Depression in Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder

Anna Merrill, 1 Beth Gershuny, 1 Lee Baer, 2 and Michael A. Jenike 2

1 2

Bard College Harvard Medical School and Massachusetts General Hospital

Previous ndings suggested a unique role that depression symptoms might play in the comorbid relationship between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). However, the nature of this role remains unclear. Thus, the current study examined ways in which OCD and PTSD symptoms vary as a function of depression, as well as the mediating role of depression in the OCD-PTSD relationship, in 104 individuals seeking treatment for refractory OCD. Findings revealed that depressed individuals in the treatment-refractory OCD sample report higher levels of overall obsessing and greater severity of PTSD. In addition, depression appeared to mediate the relation between OCD and PTSD. Implications of ndings are discussed. & 2011 Wiley Periodicals, Inc. J Clin Psychol 67:624628, 2011. Keywords: depression; obsessive-compulsive disorder; posttraumatic stress disorder; mediation; comorbidity

The relationship between obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) has received quite a bit of recent empirical attention (e.g., de Silva & Marks, 1999; Gershuny, Baer, Parker, Gentes, Ineld, & Jenike, 2008; Gershuny et al., 2006; Pitman, 1993). For example, Gershuny and colleagues (2008) examined history of traumatic experiences and current PTSD in individuals seeking therapeutic intervention for treatmentresistant OCD. Results revealed that 82% reported a history of at least one trauma, and 39.4% of the sample met criteria for PTSD based on semistructured clinical interview; 46.6% met criteria for PTSD based on self-report. Such ndings also have been observed naturalistically in case studies (de Silva & Marks, 1999; Gershuny, Baer, Radomsky, Wilson, & Jenike, 2003) of several individuals whose onset of OCD symptoms was preceded by a severe traumatic event, and in some cases was confounded by additional symptoms of depression. Furthermore, it has been postulated that OCD may serve as a form of coping ` -vis cognitive avoidance) as a response to unabated PTSD (e.g., de Silva & strategy (vis-a Marks, 1999; Gershuny et al., 2002, 2003). It remains unclear, however, how and why this seemingly functional relationship between OCD and PTSD may exist for some treatment-resistant individuals. Perhaps one possible explanation can be found via ruminative depression. Gershuny and colleagues (2008) found that PTSD prevalence was highest in treatment-resistant OCD with comorbid major depression disorder (MDD). Additionally, Huppert and colleagues (Huppert et al., 2005) found that OCD and PTSD severity correlated, but not after depression symptoms were partialled from symptom constellations. An implication of these ndings is that depression symptoms may in some way be accounting for the relationship between OCD and PTSD in the OCD and PTSD clinical samples, further suggesting that depression may function as a mediating factor between the two disorders. However, to date, this speculation has not been assessed empirically. Thus, this study will seek to disentangle in part the complex relationship that MDD might play in OCD and PTSD symptoms in a treatment-resistant OCD sample by
This article was reviewed and accepted under the editorship of Beverly E. Thorn. Correspondence concerning this article should be addressed to: Beth Gershuny, PO Box 5000, Annandale-onHudson, New York 12504; e-mail: gershuny@bard.edu

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 67(6), 624--628 (2011) & 2011 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20783

Depression, OCD, PTSD

625

addressing this question of mediation. We hypothesize that OCD and PTSD symptom severity will be signicantly higher in depressed compared to nondepressed individuals. We further hypothesize that depression may function as a mediator of the relationship between PTSD and OCD severity.

Method Participants
Participants were 104 individuals seeking cognitive-behavioral (exposure and response prevention) and pharmacological treatment over the course of one year for treatmentrefractory OCD at Massachusetts General Hospitals OCD Outpatient Clinic or Massachusetts General Hospitals/McLean Hospitals OCD Residential Treatment Facility (Boston, MA). Data was gathered as part of a naturalistic, retrospective chart review of clinical intake diagnostic interviews and self-report measures collected on each consecutive individual enrolling for treatment over the course of the year.

Measures
For the purposes of this current study (which comprises a relatively small subset of the larger data collection), severity of depression symptoms were assessed via the Beck Depression Inventory (BDI; Beck & Steer, 1987), severity and types of OCD symptoms were assessed via the ObsessiveCompulsive Inventory (OCI; Foa, Kozak, Salkovskis, Coles, & Amir, 1998), and severity PTSD symptoms were assessed via the Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997). All measures are Likert-scale self-report. In addition, diagnostic information was obtained via semistructured diagnostic interviews conducted by intake assessors (social workers with masters degrees in social work or doctoral-level postdoctoral fellows and psychologists) and conrmed by senior-level, licensed psychologists with doctorates.

Results
Over 55% of this OCD treatment-resistant sample concurrently met criteria for major depressive disorder; almost 50% met criteria for comorbid PTSD. Similarly, 32% met criteria for both MDD and PTSD. To elucidate potentially differing levels of types of OCD symptom cluster severity between depressed and nondepressed individuals, a series of one-way analyses of variance (ANOVAs) were conducted. Findings revealed depressed individuals (M 5 16.14, SD 5 7.98) reported higher levels of the OCD symptom cluster of obsessing than did nondepressed individuals (M 5 12.72, SD 5 7.48), F(1, 94) 5 4.64, p 5 o.05. No other signicant ndings were revealed (i.e., there were no differences in overall OCD symptom distress or OCD symptom frequency or in levels for the following symptom clusters: hoarding, checking, neutralizing, ordering, washing, and doubting). One-way ANOVAs also were conducted to assess potentially differing levels of PTSD symptoms between depressed and nondepressed participants. Findings revealed that depressed individuals reported greater overall PTSD severity (M 5 20.49, SD 5 17.66) than nondepressed individuals (M 5 11.41, SD 5 14.58), F(1,101) 5 7.84, p 5o.01; greater reexperiencing PTSD symptom severity (MDepressed 5 6.62, SD 5 5.39, MNot Depressed 5 4.18, SD 5 4.50), F(1,78) 5 4.63, p 5o.05; greater avoidance PTSD symptom severity (MDepressed 5 10.15, SD 5 7.10, MNot Depressed 5 6.88, SD 5 6.41), F(1,78) 5 4.48, p 5o.05; and greater arousal PTSD symptom severity (MDepressed 5 7.63, SD 5 5.27, MNot Depressed 5 5.09, SD 5 5.01), F(1,76) 5 4.55, p 5o.05. Correlations were found between depression and overall OCD symptom distress (r 5 .27, po.01), and between depression and PTSD severity (r 5 .44, po.01), and between overall OCD symptom distress and PTSD severity (r 5 .21, po.05). The signicance of these correlations allowed us to proceed with an examination of whether depression actually mediates the relationship between overall OCD symptom distress and PTSD severity using hierarchical linear multiple regression and following the procedure for assessing mediation

626

Journal of Clinical Psychology, June 2011

outlined by Baron and Kenny (1986). Findings demonstrated that initial PTSD severity predicted OCD symptom distress, B 5 .21, F(1, 94) 5 4.40, po.05; R2 5 .05. Findings also demonstrated that initial depression severity predicted OCD symptom distress, B 5 .27, F(1, 94) 5 7.45, po.01). After entering depression into the regression equation in the rst step prior to PTSD severity, F(2, 93) 5 4.24, po.01; R2 5 .08 (with PTSD severity entered as the second step), PTSD severity no longer predicted OCD symptom distress, B 5 .11, t 5 1.02, p 5 .31, DR2 5 .02, po.05. Thus, depression did indeed mediate the relationship between PTSD and OCD symptoms.

Discussion
Findings conrmed our hypothesis that depression mediates the relationship between OCD and PTSD. Furthermore, it appeared that depressed individuals experience signicantly more OCD-related obsessing as well as greater overall PTSD severity, reexperiencing PTSD symptom severity, avoidance PTSD symptom severity, and arousal PTSD symptom severity. Over half of treatment-refractory OCD sample examined also met criteria for MDD, which may highlight the relevance of these ndings within a treatment-resistant OCD population. If depression mediates the relationship between OCD and PTSD symptoms, this suggests that the severity of the posttraumatic symptoms in OCD is in some way dependent on the presence or absence of depression, which in turn affects the severity and expression of comorbid OCD. Gershuny and colleagues (2003) reported four case studies of comorbid OCD and PTSD in which symptoms of PTSD increased as a result of targeting OCD symptoms in treatment (as a speculated response to ridding symptomsOCDthat serve a coping function for the traumatic memories and symptoms), and when symptoms of OCD increased, symptoms of PTSD lessened (because the OCD-related coping responses were keeping traumatic memories and symptoms at bay). Gershuny and colleagues (2003) postulated that in these cases, OCD symptoms serve some type of coping function against trauma-related material and symptoms. However, ndings from the current study indicate that depression may serve as a conduit between the PTSD and OCD, suggesting further that perhaps OCD symptoms are providing a means of coping not only with PTSD, but with depression as well. Relations among OCD, PTSD, and depression may ultimately be linked to rumination. Papageorigiou and Wells (2003) suggest that there is a cyclical relationship between rumination as a way of coping with depressive symptoms. Perhaps such a cyclical relationship in turn interacts with coping as manifested through obsessing in the presence of comorbid OCD and PTSD, both of which have intrusive, ruminative thoughts as hallmark diagnostic criteria. Indeed, Michael, Halligan, Clark, and Ehlers (2007) found a vastly high proportion of rumination in PTSD (8994%) that was associated with PTSD and even explained 2328% of the variance in PTSD severity. Therefore, there is evidence to support the speculation that rumination may represent a central and shared cognitive style in patients that have experienced a trauma and experience PTSD, OCD, and depression. It seems the relationship between OCD and MDD could be dened through increased obsessive symptoms due to rumination that may affect the ability to treat symptoms effectively (Cassin, Richter, Zhang, & Rector, 2009). Similarly, increased PTSD symptoms in individuals seeking treatment for OCD serve to thwart effective treatment (Gershuny, Baer, Jenike, Minichiello, & Wilhelm, 2002). Obsessing and rumination in OCD, depression, and PTSD may together be considered resources for coping with traumatic material, and individuals that have experienced a trauma may be more at risk to utilize any combination of these resources to cope effectively. Similarly, the negative rumination present in all three disorders suggests that someone with the negative ruminative cognitive style, most closely linked to depression, is more likely to also develop PTSD and OCD posttrauma. If all three disorders, especially in combination, relate to a history of trauma and negative rumination, then both trauma and a ruminative cognitive style should be addressed directly in treatment when PTSD, OCD, and MDD co-occur. There is already evidence suggesting that traditional behavior therapy in patients with OCD and comorbid PTSD does not work as well. Gershuny and colleagues (2002) reviewed the

Depression, OCD, PTSD

627

impact of comorbid PTSD on behavior therapy in patients with OCD, nding that there were signicantly larger improvements in both OCD and depression severity for the patients who did not have comorbid PTSD than those patients with comorbid PTSD. In this case, Gershuny and colleagues proposed this could be because OCD symptoms serve as a coping function, by means of avoidance, against psychologically painful trauma and therefore suggested that when OCD and PTSD are present in a patient, the treatment for OCD should be combined with systematic treatment for the PTSD symptoms. However, our present ndings further suggest that treatment for depression may rst or concurrently need to be addressed as it mediates the relationship between PTSD and OCD. Future research may wish to focus on developing a greater understanding of the relations and perhaps cyclical functions of OCD, PTSD, and MDD symptoms in treatment-refractory OCD samples. Understanding such relations and function likely would help in the continued improvement of available treatments for such a refractory population and perhaps would have further implications for treatments of complex PTSD in general. The current study is not without limitations, and interpretations should be made with some degree of caution. Though depression appears to mediate the relationship between OCD and PTSD, there are numerous other possible factors that may help explain this relationship further. For example, trauma-related variables (e.g., type of trauma, duration of trauma) may help explain why some traumatized individuals with PTSD also meet criteria for OCD; an examination of such variables awaits further study. In addition, though depression seems like a key psychopathology variable in treatment-resistant OCD and its relation to PTSD, it is possible that depression simply represents some sort of general indication of severity of overall psychopathology. To try to disentangle this possibility, future studies are indicated. Furthermore, the current study represents a naturalistic review of clinical intake charts; data was not conducted via controlled collection procedures. We suggest such a study be conducted to ascertain whether our naturalistic ndings would replicate under controlled conditions.

References
Baron, R.M., & Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 11731182. Beck, A.T., & Steer, R.A. (1987). Manual for the Revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation. Cassin, S.E., Richter, M.A., Zhang, K.A., & Rector, N.A. (2009). Quality of life in treatment-seeking patients with obsessive-compulsive disorder with and without major depressive disorder. The Canadian Journal of Psychiatry, 54, 460467. de Silva, P., & Marks, M. (1999). The role of traumatic experiences in the genesis of obsessive-compulsive disorder. Behavior Research and Therapy, 37, 941951. Foa, E.B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The posttraumatic diagnostic scale. Psychological Assessment, 9, 445451. Foa, E.B., Kozak, M.J., Salkovskis, P.M., Coles, M.E., & Amir, N. (1998). The validation of a new obsessivecompulsive disorder scale: The obsessive-compulsive inventory. Psychological Assessment, 10, 206214. Gershuny, B.S., Baer, L., Jenike, M.A., Minichiello, W., & Wilhelm, S. (2002). Comorbid posttraumatic stress disorder: Impact on treatment outcome for obsessive-compulsive disorder. American Journal of Psychiatry, 159, 852854. Gershuny, B.S., Baer, L., Parker, H., Gentes, E.L., Ineld, A.L., & Jenike, M.A. (2008). Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder. Depression and Anxiety, 25, 6971. Gershuny, B.S., Baer, L., Radomsky, A.S., Wilson, K.A., & Jenike, M.A. (2003). Connections among symptoms of obsessive-compulsive disorder and posttraumatic stress disorder: A case series. Behavior Research and Therapy, 41, 10291041.

628

Journal of Clinical Psychology, June 2011

Gershuny, B.S., Keuthen, N.J., Gentes, E.L., Russo, A.R., Emmott, E.C., Jameson, M., et al. (2006). Current posttraumatic stress disorder and history of trauma in trichotillomania. Journal of Clinical Psychology, 62, 15211529. Huppert, J.D., Moser, J.S., Gershuny, B.S., Riggs, D.S., Spokas, M., Filip, J., et al. (2005). The relationship between obsessive-compulsive and posttraumatic stress symptoms in clinical and nonclinical samples. Journal of Anxiety Disorders, 19, 127136. Michael, T., Halligan, S.L., Clark, D.M., & Ehlers, A. (2007). Rumination in posttraumatic stress disorder. Depression and Anxiety, 24, 307317. Papageorigiou, C., & Wells, A. (2003). An empirical test of a clinical metacognitive model of rumination and depression. Cognitive Therapy and Research, 27, 261273. Pitman, R.K. (1993). Posttraumatic obsessive-compulsive disorder: A case study. Comprehensive Psychiatry, 34, 102107.

Copyright of Journal of Clinical Psychology is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.