Social Psychiatry and Psychiatric Epidemiology

, Volume 49, Issue 8, pp 1287–1296 | Cite as

Are trauma and dissociation related to treatment resistance in patients with obsessive–compulsive disorder?

  • Umit B. Semiz
  • Leman Inanc
  • Cigdem H. Bezgin
Original Paper



Previous research has indicated a relation between obsessive–compulsive disorder (OCD), childhood traumatic experiences and higher levels of dissociation that appears to relate to negative treatment outcome for OCD. The aim of the present study is to investigate whether childhood trauma and dissociation are related to severity of OCD in adulthood. We also intend to examine the association between treatment resistance, dissociation, and each form of trauma.


Participants included 120 individuals diagnosed with OCD; 58 (48.3 %) of them met the criteria for treatment-resistant OCD (resistant group), whereas the other 62 (51.7 %) were labeled as responder group. The intensity of obsessions and compulsions was evaluated using Yale-brown obsessive–compulsive scale (Y-BOCS). All patients were assessed with the traumatic experiences checklist, dissociative experiences scale, beck depression inventory, and beck anxiety inventory.


Controlling for clinical variables, resistant group had significantly higher general OCD severity, anxiety, depression, trauma, and dissociation scores than the responders. Correlation analyses indicated that Y-BOCS scores were significantly related to severity of dissociation, anxiety, depression, and traumatic experiences. In a logistic regression analysis with treatment resistance as a dependent variable, high dissociation levels, long duration of illness, and poor insight emerged as relevant predictors, but gender, levels of anxiety, depression, and traumatic experiences did not.


Our results suggest that dissociation may be a predictor of poorer treatment outcome in patients with OCD; therefore, a better understanding of the mechanisms that underlie this phenomenon may be useful. Future longitudinal studies are warranted to verify if this variable represents predictive factors of treatment non-response.


Obsessive–compulsive disorder Treatment resistance Childhood trauma Dissociation 


Conflict of interest

On behalf of all the authors, the corresponding author states that there is no conflict of interest.


  1. 1.
    Husted DS, Shapira NA (2004) A review of the treatment for refractory obsessive-compulsive disorder: from medicine to deep brain stimulation. CNS Spectr 9:833–847PubMedGoogle Scholar
  2. 2.
    Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF (2006) A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol Psychiatry 11:622–632PubMedCrossRefGoogle Scholar
  3. 3.
    Goodman WK, Ward HE, Kablinger AS, Murphy TK (2000) Biological approaches to treatment-resistant obsessive-compulsive disorder. In: Goodman WK, Rudorfer MV, Maser JD (eds) Obsessive-compulsive disorder: contemporary issues in management. Lawrence Erlbaum Associates, London, pp 333–369Google Scholar
  4. 4.
    Ravizza L, Barzega G, Bellino S, Bogetto F, Maina G (1995) Predictors of drug treatment response in obsessive-compulsive disorder. J Clin Psychiatry 56:368–373PubMedGoogle Scholar
  5. 5.
    Shetti CN, Reddy YC, Kandavel T, Kashyap K, Singisetti S, Hiremath AS, Siddequehusen MU, Raghunandanan S (2005) Clinical predictors of drug nonresponse in obsessive-compulsive disorder. J Clin Psychiatry 66:1517–1523PubMedCrossRefGoogle Scholar
  6. 6.
    Pigott TA, Seay S (1997) Pharmacotherapy of obsessive-compulsive disorder. Int Rev Psychiatry 9:133–147CrossRefGoogle Scholar
  7. 7.
    Hantouche EG, Bouhassira M, Lancrenon S (2000) Prospective follow-up over a 12 month period of a cohort of 155 patients with obsessive-compulsive disorder: phase III National DRT-TOC Study. Encephale 26:73–83PubMedGoogle Scholar
  8. 8.
    Alonso P, Menchon JM, Pifarre J, Mataix-Cols D, Torres L, Salgado P, Vallejo J (2001) Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry 62:535–540PubMedCrossRefGoogle Scholar
  9. 9.
    Lochner C, duToit PL, Zungu-Dirwayi N, Marais A, vanKradenburg J, Seedat S, Niehaus DJH, Stein DJ (2002) Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depress Anxiety 15:66–68PubMedCrossRefGoogle Scholar
  10. 10.
    Burnam MA, Stein JA, Golding JM, Siegel JM, Sorenson SB, Forsythe AB (1988) Sexual assault and mental disorders in a community population. J Consult Clin Psychol 56:843–850PubMedCrossRefGoogle Scholar
  11. 11.
    Caspi A, Vishne T, Sasson Y, Gross R, Livne A, Zohar J (2008) Relationship between childhood sexual abuse and obsessive-compulsive disorder: case control study. Isr J Psychiatry Rel Sci 45:177–182Google Scholar
  12. 12.
    Gershuny BS, Baer L, Wilson KA, Radomsky AS, Jenike MA (2003) Connections among symptoms of obsessive-compulsive disorder and posttraumatic stress disorder: a case series. Behav Res Ther 41:1029–1041PubMedCrossRefGoogle Scholar
  13. 13.
    Pitman RK (1993) Posttraumatic obsessive-compulsive disorder: a case study. Compr Psychiatry 34:102–107PubMedCrossRefGoogle Scholar
  14. 14.
    Gershuny BS, Baer L, Parker H, Gentes EL, Infield AL, Jenike MA (2008) Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder. Depress Anxiety 25:69–71PubMedCrossRefGoogle Scholar
  15. 15.
    Goff DC, Olin JA, Jenike MA, Baer L, Buttolph ML (1992) Dissociative symptoms in patients with obsessive-compulsive disorder. J Nerv Ment Dis 180:332–337PubMedCrossRefGoogle Scholar
  16. 16.
    Praško J, Raszka M, Adamcová K, Grambal A, Kopřivová J, Kudrnovská H, Látalová K, Vyskočilová J (2009) Predicting the therapeutic response to cognitive behavioural therapy in patients with pharmacoresistant obsessive-compulsive disorder. Neuroendocrinol Lett 30:615–623PubMedGoogle Scholar
  17. 17.
    Draijer N, Langeland W (1999) Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. Am J Psychiatry 156:379–385PubMedGoogle Scholar
  18. 18.
    Lochner C, Seedat S, Hemmings SM, Kinnear CF, Corfield VA, Niehaus DJ, Moolman-Smook JC, Stein DJ (2004) Dissociative experiences in obsessive-compulsive disorder and trichotillomania: clinical and genetic findings. Compr Psychiatry 45:384–391PubMedCrossRefGoogle Scholar
  19. 19.
    Lochner C, Seedat S, Hemmings SM, Moolman-Smook JC, Kidd M, Stein DJ (2007) Investigating the possible effects of trauma experiences and 5-HTT on the dissociative experiences of patients with OCD using path analysis and multiple regression. Neuropsychobiology 56:6–13PubMedCrossRefGoogle Scholar
  20. 20.
    Rufer M, Held D, Cremer J, Fricke S, Moritz S, Peter H, Hand I (2006) Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. Psychother Psychosom 75:40–46PubMedCrossRefGoogle Scholar
  21. 21.
    First MB, Spitzer RL, Gibbon M, Williams JBW (1997) Structured clinical interview for DSM-IV Axis I disorders: clinical version (SCIDCV). American Psychiatric Press, Washington, DCGoogle Scholar
  22. 22.
    Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, Charney DS (1989) The Yale-brown obsessive-compulsive scale I: development, use, and reliability. Arch Gen Psychiatry 46:1006–1011PubMedCrossRefGoogle Scholar
  23. 23.
    Tek C, Ulug B, Rezaki BG, Tanrivedi N, Mercan S, Demir B, Vargel S (1995) Yale-brown obsessive compulsive scale and US national institute of mental health global obsessive compulsive scale in Turkish: reliability and validity. Acta Psychiatr Scand 91:410–413PubMedCrossRefGoogle Scholar
  24. 24.
    Nijenhuis ERS, Van der Hart O, Kruger K (2002) The psychometric characteristics of the traumatic experiences questionnaire (TEC): first findings among psychiatric outpatients. Clin Psychol Psychother 9:200–210CrossRefGoogle Scholar
  25. 25.
    Semiz UB, Basoglu C, Ebrinc C, Ergun BM, Noyan CO, Cetin M (2005) Body dysmorphic disorder, trauma, and dissociation in patients with borderline personality disorder: a preliminary study. Bull Clin Psychopharmacol 15:65–70Google Scholar
  26. 26.
    Hisli N (1989) Reliability and validity of BECK depression inventory among university students. J Turk Psychol 7:3–13 (in Turkish)Google Scholar
  27. 27.
    Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (1961) An inventory for measuring depression. Arch Gen Psychiatry 4:561–571PubMedCrossRefGoogle Scholar
  28. 28.
    Beck AT, Epstein N, Brown G, Steer RA (1988) An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 56:893–897PubMedCrossRefGoogle Scholar
  29. 29.
    Ulusoy M, Erkmen H, Sahin N (1998) Turkish version of the beck anxiety inventory: psychometric properties. J Cogn Psychother 12:163–172Google Scholar
  30. 30.
    Yargic LI, Tutkun H, Sar V (1995) The reliability and validity of the Turkish version of the dissociative experiences scale. Dissociation 8:10–13Google Scholar
  31. 31.
    Bernstein EM, Putnam FW (1986) Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 174:727–735PubMedCrossRefGoogle Scholar
  32. 32.
    Mathews CA, Kaur N, Stein MB (2008) Childhood trauma and obsessive-compulsive symptoms. Depress Anxiety 25:742–751PubMedCrossRefGoogle Scholar
  33. 33.
    Briggs ES, Price IR (2009) The relationship between adverse childhood experience and obsessive-compulsive symptoms and beliefs: the role of anxiety, depression and experiential avoidance. J Anxiety Disord 23:1037–1046PubMedCrossRefGoogle Scholar
  34. 34.
    Cromer KR, Schmidt NB, Murphy DL (2006) An investigation of traumatic life events and obsessive-compulsive disorder. Behav Res Ther 4:1683–1691Google Scholar
  35. 35.
    Carpenter L, Chung MC (2011) Childhood trauma in obsessive compulsive disorder: the roles of alexithymia and attachment. Psychol Psychother 84:367–388PubMedCrossRefGoogle Scholar
  36. 36.
    Gershuny BS, Baer L, Jenike MA, Minichiello WE, Wilhelm S (2002) Comorbid posttraumatic stress disorder: impact on treatment outcome for obsessive-compulsive disorder. Am J Psychiatry 159:852–854PubMedCrossRefGoogle Scholar
  37. 37.
    Selvi Y, Besiroglu L, Aydin A, Gulec M, Atli A, Boysan M, Celik C (2012) Relations between childhood traumatic experiences, dissociation, and cognitive models in obsessive compulsive disorder. Int J Psychiatry Clin Pract 16:53–59PubMedCrossRefGoogle Scholar
  38. 38.
    Michelson L, June K, Vives A, Testa S, Marchione N (1998) The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia. Behav Res Ther 36:1011–1050PubMedCrossRefGoogle Scholar
  39. 39.
    Spitzer C, Barnow S, Freyberger HJ, Grabe HJ (2007) Dissociation predicts symptom-related treatment outcome in short-term inpatient psychotherapy. Aust N Z J Psychiatry 41:682–687PubMedCrossRefGoogle Scholar
  40. 40.
    Fontenelle LF, Domingues AM, Souza WF, Mendlowicz MV, de Menezes GB, Figueira IL, Versiani M (2007) History of trauma and dissociative symptoms among patients with obsessive-compulsive disorder and social anxiety disorder. Psychiatr Q 78:241–250PubMedCrossRefGoogle Scholar
  41. 41.
    Ball S, Robinson A, Shekhar A, Walsh K (1997) Dissociative symptoms in panic disorder. J Nerv Ment Dis 185:755–760PubMedCrossRefGoogle Scholar
  42. 42.
    Lipinski JF Jr, Pope HG Jr (1994) Do “flashbacks” represent obsessional imagery? Compr Psychiatry 35:245–247PubMedCrossRefGoogle Scholar
  43. 43.
    Grabe HJ, Goldschmidt F, Lehmkuhl L, Gänsicke M, Spitzer C, Freyberger HJ (1999) Dissociative symptoms in obsessive-compulsive dimensions. Psychopathology 32:319–324PubMedCrossRefGoogle Scholar
  44. 44.
    Kluft RP (1993) Multiple personality disorder. In: Spiegel DA (ed) Dissociative disorders: a clinical review. Sidran Press, Lutherville, pp 17–44Google Scholar
  45. 45.
    McNevin SH, Rivera M (2001) Obsessive compulsive spectrum disorders in individuals with dissociative disorders. J Trauma Dissociation 2:117–131CrossRefGoogle Scholar
  46. 46.
    Ross CA, Anderson G (1988) Phenomenological overlap of multiple personality disorder and obsessive compulsive disorder. J Nerv Ment Dis 176:295–299PubMedCrossRefGoogle Scholar
  47. 47.
    Belli H, Ural C, Vardar MK, Yesılyurt S, Oncu F (2012) Dissociative symptoms and dissociative disorder comorbidity in patients with obsessive-compulsive disorder. Compr Psychiatry 53:975–980PubMedCrossRefGoogle Scholar
  48. 48.
    Medford N, Sierra M, Baker D, David AS (2005) Understanding and treating depersonalisation disorder. Adv Psychiatr Treat 11:92–100CrossRefGoogle Scholar
  49. 49.
    Hollander E, Benzaquen SD (1997) The obsessive-compulsive spectrum disorders. Int Rev Psychiatry 9:99–110CrossRefGoogle Scholar
  50. 50.
    Hollander E, Carrasco JL, Mullen LS, Trungold S, De-Caria CM, Towey J (1992) Left hemispheric activation in depersonalization disorder: a case report. Biol Psychiatry 31:1157–1162PubMedCrossRefGoogle Scholar
  51. 51.
    Pica M, Beere D, Maurer L (1997) The overlap between dissociative and obsessive-compulsive disorders: a theoretical link. Dissociation 10:38–43Google Scholar
  52. 52.
    West M, Adam K, Spreng S, Rose S (2001) Attachment disorganization and dissociative symptoms in clinically treated adolescents. Can J Psychiatry 46:627–631PubMedGoogle Scholar
  53. 53.
    Meyer B, Pilkonis PA, Proietti JM, Heape CL, Egan M (2001) Attachment styles and personality disorders as predictors of symptom course. J Pers Disord 15:371–389PubMedCrossRefGoogle Scholar
  54. 54.
    Saxena S, Maidment KM, Vapnik T, Golden G, Rishwain T, Rosen RM, Tarlow G, Bystritsky A (2002) Obsessive-compulsive hoarding: symptom severity and response to multimodal treatment. J Clin Psychiatry 63:21–27PubMedCrossRefGoogle Scholar
  55. 55.
    Eisen JL, Rasmussen SA, Phillips KA, Price LH, Davidson J, Lydiard RB, Ninan P, Piggott T (2001) Insight and treatment outcome in obsessive-compulsive disorder. Compr Psychiatry 42:494–497PubMedCrossRefGoogle Scholar
  56. 56.
    Hardt J, Rutter M (2004) Validity of adult retrospective reports of adverse childhood experiences: review of the evidence. J Child Psychol Psychiatry 45:260–273PubMedCrossRefGoogle Scholar
  57. 57.
    Sar V, Akyuz G, Kugu N, Ozturk E, Ertem-Vehid H (2006) Axis I dissociative disorder comorbidity in borderline personality disorder and reports of childhood trauma. J Clin Psychiatry 10:1583–1590CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Umit B. Semiz
    • 1
    • 2
  • Leman Inanc
    • 1
  • Cigdem H. Bezgin
    • 1
  1. 1.Department of PsychiatryIstanbul Erenkoy Psychiatry and Neurology Education and Research HospitalIstanbulTurkey
  2. 2.Istanbul Erenkoy Ruh ve Sinir Hastaliklari Egt. ve Ars. HastanesiIstanbulTurkey

Personalised recommendations