Fears, Phobias and Rituals: Panic, Anxiety, and Their Disorders

703 Pages·1987·85.82 MB·English

by  Isaac Marks

FEARS, PHOBIAS, AND RITUALS
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FEARS,
PHOBIAS, AND
RITUALS
Panic, Anxiety, and Their Disorders
ISAAC M. MARKS, M.D., F.R.C.Psych.
Professor of Experimental Psychopathology
Institute of Psychopathology
University of London

New York Oxford
OXFORD UNIVERSITY PRESS
1987
Oxford University Press
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Copyright © 1987 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.,
200 Madison Avenue, New York, New York 10016
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Marks, Isaac Meyer.
Fears, phobias, and rituals.
Bibliography: p. Includes index.
1. Fear. 2. Anxiety. 3. Obsessive-compulsive
neurosis. 4. Psychology, Comparative. 5. Psychiatry, Comparative.
I. Title. [DNLM: 1. Anxiety Disorders. 2. Fear. WM 172 M346f]
RC535.M373 1987 616.85'223 86-23697
ISBN 0-19-503927-0

98765432 1
Printed in the United States of America
on acid-free paper
Acknowledgments
I am deeply indebted to innumerable friends and colleagues from diverse back-
grounds with whom I have enjoyed working and talking over the years. Among
the many psychologists, psychiatrists and biologists whose insights helped to
shape this volume are David Barlow, Tom Borkovec, Edna Foa, Jeffrey Gray,
Michael Gelder, John Greist, Robert Hinde, Ray Hodgson, Tom Insel, Eric
Kandel, Malcolm Lader, Peter Lang, Andrew Mathews, Sue Mineka, Arne
Öhman, Jack Rachman, Steve Suomi, Adolf Tobeña, Tom Uhde, and George
Williams.
For their patient and penetrating comments on parts of the manuscript I
wish to thank the following (numbers of the relevant chapters are in parenthe-
ses) Maria Avia (8), Christopher Coe (1-4), Robert Creek (16), Bernard Don-
ovan (7), Edna Foa (1-4, 8-10, 13-16), John Greist (9, 10, 13), Irv Gottesman
(6), Hugh Curling (6), Robert Hinde (1-4), Tom Insel (13), Eric Kandel (7),
Herb Leiderman (1), Paul Lelliott (9, 10, 13-16), Andrew Mathews (14, 15),
Peter McGuffin (6), Sue Mineka (1-4, 8), Homa Noshirvani (9, 10, 13-16),

Jackie Persons (1-4), Cliff Preston (8), Eugene Redmond (7), Dick Rodnight
(7), Diyanath Samarasingne (9), Per-Olow Sjöden (2), Steve Suomi (1-4), Eric
Taylor (5), Lila Tsaltas (8), Adolf Tobeña (1-8), George Williams (1-4), Jeffrey
Wine (1-4) and Michael Woodruff (3). It goes without saying that any errors
are mine.
The book was begun in 1982 during a year as Fellow at the Center for
Advanced Study in the Behavioral Sciences at Stanford, made possible by a
grant from the MacArthur Foundation. This facilitated stimulating discussion
with leading scholars from varied disciplines. Most of the book was written
while working at the Institute of Psychiatry and the Bethlem-Maudsley Hos-
pital, London.
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Preface
It was once said that there are three types of psychiatrists and psychologists—
those who are brainless, those who are mindless, and those who are both. The
first were said to be typified by psychotherapists, the second by biological
determinists, and the third by those experimentalists who cling to the black
box view of behavior. Such narrowness of discipline is less true today but it is
still hard to cross boundaries, partly because the literatures are so separated.
Nowhere is the need for better integration of the behavioral sciences more evi-
dent than in the study of fear.
This book brings together widely scattered literature on normal fear and
phobic and obsessive-compulsive disorders. It supercedes Fears and Phobias
which was published in 1969. Originally a new edition was intended, but it
soon became clear that the field had been so transformed that only a new vol-
ume could meld knowledge from the many disciplines bearing on anxiety and
panic.
As a result of the strides made over almost two decades, this book is more

than twice longer than its predecessor, and even its 2000 references are but a
sip of the flood of fine new work. Advances in biology, ethology, genetics, phys-
iology, pharmacology, psychology, and psychiatry have deepened and widened
what we know about normal and abnormal fears and rituals. The behavioral
revolution has enabled formerly unrelenting phobic and obsessive-compulsive
disorders to yield to treatment and—the final sophistication in therapy—has
allowed many sufferers to help themselves. Even prevention is in sight.
Crossing interdisciplinary barriers may make it a bit easier for students,
clinicians and behavioral scientists from different backgrounds to see what
insights they might share. Dealing first with normal fear and then with the clin-
ical syndromes, this book describes the phenomena and how they may be pro-
duced and modified. It tries to synthesize naturalistic and experimental work
in animals and humans so that experimentalists, ethologists, and clinicians
might better understand one another's work. Knowledge has grown about the
many influences, from conception onward, on the development of normal and
abnormal fear, the nature of fear-related syndromes, how clinicians can alle-
viate these, and some of the mechanisms involved.
In this book "fear" denotes any response that is usually defensive or pro-
viii PREFACE
tective, along with its bodily and (in humans) subjective concomitants. The
subjective elements are a late evolutionary addition to a rich repertoire of pro-
tective behavior across phyla. In this broad sense fear includes both the defen-
sive behaviors of invertebrates and the frightened fantasies of man. This gen-
eral concept of fear contrasts with the way some researchers use the term to
indicate purely physiological or subjective components of protective responses
but not their accompanying motor behavior, such as avoidance or freezing.
Most of this book concerns fear and anxiety induced by identifiable cues.
Because they are so phobialike, taste aversions, fainting at the sight of blood,
and obsessive-compulsive syndromes are included even though they may be
accompanied by the experience of nausea or distaste rather than of fear. The
book excludes general stress and syndromes in which "free-floating" anxiety
or spontaneous panic predominate despite their partial overlap with some
forms of phobic and obsessive-compulsive disorders. Also omitted are forms
of protective behavior like grooming which are unassociated with fear. Nor
does the book deal with those types of avoidance, immobility, or attack that
are unaccompanied by fear or allied emotions. We are not frightened when we
avoid sitting on a pin, nor do we shun food, music, or painting that we dislike
or move away from boring conversation at a party. The immobility of sleep or
of intense concentration is not part of fear, nor is preattack immobility during
hunting.
A broad perspective may make obvious what is hidden from a single view-
point. Learning theorists took a long time to recognize what ethologists took
for granted from the start—that according to their phylogenetic heritage, spe-
cies diifer greatly in their defensive responses and the situations that evoke
them. The same stimulus may evoke terror in one species but be ignored by
another, and species vary widely in the ease with which they learn to fear par-
ticular classes of stimuli. Such phenomena were ignored by learning theorists
in their search for universal laws of learning, despite observations of interspe-

cies differences in learning made by Thorndike as long ago as 1898.
The evolutionary background of a species can be critical in interpreting
experimental results; for example, visual cues may rapidly induce food aver-
sion in day feeders like quail but taste cues are more effective in the nocturnal
rat. Few of the wide variety of natural fear behaviors and fear-evoking stimuli
as well as the relevant environmental contexts and internal states of the organ-
ism have been studied experimentally. All too commonly a single response,
stimulus, context and internal state are studied over a short period of time,
with inevitable loss of perspective. Experimentalists can benefit from the
insights of biologists, ethologists and clinicians working in the natural environ-
ment. Broader vision would bring faster advance.
Human beings are unique in some respects but not in others, and this has
to be borne in mind when comparing emotions in man with those in other
species. Creative links are possible if we remain aware of our evolutionary her-
itage of brain and learning mechanisms as well as sociocultural capacities. We
should not only compare closely allied species but also remember that behav-
ior can converge across different taxa in the face of common pressures and
PREFACE ix
dangers. Similarly, there are important continuities and discontinuities
between normal and clinical phenomena.
Resistance to studying the evolutionary background of human behavior
carries a penalty, as Gould (1982) pointed out:
The myth of ourselves as completely separate creations, divorced from our biolog-
ical inheritance, has created an egotistical blindness to analogies which open the
way to new and important discoveries about how we live and learn.... We cannot
know where, during the course of evolution, our increasing mental capacities
spawned the will that now battles with our genes for control of our behavior ...
[but] our genes still have a powerful hand in our affairs; ... we should be treating
ourselves as one of many interesting species. ... The conviction that humans are
infinitely plastic in all things at all times... is especially debilitating and open to
ethological revision.... We must learn more about the behavioral programs spec-
ified in ourselves in order to circumvent those that, in our present social environ-
ment, predispose us to inhumane actions (Gould 1982 pp. 541).
And, I would add, to unwarranted fears.
Recent progress has strengthened links among such diverse behavioral sci-
ences as genetics; biology; neuro- and psychophysiology; neurochemistry; psy-
chopharmacology; ethology; developmental, experimental, and clinical psy-
chology; psychiatry; and sociology. These links help us understand
mechanisms behind normal fear and anxiety disorders. Clinical phobias have
a nonrandom distribution that suggests our phylogenetic predisposition to fear
special evolutionary dangers. Examples are infants' fear of strangers rooted in
infanticide from the outgroup, toddlers' fears of heights and animals stemming
from dangers faced by the young as they become mobile, and agoraphobia,
which involves hazards met in venturing outside one's territory.
Other connections soften the distinction between "innate" and "learned"
behavior. Many innate releasers of fear and "fixed" fear action patterns noted
by early ethologists have been shown by psychologists to be modifiable by

experience. Behavior with a genetic base thus need not be immutable in the
way that was once thought. Conversely, not all effects of experience are revers-
ible; early visual deprivation can lead to lasting structural changes in the opti-
cal system of kittens.
Interdisciplinary insights can thus connect apparently unrelated events.
The tendency for sensitization to be associated with intermittent stimulation,
and tolerance or habituation with continuous stimulation, is a widespread phe-
nomenon seen in the acquisition and extinction not only of fear and rituals but
also of epilepsy, drug addiction, and allergies. Understanding the influence of
neuropeptides on fear may help us explain some mysteries about the onset and
fluctuation of clinical phobias and rituals. Treatment research into these prob-
lems using antidepressant drugs and behavioral methods suggests better ways
to classify those disorders and hints at biochemical substrates that may be
involved. Knowing that withdrawal from noxious stimulation, habituation to
repeated stimulation, and simple learning are all already present in unicellular
protozoa has led to a search for similar cellular mechanisms across phyla that
mediate withdrawal from danger. Cell biology is linking up with psychology