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Habituation to contaminants : impact of threatening imagery Dorfan, Nicole Michelle 2003

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HABITUATION TO CONTAMINANTS: IMPACT^  IMAGERY by  NICOLE M I C H E L L E D O R F A N B.A., University of Pennsylvania, 1998  A THESIS SUBMITTED IN PARTIAL F U L F I L M E N T OF T H E REQUIREMENTS FOR T H E D E G R E E OF M A S T E R OF ARTS  in T H E F A C U L T Y OF G R A D U A T E STUDIES (Department of Psychology) We accept'this thesis as conforming to the required standard  T H E UNIVERSITY OF BRITISH C O L U M B I A June 2003 ® Nicole Michelle Dorfan, 2003  UBC  Rare Books and Special Collections - Thesis Authorisation Form  Page 1 of 1  In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the head o f my department o r by h i s o r h e r r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t copying o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d without my w r i t t e n p e r m i s s i o n .  Department o f The U n i v e r s i t y o f B r i t i s h Columbia Vancouver, Canada  http://www.library.ubc.ca/spcoll/thesauth.html  08/07/03  Abstract  Habituation of fear is widely studied by both researchers and clinicians. One type of fear prevalent among adults is the fear of contamination. Predominant theoretical models relevant to contamination fears focus on the role of maladaptive cognitions in the development and maintenance of anxiety disorders. However, there is a paucity of research evaluating the impact of maladaptive cognitions on habituation to phobic stimuli. The current study examined the effect of three types of imagery (looming harm, static harm, and safety) on habituation to a contaminant in a normal college sample. Both static harm and looming harm imagery were expected to retard habituation compared with safety imagery. In addition, looming imagery was expected to impede habituation above and beyond the effects of static harm, in line with the theory of looming vulnerability. Results indicated that distress ratings for participants in the looming harm condition sensitized over time, whereas distress diminished in the static harm and safety groups. Thus, looming imagery may explain why some individuals experience lingering feelings of contamination after exposure, while others recover relatively quickly. In addition, cognitions and imagery regarding movement of phobic objects may be detrimental to those engaging in exposure therapy for anxiety disorders such as obsessive compulsive disorder.  T A B L E OF CONTENTS  Abstract  ii  Table of Contents  iii  List of Tables  iv  List of Figures  v  Introduction  1  Methods  11  Results  '.  22  Discussion  33  References  41  Appendix A Betts' Questionnaire Upon Mental Imagery-Short Form  63  Appendix B Maudsley Obsessive Compulsive Inventory, Washing Subscale  66  Appendix C Obsessive Beliefs Questionnaire, Overestimation of Threat and Tolerance of Uncertainty Subscales  67  Appendix D Disgust Scale  69  Appendix E Anxiety Sensitivity Index  71  Appendix F Rating Form for Subjective Units of Discomfort  72  Appendix G Reaction to Exposure Questionnaire  73  Appendix H Imagery Usage Questionnaire  74  Appendix I  Demographics and Bathroom Habits Questionnaire  76  Appendix J  Imagery Prompts and Cue Questions for each Imagery Condition  78  iv  LIST OF T A B L E S  Table 1: Means and Standard Deviations on Questionnaires and Baseline Ratings of Distress for the Full Sample (N=90)  47  Table 2: Correlations and Reliability Coefficients for Preliminary Questionnaire Measures. .48 Table 3: Baseline Ratings of Distress for Exposure Completers and Refusers  49  Table 4: MANOVA for Manipulation Check of Imagery Usage  50  Table 5: Means and Standard Deviations for Imagery Usage During Exposure  51  Table 6: MANOVA for Imagery Ability During Exposure  52  Table 7: Means and Standard Deviations for Imagery Ability During Exposure  53  Table 8: Imagery Ability in Compliant and Noncompliant Imagers  54  Table 9: Cohen's d Effect Sizes for Comparison of Groups on Distress Indices of Change  55  Table 10: MANOVA for Reaction to Exposure Questionnaire Items  56  Table 11: Means and Standard Deviations for Reaction to Exposure Questionnaire Items  57  Table 12: MANOVA for Indices of Change in Quadratic Model  58  Table 13: Means and Standard Deviations for Quadratic Model Change Parameters  59  LIST OF FIGURES  Figure 1: Immediate Effect of Imagery  61  Figure 2: Average Distress Ratings for each Imagery Group during 30-Minute Exposure.. .62  1  Habituation to Contaminants: Impact of Threatening Imagery Habituation of fear is widely studied by both researchers and clinicians. Habituation is defined as a response decrement following repeated or prolonged presentation of a stimulus. Although many characteristics of the habituation process are strikingly similar across a wide array of animals and human populations (Thompson & Spencer, 1966), much remains unexplained regarding the mechanisms that underlie the fear reduction process. One type of fear prevalent among adults is the fear of contamination (Rozin, Haidt, & McCauley, 1993). Given that all humans encounter potentially contaminating stimuli on a daily basis (using public bathrooms, walking on dirty sidewalks, breathing polluted air), why do most individuals quickly recover from feelings of contamination, while others experience intense lingering feelings of contagion that can be symptomatic of obsessive-compulsive disorder? One possible answer lies within cognitive .theoretical models of fear. These models implicate cognitive distortions in the development and maintenance of fear, such as overestimating negative consequences and construing dangers as rapidly advancing (Freeston, Rheaume, and Ladouceur, 1996; Riskind, 1997). Thus, these models predict that maladaptive cognitions regarding threat of contaminants increase initial fear and retard habituation. Vivid imagery regarding spread of contamination and harmful consequences may be an especially powerful factor affecting the initial affective response and the speed of recovery from contaminants. However, there is a paucity of research evaluating the impact of maladaptive cognitions on habituation to phobic stimuli. Furthermore, no study to date has evaluated the impact of imagery on habituation to contaminating stimuli.  2  Most studies in this field have utilized repeated measures analysis of variance to evaluate change of fear over time (c.f. Foa & Chambless, 1978; Grayson, Foa, & Steketee, 1982). This type of analysis focuses on group averages of fear ratings at particular time intervals and attributes individual differences in reported fear as error. Given that individual variation in initial levels of fear and variation in rates of change over time are valuable data for researchers to predict, a growth curve modeling approach presents a number of advantages over the traditional repeated measures analysis. Growth curve analysis is a powerful technique for modeling each participant's underlying change process, and facilitates prediction of an individual's change parameters such as intercept, slope, and curvature based on group assignment. This technique has only recently appeared in literature on fear and cognition (Sloan & Telch, 2002; Smits, Telch, & Randall, 2002), and remains under-utilized as a statistical resource. Thus, the current study will evaluate the impact of threatening imagery on habituation using a growth curve modeling approach. Contamination Threat Appraisal Appraisals of threat are implicitly guided by a pattern of beliefs known as the "laws of sympathetic magic" that are consistent across a wide range of cultures (Rozin and Nemeroff, 1990). These laws include beliefs about contagion and similarity that are highly relevant to fears of contamination. The law of contagion holds that "things that have once been in contact with each other may influence or change each other for a period that extends well past the termination of contact, perhaps permanently" (pp. 206). Thus, the transfer of physical or psychological properties is accomplished through a transfer of "essence." Additionally, the law of similarity holds that, "things that resemble one another share fundamental properties ('the image equals the object'), or that superficial resemblance indicates deep resemblance or identity" (pp.206).  3 These laws that guide threat appraisal in many cultures do not necessarily correspond with the presence of objective danger. For instance, research indicates that college students reject beverages that have been in contact with a sterilized cockroach, and North Americans reject foods handled by people they dislike (Rozin, Millman, & Nemeroff, 1986; Rozin, Nemeroff, Wane, and Sherrod, 1989). A n irrational fear response is also demonstrated by individuals with obsessivecompulsive disorder (OCD), who feel contaminated by physical contact with an object (duration of the contact is not important), and are not able to reduce their feelings of contagion over time alone (Woody & Teachman, 2000). Cognitive Theory and Looming Vulnerability Two theories implicate threat appraisals as a key factor in the processing of contamination concerns: the cognitive model of OCD (Salkovskis, 1985), and the theory of looming vulnerability (Riskind, 1997). Although Salkovskis's original cognitive model implicated an exaggerated sense of responsibility for harm in the development and maintenance of OCD, Freeston, Rheaume, and Ladouceur (1996) have more recently identified four additional categories of faulty beliefs in individuals with OCD: overestimating the importance of thoughts, needing to seek a perfect state (e.g., complete certainty or control over thoughts), overestimating the probability and severity of negative outcomes, and believing that anxiety is unacceptable or dangerous. Overestimation of negative outcomes (e.g., disease), and the need for a perfect state of cleanliness seem particularly relevant to the study of contamination concerns. A number of researchers support the position that individuals with OCD or obsessive-compulsive symptoms overestimate the probability and severity of aversive events (Carr, 1974; Foa & Kozak, 1986; Freeston, Rheaume, and Ladouceur 1996; Salkovskis, 1985). Indeed, an empirical investigation of maladaptive beliefs indicates that individuals with O C D score higher on a self-report measure of overestimation of threat compared  4  with anxious and normal control groups (Obsessive Compulsive Cognitions Working Group, 2000). Steketee and Frost (1994) also demonstrated that individuals with O C D endorse more risk aversion on a questionnaire of everyday risk-taking. Riskind (1997) has proposed that a subjective sense of looming vulnerability, or the tendency to construe danger as rapidly evolving and advancing, is a central cognitive component of threat. He postulates that looming vulnerability elicits anxiety, sensitizes individuals to threat cues, biases cognitive processing, and impedes habituation. According to this model, danger appraisal is a dynamic and constantly changing process, as opposed to a static snap-shot of fear. The construct of looming vulnerability is distinguished from the cognitive factor of imminence (i.e., the perceived proximity of the feared object to the person), as a stimulus can be far away while rapidly approaching, or close-by but barely moving. The looming vulnerability model posits that the key factor producing fear is the "loomingness" of the stimulus. With each moment that the stimulus advances, it becomes more dangerous, and the individual feels more threatened and perceives greater risk of losing control over the situation and their bodily responses. • Riskind's model is not at odds with the cognitive model of OCD. The looming vulnerability model adds specificity to the cognitive model by indicating conditions that elicit greater threat appraisals (i.e., perceived stimulus movement). The theory of looming vulnerability posits that this looming factor predicts fear above and beyond the effects of other cognitive constructs, such as probability of harm, lack of control, and imminence (Riskind, Abreu, Strauss, and Holt, 1997). For instance, Riskind (1997) asserts that fear of contamination by toxic chemicals would be greater if the threat were considered to be rapidly growing and/or spreading, regardless of whether this looming aspect of threat is actual or imaginary.  5  In 1997, Riskind, Abreu et al. demonstrated that individuals with sub-clinical O C D respond to vignettes describing germs, dirt, and contamination with a greater sense of looming vulnerability than a low fear control group. Although looming appraisals were highly correlated with both OCD symptoms and other cognitive appraisals (likelihood of harm, imminence, and lack of control), the looming factor demonstrated significant independent contributions to contamination fears after other appraisals were removed from the analysis. In contrast, the other cognitive factors made no significant unique contributions to the prediction of OCD symptoms. This study also supported an indirect, mediational effect of looming, whereby a person's sense of looming intensifies other cognitive factors, and these other factors in turn affect contamination fear. A similarly designed study by Riskind and Maddux (1994) of HIV fears found nearly identical results. High HIV-fear subjects reported more looming and danger cognitions in response to descriptions of public encounters with HIV-positive strangers compared with the low fear control group. A mediation model was also present in which looming predicted threat cognitions, threat cognitions predicted HIV fear, and looming predicted much less HIV fear when threat cognitions were held constant than when they were not. Although the HIV and sub-clinical OCD vignette studies give some evidence that looming vulnerability has incremental value over other cognitive factors, the selection criterion used to determine high and low fear groups was confounded with the outcome measures. Therefore, more research is needed to bolster these findings, and future work should include in vivo stimuli and behavioral indices in addition to vignettes and self-report measurement. Individuals with phobias of animals also demonstrate looming appraisals of danger with both real and imagined phobic stimuli. For example, spider-fearful subjects who were asked to imagine themselves in a room with a spider and three other people were more likely to depict the  6 imagined spider moving toward them, as opposed to moving toward others (Riskind, Moore, & Bowley, 1995). Questionnaire measures also indicated that, in comparison to low-fear subjects, high-fear participants reported the imagined spider to be (a) moving more rapidly and quickly in their direction, (b) more angry and belligerent, (c) intentionally approaching the participant more, and (d) singling the participant out more. In addition, a discriminant classification analysis based on questionnaires of fearful distortions and cognitive styles correctly classified 98% of participants into their respective fear-group classification, with the biggest independent contribution coming from a two-item questionnaire measure of looming towards the self. In a related study by Rachman and Cuk (1992), perceptual distortions were displayed by spider and snake phobics during episodes of fear, and after fear-reduction. Contrary to the authors' hypotheses, distortions only occurred regarding the activity/movement of the feared stimulus (i.e., movement towards self, coming out of cage, predictability); there were no significant distortions regarding the size of the animal. After fear reduction occurred, participants reported significant declines in the perceived movement of the feared animal. The authors could not fully account for the absence of results pertaining to the size of the animal. However, they suggested that: If the size of the threatening object is unimportant or overshadowed by some other feature (such as its activity or sound), perceptual distortions of size during fear are not to be expected. So for example, a small lively snake is more likely to be feared than a large but evidently dead, immobile snake (pp. 589). Thus, the Rachman and Cuk study is another example of research lending support for the importance of looming appraisals of movement in fearful individuals, over and above static appraisals such as the size of the phobic object.  7  The theory of looming vulnerability offers added value to former cognitive models of anxiety, with its emphasis on dynamic appraisals of threat and perceived stimulus movement. The theory provides a sophisticated account of fear reactions that makes evolutionary sense and offers novel predictions regarding fear responses. Despite this fact, only a select group of researchers have attempted to test this theory empirically, and only a handful of studies are directly pertinent to contamination fears. These preliminary results suggest that looming vulnerability demonstrates incremental value over other cognitive constructs, and predicts contamination fear via direct and mediational pathways. Additionally, we have evidence that animal phobics make looming appraisals of dangerous stimuli. Manipulating Looming Threat with Imagery Riskind, Wheeler, and Picerno (1997) introduced an interesting paradigm for extending the study of looming vulnerability to include a manipulation of mental imagery regarding the movement and spread of contamination. In a study using an analog O C D sample, three types of imagery were used in parallel with video clips of dirty toilets and trashcans to determine the effect of looming versus freezing imagery on contamination fears and avoidance behavior. More specifically, the three imagery conditions were: 1) imagery of looming spread of contamination, 2) imagery of freezing contamination in its place, and 3) control imagery (i.e., imagine yourself actually in the situation, facing the scenes). The results of this study remain unclear due to poor control for Type I error. However, the imagery manipulation provides an excellent framework in which to study another important aspect of fear response: habituation. The model of looming vulnerability postulates that objects associated with a sense of looming threat will habituate more slowly than static threats (Riskind, 1997). However, no study to date has investigated the impact of looming cognitions on habituation to feared stimuli. Studies of  8 habituation typically monitor the response of a phobic individual to a constant stimulus. However, by manipulating the speed and spread of contamination, the threat value of the stimulus is also being manipulated, becoming more dangerous with each moment in the case of looming imagery, as opposed to being contained and motionless in the case of static harm imagery. In support of the mental manipulation of freezing contamination in its place, Riskind, Wheeler, and Picerno (1997) cite a clinical observation made by Foa & Kozak (1986) in their treatment of a urine phobic patient with exposure therapy. This patient was able to reduce his anxiety while urine drops were placed on his arm by imagining he could "freeze" the urine spots to prevent the spread of contamination. Thus, studying the impact of imagery on habituation to contaminants has clear clinical applications in the treatment of anxiety disorders. Cognition and Habituation Unlike in vivo exposure, imaginal exposure to phobic stimuli relies on the ability of individuals to produce anxiety-provoking images in their mind. Imagery ability can impact habituation to fearful stimuli and future avoidance behavior. Good imagers would be expected to produce more vivid and more constant images, which should keep them more engaged and produce higher levels of fear responding, at least initially. This increased initial arousal level may be linked to the superior treatment prognosis reported by Lang, Levin, Miller, and Kozak (1983) for those with good imagery ability, and is in line with Foa and Kozak's (1986) theory that the fear structure must be activated in order for fear reduction to occur. Crits-Christoph and Singer (1984) also report that imagery vividness and greater fear response to phobic images are associated with better treatment outcome for individuals with specific phobias. Studies indicate that imagery ability moderates emotional responding to phobic stimuli by increasing levels of subjective fear. Drummond, White, and Ashton (1978) demonstrated that vivid  9 imagers habituated more slowly to tones associated with imagined shock than non-vivid imagers. However, no between-group differences were evident in a threat condition requiring no imagination. Another study by Cook, Melamed, Cuthbert, McNeil, and Lang (1988) indicated that simple and social phobics who were good imagers were more fearful during personalized phobic scripts than poor imagers. Good imagers also had significantly greater increase in heart rate than poor imagers to a standard dental scene imagery script. The authors also reported a significant correlation between autonomic reactivity to phobic scenes and a questionnaire measure of imagery ability for the simple phobics. We would expect individuals with contamination concerns to respond similarly to the simple phobics, and thus evidence a positive relationship between fear responses and imagery ability. Foa and Chambless (1978) observed that patients with OCD typically show a curvilinear pattern of habituation during imaginal flooding (i.e., increasing anxiety for the first 40% of the session, then decreasing anxiety for the remainder of the session), whereas they demonstrate a linear decline of fear during in vivo flooding. The authors concluded that it takes a period of time for patients to distance themselves from the safety signals in a clinician's office and become engrossed in the imaginal exposure, which is not required when confronting stimuli in vivo. Imagery that emphasizes the somatic responses of the fearful individual can increase fear response and impede habituation. For example, Lang, Levin, Miller, and Kozak (1983) trained snake phobics and speech-anxious participants to focus on their somatic responses and their active role in the imaginal scene, as opposed to focusing on details of the stimulus. They found that response training led to significant visceral arousal during fear imagery and greater correlation between self-report and physiological measures compared to the stimulus training control. Robinson and Reading (1985) used a similar script-training paradigm with insect and small animal  10 phobics. Consistent with the Lang et al. (1983) study, their results indicated that response training led to greater physiological reactions during imagery and stronger correlations between physical and self-report arousal levels compared to stimulus training. Response training also led to slower habituation. The authors concluded that, "the Stimulus group responses were attentional in origin, wheras the Response group.. .may be a consequence of affective arousal to the fear stimuli" (p. 252).  In line with these findings, we would expect that imagery pertaining to the looming threat of  a contaminating stimulus would result in somatic responses that should increase fear and slow habituation. Certain types of beliefs are associated with failure to habituate in phobic individuals. For example, significant differences exist between the cognitions of claustrophobic-panic habituators and non-habituators, with 44% of the variance in the slope being predicted by two negative cognitions: "I am going to pass out" and "I am going to lose control of myself' (Rachman and Levitt, 1988). In another study of treatment failures, OCD patients who strongly believed their fears were realistic showed failure to habituate between sessions (Foa, 1979). Thus, research with clinically anxious samples has demonstrated a relationship between cognitions and habituation. Effect of Imagery on Habituation to Contaminants The laws of fear conditioning and habituation developed using classic and operant conditioning of animal models mirror many clinical observations of phobic patients, and have helped to form the theoretical foundation for several highly successful treatment techniques for anxiety disorders (e.g., flooding, in vivo and imaginal exposure, and response prevention). However, much remains unexplained regarding the mechanisms that underlie the fear reduction process. Animal models have not always been able to fully explain human symptomatology, especially regarding the complex and symbolic meanings often seen in contamination fearful  11  individuals with obsessive-compulsive disorder. OCD is more difficult to treat than specific phobias, and complex stimuli associated with OCD habituate more slowly than simple stimuli (Marks, 1987). Cognitive factors are assumed to play a key role in the development and maintenance of anxiety disorders (Riskind, 1997; Salkovskis, 1985), and certain cognitions are associated with lower levels of habituation to fearful stimuli (Foa, 1979; Rachman & Levitt, 1988). Riskind (1997) has proposed that looming appraisals will impede habituation to phobic stimuli. In order to test this hypothesis and determine whether cognitive factors impact on habituation to contaminants, our study will examine the effect of three types of imagery: looming harm, static harm, and safety imagery. We hypothesize that both static harm and looming harm imagery will retard the habituation process compared with safety imagery. In addition, we hypothesize that the impact of looming imagery will be above and beyond that exhibited by static harm, due to the increased threat value associated with the dynamically changing stimulus. Method Research Design In order to examine the impact of a cognitive manipulation on habituation during the exposure, a between subjects experimental design was used, with three imagery conditions (looming harm, static harm, and safety). Habituation was examined using two different statistical methods: a between groups A N O V A to evaluate change scores in subjective units of distress, and a growth curve modeling approach to evaluate the intercept, slope and curvature of participants' underlying change trajectories over time. Emotional reactions and cognitive appraisals were measured immediately after the exposure to determine the influence of threatening imagery on these outcome measures. Additional questionnaire measures were administered during the study to  12  measure imagery ability, disgust sensitivity, anxiety sensitivity, and OCD-relevant symptoms and cognitions. Participants Participants were 111 volunteers who were recruited from the Psychology Department subject pool at the University of British Columbia and from poster advertisements around campus. Participants were required to be at least 18 years old and fluent in English (i.e., English first language, or spoken at home for the past five years). Measures Berts' Questionniare Upon Mental Imagery-Short Form (QMI-Short; Sheehan, 1967a). The QMI-Short is a 35-item scale measuring imagery ability in seven sensory modalities: visual, auditory, cutaneous, kinaesthetic, gustatory, olfactory, and organic. For example, a visual question instructs people to think of seeing, "the sun sinking below the horizon" and rate the vividness or clarity of the image using a 7-point scale. The QMI-Short is highly correlated with Betts' original 150-item version (r = 0.92, Sheehan, 1967a), has a test-retest reliability of 0.78 (Sheehan, 1967b), and good internal consistency ( a = 0.90-0.94; Westcott & Rosenstock, 1976). The scale also correlates with another measure of imagery, the Paivio Individual Differences Questionnaire (r = 0.45-0.50; Hiscock, 1978). Furthermore, the QMI was used in an earlier study of cognition and habituation with demonstrated effects for vivid versus non-vivid imagers (Drummond, White, and Ashton, 1978). Thus, this measure will assess individual differences in imagery ability of participants. Only three subscales of the QMI-short were administered in the present study due to time constraints: Visual, Cutaneous (touch), and Organic (sensations). (See Appendix A.) Maudsley Obsessive Compulsive Inventory (MOCI; Hodgson & Rachman, 1977). The MOCI is a widely used 30-item true/false questionnaire relating to obsessive-compulsive  13 behaviors, including four subscales: Checking, Washing, Doubting, and Slowness. Internal consistency of the subscales range from 0.7 - 0.8 (Hodgson & Rachman, 1977). The MOCI demonstrates high test-retest reliability (r = 0.92; Kendall's tau = 0.84) and good concurrent validity with other self-report measures and clinician ratings of OCD and anxiety symptoms (Emmelkamp, Kraaijkamp, & van den Hout, 1999). For the purposes of the current study, only the Washing subscale was administered in order to determine the degree of obsessive-compulsive cleaning and contamination concerns in participants (see Appendix B). Obsessive Beliefs Questionnaire (OBQ; Obsessive Compulsive Cognitions Working Group, 2000). The OBQ is an 87-item questionnaire rated on a seven-point scale assessing six domains of obsessive beliefs: Overestimation of Threat, Tolerance of Uncertainty, Importance of Thoughts, Control of Thoughts, Responsibility,- and Perfectionism. Internal consistency and test-retest reliability for the subscales are high (a = 0.71-0.96, r = 0.75-0.90; Obsessive Compulsive Cognitions Working Group, 2000). The OBQ has demonstrated moderate to high correlations with other self-report measures of OCD cognitions and symptoms, and individuals with OCD score higher on all subscales compared with normal controls (Obsessive Compulsive Cognitions Working Group, 2000). Due to the length of this questionnaire, only two subscales were administered to assess participants' obsessive cognitions: Overestimation of Threat, and Tolerance of Uncertainty (see Appendix C). Disgust Scale (DS; Haidt McCaulev, & Rozin, 1994). The DS is a 32-item measure of disgust sensitivity, made up of 16 true/false questions and 16 items rated on a three-point scale. The scale taps into seven domains of disgust elicitors, in addition to a measure of magical thinking (i.e., similarity and contagion). Internal validity for the full scale is strong (a = 0.81), and the correlation of the true/false section with the three-point rating section is r = 0.62 (Haidt, McCauley,  14  & Rozin, 1994). The scale also correlates with disgust behavioral avoidance tasks (r = 0.71; Rozin, Haidt, McCauley, Dunlop, & Ashmore, 1999). This measure was used to determine participants' level of disgust sensitivity, a construct implicated in contamination concerns (see Appendix D). Anxiety Sensitivity Index (ASI: Peterson & Reiss, 1987). The ASI is a 16-item scale measuring danger beliefs and feared social and somatic consequences of anxiety symptoms, measured on a 5-point Likert-type scale. The ASI has demonstrated good internal consistency (a = 0.82; Telch, Shermis, & Lucas, 1989) and test-retest reliability over a three-year period (r = 0.71; Mailer & Reiss, 1992). The scale has good criterion-related validity in regards to panic symptoms; both college students with a history of panic attacks and clinical panic patients have been shown to have higher ASI scores than non-panickers (Telch, Shermis, & Lucas, 1989; Foa, 1988). The ASI also shows good predictive validity for future panic attacks and development of anxiety disorders among college students (Mailer & Reiss, 1992) (see Appendix E). Subjective Units of Distress Scale (SUDS; see Appendix F). In order to periodically measure the level of emotional distress (disgust, anxiety or contamination fears) during habituation, a 0-100 scale of emotional distress was utilized. This technique is used regularly in both clinical practice and fear research to monitor habituation during exposure. In addition, it has been demonstrated that decreases in peak subjective anxiety during exposure is predictive of clinical improvement (Foa, Grayson, Steketee, Doppelt, Turner and Latimer, 1983). The distress scale combined negative emotions of anxiety and disgust because of their high correlation in previous research (r = .61 - .85; Woody & Tolin, 2002). Reaction to Exposure Questionnaire (REQ; see Appendix G). This questionnaire assessed how contaminated and how disgusted participants felt at the end of the exposure, prior to washing their hands. It also measured three cognitive appraisals: the degree to which they felt vulnerable,  15  their likelihood of getting sick, and the likelihood of something bad occurring as a result of the exposure. Finally, the measure assessed the urge to wash their hands and how far participants believed the contamination traveled. The scale demonstrated good internal consistency (a = 0.90). Imagery Usage Questionnaire (IUQ; see Appendix H). This questionnaire assessed the types of imagery each participant utilized during the exposure in order to serve as a manipulation check. The measure begins with a free response section in which participants describe the imagery they used. This section was followed by directed questions asking about usage of four categories of imagery: loom, static, safety, and harm. The questionnaire also assessed parameters of imagery ability including the ease of producing images, ability to maintain images throughout the exposure, degree of imagery vividness, and believability of imagery. No psychometric data are available on this scale. Demographics and Bathroom Habits Questionnaire (DBH; see Appendix I). This questionnaire assessed basic demographic variables, including country of origin and amount of time living in Canada. It also assessed avoidance behavior, anxiety, and distress of contamination thoughts in regards to usage of public bathrooms as an exemplar of a commonly encountered "contaminating" place. Thus, this questionnaire asked about specific avoidance behaviors relevant to contamination fears in daily life. The Bathroom Habits Scale (items 1-5) demonstrated good internal consistency in the current study (a = 0.78). Behavioral Avoidance Index. After completing the exposure and some questionnaires, participants were offered a cookie or pretzel as a subtle measure of behavioral avoidance. Behavior approach tasks are commonly used in fear research, but are typically more overt than our task, specifically asking participants to approach a phobic object using successive approximations of the task. Rozin, Haidt, et al. (1999) demonstrated that disgust-related behavior approach tasks  16  significantly correlate with the Disgust Scale paper and pencil measure (r = -.41), indicating that more disgust sensitivity is associated with less approach of disgusting objects. Exposure Stimulus Urine was chosen as the exposure stimulus because it is a substance that is widely experienced as contaminating, while being objectively safe. Urine is a sterile body product when it comes from a healthy individual. Despite the low risk involved in using urine, extensive safety procedures were implemented. The urine was collected from a healthy volunteer (without any symptoms of urinary track infection) who was not taking any medications that are eliminated or concentrated in urine. The urine was collected using the clean catch procedure (Brunzel, 1994) and was cleaned using a disposable sterile filter system with a pore size of 0.22um. Finally, the urine was refrigerated immediately after collection and discarded after 24 hours. The ethical implications of using disgust-relevant stimuli in laboratory research have been evaluated by Rozin and colleagues (1999). Their study involved behavioral approach tasks to a variety of stimuli, in which the most difficult steps involved actions such as touching a dead sterilized cockroach, touching a live mealworm, drinking water with spit in it, drinking apple juice from a clean bedpan, or sticking a pin in the eye of a fresh pig's head from a local market. After completing the study, participants were asked to rate how interesting, enjoyable and pleasant they found the session. Results of this questionnaire, rated on scale of 1 (not at all) to 9 (extremely), supported the fact that exposure to disgust-relevant stimuli was not harmful to participants. They found the study to be interesting (M=6.9) and enjoyable (M=6.2), and pleasant ratings were above the midpoint (M=5.3). Additionally, 74% of the participants gave values above the midpoint on the question, "Would you recommend this session to a friend?" Thus, the authors concluded that if the  17 option of task refusal is made a clear and acceptable choice, such studies are ethical and nontraumatizing for participants. Procedure Participants were seated in a laboratory room where the experimenter reviewed the consent form and asked participants to read it and sign if agreeable to them. Participants were informed that as part of the experiment, they would be asked to touch a substance that some people find to be objectionable. Participants were reminded that they were free to stop their involvement at any point during the experiment. Participants were then asked to rate their baseline level of emotional distress, indicating how disgusted, anxious, or contaminated they felt at that moment using a scale of 0-100. Participants then completed one of two questionnaire packets that were counterbalanced across subjects before and after the exposure (Packet A: OBQ and QMI-Short; Packet B: MOCI, DS, ASI). Participants rated their level of distress again and then the experimenter read the following imagery instructions: "During this study, I will ask you to touch a substance that some people find to be objectionable. You will place your hand on this desk, where the clean covering is placed, and you will touch the substance for 30 minutes. However, you are free to stop the task at any time. During the task, I will ask you to rate your level of distress each minute, on the 0-100 scale. Once you are touching the substance, I will ask you to imagine certain characteristics about the substance in your mind. Please focus on the images that I describe to you, and experience them as vividly as possible. We are studying the relationship between emotions and imagery, so it is very important for the study that you focus on the imagery that I describe to you. The audiotape on that desk will beep every 60 seconds, prompting you to report your  18  rating to me. I will also remind you to continue visualizing the images, and I may ask you to describe what you are imagining during the exposure. Do you have any questions?" Participants rated their level of distress again and the experimenter then continued with the directions: "The substance you will be exposed to is urine, meaning I will place 3 drops of urine onto your hand, and ask you to spread it on your palm using your fingertips from the same hand. Try to hold your hand in a comfortable position, since the exposure will last for 30 minutes. Now I will bring out the urine, if you are ready. Which hand do you write with? Okay, please use your other hand, and I will place the urine on your palm." Once the participant had spread the urine on their hand, another distress rating was taken, and additional directions were given. "Now I will describe the imagery that I want you to visualize in your head. It is very important that you focus on the imagery that I will describe, and experience what I'm describing to you as vividly as possible. During the exposure, other thoughts or images may pop into your head that are inconsistent or incompatible with the imagery I have asked you to use. For example, some people find they are tempted to use their own imagery to manage the discomfort they feel during the task. Please let those thoughts pass by, and do not concentrate on them. Instead, as much as you possibly can, please keep returning your mind to the ideas and images that I have asked you to use." Participants were randomly assigned to one of the three imagery scripts (all with equal numbers of words). The experimenter read this script to the participant as follows: Looming Harm Imagery. "Visualize that any germs or contamination from the urine are moving across your skin and spreading through the air as they evaporate. Germs and  19  bacteria can cause diseases that are harmful to you, and the urine on your hand feels gross and dirty. Any germs or contamination can spread readily, as some bacteria are capable of movement. Picture any contamination from the urine as spreading across your skin. Germs can seep through tiny invisible tears in your skin. Some bacteria are able to bypass natural surface barriers and spread through thick substances. Therefore, think about the implications of the germs moving and spreading on your skin. Remember that the contamination is not confined to any one spot; any dangerous germs can move across your skin and spread through the air at all times." Static Harm Imagery. "Focus on the area of your hand where the urine is sitting right now. Any germs or contamination from the urine are contained within this area alone. Germs and bacteria can cause diseases that are harmful to you, and the urine on your hand feels gross and dirty. However, the contamination is restricted to the spots where it sits on your skin right now. Mentally picture any contamination from the urine as unable to move or spread from its current location. Because your skin is multi-layered, it forms a natural surface barrier that keeps contamination on the surface of your skin. Therefore, think about the implications of the germs sitting stationary on your skin's surface. Any dangerous bacteria are confined to this area alone, and cannot move or spread from their current location." Safety Imagery. "Visualize that the urine touching your skin contains no germs or contaminants, in spite of the fact that it is gross and feels dirty. The urine is a clean and sterile substance, and it comes from a healthy person. Therefore, the urine touching your hand contains no harmful germs. Many bacteria coexist within our bodies without causing any disease, and protect us from harmful bacteria. Therefore, rest assured that the urine  20  does not threaten your health in any way. The urine on your hand is not exposing you to any illnesses or diseases. Therefore, concentrate on the fact that the urine is a sterile and safe substance, although it is not pleasant. Keep reminding yourself that no possible harm or negative implications can occur from the urine touching your hand; you are safe." Immediately following the imagery script, participants rated their level of distress. They were then reminded to continue to use the imagery, and close their eyes if they found it helpful. During the 30-minute exposure, brief prompt sentences taken from the script were repeated to keep participants engaged in the imagery. The experimenter also asked participants cue questions to verify that their imagery usage was appropriate. For example, participants were asked to "describe how you are imaging the urine right now." The experimenter redirected participants who reported incorrect imagery usage by repeating relevant imagery prompts. For a full list of prompts and cue questions, see Appendix J. When participants completed the 30-minute exposure (or gave the same response for six consecutive minutes after at least a 50% drop from the initial stimulus application), they completed the Reaction to Exposure Questionnaire. The experimenter then provided participants an opportunity to use an antibacterial toilette and take a bathroom break. Participants then completed the Imagery Usage Questionnaire (i.e., the manipulation check), the Demographics and Bathroom Habits Questionnaire, and the remaining counterbalanced questionnaire packet (Packet A: OBQ and QMI-Short; Packet B: MOCI, DS, ASI). Participants were approached on their exposure hand side and offered a cookie or pretzel as a snack while they completed the final questionnaires as a subtle measure of contamination-related avoidance behavior. At the completion of all questionnaires, participants were asked how much they were still experiencing a lingering feeling  21 of disgust, anxiety, or contamination from the urine that was on their hand earlier using the same 0100 scale. They were debriefed with the following statement: "Thank you for participating in this study. We are studying the effects of different types of imagery during exposure to substances that appear to be contaminating. First of all, I want to assure you that in actuality, the substance we used is entirely safe. Although many people don't know this, urine is actually a sterile body product when it comes from a healthy individual. Our donor is healthy, and just to be especially careful, we also used a sterile filter system to clean the urine prior to using it in the study. During the study, we made reference to germs and contamination. However, because the urine we used was sterile, you do not have to worry about any contamination or germs due to participating in this study today. We know that all humans encounter potentially contaminating stimuli every day. For example, we all use public bathrooms, walk on dirty sidewalks, and breathe polluted air. However, this exposure to contaminants greatly disturbs some people, while others are not bothered. Therefore, we are trying to understand why people have such different reactions, and whether different types of imagery may affect a person's ability to recover from feelings of contamination. Specifically, we are trying to determine whether imagery regarding looming movement of contamination slows down habituation compared to imagery of freezing contamination in its place, or imagery regarding safety. Because of the nature of the study, we do not want future participants to have prior knowledge of the type of things that they will be doing if they chose to participate, so we will ask you not to discuss the study with your friends or other people. Do you have any questions or concerns? Are you experiencing any remaining distress? Thank you again for participating!"  22  After answering any final questions, participants received either ten dollars or one credit for their time (psychology subject pool). Most participants reported no remaining concerns after hearing the debriefing statement, and described the research question and study methods as interesting. Results Criteria for Inclusion in Data Analysis Of the 111 individuals who consented to participate, 11 refused the urine exposure and 10 were removed for noncompliant use of imagery. Because an effective manipulation of imagery usage requires participant compliance, we set criteria prior to running the experiment in order to eliminate participants who were using inappropriate loom imagery "most" or "all" of the time during the exposure as reported on the Imagery Usage Questionnaire. For instance, we were worried that participants in the looming harm condition would find the imagery too aversive and compensate by using static or safety imagery, thus positioning themselves in a different imagery condition. The exclusion rule involved participants assigned to the loom condition who endorsed at least 8/10 for static or safety imagery, and participants in the static or safety condition who endorsed at least 8/10 for loom imagery. Based on the decision rule, 7 loom participants were excluded for using too much static or safety imagery, and one participant from the static group and one participant from the safety group were eliminated for using too much loom imagery. In addition, one participant in the safety group was excluded for using too much harm imagery. We had originally intended to eliminate participants in the static harm group for using too much safety imagery, and participants in the safety group for using too much static imagery. However, this differentiation would have required elimination of seven more static participants and ten more safety participants. We did not feel justified in eliminating this number of participants  23  from our sample, especially since our primary focus was on evaluating the impact of looming imagery. Therefore, our final sample used for data analysis involved 90 individuals (30 per group). Sample Characteristics Of the 90 individuals retained for data analysis, 72% were female and 60% were Caucasian; these percentages did not differ across groups {% (2)=3.33,/?=.19; % (2)=.78,/>=.68, respectively). 2  2  The mean age of participants was 21.70 (£D=5.67). Table 1 presents the means and standard deviations for the full sample on all preliminary questionnaires and the three baseline ratings of distress taken prior to the stimulus presentation. There were significant differences between groups on the MOCI Washing scale (F(2, 87)=5.09,p<.01, partial n =.l 1) and Bathroom Habits 2  Questionnaire (F(2, 87)=3.18, p=.046, partial r| =.07). Tukey post hoc tests (p<.05) indicated that 2  j  the loom group (M=3.20, SD=2.63) was significantly higher on the MOCI than the safety group (M=1.50, SD=\.72); the static group (M=1.90, SD=2.02) was not different from the other two groups. Tukey post hoc tests for the Bathroom Habits Questionnaire indicated no significant differences between groups (p<.05). The one-way A N O V A s for all other questionnaires and distress ratings showed no significant differences between groups (Fs(2, 87) < 2.04,/?s > .14, partial n s < .05). Correlations between questionnaire measures and coefficient alphas are reported 2  in Table 2. Exposure Refusers Exposure refusers consisted of 6 females and 5 males; 7 were Caucasian and 4 were Asian. There were no differences between participants who completed the urine exposure compared with task refusers on gender or ethnicity (% (l)=1.45,/>=.23; % (l)=.03,/?=.87, respectively). Task 2  2  refusers reported significantly more anticipatory distress (before knowing what the stimulus would be) compared with task completers on all three baseline measurements (see Table 3). There were  24  no differences between refusers and task completers for any of the descriptive questionnaire measures listed in Table 1 (ts (109) < .74, ps > .46, Cohen's ds < .23). A logistic regression showed that neither the MOCI-Washing, Disgust Scale, nor the Bathroom Habits scale were significant predictors of refuser vs. completer status (Omnibus % (3)=1.54,/>=.67; Bs = -.26, .002, 2  .14, ps>.26). Manipulation Check A M A N O V A was conducted to compare assigned imagery groups on usage of four types of imagery: looming harm (i.e., moving and spreading germs), static harm (i.e., germs restricted to a small area), safety (i.e., urine is clean and sterile), and harm (i.e., dirt and illness). This analysis served to check that the three randomly assigned imagery scripts (looming harm, static harm, and safety) effectively manipulated participants' imagery usage during the exposure. The omnibus Hotelling's T was significant (F(8, 166) = 15.77, p < .001, partial n = .43), indicating an overall 2  effect of imagery group for the analyses. All four univariate tests also showed significant effects for imagery group (see Table 4). As seen in Table 5, on average participants in each imagery condition used their assigned type of imagery "a lot" of the time during the exposure (ratings about 6). Tukey post-hoc comparisons indicated that participants assigned to the loom group used significantly more loom imagery and more harm imagery compared with the other two groups. Participants assigned to the static group used significantly more static imagery than the loom group. Finally, participants in the safety group used significantly more safety imagery than the other two groups. To examine whether groups differed in their imagery ability during the exposure, a M A N O V A was conducted with four dependent variables: ease of producing images, ease of maintaining images throughout the exposure, vividness/clarity of imagery, and believability of  25 imagery. The omnibus Hotelling's T was significant (F(8,164)=7.42,/K.001, partial n =.27). As 2  seen in Table 6, groups did not differ on the degree to which their imagery usage was vivid and clear, but differences were apparent on ease of producing images, ease of maintaining images, and believability of the imagery. As shown in Table 7, Tukey post-hoc tests indicated that participants in the safety group found it easier to produce images compared with those in the loom group. The safety group also found it easier to maintain the imagery compared with the loom and static groups. Finally, the loom imagery was reported as less believable compared with the static and safety imagery. Noncompliant Imagers There were no differences between the 90 compliant imagers (retained for data analysis) versus the 10 noncompliant imagers (removed from the analysis) on the MOCI-Washing (£(98)= .54,p = 0.59, Cohen's d = -.18), Bathroom Habits « 9 8 ) = -.93, p = 0.36, Cohen's d = - .31), or any of the other questionnaire measures from Table 1 (£s(98)< |1.78|,p>.08, Cohen's ds < |.59|). The Anxiety Sensitivity Index had the largest effect size (d - -.59); all other questionnaires had effect sizes ranging from .13 - .30. Noncompliant imagers did not differ from compliant imagers on their baseline distress ratings or distress when the urine was initially applied to their hand (fs(98)<1.24, p>.22, Cohen's ds <|.41|). Imagery ability indices for compliant and noncompliant imagers are listed in Table 8. Both groups reported equivalently vivid images during the exposure. However, noncompliant imagers found it significantly more difficult to produce and maintain images, and they found the imagery significantly less believable. Immediate Effect of Imagery A repeated measures A N O V A was conducted to compare imagery groups on ratings of distress at two critical time points: immediately after urine was applied to their hand and  26 immediately after they heard the imagery script. There was a significant between subjects main effect of imagery condition (F(2, 87)=6.66,/?<.005, partial n =13), modified by a significant 2  interaction between time and imagery condition (F(2, 87)=23.55,/><.001, partial n =35); the main 2  effect for time within subjects was non-significant (F(l, 87)=.76,/?=.39, partial n =.01). Simple 2  main effect analyses were conducted to evaluate differences between groups at each time point. Ratings taken immediately after the urine was applied to participants' hands, but prior to imagery, did not differ across groups (F(2, 174)=2.20, p=.8>8, partial n =.02). Immediately after participants 2  began the imagery, however, the groups significantly diverged (see Figure 1), with the loom group showing significantly higher ratings compared with the other two groups (F(2, 174)=12.66,p<.00\, partial n=.13; post-hoc Tukey p<.05). A repeated measures ANCOVA was also conducted with 2  the MOCI-Washing as a covariate. The MOCI was not a significant term in the model (F(l, 86)=2.97,p=.09, partial n =03), and all group means remained in the same direction with not more 2  than a 2 point change from their original scores. Distress During Exposure Average distress ratings for each group during the 30-minute exposure are depicted in Figure 2. The experimenter terminated the exposure for participants who reported the same response for six consecutive minutes after at least a 50% drop from the initial stimulus application; however, for the purposes of data analysis, these participants' final ratings were carried forward for the full 30 minute duration. The significant difference between groups that emerged in the first minute of imagery was maintained throughout the full 30 minutes. To examine change in raw scores from start (when urine was applied) to finish (minute 30), a one-way ANOVA was conducted with change scores as the dependent variable and imagery group as the independent variable. Raw change significantly differed across groups (F(2, 87)—13.54, p<.001, partial n =.24).  27  On average, the looming group increased in distress by 10.63 points (50=31.60). This sensitizing effect in the loom group was significantly different compared with the static and safety groups that habituated over time (Tukey post-hoc, p<.05). The static group decreased by an average 11.57 points (50=19.09) and the safety group decreased by an average 19.23 points (50=15.38). Effect sizes for the comparison of each set of groups for raw change is shown in the first column of Table 9. This analysis was also conducted with the MOCI-Washing scale as a covariate. The MOCI was not a significant term in the model (F(l, 86)=.23,/?=.63, partial n <.01), and all group means 2  remained in the same direction with not more than a one point change from the original analysis. A similar A N O V A was conducted to assess imagery groups on peak ratings of distress during the exposure (i.e., the highest rating given during the 30 minutes). This analysis indicated significant differences between groups on peak distress (F(2, 87)=33.42, p<.001, partial n =.43). The loom participants reported higher maximum distress (M=63.23, 50=24.48) compared to the static (M=31.20, 50=20.53) and safety group (M=20.77, 50=17.27; Tukey post-hoc, p<.05). No differences emerged in Tukey post-hocs between the static and safety groups. This analysis was also conducted with the MOCI-Washing scale as a covariate. The MOCI was not a significant term in the model (F(l, 86)=.95,/?=.33, partial n =.01), and all group means remained in the same 2  direction with not more than a one point change from the original analysis. Reaction to Exposure A M A N O V A compared responses of each imagery group on the Reaction to Exposure Questionnaire, which assessed emotional and cognitive responses at the end of the exposure, prior to hand washing. The omnibus Hotelling's T was significant (F(14, 160)=3.30,/K.001, partial n =.22), as were all the univariate tests (see Table 10). Tukey post-hoc analyses are presented in Table 11. The loom group was significantly more distressed than the static group on all items  2  28  except urge to wash hands, and was more distressed compared to the safety group on every item. The static group was only more distressed than the safety group on feeling contaminated. The last question, asking how far the germs traveled, provides additional support for the loom imagery manipulation, since the looming participants endorsed that the germs traveled further than the other two groups. When the MOCI-Washing was included as a covariate in another M A N O V A , the Hotelling's T omnibus test was significant for the MOCI (F(7, 80)=3.40, p<.005, partial n =.23), 2  and univariate tests indicated that the MOCI was a significant factor for all items except urge to wash and how far germs traveled (Fs>4.57, /?s<.04, partial r| s>.05). When controlling for MOCI2  Washing, Tukey post-hoc analyses indicated that the loom group was no longer significantly different from the static group for feeling contaminated, disgusted, likelihood of sickness, and feeling vulnerable. However, the loom group remained statistically different from the safety group on all items. Lingering Distress Post Washing A one-way A N O V A was conducted to analyze group differences in ratings of distress after participants had washed their hands and spent 10 minutes completing questionnaires. This rating indicated how much lingering distress participants were still experiencing from the earlier urine exposure. Results indicated a significant difference between groups (F(2, 87)=10.33, /K.001, partial n =19), with Tukey post-hoc analyses demonstrating that the loom group (M=20.10, 2  Mdn=20.0, SD= 17.40) was significantly more distressed than the static (M=9.13, Mdn=5.00, SD=\3.25) and safety group (M=5.07, Mdn=2.00, SD=6.93). This effect is visually depicted as the last data points in Figure 2. This analysis was also conducted with the MOCI-Washing scale as a covariate. The MOCI approached significance in the model (F(l, 86)=3.86,/>=.053, partial  29 r|  =.04), but all group means remained in the same direction with not more than a 1.5 point change  from the original analysis. Behavioral Avoidance Of the loom, static and safety participants, 37%, 40%, and 43% respectively ate a snack after the exposure (either a cookie or pretzel). Pearson chi-square analyses indicated that participants in all groups were equally likely to eat a snack after washing their hands (x (2) = 0.28, 2  p= 0.87). Of those taking a snack in the loom, static, and safety conditions, 36%, 33%, and 46% respectively used their exposure hand. Again, the chi-square analysis indicated that group differences on hand used were not statistically significant  (% (2) = 0.47,/?= 0.79). 2  Growth Curve Modeling A growth curve modeling approach was used to analyze individual participants' change trajectories over time. In this approach, individual trajectories are first examined to determine their overall shape (i.e., linear, quadratic, cubic). Next, regression lines or curves are fitted to each participant's data, and regression parameters are calculated as indices of change for each person. In a quadratic model, these change indices include the intercept, slope, and curvature. In this study, the intercept indicates the participant's first rating of distress following the introduction of imagery. The slope indicates the instantaneous rate of change occurring at the intercept and is an indicator of the initial direction of change (i.e., immediate habituation or sensitization). Finally, curvature (also known as acceleration) indicates the magnitude and direction of the curve, whether it is speeding up or slowing down relative to an asymptote. Once these change indices have been calculated for each participant, they are then used as dependent variables in a between-group M A N O V A analysis. This allows differences between imagery groups on the intercept, slope and curvature to be examined.  30  Evaluation of individual trajectories in our sample indicated that quadratic curves accounted for a significantly greater percent of variance (M=.69, SD=.27) compared with a linear model (M=.53, SD=.21; F{\, 170)=15.06,p<.001, partial n =08). Thus, regression curves using a 2  quadratic model were fitted to each participants' ratings of distress over the 30 minutes, and curve parameter estimates for the intercept, slope, and curvature were retained for the second step of analysis. A M A N O V A was then conducted to compare imagery groups on the three change indices: intercept, slope, and curvature. The Hotelling's T omnibus test was significant (F(6, 168) = 14.86; p<.001, partial n =.35), with significant group differences for all three indices of change 2  (see Table 12). Post-hoc Tukey comparisons indicated significant differences between the loom group and the other two groups on all three change indices (see Table 13). The looming harm participants had a significantly higher intercept compared with the static and safety groups, indicating that looming participants' had greater distress levels immediately after the application of imagery, which replicates the repeated measures A N O V A results presented earlier. The loom group had a positive slope combined with negative curvature, indicating that their distress ratings increased to an asymptote over time. The static and safety groups both had negative slopes combined with positive curvature, indicating that their scores decreased over time before reaching a floor. Effect sizes for the comparison of each set of groups on indices of change is shown in Table 9. A secondary M A N C O V A was conducted with the MOCI-Washing as a covariate. The omnibus Hotelling's T and univariate F tests were not significant for the MOCI. Marginal means for imagery groups were all in the same direction as the original M A N O V A analysis. Questionnaire Predictors of Change Indices Linear regressions were conducted separately for each imagery group to determine whether questionnaire measures could predict the intercept or slope of the curves. Predictions for curvature  31 were not included in this analysis since curvature was highly correlated with slope (r = -.97,p<.01). The MOCI-Washing, Bathroom Habits Questionnaire, Disgust Scale, OBQ-Threat, and O B Q Uncertainty scales were simultaneously entered into the regression analyses. For the prediction o f distress at intercept, the overall A N O V A was significant for the loom group (F(5, 24)=3.33,/><.05) and static group (F(5, 24)=3.91,^<.05), but not the safety group (F=(5, 24)=1.00, p=A4).  In the loom group, the model explained 4 1 % o f the variance, but none o f  the individual questionnaires were significant predictors (Ss < .39,/?s>.10). In the static group, the model explained 45% o f the variance, with significant predictors o f intercept distress as follows: MOCI-Washing (B = -.41, p<.05), Disgust Scale (B = .55, p<.01), and OBQ-Threat (B = .57, p<.01). For the prediction o f slope, the overall A N O V A s were not significant for any o f the imagery groups (Fs=(5, 24)<1.58,ps>.2\). Cognitive Appraisal Mediation M o d e l W e have already demonstrated that looming imagery creates higher distress ratings at the intercept (i.e., immediately after imagery is presented) and different trajectories over time compared with other types o f imagery. To evaluate why or how looming imagery has this impact, we tested a mediational model proposed by Riskind, Abreu et al. (1997), that cognitive appraisals mediate the relationship between looming vulnerability and fear. Thus, we tested a model whereby looming imagery (the independent variable) triggers or intensifies cognitive appraisals (the mediator), which i n turn impact on distress ratings at the intercept (the dependent variable). Measurement o f cognitive appraisals was taken from three items on the Reaction to Exposure Questionnaire: likelihood o f getting sick, likelihood o f a bad outcome, and feeling vulnerable (a=.86). Following the guidelines o f Baron & Kenny (1986), we conducted three regression analyses. W e first regressed cognitive appraisals on loom imagery. L o o m imagery was a  32  significant predictor, accounting for 28% of the variance in cognitive appraisals (F=(l, 88)=33.44, /K.001; B = .53,/K.001). Second, we regressed distress at intercept on looming imagery. In this model, looming imagery accounted for 21% of the variance in distress (F=(l, 88)=23.67,/K.001; B = .46,/K.001). Finally, we regressed distress at intercept on both looming imagery and cognitive appraisals, by simultaneously entering them into the equation. This model accounted for 29% of the variance in distress (F=(2, 87)=17.83,/K.001), with both looming imagery (B = .29,/K.Ol) and cognitive appraisals (B = .33,/K.005) showing significant and unique predictive value. Although looming contributed unique variance to the equation (indicating that some effects are direct), the impact of looming imagery was lessened due to the inclusion of cognitive appraisals, which was statistically tested using the Goodman I version of the Sobel significance test (Goodman, 1960; ;(87)=2.70,/K.01). Results indicated that cognitive appraisals were a significant (partial) mediator in the relationship between looming imagery usage and distress at intercept. The mediation model was also tested with slope as the dependent variable. Results of the first analysis in which we regressed cognitive appraisals on loom imagery were reported above. For the second equation, we regressed slope on looming imagery. In this model, looming imagery accounted for 7% of the variance in slope (F=(l, 88)=6.14,/K.05; B = .26,/K.05). Finally, we regressed slope on both looming imagery and cognitive appraisals, by simultaneously entering them into the equation. This model accounted for 11% of the variance in slope (F=(2, 87)=5.60, /K.01). The presence of cognitive appraisals as a significant unique predictor (B - .26,/K.05) eliminated the impact of looming imagery, which was not significant in the simultaneous model (B = .12,/?=.32). The Sobel significance test indicated that cognitive appraisals were a significant mediator in the relationship between looming imagery usage and slope of distress over time (;(87)=2.02, /K.05).  33 Discussion For many years, researchers have focused on stimulus properties to understand the rate and degree of habituation to phobic stimuli. However, recent theories of anxiety disorders implicate cognitive factors in the development and maintenance of fear (Freeston, Rheaume, and Ladouceur, 1996; Riskind, 1997; Salkovskis, 1985). In order to integrate research of habituation with current cognitive theories, we manipulated participants' imagery usage during exposure to a contaminant to evaluate the moderating and mediating effects of cognition on habituation. Riskind (1997) proposes that looming vulnerability is a central cognitive component of threat that elicits anxiety, sensitizes individuals to threat cues, and impedes habituation. Furthermore, his theory holds that looming is a more important determinant of fear than other aspects of threat appraisal, such as probability of harm, lack of control, and imminence (Riskind, Abreu, Strauss, and Holt, 1997). We hypothesized that both static harm and looming harm imagery would retard habituation to a contaminant compared with safety imagery. Additionally, in line with Riskind's theory, we proposed that looming harm imagery would impede habituation above and beyond the effects of static harm imagery, due to the increased threat value associated with the dynamically changing stimulus. In order to establish the causal role of threatening imagery on distress ratings during exposure, we needed to verify that our groups did not differ on baseline measures of distress. Ratings of anticipatory distress were equivalent across groups and increased over the three baseline measurements. Prior to the introduction of imagery, all groups rated the stimulus as equally distressing when it was placed on their palm. However, after imagery was implemented, dramatic effects were observed between groups on measures of initial distress and change over time.  34 We found clear evidence that looming harm imagery impedes habituation to a contaminant compared with both static harm and safety imagery. This effect of loom imagery was extremely robust, occurring immediately after the presentation of imagery, maintaining throughout the full 30-minute exposure, and lingering on after participants washed their hands and completed questionnaires for 10 minutes. Various methods of statistical analysis converged on this finding, including a between-groups A N O V A using raw change scores to evaluate the impact of imagery over time, and a growth curve modeling approach using intercept, slope, and curvature as indices of change. Loom imagers did not merely habituate more slowly; they actually sensitized over time, increasing in distress after beginning to use the imagery. This sensitization of the looming harm group makes sense given that the laws of habituation predict response decrement following prolonged or repeated presentation of a constant stimulus. Although our physical stimulus was not changing, participants in the loom condition were mentally manipulating the speed and spread of contamination, creating a situation where danger and threat was increasing at every moment. This dynamically changing situation would not be expected to follow the same rules governing habituation to static stimuli. Rescorla (1988) notes that conditioned learning involves more than exposure to paired stimuli; it involves a combination of cognitive processes and prior knowledge that together form representative meanings. A manipulation of looming imagery creates new information that people must integrate with a) their present experience of the stimulus, b) prior knowledge of urine and other substances they consider to be contaminating, and c) existing threat schemas. The impact of this new information regarding moving and spreading harm does appear to trigger threat networks and influence distress ratings over a half-hour period.  35  The static harm and safety groups did not significantly differ on any measure of habituation. However, these null findings should not be over-interpreted to mean that habituation was identical in the two groups. Our data indicated small to medium effect sizes between the static and safety groups on indices of change, ranging from | d | = .18 to .47. One factor that may have contributed to the weak differences was participants' incomplete compliance with the imagery instruction. Imagery usage between the safety and static harm groups involved some overlap, so the manipulation did not result in a clean comparison of static harm versus safety imagery usage. Indeed, participants' difficulty in differentiating static harm and safety may be an interesting phenomenon in itself, suggesting that stationary harm is more difficult to distinguish from safety. Thus, our data indicate that static harm imagery may inhibit habituation somewhat, although the effect is not nearly as powerful as the impact of looming imagery. Random assignment resulted in fairly homogeneous groups on preliminary assessment measures. Participants in each group reported equal levels of disgust sensitivity, anxiety sensitivity, threat appraisals, tolerance of uncertainty, and general imagery ability. The groups were nonetheless statistically significantly different on the MOCI Washing scale, a measure of contamination fears and cleaning behavior. This difference of less than 2 points between the loom and safety group on the 11-point true/false measure had no impact on the findings of our habituation analyses. Riskind (1997) proposes that stimulus movement has a powerful influence on appraisals of threat. Our data support this claim in a number of ways. First of all, instruction to imagine moving and spreading contamination resulted in participants using not only more loom imagery, but also more imagery of harm, illness, and disease (e.g., "I may get sick") compared to other groups as reported on the Imagery Usage Questionnaire. Although this result could indicate a weakness in  36  our manipulation of looming harm versus static harm, it also suggests that for contamination fears, stimulus movement cues harm appraisals. Another interesting finding was the powerful influence of loom imagery on distress ratings despite the fact that participants reported the imagery to be relatively unbelievable. Therefore, believing in the truth of the looming thoughts and images did not appear to be a necessary component for impact on subjective distress. However, it should be noted that participants made their rating of belief after washing their hands, so their level of belief during the exposure (when distress ratings were elevated) remains unknown. Many phobic individuals express strong beliefs in the probability and severity of negative consequences when confronting a feared stimulus, but they realize these fears are irrational when they are not as aroused. Therefore, it would be interesting to know whether increases in believability would correlate with increases in distress ratings during exposure in a normal sample. Riskind, Abreu et al. (1997) propose that looming vulnerability has both direct independent effects on contamination fears, as well as indirect effects that are mediated by other cognitive appraisals. In these mediated effects, looming appraisals intensify other cognitive factors, including likelihood of harm, imminence, and lack of control, which in turn affect contamination fears. Our research found support for both direct and mediated effects of loom imagery. For distress ratings immediately after the introduction of imagery (intercept), loom imagery demonstrated unique predictive value as well as indirect effects mediated by cognitive appraisals of likelihood of getting sick, likelihood of a bad outcome, and feeling vulnerable. No direct effects of loom imagery were detected for slope; all effects were mediated via cognitive appraisals. Thus, imagery regarding spread and movement of germs appears to facilitate cognitive appraisals implicated by the cognitive model of OCD; these appraisals in turn impact on distress. Our  37  research is also consistent with the findings of Jones and Menzies (1997), who found that those individuals with OCD who reported higher estimates for likelihood and severity of disease also reported higher ratings of anxiety during exposure to a contaminant, even after controlling for other variables of interest (i.e., perceived level of responsibility, level of self-efficacy, and strength of self-efficacy). Measures of behavioral avoidance are often portrayed as superior to self-reports, since they more closely mirror real-life encounters with fearful objects or situations. However, behavioral measures are subject to their own set of response biases not found in self-reports. For instance, Rozin and colleagues found that disgust-relevant behavioral tasks in front of an experimenter involve not only disgust, but also sensitivity to embarrassment and compliance motivation (Rozin, Haidt, et al., 1999). Our null findings for group differences on a subtle measure of behavioral avoidance (offering a snack post-washing) despite differences on subjective ratings of distress postwashing support the claim that subjective and behavioral measures may not tap into the same constructs. In our sample, 40% of participants availed themselves of an opportunity to eat a snack, and of those participants, 39% used their exposure (non-dominant) hand. These rates may be reflective of a relatively easy task for a non-clinical sample such as ours. As these participants were willing to have someone else's urine on their hand for 30 minutes, eating a snack after washing their hands may not have seemed disgusting or anxiety provoking. The passive nature of our measure ("Would you like a cookie or pretzel?") also confounded avoidance due to feelings of contamination and avoidance for other reasons such as lack of hunger. Behavioral measures can provide important information regarding severity of fearful avoidance. However, due to the potential response biases and confounding variables, they should not be  38  expected to correlate with self-reports in all situations, nor should they be considered superior to other forms of measurement. This study is the first to date evaluating the impact of threatening imagery on habituation to a contaminant. Use of a college sample allowed us to identify cognitive factors apparent in a normal population of young adults. However, findings from college samples may not generalize to the general community due to differences in demographic variables such as age, education, and socioeconomic status. The university environment also produces a unique set of social pressures and life experiences. Many students live communally and share bathrooms in dormitories or group houses; they may participate in fraternity hazing and attend parties where binge drinking and vomiting occur. These experiences and living environments increase exposure to contaminants such as urine and vomit, and promote activities that might be viewed as disgusting or disturbing in other environments. Therefore, our college sample may have been less distressed by the exposure, and more willing to engage in threatening imagery compared with a community or clinical sample. Given these factors, generalizability to other samples must be tested rather than assumed. Our research suggests that thoughts and images of moving and spreading germs may explain why some individuals experience lingering feelings of contagion after exposure to a contaminant. This research has a number of important clinical implications for treatment of anxiety disorders. First and foremost, clinicians should recognize that cognitive factors have the power to impede habituation to phobic stimuli. Therefore, imagery usage, whether deliberate or involuntary, may contribute to the individual differences observed in time to habituate during exposure therapy. Furthermore, some patients do not habituate despite prolonged exposures of up to two hours. Although our exposure lasted only 30 minutes, and we do not know when or whether  39  participants in the loom group would have eventually habituated, our research suggests that threatening imagery can play a role in failure to habituate. Research indicates that habituation is related to treatment outcome in exposure therapy for phobias and OCD (Lang, Melamed & Hart, 1970; Marks, Boulougouris, & Marset, 1971; Foa, Steketee, Grayson, Doppelt, Turner and Latimer, 1983). Therefore, if the use of threatening imagery during exposure impairs habituation, it may also compromise treatment outcome. Imagery of moving and spreading germs may be especially detrimental for individuals with obsessivecompulsive washing concerns. For instance, use of looming images may inhibit habituation to a contaminant and limit the opportunity for a patient to learn that anxiety and disgust will reduce over time. Vivid threat imagery may also interfere with a patient's ability to challenge and restructure distorted cognitions about the catastrophic nature of germs during and after exposure. Therefore, looming imagery may contribute to relapse after treatment is completed. Foa and Kozak's (1996) overview of 12 OCD treatment-outcome studies indicated that 17% of patients did not respond to exposure/response prevention treatment and 24% of patients were non-responders at follow-up. It remains to be shown whether cognitive interference of habituation, such as using looming imagery during exposure, contributes to the incidence of treatment failures in OCD. Foa (1979) identified 10 O C D patients who failed to respond or quickly relapsed despite compliance with exposure therapy. In contrast to treatment responders, treatment failures presented with either severe depression or overvalued ideation (strong belief that their fears were realistic), and evidenced habituation deficits. Could loom imagery play a role in overvalued ideation? A patient with vivid images of germs spreading through the air and traveling into their body may find these ideas extremely convincing and difficult to disprove since they are not visible to the naked eye. Furthermore, these images may enhance cognitive distortions for likelihood of  40  harm and disease that can be difficult to test (e.g., getting cancer in 10 years), again increasing the belief that germs are dangerous and to be avoided at all costs. The near delusional quality of thoughts evidenced by overvalued ideators may take on an elaborate and nonsensical world of their own, a world where imagery fantasies appear real and the ability for reality testing is limited. Our study demonstrated that looming harm imagery dramatically impacts on habituation to a contaminant in a normal sample of college students. This research suggests that thoughts and images of moving and spreading germs may explain why some individuals experience lingering feelings of contagion after exposure to a contaminant, while others recover relatively quickly. Clearly, cognitive factors can moderate and mediate affective responses to phobic stimuli over time. This exciting new area of research provides resurgence to the literature on habituation in light of current cognitive theories of anxiety disorders.  References Baron, R. M . , & Kenny, D. A . (1986). 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Journal of Anxiety Disorders, 16, 543559.  47  Table 1  Means and Standard Deviations on Questionnaires and Baseline Ratings of Distress for the Full Sample (N=90)  Mean  Standard Deviation  MOCI-Washing  2.20  2.26  Bathroom Habits  9.17  2.93  Disgust Scale  17.06  5.07  Anxiety Sensitivity  17.83  8.74  OBQ-Threat  33.98  13.00  OBQ-Uncertainty  44.38  12.47  QMI-Vividness  41.29  13.25  Baseline Distress #1 (0-100)  11.22  9.42  Baseline Distress #2 (0-100)  11.53  8.59  Baseline Distress #3 (0-100)  16.74  11.64  Measure  Note. MOCI-Washing = Maudsley Obsessive Compulsive Inventory Washing Subscale; Bathroom Habits = Bathroom Habits Questionnaire; Disgust Scale = Disgust Scale; Anxiety Sensitivity = Anxiety Sensitivity Index; OBQ-Threat = Obsessive Beliefs Questionnaire Overestimation of Threat Subscale, OBQ-Uncertainty = Obsessive Beliefs Questionnaire Tolerance of Uncertainty Subscale; QMI-Vividness = Betts' Questionnaire Upon Mental Imagery-Short Form Visual, Touch, and Sensation Subscales.  48 Table 2  Correlations and Reliability Coefficients for Preliminary Questionnaire Measures Measure  1  2 .  3'  4  '5  1. MOCI-Washing  .72  2. Bathroom Habits  .68**  .78  3. Disgust Scale  .48**  .48**  .68/.77  4. Anxiety Sensitivity  .19  .16  .36**  .86  5. OBQ-Threat  .31**  .25*  .20  .52**  .86  6. OBQ-Uncertainty  29**  .28**  .26*  .55**  .62**  .85  7. QMI-Vividness  .19  .03  -.09  -.08  .04  .03  a  Note. Numbers along diagonal indicate coefficient alpha. Disgust Scale alphas given separately a  for true/false section and Likert section. MOCI-Washing = Maudsley Obsessive Compulsive Inventory Washing Subscale; Bathroom Habits = Bathroom Habits Questionnaire; Disgust Scale = Disgust Scale; Anxiety Sensitivity = Anxiety Sensitivity Index; OBQ-Threat = Obsessive Beliefs Questionnaire Overestimation of Threat Subscale, OBQ-Uncertainty = Obsessive Beliefs Questionnaire Tolerance of Uncertainty Subscale; QMI-Vividness = Betts' Questionnaire Upon Mental Imagery-Short Form Visual, Touch, and Sensation Subscales. */><.05, **p<.01.  Table 3 Baseline Ratings of Distress for Exposure Completers and Refusers Completer Distress Rating  M  SD  Refuser M  SD  df  t  P  d  Baseline #1  10.97  (9.14)  16.82  (7.51)  109  -2.04  <.05  - .65  Baseline #2  11.18  (8.62)  17.45  (11.50)  109  -2.21  <.05  - .70  Baseline #3  16.33  (11.51)  27.73  (17.37)  109  -2.95  <.005  - .94  Note. Completers n=100 (includes noncompliant imagers); Refusers n=l 1.  50 Table 4 MANOVA for Manipulation Check of Imagery Usage  Source of Variation  df  MS  F  Loom  2  170.41  47.77  <.001  .52  Static  2  54.70  7.61  <.005  .09  Safety  2  30.34  4.44  <.05  .15  Harm  2  84.23  24.26  <.001  .36  P  partial n  Between Subjects (Group)  Within Subjects (Error) Loom  87  3.57  Static  87  7.19  Safety  87  6.84  Harm  87  3.47  2  Table 5 Means and Standard Deviations for Imagery Usage During Exposure  Assigned Imagery Condition  Static Harm  Safety  Usage  Looming Harm  Loom  6.30 (2.10)  a  2.83 (1.82)  b  Static  2.93 (1.89)  a  5.63 (2.34)  b  Safety  4.37 (2.22)  a  4.57 (2.99)  a  6.20 (2.58)  b  Harm  4.40 (2.54)  a  1.87 (1.66)  b  1.23 (1.10)  b  1.73 (1.72) 4.33 (3.54)  b  a b  Note. Means in the same row that do not share subscripts are significantly different (Tukey, p<.05). Imagery usage endorsement scale ranged from 0 (never imagined) to 10 (constantly imagined).  52 Table 6  MANOVA for Imagery Ability During Exposure  Source of Variation  df  MS  F  p  partial n  Produce  2  21.38  5.14  <.01  .11  Maintain  2  65.11  14.91  <.001  .26  Vivid  2  10.62  2.56  .08  .06  Believe  2  92.72  21.01  <.001  .33  Produce  86  4.16  Maintain  86  4.37  Vivid  86  4.14  Believe  86  4.41  Between Subjects (Group)  Within Subjects (Error)  Note. Produce=ease of producing images; Maintain=ease of maintaining images throughout exposure; Vivid=how vivid or clear images were; Believe=to what extent images were true/believable.  2  53  Table 7  Means and Standard Deviations for Imagery Ability During Exposure  Assigned Imagery Condition  Ability  Looming Harm  Static Harm  Produce  5.90 (2.43)  a  Maintain  3.90 (2.37)  a  4.90 (2.16)  Vivid  5.67 (2.26)  a  Believe  4.37 (2.44)  a  6.93 (2.08)  Safety  7.59 (1.48)  b  a  6.83 (1.67)  b  6.50 (1.82)  a  6.83 (2.00)  a  6.60 (2.16)  b  7.86 (1.60)  b  a b  Note. Means in the same row that do not share subscripts are significantly different (Tukey, p<.05). Scales ranged from 0 (extremely difficult to produce/maintain; not at all vivid; didn't believe) to 10 (extremely ease to produce/maintain; extremely vivid; completely believed). Produce=ease of producing images; Maintain=ease of maintaining images throughout exposure; Vivid=how vivid or clear images were; Believe=to what extent images were true/believable.  54  Table 8  Imagery Ability in Compliant and Noncompliant Imagers Compliant  Noncompliant  Ability  M  SD  M  SD  df  t  P  d  Produce  6.72  (2.24)  4.20  (2.62)  98  3.33  <.005  1.10  Maintain  5.13  (2.45)  3.00  (2.16)  98  2.64  <.05  .88  Vivid  6.26  (2.17)  5.10  (2.42)  98  1.58  .12  .53  Believe  6.26  (2.53)  3.00  (2.49)  97  3.86  <.001  1.29  Note. Compliant «=90; Noncompliant n=10. Scales ranged from 0 (extremely difficult to produce/maintain; not at all vivid; didn't believe) to 10 (extremely ease to produce/maintain; extremely vivid; completely believed). Produce=ease of producing images; Maintain=ease of maintaining images throughout exposure; Vivid=how vivid or clear images were; Believe=to what extent images were true/believable.  55 Table 9 Cohen's d Effect Sizes for Comparison of Groups on Distress Indices of Change  Comparison  Raw Change  Intercept  Slope  Curvature  Loom vs. Safety  1.20  1.12  .85  -.97  Loom vs. Static  .85  .72  .66  -.66  Static vs. Safety  .44  .47  .18  -.28  56 Table 10  MANOVA for Reaction to Exposure Questionnaire Items  Source of Variation  df  MS  F  p  partial n  Feeling contaminated  2  15.48  17.41  <.001  .29  Feeling disgusted  2  11.20  10.63  <.001  .20  Urge to wash hands  2  8.58  8.94  <.001  .17  Likelihood of sickness  2  6.03  11.33  <.001  .21  Likelihood of bad outcome  2  5.03  11.54  <.001  .21  Feeling vulnerable  2  9.73  11.61  <.001  .21  How far germs traveled  2  16.88  11.61  <.001  .21  Between Subjects (Group)  Within Subjects (Error) Feeling contaminated  87  .89  Feeling disgusted  87  1.05  Urge to wash hands  87  .96  Likelihood of sickness  87  .53  Likelihood of bad outcome  87  .44  Feeling vulnerable  87  .84  How far germs traveled  87  1.45  2  57  Table 11  Means and Standard Deviations for Reaction to Exposure Questionnaire Items  Assigned Imagery Condition  Reaction to Exposure  Looming Harm  Static Harm  Safety  Feeling contaminated  2.20 (1.19)  a  1.40  Feeling disgusted  1.90 (1.30)  a  1.10 (.85)  Urge to wash hands  3.20 (.89)  Likelihood of sickness  •97(1.13)  a  .33 (.48)  b  -10 (.31)  b  Likelihood of bad outcome  .80 (1.06)  a  .17 (.38)  b  .03 (.18)  b  Feeling vulnerable  1.47 (1.22)  a  .33 (.48)  b  How far germs traveled  2.40 (1.45)  a  (.89)  b  .77 (.68)  c  b  .70 (.88)  b  2.60 (1.00) ab  a  .80 (.89) 1.30 (.88)  b  b  2.13 (1.04)  .97 (1.34)  b  b  Note. Means in the same row that do not share subscripts are significantly different (Tukey, p<.05). Scales for items 1-6 ranged from 0 (not at all) to 4 (extremely). Item 7 ranged from 0 (there were no germs or contamination in urine) to 5 (germs traveled through my pores and spread through the air into my lungs).  58 Table 12 MANOVA for Indices of Change in Quadratic Model  Source of Variation  df  MS  F  p  partial r\  Intercept  2  4742.50  10.86  <.001  .20  Slope  2  21.11  6.67  <.005  .13  Curvature  2  .01  7.75  <.005  .15  Between Subjects (Group)  Within Subjects (Error) Intercept  87  436.82  Slope  87  3.16  Curvature  87  <.005  Table 13 Means and Standard Deviations for Quadratic Model Change Parameters  Assigned Imagery Condition  Change Index  Looming Harm  Intercept  43.37 (26.88)  Slope Curvature  0.43 (2.28)  a  26.71 (18.68) -0.87 (1.62)  a  - 0.01 (0.05)  Static Harm  a  0.02 (0.04)  b  b  Safety  b  18.73 (15.47) -1.14 (1.30) 0.03 (0.03)  b  b  b  Note. Means in the same row that do not share subscripts are significantly different (Tukey, p<.05).  Figure Captions  Figure 1. Immediate effect of imagery. Figure 2. Average distress ratings for each imagery group during 30-minute exposure.  61  80  60  -^—Looming Harm Distress Rating (0-100)  -Static Harm  40 H  Safety 20 A  . Urine Applied  Imagery Applied  Distress  Looming Harm|  Rating  Static Harm  (0-100)  Safety  Urine Applied  Time (Minutes)  63 Appendix A Betts QMI V i v i d n e s s of Imagery S c a l e - S h o r t (3 S u b s c a l e s )  T h e aim of this test is to determine the vividness of your imagery. T h e items of the test will bring certain i m a g e s to your mind. Y o u are to rate the vividness of e a c h image by reference to an a c c o m p a n y i n g rating scale, reproduced below a n d on top of the next page. For example, if your image is "vague and dim" you give it a rating of 5. Before turning to items on the next page, familiarize yourself with the different rating scale categories printed below and on top of the following p a g e . P l e a s e do not leave any page until you have completed the items on the p a g e you are doing, and do not go back to check on the completed items. C o m p l e t e e a c h set before moving on to the next set. Try to do e a c h item separately, independently of how you m a y have d o n e other items.  T h e image a r o u s e d by an item on this test may be: Rating 1 - Perfectly clear and a s vivid a s the actual e x p e r i e n c e Rating 2 - V e r y clear a n d comparable in vividness to the actual experience Rating 3 - Moderately clear and vivid Rating 4 - Not clear or vivid, but recognizable Rating 5 - V a g u e and dim Rating 6 - S o v a g u e and dim a s to be hardly discernable Rating 7 - N o image present at all, you only "knowing" that you are thinking of the object  A n example of an item on the test would be o n e which a s k e d you to consider an image which c o m e s to your mind's e y e of a red apple. If your visual image w a s moderately clear and vivid you would c h e c k the rating scale and mark "3" on the answer sheet.  Now turn to the next p a g e when you have understood these instructions and begin the test.  64  Here is the rating scale again in brief: 1 Perfectly Clear and Vivid  2 Very Clear  3 Moderately  4 Recognizable  Clear  6  7  Hardly  No image  5 Vague and Dim  Discernable  at all  Think of s o m e relative or friend w h o m you frequently s e e , considering carefully the picture that rises before your mind's eye. Classify the i m a g e s s u g g e s t e d by e a c h of the following questions a s indicated by the d e g r e e of clearness and vividness specified on the Rating Scale. 1) T h e exact contour of face, h e a d , shoulders and body  1  2  3  4  5  6  7  2) Characteristic p o s e s of h e a d , attitudes of body, etc.  1  2  3  4  5  6  7  3) T h e precise carriage, length of step, etc. in walking  1  2  3  4  5  6  7  4) T h e different colors worn in s o m e familiar clothing  1  2  3  4  5  6  7  Think of seeing the following, considering carefully the picture which c o m e s before your mind's eye, and classify the image suggested by the question a s indicated by the degree of clearness a n d vividness specified on the Rating S c a l e . 5) T h e m o o n a s it is sinking below the horizon  3  1  4  5  6  Think of "feeling" or touching e a c h of the following, considering carefully the image which c o m e s before your mind's touch, a n d classify the images s u g g e s t e d by e a c h of the following questions a s indicated by the degree of clearness a n d vividness specified on the Rating S c a l e . 6) S a n d  2  3  4  5  6  7  7) Linen  2  3  4  5  6  7  8) Fur  2  3  4  5  6  7  9) T h e prick of a pin  2  3  4  5  6  7  10) T h e warmth of a tepid bath  2  3  4  5  6  7  65  Think of e a c h of the following sensations, considering carefully the image which c o m e s before your mind, a n d classify the i m a g e s suggested a s indicated by the d e g r e e of clearness and vividness specified on the Rating S c a l e . 11)  Fatigue  2  3  4  5  6  7  12)  Hunger  2  3  4  5  6  7  13) A sore throat  2  3  4  5  6  7  14) Drowsiness  2  3  4  5  6  7  15) Repletion as from a very full meal  2  3  4  5  6  7  66  Appendix B MOCI-Washing Scale  Instructions: Please answer each question by putting a circle around the "T" for True and "F" for False. There are no right or wrong answers. Work quickly, and do not think too long about the exact meaning of the question.  T  F  1 . 1 avoid using public telephones b e c a u s e of possible contamination.  T  F  2. I a m often late b e c a u s e I can't s e e m to get through everything o n time.  T  F  3. I don't worry unduly about contamination if I touch a n animal.  T  F  4. I do not worry unduly if I accidentally bump into s o m e o n e .  T  F  5 . 1 u s e only a n a v e r a g e amount of soap.  T  F  6. I a m not excessively c o n c e r n e d about cleanliness.  T  F  7. I c a n u s e well-kept toilets without any hesitation.  T  F  8. I a m not unduly c o n c e r n e d about germs and d i s e a s e s .  T  F  9. M y h a n d s d o not feel dirty after touching money.  T  F  10. I take rather a long time to complete my washing in the morning.  T  F  11. I d o not u s e a great deal of antiseptics.  67 Appendix C Obsessive Beliefs Questionnaire Subscale U and Subscale T This inventory lists different attitudes or beliefs that people sometimes hold. Read each statement carefully and decide how much you agree or disagree with it. For each of the statements, choose the number matching the answer that B E S T DESCRIBE H O W Y O U THINK. Because people are different, there are no right or wrong answers. To decide whether a given statement is typical of your way of looking at things, simply keep in mind what you are like M O S T OF T H E TIME. In your ratings, try to avoid using the middle point of the scale (4), but rather indicate whether you usually disagree or agree with the statements about your own beliefs and attitudes. Use the following scale: 1 2 disagree disagree very much moderately  3 disagree a little  4 neither agree nor disagree  5 agree a little  6 agree moderately  7 agree very much  U-Scale: 1. If I am uncertain, there is something wrong with me.  1 2 3 4 5 6 7  2. If I'm not absolutely sure of something, I'm bound to make a mistake.  1 2 3 4 5 6 7  3. If an unexpected change occurs in my daily life, something bad will happen.  1 2 3 4 5 6 7  4. It is essential for me to consider all possible outcomes of a situation.  1 2 3 4 5 6 7  5. I must be certain of my decisions.  1 2 3 4 5 6 7  6. In order to feel safe, I have to be as prepared as possible for anything  1 2 3 4 5 6 7  that could go wrong. 7. It is essential for everything to be clear cut, even in minor matters.  1 2 3 4 5 6 7  8. I should be 100% certain that everything around me is safe.  1 2 3 4 5 6 7  9. If something unexpected happens, I will not be able to cope with it.  1 2 3 4 5 6 7  10. It is terrible to be surprised.  1 2 3 4 5 6 7  11. I should go to great lengths to get all the relevant information before  1 2 3 4 5 6 7  I make a decision. 12. I often think that I will be overwhelmed by unforeseen events.  1 2 3 4 5 6 7  13. I need the people around me to behave in a predictable way.  1 2 3 4 5 6 7  68  T-Scale: 1. I often think things around me are unsafe.  1 2 3 4 5 6 7  2. I am much more likely to be punished than are others.  1 2 3 4 5 6 7  3. Things that are minor annoyances for most people seem like disasters to me.  1 2 3 4 5 6 7  4. Bad things are more likely to happen to me than to other people.  1 2 3 4 5 6  7-  5. Avoiding serious problems (for example, illness or accidents) requires  1 2 3 4 5 6 7  constant effort on my part. 6. Small problems always seem to turn into big ones in my life.  1 2 3 4 5 6 7  7. If I do not take extra precautions, I am more likely than others to have  1 2 3 4 5 6 7  or cause a serious disaster. 8. I believe that the world is a dangerous place. 9. I am more likely than other people to accidentally cause harm to  1 2 3 4 5 6 7 1 2 3 4 5 6 7  myself or to others. 10. Even when I am careful, I often think that bad things will happen.  1 2 3 4 5 6 7  11. Harmful events will happen unless I am very careful.  1 2 3 4 5 6 7  12. Even ordinary experiences in my life are full of risk.  1 2 3 4 5 6 7  13. When things go too well for me, something bad will follow.  1 2 3 4 5 6 7  14. When anything goes wrong in my life, it is likely to have terrible effects.  1 2 3 4 5 6 7  69 Appendix D Disgust S c a l e Please circle T (true) or F (false):  T  F  1.  It bothers me to see someone in a restaurant eating messy food with his fingers.  T  F  2.  Seeing a c o c k r o a c h in someone else's house doesn't bother me.  T  F  3.  It bothers me to hear someone clear a throat full of mucous.  T  F  4.  I think it is immoral for people to seek sexual pleasure from animals.  T  F  5.  It would bother me to be in a science class, a n d to see a human hand preserved in a jar.  T  F  6.  I would go out of my way to avoid walking through a graveyard.  T  F  7.  I never let any part of my body touch the toilet seat in public restrooms.  T  F  8.  Even if I were hungry, I would not drink a bowl of my favorite soup if it had been stirred by a used but thoroughly washed flyswatter.  T  F  9.  I might be willing to try eating monkey meat, under some circumstances.  T  F  10.  It would bother me to see a rat run across my path in a park.  T  F  11.  If I see someone vomit, it makes me sick to my stomach.  T  F  12.  I think homosexual activities are immoral.  T  F  13.  It would not upset me at all to watch a person with a glass eye take the eye out of the socket.  T  F  14.  It would bother me tremendously to touch a d e a d body.  T  F  15.  I probably would not go to my favorite restaurant if I found out that the cook had a cold.  T  F  16.  It would bother me to sleep in a nice hotel room if I knew that a man had died of a heart attack in that room the night before.  CONTINUES.  70  Please rate (0, 1, or 2) how disgusting you would find the following experiences. 0 = not disgusting at all 1 = slightly disgusting 2 = very disgusting  If you think something is b a d or unpleasant, but not disgusting, you should write "0".  17.  You see someone put ketchup on vanilla ice c r e a m , a n d eat it.  18.  You see maggots on a piece of meat in an outdoor g a r b a g e pail.  19.  While you are walking through a tunnel under a railroad track, you smell urine.  20.  You hear about a 30 year old man who seeks sexual relationships with 80 year old women.  21.  You see someone accidentally stick a fishing hook through his finger.  22.  Your friend's pet cat dies, a n d you have to pick up the d e a d body with your bare hands. You take a sip of soda, a n d then realize that you drank from the glass that an  23.  a c q u a i n t a n c e of yours had been drinking from. _____  24.  A friend offers you a p i e c e of chocolate shaped like dog-doo.  _____  25.  You are about to drink a glass of milk when you smell that it is spoiled  26.  You are walking barefoot on concrete, a n d you step on an earthworm.  27.  You see a bowel movement left unflushed in a public toilet.  28.  You hear about an adult woman who has sex with her father.  29.  You see a man with his intestines exposed after an accident.  30.  You accidentally touch the ashes of a person who has b e e n cremated.  31.  You discover that a friend of yours changes underwear only o n c e a week.  32.  As part of a sex education class, you are required to inflate a new unlubricated c o n d o m , using your mouth.  .  71  Appendix E Anxiety Sensitivity Index Circle the one phrase that best represents the extent to which you agree with the item. If any of the items concern something that is not part of your experience (e.g., "It scares me when I feel shaky" for someone who has never trembled or had the "shakes"), answer on the basis of how you think you might feel if you had such an experience. Otherwise, answer all items on the basis of your own experience. Very Little 0  1.  A Little 1  Some 2  It is important to me not to appear nervous. 0 1 2  Much 3  3  2.  When I cannot keep my mind on task, I worry that I might be going crazy. 0 1 2 3  3.  It scares me when I feel "shaky" (trembling). 0 1  4.  5.  6.  7.  8.  It scares me when I feel faint. 0  1  Very Much 4  2  2  3  3  It is important to me to stay in control of my emotions. 0 1 2  3  It scares me when my heart beats rapidly. 0 1 2  3  It embarrasses me when my stomach growls. 0 1  2  3  It scares me when I am nauseous. 0 1  2  3  9.  When I notice that my heart is beating rapidly, I worry that I might have a heart attack. 0 1 2 3  10.  It scares me when I become short of breath. 0 1 2  3  When my stomach is upset, I worry that I might be seriously ill. 0 1 2  3  It scares me when I am unable to keep my mind on a task. 0 1 2  3  Other people notice when I feel shaky. 0 1  2  3  2  3  11.  12.  13.  14.  Unusual body sensations scare me. 0  1  15.  When I am nervous, I worry that I might be mentally ill.  16.  It scares me when I am nervous. 0  0  1 1  2  3  2  3  Appendix F SUDS RATING FORM Baseline #1  Baseline #2  Rating #1  Cue:  Rating #2:  Cue: _  Rating #3:  Cue: _  Rating #4:  Cue: _  Rating #5:  Cue: _  Rating #6:  Cue: _  Rating #7:  Cue:  Rating #8:  Cue: _  Rating #9:  Cue: _  Rating #10:  Cue:  Rating #11:  Cue:  Rating #12:  Cue:  Rating #13:  Cue:  Rating #14:  Cue:  Rating #15:  Cue:  Rating #16:  Cue:  Rating #17:  Cue:  Rating #18:  Cue:  Rating #19:  Cue:  Rating #20:  Cue:  Rating #21:  Cue:  Rating #22:  Cue:  Rating #23:  Cue:  Rating #24:  Cue:  Rating #25:  Cue:  Rating #26:  Cue:  Rating #27:  Cue:  Rating #28:  Cue:  Rating #29:  Cue:  Rating #30:  Cue:  Baseline #3  Stimulus  73 Appendix G Reaction to E x p o s u r e Questionnaire P l e a s e circle your answers according to how you're feeling right now.  1. How contaminated do you feel? 0-not at all contaminated  1-a little bit  2-somewhat  3-very  4-extremly contaminated  2-somewhat  3-very  4-extremly disgusted  3-very  4-extremly strong  2 . How disgusted do you feel? O-not at all disgusted  1-a little bit  3. How strong is your urge to wash your hands? O-not at all strong  1-a little bit  2-somewhat  4. How likely is it that you could become sick from this activity? O-not at all likely  1-a little bit  2-somewhat  3-very  4-extremly likely  5. How likely is it that something bad will occur due to this exposure? O-not at all likely  1-a little bit  2-somewhat  3-very  4-extremly likely  2-somewhat  3-very  4-extremely vulnerable  6. How vulnerable do you feel? O-not at all vulnerable  1-a little bit  7. How far do you think the germs or contamination traveled? 0- there were no germs or contamination in the urine 1- the germs didn't move from their original spots on my hand 2- the germs only traveled on my palm and fingertips 3- the germs traveled to many areas on my skin, in addition to my palm and fingertips 4- the germs traveled through my pores and into my body 5- the germs traveled through my pores and spread through the air into my lungs  74 Appendix H Imagery Usage Questionnaire  Describe in your own words the imagery and thoughts you used during the exposure:  How easy or difficult was it for you to produce the pictures and images in your mind? 0  1  extremely difficult to create  2  3  4  very difficult  5  6  somewhat difficult  7  8  9  somewhat easy  very easy  10 extremely easy to create  How easy was it to constantly maintain the image throughout the exposure, versus having difficulty because you were struggling to keep bringing the image back to your mind? 0 1 extremely difficult to maintain  2 very difficult  3  4 5 somewhat difficult  .  6  7  8  somewhat easy  9 very easy  10 extremely easy to maintain  How vivid or clear were the pictures and images that you created in your head? 0  1  2  3  4  5  not at all vivid / clear  6  7  8  9  somewhat vivid / clear  10 extremely vivid / clear  To what extent did you believe that the information you were asked to imagine was true? 0 didn't believe, info was false  1  2  3  info mostly false/unbelievable  4  5  info partially false/unbelievable  6 info partially true/believable  7  8  9  info mostly true/believable  10 believed info was true  75  P l e a s e rate the d e g r e e to which you u s e d (or did not use) the following visualization images or thoughts. R e a d e a c h category carefully a n d rate how often you imagined these types of ideas during the e x p o s u r e using the scale:  0  1  Never imagined  2 Imagined a little bit  3  4  5  Imagined sometimes  6 Imagined a lot  7  8  9  Imagined most of the time  .10 Constantly imagined  How often did you imagine or think about ideas related to the m o v e m e n t and spreading of harmful g e r m s or contamination?  (For example: T h e contamination is  spreading all over my hand and through the air. T h e g e r m s are s e e p i n g under my skin.)  How often did you imagine or think about ideas related to your safety and the a b s e n c e of g e r m s ?  (For example: T h e urine is clean a n d sterile, so I a m safe.  T h e r e are no real germs, so I won't get sick.)  How often did you imagine or think about ideas related to the harmful germs being unable to move and restricted to a small a r e a ?  (For example: T h e contamination  is only on my palm and fingertips; it cannot move or s p r e a d anywhere else.  The  germs are frozen a n d motionless.)  How often did you imagine or think about ideas related to the harm, illness and disease?  (For example: T h e urine might be dirty a n d contaminated with germs. I  may get sick!)  76  Appendix I D e m o g r a p h i c s a n d Bathroom Habits Questionnaire  1)  Gender/Sex:  2)  Age:  3)  What is your ethnicity?  4)  Country where you were born:  5)  Country where your mother w a s born:  6)  Country where your father w a s born:  7)  H o w long h a v e y o u lived in C a n a d a ? If less than five years in C a n a d a , in what country have y o u spent most of your life?  B A T H R O O M HABITS:  1) Do you avoid public washrooms? a.  I never go to public w a s h r o o m s unless absolutely n e c e s s a r y .  b.  I often put off going the w a s h r o o m when I need to if I a m in a public place.  c.  If I a m going h o m e s o o n , I will sometimes wait to u s e the w a s h r o o m there rather than u s e o n e in public.  d.  I almost always u s e the nearest w a s h r o o m when the n e e d arises, even if it is a public w a s h r o o m (assuming it is reasonably clean).  2)  Do you avoid touching doorknobs or taps in public washrooms? a.  I almost always find s o m e way to avoid touching d o o r k n o b s or taps in public washrooms.  b.  I often u s e tissue or a towel to avoid touching d o o r k n o b s or taps in public washrooms.  c.  At times, I have avoided touching doorknobs or taps in public w a s h r o o m s .  d.  I almost always u s e doorknobs or taps in public w a s h r o o m s just the s a m e a s I would in m y own home.  77  3)  When using the toilet in a public washroom, do you usually: a.  Sit on the toilet seat just a s you would at h o m e  b.  C o v e r the toilet seat with paper or toilet seat cover before sitting on it  c.  Avoid touching the toilet seat at all (i.e., hover over it)  d.  Not u s e public w a s h r o o m s at all  4) How much anxiety or discomfort do you experience due to fear of contamination or germs when using a public restroom? a.  S e v e r e anxiety  b.  Moderate anxiety  c.  A Little anxiety  d.  N o anxiety  5) Are you bothered by unpleasant thoughts or images regarding contamination or germs while using a public bathroom? a.  I often h a v e thoughts or images about contamination or g e r m s in public w a s h r o o m s , a n d t h e s e ideas bother m e a lot.  b.  I occasionally have thoughts or images about contamination or g e r m s in public w a s h r o o m s , a n d these ideas bother m e a lot w h e n they occur.  c.  I often think about contamination or germs w h e n I a m in a public w a s h r o o m , but I don't worry m u c h about it.  d.  I usually don't think about contamination or g e r m s unless the public w a s h r o o m is extremely dirty or smelly, a n d even then I don't get too stressed out about it.  6) About how many times do you wash your hands each day?  Appendix J  Prompts and C u e Q u e s t i o n s  Looming H a r m Prompts  1)  "Imagine the g e r m s moving rapidly a c r o s s your skin."  2)  "Germs and bacteria can c a u s e d i s e a s e s that are harmful to you."  3) 4)  " R e m e m b e r that the contamination is mobile and airborne." "Picture the bacteria breaking through natural surface barriers and spreading through thick s u b s t a n c e s "  5) "The urine on your h a n d feels gross a n d dirty." 6)  "Think about the implications of the g e r m s moving a n d spreading on your skin."  7)  "Imagine the g e r m s spreading through the air a s they evaporate."  8)  "Visualize the contamination seeping through the tiny invisible tears in your skin."  9)  "Germs can s p r e a d readily, since bacteria are c a p a b l e of movement."  10) "Visualize the contamination moving and spreading on your skin." 11 )"Remember, the contamination is not isolated or contained."  Looming H a r m C u e Q u e s t i o n s  A . "What aspect of the urine are you focusing on right now?" B. "Describe how y o u are imagining the urine right now." C . "What do you imagine the urine to be doing as it t o u c h e s your skin?" D. "What thoughts are you having about the urine now?"  79 Static Harm Prompts  1)  "Picture the g e r m s a s unable to move or spread from their current location."  2)  "Germs and bacteria c a n c a u s e d i s e a s e s that are harmful to you."  3) "The contamination is restricted to the spots where it sits on your skin right now." 4)  " R e m e m b e r that the contamination is confined and stationary."  5)  "The urine on your hand feels gross and dirty."  6)  "Your skin is multi-layered. It forms a natural surface barrier to k e e p contamination on your skin's surface."  7) "Focus on the area of your hand where the urine is sitting right now. A n y germs are contained to this area alone." 8) 9)  "Think about the implications of the germs sitting stationary on your skin's surface." "Visualize that the contamination cannot move or s p r e a d a c r o s s your skin."  10) "Remember, the contamination is isolated and contained."  Static Harm C u e Q u e s t i o n s  A . "What aspect of the urine are you focusing on right now?" B. "Describe how you are imagining the urine right now." C . "What do you imagine the urine to be doing as it t o u c h e s your skin?" D. "What thoughts are you having about the urine now?"  80  Safety Prompts  1) "Focus on the safety a s s o c i a t e d with the a b s e n c e of g e r m s a n d contaminants." 2) "The urine touching your hand is clean and sterile. It h a s no harmful germs." 3) "You are not being e x p o s e d to any illness or disease." 4) " R e m e m b e r that m a n y bacteria coexist within our bodies without causing any disease, and protect us from the harmful bacterial." 5)  "Visualize that no harm c a n occur from the urine touching your hand; you are safe."  6)  "Keep reminding yourself that there are no harmful g e r m s or contamination."  7)  " R e m e m b e r that the urine is clean and has no germs."  8) "Rest a s s u r e d that the urine d o e s not threaten your health." 9)  "Concentrate on the fact that the urine is sterile and safe, although not pleasant."  Safety C u e Q u e s t i o n s  A. "What aspect of the urine are you focusing on right now?" B. "Describe how you are imagining the urine right now." C . "What do you imagine the urine to be doing a s it t o u c h e s your skin?" D. "What thoughts are you having about the urine now?"  

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