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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: J Anxiety Disord. 2021 Sep 28;84:102477. doi: 10.1016/j.janxdis.2021.102477

Mental Contamination, Disgust, and Other Negative Emotions Among Survivors of Sexual Trauma: Results from a Daily Monitoring Study

C Alex Brake a,b, Jordyn M Tipsword c, Christal L Badour c
PMCID: PMC8599658  NIHMSID: NIHMS1745842  PMID: 34627103

Abstract

Mental contamination (MC)—feelings of dirtiness triggered by internal sources—is a potentially important yet understudied factor for survivors of sexual trauma. MC has been linked to disgust and other negative emotions (e.g., shame, guilt) cross-sectionally and in lab-based paradigms but not yet examined in ecological contexts. Additionally, links between MC and distinct negative emotions have not been studied systematically. The present study thus modeled relationships between MC and specific emotions both across and within days over a daily monitoring period. Forty-one females with sexual trauma history and associated MC completed twice-daily assessments of MC and seven emotions (disgust, shame, guilt, anger, hopelessness, sadness, anxiety) over two weeks via a smartphone app. Baseline MC and average daily MC were largely associated with higher daily averages of negative emotions. Concurrently, within-person changes in MC and negative emotions were also positively linked. Unexpectedly, intraindividual changes in MC were largely not associated with later negative emotions, whereas several emotions were negatively associated with later MC. Notably, MC among screened sexual trauma survivors was much more prevalent compared to prior research. Clinical relevance and future recommendations for ecological research in trauma-related mental contamination are discussed.

Keywords: Mental contamination, disgust, sexual trauma, negative emotion, ecological assessment

Disgust— a universally experienced, negatively-valenced revulsion response that facilitates distancing oneself from uncleanliness or contagion (Olatunji & Sawchuk, 2005; Rozin et al., 2000)—has increasingly been recognized for its role in anxiety, trauma- and stressor- related, and obsessive-compulsive and related disorders (for a review, see Knowles et al., 2018). Disgust response characteristics include the ability to easily condition to new stimuli and endure in the absence of rational contagion risk (Matchett & Davey, 1991; Rozin et al., 2009). For example, clinical and nonclinical samples not only avoid naturally disgust-inducing stimuli but also objects that mimic these stimuli (e.g., fake feces) or food/drink that has contacted sterilized stimuli (e.g., a sterilized cockroach) despite awareness that the food/drink poses no risk (Matchett & Davey, 1991; Rozin et al., 1986). These characteristics may explain why disgust extinguishes less readily than fear responses when subjected to exposure-based treatments (de Jong et al., 2000; McKay, 2006), as well as how disgust elicitors may have proliferated beyond environmental contagion to include immoral, socially reprehensible, or sexual acts (Olatunji & Sawchuk, 2005; Rozin et al., 2009).

The related yet distinct experience of contamination—a perceived change from cleanliness/neutrality to dirtiness/impurity via direct or indirect contact with a contaminated source—exhibits unique features (Rachman, 2006). Whereas disgust is an automatic emotional response, contamination experiences involve threat appraisals about the lasting or spreading impact of the disgusting stimulus (Rachman et al., 2015). Additionally, contamination often includes a subjective physical quality (e.g., “dirtiness” sensations) and urges to alleviate/eliminate the acquired contamination (Coughtrey, Shafran, Lee, & Rachman, 2012).

Although one might experience disgust without experiencing a state of contamination (e.g., seeing maggots or gore/viscera), contamination experiences are thought to entail both disgust and anxiety reactions (Fairbrother & Rachman, 2004). Transient experiences of contamination are normative; however, persistent and clinically distressing contamination concerns, including aversion to future contamination and perceived contaminants, are also well-documented (Knowles et al., 2018; Olatunji et al., 2017; Rachman et al., 2015). Research has distinguished two forms of contamination experiences: contact contamination, arising in response to physical contact with an external contaminant (Rachman, 2004), and mental contamination, which emerges without physical contact but rather in response to internal sources such as memories, thoughts, or mental images that are perceived to be contaminating (Rachman et al., 2015).

Mental contamination has received notably less attention in clinical research despite its associations with more severe presentations (Rachman et al., 2015), perhaps because mental contamination may be mistaken for contact contamination, or because of individuals’ difficulties describing their mental contamination experiences (Coughtrey, et al., 2012). Because mental contamination is conceptualized as arising out of subjective appraisals about internal experiences, it is thought to manifest not just from internal triggers associated with contagion- based disgust (e.g., memories of touching bodily excrement) but also internal experiences judged as morally disgusting (e.g., thoughts of incest; Fairbrother & Rachman, 2004; Rachman, 2004). Such processes may explain why mental contamination has been associated with interpersonal violation and sexual trauma (Badour & Adam, 2015; Rachman et al., 2015). Building on early case examples (de Silva & Marks, 1999; Gershuny et al., 2003), Fairbrother and Rachman (2004) provided the first systematic evaluation of mental contamination in female sexual trauma survivors, noting that of the 70% who reported engaging in washing behaviors immediately after their assault, over 25% endorsed contamination and excessive washing that persisted for months or years. Though the authors noted that disgust responses were likely necessary for mental contamination to emerge, they highlighted that the psychological distress from survivors’ mental contamination was characterized by “internal dirtiness” sensations and resistance to alleviation. In comparing women with sexual versus physical assault histories, Badour and colleagues (2013) also found that while PTSD symptom severity predicted greater disgust following lab-based trauma recall regardless of assault type, symptom severity was only predictive of post-recall feelings of dirtiness and urges to wash in the sexual assault group. These findings underscore that mental contamination is distinguishable from disgust responses and particularly relevant for sexual trauma survivors.

Rachman (2004, 2006) noted that sexual trauma survivors may be especially susceptible to mental contamination given that sexual violations often involve multiple types of disgust- inducing stimuli, including those perceived to be physically contaminating (e.g., sexual penetration, contact with bodily fluids/genitals) and morally repugnant (e.g., coercion, betrayal, self-blame). Re-experiencing traumatic memories or triggers (e.g., sexual arousal, thoughts of the perpetrator) may also re-evoke disgust reactions and feelings of contamination (Badour & Adams, 2015). Through associative conditioning, repeatedly elicited mental contamination may generalize to the entire self-concept if individuals increasingly interpret their posttraumatic contamination experiences to mean they themselves are permanently contaminated (Badour & Adams, 2015; Jung & Steil, 2012, 2013; Ojserkis, McKay, & Lebeaut, 2017; Steil at al., 2011).

Supporting these theories, Badour and colleagues (2014) demonstrated that women who reported greater self-focused disgust during sexual trauma also experienced more severe posttraumatic mental contamination. Lab paradigms have also demonstrated links between sexual trauma recall and subsequent elevations in mental contamination (Badour, Feldner, Babson et al., 2013; Fairbrother & Rachman, 2004; Ishikawa et al., 2015). Furthermore, disgust propensity (i.e., frequency or ease of experiencing disgust) and sensitivity (i.e., aversion to disgust) have been positively linked to mental contamination among female sexual trauma survivors (Badour, Feldner, Blumenthal et al., 2013; Badour et al., 2014), presumably because such factors increase susceptibility to disgust cues during and following sexual violation.

Mental contamination is frequently associated with other posttraumatic emotions, usually in the context of appraisals concerning the immorality, role responsibility, and lasting impact of the sexual violation (Badour & Adams, 2015; Badour, Feldner, Babson et al., 2013; Fairbrother & Rachman, 2004; Olatunji et al., 2008; Rachman, 2004). For example, case examples of individuals with mental contamination have reported elevated shame and guilt tied to appraisals of personal responsibility for the assault or the immorality/impurity of their posttraumatic intrusions (Rachman, 2004, 2006; Jung & Steil, 2012). Elevated mental contamination following lab-based sexual trauma recall has also been linked to intensity of shame-/guilt-related appraisals of immorality and personal responsibility (Ishikawa et al., 2015). Researchers have theorized that other non-disgust emotions may elicit mental contamination if they are repeatedly associated with disgust- and contamination-laden symptoms via conditioning (Jung & Steil, 2012, 2013; Steil et al., 2011). Others have suggested that self-directed emotions—particularly shame and guilt—may show strong connections to mental contamination because they may be more readily internalized and misinterpreted as physical feelings of dirtiness (Coughtrey et al., 2013; Rachman et al., 2015; Warnock-Parkes et al., 2012). Additionally, elevated mental contamination may elicit emotions such as anxiety, sadness, or hopelessness about future triggers, difficulty managing contamination sensations, or anticipated future impairment; though not previously examined systematically, these emotions have also been discussed in the mental contamination literature (Badour, Feldner, Babson et al., 2013; Badour et al., 2014; Brake et al., 2019; Fergus & Bardeen, 2016; Ishikawa et al., 2015; Olatunji et al., 2008).

Despite a complex framework implicating multiple emotions in the development and maintenance of mental contamination, emotion-focused research has been largely limited to case examples (e.g., Jung & Steil, 2012; Rachman et al., 2015; Steil et al., 2011) or lab paradigms utilizing composite emotion variables (e.g., Fergus & Bardeen, 2016; Ishikawa et al., 2015).

Notable exceptions identifying links with depression (Badour et al., 2014; Fergus & Bardeen, 2016) and anxiety (Badour, Feldner, Babson, et al., 2013; Badour et al., 2014; Olatunji et al., 2008) have typically surveyed participants cross-sectionally. Consequently, the directionality of associations between mental contamination and specific emotions over time remains an open question. To effectively target this challenging clinical phenomenon, it is essential to better understand how mental contamination and specific negative emotions bi- or uni-directionally relate to one another in day-to-day contexts. Demonstrating feasibility of assessing daily mental contamination also necessitates distinguishing it from the emotional context in which it typically arises—particularly disgust but also other negative emotions.

The present study provided the first daily monitoring investigation of sexual trauma- related mental contamination and its functional connections to distinct negative emotions. Adult women with sexual trauma history and related mental contamination completed baseline interviews, followed by twice-daily assessments of negative emotions and mental contamination over a 14-day period using a mobile app. First, we hypothesized that mental contamination would demonstrate discriminant validity from disgust, as exhibited by distinct variability over the two-week period (Hypothesis 1). Second, baseline mental contamination would be positively linked to disgust over the 14-day period (Hypothesis 2). Third, mental contamination and disgust assessed on a given morning would each be positively linked to evening disgust and mental contamination, respectively (Hypothesis 3). Other specific negative emotions of anxiety, anger, sadness, shame, guilt, and hopelessness were also explored, though hypotheses were withheld.

Additionally, across-day relationships between emotions and mental contamination (evening to subsequent morning) were also examined in exploratory models (see Figures 1 and 2).

Figure 1.

Figure 1.

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Models A and B depicting mental contamination prospectively predicting later emotions within-day and into the next day, respectively. Bolded pathways indicate primary effect of interest (controlling for non-bolded pathways). All pathways are marked with expected directions of effects.

Figure 2.

Figure 2.

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Models A and B depicting emotions prospectively predicting later mental contamination within-day and into the next day, respectively. Bolded pathways indicate primary effect of interest (controlling for non-bolded pathways). All pathways are marked with expected directions of effects.

Method

Participants

Participants included community-recruited adult women with a history of sexual trauma and current mental contamination (i.e., scoring ≥ 10 on the Posttraumatic Experience of Mental Contamination scale [PEMC; Brake et al., 2019] and participant confirmation of ongoing sexual trauma-related mental contamination during a clinical interview). Of the 146 individuals who initiated phone screens, 14 were deemed ineligible, 22 declined participation, and 56 were unreachable after initial contact. Notably, over 85% of screen completers who endorsed sexual trauma history also endorsed posttraumatic mental contamination, with most reporting PEMC scores far above the cutoff (M = 46.92, SD = 16.93). Of the 54 remaining, ten individuals reported no current mental contamination symptoms during in-person interviews and were thus removed. Additionally, data from two male participants were removed due to low male participation. Data from one final participant was removed due to incomplete information on diagnostic interviews.

The final sample included 41 women ranging in age from 18 to 57 years (M = 33.0, SD = 12.6). The majority of the sample identified as Caucasian (73.2%), followed by African American (19.5%), Multi-Racial (4.9%), or other (2.4%). Hispanic ethnicity was endorsed by 9.8%. Participants identified as predominantly heterosexual (70.7%), followed by bisexual (22.0%), homosexual (4.9%), or other (2.4%). Most participants had completed at least some college (92.7%). Participant income ranged from < $20,000 to > $100,000, with the most commonly endorsed being < $20,000 (46.3%).

Procedures

All procedures were approved by the University of Kentucky Nonmedical Institutional Review Board. Participants were recruited by community advertisement and completed a pre-enrollment screening by phone. Eligible and interested individuals completed the study across three stages: 1) pre-visit online survey, 2) in-person interview, an additional online survey, and training on daily diary assessments, and 3) a two-week monitoring period querying participants twice daily. This period was selected in order to balance feasibility, participant burden, and inclusion of multiple weekend periods for comparison of weekday versus weekend differences (see Statistical Analysis section below); this period also aligns with prior daily monitoring research (Boh et al., 2016; Gaher et al., 2015; Kashdan, Young, & McKnight, 2012; Pe & Kuppens, 2012).

Self-report questionnaires were completed via the online survey platform Qualtrics. Daily ratings were completed using the LifeData app downloaded to participants’ smartphones or to a loaned device. Daily monitoring began the day after the laboratory visit. Participants received twice-daily notifications mornings (9:00AM) and evenings (5:00PM), followed by reminders every 30 minutes for up to four hours. Assessments could be completed anytime within each 4- hour window but were skipped if this window expired without a response.

Participants were compensated $30 at the end of their laboratory visit and were provided online and community mental health resources. Participants received $1 for each response to their 28 daily diary assessments, plus $5 bonuses for each set of four consecutive responses.

Measures

Baseline measures.

Sexual trauma history.

History of sexual trauma was assessed during the phone screen using items from the National Stressful Events Survey (NSES; Kilpatrick et al., 2011). The NSES is a structured assessment of trauma exposure and PTSD symptoms in line with DSM-5 criteria (American Psychiatric Association, 2013) and has previously been utilized to estimate population prevalence of sexual trauma (Kilpatrick et al., 2013; Wolf et al., 2015).

The sexual trauma subsection of the NSES consists of four yes/no items assessing the presence and nature of sexual trauma history. The first three items assess (1) childhood sexual contact (including penetration and/or touching of sexual parts), (2) unwanted sexual contact (including penetration and/or touching of sexual parts) under force or threat of force, and (3) unwanted sexual contact (including penetration and/or touching of sexual parts) while under the influence of substances. Endorsement of at least one of these items indicated experience of sexual trauma in line with study eligibility criteria. The fourth item was used for descriptive purposes to determine whether any events endorsed in items 1–3 involved sexual penetration (versus unwanted touching).

Sexual trauma-related mental contamination.

Mental contamination related to past sexual trauma was measured during phone screening with the Posttraumatic Experience of Mental Contamination scale (PEMC; Brake et al., 2019). The PEMC is a 20-item self-report scale modified from the Vancouver Obsessional Compulsive Inventory-Mental Contamination (VOCI-MC; Radomsky et al., 2014). As opposed to the VOCI-MC, which assesses trait mental contamination (e.g., “I often feel dirty under my skin”), the PEMC references mental contamination occurring since a traumatic event (e.g., “Since the traumatic event, I often feel dirty under my skin”). For the present study, PEMC items were indexed on participants’ most distressing sexual trauma. Participants rated items on a five-point Likert-type scale (0 = Not at all to 4 = Very much), with higher scores indicating greater mental contamination. The PEMC evidences a single factor structure, strong internal consistency and convergent validity with the VOCI-MC, as well as incremental utility over the VOCI-MC in predicting PTSD and OCD symptoms in a community sample (Brake et al., 2019). Internal consistency for the PEMC in the present study was excellent (α = .92). A score of 10 or greater on the PEMC was used as the cutoff for inclusion in the study, consistent with previous research using a cut score of 10 on the VOCI-MC to indicate moderate mental contamination in non-clinical laboratory samples (Coughtrey et al., 2014a, 2014b).

Current trauma-related mental contamination was also confirmed via two items from Fairbrother and Rachman’s (2004) sexual assault-related mental contamination interview schedule (“What, if anything brings back that feeling of dirtiness now?”; “What about memories of the unwanted sexual experience, do they bring back that feeling of dirtiness?”). These two items referenced earlier interview items regarding internal posttraumatic “feelings of dirtiness.” Negative responses to both items resulted in removal from the study following the lab visit.

Negative affect.

The Negative Affect scale of the Positive and Negative Affect Schedule (PANAS-NA; Watson et al., 1988) was used to assess general trait negative affect at baseline.

On this 10-item scale, respondents rate the degree to which they typically experience various mood states via single-word descriptors (e.g., ashamed, irritable) using a five-point scale (1 = very slightly or not at all to 5 = extremely), producing total scores ranging from 10–50. The PANAS-NA is widely used and well validated across diverse samples, evidencing good psychometric properties (Watson et al., 1988). Internal consistency for the PANAS-NA in the present study was good (α = .88).

Daily assessments.

Sexual trauma-related mental contamination.

Daily mental contamination was assessed using an adapted version of the State Mental Contamination Scale (SMCS; Lorona et al., 2018). The SMCS is a 15-item scale assessing state mental contamination in response to a precipitating trigger. The SMCS has been utilized in lab-based mental contamination induction tasks and proposed for use in ecological contexts (Lorona et al., 2018). The SMCS was developed via modification of VOCI-MC items to frame questions in the present moment (e.g., VOCI-MC: “I often feel dirty under my skin”; SMCS: “I feel dirty under my skin”). Participants rate items on a five-point Likert-type scale (0 = Not at all to 4 = Very much), producing total scores ranging from 0–60. In the present study, SMCS instructions were adjusted to ask about mental contamination specific to participants’ worst sexual trauma since their last daily assessment prompt. Initial research utilizing the SMCS has demonstrated excellent internal consistency and good convergent and discriminant validity (Lorona et al., 2018). In this study, average reliability of the SMCS over 28 assessments (between-person; Rkf = .99) and reliability of change (within- person; Rc = .95) were excellent.

Negative emotions.

Participants rated the degree to which they had experienced specific negative emotions since their last daily assessment prompt using seven visual analog scales (VAS; Freyd, 1923). Each 0 to 100 scale presented the participant with a single-word descriptor of seven emotions: anxiety, anger, sadness, disgust, shame, guilt, and hopelessness. Scales were anchored with emotion-specific descriptors (e.g., no [emotion]/extreme [emotion]), with participants responding via digital sliders. Prior research has successfully utilized VAS ratings to assess emotional states in similar contexts (Badour, Feldner, Babson et al., 2013; Millar et al., 2016), including in daily monitoring designs (Boh et al., 2016; Bruehl et al., 2012; Pe & Kuppens, 2012).

Statistical Analysis

In addition to demographic information, the following variables were examined for covariate consideration: years since participants’ index trauma; whether participants’ index trauma involved penetration (vaginal, anal, and/or oral; no = 0, yes = 1); race (white = 0, non-white = 1); and sexual orientation (heterosexual = 0, non-heterosexual = 1).

Descriptive analyses examined frequencies or means and standard deviations of demographic variables, sexual trauma characteristics, sexual trauma-related mental contamination (PEMC, SMCS), and negative emotion (PANAS-NA, VAS ratings). Baseline and average scores across the daily monitoring period (i.e., person-mean scores) of all variables evidenced acceptable levels of skewness (−0.08 – 1.20) and kurtosis (−0.94 – 0.60). Bivariate correlations examined associations among baseline and person-mean scores during the daily diary period for primary study variables. To examine within-person variability correlations between specific emotions and state mental contamination, two sets of mean square successive difference (MSSD) scores were calculated for daily emotion items and the SMCS. For each participant, the mean of the squared differences between adjacent emotion or SMCS residual scores were computed for each 1) morning to evening pair and 2) evening to next-morning pair after detrending (hours, day, weekday vs. weekend). These values were then square-root transformed prior to examination. MSSD is an indicator of longitudinal instability that accounts for both overall variability and temporal dependence (Jahng et al., 2008) and has been previously utilized in trauma-focused daily monitoring research (e.g., Naragon-Gainey et al., 2012).

Subsequent primary analyses involved a series of multilevel linear models with restricted maximum likelihood estimation to account for the nested structure of daily assessments within participants. First, intercepts and slopes of change in mental contamination and negative emotions from the first to the last day of the daily assessments were examined using conditional random intercept and slope linear mixed models (day coded as −6.5 [day 1] to 6.5 [day 14]) controlling for time of the day (morning = 0, evening = 1), and day of the week (Monday through Friday = 0, Saturday/Sunday = 1) to determine if average scores on any variables a) differed during mornings versus evenings, b) differed during weekdays versus weekends, and c) changed systematically across the 14-day period.

Next, conditional multilevel linear models were used to identify concurrent and prospective relationships between mental contamination and specific negative emotions. Daily diary scores for mental contamination and negative emotions did not differ between morning and evening assessments. Thus, when these variables were used as level 1 predictors, they were grand-mean centered and split into two orthogonal components for each participant: a between- subjects component (one person-mean for all 28 daily diary assessments) and a within-subjects component (series of 28 [14 – morning, 14 – evening] assessment-specific deviations from the person-mean). Concurrent and lagged within-subjects deviations for all level 1 predictors were calculated to allow for concurrent, same-day (morning to evening), and next-day (evening to subsequent morning) associations. All models controlled for the fixed effect of time. The random effect of time was only included when indicated based on log-likelihood tests of model fit comparing the random intercept only to the random intercept and slope alternative model. Pseudo-R2 effect sizes, or the amount of residual variance explained by including model fixed effects, were calculated and reported for each model as an across-model comparison metric; pseudo-R2s were not reported on occasions when inclusion of fixed effects increased model variance (resulting in negative and uninterpretable pseudo-R2s; Raudenbush & Bryk, 2002).

Age, race/ethnicity, sexual orientation, years since index trauma, and penetration during index trauma were all tested as possible covariates in primary models. Patterns of effect for all models were largely unchanged; thus, these variables were not retained in final results.

Results

Descriptive Statistics

Descriptive statistics are presented in Table 1. Participants completed a total of 974 out of 1148 possible daily surveys, resulting in an 84.8% response rate for the sample. The mean number of responses per participant was 23.76 (SD = 5.24, range 7–28), with over 90% of participants completing 16 or more of the 28 daily diaries.

Table 1.

Demographic and Descriptive Information

M (SD) or n (%)
Demographic
 Age 32.95 (12.59)
 Race (nonwhite) 11 (26.8%)
 Ethnicity (hispanic) 4 (9.8%)
 Sexual orientation (nonheterosexual) 12 (29.3%)
Descriptive
 Years since index trauma 16.51 (15.29)
 Index trauma involving penetration 32 (78.0%)
Baseline
 PEMC 50.32 (14.67)
 PANAS-NA 31.76 (8.49)
Daily averages
 SMCS 14.33 (15.54)
 Anger 35.41 (24.89)
 Anxiety 47.95 (26.52)
 Disgust 32.72 (25.34)
 Guilt 30.75 (26.19)
 Hopelessness 32.52 (28.03)
 Sadness 40.62 (25.43)
 Shame 31.60 (28.00)
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Note: PEMC = Posttraumatic Experience of Mental Contamination scale; PANAS-NA = Positive and Negative Affect Schedule-Negative Affect scale; SMCS = State Mental Contamination Scale.

Baseline and daily between-person correlations are reported in Table 2. Baseline mental contamination was positively associated with average daily levels of disgust over the diary period, as well as negative emotions of anger, anxiety, guilt, and shame; associations with hopelessness and sadness were nonsignificant. Baseline negative affect was also positively associated with average daily mental contamination.

Table 2.

Zero-Order Correlations of Primary Variables

1 2 3 4 5 6 7 8 9
1. Baseline MC (PEMC) -
2. Baseline negative affect .56*** -
3. Daily MC (SMCS) .51*** .57*** -
4. Daily anger .44** .52*** .72*** -
5. Daily anxiety .50*** .65*** .70*** .82*** -
6. Daily disgust .42** .62*** .73*** .82*** .76*** -
7. Daily guilt .36* .53*** .50*** .57*** .64*** .87*** -
8. Daily hopelessness .18 .51*** .55*** .68*** .70*** .83*** .78*** -
9. Daily sadness .19 .51*** .55*** .65*** .72*** .77*** .71*** .92*** -
10. Daily shame .33* .54*** .60*** .63*** .66*** .92*** .95*** .83*** .74***
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Note: Daily variables represent Level 2 person-means across the daily monitoring period. MC = mental contamination; PEMC = Posttraumatic Experience of Mental Contamination scale; SMCS = State Mental Contamination Scale.

*

p < .05,

**

p < .01,

***

p < .001

Average daily mental contamination exhibited a strong positive correlation with average daily disgust (r = .73, p < .001) and moderate to strong correlations with all other negative emotions (rs ranging .50 – .72, ps < .001). Of note, correlations between average daily disgust, shame, and guilt (rs ranging .87 – .95, ps < .001), and between hopelessness and sadness (r = .92, p < .001) were very strong. As such, particular attention was paid to the degree of correlation for within-person variability among detrended MSSD scores to determine whether to retain these variables as separate emotional states or collapse into composite variables prior to further analyses. Correlations among square-root transformed MSSDs are presented in Table 3.

Table 3.

Correlations among Square-Root Transformed Mean Square Successive Difference Scores

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Transforme dMSSD
M (SD)
1. SMCS (within-day) - 7.27 (5.95)
2. SMCS (next-day) .82*** - 7.52 (6.52)
3. Anger (within-day) .48** .27 - 25.16 (14.97)
4. Anger (next-day) .56*** .45** .74*** - 23.10 (13.16)
5. Anxiety (within-day) .50*** .42** .68*** .66*** - 23.13 (15.10)
6.Anxiety (next-day) .52*** .38* .58*** .66*** .78*** - 23.67 (14.60)
7. Disgust (within-day) .67*** .47** .53*** .51*** .46** .55*** - 22.36 (14.21)
8. Disgust (next-day) .55*** .50*** .53*** .69*** .66*** .65*** .75*** - 21.82 (12.80)
9. Shame (within-day) .58*** .51*** .55*** .50*** .58*** .58*** .74*** .65*** - 18.86 (13.02)
10. Shame (next-day) .52*** .55*** .44** .57*** .59*** .51*** .60*** .68*** .87*** - 18.52 (13.07)
11. Guilt (within-day) .49** .56*** .48** .31* .64*** .37* .46** .54*** .68*** .68*** - 20.23 (15.36)
12. Guilt (next-day) .63*** .63*** .46** .52*** .64*** .61*** .65*** .72*** .85*** .83*** .81*** - 19.71 (12.79)
13. Sadness (within-day) .37* .22 .64*** .63*** .69*** .68*** .48** .61*** .63*** .61*** .40** .53*** - 23.90 (13.93)
14. Sadness (next-day) .51*** .34* .68*** .59*** .73*** .75*** .48** .57*** .60*** .60*** .59*** .62*** .77*** - 24.52 (14.16)
15. Hopeless (within-day) .37* .43** .58*** .32* .68*** .40** .40** .45** .61*** .52*** .80*** .63*** .39* .54*** - 20.62 (16.49)
16. Hopeless (next-day) .39* .36* .54*** .28 .57*** .46** .51*** .46** .65*** .56*** .78*** .70*** .39* .64*** .89*** 20.50 (15.66)
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Note: Within-day variables represent square-root transformed mean square successive difference (MSSD) scores within-person from same-day morning to evening. Next-day variables represent square-root transformed mean square successive difference (MSSD) scores within-person from evening to subsequent morning. SMCS = State Mental Contamination Scale.

*

p < .05,

**

p < .01,

***

p < .001

Corresponding within-day and next-day scores for mental contamination and disgust demonstrated moderately strong correlations (rs = .67 and .50, respectively, ps < .001), suggesting that participants’ timepoint-by-timepoint experiences of these states changed in related but distinct ways, relative to their own averages. Emotions of disgust, shame, and guilt evidenced similarly related but distinct within-person variability (within-day rs ranging .46 to .74, next-day rs ranging .68 to .83, all ps < .01), as did sadness and hopelessness (within-day r = .39, next-day r = .64, ps < .001). Thus, separate emotion variables were retained for further analyses.

Primary Analyses

Examination of slopes over two weeks found no significant systematic changes over time in mental contamination (B = −0.02, SE = 0.06, t = −0.39, p = .70), or in emotions of anger (B = −0.13, SE = 0.14, t = −0.97, p = .34), anxiety (B = −0.06, SE = 0.17, t = −0.34, p = .74), hopelessness (B = 0.10, SE = 0.10, t = 0.92, p = .37), sadness (B = −0.04, SE = 0.14, t = −0.31, p = .76), or shame (B = −0.10, SE = 0.11, t = −0.87, p = .39). However, significant changes were observed for disgust (B = −0.33, SE = 0.13, t = −2.51, p = .02) and guilt (B = −0.23, SE = 0.10, t = −2.28, p = .03), suggesting participants may have experienced reactivity to repeated assessment of these two emotions. All subsequent multilevel models controlled for assessment timepoint, regardless of slope change significance.Multilevel model results are reported in Table 4. Higher-than-average levels of mental contamination were associated with greater disgust and all other negative emotions when examined at concurrent timepoints, in line with similar between-person positive associations. However, these positive associations were not evidenced prospectively. Counter to our hypothesis, morning mental contamination was not significantly associated with evening disgust, nor of other evening emotions, after controlling for morning emotion levels. Interestingly, when exploring next-day models, higher-than-average evening mental contamination was prospectively linked to higher next-morning anger and shame after accounting for respective prior-evening emotions; models examining other next-morning emotions were nonsignificant.

Table 4.

Change Slopes for Mental Contamination, Disgust, and Other Negative Emotions by Assessment Timepoint

B SE t
SMCS
 Intercept 1.74 2.42 0.72
 Assessment −0.02 0.06 −0.39
Disgust
 Intercept 6.06 4.33 1.40
 Assessment −0.33 0.13 −2.51*
Shame
 Intercept 2.90 4.42 0.66
 Assessment −0.10 0.11 −0.87
Guilt
 Intercept 4.56 4.17 1.09
 Assessment −0.23 0.10 −2.28*
Anger
 Intercept 3.00 3.89 0.77
 Assessment −0.13 0.14 −0.97
Hopelessness
 Intercept −0.06 4.19 −0.01
 Assessment 0.10 0.10 0.92
Sadness
 Intercept 1.97 3.97 0.50
 Assessment −0.04 0.14 −0.31
Anxiety
 Intercept 2.15 4.22 0.51
 Assessment −0.06 0.17 −0.34
Open in a new tab

Note: SMCS = State Mental Contamination Scale.

*

p < .05,

**

p < .01,

***

p < .001

In our reverse models, links between morning anxiety, guilt, hopelessness, sadness, and shame and evening mental contamination were all significant but notably negative after controlling for morning mental contamination, whereas links with anger and disgust were nonsignificant. Similarly, links between evening anger, anxiety, disgust, sadness, and shame and morning mental contamination were negative after controlling for prior-evening mental contamination; models of guilt and hopelessness were nonsignificant.

Discussion

Mental contamination following sexual trauma is a complex yet understudied phenomenon, despite its prevalence and association with multiple forms of emotional distress. Theories have suggested unique pathways by which specific emotions may elicit or emerge from mental contamination ecologically: disgust is conceptualized as essential to its emergence; self- directed emotions (e.g., shame, guilt) are thought to show strong relationships with mental contamination because they are more easily associated with internal contamination; other emotions (e.g., anger, anxiety, sadness, hopelessness) may follow mental contamination due to appraisals about the contamination experience itself. Extant evidence, however, has been largely cross-sectional or drawn from lab-based paradigms that do not examine emotions independently. This study provided an initial ecological window into the temporal relationships between mental contamination and separate emotions.

Our study aimed to demonstrate the feasibility and utility of assessing daily mental contamination by illustrating its added value beyond single-timepoint (i.e., baseline) assessment, as well as its discriminant validity from disgust and other emotional responses.

First, findings revealed that overall negative affect at baseline was moderately associated with both baseline mental contamination and average daily mental contamination. Furthermore, daily average emotion ratings showed moderate to strong correlations with average daily mental contamination compared to moderate to weak correlations with baseline mental contamination. These results suggest that assessing mental contamination day-to-day may capture important emotional links otherwise missed by single-timepoint retrospective report.

Average levels of mental contamination were strongly correlated with disgust, anger, and anxiety across the two-week period, whereas correlations with shame, guilt, sadness, and hopelessness were more moderate. By comparison, correlations of MSSD instability scores between daily mental contamination and emotions over corresponding periods (morning-to- evening, evening-to-morning) ranged from weak to moderate. Instability correlations were generally higher for disgust, shame, and guilt, followed by anger and anxiety, and finally sadness and hopelessness. These findings have several important takeaways. First, although mental contamination and disgust show prominent overlap when averaged across two weeks, these constructs show related but differing variability timepoint by timepoint. Thus, individuals reported on changes in disgust and mental contamination in distinct ways, supporting our first hypothesis. A similar pattern emerged when comparing daily mental contamination with other emotions: whereas daily averages were highly correlated, instability correlations were lower, suggesting divergent patterns of variability within and across days.

Our second hypothesis was also supported: mental contamination assessed at baseline was positively associated with daily disgust averaged across the two-week period.

Greater baseline mental contamination was also associated with greater average daily levels of anxiety, anger, disgust, guilt, and shame. Similarly, multilevel models showed that individuals who reported higher-than-average mental contamination at a given assessment were more likely to report higher levels of all seven individual emotions concurrently. Notably, disgust and shame showed the strongest concurrent relationships, further supporting the notion that increases in disgust and shame are most likely to co-occur with participants’ elevated feelings of dirtiness.

Counter to our third hypothesis, within-person prospective links revealed a different pattern. Higher-than-average morning mental contamination was not associated with any elevations in any later-day emotions, and higher-than-average evening mental contamination was only linked to next-morning elevations in anger and shame. Conversely, reverse models showed that higher-than-average shame, guilt, anxiety, hopelessness, and sadness were all associated with lower levels of mental contamination in the evening. Similarly, higher than typical disgust, shame, anxiety, anger, and sadness were all linked with lower levels of mental contamination when assessed the subsequent morning. Although causal conclusions cannot be drawn from correlational data, this pattern of effects suggests that higher levels of negative emotions may contribute to less mental contamination later when examined over half-day intervals, despite findings that negative emotions and mental contamination may be concurrently elevated within that same timeframe.

Pe and Kuppens’ (2012) exploration of the temporal dynamics among daily emotions elucidates several mechanisms that may help explain these counterintuitive findings. The authors highlight the importance of valence and appraisals in determining the impact a given emotion is likely to have on subsequent emotions in ecological contexts. Whereas ordinarily a current emotion will increase the intensity of a subsequent emotion with the same valence (i.e., positive or negative), this effect may be moderated by how much appraisals of the two emotions overlap. In this way, an emotion may actually blunt a later similarly-valenced emotion if they have strongly divergent appraisals. In the present study, concurrent ratings demonstrated that mental contamination was positively associated with many negative emotions at any given time.

Because this range of emotions could have involved multiple competing appraisals (e.g., responsibility, tolerability, future expectancies), subsequent mental contamination may have been blunted.

Interpersonal transgression appraisals may explain our present findings linking elevated evening mental contamination with greater next-day shame and anger. Research on borderline personality disorder has evidenced strong connections between daily appraisals of interpersonal transgressions (particularly rejection or abandonment) and later anger and shame responses (Scott et al., 2017). In the context of sexual trauma, mental contamination has also been strongly linked to interpersonal appraisals of responsibility and violation (Rachman et al., 2015; Ishikawa et al., 2015). Speculatively, mental contamination may lead to strong activation of angry and shameful emotional responses as individuals reflect on their past interpersonal violation, and the strength of these responses may allow anger and shame to endure across days more so than other emotions. Assessing appraisals about one’s sexual trauma may be an important next step in daily mental contamination research.

It may also be helpful to consider how individuals are coping with experiences of negative emotion and mental contamination day-to-day. It is possible that lower mental contamination later may result from efforts to reactively cope with and reduce earlier elevations in emotional distress and feelings of dirtiness. Sexual trauma-related mental contamination has been linked to coping behaviors such as washing/cleaning, substance use, and thought suppression (Fairbrother & Rachman, 2004; Jung & Steil, 2012; Rachman et al., 2015), which participants may have employed to avoid or eliminate emotional and contamination-related distress in tandem. Alternatively, it may be that individuals are effectively coping via emotional approach strategies (e.g., increased emotional acceptance and processing; Cantón-Cortés & Cantón, 2010; Wolfsdorf & Zlotnick, 2001). Rachman and others have previously suggested that mental contamination may partially result from misinterpretation of emerging emotional states as present-moment dirtiness (Coughtrey et al., 2013; Rachman et al., 2015; Warnock-Parkes et al., 2012), especially when negative emotions are triggered by trauma-related cues that the individual is not consciously aware of (i.e., affect without recollection, as outlined in cognitive-behavioral models of PTSD; Ehlers & Clark, 2000). Reporting more negative emotion over the previous half-day could possibly reflect participants’ increased awareness and processing of their emotional states, which may in turn lead to less mental contamination later once these emotions have been correctly interpreted.

Limitations

Results of this study must be considered alongside its limitations. First, screening cutoffs for baseline mental contamination were based on nonclinical norms, and future studies should evaluate whether present findings replicate in more severe mental contamination populations.

Second, the present sample consisted of female sexual trauma survivors, and it is possible that our findings may not generalize to males, or that mental contamination related to other trauma types (e.g., traumatic encounters with gore, viscera, dead bodies) may operate differently. Daily measures in the present study also assessed emotions via single-item ratings, which may have contributed to smaller model effect sizes. Though our study presented a notably conservative exploratory analysis of prospective relationships while controlling for prior-timepoint values, future use of more frequent and/or multi-item emotion scales may further elucidate the ebb and flow of specific emotions in mental contamination contexts. Lastly, these preliminary findings are limited by their correlational nature and should not be overinterpreted to infer causality.

These findings may help illuminate possible causal pathways needing further study, and additional experimental research should seek to replicate effects and rule out possible confounds (e.g., other psychopathology, coping behaviors, environmental triggers).

Future Directions and Implications

In considering future directions and implications, we return to underscoring the prevalence of mental contamination in our sample. Over 83% of individuals screening positive for any sexual trauma history also reported at least moderate mental contamination, with the majority significantly exceeding this threshold. This finding is notable given that we advertised only for history of sexual trauma (but not contamination concerns) and suggests that the prevalence of mental contamination following sexual trauma may be higher than previously evidenced (e.g., by Fairbrother & Rachman, 2004). Thus, future research will address not a rare and idiosyncratic presentation, but rather a normative posttraumatic experience for survivors of sexual trauma.

A primary direction for future research lies in more fine-tuned ecological assessment.

Discrepancies between positive between-person versus negative or nonsignificant within-person prospective links, as well as differentiation of mental contamination from negative emotions when examining instability estimates, suggest that these constructs are independently interacting in important ways that cannot be captured without a “zoomed in” experience sampling approach. The current study assessed these constructs at half-day intervals as an exploratory first step, as the time course of mental contamination and associated emotions is still not well understood.

Furthermore, the present data cannot predict whether mental contamination and specific emotions are triggered by one another versus separate trauma or non-trauma cues, or how long each tends to endure in the context of the other. Future research utilizing more frequent assessments may better articulate the timing, duration, and temporal interaction of these constructs. Event-triggered responses (e.g., at mental contamination or traumatic intrusion onset) may also be well-suited for capturing frequency of discrete mental contamination episodes and how long specific emotions are persisting after its emergence. In addition to frequency and timing, assessing appraisals such as directionality (e.g., are individuals disgusted with themselves or their assailant?) and coping strategies (e.g., washing/cleaning versus other avoidance/approach coping for contaminated or emotional states) may clarify these relationships, as well as how individuals are experiencing and responding to mental contamination.

These future assessment targets are also the essential bridge to incorporating mental contamination into posttraumatic case formulation and treatment planning. For example, identifying appraisals may implicate cognitive processing targets and understanding coping may illuminate opportunities for replacing avoidant coping with tailored emotion regulation skills or exposure techniques. Contamination triggers and emotional distress are complex and varied in mental contamination presentations, and a more refined understanding of their interaction will enable clinicians and patients to collaboratively monitor, demystify, and intervene on what is likely a heterogeneous process.

Conclusion

The present study was the first to investigate daily experiences of sexual trauma-related mental contamination and to consider how such experiences are related to specific negative emotions. Between participants, baseline and average daily mental contamination levels were largely associated with average levels of negative emotions over two weeks of daily monitoring. Mental contamination also evidenced strong positive links with disgust, shame, and guilt concurrently, and with higher shame and anger the next day. Unexpectedly, higher negative emotions were linked to lower mental contamination both within-day and into the next day.

Taken together, these findings suggest a variety of negative emotions beyond disgust play a significant role in sexual trauma-related mental contamination, and that these constructs often interact in survivors’ day-to-day experiences. Furthermore, prevalence of sexual trauma-related mental contamination notably exceeded previously reported figures. The widespread nature of sexual trauma, in combination with the relative clinical obscurity of mental contamination, highlights a significant gap in current research and practice. Better understanding this phenomenon as it emerges from or contributes to posttraumatic emotions can only improve case formulation of complex presentations characterized by non-fear emotions such as disgust, shame, guilt, or anger. Continued refinement of ecological assessment approaches is an essential next step in better understanding this important yet understudied phenomenon.

Table 5.

Multi-Level Models Examining Same-Day and Next-Day Relationships Between Mental Contamination, Disgust, and Other Negative Emotions

SMCS → Disgust SMCS → Shame SMCS → Guilt SMCS → Anger
B SE t B SE t B SE t B SE t
Concurrent
 Intercept −0.36 2.80 −0.13 −0.18 3.56 −0.05 0.13 3.62 0.04 −0.39 2.80 −0.14
 Assessment −0.30 0.13 −2.31* −0.09 0.10 −0.90 −0.22 0.10 −2.21* −0.12 0.14 −0.83
 SMCS (between) 1.24 0.17 7.09*** 1.12 0.22 5.04*** 0.84 0.23 3.60*** 1.12 0.17 6.45***
 SMCS (within) 0.91 0.08 12.03*** 0.71 0.07 10.40*** 0.63 0.07 9.19*** 0.76 0.09 8.55***
Within-Day: Morning Predicting Evening
 Intercept 1.17 2.44 0.48 0.59 3.00 0.20 1.10 3.36 0.33 1.92 2.47 0.78
 Day −0.44 0.23 −1.88 −0.03 0.19 −0.18 −0.16 0.29 −0.56 −0.47 0.25 −1.92
 SMCS (between) 0.91 0.17 5.30*** 0.83 0.20 4.09*** 0.68 0.22 3.07** 0.80 0.17 4.73***
 Morning SMCS (within) −0.18 0.14 −1.32 −0.01 0.12 −0.11 −0.15 0.11 −1.30 −0.16 0.14 −1.14
 Morning emotion level 0.27 0.05 5.38*** 0.24 0.05 5.04*** 0.17 0.05 3.59*** 0.36 0.05 7.97***
Next-Day: Evening Predicting Subsequent Morning
 Intercept −1.83 2.12 −0.86 −1.66 2.73 −0.61 −1.05 3.22 −0.33 −2.80 2.40 −1.17
 Day −0.18 0.25 −0.73 −0.16 0.23 −0.69 −0.42 0.22 −1.94 0.17 0.32 0.53
 SMCS (between) 0.95 0.15 6.17*** 0.86 0.19 4.56*** 0.74 0.22 3.43** 0.97 0.16 6.06***
 Prior evening SMCS (within) 0.18 0.13 1.37 0.35 0.12 2.96** 0.13 0.12 1.16 0.30 0.14 2.07*
 Evening emotion level 0.22 0.05 4.80*** 0.26 0.05 5.10*** 0.14 0.05 2.72** 0.21 0.05 4.54***
Disgust → SMCS Shame → SMCS Guilt → SMCS Anger → SMCS
Within-Day: Morning Predicting Evening
 Intercept −0.16 1.03 −0.16 −0.16 1.03 −0.15 −0.11 1.23 −0.09 −0.05 1.15 −0.05
 Day 0.05 0.09 0.53 0.06 0.09 0.61 0.03 0.09 0.29 0.07 0.09 0.74
 Emotion level (between) 0.27 0.05 5.76*** 0.19 0.04 4.59*** 0.17 0.05 3.40** 0.26 0.05 5.00***
 Morning emotion (within) −0.04 0.02 −1.79 −0.08 0.02 −3.49*** −0.09 0.02 −3.97*** −0.02 0.02 −1.38
 Morning SMCS 0.38 0.05 8.04*** 0.45 0.05 9.82*** 0.41 0.05 8.97*** 0.36 0.05 7.62***
Next-Day: Evening Predicting Subsequent Morning
 Intercept −0.20 1.10 −0.18 −0.23 1.22 −0.19 −0.17 1.30 −0.13 −0.14 1.08 −0.13
 Day −0.03 0.09 −0.29 0.00 0.09 0.00 0.00 0.09 0.00 −0.01 0.09 −0.14
 Emotion level (between) 0.22 0.05 4.57*** 0.17 0.05 3.68*** 0.14 0.05 2.63* 0.25 0.05 5.11***
 Evening emotion (within) −0.06 0.02 −2.96** −0.06 0.02 −2.79** −0.04 0.02 −1.54 −0.04 0.02 −2.49*
 Prior evening SMCS 0.46 0.05 10.15*** 0.44 0.04 10.23*** 0.45 0.04 10.17*** 0.44 0.04 10.12***
SMCS → Hopelessness SMCS → Sadness SMCS → Anxiety
B SE t B SE t B SE t
Concurrent
 Intercept −0.005 3.73 −0.001 0.13 3.41 0.04 −0.20 3.06 −0.07
 Assessment 0.12 0.09 1.28 −0.01 0.14 −0.08 −0.04 0.17 −0.25
 SMCS (between) 0.98 0.23 4.37*** 0.92 0.21 4.45*** 1.15 0.19 6.16***
 SMCS (within) 0.59 0.07 8.16*** 0.81 0.08 9.69*** 0.83 0.08 9.87***
Within-Day: Morning Predicting Evening
 Intercept 1.38 3.17 0.44 −0.07 2.82 −0.02 0.81 2.64 0.31
 Day 0.26 0.30 0.87 −0.11 0.32 −0.36 0.15 0.40 0.38
 SMCS (between) 0.86 0.21 4.12*** 0.65 0.19 3.41** 1.02 0.18 5.67***
 Morning SMCS (within) 0.17 0.12 1.42 −0.03 0.14 −0.24 −0.21 0.14 −1.58
 Morning emotion level 0.24 0.05 4.93*** 0.29 0.05 6.32*** 0.25 0.05 5.50***
Next-Day: Evening Predicting Subsequent Morning
 Intercept −0.90 3.46 −0.26 −1.48 2.77 −0.53 −2.01 2.72 −0.74
 Day 0.17 0.24 0.71 0.04 0.28 0.12 0.08 0.38 0.21
 SMCS (between) 0.87 0.24 3.68*** 0.68 0.19 3.48** 0.88 0.19 4.55***
 Prior evening SMCS (within) 0.14 0.12 1.15 0.14 0.14 1.00 0.24 0.14 1.67
 Prior evening emotion level 0.13 0.05 2.54* 0.24 0.05 4.81*** 0.24 0.05 4.70***
Hopelessness→ SMCS Sadness → SMCS Anxiety → SMCS
Within-Day: Morning Predicting Evening
 Intercept 0.01 1.34 0.01 −0.03 1.20 −0.03 −0.05 1.14 −0.05
 Day 0.10 0.12 0.88 0.07 0.09 0.80 0.06 0.09 0.64
 Emotion level (between) 0.21 0.05 4.36*** 0.20 0.05 4.12*** 0.22 0.05 4.76***
 Morning emotion (within) −0.05 0.02 −2.36* −0.04 0.02 −2.01* −0.04 0.02 −2.35*
 Morning SMCS 0.33 0.05 7.18*** 0.40 0.05 8.67*** 0.38 0.05 8.16***
Next-Day: Evening Predicting Subsequent Morning
 Intercept −0.14 1.31 −0.11 −0.17 1.29 −0.13 −0.19 1.10 −0.17
 Day 0.02 0.09 0.21 0.01 0.09 0.09 0.02 0.09 0.23
 Emotion level (between) 0.15 0.05 3.08** 0.17 0.05 3.19** 0.21 0.05 4.53***
 Prior evening emotion (within) −0.02 0.02 −1.17 −0.04 0.02 −2.10* −0.07 0.02 −3.62***
 Prior evening SMCS 0.44 0.04 9.86*** 0.44 0.04 10.09*** 0.46 0.04 10.53***
Open in a new tab

Note: Between variables represent Level 2 person-means across the daily monitoring period. Within variables represent Level 1 within-person deviations from person means. SMCS = State Mental Contamination Scale

*

p < .05,

**

p < .01,

***

p < .001

Highlights.

  • Daily mental contamination and negative emotions are modeled over a two-week period

  • Mental contamination and emotions are positively linked when assessed concurrently

  • Mental contamination was largely not predictive of next-timepoint emotions

  • Notably, most emotions negatively predicted next-timepoint mental contamination

  • Mental contamination may be more prevalent in sexual trauma than previously noted

Acknowledgments

Dr. Brake received support to conduct this project from the Office for Policy Studies on Violence Against Women at the University of Kentucky. This project was also supported by the National Center for Advancing Translational Sciences through grant number UL1TR001998 at the National Institute of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or of the Office for Policy Studies on Violence Against Women.

Footnotes

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