Change in disgust reactions following cognitive-behavioral therapy for childhood anxiety disorders

Disgust-reduction evaluative conditioning (DREC) and brain stimulation in patients with contamination-based obsessive-compulsive disorder: a protocol for a randomized control trial

BACKGROUND

The negative emotional valence of a stimulus can be altered if paired with a pleasant stimulus, a phenomenon referred to as evaluative conditioning. Disgust, as a central emotion in obsessive-compulsive disorder (OCD), particularly in the contamination subtype, may be an appropriate target for such a method. We know that disgust processing and OCD pathophysiology share in some brain areas, including the orbitofrontal cortex, as the neuromodulation techniques targeted in this area have been able to decrease OCD symptoms. We aim to conduct a randomized clinical trial to investigate the evaluative conditioning effect on disgust reduction in patients with contamination-based OCD when administered with or without neuromodulation targeted orbitofrontal cortex.

METHOD

In a single-blind randomized control trial (RCT), 55 patients with contamination-based OCD will be randomly assigned to four arms. In a factorial design, they will receive 10 sessions of evaluative conditioning training (either sham or real) plus cathodal transcranial direct current stimulation (tDCS) over the orbitofrontal cortex (either sham or real). The intensity of disgust experience and clinical symptoms will be investigated as primary outcomes and quantitative electroencephalogram and cognitive functions as secondary outcomes. The data will be collected at three assessment levels: baseline, after completing intervention sessions, and 2-month follow-up.

DISCUSSION

The present RCT is the first study that applies evaluative conditioning training in the OCD clinical sample. It will clarify the effect of the evaluative conditioning method alone and with tDCS on disgust reduction in patients with contamination-based OCD. It will provide initial evidence for such an emotion modulation method in the OCD population. The effect of this emotion-focused protocol on cognitive functions and electroencephalogram components is also of interest.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05907369. Registered on 16 June 2023. Retrospectively registered.

Treatment of disgust in specific emotional disorders

Although conditioning approaches have highlighted potential characteristics of disgust in anxiety disorders, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), these findings have yet to be translated into evidence-based treatments. Examination of the literature suggests various indicators of disgust that predict treatment outcome in these disorders. However, mechanisms remain unclear because studies examining disgust during the course of treatment are limited. Increasingly, the field has moved toward experimental investigation of strategies that reduce disgust. While cognitive reappraisal and imagery techniques appear promising, such techniques have yet to be examined as anxiety disorder treatments in large-scale randomized clinical trials. The literature also points to novel approaches to treating disgust, ranging from an inhibitory-informed approach to exposure therapy to transcranial direct current stimulation. However, the development of novel treatment approaches will require more rigorous experimental psychopathology approaches that can further elucidate processes that contribute to the etiology and/or maintenance of disorders of disgust.

Acquisition and maintenance of disgust reactions in an OCD analogue sample: Efficiency of extinction strategies through a counter-conditioning procedure

BACKGROUND

Obsessive-compulsive disorder (OCD) has long been considered as an anxiety disorder, disgust is the dominant emotion in contamination-based OCD. However, disgust seems resistant to exposure with response prevention partly due to the fact that disgust is acquired through evaluative conditioning.

AIMS

The present research investigates a counter-conditioning intervention in treating disgust-related emotional responses in two groups of individuals with high (High contamination concerns, HCC, n = 24) and low (Low contamination concerns LCC, n = 23) contamination concerns.

METHODS

The two groups completed a differential associative learning task in which neutral images were followed by disgusting images (conditioned stimulus; CS+), or not (CS-). Following this acquisition phase, there was a counter-conditioning procedure in which CS+ was followed by a very pleasant unconditional stimulus while CS- remained unreinforced.

RESULTS

Following counter-conditioning, both groups reported significant reduction in their expectancy of US occurrence and reported less disgust with CS+. For both expectancy and disgust, reduction was lower in the HCC group than in the LCC group. Disgust sensitivity was highly correlated with both acquisition and maintenance of the response acquired, while US expectation was predicted by anxiety.

CONCLUSION

Counter-conditioning procedure reduces both expectations and conditioned disgust.

Disgust sensitivity mediates the link between homophobia and sexual orientation obsessive-compulsive symptoms

Previous research has shown that intrusive thoughts in obsessive-compulsive disorder (OCD) often focus on emotionally significant aspects of individuals' lives (e.g., values and beliefs). The current study sought to expand our understanding of OC symptoms related to sexual orientation (SO-OC symptoms) by investigating the roles of homophobia (i.e., negative attitudes, affect, and behaviors toward individuals with a same-gender orientation) and disgust propensity and sensitivity. A total of 592 self-identified heterosexual college students were recruited to complete measures of homophobia, disgust propensity and sensitivity, and SO-OC symptoms. Results of separate parallel mediation analyses indicated that the relationships between homophobic affect/attitudes and avoidance/aggression on one hand, and SO-OC symptoms on the other, were partially mediated specifically by disgust sensitivity, after controlling for gender. Theoretical and clinical implications are discussed, including how homophobia can be conceptualized as a disgust response in the treatment of SO-OC symptoms, as well as how other constructs of potential interest (sexual and moral disgust, religiosity, conservative sexual ideology) can be examined in future research.

Watching Disgustedly? Game of Thrones and Disgust Sensitivity

The HBO show Game of Thrones is fascinating, because despite many of its plot points involving the elicitation of disgust, an emotion associated with avoidance behaviors, its viewership has only surged. We explore the relationship between disgust sensitivity and perception of scenes involving moral, sexual, and pathogen disgust in the show by providing participants with descriptions of such scenes. Participants included those who had never seen the show, those who had seen the show at least once, and those who had seen the show multiple times. We found that those who had watched the show once rated the scenes as less disgusting (overall and for moral and sexual disgust) than those who had not. We also investigated sex differences in disgust and found that women rated the scenes as more aversive than men, especially those involving moral and sexual disgust. Finally, those with more opposite sex siblings were more repulsed by the scenes, especially those involving sexual disgust. The present study adds to a long list of studies that analyses popular culture from an adaptive lens and adds to the notion that popular culture is a 'cultural remain' of the evolved human mind.

Incompleteness, harm avoidance, and disgust: A comparison of youth with OCD, anxiety disorders, and no psychiatric disorder

Psychological models of pediatric obsessive-compulsive disorder (OCD) place a heavy emphasis on harm avoidance as a maintaining factor and target for treatment. Incompleteness and disgust may also play a role in pediatric OCD but remain understudied. Youth with OCD (n = 100), anxiety disorders (n = 96), and no impairing psychiatric symptoms (n = 25) completed self-report measures of trait-level incompleteness, harm avoidance, and disgust and current symptoms of OCD, anxiety, and depression. Group differences and associations between emotions, symptoms, and pre- to post-treatment change in overall OCD severity were examined. Youth with OCD and anxiety disorders scored higher on harm avoidance and disgust than youth with no psychiatric disorder. Youth with OCD scored higher on incompleteness than youth with anxiety disorders and youth with no psychiatric disorder. Harm avoidance showed unique associations to self-reported symptoms of OCD, anxiety, and depression while incompleteness was uniquely related to OCD and disgust to anxiety. Within the OCD sample, incompleteness and harm avoidance were differentially related to the major OCD symptom dimensions, and change in incompleteness was uniquely related to pre- to post-treatment change in OCD severity. Trait-level incompleteness appears to play a central role in pediatric OCD and studies investigating its direct involvement in symptoms and associations with treatment outcome are needed. The role of disgust in relation to pediatric OCD remains unclear.

Cognitive flexibility and response inhibition in patients with Obsessive-Compulsive Disorder and Generalized Anxiety Disorder

BACKGROUND/OBJECTIVE

The main aim of this study was to analyze differences in inhibition and cognitive flexibility, taking into account some variables that may influence results (non verbal reasoning, depression, anxiety, intolerance of uncertainty, comorbidity, medication consumption).

METHOD

The participants were 95 adults aged 17-61 years old (M = 33.48, SD = 11.13), primary (most severe) Generalized Anxiety Disorder or Obsessive-Compulsive Disorder and a healthy control group. Neuropsychological neasures were completed using computerized Wisconsin Card Sorting Test, Stroop Color Word Test and Go/NoGo Task.

RESULTS

Clinical groups presented worse results in cognitive flexibility to the control group. The obsessive-compulsive group showed worse scores in flexibility than the generalized anxiety group, once non-verbal reasoning and tolerance to uncertainty were controlled. Comorbidity and medication use did not affect results in the obsessive compulsive group but did however influence the generalized anxiety group.

CONCLUSIONS

Cognitive flexibility could be included treatment in the treatment of obsessive-compulsive disorder and generalized anxiety disorder.

Validation of the Visual Analogue Scale for Anxiety-Revised and school refusal across anxiety profiles

BACKGROUND/OBJECTIVES

This paper aimed to validate the Spanish version of scores of the Visual Analogue Scale for Anxiety-Revised (VAA-R) in child population, and to verify the existence of anxiety profiles and to relate them to school refusal.

METHOD

The sample was made up of 911 Spanish students between 8 and 12 years old (M = 9.61, SD = 1.23). The measures used were the VAA-R and the School Refusal Assessment Scale-Revised for Children (SRAS-R-C).

RESULTS

Confirmatory factorial analysis supported the three-dimensional VAA-R structure: Anticipatory Anxiety (AA), School-based performance Anxiety (SA) and Generalized Anxiety (GA). The VAA-R has an adequate reliability and structural invariance across sex and age. No latent mean differences were found across sex, but did occur through age in AA and GA factors. Cluster analysis identified four child anxiety profiles: High Anxiety, High Anxiety School-type, Low Anxiety, and Moderate Anxiety, which differed significantly in all dimensions of school refusal.

CONCLUSIONS

These findings may be useful for the assessment and treatment of anxious symptoms originated at school.

Disgust in Anxiety and Obsessive-Compulsive Disorders: Recent Findings and Future Directions

PURPOSE OF REVIEW

In the past 20 years, the role of disgust in anxiety disorders and obsessive-compulsive disorder (OCD) has been investigated with increasing precision. In this review, we examine recent evidence implicating disgust in anxiety and OCD, highlighting recent measurement and methodological improvements. Specific emphasis is placed on understanding the mechanisms that may account for the role of disgust in OCD and related disorders.

RECENT FINDINGS

Recent developments include clarification of the role of distinct disgust-relevant vulnerabilities in the etiology of anxiety and OCD, an improved understanding of the neurobiology of disgust processing in OCD, and an increased focus on disgust-related mechanisms that contribute to psychopathology, such as disgust-based learning and emotion regulation. Disgust proneness is increasingly linked with symptoms of anxiety and OCD. However, further examination of the mechanisms that account for the roles of distinct disgust-relevant vulnerabilities is needed, and studies that directly examine disgust during the course of treatment are limited. Increasingly, the field has moved toward experimental investigation of specific disgust-relevant mechanisms that influence the etiology and treatment of OCD and related anxiety disorders.

OCD: obsessive-compulsive … disgust? The role of disgust in obsessive-compulsive disorder

Recent research has identified the important role of disgust in the symptomatology of obsessive-compulsive disorder (OCD). Exaggerated and inappropriate disgust reactions may drive some of the symptoms of OCD, and in some cases, may even eclipse feelings of anxiety. This paper reviews behavioural and neuroimaging research that recognizes the prominent role of disgust in contributing to OCD symptoms, especially contamination-based symptoms. We discuss how elevated behavioural and biological markers of disgust reported in OCD populations support the need for alternative clinical treatment strategies and theoretical models of OCD.

Disgust proneness predicts obsessive-compulsive disorder symptom severity in a clinical sample of youth: Distinctions from negative affect

BACKGROUND

Although studies have linked disgust proneness to the etiology and maintenance of obsessive-compulsive disorder (OCD) in adults, there remains a paucity of research examining the specificity of this association among youth.

METHOD

The present study employed structural equation modeling to examine the association between disgust proneness, negative affect, and OCD symptom severity in a clinical sample of youth admitted to a residential treatment facility (N =471).

RESULTS

Results indicate that disgust proneness and negative affect latent factors independently predicted an OCD symptom severity latent factor. However, when both variables were modeled as predictors simultaneously, latent disgust proneness remained significantly associated with OCD symptom severity, whereas the association between latent negative affect and OCD symptom severity became nonsignificant. Tests of mediation converged in support of disgust proneness as a significant intervening variable between negative affect and OCD symptom severity. Subsequent analysis showed that the path from disgust proneness to OCD symptom severity in the structural model was significantly stronger among those without a primary diagnosis of OCD compared to those with a primary diagnosis of OCD.

LIMITATIONS

Given the cross-sectional design, the causal inferences that can be made are limited. The present study is also limited by the exclusive reliance on self-report measures.

CONCLUSIONS

Disgust proneness may play a uniquely important role in OCD among youth.

Trajectories of anxiety symptoms in adolescents: Testing the model of emotional inertia

Two predictions derived from a recently introduced model of psychotherapy outcome were tested, assuming the dynamical relationship between the individual's emotional trajectory and the force of intervention necessary to change this trajectory: (a) only a high intensity treatment would succeed to lower the increasing trajectory of anxiety, and (b) high as well as low intensity treatments would equivalently lower the non-increasing trajectory of anxiety. Methods: Seventy-four adolescents (58.40% girls; M = 14.65 years, SD = 0.53) were randomly assigned to a high intensity treatment condition, a low intensity treatment condition, or a waiting list condition. Results: Only the high intensity treatment reduced the anxiety when participants showed an increasing trajectory (p < .01). None of the treatments reduced anxiety when a previously non-increasing trajectory was shown. Conclusions: These findings support the theoretical predictions and underscore the need to consider not only how severe the anxiety is but also the time course of anxiety in applied treatment settings.

Is disgust proneness sensitive to treatment for OCD among youth?: Examination of diagnostic specificity and symptom correlates

Although disgust proneness has been implicated in obsessive-compulsive disorder (OCD), there is a paucity of research examining change in disgust proneness during treatment as well as the correlates of such change, especially in children. This study examined the relationship between changes in disgust proneness and disorder-specific symptoms during residential treatment among youth with OCD, anxiety, and mood disorders. Youth ages 12-18 (n=472) completed pre- and post-outcome measures of OCD, anxiety, and mood symptoms and disgust proneness. Results indicate that although disgust proneness decreases during treatment for youth with OCD, anxiety, and mood disorders, youth with primary OCD experienced the greatest decrease in disgust proneness over the course of treatment. Reductions in disgust proneness during treatment were significantly correlated with reductions in multiple symptom measures, with the strongest correlations between reductions in disgust proneness and OCD symptoms. Implications and directions for future research are discussed.

Factors Predicting Youth Anxiety Severity: Preliminary Support for a Standardized Behavioral Assessment of Parental and Youth Avoidance Behaviors

Anxiety severity in youth is associated with a host of negative outcomes including poor response to treatment. Thus, a better understanding of factors that contribute to anxiety severity is needed. Such factors may include parental anxiety as well as anxiety-related approach and avoidance behaviors in both children and parents. In this study, we examined automatic behavioral tendencies as a method of quantifying anxiety-related approach and avoidance behaviors in children and their parents. Clinically anxious youth (N = 19) with mixed anxiety diagnoses and their parents completed an approach-avoidance task (AAT) comprising different emotional expressions. Our results suggest that in addition to parent report of youth anxiety, both youth and parent automatic avoidance biases predict clinician-rated youth anxiety severity accounting for 62% of the variance in clinician-rated youth anxiety. These results suggest that the AAT may be a useful measure of automatic behavioral tendencies in clinically anxious youth and their parents and that these factors may be relevant to youth anxiety severity.