CHILDHOOD TRAUMA & OBSESSIVE COMPULSIVE DISORDER
Exploring the Relationship between Childhood & Adolescent Trauma and the
Development of Obsessive-Compulsive Disorder: A Review of Current Literature
Emily Shields
University at Buffalo
The State University of New York
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CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER
Abstract
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Recent research has explored the relationship between traumatic experiences during childhood and development of obsessive-compulsive symptoms (OCS) and diagnosed obsessivecompulsive disorder (OCD). Numerous empirical studies have been conducted over the last decade that have investigated the causes of OCD, severity of obsessive-compulsive symptoms, types of trauma associated with anxiety spectrum disorders, and the link between OCD and posttraumatic stress disorder (PTSD). With a thorough examination of the current literature, I have concluded that there is a positive correlation between childhood trauma and development of
OCD. This review will cover the most relevant empirical studies available and scholarly articles from a variety of reputable sources. I conducted several tailored searches using Academic Search
Complete, PsychInfo, PsychArticles, MEDLINE, and PubMed, focusing on these keywords: obsessive-compulsive disorder, childhood, children , and trauma . I selected studies for this literature review based on research questions and methods, sample size, generalizability, and statistical rigor. To support my findings further, I will reference some literature that is not specific to obsessive-compulsive disorder, but illustrates the baseline truth that childhood trauma has profound neurological, psychological, and developmental effects. In conclusion, I found that there is much valuable research available on this topic, but there are some limitations. There is a need for further study with more diverse sample groups to increase external validity. Diversity includes but is not limited to: socioeconomic status, gender, ethnicity, sexual orientation, and culture. Few studies view obsessive-compulsive disorder and trauma cross-culturally or with sufficiently varied socioeconomic groups. This literature review seeks to present the most relevant clinical findings and their meaning for this specific topic as well as explore possible areas for further research.

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER
Exploring the Relationship between Childhood & Adolescent Trauma and the
Development of Obsessive-Compulsive Disorder: A Review of Current Literature
This paper will explore the recent literature regarding the possible link between
3 childhood and adolescent psychological trauma and the development of obsessive-compulsive disorder (OCD) or obsessive-compulsive symptoms (OCS). While trauma has been studied in depth with some populations, study of youth trauma is relatively new, especially in regard to its developmental consequences. I uncovered several articles linking post-traumatic stress disorder
(PTSD) to the onset of OCD. Some studies also make distinctions between types of trauma, such as physical abuse, physical and emotional neglect, sexual abuse, accidents, and witnessing violence. In these studies, researchers found some differences regarding the type and severity of presenting OCD symptoms. The resources I will cite in this paper are an assortment of critical reviews and empirical studies published during the last decade from both a psychological perspective and a medical perspective. Through this synthesis of current findings, I will illustrate that trauma during childhood and adolescence is positively correlated with higher rates of diagnosed OCD and development of OCS. An understanding of the relationship between trauma and OCD is integral to the expansion of comprehensive treatment methods for this client population. With the knowledge that childhood trauma may be at the core of OCD-related issues for many clients, we can address individual problems and needs more effectively.
Psychological Viewpoints
Obsessive-compulsive disorder is classified by the DSM-IV-TR as an Axis I anxiety disorder, characterized by marked psychological and physical impairments that include intrusive thoughts and habitual behaviors (American Psychiatric Association, 2000). OCD is observable in

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER adults, children, and adolescents, with a lifetime prevalence of 1-2% (Kessler, Demler, et al.,
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2005 & Valleni-Basile et al., 1994, as cited in Lafleur, Petty, Mancuso, McCarthy, Biederman,
Faro, Levy, & Geller, 2011). Other sources estimate the lifetime prevalence at 4% (D’Alessandro,
2009). There has been significant research on the causes and mediating factors associated with
OCD. Numerous studies have found that traumatic or stressful life events are associated with the onset of OCD and obsessive-compulsive symptoms. The aims of each study are varied and include breakdowns of specific types of trauma, severity of OCD symptoms, types of obsessions and compulsions, and demographics such as sex, ethnicity, and age. The following studies illustrate important findings as well as strong validity and reliability. While some of these studies are psychologically-oriented, I thought it valuable to cite several with a medical perspective to offer a broader look at OCD as an interdisciplinary issue.
One of the first studies to undertake the childhood trauma-OCD link was conducted in
2002 by Gershuny, Baer, Parker, Gentes, Infield, and Jenike. This study addressed history of traumatic experiences and current PTSD diagnoses in individuals already seeking therapy for treatment-resistant OCD. One-hundred and four individuals (54 females and 50 males) between the ages of 16 and 76 (with 95% falling between age 18 and 52) who were seeking treatment from the Harvard Medical School, Massachusetts General Hospital OCD Clinic or Institute comprised the sample. Self-report questionnaires such as the Traumatic Events Scale-Lifetime
(TES-L) and Posttraumatic Diagnostic Scale (PDS) were used to evaluate lifetime history of trauma as well as a semi-structured diagnostic interview based on DSM-IV-TR criteria.
Eighty-two percent of the total sample reported a history of at least one childhood trauma
(Gershuny et al., 2002). Forty-eight percent reported witnessing violence; 46.5% reported a major life-threatening accident; 24.8% reported robbery/mugging; 25.7% reported physical

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER assault in adulthood; 28.7% physical abuse in childhood; 26% sexual abuse in childhood; 23.8%
5 experienced a natural disaster; 16.3% reported sexual violation in adulthood, and 2% reported combat experience. The overall occurrence of trauma in this study is startling. This study was less focused on the severity of obsessive-compulsive symptoms and geared more toward establishing commonalities in trauma experience and illustrating the abnormally high rate of
PTSD in the OCD-diagnosed population. Almost 40% of the overall sample met criteria for diagnosable PTSD, while the approximate rate in the general psychiatric population is 28%
(McFarlane et al., 2001, as cited in Gershuny et al., 2002). This study focused on individuals with treatment-resistant OCD, and the researchers carefully pointed out that more research is needed in order for the findings to be generalizable to the full spectrum of individuals with OCD.
A 2011 study sought to clarify the link between traumatic life events and OCD by assessing children and adolescents with OCD with the Children’s Yale-Brown OCD Scale (CY-
BOCS) and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age
Children-Epidemiologic (KSADS-E) interview, which was used to determine diagnoses of posttraumatic stress disorder (Lafleur, Petty, Mancuso, McCarthy, Biederman, Faro, Levy, &
Geller, 2011). Comparisons between subjects with (N=263) and without (N=151) OCD and between OCD subjects with (N=17) and without (N=246) PTSD. It is important to note that while only 17 subjects were diagnosed with PTSD, numerous subjects experienced trauma during childhood or adolescence, and thus simply did not meet the full diagnostic criteria for
PTSD. Those cases were detailed in the study, including the nature of the trauma and the experienced obsessive-compulsive symptoms. Subjects experiencing OCD and/or trauma were compared against a control group of boys and girls with and without attention deficit hyperactivity disorder (ADHD). Controls for age, gender, family socioeconomic status were

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER implemented, and subjects were excluded if they were adopted, had major sensorimotor handicaps, psychosis, autism, or a full scale IQ or less than 80.
The study found that there is a significant association between OCD and trauma (with or without diagnosed PTSD) (Lafleur et al., 2011). Although only 6% of OCD subjects had co-
6 occurring PTSD, obsessions and compulsions were more intrusive, distressing, and difficult to control in the comorbid group. Children with OCD also reported higher rates of psychological trauma compared with the non-OCD cohort. The researchers suggested further research to study this population and concluded that the correlation between OCD and trauma has significant clinical implications for treatment.
While Lafleur et al. and Gershuny et al. studies were based upon ex post facto designs to investigate the relationship between OCD and trauma, Matthews, Kaur, and Stein (2007) adopted a quasi experimental research design to approach a similar hypothesis. They hypothesized that childhood trauma, particularly emotional abuse and neglect, would be correlated with higher rates of obsessive-compulsive symptoms. Nine-hundred thirty-eight college students were given the Childhood Trauma Questionnaire, the Leyton Obsessional Inventory, the NEO Personality
Inventory-Revised, the State Trait Anxiety Inventory (STAIT), and the PTSD Checklist-Civilian
Version (PCL-C) assessments. Subjects were mostly college freshmen (91% under the age of 21) taking an introductory psychology course with varied ethnicities including Caucasian, Asian
American, Latino, Filipino, African American, and Native American. While this sample was drawn out of convenience from an academic setting, no previous diagnostic information was included and all information gathered was from self-report assessments.
The study found that approximately 50% of the total sample met criteria for any childhood trauma, with between 13 and 30% meeting criteria for significant trauma (Matthews et

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER al., 2007). Trauma was categorized under physical abuse, physical neglect, emotional neglect,
7 emotional abuse, and sexual abuse. It was found that emotional abuse, physical abuse, and physical neglect in particular were most consistently associated with obsessive-compulsive symptoms. The study also documented personality type and ethnicity-specific results that were interesting, though outside the scope of this literature review. The large sample size of both males and females was a strength of this study, but the researchers acknowledged that the small number of high OCS scores was a limitation. Also, since all the testing instruments used were self-reporting measures, there was a risk of inaccurate data. Despite the limitations of this study, it produced important conclusions for the clinical community. With this study and future research regarding the complex nature of OCD onset, individuals with OCD and a history of trauma may receive care that is sensitive, far-reaching, and effective.
A study by Cromer, Schmidt, and Murphy (2007) was cited several times throughout the literature. Two-hundred and sixty-five individuals who were admitted to the Adult OCD Clinic at the National Institute of Mental Health (NIMH) were interviewed using the Structured Clinical
Interview for DSM-IV and all had a primary diagnosis of OCD. Subjects were excluded for active schizophrenia or psychosis, severe mental retardation, or OCD symptoms that were exclusively associated with depression. Subjects were also evaluated with the Y-BOCS,
Traumatic Life Events (TLE) list, and Beck Depression Inventory (BDI). It is important to note that this sample was more homogenous than other studies, with 62.9% of subjects being female and 95% Caucasian. Sixty-seven percent had earned a college degree or higher, and 90% were also diagnosed with at least one other Axis 1 psychological disorder over the lifespan.
Results of this study showed that 54% of the total sample had experienced at least one traumatic life event (Cromer et al., 2007). Ten percent of the sample qualified for a PTSD

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER diagnosis. Consistent with the hypothesis, traumatic life events were associated with increased
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OCD symptom severity, as indicated by a higher Y-BOCS score. Even though the mean age of this sample was 41 (SD=15.02), the mean age of OCD onset was 14.18 (SD=8.67). This study did not focus on children, but traumatic life events and obsessive-compulsive symptoms were assessed across the total lifespan of each subject. To increase the validity of this study, researchers conducted a covariance strategy with depression using the BDI test scores. To summarize, it was found that traumatic life events are more specifically associated with OCD than with depressive symptoms. Categories of symptoms were also specified in the data and the researchers were able to see some trends in the specific types of symptoms that increased as a result of trauma, including obsessions/checking, and symmetry/ordering. However, obsessions and compulsive behaviors in the contamination/cleaning and hoarding categories were not positively correlated with the experience of trauma. While several limitations including retrospective collection of data, lack of sample diversity, and skew of self-reporting measures are apparent in this study, it draws some noteworthy conclusions from closely controlled statistics and analyses. With more than 40 references, thorough methods, and conclusions that are valuable but not overreaching, this study is both reputable and meaningful.
Neurological Viewpoints
The findings of these research studies are even more significant when viewed in the context of well-established medical research that details the neurobiological effects of trauma on the brain. Through modern brain scanning technology, effects of trauma are physically observable, particularly in the limbic system, which includes the amygdala, hippocampus, and hypothalamus (Weber & Reynolds, 2004). As a result of trauma and prolonged stress, the hippocampus can become overly aroused, resulting in an eventual deactivation that can be

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER detrimental to cognitive and memory function. Damage to the hippocampus is acknowledged as
9 a critical factor in the development of anxiety and panic disorders (Teicher et al., 1997, as cited in Weber et al., 2004). Additionally, childhood maltreatment and high stress levels are associated with damage to the pre-frontal cortex and corpus callosum. Changes to these areas of the brain can result in high levels of anxiety, poor self-regulation, and abnormal behaviors (Delima &
Vimpani, 2011). Using this research as a baseline, it is logical that we have begun to study the nature of link between trauma and psychological disorders (specifically OCD and related anxiety disorders) on a deeper, more meticulous level.
The definition of trauma is broad, and therefore I thought it important to include a study on traumatic brain injury (TBI). Grados, Vasa, Riddle, Slomine, Salorio, Christensen, and
Gerring (2008) conducted a study of 80 children and adolescents from 6 to 18 years old who had experienced severe TBI. A one-year prospective study of 72 of those 80 subjects revealed that 21 children developed new onset obsessions and/or compulsions. The study displayed demographics, types of obsessions and compulsions (such as concern with cleanliness, repetitive behaviors, and intrusive violent thoughts), comorbid psychiatric disorders (including PTSD, phobias, and
ADHD, among others), and brain lesion distributions in pediatric brain injury. The depth of study of brain lesions and comorbid disorders is beyond the scope of my research question; however, it provides valuable information about how alterations in the brain affect behavior.
The rate of new onset OCS was significantly higher in female subjects (70%, compared with 37% prevalence in male subjects) which led the researchers to cite environmental and genetic factors that could also be at play. Specific brain abnormalities such as increased mesial prefrontal brain lesions and temporal lesions were found to be associated with new onset obsessions. A constraint of this study lies in the difficulty distinguishing true obsessive-

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER compulsive symptoms from expected repetitive behaviors often seen in TBI patients with neurocognitive impairment or memory loss. The results are also lacking in external validity for
10 male individuals with TBI. Overall, the neurobiological roots of this study have meaningful implications for therapy design and treatment of individuals with OCD.
The final work in this discussion is a medically-oriented commentary that incorporates all of the existing theories about childhood OCD onset with current research. Tina M. D’Alessandro,
MSN, ARNP conducted an overview of recent literature and implications for clinical practice
(D’Alessandro, 2009). She discussed several theories of OCD onset in children, including neural circuitry, genetics, immunology, cognitive behavioral, thought-action fusion, and psycho-social theories. Each of these theoretical models is different and subject to debate. D’Alessandro integrated these viewpoints in her article to suggest that clinicians must understand all of these perspectives to provide care for children with this debilitating disorder. While this article mainly suggested that primary care practitioners use an interdisciplinary treatment approach, I thought its psychology of development perspective pertinent.
D’Alessandro references numerous empirical studies that point to the link between life stressors and/or trauma and social-psychological adjustment in children and adolescents, which directly relates to the development of OCD symptomatology (2009). Although she acknowledges this correlation, she stressed the importance of identifying specific stressful events and the onset of OCD with further research. This article was valuable because of its multi-faceted assimilation of biological, psychological, social, and behavioral theories. The fusion of these ideas in a clear manner brought light to the fact that OCD is a complex disorder that has seemingly many roots and more investigation is needed to understand direct causality and develop more comprehensive treatments specifically for children.

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER
Implications for Research and Practice
There is a relatively wide range of data available on this topic across disciplines. From
11 both a medical and psychological standpoint, the investigation into the relationship between trauma and all types of psychological disorders is necessary to developing better treatments.
Obsessive-compulsive disorder is particularly interesting to me because of its prevalence and propensity for major interference in people’s daily lives. The assortment of studies I discussed in this paper each had different focuses, strengths, and limitations. However, together they indicated clearly to me that trauma should be considered a common factor of OCD. While I cannot make a direct causal association with these two variables, there is evidence of a relationship that should certainly be explored with different populations.
In the process of researching the trauma/OCD relationship, I came across several themes that seemed to be present in numerous studies. Across several sources, I found that emotional neglect and emotional abuse were found to be the highest predictors of OCD and OCS in studies which made distinctions between different types of childhood trauma (Matthews et al., 2007;
Lochner, Du Toit, Zungu-Dirwayi, Marais, Van Kradenburg, Seedat, Dana, Neihous, & Stein,
2002; and Hovens, Giltay, Wiersma, Spinhoven, Penninx, & Zitman, 2012). This indicates that perhaps the nature of trauma is more important than the number of times it was experienced.
With more specific study of different forms of trauma and their potential links to the onset of
OCD, we could make more concrete conclusions about causality and/or mediating factors.
Another factor present in several studies was comorbidity. It appears that OCD is often viewed in context with other co-occurring issues or diagnoses. While this could present a challenge for researchers looking to isolate participants with OCD in empirical studies, it could also offer an opportunity to explore how OCD interacts with, and is affected by, other psychiatric problems.

CHILDHOOD TRAUMA & OBSESSIVE-COMPULSIVE DISORDER
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