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Clin Psychol Rev. Author manuscript; available in PMC 2019 April 12.
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Clin Psychol Rev. 2019 April ; 69: 30–50. doi:10.1016/j.cpr.2018.06.002.

Cognitive Mechanisms of Disgust in the Development and

Maintenance of Psychopathology: A Qualitative Review and
Synthesis
Kelly A. Knowles1, Rebecca C. Cox1, Thomas Armstrong2, and Bunmi O. Olatunji1
1Vanderbilt University
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2Whitman College

Abstract
A growing body of research has implicated disgust in various psychopathologies, especially
anxiety-related disorders. Although the observed role of disgust in many disorders is robust, the
mechanisms that may explain this role are unclear. Cutting-edge research in cognitive science has
the potential to elucidate such mechanisms and consequently improve our understanding of how
disgust contributes to the etiology and maintenance of psychopathology. In this qualitative review,
we systematically assess cognitive bias mechanisms that have been linked to disgust and its
disorders. This review suggests that disgust-related biases may be observed in memory,
interpretation, judgment of expectancies, and attention, as well as at implicit levels. Of these
cognitive domains, the most robust bias appears to be observed at the level of attention. However,
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reliable moderators of attentional biases for disgust have not yet been identified, and this bias has
not been systematically linked to other levels of analysis. Despite these limitations, the available
research indicates that attentional avoidance rather than orienting or maintenance may be the most
characteristic of disgust. Attentional avoidance of disgust may have important implications for
etiological and treatment models of disorders characterized by excessive disgust reactions. The
implications for advancing such models are discussed in the context of a combined cognitive bias
hypothesis.

Keywords
Disgust; Attentional Bias; Expectancy Bias; Memory Bias; Interpretation Bias; Implicit Bias;
Avoidance
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Disgust is a negatively-valenced emotion that serves a disease-avoidance function (Rozin &

Fallon, 1987; Tybur, Lieberman, Kurzban, & DeScioli, 2013) by motivating avoidance of
stimuli that may result in physical or psychological contamination (Rozin, Haidt, & Fincher,
2009)1. Although the experience of disgust is normative, for some individuals this

Correspondence concerning this article should be addressed to Bunmi O. Olatunji, Tel: 1-615-322-0060, Fax: 1-615-343-8449,
[email protected].
1Note that previous research has identified an impact of moral disgust on cognitive processes (e.g., Olatunji, Puncochar, & Cox,
2016). However, given limited research examining the role of moral disgust in the cognitive biases reviewed here, moral disgust is not
given further treatment.
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experience can interfere in everyday life. Individuals with high disgust proneness, who
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experience disgust more frequently and perceive disgust as more harmful, are more likely to
experience anxiety-related psychopathology; this relationship is robust and remains
significant even when accounting for negative affect (Olatunji, Armstrong, & Elwood,
2017). While most commonly linked to anxiety-related disorders such as spider phobia,
blood-injection-injury (BII) phobia, health anxiety, and obsessive-compulsive disorder
(OCD), disgust proneness has also been associated with borderline personality disorder,
schizophrenia (Schienle et al., 2003), eating disorders (Davey, Buckland, Tantow, & Dallos,
1998; Troop, Treasure, & Serpell, 2002), and sexual dysfunction (de Jong, van Overveld, &
Borg, 2013).

A disease-avoidance motivation may explain the link between disgust proneness and some
disorder symptoms. For example, the excessive experience of disgust may motivate
contamination fear, which underlies many cases of OCD (Moretz & McKay, 2008;
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Rachman, 2004). Similarly, disgust is evident in spider and other small-animal phobias,
possibly because small animals such as spiders, rats, and insects can spread pathogens or are
otherwise associated with contagion (Matchett & Davey, 1991; Mulkens, de Jong, &
Merckelbach, 1996). Blood is also a disease vector that may explain the robust relationship
between measures of BII phobia and disgust proneness (Sawchuk, Lohr, Tolin, Lee, &
Kleinknecht, 2000). Disgust proneness may also be observed in health anxiety due to
concerns with contracting a serious disease (Davey & Bond, 2006). Although a disease-
avoidance process may explain the role of disgust in some anxiety-related disorders, disgust
has been observed in other disorders that are not primarily characterized by disease-
avoidance concerns. This suggests that additional mechanisms may account for the role of
disgust in psychopathology.
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Cognitive Mechanisms of Disgust in Psychopathology

Although findings from extant research implicate disgust in psychopathology, it remains
largely unclear how disgust contributes to the development of psychopathology. Functional
systems have evolved that allow humans to associate cues in the environment with the
presence of pathogens (Tybur, Lieberman, Kurzban, & DeScioli, 2013). However, some
individuals develop heightened sensitivity to pathogen-related cues, which may lead to an
attentional bias toward disgust-relevant information. While improved detection of disgust
may help an individual avoid pathogen contamination, it may also increase the number of
false alarms, leading to increased avoidance behavior. Cognitive biases describe errors
and/or variability in cognitive function that result in maladaptive behavior and/or subsequent
cognition (Beck, 2008). Such biases can affect multiple cognitive processes, including
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memory of events, interpretations of ambiguous stimuli, judgments of likelihood of potential

outcomes, and allocation of attention. These biased processes may contribute to the
development of psychopathology via excessive processing of and attention to disgust-
relevant information (Mathews & MacLeod, 2005; Muris & Field, 2008). For example,
individuals who have a biased memory for disgusting events may discount their relative
infrequency and spend increased cognitive resources worrying about the possibility of
contamination.

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Memory bias refers to the preferential recall of memories that are consistent with a given
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emotional state (Muris & Field, 2008). Experiments measuring memory bias are comprised
of two stages. In the encoding stage, participants are exposed to stimuli for subsequent
retrieval, such as faces, words, or scenes. In the retrieval stage, memory for these stimuli is
tested, either through explicit instruction to recall the encoded material or through implicit
memory tasks, such as a word stem completion test (Mitte, 2008a). Remembering more
negative or threatening stimuli (i.e., threat words, angry faces, sad scenes) than other stimuli
suggests a memory bias. In the context of psychopathology, memory bias typically involves
selective memory for negative or threatening information (Coles & Heimberg, 2002; Gilboa-
Schechtman, Erhard-Weiss, & Jeczemien, 2002; Mitte, 2008a; Watkins, Martin, & Stern,
2000). Memory bias for disgust-relevant cues may maintain psychopathology by increasing
the saliency of disgust information and related experiences.

Interpretation bias refers to the tendency to generate negative interpretations of ambiguous

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events or stimuli (Beard, Rifkin, & Björgvinsson, 2017), and this bias is observed in many
disorders (Hirsch, Meeten, Krahé, & Reeder, 2016; Mathews & MacLeod, 2005; Mathews,
Richards, & Eysenck, 1989; Nunn, Mathews, & Trower, 1997). For example, an
interpretation bias may manifest as catastrophic misinterpretation of bodily sensations (i.e.,
heart attack) in panic disorder (Richards, Austin, & Alvarenga, 2001). A common method
for sampling interpretation bias involves presenting participants with an ambiguous stimulus
(e.g., photo, vignette, incomplete sentence) and having participants choose an interpretation
in a forced-choice format with options such as neutral, positive, and threat/negative/etc.
Another commonly used method involves presenting participants with auditory recordings of
homophones with neutral or threatening interpretations (e.g., die/dye) and having
participants spell the word they hear. Interpretation bias may reflect increased endorsement
of disgust-relevant interpretations of ambiguous stimuli or homophones. This bias may then
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maintain disorders via overestimation of the likelihood or consequences of contact with

disgusting stimuli.

Expectancy bias is the tendency to overestimate the relationship between a stimulus and an
aversive outcome (Davey, 1995). Expectancy bias is a form of biased judgment found in
anxious individuals, in which the likelihood of the occurrence of a negative outcome is
exaggerated (Foa, Franklin, Perry, & Herbert, 1996; MacLeod & Byrne, 1996). Indeed,
negatively biased expectations of disgust-relevant outcomes (i.e., disease) may be a key
component in the development of anxiety by motivating avoidance behavior (Reiss, 1991).
Expectancy bias can be assessed by asking participants to rate the likelihood that a given
outcome will occur after viewing a given stimulus (a priori), or by asking participants to
report how often two types of stimuli co-occurred during the course of the experiment (a
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posteriori; Davey & Dixon, 1996). In anxious samples, two kinds of expectancy bias have
been found: expecting positive outcomes to occur less frequently and expecting negative
outcomes to occur more frequently (Cabeleira et al., 2014; Chan & Lovibond, 1996).
Expectancy bias is sometimes referred to as covariation bias, as anxious individuals
demonstrate a tendency to form illusory correlations between randomly presented stimuli
(Tomarken, Mineka, & Cook, 1989).

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Attentional biases refer to a variety of ways in which individuals preferentially attend to

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threat-related information over non-threat information. Manifestations of attentional bias

include threat-distractor interference, preferential orienting toward threat, maintenance of
attention on threatening stimuli, and avoidance of threat (Cisler & Koster, 2010; Mogg &
Bradley, 2016). These biases can be further divided by whether they involve dysfunction in
bottom-up cognitive functions (such as automatic evaluation of threat and initial orienting to
threat) or top-down cognitive control (such as controlled attention, task-switching, goal-
directed inhibitory control, and motivated avoidance; Mogg & Bradley, 2016). Several
experimental paradigms have been developed to assess different aspects of attentional bias.
Common performance-based methods for sampling threat-distractor interference include the
emotional Stroop task (Williams, Mathews, & MacLeod, 1996) and emotional attentional
blink task (Most, Chun, Widders, & Zald, 2005). The dot-probe task (MacLeod, Mathews, &
Tata, 1986) is typically used to assess initial orienting to threat, while the emotional spatial-
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cueing task (Fox, Russo, Bowles, & Dutton, 2001) can provide information on orienting as
well as maintained attention toward threat. The visual search task (Öhman, Flykt, & Esteves,
2001) has been used to examine orienting to threat and threat-distractor interference.
Importantly, seemingly small modifications in each of these tasks, such as the length of
stimuli presentation, can affect whether a task is measuring automatic, bottom-up processes
or strategic, top-down processes (Mogg & Bradley, 2016).

Research using various attentional paradigms in anxious samples suggests that a vigilant-
avoidant attentional pattern is commonly observed, in which anxious individuals quickly
orient toward a threatening stimulus and then avoid it (Mogg & Bradley, 1998; Rinck &
Becker, 2006). However, the relationship between attention and psychopathology is highly
complex (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van IJzendoorn, 2007;
Rinck & Becker, 2006), and the pattern of attentional bias observed may vary by the nature
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of the disorder (i.e., Beevers, Lee, Wells, Ellis, & Telch, 2011; Chen, Ehlers, Clark, &
Mansell, 2002; Mogg, Philippot, & Bradley, 2004; Olatunji, Armstrong, McHugo, & Zald,
2013). Accordingly, disgust-based disorders may be characterized by a unique pattern of
attentional bias that consists of a different imbalance in bottom-up and top-down processing
compared to fear-based disorders. It has also been suggested that attentional biases may vary
as a function of individual differences (Taylor, Cross, & Amir, 2016). Disgust proneness
may be one individual difference that moderates patterns of attentional biases for disgust-
relevant cues in the environment to influence anxiety-related symptoms.

Cognitive Biases and Disgust: What Have We Learned?

Considering research linking disgust to psychopathology (Olatunji, Cisler, McKay, &
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Phillips, 2010; Olatunji et al., 2017), as well as research highlighting the impact of emotion
on cognitive processes (Kissler & Keil, 2008; Most et al., 2005), cognitive biases may be
one set of mechanisms by which disgust contributes to psychopathology. For example,
biased memory for disgust-relevant stimuli, disgusting interpretations of ambiguous stimuli,
and increased expectations of aversive outcomes in the presence of disgust-relevant stimuli
likely reinforce psychopathological processes such as experiential avoidance (Hayes,
Wilson, Gifford, Follette, & Strosahl, 1996) and negative beliefs (Clark, 1999) by
contributing to an overestimation of threat (Cisler et al., 2011). Similarly, increased

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vigilance for disgust-relevant information or prolonged maintenance of attention toward

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disgust-eliciting stimuli may also lead to failure to detect relevant non-threatening

information, which may lead to less accurate estimations of the likelihood and severity of the
potential threat. However, no review to date has examined the role of disgust or disgust
proneness in these cognitive biases. To determine what can be learned from this literature,
we conducted a systematic review and synthesis of extant findings on disgust and cognitive
biases in order to delineate which cognitive bias has the most robust link to disgust and
identify areas for future research.

Selection of Studies for Review and Synthesis

A systematic literature search was conducted in PsycINFO and PubMed using the terms
“memory,” “interpretation,” “expectancy,” “attention,” and “implicit” in combination with
the term “disgust.” Additional searches of disgust with the terms “judgment bias,”
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“judgmental bias,” and “covariation bias” were also completed, due to their close association
with the term expectancy bias. The initial search yielded 1,382 articles. After duplicate
records (n = 617) were removed, the abstracts of 765 were screened for inclusion. Abstracts
that did not discuss bias or a similar cognitive process were excluded. Figure 1 shows that of
these articles, 190 were read in full, and 98 were included in the final sample. Articles were
selected for inclusion based on the following criteria: (1) published in English, (2) peer-
reviewed, and (3) empirically tested a relationship between disgust and biases in memory,
interpretation, judgments of expectancy, or attention. The findings of these studies were then
reviewed with regards to the extent to which biases in domains of memory, interpretation,
judgments, and attention, at both the explicit and implicit levels, are observed.

Disgust and Memory Bias

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Disgust-related memory bias can take at least two forms. First, there can be increased
memory for disgusting stimuli. Second, the experience of disgust can enhance subsequent
memory performance. Research from cognitive science has found evidence for both effects,
though the majority of findings implicate enhanced memory for disgust-related stimuli. For
example, recognition of disgust words is increased compared to negative and neutral words
(Duesenberg et al., 2016), and disgust words are more likely than threat or neutral words to
be recalled in an implicit memory task (Charash & McKay, 2009). Likewise, previous
findings indicate increased memory for disgust faces compared to neutral and positive faces
(Román et al., 2015) and enhanced memory for disgusting images compared to fearful
(Chapman, Johannes, Poppenk, Moscovitch, & Anderson, 2013; Croucher, Calder,
Ramponi, Barnard, & Murphy, 2011) and neutral images (Chapman et al., 2013). Notably,
one study found that though disgusting images were most likely to be recognized, they also
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resulted in the highest rates of false alarms (Marchewka, Wypych, Michałowski, et al.,
2016), suggesting a sensitivity-specificity trade-off for memory for disgust-related stimuli.
Table 1 summarizes available research that has examined disgust-related memory biases.
Taken together, these findings suggest a memory bias for disgust-related stimuli, such that
memory for these stimuli is enhanced relative to neutral stimuli. Importantly, results
showing such an effect over and above the impact of negative and threat stimuli suggest that
enhanced memory for disgust-related stimuli is not simply an epiphenomenon of elevated
arousal.

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Individual differences in disgust may also enhance the memory bias for disgust-related
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stimuli. For example, research has shown that those high in contamination concerns recall
more disgust words than those low in contamination concerns (Charash & McKay, 2009),
and disgust proneness predicts increased disgust words recalled following disgust priming
(Charash & McKay, 2002). Further, those with BII phobia, a disorder characterized by
elevated levels of disgust (Page, 1994), recall more disgust words in an implicit memory task
than healthy control participants (Sawchuk, Lohr, Lee, & Tolin, 1999). In contrast, another
study found no differences in recognition of disgust images between BII phobia, spider
phobia, and healthy control participants (Sawchuk, Meunier, Lohr, & Westendorf, 2002).
These discrepant findings suggest that features of the stimuli may moderate the extent to
which biases in memory are observed. Research has also shown that recognition of images
rated as disgusting is greater for higher intensity images after 6 months (Marchewka,
Wypych, Moslehi, et al., 2016), suggesting a relationship between prospective memory and
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initial emotional experience. Interestingly, one study found decreased recognition of disgust
faces in the follicular phase of the menstrual cycle (Gasbarri et al., 2008), suggesting that
variation in hormone levels may attenuate the memory enhancement effect for disgust
stimuli.

Though less consistent, research also suggests that elevated levels of disgust enhance
memory. For example, anti-tobacco advertisements are better remembered when the
message includes disgusting content (Clayton, Leshner, Tomko, Trull, & Piasecki, 2017;
Leshner, Bolls, & Wise, 2011). Further, disgust propensity predicts increased memory
intrusions after viewing a disgusting video (Bomyea & Amir, 2012). Importantly, these
findings are strengthened by independence of the outcome measurement and the elicitation
of disgust. Finally, one study found that exposure to a large spider increased disgust levels,
and memory for spider words was increased if the spider was present during encoding
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(Teachman & Saporito, 2009). However, the relationship between state and trait levels of
disgust and memory performance was not significant when state anxiety was controlled,
suggesting that more general negative affect may better account for this effect. In contrast,
one study found decreased memory for details of a disgusting stimulus compared to a
neutral stimulus (Medina, Clark, & Thorne, 2016), suggesting that the memory enhancement
effect of disgust may promote more general stimulus memory that does not extend to
specific elements of the stimulus. In contrast to the evidence for the specificity of enhanced
memory for disgust-related stimuli, it remains unclear whether there is a unique
enhancement effect of elevated disgust on memory.

The findings of multiple studies that indicate enhanced memory for disgust-related stimuli
are consistent with evolutionary function of disgust in facilitating disease avoidance. That is,
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it is adaptive to remember disgust-related stimuli in order to avoid future contact and

potential contamination (Chapman et al., 2013). Notably, this effect is facilitated by
individual differences in disgust, including disgust sensitivity and contamination concerns.
These relationships highlight one pathway by which an adaptive process may become
maladaptive. Specifically, excessive memory for disgust-related stimuli among those high in
trait disgust may contribute to the development of some disorders. However, it is important
to note that currently available studies examining memory biases for disgust have largely
utilized relatively short-term memory paradigms, and few studies have examined the long-

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term effect of disgust on memory. Furthermore, currently available studies have largely
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relied on static disgust stimuli (i.e., photos, words), which limits the ability to generalize
these findings to real-world situations.

Disgust and Interpretation Bias

Available studies suggest that the experience of disgust may cause negative interpretations of
ambiguous cues. For example, inducing disgust results in increased threat interpretations of
homophones (Davey, Bickerstaffe, & MacDonald, 2006; Leathers-Smith & Davey, 2011)
and more negative interpretations of ambiguous scenarios (Mayer, Muris, Busser, &
Bergamin, 2009). Similarly, inducing disgust leads to increased anxiety to emotional images
(Davey, MacDonald, & Brierley, 2008). Further, one recent study found that a disgust
induction resulted in high estimation of imminence of an anthropomorphic figure,
suggesting a disgust-induced overestimation of threat (Krusemark & Li, 2013). This
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interpretation bias is also evident in children. When given disgust-related information about
a novel animal, children provide more negative interpretations of ambiguous situations with
the animal than children given neutral information about the novel animal (Muris, Huijding,
Mayer, & de Vries, 2012). Research also suggests that individual differences in disgust may
moderate biases in interpretation. Compared to those with high trait anxiety and control
participants, those with high contamination concerns are more likely to choose a disgust-
related interpretation of an ambiguous scenario. Further, disgust sensitivity was associated
with increased disgust-related interpretations in the total sample (Charash & McKay, 2009).
Interestingly, one recent study found that disgust training does not affect subsequent
interpretations (Whitton, Grisham, Henry, & Palada, 2013), suggesting that disgust-related
interpretation bias may be resistant to modification. However, no study to date has employed
a cognitive-bias modification paradigm to attempt to reduce disgust-related interpretation
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bias.

Table 2 summarizes available research suggesting that increased disgust, either through
experimental disgust induction or elevated disgust-related traits, leads to more negative
interpretation of ambiguous stimuli. Although extant research has implicated disgust in
interpretation bias, evidence for the specificity of this effect has been mixed. Importantly,
some studies that have revealed a disgust-related interpretation bias did not include a
negative emotion comparison group, which precludes specific inferences (Davey et al., 2008;
Muris et al., 2012). One study did find some evidence for a disgust-specific interpretation
bias (Charash & McKay, 2009). However, other studies indicate a similar pattern of
interpretation bias for disgust and anxiety inductions (Davey et al., 2006; Leathers-Smith &
Davey, 2011; Mayer et al., 2009). This suggests that while experiencing disgust results in a
biased interpretation of ambiguous stimuli, this bias may not be distinct from that which is
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observed for other negative emotions/traits.

Disgust and Expectancy Bias

The literature on expectancy bias for disgust suggests that people generally have a bias to
expect negative outcomes to follow exposure to disgust stimuli. A study of unselected adults
found that a painful outcome (i.e., shock) was anticipated after viewing predatory animals,
while disgust-related outcomes (i.e., juice that makes you vomit) were associated with

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viewing phobic but non-predatory animals (spider, maggot, cockroach, and slug); disgust
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proneness was not associated with an increased expectancy bias for disgust-related outcomes
(Davey, Cavanagh, & Lamb, 2003). A similar study found that disgust sensitivity
significantly predicted an expectancy bias for contracting a disease after performing an
imagined disgust-relevant behavior, such as cleaning other people’s hair from a drain (Mitte,
2008b). In contrast to these two studies, Thorpe and colleagues collected information
regarding participants’ estimates of the likelihood of catching a disease and the severity of
any potential illness after submerging their hands in dirt for five minutes. While estimates of
the likelihood of catching a disease were not significantly related to disgust proneness or the
length of time spent washing their hands after the task, individuals with higher disgust
proneness expected that their potential illness would be more severe, and they spent more
time washing their hands after dirt exposure (Thorpe, Barnett, Friend, & Nottingham, 2011).

In analogue samples, however, there is mixed evidence for a greater expectancy bias for
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disgust-related fears, such as contamination, BII, and spider fears. Table 3 summarizes the
available research examining expectancy bias for disgust. Individuals with high
contamination fear did not demonstrate a greater bias for disgust outcomes paired with
disgust stimuli than individuals with low contamination fear, although they did show a
marginally greater expectancy for disgust outcomes to follow fear stimuli (Olatunji, Lohr,
Willems, & Sawchuk, 2006). Similarly, individuals with high contamination fear
overestimated the contamination/fear stimulus/outcome pairing and underestimated the
contamination/neutral stimulus/outcome pairing compared to individuals with low
contamination fear (Connolly, Lohr, Olatunji, Hahn, & Williams, 2009). Individuals with BII
phobia did not show a greater expectancy bias for disgust or harm outcomes after viewing
fear-relevant stimuli compared to a control group in one study (de Jong & Peters, 2007a),
but did show a greater bias toward aversive outcomes and blood images in another study
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(van Overveld, de Jong, & Peters, 2010a). A third study found only a general expectancy
bias for affect-congruent stimuli in high versus low BII-fearful individuals (Connolly, Lohr,
Williams, et al., 2009). However, Olatunji, Cisler, Meunier, Connolly, and Lohr (2008)
found that spider-fearful individuals demonstrated increased expectancy for pairings of
spider pictures with disgust expressions compared to non-fearful individuals, and this
expectancy bias was associated with behavioral avoidance. In another study, spider-fearful
individuals displayed a contamination-relevant expectancy bias associated with spiders,
while control participants displayed a harm-relevant expectancy bias, but these biases were
not present after the image viewing was complete (de Jong & Peters, 2007b). Finally, one
study found that expectancy bias toward disgust-relevant consequences was the best
predictor of spider fear (van Overveld, de Jong, & Peters, 2006). Thus, while an expectancy
bias for disgust outcomes and spiders appears to be present for spider-fearful individuals,
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implicating the role of disgust in spider phobia through a cognitive mechanism, this bias is
not robust in BII phobia. Individuals with contamination fear appear to have a more general
expectancy bias, where more aversive (but not disgust-specific) outcomes were expected
after contamination stimuli.

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Disgust and Attentional Bias

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Interference effects: The emotional Stroop and attentional blink tasks.—The

first studies of attentional bias for disgust used the emotional Stroop task to examine the
interference of disgust-related words (i.e., vomit, phlegm, feces) in the processing of other
information (i.e., word color). In some studies, priming effects were also examined;
participants were asked to read a brief story that elicited either disgust (a cockroach crawls
into your mouth), fear (two intruders break into your apartment), or a neutral emotion
(running errands after work) before completing the emotional Stroop task (Charash &
McKay, 2002; Charash, McKay & Dipaolo, 2006). Slow performance on the emotional
Stroop task is hypothesized to reflect a low threshold for threat-relevant information (an
attention bias). Priming participants with threat-relevant information may also increase
attentional awareness for threats. In one study, unselected participants demonstrated an
attentional bias for disgust, such that the latency of response time for disgust words and fear
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words was significantly greater than for neutral words, regardless of what kind of story was
used for priming; disgust proneness was correlated with response latency for disgust words
only for those primed with a disgust story (Charash & McKay, 2002). The emotional Stroop
has been used to explore attentional bias for disgust in clinical and analogue clinical
samples, but an attentional bias for disgust was not found in individuals with elevated
contamination fear (Charash & McKay, 2009) or BII phobia (Sawchuk et al., 1999), or using
an adapted pictorial Stroop task in children with anxiety disorders (Benoit, McNally, Rapee,
Gamble, & Wiseman, 2007). These findings are not surprising, given that interference
effects are strongly related to individuals’ present mood state (cf., Mathews & MacLeod,
2005); other measures may demonstrate a more robust effect of attentional bias for disgust
on psychopathology.

The attentional blink task has also been employed to probe for disgust-related attentional
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biases. In the emotional attentional blink task, participants are asked to respond to a target
stimulus that occurs at various lags subsequent to an emotional distractor in a rapid serial
visual presentation (RSVP; Most et al., 2005). The task is predicated on the attentional
blink, a phenomenon by which a stimulus captures attention, and subsequent stimuli are not
perceived for a limited period of time (Chun & Potter, 1995). While the attentional blink
phenomenon is an interference effect, the specific time lags used in the RSVP task may help
discriminate between automatic and strategic attentional processes. For example, decreased
target detection when the distractor is placed earlier in the visual presentation (i.e., 200 ms)
suggests an initial orienting bias, while decreased target detection when the distractor is
placed later in the visual presentation (i.e., 800 ms) may reflect impaired goal-directed
inhibitory control.
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In one study comparing fear and disgust faces, results indicated that the attentional blink was
greater for fear faces than for disgust faces (Vermeulen, Godefroid, & Mermillod, 2009).
However, these findings might not generalize to stimuli that evoke emotion without relying
on facial expressions, which may be processed differently due to the importance of social
cuing. Results from a study comparing fear, disgust, erotic, and neutral images found that
emotional images, regardless of specific content, led to an attentional blink at 200 ms, 400
ms, and 600 ms, but enhanced target processing at a lag of 800 ms (Ciesielski, Armstrong,

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Zald, & Olatunji, 2010). Here, emotional images appear to have captured but not held
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attention for a significant period of time, and disgust was not observed to have a unique
effect on attention.

Specific temporal aspects of the attentional blink may explain the difference between the
processing of fear and disgust. In an RSVP task, task-irrelevant disgust stimuli influenced
attention 240 ms after the onset of disgust stimuli, but at 120 ms after the onset of fear
stimuli (Cisler, Olatunji, Lohr, & Williams, 2009). Similarly, for targets presented 200 ms
after disgust, fear, or neutral images, disgust stimuli led to slower reaction times and lower
accuracy than both fear and neutral images (van Hooff, Devue, Vieweg, & Theeuwes, 2013).
Additionally, an attentional blink was found for targets presented at 100 ms after disgust
stimuli, but not for fear or happiness stimuli (van Hooff, van Buuringen, El M’rabet, de Gier,
& van Zalingen, 2014), suggesting a specific early effect of disgust on attention compared to
other emotional stimuli. It appears that the overall attentional blink for disgust may be
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greater (i.e., maintained longer) than for fear, but it is unclear why differences have been
found at very short (100–120 ms) intervals.

Disgust proneness may also be related to the attentional blink for disgust, but findings are
inconsistent. One study found that individuals with higher disgust proneness had difficulty
disengaging from task-irrelevant disgust targets, but not fear targets, and individuals with
lower disgust proneness did not demonstrate a maintenance bias for disgust stimuli (Cisler,
Olatunji, et al., 2009). However, this relationship was not found in a similar sample (van
Hooff et al., 2014). One potential explanation for this difference is that the Cisler et al.
sample included both male and female university students, while van Hooff and colleagues’
sample was restricted to females. Indeed, there are important gender differences in the
experience of disgust (Oaten, Stevenson, & Case, 2009) and frequency of attending to
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disgust cues (Kraines, Kelberer, & Wells, 2016). Differences in stimulus cues may also
account for discrepant findings, as Cisler and colleagues used emotion-relevant words,
whereas van Hooff and colleagues used emotional images. These differences may reflect an
important distinction between linguistic and visual processing of disgust that may yield
different attentional effects.

Studies examining the attentional blink have consistently shown that disgust information
captures attention when stimuli are presented one at a time in rapid succession. However, it
is important to note that a specific attentional blink for disgust has not been found in clinical
populations. In a study examining veterans with PTSD, healthy veterans, and a healthy non-
veteran control group, a large attentional blink for disgust images was apparent for all
groups, regardless of veteran or clinical status (Olatunji et al., 2013). Additionally,
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individuals with GAD did not differ from healthy control participants with regard to an
attentional blink for disgust (Olatunji, Ciesielski, Armstrong, Zhao, & Zald, 2011). These
results are not surprising, however, as disgust is not usually implicated in the development
and maintenance of PTSD and GAD. Olatunji, Ciesielski, and Zald (2011) examined
patients with OCD and a control group during an emotional attentional blink paradigm in
which participants searched for a target embedded within a series of rapidly presented
images. Critically, an erotic, fear, disgust, or neutral distracter image appeared 200 ms or
800 ms before the target. Impaired target detection was observed among OCD patients

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relative to control participants following only erotic distracters, but only when presented 800
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ms, and not 200 ms, prior to the target. These findings indicate maintained attention toward
threat in OCD, but not for disgust-related stimuli specifically. Although specific interference
effects of disgust stimuli have not been found in clinical or clinical analogue populations,
effects may be found in future research if the disgust stimuli are more directly relevant to the
disorder of interest (i.e., images of bodies in a war zone for participants with PTSD, or
images of needles for individuals with BII phobia). Larger interference effects may also be
found for images of disgusting objects that more specifically signal contagion.

Biases in initial orienting.—The dot-probe task has also been employed to examine
attentional biases for disgust. In the task, one threat-related cue and one neutral cue appear
simultaneously at different locations, and one of the cues is subsequently replaced with the
target. Participants are asked to respond to the target as quickly and accurately as possible
(MacLeod et al., 1986). Assessment of both orienting and maintenance bias is possible with
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a dot-probe task. Decreased reaction time on congruent versus incongruent trials suggests an
orienting bias, while increased reaction time on incongruent versus congruent trials suggests
a maintenance bias (Fox et al., 2001). One study found that individuals attended more
rapidly to disgusting cues than neutral cues, regardless of whether they underwent a disgust-
induction procedure. In addition, individuals in the disgust-induction condition demonstrated
an orienting bias for images representing cleanliness (Vogt, Lozo, Koster, & de Houwer,
2011). Similarly, individuals who were asked to suppress their emotions after a disgust
induction attended more rapidly to disgust images compared to neutral images, but they
attended more rapidly to cleanliness images compared to disgust images (Vogt & de
Houwer, 2014). These findings suggest a robust orienting bias for disgust that may then
motivate a unique pattern of regulatory strategies. Versions of the dot probe task have also
revealed important attentional differences for disgust and fear. For example, a discrimination
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task is similar to a dot-probe task, in that reaction times are used as a measure of the ability
of a stimulus to capture attention. In the task, an image (disgusting, fearful, or neutral) is
displayed with a white line positioned either below or above the image; participants press a
key to indicate if the line is above or below the image. Latencies for disgusting images were
found to be slower than for fear images, indicating enhanced attentional capture for disgust
compared to fear (Chapman et al., 2013).

Dot-probe studies have also found an orienting bias for disgust in some disorders. For
example, individuals with OCD demonstrated an orienting bias for disgust-relevant words
compared to individuals with high trait anxiety (Tata, Leibowitz, Prunty, Cameron, &
Pickering, 1996). Individuals with anxious attachment attended to open-mouthed disgust
faces, which are associated with core disgust (Rozin, Lowery, & Ebert, 1994), but avoided
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close-mouthed or other emotional faces, which the authors suggest reflects social-moral
disgust and social rejection (Westphal, Bonanno, & Mancini, 2014). In a treatment study,
socially anxious individuals who underwent an attention modification protocol demonstrated
reduced orienting bias toward disgust faces in a dot-probe task compared to individuals in a
control condition, and individuals in the treatment group also had reduced anxiety in
response to a social stressor (Amir, Weber, Beard, Bomyea, & Taylor, 2008). However, the
use of disgust facial expressions as the threat cue likely indicates increased sensitivity to

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social threat rather than concerns of contagion or disease. Another study examined the effect
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of oxytocin, a neuromodulatory hormone hypothesized to affect social emotional processing,

on a disgust orienting bias in individuals with anorexia nervosa. No initial differences in
attentional bias toward disgust were found between individuals with anorexia and a healthy
control group, although both groups oriented more rapidly toward disgust faces than other
emotional faces. Individuals who received an intranasal dose of oxytocin had a reduced
orienting bias toward disgust faces, with a larger effect found in healthy control participants
than in those with anorexia (Kim, Kim, Park, Pyo, & Treasure, 2014). One interpretation of
these findings is that disgust-related attentional biases may be malleable processes that can
be targeted during treatment.

Although improved reaction time measures have been developed to better differentiate
components of attention, many researchers have turned to eye-tracking technology as an
alternative to manual reaction time measures. Eye movements are more closely linked to
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attention than key press behavior, which occurs downstream of intervening response
selection and skeletal muscle movement (Weierich, Treat, & Hollingworth, 2008). Eye-
tracking tasks measure spontaneous viewing patterns; indeed, eye movements are a direct
indicator of overt attention, and eye-tracking devices are one method that enables
researchers to parse the orientation and maintenance of attention, as the locations of initial
fixations indicate orientation (i.e. where one looks first), while the duration of these fixations
indicate the maintenance of attention (i.e. how long one looks). When spontaneous viewing
favors disgust cues when other cues are available, this may be a risk factor for
psychopathology, especially for individuals high in disgust proneness. Research employing
eye-tracking methods has revealed an orienting bias for disgust similar to that commonly
observed for fear cues. For example, three-year-old children oriented to disgust and fear
images after hearing a disgust or fear vocalization, but not a sad vocalization. Additionally,
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children whose parents had higher disgust proneness looked longer at fear and disgust
images when hearing disgust and fear sounds (Stevenson, Oaten, Case, & Repacholi, 2014).
Although these results suggest an orienting bias toward threatening information in young
children that is not specific to disgusting cues, parental disgust proneness does appear to be
associated with that general threat bias.

Eye-tracking studies examining the orienting bias toward disgust faces in clinical and
analogue samples have also revealed an orienting bias to threat that is not specific to disgust
(Çek, Sánchez, & Timpano, 2016). For example, individuals with high trait anxiety were
found to orient more quickly to disgust and fear faces than individuals with low trait anxiety
(Holas, Krejtz, Cypryanska, & Nezlek, 2014). Individuals high in contamination fear have
also been found to orient more quickly to fear faces compared to individuals low in
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contamination fear, but there were no differences between the groups in orienting biases for
disgust faces (Armstrong, Olatunji, Sarawgi, & Simmons, 2010). However, one study using
threat images rather than facial expressions found that individuals high in contamination fear
oriented toward disgust-relevant images more often than individuals low in contamination
fear, and this orienting bias mediated group differences in behavioral avoidance (Armstrong,
Sarawgi, & Olatunji, 2012). Individuals high in contamination fear also show a fragmented
viewing style by making more but shorter fixations on disgust-relevant images compared to

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those low in contamination fear. This particular style may represent a vigilant-avoidant
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pattern of attention (Mogg & Bradley, 1998).

Examination of psychophysiological correlates may provide important insights into

mechanisms associated with an attentional bias for disgust. This has often been done using
electroencephalography (EEG), which records electrical activity in the brain using
electrodes placed at multiple locations on the scalp. EEG has high temporal resolution and
thus can monitor rapid changes in neural electrical activity, referred to as event-related
potentials (ERPs). Several ERPs are considered important in the study of the early allocation
of attention, including the P1, P2, N1, and N2 components, which occur between 50 and 350
ms after stimulus onset. For example, P2 amplitudes are higher in response to emotional
stimuli, reflecting automatic, bottom-up attention allocation to these stimuli (Carretié,
Hinojosa, Martín-Loeches, Mercado, & Tapia, 2004). In two ERP studies of healthy adults,
larger P2 amplitudes were found for disgust compared to fearful and neutral images (Lu et
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al., 2016; Xu et al., 2015), whereas both fearful and disgust stimuli produce greater N2
amplitudes than neutral stimuli (Lu et al., 2016). Another study found that P2 amplitudes
were greater during disgust distractors than during fear and neutral image distractors, and
participants responded more slowly and made more errors in a digit task when disgust
images were displayed (Carretié, Ruiz-Padial, López-Martín, & Albert, 2011). Attentional
biases for disgust and fear have also been compared using ERP under conditions of attention
and inattention. During the superimposed face/place task, when attention was directed away
from faces, fear faces produced greater P1 amplitudes than disgust faces. Additionally, when
attention was directed toward faces, fear faces elicited greater N1 amplitudes than neutral
faces, while the same pattern was not present for disgust (Santos, Iglesias, Olivares, &
Young, 2008). The authors suggest that fear may attract automatic attention, while attention
to disgust is more voluntary, as it is less relevant for avoiding danger. This suggests that fear
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may involve a greater reliance on bottom-up attentional processes, while disgust biases may
involve more top-down cognitive control.

Early selective attention to disgust, as evidenced by ERP, has not been consistently found in
anxious individuals. In a study comparing individuals with high and low trait anxiety during
a visual search task, fear images produced greater P2 amplitudes than neutral images, and
disgust images elicited reduced amplitudes compared to neutral images. The same pattern
was found for P1, but trait anxiety moderated this result, such that individuals with higher
trait anxiety had a greater differential between the amplitudes during fear and disgust trials
(Krusemark & Li, 2011). Because individuals in this study were selected based on their
relative high or low trait anxiety, it is possible that this finding may be driven by a
particularly large potential amplitude for fear images, rather than a diminished amplitude for
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disgust images. However, another study of socially anxious individuals found a significantly
increased N2 amplitude in response to disgust faces compared to neutral faces, but no such
effect for control participants (Judah, Grant, & Carlisle, 2016).

Another component of the ERP response is the late positive potential (LPP), which typically
occurs after 300 to 400 ms from stimulus onset. The LPP is an index of motivated attention
toward emotional stimuli (Olofsson, Nordin, Sequeira, & Polich, 2008). While it does not
represent an orienting bias per se, it is a marker of attention that has been found in response

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to disgust in healthy samples as well as in individuals with psychopathology. In healthy

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adult women, attending to disgust faces produced a greater LPP amplitude relative to neutral
faces, and no difference was found between fearful and neutral faces during this period
(Santos et al., 2008). A similar larger LPP amplitude was found for healthy adults viewing
disgusting and fearful images compared to neutral images, with no differences between the
former two (Lu et al., 2016). For both adults and children with spider phobia, fear and
disgust images produced greater LPP amplitudes than neutral images, but this response
pattern did not differ from that of control participants (Leutgeb, Schäfer, Köchel,
Scharmüller, & Schienle, 2010; Scharmüller, Leutgeb, Schäfer, Köchel, & Schienle, 2011).
Finally, a study of healthy female children found that those administered a placebo that was
said to reduce disgust symptoms reported experiencing less disgust when viewing disgusting
pictures but had greater LPP amplitudes in response to both fear and disgust pictures than
those who did not receive the placebo (Übel, Leutgeb, & Schienle, 2015). This finding
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suggests that some cues may modulate the physiology of attention to disgust cues in
meaningful ways. Overall, while some studies demonstrate a specific orienting bias toward
disgust stimuli, the majority of research shows a more general initial orienting response to
threat in both anxious and disgust-prone individuals.

Maintenance bias.—A maintenance bias toward disgusting cues may play a role in
anxiety symptoms. For instance, individuals high in social anxiety maintained attention on
disgust faces significantly more slowly than those with low social anxiety (Buckner, Maner,
& Schmidt, 2010). However, this result may demonstrate a more general propensity to
maintain attention on negative social cues rather than disgust specifically, as the only social
cues used in this study were happy and disgust faces. Another study of socially anxious
participants used a dot-probe task along with a concurrent n-back task in order to assess
attention with and without a working memory load. Socially anxious participants avoided
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disgust faces when sufficient cognitive resources were available, but had difficulty
disengaging their attention from disgust faces during a working memory load, suggesting
that they lacked the cognitive resources to shift their attention away from social threat
(Judah, Grant, Lechner, & Mills, 2013).

Using a spatial cueing task, individuals high in contamination fear demonstrated maintained
attention for fear and disgust stimuli compared to individuals low in contamination fear
(Cisler & Olatunji, 2010). Notably, this pattern was found over viewing intervals of 100 and
500 ms but was not examined over longer intervals. A similar study extended these findings
by demonstrating the role of maintained attention toward disgust in contamination fear and
found that maintained attention on disgust cues predicted performance on a chain of
contagion task, in that participants who exhibited a maintenance bias for disgust cues rated
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pencils with a more distal relationship to an original contaminated pencil as more

contaminated than individuals who did not demonstrate this bias (Cisler et al., 2011).
Similarly, eye-tracking results demonstrated that individuals high in contamination fear
maintained greater attention on both disgust and fear faces compared to individuals low in
contamination fear over longer (3 s) trials (Armstrong et al., 2010). When the stimuli were
disgust-relevant, general threat, pleasant, and neutral images, however, there was no
difference in gaze maintenance between high and low contamination fear individuals over a

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30 s interval (Armstrong et al., 2012). Evidence for the absence or presence of a

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maintenance bias in contamination fear seems at least partially dependent on the time course
that is examined. While one study has demonstrated an association between disgust
proneness and a maintenance bias for contamination stimuli at a short interval (500 ms or
less; Cisler et al., 2011), longer intervals do not appear to demonstrate a consistent, specific
maintenance bias toward disgust stimuli. Together, the available research suggests that
maintenance of attention on disgust is driven primarily by goal-directed, strategic processes
directed toward threat.

Attentional avoidance.—Attentional avoidance may maintain anxiety disorders by

preventing elaborative processing of disgusting stimuli, which in turn prevents reappraisal
and maintains learned associations with harm/contamination. Multiple studies have
examined the extent to which attentional avoidance is characteristic of disgust. For example,
choice viewing behavior in a selective looking paradigm was initially heightened for all
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affective content but was subsequently followed by significant avoidance of scenes depicting
contamination or nude males (Bradley, Costa, & Lang, 2015). Other studies have found a
significant relationship using eye tracking in non-clinical samples, in which individuals with
high disgust proneness demonstrated greater attentional avoidance of disgust stimuli
(Armstrong, McClenahan, Kittle, & Olatunji, 2014; Mason & Richardson, 2010). Similar
results were found in a disgust conditioning study, which demonstrated that disgust reactions
were resistant to extinction as measured by attentional avoidance, and individuals with
higher disgust proneness exhibited higher resistance to extinction (Mason & Richardson,
2010). These findings suggest that attentional avoidance may be a coping strategy used by
disgust-prone individuals to down-regulate their experience of disgust (Armstrong et al.,
2014).
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Other studies have examined anxious populations and found relationships between
attentional avoidance and disgust proneness. For example, socially anxious participants were
found to spend less time viewing anger and disgust faces than non-socially anxious
participants, potentially because anger and disgust faces are viewed as socially threatening
(Grisham, King, Makkar, & Felmingham, 2015). Another eye-tracking study found that
socially anxious individuals had shorter fixations on sad and disgust faces compared to non-
anxious control participants, specifically avoiding the eyes (Staugaard & Rosenberg, 2011).
Similarly, in a study comparing youth with and without autism spectrum disorder (ASD),
both participants with and without ASD had shorter average fixation durations for disgust
and anger faces than for happy faces, which was significantly correlated with fear of
negative evaluation (White, Maddox, & Panneton, 2015). Finally, attentional avoidance was
also found in individuals with snake phobia using an attention-shifting task of emotional and
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neutral faces while measuring ERP. While no behavioral differences were found on the
shifting task between individuals with snake phobia and a control group, those with snake
phobia had a lower P200 amplitude in response to fear and disgust faces, suggesting
avoidance in the early stages of attention (Sarlo & Munafò, 2010). Table 4 summarizes
available research that has examined disgust-related attentional biases. Taken together, these
findings suggest that specific attentional biases for disgust-related stimuli can be found in
both bottom-up processes, such as initial orienting, and top-down cognitive control

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processes, such as avoidance. However, the majority of research suggests that bottom-up
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processes are influenced by general threat detection, rather than disgust specifically.
Furthermore, motivated avoidance appears to be specific to disgust stimuli among
individuals high in contamination fear (i.e., Armstrong et al., 2012; Tata et al., 1996).

Implicit Biases in Disgust

Cognitive biases in disgust processing have also been examined at the implicit level (for a
comprehensive listing, see Table 5). For example, an implicit memory bias has been
demonstrated for disgust words over threat or neutral words (Charash & McKay, 2009), and
individuals with BII phobia remembered more implicitly-presented disgust words than
healthy control participants (Sawchuk, Lohr, Lee, & Tolin, 1999). Similarly, a version of the
emotional Stroop task that masked stimuli after brief presentation found that individuals
high in disgust proneness responded more quickly to disgust words (Charash, McKay, &
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Dipaolo, 2006). Disgust proneness can also be assessed at an implicit level, using either an
Implicit Association Task (IAT) or Implicit Relational Assessment Procedure (IRAP).
Implicit disgust proneness had a unique effect on automatic avoidance behavior towards a
worm (Zinkernagel, Hofmann, Dislich, Gschwendner, & Schmitt, 2011) and predicted
obsessional beliefs and concerns (Nicholson & Barnes-Holmes, 2012; Nicholson, McCourt,
& Barnes-Holmes, 2013).

Other studies demonstrate implicit associations between disgust and broad constructs like
negative personality traits (Niedenthal, 1990, Study 2) and asymmetry (Evans et al., 2012),
and even self-concept in women with a history of sexual trauma (Rüsch et al., 2011).
However, implicit associations between sex and disgust may be specifically relevant for
understanding sexual dysfunction. Women implicitly associate sex with disgust more than
men (Grauvogl et al., 2015). Women also tend to implicitly associate pornography with
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disgust (Borg, de Jong, & Georgiadis, 2014), and women with sexual dysfunction associate
sex with disgust more than healthy women (Borg, de Jong, & Schultz, 2010). For individuals
with spider or snake fear, disgust is implicitly associated with their feared animal
(Teachman, Gregg, & Woody, 2001). Additionally, individuals who implicitly associate
disgust with personal responsibility have higher obsessive-compulsive symptoms than those
who do not (Nicholson, Dempsey, & Barnes-Holmes, 2014).

Findings that implicit disgust associations can be modified are mixed. Although one study
found that implicit associations between spiders and disgust were reduced over the course of
exposure therapy (Teachman & Woody, 2003), these findings did not replicate in a second
treatment study (Huijding & de Jong, 2007). Furthemore, an implicit bias modification was
unable to reduce implicit associations between disgust and contamination (Green &
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Teachman, 2013). While implicit associations between disgust and feared stimuli in those
with psychopathology appear to be as strong as explicit associations, more research is
needed to determine if these associations are malleable over the course of treatment.

A Combined Cognitive Bias Hypothesis for Disgust

It has been proposed that biased cognitive processes influence each other in that a bias at one
stage (e.g., attention) affects information processing at other stages (e.g., interpretation).

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This notion has been referred to as the combined cognitive bias hypothesis (Hirsch, Clark, &
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Mathews, 2006). Unfortunately, there has been no systematic research examining the
functional relation or dependence between disgust-related cognitive biases in healthy,
analogue, or clinical samples. Existing research supports the notion that biased cognitive
processes associated with disgust may not be isolated mechanisms but instead influence each
other (i.e., Everaert, Duyck, & Koster, 2014). Research on functional relations between
attention biases at elaborative stages and memory suggests that emotional biases in attention
explain congruent biases in recall and recognition (Everaert, Tierens, Uzieblo, & Koster,
2013). This research would be consistent with the hypothesis that selective orienting of
attention to disgust-relevant cues may lead to an interpretation bias (harm/contamination),
which in turn is associated with a congruent bias in memory. This hypothesis highlights the
interplay between cognitive science mechanisms that contribute to maladaptive emotion
regulation in various anxiety and related disorders. Disgust associated biases in attention,
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interpretation, and memory processes may result in maladaptive emotion regulation

strategies (e.g., avoidance) which then maintain anxious symptoms.

Potential Moderators of Cognitive Bias in Disgust Processing

Although cognitive biases in disgust processing likely influence one another to confer risk
for clinical anxiety, individual differences in disgust proneness may differentially affect
cognitive processing of disgust cues in the environment. Disgust proneness can be further
separated into disgust propensity, or how frequently a person experiences disgust, and
disgust sensitivity, or how harmful the experience of disgust is perceived to be (Olatunji,
Cisler, Deacon, Connolly, & Lohr, 2007; van Overveld, Jong, & Peters, 2010b). Of the 98
studies reviewed, only four directly examined both disgust propensity and disgust sensitivity
as moderators of the effect of cognitive bias. One found that neither disgust propensity nor
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disgust sensitivity moderated the effect of the interpretation bias (Leathers-Smith & Davey,
2011), while a study of interpretation bias modification found that disgust propensity, but not
disgust sensitivity, moderated the efficacy of the training, although this was largely driven by
changes in negative affect (Whitton et al., 2013). Mitte (2008b) found that expectancy bias
was related to disgust sensitivity, but not disgust propensity. Disgust sensitivity measured at
an implicit level predicted avoidance of disgusting stimuli and washing concerns, while
implicit disgust propensity predicted obsessing (Nicholson & Barnes-Holmes, 2012).
Delineating the roles of disgust propensity and disgust sensitivity in cognitive biases in
disgust is an important next step in understanding the cognitive mechanisms underlying
psychopathology.

In additional to individual differences in disgust proneness, various demographic

characteristics may interact with disgust biases to explain variance in psychopathology. For
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example, women are consistently found to have greater disgust proneness than men (Oaten,
Stevenson, & Case, 2009), which may be related to evolutionary pressures (Fessler, Eng, &
Navarrete, 2005; Fleischman & Fessler, 2011). Although there is a paucity of research
examining gender differences in cognitive bias for disgust, one study did find that women
demonstrate a greater attentional bias toward disgust compared to men, based on analysis of
viewing patterns of emotional faces (Kraines, Kelberer, & Wells, 2016). However, it remains
unclear if gender differences in cognitive bias for disgust account for the gender differences

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in some anxiety disorder. Ethnic and racial differences in cognitive biases in disgust
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processing may also be relevant but they are also not well-studied. Although African-
Americans consistently exhibit higher contamination fear compared to white participants
(Williams, Abramowitz, & Olatunji, 2012), differences in disgust proneness are less
consistent, with higher disgust proneness found in two studies (Haidt, McCauley, & Rozin,
1994; Tolin, Woods, & Abramowitz, 2006), but not in a study that specifically examined the
effects of race on disgust proneness (Williams et al., 2012). Given the pattern of findings
observed in gender and ethnic differences in disgust proneness, future programmatic
research is clearly needed to examine if such differences also translate to biases in the
cognitive processing of disgust.

Attentional Avoidance as a Distinct Disgust Response?

A combined cognitive bias hypothesis should inform future research examining the role of
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disgust in the development of anxiety and related disorders. However, the extant literature
clearly demonstrates that disgusting stimuli have several modulatory effects on attention.
However, other motivationally-relevant stimuli also capture and hold attention at early levels
of processing, including stimuli that elicit fear (e.g., Ciesielski et al., 2010). Our qualitative
review of the available literature suggests that the effects of disgusting stimuli on attention
appear to emerge later in exposure, after the transition from stimulus-driven to goal-driven,
strategic processing (Cisler & Koster, 2010; Mogg & Bradley, 2016). These effects lie
beyond the early time window (< 1000 ms) typically probed by measures of attention (Bar-
Haim et al., 2007) and thus have largely eluded research on the emotional modulation of
attention. Although attentional avoidance is not unique to disgust, it tends to be more
characteristic of disgust cues compared to threat cues. However, this pattern of findings may
be an artifact of the observation that disgusting stimuli, such as an unflushed toilet, are
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intrinsically more visually aversive than stimuli representing physical harm, such as a gun.

The first study to document possible strategic attentional avoidance of disgust-relevant

stimuli in disorders characterized by heightened disgust proneness used an ad libitum
viewing task, in which participants voluntarily decided when to terminate viewing of stimuli
through a key press (Tolin, Lohr, Lee, & Sawchuk, 1999). Tolin and colleagues (1999) found
that BII phobic participants terminated viewing of BII-relevant stimuli faster than spider
phobic participants and control participants, and spider phobic individuals terminated
viewing of spider stimuli faster than BII phobic individuals and control participants.
However, a recent study (Kron et al., 2014) suggests visual avoidance in the context of ad
libitum viewing may be driven by the general unpleasantness of stimuli. Thus, it is unclear if
phobic individuals in Tolin et al.’s (1999) study were motivated to avoid viewing phobic
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stimuli due to disgust specifically. Improving upon this early measure of visual avoidance,
more recent studies have used eye tracking to measure visual attention on a larger time scale
that encompasses strategic processing (Armstrong & Olatunji, 2012). Consistent with the
findings of Tolin et al. (1999), Rinck and Becker (2006) found that spider phobic
individuals, but not control participants, avoided attending to spiders within the first 3
seconds of a trial, and this pattern was maintained for the full 60 s of stimulus exposure.
Likewise, Armstrong, Hemminger, and Olatunji (2013) found that injection phobic
individuals, but not control participants, avoided attending to images of injection over the

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course of 18 s trials. Furthermore, a meta-analysis of the eye-tracking literature (Armstrong

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& Olatunji, 2012) found that attentional avoidance was only characteristic of specific
phobias linked to disgust.

Although the eye-tracking literature on anxiety-related disorders has not conclusively

established that attentional avoidance is specifically linked to disgust, more direct evidence
that attentional avoidance is specific to disgust comes from basic research on Pavlovian
conditioning. Two studies (Armstrong et al., 2014; Mason & Richardson, 2010) have found
that attentional avoidance is both an unconditioned and a conditioned disgust response; that
is, both disgusting stimuli and neutral stimuli previously associated with disgusting stimuli
elicit attentional avoidance. Further, one of these studies (Armstrong et al., 2014) included a
group that underwent conditioning with a generally threatening US, which did not exhibit
attentional avoidance as an unconditioned or conditioned response. This study is in line with
a handful of other eye-tracking studies that have observed attentional avoidance of disgust-
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relevant stimuli, but not fear-relevant stimuli (Armstrong et al., 2012; Bradley et al., 2015).

A Functional Perspective on Attentional Avoidance of Disgust

In their review of attentional biases for threat in anxiety disorders, Cisler and Koster (2010)
suggest that attentional avoidance at later stages of processing serves the function of emotion
regulation. Attending away from locations that might contain an unpleasant stimulus can
mitigate the distress caused by perceiving and contemplating the stimulus. Thus, attentional
avoidance provides a strategy for down-regulating disgust. Armstrong and Olatunji (2012)
suggest that attentional avoidance is a mode of strategic processing reserved for low-urgency
stimuli. Fear and disgust have been contrasted in terms of the appraisal of urgency (Scherer,
2001), which refers to the evaluation of how rapidly one must respond to a stimulus. Fear-
eliciting stimuli, such as a stray dog baring its teeth, demand an immediate behavioral
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response in order to prevent harm. Accordingly, attention may be maintained upon fear-
eliciting stimuli at the cost of experiencing more distress, in order to promote the goal of
harm avoidance (Armstrong & Olatunji, 2012). Indeed, eye-tracking studies have found that
veterans with PTSD continue monitoring threat cues, rather than avoiding them, perhaps due
to the perceived urgency of trauma cues in this disorder (Armstrong & Olatunji, 2012;
Armstrong, Bilsky, Zhao, & Olatunji, 2013). Disgusting stimuli, in contrast, are usually low
in urgency. Disgusting stimuli present the risk of contamination, rather than imminent bodily
harm (Armstrong & Olatunji, 2017; Woody & Teachman, 2000), and preventing
contamination typically does not require a rapid or sophisticated response. In light of this
low urgency, individuals may use strategic attention to pursue emotion regulation goals in
the presence of disgusting stimuli, choosing to attend away from disgusting stimuli (and
experience less displeasure) rather than monitoring the stimuli in the service of harm
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avoidance.

Another perspective on the link between disgust and attentional avoidance is provided by
Royzman and Sabini’s (2001) theory of disgust. These authors argue that disgust is not
elicited by cognitive appraisals (e.g., urgency) about the state of affairs in the world and is
thus not an emotion. On their account, disgust is more akin to a drive or a reflex, because it
is elicited by the concrete perceptual features of a stimulus, rather than its abstract meaning.

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 Knowles et al. Page 20

Indeed, others have noted that disgust is “peculiar” as an emotion, because it is so

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consistently elicited by certain sensory qualities, regardless of context (Inbar, Pizarro,

Knobe, & Bloom, 2009). Setting aside debates about the status of disgust as an emotion,
several theoretical accounts of disgust argue that disgusting stimuli are intrinsically
unpleasant to perceive. The eyes and legs of a spider or the oozing of pus in a wound for
example, may be repulsive in themselves, regardless of the potential harm they signify. In
line with this thinking, Rozin and colleagues (2008) suggest that whereas fear protects the
body, disgust protects the mind. This perspective would predict that disgusting stimuli,
compared to other negatively-valenced stimuli, would most reliably elicit attentional
avoidance, because these stimuli are intrinsically unpleasant to perceive and will thus be
unpleasant regardless of what a stimulus signifies in a particular context.

Looking Ahead: Treatment Implications of Attentional Bias for Disgust

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The effects of attentional avoidance may be functionally equivalent to the effects of

behavioral avoidance. By avoiding perceptual contact with spiders, injuries, or other
disorder-relevant stimuli, individuals prevent disgust responding from undergoing
habituation. Although disgust appears to habituate more slowly than fear during repeated
exposure (Olatunji, Wolitzky-Taylor, Willems, Lohr, & Armstrong, 2009), there is evidence
that disgust responding eventually undergoes habituation. Rozin (2008), for example, found
that disgust at touching a cadaver was reduced by over 50% in medical students following
extensive exposure. From a cognitive perspective, attentional avoidance may preclude the
possibility of reframing a disgust-eliciting stimulus as less aversive. For example, Mason
and Richardson (2012) suggest that disgust may be reduced by rethinking the nature of a
disgusting stimulus. Specifically, individuals may “deconstruct” a disgusting stimulus by
attending to its constituent parts, thereby interrupting the holistic processing and
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categorization that leads to an evaluative response. Such “conceptual reorienting” (Mason &
Richardson, 2012) would likely require viewing a stimulus (e.g., Gross, 1998) and thus
would be undermined by attentional avoidance.

In light of the potential role of attentional avoidance in maintaining anxiety-related

disorders, it may be worth considering as a treatment target. Indeed, there is evidence
(Hellström, Fellenius, & Öst, 1996; Öst, Fellenius, & Sterner, 1991) that merely attending to
BII-related stimuli provide clinically significant symptom reduction for individuals with BII
phobia. Attention modification procedures (Beard, Sawyer, & Hofmann, 2012) that train
individuals to attend towards disgust eliciting stimuli could be utilized to ‘reverse’ attention
avoidance. However, such procedures appear to target early, relatively automatic attentional
processes (Beard et al., 2012). One approach to targeting later, more strategic biases in
selective attention would be to reward dwelling on disgusting stimuli, through a gaze-
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contingent operant conditioning procedure (see Price, Greven, Siegle, Koster, & de Raedt,
2016). By reversing attentional avoidance, these procedures could facilitate beneficial
processes such as habituation and reappraisal.

Is Disgust Cognitively Impenetrable?

An important issue that must be addressed by cognitive science is the extent to which disgust
responding is encapsulated from corrective information. This research question has direct

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 Knowles et al. Page 21

implications for the extent to which excessive disgust reactions can effectively be treated in
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various disorders. Dating back to the earliest laboratory studies of disgust (e.g., Rozin,
Millman, & Nemeroff, 1986), researchers have noted the emotion’s stubborn resistance to
reason. For example, Rozin and colleagues (1986) observed that appraisals of disgust
operate according to ‘laws of sympathetic magic.’ These include the law of contagion,
which holds that a negative essence transfers from one stimulus to another through contact
and cannot be reversed (‘once in contact, always in contact’) and the law of similarity, which
holds that the essence of an object is contained in its image, such that bearing the image of a
contaminant, for example, constitutes possessing some of that contaminant. Rozin and
colleagues demonstrated the law contagion by showing that participants refused to drink
their preferred juice after a sterilized cockroach was dipped in the juice. Similarly, they
demonstrated the law of similarity by showing that participants refused to eat a brownie in
the shape of dog poop. In both cases, corrective information was provided to ensure that
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participants knew there was no actual risk of contamination. However, participants were
unable to use reason to overcome the laws of sympathetic magic, which Rozin and
colleagues believe constitute a deeply ingrained, rudimentary form of thinking.

Taking this argument a step further, Royzman and Sabini (2001) argue that disgust is entirely
impenetrable to reason. On their account, disgust is not based on cognitive appraisals
(propositions about a state of affairs in the world). Instead, Royzman and Sabini (2001)
argue that disgust is a reflexive response to concrete perceptual features of a stimulus. Thus,
reappraising the meaning of a stimulus is futile, because disgust responding is based on
concrete rather than abstract (i.e., semantic) properties of a stimulus. Royzman and Sabini’s
(2001) account nicely explains the law of similarity, as perceptual qualities (i.e. appearance)
of a contaminating object appear sufficient to elicit disgust. However, their theory has more
difficulty accounting for the law of contagion, as contaminated objects elicit disgust without
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possessing the perceptual qualities of an original contaminant. Royzman and Sabini (2001)
address this inconsistency by arguing that contaminated stimuli activate imagery of the
original contaminant, which in turn reflexively elicits disgust. A further limitation of
Royzman and Sabini’s (2001) theory is that disgust does appear to yield to some forms of
reappraisal. For example, Feinberg, Antonenki, Willer, Horberg, and John (2014) found that
using reappraisal to modify initial disgust reactions reduced disgust-based forms of
prejudice. In addition, several of the classic studies of emotion regulation have used disgust-
eliciting stimuli (e.g., videos depicting body envelope violation; Gross, 1998) to show that
changing the meaning of a stimulus can reduce the intensity of one’s emotional reaction.

Conclusion
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Disgust has been implicated in the development of various forms of psychopathology,

especially anxiety-related disorders. Cognitive science theories may have utility in clarifying
the underlying mechanisms that may explain how disgust confers risk for these disorders.
Our review of the literature suggests that attentional avoidance may be the most
characteristic of disgust. However, this attentional avoidance feature does not appear to be
fully consistent with the adaptive function of disgust. For example, monitoring disgust
stimuli (i.e., not avoiding) in one’s environment facilitates disease avoidance; it is adaptive
to maintain attention on the sneezing waiter at a restaurant to ensure that he does not

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 Knowles et al. Page 22

contaminate your food. Future research is need to clarify the conditions in which visual
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avoidance that is motivated by the experience of disgust becomes maladaptive. Adaptive

visual avoidance may function to monitor actual contagion threat, whereas maladaptive
visual avoidance may function to regulate one’s distress about contagion (independent of
threat value). Focusing on attentional avoidance also offers avenues for developing novel
treatments for disgust-based disorders. For example, attention bias modification tasks that
direct attention toward disgusting stimuli may be clinically useful as adjunctive treatments
alongside in vivo exposure to disgust and psychoeducation regarding the functional nature of
disgust.

Although this review suggests that attentional avoidance may be uniquely associated with
disgust, a combined cognitive bias hypothesis suggests that attentional biases for disgust
may confer risk for various disorders by having a downstream biasing influence on
interpretation, memory, and judgment. However, future research is needed to test this
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hypothesis and the extent to which it accounts for meaningful variance in different disorders.
Importantly, a combined cognitive bias hypothesis also highlights the potential value of
examining the extent to which disgust responds to a wider range of cognitive interventions.
Mason and Richardson (2012) suggest that efforts to directly reframe the evaluation of a
disgusting stimulus (i.e., “that is not disgusting”) are likely futile. Instead, they recommend
multiple strategies for rethinking the nature of a stimulus, either through subsuming the
stimulus under a different category (e.g., yogurt instead of rotten milk) or by deconstructing
the stimulus into constituent elements (e.g., blood cells, platelets, and plasma instead of
blood). In the event that disgust proves impenetrable to these cognitive interventions, Mason
and Richardson suggest focusing on secondary disgust appraisals that include cognitions
about one’s disgust response (e.g., if I feel nauseated it is bad for me; van Overveld et al.,
2010b). Indeed, studies of expectancy bias in disgust suggest that individuals high in disgust
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sensitivity appraise disgust stimuli as being more likely to cause contamination or illness
compared to individuals low in disgust sensitivity (e.g., Mitte, 2008b); however, no studies
have examined the effects of an expectancy bias modification procedure in highly disgust-
sensitive individuals. There is some evidence that such appraisals predict unique variance in
symptoms of anxiety-related disorders and may be more clinically important than the
magnitude of initial disgust responding (i.e., propensity; Engelhard, Olatunji, & de Jong,
2011). Thus, targeting such appraisals appears to be an important next step in the treatment
of psychopathology in which disgust is central. There have been important advances in
cognitive science that have improved our understanding of the etiology and maintenance of
psychopathology, and these advances may also be translated in meaningful ways to develop
interventions that can more effectively treat excessive disgust reactions in various disorders.
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Figure 1.
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Flow diagram illustrating the search process.

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Table 1.

Characteristics of studies assessing disgust-related memory bias.

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Bias Authors Sample Disgust Measure Cognitive Measure

Memory bias: Increased Charash & Unselected adults DS Recall of disgust, fear, and neutral
memory for disgust McKay, 2002 primed with disgust (n words used in Stroop task
= 20), fear (n = 20), or
neutral (n = 20)
stories

Memory bias: Increased Charash & High contamination DS Completion of disgust, threat, and
memory for disgust McKay, 2009 fear (n = 20), high neutral stems of words used in Stroop
trait anxiety (n = 20), task
and healthy control
participants (n = 20)

Memory bias: Increased Chapman et al., Unselected adults (N Self-reported Recall of disgust, fear, and neutral
memory for disgust 2013 = 51) disgust response to images previously displayed during a
emotional images line discrimination task

Memory bias: Increased Croucher et al., Unselected adults (N Self-reported Recognition of previously encoded
memory for disgust 2011 = 32) disgust response to disgust, fear, and positive images
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emotional images

Memory bias: Increased Duesenberg et Unselected adults (N None Recognition of previously encoded
memory for disgust al., 2016 = 75) disgust, negative, positive, and neutral
words

Memory bias: Increased Marchewka, Unselected women (N None Directed forgetting task with disgust,
memory for disgust Wypych, = 18) fear, sad, and neutral images
Michałowski, et
al., 2016

Memory bias: Increased Marchewka Unselected adults (N None Directed forgetting task with positive,
memory for disgust Wypych, = 17) negative, and neutral images
Moslehi, et al.,
2016

Memory bias: Increased Román et al., Unselected adults (N None N-back task with disgust, positive, and
memory for disgust 2015 = 76) neutral faces

Memory bias: Increased Sawchuk et al., BII participants who MDES Completion of disgust, medical,
memory for disgust 1999 underwent a disgust negative, and neutral stems of words
(n = 28) or neutral (n used in Stroop task
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= 25) mood induction

and healthy control
participants who
underwent disgust (n
= 25) or neutral (n =
29) mood induction
Memory bias: Enhancement Bomyea & Unselected adults (N DS-R Thought monitoring task following
Amir, 2012 = 30) exposure to trauma-related film

Memory bias: Enhancement Clayton et al., Nicotine-deprived 3 disgust items Recognition of audio clips from
2017 adults (N = 50) about response to previously viewed anti-tobacco
anti-tobacco advertisement
advertisement

Memory bias: Enhancement Leshner et al., Unselected adults (N None Recognition of audio clips from
2011 = 49) previously viewed anti-tobacco
advertisement

Memory bias: Enhancement Teachman & Adults with high (n = DS Free recall of previously displayed
Saporito, 2009 158) or low (n = 108) spider, panic, and neutral words
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spider fear

Memory bias: Decreased Gasbarri et al., Women in mentrual (n None Delayed matching-to-sample task
memory for disgust 2008 = 14), follicular (n =
21), or luteal phase (n
= 21)

Memory bias: Decreased Medina et al., Unselected adults who None One story from logical memory subtest
memory for disgust 2016 viewed disgust photo of the Wechsler Memory Scale-III

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Bias Authors Sample Disgust Measure Cognitive Measure

(n = 41) or neutral
photo (n = 40)
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Memory bias: No effect Sawchuk et al., BII (n = 37), spider None Recognition of disgust, surgical, spider,
2002 phobic (n = 39), and and neutral images
heatlhy control
participants (n = 40)

Note. BII = Blood-injection-injury; DS = Disgust Scale; DS-R = Disgust Scale-Revised; MDES = Modified Differential Emotion Scale
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Table 2.

Characteristics of studies assessing disgust-related interpretation bias.

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Bias Authors Sample Disgust Measure Cognitive Measure

Interpretation Charash & High contamination fear (n = 20), DS; Disgust interpretations Ambiguous scenarios with
bias (disgust McKay, high trait anxiety (n = 20), and disgust, threat, and neutral
interpretation) 2009 healthy control participants (n = 20) interpretation choices (i.e., “A
powerful smell occurs to you.
What is it?” Disgust interpretation
= Vomit

Interpretation Davey et al., Unselected adults who underwent a DPSS Homophone spelling task (e.g.,
bias (disgust- 2006 disgust (n = 25), anxiety (n = 25), threat vs neutral, “die/dye”)
induced negative happy (n = 25), or neutral (n = 25)
interpretation) mood induction (e.g., disgust
induction = audio of disgusting
noises [e.g., burping, vomiting]
while reading a disgusting vignette
[e.g., “You go into a public toilet and
find it has not been flushed. The
bowl of the toilet is full of
diarrhoea”)
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Interpretation Davey et al., Unselected adults who underwent a DPSS Self-reported anxiety to
bias (disgust- 2008 disgust induction (n = 30) or neutral ambiguous scenario images (e.g.,
induced negative induction (n = 30) (e.g., disgust a person holding a snake [fear and
interpretation) induction = audio of disgusting disgust relevant], a person in an
noises [e.g., burping, vomiting] enclosed pothole [fear relevant,
while reading a disgusting vignette disgust irrelevant], a person riding
[e.g., “You go into a public toilet and a bike [fear and disgust
find it has not been flushed. The irrelevant]) following mood
bowl of the toilet is full of induction
diarrhoea”)

Interpretation Krusemark Unselected adults (N = 39) None Rating of distance from Greeble
bias (disgust- & Li, 2013 following viewing disgust (e.g.,
induced negative roaches), fear (e.g., guns), or
interpretation) neutral (e.g., animals) image

Interpretation Leathers- Unselected adults who underwent a DPSS-R Homophone spelling task (e.g.,
bias (disgust- Smith & disgust (n = 20), anxiety (n = 20), or threat vs neutral, “grown/groan”)
induced negative Davey, 2011 neutral (n = 20) mood induction
interpretation) (e.g., disgust induction = audio of
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disgusting noises [e.g., burping,

vomiting] while reading a disgusting
vignette [e.g., “You are walking
barefoot along the beach. You tread
in a dog poo, it is warm and squishes
between your toes)

Interpretation Mayer et al., Unselected adults who underwent a DS Open-ended ambiguous secnarios
bias (disgust- 2009 disgust (n = 30), anxiety (n = 30), (e.g., threat-related scenario =
induced negative happy (n = 30), or neutral (n = 30) “You are waiting for a good friend
interpretation) mood induction (e.g., disgust to come. Normally she is very
induction = audio of disgusting punctual, but now she is already
noises [e.g., burping, vomiting] more than a quarter of an hour
while reading a disgusting vignette late. Her cell phone is switched
[e.g., “You go into a public toilet and off.”; threat related interpretation
find it has not been flushed. The = She has had an accident”)
bowl of the toilet is full of
diarrhoea”)

Interpretation Muris et al., Children given disgust information DEC Open-ended ambiguous secnarios
bias (disgust 2012 (n = 47; e.g., “The Cuscus eats (e.g., “You discover the nest of a
interpretation) brown grunge”) or neutral inforation Cuscus in the woods”
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(n = 47) about a novel animal

Interpretation Whitton et Unselected adults who participated DPSS-R; EMG; BAT Ratings similarity of disgust and
bias (disgust al., 2013 in cognitive bias modification to neutral sentences to ambiguous
interpretation) train disgust (n = 30; e.g., unfinished sentences (e.g., ambiguous =
sentence = “Squelching mud “When I go to a restaurant where I
between my toes reminds me of can watch the chef prepare my
___”; disgust solution = “St_pping meal, I always think the same

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 Knowles et al. Page 39

Bias Authors Sample Disgust Measure Cognitive Measure

in do_ poo”) or neutral (n = 30) thing.”; disgust = “When I go to a
interpretive biases restaurant where I can watch the
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chef prepare my meal, I always

think about how dirty the chef’s
hands might be.”)

Note. BAT = Behavioral approach task; EMG = Electromyography; DEC = Disgust Emotion Scale for Children; DS = Disgust Scale; DS-R =
Disgust Scale- Revised; DPSS = Disgust Prospensity and Sensitivity Scale; DPSS-R = Disgust Prospensity and Sensitivity Scale-Revised
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Table 3.

Characteristics of studies assessing disgust-related expectancy bias.

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Bias Authors Sample Disgust Measure Cognitive Measure

Expectancy bias: a Armstrong & High (n = 32) and low (n DS-R; Self- Expectancy ratings of disgust image
priori Olatunji, 2017 = 30) contamination- reported disgust (US) following neutral faces (CS) after
fearful adults response different stages of an associative
learning task (habituation, acquisition,
and extinction)

Expectancy bias: a Connolly Lohr, High (n = 32) and low (n DS Percentage estimates of given stimulus-
posteriori Olatunji, et al., = 30) contamination- outcome pairings (fear, disgust, and
2009 fearful adults neutral images with fear, disgust, or
neutral facial expressions)

Expectancy bias: a Davey et al., Unselected adults (N = DS Expectancy ratings of hypothetical pain
priori 2003 91) and disgust-related outcomes for
predatory, disgusting, and safe animals

Expectancy bias: a de Jong & Peters, High (n = 25) and low (n None Expectancies of harm and disgust-
priori and a posteriori 2007b = 24) spider-fearful related outcomes after viewing safe,
women disgusting, and harm-related animals
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and spiders

Expectancy bias: a Mason & Unselected adults DS-R Expectancy ratings of disgust image
priori Richardson, 2010 assigned to extinction (n = (US) following neutral faces (CS)
27) or no extinction (n = during acquisition and after extinction;
28) eye tracking during passive viewing of
CS and US

Expectancy bias: a Mayer et al., Unselected women (N = DS Expectancy ratings of hypothetical pain
priori and a posteriori 2011 61) and disgust-related outcomes for images
of obese bodies, slim bodies, and
neutral scenes; percentage estimates of
given stimulus-outcome pairings (obese
bodies, slim bodies, and neutral scenes
with fear, disgust, or neutral facial
expressions)

Expectancy bias: a Mayer et al., Unselected adolescents (N None Expectancy ratings of hypothetical pain,
priori and a posteriori 2012 = 148) disgust, and positive outcomes after
viewing words describing controlled or
uncontrolled eating behavior;
percentage estimates of given stimulus-
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outcome pairings (words describing

controlled or uncontrolled eating
behavior with fear, disgust, happy, or
neutral facial expressions)

Expectancy bias: a Mitte, 2008b Unselected adults (N = DPSS-R Rating likelihood of catching a disease
priori 86) after performing a hypothetical disgust-
related behavior

Expectancy bias: a Olatunji et al., High (n = 30) and low (n DES Expectancy ratings for hypothetical
priori 2006 = 30) contamination- pairings of fear, disgust, and neutral
fearful adults images with fear, disgust, or neutral
facial expressions

Expectancy bias: a Olatunji et al., High (n = 22) and low (n None Expectancy ratings for hypothetical
priori 2008 = 28) spider-fearful adults pairings of spiders, disgust images, and
neutral images with fear, disgust, or
neutral facial expressions

Expectancy bias: a Olatunji, Etzel, Adult blood donors (N = None Rating expected disgust during blood
priori & Ciesielski, 446) donation
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2010

Expectancy bias: a Sharvit et al., Unselected adults (N = Self-reported Subjective ratings of disgust and pain
priori 2010 18) disgust rating; skin after “low,” “medium”, or “high”
conductance; HR; disgust or pain cue
respiration

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Bias Authors Sample Disgust Measure Cognitive Measure

Expectancy bias: a Thorpe et al., Unselected adults (N = DS; Self-reported Expectancies of likelihood of becoming
priori 2011 30) disgust rating ill and severity of illness after
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contamination BAT

Expectancy bias: a van Overveld et High (n = 27) and low (n None Expectancies of hypothetical harm and
priori al., 2006 = 28) spider-fearful disgust-related outcomes after viewing
women safe, disgusting, and harm-related
animals and spiders

Expectancy bias: a van Overveld et High (n = 30) and low (n DS; DPSS-R Expectancies of hypothetical harm and
priori al., 2010a = 30) blood-fearful disgust-related outcomes after viewing
individuals blood, fear, disgust, combined fear and
disgust, and neutral images

Expectancy bias (a Connolly, Lohr, High (n = 32) and low (n DS-R Percentage estimates of given stimulus-
posteriori) for affect- Williams, et al., = 30) BII-fearful adults outcome pairings (fear, disgust, and
congruent stimuli 2009 neutral images with fear, disgust, or
neutral facial expressions)

Expectancy bias (a Engelhard et al., Unselected adults None Expectancy ratings of disgust image
priori) for negative only 2014 (Study 1) assigned to extinction (n = (US) following neutral faces (CS)
20) or no extinction (n = during acquisition and after extinction
20)
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No expectancy bias de Jong & Peters, High (n = 25) and low (n DES Expectancies of harm and disgust-
2007a = 27) BII-fearful women related outcomes after viewing fear-
irrelevant and fear-relevant (blood
donation) images

Note. CS = conditioned stimulus; DES = Disgust Emotion Scale; DPSS-R = Disgust Prospensity and Sensitivity Scale-Revised; DS = Disgust
Scale; DS-R = Disgust Scale- Revised; HR = heart rate; US = unconditioned stimulus
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Table 4.

Characteristics of studies assessing disgust-related attentional bias.

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Bias Authors Sample Disgust Measure Cognitive Measure

Attentional bias: Charash & Unselected adults primed with DS Stroop task with disgust, threat, and
Interference effect McKay, 2002 disgust (n = 20), fear (n = 20), or neutral words
neutral (n = 20) stories

Attentional bias: Charash et al., Unselected adults primed with DS Stroop task with disgust, threat, and
Interference effect 2006 disgust (n = 20), fear (n = 20), or neutral words
neutral (n = 20) stories

Attentional bias: Cisler et al., 2009 Unselected adults (N = 99) DS RSVP with disgust, fear, or neutral
Interference effect word targets

Attentional bias: Olatunji et al., GAD (n = 30) and healthy None ACS; RSVP with disgust, fear,
Interference effect 2011 control adults (n = 30) erotic, or neutral image distractors

Attentional bias: Olatunji et al., Veterans with PTSD (n = 20), None RSVP with disgust, combat,
Interference effect 2013 veterans without PTSD (n = 16), pleasant, or neutral image
and healthy control non-veterans distractors
(n = 22)
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Attentional bias: van Hooff et al., Unselected adults (N = 30) DS-R RSVP with disgust, fear, and
Interference effect 2013 neutral images

Attentional bias: Ciesielski et al., Unselected adults (N = 50) None RSVP with disgust, fear, erotic, or
General emotion 2010 neutral image distractors
interference effect

Attentional bias: No Benoit et al., Children with an anxiety disorder Self-reported disgust Stroop task with disgust, anger,
interference effect 2007 (n = 52) and healthy control in response to happy, and neutral faces
children (n = 46) emotional faces

Attentional bias: No Charash & High contamination fear (n = 20), DS Stroop task with disgust, social
interference effect McKay, 2009 high trait anxiety (n = 20), and threat, and neutral words
healthy control participants (n =
20)

Attentional bias: No Sawchuk et al., BII participants who underwent a MDES Stroop task with disgust, medical,
interference effect 1999 disgust (n = 28) or neutral (n = negative, and neutral words
25) mood induction and healthy
control participants who
underwent disgust (n = 25) or
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neutral (n = 29) mood induction

Attentional bias: No van Hooff et al., Unselected adults (N = 46) DS-R RSVP with disgust, fear, happy, and
interference effect 2014 neutral images

Attentional bias: No Vermeulen et al., Unselected adults (N = 18) None RSVP with disgust, fear, sad, and
interference effect 2009 happy face primes before each trial
Attentional bias: Armstrong et al., Adults with high (n = 19) and DS-R; BAT Eye tracking during free viewing of
Orienting (not 2012 low contamination fear (n = 20) array of contamination, threat,
maintenance) pleasant, and neutral images
(disgust-specific)

Attentional bias: Carretié et al., Unselected adults (N = 26) Self-reported disgust EEG; EOG; Digit categorization
Orienting (disgust- 2011 response to task with disgust, fear, and neutral
specific) emotional images image distractors

Attentional bias: Chapman et al., Unselected adults (Study 1 N = Self-reported disgust Line discrimination task with
Orienting (disgust- 2013 51; Study 2 N = 23) response to disgust, fear, or neutral images
specific) emotional images

Attentional bias: Lu et al., 2016 Unselected adults (N = 22) Self-reported disgust EEG; EOG; Oddball task with
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Orienting (disgust- response to disgust, fear, and neutral images

specific) emotional images

Attentional bias: Santos et al., Unselected adults monitoring None EEG; EOG; Identification of
Orienting (disgust- 2008 disgust/neutral faces (n = 8) or previously seen faces (disgust, fear,
specific) fear/neutral faces (n = 8) or neutral) and houses

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Bias Authors Sample Disgust Measure Cognitive Measure

Attentional bias: Tata et al., 1996 Adults with contamination OCD None Dot-probe task with contamination
Orienting (disgust- (n = 13), high trait anxiety (n = and social threat words
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specific) 18), and low trait anxiety (n =

26)

Attentional bias: Xu et al., 2015 Unselected adults (N = 18) None EEG; EOG; Go/no go task
Orienting (disgust- superimposed on disgust, fear, and
specific) neutral images

Attentional bias: Vogt et al., 2011 Unselected adults who underwent DS-R Dot-probe with disgust, clean, or
Orienting a disgust (n = 20) or neutral neutral image cues
(cleanliness > mood indunction (n = 19)
disgust)

Attentional bias: Vogt & de Unselected adults instructed to Self-reported disgust Dot-probe with disgust, clean, or
Orienting Houwer, 2014 suppress (n = 19) or maintain (n response to disgust neutral image cues
(cleanliness > = 19) disgust response following induction
disgust) disgust induction

Attentional bias: Çek et al., 2016 Unselected adults (N = 55) None Eye tracking during free viewing of
Orienting (threat) pairs of emotional (disgust, angry,
or happy) and neutral faces
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Attentional bias: Holas et al., 2014 Adults with high (n = 22) or low None Eye tracking during free viewing of
Orienting (threat) trait anxiety (n = 26) pairs of emotional (disgust, fear,
angry, sad, or happy) and neutral
faces

Attentional bias: Judah et al., 2016 Social anxiety disorder (n = 20) None EEG; Change detection task with
Orienting (threat/ and healthy control adults (n = disgust and neutral faces
rejection) 22)

Attentional bias: Leutgeb et al., Spider phobia adolescent females QADS; Self-reported EEG; EOG; Free-viewing task with
Orienting (threat) 2010 (n = 14) and healthy control disgust response to disgust, spider, fear, or neutral
participants (n = 14) emotional images images

Attentional bias: Scharmüller et Spider phobia females (n = 25) QADS; Self-reported EEG; EOG; Free-viewing task with
Orienting (threat) al., 2011 and healthy control females (n = disgust response to disgust, spider, fear, or neutral
20) emotional images images

Attentional bias: Stevenson et al., Unselected children (n = 20) and DS Eye tracking during free viewing of
Orienting (threat) 2014 adults (n = 23) pairs of emotional (disgust, fear, or
happy) and neutral images

Attentional bias: Übel et al., 2015 Disgust-prone adolescent girls (n QADP-C EEG during passive viewing of
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Orienting (threat) = 28) disgust and neutral images

Attentional bias: Krusemark & Li, Unselected adults (N = 43) Self-reported disgust EEG; Visual search task with
Reduced orienting to 2011 response to disgust, fear, or neutral images
disgust emotional images displayed before each trial

Orienting bias Amir et al., 2008 High social anxiety adults who None Dot-probe with social threat or
reduced after ABM underwent attention modification neutral word cues
program (n = 47) or control
training (n = 47)

Orienting bias Kim et al., 2014 Anorexia nervosa (n = 31) and None Dot-probe with disgust, angry,
reduced with healthy control adults (n = 33) happy, or neutral image cues
oxytocin

Attentional bias: Westphal et al., Unselected adults (N = 92) None Dot-probe with disgust, angry,
Orienting to open- 2014 happy, or sad image cues
mouth disgust faces;
avoidance of closed-
mouth disgust faces

Attentional bias: Armstrong et al., Adults with high (n = 23) or low DS-R; BAT Eye tracking during free viewing of
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Maintenance (not 2010 contamination fear (n = 25) pairs of emotional (disgust, fear, or
orienting) (disgust- happy) and neutral faces
specific)

Attentional bias: Cisler et al., 2011 Unselected adults (N = 108) DPSS-R: disgust Spatial cueing task with disgust,
Maintenance propensity subscale; fear, or neutral images
(disgust-specific) Chain of contagion
task

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 Knowles et al. Page 44

Bias Authors Sample Disgust Measure Cognitive Measure

Attentional bias: Buckner et al., Unselected adults (N = 46) Self-reported disgust Eye tracking during free viewing of
Maintenance (threat/ 2010 to emotional faces disgust and happy faces
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rejection)

Attentional bias: Cisler & Olatunji, High contamination fear (n = 23) Self-reported disgust Spatial cueing task with disgust,
Maintenance (threat) 2010 and healthy control adults (n = to emotional images fear, or neutral images
28)

Attentional bias: Armstrong et al., Unselected adults conditioned DS-R Eye tracking during Pavlovian
Avoidance (disgust- 2014 with disgust US (n = 55) or conditioning paradigm
specific) negative US (n = 65)

Attentional bias: Bradley et al., Unselected adults (N = 42) 16 items from DS; Eye tracking during free viewing of
Avoidance (disgust- 2015 Skin conductance contamination, mutilation, threat,
specific) food, nude male, or nude female
images paired with neutral images

Attentional bias: Mason & Unselected adults (N = 61) DS-R Eye tracking during Pavlovian
Avoidance (disgust- Richardson, 2010 conditioning paradigm with disgust
specific) US

Attentional bias: Zimmer et al., Unselected adults (N = 32) None fMRI and eye tracking during a
Avoidance (disgust- 2016 spatial cueing task with disgust and
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specific) fear auditory cues

Attentional bias: Grisham et al., High social anxiety adults (n = None Avoidance view-time task with
Avoidance (threat) 2015 29) and low social anxiety adults disgust, anger, happy, and neutral
(n = 28) faces

Attentional bias: Sarlo & Munafò, Snake phobia (n = 15) and None EEG during target detection task
Avoidance (threat) 2010 healthy control adults (n = 15) with disgust, angry, fear, and
neutral faces

Attentional bias: Staugaard & Social anxiety disorder (n = 8) None Eye tracking during free viewing of
Avoidance (threat) Rosenberg, 2011 and healthy control adults (n = disgust, angry, happy, sad, or
34) neutral faces

Attentional bias: White et al., 2015 Adolescents with autism (n = 15) None Eye tracking during free viewing
Avoidance (threat) and healthy control adolescents task with disgust, fear, angry,
(n = 18) happy, sad, and surprise faces

Attentional bias: Judah et al., 2013 Social anxiety disorder (n = 19) None Dot-probe task with disgust, happy,
Avoidance; orienting and healthy control adults (n = and neutral faces
under cognitive load 22)
(threat/rejection)
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Note. ABM = Attention Bias Modification; ACS = Attentional Control Scale; BAT = Behavioral approach task; DPSS-R = Disgust Prospensity and
Sensitivity Scale-Revised; DS = Disgust Scale; DS-R = Disgust Scale- Revised; EEG = electroencephalography; EOG = electroocculography;
fMRI = Functional magnetic resonance imaging; GAD = Generalized anxiety disorder; PTSD = Posttraumatic stress disorder; QADP-C =
Questionnaire for the assessment of disgust propensity in children; QADS = Questionnaire for the Assessment of Disgust Sensitivity; RSVP =
Rapid serial visual presentation; US = unconditioned stimulus
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 Knowles et al. Page 45

Table 5.

Characteristics of studies assessing disgust-related implicit biases.

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Bias Authors Sample Disgust Measure Cognitive Measure

Amygdala activation during Anderson et al., Unselected adults (N = 12) None fMRI while viewing
implicit attention to disgust 2003 disgust, fear, and neutral
faces superimposed on
scene images

Implicit association between Borg et al., 2010 Women with vaginismus (n = Subjective disgust IAT
disgust and sex for women with 24), dyspareunia (n = 24), and ratings; facial EMG
vaginismus and dyspareunia healthy control women (n =
31)

Implicit association between Borg et al., 2014 Healthy women (N = 20) Subjective disgust IAT
disgust and pornography ratings of
pornographic stimuli

Implicit memory bias Charash & High contamination fear (n = DS Completion of disgust,
McKay, 2009 20), high trait anxiety (n = threat, and neutral stems
20), and healthy control of words used in implicit
participants (n = 20) Stroop task
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Implicit bias: Interference effect Charash et al., Unselected adults primed with DS Implicit Stroop task with
2006 disgust (n = 20), fear (n = 20), disgust, threat, and
or neutral (n = 20) stories neutral words

Implicit association between Evans et al., Unselected adults (Study 1 N None IAT
disgust and asymmetry 2012 = 82; Study 2 N = 26)

Implicit association between sex Grauvogl et al., Healthy, sexually active DPSS-R; DS-R IAT
and disgust greater for women 2015 (Study 2) women (n = 24) and men (n =
than men 19)

No effect of implicit bias Green & High contamination fear DS-R IAT
modification on implicit Teachman, 2013 adults (N = 81)
associations between disgust
and contamination

No effect of treatment on Huijding & de Adults seeking treatment for AMDS IAT
implicit associations between Jong, 2007 spider phobia (n = 60) and
disgust and spiders non-phobic (n = 30) adults

Implicitly measured disgust Nicholson & Unselected adults (N = 33) DS-R IRAP
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sensitivity predicted avoidance Barnes-Holmes,

and washing concerns; disgust 2012
propensity predicted obsessing

Implicit negative-disgust Nicholson et al., Unselected adults (N = 44) None IRAP

association predicted 2013
obsessional beliefs
Implicit association between Nicholson et al., Unselected adults (N = 29) DS-R IRAP
responsibility and disgust 2014
predicted high OC symptoms

Implicit association between Niedenthal, 1990 Unselected adults (N = 72) None Masked presentation of
disgust and negative traits (Study 2) joy, disgust, or neutral
faces with a cartoon

Explicit (but not implicit) spider Ouimet et al., Unselected adults (N = 134) DPSS-R GNAT
fear associated with high disgust 2017
proneness

No implicit association between Ritzert et al., Unselected adults (N = 75) DPSS-R IRAP
fat (self) and disgust 2016
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Women with BPD and/or PTSD Rüsch et al., Women with BPD, (n = 20), QADS IAT
implicitly associated self- 2011 PTSD (n = 20), both BPD and
concept with disgust PTSD (n = 15), and healthy
women (n = 37)

Implicit memory bias Sawchuk et al., BII participants who MDES Completion of disgust,
1999 underwent a disgust (n = 28) medical, negative, and
or neutral (n = 25) mood

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 Knowles et al. Page 46

Bias Authors Sample Disgust Measure Cognitive Measure

induction and healthy control neutral stems of words
participants who underwent used in Stroop task
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disgust (n = 25) or neutral (n

= 29) mood induction

Implicit extraversion positively Suslow et al., Healthy adults (N = 40) None IAT; implicitly presented
related to cerebellar response to 2017 emotional faces
masked disgust faces

Implicit associations between Teachman et al., Snake-fearful (n = 30) spider- None IAT
disgust and feared animal 2001 fearful (n = 37) adults

Implicit associations between Teachman & Spider-phobic (n = 31) and None IAT
spiders and disgust reduced over Woody, 2003 healthy control participants (n
the course of exposure therapy = 30)

Implicit disgust proneness had a Zinkernagel et Unselected adults (N = 75) DS (German version) IAT
unique effect on automatic, but al., 2003
not strategic, avoidance behavior

Note. AMDS = Armfield and Mattiske (Spider) Disgust Scale; DES = Disgust Emotion Scale; DPSS-R = Disgust Prospensity and Sensitivity
Scale-Revised; DS = Disgust Scale; DS-R = Disgust Scale-Revised; GNAT = Go/No-go Association Task; IAT = Implicit Association Test; IRAP =
Implicit Relational Assessment Procedure; MDES = Modified Differential Emotions Scale; OC = obsessive-compulsive; QADS = Questionnaire
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for the Assessment of Disgust Sensitivity

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