The Book of Phobias and Manias: A History of Obsession

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ABLUTOPHOBIA

A fear of washing – or ablutophobia, from the Latin abluere, to wash, and the Greek phobia, or fear – especially affects children. It is often a temporary terror, experienced in infancy, though in some cases it can last for years. A seventeen-year-old girl once told the American psychologist Granville Stanley Hall that until the age of eleven she used to scream in horror if bathed. Another teenager informed him: ‘To be washed always made me stiffen out, my eyes bulge, and I was almost convulsed with fear.’

The fear of washing was common in France in the early nineteenth century, when many believed that dirt was a shield against disease and the stink of sweat was proof of health and sexual vigour. As the historian Steven Zdatny explains, thorough washing was in any case difficult in a society that considered nudity shameful. A woman in a rural French hospital was outraged by the suggestion that she take a bath. ‘I am sixty-eight,’ she said indignantly, ‘and never have I washed there!’ The upper classes were similarly fastidious. ‘No one in my family ever took a bath!’ recalled the comtesse de Pange. ‘The idea of plunging into water up to our necks seemed pagan.’ In the second half of the century, as scientists established a link between dirt and the spread of disease, teachers tried to teach modern hygiene practices to children who had never used a sponge or immersed themselves in water. The French army, too, tried to instil cleaner habits in its recruits, and in 1902 published a Manuel d’hygiène that instructed soldiers to brush their teeth, scrub their bodies and wear underclothes. In Douai, northern France, a military commander ordered his men to forcibly clean a young artilleryman who claimed to be afraid of bathing. The soldiers dragged their dirty comrade into the bathhouse and held him under a shower. According to Zdatny, the artilleryman’s death eight days later was attributed to his shock and horror at the sensation of water on his skin. His fear, it seemed, had killed him.

See also: aquaphobia, hydrophobia, mysophobia, thalassophobia

ABOULOMANIA

In 1916 the American psychoanalyst Ralph W. Reed treated a pathologically indecisive bank clerk of twenty-two who was ‘continually doubting the validity or correctness of anything he has done in the course of his daily duties’. Each time he added up a column of figures, the clerk felt compelled to check it, and then check it again. He made the same agonised return to every calculation, however trivial. Reed noted that this kind of mental paralysis often coincided with paranoid delusions: both were disabling doubts about what had happened or what might take place. He diagnosed the clerk with aboulomania.

The term aboulomania – from the Greek a (without), boulē (will) and mania (madness) – was coined by the neurologist William Alexander Hammond in 1883. Aboulomania, explained Hammond, was ‘a form of insanity characterised by an inertness, torpor, or paralysis of the will’. He described one patient, a Massachusetts man, who was seized by indecision when dressing or undressing himself. As soon as he started to take off one shoe, he would wonder whether he should take the other off first. He would switch helplessly between the shoes for several minutes, before deciding to walk around the room to deliberate on the matter. Then he might catch sight of himself in the mirror, and, noticing his necktie, think, ‘Ah, of course that is the thing to take off first.’ But when he tried to remove the tie, he would again hesitate and become powerless. ‘And so it went on, if he was left to himself,’ wrote Hammond, ‘till it has frequently happened that daylight would find him still with every stitch of clothing on his body.’

In 1921 the French psychiatrist Pierre Janet described the feeling of ‘incompleteness’ that affected such individuals, rendering them continually unsatisfied, as if something was missing. They ‘watch themselves’, he wrote, ‘and by dint of observations, through anxiety about themselves, they fall into a sort of perpetual auto-analysis. They become psychologists; which is in its way a disease of the mind.’ Aboulomania is an obsession that springs from self-consciousness, Janet suggested, a disorder made possible by our tendency to reflect on our own thoughts.

It seems odd to categorise a state of chronic uncertainty as a compulsion: an inability to make choices looks more like a fear of error than a passion for indecision. But by identifying pathological doubt as a mania, Hammond reminded us that it is not just an absence of conviction. Rather, it is a powerful emotional state, a turbulent and painful condition in which all possibilities are still available; several futures are jostling and nothing has been closed off.

See also: arithmomania, mysophobia, syllogomania

ACAROPHOBIA

Acarophobia (from the Greek akari, or mite) is an extreme fear of tiny insects, first identified by the French dermatologist Georges Thibierge in 1894, which can develop into a belief that minuscule creatures have invaded the body. The itchy feeling of ‘formication’ may be caused by the imagination alone, or by a physical condition such as shingles, tuberculosis, syphilis, skin cancer, the menopause or malnutrition. It can also be provoked by substances such as pesticides, methamphetamine and cocaine.

Since itchiness is very suggestible, acarophobic delusions are sometimes transmitted from person to person. The public health officer William G. Waldron investigated several reports of biting insects in Los Angeles workplaces in the 1960s. At a flight-booking centre that he visited, all the female employees were experiencing a tingling sensation and a slight ‘pulling’ on their nylon stockings, just above the ankle. Waldron could find no insects on the premises, but he speculated that the women might be picking up a static electric charge from an uncovered telephone cable beneath their desks. He noticed that morale among the 150 employees was low. Perhaps, he thought, the oppressive working conditions were contributing to their prickly unease – the workers sat at their desks for hours on end, making complex telephone bookings, while three bosses watched them constantly from a darkened booth at one end of the room. Waldron recommended that the airline company cover the phone cable and turn on the light in the supervision booth. After this, the women told him, the itching stopped.

In attempts to dislodge insects, some acarophobes gouge out the flesh of their faces, necks or arms, scalps, chests, armpits or groins. ‘I found him stripped to the waist,’ wrote Luis Buñuel after visiting the artist Salvador Dalí in a Parisian hotel in the 1920s, ‘an enormous bandage on his back. Apparently he thought he’d felt a flea or some other strange beast and had attacked his back with a razor blade. Bleeding profusely, he got the hotel manager to call a doctor, only to discover that the flea was in reality a pimple.’ Buñuel’s film Un Chien Andalou, on which Dalí collaborated in 1928, opens with a razor blade slicing into an eyeball, releasing a swell of jelly, and goes on to show a swarm of ants teeming from a man’s palm, the flesh erupting with alien life.

See also: arachnophobia, dermatillomania, entomophobia, zoophobia

ACROPHOBIA

Andrea Verga, the Italian physician who invented the term acrophobia in 1887, himself suffered from a morbid fear of heights. An acrophobe, he explained, ‘has palpitations on mounting a step-ladder, finds it unpleasant to ride on the top of a coach or to look out of even a first-storey window’. Verga derived his term from the Greek acron, meaning peak, and described its chief symptom as the dizzy, spinning sensation known as vertigo.

Almost 20 per cent of us have a fear of heights, and for about 5 per cent of us it is a terror. The condition is sometimes attributed to traumatic experience – the detective in Alfred Hitchcock’s Vertigo (1958) develops a horror of heights after seeing a fellow policeman fall to his death – but only about one in seven acrophobes can recall an incident of this kind. In fact, in 2002 a study of eleven- and eighteen-year-olds with acrophobia found that both groups had unusually little experience of heights. If anything, it seemed that their phobia had been caused or exacerbated by a lack of familiarity with high places.

In 1897, Granville Stanley Hall analysed eighty-three accounts of acrophobia and other ‘gravity-related’ fears, from which he deduced that the phobia was rooted in a primordial anxiety, an ‘instinct-feeling’ that was ‘incalculably more ancient than the intellect’. Many of Hall’s subjects said that when they found themselves in high places they experienced a ‘sudden giddiness, nausea, tremor, gasping, or sense of smothering’. In response, they ‘grew rigid, livid, clenched their hands and teeth’. But, oddly, he noticed that many acrophobes seemed to fear not an accidental fall but their own ‘jumping-off instinct’. ‘Very common is the impulse,’ he wrote, ‘usually very sudden, to hurl oneself down from towers, windows, roofs, bridges, high galleries in church or theatre, precipices, etc.’ Some acrophobes clung to railings or bystanders in order to stop themselves from plunging over a precipice and ‘ending it all’. One man admitted that he was tempted by ‘the exquisite pleasure of dropping’. Others were drawn to the ‘beautiful sensation’ of leaping into the air, wrote Hall, imagining that they might be ‘upborne by their clothes, a parasol, flapping hands or arms like wings’.

Hall suggested that to be afraid of heights was to be afraid not only of a deathly plunge but also of one’s own primitive impulses, which might include a longing to jump or to fly. ‘What man really most fears is himself,’ he wrote, ‘because his inner primal nature is that which he knows least and which might seize and control most completely his body and soul.’ Hall, who was fascinated by both Charles Darwin and Sigmund Freud, was edging towards a new understanding of phobias, in which fear was forged not only by the adaptations of evolution, but also by conflicts in an individual’s psyche. The whirl of vertigo could seem like the giddiness of yearning.

‘What is vertigo?’ asks the novelist Milan Kundera in The Book of Laughter and Forgetting (1980). ‘Fear of falling? No. Vertigo is something other than fear of falling. It is the voice of the emptiness below us which tempts and lures us, it is the desire to fall, against which, terrified, we defend ourselves.’

Some psychologists believe that acrophobia affects individuals who overattend to and dramatically misinterpret their bodily sensations. In exposure treatments, acrophobes are encouraged to climb to a height and wait until their terror recedes – at first, their hearts race, adrenaline courses through them, their breathing quickens; but after ten to fifteen minutes, the heart rate will usually subside, adrenaline levels will drop, and breathing will slow. By waiting for the symptoms of fear to pass, they can learn to associate heights with normal feelings.

In 2018 a hundred acrophobes were recruited by Oxford University for a randomised experiment. After they had filled out a questionnaire to measure their fear of heights, half were assigned to receive immersive virtual-reality therapy and half to a control group. At six thirty-minute sessions, over about two weeks, the virtual-reality group wore headsets that enabled them to undertake different activities while they navigated ascending floors of a simulated ten-storey office block. They might rescue a cat from a tree on one floor, play a xylophone near the edge of the next floor, throw balls out of the window on another. In this way, they acquired memories of being secure while high up.

When they answered a questionnaire at the end of the trial, the virtual-reality group reported a reduction in acrophobic symptoms of almost 70 per cent, while the control group’s fear had reduced by less than 4 per cent. When they filled out the questionnaire again two weeks later, more than two-thirds of the people in the virtual-reality group fell below the trial’s fear-of-heights entry criteria: they were no longer acrophobic. ‘The treatment effects produced,’ concluded the study’s authors, ‘were at least as good as – and most likely better – than the best psychological intervention delivered face-to-face with a therapist.’

See also: aerophobia, agoraphobia

AEROPHOBIA

Aerophobia (from the Greek aer, or air) originally described a terror of breezes that was common in rabies victims; but it is now often used to describe a fear of flying. Many of us experience this fear, and for an estimated 2.5 per cent of the population it is a phobia. The Boeing corporation estimated in 1982 that the US airline industry would be making an extra $1.6 billion a year if everyone conquered their fear of flying, and in 2002, the year after the 9/11 terrorist attacks, aerophobia had a tangible effect on mortality rates, too: so many Americans chose to travel by car rather than plane that an extra 1,595 people died in road accidents.

The risks of air travel are very low. A study by Harvard University in 2006 found that the odds of an individual dying in a plane crash were 1 in 11 million – compared to a 1 in 5,000 chance of dying in a road accident. But recent psychological research has shown that we notice rare events more than we do common ones. And Aaron T. Beck, who pioneered cognitive behavioural therapy in the 1970s, pointed out that anxiety is based not only on the chances of a feared event taking place, but also on our perception of how devastating and inescapable the event would be. Those of us with a fear of flying aren’t alarmed by the probability that our plane will crash, after all: what terrifies us is the barely imaginable horror that we would undergo if it were to do so.

A character in Julian Barnes’s novel Staring at the Sun (1986) articulates the tormenting thoughts that air travel can inspire. A plane crash, thinks Gregory, would be the worst way to die. Strapped into your seat on a plummeting aircraft, amid the screaming of the other passengers, you would know that your death was imminent, and that it would be both violent and tawdry. ‘You died with a headrest and an antimacassar,’ reflects Gregory. ‘You died with a little plastic fold-down table whose surface bore a circular indentation so that your coffee cup would be held safely. You died with overhead luggage racks and little plastic blinds to pull down over the mean windows.’ As the plane hit the earth, smashing these tinny tokens of civilisation, your life would be rendered meaningless. ‘You died domestically,’ thinks Gregory, ‘yet not in your own home, in someone else’s, someone whom you never met before and who had invited a load of strangers round. How, in such circumstances, could you see your own extinction as something tragic, or even important, or even relevant? It would be a death which mocked you.’

Aerophobes hate the surrender of personal agency that flight entails. Some fear that the pilot will lose control of a malfunctioning aircraft, while others fear that they will experience a panic attack in which they themselves lose control. The phobia can be fuelled by the memory of an alarming flight, by news stories about crashes and hijackings, by disaster movies. Some aerophobes are physiologically vulnerable to the effects of air travel. They may, for instance, suffer from a dysfunction of the inner ear that leads to vertigo or to spatial disorientation during a flight; or from an undetected hypoxia (a lack of oxygen) that creates panicky feelings. Among those aerophobes who do fly, a fifth say that they use alcohol or sedatives to blunt their anxiety.

As a condition with behavioural, physiological and cognitive components, aerophobia is often treated with cognitive behavioural therapy (CBT). Typically, the phobic individual is encouraged to analyse the distortions in his or her automatic thoughts about flight – for instance a tendency to catastrophise (a process of negative overgeneralisation) or to polarise (all-or-nothing thinking) or to attend too much to distressing perceptions and internal sensations. The therapist provides information about air travel: how a plane works, the causes of turbulence, the chances of a crash, and so on. The patient then draws up a hierarchy of flight-related fears, from packing a suitcase to takeoff to landing, and is taught to use relaxation techniques while imagining each stressful situation in turn. The treatment often culminates with the aerophobe taking a flight, real or simulated.

Some aerophobes feel a superstitious attachment to their phobia, in case it is their fear that has so far protected them from disaster. As the plane takes off at the beginning of Erica Jong’s novel Fear of Flying (1973), Isadora Wing’s fingers and toes and nipples turn to ice, her stomach leaps, her heart screams in concert with the aircraft’s engines. She maintains a fierce focus while the plane climbs. ‘I happen to know that only my own concentration  . . . keeps this bird aloft,’ she explains. ‘I congratulate myself on every successful takeoff, but not too enthusiastically because it’s also part of my personal religion that the minute you grow overconfident and really relax about the flight, the plane crashes instantly.’ By the end of the book, Wing has achieved liberation – creative, sexual, emotional – and she has shed her delusion that only her anxiety keeps a plane in the air.

See also: acrophobia, agoraphobia, claustrophobia, emetophobia, siderodromophobia

AGORAPHOBIA

The word agoraphobia was coined in 1871 by Carl Otto Westphal, a Berlin psychiatrist who found himself treating several men with a terror of traversing the city. One patient, a thirty-two-year-old travelling salesman, had a dread of certain neighbourhoods, especially if the streets were deserted and the shops shut. At the edge of the city, where the houses ran out, his nerve would fail him entirely. He was disturbed by busy spaces, too, and experienced palpitations when boarding an omnibus or entering a theatre.

Another patient, an engineer aged twenty-six, said that when he encountered an open space he felt as if something grabbed his heart. ‘He becomes red and hot in the face,’ wrote Westphal; ‘his fear becomes more intense and can become a real fear of death, there is a feeling of insecurity in him, as he can no longer walk with certainty, and it also seems to him that the cobblestones are melting into each other.’ The engineer compared his fear of crossing a city square to the feeling of swimming out of a narrow channel into a lake. He lost his bearings, and if he succeeded in reaching the other side would barely be able to remember having done so: the crossing was hazy, like a dream.

Westphal’s patients told him that they were less frightened if they had a companion on their walks through town, or could keep close to the buildings in a square, or follow a carriage through the streets. One felt consoled by the sight of the red lanterns outside the taverns on his route home. Using a cane could relieve anxiety a little, as could the consumption of beer or wine. Westphal heard of a priest in the town of Driburg who would cover himself with an umbrella when he stepped outside, as if to carry with him the vaulted roof of his church.

Agoraphobia – from the Greek agora, or marketplace – is a wide-ranging term that can mean fear of social contact, of leaving one’s home, of crowded spaces or empty spaces, even a fear of being afraid. As David Trotter explains in The Uses of Phobia, the condition was associated from the start with the stresses of modern life. In 1889 the Viennese architect Camillo Sitte ascribed agoraphobia to the rapid changes in the cities of Europe, where winding alleys and wonky buildings were being razed to make way for wide boulevards and blank monumental blocks. A city square could seem an abyss; an avenue a chasm.

The psychiatrist Henri Legrand du Saulle was consulted by Parisians whose ‘peur des espaces’ made them hesitate at a boundary, whether the edge of a city square, the kerb of a pavement, the ledge of a window or the rise of a bridge. His patient ‘Madame B’ could not cross a boulevard or square alone. She was scared of empty restaurants and of climbing the wide staircase to her apartment. Once indoors, she was unable to look out of the window. Another of Legrand du Saulle’s patients was an infantry officer who could cross open spaces when wearing a uniform but not in civilian clothes. ‘Here,’ writes Trotter, ‘it is not companionship but performance that saves an agoraphobe from his anxiety. Putting on a show, one accompanies oneself across the empty space.’ A third patient, who had to be escorted everywhere by his wife, would stop at the entrance to a square, frozen with fear, and mutter to himself: ‘Mama, Rata, bibi, bitaquo, I’m going to die.’

Legrand du Saulle argued that spatial phobias had multiplied in Paris after the German siege of the city in 1871. ‘In Legrand’s terms,’ writes the architectural historian Anthony Vidler, ‘the successive closing and sudden opening of the city, its passage so to speak from claustrophobia to agoraphobia, had the effect of fostering the veritable cause of spatial fear.’

In the years after Westphal and Legrand du Saulle published their findings, other agoraphobes came forward to detail their symptoms. ‘I stop,’ wrote Dr J. Headley Neale in The Lancet in 1898; ‘the earth seems seized in an iron grip. I feel as though I were going down into the earth and the earth were coming up to meet me. There is no semblance of giddiness or faintness in these attacks, it is more a feeling of collapse as though one were being shut up like a crush hat or a Chinese lantern.’ Some argued that the condition was a sign of hereditary degeneracy, but Sigmund Freud disagreed: ‘The more frequent cause of agoraphobia as well as of most other phobias lies not in heredity,’ he wrote in 1892, ‘but in abnormalities of sexual life.’ Freud proposed that agoraphobes, fearing that they might succumb to the sexual temptations of the street, converted their dread into a fear of the street itself. ‘The phobia,’ he said, ‘is thrown before the anxiety like a fortress on the frontier.’

Agoraphobia can manifest as a terror of open country and wide skies. David Trotter describes how the novelist Ford Madox Ford kept panic at bay while walking in the fields of southern England by sucking on lozenges and choosing paths that were punctuated by benches. Like Westphal’s city dwellers, he tackled his horror of vacancy by focusing on small, particular objects and actions. When his friend