Saveedra and Silverman

• Disgust was recently touted as "the forgotten emotion of psychiatry" and as playing a potentially important role in both the genesis and treatment of phobias
• Disgust has been hypothesized as a concurrent emotion that in interaction with fear may result in increased avoidance behavior
• Evaluative learning


  A form of classical conditioning that is qualitatively distinct from expectancy learning
• Evaluative learning


  • Does not depend on the individual's expecting, or being aware, of the association between the neutral/nonthreatening object or event and the negative outcome
  • The individual comes to perceive or "evaluate" the previously neutral object or event negatively
• Evaluative learning is better conceptualized as eliciting disgust rather than fear
• Only one study to date has targeted disgust and found it to be beneficial for fear/phobia reduction
• De Jong et al. (1997) found that ratings of disgust decreased among spider phobics concomitant with decreases in fear ratings, highlighting a functional relation between fear and disgust
• De Jong et al. (1997) did not examine the effects of targeting disgust in phobia reduction
• The purpose of this article is to bring the issues of disgust and evaluative learning to the forefront via a case study of a child with a specific phobia of buttons
• Participant


  1. year-old Hispanic American boy with a specific phobia of buttons
• Onset of phobia


  1. Occurred at age 5 during an art project involving buttons

  2. Boy's hand slipped and all the buttons in a bowl fell on him, which he described as distressful

  3. Avoidance of buttons continually increased since then
• The phobia did not present many difficulties at first, but as time progressed, it became more difficult for the boy to handle buttons
• The phobia led to several areas of interference for the boy and his family, such as not being able to dress himself and difficulties concentrating in school due to excessive preoccupation with not touching his school uniform or anything that his buttoned shirt touched
• The symptom presentation did not meet the criteria for DSM-IV obsessive-compulsive disorder
• Intervention procedure


  1. Exposure-based treatment involving cognitive and behavioral procedures

  2. Contingency management with positive reinforcement from mother for successful exposures

  3. Gradual exposures to buttons of increasing difficulty
• Despite behavioral progress in approaching buttons

  The boy's subjective ratings of distress increased dramatically
• The increasing distress ratings were consistent with evaluative learning, where despite in vivo exposures, evaluative reactions (disgust emotions) remained and even increased
• Classical conditioning


  Learning through association
• Classical conditioning


  Phobias can be learned and unlearned just like other behaviours
• Evaluative learning


  A type of classical conditioning where the individual forms an association between a previously neutral stimulus and a negative emotion
• Disgust


  An emotion that involves a strong aversion to something perceived as unpleasant, unclean, or offensive
• Hepburn and Page (1999) found that treating patients' disgust and fear would help them to make progress with a blood phobia
• Research method, design and variables

  • Case study involving one participant, his life history and treatment were studied in-depth, data collected using self-report measures, boy and mother interviewed about onset of phobia and subsequent behaviour
• Phobia


  An extreme or irrational fear of or aversion to something
• Procedure


  Exposure-based treatment programme that tackled cognition and behaviours, special disgust and fear hierarchy devised with boy's suggestion, boy rated 11 different scenarios involving buttons
• This is the first report in the child psychiatric literature documenting the importance of targeting disgust in treating a specific childhood phobia
• This case study complements similar work conducted on adult samples with blood-injury concerns
• This is the first report in the child psychiatric literature suggesting that the interaction between phobias and disgust may be conceptualized via evaluative learning
• Fear


  An unpleasant emotion caused by an organism's defensive response to an imminent threat
• Phobia


  A persistent and unreasonable fear of an object. This fear is disproportionate to the danger posed and leads to avoidance of the object
• Disgust


  A feeling of revulsion or disapproval aroused by something unpleasant or offensive (can manifest in physical reactions, such as nausea and facial expressions)
• Expectancy Learning (fear): presentation of a previously neutral/non-threatening object associated with a potentially threatening negative outcome increases individual's expectation of coming into contact with that negative outcome i.e. an object is associated with a negative outcome +, as a result, elicits a fear response
• The boy was initially avoiding buttons (a neutral, non-threatening object)

  Although the behavioral exposures were "successful" in reducing his avoidance, he felt a strong disgust for buttons
• Evaluative Learning (disgust): individual comes to perceive or 'evaluate' a previously neutral stimulus as negative. This means that object is perceived as itself being negative, rather than it causing a negative event to occur. This is better described as a disgust reaction to an object.
• The sample


  • 9 year-old boy
  • Meets DSM-IV criteria for specific phobia
  • Referred by Child Anxiety and Phobia program at the Florida International University
  • Informed consent from mother and boy
• Only upon switching from behavioral exposures to disgust imagery exposures and cognitions


  Was the specific phobia effectively diminished
• Origin of the phobia

  • When he was 5 years old, the boy had been in an art class in which they were using buttons. He asked for more buttons and was told to collect some from a bowl on the teacher's desk. When he grabbed the bowl, it fell and all the buttons fell onto him and the floor. He described the experience as distressing and from there, his aversion to buttons steadily increased.
• The focus on disgust-related imagery exposures was more successful in targeting the emotion of disgust because the images "exposed" the child directly to disgust emotions as opposed to the fear-related exposures that focused on merely presenting the child with the stimulus and not addressing the associated emotions
• Problems experienced as the phobia progressed

  • Avoidance of buttons did not present many difficulties at first, but as time progressed, it became more difficult for him to handle buttons
  • He could no longer dress himself and found it difficult to concentrate in school due to excessive preoccupation with not touching his school uniform or anything that his buttoned shirt touched
  • His avoidance of buttons was cued by presence and anticipation of buttons
• Duration of the phobia

  • The boy had been suffering from an extreme phobia of buttons for the last 4 years