Phobias: Fighting the Fear

He moved back to Paris for a few years, eventually leaving again for a life of near-seclusion in Holland. His interests included mathematics, optics, astronomy, chemistry and botany and out of this unlikely mix came key ideas in the history of psychology.

His views on early learning, for example, are still vividly contemporary. In 1649, shortly before his death, he wrote that learning can start before birth.

It is easy to conceive that the strange aversion of some, who cannot endure the smell of roses, the sight of a cat, or the like, come only from hence, that when they were but newly alive they were displeased with some such objects, or else had a fellow-feeling of their mother’s resentment who was so distasted when she was with child; for it is certain there is an affinity between the motions of the mother and the child in her womb, so that whatsoever is displeasing to one offends the other; and the smell of roses may have caused some great headache in the child when it was in the cradle; or a cat may have affrighted it and none took notice of it, nor the child so much as remembered it; though the idea of that aversion he then had to roses or a cat remain imprinted in his brain to his life’s end.

Descartes’ major contribution applies to the whole of psychiatry, not just to phobias and anxiety. However, the respect in which he was held rather unfortunately cast in stone the mind-body split still so relevant to the treatment of phobias.

Descartes set out to question all accepted wisdom and build up his own philosophy from scratch. He was a firm believer in reason and thought all experience was fallible for he could never be completely sure that he had not been dreaming, or even tricked by a malicious demon. Bodily experiences were unreliable, he said, and the only thing he could be absolutely sure of was that he was thinking. His first principle of philosophy was, famously, ‘Cogito, ergo sum’, ‘I think, therefore I am’, and he came to regard the mind or soul as totally separate from the body. They are simply two different entities, he said: the mind is not a physical thing and therefore it can never truly merge with the body.

Descartes was searching for absolute truths and was not attempting to pit future psychiatrist against future psychiatrist. However, his reasoning led to Cartesian dualism, which has translated into medical circles as the great divide between mind and body. Does the cause of a psychological problem such as a phobia lie in the thinking mind or in the physical brain? The question has never been answered and professionals line up on opposite sides of this divide. Geneticists, molecular biologists and neurophysiologists, looking ever more closely into the physical and mechanistic workings of the brain, represent the ‘body’ side of the argument. Their remit is to explore the parts of the brain that can make us susceptible to phobias, anxiety and panic, somehow change its delicate chemistry and reduce our fear. On the ‘mind’ side, psychologists and psychotherapists examine past experiences or current beliefs and aim to challenge and change our thinking patterns to dispel our phobias.

Descartes believed that mind and body were closely linked and he would not have supported this interpretation of his work. In The Passions of the Soul he wrote: ‘There is such a tie between our soul and body that when we once have joined any corporal action with any thought, one of them never presents itself without the other.’ It is ironic that a philosopher who gave himself the widest possible brief is best remembered for naming the rift between some of the most polarised views in medicine and psychiatry.

He even named the meeting place between mind and body as the pineal gland. We now know that the pineal is sensitive to light and one of the hormones produced there, melatonin, regulates our sleep-wake cycle. Scientists researching jet lag and shift-work patterns have long been interested in the pineal but their work apparently had little relevance to phobias. However, some researchers now believe that certain light frequencies, acting via the pineal, may influence our susceptibility to both anxiety and phobias (discussed further in chapter 9).

Descartes’ belief in the central nature of thinking and reason makes him, like the Stoics before him, a rationalist. Cognitive therapists say that our beliefs fuel our fear, almost ‘I think, therefore I am frightened.’ Chapter 6, on cognition, examines at this in depth and it is quite possible that Descartes would have agreed with some of the main ideas.

Immanuel Kant, more than a hundred years after Descartes, was another rationalist, and his ideas fit equally well with cognitive therapy. Again, he stressed the importance of reason. He said, ‘The understanding cannot see. The senses cannot think. Only by their union can knowledge be produced.’

Kant believed that our ideas shape our view of the world. It is as if our ideas are spectacles that distort what we see. They determine what we focus on and how appealing it looks. We do not see an event itself, but only its appearance through these unreliable glasses. Put simply, there are alternative ways of looking at any event. Cognitive therapists today would agree. They aim to change people’s interpretation of events, just like adjusting their spectacles to change the focus or the tint.

Locke and Empiricism

An alternative view is that reason does not come into it at all. The human mind is, in fact, like a blank sheet of paper. Ideas are generated through our physical senses and our experiences, and projected on to this blank sheet. We work on the information derived from our senses, make associations and generalisations and build up our psychological picture of the world. No matter how abstract or complex the idea, it begins with physical sensations. Even belief in the existence of God can be built up in this way.

These are the thoughts of John Locke, who was working soon after Descartes. He belonged to the opposite tradition in philosophy, empiricism, which rated experience above all else.

Learning and memory are built on experience alone, Locke said. Phobias are therefore learnt as the result of a bad experience. And like behavioural therapists today, he said that fear can also be unlearnt through experience. Locke’s most important work was the Essay Concerning Human Understanding, published in 1690. His advice on dealing with irrational fears could have come straight out of a modern behaviour therapy textbook:

If your child shrieks and runs away at the sight of a frog, let another catch it and lay it down at a good distance from him; at first accustom him to look upon it; when he can do that, to come nearer to it and see it leap without emotion; then to touch it lightly, when it is held fast in another’s hand; and so on, until he can come to handle it as confidently as a butterfly or sparrow.

Empiricists like Locke would be at home talking to behaviour therapists in the twenty-first century.

Behaviourism aligns itself with empiricism in the same way that cognitivism is linked with rationalism. These two schools of thought have continued through history like parallel lines, never getting any closer to each other. They ask different questions and look for different answers. Empiricists and behaviourists want to know what a boy does if you send a dog into the room where he is sitting. Rationalists and cognitivists ask why the boy starts screaming and climbs out of the window.

Unfortunately, accurate observation and brilliant insights did not necessarily translate into practical and humane treatments. The seventeenth and early eighteenth centuries may have been a time of rapid progress in theories of learning and thinking, but people with anxiety disorders probably shrank from some of the proffered cures. The physician Thomas Sydenham suggested that hysterical disorders or today’s anxiety disorders could be helped with ‘bleeding, purging, opiates, foetid medicines, chalybeate medicines, filings of steel and rhenish wines, plaister at the navel, hysteric julap, opening pills or electuary’. Another writer regarded anxiety as a symptom of cardiac disease and recommended ‘narcotics and anodynes, mucilages, things fat and emplastik, emulsions and roborants’. Royalty escaped lightly in comparison, and Queen Anne’s physician Sir Richard Blackmore used opium because, he wrote in 1725, ‘It calms and soothes the disorders and perturbations of the animal spirits.’

Treatment provided by the clergy was, perhaps predictably, more orientated towards ‘mind’ than ‘body’. One minister thought that the key to treating anxiety was to ‘put them in a Pleased condition’. Another clergyman who specialised in ‘Spiritual physicke to cure the diseases of the soule’ was effectively an early psychotherapist and recommended the use of silence.

Darwin and the Dawn of

Modern Science

Charles Darwin had no desire for a head-on collision with the Church. By nature he was diplomatic and unassuming, certainly not confrontational. On top of this, his beloved wife Emma Wedgewood was deeply religious. But he was exasperated by the Church’s stranglehold on biology. The doctrine that we are made in the image of God, implying our perfection, was a particular problem. It elevated any study of humans into a direct challenge to God’s greatness and effectively stifled scientific thought.

Scientists in other disciplines in the early nineteenth century had much more freedom than biologists. Darwin viewed them jealously as he wrote: ‘What would the Astronomer say to the doctrine that the planets moved [not] according to the laws of gravitation, but from the Creator having willed each separate planet to move in its particular orbit?’

Another problem facing biology was the legacy of rationalist philosophy. It had produced great insights and set up trains of thought still followed today, but in practical terms it had come to a dead end. The philosophical view of the brain did not lend itself to systematic study. Kant even said that the mind was unquantifiable and beyond direct investigation so that a science of the mind was a logical impossibility.

Darwin eventually overcame these obstacles and his work paved the way for an explosion of activity in mind and brain research. The parts relevant to phobias are explored in detail in the next chapter, but his greatest contribution was, in the mildest possible manner, to wrest control of biology from the Church.

The Origin of Species, published in 1859, simply observed that living things adapt themselves to their surroundings. Species change over generations, he said. And if living things are not God-given, created once for all time, this implies that they are a legitimate target for scientific study. Darwin carefully excluded humans so as not to court more problems with the Church than was absolutely necessary, but his argument plainly implied that we are not distinct from animals. And if we have not been selected by God for special treatment, there is no reason why we cannot be studied scientifically.

The work caused a social and moral storm on publication but it was assimilated by scientists and the public alike within a decade. From there, developments in the many fields of science relevant to anxiety, fear and phobias started to snowball. Psychologists started collecting data. They devised experiments and studied the behaviour of animals and humans. Wilhelm Wundt, who set up the first psychology laboratory in Leipzig, epitomised this new approach. His followers were trained to look for traits that could be measured, and then collect data before they started building their theories.

The foundations were laid for the modern neurosciences. Spanish physiologist Santiago Ramón y Cagal was awarded the Nobel prize for his discovery that the brain is made up of neurones, or nerve cells. Afterwards, scientists went on to establish that the brain consists of a vast interconnected network of these cells. Scientists today are still trying to determine how far communication between these cells determines emotions like fear or anxiety.

Medicine progressed. Psychiatrists like C. Westphal started closely observing and defining phobias. The American Civil War brought tragic opportunities for clinicians to study fear at close quarters. Doctors who might once have moralised about courage or faith started taking measurements and looking more dispassionately at the effect of fear on the heart, lungs and other body systems. They wrote up their observations and developed theories, some of which are explored in chapter 4, on neurophysiology.

All of this work set the scene for probably the single most influential figure in the history of thought on phobias.

Freud on Fear

Five-year-old Hans was walking along the street with his mother. It was in the early years of the twentieth century and there were horses trotting by, pulling carriages, vans and buses. Wheels and hooves clattered on the cobbled road, people walked across and between them and it was an ordinary, busy day.

Hans’ mother stopped to greet an acquaintance and he looked idly down the street. A bus came towards them, pulled by two black horses. Just as it reached them, one of the horses stumbled and fell heavily on to its belly, jolting the bus. The other horse swished its tail in distress, shook its head and stamped its feet. The driver jumped down to help, and people peered out of the bus to see what was going on.

The horse looked enormous as it lay on the ground, covered in dust, in front of Hans. It snorted and tried unsuccessfully to get up. Its harness was twisted, making it difficult for the horse to move. A crowd started to gather and the noise grew. Hans stared in fright and his mother led him away from the scene.

Hans was agitated and could think and speak of nothing else for the rest of the day. Soon afterwards, he developed a phobia of horses. He started crying on his normal walk to the park with his nursemaid, and wanted to be taken home. He was afraid a horse would bite him and later, at home, afraid that a horse would come into the room. He became reluctant to go out at all and was quiet and withdrawn in the evenings.

Hans led an unexceptional, if somewhat closeted, middle-class life. He had a younger sister but few friends of his own age. His parents had, for the previous two years, noticed what they considered to be a precocious interest in sex. He asked questions about his parents’ and his younger sister’s genitalia. Both parents told him that he had the phobia because he often touched his ‘widdler’.

His parents were devotees of Sigmund Freud and Hans’s father wrote to Freud about the horse phobia. The case of Little Hans, as it became known, was the first published account of child analysis, and became celebrated as a key success in psychoanalysis. Freud believed it was proof that sexual urges are an essential part of the development of phobias.

Freud said Hans had an Oedipus complex. He loved his mother and wanted to be taken into her bed. He wanted his father, his rival, dead, and was therefore afraid of him. Hans transferred his fear of his father on to horses and the phobia erupted after some months of longing for sexual contact with his mother. According to Freud, ‘His sexual excitement suddenly changed into anxiety.’ The affection for his mother ‘triumphantly achieved its aim’, by making Hans afraid of going out into the street and allowing him to stay at home with his mother.

These were tendencies in Hans which had already been suppressed [wrote Freud] and which, so far as we can tell, had never been able to find uninhibited expression: hostile and jealous feelings against his father, and sadistic impulses (premonitions, as it were, of copulation) towards his mother. These early suppressions may perhaps have gone to form the predisposition for his subsequent illness. These aggressive propensities of Hans found no outlet, and as soon as there came a time of privation and of intensified sexual excitement, they tried to break their way out with reinforced strength. It was then that the battle which we call his phobia burst out.

Hans’s father received Freud’s letters over a period of months and Hans recovered gradually.

The case of Little Hans, which has been argued about ever since, was a fascinating example of Freud’s theory of mind. Freud said the ‘id’ stands for untamed passion, and the ‘ego’ for reason and good sense. The id generates inappropriate sexual or aggressive impulses, which the ego tries to make socially acceptable. The ego receives the id’s dangerous urges, and represses them if at all possible. Failing that, the ego has to find another outlet and may alter excessive excitement so far that it ceases to be pleasurable and becomes a psychosomatic symptom such as palpitations or fainting.

So, according to Freud, Hans’s sexual desire for his mother and his longing for his father to be dead were unacceptable urges created by the id. They created more excitement than the ego could deal with and were converted into anxiety and a fear of horses.

A single anxiety attack, with palpitations or breathlessness, can be enough to trigger a phobia, said Freud, and many today would agree with this part of the theory, if not with the underlying explanation. The ego feels helpless during the attack, Freud says, and deals with this by projecting the anxiety on to the external situation. The anxiety attack then becomes associated with a bus or train journey, for example, rather than with forbidden excitement. It is easier to control external situations than internal thoughts and the phobia becomes a convenient way of explaining away a terrifying reaction. This process is carried out at a subconscious level; at the conscious level, all we know is that we are afraid of the situation. The ego then prompts us to avoid the situation in future as a defence against the impulse and the feeling of helplessness. So an external, tangible fear replaces an internal, instinctual danger and a phobia develops.

Freud’s theory was at once brilliant – and mistaken. On the positive side, he founded psychoanalysis and highlighted, long before mainstream science, the importance of relationships and childhood experience in shaping adult personalities. Furthermore, his emphasis on the subconscious opened up a whole new way of thinking about mental pain and inner conflicts. But his emphasis on sex was questionable. Other scientists have combed the 140 pages’ worth of his analysis of Little Hans and found no evidence that the boy sexually desired his mother. Nor are there any signs that he feared his father. But the link between sex and phobias, started by Freud, has hampered phobia treatment for decades.

Specialists and theorists today have largely given up the idea but it still lingers and can cause problems. Referral for a phobia from GP to psychiatrist can still lead to a discussion about relationships with parents and possible abuse. It is impossible to completely rule out a link between sex and a phobia; complex phobias can develop from a background of troubled emotions and difficult experiences and there are, of course, phobias of sex itself. But most phobias do not stem from sex or have anything to do with it.

Psychoanalysis itself is largely out of fashion in scientific circles, partly because it has failed to keep up to date and incorporate new findings from cognitive science or physiology. But its legacy in phobia treatment is the enduring idea that phobias are the visible signs of terrible inner conflict. For many years psychiatrists have approached phobias with extreme caution for fear of what might be uncovered.

The whole basis of recent progress (and this book’s premise), is that delving in someone’s unconscious, looking for the cause of a phobia, does not get results. Good treatments work regardless of the cause.

Other, less celebrated parts of Freud’s work provided a solid framework within psychiatry which still largely exists. He had a genius for making sense of the experiences described by his clients and categorising the different aspects of anxiety. The remnants of his classification are still apparent today in the mighty DSM, the Diagnostic and Statistical Manual of Mental Disorders, the bible of the American Psychiatric Association.

Until Freud’s paper in 1894, anxiety disorders were collectively known as neurasthenia. Freud’s achievement was to distinguish ‘anxiety neurosis’, or what we now call panic disorder, from general anxiety and to describe its three aspects. The first is the anxiety or panic attack; the second is anxious expectation, or anticipatory anxiety; and the third is phobic avoidance. Further, Freud recognised that people could have more than one anxiety syndrome, and that people could have mild forms of anxiety.

He described heart ‘spasms’ and the difficulty in breathing that can accompany anxiety attacks. In fact, ten of the thirteen symptoms included in the DSM as late as 1987 had been previously noted by Freud. Freud also recognised that specific phobias – not the term he used – were quite different from agoraphobia, and described them as an exaggerated reaction to dangers instinctively feared by everyone. The idea that most specific phobias are an overblown but essentially normal reaction surfaced again recently and is explored in the following chapter.

Freud, who was a neurologist, drew together much of the work that preceded him and his early work reflects his interest in neurophysiology. He cut across the nature-nurture debate and claimed, in a truly modern fashion, that inborn and biological factors interact with experience in causing anxiety disorders. Interestingly enough, he was himself phobic about travel.

Little Albert

J. B. Watson was an impatient young American. He was irritated by the state of psychology in the early twentieth century, by its lingering obsession with philosophical questions and its fascination with the subconscious. He set out to drag it into the realms of science.

Watson did not claim that mental phenomena do not exist, but rather that they cannot be measured and therefore might as well be ignored. In an unlikely agreement with Kant, he said that the mind, or consciousness, could not be investigated scientifically. Following on from Wundt, mentioned earlier, Watson stressed the importance of collecting data and measuring overt, visible behaviour. Little Albert, an 11-month-old baby, was the unfortunate guinea pig chosen.

Watson’s masterstroke was a direct challenge to Freud. He and his colleague, Rosalie Rayner, allowed Albert to play happily for a while and then showed him a furry white rat, at the same time banging an iron bar on metal just behind his head. The little boy got a terrible fright. A few days later, they showed Albert the rat again, this time without the noise. He was still obviously frightened. In fact, weeks after the experiment, he remained afraid of rats, dogs and anything furry, even fur coats.

A single, frightening event was enough to create a lasting fear in Little Albert. By extension, it suggests that the horse’s fall in front of Little Hans may have been sufficient in itself to cause his subsequent phobia. Analysis of his subconscious was therefore unnecessary.

Russian neurophysiologist Ivan Pavlov, working at the same time, would have agreed. He famously rang a bell every time he fed a group of dogs. Eventually, the dogs started to salivate at the sound of the bell whether or not there was any food. Pavlov said they had come to associate the bell with the food so strongly that either would make them salivate. The dogs were conditioned, to use Pavlov’s term, to salivate when the bell rang.

White rats were a convenient vehicle for studying behaviour because, like dogs, they can be conditioned. Simple experiments with rats produced simple results and fuelled enthusiasm for behaviourism. In variants of Pavlov’s experiments, rats were shown something innocuous, like a coloured light, at the same as they received a mild electric shock. With repetition, the rats came to fear the light alone.