Phobias: Fighting the Fear - Helen Saul

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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.

      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.

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