Anxiety, Stress, and Coping, December 2006; 19(4): 335Á351 Pathological disgust: In the thoughts, not the eye, of the beholder BETHANY A. TEACHMAN University of Virginia Abstract There is now mounting evidence that disgust is critically involved in anxiety disorders. Despite the emphasis on irrational fear in understanding these disorders, there has been little investigation into the cognitive component of disgust. In this theoretical paper, a process to distinguish normal versus pathological disgust responding is proposed and its clinical implications considered. Similar to intrusive thoughts in obsessive-compulsive disorder (OCD), it is the interpretation of a disgust reaction as personally meaningful or threatening that will lead to pathological disgust. Building upon the belief domains thought to contribute to OCD (Obsessive Compulsive Cognition Working Group [OCCWG], 1997) and the laws of sympathetic magic in normal disgust (Rozin & Nemeroff, 1990), it is suggested that beliefs about one’s ability to cope with being contaminated, dirty, or disgusted may help predict avoidance and pathological disgust. Keywords: Anxiety, appraisals, disgust, interpretations, obsessive-compulsive disorder Disgust has long been recognized as a basic emotion. Darwin (1965) defined disgust as: ‘‘something revolting, primarily in relation to the sense of taste, as actually perceived or vividly imagined; and secondarily to anything that causes a similar feeling, through the sense of smell, touch, and even eyesight’’ (p. 253). While there is certainly variability in people’s general disgust sensitivity levels (Haidt, McCauley, & Rozin, 1994), the emotion has a fairly recognizable set of elicitors within a given culture. For instance, the popular Disgust Scale evaluates seven common disgust-eliciting domains (food, animals, body products, sex, body envelope violations, death, and hygiene), and the authors of the scale have more recently recognized the domains of moral and interpersonal disgust (Haidt, Rozin, McCauley, & Imada, 1997). A number of theories have been offered to account for this varied group of elicitors (e.g., Angyal, 1941; Rozin, Haidt, & McCauley, 1993; Tomkins, 1963), but there are fewer coherent theories to explain why one person becomes significantly more disgusted than another. In particular, it is unclear why disgust responding becomes so extreme for some that it might be characterized as pathological. There is now mounting evidence for a role of disgust in anxiety disorders, including phobias of small animals like spiders and snakes (e.g., Merckelbach, de Jong, Arntz, & Schouten, 1993), bloodÁinjury phobias (e.g., Tolin, Lohr, Sawchuk, & Lee, 1997), and perhaps even obsessive-compulsive disorder (OCD; e.g., Sprengelmeyer et al., 1997). Correspondence: Bethany A. Teachman, Department of Psychology, University of Virginia, P.O. Box 400400, Charlottesville, VA 22904-4400, USA. E-mail: [email protected] ISSN 1061-5806 print/ISSN 1477-2205 online # 2006 Taylor & Francis DOI: 10.1080/10615800601055923 336 B. A. Teachman Notwithstanding, there continues to be debate about the specific nature of the relationship between disgust and fear when it becomes disordered. For example, some researchers have found significantly greater disgust sensitivity among individuals with particularly high fears (e.g., Klieger & Siejak, 1997), while others have not (e.g., Thorpe and Salkovskis, 1998). How can we make sense of these incongruent findings, and under what circumstances will disgust contribute to psychopathology? Pathological Disgust To date, there is no agreed upon definition of pathological disgust, nor agreement on whether disgust will contribute to psychopathology. Defining pathological fear has rested on assumptions that excessive fear and avoidance in situations where significant harm is unlikely is irrational and disordered. It is not clear that the same criteria can be used to define pathological disgust (Woody & Teachman, 2000). As discussed below, there are numerous instances where healthy populations experience disgust and threat of contam- ination despite no objective danger (Rozin & Nemeroff, 1990). This suggests that simply defining a response as irrational will be insufficient to identify pathological disgust reactions. Although the field is in its infancy in terms of empirically demonstrating the existence of pathological disgust, a preliminary set of principles are suggested to guide future investigations. The following criteria are expected to be part of most pathological disgust reactions (though it is not yet clear which of these criteria will constitute a necessary or sufficient criterion): 1. Evaluation of the threat posed by the disgust elicitor or response should be excessive relative to others’’ evaluations (and not simply part of an accepted sub-cultural response). This can refer to exaggerated perceptions of the likelihood of contamination and subsequent harm, or beliefs about the consequences of emotional dysregulation (i.e., that becoming disgusted is harmful or dangerous). 2. The disgust response should cause clinically significant distress or impairment, most typically through excessive avoidance behaviors. 3. It is unlikely that simple factual information about the low probability of harm resulting from threat of contamination (physical, psychological, or moral) will be sufficient to reduce emotional distress or avoidance. Thus, informing a disgusted person that touching a snake’s skin will not leave a harmful residue or pose any danger is not likely to reduce distress or avoidance, suggesting a rigidly held belief despite objective evidence to the contrary. This paper focuses on how interpretations following normal disgust reactions will contribute to this disordered emotional response system. The range of interpretations discussed below are hypothesized to be present on occasion in both normal and disordered populations, but they will occur with greater frequency, intensity, and be held more rigidly when disgust becomes pathological. Role of Cognition in Disgust The subjective feeling, behavioral, and physiological components of disgust have been examined, but there has been little investigation into the cognitive component of disgust (though see intriguing investigations of information processing biases in disgust, such as Charash & McKay, 2002; Sawchuk, Meunier, Lohr, & Westendorf, 2002). This is Pathological disgust thoughts 337 surprising given that disgust is often described as a complex emotion because of its ideational component, whereby disgusted individuals experience revulsion in thinking about the origins of a substance. In addition, the belief that understanding of germ transmission may be required for a full experience of disgust has been offered as one explanation for the limited disgust reactions typically observed in children (see Fallon, Rozin, & Pliner, 1984; Rozin & Fallon, 1987). The suggestion is that children do not yet have the cognitive capacity to become fully disgusted because they lack the ideational piece. Thus, while cognitive processing has been considered from a developmental perspective in disgust, and unusual beliefs about germ transmission have been noted among normal, healthy samples (e.g., Nemeroff & Rozin, 1994; Rozin, Markwith, & Nemeroff, 1992), there has been little research to date on the content of disgust cognitions. Perhaps we can distinguish between normal and disordered disgust from the standpoint of its associated cognitions. In earlier work, we suggested that appraisals of threat of contamination are often common to disgust and fear (Woody & Teachman, 2000), and this link has also been suggested in the empirical literature (e.g., Davey, 1993). This common threat appraisal likely has adaptive value in protecting the individual from touching or ingesting a potentially noxious substance. Given its adaptive value and its high prevalence among healthy samples, appraisals of contamination threat may not be sufficient to explain why disgust becomes pathological for some but not others. Because disgust is a basic emotion with a common set of elicitors within a given culture, it seems likely that most individuals, regardless of whether they are vulnerable to emotional dysregulation, will experience thoughts relevant to disgust and contamination when they confront a relevant elicitor. Accordingly, it may be necessary to look beyond the common content of disgust thoughts or initial appraisals, and look instead to the secondary interpretations that follow disgust reactions. Secondary interpretations are used here to refer to the metacognitive process of reflecting on the implications of an initial appraisal of a situation (e.g., if my primary appraisal is true, what are the repercussions?). In Salkovskis’ (1996) discussion of appraisals in OCD, primary appraisals reflect beliefs about the subjective likelihood and consequences of a perceived danger, and the secondary appraisals reflect one’s perceived ability to cope with that danger. Thus, the primary appraisal is based on the initial reaction to the stimulus, and the secondary appraisal is based on the significance of that reaction to the individual. Applying this model to understand pathological disgust, it is hypothesized that primary appraisals of disgust will likely reflect beliefs about the contaminating properties of a disgusting object (e.g., This is going to get all over me) or likelihood of a disgust reaction (e.g., I think I might vomit), and the secondary interpretations will center on beliefs about