Miscellaneous disgustrelated disorders

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The focus of this book is primarily on normal emotions and their associated disorders. However, there are a number of appetitive and drive-related disorders that may be based, in part, on a particular drive becoming the focus of a disgust-based reaction either as a primary part of the disorder or as a secondary feature in which some other motive is primary. Two groups of disorders to which this approach may usefully be applied are the eating disorders and the sexual disorders. The role of disgust in these groups of disorders can often be glimpsed indirectly through reports of high comorbidity of certain eating and sexual disorders with depression. Our analysis would suggest, however, that such comorbidity is likely in part to be more due to the disgust-based aspects of depression, especially in relation to the experience of shame and guilt, rather than depression in the sense that we have defined it in Chapter 6 as the coupling of the basic emotions of sadness and disgust. However, it is an open empirical question as to whether the apparent comorbidity with depression is primarily because of the association between depression and disgust.

In relation to eating disorders, rates of major depression have been identified in underweight patients with anorexia of between 40% and 60% (Patton, 1988). High rates of affective disorders have also been observed in the relatives of individuals with anorexia. In the case of bulimia, the rates of depression have been estimated at between 24% and 79% (Patton, 1988). Two disgust-based reactions provide defining features of anorexia (Mitchell & McCarthy, 2000). First, there is a disgust-based avoidance of foods that are considered to be fattening. Second, there is a disgust-based reaction towards the body or certain parts of the body which are either perceived to be fat or prone to becoming fat. Preliminary evidence that some aspects of disgust sensitivity may correlate with the drive for thinness comes from a study of eating disorder cases by Troop, Murphy, Bramon, and Treasure (2000). Our emphasis on disgust and disgust-based avoidance contrasts with the normal fear-based definitions, such as Russell's (1970) widely cited one which emphasises a "morbid fear" of becoming fat (cf. the discussion of specific phobias earlier). In contrast to anorexia, individuals with bulimia may be normal weight or even overweight. Bulimic people are also less likely to come from middle- or upper-class backgrounds, tend to be older, and are more likely to engage in anti-social behaviour, drug abuse, and deliberate self-harm (Mitchell & Mccarthy, 2000). Again, Russell (1979), in the first definition of the disorder, focused on a "morbid fear" of becoming fat, which, following periods of overeating up to 27 times the normal calorific intake, leads the individual to vomit or abuse laxatives.

Sandra was a 30-year-old woman from a religious background. Over the past 4 or 5 years she had come to see her thighs as disgusting because they always seemed to be fat. She had periods, however, of feeling extremely alone and miserable, in which she felt loathsome and believed that everyone else found her loathsome too. During these times, she increasingly comforted herself by eating large quantities of cakes and chocolate, foods that she reacted with disgust towards at other times. After these binges she felt ashamed of herself and worried that her thighs would get fatter; therefore, she would either vomit or take large quantities of laxatives, or even on "bad days" do both.

As noted in the discussion of suicide and parasuicide, there are important cultural factors that need to be taken into account in the role of disgust in eating disorders in addition to disgust reactions in the individuals themselves. For example, the fact that 90-95% of anorexic people are female (Mitchell & McCarthy, 2000) and are teenagers highlights the role of such cultural factors. Indeed, the "ideal" body size for women shows considerable variation across cultures and across time within the same culture; thus, in the interests of science Garfinkel and Garner (1982) carried out a study of the magazine Playboy, and discovered that over a period of 20 years the ideal size for female centrefolds had decreased substantially. The societal pressure to diet and be thin therefore provides a context in which overeating and being overweight is viewed with disgust—the majority of American women, for example, report being dissatisfied with their weight and approximately 56% diet on a regular basis (Vitousek & Ewald, 1993). Finally, there is also some evidence that there may be higher rates of a history of sexual abuse among women with eating disorders. Oppenheimer, Howells, Palmer, and Chaloner (1985) reported that 64% of a sample of anorexic and bulimic patients had experienced sexual abuse, commenting that "frequently the sexually molested subject has feelings of inferiority or disgust about her own femininity and sexuality" (p. 359). Waller (1992) has reported that sexual abuse may be more common in bulimia than in anorexia and, furthermore, that the amount of reported vomiting and bingeing was greater when the abuse was by family members rather than non-family and involved more force.

In relation to sexual disorders, again there is a clear role for disgust at a number of individual and social levels. Kaufman (1989) states: "In sexual dysfunction syndromes . . . the sexual drive has become fused with shame, either by itself or in combination with disgust and fear" (p. 115). Unlike Kaufman, we would not of course derive shame and disgust separately from each other, but we would concur with his statement that "fear" has been overemphasised in sexual dysfunction at the expense of disgust and shame, although it is clearly possible that the anticipation of shame could lead to excessive anxiety being experienced in certain situations. For example, as Kaufman argues, so-called "performance anxiety" is more likely to be based on feelings of shame than it is on fear.

Early fusion of sexuality with shame . . . is a developmental precursor of adult sexual dysfunction. The patterning of affect with drive is a process spanning years. Sex-shame binds create the nuclei of eventual dysfunction in the sexual life. (Kaufman, 1989, p. 146)

The range of sexual disorders in which disgust may play a major part includes, in women, vaginismus, dyspareunia, and orgasmic dysfunction; in men it includes premature ejaculation, retarded ejaculation, and erectile dysfunction (see d'Ardenne, 2000, for an overview). A more general impairment of interest in sex, termed "disorders of sexual desire" by Helen Singer Kaplan (1979), rather than specific impairments, may also occur in both men and women. As with many of the disorders discussed in this chapter, the occurrence of childhood sexual abuse often leads to adult sexual dysfunction. Jehu (1988) reported that 94% of a group of women who had been sexually abused in childhood experienced sexual dysfunction in adulthood. However, traumatic experiences in adulthood—for example, following the experience of rape or following childbirth—can also lead to sexual problems in which the individual may react with fear and disgust in subsequent sexual situations.

One final disorder that can be mentioned in this context is body dysmorphic disorder, in which the sufferer has an excessive preoccupation with one or more specific parts of the body that are believed to be defective, and which consequently causes severe distress and impairment in functioning. The disorder is highly comorbid with depression, OCD, and social anxiety (e.g., Cororve & Gleaves, 2001). We have previously interpreted this type of comorbidity as possible evidence for the role of self-focused disgust and would therefore make a similar prediction for the potential role of disgust in the disorder. There is some evidence now that the disorder is responsive to adapted cognitive behaviour therapy interventions (e.g., Veale, 2004).

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