Saavedra, L M and Silverman, W K (2002), Case study: disgust and a specific phobia of buttons. Journal of the American Academy of Child and Adolescent Psychiatry, 41(11): 1376–79

Psychology Being Investigated

Role of Disgust in Phobias – The study examines disgust as a critical emotion in the development and maintenance of phobias. Disgust, often overlooked in psychiatric literature, is suggested to interact with fear, resulting in increased avoidance behavior.

Evaluative Learning – The concept of evaluative learning, a form of classical conditioning, is explored. This differs from expectancy learning in that it does not depend on the anticipation of a threat. Instead, an individual negatively evaluates a previously neutral object or event, leading to disgust rather than fear. This is central to understanding the child’s phobia of buttons.

Intervention Focusing on Disgust – The treatment used in this case includes exposure-based cognitive-behavioral therapy, targeting not only the fear but also the disgust associated with buttons. The study highlights the importance of addressing disgust in treating specific childhood phobias.


Previous Research on Disgust and Phobias – The study references previous research that has investigated the role of disgust in phobias. For instance, a study on adults with blood-injury phobias found that targeting disgust was beneficial for reducing fear/phobia (Hepburn & Page, 1999). Additionally, a study on children with spider phobia indicated a functional relation between fear and disgust, although it did not examine the effects of targeting disgust in phobia reduction De Jong et al. (1997).

Importance of Targeting Disgust in Phobia Treatment – The study underscores the significance of addressing disgust in treating specific phobias in children. It suggests that in certain phobias, particularly those where disgust is a predominant emotion, treatment approaches should include components that target disgust.

Contribution to Psychiatric Literature – The study aims to bring attention to the roles of disgust and evaluative learning in childhood phobias, areas that the authors believe are insufficiently covered in child psychiatric literature.


To explore the role of disgust and evaluative learning in the treatment of a specific childhood phobia, in this case, a phobia of buttons (koumpounophobia).


Research Method – Case study approach.

Sample – Single participant, a 9-year-old Hispanic American boy.

Question Types and Research Technique for Data Collection – Data were collected through clinical interviews and subjective ratings of distress by the participant, using the Anxiety Disorders Interview Schedule for DSM-IV–Child and Parent versions (ADIS-C/P).

Measured and Manipulated Variables – The primary measured variable was the boy’s subjective distress related to buttons, assessed on a 9-point scale. The manipulated variables were the interventions (behavioral exposures and disgust-related imagery exposures).


  1. Initial Assessment – The boy met DSM-IV criteria for a specific phobia of buttons, which began at 5 years of age.
  2. Treatment Approach – The intervention included:
    • Contingency management with positive reinforcement by the mother for the child’s successful completion of gradual exposures to buttons.
    • Behavioral exposures: Treatment sessions lasted about 30 minutes with the boy and 20 minutes with the boy and his mother​​.
    • Imagery exposures: This involved the boy imagining scenarios involving buttons and included cognitive restructuring. The exposures progressed from images of larger to smaller buttons​​.

Ethical Considerations

  • Informed Consent – The boy’s mother provided informed consent for both participation in the assessment and intervention procedures and for the publication of the case study​​.
  • Participant’s Well-being – Care was taken to ensure the participant’s comfort and to address his phobia effectively.
  • Confidentiality – The study maintained the confidentiality and anonymity of the participant.


    The graph visually represents the change in subjective distress ratings over the course of the treatment and follow-up sessions. ​

    The results of the study by Saavedra and Silverman showed a significant decrease in the boy’s subjective distress related to buttons over the course of treatment and follow-up sessions.

    Quantitative Findings:

    • Imagery Exposure Sessions – There was a notable reduction in the boy’s distress ratings during these sessions. For example, his distress rating decreased from 8 to 5 to 3 during an imagery exposure session where he imagined hundreds of buttons falling over his body​​.
    • Increased Distress Initially – During the early sessions, there was an increase in distress ratings, especially when the number of buttons was manipulated. This was observed from session 2 to session 4, indicating an initial intensification of the phobia​​.
    • Posttreatment Follow-up – At the 6-month and 12-month follow-ups, the boy reported minimal distress about buttons and no longer met the DSM-IV criteria for a specific phobia of buttons. He was able to wear clear plastic buttons, which he had previously rated as most distressful​​.

    Qualitative Findings:

    • Improvement in Daily Life: The boy’s ability to wear buttons on a daily basis, such as on his school uniform, indicated a substantial improvement in his daily life.
    • Reduction in Phobia – The remission of the DSM-IV-specific phobia diagnosis at the follow-up sessions highlights the effectiveness of the treatment.


    • Successful Intervention – The gradual reduction in distress ratings and the eventual remission of the phobia suggest that the cognitive-behavioral interventions, focusing on both disgust and fear, were effective.
    • Importance of Addressing Disgust in Phobias – The study underscores the significance of targeting disgust in phobias, not just fear.


    Effectiveness of Targeting Disgust – The case study demonstrated the importance of targeting the emotion of disgust in treating specific childhood phobias. The use of disgust-related imagery exposures was found to be more effective in directly addressing the child’s disgust emotions, as opposed to traditional fear-focused exposures that did not address the associated emotions. This approach led to a significant diminution of the phobia, aligning with the principles of evaluative learning​​.

    Evaluative Learning in Phobias – This study is notable for being the first in child psychiatric literature to document the interaction between phobias and disgust, conceptualized via evaluative learning. The case showed that while behavioral exposures were successful in reducing avoidance behavior, they did not address the underlying disgust the child felt towards buttons. This realization led to the incorporation of disgust imagery exposures and cognitive restructuring, which significantly reduced the child’s distress and phobia​​.

    Recommendations for Future Research – The study highlights the need for further research to examine specific types of phobias in which disgust plays a predominant role. Additionally, the authors suggest the importance of conducting controlled group studies that manipulate disgust in treatment, aiming to assess the efficacy of such interventions and to test specific theoretical mechanisms underlying phobia treatment​​.


    Detailed Case Study Methodology – The study provides a detailed and thorough case study of a child with a specific phobia of buttons. This approach allowed for an in-depth analysis of the phobia’s onset, progression, and response to treatment, offering valuable insights into the complexity of specific phobias in children and the efficacy of tailored treatment approaches​​.

    Pioneering Conceptual Framework – The study is the first to suggest that the interaction between phobias and disgust in children can be conceptualized via evaluative learning. This conceptual framework offers a new perspective in understanding and treating childhood phobias, particularly by considering both fear and disgust as concurrent emotions that contribute to phobic avoidance behaviour

    ​​Specificity and Relevance of Treatment – The study’s treatment approach was specifically tailored to address the unique aspects of the child’s phobia, making it highly relevant and potentially more effective. By focusing on disgust-related imagery exposures, the study directly targeted the specific emotions involved in the child’s phobia, aligning with the principles of evaluative learning. This specificity increases the validity of the findings, as the treatment was directly relevant to the phobia being addressed​​.


    Limited Generalisability – As a case study focusing on a single child, the findings cannot be easily generalized to all children with phobias or to other types of phobias. The unique characteristics of the child and the specific phobia of buttons may limit the applicability of the findings to other cases or broader populations.

    Lack of a Control Group – The absence of a control group in the study design means that there is no direct comparison to evaluate the effectiveness of the treatment against other methods or against no treatment at all. This limits the ability to conclusively attribute the child’s improvement solely to the treatment provided.

    Subjective Measurement – The study largely relied on subjective measures of distress, such as the child’s self-reported feelings on a 9-point scale. While subjective measures are valuable, they can be influenced by various factors and may not provide an objective assessment of the phobia’s severity or the treatment’s effectiveness.