Phobias: Fighting the Fear

Phobias are truly international, crossing the boundaries of language and culture. A study within the mainly Hispanic population of Puerto Rico relied on translated questions asked in the ECA. It found 12 per cent of people had phobias at some stage in their lives, a figure on the same range as mainland North America.

Studying phobias across cultures is more difficult: they were, for instance, once thought almost non-existent in sub-Saharan Africa. More recent work suggests that phobias are as common, just less obvious than in the West. Africans are likely to develop physical complaints as a result of fear and this can mask the underlying phobia. They also fear different things. Witchcraft, sorcery and supernatural phenomena are still important among peoples such as the Yoruba in Nigeria. Within Yoruba communities, people with no psychological problems routinely believe that others (who appear harmless) may be plotting against them. They cannot talk about specific concerns for fear of the sorcerer’s retaliation. Nigerian research had to rely on drug-assisted interviews to break down some of this reluctance and found that at least 20 per cent of outpatients at psychiatric units were definitely phobic.

In the US, the ECA study estimated that between 1.5 and 12.5 per cent of the population has agoraphobia at some stage of their lives. Agoraphobia – literally, fear of the market place – usually translates to a fear of being away from home or a safe place. Using public transport, going to shopping centres or any crowded area is often out of the question. People with agoraphobia may become housebound, unable to work or have any sort of social life. Some are so anxious that they need someone with them constantly, even at home, which places a huge burden of responsibility on family and friends. The entire family set-up frequently revolves around the agoraphobia.

Agoraphobia is defined as a complex phobia because it is often interlinked with generalised anxiety and fear. Most sufferers are women. It typically starts after the late teenage years and before the mid thirties, but can linger for years, even decades. Arguably the most debilitating of all phobias, it can touch every aspect of life.

Social phobia, another complex, all-pervading fear, was found by Swedish researchers to affect between 2 and 20 per cent at any one time, depending on the precise definition. It is a fear of being scrutinised by other people and embarrassed. Social situations, any sort of public performance, even eating or drinking out, may be impossible. For some, anxiety is limited to a single situation such as being unable to write in front of others – tricky when most of us rely on credit cards – being unable to speak in public or urinate in public toilets. Well-defined social phobias like these may have an important but relatively limited impact on someone’s life. However, like agoraphobia, social phobia can often have far-reaching effects.

Social phobia is more evenly distributed between the sexes and, if anything, more men than women are affected. It often develops from childhood shyness, becoming full-blown in adolescence, just as young people are starting to establish their own social lives. Parties, eating out and shared activities are a misery for those with social phobia. Dating can be a nightmare. Solitary leisure pursuits and a career that avoids any sort of public speaking are possible, but most families and jobs demand some level of socialising. Some manage to endure situations they dread, but their social anxiety effectively quashes all enjoyment.

This phobia takes varying forms in different cultures. In Japan and Korea, people with social phobia do not worry about being embarrassed, but are more likely to be excessively afraid that they will offend others, either through body odour, blushing or eye contact.

Specific phobias, considered the least serious group of phobias, are more easily pinpointed and sufferers can say exactly what they are afraid of. Specific phobias often start in childhood and last a lifetime. They include fears of animals or insects, or of something in the natural environment such as storms, heights or water. Fear of blood, injections and injury come into this group, as do fears of specific situations such as tunnels, bridges or lifts. The same New York researchers estimated that one in ten of us has a specific phobia at some stage.

Specific phobias give flashes of extreme anxiety in set circumstances. They tend not to dominate lives as phobics may only need to avoid well-defined situations, such as lifts carrying more than six people beyond the tenth floor. But while phobias of buttons, wallpaper or cotton wool can sound trivial, bizarre or even funny, such fears can still affect career decisions or cast shadows over family life. A driver with arachnophobia could swerve dangerously if a spider appeared on his dashboard. Women with blood and injury phobias may decide not to have children because they cannot bear the thought of giving birth. Less dramatically, a fear of dogs can put a stop to picnics, and a fear of tunnels or bridges can make travelling extremely complicated.

Phobias fit into neat categories on paper, but in practice overlap and are difficult to distinguish. Someone who never goes out is probably agoraphobic, but may have social phobia if they avoid only social situations and fear being embarrassed in front of others. Someone terrified of buses or trains might have agoraphobia, but if they fear public transport and nothing else, it would be considered a specific phobia. Specific phobias exist of, say, dirty cutlery in restaurants, but someone who obsesses about dirt and has developed time-consuming cleaning rituals has an obsessive-compulsive disorder.

A single phobia such as fear of flying can have many roots and people on ‘Fly with Confidence’ courses tend to have mixed problems. Some are claustrophobic, some scared of heights; others are afraid of dying and convinced that flying is unsafe. The organisers estimate that a third of the attendees have never flown before but are terrified of the very idea. They are the easiest to treat, and some, like John, hardly need to get both feet inside the plane to feel better. Part of his fear was based on the assumption that planes are very cramped: one look was enough to disprove it. Another third have flown happily for years before having a bad experience which precipitated their phobia, either a physical event such as extreme turbulence, or a personal crisis which happened to coincide with a flight. The final third might still be flying regularly but feeling progressively worse about it. Their fear is likely to be part of a complex phobia – agoraphobia or social phobia – and they are the hardest to treat. They have seen inside planes, they know the statistics of aeroplane crashes, but no amount of information will help. Their fear is inside – they fear their own reactions, afraid of having a panic attack, terrified by the total lack of an escape route. They are sure that they will be the one running up and down the aisle, hammering at the door, screaming, ‘Don’t panic! Don’t panic!’ For these people, a quick-fix solution is unlikely to be all that is needed.

Clinical classification of phobias is important because of the seriousness of the complex phobias. Agoraphobia and social phobia routinely lead to missed opportunities in life but are also likely to be associated with other disorders. People with social phobia are more than twice as likely to have problems with alcohol as non-phobics. Agoraphobics too are at an increased risk of alcoholism. Agoraphobia is also linked with some unfortunate personality measures such as dependency, unassertiveness and a lack of self-confidence as well as anxiety and avoidant behaviour. American research suggests that one in five with panic disorder, which is often associated with agoraphobia, attempt suicide. This is more even than people with major depression and twenty times the normal rate.

The tragedy is that phobias can be helped today but usually are not. Many different effective treatments exist but people continue to suffer. Phobias do have a stigma and it can be difficult to admit to a fear which you know, rationally, is out of proportion with reality. Why someone with a fear of heights should be more afraid of ridicule than someone with a broken arm or with high blood pressure is hard to say, though mental disorders traditionally have attracted less sympathy than physical ones.

Commercial one-day courses addressing fear of flying or spiders have the advantage of being based, respectively, at an airport or a zoo. Many find it easier to turn up there rather than at the local psychiatric unit and these courses have proved acceptable to those who might never seek help elsewhere. It seems likely, though, that their greatest appeal is among those whose phobias are least severe. In fact, drawing a line between normal fear and phobia is far from straightforward. Many, if pushed, would admit to disliking and fearing heights or spiders but do not have a phobia as this feeling causes no distress or infringement on their lives. A speaker at a recent meeting of the American Psychiatric Association pointed out that if she was not nervous about speaking to a room full of her most discerning peers, they might reasonably assume she was pathologically narcissistic. Some anxiety is not only inevitable in such a situation, it is probably good, prompting her to prepare her talk properly and deliver it well. If, however, she was so anxious about speaking that she refused to give lectures, or changed her job to avoid it, a diagnosis of social phobia would be appropriate.

Up in the Clouds

On the ‘Fly with Confidence’ course, comradeship built up through the morning as people derived comfort from each other’s questions and shared fear. The group started to bond. But as the day wore on they became more subdued, less friendly, some even angry at how ill-prepared they felt to climb aboard. People kept looking at their watches in alarm at how quickly the flight was approaching. During a desensitisation exercise, they were asked to imagine various scenes, such as checking in, waiting to board, climbing the steps to the plane. After each scene they were to return to deep relaxation. ‘Impossible,’ muttered the man on my right.

Despite such misgivings, all but one or two got on the plane and their relief was unmistakable. However, this was not universal. Across the aisle, a pale young man sat with his eyes closed, his head against the headrest. He was probably trying out newly learned relaxation exercises but he could have been praying. Helpful stewards provided numerous glasses of water, eliciting wan smiles, but did not make him much more comfortable. Occasionally he would open his eyes, look round, run his fingers through his hair and exchange a word with his neighbour. Then it was back to his private hell.

The man beside me seemed coolly confident, but confided that it was only OK because we were flying British Airways. The woman on the other side looked close to tears but chatted incessantly. ‘I must be all right because I’m talking,’ she said. ‘If I was really bad I would be in a corner taking no notice of anyone.’

People are recovering in their thousands through courses like this, but the process is demanding. The pale young man only slowly regained his colour and back in the terminal he was still, inexplicably, clutching his untouched airline meal.

CHAPTER 1 History

In the Beginning

The doctor was intrigued. His patient was in good physical health but he was so afraid of crowds and of the light that he hated leaving home. Whenever he went out, he chose if possible to go in the evening so that he could scuttle through deserted, dark streets to his destination. If he had to go out in the day-time, he would cover his head. He wanted to avoid seeing, and being seen by, anyone.

The man had done no wrong and had crossed nobody, but he was behaving like an escaped convict. He did not trust anyone outside his immediate circle. He was tremendously timid and the doctor became convinced that his fear of leaving home was due more to natural shyness than any real threat posed to him by the world at large.

The doctor was reminded of another patient who had yet another baffling fear. This man never went to parties, the theatre or any public gathering because he was convinced that he would disgrace himself. He thought he was bound to say something unacceptable, fall over or perhaps be sick in the middle of a crowd. Whatever it was, he believed that everyone would look at him, spit at him, jeer and mock him. He was so sure that everyone hated him that he avoided public events at all costs.

The doctor mused over the two cases and went home and wrote in his journal about the ‘men who feared that which need not be feared’, a fair definition of phobias. The men’s thoughts and behaviour will sound familiar today to anyone with experience of agoraphobia and social phobia even though the doctor was the Greek physician Hippocrates and he was writing 2,400 years ago.

Time has passed, language changed, but people’s experience of phobias remains much the same. The first patient, according to Hippocrates, ‘through bashfulness, suspicion and timorousness will not be seen abroad, loves darkness as life and cannot endure the light, or to sit in lightsome places, his hat over his eyes, he will neither see nor be seen by his good will.’ The second, he said, ‘dared not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speech, or be sick; he thinks every man observes him, aims at him, derides him, owes him malice.’

Hippocrates saw people with many different phobias over the years, ranging from agoraphobia and social phobia to animal phobias and other fears still common today. Damocles, he said, was terrified of heights and ‘could not go near a precipice, or over a bridge, or beside even the shallowest ditch; and yet he could walk in the ditch itself’. He described other, quirkier phobias such as that of Nicanor, who was untroubled by the sound of someone playing a flute through the day but ‘beset with terror’ when he heard the same sound at an evening banquet.

Hippocrates’ writing may be more poetic than modern medical notes but it demonstrates that the nature of fear has not changed over two thousand years. The ancient Greeks had the same experience of strange and unreasonable fears as we do today. Phobias have been around as long as we have, they are deeply ingrained in us, an integral part of human existence. This may not be much comfort to anyone with a phobia now but it does mean we have more than two thousand years’ worth of thought and insight into fears and phobias.

Unfortunately, this does not mean two thousand years of steady advances in understanding. Periods of intense activity by scientists, philosophers and doctors have been separated by gaps of hundreds of years when little happened. Early insights were overtaken by other bogus or unhelpful ideas and progress has been as likely to move backwards as forwards. But sometimes an apparently new idea chimes with an ancient one. Many modern theories are updated versions of ancient thoughts and some of the questions that puzzled the ancient Greeks still go unanswered.

Hippocrates’ careful observation of fear and phobias was exceptional at a time when most of his contemporaries thought that fear was sent down from the heavens. In Greek mythology, Phobos was the god of fright, son of Ares, the god of war. His brother was the god of fear, Deimos. Their companions included Eris, who represented strife and was insatiable in her fury; Enyo, who destroyed cities; and the Keres, who liked to drink the black blood of the dying. Myths related that this cheerful crew would stride on to the battlefield together, sowing disease and striking terror into the hearts of anyone they came across.

The god of nature, Pan, was responsible for contagious fear sweeping through crowds of people. Frightening sounds heard on mountains or in valleys at night-time were attributed to Pan, and he was thought to be the cause of sudden, groundless fear.

With the notable exception of the Stoics, the Greek people went along with mythology so far as to call on their gods for help and to blame them if they themselves were suffering. They would plead with Phobos to terrify their enemies, and at the same time assume that he was causing their own fear. They thought that Pan could determine the outcome of wars by generating mass hysteria throughout the ranks of one or other side and causing whole armies to disintegrate.

The Greeks were clearly comfortable with the concept of different types of fear. Phobos represented a sudden and acute fright, different from Deimos’ ongoing, rumbling fear. Pan symbolised the sort of fear which can spread through groups of people. This classification has been modified over thousands of years but still exists, another clue that our experience of fear has not changed much.

The words we use to describe these emotions reflect the ancient beliefs. Today’s Greek word phobos means intense fear or terror and translates directly into our word, phobia. The word panic is derived from Pan and has shifted its meaning more recently. It was once used to refer to the group process of mass panic, but now refers to an individual’s experience, including panic attack or panic disorder.

Our word anxiety comes from the Latin anxietas, which means troubled in mind. Again, the meaning has held steady despite translation into numerous other languages. French, Italian and Spanish all contain words derived from the Latin. Anxo in Greek means to squeeze, embrace or throttle, which came to mean weighted down with grief, burdens and trouble and has passed into German as angst. The sensation of constriction or tightening across the chest, of being unable to breathe freely, is a classic feature of panic.

Agoraphobia may have been described by Hippocrates, but it was not given the name until much later. The German psychiatrist C. Westphal coined the term ‘die agorophobie’, in a paper published in 1871. He described three men who either could not walk alone through certain streets or squares, or could do so only with great anxiety or a couple of stiff drinks inside them. Thinking about the feared situation could be every bit as alarming as actually walking into it. Westphal wrote:

The patients derived great comfort from the companionship of men or even an inanimate object such as a vehicle or cane. The use of beer or wine also allowed the patient to pass through the feared locality with comparative comfort. One man even sought, without immoral motives, the companionship of a prostitute as far as his own door.

Westphal’s choice of name harks back to Hippocrates’ time when the agora was a public meeting place, used for discussions of public affairs, games or contests. In ancient Greece a contest could be athletic, poetic or a mental challenge between dramatists, and was known as an agonia. An agonia demanded that individuals tested their skills and later the word came to mean mental anguish. After Westphal, confusion arose and agoraphobia came to mean not only a fear of open spaces or public places, the agora, but also the fear of deficiency in one’s performance, or agonia. It was not until the 1970s that the term ‘social phobia’ was brought into use to refer distinctly to the second of these, the fear of public scrutiny. It took a long time to get back to the starting point. Hippocrates may not have named these fears, but he certainly described the difference between agoraphobia and social phobia.

Hippocrates also explored possible causes. Unlike most Greeks, he thought it ridiculous to blame the gods for fear. He insisted that there was a physical cause within the individual. Neurotic symptoms fell into the class of melancholia, a type of insanity. It was caused by a build-up of black bile which made the brain overheat and caused passing terrors. Treatment was a regimen of diet, activity and exercise, designed to rid the body of the excess black bile. If this was not successful, drugs such as the poisonous hellebore were often given. The resulting vomiting and diarrhoea were taken as signs that the bile was being eliminated.

Hippocrates’ confidence in this particular scheme was somewhat misplaced but his belief in a physical cause for mental disorders has been shared by scientists ever since. One of his younger contemporaries, the philosopher Aristotle, also searched for a physical cause for nervousness. Aristotle decided that the heart was the seat of all sensations and the brain a cold, bloodless part of the body which absorbed hot vapours arising from the heart. This led much later to the old English idea of ‘the vapours’, meaning a nervous disorder, low spirits or boredom.

Great Greek thinkers and twentieth-century neuroscientists may be united in their belief in a physical, biological cause of fear but there have always been other ideas. The Stoic school of philosophy grew up shortly after the time of Hippocrates and survived for five hundred years, well into the Roman empire. The Stoics included emperors (Marcus Aurelius), slaves (Epictetus) and even Nero’s tutor, Seneca. Stoicism stressed the importance of human reason in finding an accord with nature. Emotions had to be conquered and passions shed in order to achieve imperturbability. People can be happy in the midst of the severest pain if they can master themselves and let nothing overwhelm them. We are not at the mercy of external events. (Cognitive therapy (chapter 6) still relies on some of these ideas.) More specifically, the Roman Caelius Aurelianus wrote that phobias were a type of mania and arose from problems in the mind, not from the body or physical brain:

Mania fills the mind now with anger, now with gaiety, now sadness, now with nullity, now with the dread of petty things. As some people have told; so that they are afraid of caves at one time, and chasms at another, lest they fall into them; or there may be other things which frighten them.

More than two thousand years ago, then, philosophers and medics could give a good description of phobias. Ideas about the causes may have been primitive but they were forerunners of some of the main schools of thought still in existence. Sadly, the brilliance of these great thinkers probably had little impact on most people of the day. The prevailing view was that fear was sent down from the heavens and that phobias were best treated by trying to appease some god.

The Roman empire, which had assimilated Greek civilization, itself collapsed in about AD 400. The Church then dominated society and effectively put a halt to studies into individuals’ emotional experience. Phobias obviously still existed, and fears of plague or syphilis were especially common. However, in a backward step for science, excessive or strange fears were assumed to be caused by an interaction between forces of good and evil, and people with phobias thought to have been overtaken by demons or evil spirits.

Throughout the Middle Ages, the Church dominated scholastic thought and pre-eminent thinkers were occupied with big theological questions. Not until the fourteenth century did attention turn gradually back to the individual. This paved the way for the golden age of philosophy, out of which grew psychology as we know it today. And it started with Descartes, once described as the first modern man.

Cartesian Logic

Born into a rich and noble family at the end of the sixteenth century, Descartes studied languages, literature and philosophy at one of the top French schools of the period. But even as a young man he became disillusioned with the limited nature of the teaching and quit his studies to lead a life of pleasure in Paris.

Boredom eventually set in and he joined the army in Holland, where he learned about mathematics and the natural sciences. Then later on, he joined the Bavarian imperial army in the Thirty Years War, which allowed him to travel through Germany, Austria, Hungary, Switzerland and Italy. He was constantly observing, contemplating reality, and working on his own philosophical method.