primarily psychological symptoms; namely, “repeated and unwanted re-experiencing of the event, hyperarousal, emotional numbing, and avoidance of stimuli (including thoughts) which could serve as reminders for the event” (Ehlers & Clark, 2000, p. 319).
As with OCD, many people experience at least some of these symptoms at some point in their lives. Most people's symptoms dissipate after a few months and no longer cause distress. There is a subgroup of the population, however, who experience these symptoms for many years after the event.
As will be noted, cognitive-behavioural models of PTSD contain many similarities with cognitive-behavioural models of OCD.As with OCD, PTSD problems begin with the individuals' thought appraisal. An individual is required to interpret and/or make meaning of the traumatic event and/or the thoughts immediately following the traumatic event (Ehlers & Clark, 2000).
The individual interprets the events or event-related thoughts in a way that produces an immediate sense of threat or danger. As with OCD while the individual interprets intrusive thoughts as being personally significant and/or meaningful, individuals with PTSD interpret their intrusive thoughts about the traumatic event as being current, real, and personally significant. According to Ehlers and Clark (2000), this negative appraisal leads to an external threat (e.g. the world is unsafe) or, often, an internal threat (e.g. I am incapable of achieving the things I want in life).
Furthermore, individuals can interpret events and event-related thoughts in a number of different ways: (1) they may interpret the threat as being more common by overgeneralizing the probability of threat reoccurrence; (2) they may interpret their emotional reactions as being revealing about who they are as a person (this can be seen in OCD, as well); and (3) they may interpret the event or event-related thoughts as having catastrophic consequences (again, similar to OCD); etc. (Ehlers & Clark, 2000).
Another similarity between cognitive-behavioural models of OCD and PTSD is the effort to neutralize the negative consequences of the misinterpretation of intrusive thoughts. The neutralization strategies used in PTSD range from thought suppression to safety behaviours, to isolation, etc. (Ehlers & Clark, 2000).
The neutralizing behaviours anticipated to manage the distress experienced by the individual are dysfunctional for three reasons: (1) resulting in PTSD symptoms; (2) inhibiting change in negative interpretations of the trauma and/or trauma-related thoughts; and (3) inhibiting change in the nature of the trauma memory (Ehlers & Clark, 2000, p. 328).
The cognitive-behavioural model of understanding OCD has been combined with a trauma-response model of OCD to better understand the impact of traumatic experiences on the onset, development, maintenance, and treatment of OCD.
2. OCD and traumaA traumatic event, as defined in the DSM-V (APA, 2013), is the “exposure to actual or threatened death, serious injury, or sexual violence … ” (p. 271). The author is suggesting a more liberal definition of trauma. Perhaps labelling it as “adverse experiences” or “stressful life events” (Briggs & Price, 2009; Fontenelle et al., 2012; McLaren & Crowe, 2003; Real et al., 2011; Rosso, Albert, Asinari, Bogetto, & Maina, 2012) would be more appropriate. Regardless, the author defines traumatic event as any event that causes the individual physical, emotional, or psychological distress. Thus, these events may include but are not limited to interpersonal conflict, loss of personal property, victimization, criticism or ridicule, illness, loss of trust, death of a loved one, war, natural disasters, car accidents, and/or divorce or separation from loved ones.
Essentially, any event can be considered traumatic if the individual experiences it as such. By adopting this liberal definition of trauma, the author is better able to value the impact of critical life events on the individual.
More specifically, the author is able to synthesize the current literature and research defining the impact of life events on the onset, development, maintenance, and treatment of OCD.2.1.
Developmental factors linking trauma and OCDThe developmental factors of a client presented with OCD are worth considering.
Although there seems to be a gap in the literature regarding neurodevelopmental markers of the onset of OCD, other areas of development have been researched. As a client develops and creates ways of functioning in the world, tendencies towards maladaptive functioning and/or cognitive distortions may be present.
By recognizing the possible developmental factors that may contribute to the manifestation of OCD, the clinician can be better equipped to provide adequate services to the individual. Briggs and Price (2009) found that a predisposition towards anxiety and depression tended to enhance the link between traumatic childhood experiences and OCD symptoms.
Traumatic childhood experiences have an aversive impact on most children, not all children however respond to these experiences in the same way. Briggs and Price (2009) conclude that children, who have a tendency to be more anxious and/or depressed before the traumatic experience, are more likely to respond to the development of OCD.
Along the same lines, the occurrence of trait-anxiety within the family structure appears to be related to the sensitivity towards both traumatic events and the development of OCD (Huppert et al., 2005). Trait-anxiety is both taught and genetically passed on to children within the family unit.
Once the individual has reached his/her anxiety threshold and OCD symptoms start to emerge, the severity of symptomatology appears to be related to the individual's level of distress tolerance, which is often modelled by caregivers.
If caregivers are unable to teach and model adequate anxiety coping and distress tolerance skills, children are left to learn coping skills themselves and thus a personal responsibility for control of possible negative outcomes is established.
This may develop as maladaptive coping techniques such as obsessions and compulsions as a way to manage the distress felt about situations that seem uncontrollable.2.2. Possible links between OCD and PTSDRecent research has suggested that OCD and PTSD are, in fact, two disorders on the same continuum (Gershuny, Baer, Radomsky, Wilson, & Jenike, 2003). Gershuny et al. (2003) suggest that there is a tremendous overlap between the symptomatology of both OCD and PTSD. Both are characterized by recurrent and intrusive thoughts that are experienced as anxiety/fear inducing. They discovered that as PTSD symptoms reduce, OCD symptoms increase, and as OCD symptoms are treated, PTSD symptoms take over.
They argue that OCD symptoms do not appear to “replace” the PTSD symptoms, but rather OCD symptoms are used to cope with, reduce, and avoid the trauma-related symptoms and memories.
Furthermore, the link between OCD and PTSD has been evidenced by a significant number of researchers (Badour et al., 2012; Huppert et al., 2005; Lafleur et al., 2011; Nacasch, Fostick, & Zohar, 2011; de Silva & Marks, 2001).2.3. Post-traumatic OCDSeveral theories of post-traumatic OCD have been suggested. Badour et al. (2012) suggest that the role of “disgust” in both OCD and PTSD is significant and worthy of further research.
Those who experience traumatic victimization (sexual/physical/criminal assault) experience intense feelings of disgust. Feelings of disgust can lead to both PTSD (other-focused disgust) and a contamination-based OCD (self-focused disgust).
These feelings lead to a need to remove oneself from sources of contamination and may result in hand washing, showering, and avoidance rituals. The intrusive recollections and thoughts, that are a result of the traumatic event, become generalized to other life experience (Sasson et al., 2004). They no longer appear to be conceptually associated with the traumatic event, but rather take on the typical patterns of obsessional thoughts found in OCD.
Nevertheless, they can be traced back to the original traumatic event with time.Rachman's (2010) theory of betrayal and contamination preoccupation adds additional evidence for the link between traumatic experiences and OCD.
Although betrayal and physical contamination are not conceptually similar, sufficient evidence has been found that betrayal is relevant to anxiety disorders, OCD, and PTSD-like symptoms (Rachman, 2010, p. 304).
Previously, clinicians have been focused on the traumatic event of PTSD and the compulsive behaviours and intrusive thoughts/obsessions of OCD, but Rachman (2010) argues that most patients can identify a critical betrayal event significant to the development of their disorder.
As noted above, the current definition of trauma allows for the experience of personal betrayal to be considered even if it is not life threatening in nature. “Betrayal is a sense of being harmed by the intentional actions, or omissions, of a person who was assumed to be a trusted and loyal friend, relative, partner, colleague, or companion” (Rachman, 2010, p. 304). The five kinds of betrayal identified by Rachman (2010) are: “harmful disclosures of confidential information, disloyalty, infidelity, dishonesty, and failures to offer expected assistance during significant times of need” (p. 305).
Rachman (2010) provides evidence that betrayal can lead to both OCD and PTSD-like symptoms. Given this overlap, one may deduce that OCD and PTSD are conceptually related.Briggs and Price posited another theory of post-traumatic OCD in 2009. They suggested that early-life experiences created schemas and assumptions about the world. If these early experiences are seen as adverse and traumatic, children develop beliefs about personal responsibility. These children then inaccurately interpret intrusive thoughts as being the cause of negative events. For example, a child interpreting his/her negative thoughts about a parent as causing the car accident, or a child's belief that wishing his/her parents would stop arguing has caused his/her parents' divorce.
An excessive number of negative events and propensity towards experiencing these events as being more impactful, may lead to the development of OCD (Gothelf, Aharonovsky, Horesh, Carty, & Apter, 2004).
This theory also suggests the use of operant conditioning in the reinforcement of ritualistic behaviours to reduce anxiety. When an individual takes on personal responsibility for an intrusive thought, reacts by engaging in a compulsive behaviour, and then observes that something negative did not occur, he/she is reinforced to believe that the action is what prevented the negative event (Briggs & Price, 2009).
Essentially, the development of OCD serves a protective function for those who have experienced traumatic events.
The OCD obsessions and compulsions prevent the client from being further traumatized and thus help to reinforce the development of OCD (Fontenelle et al., 2007).
Finally, Lafleur et al. (2011) suggest that traumatic events may not cause OCD, but rather mediate the link between the environmental-genetic expression of OCD. In other words, the necessary environmental and genetic factors need to be present in order for a traumatic experience to trigger the onset of OCD.
Therefore, the report of traumatic experiences in children with OCD may be over-represented because the child may have developed OCD later in life without the impact of the traumatic event.
Stressful life events at onset of obsessive–compulsive disorder are associated with a distinct clinical pattern.
Exposure treatments and cognitive-behavioural therapy (CBT) have been largely accepted as best practice for those with OCD, and yet there are still many who are left with “treatment-resistant OCD”
Exposure treatments and CBT have been accepted as best practice for trauma-related distress. From a literature review, evidence has been provided that demonstrates a high prevalence rate (30–82%) of OCD among individuals with a traumatic history in comparison to the prevalence rate of the general population.
Evidence was collected for a post-traumatic OCD and treatments of trauma-related OCD were considered. OCD and traumatic histories have a significant enough overlap that trauma should be a consideration when treating an individual with OCD.
Given the overlap of the client base with OCD and traumatic histories, as well as the overlap in treatment options for those who experience OCD and trauma-induced symptoms, the author will discuss the importance of assessing for traumatic history in clients with OCD as well as approaching treatment from a dual-focus orientation.
Females experience slightly higher rates in adulthood, while males have slightly elevated rates in childhood. Additionally, the 12-month prevalence rate for post-traumatic stress disorder (PTSD) is approximately 3.5% (APA, 2013). This, however, does not include individuals who have experienced trauma-related distress, but do not meet the criteria for PTSD as defined by the DSM-V.
According to Gershuny and Thayer (1999), many people experience some kind of traumatic incident that results in psychological distress.
Kristy L. Dykshoorn
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