The effect of trauma on the severity of obsessive-compulsive spectrum symptoms: A meta-analysis

Accepted Manuscript Title: The Effect of Trauma on the Severity of Obsessive-Compulsive Spectrum Symptoms: A Meta-Analysis Authors: Michelle L. Miller, Rebecca L. Brock PII: DOI: Reference:

S0887-6185(16)30311-5 http://dx.doi.org/doi:10.1016/j.janxdis.2017.02.005 ANXDIS 1921

To appear in:

Journal of Anxiety Disorders

Received date: Revised date: Accepted date:

9-10-2016 3-2-2017 8-2-2017

Please cite this article as: Miller, Michelle L., & Brock, Rebecca L., The Effect of Trauma on the Severity of Obsessive-Compulsive Spectrum Symptoms: A MetaAnalysis.Journal of Anxiety Disorders http://dx.doi.org/10.1016/j.janxdis.2017.02.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Running head: TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

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The Effect of Trauma on the Severity of Obsessive-Compulsive Spectrum Symptoms: A MetaAnalysis Michelle L. Millera & Rebecca L. Brockb a

University of Iowa, bUniversity of Nebraska-Lincoln

Corresponding Author: Michelle L. Miller [email protected] P: (317) 409-2658 Department of Psychological and Brain Sciences University of Iowa 11 Seashore Hall E. Iowa City, IA 52242

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

Article Highlights • Past trauma and current Obsessive-Compulsive Spectrum (OCS) symptoms were examined • Past trauma is associated with more severe OCS symptoms, particularly compulsions • The relation between trauma and OCS symptom severity is stronger for females • Multiple types of interpersonal trauma are associated with OCS symptom severity

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Abstract It is important to consider trauma-related sequelae in the etiology and maintenance of psychopathology, namely understudied disorders such as those belonging to the ObsessiveCompulsive Spectrum (OCS). This meta-analysis examined the association between past trauma exposure and current severity of OCS disorder symptoms. A systematic literature search was conducted with 24 (N = 4,557) articles meeting inclusion criteria. A significant overall effect size was obtained (r =.20), indicating that exposure to past trauma is associated with a higher severity of OCS symptoms, with a stronger association for females (β = 0.01, p <.001) but not varying as a function of relationship status. Four types of interpersonal trauma (violence, emotional abuse, sexual abuse, and neglect) were associated with OCS symptom severity (r = .19 -.24) and past trauma was significantly associated with more severe compulsions (r =.17), but not obsessions. Results suggest an important link between multiple types of past trauma exposure and OCS symptoms. Keywords: Trauma; Obsessive-Compulsive Spectrum; Anxiety Disorders; Meta-analysis

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1. Introduction Experiencing a trauma can be a life-changing event with far-reaching consequences, including the development or exacerbation of psychiatric symptoms (Brewin, Andrews, & Valentine, 2000). Posttraumatic stress disorder (PTSD) is one of the most common sequelae of trauma exposure across populations (Breslau et al., 1998). However, PTSD may not adequately encompass all of the possible symptoms developing from trauma exposure (Heim, Newport, Mletzko, Miller, & Nemeroff, 2008; van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005). Indeed, current conceptualizations of PTSD (see Rosen & Lilienfeld, 2008) overlook the role of trauma exposure in the development of other forms of psychopathology such as substance abuse (Stewart, 1996), depression and anxiety (Heim & Nemeroff, 2001), and obsessivecompulsive spectrum (OCS) disorders symptoms (de Silva & Marks, 1999; Gershuny, Baer, Radomsky, Wilson, & Jenike, 2003). There is no question that the experience of PTSD symptoms post-trauma can lead to intense emotional pain and physical suffering (Stein, Walker, Hazen, & Forde, 1997). Yet, the potential effect of trauma exposure on other psychopathology, namely OCS symptoms, warrants particular attention. PTSD and obsessive-compulsive disorder (OCD) symptoms have been shown to be extensively comorbid (Brown et al., 2001) and the two disorders share similar symptomology (e.g. intrusive thoughts, avoidance of stimuli, heightened physiological arousal, etc.; American Psychiatric Association [APA], 2013). However, trauma exposure has been found to predict obsessive-compulsive (OC) symptoms independently of a PTSD diagnosis (Boudreaux et al., 1998). Extending the review to all OCS disorders, there is evidence of an association between past trauma and OCS symptom severity yet there are also inconsistencies in this research (Borges et al., 2011; Fontenelle et al., 2012; Voderholzer et al., 2013).

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Important life events have been considered important to the etiology of OCD for decades (McKeon, Roa, & Mann, 1984). This review aimed to examine if trauma exposure could be conceptualized as a precursor to the development and/or exacerbation of OCS symptoms for particular individuals. Because OCS symptoms frequently are impairing (Eisen & Steketee, 1998) and affect significant portions of the population (Angst et al., 2004), it is imperative that we understand the nature of the impact that trauma exposure can have on the development and maintenance of OCS symptoms. The purpose of this meta-analysis was to quantify the relation between OCS symptoms and past trauma exposure, and to identify for whom, and under what conditions, past trauma is associated with OCS symptoms. 1.1. Trauma Exposure & the Obsessive-Compulsive Spectrum 1.1.1. Trauma exposure. Trauma exposure is a complex combination of intense sensory, physiological, emotional, and cognitive experiences (Pynoos, Steinberg, & Aronson, 1997). For nearly all individuals exposed to trauma, there is some change in physiological, emotional, and cognitive functioning immediately post-trauma, even if psychiatric symptoms do not emerge (Tull, Gratz, Salters, & Roemer, 2004; Basu, Levendosky, & Lonstein, 2013). Physical, emotional, and cognitive reactions during the peritraumatic period (i.e., during and immediately after a traumatic event), such as negative emotional reactions, panic symptoms, and dissociation, have been found to predict later psychopathology (Bernat, Ronfeldt, Calhoun, & Arias, 1998; Brunet et al., 2001). In addition to peritraumatic experiences, an individual‘s assessment of their own thoughts, feelings, and behaviors after a traumatic event can aid in the development and exacerbation of psychopathology, especially depression and PTSD (Ehlers & Clark, 2000). In particular, negative cognitive appraisals, especially self-blame, have been shown to account for

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psychopathology symptoms after trauma exposure over and above the amount and severity of the trauma (Andrews, Brewin, Rose, & Kirk, 2000; Cromer & Smyth, 2010; Ellis, Nixon, & Williamson, 2009). 1.1.2. The obsessive-compulsive spectrum. In the most recent edition of the Diagnostic and statistical manual of mental disorders (DSM-5; APA, 2013), the disorders that are currently classified as OCS disorders include: Obsessive-Compulsive Disorder, Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania (TTM; hair-pulling disorder), and Excoriation (skin-picking) disorder. The OCS disorders are clustered together in a discrete spectrum, highlighting their shared features and possible shared etiology (Phillips et al., 2010). Thus, a dimensional approach to conceptualizing psychopathology is advantageous, such that the focus is on the symptoms underlying all OCS disorders—obsessions and compulsions—as opposed to a categorical approach focused on discrete OCS diagnoses. The presentation of specific obsessions and compulsions will vary as the symptomology for each disorder is markedly different. However, examining shared symptom dimensions broadens the implications of etiological research by identifying risk factors for a broad range of disorders as opposed to factors putting individuals at risk for one specific diagnosis. Empirical studies have found significant relations between trauma exposure and severity of OCS symptoms. For example, emotional, physical, or sexual abuse during childhood is associated with greater obsessive-compulsive disorder symptoms, body dysmorphic disorder symptoms, and trichotillomania (Lochner et al., 2002; Mathews, Kaur, & Stein, 2008, Didie et al., 2006). Trauma exposure during the life span is also associated with greater hoarding symptom severity (Cromer, Schmidt, & Murphy, 2007) and excoriation disorder (especially sexual abuse) (Misery, 2013).

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1.2. The Theoretical Intersection of OCS Symptoms & Trauma Exposure 1.2.1. Obsessions and compulsions. Intrusive thoughts are not unique to individuals with diagnosable OCS symptoms. Up to 90% of the population experience intrusive thoughts at some point (Rachman & De Silva, 1978). However, the cognitive-behavioral model posits that intrusive thoughts are evaluated differently in individuals with OCS symptoms (Salkovskis & McGuire, 2003). For individuals with OCS symptoms, the difference appears to be underlying beliefs about personal responsibility for thoughts (Bouchard, Rheaume, & Ladouceur, 1999). An essential component of the cognitive theory of OCS symptoms is thought-action fusion (TAF) (Shafran, Thordarson, & Rachman, 1996). Thought-action fusion arises when an individual believes their unwanted thoughts about an action are the same as completing the action (moral TAF), or thinking about an unwanted event makes it more likely to occur (likelihood TAF; Abramowitz, Whiteside, Lynam, & Kalsy, 2003). Thought-action fusion creates distress over the obsessive beliefs and the subsequent drive to complete a compulsion to banish the thought, resulting in the development and maintenance of OCS symptoms (Rachman, 1998). These maladaptive interpretations of intrusive thoughts subsequently turn into clinical obsessions (Salkovskis & McGuire, 2003), which are often accompanied by compulsions, such as counting, conducted to reduce anxiety and neutralize the thought (Abramowitz, Lackey, & Wheaton, 2009). These compulsions reinforce the belief that intrusive thoughts are dangerous, which gives rise to more anxiety, and the vicious cycle continues (Taylor, Abramowitz, & McKay, 2007). 1.2.2. Experiential avoidance. A cognitive-behavioral framework provides a compelling explanation for why OCS symptoms may develop and continue to be maintained in response to

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trauma exposure: Trauma may trigger obsessive thoughts, and individuals may engage in compulsions to banish such intrusive and distressing cognitions. Thus, in accord with this model, compulsions can be conceptualized as a relatively extreme form of experiential avoidance (Eifert and Forsyth, 2005). Experiential avoidance occurs when an individual is unwilling to remain in contact with his or her internal mental imagery (composed of thoughts, emotions, memories, and/or bodily sensations; Hayes, Wilson, Gifford, Follette, & Strosahl, 1996). When an individual avoids experiencing negative mental imagery, the frequency of those internal experiences increases, as does the distress associated with them (Purdon, 1999). Leaders in the field of trauma research acknowledge the pervasiveness of experiential avoidance strategies in response to trauma exposure, and have emphasized its role in long-term dysfunction (Batten, Follette, & Aban, 2002; Gilboa-Schechtman & Foa, 2001). Given the salience of experiential avoidance in response to trauma, OCS symptoms that facilitate the avoidance of distressing internal events (i.e., compulsions) may be more likely to develop in response to trauma exposure relative to other OCS symptoms (e.g., obsessions); however, this hypothesis has yet to be tested. 1.2.3. Behavioral inhibition. Thought-action fusion may be particularly important for the development and maintenance of OCD specifically. When conceptualizing of development and maintenance of symptoms of all OCS disorders, it is particularly important to consider the role of response inhibition, especially for TTM and excoriation disorder. Response inhibition is the ability to suppress behavior that is inappropriate or not required for the situation (Chambers, Garavan, & Bellgrove,, 2009). A deficit in response inhibition has been posited as underlying trichotillomania and excoriation symptoms (Chamberlain, Fineberg, Blackwell, Robbins, & Sahakian, 2006; Grant, Leppink, & Chamberlain, 2015). For individuals with an OCD diagnosis, compulsions are often utilized to reduce anxiety or prevent a feared event from occurring but for

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individuals with TTM or excoriation disorder, the repetitive nature of hair-pulling or skin picking is commonly done to reduce feelings of tension or to produce a pleasant sensation (Radomsky, Bohne, & O'Connor, 2007). In essence, for individuals experiencing TTM or excoriation symptoms, individuals may feel the repetitive behaviors occur immediately and without voluntary control (Bari & Robbins, 2013). For the other OCS disorders, individuals with BDD disorder symptoms appear to spend the same amount of excessive time on body-focused obsessions and find the obsessions distressing, as found in individuals presenting with OCD symptoms (Hollander, Braun & Simeon, 2008). Individuals displaying symptoms of hoarding disorder appear to be in a unique class. While hoarding symptoms can be conceptualized as avoidance of pain associated with discarding unnecessary items, the act of acquiring new objects is not associated with the repetitiveness of other OC symptoms such as counting or checking (Rachman, Elliott, Shafran, & Radomsky, 2009). Further, an individual displaying hoarding disorder symptoms doesn‘t necessarily see the urge to hoard as intrusive or unwanted but rather feels distress when prevented from engaging in the urge rather than from the urge itself. Within this context, if there is an association between trauma exposure and increased severity of OCS symptoms, there may be a more automatic behavioral response for individuals experiencing hoarding, excoriation, or TTM symptoms. This focus on behavior to address an urge rather than escape an obsession may also suggest that there is a stronger association between severity of trauma and severity of compulsions for all OCS disorders, although through different mechanisms. 1.3. Identifying for Whom Trauma Leads to OCS Symptoms 1.3.1. Sex. Sex appears to be a risk factor for the development of post-trauma emotional and psychological difficulties (Brown, 2008). Women are more likely than men to perceive the

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same types of traumatic events as threatening (Irish et al., 2011) and perceive traumatic events with negative appraisals such as helplessness and fear (Norris, Foster, &Weisshaar, 2002). These negative cognitive appraisals of trauma result in higher risk for psychopathology symptoms, especially PTSD (Dunmore et al., 1999) and have been found to be as important as trauma severity and pre-trauma variables (Foa, Steketee & Rothbaum, 1989; Ehlers & Steil, 1995). Women appear to be disproportionately affected by cognitive appraisals (e.g., helplessness); thus, the association between trauma and OCS symptoms may be greater for women than men. 1.3.2. Relationship Status. Social support has been shown to be instrumental in helping victims function after a trauma (Ruch & Leon, 1986; Thompson et al., 2000). One classic theory, the stress-buffering model, offers that social support protects an individual from the negative effects of the stressful experience by providing needed interpersonal resources, such as reducing negative appraisals of the event and encouraging coping skills (Cohen & Wills, 1985). Further, as indicated by the results of a meta-analysis of trauma-exposed adults, lack of social support appears to amplify the risk for developing PTSD symptoms following a trauma (Brewin, Andrews, & Valentine, 2000). An individual‘s committed relationship status, partner support in particular, can be conceptualized as an indicator of access to social support. 1.4. Type of Trauma in Relation to OCS Symptom Severity Another variable that needs to be considered when conceptualizing the role of trauma in the genesis of OCS symptoms is type of trauma. Interpersonal trauma (such as sexual assault or physical violence), when compared to non-interpersonal trauma, has been found to more severely affect an individual, especially in the development of psychological symptoms (Breslau, 2009).

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While there are numerous types of interpersonal traumas (e.g., physical violence, emotional abuse, sexual abuse, neglect), there is evidence that sexual abuse may be the most damaging (Browne, & Finkelhor, 1986; Seehuus, Clifton, & Rellini, 2014). One theoretical perspective explaining the particularly detrimental effects of sexual abuse on victims suggests that the individual is more likely to experience disgust during and after the trauma, negatively affecting their views of themselves and the event (Badour, Feldner, Babson, Blumenthal & Dutton, 2013; Davey, 1994). For example, sexual abuse has been associated with disgust during the peritraumatic period (Feldner, Frala, Badour, Leen-Feldner, & Olatunji, 2010), with intensity of peritraumatic disgust predicting psychopathology symptoms (Engelhard, Olatunji, & de Jong, 2011). Beyond the peritraumatic period, victims of sexual abuse experience greater levels of self-disgust than victims of physical abuse (Petrak, Doyle, Williams, Buchan, & Forster, 1997). Because victims of sexual abuse are prone to experiencing feelings of disgust, they may be at particular risk for engaging in acts of experiential avoidance. 1.5. The Current Study The principal goal of the present study was to examine the strength of the association between trauma exposure and OCS symptoms through meta-analysis to better understand relevant trauma sequelae outside of PTSD symptoms. It is hypothesized that the mean weighted effect size would demonstrate that past trauma exposure is positively associated with current severity of OCS symptoms (H1). It is hypothesized that sex would be a significant moderator, such that the association between past trauma and OCS symptoms would be stronger for women (H2). Consistent with a stress-buffering model, it is hypothesized that relationship status would significantly interact with past trauma, buffering its effect on OCS symptoms (H3). In addition to examining the overall effect of past trauma on OCS symptoms, effect sizes were calculated

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separately for (a) each of four types of interpersonal trauma exposure (violence, emotional abuse, sexual abuse, and neglect), and (b) two dimensions of OCS symptoms (obsessions and compulsions). We hypothesized that individuals who experienced more severe sexual trauma would report greater OCS symptoms (H4). We also predicted that past trauma exposure would be more strongly associated with severity of compulsions (H5). 2. Method 2.1. Search Strategies The first author, who has a background in psychopathology research, conducted the search and screening process. Electronic searches were conducted in Google Scholar, PsycINFO, ProQuest, PILOTS (Published International Literature on Traumatic Stress), and Cochrane Review databases throughout October 2015. Keywords included: “obsessive compulsive disorder,” “obsessive compulsive spectrum,” “intrusive thoughts,” “compulsive rituals,” “hoarding,” “body dysmorphic,” “trichotillomania,” or “excoriation” paired with “trauma,” “traumatic event,” or “traumatization,” for studies published in English. Search dates were limited to studies published between 1980 (the publication date of the DSM-III; APA, 1980) and 2015. Publish or Perish software was used to amass records from Google Scholar (Harzing, 2007). Only empirical studies (both published and unpublished) were included in the analyses. The abstracts of all articles (n = 4,969) were examined, and if an article appeared to meet the inclusion criteria, the full text was obtained (n = 356). Of these studies, 332 were ultimately excluded, and 24 were included in analyses (Appendix A for included studies; Appendix B for flow diagram). 2.2. Inclusion Criteria

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For all included studies in this meta-analysis, a measure of past trauma and current OCS severity were required. Trauma exposure was defined as exposure to a traumatic event that involves an actual or perceived threat to the physical integrity of an individual or others (APA, 2000). Traumatic events include: child abuse; sexual, emotional, or physical abuse; sexual, emotional, or physical neglect; interpersonal violence; life-threatening illness; school or community violence; unexpected death of a family member or close friend; natural disaster; and motor vehicle accident or other serious accident. Trauma exposure is not synonymous with PTSD; all assessment of trauma exposure utilized trauma-specific measures (e.g. Childhood Trauma Questionnaire, Traumatic Experiences Checklist, etc.). Studies only utilizing PTSD measures were excluded, as they only assess a subset of the trauma-exposed population. Samples were not excluded by location or specific psychiatric population (e.g., psychiatric hospital, community, university). Included studies primarily assessed interpersonal trauma (e.g. abuse, neglect, sexual assault), although studies that assessed non-interpersonal traumatic events (e.g. severe injury) were also included. Retrospective trauma exposure was indicated in a variety of ways. In the included studies, trauma assessments utilized categorical self-report measures or clinical interviews to determine the presence or absence of trauma for all participants. Continuous measures assessed different facets of trauma for all participants (e.g. the type of trauma a person experienced, length of time of the trauma, etc.). If a study measured number of traumas among trauma-exposed individuals and did not include individuals who reported no traumatic experiences, that study was excluded. OCS symptom severity was defined as the severity of symptoms that are explicitly characteristic of obsessive-compulsive disorder, hoarding disorder, body dysmorphic disorder, trichotillomania, or excoriation disorder. Current OCS symptom severity was assessed with self-

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report measures or evaluated by study clinicians. Included studies determined severity of symptoms based on direct questioning over several continuous facets of the disorder (e.g. time spent engaging in symptoms, distress experienced, etc.) or based on number of items a participant endorsed, with greater numbers indicating increased severity. Included studies could also indicate the presence or absence of an OCS disorder using a categorical measure (e.g. a structured clinical interview). When studies utilized this type of dichotomous OCS measurement, trauma severity scores were compared between OCS diagnoses group and healthy controls. All of the included studies examined variability in OCS symptoms among traumaexposed vs. non-trauma exposed individuals or variability in trauma severity scores among individuals endorsing OCS symptoms compared to healthy controls. Both types of studies were utilized to be able to quantitatively assess association between trauma exposure and OCS symptoms rather than only compare trauma-exposed and non-trauma-exposed groups. For the calculation of the effect size between trauma exposure and current OCS symptom severity, the overall number or severity of past traumas was not utilized as a variable because of the vast range in responses; only the absence or presence of past trauma was critical. For any study to be included, the OCS symptom severity and trauma measures utilized had to be face-valid, with tested psychometric properties established in the literature. All studies were aggregated for statistical analyses because each type of study fundamentally assessed past trauma exposure, despite differing methodology. Using all types of assessment methodologies to perform statistical analyses allowed for maximal power to detect moderation effects. 2.3. Exclusion Criteria In order to clearly elucidate the relation between trauma exposure and OCS symptom severity, several specific exclusion criteria were employed (see Table 1). OCS symptoms could

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not be grouped with general anxiety, PTSD or obsessive-compulsive personality disorder (OCPD) symptoms [n = 39 (of excluded full-text articles)]. Studies that combined ―trauma‖ with stressful life events, negative life events, negative quality of life, or stress were excluded (n = 16). If attempted suicide, suicidal ideation, or self-injury was the only indication of trauma in a sample, the study was excluded (n = 12). If a trauma-exposed group could not be clearly distinguished from a non-trauma-exposed group, the study was excluded (n = 13). If OCS symptoms were associated with organic brain damage (e.g., traumatic brain injury, Alzheimer‘s disease) (n = 9) or a medical condition (e.g. cancer) that did not meet criteria trauma exposure (n = 17), those studies were excluded. Finally, studies that only reported trauma exposure and/or OCS disorder prevalence as opposed to measuring the relationship between trauma and severity of OCS were excluded (n = 7). All studies were coded by the first author, along with trained undergraduate research assistants, each of whom coded 50% of included studies. Overall, interrater reliability suggested excellent reliability (κ =. 90). All disagreements on variable values were discussed until discrepancies were resolved (Landis & Koch, 1977). 2.4. Moderators When multiple groups (e.g. a group of individuals with OCD and a control group) within one study reported moderator data, the moderator data were averaged. This approach was also utilized to account for group by group comparisons in several studies‘ design. By averaging across moderator data, one moderator value was associated with one effect size; this was necessary so not to violate independence assumptions (Benassi, Sweeney, & Dufour, 1988). Moderation analyses were conducted when there was an effect size from at least three eligible studies (Grekin & O‘Hara, 2014).

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The sex moderator was represented by the percentage of the sample that was female. Relationship status was calculated as the percentage of the sample that was in a committed relationship. Committed relationships encompassed marriage, cohabitation, engagement, or a committed relationship. The year of publication was examined as a potential study characteristic moderator as effect sizes are typically higher in earlier publications (Ioannidis, 2005). The extent to which a moderator impacted the observed heterogeneity was analyzed using an unrestricted maximum likelihood estimator in mixed effects meta-regression for continuous variables. 2.5. Effect Size Calculation For each study, an unadjusted correlation coefficient (Pearson‘s r) was recorded for the association between trauma exposure and OCS symptoms. When correlation coefficients were not reported, correlations were calculated from available study data. Equations provided by Lipsey and Wilson (2001) were used for transforming data into correlations as well as for overall analyses and test of moderation. Across all studies, a total of 70 unique effect sizes (k) were aggregated from the 24 studies that were utilized for the analyses. If effect sizes were nested within samples, all effect sizes were summed and divided by the number of unique effect sizes to create an average effect size. This occurred when more than one effect size was reported in a study (e.g. correlations for the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) & Childhood Trauma Questionnaire (CTQ) and for the Obsessive-Compulsive Inventory-Revised (OCI-R) & CTQ) or the effect sizes for multiple subscales were reported rather than the overall effect size between the OCS and trauma scores, This approach allowed for one effect size per study to be utilized in the analyses so as to not violate independence assumptions (O'Boyle et al., 2012). Additionally, given the

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novelty of the question and limited number of studies, aggregation of unique effect sizes from the 24 included studies was the most conservative approach to handle nested data. In addition to computing a weighted mean effect size representing the overall relation between trauma exposure and OCS symptom severity, sub-analyses were conducted such that effect sizes representing the association between past trauma and OCS symptoms were computed separately for (a) each of four types of interpersonal trauma and (b) each dimension of OCS symptoms (obsessions and compulsions). There were not enough studies available to compute non-interpersonal trauma sub-type analyses. An unadjusted correlation coefficient (Pearson‘s r) was recorded for these associations. Notably, this approach was adopted, rather than examining trauma type and symptom dimension as categorical moderators, due to a lack of independent data across categories. Dependent data analyses would have required information on the degree of interdependence to adequately estimate effect size heterogeneity; however, degrees of interdependence were not reported in the included studies (Cheung & Chan, 2004). For the overall analysis, a weighted mean effect size with 95% confidence intervals was calculated. The null hypothesis (mean effect size = 0) was tested with the Z statistic (= .05). Standard error was included to provide information on the stability of effect sizes (Olatunji & Wolitzky-Taylor, 2009) and was calculated with Borenstein, Hedges, Higgins, and Rothstein (2009) equations (p. 52). Effect size strengths were interpreted according to Cohen‘s (1988) guidelines: r = .10 is considered a small effect size, r = .30 is considered a medium effect size, and r = .50 is considered a large effect size. A variable was determined to significantly moderate the overall effect size when the p-value of β was p <.05. Heterogeneity between studies was examined with the Q and I2 statistics (Borenstein et al., 2009). Benchmarks for heterogeneity estimates are low (25%), moderate (50%), and high

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(75%) amounts of real variance (Higgins, Thompson, Deeks, & Altman, 2003). The reliability of each measure was recorded when available. Mean internal consistency was adequate among OCS measures (mean α=.88, range of .65 - .98) and trauma measures (mean α =.84, range of .51 - .95). All correlations were corrected for OCS symptom and trauma measurement unreliability. When reliability estimates were not available, the reliability estimate from the original article that evaluated a questionnaire‘s psychometric properties was used (Card, 2012, p. 145). A random-effects model was utilized for this meta-analysis because it was expected that the studies would represent a distribution of true effect sizes, and the studies included were not functionally identical (Hedges, & Vevea, 1998; Borenstein et al., 2009). All analyses (including moderation analyses) were conducted using the Comprehensive Meta-Analysis (Version 2) program (Biostat, 2005). 2.6. Publication Bias The Duval & Tweedie ―trim-and-fill‖ analyses and funnel plots were examined for evidence of publication bias (Biostat, 2005). Publication bias is thought to be present if studies with small or counterintuitive effect sizes appear to be missing from analyses (Duval & Tweedie, 2000). Rosenthal's (1979) fail-safe N was also utilized to assess evidence of publication bias (Rosenthal, 1979). The fail-safe N test assess sampling bias by indicating the number of studies needed to raise a p-value past a critical value (usually α = 0.05) (Orwin, 1983). If a smaller number of ‗missing studies‘ would be needed to nullify the effect (e.g. 5-10), there would be more concern that the true effect size is not significant. However, if a large number of studies (e.g. 10,000) were needed to render the effect size not-significant, there would be less concern of publication bias (Borenstein et al., 2009).

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No significant effect size outliers were present. Because this review uses a random effects model, a visualization procedure (one-study removed analysis) was used to assess if any outliers were present (Borenstein et al., 2009). No single effect size caused significant mean effect size drift (all effect sizes r = .18 to .21). Cumulative analyses were also conducted to visually assess if year of publication had an effect on overall effect size, supplementing statistical moderator analyses (Borenstein et al., 2009). 3. Results 3.1. Overall Mean Effect Size The overall relation between past trauma exposure and severity of OCS symptoms for the total sample (k = 24, N = 4,557) was small but statistically significant (r =.20 [.14, .26], z = 5.96, p <.001) (all effect sizes in Table 2). High amounts of heterogeneity in effects across studies was indicated (Q = 100.79, I2 = 77.18), suggesting the presence of moderator variables. Given the diversity of studies, moderators were expected, and analyses are shown below (all moderator analyses in Table 3). 3.2. Publication Bias Trim-and-fill analyses indicated evidence of publication bias (Table 2). Duval and Tweedie‘s statistics estimated that six studies with small or counterintuitive effect sizes were missing from analyses. With six studies missing, the overall effect size was adjusted from the existing r =.20 to r = .14, which was still within the confidence interval of the observed effect size (funnel plot in Appendix C). Fail-safe N analyses did not indicate significant publication bias (Appendix D); it was indicated that 817 studies would need to be added for the effect size to lose statistical significance. 3.3. Moderator Analyses

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3.3.1. Sex. Sex significantly moderated the relation between trauma exposure and total OCS symptom severity. Across 21 studies (n =3,782), a higher percentage of females in a study was associated with a stronger relation between OCS symptom severity and trauma exposure (β = 0.01, p <.001). 3.3.2. Relationship status. Relationship status did not significantly moderate the relation between trauma exposure and total OCS symptom severity. Across seven studies (n =718), the percentage of the sample that was in a committed relationship did not affect the association between OCS symptom severity and trauma exposure (β = 0.00, p = 0.32). Both moderators had some unexplained variance [sex (Qw = 22.08, p =.28); relationship status (Qw = 6.85, p =.23)], suggesting additional moderators are present. 3.3.3. Year of publication. Across all 24 studies, the overall strength of the association between total OCS symptom severity and trauma exposure did not vary as a function of year of publication (β = -0.01, p = 0.39). The cumulative analysis showed effect sizes decreasing as the years increased; effect size drift is not unusual. 3.4. Sub-analyses: Effect Sizes by Trauma Type 3.4.1. Violence. Across nine studies (n = 1,082), the relation between severity of OCS symptoms and violent trauma exposure was statistically significant (r =.19 [.08, .30], z= 3.42, p < .001). Exposure to violent trauma is significantly associated with OCS symptom severity. A moderate amount of heterogeneity in effects across studies was indicated, (Q=24.38, I2 =67.19). 3.4.2. Emotional abuse. Across nine studies (n = 1,022), the relation between severity of OCS symptoms and emotional abuse was statistically significant (r =.24 [.18, .30], z = 7.25, p < .001). Exposure to emotional abuse is significantly associated with OCS symptom severity. A low amount of heterogeneity in effects across studies was indicated (Q = 8.58, I2 = 6.78).

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3.4.3. Sexual abuse. Across 10 studies (n = 1,207), the relation between severity of OCS symptoms and sexual trauma exposure was statistically significant (r =.21 [.12, .31], z = 4.35, p < .001). Sexual abuse is significantly associated with OCS symptom severity. A moderate amount of heterogeneity in effects across studies was indicated (Q = 24.38, I2 = 63.08). 3.4.4. Neglect. Across nine studies (n = 1,022), the relation between severity of OCS symptoms and neglect was statistically significant (r =.23 [.11, .34], z = 3.62, p < .001). Exposure to neglect is significantly associated with OCS symptom severity. A high amount of heterogeneity in effects across studies was indicated (Q = 29.09, I2= 72.50). 3.5. Sub-analyses: OCS Symptom Dimension 3.5.1. Severity of obsessions. Across five studies (n = 659), the relation between severity of obsessions specifically and trauma exposure was not statistically significant (r =.32 [-.01, .59], z=1.93, p = .05). Exposure to trauma is not significantly associated with the severity of OCS obsessions. A high amount of heterogeneity in effects across studies was indicated (Q = 71.23, I2= 94.38). 3.5.2. Severity of compulsions. Across four studies (n = 562), the relation between severity of compulsions specifically and trauma exposure was small but statistically significant (r =.17 [.03, .30], z =2.33, p = .02). Exposure to trauma is significantly associated with severity of OCS compulsions. A moderate amount of heterogeneity in effects across studies was indicated (Q= 7.72, I2 = 61.11). 3.6. Sub-analyses: Publication Bias Trim-and-fill analyses indicated no evidence of publication bias for severity of obsessions, severity of compulsions, violence, emotional abuse, sexual abuse, or neglect effect size analyses (Table 2). Fail-safe N analyses also did not indicate publication bias (Appendix D).

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22

4. Discussion The goal of this meta-analysis was to ascertain the strength of the association between trauma exposure and OCS symptoms, and to clarify for whom and under what conditions past trauma is associated with symptoms from the broad spectrum of obsessive-compulsive disorders. A significant overall effect size between past trauma exposure and current severity of OCS symptoms was detected, suggesting that individuals who were exposed to past trauma report a higher severity of OCS symptoms. This association between past trauma and OCS symptom severity was larger for females but was not weakened in the context of committed relationships. A closer examination of effect sizes for specific types of interpersonal traumas revealed that past violence, emotional abuse, sexual abuse, and neglect were each associated with more severe OCS symptoms, and effects were similar in magnitude. Consistent with hypotheses, the association between past trauma and OCS symptoms was present for compulsions, but not for obsessions. Results of the present study highlight the importance of examining the relation between trauma exposure and current OCS symptom severity. This meta-analysis provides a quantifiable estimate of the magnitude of that effect; however, it is important to note that, while significant, the overall effect size was small in magnitude. 4.1. Implications of the Current Study It is important to understand the theoretical and clinical implications of the relation between trauma and OCS symptoms. The results of this review add to existing research that has continually described a significant link between trauma and OCS symptomology. Beyond understanding the overall relation between trauma and OCS symptoms, it is important to understand under what conditions this association is strongest. A series of moderation analyses indicated that the link between past trauma and OCS symptom severity varied as a function of

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

23

sex but not relationship status. Further, all four types of interpersonal trauma—violence, emotional abuse, sexual abuse, and neglect—were associated with OCS symptoms. Effect sizes of all types of trauma had mostly overlapping confidence intervals, indicating that the effect of trauma is not significantly different for each type of trauma. The important component of trauma in relation to OCS symptom severity appears to be trauma severity, rather than type of trauma. Results of analyses suggest that exposure to trauma may contribute to severity of compulsions but not to the severity of obsessions. This is noteworthy given that obsessive beliefs (especially aggressive or religious obsessions) can be some of the most difficult OCS symptom to treat (Salkovskis &Westbrook, 1989). Compulsions may represent a more behavioral response to trauma while strength of obsessions may be more innate in origin. This may be particularly relevant for individuals presenting with OCD & BDD symptoms as compulsions may serve as a way to escape the intrusive trauma-related imagery. However, the mechanism through which trauma exposure affects severity of compulsions may be different for individuals displaying excoriation, TTM, and hoarding disorder symptoms. For those individuals, trauma exposure may exacerbate response inhibition deficits that present as an urge to engage in a compulsive behavior rather than a concentrated mental effort to avoid a trauma-related obsession. Nonetheless, the mechanism through how trauma exposure affects severity of OCS symptoms is not yet understood and remains an important empirical question. Sex significantly moderated the overall effect size such that women appear to be more likely to experience OCS symptoms in response to trauma than men. A significant proportion of both men and women experience trauma sometime in their lives (Gradus, 2014). However, the cognitive model of trauma focuses on how an individual appraises the threat of trauma exposure and their ability to cope with that threat (Ehlers & Clark, 2000). If an individual appraises the

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

24

event as extremely negative, they will continue to feel the presence of a threat and struggle to return to feeling safe in their environment. As women are more likely than men to perceive traumatic events as threatening (Irish et al., 2011), this cognitive model suggests that women may be more prone to maladaptive cognitions and, thus, more susceptible to the deleterious effects of trauma exposure. Brown (2008) proposed several explanations for sex differences in responses to trauma exposure, from cultural expectations about appropriate ways of coping with trauma for men versus women to biological aspects of the post-trauma response (e.g., differences in hypothalamic–pituitary–adrenal (HPA) axis activation and sex hormones). Future research should clarify what, exactly, explains why women may be more susceptible to developing OCS symptoms in response to trauma. Relationship status did not significantly moderate the relation between trauma and OCS symptom severity; however, relationship status may be too indirect to function as a proxy for social support. A specific facet of social support—perceived support—appears to be especially important for health and well-being (Dolbier & Steinhardt, 2000). Psychological distress has been found to decrease as perceived social support increases in range of traumatized populations (Kaniasty & Norris, 1993; Thompson et al., 2000) and it may help to provide counterexamples to a traumatized individual‘s maladaptive cognitive appraisals. If a more direct measure of social support (e.g., perceived partner support) had been available, we may have found evidence for the hypothesis that trauma is associated with OCS symptoms to the extent that social support is limited. Thus, access to interpersonal coping resources—as indicated by relationship status or perceived social support—should not be ruled out as a potential moderator of the relation between trauma exposure and OCS symptom severity.

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

25

Importantly, significant heterogeneity was found in the overall relation between trauma exposure and OCS symptom severity that was not fully explained by the results of this metaanalysis. This may be due, in part, to the fact that a meta-analytic approach to examining the relation between trauma and OCS symptoms is restricted to variables that have been examined in past research, limiting the range of possible moderators that can be tested. Other variables such as dissociation, alexithymia, and temporal order may be particularly important to the relation between trauma exposure and OCS symptoms (Carpenter, & Chung, 2011; Rufer, Fricke, Held, Cremer, & Hand, 2006). It appears that trauma exposure often precedes OCS symptoms (Borges et al., 2011; Przeworski et al., 2014), although there is not enough literature on the temporal order of trauma and the development/exacerbation of OCS symptoms. Further, the analyses presented in this report were restricted to groups comprised of relatively few studies (4-21 studies per analysis) and, accordingly, results need to be interpreted with caution. Lastly, this review incorporates all the OCS disorders, although the disorders primarily represented were OCD, BDD, and hoarding disorder. While examining all the disorders that compose the OCS can add to our knowledge of how these disorders may behave as a group, there may be a significant difference between OCD, BDD, & hoarding disorder compared to the disorders that were previously classified as impulse control disorders (TTM and excoriation disorder). There is not enough existing literature to examine these subclasses within this spectrum at this time but it could be an important area for future research. 4.2. A Potential Model of Trauma Exposure and OCS Symptoms By integrating theory and research embedded within a cognitive-behavioral framework, we can begin to conceptualize the processes unfolding in response to trauma exposure, ultimately resulting in OCS symptoms. One potential model to explain this phenomenon begins with trauma

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26

exposure. After an individual is exposed to trauma, he or she typically experiences heightened physiological arousal, as well as emotional and cognitive reminders of the trauma. Further, as someone enters the peritraumatic period, physiological, emotional, and cognitive distress intensifies. During post-trauma processing, maladaptive cognitions centering on self-blame or guilt may arise. It is during this extremely vulnerable post-trauma time that an individual may attempt to avoid the experience of physiological, emotional, and cognitive aspects of trauma exposure. An individual may misinterpret these intrusive thoughts, images or memories as significant and meaningful, spending more time and energy trying to avoid them, creating an obsession. An individual may attempt to avoid the negative thoughts, bodily sensations, and emotions that accompany the obsessions (i.e., experiential avoidance) by completing compulsive acts, such as hoarding belongings, counting, or cleaning repeatedly. The next time an individual experiences trauma-related negative mental imagery, they engage in compulsive behaviors to avoid experiencing negative emotions and anxiety, which is a powerful negative reinforcer, and the cycle continues (Figure 1). This preliminary model can be conceptualized similarly to a diathesis-stress model, in which trauma can be a catalyst that leads to the development/exacerbation of OCS symptoms. The diathesis component of this model can be conceptualized as individual differences that represent pre-existing vulnerabilities to developing psychopathology (McKeever & Huff, 2003). This hypothesized cognitive-behavioral model does not explicitly account for other genetic and neurobiological factors but those factors should be considered vital to the diathesis component. Of note, existing research examining OCS symptoms and trauma exposure did not test possible mechanisms linking trauma exposure to OCS symptom severity (as proposed in Figure 1), and this represents an important direction for future research. This would require prospective,

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27

longitudinal research designs that establish temporal precedence of mechanisms leading to subsequent OCS symptoms, such as maladaptive cognitions and peritraumatic distress. 4.2. Clinical Implications The significant relationship between trauma exposure and OCS symptom severity has important clinical implications for psychotherapy and mental health screening. The results from this meta-analysis could be important to any clinician who works with or will work with traumaexposed individuals. Awareness that individuals who have experienced a trauma may experience exacerbation of their OCS symptoms can inform psychodiagnostic assessments and case conceptualizations. For example, a clinician may routinely screen for depression or PTSD for individuals who have experienced trauma, but might overlook the possibility that OCS symptoms may develop or worsen in response to trauma exposure. Routinely screening for OCS symptomatology when patients present with trauma history could help those individuals receive treatment directed at their OCS symptoms more quickly. In addition to severity, it is important to consider chronicity of OCS disorder symptoms. OCD is one of the most chronic forms of psychopathology (Lopez & Murray, 1998) and trauma exposure has been found to complicate treatment for OCD (de Silva & Marks, 1999; Gershuny, Baer, Radomsky, Wilson, & Jenike, 2003; Pitman, 1993). A particularly important component in the relation between trauma exposure and chronicity of OCD symptoms may be comorbidity. Individuals with a comorbid diagnosis of OCD and another Axis-I disorder are more likely to experience chronic symptoms (Visser, van Oppen, van Megen, Eikelenboom, & van Balkom, 2014) and report more severe compulsions (Tukel, Oflaz, & Ozyildirim, 2007). Further, individuals with a diagnosis of OCD and comorbid affective, eating, and substance use diagnoses have endorsed experiencing more traumatic events than individuals only diagnosed with OCD

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28

(Visser et al., 2014). A better understanding of the relation between trauma exposure and symptom presentation, both in chronicity and severity, could have important treatment outcomes. Of note, the majority of the articles in this review assessed OCD symptoms. It is unknown how trauma can affect chronicity of other OCS symptoms. However, trauma exposure is associated with an increase in risk of developing psychiatric symptoms (Nemeroff, 2004); future research should examine the relation between trauma and all OCS symptoms to improve clinical outcomes. The most empirically supported treatment interventions for addressing OCS symptoms include pharmacotherapy, cognitive therapy, and exposure and response prevention (ERP) (Lee & Rees, 2011). ERP has been found to be the most effective treatment option, although it can also be highly aversive (Abramowitz, Taylor, & McKay, 2009). An additional treatment intervention to consider may be Acceptance and Commitment Therapy (ACT; Hayes et al., 2004). A primary component of ACT is a focus on pursuing goals that are consistent with an individual‘s values, even when aversive mental and physical stimuli are present (Gloster, Hummel, Lyudmirskaya, Hauke, & Sonntag, 2012). ACT has been shown to be effective in the treatment of nearly every OCS disorder, including OCD, excoriation, trichotillomania, and body dysmorphic disorder (Twohig et al., 2010; Twohig, Hayes, & Masuda, 2006; Woods, Wetterneck, & Flessner, 2006; Linde et al., 2015). Treatment from an ACT orientation may be beneficial in helping an individual navigate the maladaptive cognitions arising from exposure to a traumatic event and minimize avoidance of trauma reminders, which might escalate into more extreme forms of experiential avoidance such as compulsions. 4.3. Strengths & Limitations

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29

This review was the first to quantify the association between trauma exposure and severity of OCS symptoms, an important step in the exploration of trauma-related sequelae outside of PTSD. Another strength of the present report was the inclusion of symptoms from all of the OCS disorders as they are currently classified in the DSM-5. By combining samples of individuals reporting symptoms from the broad range of disorders falling under the OCS, rather than conducting separate studies for each disorder, we are better able to understand the true commonalties and differences among them (Taylor, Jang, & Asmundson, 2010). Importantly, we also proposed a theoretical model that could begin to explain the link between trauma and OCS symptoms, laying a foundation for future empirical research. There were also several limitations in this review. There were a small number of studies overall and, although there was a significant link between trauma exposure and OCS symptom severity, none of the studies were longitudinal in nature. Further, the articles examined primarily assessed OCD symptoms; no articles strictly examined excoriation disorder. Excoriation disorder is a fairly new term to denote a specific type of psychopathology. Other search terms (such as nail-biting, severe self-injury, etc.) could have been included in the literature search and should be considered in the future. An additional limitation is the lack of articles primarily examining non-interpersonal traumatic events. Because of the primarily interpersonal trauma exposure examined, the overall effect size may be best conceptualized as the relation between interpersonal traumatic events and OCS symptoms. Further research on the relation between trauma exposure and non-interpersonal trauma exposure is needed. Lastly, the proposed model outlined in the discussion describes one potential path for how trauma can impact severity of OCS symptoms, although other paths are certainly plausible.

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30

In terms of methodological limitations, the Duval & Tweedie publication bias analysis for the overall weighted mean effect size suggested that six hypothetical studies were not present in the literature, suggesting the true effect size may be smaller than reported in this review. Further, Rosenthal's fail-safe N publication bias tests of moderators indicated smaller numbers of studies were needed to render the effect size non-significant for severity of obsessions and severity of obsessions. This indicates the true effect size of these moderators may not be significant, yet only the addition of more studies in analyses would allow for certainty. Additionally, many of the moderation analyses were conducted with small numbers of studies, producing less reliable estimates. Thus, it is important to interpret this review‘s moderator analyses with caution and understand that the reported values are subject to change if more studies were to be are added or deleted (O‘Boyle, Forsyth, Banks, & McDaniel, 2012; Borenstein et al., 2009). Another important limitation to consider is the role of pre-existing OCS symptoms. There was limited discussion in this review on the role of pre-existing OCS symptoms as the existing literature is unclear on the temporal relation between OCS symptoms and trauma. The theoretical model that we have proposed does not distinguish between individuals who were experiencing OCS symptoms before trauma compared to individuals who began experiencing OCS symptoms after trauma. The model proposes that OCS symptoms may develop, or worsen, following exposure to trauma, regardless of premorbid psychological functioning. Future research should carefully examine if trauma exposure affects individuals with pre-existing OCS symptoms differently than those experiencing an initial onset of symptoms. Individuals with a history of OCS symptoms may possess certain vulnerabilities that result in a heightened sensitivity to

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trauma exposure, amplifying the effect of trauma exposure on the development of subsequent OCS symptoms. Additionally, similar to the limitation of examining relationship status rather than perceived support, examining traumatic event type may have been too indirect a proxy for the peritraumatic processes that are hypothesized as important in the severity of OCS symptoms (Figure 1). Experiencing disgust, especially intense disgust, during the peritraumatic period, appears to represent a key vulnerability for the development of psychopathology (Feldner, Frala, Badour, Leen-Feldner, & Olatunji, 2010; Engelhard, Olatunji, & de Jong, 2011). An empirical examination of peritraumatic physiological, emotional, and cognitive processing and subsequent exacerbation of OCS symptoms is needed to directly test if there is a role for disgust in the relation between trauma and severity of OCS symptoms. Finally, it is important to note that some OCS symptoms, such as checking, may arise or worsen after a trauma to promote feelings of safety and security. OCS symptoms might function as coping mechanisms or even as necessary tools for survival. Thus, it is important to consider the possibility that OCS symptoms can actually serve an adaptive function and, ultimately, result in better long-term functioning after a trauma. This further highlights the need for prospective, longitudinal research investigating the long-term consequences of trauma for the developmental course of OCS symptoms and co-occurring dysfunction. 4.4. Conclusions This study provided a quantitative analysis of the association between trauma exposure and OCS symptom severity. In the context of a meta-analysis of 24 studies, we have presented a preliminary conceptual framework, drawing from multiple theoretical models, explaining why trauma exposure may ultimately lead to OCS symptoms (e.g., due to maladaptive cognitions,

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negative mental imagery and avoidance of distressing internal events), and clarified under what conditions trauma is associated with OCS symptom severity. The proposed framework and results of the meta-analysis add to the existing literature focused on the impact of trauma on anxiety symptoms while also laying a theoretical foundation for future research.

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Appendix A. Studies Included Study

N

OCS & Trauma Measures Validity Citations SCID (Steiner, Tebes, Sledge, & Walker, 1995), RFQ (Felitti et al., 1998) VOCI (Thordarson et al., 2004); OBQ (Obsessive Compulsive Cognitions Working Group, 2005), CATS (Kent & Waller, 1998)

OCS Disorder Sym

Benedetti et al., 2014

97

Briggs & Price, 2009

313

Brooks et al., 2015

46

Y-BOCS (Goodman et al., 1989), CTQ (Bernstein et al., 2003)

O

Buhlmann, Marques, & Wilhelm, 2012

37

BDD-YBOCS (Phillips, Hart, & Menard, 2014), LEQ-SF (MacIan, & Pearlman, 1992)

B

Carpenter & Cheung, 2011

82

Y-BOCS-SR (Steketee, Frost, & Bogart, 1996), CTQ (Bernstein et al., 2003)

O

265

Y-BOCS (Goodman et al., 1989), SCID (Steiner, Tebes, Sledge, & Walker, 1995)

O

Cromer, Schmidt, & Murphy, 2007 Desmarais, Pritchard, Lowder, & Janssen, 2014

100

Y-BOCS (Goodman et al., 1989), CTS2 (Straus, Hamby, BoneyMcCoy, & Sugarman, 1996) BDD-YBOCS (Phillips, Hart, & Menard, 2014); BDDE (Rosen & Reiter, 1996), CTQ (Bernstein et al., 2003) SI-R (Frost, Steketee, & Grisham, 2004); OCI-R (Foa et al., 2002), TES-L (Gershuny, Cloitre, & Otto, 2002)

O

B

O

Didie et al., 2006

75

Hartl, Duffany, Allen, Steketee, & Frost, 2005

62

Hemmings et al., 2013

322

Y-BOCS (Goodman et al., 1989), CTQ (Bernstein et al., 2003)

O

Kovacs et al., 2011

553

BDDE (Rosen & Reiter, 1996), HISS (Campbell & Kay, 1996)

B

Landau et al., 2011

81

Lochner et al., 2002

141

Long, 2013 (diss.)

97

Study

SCID (Steiner, Tebes, Sledge, & Walker, 1995), THQ (Hooper, Stockton, Krupnick, & Green, 2011) SCID (Steiner, Tebes, Sledge, & Walker, 1995), CTQ (Bernstein et al., 2003) SI-R (Frost, Steketee, & Grisham, 2004), SLE (Bieliauskas, Counte, & Glandon, 1995)

N

OCS & Trauma Measures Validity Citations

Mak, 2014 (thesis)

40

Y-BOCS (Goodman et al., 1989), CTQ (Bernstein et al., 2003)

Matthews, Kaur, & Stein, 2008

927

Mills, 2013 (diss.)

211

Peles, Potik, Schreiber, Bloch & Adelson, 2012

125

Selvi et al., 2012

95

LOI-SF (Mathews, Jang, Hami, & Stein, 2004), CTQ (Bernstein et al., 2003) SI-R (Frost, Steketee, & Grisham, 2004); OCI-R (Foa et al., 2002); OBQ (Obsessive Compulsive Cognitions Working Group, 2005), ADIS-IV-L (DiNardo, Brown, & Barlow, 1994) Y-BOCS (Goodman et al., 1989), SAEQ (Rowan, Foy, Rodriguez, Ryan, 1994) Y-BOCS (Goodman et al., 1989), CTQ (Bernstein et al., 2003)

B

Hoardin

Hoardin

TTM

Hoardin

Type of OCS S

O

O

Hoardin

O

O

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

Semiz, Inanc, & Bezgin, 2014

120

Shavitt et al., 2010

215

Thiel et al., 2014

70

Visser et al., 2014

382

Voderholzer et al., 2013

101

34

Y-BOCS (Goodman et al., 1989), TEC (Nijenhuis, Van der Hart, & Kruger, 2002) Y-BOCS (Goodman et al., 1989); DY-BOCS (Rosario-Campos et al., 2006), SCID (Steiner, Tebes, Sledge, & Walker, 1995) Y-BOCS (Goodman et al., 1989); OCI-R (Foa et al., 2002), CTQ (Bernstein et al., 2003) Y-BOCS (Goodman et al., 1989), STI (Semiz, Basoglu, Ebrinc, & Cetin, 2007) Y-BOCS-SR (Steketee, Frost, & Bogart, 1996); OCI-R (Foa et al., 2002), CTQ (Bernstein et al., 2003)

Note: Trauma measures: ADIS-IV-L = Anxiety Disorders Inventory Schedule for DSM-IV Lifetime version; CATS = Child Abuse and Trauma Scale; CTQ = Childhood Trauma Questionnaire; CTQ-SF = Childhood Trauma Questionnaire-Short Form; CTS2 = Conflict Tactics Scale Revised; RFQ = Risky Families Questionnaire; HISS = Hand Injury Severity Scale; LEQSF=Traumatic Stress Institute Life Event Questionnaire; SAEQ = Sexual Abuse Exposure Questionnaire; SCID =Structured Clinical Interview for DSM Disorders; SLE = Schedule of Life Events; STI = Structured Trauma Interview; TEC = Traumatic Experiences Checklist; TES-L = Traumatic Events Scale—Lifetime; THQ = Trauma History Questionnaire. OCS severity measure: BDDE =Body Dysmorphic Disorder Examination; BDD-YBOCS = Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder; DY-BOCS = Dimensional Yale-Brown Obsessive Compulsive Scale; LOI-SF = Leyton Obsessional Inventory-Short Form; OBQ = Obsessive Beliefs Questionnaire; OCI-R = Obsessive Compulsive InventoryRevised; SI-R = Savings-Inventory-Revised; VOCI = Vancouver Obsessional Compulsive Inventory; Y-BOCS = Yale-Brown Obsessive Compulsive Scale; Y-BOCS-SR = Yale-Brown Obsessive Compulsive Scale-Self-Report.

O

O

O

O

O

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS Appendix B. Flowchart describing identification and screening of studies.

4,969 unique records identified through databases searches

356 full-text records assessed for eligibility

24 studies included in meta-analysis

Figure 2.

4,613 Records Excluded *499-Books or book chapters *167-Case studies *187-Citations (encyclopedia entries, definitions, table of contents, etc.) *2,865-Missing measures of OC and/or trauma suitable to this analysis *144-Non-empirical (editorials, patents, CVs, etc.) *101-Not able to locate text *416-Reviews *283-Unable to translate

332 Full-text Articles Excluded *12-Attempted suicide, suicidal ideation, or self-injury as trauma *9-Brain damage or neurochemistry as trauma *16-Combined ―trauma‖ with stress or stressful life events *3-Duplicate population from same authors *17-Medical condition (e.g. cancer or pregnancy complications) as trauma *120-Missing usable assessment of trauma (definition of trauma and/or assessment measure not meeting inclusion criteria) *96-Missing usable assessment of OCS (not OCS-specific) *13- No clear differentiation between trauma and no-trauma groups *39-Other psychopathology (esp.

Appendix C. anxiety, PTSD, or OCPD) Graph (1/Standard Error) Trim and Fill Funnel Plot for Weighted Mean Effect Size-Precision *7-Prevalence rather than severity

35

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS

36

Funnel Plot of Precision by Fisher's Z 40

Precision (1/Std Err)

30

20

10

0

-2.0

-1.5

-1.0

-0.5

0.0

0.5

1.0

1.5

2.0

Fisher's Z

Note. Funnel plots for effect sizes analyses for all studies. Vertical lines indicate the weighted mean effect size for each analysis. White circles indicate actual data points, and black circles indicate imputed data points from the trim and fill analyses. Black diamonds indicate adjusted weighted mean effect size after trim and fill. Clear diamonds indicate unadjusted weighted mean effect sizes. A random effects method set to assess for studies that fall to the left of the mean was utilized. Six studies have been trimmed from the left of the mean, indicating that six studies with small or counterintuitive results indicating a weak association between OCS severity and trauma exposure are not represented in analyses.

Appendix D. Rosenthal's Fail-Safe N Analyses Observed Effect Size Z Studies Overall Sev. Obsessions Sev. Compulsions Violence Emotional Abuse Sexual Abuse Neglect

11.56* 7.84* 3.86* 7.21* 7.21* 7.07* 7.01*

24 5 4 9 9 10 9

Missing Studies Needed 817 76 12 113 113 121 107

TRAUMA AND OBSESSIVE-COMPULSIVE SYMPTOMS Note: Sev. = severity of; Observed Studies = studies utilized in the analyses; Missing Studies Needed = number of missing studies needed to make the p-value greater than alpha; α = 0.05; *= significance at p<.05.

37

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38

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Research and Therapy, 42(11), 1289-1314. doi: 10.1016/j.brat.2003.08.007 Tükel, R., Oflaz, S.B., & Ozyildirim, I. (2007). Comparison of clinical characteristics in episodic and chronic obsessive-compulsive disorder. Depression and Anxiety, 24(4), 251–255. doi: 10.1002/da.20234 Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. The Journal of Nervous and Mental Disease, 192(11), 754-761. doi: 10.1097/01.nmd.0000144694.30121.89 Twohig, M. P., Hayes, S. C., & Masuda, A. (2006). A preliminary investigation of acceptance and commitment therapy as a treatment for chronic skin picking. Behaviour Research and Therapy, 44, 1513–1522. doi: 10.1016/j.brat.2005.10.002 Twohig, M. P., Hayes, S. C., Plumb, J. C., Pruitt, L. D., Collins, A. B., Hazlett-Stevens, H., & Woidneck, M. R. (2010). A randomized clinical trial of acceptance and commitment therapy versus progressive relaxation training for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology, 78(5), 705-716. doi: 10.1037/a0020508 Visser, H. A., van Oppen, P., van Megen, H. J., Eikelenboom, M., & van Balkom, A. J. (2014). Obsessive-compulsive disorder: Chronic versus non-chronic symptoms. Journal of Affective Disorders, 152, 169-174. doi: 10.1016/j.jad.2013.09.004 Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy, 44, 639–656. doi: 10.1016/j.brat.2005.05.006

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Figure 1. Proposed Model of Trauma Exposure and OCS Symptom Severity

Peritraumatic Period

Trauma Exposure

Distressing physiological, emotional, and cognitive internal events

Post-Trauma Processing

Maladaptive cognitions, impaired response inhibition, and/or avoidance of trauma reminders

Moderators Sex of Victim Access to Social Support

Negative reminders of trauma, avoidance of reminders, and/or increased urges

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Table 1. Exclusionary Criteria Exclusionary Criteria

Rationale

General anxiety, mixed psychopathology, or obsessive-compulsive personality disorder (OCPD)

To ensure assessment of only OCS symptoms and not comorbid psychopathology.

Stressful life events, negative life events, negative quality of life, or stress

Trauma exposure is a distinct phenomenon outside of the common experience of stress.

Attempted suicide, suicidal ideation, or self-injury

Organic brain damage (e.g., traumatic brain injury, Alzheimer‘s disease)

Those acts involve some degree of autonomy; not the same lack of control that constitutes other traumatic events1. Parsing out the biological effects of head trauma from the psychological effects of head trauma on the development of OCS symptoms is beyond the scope of the review.

Medical condition (e.g. cancer)

While a medical condition may be extremely stressful, it is not appropriate to assume a medical diagnosis is traumatic without assessment2.

Prevalence statistics

Prevalence statistics do not provide enough information for analyses to be conducted.

Note: OCS – Obsessive-Compulsive Spectrum; 1 = Hill & Pettit, 2013; 2 = Tedeschi & Calhoun, 2004.

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Table 2. Overall and Sub-Analyses Effect Sizes 95% CI

Total Sev. obsessions Sev. compulsions Violence Emotional abuse Sexual abuse Neglect

Homogeneity Test

k

N

r

LL

UL

SE

Z

QB

I2

kI

24

4,557

5 4 9 9 10 9

659 562 1,082 1,022 1,207 1,022

.20 .32 .17 .19 .24 .21 .23

.14 -.01 .03 .08 .18 .12 .11

.26 .59 .30 .30 .30 .31 .34

0.01 0.11 0.02 0.02 0.01 0.01 0.02

5.96* 1.93 2.33* 3.42* 7.25* 4.35* 3.62*

100.79* 71.23* 7.72 24.38* 8.58 24.38* 29.09*

77.18 94.38 61.11 67.19 6.78 63.08 72.50

30 5

Note: N = number of participants; k = number of effect sizes; r = weighted mean effect size; CI = confidence interval; LL= lower limit; UL =upper limit; SE = standard error; v = random-effects variance component; QB = heterogeneity between studies df=degrees of freedom; I2= percentage of total variability in the set of effect sizes due to true heterogeneity; Trim and fill adjusted = Duval & Tweedie publication bias test to assess true r and corresponding CI if publication bias is present; kI = the number of studies adjusted for imputed effect sizes based on publication bias tests; Sev. = severity of .; Other = all studies that were not used to compute sub-analyses were used to create the ‗Other‘ effect size to determine if significantly different from studies that were used in sub-analyses; The sum of N and k of sub-analyses surpasses the Total N and k because the data is nested; *= significance at p<.05.

4 9 9 10 9

Trim adj

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Table 3. Continuous Moderators for Weighted Mean Effect Size 95% CI Variable (unrestricted ML)

K

n

Sex Relationship Status Publication Year

21 7 24

3,782 718 4,557

β

β SE

LL

UL

QB (df)

0.01* 0.00 0.00 0.01 11.29(1) 0.00 0.00 -0.00 0.01 0.98(1) -0.01 0.01 -0.03 0.01 0.73(1) Note: k = number of studies; n = number of participants; β = standardized coefficient (Beta) of analysis; SE = standard error of β; CI = confidence interval; LL= lower limit; UL =upper limit; QB = between-group heterogeneity; df = degrees of freedom; QW = within-group heterogeneity; *= significance at p<.05.

QW (df) 22.08(19) 6.85(5) 23.08(22)