Available via license: CC BY 4.0
Content may be subject to copyright.
Citation: D’Angelo, M.; Valenza, M.;
Iazzolino, A.M.; Longobardi, G.; Di
Stefano, V.; Visalli, G.; Steardo, L.;
Scuderi, C.; Manchia, M.; Steardo, L.,
Jr. Exploring the Interplay between
Complex Post-Traumatic Stress
Disorder and Obsessive–Compulsive
Disorder Severity: Implications for
Clinical Practice. Medicina 2024,60,
408. https://doi.org/10.3390/
medicina60030408
Academic Editor: Martin Schäfer
Received: 26 January 2024
Revised: 20 February 2024
Accepted: 24 February 2024
Published: 28 February 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
medicina
Article
Exploring the Interplay between Complex Post-Traumatic Stress
Disorder and Obsessive–Compulsive Disorder Severity:
Implications for Clinical Practice
Martina D’Angelo 1, Marta Valenza 2, Anna Maria Iazzolino 1, Grazia Longobardi 1, Valeria Di Stefano 1,
Giulia Visalli 1, Luca Steardo 2,3, Caterina Scuderi 2, Mirko Manchia 4,5,6,* and Luca Steardo, Jr. 1
1Psychiatry Unit, Department of Health Sciences, University of Catanzaro Magna Graecia,
88100 Catanzaro, Italy; martina.dangelo001@studenti.unicz.it (M.D.); iazzolinoanna@gmail.com (A.M.I.);
grazia.longobardi@studenti.unicz.it (G.L.); valeria.distefano@studenti.unicz.it (V.D.S.);
giulia.visalli@studenti.unicz.it (G.V.); steardo@unicz.it (L.S.J.)
2Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome,
00185 Rome, Italy; marta.valenza@uniroma1.it (M.V.); luca.steardo@uniroma1.it (L.S.);
caterina.scuderi@uniroma1.it (C.S.)
3Department of Clinical Psychology, University Giustino Fortunato, 82100 Benevento, Italy
4Unit of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari,
09124 Cagliari, Italy
5Unit of Clinical Psychiatry, University Hospital Agency of Cagliari, 09124 Cagliari, Italy
6Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
*Correspondence: mirko.manchia@unica.it
Abstract: Background and Objectives: Traumatic events adversely affect the clinical course of obsessive–
compulsive disorder (OCD). Our study explores the correlation between prolonged interpersonal
trauma and the severity of symptoms related to OCD and anxiety disorders. Materials and Methods:
The study follows a cross-sectional and observational design, employing the International Trauma
Questionnaire (ITQ) to examine areas linked to interpersonal trauma, the Hamilton Anxiety Rating
Scale (HAM-A), and the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) to assess anxious and
obsessive–compulsive symptoms, respectively. Descriptive analysis, analysis of variance (ANOVA),
and logistic regression analyses were conducted. Results: We recruited 107 OCD-diagnosed patients,
categorizing them into subgroups based on the presence or absence of complex post-traumatic stress
disorder (cPTSD). The ANOVA revealed statistically significant differences between the two groups
in the onset age of OCD (p= 0.083), psychiatric familial history (p= 0.023), HAM-A, and Y-BOCS
(p< 0.0001).
Logistic regression indicated a statistically significant association between the presence
of cPTSD and Y-BOCS scores (p< 0.0001). Conclusions: The coexistence of cPTSD in OCD exacerbates
obsessive–compulsive symptoms and increases the burden of anxiety. Further advancements in this
field are crucial for mitigating the impact of early trauma on the trajectory of OCD and associated
anxious symptoms.
Keywords: observational study; trauma; stress; clinical course
1. Introduction
Recently, studies on psychological trauma have witnessed significant growth [
1
].
Between 13 and 30% of individuals report having encountered traumatic experiences
during childhood [
2
], which have enduring ramifications on their physical and mental
well-being [
3
]. Consequently, chronic exposure to childhood traumatic events is closely as-
sociated with an elevated likelihood of developing Complex Post-traumatic Stress Disorder
(cPTSD) [
3
]. Indeed, cPTSD has gained recognition as a novel diagnosis in the Eleventh
International Classification of Diseases (ICD-11) [
4
,
5
]. The proposition of a repeated trauma-
related disorder, as articulated by Herman, underscores the potentially profound impact
Medicina 2024,60, 408. https://doi.org/10.3390/medicina60030408 https://www.mdpi.com/journal/medicina
Medicina 2024,60, 408 2 of 12
of prolonged traumatic stressors, particularly on self-organization, with a focus on the
affective and relational domains [
6
]. cPTSD manifests as a severe mental disorder emerging
in response to traumatic life events, encompassing a constellation of symptoms stemming
from cumulative interpersonal traumas experienced throughout developmental stages [
7
].
Notably, cPTSD is characterized by three primary clusters of post-traumatic symptoms
alongside chronic, pervasive disturbances in emotion regulation, identity, and relation-
ships [
7
]. A burgeoning body of literature demonstrates how traumas might serve as
causal factors for a spectrum of outcomes, including emotional dysregulation, behavioral
dysfunction, challenges in interpersonal relationships, and dissociative symptoms in adult-
hood [
8
]. cPTSD often ensues from unstable and distressing environmental contexts that
negatively impact a child’s self-regulation skills, emotional equilibrium, psychological
well-being, and interpersonal bonds [
9
]. Notably, particular attention has been devoted to
the manifestation of self-organization disorders (DSO) observed within this condition, en-
compassing symptomatology spanning affective dysregulation, negative self-concept, and
disrupted relationships [
4
]. Dysregulation, in this scenario, is a state of distress or impair-
ment associated with the inability to tolerate aspects of one’s internal experience, including
emotions, thoughts, bodily sensations, and physiological arousal. Activated by an actual or
perceived threat, traumatic reminders, and other environmental or internal cues that trigger
a person’s survival-driven alarm response. This can take a variety of forms, including
heightened reactivity or shutdown. Strengthening one’s capacity for healthy self-regulation
is a primary focus of complex trauma intervention with children and adults, leading to
a higher psychopathological burden [
10
]. Moreover, alterations in consciousness and the
emergence of dissociative symptoms disorganize individuals’ functioning across various
levels, encompassing the biological, physiological, relational, and behavioral domains [
11
].
Individuals afflicted with cPTSD typically undergo prolonged or recurrent exposures to
interpersonal trauma, such as childhood abuse or domestic violence [
12
–
14
]. The lifetime
prevalence of Post-Traumatic Stress Disorder (PTSD) varies from 3 to 9% within the adult
population, contingent upon the nature and frequency of traumas experienced. Meanwhile,
the prevalence of cPTSD ranges from 1 to 8% in the general population, escalating to 50%
within mental health settings [15].
Notably, childhood trauma has been associated with the onset of obsessive–compulsive
disorder (OCD). Scientific literature posits that predisposing factors for this disorder, such
as genetic vulnerability and typical OCD characteristics, interact with prolonged exposure
to stressful and traumatic events during a child’s formative years [
16
–
20
]. Psychological
distress often manifests as intrusive thoughts (flashbacks, nightmares) related to the trau-
matic experience, occasionally leading to anxiety, fear, aggression, anger, or depressive
symptoms [
21
,
22
]. Recent studies suggest that OCD can emerge as a response to pro-
foundly distressing events, with individuals exposed to trauma being more susceptible to
developing OCD [
23
]. Childhood trauma exerts a profound impact on the development,
progression, and severity of obsessive–compulsive symptoms, encompassing diverse clini-
cal presentations [
24
]. Furthermore, previous trauma exposure among individuals with
OCD has been correlated with greater functional impairment [25,26].
Childhood maltreatment, encompassing emotional, physical, and sexual abuse, as well
as emotional and physical neglect, amplifies the vulnerability to physical ailments [
27
] and
mental health conditions in adulthood [
28
], determining significant costs for both individu-
als and society [
29
]. Previous investigations into the impact of childhood maltreatment on
psychopathology have predominantly centered on mental health disorders such as PTSD,
mood disorders, personality disorders, and substance use disorders [
30
]. While preliminary
evidence suggests a link between child abuse and neglect and the onset and persistence
of OCD, the available data are limited and conflicting. While many prior studies have
reported higher rates of childhood maltreatment among individuals with OCD compared
to control groups [
31
–
35
], other well-powered studies have not found elevated prevalence
rates of any form of childhood trauma in OCD patients [
36
,
37
]. Research indicates that
exposure to emotional, physical, and sexual abuse correlates with heightened symptoms
Medicina 2024,60, 408 3 of 12
of OCD overall, implying that various traumatic experiences contribute to the severity of
symptoms. Studies also reveal that exposure to childhood trauma is linked to increased
symptoms across specific domains of OCD, including contamination, responsibility for
harm, unacceptable thoughts, symmetry, aggression, sexual and religious obsessions, as
well as ritualistic compulsions [
38
]. These individual differences and the overarching
impact of childhood trauma on OCD severity underscore the importance of examining
different subtypes of childhood trauma and OCD symptoms rather than solely focusing
on total scores. Previous findings align with this line of research, suggesting that different
subtypes of childhood trauma may be associated with distinct OCD symptoms such as
obsessions or compulsions [39,40].
In addition, studies exploring the relationship between OCD severity and different
subtypes of childhood trauma across various clinical presentations beyond OCD also high-
light such association. Specifically, physical abuse, emotional abuse, and physical neglect
are commonly associated with heightened OCD severity. The prevalence of OCD symptoms
extends beyond OCD itself, suggesting the importance of investigating OCD symptoms
across a spectrum of psychiatric disorders. Indeed, the co-occurrence of childhood trauma
and OCD symptoms may heighten the risk of developing psychiatric disorders overall.
For example, Barzilay et al. (2019) discovered in a community sample that individuals
reporting sub-threshold OCD symptoms and exposure to stressful life events also reported
elevated rates of depression, suicidal ideation, and psychosis [
41
]. Furthermore, epidemi-
ological studies have identified numerous potential risk factors for OCD, such as age,
gender, employment, and socioeconomic status, which are not exclusive to OCD [
42
]. This
underscores the value of adopting a transdiagnostic approach to mental health. Similarly,
childhood exposure to trauma has been linked to unfavorable outcomes across a range of
psychiatric disorders, including functional impairment, a more severe illness trajectory,
and an increased risk of chronic fatigue or pain [
33
]. Traumatic experiences, particularly
those occurring during childhood, represent the most extensively studied etiological factor
in the development of dissociation [
43
]. In clinical contexts, dissociation constitutes a core
symptom across various disorders, including obsessive–compulsive disorder and Complex
Post-traumatic Stress Disorder [
44
]. Dissociative phenomena serve as defense mechanisms
against external traumatic experiences, with obsessions and compulsions often arising as
responses to thoughts that intensify dissociation [
45
]. Psychological trauma is recognized
as a risk factor in the development of dissociation, with numerous empirical studies sub-
stantiating the association between dissociation and trauma, especially severe childhood
maltreatment [
46
–
48
]. Despite the numerous studies conducted on the topic and the signifi-
cant clinical implications it may have, to date, no study has been conducted to assess the
impact of cPTSD on OCD. In this context, this study aims to ascertain whether the presence
of cPTSD is linked to heightened obsessive–compulsive symptoms and related anxiety
symptomatology. Given that cPTSD represents a substantial domain of symptoms within
the spectrum of psychiatric disorders, unraveling this correlation might assist clinicians in
optimizing treatment strategies for OCD in the context of this comorbidity.
2. Materials and Methods
2.1. Clinical Assessment
The present study was designed as an observational cross-sectional investigation
conducted in a clinical setting. The study recruited consecutive patients with OCD at the
Psychiatry Unit of the “Magna Graecia” University of Catanzaro from January 2021 to April
2022. All participants were thoroughly informed about the research protocol’s objectives,
data protection, privacy, and anonymity maintenance. Their participation was voluntary,
contingent on providing formal consent in writing after a comprehensive explanation of
the study’s aims and design. The study adhered to the latest version of the Declaration of
Helsinki and gained approval from the Ethics Committee of the University of Catanzaro
on 25 November 2020 (Ethics Committee Approval No. 307/2020).
Medicina 2024,60, 408 4 of 12
Inclusion criteria were the following: (1) Patients diagnosed with OCD based on DSM-
5 criteria, as determined by clinical interviews and psychometric assessments (Structured
Clinical Interview for DSM-5—Clinical Version, SCID-5-CV). (2) Patients aged between
18 and 75 years. The exclusion criteria were as follows: (1) Patient refusal to participate.
(2) Presence of significant neurological or psychiatric disorders (e.g., epilepsy, cognitive
disability, dementia, Parkinson’s, genetic syndromes with psychiatric symptoms, and
substance abuse). (3) Any condition hindering comprehensive assessment, such as language
barriers or severe cognitive disabilities (e.g., dyslexia). Participants underwent a series of
clinical and psychopathological evaluations conducted during outpatient clinical visits.
Psychometric rating scales and sociodemographic data collection were carried out by
researchers, medical specialists in training, and PhD students. OCD diagnoses were
established according to the DSM-5 criteria, utilizing the SCID-5-CV [
49
,
50
]. Each enrolled
patient underwent a semi-structured clinical interview to gather clinical and anamnestic
information. Sociodemographic and clinical data were collected using a customized medical
history questionnaire developed within our department.
Patients clinical and sociodemographic characteristics, including gender, age at study
entry, employment status, educational level, family history of psychiatric illnesses, type
of onset, the pattern of illness course, treatments, suicidal ideation, previous psychiatric
hospitalizations, and the presence of trauma were recorded according to an ad hoc schedule.
In the schedule we developed for this study, there were a series of questions aimed at
investigating the presence of trauma, including the following categories: natural disasters;
serious work-related accidents or potentially life-threatening injuries (confirmed through
medical reports); physical abuse; sexual abuse; and a subsection labeled “other” where we
described the particularly stressful event witnessed.
The assessment instruments employed included the Yale–Brown Obsessive–Compulsive
Scale (Y-BOCS), the International Trauma Questionnaire (ITQ), and the Hamilton Anxiety Scale
(HAM-A). Y-BOCS, renowned as the gold standard for assessing obsessive–compulsive
symptoms, comprises a comprehensive symptom checklist categorized into various groups.
This scale, which assesses obsessions distinct from compulsions, precisely gauges the
intensity of symptoms related to obsessive–compulsive disorder without exhibiting prej-
udice toward or against the content of the obsessions or compulsions. Additionally, it
incorporates a 10-item severity scale evaluating time, interference, discomfort, resistance,
and symptom control [
50
,
51
]. Each item is rated on a scale of 0 to 4, yielding a total score
ranging from 0 to 40, with higher scores indicating more severe OCD symptoms [
52
].
The ITQ was used to assess the trauma experienced and to diagnose cPTSD according to
the ICD-11 guidelines. The questionnaire consists of eighteen items measuring the main
symptoms of PTSD and DSO. The items can be answered on a 5-point Likert scale from 0
(not at all) to 4 (very strongly). The maximum score for PTSD and/or DSO is, therefore,
24 (range 0–24), while the maximum score for cPTSD is 48 (range 0 to 48). All items can
only be considered present if they have a value
≥
2 on the Likert scale. Diagnosis of cPTSD
requires the endorsement of one of two symptoms from each of the three PTSD symptoms
clusters (re-experiencing, avoidance, and sense of current threat) and one of two symp-
toms from each of the three Disturbances in Self-Organization (DSO) clusters: (1) affective
dysregulation, (2) negative self-concept, and (3) disturbances in relationships. Functional
impairment is present when at least one cluster of functional impairment is associated with
PTSD symptoms and one with DSO symptoms. In principle, a person can only receive
one of the two diagnoses, namely PTSD or cPTSD. Furthermore, cPTSD is characterized
by the predominance of symptoms of disturbances in self-organization and is defined as
that set of symptoms resulting from cumulative interpersonal traumas experienced during
development: stories of abuse and repeated maltreatment in the family, severe neglect and
abandonment, conditions of torture or imprisonment, wars, and forced migrations. When a
person cannot escape the threat for a long time or when the threat occurs within the family
upon which one must continue to depend for survival, the mind deploys more intense
strategies to overcome the paradox and the pervasive state of fear. This is referred to as
Medicina 2024,60, 408 5 of 12
chronic traumatization rather than a single traumatic event. This questionnaire aligns with
the principles of ICD-11, providing both categorical diagnostic scores and dimensional
severity scores [
53
,
54
]. HAM-A, a 14-item rating scale, assesses the severity of anxiety
symptoms, encompassing both psychological and somatic manifestations. It is one of the
most widely used tests both in scientific research and in clinical practice and measures both
psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical
complaints related to anxiety). Each item is scored from 0 (absent) to 4 (severe), resulting
in a total score ranging from 0 to 56. Severity levels are categorized as mild (<17), mild to
moderate (18–24), and moderate to severe (25/30) [55–57].
2.2. Statistical Analysis
Data for all variables were entered into an electronic dataset. Descriptive statistical
analyses were conducted to assess the distributional characteristics of sociodemographic
and clinical variables within the sample. Continuous variables were presented as means
with standard deviations (SD), while categorical variables were expressed as frequencies
and percentages (%). The sample was categorized into two groups: those with a history
of cPTSD (cPTSD+) and those without (cPTSD
−
). Analysis of variance (ANOVA) was
employed to compare variances among the means of different groups, considering p< 0.005
as statistically significant. Regression analysis was performed to investigate the association
between cPTSD and the Y-BOCS scale score. Statistical analyses were carried out using the
Statistical Package for the Social Sciences version 26 (SPSS, Chicago, IL, USA).
3. Results
Socio-Demographic Data
The final cohort for our investigation comprised 107 individuals diagnosed with OCD,
with 50 of them (46.7%) additionally diagnosed with comorbid cPTSD. The sociodemographic
profile of the sample exhibited homogeneity, with 54 (50.5%) male participants. 84 subjects
(78.5%) had diploma. Patients with a co-occurrence of OCD and cPTSD exhibited a familial
psychiatric history prevalence of 69.2%. Within this segmented sample, the average age among
OCD patients was 45.75 years (SD
±
13.9). From a psychopathological perspective, patients
scored an average of 11.50 (SD
±
9.9) on the Hamilton Anxiety Rating Scale (HAM-A), while
the score reflecting obsessive–compulsive symptoms on the Yale–Brown Obsessive–Compulsive
Scale
(Y-BOCS)
was approximately 10.49 (SD
±
6.9). Table 1presents the clinical and sociode-
mographic characteristics of the study sample.
Table 1. Sociodemographic characteristics of the sample (N = 107).
Variable N or Mean % or SD
Male 54 50.5
Diploma 84 78.5
Presence of psychiatric familiarity
74 69.2
Presence pf cPTSD 50 46.7
Age 45.75 13,902
HAM-A total score 11.50 9999
Y-BOCS total score 10.49 6931
HAM-A: Hamilton Anxiety Rating Scale; Y-BOCS: Yale–Brown Obsessive–Compulsive Scale; cPTSD: complex
posttraumatic disorder; N: total number; SD: standard deviation; %: percentage.
Statistically significant differences emerged between the two groups in the age of onset
of the OCD (p= 0.083), psychiatric familiarity (p= 0.023), HAM-A total score (p< 0.0001),
and Y-BOCS (p< 0.0001). These results are listed in Table 2.
Medicina 2024,60, 408 6 of 12
Table 2. Analysis of variance between the group with and without cPTSD.
Variable df F-Value p-Value
Age of OCD onset 1 3.073 0.083
Familiarity with other disorders 1 0.065 0.799
Psychiatric family history 1 5.333 0.023
HAM-A total score 1 64.803 <0.0001
Y-BOCS total score 1 38.462 <0.0001
HAM-A: Hamilton Anxiety Rating Scale; Y-BOCS: Yale–Brown Obsessive–Compulsive Scale; cPTSD: complex
posttraumatic disorder; df: degrees of freedom. Bold p-values indicate statistical significance.
The logistic regression analysis revealed a statistically significant association between
the presence of cPTSD and the Y-BOCS total score (p< 0.0001), as displayed in Table 3.
Table 3. Logistic regression beetween complex Post Traumatic Stress Disorder and Y-BOCS total score.
Variable Beta SD Wald Statistics df p-Value
Y-BOCS_TOT 0.202 0.043 22.111 1 <0.0001
Intercept −4.759 1.028 21.453 1 <0.0001
Y-BOCS: Yale–Brown Obsessive–Compulsive Scale.
4. Discussion
4.1. Exploring the Interplay between cPTSD and OCD Severity: Insights and Implications
The present study addresses a topic of great interest that is still little debated, probing
the intriguing link between cPTSD and the clinical severity of OCD. Our data unveiled a
compelling correlation between the presence of cPTSD and a notably exacerbated clinical
trajectory of OCD, as evidenced by higher scores on the Hamilton Anxiety Rating Scale
(HAM-A) and the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS). These findings are
in line with existing literature, reinforcing the notion that cPTSD predisposes individuals
to compromised outcomes across a spectrum of psychiatric disorders [
19
]. Furthermore,
our logistic regression analysis has demonstrated a significant association between Y-BOCS
scores and the Impact of Event Scale (ITQ), underscoring the profound influence of cPTSD
on the augmentation of obsessive–compulsive symptoms. This finding warrants elucida-
tion, as it implies that exposure to traumatic stressors during critical phases of psychological
development may catalyze the intensification of affective disturbances and relational chal-
lenges. These disturbances, in turn, give rise to disruptions in self-organization, thereby
exacerbating obsessive symptoms. This alignment with prior literature substantiates the
link between traumatic stressors and the severity of OCD symptomatology [
6
,
58
]. The mul-
tifaceted consequences of trauma on OCD encompass a spectrum of distressing phenomena,
including dissociative symptoms, intrusive thoughts and images, profound anxiety, a sense
of helplessness, and heightened vigilance, all of which contribute to the chronicity and
severity of the disorder. These manifestations often intertwine, creating a complex web of
psychological distress that can significantly impair daily functioning and exacerbate the
individual’s overall distress and impairment in quality of life. [
59
]. Empirical studies have
reported that traumas, especially when occurring during childhood, disproportionately
impact the obsessive dimension of OCD. Trauma types encompass sexual abuse, adverse
living conditions, bullying, and exposure to traumatic events such as bereavement [
60
,
61
].
Notably, prolonged exposure to such trauma has been correlated with the emergence of
Complex cPTSD, with higher incidence rates among individuals exposed to chronic abuse
or neglect [
62
]. It is pertinent to highlight that interpersonal trauma assumes a pivotal role
in the psychopathology of both cPTSD and OCD [
48
,
63
,
64
]. Compared to non-interpersonal
trauma, interpersonal trauma has a more profound impact on self-regulation, frequently
inducing dissociation [
65
]. Consistent with contemporary literature, higher rates of child-
hood trauma correlate positively with increased levels of dissociation, which serves as a
mediating factor between trauma exposure and psychiatric symptoms [66].
Medicina 2024,60, 408 7 of 12
cPTSD often leads to dissociation, a mental mechanism that can be employed adap-
tively or maladaptively in response to distressing life experiences [
67
]. Studies indicate
that among individuals with minimal exposure to trauma, dissociation may serve as a
normal and even constructive aspect of the mind, possibly linked to typical self-absorption
phenomena and creative coping strategies during distressing events [
68
]. Moreover, among
individuals with high levels of repetitive trauma exposure, as seen in cPTSD, dissociation
might become pervasive, significantly impacting their overall mental well-being. In such
cases, the mind appears to retain a memory of past traumas, with dissociation potentially
serving as a primary psychological mechanism organizing the individual’s sense of self and
contributing to the development and reinforcement of maladaptive personality traits [
69
].
This issue plays a pivotal role in exacerbating obsessions and compulsions, while also
potentially reinforcing the character rigidity of individuals affected by OCD, leading to iso-
lation and consequently a greater severity of symptoms, as evidenced by our results. This
can be attributed to patients with OCD, who have experienced multiple traumatic events,
exhibiting a greater propensity for decompensation, a lack of functional and cognitive
recovery, and the onset of dissociative symptoms [70,71].
4.2. Integrating Trauma-Focused Treatments in OCD Management: A Holistic Approach to
Healing and Recovery
Cognitive-behavioral and pharmacological interventions and trauma-focused treat-
ments have emerged as crucial components in the comprehensive management of OCD.
Recognizing the intricate relationship between trauma and OCD symptomatology, it has
become increasingly evident that addressing underlying traumatic experiences is essential
for effective treatment outcomes. Trauma-focused therapies aim to directly target the
distressing memories, emotions, and physiological responses associated with traumatic
events, thereby reducing their impact on OCD symptoms [
72
]. These interventions provide
individuals with the tools and resources needed to process and integrate their traumatic
experiences, ultimately facilitating symptom relief and promoting psychological resilience.
Mindfulness-based interventions offer individuals a non-judgmental awareness of their
thoughts, emotions, and bodily sensations, enabling them to cultivate greater acceptance
and self-regulation in the face of distress. Sensorimotor psychotherapy focuses on the
interconnection between bodily sensations, emotions, and cognitive processes, allowing in-
dividuals to access and process traumatic memories stored in the body [
73
]. Eye Movement
Desensitization and Reprocessing (EMDR) is another evidence-based treatment modal-
ity that has shown promise in addressing trauma-related symptoms. By engaging in
bilateral stimulation while revisiting traumatic memories, individuals can reprocess these
experiences in a safe and controlled manner, leading to a reduction in distress and symp-
tom severity [
74
]. The integration of trauma-focused approaches within the therapeutic
framework of OCD treatment underscores the importance of addressing the root causes
of psychological distress and dysfunction. By targeting both the symptoms of OCD and
the underlying trauma, clinicians can help individuals achieve meaningful recovery and
improved quality of life. As research continues to evolve, it is imperative to further explore
the efficacy and mechanisms of trauma-focused treatments in the context of OCD. Contin-
ued collaboration between researchers, clinicians, and individuals with lived experience
will facilitate the development of tailored interventions that address the diverse needs of
those grappling with the intersection of trauma and OCD. Through comprehensive and
compassionate care, individuals can find healing and reclaim agency over their mental
health journey [
75
]. Recognizing the complexities introduced by prior prolonged trauma
is paramount, as individuals may exhibit resistance to traditional OCD treatment and
may resort to alternative maladaptive coping mechanisms to mitigate the distress associ-
ated with traumatic memories [
76
]. An in-depth exploration of the physical, emotional,
and psychological turmoil stemming from trauma is essential for tailoring therapeutic
approaches, ultimately enhancing the quality of life for patients [
16
]. Future investigations
should focus on elucidating how complex trauma influences an individual’s quality of
Medicina 2024,60, 408 8 of 12
life and interpersonal functioning. This knowledge can inform psychosocial interventions,
including rehabilitation activities aimed at fostering relationships and mitigating social
isolation. In our opinion, interventions that focus on the psychosocial aspects are par-
ticularly important for patients with OCD comorbid with cPTSD, as the persistence of
trauma can exacerbate symptoms, and such interventions would act on various levels,
including the interpersonal one. Indeed, merely focusing on the patient’s resilience capacity
with OCD might not suffice. Structured psychoeducation sessions involving cohabiting
figures, or at least significant ones, would be necessary [
77
]. All of this would serve to
break the continuity of trauma and reduce expressed emotionality, which could re-trigger
symptoms while creating an environment and context around the patient conducive to
healing. Additionally, it would assist the clinician in identifying triggers that can precip-
itate and worsen obsessive symptoms. In this regard, psychoeducational interventions
involving family members have been developed, but studies are mostly conducted in
pediatric and adolescent age groups and do not focus well on trauma [
78
]. The gold
standard should represent a psychoeducational intervention aimed at identifying early
signs of decompensation, which in this case are the effects of traumatic events perpetrated
over time, and intervening on different levels, such as the following: the family, which in
this case should be supportive and collaborate in implementing skills, pharmacological,
social, and intervening on the traumatic experience. Psychoeducation modules adapted to
traumatic experiences are already present in other disorders, such as bipolar disorder [
79
].
Therefore, there is still much to be done in this regard. Identifying optimal strategies for
enhancing cognitive functioning and managing behavioral disorders holds the promise of
improving the well-being of patients and their families. This study serves as an incentive
to intensify research efforts, delving into the intricate interplay between complex trauma
and the severity of obsessive–compulsive symptoms. The dearth of studies addressing
this critical nexus necessitates further exploration, highlighting the urgency of continued
research. Additionally, our findings illuminate the earlier onset of cPTSD, likely attributed
to prolonged or repeated exposure to interpersonal traumas, such as childhood abuse or
domestic violence [
74
]. Notably, the present study reaffirms the familial component in
psychiatric disorders, particularly in cases of early-onset OCD.
4.3. Limitation
There are several caveats to consider when interpreting the findings of this study.
Firstly, as is typical in much research within this domain, cPTSD was evaluated retro-
spectively and through self-report measures. This introduces the possibility of recall bias
regarding traumatic events experienced. Nonetheless, research has demonstrated the reli-
ability of self-reporting concerning recurrent traumatic experiences using the ITQ, even
in cases where psychopathology diminishes following therapy [
76
]. Secondly, like other
studies exploring the effects of treatment on cPTSD, our investigation focused on an outpa-
tient clinical sample with relatively stable symptomatology. Therefore, the findings may
not be generalizable to a more severely affected inpatient population. Thirdly, certain
potentially confounding variables, such as the frequency of exposure sessions or the nature
of the trauma, were not controlled for. However, the ITQ is adept at discerning cumulative
trauma. While it is considered the current standard measure of cPTSD and is widely used
in the literature, future research should strive to enhance the reliability of childhood trauma
assessment. Encouragingly, multilevel models do not necessitate complete datasets, and
missing value analyses indicated no discernible differences in OCD symptom severity
or levels of cPTSD between the dropout and completer groups. Moreover, a thorough
examination of the accumulated trauma endured by individuals with OCD and the varying
impact of distinct forms of trauma should be undertaken. Maercker and colleagues have
identified significant distinctions based on the nature of trauma experienced by individuals
predisposed to PTSD (such as abduction and sexual assault) versus those prone to cPTSD
(childhood abuse and intimate partner violence) [
80
]. This will serve as the focal point of
Medicina 2024,60, 408 9 of 12
our forthcoming research. Subsequent investigations should compare different cohorts of
individuals with cPTSD, PTSD, and OCD who lack a history of lifetime trauma.
5. Conclusions
In conclusion, our study has illuminated the complex relationship between cPTSD
and the severity of OCD. Despite recognizing limitations such as sample size and study
design, our results emphasize the critical need for a holistic understanding of how trauma
influences the course of OCD. It is essential to recognize that trauma can significantly shape
the development and manifestation of OCD symptoms. This understanding is crucial for
developing interventions that address the multifaceted effects of trauma and its profound
impact on individuals’ lives.
Moving forward, future research efforts should build upon these findings to create a
comprehensive framework aimed at improving the well-being of individuals grappling
with the intersection of complex trauma and obsessive–compulsive challenges. By delving
deeper into these dynamics, researchers and clinicians can better tailor interventions to
address the unique needs of individuals with comorbid cPTSD and OCD, ultimately
enhancing their quality of life and promoting recovery.
Author Contributions: Conceptualization, L.S.J. and M.M.; methodology, L.S.J., M.V. and M.M.; formal
analysis, M.M., A.M.I., G.V., G.L., V.D.S. and L.S.; data curation, M.D. and M.M.; writing—original draft,
A.M.I., M.V., C.S. and L.S.J.; investigation, review and editing, M.D., M.M., G.V., C.S., L.S., A.M.I. and
L.S.J. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was carried out in compliance with the principles
outlined in the Declaration of Helsinki and received approval from the Ethics Committee of the
University of Catanzaro on 25 November 2020 (protocol code 307/2020).
Informed Consent Statement: All participants in the study provided informed consent. Written
consent has been acquired from the participant(s) for the publication of this paper.
Data Availability Statement: The data supporting the conclusions of this study can be obtained from
the corresponding author upon a reasonable request.
Conflicts of Interest: The authors declare no conflicts of interest.
References
1.
Singh, J.; Prakash, J.; Yadav, P.; Bharti, A.; Chatterjee, K. Complex psychological trauma. Ind. Psychiatry J. 2021,30, 305. [CrossRef]
2.
Mathews, C.A.; Kaur, N.; Stein, M.B. Childhood trauma and obsessive-compulsive symptoms. Depress. Anxiety 2008,25, 742–751.
[CrossRef]
3. Benjet, C.; Bromet, E.; Karam, E.G.; Kessler, R.C.; McLaughlin, K.A.; Ruscio, A.M.; Shahly, V.; Stein, D.J.; Petukhova, M.; Hill, E.;
et al. The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium.
Psychol. Med. 2016,46, 327–343. [CrossRef] [PubMed]
4.
Cruz, D.; Lichten, M.; Berg, K.; George, P. Developmental trauma: Conceptual framework, associated risks and comorbidities,
and evaluation and treatment. Front. Psychiatry 2022,13, 800687. [CrossRef] [PubMed]
5.
Shevlin, M.; Hyland, P.; Roberts, N.P.; Bisson, J.I.; Brewin, C.R.; Cloitre, M. A psychometric assessment of Disturbances
in Self-Organization symptom indicators for ICD-11 Complex PTSD using the International Trauma Questionnaire. Eur. J.
Psychotraumatol. 2018,9, 1419749. [CrossRef]
6.
Cloitre, M.; Garvert, D.W.; Brewin, C.R.; Bryant, R.A.; Maercker, A. Evidence for proposed ICD-11 PTSD and complex PTSD: A
latent profile analysis. Eur. J. Psychotraumatol. 2013,4, 20706. [CrossRef] [PubMed]
7.
Maercker, A.; Cloitre, M.; Bachem, R.; Schlumpf, Y.R.; Khoury, B.; Hitchcock, C.; Bohus, M. Complex post-traumatic stress
disorder. Lancet 2022,400, 60–72. [CrossRef]
8.
Boyer, S.M.; Caplan, J.E.; Edwards, L.K. Trauma-Related Dissociation and the Dissociative Disorders: Neglected Symptoms with
Severe Public Health Consequences. Del. J. Public Health 2022,8, 78–84. [CrossRef]
9.
Dvir, Y.; Ford, J.D.; Hill, M.; Frazier, J.A. Childhood maltreatment, emotional dysregulation, and psychiatric comorbidities. Harv.
Rev. Psychiatry 2014,22, 149–161. [CrossRef]
10.
van Dijke, A.; Hopman, J.A.B.; Ford, J.D. Affect dysregulation, psychoform dissociation, and adult relational fears mediate the
relationship between childhood trauma and complex posttraumatic stress disorder independent of the symptoms of borderline
personality disorder. Eur. J. Psychotraumatol. 2018,9, 1400878. [CrossRef]
Medicina 2024,60, 408 10 of 12
11.
Seligman, R.; Kirmayer, L.J. Dissociative experience and cultural neuroscience: Narrative, metaphor and mechanism. Cult. Med.
Psychiatry 2008,32, 31–64. [CrossRef]
12.
Giourou, E.; Skokou, M.; Andrew, S.P.; Alexopoulou, K.; Gourzis, P.; Jelastopulu, E. Complex posttraumatic stress disorder: The
need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?
World J. Psychiatry 2018,8, 12–19. [CrossRef]
13.
Daniunaite, I.; Cloitre, M.; Karatzias, T.; Shevlin, M.; Thoresen, S.; Zelviene, P.; Kazlauskas, E. PTSD and complex PTSD in
adolescence: Discriminating factors in a population-based cross-sectional study. Eur. J. Psychotraumatol. 2021,12, 1890937.
[CrossRef]
14.
Sareen, J. Posttraumatic stress disorder in adults: Impact, comorbidity, risk factors, and treatment. Can. J. Psychiatry 2014,59,
460–467. [CrossRef]
15.
Carbone, E.A.; Menculini, G.; de Filippis, R.; D’Angelo, M.; Zebi, L.; Steardo, L. Sleep Disturbances in Panic Disorder with
Comorbid Complex PTSD: A Possible Relationship and Different Psychopathology? Life 2023,13, 1636. [CrossRef] [PubMed]
16.
Dykshoorn, K.L. Trauma-related obsessive-compulsive disorder: A review. Health Psychol. Behav. Med. 2014,2, 517–528. [CrossRef]
17.
Cromer, K.R.; Schmidt, N.B.; Murphy, D.L. An investigation of traumatic life events and obsessive-compulsive disorder. Behav.
Res. Ther. 2007,45, 1683–1691. [CrossRef]
18.
Gershuny, B.S.; Baer, L.; Parker, H.; Gentes, E.L.; Infield, A.L.; Jenike, M.A. Trauma and posttraumatic stress disorder in
treatment-resistant obsessive-compulsive disorder. Depress. Anxiety 2008,25, 69–71. [CrossRef]
19.
Murayama, K.; Nakao, T.; Ohno, A.; Tsuruta, S.; Tomiyama, H.; Hasuzawa, S.; Mizobe, T.; Kato, K.; Kanba, S. Impacts of Stressful
Life Events and Traumatic Experiences on Onset of Obsessive-Compulsive Disorder. Front. Psychiatry 2020,11, 561266. [CrossRef]
[PubMed]
20.
Vidal-Ribas, P.; Stringaris, A.; Rück, C.; Serlachius, E.; Lichtenstein, P.; Mataix-Cols, D. Are stressful life events causally related
to the severity of obsessive-compulsive symptoms? A monozygotic twin difference study. Eur. Psychiatry 2015,30, 309–316.
[CrossRef] [PubMed]
21.
Wang, Y.; Hong, A.; Yang, W.; Wang, Z. The impact of childhood trauma on perceived stress and personality in patients with
obsessive-compulsive disorder: A cross-sectional network analysis. J. Psychosom. Res. 2023,172, 111432. [CrossRef] [PubMed]
22.
Ojserkis, R.; Boisseau, C.L.; Reddy, M.K.; Mancebo, M.C.; Eisen, J.L.; Rasmussen, S.A. The impact of lifetime PTSD on the
seven-year course and clinical characteristics of OCD. Psychiatry Res. 2017,258, 78–82. [CrossRef]
23.
Wadsworth, L.P.; Van Kirk, N.; August, M.; Maclaren Kelly, J.; Jackson, F.; Nelson, J.; Luehrs, R. Understanding the overlap
between OCD and trauma: Development of the OCD trauma timeline interview (OTTI) for clinical settings. Curr. Psychol. 2021,
42, 6937–6947. [CrossRef] [PubMed]
24.
Boger, S.; Ehring, T.; Schwarzkopf, W.; Werner, G.G. Potential mediators of the association between childhood maltreatment and
obsessive-compulsive disorder in adulthood. J. Obs. Compuls. Relat. Disord. 2020,27, 100587. [CrossRef]
25.
Nacasch, N.; Fostick, L.; Zohar, J. High prevalence of obsessive-compulsive disorder among posttraumatic stress disorder patients.
Eur. Neuropsychopharmacol. 2011,21, 876–879. [CrossRef] [PubMed]
26.
Destrée, L.; Brierley, M.-E.E.; Albertella, L.; Jobson, L.; Fontenelle, L.F. The effect of childhood trauma on the severity of
obsessive-compulsive symptoms: A systematic review. J. Psychiatr. Res. 2021,142, 345–360. [CrossRef] [PubMed]
27.
Clemens, V.; Huber-Lang, M.; Plener, P.L.; Brähler, E.; Brown, R.C.; Fegert, J.M. Association of child maltreatment subtypes and
long-term physical health in a German representative sample. Eur. J. Psychotraumatol. 2018,9, 1510278. [CrossRef] [PubMed]
28.
Piras, F.; Spalletta, G. Childhood Trauma in Obsessive-Compulsive Disorder. In Childhood Trauma in Mental Disorders; Springer
International Publishing: Cham, Switzerland, 2020; pp. 287–312.
29.
Magruder, K.M.; McLaughlin, K.A.; Elmore Borbon, D.L. Trauma is a public health issue. Eur. J. Psychotraumatol. 2017,8, 1375338.
[CrossRef]
30.
Norman, R.E.; Byambaa, M.; De, R.; Butchart, A.; Scott, J.; Vos, T. The Long-Term Health Consequences of Child Physical Abuse,
Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med. 2012,9, e1001349. [CrossRef]
31.
Carpenter, L.; Chung, M.C. Childhood trauma in obsessive compulsive disorder: The roles of alexithymia and attachment.
Psychol. Psychother. Theory Res. Pract. 2011,84, 367–388. [CrossRef]
32.
Caspi, A.; Vishne, T.; Sasson, Y.; Gross, R.; Livne, A.; Zohar, J. Relationship between childhood sexual abuse and obsessive-
compulsive disorder: Case control study. Isr. J. Psychiatry Relat. Sci. 2008,45, 177–182.
33.
Grisham, J.R.; Fullana, M.A.; Mataix-Cols, D.; Moffitt, T.E.; Caspi, A.; Poulton, R. Risk factors prospectively associated with adult
obsessive–compulsive symptom dimensions and obsessive–compulsive disorder. Psychol. Med. 2011,41, 2495–2506. [CrossRef]
34.
Hemmings, S.M.J.; Lochner, C.; van der Merwe, L.; Cath, D.C.; Seedat, S.; Stein, D.J. BDNF Val66Met modifies the risk of
childhood trauma on obsessive-compulsive disorder. J. Psychiatr. Res. 2013,47, 1857–1863. [CrossRef]
35.
Lochner, C.; du Toit, P.L.; Zungu-Dirwayi, N.; Marais, A.; van Kradenburg, J.; Seedat, S.; Niehaus, D.J.H.; Stein, D.J. Childhood
trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depress. Anxiety 2002,15, 66–68. [CrossRef]
36.
Grabe, H.J.; Ruhrmann, S.; Spitzer, C.; Josepeit, J.; Ettelt, S.; Buhtz, F.; Hochrein, A.; Schulze-Rauschenbach, S.; Meyer, K.; Kraft, S.;
et al. Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder. Psychopathology 2008,41, 129–134. [CrossRef]
37.
Voderholzer, U.; Schwartz, C.; Thiel, N.; Kuelz, A.K.; Hartmann, A.; Scheidt, C.E.; Schlegl, S.; Zeeck, A. A Comparison of Schemas,
Schema Modes and Childhood Traumas in Obsessive-Compulsive Disorder, Chronic Pain Disorder and Eating Disorders.
Psychopathology 2014,47, 24–31. [CrossRef] [PubMed]
Medicina 2024,60, 408 11 of 12
38.
Kadivari, F.; Najafi, M.; Khosravani, V. Childhood adversity affects symptomatology via behavioral inhibition in patients with
obsessive-compulsive disorder. Curr. Psychol. 2023,42, 13560–13570. [CrossRef]
39.
Ou, W.; Li, Z.; Zheng, Q.; Chen, W.; Liu, J.; Liu, B.; Zhang, Y. Association Between Childhood Maltreatment and Symptoms of
Obsessive-Compulsive Disorder: A Meta-Analysis. Front. Psychiatry 2021,11, 612586. [CrossRef] [PubMed]
40.
Miller, M.L.; Brock, R.L. The effect of trauma on the severity of obsessive-compulsive spectrum symptoms: A meta-analysis. J.
Anxiety Disord. 2017,47, 29–44. [CrossRef]
41.
Barzilay, R.; Patrick, A.; Calkins, M.E.; Moore, T.M.; Wolf, D.H.; Benton, T.D.; Leckman, J.F.; Gur, R.C.; Gur, R.E. Obsessive-
Compulsive Symptomatology in Community Youth: Typical Development or a Red Flag for Psychopathology? J. Am. Acad. Child
Adolesc. Psychiatry 2019,58, 277–286.e4. [CrossRef]
42.
Yilmaz, Z.; Larsen, J.T.; Nissen, J.B.; Crowley, J.J.; Mattheisen, M.; Bulik, C.M.; Petersen, L.V. The role of early-life family
composition and parental socio-economic status as risk factors for obsessive-compulsive disorder in a Danish national cohort. J.
Psychiatr. Res. 2022,149, 18–27. [CrossRef]
43.
Soffer-Dudek, N. Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and
implications for science and practice. Front. Psychol. 2023,14, 1132800. [CrossRef]
44.
Tatlı, M.; Cetinkaya, O.; Maner, F. Evaluation of Relationship between Obsessive-compulsive Disorder and Dissociative Experi-
ences. Clin. Psychopharmacol. Neurosci. 2018,16, 161–167. [CrossRef]
45. Vonderlin, R.; Kleindienst, N.; Alpers, G.W.; Bohus, M.; Lyssenko, L.; Schmahl, C. Dissociation in victims of childhood abuse or
neglect: A meta-analytic review. Psychol. Med. 2018,48, 2467–2476. [CrossRef]
46.
Krause-Utz, A. Dissociation, trauma, and borderline personality disorder. Borderline Personal. Disord. Emot. Dysregulation 2022,9,
14. [CrossRef] [PubMed]
47.
Lynn, S.J.; Maxwell, R.; Merckelbach, H.; Lilienfeld, S.O.; van Heugten-van der Kloet, D.; Miskovic, V. Dissociation and its
disorders: Competing models, future directions, and a way forward. Clin. Psychol. Rev. 2019,73, 101755. [CrossRef] [PubMed]
48.
Shabani, A.; Masoumian, S.; Zamirinejad, S.; Hejri, M.; Pirmorad, T.; Yaghmaeezadeh, H. Psychometric properties of Structured
Clinical Interview for DSM-5 Disorders-Clinician Version (SCID-5-CV). Brain Behav. 2021,11, e01894. [CrossRef] [PubMed]
49.
First, M.B. Structured Clinical Interview for the DSM ( SCID ). In The Encyclopedia of Clinical Psychology; Wiley: Hoboken, NJ, USA,
2015; pp. 1–6.
50.
Rosario-Campos, M.C.; Miguel, E.C.; Quatrano, S.; Chacon, P.; Ferrao, Y.; Findley, D.; Katsovich, L.; Scahill, L.; King, R.A.;
Woody, S.R.; et al. The Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS): An instrument for assessing obsessive-
compulsive symptom dimensions. Mol. Psychiatry 2006,11, 495–504. [CrossRef]
51.
Deacon, B.J.; Abramowitz, J.S. The Yale-Brown Obsessive Compulsive Scale: Factor analysis, construct validity, and suggestions
for refinement. J. Anxiety Disord. 2005,19, 573–585. [CrossRef]
52.
Cloitre, M.; Hyland, P.; Prins, A.; Shevlin, M. The international trauma questionnaire (ITQ) measures reliable and clinically
significant treatment-related change in PTSD and complex PTSD. Eur. J. Psychotraumatol. 2021,12, 1930961. [CrossRef]
53.
Rossi, R.; Socci, V.; Pacitti, F.; Carmassi, C.; Rossi, A.; Di Lorenzo, G.; Hyland, P. The Italian Version of the International Trauma
Questionnaire: Symptom and Network Structure of Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder
in a Sample of Late Adolescents Exposed to a Natural Disaster. Front. Psychiatry 2022,13, 859877. [CrossRef]
54. Thompson, E. Hamilton rating scale for anxiety (HAM-A). Occup. Med. (Chic. Ill) 2015,65, 601. [CrossRef]
55.
Rodriguez-Seijas, C.; Thompson, J.S.; Diehl, J.M.; Zimmerman, M. A comparison of the dimensionality of the Hamilton Rating
Scale for anxiety and the DSM-5 Anxious-Distress Specifier Interview. Psychiatry Res. 2020,284, 112788. [CrossRef]
56.
Rabinowitz, J.; Williams, J.B.W.; Hefting, N.; Anderson, A.; Brown, B.; Fu, D.J.; Kadriu, B.; Kott, A.; Mahableshwarkar, A.; Sedway,
J.; et al. Consistency checks to improve measurement with the Hamilton Rating Scale for Anxiety (HAM-A). J. Affect. Disord. 2023,
325, 429–436. [CrossRef]
57.
McFarlane, A.C. The long-term costs of traumatic stress: Intertwined physical and psychological consequences. World Psychiatry
2010,9, 3–10. [CrossRef] [PubMed]
58.
van der Kolk, B. Posttraumatic stress disorder and the nature of trauma. Dialogues Clin. Neurosci. 2000,2, 7–22. [CrossRef]
[PubMed]
59.
Moore, S.E.; Norman, R.E.; Suetani, S.; Thomas, H.J.; Sly, P.D.; Scott, J.G. Consequences of bullying victimization in childhood and
adolescence: A systematic review and meta-analysis. World J. Psychiatry 2017,7, 60. [CrossRef] [PubMed]
60.
Pinciotti, C.M.; Riemann, B.C.; Wetterneck, C.T. Trauma type and obsessive-compulsive symptom domains: The unique
relationship between indirectly experienced trauma and just right symptoms. J. Obs. Compuls. Relat. Disord. 2021,29, 100624.
[CrossRef]
61.
Cloitre, M.; Cohen, L.R.; Edelman, R.E.; Han, H. Posttraumatic Stress Disorder and extent of trauma exposure as correlates of
medical problems and perceived health among women with childhood abuse. Women Health 2001,34, 1–17. [CrossRef]
62.
Ferrão, Y.A.; Radins, R.B.; Ferrão, J.V.B. Psychopathological intersection between obsessive-compulsive disorder and post-
traumatic stress disorder: Scoping review of similarities and differences. Trends Psychiatry Psychother. 2023,45, e20210370.
[CrossRef] [PubMed]
63.
Medina Rodríguez, J.C.; Solís Villegas, E.M. Overlap of obsessive and posttraumatic symptoms: A systematic review. Salud Ment.
2022,45, 135–143. [CrossRef]
Medicina 2024,60, 408 12 of 12
64.
Berfield, J.B.; Goncharenko, S.; Forkus, S.R.; Contractor, A.A.; Weiss, N.H. The differential relation of trauma types with negative
and positive emotion dysregulation. Anxiety Stress Coping 2022,35, 425–439. [CrossRef]
65.
Uyan, T.T.; Baltacioglu, M.; Hocaoglu, C. Relationships between childhood trauma and dissociative, psychotic symptoms in
patients with schizophrenia: A case-control study. Gen. Psychiatry 2022,35, e100659. [CrossRef]
66.
Dorahy, M.J.; Brand, B.L.; Sar, V.; Krüger, C.; Stavropoulos, P.; Martínez-Taboas, A.; Lewis-Fernández, R.; Middleton, W.
Dissociative identity disorder: An empirical overview. Aust. N. Z. J. Psychiatry 2014,48, 402–417. [CrossRef]
67.
Fung, H.W.; Chien, W.T.; Lam, S.K.K.; Ross, C.A. The Relationship Between Dissociation and Complex Post-Traumatic Stress
Disorder: A Scoping Review. Trauma. Violence Abus. 2023,24, 2966–2982. [CrossRef]
68.
Granieri, A.; Guglielmucci, F.; Costanzo, A.; Caretti, V.; Schimmenti, A. Trauma-Related Dissociation Is Linked with Maladaptive
Personality Functioning. Front. Psychiatry 2018,9, 206. [CrossRef]
69.
Belli, H. Dissociative symptoms and dissociative disorders comorbidity in obsessive compulsive disorder: Symptom screening,
diagnostic tools and reflections on treatment. World J. Clin. Cases 2014,2, 327–331. [CrossRef]
70.
Borges, M.C.; Braga, D.T.; Igo, S.; D’Alcante, C.C.; Sidrim, I.; MacHado, M.C.; Pinto, P.S.P.; Cordioli, A.V.; Do Rosrio, M.C.;
Petrib, K.; et al. Cognitive dysfunction in post-traumatic obsessivecompulsive disorder. Aust. N. Z. J. Psychiatry 2011,45, 76–85.
[CrossRef] [PubMed]
71.
Foa, E.B.; Gillihan, S.J.; Bryant, R.A. Challenges and Successes in Dissemination of Evidence-Based Treatments for Posttraumatic
Stress. Psychol. Sci. Public Interes. 2013,14, 65–111. [CrossRef] [PubMed]
72.
Pérez-Peña, M.; Notermans, J.; Desmedt, O.; Van der Gucht, K.; Philippot, P. Mindfulness-Based Interventions and Body
Awareness. Brain Sci. 2022,12, 285. [CrossRef] [PubMed]
73.
de Jongh, A.; de Roos, C.; El-Leithy, S. State of the science: Eye movement desensitization and reprocessing (EMDR) therapy.
J. Trauma. Stress 2024. [CrossRef]
74.
Coventry, P.A.; Meader, N.; Melton, H.; Temple, M.; Dale, H.; Wright, K.; Cloitre, M.; Karatzias, T.; Bisson, J.; Roberts, N.P.;
et al. Psychological and pharmacological interventions for posttraumatic stress disorder and comorbid mental health problems
following complex traumatic events: Systematic review and component network meta-analysis. PLoS Med. 2020,17, e1003262.
[CrossRef]
75.
Scelles, C.; Bulnes, L.C. EMDR as Treatment Option for Conditions Other Than PTSD: A Systematic Review. Front. Psychol. 2021,
12, 644369. [CrossRef]
76.
McGrath, C.A.; Abbott, M.J. Family-Based Psychological Treatment for Obsessive Compulsive Disorder in Children and Adoles-
cents: A Meta-analysis and Systematic Review. Clin. Child Fam. Psychol. Rev. 2019,22, 478–501. [CrossRef] [PubMed]
77.
Do Rosario-Campos, M.C.; Leckman, J.F.; Curi, M.; Quatrano, S.; Katsovitch, L.; Miguel, E.C.; Pauls, D.L. A family study of
early-onset obsessive-compulsive disorder. Am. J. Med. Genet. Neuropsychiatr. Genet. 2005,136B, 92–97. [CrossRef] [PubMed]
78.
Thompson-Hollands, J.; Edson, A.; Tompson, M.C.; Comer, J.S. Family involvement in the psychological treatment of obsessive–
compulsive disorder: A meta-analysis. J. Fam. Psychol. 2014,28, 287–298. [CrossRef] [PubMed]
79.
Iazzolino, A.M.; Valenza, M.; Angelo, M.D.; Longobardi, G.; Stefano, V.; Scuderi, C.; Steardo, L. How effective are mood stabilizers
in treating bipolar patients comorbid with cPTSD? Results from an observational study. Int. J. Bipolar Disord. 2023.Under review.
[CrossRef]
80.
Maercker, A.; Hecker, T.; Augsburger, M.; Kliem, S. ICD-11 Prevalence Rates of Posttraumatic Stress Disorder and Complex
Posttraumatic Stress Disorder in a German Nationwide Sample. J. Nerv. Ment. Dis. 2018,206, 270–276. [CrossRef] [PubMed]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
