452 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Lensi et al., 1996; Rasmussen & Eisen, 1992). Rates of OCD appear to be quite con-
sistent across countries, although cultural differences probably affect rates of symptom
presentation in different countries. For example, religious obsessions are more prevalent
in cultures with strict religiously based moral codes, and washing/cleaning compulsions
may be more prevalent in Muslim countries which emphasize the importance of cleanli-
ness (Okasha, Saad, Khalil, El Dawla, & Yehia, 1994; Tek & Ulug, 2001). Recent stud-
ies indicate that OCD is not associated with higher educational attainment or signifi-
cantly higher intelligence, as was previously concluded from earlier studies (Rasmussen
& Eisen, 1992).
Life Events
Onset of OCD can be gradual or an acute response often to a life stressor (see Clark,
2004). Stressful life events, whether related or unrelated to the individual’s primary
obsessional concern, can lead to disorder onset, while important developmental changes
like pregnancy or childbirth are also associated with increased risk for OCD (Abramow-
itz, Schwartz, Moore, & Luenzmann, 2003; McKeon, Roa, & Mann, 1984). In some
cases a traumatic event that is directly relevant to the OCD might trigger an episode
through the development of faulty appraisals that are considered responsible for OCD
(e.g., a person develops a heightened sense of personal responsibility and subsequent
harm and injury obsessions after accidentally causing injury to her child; Rhéaume,
Freeston, Léger, & Ladouceur, 1998; Tallis, 1994). In their investigation of traumatic
life events in OCD, Cromer et al. (2007) concluded that traumatic events might be a vul-
nerability factor in OCD by influencing the manifestation of the disorder. However, a
critical incident that falls more toward the normal range of life experience can also lead
to the onset of OCD (Salkovskis, Shafran, Rachman, & Freeston, 1999). For example,
a man with a 10-year history of obsessive fear of HIV infection reported that it began
after he had a lap dance at a strip club. Many individuals with OCD, however, can not
report any precipitants to the disorder (Rasmussen & Tsuang, 1986).
Personality Correlates
Over the years various studies have examined the personality correlates of OCD.
Although early psychodynamic writers considered obsessive– compulsive personality
disorder (OCPD) or obsessional personality traits a premorbid condition for OCD,
empirical research has cast doubt on this connection (e.g., for discussion of the Freudian
concept of the anal character, see Kline, 1968; for discussion of Pierre Janet’s concept
of the psychasthenic state, see Pitman, 1987). In their review Summerfeldt, Huta, and
Swinson (1998) concluded that obsessional personality traits are less frequent in OCD
than previously expected, with avoidant personality disorder actually more frequent in
OCD samples than OCPD. However, they did conclude that the personality dimensions
of harm/avoidance or trait anxiety, certain impulsivity constructs like responsibility
and indecisiveness, and self- oriented perfectionism might have particular relevance for
OCD.
Research on childhood correlates of adult OCD have produced mixed results.
Although children and adolescents with diagnostic OCD most often have a chronic
course that persists into adulthood (see Geller, 1998; Shafran, 2003) and a large num-