Phobias: Fighting the Fear. Helen Saul

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СКАЧАТЬ 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.

      It provided a simple way of thinking about phobias. A single event causes lasting fear. A child is frightened when a big dog snarls and attempts to bite and afterwards fears and avoids all dogs, even small and friendly ones. Behavioural therapy attempts to reverse the process. By gradually reintroducing the child to dogs, the link between the snarling dog and others is broken, the child gains confidence and the fear disappears.

      However, СКАЧАТЬ