Specificity of fear and disgust experienced during traumatic interpersonal victimization in predicting posttraumatic stress and contamination-based obsessive–compulsive symptoms
Highlights
► Obsessive–compulsive (OC) and posttraumatic stress symptoms frequently co-occur. ► Unique affective predictors were examined following interpersonal victimization. ► Peritraumatic fear uniquely predicted posttraumatic stress symptoms. ► Other-focused disgust uniquely predicted posttraumatic stress symptoms. ► Peritraumatic self-focused disgust uniquely predicted contamination OC symptoms.
Introduction
Multiple lines of evidence indicate that elevated posttraumatic stress and obsessive–compulsive (OC) symptoms frequently co-occur among individuals with a history of traumatic experiences. In fact, the 12-month prevalence of obsessive–compulsive disorder (OCD) is approximately 30% among people with posttraumatic stress disorder (PTSD) compared to only 1% in the general population (Boudreaux et al., 1998, Brown et al., 2001, Kessler et al., 2005). Individuals with PTSD report elevated OC symptoms compared to both anxious controls and the general population (Boudreaux et al., 1998, Huppert et al., 2005, Solomon et al., 1991). Those with OCD also endorse greater posttraumatic stress symptoms compared to anxious controls (Fontenelle et al., 2007, Huppert et al., 2005). Despite this growing recognition of the overlap between posttraumatic stress and OC symptoms, there is a dearth of research aimed at understanding the nature of these problems among individuals with a history of traumatic experiences.
Both PTSD and OCD have traditionally been conceptualized as disorders of anxiety (American Psychiatric Association [APA], 2000). However, a growing body of research has begun to identify an important role of disgust, defined as a rejection/revulsion response aimed at removing oneself from a potential source of contamination (Davey, 1994), in understanding both OC and posttraumatic stress symptomatology, independent of fear or anxiety. For example, a host of self-report, behavioral, and neuroimaging evidence (see Brady et al., 2010, Olatunji et al., 2010a, Stein et al., 2001 for reviews) supports a link between disgust and specifically contamination-based OCD (i.e., obsessive concerns of being contaminated as well as compulsive washing behaviors), which is the most commonly occurring subtype of obsessive–compulsive symptoms (Rasmussen and Tsuang, 1986, Steketee et al., 1985). For example, neuroimaging studies have identified increased activation of neural structures associated with the processing of disgust (i.e., insula) in the context of contamination-based OCD (Lawrence et al., 2007, Phillips et al., 2000). Additionally, a number of cross-sectional studies have established correlations between elevated contamination fear and the trait-like vulnerabilities of disgust propensity (Deacon and Olatunji, 2007, Moretz and McKay, 2008, Olatunji et al., 2007b, Tolin et al., 2006) and disgust sensitivity (Beike et al., 2009, Mitte, 2008), defined as the tendency to experience disgust in response to an array of stimuli, and to be bothered by feelings of disgust; respectively (Overveld, de Jong, Peters, Cavanagh, & Davey, 2006). Evidence drawn from prospective research further suggests disgust vulnerabilities may serve as specific risk factors involved in the etiology and/or maintenance of OC symptomatology (Berle et al., 2012, Olatunji, 2010, Olatunji et al., 2010b).
In contrast to contamination-based OCD, the role of disgust in posttraumatic stress has only recently begun to receive attention in the literature. This emerging work has documented elevated feelings of disgust among individuals with PTSD generally (Finucane et al., 2012, Foy et al., 1984) as well as in response to reminders of traumatic experiences (Shin et al., 1999). Significant associations have been identified between posttraumatic stress symptom severity and elevations in disgust propensity among sexual assault/abuse victims (Rüsch et al., 2011) and disgust sensitivity among combat Veterans (Engelhard, Olatunji, & de Jong, 2010) in cross-sectional designs. However, these results are far from conclusive, as Engelhard et al. (2010) failed to observe a significant association between disgust propensity and posttraumatic stress symptoms. Furthermore, disgust propensity and disgust sensitivity assessed at 6 months post-deployment showed no significant associations with posttraumatic stress symptom severity at 15 months.
Although researchers have begun to consider the general feelings of disgust and trait-like disgust vulnerabilities in relation to posttraumatic stress, there is a need to specifically examine the implications of disgust experienced during a traumatic event (i.e., peritraumatically). Indeed, etiological models of PTSD emphasize the importance of conditioned emotional learning during a traumatic event in contributing to the maintenance of initial symptomatic reactions to traumatic event exposure (e.g., Foa and Kozak, 1986, Keane et al., 1985); however, the bulk of this research has centered on the emotions of fear and to a lesser degree helplessness and horror (Andrews et al., 2000, Bovin and Marx, 2011). The studies that have examined this issue have found retrospective report of disgust intensity experienced during a traumatic event to be a significant predictor of posttraumatic stress symptoms even after accounting for variance associated with peritraumatic fear, helplessness, and horror (Engelhard et al., 2010, Lancaster et al., 2011). This relation appears to be particularly strong among individuals high in disgust sensitivity (Engelhard et al., 2010), highlighting the importance of examining pre-existing individual differences in disgust vulnerabilities. In summary, although data have implicated disgust in both contamination-based OCD and PTSD independently, research has yet to examine links between disgust and both symptom types concurrently among individuals with a history of traumatic event exposure.
As compared to other events, traumatic interpersonal victimization (e.g., sexual assault, physical assault, and criminal victimization) is particularly likely to lead to PTSD (Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993), and experiences of rape, molestation, and life threatening criminal victimization have all been shown to positively relate to a diagnosis of OCD (Boudreaux et al., 1998, Peles et al., 2009, Saunders et al., 1992). Indeed, experiences involving interpersonal victimization are the most common type of traumatic event documented among individuals with comorbid PTSD and OCD (Gershuny et al., 2008). Interpersonal victimization may involve exposure to an array of stimuli capable of eliciting feelings of disgust (Badour et al., 2011a, Bonanno et al., 2002, Shin et al., 1999). For example, these events may involve a repulsive individual (e.g., perpetrator) as well as physical contact with bodily products, such as blood or semen. Such experiences may also result in internal perceptions of self-debasement or violation (Rozin & Fallon, 1987). Consistent with this idea, individuals with a history of interpersonal victimization have been found to respond to reminders of their traumatic experience with increased disgust as compared to those with a history of non-interpersonally relevant traumatic experiences (e.g., accidents, natural disasters; Badour et al., 2011).
In considering the role of disgust within the context of interpersonal victimization it may be especially important to examine the target of the emotional reaction (Andrews et al., 2000, Ulrich and Maercker, 2009). For example, disgust reactions might involve external or other-focused disgust (e.g., toward the perpetrator), which may be elicited by perceptions of danger in the external environment, similar to fear. This type of conditioned emotional learning might be particularly likely to lead to hypervigilance for threat in the external environment, characteristic of symptoms seen within the context of posttraumatic stress reactions. Consistent with this proposition, research has shown that perceived disgustingness of stimuli is causally related to perceived threat (Muris, Mayer, Huijding, & Konings, 2008). Self-focused disgust reactions may also be particularly important to examine. Although research on internalized or self-focused disgust in relation to psychopathology is particularly limited (Overton et al., 2008, Power and Dalgleish, 1997, Simpson et al., 2010), preliminary findings among women with a history of sexual victimization may offer some direction in this domain. For example, Petrak, Doyle, Williams, Buchan, and Forster (1997) found that the majority of women reported ongoing distress related to feelings of self-disgust following a sexual assault. Similarly, Fairbrother and Rachman (2004) found that 70% of women experienced urges to wash, with 25% reporting excessive washing that persisted for several months or more than a year after the assault. It has been hypothesized that the persistent internal feelings of dirtiness and urges to wash may result from an internalization of feelings of disgust (Olatunji, Elwood, Williams, & Lohr, 2008) leading to a view of the self as being contaminated or morally tainted (Elliott and Radomsky, 2009, Fairbrother and Rachman, 2004). This perception may result in persistent contamination-focused obsessions that are accompanied by compulsive washing behavior comparable to washing observed among people with contamination-based OCD. Importantly, these internal feelings of dirtiness and urges to wash have also been found to positively correlate with posttraumatic stress symptoms (Fairbrother and Rachman, 2004, Olatunji et al., 2008) highlighting the importance of further elucidating the nature of this phenomenon.
Based on this backdrop, the current study examined the relative contributions of peritraumatic intensity of both other- and self-focused disgust in uniquely predicting posttraumatic stress symptoms and contamination-based OC symptoms among females with a history of interpersonal victimization. As a test of specificity, the unique contribution of peritraumatic fear was also examined. It was hypothesized that peritraumatic fear and other-focused disgust should uniquely predict posttraumatic stress symptoms after accounting for variance associated with contamination-based OC symptoms and other theoretically relevant covariates. Conversely, it was hypothesized that self-focused disgust should predict contamination-based OC symptoms after accounting for variance associated with posttraumatic stress symptoms and other theoretically relevant covariates.
Section snippets
Participants
Participants included 49 women (Mage = 28.37, SD = 13.86) recruited via announcements and postings placed throughout a community in the south-central United States as part of a larger laboratory-based study examining emotional reactivity to reminders of traumatic interpersonal victimization. Participants were included in the study if they met criteria for a Diagnostic and Statistical Manual—Fourth Edition Text Revision (DSM-IV-TR; APA, 2000)-defined traumatic sexual or physical assault. Of the
Descriptive statistics and zero-order correlations
Fifty-five percent (n = 27) of participants reported a history of sexual assault and 44.9% (n = 22) reported a history of physical assault. Eight percent (n = 4) of participants reported that a stranger perpetrated their index traumatic assault, while the remaining individuals indicated that the index assault was perpetrated by someone known (e.g., family member, romantic partner, friend, acquaintance). Time since the index assault ranged from less than 1 year to 58 years (M = 10.94, SD = 14.35).
Discussion
Despite a documented association between posttraumatic stress and OC symptoms following exposure to traumatic events (Boudreaux et al., 1998, Brown et al., 2001, Kessler et al., 2005), there is a dearth of research examining possible factors associated with the nature of this comorbidity. Disgust has been proposed as one possible mechanism involved in the etiology of both PTSD and certain types of OCD (Cisler et al., 2008, Engelhard et al., 2010, Olatunji et al., 2010a). Specifically, a number
Acknowledgements
This research was supported, in part, by a NIMH National Research Service Award (F31 MH092994-01) as well as a grant from the Marie Wilson Howells Foundation in the Department of Psychological Science at the University of Arkansas, both awarded to the first author.
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