Obsessive–compulsive disorder (OCD) is a heterogenous condition that encompasses a range of symptoms, including contamination and washing symptoms. The contamination/washing symptom dimension is the most common presentation of OCD with distinct behavioral, cognitive, and physiological components. Transdiagnostic individual difference factors such as disgust propensity and distress intolerance may function—both independently and synergistically—to maintain contamination OCD symptoms. Little empirical research has examined the direct and interactive relationship between these constructs and contamination OCD symptoms. The current study examined the association of disgust propensity and distress intolerance with contamination OCD symptoms using a multimethod approach. A sample of young adults (N = 173) completed a series of questionnaires, including self-report measures of disgust propensity, distress intolerance, and OCD symptoms. Participants also completed several behavioral tasks which captured their emotional responding to visual disgust stimuli, behavioral avoidance, and washing behaviors. Results suggest that disgust propensity and distress intolerance relate to contamination OCD symptoms, both independently and synergistically. However, findings differed across outcome measures. Overall, this study provided novel information about the independent and synergistic relationships of disgust propensity and distress intolerance with multiple assessments of contamination OCD symptoms. Our findings highlight the utility of multimodal assessment to inform a more nuanced understanding of the association between OCD symptoms and relevant risk factors. Interventions targeting both disgust propensity and distress intolerance may be most effective for treating individuals with contamination OCD symptoms specifically, and general OCD symptoms more broadly.
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Obsessive–compulsive disorder (OCD) is characterized by obsessions, defined as unwanted and intrusive thoughts, images, or impulses, and compulsions, which are repetitive rituals or behaviors (American Psychiatric Association, 2013). Obsessions and compulsions are functionally related (Conelea et al., 2012; Gillihan et al., 2012; Starcevic et al., 2011), such that an obsession (e.g., a worry about contamination) prompted by an environmental trigger (e.g., touching a doorknob) engenders significant distress, which is then neutralized by a targeted compulsion (e.g., hand-washing). A hallmark feature of OCD is the heterogeneity of symptom presentations (Mataix-Cols et al., 2005), including contamination/washing, hoarding, symmetry/ordering, obsessions/repugnant thoughts, and responsibility/checking symptom dimensions (Bloch et al., 2008; Mataix-Cols et al., 2005; McKay et al., 2004). The contamination/washing dimension is the most common manifestation of OCD symptoms (Rasmussen & Eisen, 1992; Rasmussen & Tsuang, 1986), encompassing distinct behavioral, cognitive, and physiological components (Brady et al., 2010).
To better understand the etiology and maintenance of contamination OCD symptoms, researchers have investigated the core emotions that underlie this symptom dimension. Disgust is one basic emotion that plays a key role in contamination OCD symptoms (Bhikram et al., 2017; Cisler et al., 2009a; Melli et al., 2016; Olatunji & Sawchuk, 2005; Olatunji et al., 2010). Disgust propensity, defined as one’s general predisposition to experiencing disgust (Olatunji et al., 2010; Van Overveld et al., 2006) is an individual difference factor that has been robustly linked to the development of contamination OCD symptoms (e.g., Olatunji et al., 2005; Olatunji et al., 2010, 2019; Schienle et al., 2003). Disgust propensity significantly predicts both behavioral and cognitive components of contamination OCD symptoms (e.g., David et al., 2009; Goetz et al., 2013; Moretz & McKay, 2008; Olatunji et al., 2007a, 2010; Thorpe et al., 2003) and mediates the relationship between contamination OCD symptoms and behavioral avoidance of disgust-evoking stimuli (Deacon & Olatunji, 2007). Disgust propensity also has important implications for the treatment of contamination OCD symptoms, as evidence suggests that disgust decreases more slowly than other emotions (e.g., fear) in response to exposures (Olatunji et al., 2009). In addition to examining disgust propensity, researchers have also explored the role of individual differences in reactivity to the experience of disgust (i.e., disgust sensitivity) and reactivity to the experience of strong emotions more broadly in order to better understand the mechanism through which disgust propensity influences contamination OCD symptoms. Existing literature suggests that the influence of disgust propensity on contamination symptoms may be potentiated by other mechanisms, including anxiety sensitivity (Cisler et al., 2007, 2008) and emotion dysregulation (Cisler et al., 2009b) among other forms of broad emotional intolerance. Heightened responses to disgust may only be problematic (i.e., lead to contamination OCD symptoms) for individuals who are less tolerant of the resulting aversive emotions. Further research is needed to examine the potential synergistic relationships between disgust propensity and other dimensions of emotional intolerance, such as distress intolerance, and OCD symptoms.
Distress intolerance—defined as the inability to bear unpleasant or uncomfortable emotions (Simons & Gaher, 2005)—is a key factor underlying emotional intolerance. Distress intolerance is a transdiagnostic risk factor for psychopathology (e.g., Michel et al., 2016) and a key treatment target in many transdiagnostic interventions (e.g., Sherman & Ehrenreich-May, 2020). Distress intolerance significantly predicts OCD symptoms in both non-clinical and clinical samples, even when accounting for other relevant constructs (see Robinson & Freeston, 2014 for a review). Distress intolerance may also be specifically implicated in the etiology of contamination OCD symptoms. Some studies have found significant associations between distress intolerance and contamination OCD symptoms (e.g., Blakey et al., 2016; Cougle et al., 2011b), although another study found no relationship between these constructs when controlling for comorbid affective symptoms (e.g., Cougle et al., 2012). Further research is needed to clarify the relationship between distress intolerance and the development of contamination OCD symptoms. Moreover, while distress intolerance may have direct effects on contamination OCD symptoms, distress intolerance may also potentiate the effects of other cognitive variables on contamination OCD symptoms. The amplifying (i.e., moderating) role of distress intolerance on OCD and anxiety symptoms has previously been examined in relation to other cognitive factors, such as anxiety sensitivity (Allan et al., 2014; Timpano et al., 2009), intolerance of uncertainty (Katz et al., 2017), and negative urgency (Cougle et al., 2012); however, to our knowledge, no study has examined distress intolerance as a potential moderator of the relationship between disgust propensity and contamination OCD symptoms.
One important consideration for this line of research on disgust propensity, distress intolerance, and contamination OCD symptoms is that few studies have examined these relationships across different assessment modalities. Although clinician-rated interviews are the ‘gold standard’ tools for OCD symptoms assessment (Grabill et al., 2008), there may be additional information gained from self-report measures and behavioral assessments (e.g., behavioral avoidance, time spent engaging in compulsive behavior). Behavioral assessments are particularly relevant to the assessment of contamination OCD symptoms (e.g., avoidance of contaminated objects, time spent hand-washing; Najmi et al., 2012; Steketee et al., 1996) compared to other symptom dimensions that may have less evident behavioral components (e.g., obsessions/repugnant thoughts). Specifically, greater levels of contamination OCD symptoms have been linked to greater avoidance of disgust-evoking stimuli (Olatunji et al., 2007a) and increased washing compulsions (Rachman, 2004). Greater disgust propensity and distress intolerance are also significantly associated with greater behavioral avoidance (Blakey et al., 2016; Deacon & Olatunji, 2007; Fan & Olatunji, 2013; Goetz et al., 2013; Olatunji et al., 2014) and increased washing time (Thorpe et al., 2011). Still, no studies have examined the synergistic relationships of disgust propensity and distress intolerance with contamination OCD symptoms and whether these relationships differ across assessment modalities.
The current study aimed to address this gap by investigating the independent and synergistic relationships of disgust propensity and distress intolerance with contamination/washing OCD symptoms in a young adult sample using a multimethod approach. We assessed the associations between disgust propensity, distress intolerance, and three types of OCD symptom assessments: self-reported OCD symptoms (Aim 1), emotional responding to visual disgust stimuli (Aim 2), and behavioral indicators (Aim 3), including behavioral avoidance and washing behaviors. Consistent with prior research, we hypothesized that greater levels of disgust propensity and distress intolerance, independently, would be associated with greater contamination OCD symptoms. We also hypothesized that distress intolerance would amplify the relationship between disgust propensity and contamination OCD symptoms, such that disgust propensity would be more strongly associated with contamination OCD symptoms when distress intolerance levels are high. In addition, we examined whether these associations differed across assessment modalities. We hypothesized that distress intolerance would moderate the relationship between disgust propensity and contamination OCD symptoms to a similar extent across assessment modalities but considered these comparisons to be exploratory.
Method
Participants
A total of 173 young adults participated in this study. All participants were students at a large university in the Southeastern United States who participated in the Psychology Department’s undergraduate participant pool that serves to familiarize students with research. Interested participants first completed a general pre-screen survey battery as part of their Introductory Psychology course (N = 1721). While all participants were invited to participate after completing the pre-screen, we oversampled individuals with elevated washing OCD symptoms to ensure greater variability symptom severity and to obtain a more normal distribution of OCD symptoms in our sample. We selected two subscales of the Obsessive Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) to over-sample individuals: the washing/contamination subscale was selected given the strong association between washing and disgust (Olatunji et al., 2019), while the obsessions subscale was selected given that it is the strongest predictor of OCD status out of all of the OCI-R subscales (Foa et al., 2002). Of the 1721 participants who completed the pre-screen, 343 participants scored greater than 4, the recommended cut-off, on both the OCI-R obsessions and washing subscale, and were sent a separate invitation to participate in our study. Approximately 45% of our final sample (n = 78) reflected individuals who were preselected in this manner and reported elevated OCD symptoms. A statistical power analysis was performed to determine the sensitivity of our sample size to detect small effects in regression analyses. With alpha = 0.05 and power = 0.80, the sample size needed to detect a small to moderate effect (0.15) was 77. Thus, our study was well-powered to detect even small effects.
Participants were predominantly young adults (Age: M = 19.1, SD = 2.5) and 78.6% self-reported their gender as female. Most participants identified as White (n = 114; 65.9%), 26 participants identified as Asian (15.0%), and 10 participants identified as African American (5.8%). Thirty-nine participants identified as Hispanic or Latino (22.5%).
Measures
Self-Report Symptom Measures
Disgust Scale-Revised (DS-R; Olatunji et al., 2007b)
The DS-R is a 25-item questionnaire that measures disgust propensity first developed by Haidt and colleagues (1994) and later refined by Olatunji and colleagues (2007b). Participants rate the extent to which they agree with certain emotional statements of how disgusting different experiences would be using a 0 to 4 Likert scale (0 = strongly disagree to 4 = strongly agree). A total score is calculated by averaging across all items, with higher scores indicating higher levels of disgust propensity. Psychometric studies have confirmed the content validity and reliability of the DS-R to assess multiple domains of disgust (van Overveld et al., 2011). In this study, the DS-R demonstrated strong internal reliability (Cronbach’s alpha = 0.89).
The DTS is a 15-item self-report questionnaire that assesses distress tolerance. Participants rate the extent to which they believe they can experience and withstand distressing emotional states on a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). Prior studies support the convergent and discriminant validity of the DTS (Simons & Gaher, 2005). For the current study and to assist with interpretability, the DTS scale was reverse scored to measure levels of low distress tolerance (i.e., distress intolerance). Scores range from 15 to 75, with higher scores indicating higher levels of distress intolerance. In this study, the DTS demonstrated strong internal reliability (Cronbach’s alpha = 0.88).
Dimensional Obsessive Compulsive Scale (DOCS; Abramowitz et al., 2010)
The DOCS is a 20-item questionnaire that measures OC symptom severity in the past month across four symptom dimensions: (a) contamination/washing, (b) harm obsessions/checking compulsions, (c) symmetry/ordering, and (d) unacceptable thoughts. The DOCS assesses symptom severity separately for each dimension across several parameters: (a) time occupied by obsessions and compulsions, (b) avoidance, (c) associated distress, (d) functional interference, and I refraining from compulsions. Participants rate each item on a 0 to 4 scale. Items are summed to create subscale scores for each symptom dimension (ranging from 0 to 20) and one total OCD symptoms score (ranging from 0 to 80). Higher scores indicate greater severity of OC symptoms. The DOCS has demonstrated good reliability, validity, and sensitivity to change in prior studies (Abramowitz et al., 2010). In this study, only the contamination subscale score was computed and it demonstrated acceptable internal reliability in our sample (Cronbach’s alpha = 0.77).
Obsessive Compulsive Inventory-Revised (OCI-R; Foa et al., 2002)
The OCI-R is an 18-item self-report questionnaire that assesses OC symptoms in the past month across six subscales: washing, checking, neutralizing, obsessing, ordering, and hoarding. Participants rate how much they have been distressed by certain experiences in the past month using a 0 to 4 Likert scale (0 = Not at all to 4 = Extremely). Total scores range from 0 to 72, with higher scores indicating greater levels of OC symptoms. The OCI-R has been extensively validated and is a standard, reliable instrument to capture OCD symptoms in nonclinical and clinical samples (Abramovitch et al., 2021; Foa et al., 2002). Only the OCI-R washing subscale was used in the current study. In this study, the OCI-R washing subscale demonstrated strong internal reliability (Cronbach’s alpha = 0.88).
Measure of Emotional Responding
Image Ratings Task
Participants were shown a series of 9 disgust-evoking images from the International Affective Picture System picture set (Lang et al., 2008) and asked to rate how each image made them feel. Participants completed ratings of disgust on a scale from 0 to 10 (0 = Not at all disgusting to 10 = Extremely disgusting), as well as ratings of fear on a scale from 0 to 10 (0 = Not at all scary to 10 = Extremely scary). Fear and disgust image ratings were calculated by summing each participant’s respective disgust and fear ratings across the stimuli.
Behavioral Tasks
Behavioral Approach Task (BAT)
BAT tasks have long been used as a behavioral measure of avoidance and anxious responding to standardized triggers. While there are multiple types of BAT tasks for OCD, we chose a BAT developed by Najmi and colleagues that has validated procedures and has been used in previous research on OCD symptoms (Najmi et al., 2012). Participants completed two separate BATs, which were administered in a counter-balanced order, and included (a) a pile of clothes staged to look worn and soiled and (b) a toilet with an open lid that was staged to look dirty. Instructions for each BAT were in line with the standardized instructions outlined by Najmi and colleagues (2012) and included a graduated hierarchy of six steps (i.e., touch with tissue; touch with finger; touch with one hand; touch with both hands; touch with hands then touch arms and chest; touch with hands then touch face). If participants completed a step, they were asked to complete the next step on the hierarchy. If participants refused to complete a step, the researcher terminated the BAT. Participants rated their anxiety and disgust levels, separately, during each step on a scale from 0 to 100 (0 = no anxiety to 100 = extreme anxiety). A composite BAT score was calculated by adding the standardized values of the percentage of steps avoided, the mean anxiety score, and the mean disgust score (adapted from Steketee et al., 1996).
Washing Behaviors Task (WBT; Cougle et al., 2011a)
The WBT consisted of a task that measured emotional response and washing behaviors associated with exposure to contaminant stimuli. Procedures mirrored those developed and validated by Cougle and colleagues (2011a). The WBT used a mixture of animal hair, dirt, and dead crickets in a shallow box. Participants were instructed to place both hands in the mixture and were encouraged to try and touch as much of the mixture as they could with both hands. Following exposure to the mixture, participants were given the opportunity to wash their hands. The handwashing sessions were video-recorded and independently rated by trained research assistants for time spent washing. Washing duration was coded to the nearest second from when the participant touched the water to the end of the wash. Participants also completed a measure of their anxiety before the exposure (pre-washing anxiety) and directly after washing (post-washing anxiety) on a scale from 0 to 100 (0 = no anxiety to 100 = extreme anxiety). Sixteen participants refused to touch the stimulus, and their data were not included in the WBT analyses. The sample of participants who refused to touch the stimulus reported greater disgust propensity than the overall sample, however they did not differ in levels of distress intolerance (see Supplemental Materials for more details). The video-camera malfunctioned and we were not able to code washing duration for an additional twelve participants, though these participants did provide post-washing anxiety scores.
Procedure
All procedures were approved by the Institutional Review Board. Participants completed informed consent prior to participating in the study and were provided research familiarization credits for their time. Experiment sessions lasted around an hour and a half, during which time participants completed the battery of self-report questionnaires and a series of behavioral tasks. The order of the behavioral tasks was held constant across participants, so that participants completed the BAT, then the Washing Behaviors Task, and then the Image Ratings Task.
Data Analytic Procedure
We first examined descriptive statistics for the variables of interest to assess if the data were normally distributed (i.e., skew < 1 and kurtosis < 3). All variables of interest met these criteria. We also tested the assumptions of linearity, homoscedasticity, and independence for all outcomes – all assumptions were met for our variables of interest. The residual errors of each model were also plotted and visually inspected for the assumption of normality – all were normally distributed. We then conducted correlations between disgust propensity, distress intolerance, and each outcome variable of interest. Next, we conducted a series of linear regression analyses to examine whether distress intolerance moderated the relationship between disgust propensity and the outcome variables of interest. DTS and DS-R were first centered to reduce multicollinearity, after which we calculated the interaction term (Holmbeck, 2002). We then examined separate linear regression models for each of the respective dependent variables, including the self-reported OCD symptoms (Aim 1), emotional responses to disgust-evoking images (Aim 2), and behavioral indicators (Aim 3). For each aim, we identified a primary dependent variable, along with secondary analyses. Each model included the main effects of distress intolerance and disgust propensity and the interaction term, which ensured that any observed effects for the interaction could not be attributed to shared variance with the main effect variables (Cohen et al., 2013). As suggested by Holmbeck (2002) and based on our a priori hypotheses, the form of any significant interaction was examined by considering the simple slopes using centered depletion. We chose to run these models with distress intolerance as the moderator based on existing theory and previous literature.
Results
Descriptive statistics for all variables of interest are presented in Table 1 and correlations among all variables of interest are presented in Table 2. Distress intolerance and disgust propensity were only moderately positively correlated with one another (r = 0.25, p < 0.001).
Table 1
Descriptive statistics for all variables of interest
Results for Aim 1 are presented in Table 3. Higher levels of disgust propensity were significantly and positively correlated with greater self-reported contamination OCD symptoms. Similarly, greater distress intolerance was significantly and positively correlated with greater contamination OCD symptoms. The regression model explaining variance in contamination OCD symptoms was significant (F(3, 168) = 15.41, p < 0.001) and explained 22% of the variance in DOCS contamination subscale. A significant interaction emerged between disgust propensity and distress intolerance on contamination OCD symptoms. Participants with higher levels of distress intolerance demonstrated a stronger relationship between disgust propensity and contamination OCD symptoms (see Fig. 1). Additional analyses exploring the relationship between disgust propensity and distress intolerance with overall OCD symptoms as the outcome found a similar pattern of results (see Supplemental Materials).
Table 3
Effects of disgust propensity and distress intolerance on self-reported contamination OCD symptoms (Aim 1)
Plots of the interactive effects of disgust propensity and distress intolerance on a) self-reported contamination OCD symptoms and b) image fear ratings
×
Results for Aim 2 are presented in Table 4. Greater disgust propensity was significantly and positively correlated with greater disgust and fear ratings in response to the disgust-evoking IAPS stimuli. Similarly, though to a much lower degree, greater distress intolerance was significantly and positively correlated with greater image disgust and fear ratings. The overall regression model explaining variance in image disgust ratings was significant (F(3, 167) = 39.17, p < 0.001) and explained 41.3% of the variance in image ratings. There was no significant interaction between disgust propensity and distress intolerance on image disgust ratings, and there was no main effect of distress intolerance on image disgust ratings; however, there was a main effect of disgust propensity on image disgust ratings. The overall regression model explaining variance in image fear ratings was also significant (F(3, 167) = 28.91, p < 0.001, R2 = 0.34). There was a significant interaction between disgust propensity and distress intolerance on image fear ratings, such that participants with greater levels of distress intolerance demonstrated a stronger relationship between disgust propensity and fear ratings to disgust-evoking images (see Fig. 1).
Table 4
Effects of disgust propensity and distress intolerance on emotional responding to IAPS disgust images (Aim 2)
Results for Aim 3 are presented in Table 5. Greater disgust propensity was significantly and positively correlated with greater behavioral avoidance of disgust-evoking stimuli. In contrast, distress intolerance was not associated with behavioral avoidance of disgust-evoking stimuli. The regression model explaining variance in the composite BAT score was significant (F(3, 167) = 20.59, p < 0.001) and explained 27% of the variance in the composite BAT score. There was no significant interaction between disgust propensity and distress intolerance on behavioral avoidance of disgust-evoking stimuli, but there was a significant main effect of disgust propensity on this outcome. Greater levels of disgust propensity were associated with greater behavioral avoidance of disgust-evoking stimuli. While the composite BAT score is the standard approach for this measure (e.g., Najmi et al., 2012), we also wanted to explore whether the pattern of findings was similar using the number of steps avoided as a more concrete measure of behavioral avoidance. The pattern of findings was the same with number of steps avoided as the outcome.
Table 5
Effects of disgust propensity and distress intolerance on behavioral indicators (Aim 3)
For the WBT, neither disgust propensity nor distress intolerance was associated with washing duration, and there were no significant interaction or main effects of either variable on this outcome (F(3, 141) = 0.98, p = 0.41, R2 = 0.02). In contrast, the regression model explaining variance in pre-washing anxiety (F(3, 168) = 19.27, p < 0.001, R2 = 0.26) and the model of post-washing anxiety (F(3, 152) = 14.32, p < 0.001, R2 = 0.22) were both significant. Greater disgust propensity was the only variable significantly associated with pre-washing anxiety; however, both disgust propensity and distress tolerance were significantly associated with greater post-washing anxiety.
Discussion
The current study examined the relationships between disgust propensity, distress intolerance, and OCD symptoms using a multimodal assessment strategy. Our findings generally suggest that disgust propensity and distress intolerance are associated—both independently and synergistically—with OCD symptoms broadly and contamination OCD symptoms specifically. However, findings differed across outcome measures, as the synergistic interaction between disgust propensity and distress intolerance was significantly associated with self-report affective outcomes, such as contamination OCD symptoms and image fear ratings, but was not significantly associated with disgust ratings or any behavioral outcomes. This discrepancy in our findings highlights the value of using multimodal assessments to inform a more nuanced understanding of the association between OCD symptoms and relevant risk factors or correlates. In addition to considering self-reported OCD symptoms, we further elicited affective and behavioral responses to three separate symptom provocation tasks: one that examined emotional responses to seeing disgust-eliciting pictures, one that measured levels of behavioral avoidance when engaging with a disgust-eliciting object, and one that captured behavioral and affective responses to an act of decontamination. Our outcomes therefore jointly capture differences across specific behavioral, cognitive, and emotional domains at different stages of engaging with contamination-related stimuli.
We selected disgust propensity and distress intolerance as both are risk factors that have independently been associated with OCD. Preliminary evidence suggests that heightened responsiveness to disgust (i.e., disgust propensity) may only lead to contamination-related OCD symptoms for individuals who are unable to regulate this emotion (Cisler et al., 2009b), but no studies thus far have examined distress intolerance as a moderator of the relationship between disgust propensity and contamination OCD symptoms. Our hypothesis of a synergistic relationship between disgust propensity and distress intolerance was supported for self-reported contamination-related OCD symptoms and fear responses to disgust-evoking stimuli, such that greater distress intolerance strengthened the association between disgust propensity and these outcomes. Individuals with high disgust propensity and high distress intolerance may be at increased risk for the development of contamination-related OCD symptoms compared to individuals with high disgust propensity without high distress intolerance, although future experimental or longitudinal research is needed to confirm the directionality of this relationship. These findings contribute to the growing body of literature demonstrating that distress intolerance may act as a catalyst for other cognitive risk factors. For example, distress intolerance has been found to magnify the effects of both anxiety propensity (Allan et al., 2014; Timpano et al., 2009) and intolerance of uncertainty (Katz et al., 2017). Our findings further underscore the suggestion that distress intolerance could be an important target for OCD prevention efforts (Macatee et al., 2013).
While we found a synergistic relationship between disgust propensity and distress intolerance and subjective and affective outcomes, we found no evidence of this interaction for the more overtly behavioral and situation-specific outcomes, including behavioral avoidance of disgust-evoking stimuli, washing behaviors, and pre- and post-washing anxiety. These results suggest that the moderating effect of distress intolerance may be particularly relevant for affective compared to behavioral symptom indices. Previous literature has noted a distinction between perceived (i.e., self-reported) and “actual” (i.e., behavioral) distress intolerance, each of which may represent distinct facets of distress intolerance with distinct clinical and mechanistic correlates (Leyro et al., 2010; Zvolensky et al., 2010). This distinction provides one potential explanation for our discrepant findings. In addition, self-report measures of distress intolerance exhibit surprisingly low associations with behavioral assessments (Hsu et al., 2023; McHugh et al., 2011), likely due to a combination of method variance and the distinction between perceived and actual ability to tolerate distress. Future research may aim to expand upon the current study’s findings by examining the moderating role of behaviorally measured distress intolerance on both affective and behavioral outcomes relevant to contamination OCD symptoms.
For most models in which the interaction was non-significant, disgust propensity emerged as a strong, independent correlate across outcome measures. While we found significant main effects of both disgust propensity and distress intolerance on post-washing anxiety, we found only a main effect of disgust propensity on the other outcome measures (image disgust ratings, behavioral avoidance, and pre-washing anxiety). The greater association of disgust propensity compared to distress intolerance with these outcomes appears to be a function of domain specificity: disgust propensity is more strongly associated with the experience of disgust (i.e., image disgust ratings) and avoidance of disgust-evoking stimuli (i.e., behavioral avoidance) than distress intolerance. Our results suggest that disgust propensity may be most closely related to certain behavioral outcomes in OCD. Our findings further indicate that individuals’ perceived inability to tolerate distress related to OCD symptoms may not accurately reflect their actual ability to tolerate this distress. The only outcome for which there was a main effect of self-reported distress intolerance (and no interactive effect) was post-washing anxiety. This finding is intriguing. Should this finding be replicated in an experimental study, it would indicate that while distress intolerance may not impact emotional and behavioral responses during an exposure, it could still influence post-exposure emotional responses, thereby potentially shaping ultimate exposure learning outcomes.
Finally, we failed to find a main effect of either disgust propensity or distress intolerance for washing duration, suggesting that this outcome may be a function of broad symptom severity or other factors not examined in the current study. In other words, disgust propensity may be associated with the presence of washing as a compulsive behavior (as washing often serves to eliminate germs, which are a source of disgust), but may not relate specifically to the severity (i.e., duration) of this behavior. It is also possible that our use of a non-clinical sample influenced these findings; perhaps washing duration is more influenced by disgust propensity and distress intolerance for individuals with clinical levels of OCD symptoms. Future research is needed to better understand the predictors of washing severity and duration.
Study findings should be considered in the context of study limitations. First, the sample of participants included in this study differed in some ways from the larger population of people who experience OCD symptoms and thus findings may not generalize to all groups. Participants included in this study were predominantly female, White, and non-Hispanic, differing notably from prevalence data that suggest similar prevalence of OCD symptoms across gender, racial, and ethnic groups (Himle et al., 2008; Kessler et al., 2005). Additionally, as this sample was not a clinical sample, the findings from this study may not generalize to clinical populations. While existing research suggests that behavioral tasks designed to experimentally induce obsessive–compulsive symptoms in subclinical and nonclinical populations are effective, results of such studies may underestimate true relationships among variables within clinical populations (i.e., larger effect sizes in clinical samples; De Putter et al., 2017). Even within this nonclinical sample, several participants refused to complete the washing behavioral task included in this study, possibly due to heightened disgust triggered by the tasks. The exclusion of these participants from the behavioral analyses may have led to the underestimation of the true relationships among the variables of interest in this study. Further research is needed to examine these relationships within a clinical sample of individuals with OCD.
There are also several procedural and measurement limitations that warrant consideration. Most importantly, the current study examined cross-sectional rather than longitudinal data, and it is therefore not possible to make conclusions regarding causality or the directionality of the relationships observed. While existing literature indicates that disgust propensity and distress intolerance often precede the onset of OCD symptoms (e.g., Cougle et al., 2011a, 2011b; Olatunji et al., 2017), it is also possible that OCD symptoms could lead to the exacerbation of disgust propensity and distress intolerance. The findings of main and interactive effects of disgust propensity and distress intolerance on OCD symptoms in this study represent cross-sectional relationships between these factors, and further experimental or longitudinal research is needed to confirm whether the interaction between disgust propensity and distress intolerance poses risk for OCD symptoms in a causal sequence. In addition to the observational nature of the data collected, it is also important to note that all participants completed the three study tasks in fixed order (BAT, WBT, Image Ratings Task). While we initially determined this order so that the image ratings did not prime participant responses to the other two tasks, it is possible that this fixed order may have led to order effects across the three tasks. Future research using multimodal assessments should randomize the order of these assessments to avoid any possible order effects. An additional limitation is that we only measured anxiety in the WBT task. While we included measures of anxiety before and after washing to mimic standard practice during exposure situations, disgust would be an interesting additional emotional valence to measure in relation to the current study aims. Future research using this task should consider adding measures of momentary disgust.
While this study included several different measures of OCD symptoms, notably, we did not include a behavioral assessment of distress intolerance, a clinician-rated measure of OCD symptoms, or a measure of cognitive or physiological components of contamination OCD symptoms. Moreover, this study only used the total score for our measure of disgust propensity and did not consider multiple domains of disgust (e.g., pathogen, sexual, moral) in our analyses as this was not the aim of our study. Future research should expand on our findings to better understand whether distress intolerance differentially impacts different domains of disgust. Lastly, this study is limited in that we did not measure other constructs that are likely related to our constructs of interest, such as disgust sensitivity (Van Overveld et al., 2006), anxiety sensitivity (Allan et al., 2014; Cisler et al., 2007, 2008; Timpano et al., 2009), intolerance of uncertainty (Katz et al., 2017), and negative urgency (Cougle et al., 2012). While this study aimed to focus on disgust propensity and distress intolerance specifically, it is likely that these other constructs are also implicated in a complex set of relationships that serve to maintain contamination OCD symptoms as well as other OCD dimensions.
Despite these limitations, this study provides novel information about the independent and synergistic relationships of disgust propensity and distress intolerance with multiple assessments of contamination OCD symptoms. Evidently, a multimodal assessment strategy such as that employed in the current study is necessary to elucidate the precise impacts of risk factors such as disgust propensity and distress intolerance on contamination OCD symptoms specifically and OCD symptoms more broadly. Future research in this area should replicate this study with more racially, ethnically, and gender diverse participants and participants with more severe OCD symptoms to assess the generalizability of this study’s results. Future research should also expand this work to examine the independent and synergistic relationships of disgust propensity and distress intolerance with other OCD symptom dimensions. While the relationship between disgust propensity and contamination OCD symptoms is more intuitive, it is also possible that disgust propensity plays a role in other domains of OCD symptoms, such as harm or morality obsessions. Furthermore, future studies should incorporate other measurements not included in this study for a more comprehensive examination of the various factors that contribute to the onset and maintenance of OCD symptoms, particularly given our findings of differing outcomes per assessment modality. Finally, future research should use these findings to inform strategies to tailor OCD treatment based on individuals’ unique symptom presentations. Our findings suggest that both disgust propensity and distress intolerance may be important treatment targets to consider when treating OCD. Interventions targeting both disgust propensity and distress intolerance may be most effective for treating individuals with contamination OCD symptoms specifically, and general OCD symptoms more broadly. Through this work, we can continue to refine etiological models and improve treatment outcomes for individuals with OCD.
Declarations
Ethics Approval
This study and associated procedures received approval from the Institutional Review Board.
Competing Interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Consent
All individuals who participated in this study were informed of the study procedures and provided informed consent.
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