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

Contamination-Focussed Vignettes as an Analogue of Infectious Pandemics: An Experimental Validation using the State Disgust and Anxiety Responses in OCD

Despite infectious pandemics proving particularly detrimental to those with Obsessive-Compulsive Disorder (OCD), the investigation of analogous experimental paradigms is lacking. To address this gap, we conducted two studies employing vignettes that depicted contamination-related situations commonly experienced during a pandemic (e.g., Coughing into hands and failing to use hand sanitizer). We manipulated the salience of these vignettes across three levels: high contamination, low contamination, and a neutral control condition. Our examination of state anxiety and disgust responses in all participants revealed the successful manipulation of the vignettes' impact. Specifically, individuals with more severe OCD symptoms reported significantly higher levels of state disgust and anxiety for both high and low contamination vignettes, in contrast to the group with lower symptom severity. No significant differences were observed in the neutral vignette condition between the high- and low-scoring groups. Interestingly, for those with higher OCD symptoms, high salience contamination-focused vignettes resulted in similarly elevated state disgust and anxiety, regardless of whether the vignettes were situated in public (Study 1) or domestic (Study 2) settings. This suggests that the heightened sensitivity to contamination-related scenarios observed in individuals with OCD symptoms in the present study is not confined to a specific context. These findings support the use of contamination-focused vignettes as analogues for studying infectious pandemics and provide valuable insights into OCD models, interventions, and future research.

Examining reciprocal relations between disgust proneness and OCD symptoms: A four-wave longitudinal study

BACKGROUND AND OBJECTIVES

Although disgust proneness has been implicated in the development of obsessive-compulsive disorder (OCD), available studies have largely employed cross-sectional designs and the prospective and potentially reciprocal association between disgust proneness and OCD symptoms remains unclear. The present study employs cross lagged panel analysis to examine the prospective and reciprocal association between disgust proneness and OCD symptoms.

METHOD

A community sample of adults (N = 307) completed symptom measures of disgust proneness and OCD symptoms at four time points with 1 month intervals.

RESULTS

The results showed that the cross-lagged paths from disgust proneness to OCD symptoms were significant (average β = 0.07, p's < 0.001) when controlling for depression. However, the paths from total OCD symptoms to disgust proneness were not significant. In contrast, the cross-lagged paths from disgust proneness to washing OCD symptoms were not significant. However, the paths from washing OCD symptoms to disgust proneness were significant (average β = 0.05, p's < 0.01) when controlling for depression.

LIMITATIONS

The study is limited is limited by exclusive reliance on self-report in a nonclinical sample.

CONCLUSIONS

The findings offer preliminary evidence suggesting that disgust proneness may be a cause and consequence of OCD depending on the nature of the symptoms. Thus, the longitudinal relation between disgust proneness and OCD may be transactional where one influences the effect of the other.

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.

Specific Contamination Symptoms are Associated with Experiencing a Limited Response of Cognitive-Behavioral Therapy in Pediatric Patients with OCD

A recent study identified three distinct treatment-response trajectories in pediatric OCD where higher levels of contamination symptoms predicted a limited response to cognitive-behavioral therapy (CBT). This study extends these findings by examining which specific symptoms characterize limited CBT response from baseline to 3-year follow-up, with an emphasis on contamination symptoms. The study sample comprised 269 pediatric patients with OCD, all receiving stepped-care treatment with manualized CBT. Differences in single item-reporting between the three trajectory groups were examined using linear mixed-effect modeling. Limited responders displayed a higher symptom load across all OCD symptom categories at 3-year follow-up, dominated by contamination symptoms. Five of these (obsessions about dirt and germs, about bodily fluids, about the feeling of contamination and compulsions regarding handwashing and showering) showed persistence from baseline to 3-year follow-up. The results indicate that presence of specific contamination symptoms may influence long-term symptom severity trajectories in young patients with OCD.

The Development of Disgust and Its Relationship to Adolescent Psychosocial Functioning

Experiences of excessive disgust have been implicated in several psychopathologies. Research, however, has rarely examined disgust and its role in psychosocial functioning from a developmental standpoint. This study examines the relationship between disgust expression in early life and subsequent adolescent psychosocial functioning. Data from 165 children were collected as part of a longitudinal study. Disgust propensity in infancy and childhood was assessed using a facial expressivity task and food aversion task, respectively. Adolescent psychosocial functioning was measured through several self-report measures. Results suggest that there exists a degree of consistency in disgust expression within the first year of life, and that childhood disgust propensity may be related to impairment in early adolescent psychosocial functioning. These findings highlight the potential importance of identifying early disgust expression as a marker for later psychopathology.

Attentional bias of subliminal emotional faces in adolescents with obsessive-compulsive disorder

Attentional bias to threatening information may play a vital role in the onset and maintenance of obsessive-compulsive disorder (OCD). This study aimed to explore whether adolescents with OCD exhibited attentional bias toward faces that express disgust or fear. Participants were 27 adolescents with a first-time primary diagnosis of OCD and 27 healthy controls. To assess OCD, depression, and anxiety symptoms, all participants completed the Yale-Brown Obsessive Compulsive Scale, the Hamilton Depression Scale, and the Hamilton Anxiety Scale, respectively, followed by the modified dot probe task. Repeated measures ANOVA revealed a main effect of validity type and a significant group × validity type interaction effect. The results of one sample t-tests showed that participants in the OCD group had an attentional bias toward both disgusted and fearful faces. Further analysis indicated that adolescents in the OCD group showed facilitated attention toward the fearful faces and difficulty disengaging from disgusted faces. Adolescents with OCD exhibited facilitated attention toward threat stimuli, and when they allocated attention to threat, they experienced difficulty disengaging from it. Treatment procedures to modify the attentional bias may be effective.

Involvement of fear, incompleteness, and disgust during symptoms of pediatric obsessive-compulsive disorder

Fear has been assigned a central role in models of obsessive-compulsive disorder (OCD), but empirical investigations into the emotions that underpin OCD symptoms are few, especially in pediatric samples. Using validated, clinician-led structured interviews, 124 youth with OCD reported on the presence and severity of symptoms across the main symptom dimensions of OCD (aggressive, symmetry, contamination) and the degree to which fear, incompleteness, and disgust accompanied these symptoms. For comparison purposes, the degree of fear, incompleteness, and disgust during symptoms was obtained also from youth with social anxiety disorder (SAD; n = 27) and generalized anxiety disorder (GAD; n = 28). Participants with OCD reported that all three emotions were involved in their symptoms; however, fear was most strongly linked to aggressive symptoms, incompleteness to symmetry symptoms, and disgust to contamination symptoms. Incompleteness differentiated youth with OCD from those with SAD and GAD. No differences for these emotions were found for youth with OCD with versus without the tic-disorder subtype or comorbid autism. A positive association between incompleteness and self-reported hoarding emerged among youth with OCD. Further studies of the emotional architecture of pediatric OCD, and its relationship to etiology and treatment, are warranted.

Incompleteness and Disgust Predict Treatment Outcome in Pediatric Obsessive-Compulsive Disorder

Increasing evidence suggests that pediatric obsessive-compulsive disorder (OCD) is motivated not only by fear but also by feelings of incompleteness and disgust. However, it is currently unclear whether emotion involvement in OCD symptoms is associated with treatment response in youth with OCD. The present study examined whether treatment outcome for youth with OCD was predicted by the degree to which fear, disgust, and incompleteness were involved in baseline OCD symptoms. Children and adolescents with OCD entering treatment for this condition (N = 111) were administered standardized OCD symptom measures and an interview designed to assess the degree of fear, incompleteness, and disgust experienced during current OCD symptoms. Follow-up assessments occurred on average 13 months after baseline with each participant coded for outcome according to internationally acknowledged change criteria for pediatric OCD. Higher levels of incompleteness and disgust as part of baseline OCD symptoms predicted poorer outcome. The degree of fear during baseline OCD symptoms did not predict outcome. If replicated under controlled conditions, these results suggest that incompleteness and disgust may act as barriers to improvement in pediatric OCD and that treatment modifications that target these emotion-related motivators may improve outcome for a subset of youth.

Disgust propensity and sensitivity in childhood anxiety and obsessive-compulsive disorder: Two constructs differentially related to obsessional content

The role of disgust in anxiety and related disorders has been extensively studied in adults, however its role in childhood psychopathology is in need of further investigation. The adult literature has suggested that two distinct sub-constructs within "disgust proneness" may differentially predict anxiety-related disorders. Namely, disgust propensity (DP) has been defined as the likelihood an individual will experience a disgust reaction, and disgust sensitivity (DS) as the degree to which an individual is distressed by their experience of disgust. The current study aimed to validate the Disgust Propensity and Sensitivity Scale-Revised (DPSS-R) in a sample of youth receiving intensive services for OCD and anxiety, examine the relationship between disgust sub-constructs and obsessional content in a sample of youth with OCD, and examine the relationship between disgust change and symptom severity at discharge. A confirmatory factor analysis supported a two-factor structure of the DPSS-R. DP was found to be uniquely predictive of contamination obsessions, and DS was found to be uniquely predictive of moral obsessions. Lastly, change in DP, but not DS, predicted overall change in OCD symptom severity. The present study provides a valid measure of DS and DP in youth with anxiety and related disorders, and suggests that subconstructs of disgust may serve as distinct risk factors for obsessional content in youth with OCD. Future research should examine the predictive validity of DP and DS longitudinally, as well as examine effective ways to more effectively target DP with exposure therapy.

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.

Prospective associations between disgust proneness and OCD symptoms: Specificity to excessive washing compulsions

Although considerable evidence has linked disgust proneness (DP) to obsessive-compulsive disorder (OCD), few studies have examined the extent to which DP predicts OCD symptoms over time. Further, it remains unclear if DP is a risk factor for the contamination subtype of OCD specifically or if it is prospectively associated with other OCD symptom subtypes. The present study sought to address these gaps in the literature with a large sample of unselected community participants (n = 497) that completed measures of DP and OCD symptoms monthly over a 6-month period. Latent growth analysis revealed that initial levels of DP were associated with higher initial level of total OCD symptoms when controlling for depression, but not the slope of change in total OCD symptoms over time. Initial levels of total OCD symptoms were also associated with higher initial levels of DP when controlling depression, but not the slope of change in DP over time. Examination of symptom specificity revealed that initial levels of DP were associated with initial levels of washing, neutralizing, obsessing, ordering, and hoarding symptoms. However, initial levels of DP were associated only with the slope of change in the washing subtype when controlling for depression such that high initial levels of DP were associated with steeper increases in washing symptoms of OCD over the 6-month period. These findings suggest that although DP may have concurrent associations with symptoms of OCD more broadly, prospective associations are specific to the contamination/washing subtype of OCD. The implications of these findings for the etiology and treatment of contamination-based OCD are discussed.

Is Heightened Disgust Propensity Truly a Risk Factor for Contamination-Related Obsessive-Compulsive Disorder?

Disgust propensity (DP) has been conceptualized as a stable personality trait that confers risk for contamination-related OCD (C-OCD). However, the extent to which DP leads to the subsequent development of C-OCD is unclear. In fact, the presence of C-OCD might lead to an increase in DP rather than the inverse. The present study was aimed to test this hypothesis in a large clinical sample of OCD patients (≥ 21 years of age) with (C-OCD; n = 56) and without (NC-OCD; n = 103) contamination-related symptoms that completed measures of OCD symptoms, depression, anxiety, and DP. DP was assessed twice, in reference to the present situation (T1) and to when the participant was 18 years old (T0). The two groups did not significantly differ in DP at T0. However, C-OCD participants reported higher DP scores than NC-OCD at T1. Furthermore, the T1 vs T0 difference in DP was significant only in the C-OCD group. Subsequent analyses also showed that T1 DP levels, but not T0 levels, significantly predicted contamination-related symptoms. Despite study limitations, these findings question the role of DP as a risk factor for C-OCD.

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.

Is Disgust Proneness Associated With Anxiety and Related Disorders? A Qualitative Review and Meta-Analysis of Group Comparison and Correlational Studies

Research suggests that disgust may be linked to the etiology of some anxiety-related disorders. The present investigation reviews this literature and employs separate meta-analyses of clinical group comparison and correlational studies to examine the association between disgust proneness and anxiety-related disorder symptoms. Meta-analysis of 43 group comparison studies revealed those high in anxiety disorder symptoms reported significantly more disgust proneness than those low in anxiety symptoms. Although this effect was not moderated by clinical versus analogue studies or type of disorder, larger group differences were observed for those high in anxiety symptoms associated with contagion concerns compared to those high in anxiety symptoms not associated with contagion concerns. Similarly, meta-analysis of correlational data across 83 samples revealed moderate associations between disgust proneness and anxiety-related disorder symptoms. Moderator analysis revealed that the association between disgust proneness and anxiety-related disorder symptoms was especially robust for anxiety symptoms associated with contagion concerns. After controlling for measures of negative affect, disgust proneness continued to be moderately correlated with anxiety-related disorder symptoms. However, negative affect was no longer significantly associated with symptoms of anxiety-related disorders when controlling for disgust proneness. The implications of these findings are discussed in the context of a novel transdiagnostic model.