Pathological Disgust: in the Thoughts, Not the Eye, of the Beholder
Anxiety, Stress, and Coping, December 2006; 19(4): 335 351
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), blood injury 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 the perceived consequences if that thought is true (e.g., If it gets all over me, I’ll never feel clean again; I can’t cope with being that disgusted; If I vomit, I’ll be humiliated). These secondary interpretations would include beliefs about one’s ability to cope with being contaminated, beliefs about whether the disgust reaction will ever dissipate, and beliefs about the dire consequences of becoming disgusted and losing emotional control. Thus, it is predicted that while the majority of individuals will report some level of disgust in response to a large, hairy spider, it is those individuals who believe that becoming disgusted is in some way dangerous or meaningful whose disgust responses will increase and interfere with their functioning (e.g., contribute to phobic avoidance). 338 B. A. Teachman
Cognitive Theory of OCD Cognitive models of OCD provide a useful starting point to examine potential thought processes in pathological disgust responding (e.g., Rachman, 1997; Salkovskis, 1996; Wells, 1997). These models note that the vast majority of the population has intrusive, unwanted thoughts that are similar in content to obsessions found in people with OCD (Rachman & de Silva, 1978). Thus, it is not the content of the thoughts, but the interpretation of the personal significance of the thoughts or responsibility for their perceived consequences that causes the severe distress and repetition that characterizes OCD (Rachman, 1998; Salkovskis, 1996). If an individual had a bizarre intrusive thought, and reflected simply ‘‘what a weird idea,’’ the thought would cause little disturbance. However, a person who has the identical intrusive thought, but follows the thought with an interpretation about the importance of the thought (such as ‘‘that must mean I’m an evil person’’) will be vulnerable to developing OCD. In fact, the Obsessive Compulsive Cognitions Working Group (OCCWG; 1997) have noted a range of critical interpretations that follow intrusive thoughts, such as beliefs about the need to control one’s thoughts, the importance one attaches to thoughts, and the need to be certain about thoughts. These maladaptive interpretations are thought to differentiate persons with OCD. In this paper, an analogous process is proposed to distinguish normal versus pathological disgust responding. Similar to obsessions in OCD, it is the interpretation of a disgust reaction as meaningful, dangerous or beyond one’s coping resources that will lead to phobic avoidance.
Overlap Between OCD and Disgust Interpretation Domains Akin to OCD, where the majority of the population has comparable content in their intrusive thoughts, it is assumed that most individuals will have a range of disgust cognitions when they encounter a relevant elicitor. Examples of primary disgust appraisals include: I am going to gag; This will rub off on me; It will make me smell bad; I might vomit; etc. Each of these primary appraisals (i.e., initial responses to the stimulus) are expected to be normative responses to disgust elicitors. Of interest are the secondary interpretations that follow these appraisals, which are expected to distinguish normal from pathological disgust. To develop a list of possible maladaptive disgust interpretations, the unhealthy belief domains already established in OCD provide a natural foundation. There are now multiple cognitive models of OCD, and these models have varied with respect to the cognitive elements believed to be most central to explaining obsessions and compulsions. For example, Salkovskis considered beliefs about exaggerated responsibility for harm as most critical to explaining the onset and maintenance of intrusive thinking, while Rachman focused more on overvalued ideation or excessive beliefs about the personal significance of intrusions. Further, cognitive models have relied on different terminology to reflect the beliefs people hold about their intrusive thoughts, including secondary appraisals (e.g., Salkovskis, 1996), metacognitive beliefs (Wells, 1997), and interpretations (e.g., OCCWG, 1997). However, these models are not necessarily in conflict with one another. Instead, they reflect alternate emphases on the same central process*it is the beliefs that follow intrusive thoughts, which account for the distress, intensity, and frequency of OCD obsessional thinking. For simplicity and because of the match to popular measurement approaches (e.g., Interpretation of Intrusions Inventory; OCCWG, 1997), the current paper will rely on the term ‘‘interpretations’’ of intrusive thoughts to refer to the body of ‘‘thoughts about thoughts’’ that may help to explain the distinction between pathological and normal disgust responding. Pathological disgust thoughts 339
The OCCWG has developed a list of common beliefs associated with obsessional thinking, and these provide a useful base to determine comparable interpretation processes that might be important in disgust. The original Obsessional Beliefs Questionnaire (OBQ; OCCWG, 1997, 2001, 2003) assesses six general belief domains (Over-importance of thoughts, Need to control thoughts and/or actions, Overestimation of threat, Lack of tolerance for uncertainty, Excessive responsibility, and Perfectionism). In addition, Sabine Wilhelm and Gail Steketee have added two further domains in their development of a manual for cognitive therapy for OCD: Tolerance for emotional discomfort and Fear of positive experiences (Wilhelm, Steketee, Fama, & Golan, 2003). Each of these cognitive domains will be considered from the perspective of its potential to explain analogous disgust interpretations. In addition, building from Rozin and others’ work on the properties that may explain how stimuli come to elicit disgust, interpretations that follow from the ‘‘laws of sympathetic magic’’ (Rozin & Nemeroff, 1990) are suggested as additional disgust interpretation domains. See Table I for examples of OCD-relevant interpretations from each of the cognitive belief domains (drawn from the OBQ) and proposed comparable disgust interpretations. These interpretations are expected to occur regularly only among individuals with pathological disgust, though they may occur occasionally in the context of normative disgust. Thus, when these interpretations either occur frequently or are rigidly believed, they are hypothesized to distinguish healthy from abnormal disgust and contribute to disordered avoidance.
Over-importance of Thoughts The idea that intrusive thoughts are viewed as personally significant and important was implicit in the writings of Rachman (1971, 1976) more than 30 years ago, but was made explicit as a belief domain by the OCCWG (1997). The domain encompasses beliefs that unwanted, intrusive thoughts indicate something meaningful and negative about oneself, such as being immoral, and that having these thoughts increases the likelihood that bad things will happen (i.e., the thoughts will come true), and further, that intrusive thoughts must be important simply by nature of their occurrence (Thordarson & Shafran, 2002). These beliefs are tied closely to the idea of ‘‘Thought Action Fusion’’ (TAF; Rachman, 1993; Rachman, Thordarson, Shafran, & Woody, 1995), which is thought to inflate the importance ascribed to intrusive thoughts. TAF is based on beliefs that having a thought makes it more likely that it will come true or that an individual will act upon it (e.g., ‘‘Having bad thoughts or urges means I’m likely to act on them’’) and that having immoral thoughts is equivalent to engaging in immoral behavior. How might this form of magical or distorted thinking link to pathological interpretations in disgust responding? It seems plausible that vulnerable individuals might exaggerate the importance of having disgust thoughts (either thoughts about something disgusting, or thoughts that they judge to be disgusting or immoral in some way), and could overstate the meaningfulness of feeling disgusted. This could lead to avoidance of even mildly disgusting stimuli because the person exaggerates the need to prevent disgust thoughts and feelings at all costs. As in Mowrer’s two-factor theory of avoidance in fear and anxiety (Mowrer, 1947), the avoidance may quickly increase and generalize because it is reinforced as an effective method to escape from negative affect. In consequence, the individual misses opportunities to learn that having disgust thoughts is not dangerous. Similarly, disgust beliefs could easily align with ideas of though-action fusion, such as ‘‘Having disgusting thoughts is as bad as doing something disgusting’’ and ‘‘Just feeling gross means I’ve been contaminated in some way’’. 340 B. A. Teachman Table I. Cognitive domains reflected in OCD and disgust interpretations.
OCD-relevant examples Comparable disgust Cognitive domain (from the OBQ) interpretations
Over-importance of thoughts . Having bad thoughts or urges . Having disgusting thoughts is as means I’m likely to act on them. bad as doing something disgusting. . For me, having bad urges is as bad . Just feeling gross means I’ve been as actually carrying them out. contaminated in some way. . Having disgusting thoughts means there is something disgusting about me as a person. . Thinking a lot about gross things means it’s likely I will do something disgusting. . Other people will judge me for having disgusting thoughts. Need to control thoughts . Having control over my thoughts . Having control over my thoughts is and/or actions is a sign of good character. a sign of being clean or moral. . I can have no peace of mind as long . Having disgusting thoughts means as I have intrusive thoughts. I’m out of control. . Being unable to control disgusting thoughts will make me physically ill. . Being unable to control disgusting thoughts will make me crazy. . Having one disgusting thought will inevitably lead to another. Overestimation of threat . When anything goes wrong in my . I often think people around me life, it is likely to have terrible effects. could make me ill. . I often think things around me are . When anything gross touches me, it unsafe. is likely to have terrible effects. . This feeling is going to last forever. . There are contaminants every- where. . Eating at restaurants is risky because they’re often not clean. . I have to clean myself immediately, or I’ll never be able to get clean. . There are more gross things than anyone can possibly keep track of. Lack of tolerance for uncertainty . If I’m not absolutely sure of . If I have any doubts about whether something, I’m bound to make a something is dirty, I stay far away mistake. from it. . In order to feel safe, I have to be . You shouldn’t touch or eat some- as prepared as possible for anything thing unless you’re 100% it is that could go wrong. clean. . I feel nervous if I don’t know exactly how my food was prepared . If in doubt, do NOT touch. Excessive responsibility . When I hear about a tragedy, I . If I think something is gross, I can’t stop wondering if I am should stop others from touching responsible in some way. it. . Even if I think harm is very un- . I have to be watchful for germs likely, I should still try to prevent it. even outside my own home. Pathological disgust thoughts 341 Table I (Continued) OCD-relevant examples Comparable disgust Cognitive domain (from the OBQ) interpretations
. I need to warn people about germs because they might not recognize them. . Other people don’t know how to make things really clean*I have to do it. . I should always keep my home clean. Perfectionism . There is only one right way to do . For me things are not clean enough things. if they are not perfectly clean. . For me things are not right if they . I can’t touch anything gross, even if are not perfect. it’s only a little disgusting. . No matter how hard I try, I can’t get things clean enough. Tolerance for emotional . I’m often afraid that I’ll be . Feeling really disgusted makes me discomfort overwhelmed by anxiety. feel crazy. . If I get very anxious, I won’t be able . It is important to me to stay in to manage it. control of my emotions. . I can’t cope with being disgusted. . I don’t know what I’d do if I felt unclean and couldn’t wash. Fear of positive experiences . Good feelings are always replaced . I’ll be punished if I enjoy dirty by bad ones. things. . I don’t deserve to feel good. . If something is gross, it can’t also be fun or funny. . Even if I feel clean for a little while, I will feel dirty again soon. . I’m a bad person if I get pleasure from something disgusting. Additional disgust . Law of contagion: If someone is interpretation domains dirty, I should not associate with him or her. . Law of similarity: If it looks like something gross, it probably is gross. . Mental pollution: There is no way to be clean if you are dirty on the inside. . Social pressures: It is important to show others that you are clean.
Note. The term ‘‘Disgusting’’ in these examples can be interpreted both as thoughts about the disgust value of stimuli, or as an appraisal that a thought is in some way disgusting or immoral. Further, it is clear that some of these interpretations could fall into more than one belief domain, depending on the situation and primary appraisals that precede them. The categorizations were determined based on the contexts in which they were judged most likely to occur.
Need to Control Thoughts and/or Actions The ability to direct our attention and control our information processing is clearly an adaptive and prominent aspect of human cognition, but this ability is by no means perfect (Purdon & Clark, 2002). In fact, Wegner (1994) has demonstrated that under the right conditions, those very efforts to control our thoughts, such as attempting to suppress 342 B. A. Teachman thoughts from awareness, can actually backfire and lead to an increase in unwanted thoughts. While the role of thought suppression and subsequent rebound of intrusive thoughts in OCD is not entirely clear, there is evidence that persons with OCD symptoms have beliefs about the need to exert rigid control over their thoughts and actions (see Purdon & Clark, 1993, 1994), and that successful treatment has been associated with healthier beliefs about the need to self-regulate one’s thoughts (Rachman & Hodgson, 1980). The interpretation of intrusive thoughts in this domain underscores the significance of attaining and maintaining the content and direction of one’s thoughts (‘‘Having control over my thoughts is a sign of good character’’). These beliefs map on naturally to disgust responding with only minor shifts in content: ‘‘Having control over my thoughts is a sign of being clean or moral’’ and ‘‘Having disgusting thoughts means I’m out of control.’’ Importantly, disgust thoughts are likely to come unbidden to the vast majority of the population given the right elicitor, just as most people experience intrusive thoughts. It is an empirical question whether efforts to suppress disgust thoughts will result in increased frequency of these thoughts, analogous to the rebound sometimes seen for other unwanted thoughts when deliberate suppression attempts are terminated or cognitive resources are taxed.
Overestimation of Probability or Severity of Threat This domain, as the title suggests, reflects the belief that the consequences of various situations or interactions with stimuli are more dangerous than is objectively the case. The tendency to predict the worst is a hallmark of many anxiety problems, not simply OCD (Beck & Clark, 1997), and helps explain the anxious person’s hypervigilance to potential threat cues and avoidance of any stimuli perceived as even mildly threatening. These maladaptive beliefs are reflected in obsessional thinking and subsequent interpretations, such as ‘‘When anything goes wrong in my life, it is likely to have terrible effects’’ and ‘‘I often think things around me are unsafe.’’ The parallels with disgust interpretations are perhaps most obvious in this belief domain because of the natural overlap in threat appraisals in fear and disgust. In earlier work, we suggested that, ‘‘Appraisals in disgust may overlap with fear in their shared assessments of danger, but disgust appraisals seem to focus more specifically on the threat of contamina- tion (either physical or symbolic/social), rather than on a broad range of perceived threats’’ (Woody & Teachman, 2000, p. 295). The overestimation of threat of contamination may contribute to exaggerated perceptions of the likelihood of harm (‘‘I often think things around me could contaminate me’’), and consequences of disgust exposure (‘‘When anything gross touches me, it is likely to have terrible effects’’, ‘‘This feeling is going to last forever’’). It seems probable that these interpretations would amplify disgust responding just as they exaggerate normal fear reactions. However, as discussed in the section on treatment implications below, it is unclear whether more realistic appraisals of threat of contamination will be sufficient to alleviate disgust. As Woody and Teachman (2000) note, knowing that a cockroach has been fully sterilized and presents no physical danger is not likely to make people comfortable with the roach floating in their drink.
Lack of Tolerance for Uncertainty Difficulties making decisions, accepting uncertainty, and doubt have long been recognized as hallmarks of OCD (Janet, 1908; cited in Ey, Bernard, & Brisset, 1963). This difficulty plays out in the onset of symptoms (Did I hit something on the road?) and the adequacy of Pathological disgust thoughts 343 rituals (Have I washed my hands enough?; Langlois, Freeston, & Ladouceur, 2000). This interpretation system maintains an agonizing cycle of obsessions, compulsions, and appraisals that the corrective action was insufficient, which leave the anxious individual feeling constantly vulnerable. Again, this interpretation style maps on easily to the disgust domain when an individual feels that extreme avoidance is required unless they can be absolutely sure that there is no risk of dirt or contamination (‘‘You shouldn’t touch or eat something unless you’re 100% sure it is clean’’).
Excessive Responsibility Salkovskis’ (1985, 1989, 1996) seminal work on a cognitive behavioral model of obsessions and compulsions proposes that persons with OCD feel excessive responsibility to prevent harm occurring to themselves or others. The critical feature of the model is that the person is not simply conscientious, but has an exaggerated idea of their liability for dangerous or terrible events, believing that they have pivotal powers to bring about or avert disaster. The negative outcomes are considered essential to prevent, either because they could have real-world harmful effects or could cause moral harm. The inflated sense of responsibility can follow an actual event (‘‘When I hear about a tragedy, I can’t stop wondering if I am responsible in some way’’) or can follow the idea of a future, potential danger (‘‘Even if I think harm is very unlikely, I should still try to prevent it’’). Excessive responsibility for preventing contamination provides a likely parallel for disgust. This may relate to concerns about protecting others, such as ‘‘I need to warn people about germs because they might not recognize them,’’ or feelings of responsibility that extend beyond natural limits on the environment that a person can influence (‘‘I have to be watchful for germs even outside my own home’’).
Perfectionism Perfectionism is a relatively broad construct, characterized variously as concerns over performing actions in just the right way (Hewitt & Flett, 1991; Janet, 1903; as cited in Pitman, 1987), a need for perfection to overcome or avoid feelings of uncertainty (Straus, 1948), and desire to have perfect control over one’s environment to reduce the risk of harm (Mallinger, 1984). In 1997, the OCCWG developed a measure of perfectionism designed to be especially relevant to OCD: ‘‘perfectionism was defined as the tendency to believe there is a perfect solution to every problem, that doing something perfectly (i.e., mistake free) is not only possible, but also necessary, and that even minor mistakes will have serious consequences’’ (OCCWG, 1997, p. 678). This definition maps onto disgust primarily through beliefs that the self and one’s environment must be completely clean and that even minor signs of dirt or contaminants can have disastrous effects. Thus, the disgust-prone individual is likely to wash excessively based on the interpretation that, ‘‘For me things are not clean enough if they are not perfectly clean.’’ Further, the individual may avoid situations or persons who do not meet their unrealistic standards of cleanliness and purity because of the belief that, ‘‘I can’t touch anything gross, even if it’s only a little disgusting.’’ For these individuals, the idea of ‘‘mildly disgusting’’ is an oxymoron because their dichotomous, perfectionist ideals split the world into only two categories*entirely clean or entirely unacceptable.
Tolerance for Emotional Discomfort Although tolerance for emotional discomfort was not originally identified as one of the primary cognitive domains by the OCCWG, the belief that anxious individuals have 344 B. A. Teachman difficulty tolerating anxiety has long been recognized. In fact, the use of anxiety exposures in behavioral therapy is premised in part on the idea that the avoidant individuals need to learn that they can tolerate anxiety, and that the feeling is uncomfortable but not dangerous. OCD-relevant examples of intolerance of emotional discomfort developed by Sabine Wilhelm, Gail Steketee and colleagues (Wilhelm et al., 2003) include, ‘‘I’m often afraid that I’ll be overwhelmed by anxiety’’ and ‘‘If I get very anxious, I won’t be able to manage it.’’ Clearly, one need simply substitute disgust for anxiety to see the analogous interpretation pattern. The belief that it is critical to avoid extreme emotions because of a perceived inability to cope with intense emotional experiences could serve as a common vulnerability to both anxiety and disgust (and perhaps other negative emotions).
Fear of Positive Experiences For some individuals with OCD, they follow a superstitious belief system based on the idea that positive experiences are in some way dangerous or a bad omen. This belief can derive from feelings of unworthiness (‘‘I don’t deserve to feel good’’), or from concerns that good things either will not last because that is the natural cycle of events or because they will be punished for enjoying themselves. It is unclear how common this interpretation system is among persons with OCD, but it can be a critical impediment in treatment if clients believe that it is risky, or they do not have the right, to get better. It is possible that pathological disgust interpretations could operate in a similar fashion. However, it seems more likely that fear of positive experiences in disgust will relate to moral concerns about the significance of enjoying disgusting things (‘‘I’ll be punished if I enjoy dirty things’’), or rigid thinking about the consequences of perceiving an object as disgusting (‘‘If something is gross, it can’t also be fun or funny’’). Interpretations of this kind would likely motivate attempts to suppress any positive affect associated with disgust stimuli, which in turn could exacerbate both the disgust response and hypervigilance to avoid disgust-evoking situations. Further, interest in these ‘‘dirty’’ items would likely increase because the items would be perceived as taboo since they elicit both disgust and positive affect. Pornography might elicit this interpretation for persons who report experiencing both repulsion and a guilty pleasure watching pornographic films.
Additional Disgust Interpretation Domains In addition to the OCD-relevant domains cited above, it is likely that there are certain categories of interpretations that are particular to disgust cognitions. These domains follow from research conducted by Rozin and his colleagues on the rules that guide normal appraisals of contamination threat. These rules are known as ‘‘laws of sympathetic magic’’ (Rozin & Nemeroff, 1990), and help explain why individuals find harmless items disgusting and contaminating, and feel the need to avoid situations even when there is no objective threat or chance of pollution. The first rule, the ‘‘law of contagion,’’ suggests that the effects of contact remain even after the actual physical connection has been terminated and no realistic opportunity to transfer germs or other properties remains. This magical belief system looks much like the childhood game of ‘‘cooties,’’ premised on the notion that ‘‘once in contact, always in contact.’’ While this belief system appears in normal disgust reactions, it is expected that the rigidity of interpretations regarding what types of minimal contact can activate the law of contagion and beliefs about the likelihood of contagion will differentiate those who develop pathological disgust reactions. Examples of interpretations in this domain include: ‘‘If something gross has even come close to my food, I don’t want to eat it’’ and ‘‘If someone I know is dirty, I should not associate with them’’. Pathological disgust thoughts 345
The second law of sympathetic magic, termed the ‘‘law of similarity,’’ holds that items that resemble one another in some way share fundamental properties. Thus, eating chocolate in the shape of dog poop would be considered disgusting because the appearance would be similar to a common disgust elicitor, even though the chocolate itself contains no disgusting elements. Interpretations in this domain might include: ‘‘If it looks like something gross, it probably is gross’’ and ‘‘If it smells gross, it probably could contaminate me.’’ Clearly, the laws of sympathetic magic overlap with some of the OCD-relevant interpretation domains above, such as overestimation of threat and over-importance of thoughts, but the emphasis on perceived risk of contamination through magical properties makes them particular to disgust. While some magical thinking is clearly present in normal disgust responding (Nemeroff & Rozin, 1989, 1992), rigid interpretations about the likelihood and frequency of these magical transfers is expected to distinguish maladaptive disgust reactions. A related concept to the laws of sympathetic magic is the notion of mental pollution, which involves a sense of internal dirtiness despite minimal contact with objective dirt (Fairburn & Rachman, 2004). ‘‘Feelings of mental pollution can be produced by ‘mental’ events such as images, words, unacceptable thoughts or urges. ... Unlike ordinary feelings of dirtiness, feelings of mental pollution cannot be fully alleviated by washing’’ (Fairburn & Rachman, 2004, p. 175). In an interesting investigation into the properties of mental pollution, Fairburn and Rachman found that 60% of female victims of sexual assault experienced feelings of dirtiness and/or the urge to wash following recall of the assault. These authors suggest that most cases of mental pollution likely also involve disgust (though disgust reactions can frequently occur in the absence of mental pollution). It is expected that, analogous to the laws of sympathetic magic, rigid belief in the negative consequences of mental pollution will predict when the process contributes to psychopathology. For instance, Fairburn and Rachman hypothesize that individuals who interpret their sexual assault as indicating that they are now psychologically or morally dirty will be vulnerable to the development of post-traumatic stress disorder. Thus, while the current paper has focused on the nature of pathological disgust interpretations following from the literature on obsessional thinking, mental pollution provides an intriguing example of a disgust interpretation that will likely contribute to a variety of anxiety problems. Concerns related to social anxiety might also contribute to maladaptive disgust interpretations based on exaggerated perceptions of social pressure to be appropriately disgusted by certain stimuli, and beliefs that not exhibiting disgust will lead to criticism and interpersonal rejection (S. Woody, personal communication, 7 April 2004). There is clearly a realistic component to concerns that an individual who does not feel some discomfort in common disgust situations (e.g., coming into contact with feces other than a baby’s) will disgust others, but it also seems likely that pathological disgust could be fueled by exaggerated interpretations of the likelihood of this social disapproval.
Making Sense of Previous Inconsistencies in the Literature on Disgust and Anxiety Disorders Emphasizing secondary appraisals or interpretations to explain pathological disgust, rather than focusing on primary appraisals, may help clarify past findings in the literature on disgust and anxiety disorders that have been difficult to explain. For instance, results have been mixed on whether individuals with phobias that seem to involve disgust as well as fear (e.g., small animals like spiders and snakes, and blood injury injection fears) have elevated general disgust sensitivity to a wide variety of elicitors (e.g., de Jong, Andrea, & Muris, 1997; Klieger & Siejak, 1997; Merckelbach et al., 1993; Tolin et al., 1997), or whether the 346 B. A. Teachman strong disgust response is specific to the phobic stimuli and not associated with higher general disgust sensitivity (e.g., Merckelbach, Muris, de Jong, & de Jongh, 1999; Thorpe & Salkovskis, 1998). One possible explanation for the mixed findings may lie in the overlap between secondary interpretations that lead to elevated general disgust sensitivity and those that lead to specific phobias. Perhaps when phobic stimuli and general disgust stimuli both trigger similar maladaptive secondary interpretations (such as beliefs about an inability to cope with the disgust response), a person will show heightened disgust responding in both domains. However, when initial disgust appraisals are interpreted in different ways, then no relationship between phobic disgust and general disgust sensitivity would be expected. For example, this would occur in a situation where phobic stimuli activate interpretations about likely threat or the importance of the disgust response, whereas general disgust stimuli elicit responses that are not perceived as personally significant. An additional area of controversy surrounding the role of disgust in anxiety problems concerns the ‘‘Disease avoidance model’’ outlined by Davey and his colleagues (Davey, 1992; Davey, Forster, & Mayhew, 1993; Matchett & Davey, 1991; Webb & Davey, 1992). The model proposes that evolutionary pressure has shaped a disgust response to certain animals to prevent the transmission of disease. They suggest that disgust mediates the oft- cited evolutionary influence in animal phobias (see ‘‘preparedness theory’’; Seligman, 1971), such that strong disgust sensitivity would have been adaptive by promoting avoidance of animal-borne disease or contaminants from animals that are considered disgusting, but are unlikely to cause physical harm or prey on humans. This theory has intuitive appeal, but it has been difficult to replicate their initial findings that disgust sensitivity was related to fear of animals described as non-predatory and repulsive, but not to predatory animals (Matchett & Davey, 1991). Further, the model implies that this adaptive disgust-mediated avoidance should be evident across various situations that have the potential to transmit contaminants. Yet, results from an intriguing study by Mulkens, de Jong, and Merckelbach (1996) found that individuals with spider phobia drank from a dirty teacup as frequently as non-phobic participants did, suggesting no generalized disease avoidance in the phobic sample. These null findings have raised doubts about the model’s ability to predict when disgust sensitivity and disease avoidance will result in phobias, and the extent of avoidance to be expected based on concerns about disease transmission. Perhaps some of the confusion can be resolved by considering disease avoidance from the perspective of secondary interpretations, rather than objective disease potential. For instance, if a dirty teacup activates primary appraisals regarding threat of contamination, but not secondary interpretations about the ability to cope with contamination or the likelihood of disease, then avoidance behaviors will not differentiate persons with and without phobias. However, where disease avoidance beliefs intersect with catastrophic secondary interpretations, more consistent disease avoidance may be expected. Notwith- standing, the idea that secondary interpretations will motivate avoidance raises doubts about whether the model can be understood from an evolutionary perspective (as originally suggested by Davey and colleagues) because it may be difficult to posit an advanced cognitive mechanism to explain how our primitive ancestors benefited from avoiding disease. A third challenging issue in the literature on disgust and anxiety disorders concerns the expected relationship between OCD and disgust sensitivity. Given the obvious link between fears of contamination and washing and cleaning rituals, it seems natural to expect higher disgust sensitivity among persons with OCD, particularly with regard to the hygiene subscale of the Disgust Scale. However, using a clinical sample of obsessive-compulsive Pathological disgust thoughts 347 washers, Tolin, Brigidi, Donde, and Foa (1999) found elevated disgust sensitivity compared with non-anxious controls on the total Disgust Scale, but no interaction with particular disgust domains. Further, the obsessive-compulsive washers did not show elevated disgust sensitivity relative to persons with generalized social phobia, raising doubts about a unique relationship between OCD and disgust. Again, it may be that the common denominator that makes a person vulnerable to both general disgust sensitivity and OCD is not the seemingly shared content regarding disgust elicitors, but the tendency for elicitors to evoke similar maladaptive secondary interpretations about the meaning of experiencing disgust or becoming contaminated.
Treatment of Pathological Disgust The field is still in the early stages of considering the effectiveness of current anxiety disorder treatments when fear and disgust are comorbid, though initial findings in the area of spider fear and phobia are encouraging. High trait levels of disgust sensitivity do not seem to interfere with the effectiveness of exposure therapy for spider phobia (Merckelbach et al., 1993), and disgust specific to spiders is reduced following exposure therapy (de Jong et al., 1997; Smits, Telch, & Randall, 2002). Further, standard exposure therapy was as effective at reducing avoidance and negative affect towards spiders as an experimental procedure combining exposure with counter-conditioning techniques to uniquely target negative valence (incorporating liked foods and music during an exposure session; de Jong, Vorage, & van den Hout, 2000). These results may indicate that disgust-specific interventions are not necessary. However, many questions remain unresolved, including the influence of state versus trait disgust, the importance of reducing general disgust sensitivity for maintenance of treatment gains (which did not diminish in studies of de Jong et al., 1997, or Smits et al., 2002), and of course, the significance of disgust interventions in other anxiety problems, particularly OCD. Further, Hepburn and Page (1999) found differential impacts of scripts designed to elicit fear versus disgust following presentation of a BII-stimulus to an analogue sample of undergraduates with some symptoms of blood injury phobia. Following repeated exposures, fear and feelings of faintness were reduced in all conditions, supporting the predicted habituation pattern for both fear and disgust. However, relative to the control condition (a frustration script), images of fear resulted in increased symptoms of both fear and faintness, whereas images of disgust increased symptoms of faintness but not fear. These preliminary findings suggest variability in disgust and fear responsiveness during exposures. Woody and Teachman (2000) point out natural parallels that might be expected in treating pathological disgust and fear, including the role of exposure in learning to tolerate and habituate toward disgust-evoking stimuli, but also highlight some potential differences:
It appears that cognitive re-evaluation in the case of contamination ideation does not inspire subjects to rescind their judgment that a stimulus is disgusting (Fallon, Rozin, & Pliner, 1984). Thus, although the perceived threat of contamination may be attenuated, the evaluation of the stimulus as disgusting is not modified. This desynchrony may imply that cognitive approaches used in the treatment of fear (in which reformulation of maladaptive thoughts and beliefs about the feared object are presumed to lead to affective change) may require adjustment before they would affect disgust. (Woody & Teachman, 2000, p. 308) 348 B. A. Teachman
If empirical evidence supports the idea that it is the secondary interpretations of disgust cognitions that are critical to pathological disgust responding, analogous to the interpreta- tions of unwanted, intrusive thoughts in OCD, then similar interventions aimed at shifting the interpretations may be required. In recent cognitive therapies for OCD (e.g., Freeston, Le´ger, & Ladouceur, 1996, 2001; Wilhelm et al., 2003), the goal is not to change the content of intrusive thoughts or obsessions, but to minimize the importance ascribed to these thoughts and alter the subsequent, maladaptive interpretations. Mindfulness training may be particularly helpful to reduce the over-importance attached to disgust thoughts because of its focus on observing, rather than evaluating, thoughts. Similarly, the cognitive interventions proposed to shift OCD interpretations would likely be of value. Collaborative empiricism (i.e., using a scientific approach to question the helpfulness of thoughts) would still underlie the approach, but clients would be encouraged to reconsider the accuracy and utility of their secondary interpretations, rather than restructuring their primary disgust appraisal. Thus, when an individual with contamination fears in OCD is challenged to touch the soap scum on the floor of a shower, she would be taught to simply observe the initial disgust thoughts that ‘‘it will get on me and make me feel dirty,’’ and instead focus on considering the evidence for and against her interpretations that she could not cope if she felt dirty or that she would never get the soap scum off her skin if she did not wash right away. Behavioral experiments to test predictions regarding overestimations of the probability or severity of contamination would also be useful. A person with a snake phobia who fears that his skin will immediately become infected and sore if a snake touches him would be encouraged to directly examine this hypothesis.
Conclusion The suggestion that secondary disgust interpretations will predict distress and avoidance provides the foundation for a theory to explain how we might distinguish normal from pathological disgust responding in anxiety disorders, and may help resolve previous inconsistencies in the literature about the role of disgust in fear and anxiety problems. The next step is to examine this theory empirically to determine whether disgust interpretations play a functional role in emotional disorders (as opposed to simply co-occurring with the negative emotional state), and to test which interpretations are important (i.e., predict psychopathology above and beyond the variance already explained by irrational fear cognitions). To evaluate whether irrational disgust interpretations are involved in the onset and maintenance of particular anxiety disorders we first need to determine what the critical cognitions are that predict disgust-motivated phobic avoidance, OCD rituals, and distress. Beliefs about intrusive, obsessional thoughts were proposed as a natural parallel for likely disgust interpretations. Building from the belief domains thought to make individuals vulnerable to OCD, it was suggested that over-emphasizing the importance of disgust thoughts, believing that one needs to control disgust thoughts, overestimating the likelihood and severity of contamina- tion threat, being intolerant of uncertainty about cleanliness, taking on excessive responsibility for germ transmission, perfectionist beliefs about cleanliness, an inability to tolerate disgust, and fear of experiencing positive affect at the same time as disgust will all make a person vulnerable. Taken together, these domains imply that beliefs about one’s ability to cope with being contaminated, dirty or disgusted and the perceived likelihood of harm following contamination form the basis of pathological, irrational disgust. Yet, it is clear from the laws of sympathetic magic (the laws of contagion and similarity) that beliefs Pathological disgust thoughts 349 about contamination are not rational even among healthy, non-anxious persons. It is likely that rigidly held and exaggerated beliefs about the probability and seriousness of the magical transfer of germs will also be needed to distinguish maladaptive from protective disgust reactions. Once we have a clearer understanding of which disgust interpretations predict anxiety disordered behavior, it will be feasible to evaluate whether dysregulated disgust requires different cognitive interventions than fear and anxiety seem to benefit from. Our current terminology for the ‘‘anxiety disorders’’ may be something of a misnomer, given the likely role of multiple negative emotions (including not only disgust, anxiety, worry, panic, and fear, but also sadness, guilt, shame, embarrassment, frustration, and anger) in explaining the distress and avoidance characteristic of anxiety problems. We have efficacious and effective treatments for most of the anxiety disorders, but not everyone benefits from these treatments, and there is still much we do not understand about why some people are more vulnerable to developing anxiety disorders than others, why some individuals fail to improve in treatment, and why so many seemingly recovered individuals experience later relapse or return of fear. Recognizing and then learning to modify or restructure maladaptive disgust cognitions may help answer some of these unresolved questions. Perhaps the key to understanding pathological disgust and determining its role in the onset and maintenance of anxiety disorders lies in the thoughts, not the eyes of the beholder.
Acknowledgements Thank you to Sheila Woody and members of the Program for Anxiety, Cognition and Treatment (PACT) Lab at the University of Virginia for their helpful comments in the development of this manuscript.
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