Disorders Of Disgust Fears and phobias

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It has long been the tradition to derive the anxiety disorders from the basic emotion of fear (see Chapter 6) and, of course, we do not dispute that many fears and phobias have their origins in fear-based responses. However, there are a number of early-onset specific phobias that do not conform to the original Mowrer (e.g., 1939) two-factor theory of phobias, as Rachman has argued for many years (see Rachman, 2004, for a recent summary). In an attempt to deal with some of these problems, theorists such as Rachman (e.g., 1990) have proposed that in addition to the classical or traumatic conditioning route to the acquisition of phobia, there are two further routes that consist of observational learning and of information transmission (see Field, 2006). Although these three routes map onto the associative and effortful appraisal routes in SPAARS, nevertheless, these additional routes also fail, we believe, to explain the onset and characteristics of a number of specific phobias. Instead, as we and others have argued, many of these phobias appear to be disgust-based rather than fear-based.

As discussed in Chapter 6, the majority of specific phobias such as animal, blood, and dental phobias begin in childhood, with the animal phobias typically arising earliest. Of course, it is clear that emotional problems are very common in childhood, although the majority tend to be transient and show only modest continuity across time (Rutter, 1984). When emotional problems do continue into adulthood, they tend to be homotypic—that is, they remain consistent in their presentation—thus, many individuals presenting in adulthood with specific phobias report that the problems started in childhood. The majority of such individuals tend to be women even though the ratios for fears in childhood are similar for boys and girls (Power, 1993).

Jane had been frightened of dogs from about the age of 5 or 6. She could not recall any specific incident that had occurred to start the phobia, only that she had always disliked dogs, but had managed to cope with her phobia for nearly 30 years. She had worked as a nurse for many years on an inpatient psychiatric ward so had easily avoided dogs both at home and at work. However, the problem that finally brought her to seek help was the proposed closure of the psychiatric ward. Her new post was going to be community based, part of which would involve home visits and, therefore, the risk of coming across dogs in situations from which she could not escape. Her only choice, she thought, was that she would have to give up work altogether. As well as finding large dogs frightening, Jane reported that all dogs were disgusting, because of the things she had witnessed them doing in public such as soiling the pavements and sniffing and mounting each other. Her reactions therefore seemed to contain both fear-based and disgust-based elements.

Data reported by Hekmat (1987) based on the retrospective reports of people with phobias showed that only 22.5% of a group of animal-phobic individuals reported aversive encounters with the animal in question. A further 36% reported that they had been "teased" with the appropriate animal, for example, by an older sibling—we would speculate that such teasing would more than likely involve a disgust reaction on the part of the child which could encourage the propagator of the teasing even more, although this possibility remains to be tested. Hekmat also reported that 57% of his animal-phobic respondents attributed onset either to information given to them about the animal in question or to watching someone else reacting negatively in the presence of the animal; the child's mother was the most common source of such information or observation. Again, we suggest that this information is just as likely to be about disgust-related aspects of the particular animal, for example because of the animal's potential to cause disease or contamination (e.g., dogs, cats, rats, mice, spiders, wasps, flies) or because of its similarity to mucus and faeces (e.g., worms, snakes).

The so-called blood-injury-injection (BII) phobia has always provided a puzzle because of its clear differences from other phobias. For example, Ost, Sterner, and Lindahl (1984) reported that blood-phobic people show bradycardia, lowered blood pressure, and other parasympathetic system activity in contrast to other phobic people who tend to show an increase in heart rate, in blood pressure, and in sympathetic system activity. The pattern of lowered heart rate has, notably, also been found to be characteristic of the basic emotion of disgust, in contrast to fear which is associated with an increase in heart rate (Ekman, Levenson, & Friesen, 1983). Lumley and Melamed (1992) found that disgust facial expressions were more characteristic of BII phobia than were fearful facial expressions. It is possible to speculate therefore that blood phobia may be primarily a disgust-based rather than a fear-based disorder. Additional recent support for this proposal comes from several studies. Woody and Tolin (2002) found for BII fearful students that viewing times of disgust-related pictures decreased with an increase in disgust sensitivity. Koch, O'Neill, Sawchuk, and Connolly (2002) found a synergism between disgust and fear on a range of behavioural avoidance tasks in BII fearful individuals.

Social phobia is typically of later onset than the animal, blood, and dental phobias; Ost (1987) reported a mean age of onset of 16.3 years. Although one or two studies have reported a slightly higher rate for women (e.g., Marks, 1969), the different rates for men and women are probably not significant (e.g., Bourdon et al., 1988). Because social phobia tends to be less debilitating than conditions such as agoraphobia, it is less commonly seen in the clinic (Mannuzza et al., 1990). The DSM-IV criteria for social phobia are presented in Table 9.1 (APA, 1994) with a clear emphasis on fear. However, we suggest that the social-phobic person's reactions may be as much disgust-based as they are fear-based, in that the central theme in social phobia is an imagined negative evaluation or rejection of the self by other people (e.g., Butler, 1989). As Beck and Emery state:

The experience of shame is important in discussions of social anxiety because the socially anxious person is fearful of being shamed in many situations. (1985, p. 156)

Beck and Emery go on to say:

In his mind, the antidote for shame is to vanish from the shameful situation. A person will say, for example, "I should like to fade away," or, "I felt like merging into the woodwork." In contrast, anxiety is generally accompanied by the inclination to flee or by passive immobility. (p. 157)

It is apparent from these quotes that Beck and Emery (1985) identify the importance of a disgust/shame-based response in socially anxious individuals in which the label "anxiety" may be misleading. Of course, prior to entering a social situation the social-phobic person may feel an anticipatory anxiety, but the key emotion in the situation itself may be shame. The more severe and disabling the social phobia, therefore, the

Table 9.1 DSM-IV criteria for social phobia

DIAGNOSTIC CRITERIA

(a) A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

(b) Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children the anxiety may be expressed by crying, tantrums, freezing or shrinking from social situations with unfamiliar people.

(c) The person recognises that the fear is excessive or unreasonable. Note: In children this feature may be absent.

(d) The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

(e) The avoidance, anxious anticipation or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

(f) In individuals under age 18 years, the duration is at least 6 months.

(g) The fear or avoidance is not due to the direct physiological effects of a substance (e.g. a drug abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g. Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).

(h) If a general medical condition or another mental disorder is present, the fear in Criterion (a) is unrelated to it, e.g. the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behaviour in Anorexia Nervosa or Bulimia Nervosa.

more likely it would seem that the basic emotions of disgust and fear become coupled, in the sense outlined in Chapter 5, and thereby continually reactivate each other. As Dickerson, Gruenewald, and Kemeny (2004) have summarised, the experience of chronic shame and threat to the social self may have considerable health implications through the lowering of immune system functioning and increases in proinflamma-tory biochemical actvitiy. Moreover, social-phobic people have shown a characteristic cingulate cortex response to disgust faces in an fMRI study (Amir et al., 2005). In summary, there is accumulating evidence that social phobia might be more appropriately considered to be a combined fear-disgust disorder rather than simply a fear-based disorder.

One further point we would make about studies of cognitive biases in anxiety (discussed in detail in Chapter 6) relates to the distinction made between materials based on physical threat versus those based on social threat (e.g., Mathews, MacLeod, & Tata, 1986). On closer examination, the social threat words in these studies seem to fall into two categories, the first being a group of social anxiety terms (e.g., Ignored, Insecure, Indecisive) and the second being a group of shame terms (e.g., Humiliated, Ashamed, Despised). These studies have unwittingly made the distinction between true social anxiety and shame, but have failed to analyse these two groups of materials separately. We would therefore recommend that studies of cognitive biases should analyse the fear-based and the disgust-based materials separately in the way that more recent studies have attempted (Charash & McKay, 2002; de Jong, Peters, & Vanderhallen, 2002), because there may be important individual differences in the extent to which so-called anxiety disorders may be disgust-based rather than fear-based (cf. Dalgleish & Power, 2004b; Lee, Scragg, & Turner, 2001).

To return to the issue of specific phobias and disgust, Graham Davey and his colleagues (e.g., Davey, Forster, & Mayhew, 1993; Marzillier & Davey, 2004) have carried out a number of studies that demonstrate the importance of disgust reactions rather than fear reactions for these disorders. Davey has argued that many of the animal phobias are not simply fear-based reactions to predatory animals, but are disgust-based reactions to, for example, associations with disease, contamination, mucus, and faeces. Davey (1994b) reported from a fear survey that the number of fears was positively correlated with disgust sensitivity levels and that females had higher disgust sensitivity levels and higher rates of fears than did males. In an experimental manipulation, Webb and Davey (1992) found that if participants were primed with either a violent film or with a disgust-based film, the violent film was found to increase subsequent fear ratings for predatory animals but not for "revulsion" animals, whereas the disgust film increased the ratings for non-predatory revulsion animals, but not for predatory animals. In a further correlational study, Ware, Jain, Burgess, and Davey (1994) found significant correlations between disgust sensitivity, "fear" ratings towards revulsion animals, and the Washing subscale of the Maudsley Obsessive-Compulsive Inventory (MOCI; Hodgson & Rachman, 1977). Taken together, these studies provide some empirical support for the proposal that disgust sensitivity provides a factor of crucial importance in the development of many simple animal phobias, and that the three pathways to fear model (e.g., Rachman, 1976) needs to be revised to take account of one or more additional disgust pathways that have only recently begun to receive attention. We also suggest that there may be important treatment differences for disgust-based as opposed to fear-based phobias, as the preliminary study by Smits et al. (2002) discussed earlier might begin to suggest, although we will discuss the treatment implications of the current approach in more detail in the final chapter (Chapter 11).

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