Phobias are truly international, crossing the boundaries of language and culture. A study within the mainly Hispanic population of Puerto Rico relied on translated questions asked in the ECA. It found 12 per cent of people had phobias at some stage in their lives, a figure on the same range as mainland North America.
Studying phobias across cultures is more difficult: they were, for instance, once thought almost non-existent in sub-Saharan Africa. More recent work suggests that phobias are as common, just less obvious than in the West. Africans are likely to develop physical complaints as a result of fear and this can mask the underlying phobia. They also fear different things. Witchcraft, sorcery and supernatural phenomena are still important among peoples such as the Yoruba in Nigeria. Within Yoruba communities, people with no psychological problems routinely believe that others (who appear harmless) may be plotting against them. They cannot talk about specific concerns for fear of the sorcerer’s retaliation. Nigerian research had to rely on drug-assisted interviews to break down some of this reluctance and found that at least 20 per cent of outpatients at psychiatric units were definitely phobic.
In the US, the ECA study estimated that between 1.5 and 12.5 per cent of the population has agoraphobia at some stage of their lives. Agoraphobia – literally, fear of the market place – usually translates to a fear of being away from home or a safe place. Using public transport, going to shopping centres or any crowded area is often out of the question. People with agoraphobia may become housebound, unable to work or have any sort of social life. Some are so anxious that they need someone with them constantly, even at home, which places a huge burden of responsibility on family and friends. The entire family set-up frequently revolves around the agoraphobia.
Agoraphobia is defined as a complex phobia because it is often interlinked with generalised anxiety and fear. Most sufferers are women. It typically starts after the late teenage years and before the mid thirties, but can linger for years, even decades. Arguably the most debilitating of all phobias, it can touch every aspect of life.
Social phobia, another complex, all-pervading fear, was found by Swedish researchers to affect between 2 and 20 per cent at any one time, depending on the precise definition. It is a fear of being scrutinised by other people and embarrassed. Social situations, any sort of public performance, even eating or drinking out, may be impossible. For some, anxiety is limited to a single situation such as being unable to write in front of others – tricky when most of us rely on credit cards – being unable to speak in public or urinate in public toilets. Well-defined social phobias like these may have an important but relatively limited impact on someone’s life. However, like agoraphobia, social phobia can often have far-reaching effects.
Social phobia is more evenly distributed between the sexes and, if anything, more men than women are affected. It often develops from childhood shyness, becoming full-blown in adolescence, just as young people are starting to establish their own social lives. Parties, eating out and shared activities are a misery for those with social phobia. Dating can be a nightmare. Solitary leisure pursuits and a career that avoids any sort of public speaking are possible, but most families and jobs demand some level of socialising. Some manage to endure situations they dread, but their social anxiety effectively quashes all enjoyment.
This phobia takes varying forms in different cultures. In Japan and Korea, people with social phobia do not worry about being embarrassed, but are more likely to be excessively afraid that they will offend others, either through body odour, blushing or eye contact.
Specific phobias, considered the least serious group of phobias, are more easily pinpointed and sufferers can say exactly what they are afraid of. Specific phobias often start in childhood and last a lifetime. They include fears of animals or insects, or of something in the natural environment such as storms, heights or water. Fear of blood, injections and injury come into this group, as do fears of specific situations such as tunnels, bridges or lifts. The same New York researchers estimated that one in ten of us has a specific phobia at some stage.
Specific phobias give flashes of extreme anxiety in set circumstances. They tend not to dominate lives as phobics may only need to avoid well-defined situations, such as lifts carrying more than six people beyond the tenth floor. But while phobias of buttons, wallpaper or cotton wool can sound trivial, bizarre or even funny, such fears can still affect career decisions or cast shadows over family life. A driver with arachnophobia could swerve dangerously if a spider appeared on his dashboard. Women with blood and injury phobias may decide not to have children because they cannot bear the thought of giving birth. Less dramatically, a fear of dogs can put a stop to picnics, and a fear of tunnels or bridges can make travelling extremely complicated.
Phobias fit into neat categories on paper, but in practice overlap and are difficult to distinguish. Someone who never goes out is probably agoraphobic, but may have social phobia if they avoid only social situations and fear being embarrassed in front of others. Someone terrified of buses or trains might have agoraphobia, but if they fear public transport and nothing else, it would be considered a specific phobia. Specific phobias exist of, say, dirty cutlery in restaurants, but someone who obsesses about dirt and has developed time-consuming cleaning rituals has an obsessive-compulsive disorder.
A single phobia such as fear of flying can have many roots and people on ‘Fly with Confidence’ courses tend to have mixed problems. Some are claustrophobic, some scared of heights; others are afraid of dying and convinced that flying is unsafe. The organisers estimate that a third of the attendees have never flown before but are terrified of the very idea. They are the easiest to treat, and some, like John, hardly need to get both feet inside the plane to feel better. Part of his fear was based on the assumption that planes are very cramped: one look was enough to disprove it. Another third have flown happily for years before having a bad experience which precipitated their phobia, either a physical event such as extreme turbulence, or a personal crisis which happened to coincide with a flight. The final third might still be flying regularly but feeling progressively worse about it. Their fear is likely to be part of a complex phobia – agoraphobia or social phobia – and they are the hardest to treat. They have seen inside planes, they know the statistics of aeroplane crashes, but no amount of information will help. Their fear is inside – they fear their own reactions, afraid of having a panic attack, terrified by the total lack of an escape route. They are sure that they will be the one running up and down the aisle, hammering at the door, screaming, ‘Don’t panic! Don’t panic!’ For these people, a quick-fix solution is unlikely to be all that is needed.
Clinical classification of phobias is important because of the seriousness of the complex phobias. Agoraphobia and social phobia routinely lead to missed opportunities in life but are also likely to be associated with other disorders. People with social phobia are more than twice as likely to have problems with alcohol as non-phobics. Agoraphobics too are at an increased risk of alcoholism. Agoraphobia is also linked with some unfortunate personality measures such as dependency, unassertiveness and a lack of self-confidence as well as anxiety and avoidant behaviour. American research suggests that one in five with panic disorder, which is often associated with agoraphobia, attempt suicide. This is more even than people with major depression and twenty times the normal rate.
The tragedy is that phobias can be helped today but usually are not. Many different effective treatments exist but people continue to suffer. Phobias do have a stigma and it can be difficult to admit to a fear which you know, rationally, is out of proportion with reality. Why someone with a fear of heights should be more afraid of ridicule than someone with a broken arm or with high blood pressure is hard to say, though mental disorders traditionally have attracted less sympathy than physical ones.
Commercial one-day courses addressing fear of flying or spiders have the advantage of being based, respectively, at an airport or a zoo. Many find it easier to turn up there rather than at the local psychiatric unit and these courses have proved acceptable to those who might never seek help elsewhere. It seems likely, though, that their greatest appeal is among those whose