Mental contamination and trauma: Understanding posttraumatic stress, risky behaviors, and help-seeking attitudes
Introduction
Mental contamination has been defined as an internal feeling of dirtiness, experienced in the absence of contact with a physical contaminant (Rachman, 1994, Rachman et al., 2015). Distinct from traditional contact contamination, through which an individual experiences external feelings of dirtiness and urges to wash or clean as a result of contact with a tangible object or substance, mental contamination may arise in response to situations involving moral violation or betrayal; or in response to distressing mental images, thoughts, and memories. Furthermore, unlike traditional contact contamination, which is focused on a particular site of contact, individuals experiencing mental contamination may be unable to pinpoint the location of the contamination, and instead may endorse feelings of dirtiness or corruption spread throughout the body. Consequently, compulsive washing or cleansing behaviors often fail to alleviate these feelings of contamination (Fairbrother et al., 2005, Rachman, 1994, Rachman et al., 2015). The experience of mental contamination may also be accompanied by several strong negative emotions including disgust, anxiety, shame, anger, and sadness (Badour et al., 2013, Elliott and Radomsky, 2012, Fairbrother et al., 2005, Lee et al., 2013). Although much of the existing literature in mental contamination has focused on its role in obsessive-compulsive disorder (OCD; Coughtrey, Shafran, Knibbs, & Rachman, 2012; Rachman, 1994, Rachman, 2013), a growing body of evidence has begun to link mental contamination with other disorders involving strong negative emotions and sources of violation, including posttraumatic stress disorder (PTSD).
In the context of OCD, obsessive thoughts may elicit distress, anxiety, and disgust responses that involve feelings of dirtiness, infection, and impurity. Similarly, individuals with PTSD experience intrusive thoughts in the form of traumatic memories, dreams, and/or dissociative reactions (e.g., flashbacks), all of which may result in intense, prolonged psychological and/or physiological distress. For some individuals with PTSD, trauma-related distress may include contamination-based sensations. For example, an individual may experience a feeling of dirtiness within his or her body when reminded of a sexual violation. Because this feeling is likely to be diffuse and resistant to amelioration through cleaning or washing methods, the individual may make significant efforts at avoidance, experience increased distress both during and in anticipation of future mental contamination onset, and adopt increasingly negative cognitions and mood related to the traumatic event, one's self, or hope for future improvement. These putative processes are reflective of fear conditioning models of PTSD (Foa and Kozak, 1986, Rauch and Foa, 2006), and mental contamination may be a particularly powerful risk factor for symptom escalation because of its perseverance, associations with multiple negative emotions, and links to negative self-appraisals (Rachman et al., 2015).
Consistent with this example, empirical research linking mental contamination to PTSD has primarily focused on understanding mental contamination as a response to sexual assault among women. Several studies have documented positive correlations between PTSD symptom severity and scores on both sexual assault-specific (e.g., Sexual Assault and Rape Appraisals [SARA] Inventory; Fairbrother & Rachman, 2004) and general measures of mental contamination (i.e., Vancouver Obsessional Compulsive Inventory-Mental Contamination Scale [VOCI-MC]; Radomsky, Rachman, Shafran, Coughtrey, & Barber, 2014) among this population (Badour et al., 2013, Badour et al., 2013, Badour et al., 2014, Fergus and Bardeen, 2016, Olatunji et al., 2008). Relatedly, several studies have demonstrated that recalling memories of a sexual assault (Badour et al., 2013, Fairbrother and Rachman, 2004) or imagining a sexual violation (Elliott and Radomsky, 2009, Elliott and Radomsky, 2012, Fairbrother et al., 2005, Herba and Rachman, 2007) leads to increases in feelings of dirtiness, urges to wash, and actual washing behavior in the laboratory. Both history of sexual assault and severity of PTSD symptoms have been shown to predict the intensity of mental contamination evoked in response to such memories/images (Badour et al., 2013, Fairbrother et al., 2005, Herba and Rachman, 2007). Additional research has documented increased mental contamination and washing urges following imagined violations in which participants adopt the role of the perpetrator (Rachman, Radomsky, Elliott, & Zysk, 2012), suggesting that perceived immorality of one's actions may play a unique role in mental contamination development apart from sexual victimization alone. Although case studies have documented the emergence of symptoms akin to mental contamination among both men and women following a range of traumatic events (Gershuny et al., 2003, de Silva and Marks, 1999), other research did not find a correlation between PTSD symptom severity and feelings of dirtiness and urges to wash evoked in response to memories of a physical assault (Badour, Feldner, Babson et al., 2013), highlighting the need to examine whether mental contamination may be an important factor in understanding PTSD reactions to a range of traumatic events beyond sexual assault alone.
Previous work examining behavioral outcomes for individuals with PTSD has also linked the disorder with increased participation in risky behaviors (i.e., behaviors that put one at risk for a negative outcome; Danielson et al., 2010; James, Strom, & Leskela, 2014; Weiss, Tull, & Gratz, 2014), and importantly, heightened engagement in risky or impulsive activities is itself a hallmark component in the PTSD symptom cluster of alterations in arousal and reactivity (criterion E; American Psychiatric Association, 2013). These behaviors may include activities such as maladaptive substance use, unsafe sex, self-harm, problematic eating behaviors, physical violence, or other legal transgressions (Weiss, Tull, Dixon-Gordon, & Gratz, 2016). Increasingly, researchers have noted the importance of positive versus negative mood states as a precursor to risky behavior engagement for individuals with PTSD. Veterans with PTSD have been shown to engage in riskier behaviors (i.e., unsafe sex, substance abuse) compared to controls, and this increase was particularly pronounced during negative mood states (James et al., 2014).
Conversely, other research has identified positive urgency, or difficulty controlling behaviors when experiencing intense positive emotions, as a significant mediator of the relationship between PTSD symptoms and risky behaviors (Weiss, Tull, Sullivan, Dixon-Gordon, & Gratz, 2015); in other words, PTSD symptoms were associated with increased positive urgency, which in turn was associated with increased engagement in risky behaviors. Considering increased PTSD symptom severity has also been associated with emotion regulation difficulties and increased affect intensity (Ehring & Quack, 2010), it is unsurprising that individuals with PTSD are more vulnerable to such behaviors amidst intense negative and positive mood states. This evidence highlighting the importance of mood states may also hold particular significance for individuals with PTSD experiencing mental contamination, given that mental contamination has been linked to strong negative emotions. Individuals with elevated mental contamination may experience more frequent and intense negative emotions, as well as internal feelings of dirtiness, and resulting prolonged distress from unresponsiveness to washing. These negative mood states may thus encourage more risky behaviors in attempts to alleviate negative mood and avoid the contamination source; however, no research to date has examined these specific links among mental contamination, PTSD, and risky behaviors.
Although the preponderance of research findings point to a positive association between PTSD symptomatology and help-seeking behavior, including among trauma-exposed college student samples (Elhai & Simons, 2007; for reviews, see Elhai, North, & Frueh, 2005; Gavrilovic, Schützwohl, Fazel, & Priebe, 2005), the estimated median delay between symptom onset and first seeking treatment for a mental disorder in the U.S is nearly a decade, and for individuals with PTSD, the probability of connecting with a treatment provider after 10 years post-disorder onset is only 20% (Christiana et al., 2000, Wang et al., 2005). Research has further demonstrated an inverse relation between duration of PTSD symptoms and likelihood of symptom remission, as well as poorer outcomes for individuals with comorbid disorders and limited social support (Steinert, Hofmann, Leichsenring, & Kruse, 2015). These findings highlight the need to identify factors that may serve as barriers to help-seeking, particularly among younger adults who may have a relatively recent onset of PTSD symptomatology.
Several factors may contribute to negative help-seeking attitudes among individuals with PTSD, including doubts about the efficacy of existing treatments (Rickwood, Deane, Wilson, & Ciarrochi, 2005), public stigma about mental illness and mental health care (Corrigan, 2004), and self-stigma (i.e., internally-directed stigma in which a person perceives him or herself as flawed or unacceptable for having mental health concerns; Vogel, Wade, & Haake, 2006). For individuals with mental contamination, these factors may be particularly salient. Rachman and colleagues (2015) noted that common beliefs and appraisals associated with mental contamination include feeling undeserving of forgiveness because of immoral/nasty thoughts, thinking that contaminated feelings will never be completely eliminated, worrying about declining mental stability, and fearing rejection from others if horrible thoughts are disclosed. Thus, mental contamination may have a significant, yet unexplored, negative impact on help-seeking attitudes via negative emotions, cognitions, and beliefs following a traumatic event.
Extant literature linking mental contamination to PTSD is growing; however, no previous work has examined the role of mental contamination in understanding risky behaviors and help-seeking attitudes among individuals with a history of trauma. Thus, elucidating the role of mental contamination as a potential vulnerability factor in development of posttraumatic stress (PTS) symptoms and associated behaviors and attitudes is a vital next step in identifying potential targets for preventative treatment and intervention, as well as in screening for individuals who may be more susceptible to negative posttraumatic outcomes (e.g., damaging or life-threatening behaviors, limited help-seeking). The present study thus sought to expand upon existing literature that has separately linked mental contamination to PTS symptoms and PTS symptoms to risky behaviors and attitudes toward help seeking. This study was also the first to examine the link between mental contamination and PTS symptomatology among a sample of men and women with a heterogeneous history of traumatic events.
Consistent with previous findings using a general measure of mental contamination (Badour et al., 2014, Fergus and Bardeen, 2016), it was first hypothesized that mental contamination would be positively associated with PTS symptoms. Second, it was hypothesized that both mental contamination and PTS symptom severity would be positively associated with risky behaviors in negative mood states, and an indirect effect of mental contamination on negative mood-dependent risky behavior would emerge through the path of increased PTS symptoms. Third, it was expected that PTS symptom severity would positively correlate with risky behaviors in positive mood states (e.g., Weiss et al., 2015), but there was insufficient evidence to inform a hypothesis regarding whether mental contamination should exhibit either a direct or indirect effect on positive mood-dependent risky behavior. Finally, it was expected that PTS symptom severity would positively correlate with help-seeking attitudes (Elhai et al., 2005, Elhai and Simons, 2007, Gavrilovic et al., 2005), but mental contamination would evidence a negative association with help-seeking attitudes. It was expected that the negative direct effect of mental contamination on help-seeking attitudes would remain even after accounting for the indirect effect of mental contamination on help-seeking attitudes through the pathway of PTS symptoms. These hypotheses were constructed in line with the fact that this study employed a trait-based measure of general mental contamination, as opposed to a measure of mental trauma-related contamination, and thus is best conceptualized as a precursor to clinical symptom development. However, given the novel relationships examined in this study, a second reversed model was additionally explored (i.e., testing indirect effects of PTS symptoms on criterion variables via mental contamination) in order to consider alternative putative pathways in which mental contamination may increase as a result of elevated PTS symptoms. Contact contamination, biological sex, and history of unwanted sexual contact were included as covariates in all models given research linking these constructs to mental contamination and/or PTS symptoms among trauma-exposed samples (Badour et al., 2012, Badour et al., 2013, Norris et al., 2002).
Section snippets
Participants
Participants were 236 young adults (Mage = 18.67, SD = 0.95) with a history of at least one DSM-5-defined Criterion A traumatic event (involving life threat, serious injury, sexual violation, or deaths that are accidental or violent; American Psychiatric Association, 2013), recruited from the university's undergraduate psychology pool. The sample was predominantly female (n = 181; 76.7%) and non-Hispanic (n = 224; 94.9%). The majority of the sample identified as Caucasian (n = 201; 85.2%), with
Descriptive statistics
Four participants in the sample did not complete all measures and were thus excluded from analyses, resulting in a final N = 232. Among the final sample, 9.3% (n = 22) scored at or above the recommended cutoff of 37 on the PCL-5 for probable PTSD established in trauma-exposed college student samples (Blevins et al., 2015). However, the mean PCL-5 score for the sample was notably well below this recommended cutoff. Correlations among predictor and criterion variables as well as means and
Discussion
In order to better address the clinical relevance of mental contamination within the context of PTS symptomatology, the present study aimed to extend the existing literature by investigating patterns of relationships among mental contamination, PTS symptoms, risky behaviors (in both negative and positive mood states), and help-seeking attitudes. Consistent with hypotheses, mental contamination was found to positively correlate with PTS symptom severity. This finding adds to a growing body of
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