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High Prevalence of Obsessive-Compulsive Disorder Among Posttraumatic Stress Disorder Patients

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High Prevalence of Obsessive-Compulsive Disorder Among Posttraumatic Stress Disorder Patients Nacasch, N., Fostick, L. , Zohar, J. (2011). High prevalence of obsessive-compulsive disorder among posttraumatic stress disorder patients. European Neuropsychopharmacology, 21, 876– 879. ***This is a self-archiving copy and does not fully replicate the published version*** High prevalence of obsessive -compulsive disorder among posttraumatic stress disorder patients Nitsa Nacasch 1, Leah Fostick 2, Joseph Zohar 1 1Division of Psychiatry, Chaim Sheba Medical Center, Tel Hashomer, 52621, Israel 2Ariel University Center, Ariel, 40700, Israel Corresponding author: Prof. J. Zohar, Department of Psychiatry; Sheba Medical Center; Tel Hashomer 52621; Israel. Telephone: 972-3530-3300. Fax: 972-3535-2788. Email: [email protected] 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. Keywords: Posttraumatic obsessions, Posttraumatic stress disorder, Obsessive-compulsive disorder, Comorbidity, Prevalence High prevalence of obsessive compulsive disorder among posttraumatic stress disorder patients Obsessive compulsive disorder (OCD) is characterized by repeated intrusive thoughts (obsessions) and repetitive actions (compulsions) that provoke distress and/or interfere significantly with everyday functioning. OCD affects 0.7 to 2.3% of the adult population (Kessler, Berglund, Demler, Jin, Merikangas & Walters, 2005) and has negative impact on patients' daily functioning and quality of life (Murray & Lopez, 1996). Evidence from family studies and twin studies show strong heredity effect (Hanna, Fischer, Chadha, Himle & Van Etten, 2005; Pauls & Alsobrook, 1999) and several candidate genes have been identified to be associated with OCD (see Nicolini, Arnold, Nestadt, Lanzagorta & Kennedy, 2009, for a review). However, other reports have point out toward the role of environmental factors and the development of OCD. Among them are prenatal and perinatal factors (Vasconcelos, Sampaio, Hounie, Akkerman & Curi et al., 2007; Santangelo, Pauls, Goldstein, Faraone et al., 1994) and the exposure to stressors such as pregnancy, childbirth and other traumatic events (Forray, Focseneanu, Pittman, McDougle & Epperson, 2010; Gershuny, Baer, Radomsky, Wilson& Jenike, 2003; Sasson, Dekel, Nacasch, Chopra, Zinger, Amital & Zohar, 2005; Zohar, Fostick, Black & Lopez-Ibor, 2007). Several case reports and case series have documented the co-occurrence of OCD and PTSD following an exposure to traumatic event (Gershuny et al., 2003; Pitman, 1993; Sasson et al., 2005). Others, however, have suggested that the recurrent ideas, thoughts, and images of OCD overlap the recurrent intrusive recollections of PTSD and do not point on a co-morbidity of these two diseases independently (Solomon, Bleich, Koslowsky, Kron, Lehrer, & Waysman, 1991; Huppert, Moser, Gershuny, Riggs & Spokas et al., 2005; Lipinski & Pope, 1994). Indeed, PTSD and OCD have similar elements in symptomatology and etiology. Both PTSD and OCD have repeated intrusive thoughts that cause distress and are hard to neutralize; have avoidance behavior that is directed by the need to avoid any cue cause distress; and include behaviors that are performed in order to reduce the anxiety (De Silva & Marks, 1999, 2001). PTSD and OCD are also associated with negative thoughts and memories which evoke and intensify anxiety and lead to labeling of stimuli as threatening (Dinn, Harris, & Raynard, 1999), and both are associated with classical conditioning to an anxiety-provoking stimulus that, in turn, is reinforced by behaviors that reduce this anxiety (De Silva & Marks, 1999; Zohar, Fostick & Juven-Wetzler, 2009). Although studies point on the comorbidity of OCD and PTSD following traumatic event, it is not known what is the magnitude of this phenomenon. Among patients with OCD, cross-sectional studies have shown rates of PTSD ranging from 12 to 75% (Huppert et al., 2005). However, the current paper is focusing on the diagonal phenomena, i.e., the emerging of OCD in PTSD patients. The studies documenting the comorbidity of OCD and PTSD following traumatic event are mostly case studies and case reports and accordingly lack control. The aim of the current study was to evaluate systematically the prevalence of OCD in a sample of PTSD patients. In addition, we compared the demographic, symptomatic, and trauma-related characteristics of the PTSD and PTSD-OCD groups, in order to point out possible factors that could explain why some of PTSD patients also develop OCD. Method The study was conducted in the Chaim Sheba Medical Center psychiatric clinic, a secondary referral with specific expertise in behavioral therapy. During the period of 2005 to 2006, all referrals to the study psychiatrist (N.N.) who had a current diagnosis of PTSD also underwent a diagnostic interview for current OCD. The diagnosis of PTSD, OCD, OC symptoms and other comorbidities was based on the Mini International Neuropsychiatric Interview (MINI ; Sheehan, Lecrubier, Sheehan, Amorim & Janavs et al., 1998). Diagnosis of OCD was done only when the content of the symptoms was not related only to PTSD. Verification of diagnosis was done by a second psychiatrist (J.Z.). The study was approved by the institutional review boards and written informed consent was obtained from the patients after they received full explanations regarding study procedures. Student’s t test and χ 2 test were used to analyze the data. Results Out of 44 referrals who were diagnosed with current PTSD, 18 (41%) also diagnosed as current OCD with PTSD (PTSD-OCD), 19 (43%) were diagnosed with PTSD without current or lifetime OCD, and seven participants were diagnosed with PTSD and OC symptoms. All the PTSD-OCD participants had the onset of PTSD before the onset of OCD. Table 1 presents demographics, trauma-related factors, and other psychiatric co-morbidity for PTSD and PTSD-OCD participants. Table 2 details psychiatric comorbidity for the participants. No difference was found between PTSD and PTSD- OCD participants in any of these measures. Data regarding OCD in the family was obtained to six PTSD and to 17 PTSD-OCD participants. Only two participants had OCD in the family. Both were diagnosed with PTSD-OCD. Discussion The presentation of OCD following PTSD has been documented previously in the literature in several case reports and case series (Gershuny et al., 2003; Pitman, 1993; Sasson et al., 2005). The current paper is the first attempt to systematically evaluate the prevalence of OCD in a sample of PTSD patients. In the tested population – terror and combat related PTSD – a surprisingly high number of obsessions were identified – 41% of consecutively examined PTSD had comorbid OCD, which developed after the exposure. These results show that following an exposure to combat or terror related trauma, many participants (59%) develop OC symptoms. In addition, for the majority of those who will develop OC symptoms (72%), these symptoms will be severe enough to meet the criteria of OCD. The data about comorbidity of PTSD and OCD is relatively sparse. How is it, therefore, that in spite of the dramatic prevalence of OCD in PTSD reported in the current study, this has not been noticed? One possible explanation is the setting of the study. As the clinic in which the current study was carried out serves as a secondary referral, it might represent a selection of patients, whom might be more prone to have a multifaceted symptom profile. As a result, the current results might be biased to show a higher prevalence of PTSD-OCD than in other settings. Second, the high prevalence of PTSD-OCD found in the current study may be due to the direct assessment of OCD that was carried to all PTSD patients, even those who initially did not complain on such symptoms. Surprisingly, we have found that although some of the PTSD patients were engaged in treatment for several years, they never mentioned any OC symptoms until actively being asked. This might suggest that PTSD-OCD might be frequently underdiagnosed. The findings of the current study raise several questions regarding the mechanism underlies post-traumatic OCD. Does exposure to traumatic events associate to the emergence of OCD or does the pathological path which leads to PTSD open the gate to OCD as well? Is there an a priori vulnerability to OCD for which the exposure to trauma served as a pressure on the OCD trigger? Is the emergence of PTSD associated with "liberation" of an "archaic" pattern of behaviors such as OCD? To what extent are OCD symptoms present before PTSD, serves as a risk factor to develop OCD, directly or via mediation or moderation of certain personality traits? Is this high than expected prevalence of OCD which is also observed to some extent in schizophrenia
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