Psychotherapy

These learned words are all formed on the same etymological principle as hydrophobia, but they are entirely psychic in origin, while hydrophobia, as it is well to explain to patients who think of the word phobia in connection with their symptoms, is, of course, a misnomer for an infectious disease—rabies—which develops as the consequence of a bite of a rabid animal, and the principal symptom of which is not fear of water, but the impossibility of swallowing any liquid because of spasm of the esophageal muscles.

Almost any function of the body may become the subject of a dread or phobia that may interfere even seriously with it. Any disturbance of any function is likely to be emphasized by such dreads. The French have described the basophobia, which makes the patients suffering from beginning tabes dread so much walking that it becomes a much greater effort than it would otherwise be and often interferes with walking rather seriously. Then there is the fear of tremor which exaggerates a tremor due to some organic cause, but yet not necessarily of grave import, nor likely to increase rapidly. Many of the hysterical palsies are really due to dreads, consequent upon some incident, motor or sensory, which produced a profound effect upon the patient's mind. A patient who has been surprised by a digestive vertigo while descending a stairs, even though nothing more happened than the dizziness which required him to grasp the balustrade, will sometimes develop a fear of vertigo that will actually make it difficult for him to go down stairs without such an effort of will as is very exhausting. Even the slightest functions may be thus disturbed. Pitres and Regis described some ten years ago what they called the obsession of blushing, or erythrophobia, the fear of turning red. Patients make themselves extremely miserable in this way. Only training and self-control will help them.

These names are long and mouth-filling and consequently satisfying, and most people who are suffering from a particular phobia are almost sure to think that they have a very special affliction. When the word dread is used instead of the word phobia they are less likely to misunderstand the character of their affection and to realize that it is not a disease but only an unfortunate mental peculiarity that needs control and discipline, and not fostering care. Neurasthenia only means nervous weakness, as we have pointed out, but most people are rather rejoiced when informed that they have so high-sounding a disease as neurasthenia, while to be told that they are nervously weak or suffer from nervous weakness seems quite a come-down from their interesting Greek-designated affection. Most psychiatrists feel that it is better not to give the long Greek term, but to state in simple short Saxon words just what is the matter with the patient. They are suffering from the dread of a height, or the dread of a narrow street, or the dread of open spaces, or the dread of dirt, or of cats, or of whatever else it may be. This makes it easier for them to begin to discipline themselves against the state of mind into which they allow themselves to fall with regard to these various objects, and mental discipline is the only therapeutic adjuvant that is of any avail in lessening these conditions. With reasonable perseverance most people can, if not cure themselves of these affections, at least greatly lessen the discomfort due to them. A consideration of particular dreads brings out the specific suggestions that may be made with regard to each and the directions that may be helpful to the patients. Probably the commonest is acrophobia, so that the detailed consideration of it shows the indications for other dreads.

Dread of Heights.—Almost without exception men have a sort of instinctive dread of looking down from a height. In most people this can be conquered to such a degree that almost anyone, if compelled by necessity, can learn to work on a skyscraper and continue to do good work without much bother about the height, though he may have to go up ten to twenty stories, or even more. When he takes up the work at first every workman finds it difficult. It gives most of us a trembly feeling even to sit in our chair and think of looking down from such a height. To see pictures of men standing on the iron frames of skyscrapers twenty or thirty stories up in the air looking down 300 to 500 feet below them gives one a series of little chilly feelings in the back and in many people a goneness or sense of constriction around the abdomen that is almost a girdle feeling. To sit at a window opposite where a skyscraper is going up and to see the men lean over the edge of a beam calling directions of various kinds to workmen below will give most people, even those who are not nervous or especially sensitive, creepy feelings with sometimes a little catch in the breath and an iciness in the hypochondria. It would seem absolutely impossible that we should ever be able to perform these feats of looking from a height, yet experience shows that most of us, after a little training, learn to do it without difficulty.

Even the men who work most confidently have some creepy feelings return to them whenever they stop and think about this and let their eyes wander to the distance below them. It is not difficult for us to walk across a plank raised a foot or two from the ground, though to walk across the same plank at a height of ten feet may be quite a trial and at thirty feet may become quite impossible. This is all due to lack of confidence on our part and there is no reason in the world why, if the plank is amply wide for us at two feet from the ground, it should not be just as wide and safe at 30 or 60 or even 100 feet. This is what the men who have learned to work on skyscrapers have disciplined themselves to. They have learned to disregard the wide vacant space around them and the yawning chasm beneath their feet; they keep their eyes fixed on something in the immediate vicinity, excluding thoughts of all that might happen if they should lose their balance.

Physical Basis .—There is a physical basis in many of these cases that constitutes the underlying occasion, at least, for the development of the psychic dread. Our eyes have grown accustomed to being fixed on near objects. Whenever they are not so fixed we get a feeling of trepidation. Even those who have done a little day-dreaming know that sometimes when they have been looking into space, objects around them have suddenly seemed to be transferred to a long distance and at the same time a curious sense of insecurity came over them. Anyone can get this feeling experimentally by making two large dots on a piece of paper about two inches apart and then gazing between the dots into vacancy beyond the paper as it were, until the dots have a tendency to become four because of the fact that each eye sees each of the dots on a part of the retina not corresponding to that on which the other eye sees it (see Fig. 25).

Fig. 25.

When the experiment is successfully performed the dots begin to float before the eyes, then they may coalesce into one or become three, but any number up to four may readily be seen. This will give the sense of insecurity that comes from the eyes not having any fixed object to look at and illustrates the discipline of the eyes that must be learned in order that looking down from a height may not be productive of the usual dread.

Dread of Small Heights .—It is often thought that acrophobia, or the fear of a height, concerns only great heights and that ordinary elevations produce no discomfort. I have had patients, however, who, when compelled by circumstances over which they had no control or at least by social obligations that were hard to break, to sit on the front row of even a low balcony, have been extremely uncomfortable. There was a sense of tightness and oppression about the chest that made it difficult for them to breathe, that disturbed their heart action and gave them a general sense of ill-feeling. I have had a curiously interesting series of cases in clergymen who found it trying to say Mass or conduct services or to preach from the step of a high altar. One would be inclined at first to make little of their description of their utter discomfort. There is no doubt at all, however, of their real torture of mind and of the extreme effort required to enable them to support themselves in the trying ordeal. They are often so exhausted because of the effort required that only with difficulty can they do anything else during the day.

To most people such a state of mind is inexplicable. There are deeply intellectual men who, in my experience, are quite disturbed by apparently so simple a thing as having to say Mass on an altar that has three or four steps to it and is elevated five or six feet above the surrounding floor. As for higher altars, like the main altar of a cathedral, they usually find it quite impossible to conduct services unless they are in company with others, when their feelings are much relieved. This same thing is true of agoraphobia in some people. To go alone across an open place or square is agony, but even the company of a little child is sufficient to relieve them to a great degree. I told a distinguished American prelate of this curious dread in priests so often called to the physician's attention, and he said that he had never heard of it. To his surprise some of his clergymen present at the table told him that there were two examples of it in brothers in his own diocese.

Mental Discipline .—The lesson of the many men who, by discipline, have succeeded in conquering the aversion and the dread of heights that everyone has to some extent at least, shows the possibility there is for even those who are extremely sensitive in this matter to so lessen their timidity and the uncomfortable oppression that comes over them, as to make it possible to accomplish whatever is in their line of duty. It is no more difficult for the sensitive clergyman to learn by practice and discipline to walk with confidence on a reasonably high altar or platform, than it is for the workman to learn to walk a beam on the top of a twenty-story building without a thought of the dangers of his position, or at least putting the thought away from him so that it does not interfere with his work. At the beginning he cannot do it, but he disciplines himself to form a habit that makes it easy. Yielding to his feelings makes it difficult to withstand the discomforts that come to him. After an accident on a high building, as a rule, men have to be sent home for the day to get their nerves settled by the night's sleep before they can work with sufficient confidence, and yet accomplish their usual amount of work.

So-called Misophobia—Dread of Dirt.—Misophobia, or the fear of dirt, has grown much more common in recent years, and the spread of the knowledge of the wide diffusion of bacteria has added to the unreasoning dread that possesses these people. Some of them wash their hands forty to fifty times a day, and one young man who was brought to me with the worst looking hands, because of irritation from soap and water, that I have ever seen, seemed to be always either just plunging his hands into water or wiping them dry. These people make themselves supremely miserable. They do not care to shake hands with friends and, above all, with physicians, and they invent all sorts of excuses so as to wait outside of doors till someone else opens them so as to avoid touching the knob or door pull, "which" with a poignant expression of repugnance they tell you "is handled by so many people." When the patients are women, getting on and off cars becomes a nightmare to them, because they do not want to touch the handle bars and unless they do they find it difficult to ascend and descend. The curious excuses they offer for their peculiar actions in avoiding the touch of objects around them are interesting.

Claustrophobia.—This sort of dread seems quite irrational to most people and many would probably conclude that individuals thus affected could not possibly be quite in their right minds, or must surely be rather weak-minded. On the contrary, many of the people who are affected by these curious dreads are above the average in intelligence and sometimes also in their power to do intellectual work. A typical example, for instance, of claustrophobia, or the fear of closed spaces, is found in the life of Philip Gilbert Hamerton. He was a distinguished painter and essayist, editor and novelist. Few men of his generation were able to do better intellectual work than he. His book on "The Intellectual Life" was more read perhaps than any work of its kind in the last generation. He was not a profound thinker, but he was a very talented practical man. The fact that besides being a writer whose books sold he was a painter whose works were in demand, shows a breadth of artistic quality that is quite unusual. His was not the sort of genius, however, that is so often supposed to be allied to insanity, for he was rather a worker who obtained his effects by plodding, than a brilliant genius that got his thoughts by intuition.

In a word, in spite of the fact that he was just the sort of man that one would not think likely to be affected by a phobia, he had a series of attacks of claustrophobia, some of which were intensely annoying to him and seriously disturbing to his friends. His wife has described some of them in his "Life and Letters." Once after crossing the English Channel, he had a severe attack in the railroad carriage on the way up to London. He had not been nervous on the voyage and had not been seasick. He was returning from a vacation and was in the best of health and spirits, yet suddenly the feeling of inordinate dread that he was shut in came over him and he could scarcely control himself or keep from plunging out of the window in order to get into the open. His wife says that "His hands became cold, his eyes took on a far-reaching look, his expression became hard and set and his face flushed." He seemed "as if ready to overthrow any obstacle in his way; and indeed it was the case, for, unable to control himself any longer, he got up and told me hoarsely that he was going to jump out of the train. I took hold of his hand and said I would follow him, only I entreated him to wait a short time, as we were near the station. I placed myself quite close to the door of the railway carriage and stood between him and it. Happily the railway station was soon reached, when he rushed from the train and into the fields." His wife followed him like one dazed, and almost heart-broken. After half an hour he lessened his pace, turning to her and said, "I think it is going." For two hours they continued to walk, at the end of which Gilbert said tenderly in his usual voice, "You must be terribly tired, poor darling. I think I could bear to rest now. We may try to sit down."

Dread of Cats.—One of the most interesting of dreads, very frequently seen and producing much more discomfort than could possibly be imagined by anyone who had not seen striking cases of it, is the dread of cats which has been dignified and rendered more suggestively significant by the Greek designation ailurophobia. While the great majority of individuals suffering from this unreasoning dread of cats are women and usually of a delicate nervous organization, it must not be thought that it is by any means confined to them or has any necessary connection with hysterical symptoms. One of the most striking cases of this dread of which I know personally occurs in a large, rather masculine-looking woman, who cannot abide being in a room with a cat, and who is quite unable to do anything while one of these animals is within sight. Yet she is not at all what would be called timorous and she has more manly than womanly characteristics in every way. She once proceeded to thrash within an inch of his life a small burglar who entered her house and she rather prides herself on being able to protect herself. Nor is this dread necessarily associated with any other disturbances of mind or nervous system. Some of the patients I have seen, who confess to suffering from it, were thoroughly sensible, brave little women, able to stand suffering well, not at all hysterical in nature, and who in the midst of worries found time to be thoughtful of others and not to have that selfishness which, even more than physical symptoms, is so apt to characterize hysterical patients.

I have had men confess to me their dread of cats, and while, as a rule, they were of delicate constitution and inclined to be nervous and did not have the phobia to an inordinate degree, there was no doubt that they were extremely uncomfortable whenever a cat was near them. On the other hand, some of them were vigorous, husky men with strong aversions. One of the most marked cases of ailurophobia that was ever brought to my attention was in an army officer who had exhibited bravery in battle on many occasions, and what requires much more strength of mind, calm fortitude in difficult campaigning, yet for whom a cat had many more terrors than the battery of an enemy or even an ambuscade of Filipinos. More cases of this particular aversion seem to occur in clergymen than in other men, yet one of the worst cases I ever saw was in a priest of great moral courage, who had served a pest-house over and over again in smallpox epidemics.

All that can be said about such a dread is that it exists, that it is unreasoning, that some patients have been known by discipline of mind to overcome the abhorrence to a great degree but never quite entirely. In this regard, however, it must not be forgotten that there are many things abhorrent to human nature that seem impossible to overcome the aversion for, yet discipline does much to relieve them. For instance, the handling of dead bodies so familiar to physicians brings with it an aversion that we never quite get over and which resumes most of its original strength with disuse, but that can be overcome to such an extent as to make pathological work produce very little aversion. Even Virchow, after all his years of occupation with pathological material, confessed toward the end of his life, that whenever he was away from his work for a few months his aversion had to be overcome anew.

The Spectator on Dreads .—There might be a tendency to think that these curious dreads came only as the result of the individualistic over-occupation with self and the introspective sophistication of the modern time, but the dread is not confined to our time nor special to it in any way, for we find Shakespeare talking of those who cannot bear a harmless, necessary cat. A number of other writers of different periods refer to it. As in so many other things The Spectator reflects his time in this and so we have a letter with regard to the dread of cats. It would not have been a subject for discussion in one of these popular communications only that the writer felt that a good many people would realize how like it was to things that they themselves knew of. In number 609 the following letter, supposed to be from a correspondent, seems worth giving in full, because it touches on other subjects in which uncontrollable, unreasoning feeling plays a role:

I wish you would write a philosophical paper about natural antipathies, with a word or two concerning the strength of imagination. … A story that relates to myself on this subject may be thought not unentertaining, especially when I assure you that it is literally true. I had long made love to a lady, in the possession of whom I am now the happiest of mankind, whose hand I should have gained with much difficulty without the assistance of a cat. You must know then that my most dangerous rival had so strong an aversion to this species, that he infallibly swooned away at the sight of that harmless creature. My friend, Mrs. Lucy, her maid, having a greater respect for me and my purse than she had for my rival, always took care to pin the tail of a cat under the gown of her mistress, whenever she knew of his coming; which had such an effect that every time he entered the room, he looked more like one of the figures in Mrs. Salmon's wax-work than a desirable lover. In short, he grew sick of her company, which the young lady taking notice of (who no more knew why than he did), she sent me a challenge to meet her in Lincoln's Inn Chapel, which I joyfully accepted; and have, amongst other pleasures, the satisfaction of being praised by her for my stratagem.

Cat Fear and Furs .—This dread of cats is sometimes exhibited to a surprising degree under rather unexpected circumstances. For instance, it is not unusual, since the fashion for the longer-haired furs came in, to find that some of these patients cannot wear certain supposedly elegant furs, since they are really dyed catskin. At times this is not suspected until other possible causes for the discomfort have been eliminated. Some women cannot even bear to be near catskins in muffs and other such furs, though the imitation may be so good as to deceive any but an expert, and they apparently had no suspicion at the beginning of the presence of cat fur near them. I have been told by a physician the story of a man, poignantly sensitive to cats, who purchased a fur-lined coat and found it quite impossible to wear it because of the sensations it produced in him, though he had no suspicion of any connection between cats and the fur when he purchased it.

Recognition of Presence .—Why this dread of cats occurs and, above all, the reason for the ability to know that a cat is near when the animal is concealed and others are not at all aware of its presence, or that its fur should produce a disagreeable sensation, is not easy to decide. Its discussion is suggestive for other forms of dreads, for there are probably like refinements of sensation, normal and abnormal, connected with them. Much has been said about this as a reversion to powers possessed by man in a savage state when there was necessity for guarding against animal attacks. Unfortunately for any such supposition as this, these people, who are most fearful of cats, that is, of the ordinary domestic animal, have no uneasiness in the presence of the huge cats in the menageries—the lions and the tigers. It is with regard to these that such a specialization of scent would be particularly valuable for men. There seems no doubt but that it is an odor or a sensation allied to an odor, though perhaps below the ordinary threshold of recognition as such, that enables these people to detect the presence of a cat. Dr. Weir Mitchell in his article on "Ailurophobia and The Power to Be Conscious of the Cat as Near While Unseen and Unheard," in the Transactions of the Association of American Physicians, 1905, discusses odor in this connections as follows:

To be influenced by an olfactory impression of which (as odor) the subject rests unconscious, may seem an hypothesis worthy of small respect and beyond power of proof. Nevertheless it seems to me reasonable. There are sounds beyond the hearing of certain persons. If they ever cause effects we do not know. There are rays of which we are not conscious as light or heat, except through the effects to which they give rise. There may be olfactory emanations distinguished by some as odors and by others felt, not as odors, but only in their influential results on nervous systems unusually and abnormally susceptible. No other explanation seems to me available, and this gains value from certain contributory facts.

We must admit that all animals and human beings emit emanations which are recognizable by many animals and are in wild creatures protectively valuable.

This delicate recognition is commonly lost in mankind, but some abnormal beings like Laura Bridgeman and a perfectly normal lad I once saw, have possessed the power of distinguishing by smell the handkerchiefs of a family after they had been washed and ironed. In this lad I made a personal test of his power to pick out by their odor from a heap of clean handkerchiefs mine and those of others, the latter two belonging to his father and mother.

I have seen a woman, well known to me, who can distinguish by mere odor the gloves worn by relatives or friends. This lady, who likes cats as pets, is able to detect by its odor the presence of a cat when I and others cannot.