Conditioning clearly plays a big role in the development of fears and phobias. But, as with virtually all psychological problems, other factors are usually involved. For example, the cognitive perspective highlights the contribution of distinctive – and distinctly unhelpful – styles of thinking.
When researchers analysed the thoughts of people with a spider phobia, for instance, they unearthed some very pessimistic assumptions. Asked what they thought a spider might do if it was near them, the responses included: ‘bite me’, ‘crawl towards my private parts’, and ‘crawl into my clothes’. When questioned as to their own likely reaction when encountering a spider, the participants believed they would ‘feel faint’, ‘lose control of myself’, ‘scream’, or ‘become hysterical’. In other words, fearful thoughts play a crucial role in causing phobias.
People with phobias tend to overestimate the likelihood of coming to harm and underestimate their ability to cope with the situation they fear. They are also constantly on the look-out for any sign of the situation they dread. As Cervantes wrote: ‘Fear is sharp-sighted, and can see things underground, and much more in the skies.’ This threat-focused style of thinking, of course, serves only to fuel anxiety. (Incidentally, it’s difficult to reconcile these findings with the DSM’s stipulation that ‘the [phobic] person recognises that the fear is excessive or unreasonable’. On the contrary, for many individuals, their anxiety appears absolutely justified.)
The final piece in the puzzle of phobia causation comprises biological factors. Scientists believe that susceptibility to anxiety problems may be linked to an imbalance in what we might call the ‘fear system’ of the brain: the amygdala, the hippocampus, and the prefrontal cortex (see pp. 28–32 for more on this). That imbalance is partly genetic in origin.
One study of twins put phobia heritability at around 30% (to refresh your memory on the concept of heritability and the field of genetic epidemiology, see pp. 35–36). An analysis of male twins estimated heritability at 25–37%. A third experiment assessed how easily twins could be conditioned to fear a range of stimuli. Identical twins performed more similarly than fraternal twins, leading the researchers to conclude that the heritability of fear learning is around 35–45%.
Genetic make-up, then, is clearly part of the reason why some people develop phobias and others do not. Genes probably don’t play a dominant role; the heritability figures we’ve quoted suggest their contribution is moderate. But without a genetic vulnerability, we are much less likely either to learn to be afraid of something, or to see that fear develop into a full-blown phobia.
Chapter 6
Social phobia
It’s like a camera zooming in on a horrible, red, panicky face … I look really put-on-the-spot and nervous.
Picture of me looking guilty, nervous, anxious, embarrassed. It’s my face – features distorted, intensified, big nose, weak chin, big ears, red face. Slightly awkward body posture, introverted body posture, turning in on myself. Accent more pronounced. I sound stupid, not articulate or communicating well.
See the room – big room – tables all the way round in a square, people sitting behind the tables. I am sitting at a table. Everyone else is looking at me, really staring. I look petrified – can see it in my eyes, shaking, I am talking but can’t hear myself. I am leaning forward, hands in front, fiddling with my ring. The people are closer to me than they would really be.
The first of these vivid descriptions comes from a woman who fears blushing in public. Next are the words of a man who dreads being thought stupid, inarticulate, and boring. The final comment is from a woman who worries about shaking and appearing nervous in social situations.
All three individuals suffer from social phobia. They believe that they are not up to the task of social interaction; that they will fall short of the standards they and everyone else expects; and that they will pay a high price for their incompetence, being dismissed as foolish, inadequate, or unintelligent. In a stressful social situation, their thoughts automatically turn inwards. Rather than concentrating on the world around them, they focus on their own failings. Yet the images that spring up in their mind have little connection with reality; in fact, they are often wildly distorted and brutally unkind.
What is social phobia?
Social phobia – sometimes called social anxiety disorder – takes many forms. Some people find all social situations distressing. For others, the fear only kicks in when they have to perform a particular activity in front of others. Most often, that activity is public speaking, but social phobia can concern everything from dating to eating to using a public toilet.
These are the criteria for social phobia listed in the Diagnostic and Statistical Manual of Mental Disorders:
• Having a marked fear of a social situation in which the person is exposed to unfamiliar people or in which other people might judge them. The person is afraid that they will show their anxiety or do something humiliating or embarrassing.
• Almost always getting anxious in particular situations.
• Recognizing that their fears are unreasonable or exaggerated.
• Avoiding the feared situations or enduring them with distress.
• Finding it difficult to function normally because of the anxiety.
Social phobia can seem rather like shyness. The two share many features: for example, anxious thoughts about social situations; the desire to avoid those situations; and, if forced to endure them, a tendency to tremble or sweat or blush. Is social phobia simply an extreme form of shyness? Research indicates that, to some degree, this is true. When scientists compare the experiences of many highly shy and socially phobic people, they are sufficiently similar to suggest that shyness and social phobia occupy different positions on the same spectrum. On the other hand, some shy people report no fear of social situations such as parties, conversations, meetings, formal speaking, or eating in public. This implies that their form of shyness isn’t simply a milder version of social phobia. So ‘shyness’, it seems, is a fairly broad category.
Social phobia is found worldwide, but the precise forms can vary from culture to culture. Common in Japan, for example, is the disorder taijin kyofusho (TKS), which translates literally as a fear of interpersonal relations. TKS and Western social phobia are alike in many respects: for example, the belief that other people will think badly of us, the feeling that we are not up to the task of social interaction, and the desire to avoid certain social situations. But there is a major difference. Rather than fearing that they will embarrass themselves, the individual with TKS primarily dreads embarrassing or offending other people. As a result, they may worry about their appearance (their facial expression, perhaps, or a supposed deformity), body odour, or an imagined tendency to stare inappropriately at others.
How common is social phobia?
Social phobia is one of the most common anxiety disorders. The US National Comorbidity Survey (NCS), for instance, estimated that 13.3% of Americans will experience it at some point during their life. The NCS’s follow-up study, the National Comorbidity Survey Replication (NCSR), found that 6.8% of those questioned had suffered from social phobia in the previous twelve months. When the NCSR analysed the severity of those cases, the 6.8% figure broke down into roughly equal thirds for ‘serious’, ‘moderate’, and ‘mild’. But these are relative terms: even ‘mild’ cases met the criteria for a clinical disorder.
Social phobia normally begins in adolescence. A major US survey found that 9% of young people aged 13–18 had experienced problems at some point in their life, with 1.3% having been severely affected. Like anxiety disorders in general, social phobia is more common in women than men (by a ratio of approximately 3:2).
What causes social phobia?
Social phobia seems to run in families, with genes believed to exert a moderate influence. Heritability has been estimated at around 40%. However, what is inherited is probably a vulnerability to anxiety in general rather than social phobia in particular.
> Making a larger contribution are what scientists call non-shared environmental factors: that is, the experiences that are personal to each of us alone. What those environmental factors might be is mostly unclear. There is, though, some evidence to suggest that parents who are overly protective of their children, or who reject them, may contribute to the development of social phobia in their offspring. Certainly, it seems reasonable to assume that rejection could harm a child’s self-confidence, and leave them with some unhelpful assumptions about themselves and other people. In the case of overprotective parents, it’s been suggested that they may limit their children’s opportunities to develop social skills.
For some theorists, social phobia is a remnant from human prehistory. Our ancestors had two options when faced with threats from within the social group: to stand up for themselves or submit. Fighting and losing could result in marginalization – or, even worse, expulsion from the group. With so much at stake, less aggressive or domineering individuals may have found it wiser simply to accept a lower social status.
What we see in social phobia today, so the theory goes, is a damaging internalization of this once useful strategy. Acutely sensitive to social rank, these individuals regard themselves as inferior. Because they are convinced that their inadequacy will be evident to all, they dread social situations. If they can’t avoid such situations entirely, people with social phobia will try to be as meek and self-effacing as possible.
Does the theory stand up to scrutiny? While plausible for some cases of shyness and less severe social anxiety, it hasn’t been properly tested in people with social phobia. So, for now at least, it’s largely speculation.
The psychology of social phobia
When it comes to understanding the psychological processes involved in producing and maintaining the disorder, however, the picture is much clearer.
The most influential model of these processes was developed in the 1990s by the UK clinical psychologists David Clark and Adrian Wells. We’ll illustrate it using a fictional case study.
Alice is a thirty-year-old copywriter in an advertising agency. She is required to give regular presentations of her work to colleagues and clients. Alice has never enjoyed this aspect of her role, but over the last couple of years her anxiety has increased to such an intensity that she wonders whether she may have to switch careers. Sure that she is going to make a fool of herself, she can’t sleep the night before a presentation. Alice is tempted to avoid the situation entirely by phoning in sick. During the presentation itself, all she can think about is how awful she feels, and how ridiculous she must look to her audience. If anyone compliments her on the presentation, she presumes their praise is motivated by irony or, even worse, pity.
Let’s explore Alice’s social phobia using the Clark and Wells model. Although she is unaware of them, Alice has carried with her since adolescence a number of unhelpful assumptions about herself and other people. These assumptions developed after Alice had moved to a new school where she found it difficult to make friends. She desperately wants to create a good impression, but deep down – and despite all evidence to the contrary – believes she is unattractive and inarticulate.
Not only does Alice underrate her own qualities, she exaggerates those of the people she meets, presuming that they possess all the confidence and ability she feels she lacks. And she expects other people to notice – and remember – even the smallest problem in her performance. Only perfection will do.
Almost everyone experiences a degree of nervousness when giving a presentation, but Alice’s unconscious assumptions mean that the situation seems much more threatening to her than it really is. She has been worrying about the presentation for days. Now the moment has arrived, the danger of making a fool of herself seems greater than ever. Negative automatic thoughts flood her mind: ‘I can’t do this. I have to get out of here. I feel sick. Everyone knows I’m a fraud.’ Predictably, her anxiety skyrockets.
This anxiety manifests itself in three ways.
First are physiological symptoms: sweating, blushing, trembling, difficulty concentrating. Alice is quick to notice these bodily changes. Rather than accepting them as normal in stressful situations, she worries that her anxiety is spiralling out of control and that it will be evident to her audience – which only increases her anxiety.
Alice’s worry about the physical signs of anxiety, and her acute sensitivity to them, is typical of people with social phobia. In fact, researchers have found that merely telling someone that they are undergoing an intense physiological reaction – even if it is untrue – can have a profound effect on the person’s thinking. In one study, students were asked to have a conversation with a stranger. Those who were led to believe that a sensor had detected blushing, trembling, sweating, and an increase in their heart rate reported feeling more anxious, claimed to have experienced more physical signs of that anxiety, and believed that they’d made a worse impression than those who hadn’t been given such information. They behaved, in other words, like people with social phobia.
Next, and crucially, Alice finds herself imagining how she must look to her audience. She sees a babbling, trembling, incoherent wreck. Not only does the image bear no relation to reality, it’s so vivid that she doesn’t check to see how her audience is actually responding. Instead she looks inwards for an indication of how things are going.
People with social phobia are much more likely than other people to experience images in social situations, and those images are both more negative and more likely to be from an observer’s viewpoint. Research has shown that simply asking people to think of a negative rather than positive self-image leads to greater anxiety – both felt by the individual and evident to an observer. It also causes people to believe they’ve performed poorly in a social situation.
Finally, Alice adopts a number of safety behaviours – actions she believes will help her get through her ordeal (see p. 26). She overlearns her speech; quickens her presentation of it; avoids looking at her audience; and tries to think of happy times, such as her recent holiday.
But, in fact, these strategies don’t help Alice. Like all safety behaviours, they prevent her from discovering that her anxiety is excessive: when she successfully makes it through to the end of the presentation, Alice credits her safety behaviours rather than her own ability to tackle a stressful task. Moreover, these behaviours – just like the self-images and physical symptoms of anxiety – pull her attention inwards and away from the task in hand, potentially hampering her performance. And they can be noticed by her audience. For all her distraction, Alice’s ability to spot a quizzical look or wandering attention is razor-sharp. And when she does, her anxiety ratchets up yet another notch.
(Interestingly, the idea that people with social phobia are hypersensitive to criticism has been confirmed by neurological studies. When researchers ask individuals to read negative remarks about themselves, those with social phobia – but not those without – show significantly increased levels of activity in the amygdala, the brain’s ‘emotional computer’ (see p. 30), and in the medial prefrontal cortex, which plays a crucial role in thinking about the self.)
Alice’s anxiety doesn’t diminish much at the end of her presentation. Because, just like so many people with social phobia, she endlessly mulls over her performance (Clark and Wells call this a ‘postmortem’). And the more she dwells on the presentation, the worse she feels it was – and the more intensely she fears the next one.
The Clark and Wells model is often reproduced in textbooks as a sort of flow diagram. In fact, it might equally well be represented as a series of vicious circles, each of them both triggering and increasing the person’s anxiety. With therapy, the cycle of social phobia can be broken. Left untreated, it can feel like being trapped within the gears of an unrelenting and remorseless machine.
Chapter 7
Panic disorder
In 1837, just a few months after returning from his epic five-year voyage around the globe on the Be
agle, the 28-year-old Charles Darwin began to experience a number of puzzling and distressing symptoms, including palpitations, breathlessness, trembling, nausea, faintness, and sudden fear:
I have awakened in the night being slightly unwell and felt so much afraid though my reason was laughing and told me there was nothing and tried to seize hold of objects to be frightened of.
The attacks persisted until the end of Darwin’s life, 45 years later, and the scientist-adventurer rapidly became a recluse, unwilling even to leave his home unless in the company of his wife: ‘I have long found it impossible to visit anywhere; the novelty and excitement would annihilate me.’
Darwin’s doctors diagnosed a variety of illnesses, among them ‘dyspepsia with an aggravated character’, ‘catarrhal dyspepsia’, and ‘suppressed gout’. Today, discussion in clinical journals concludes that what he may actually have been suffering from was panic disorder.
What is panic?
For most of us, the word ‘panic’ describes a sudden feeling of intense anxiety. It’s what we experience when we can’t find our passport at the airport, or suspect that we’ve deleted a crucial file on our computer.
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