Background: Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD. Methods: Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy. Results: Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs. Conclusions: Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.

Keywords:
Dissociation, Obsessive-compulsive disorder, Cognitive behavior therapy, Exposure therapy, Outcome predictors
1.
Bernstein EM, Putnam FW: Development, reliability, and validity of a dissociation scale. J Nerv Ment Dis 1986;174:727–735.
2.
Warshaw MG, Fierman E, Pratt L, Hunt M, Yonkers KA, Massion AO, Keller MB: Quality of life and dissociation in anxiety disorder patients with histories of trauma or PTSD. Am J Psychiatry 1993;150:1512–1516.
3.
Ball S, Robinson A, Shekhar A, Walsh K: Dissociative symptoms in panic disorder. J Nerv Ment Dis 1997;185:755–760.
4.
Saxe GN, Chinman G, Berkowitz R, Hall K, Lieberg G, Schwartz J, van der Kolk BA: Somatization in patients with dissociative disorders. Am J Psychiatry 1994;151:1329–1334.
5.
Guz H, Doganay Z, Ozkan A, Colak E, Tomac A, Sarisoy G: Conversion and somatization disorders: Dissociative symptoms and other characteristics. J Psychosom Res 2004;56:287–291.
6.
Spitzer C, Spelsberg B, Grabe HJ, Mundt B, Freyberger HJ: Dissociative experiences and psychopathology in conversion disorders. J Psychosom Res 1999;46:291–294.
7.
Goldner EM, Cockhill LA, Bakan R, Birmingham CL: Dissociative experiences and eating disorders. Am J Psychiatry 1991;148:1274–1275.
8.
Demitrack MA, Putnam FW, Brewerton TD, Brandt HA, Gold PW: Relation of clinical variables to dissociative phenomena in eating disorders. Am J Psychiatry 1990;147:1184–1188.
9.
Herman JL, Perry JC, van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry 1989;146:490–495.
10.
Gast U, Rodewald F, Nickel V, Emrich HM: Prevalence of dissociative disorders among psychiatric inpatients in a German university clinic. J Nerv Ment Dis 2001;189:249–257.
11.
Putnam FW, Carlson EB, Ross CA, Anderson G, Clark P, Torem M, Bowman ES, Coons P, Chu JA, Dill DL, Loewenstein RJ, Braun BG: Patterns of dissociation in clinical and nonclinical samples. J Nerv Ment Dis 1996;184:673–679.
12.
Lochner C, du Toit PL, Zungu Dirwayi N, Marais A, van Kradenburg J, Seedat S, Niehaus DJ, Stein DJ: Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depress Anxiety 2002;15:66–68.
13.
de Silva P, Marks M: The role of traumatic experiences in the genesis of obsessive-compulsive disorder. Behav Res Ther 1999;37:941–951.
14.
Pitman RK: Posttraumatic obsessive-compulsive disorder: A case study. Compr Psychiatry 1993;34:102–107.
15.
Watson D, Wu KD, Cutshall C: Symptom subtypes of obsessive-compulsive disorder and their relation to dissociation. J Anxiety Disord 2004;18:435–458.
16.
Goff DC, Olin JA, Jenike MA, Baer L, Buttolph ML: Dissociative symptoms in patients with obsessive-compulsive disorder. J Nerv Ment Dis 1992;180:332–337.
17.
Hodgson RJ, Rachman S: Obsessional compulsive complaints. Behav Res Ther 1977;15:389–395.
18.
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, Heninger GR, Charney DS: The Yale-Brown Obsessive-Compulsive Scale. 1. Development, use, and reliability. Arch Gen Psychiatry 1989;46:1006–1011.
19.
Merckelbach H, Wessel I: Memory for actions and dissociation in obsessive-compulsive disorder. J Nerv Ment Dis 2000;188:846–848.
20.
Mataix-Cols D, Fullana MA, Alonso P, Menchon JM, Vallejo J: Convergent and discriminant validity of the Yale-Brown Obsessive-Compulsive Scale symptom checklist. Psychother Psychosom 2004;73:190–196.
21.
Rasmussen SA, Eisen JL: Clinical and epidemiological findings of significance to neuropharmacologic trials in obsessive-compulsive disorder. Psychopharmacol Bull 1988;24: 466–470.
22.
Grabe HJ, Goldschmidt F, Lehmkuhl L, Gansicke M, Spitzer C, Freyberger HJ: Dissociative symptoms in obsessive-compulsive dimensions. Psychopathology 1999;32:319–324.
23.
Michelson L, June K, Vives A, Testa S, Marchione N: The role of trauma and dissociation in cognitive-behavioral psychotherapy outcome and maintenance for panic disorder with agoraphobia. Behav Res Ther 1998;36:1011–1050.
24.
Bouvard MA, Milliery M, Cottraux J: Management of obsessive compulsive disorder. Psychother Psychosom 2004;73:149–157.
25.
Abramowitz JS, Foa EB, Franklin ME: Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly sessions. J Consult Clin Psychol 2003;71:394–398.
26.
Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ, Henk HJ: Behavioral versus pharmacological treatments of obsessive compulsive disorder: A meta-analysis. Psychopharmacology 1998;136:205–216.
27.
Ruhmland M, Margraf J: Effektivität psychologischer Therapien von spezifischer Phobie und Zwangsstörung: Meta-Analysen auf Störungsebene. Verhaltenstherapie 2001;11:14–26.
28.
Volpato Cordioli A, Heldt E, Braga Bochi D, Margis R, Basso de Sousa M, Fonseca Tonello J, Gus Manfro G, Kapczinski F: Cognitive-behavioral group therapy in obsessive-compulsive disorder: A randomized clinical trial. Psychother Psychosom 2003;72:211–216.
29.
Hand I: Out-patient, multimodal behaviour therapy for obsessive-compulsive disorder. Br J Psychiatry 1998;173:45–52.
30.
Hand I, Peter H, Rufer M: Kombinationsbehandlung mit Verhaltenstherapie und Pharmakotherapie bei Zwangsstörungen. Verhaltenstherapie 2001;11:206–216.
31.
Rufer M, Hand I, Braatz A, Alsleben H, Fricke S, Peter H: A prospective study of alexithymia in obsessive-compulsive patients treated with multimodal cognitive-behavioral therapy. Psychother Psychosom 2004;73:101–106.
32.
Rufer M, Hand I, Alsleben H, Braatz A, Ortmann J, Katenkamp B, Fricke S, Peter H: Long-term course and outcome of obsessive-compulsive patients after cognitive-behavioral therapy in combination with either fluvoxamine or placebo: A 7-year follow-up of a randomized double-blind trial. Eur Arch Psychiatry Clin Neurosci, in press.
33.
Bartlett AE, Drummond LM: Hysterical conversion and dissociation arising as a complication of behavioural psychotherapy treatment of obsessive-compulsive neurosis. Br J Med Psychol 1990;63:109–115.
34.
Fricke S, Moritz B, Andresen B, Hand I, Jacobsen M, Kloss M, Rufer M: Einfluss von Persönlichkeitsstörungen auf den Erfolg einer multimodalen Verhaltenstherapie bei Zwangserkrankungen. 2. Ergebnisse einer empirischen Studie. Verhaltenstherapie 2003;13:172–182.
35.
Andresen B: Inventar klinischer Persönlichkeitsakzentuierung (IKP). In Testkatalog. Göttingen, Hogrefe, 2004, p 78.
36.
Marks IM: Cure and Care of Neurosis: Theory and Practice of Behavioural Therapy. New York, Wiley, 1981.
37.
McKenzie N, Marks I: Routine monitoring of outcome over 11 years in a residential behavioural psychotherapy unit. Psychother Psychosom 2003;72:223–227.
38.
Ackenheil M, Stotz G, Dietz-Bauer R, Vossen A: Mini International Interview – German Version 5.0.0. München, Psychiatrische Universitätsklinik München, 1999.
39.
Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A, Schinka J, Knapp E, Sheehan MF, Dunbar GC: The validity of the Mini International Neuropsychiatric Interview (MINI) according to the SCID-P and its reliability. Eur Psychiatry 1997;12:232–241.
40.
Lecrubier Y, Sheehan DV, Weiller E, Amorim P, Bonora I, Sheehan KH, Janavs J, Dunbar GC: The Mini International Neuropsychiatric Interview (MINI). A short diagnostic structured interview: Reliability and validity according to the CIDI. Eur Psychiatry 1997;12:224–231.
41.
Hand I, Büttner-Westphal H: Die Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): Ein halbstrukturiertes Interview zur Beurteilung des Schweregrades von Denk- und Handlungszwängen. Verhaltenstherapie 1991;1:223–225.
42.
Freyberger HJ, Spitzer C, Stieglitz RD, Kuhn G, Magdeburg N, Bernstein-Carlson E: Fragebogen zu dissoziativen Symptomen (FDS). Deutsche Adaptation, Reliabilität und Validität der amerikanischen Dissociative Experience Scale (DES). Psychother Psychosom Med Psychol 1998;48:223–229.
43.
Carlson EB, Putnam FW, Ross CA, Torem M, Coons P, Dill DL, Loewenstein RJ, Braun BG: Validity of the Dissociative Experiences Scale in screening for multiple personality disorder: A multicenter study. Am J Psychiatry 1993;150:1030–1036.
44.
Spitzer C, Freyberger HJ, Stieglitz RD, Carlson EB, Kuhn G, Magdeburg N, Kessler C: Adaptation and psychometric properties of the German version of the Dissociative Experience Scale. J Trauma Stress 1998;11:799–809.
45.
Carlson EB, Putnam FW: An update on the Dissociative Experience Scale. Dissociation 1993;6:16–27.
46.
Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J: An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–571.
47.
Hautzinger M, Bailer M, Worall H, Keller F: Beck-Depressions-Inventar (BDI). Bearbeitung der deutschen Ausgabe. Testhandbuch. Bern, Huber, 1994.
48.
Derogatis LR: SCL-90: Administration, Scoring and Procedures Manual. Clinical Psychometric Research. Baltimore, Johns Hopkins University School of Medicine, 1977.
49.
Franke G: SCL-90-R. Symptom Checkliste von Derogatis – Deutsche Version. Weinheim, Beltz, 1995.
50.
Cohen D: Statistical Power Analysis for Behavioral Sciences, ed 2. Hillsdale, Erlbaum, 1988.
51.
Moritz S, Fricke S, Jacobsen D, Kloss M, Wein C, Rufer M, Katenkamp B, Farhumand R, Hand I: Positive schizotypal symptoms predict treatment outcome in obsessive-compulsive disorder. Behav Res Ther 2004;42:217–227.
52.
Hohagen F, Winkelmann G, Rasche-Räuchle H, Hand I, Münchau N, Hiss H, Geiger-Kabisch C, Käppler P, Schramm P, Rey E, Aldenhoff J, Berger M: Combination of behaviour therapy with fluvoxamine in comparison with behaviour therapy and placebo. Results of a multicentre study. Br J Psychiatry 1998;173:71–78.
53.
Grant JE, Kim SW: Dissociative symptoms in pathological gambling. Psychopathology 2003;36:200–203.
54.
Coons PM, Bowman ES, Milstein V: Multiple personality disorder. A clinical investigation of 50 cases. J Nerv Ment Dis 1988;176:519–527.
55.
Ross CA, Anderson G: Phenomenological overlap of multiple personality disorder and obsessive-compulsive disorder. J Nerv Ment Dis 1988;176:295–299.
56.
Putnam FW, Guroff JJ, Silberman EK, Barban L, Post RM: The clinical phenomenology of multiple personality disorder: Review of 100 recent cases. J Clin Psychiatry 1986;47:285–293.
57.
Butler LD, Duran RE, Jasiukaitis P, Koopman C, Spiegel D: Hypnotizability and traumatic experience: A diathesis-stress model of dissociative symptomatology. Am J Psychiatry 1996;153:42–63.
58.
Zlotnick C, Shea MT, Zakriski A, Costello E, Begin A, Pearlstein T, Simpson E: Stressors and close relationships during childhood and dissociative experiences in survivors of sexual abuse among inpatient psychiatric women. Compr Psychiatry 1995;36:207–212.
59.
Zlotnick C, Shea MT, Pearlstein T, Simpson E, Costello E, Begin A: The relationship between dissociative symptoms, alexithymia, impulsivity, sexual abuse, and self-mutilation. Compr Psychiatry 1996;37:12–16.
60.
Draijer N, Langeland W: Childhood trauma and perceived parental dysfunction in the etiology of dissociative symptoms in psychiatric inpatients. Am J Psychiatry 1999;156:379–385.
61.
Dancu CV, Riggs DS, Hearst Ikeda D, Shoyer BG, Foa EB: Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape. J Trauma Stress 1996;9:253–267.
62.
Kooiman CG, van Rees Vellinga S, Spinhoven P, Draijer N, Trijsburg RW, Rooijmans HG: Childhood adversities as risk factors for alexithymia and other aspects of affect dysregulation in adulthood. Psychother Psychosom 2004;73:107–116.
63.
Elzinga BM, Bermond B, van Dyck R: The relationship between dissociative proneness and alexithymia. Psychother Psychosom 2002;71:104–111.
64.
Gershuny BS, Baer L, Jenike MA, Minichiello WE, Wilhelm S: Comorbid posttraumatic stress disorder: Impact on treatment outcome for obsessive-compulsive disorder. Am J Psychiatry 2002;159:852–854.
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