Obsessive-compulsive and posttraumatic stress symptoms among civilian survivors of war

In recent years, increasing attention has been given to the long-term psychological consequences of war-related trauma in civilian populations, e.g. survivors of the Balkan wars [10, 29, 35, 43]. Studies performed in Bosnia [1, 22], Croatia [44, 45], Serbia [39, 44] and Kosovo [11, 36, 39, 48] indicate current rates of 57 % for depression and 13–36 % for posttraumatic stress disorder (PTSD) in the civilian population. Moreover, up to 75 % of people with current PTSD have been reported to have at least one comorbid psychiatric disorder [1].

Beyond that, the relationship between war-related experiences and the occurrence of other mental health disorders such as obsessive-compulsive disorder (OCD) in civilians has begun to receive attention. Studies and case reports of civilians and veterans indicate that elevated posttraumatic stress and obsessive-compulsive symptom levels frequently co-occur in individuals with a history of traumatic exposure [26] and that trauma may play a major role in the development of OCD [7]. The prevalence of OCD has been reported to be up to 47 % in people with PTSD, compared to approximately 1 % in the general population [23, 26, 38]. On the other hand, up to 54 % of individuals with OCD reported having experienced at least one traumatic life event [6, 17] and indicated higher levels of posttraumatic stress symptoms [15, 25, 50]. In contrast, Grabe et al. [21] compared 210 OCD patients with 133 gender- and age-matched controls in a German multi-centre study, and they identified a higher lifetime rate of past severe traumatization in controls than in OCD patients. The investigators also reported low rates of trauma-related disorders either before or within the same year as OCD onset, at 2.9 and 1.5 %, respectively.

OCD and PTSD share several common elements of clinical symptomatology, with the occurrence of intrusive images or thoughts being common in both conditions. Whereas OCD patients tend to experience intrusive images of distressing events that may befall themselves or others, PTSD patients typically experience recurrent memories of their traumatic experience. Both disorders tend to result in responses to the distress, including avoidance behaviours or rituals [2, 47]. Various authors have described a “posttraumatic obsessive-compulsive disorder” [15, 16, 42, 47] in which the onset of OCD is clearly associated with the experience of a potentially traumatic event. Furthermore, studies indicate that patients with comorbid OCD and PTSD may be less responsive to psychotherapy than OCD patients without PTSD [18, 19].

Based on these studies, it could be hypothesized that war-related posttraumatic OCD can lead to high levels of mental health problems among civilian survivors of war. Therefore, there is a need to understand the relationship between both disorders, particularly as targeted therapy could lead to a lessening and eventually a decrease of the obsessive-compulsive symptoms [40]. A large representative study performed in five Balkan countries five to 15 years after the war in the Balkans estimated the prevalence of OCD among civilian post war survivors as between 0.2 and 6.1 % [43]. In a study of bereaved and non-bereaved war survivors in Kosovo, Morina et al. [37] identified OCD rates of 3.4 and 0.6 %, respectively. However, to our knowledge, there are no published studies that have specifically assessed obsessive-compulsive symptoms among survivors of war after migration to a new host country. Furthermore, research suggests that mental health problems in refugees and migrants persist for many years after their first occurrence [49] and that comorbidity presents a therapeutic challenge. Therefore, the main objectives of this study were to assess the severity and characteristics of obsessive-compulsive symptoms among survivors of the 1998–1999 Kosovo War living in Switzerland and to identify possible associations between obsessive-compulsive and posttraumatic stress symptoms. Finally, as PTSD has been reported to be strongly associated with the severity of depressive symptoms, we will additionally test whether PTSD or depressive symptoms alone or in interaction with each other account for OCD symptoms.

In the present study, we examined obsessive-compulsive symptoms and their associations with posttraumatic stress and depression in civilian survivors of war living outside their country of origin. To our knowledge, this is the first study that assessed the relationship of obsessive-compulsive symptoms and traumatic experiences in civilian war survivors a decade after the war had ended. High levels of obsessive-compulsive symptoms were found, affecting roughly one in three in our sample, with significantly higher levels in women. Our main finding was a strong association between OCD and PTSD symptoms, with more than 80 % of the individuals reporting symptoms of one disorder also displaying symptoms of the other. In multiple regression analysis, obsessive-compulsive symptoms were mainly related to gender and PTSD severity, but not to potentially traumatic events and depression.

Our results confirm several previously published studies that have identified significant associations between OCD and both traumatic exposure and PTSD [25, 26], as well as between obsessive-compulsive symptoms and childhood trauma [27, 30]. Our results are similar to Grabe et al.’s [21] study, which did not find any significant associations between trauma and OCD. However, in contrast to the Grabe et al. study, our sample was characterized by a high number of self-reported potentially traumatic events. This might be one explanation for the different findings. Furthermore, our population was recruited from a community sample, as opposed to a psychiatric or a clinical sample.

Several explanations could account for the frequent co-occurrence of obsessive-compulsive and posttraumatic stress symptoms (see review; [8]). Cognitive models of PTSD posit that negative appraisals lead to the exaggerated interpretation of stimuli as threatening, which results in elevated distress [9]. Following war, affected civilians may develop cognitive patterns involving concerns about safety, contamination, or the need to hoard, which may in turn lead to compulsive rituals to reduce arousal [46]. In the wake of war in particular, it is possible that threats to one’s safety may trigger specific OCD-related concerns. For example, people may develop excessive checking rituals to maintain their sense of safety. Alternatively, those exposed to sexual violence or body dismemberment may develop concerns regarding contamination. Further, Gershuny and colleagues [19] postulate that OCD and PTSD are two disorders on the same continuum. Thus, the authors suggest that there is a substantial overlap between the symptomatologies of OCD and PTSD, meaning that both disorders are characterized by anxiety-provoking recurrent and intrusive thoughts. There is also evidence of the link between trauma experience and OCD being moderated by genetic factors that are similarly implicated in PTSD development, raising the possibility of shared genetic risk factors for developing both conditions following trauma [24].

Of note, women reported more obsessive-compulsive symptoms. Men and women have the disorder with equal frequency in epidemiological studies [53]. Despite this apparent similarity, there is evidence that gender plays a relevant role in OCD phenotypic expression [31]. Considering that we studied obsessive-compulsive symptoms in a sample who fled significant trauma experienced during years of war, it is possible that exposure or response to traumatic events occurred differentially across genders in this sample. Further, we note that admission of OCD symptoms is sometimes hindered by embarrassment about the nature of the images or impulses experienced, and this may have particularly impacted responses from female participants.

The high percentage of individuals scoring above the cut-off for probable PTSD (39 %) and clinically relevant depression (45 %) should also be noted. This finding is remarkable because this was not a treatment-seeking sample, and participants were interviewed more than ten years after the war while living in a safe context. We note, however, that there is good evidence that the rate of psychiatric disorders in refugee groups tends to be elevated in small samples [51]. Accordingly, it is possible that a study with a larger and more representative sample of Kosovar war survivors living in Switzerland would yield lower psychopathology rates. Having said that, the literature suggests that after exposure to a traumatic event, the co-occurrence of PTSD and other disorders is almost the rule and not an exception [4]. The high correlation between post-traumatic stress, obsessive-compulsive symptoms and clinically relevant depression in the current sample can be understood under this perspective.

However, we found no gender differences regarding exposure to potentially traumatic events and probable PTSD in the current sample, which is in contrast to the epidemiological literature, but has been shown in samples of military personnel [41]. This somewhat surprising finding may be explained by comparable trauma exposure in men and women during and after the war.

A further result to be noted is the high negative correlation between occupation and mental health symptoms and education and mental health symptoms, respectively. Those two factors seem to be as protective factors and are in line with literature for obsessive-compulsive symptoms [5], posttraumatic stress symptoms [55] and depression [28].

Several limitations suggest that these preliminary results should be interpreted with caution. First, given the small sample size we cannot make any firm statements with regard to the representativity of our sample. Also, we cannot rule out the possibility that respondents to the various recruitment efforts had a vested interest in the study. In other words, the high levels of likely OCD, probable PTSD and clinically relevant depression might have been influenced by the sampling process. Second, our sample was restricted to those who had left Kosovo to immigrate to Switzerland, a group that may be psychologically and demographically different from those who chose to remain in Kosovo; a study of comparable data in a parallelized sample of participants still living in Kosovo would be of interest. Third, given the cross-sectional design of our study, we cannot make any inferences regarding the sequence of OCD, PTSD, or depression symptom onset in relation to each other. Relatedly, this study did not assess the extent to which the symptoms existed before the war. Fourth, while we used measures that have been validated across cultural groups, they have not been validated in Albanian-speaking samples. Further, we did not conduct clinical interviews, and consequently the extent to which self-reported symptom levels of OCD, PTSD and depression would correspond to clinical diagnoses is unclear. Finally, the fact that symptoms of OCD, PTSD and depression correlated highly in the current sample might suggest that participants were suffering from an underlying general distress that led to an over-endorsement of all psychiatric symptoms.

Taken together, our results suggest that the screening of war-related traumatized populations should not be restricted to and focused on PTSD symptoms, but should also take into account other mental disorders or psychopathological symptoms, such as obsessive-compulsive and depressive symptoms. As symptomatology of PTSD-related intrusions is in some ways similar to obsessive images and thoughts and depressive ruminations, differential diagnosis of OCD, PTSD and depression should be considered. Further investigations with respect to the role of traumatic experiences, such as war, in OCD aetiology are needed because post-traumatic OCD may be seen as a specific subtype, which has clinical implications. In consequence it would be important to provide specific support and treatment aimed at reducing long-term posttraumatic psychosocial disability, including obsessive-compulsive symptoms.