Behaviour Research and Therapy 41 (2003) 1029–1041

www.elsevier.com/locate/brat

Connections among symptoms of obsessive–compulsive

disorder and posttraumatic stress disorder: a case series
Beth S. Gershuny a,∗, Lee Baer a, Adam S. Radomsky b, Kimberly A. Wilson a,
Michael A. Jenike a
a
Harvard Medical School and Massachusetts General Hospital, Department of Psychiatry, Charlestown, MA 02129,
USA
b
Concordia University, Department of Psychology, Montreal, Quebec, Canada
Accepted 18 August 2002

Abstract

Theoretical, clinical, and empirical implications of the functional connections between symptoms of
obsessive–compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are abundant. As such,
four cases are presented here of men and women who met criteria for comorbid OCD and PTSD. All had
been diagnosed with treatment-resistant OCD and were seeking treatment from an OCD specialty clinic
or institute, all reported a history of traumatic experiences prior to the onset of OCD, and all appeared to
demonstrate negative treatment outcomes. Upon examination, it appeared that symptoms of OCD and PTSD
were connected such that decreases in OCD-specific symptoms related to increases in PTSD-specific symp-
toms, and increases in OCD-specific symptoms related to decreases in PTSD-specific symptoms. Specu-
lations about the function of OCD symptoms in relation to post-traumatic psychopathology are put forth;
and theoretical, research, and treatment implications are discussed.
 2003 Elsevier Science Ltd. All rights reserved.

Keywords: Obsessive–compulsive disorder; Posttraumatic stress disorder; Comorbid; Symptom connection

Recently, a sparse literature has begun to emerge that describes a relation between traumatic
events and the development and maintenance of obsessive–compulsive disorder (OCD). This
literature, composed of case studies illustrating the role of traumatic events in the etiology of
OCD, indicates that in a subset of OCD sufferers, psychological trauma may play a role in the

∗
Corresponding Author.
E-mail address: gershuny@psych.mgh.harvard.edu (B.S. Gershuny).

0005-7967/03/$ - see front matter  2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0005-7967(02)00178-X
1030 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

development of OCD and co-exist as a comorbid disorder with posttraumatic stress disorder
(PTSD) (de Silva & Marks, 1999, 2001; Pitman, 1993).
Though behavior therapy and pharmacotherapy are usually effective in reducing OCD symp-
toms, a significant minority of patients do not benefit from such treatments (e.g., Franklin, Abra-
mowitz, Kozak, Levitt, & Foa, 2000; Marks, 1981). Prior studies investigating comorbid psychi-
atric disorders that may impede treatment effectiveness have to date proven inconclusive. Some
found that major depressive disorder adversely affected treatment outcome for OCD (e.g., Stek-
etee, Chambless, & Tran, 2001) while others found that major depressive disorder did not have
an adverse affect (e.g., Zitterl et al., 2000). Similarly, some studies demonstrated that a comorbid
Axis II diagnosis (particularly Cluster A personality disorders) predicted poorer treatment outcome
for OCD (e.g., AuBuchon & Malatesta, 1994; Minichiello, Baer, & Jenike, 1987), while other
studies demonstrated no such impact (e.g., Steketee et al., 2001).
A recent study indicated that a diagnosis of comorbid PTSD impeded successful treatment of
OCD (Gershuny, Baer, Jenike, Minichiello, & Wilhelm, 2002): patients without comorbid PTSD
improved significantly with behavior therapy (i.e., exposure and response prevention) on measures
of OCD and depression, but those with comorbid PTSD did not improve (indeed, some with
PTSD reported an increase in OCD and depression symptoms). Similarly, a case study reported
by Pitman (1993) demonstrated that a diagnosis of comorbid PTSD and OCD was a negative
predictor of treatment outcome. The question remains as to why such impediments occurred.
It has been posited elsewhere that the study of comorbid disorders would increase in value if
more attention were paid to the connectedness between disorders (Rachman, 1991). For example,
understanding whether the connection between disorders is static or dynamic (e.g., increases or
decreases in symptoms of one disorder impact the symptoms of the other disorder) may aid in
the development of more fruitful treatment approaches and allow us to make better prognoses
(de Silva & Marks, 1999; Rachman, 1991); examining the connection between symptoms may
also increase our understanding of the impact of comorbid disorders on treatment outcome.
In some cases, connections between PTSD and OCD symptoms may appear quite straightfor-
ward, such as a person who reports feeling “unsafe” following a household robbery and sub-
sequently engages in compulsive checking behaviors involving his or her doors and locks. In
other cases, however, connections between symptoms may be less obvious and require more in-
depth scrutiny and assessment.
We present here a retrospective naturalistic review of four cases of patients who met criteria
for both OCD and PTSD upon admission to a residential treatment facility for treatment-resistant
OCD. Each patient presented here reported a history of traumatic experiences that reportedly
predated the onset of OCD. We present reported symptoms, diagnoses, and treatment outcome
for each patient. To expand the pioneering case study papers of de Silva and Marks (1999) and
Pitman (1993), we place particular emphasis on the seeming connections (Rachman, 1991)
between traumatic experiences, symptoms of PTSD, and symptoms of OCD, and the impact of
such connections on treatment outcome. We also provide impressions derived from post-treatment
contact after discharge from the facility. Because prior work has indicated that comorbid PTSD
has an adverse affect on treatment outcome for OCD (Gershuny et al, 2002), it also seems
important to systematically examine related individual cases to potentially gain greater understand-
ing of why such adverse impact may have occurred. Though exposure-based treatments are argu-
ably the treatment of choice for both OCD and PTSD, exposure-based treatment of the symptoms
 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041 1031

of one disorder (e.g., OCD) may not generalize to the treatment of the symptoms of another
disorder (e.g., PTSD) and may indeed result in an increase in symptoms of the other disorder.
This will be discussed in further detail later in this paper.

1. Methods

1.1. Materials and procedure

As part of hospital-related, routine clinical procedures, each patient was administered a semi-
structured diagnostic interview at intake and self-report questionnaires at both intake and dis-
charge. For the purposes of this paper, self-report questionnaires administered at intake included:
Traumatic Events Survey—Lifetime (TES-L; Gershuny, 1999), Yale–Brown Obsessive–Compul-
sive Inventory (YBOCS; total possible score ranges from 0 to 40; Goodman, Price, Rasmussen
et al., 1989), Beck Depression Inventory (BDI; total possible score ranges from 0 to 63; Beck &
Steer, 1987), and Posttraumatic Diagnostic Scale (PDS; total possible score ranges from 0 to 51;
Foa, Cashman, Jaycox, & Perry, 1997). Questionnaires administered at discharge included:
YBOCS and BDI. A review of medical charts was used to obtain pre- (i.e., intake) and post-
(i.e., discharge) treatment scores as well as to obtain information regarding course of symptoms.

1.2. Cases

Four cases are presented of patients who met criteria for both OCD and PTSD based on inter-
view and self-report. Each patient was referred to a residential treatment program for treatment-
resistant OCD (the Massachusetts General Hospital OCD Institute) due to lack of benefit from
prior courses of treatment (e.g., psychodynamic, behavioral, pharmacological). Interestingly,
though all of the patients presented below had received a diagnosis of OCD from other treaters
prior to their referral to the OCD Institute, none had arrived at the Institute with a diagnosis of
PTSD and received this comorbid diagnosis only after a comprehensive semi-structured diagnostic
interview (validated by data also obtained from self-report questionnaires) revealed a history of
trauma(s) with associated PTSD symptoms. None of the patients included met criteria for a psy-
chotic disorder. All of the patients were taking psychotropic medications, most commonly SSRIs,
tricyclic antidepressants, neuroleptics, benzodiazepines, and/or hypnotics. Though we were unable
to ascertain quantifiable follow-up data for each of the patients included here, we were able to
gather information indicative of follow-up functioning via unsolicited post-treatment contact (or
in the cases of Ms. A. and Ms. D., continued and re-commenced outpatient treatment contact,
respectively).

1.3. Case 1: Ms. A.

1.3.1. OCD symptoms

At admission, Ms. A., a single Caucasian female in her early forties, reported obsessions that
included: number 54 as well as numbers 50 through 53 because they are approaching her “most
unlucky number” of 54, fears and feelings that she is “contaminated” whenever confronted in
1032 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

some way by these numbers. Her rituals included: washing her hands and body and clothes with
industrial strength detergents immediately after contact with “unlucky” numbers, repeating some-
thing a certain number of times so that she does not say something related to any part of her
“unlucky” number, and ritualistic avoidance that includes anything which might reveal her
“unlucky” number (e.g., clocks, television, radio, driving because of seeing license plates, shop-
ping because of certain prices) or which might have come into contact with her “unlucky” number
and thus become “contaminated” (e.g., any places and situations during which she encountered
her unlucky number, clothing she was wearing when she encountered her unlucky number). Ms.
A.’s total YBOCS score at intake was 18, suggestive of “moderate” clinical OCD.

1.3.2. Psychological trauma

Upon further assessment, a trauma history was reported that included: witnessing repeated
violence from father to mother (father reportedly threatened to kill mother with knife at least
once per week), sexual molestation from father (i.e., kissing, fondling Ms. A.’s breasts, vaginal
penetration with fingers), and father murdered stepmother with a knife when stepmother was 54
years old and Ms. A. arrived at the crime scene to help clean blood from the carpet.

1.3.3. PTSD symptoms

Ms. A. met criteria for PTSD related to sexual molestation and murder of stepmother (she
endorsed 5 of 5 re-experiencing symptoms, 6 of 7 avoidance symptoms, and 5 of 5 arousal
symptoms; her total PDS severity score at intake was 38; total re-experiencing score was 9,
avoidance was 16, and arousal was 13). Specific PTSD symptoms included: intrusive
thoughts/images of traumas, emotional and physiological reactivity to reminders, nightmares,
avoidance of thoughts and reminders, lack of interest, irritability, emotional numbing, sense of
detachment from others, sense of foreshortened future, sleep difficulties, concentration problems,
excessive startle response, and hypervigilance.

1.3.4. Other associated symptoms

Ms. A. also reported intense fear of negative affect as well as shame, and she received a
depression (BDI) severity score of 29.

1.3.5. Connection among OCD, trauma, and PTSD

Though Ms. A. reported and exhibited a great deal of anxiety since the violence began in her
home as a child, the onset of her OCD symptoms in particular occurred after her father murdered
her stepmother (Ms. A. was in her early twenties). There also does not appear to be a family
history of OCD. It became apparent that Ms. A.’s obsessions could be conceptualized as intrusive
thoughts related to trauma (her “most unlucky number” of 54 is the age at which her stepmother
was murdered); feeling “contaminated” was experienced by patient as a sense of being tainted in
some way by the past trauma(s); and rituals and ritualistic avoidances seemed like manifestations
of attempts to avoid trauma-related memories and affect, particularly related to murder of step-
mother and childhood sexual abuse. During exposure and response prevention (ERP) treatment
for OCD-related obsessions (numbers 50–53, and 54) and rituals (excessive washing and ritualistic
avoidance), Ms. A. became more depressed and reported experiencing higher levels of trauma-
related intrusive thoughts, emotional numbing, social detachment, and avoidance of trauma-related
 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041 1033

thoughts as obsessions and rituals appeared to decrease a bit. In following, these rituals re-intensi-
fied in frequency and duration. Core obsessions never seemed to lessen, habituation to fears never
seemed to take place, and rituals returned and intensified. Indeed, it seems that the moment direct
thoughts regarding past trauma emerged, OCD symptoms would flare and avoidance would
become particularly intense.

1.3.6. Treatment outcome

Ms. A. received behavior therapy (ERP) for OCD and medications (i.e., SSRIs, benzodiazepine,
neuroleptic); she was admitted four times to the treatment program (we have data from two most
recent admissions). Upon discharge from her third admission (after one month), she reported no
change in YBOCS score (total remained 18) or BDI score (total remained 29); and upon discharge
from her fourth admission (after two weeks), she reported a 22% increase in YBOCS score with
a total score of 23 and a 28% decrease in BDI score with a total score of 21. Since her last
discharge from the program, Ms. A. has remained in outpatient behavior therapy for OCD (does
not want to engage in CBT for PTSD) as well as intensive outpatient psychoanalytic therapy for
trauma-related symptoms. Her OCD and PTSD symptoms remain, and she has difficulty func-
tioning day to day, unable to complete basic functions such as grocery shopping and driving more
than 0.5 miles. She reports continuation of multiple showers per day and approximately 5–8 hours
of hand-washing per day that often lasts throughout the night. In addition, Ms. A. continues
excessive ritualistic avoidance of triggers.

1.4. Case 2: Mr. B.

1.4.1. OCD symptoms

At admission, Mr. B., a married Caucasian male in his late twenties, reported obsessions that
included: graphically violent thoughts, fears of not doing something in exactly the right way
because of fear that something “bad” will happen to him or a loved one, fears that he is a homosex-
ual, and fears of “contamination” particularly from his own sweat. Rituals included: doing things
a particular number of times with certain numbers being deemed “good” and certain numbers
being deemed “bad”, repetitive wiping of anus, and ritualistic avoidances such as refusing to
touch things (particularly medicine) if he had not showered. Mr. B.’s total YBOCS score at intake
was 31, suggestive of “marked” clinical OCD.

1.4.2. Psychological trauma

Upon further assessment, a trauma history was reported that included: physical abuse from
father during childhood and adolescence (e.g, father punching him and breaking teeth), almost
drowning in childhood, death of younger brother from illness during adolescence, ongoing physi-
cal and emotional abuse from boarding school staff during late adolescence (e.g., being forced to
sit in a corner as punishment for 1.5 months in pajamas without moving and without being allowed
to use a restroom, witnessing sexual molestations of other students, witnessing peer cutting his
arm and having blood spurt on patient, being forced to sleep in the snow only in underwear), a
single assailant rape (anal) by a male during adolescence, a gang rape (anal) by four male per-
petrators during adulthood.
1034 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

1.4.3. PTSD symptoms

Mr. B. met criteria for PTSD related to brother’s death and both instances of anal rape (he
endorsed 5 of 5 re-experiencing symptoms, 4 of 7 avoidance symptoms, and 5 of 5 arousal
symptoms; his total PDS severity score at intake was 33; total re-experiencing score was 12,
avoidance was 10, and arousal was 11). Specific PTSD symptoms included: intrusive
thoughts/images about traumas, emotional and physiological reactivity to reminders, flashbacks,
very frequent and severe nightmares, sleep difficulties, extreme avoidance of thoughts and
reminders, loss of interest, sense of detachment from others, emotional numbing, sense of fore-
shortened future, irritability, excessive startle response, and hypervigilance.

1.4.4. Other associated symptoms

Mr. B. also reported intense fear of negative affect, shame, pathological doubt, and a depression
(BDI) severity score of 6.

1.4.5. Connection among OCD, trauma, and PTSD

Though Mr. B. reported behavioral problems and fears since childhood, it remains unclear
whether his OCD-like symptoms appeared after initial traumas occurred or before. It is, however,
clear that his OCD became exacerbated in particular by the sexual traumas. Mr. B. reported that
his brother also suffered from OCD, though upon further evaluation, it appears likely that his
brother suffered more from obsessive–compulsive personality disorder (OCPD) symptoms than
OCD per se. No other family history of OCD was reported. It was further revealed that sweat
was a trauma reminder for Mr. B. of the first rape in that one of his trauma-related intrusive
thoughts was about the smell and feel of the sweat of his perpetrator. Thus, “contamination” from
his sweat was in actuality a reminder of the rape and a signal to him that he may in some way
taint something else with aspects of the trauma that would then hurt him as well (e.g., he became
terrified when he did not have time to shower before taking his morning medications, fearing that
he would in some way contaminate his medications with the sweat from his fingers and hands
and be harmed as a result). Mr. B.’s rituals related to needing to do things just right and a
certain number of times may be conceptualized as conditioned fear reactions to father’s excessive
punishments as well as school’s excessive punishments. Ritual of wiping anus may be concep-
tualized as relating to intrusive thoughts and flashbacks and contamination fears regarding past
anal rapes; whenever Mr. B. experienced a flashback he reported an intense need to wipe his
anus, and whenever Mr. B. awoke from a nightmare he reported an intense need to shower. He
experienced a great deal of anxiety until he could wash. In addition, Mr. B.’s violent thoughts
and images occurred and became more frequent and intense in response to thoughts and reminders
about past traumas, particularly the incidents of anal rape. His intrusive fears about homosexuality
began after the first rape incident, and he reports that many of his rituals were attempts to neu-
tralize these thoughts (e.g., belief that if he did certain things a certain number of times, the
ruminative fears about being homosexual would dissipate). Though ERP (and medications) for
OCD were helpful in lessening some of Mr. B.’s avoidances and rituals such as doing things a
certain number of times, it appeared that after approximately one month, other obsessions not yet
targeted in treatment began to intensify as his overall level of functioning seemed to decrease
(with an associated increase in overall level of depression and fear, frequency of nightmares,
sleep disturbances, and trauma-related intrusive thoughts).
 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041 1035

1.4.6. Treatment outcome

Mr. B. received behavior therapy (ERP) for OCD and medications (i.e., SSRI, benzodiazepine,
hypnotic, neuroleptic). Upon discharge from the treatment program (after two months), Mr. B.
reported a 35% decrease in total YBOCS score (total of 20) but an 85% increase in total BDI
score (total of 40) (note that his YBOCS score at discharge, though improved, remained in the
“clinical” range). Since discharge, Mr. B. has not participated in outpatient therapy but has been
hospitalized as an inpatient on several occasions. Improvements in his OCD that took place during
intensive residential treatment did not persist, and again, symptoms were severe enough to warrant
several hospitalizations.

1.5. Case 3: Mr. C.

1.5.1. OCD symptoms

At admission, Mr. C., a divorced Caucasian male in his early fifties, reported obsessions that
included: violent thoughts and images about others, fears that harm will come to loved ones, and
his appearance (thinking he looks like a “freak”). His rituals included: looking in mirrors to try
to determine what is “freakish” about his appearance, counting numbers in his mind and/or saying
names of loved ones to try to rid violent thoughts/images, going in and out of doorways until it
“feels right” so that nothing bad happens to loved ones, and ritualistic avoidance of knives (remind
him of serial killers) and refrigerators (remind him of serial killer who stored bodies in
refrigerator). Mr. C.’s total YBOCS score at intake was 28, suggestive of “marked” clinical OCD.

1.5.2. Psychological trauma

Upon further assessment, a trauma history was reported that included: physical and emotional
abuse from father (e.g., father would hit and punch Mr. C. for saying the wrong thing or appearing
“too thin or too fat”), witnessing combat during duty in the Vietnam war with associated difficulty
transitioning back into society (perceived himself as being treated like a “freak” by others upon
return to US and noted that he was extremely thin, very tan, and had very long hair and that
others would point at him and stare) and went into hiding in the mountains for 1.5 years and
lived in his van.

1.5.3. PTSD symptoms

Mr. C. met criteria for PTSD related to childhood physical abuse and combat (he endorsed 5
of 5 re-experiencing symptoms, 7 of 7 avoidance symptoms, and 4 of 5 arousal symptoms; his
total PDS severity score at intake was 26; total re-experiencing score was 5, avoidance was 16,
and arousal was 5). Specific PTSD symptoms included: intrusive thoughts/images, emotional and
physiological reactivity to reminders, flashbacks, avoidance of thoughts and reminders, loss of
interest, sense of foreshortened future, irritability, emotional numbing, sense of detachment from
others, concentration problems, and excessive startle response.

1.5.4. Other associated symptoms

Mr. C. also reported intense fear of negative affect and shame, as well as a depression (BDI)
severity score of 13.
1036 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

1.5.5. Connection among OCD, trauma, and PTSD

Mr. C. did not report OCD-like symptoms or behaviors prior to trauma(s). Though he reported
no history of OCD in his siblings or parents, he did report some OCD-like behaviors in his son.
It became apparent that there were connections between Mr. C.’s current OCD symptoms and
past trauma(s). Mr. C. received messages from father and society that indeed he was a “freak”
of some sort, and he received messages from father that he was responsible for all wrong-doings.
Thus, these experiences appear linked to his obsessive fears about looking like a “freak” and
thinking he did something wrong. In addition, Mr. C. witnessed violence and multiple deaths
during the war. His violent thoughts/images seemed to become more frequent and intense when
he was reminded in some way of abuse from his father and/or the Vietnam War (e.g., on Veterans
Day and for several weeks afterward, Mr. C. reported an increase in violent obsessions as well
as an increase in obsessions related to believing he is a “freak” with associated intensified suicidal
ideation). ERP for OCD was helpful in lessening rituals related to entering and exiting doorways
a certain number of times until it “feels right”, but ERP specifically targeting violent thoughts
was not at all effective and indeed had an immediate effect of eliciting intense thoughts and
images of self-harm as well as intrusive thoughts and flashbacks related to past traumas with
associated depression, and anger. It became necessary to discontinue ERP related to violent
thoughts.

1.5.6. Treatment outcome

Mr. C. received behavior therapy (ERP) for OCD and medications (i.e., SSRI, tricyclic, benzod-
iazepine, neuroleptic). Upon discharge from the treatment program (after 3.5 months), Mr. C.
reported no change in YBOCS score (total of 28) as well as a significant increase in depression
symptoms (52% increase with total score of 27). Since leaving the program, Mr. C.’s symptoms
reportedly have remained similar in frequency and severity, and he has had trouble leaving the
house because of excessive fears.

1.6. Case 4: Ms. D.

1.6.1. OCD symptoms

At admission, Ms. D., a single Caucasian female in her early thirties, reported obsessions that
included: feeling “dirty” and not clean enough, general “dirtiness” of her surroundings, her appear-
ance with associated intrusive fears that she is “ugly,” and general fears about contamination.
Her rituals included: excessive showering, excessive cleaning and ordering of surroundings, and
picking her skin. Ms. D.’s total YBOCS score at intake was 34, suggestive of “severe” clinical
OCD.

1.6.2. Psychological trauma

Upon further assessment, a trauma history was reported that included: severe illness and near
death of younger sister (Ms. D. was approximately 6 years old at the time); vaginal and anal
gang rape by three perpetrators (two male, one female) when patient was approximately 7 years
old; ongoing sexual abuse/assault by a counselor during high school.
 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041 1037

1.6.3. PTSD symptoms

Ms. D. met criteria for PTSD related to gang rape and sexual abuse by counselor (she endorsed
5 of 5 re-experiencing symptoms, 6 of 7 avoidance symptoms, and 4 of 5 arousal symptoms; her
total PDS severity score was 43; re-experiencing score was 15; avoidance score was 18; arousal
score was 10). Specific PTSD symptoms included: intrusive thoughts/images about traumas,
emotional and physiological reactivity to reminders, nightmares, flashbacks, avoidance of thoughts
and reminders, psychogenic amnesia, lack of interest, sense of detachment from others, emotional
numbing, sense of foreshortened future, sleep difficulties, irritability, concentration problems, and
excessive startle response.

1.6.4. Other associated symptoms

Ms. D. also reported additional associated symptoms such as sexual disinterest and fears, shame,
and a depression (BDI) severity score of 45. In addition, Ms. D. engaged in self-injurious
behaviors that include cutting and burning herself, particularly in her vaginal area and breasts,
and picking the skin on her back and face.

1.6.5. Connection among OCD, trauma, and PTSD

OCD symptoms seemed to have appeared after traumas and reportedly were not present before.
Ms. D. denies any family history of OCD. She further reported that trauma-related intrusive
thoughts and nightmares immediately triggered obsessions related to cleanliness and a feeling of
being “dirty” which then lead to her showering an excessive number of times throughout the day
and evening. Trauma-related thoughts/images and affect also seemed to trigger a sense of Ms.
D.’s surroundings being unclean with resulting need to clean excessively. Ms. D. also reported
that picking her skin as well as cutting and burning herself served to numb and distract from
emotional reactions related to trauma memories; picking skin specifically around breasts and
vaginal area were reportedly intended to make those areas “ugly” and undesirable to men.

1.6.6. Treatment outcome

Ms. D. received behavior therapy (ERP) for OCD and medications (i.e., tricyclic, benzodiazep-
ine, neuroleptic). Upon discharge, Ms. D. reported an 88% decrease in YBOCS score (total of 4)
and an 83% decrease in BDI score (total of 8). Though she reported significant improvements
immediately after discharge from intensive residential treatment, these apparent improvements are
actually quite misleading. After discharge, Ms. D. did not remain in outpatient follow-up therapy.
Within weeks of discharge from the program, symptoms returned and intensified with
accompanying serious suicidal ideation. Indeed, Ms. D. went to a hospital emergency room on
four occasions over a period of four months due to extreme anxiety, associated physical symptoms
(e.g., nausea, trembling), insomnia with associated nightmares, and suicidal ideation with plan
and intent. Ms. D. has recently resumed outpatient CBT for OCD and PTSD, but her symptoms
remain severe.

2. Discussion

For at least some patients with comorbid OCD and PTSD seemingly subsequent to traumatic
experiences, there appears to be a relation between symptoms of both disorders: when symptoms
1038 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

of OCD lessen, symptoms of PTSD increase; when symptoms of OCD increase, symptoms of
PTSD lessen. Given this seemingly dynamic connection (Rachman, 1991), targeting OCD (and
perhaps PTSD) in isolation may impede therapy effectiveness (Gershuny et al., 2002), a conse-
quence demonstrated by the cases described in this paper.
Consistent with a behavioral theoretical perspective, obsessive–compulsive symptoms (e.g.,
excessive checking and/or cleaning, hyper-attention to obsessive thoughts) may facilitate avoid-
ance of the emotional discomfort generated by trauma cues (much as they facilitate the avoidance
of anxiety associated with OCD-related obsessions). These obsessive–compulsive behaviors may
then be negatively reinforced and strengthened by a reduction in discomfort (e.g., anxiety) if these
strategies are at least temporarily effective. Thus, OCD symptoms may be construed as serving
some type of coping or protective function against trauma-related thoughts and emotions that are
too psychologically uncomfortable for the person to bear. Note that we are not referring here to
a process of ‘symptom substitution;’ it does not seem that OCD symptoms replace PTSD or that
PTSD symptoms replace OCD. Rather, it appears that OCD symptoms serve as a form of coping
with trauma-related material (e.g., affective, cognitive) and symptoms.
Relatedly, Borkovec and Roemer (1995) found that people with GAD were more likely than
non-anxious controls to cite “distraction from more emotional topics” as a reason to worry. In a
later paper, Borkovec and his colleagues (Borkovec, Ray, & Stoeber, 1998) postulated that, for
those with GAD, worrying served as cognitive avoidance and inhibited emotional processing of
more difficult material. This process may mimic the role of obsessive–compulsive symptoms for
at least a subset of those with comorbid PTSD.
Furthermore, in his discussion of the need to assess connections among symptoms of seemingly
comorbid disorders, Rachman (1991) described the inter-relatedness of fear and related processes
(e.g., cognitive, physiological) and the necessity of evaluating such potential inter-relatedness. In
the cases described in this paper, a thorough assessment of core cognitions was not completed
and should indeed be completed with future cases (Rachman, 1991). Based on observations and
discussions of symptoms and behaviors, we can speculate that perhaps all had a fundamental
belief that “I am in danger or I might die,” and/or “I am not in control.” For people diagnosed
with OCD, it is not uncommon to hold such beliefs; it also is not uncommon for people diagnosed
with PTSD to hold such beliefs. A key difference may revolve around the “reality” of such beliefs.
During a traumatic experience, the individual is faced with danger and possible death either per-
sonally or vicariously. The individual also is faced with a situation in which he or she likely does
not have control. Thus, such core beliefs are born from reality even if over time they are main-
tained and no longer associated with current reality.
It is possible that when asked to confront what seem to be OCD-related triggers (e.g., for Ms.
A: number 54), fear is indeed elicited as are the related cognitions of “I am in danger,” and “I am
not in control.” However, rather than habituating to such fear and ameliorating such “unrealistic”
cognitions (i.e., the number 54 itself cannot actually cause harm), the individual may be enveloped
by fears related to precipitating trauma (i.e., murder of stepmother) and the associated core cog-
nitions mentioned above. Thus, rather than learning that she indeed is not in danger when con-
fronted with the number 54, she is reminded that the world is dangerous, that she does not have
total control, and that someone who was supposed to take care of her and be safe was capable
of murder and molestation. Hence, habituation to the OCD-related obsession would not occur.
In addition, some of the cases presented in this paper seem to be experiencing a phenomenon
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previously conceptualized as “mental pollution” (Rachman, 1994). For Ms. A, Mr. B, and Ms. D
in particular, it seems that some of their contamination fears are not actually related to germs or
filth. Rather, they seem to feel “dirty from within” or tainted in some way. And such perceptions
appear triggered by “contaminants” even without physical contact to such “contaminants” (e.g.,
number, nightmare, trauma-related intrusive thought and/or flashback). Indeed, even what is per-
ceived as “contaminating” in and of itself cannot cause “contamination” per se, and again seems
to refer to a stimulus agent that was associated at some point in the individual’s history with
thoughts, images, emotions, and sensations that were, and are, horrifying, frightening, and/or
disgusting to the person, relate to a sense of helplessness, and are seemingly inextricably tied to
prior trauma(s). Because we speculate here that a process like that of “mental pollution”
(Rachman, 1994) is indeed underlying some, if not most, of the contamination fears reported by
the individual cases presented in this paper, it then follows that related obsessions and rituals
would not abate with standard exposure and response prevention treatment.
Empirical research is needed to confirm or disconfirm the aforementioned speculations regard-
ing coping, cognitions, and mental pollution; either way, however, treatment implications abound.
While the mechanisms of the connection between PTSD and OCD are speculative, what seems
most apparent is that a treatment strategy incorporating management of symptoms of OCD and
PTSD simultaneously is necessary for patients in whom the trauma(s) seemingly preceded the
onset of OCD. For example, while engaging in CBT treatment of PTSD via prolonged imaginal
exposure and/or stress inoculation training (Foa et al., 1999) and/or imagery restructuring
(Smucker & Dancu, 1999), it is imperative to gauge the use of compulsive rituals as a means of
coping with the cognitive and affective responses related to such treatment. Not gauging and
managing rituals could result in ineffective treatment as emotional processing (Foa & Kozak,
1986; Rachman, 1980, 2001) of trauma-related material is thwarted. Conversely, while engaging
in CBT treatment for OCD via exposure and response prevention, it is imperative to gauge the
possible elicitation and exacerbation of PTSD symptoms, particularly flashbacks, nightmares,
sleep disturbances, hypervigilance, excessive startle response, emotional numbing, and social
detachment. Not gauging and managing such symptoms could again result in ineffective treatment
as habituation to feared stimuli is derailed.
It is unclear whether or not the patients described in this paper would have received greater
treatment benefit if referred to an intensive trauma/PTSD program instead of an intensive OCD
program; it is unclear whether a “dynamic connection” (Rachman, 1991) between symptoms
would be similar if PTSD symptoms were addressed first. For example, would an increase in
PTSD symptoms relate to an increase rather than a decrease in OCD symptoms? Certainly, based
on our hypothesis, one would expect this to be the case. And would a decrease in PTSD symptoms
relate to a decrease rather than an increase in OCD symptoms? Perhaps the answer is “yes,” but
these questions remain open to examination and empirical test.
Because of the complexity and severity of symptoms (and the severity of endured traumas), it
is likely that long-term therapy would be necessary regardless of the referred treatment program.
Indeed, prior research has found that comorbid PTSD negatively affects behavior therapy outcome
for OCD (Gershuny et al., 2002). Research has yet to take place that examines the impact of
OCD on CBT outcome for PTSD, and such research is necessary to piece together a more com-
plete picture of the treatment-related issues inherent in cases of comorbid OCD and PTSD.
Assessment implications also abound. If a dynamic connection (Rachman, 1991) exists in some
1040 B.S. Gershuny et al. / Behaviour Research and Therapy 41 (2003) 1029–1041

patients with comorbid OCD and PTSD, and this connection relates to negative treatment outcome
in patients seeking treatment for OCD, then how might assessments be revised at the beginning
and throughout treatment to better guide therapy approaches? This is a complex question, the
answer to which still seems elusive to us. At this point, we recommend that a thorough evaluation
that includes an assessment of trauma history and PTSD be conducted at intake for patients
referred for treatment of OCD; we recommend the same be done for patients referred for treatment
of PTSD such that a thorough assessment of OCD-related symptoms be conducted at intake. In
addition, an individualized and comprehensive functional analysis of the interplay of triggers,
cognitions, emotions, and behaviors may be helpful in generating case conceptualizations that
guide effective interventions.
Though one empirical treatment study has revealed a negative impact of comorbid PTSD on
treatment outcome for OCD (Gershuny et al., 2002), it is not yet clear if such a negative impact
exists for all, or even most, patients diagnosed with these comorbid disorders. In this paper and
in the prior study, we focused exclusively on an examination of patients who reported an onset
of OCD symptoms after experiencing trauma(s), and had failed prior courses of treatment (i.e.,
were treatment-refractory). Perhaps there are OCD/PTSD patients referred to outpatient clinics
who do just fine with treatment, particularly patients for whom trauma(s) and PTSD are sub-
sequent to OCD. This question still begs empirical investigation. It is also possible that the forms
of OCD and PTSD we are seeing in the patients presented here are more in line with Herman’s
conceptualization of Complex PTSD (Herman, 1997) that is widely regarded as difficult to treat
and requiring of long-term care. Indeed, trying to ascertain diagnostically the best way to concep-
tualize these patients is a challenge. Should they be viewed as having two separate diagnoses, or
are they better served if viewed as having Complex PTSD? Again, to date this remains unclear.

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