Saavedra, L. M., & Silverman, W. K. (2002). Case study: Disgust and a specific phobia of buttons. Journal of the American Academy of Child & Adolescent Psychiatry, 41(11), 1376-1379.
Saavedra and Silverman (2002) is a case study of a 9-year-old boy whose intense phobia of buttons was driven by disgust rather than fear of harm. Standard exposure therapy made his distress worse, but treatment that targeted his disgust and negative evaluations of buttons resolved the phobia within a year.
Psychology Being Investigated
Disgust
Disgust has been largely neglected in the study of phobias, with most research and treatment focusing on fear.
The presence of both fear and disgust can make a phobia more complex and harder to treat than one driven by fear alone.
Disgust may play a significant role in the development and maintenance of phobias, particularly in cases where the phobic stimulus is perceived as contaminated or repulsive.
Disgust can interact with fear, amplifying avoidance behaviors.
Fear and disgust protect against different things. Fear evolved to warn of physical harm, while disgust evolved to prevent contact with contamination and disease.
This distinction matters for treatment. A fear-based phobia responds to exposure that disconfirms the danger, because safe contact proves nothing bad happens. A disgust-based phobia has no danger prediction to disconfirm, so repeated safe exposure can leave the disgust untouched, or even draw more attention to it.
Expectancy Learning vs. Evaluative Learning
The study distinguished between two types of classical conditioning: expectancy learning and evaluative learning.
- Expectancy Learning: In expectancy learning, a neutral stimulus becomes linked to a threatening outcome, so the person learns to expect harm and develops fear. For example, someone bitten by a dog may fear dogs, expecting to be bitten again.
- Evaluative Learning: In evaluative learning, a neutral stimulus becomes disliked rather than feared, without any belief that it will cause harm. For example, someone might develop a disgust response to buttons after a bad experience, even without expecting buttons to hurt them.
Exposure-Based Cognitive-Behavioral Therapy
This treatment approach combines behavioral exposure, gradually exposing the patient to buttons, with imagery exposure, having the patient imagine button-related scenarios. It also uses cognitive restructuring to help the patient change negative thought patterns about buttons.
This approach is designed to address both fear and disgust associated with phobia and aims to reduce avoidance behavior and negative evaluations.
Background
Traditional classical conditioning paradigms, like the Little Albert experiment, provided a basis for understanding how phobias could be learned through association.
However, the focus on fear conditioning in these studies did not fully explain the boy’s disgust-based reaction to buttons.
Studies on blood-injury and spider phobias provided evidence that targeting disgust could be beneficial for reducing phobia symptoms, further influencing Saavedra and Silverman’s approach.
Therefore, Saavedra and Silverman explored alternative mechanisms like evaluative learning to understand the origins and maintenance of his phobia.
They also drew upon the understanding of systematic desensitization from behavioral therapies, which involved gradual exposure to feared stimuli, to develop the exposure component of their treatment.
But conditioning alone is not enough. Phobias often persist for years instead of fading with harmless contact. Psychologists explain this using two-process theory: fear is learned by conditioning, then kept alive because avoiding the object relieves anxiety, and that relief reinforces more avoidance.
The fear is never disconfirmed, so it never fades.
Phobias also cluster around a narrow set of threats, like snakes, spiders and heights, rather than more dangerous modern hazards such as cars. Preparedness theory explains why: evolution left us predisposed to fear ancestral threats, and to hold onto those fears more stubbornly than fears of modern dangers.
Buttons are not a stimulus evolution prepared us to fear. That makes the case unusual: its emotional core turned out to be disgust, not fear of harm, unlike the conditioned fear of a rat in the Little Albert study.
Aims
- To examine the role of disgust and evaluative learning in the development and maintenance of button phobia (koumpounophobia).
- To demonstrate the importance of addressing disgust in phobia treatment, especially when traditional fear-focused approaches prove ineffective.
Method
Design & Variables
The study employed a case study design, focusing on a single participant to gather in-depth qualitative and quantitative data.
Sample
The participant was a 9-year-old Hispanic-American boy, presented by his mum to a Child Anxiety and Phobic Program.
The child and parent were interviewed about the phobia. The psychologist consulted the DSM to see if the boy met the criteria for a specific phobia of buttons.
The boy’s presentation of symptoms did not meet the criteria for OCD.
Sampled through the opportunity sampling technique.
He had been experiencing symptoms for four years, beginning at the age of five when he knocked over a bowl of buttons in his classroom.
This incident was identified as the likely origin of his phobia.
- There was an art project using buttons (in kindergarten),
- He had run out of buttons (for his project),
- He was asked to go to the front of the class to get more (buttons),
- All of the buttons fell down on him,
- They were in a large bowl (on the teacher’s desk),
- His hand slipped as he reached for the bowl.
Procedure
Several data collection methods were used:
Interviews:
Semi-structured interviews were conducted with both the boy and his mother to gather information about the onset, development, and impact of the phobia on his daily life.
The Anxiety Disorders Interview Schedule (ADIS-C/P) is a semistructured interview for assessing DSM-IV psychiatric disorders in children.
This interview provided rich qualitative data about the boy’s experiences and helped researchers understand the context of his phobia.
Feelings Thermometer:
The hierarchy of fear, called the Feelings Thermometer, rates button-related distress from 0 (none) to 8 (maximum).
The boy and clinicians built an 11-item hierarchy of button stimuli, from least to most distressing. Large denim buttons caused the least distress; small, clear plastic buttons caused the most.
This hierarchy became the treatment baseline.
Comparing his ratings before, during, and after therapy let researchers judge how well each treatment worked.
| Stimuli | Distress Rating (0-8) |
|---|---|
| Large denim jean buttons | 2 |
| Small denim jean buttons | 3 |
| Clip-on denim jean buttons | 3 |
| Large plastic buttons (colored) | 4 |
| Large plastic buttons (clear) | 4 |
| Hugging Mom when she wears large plastic buttons | 5 |
| Medium plastic buttons (colored) | 5 |
| Medium plastic buttons (clear) | 6 |
| Hugging Mom when she wears regular medium plastic buttons | 7 |
| Small plastic buttons (colored) | 8 |
| Small plastic buttons (clear) | 8 |
Treatment Procedures
- Behavioral Exposure (4 sessions): This intervention, grounded in expectancy learning and systematic desensitization, aimed to gradually reduce avoidance behavior by exposing the boy to increasingly distressing button-related stimuli.
- Gradual Exposure: The exposure tasks were based on the boy’s individualized hierarchy of distress, starting with large denim buttons (rated 2) and progressing to smaller, clear plastic buttons (rated 8). This gradual progression allowed him to confront his phobia at a manageable pace.
- Contingency Management/Positive Reinforcement: As the boy completed each exposure task, his mother provided positive reinforcement. The intention was to associate positive experiences with the previously distressing stimuli, thus promoting a positive emotional response.
- Session Duration and Structure: Sessions lasted 30 minutes with the boy alone, followed by 20 minutes with both the boy and his mother. The presence of his mother during the second part of the session facilitated the contingency management component, as she directly reinforced his progress. Four sessions of behavioral exposure were conducted
- Imagery Exposure (7 sessions): This involved having the boy imagine various scenarios involving buttons, including those he rated as highly distressing. He was prompted to describe what he saw, felt, and smelled, and cognitive restructuring techniques were used to challenge and change his negative evaluations of buttons.
- Cognitive Restructuring: The researchers incorporated cognitive restructuring techniques to help the boy challenge his negative thoughts and evaluations about buttons. This process involved exploring the reasons why he found buttons disgusting and assisting him in reframing those negative cognitions.
- Session Duration and Structure: Seven sessions were planned for this intervention, with an emphasis on disgust-related imagery and cognitive techniques. The sessions were structured to guide the boy through increasingly challenging imaginal exposures while providing support and cognitive restructuring.
- Follow-up Assessments: The boy was assessed at 6 and 12 months after treatment to evaluate the long-term effectiveness of the interventions. During these follow-ups, his distress levels and ability to interact with buttons were assessed using the Feelings Thermometer and interviews.
Results
Behavioral Exposure
Although the boy completed all the exposure tasks and could handle larger numbers of buttons by session, his subjective distress ratings unexpectedly increased between sessions 2 and 4.
This paradoxical finding suggests that while behavioral exposure addressed avoidance behavior, it failed to alleviate the underlying disgust.
Reinforcing approach did not reduce his underlying disgust, and it may even have drawn his attention to it. Standard fear-reduction exposure was targeting the wrong emotion.
Imagery Exposure
In contrast to the behavioral exposure, imagery exposure combined with cognitive restructuring showed positive outcomes in reducing the boy’s distress.
- The distress ratings dropped between session 1 and 2.
- They dropped again between session 2 and 3.
- As the sessions advanced there was a lower level of disgust.
- It dropped from 8 to 5 midway through the imagery exposure/session 1 to 2.
- Then dropped from 5 to 3 after the imagery exposure/session 2 to 3.
Imagery exposure worked. The boy’s distress ratings fell markedly across the sessions. For instance, imagining hundreds of buttons falling on him, his rating dropped from 8 to 3 across the three imagery sessions.
His distress about imagining hugging his mother while she wore buttons also fell across the sessions. The pattern was consistent.
The boy’s own words showed the emotion behind his phobia was disgust, not fear. He described buttons as “disgusting” and “gross,” and said they had a bad smell, even though buttons have none.
This emphasized the role of disgust, rather than fear of a tangible threat, in the maintenance of his phobia.
Follow-Up Assessment (6 and 12 months after treatment)
- Sustained Improvement: He reported minimal distress about buttons.
- Remission of Phobia: At both follow-up assessments, the boy no longer met the DSM-IV criteria for a specific phobia of buttons.
- Improved Functioning (qualitative data): The boy’s improved functioning was evident in his ability to wear clothes with buttons, including his school uniform, without significant distress.
Conclusion
The contrasting outcomes of the two treatments show why addressing disgust and evaluative learning matters for treating specific phobias. Behavioral exposure reduced avoidance, but it left the underlying emotional response of disgust untouched.
Imagery exposure combined with cognitive restructuring worked better. It directly targeted and changed the boy’s negative evaluations of buttons, producing a lasting drop in his phobic symptoms.
The boy’s continued remission at follow-up, including his ability to wear his buttoned school uniform without distress, is strong evidence for the intervention’s lasting impact.
Ethics
- Informed Consent: The study obtained informed consent from the boy’s mother for his participation in the assessment and treatment. She also consented to publication of the case study. The boy himself also provided consent, implying his agreement to participate.
- Confidentiality: The study maintained the confidentiality and anonymity of the participant by not revealing his identity, school, or other personal information in the published report.
- Protection from Harm: They started the therapy with his least distressing scenario. The mother used positive reinforcement during the therapy so the boy would not get too distressed. Therefore, the boy was protected from any harm throughout the therapy.
- The study could have easily caused psychological stress. The boy was having to confront his button phobia throughout the therapy. He also had to discuss potential causes/effects of the phobia (e.g. buttons falling on him in art class) which would be stressful.
- Beneficence and the Therapeutic Context: The study was conducted within a therapeutic context, aiming to treat the boy’s phobia and improve his quality of life. This therapeutic aim aligns with the ethical principle of beneficence, where researchers strive to maximize benefits for the participant. The long-term positive outcomes of the treatment, including the remission of his phobia and improved daily functioning, support the beneficence of the study.
- Debriefing and Follow-Up: The thorough follow-up assessments conducted at 6 and 12 months indicate a commitment to monitoring the boy’s well-being beyond the immediate treatment period.
Strengths
- Detailed and In-Depth Exploration: The researchers collected detailed qualitative data through interviews with the boy and his mother, exploring the phobia’s onset, development, and his experience of different types of buttons. This context helped explain the quantitative findings.
- Reaching for the large bowl of buttons on the teacher’s desk during a kindergarten art project, his hand slipped and the buttons fell on him.
- Focus on Disgust and Evaluative Learning: The study centers on disgust and evaluative learning. This is a real contribution to child psychiatry. It moves treatment beyond fear-focused models toward disgust itself.
- Longitudinal Design and Follow-Up: Follow-up assessments at 6 and 12 months strengthen the findings by showing the treatment’s effects lasted. That gives the study strong internal validity.
- Ecological Validity: The therapy took place in a real clinical setting, giving the study ecological validity. Findings should generalize to similar therapeutic contexts for treating child phobias.
Weaknesses
- Limited Generalizability: As a case study of one 9-year-old Hispanic American boy, the findings may not generalize to other children, other phobias, or other cultural backgrounds.
- Lack of a Control Group: The absence of a control group makes it hard to attribute the improvement to treatment alone. Time, spontaneous remission, or the extra therapeutic attention could also explain his progress.
- Subjectivity of Measurements: The study relied on the boy’s self-reported distress ratings on the Feelings Thermometer, a nine-point scale. Self-report in a young child is open to demand characteristics: he may have reported feeling better simply to please the researchers or his mother.
- Distress: The study could have easily caused psychological stress. The boy was having to confront his button phobia throughout the therapy. He also had to discuss potential causes/effects of the phobia (e.g. buttons falling on him in art class) which would be stressful.
Issues and Debates
Application to Everyday Life: Recognizing Disgust in Everyday Aversions
Disgust can drive everyday aversions too, not just phobias.
We often blame fear, but disgust plays a bigger role when there is no real threat involved.
For example, someone might develop a food aversion after one bad experience, even though the food itself is harmless.
The aversion comes from memory of disgust, not from expecting future harm.
Key Takeaways
- Disgust vs. Fear: The boy’s button phobia was maintained by disgust, not fear of being harmed by buttons.
- Onset: The phobia began at age 5, after a bowl of buttons spilled over him during a kindergarten art class.
- Behavioral Exposure: Standard graded exposure with positive reinforcement backfired: his distress rose over four sessions instead of falling.
- Imagery Exposure: Imagery exposure combined with cognitive restructuring, targeting his disgust directly, cut his distress ratings from 8 to 3.
- Follow-Up: At 6 and 12 months he no longer met the criteria for a specific phobia and could wear buttoned clothing without distress.
- Treatment Matching: Treatment must match the emotion driving a phobia: fear-based phobias need exposure, disgust-based phobias need reappraisal.
Application to Everyday Life: Recognizing Emotions in School
The boy’s disgust and fear of buttons were measured using a Feelings Thermometer, on a 0-8 scale.
Schools could use a similar scale with students who show fear or anger. It helps adults understand what is really causing a child’s distress.
Nature versus nurture
nurture
During an art class, the boy reached for a bowl of buttons, his hand slipped, and the bowl fell on him.
After that stressful experience, he developed a fear of buttons.
This supports the nurture side of the debate because the phobia developed due to a lived experience (classical conditioning).
nature
Individuals might have varying levels of susceptibility to developing phobias based on their temperament, personality traits, or genetic predispositions, factors that fall under the domain of nature.
Some individuals might be more prone to developing strong negative associations or experiencing heightened disgust responses.
Individual and situational explanations
individual differences
The boy’s phobia is deeply rooted in his individual, subjective experience of the button-dropping incident at age five.
While objectively harmless, he perceived it as traumatic, leading to the development of the phobia.
His personal interpretation of the event, likely influenced by individual factors such as temperament and prior experiences, played a crucial role in shaping his emotional response.
situational explanations
The initiating event for the phobia, the button-dropping incident in kindergarten, is a clear situational factor.
This specific situation, occurring in front of his class and teacher, likely amplified the emotional impact, contributing to the development of a phobia.
The public nature of the incident and the potential for embarrassment likely exacerbated his distress, highlighting how specific situational contexts can shape the development of phobias.
Reductionism versus holism
Reductionist elements: The study isolates disgust, a single emotion, as the key factor in the boy’s button phobia.
This targeted focus exemplifies a reductionist approach. It separates disgust from the wider mix of emotions and cognitive processes involved in phobias.
Holistic elements: The study also weighs how fear and disgust interact, suggesting the combination affects the boy’s phobia more than either emotion alone.
This attention to combined effects points toward a more holistic view.
Keep Learning
To help reinforce your understanding and prepare for potential exam questions, here are some practice questions related to this study for AICE Psychology:
- Evaluate the Saavedra and Silverman study (button phobia) in terms of two strengths and two weaknesses. At least one of your evaluation points must be about ethics. [10]
- From the study by Saavedra and Silverman (button phobia) describe how the boy in the study was diagnosed with his phobia. [2]
- Outline one piece of information from this study that supported the nurture side of the nature- nurture debate. [2]
- Saavedra and Silverman studied a boy with a button phobia. Describe what happened during the behavioural exposures intervention phase of the therapy. [4]
- Outline one assumption of the learning approach, including any example in your answer. [2]
- Studies from the learning approach can help with real-world applications. Describe how the results of the study by Saavedra and Silverman (button phobia) can help with understanding and/or treating phobias. [4]
- Outline one other real-world application based on the results or conclusions from the study by Saavedra and Silverman. [2]
- Outline how the subjective rating of distress was measured in this study. [2]
- Describe how the boy’s distress rating changed over the first three sessions in response to imagining hundreds of buttons falling on his body. [2]
- Describe the psychology that was being investigated in the Saavedra and Silverman study (button phobia). [4]
- Describe the Disgust/Fear Hierarchy. [3]
- Identify one weakness of the Disgust/Fear Hierarchy. [3]
- Outline the results from the post-treatment assessment session. [3]
- Explain one problem when using children in psychological research, using this study as an example. [2]
- Describe the incident that the boy recalls that started his phobia of buttons. [3]
