Around phobias

An excursion which was kicked off by a table about phobias in the context of a discussion about the place of snakes in our world, in the context of the book about venom noticed at reference 1.

From there I was pointed to reference 2, of which I failed to turn up a free copy. I failed to turn up much in the way of statistics about the incidence of phobias in populations at large and I failed to get to grips with the large WHO website. So I let the matter rest.

But then I was sent, seemingly quite by chance, a copy of the paper at reference 3 about blood, injury, and needle fears and phobias. So I thought I would give it a go. 

After noting various problems with previous work, the authors explains that they wanted to investigate the route by which medical/blood/injury/injection phobias came to be, starting with a sample of around 1,000 US students. Were any phobias they found among them the result of conditioning by bad experience, by vicarious observation or by verbal information?

They started with a pool of 933 subjects and screened that down to 247 for interview. The results for the 128 fearful students made up the body of the paper. Screening included a number of questionnaires, one of them the Mutilation Questionnaire (MQ). I wanted to know what this questionnaire looked like and how it worked, but despite extensive digging failed to turn one up, although I did turn up a self-help chap, one Dr. Karl Albrecht, who tells me that the fear of mutilation is one of five basic fears: ‘… the fear of losing any part of our precious bodily structure; the thought of having our body's boundaries invaded, or of losing the integrity of any organ, body part, or natural function. Anxiety about animals, such as bugs, spiders, snakes, and other creepy things arises from fear of mutilation’. Which seems to cast a rather wider net than is needed here.

I had more luck with comparable questionnaires about snakes (SNAQ) and spiders (SPQ), both of which are the objects of common phobias and eventually, found my way to reference 4, which actually appended a copy of a short versions of both.

It seems that a common format for these screening questionnaires is a list of questions which require a yes-no answer, the subjects being told to choose the one of the two which is the nearest for them. By way of example, one of the spider questions was: ‘I would not go down to the basement to get something if I thought there might be spiders down there’. To which one might think that it all depended, but the idea is choose the best fit from yes-no, preferably without thinking too much about it. A simple scoring algorithm would then be to count the number of yes answers and to screen by setting a threshold. Those above the threshold have a problem with spiders.

And I found lots of work that has been done on statistical aspects of this approach, used in all kinds of health screening questionnaires. Including, for example, something called item response theory. Also including reference 5 which deals with ordinal dominance graphs and receiver operating characteristic graphs – these last originating many years ago in the world of signal processing – more precisely among radar engineers at the beginning of the second world war. Was that bleep a battleship or a bumboat? Or nothing at all?

I found the ordinal dominance graphs a rather attractive business, an attractive approach to the analysis of linked pairs of random variables. 

In terms of the definition above, such a graph is a trace as the variable c runs from minus infinity to plus infinity from bottom left of the unit square (0, 0) to top right (1, 1). But a trace which is constrained to increase; no dipping is allowed. So in the snap above, not the trace sketched bottom right. While that in the middle of the top row says that for every value of c, P(X ≤ c) = P(Y ≤ c). Which does not assert the equality of X and Y, but it is, nevertheless, quite a strong condition; for many purposes they can be thought of as equal.

The paper goes on to discuss the relationship between continuous distributions and finitely discrete distributions and then to discuss the significance of various common shapes and forms. And then the significance of the area above the curve – equal to the probability that Y > X – and the link to receiver operating characteristic graphs, widely used in this sort of statistics. Perhaps the people in what was then called the Government Social Survey and with whom I once had occasional dealings knew all about them – I certainly did not.

I then moved back to reference 3 and it slowly dawned on me that the point of these questionnaires was that, given that most people with phobias don’t declare them to the medical authorities and even fewer get treated – this despite treatment being reasonably effective, we don’t have much idea how prevalent they are and some sort of screening questionnaire which could be widely deployed would be useful.

I then went back to reference 4 where, as mentioned above, I got a copy of a short version of the snake questionnaire, short and easy enough to be included in a battery of same to be used in screening a good size population.

I might say that while questions of this sort might work, in the surveys I do for YouGov, which include a lot of them, I find them rather irritating, even though I sort of understand that they might work. If I am asked a question which interests me, some large part of me wants to answer properly, for the person asking to pay attention to what I think about the matter in question. For me not to be reduced to some straw in the wind, one straw among thousands of others. While if am asked a question which does not interest me, for example to rate my view of some financial services brand I have barely heard of on a five-point Likert scale, I will click through if that is allowed. And if too much of it is forced on me, I will just abandon ship. I perhaps ought to add, that snake phobia questionnaires do interest me – they are among the questions that I do want to answer properly.

From there, back to the matter of prevalence, where I am not sure I am going to do better than the table that I started with back at reference 1. But I do learn from reference 7 that blood, injection and injury apart, the incidence of phobias is about twice as high in women as in men.

While the snap above is taken from a survey, taken just after reunification, of young women in Dresden, reported at reference 6, suggesting a lifetime prevalence of phobias of more than 10%. A result drawn from the 2,000 odd respondents of an initial sample of more than 5,000 – and one might suppose that people with some kind of mental disorder were more likely to respond than those without. There will be interest and motivation. Nor do I yet understand the ‘N’ figures at the top of the table.

The point being that in the population at large, phobias are a significant cause of distress, significant enough to be worth bothering a bit more about. And in the case of medically flavoured phobias, significant more for the things they make one avoid than in themselves.

It was also good to be reminded that fancy statistics are usually about real problems, in this case finding out how many people have this or that phobia. A connection with the real world which was missing from my undergraduate forays into statistics and a gap which not subsequently filled by my stint as a government statistician, in a part of government where statistics was more like accounting than the sort of statistics you might do, for example, in an agricultural research station.

Classification

Looking at tables like that snapped above from Dresden took me onto the question of catalogue and classification, to the world of DSM and ICD, with our own NHS chipping in with reference 9. With DSM being the US version of the mental disorders part of ICD, the International Classification of Diseases, which comes from WHO. And with my effort at catalogue snapped above serving to remind me how difficult it is to arrive at something nice and tidy – and agreed by all. And then there is reference 10, which includes a very long list of phobias.

The serious classifiers at DSM and ICD prefer a short list, this perhaps reflecting both the significance of phobias in the health world at large and the fact the treatment for many of the specific phobias is much the same. It does not make all that much difference to treatment whether someone is terrified by cocker spaniels or dachshunds – although, of course, it makes a big difference to the person concerned. 

The medical and mental part of ICD 11 (CDDR) is covered at reference 7, while the statistical part (MMS) is covered at reference 8, this last seemingly only in browser form just presently.

With the relevant summary page from CDDR being snapped above. Phobias get just three sub-headings among other anxiety and fear-related disorders, with a fairly widely cast agoraphobia being separated out from the rest. With the snakes and spiders being among the specific phobias and fear of public speaking and blushing being among the social anxiety disorders.

What we do not have, as we have in systematics, noticed recently at reference 11, is the gold standard of the tree of life from which to derive a classification. Diseases and disorders are not like that and it is not clear to me that there can be one guiding principles of a classification of disorders. In ICD-11 there is talk of two sorts of organisation, one based on organ systems, say hearts and livers, another based on mechanisms, say cancers or bacterial infections. There is, inevitably, some tension between them, and ICD-11 tries to effect a reasonable compromise, with the second parent system allowing a certain amount of cross referencing between different ways of doing things. I suppose the good news is that we do not need as many diseases and disorders as there are species; in that sense at least the problem is a lot smaller.  

Notwithstanding which, my impression is that ICD-11 is work in progress: it is how things look today, which is not the same as they looked 30 years ago and will not be the same as they will look in 30 years time. Furthermore, maybe they are trying to extract too much out of a system of classification, maybe it has all got too big and complicated – as evidenced by the snap above. No doubt time will tell.

Fear

All this has prompted to think a little about my own fear of injections.

First, the physiological reaction, including fainting, came first. The fear of injections came later.

Second, it is not fear, not conscious fear at least, of what I might call primary matters – say fear of dirty needles, fear of contaminated products or fear of some adverse reaction in the days or weeks to come. Rather more secondary matters – say fear of going into shock, of fainting or of looking a bit feeble. The knowledge that some injections could be painful, for example the BCG injections against the once very common – and often fatal – tuberculosis that were routine when I was young. The knowledge that reactions such as going into shock or fainting might actually be dangerous came later.

BCG for bacillus Calmette-Guerin, which I do not think I ever knew before – although, digressing, unwise to be too sure about such a thing: if the memory has really gone, there will not be any traces left for reinforcement to stir up. From where I associate to all the many copies of computer files which you think you have deleted which are left lying around, quite possibly more or less for ever. Just invisible to casual inspection. The sort of thing that catches you out when you have your laptop checked over by the sort of IT specialists employed by the police.

Perhaps the object of the fear, of the phobia, has the same sort of complicated standing in psychology as the object of consciousness.

The physiological reaction nearly always comes after the event, perhaps in a few seconds, in one case as long as fifteen minutes or so. The exception that I can think of being that I sometimes get a bit queasy if there is close visibility of injections on television, something which I believe audiences in the US are keener on than audiences in the UK.

And generally speaking, I am not bothered by medical matters in general or by the sight of my own blood, at least not in the modest quantities one is apt to encounter on a day-to-day basis. Not bothered by being in an operating theatre, at least not so far, but I think I would be bothered by watching an operation in one. And I am not very keen on watching or listening my own insides. Not that keen on feeling my own pulse. From where I associate to a carpenter whom I once knew who took all that sort of thing in this stride – to the extent of nipping out to his car to get the right spanner for a bolt which the surgeon wanted to take out of his arm – but for which he had mislaid the spanner appropriate. At least, that was his story.

The Freudian angle

Moving on again, I have learned something about how you find out how much phobia there is out there and how you might record your results. I have not learned anything about how phobias are treated, beyond various hints that treatment is often successful. But I have been reminded that the Freudians and the psycho-analysts started out with phobias, with reference 12 being a report of one of Freud’s early cases. Otherwise, Little Hans and the horse phobia: a famous and controversial case with lots of commentary available on the Internet, for example the snap which opens this post - with the good news being that Little Hans, despite all this attention, went on to become a successful opera producer. While reference 13 is one of Freud’s even earlier papers.

Of present interest because the Freudians try to dig up and unpick whatever were the underlying causes of the phobia, rather than just squashing the phobia itself with therapy or pharmaceuticals, that is to say pills. One might argue about the merits of their approach – but not so easy to argue about the cost: Freudian interventions are very expensive in time and pills are cheap.

Other matters

I have been reminded in writing this post, that after the event, in this case an excursion into the world of phobias, one sometimes makes a coherent and plausible narrative, which does not bear much relation to what actually went on, which was much more chaotic. I associate to the business of writing down dreams, even quite shortly after waking, when it is all too easy to cook up a narrative which was not really there.

Conclusions

Another interesting excursion, with all kinds of interesting oddments being turned up along the way. And I do know a little more about both phobias and questionnaires than I did.

References

Reference 1: https://psmv5.blogspot.com/2024/05/venomous.html.

Reference 2: Specific fears and phobias in the general population: Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) – Marja F. I. A. Depla, Margreet L. ten Have, Anton J. L. M. van Balkom, Ron de Graaf – 2008.

Reference 3: Acquisition of Blood, Injury, and Needle Fears and Phobias – Ronald A. Kleinknech – 1993.

Reference 4: Short Versions of Two Specific Phobia Measures: The Snake and the Spider Questionnaires – Andras N. Zsido, Nikolett Arato, Orsolya Inhof, Jozsef Janszky, Gergely Darnai – 2017.

Reference 5: The area above the ordinal dominance graph and the area below the receiver operating characteristic graph – Bamber DC. – 1975.

Reference 6: Epidemiology of specific phobia subtypes: Findings from the Dresden Mental Health Study – Eni S. Becker, Mike Rinck, Veneta Türke, Petra Kause, Renee Goodwin, Simon Neumer, Jürgen Margraf – 2007.

Reference 7: Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders (CDDR) - WHO – 2024.

Reference 8: ICD-11 for Mortality and Morbidity Statistics (MMS) – WHO – 2023. 

Reference 9: https://classbrowser.nhs.uk/ICD-10-5TH-Edition/vol1/block-f40-f48.htm. 

Reference 10: https://www.verywellmind.com/list-of-phobias-2795453. 

Reference 11: https://psmv5.blogspot.com/2024/05/outgroups.html. 

Reference 12: Analysis of a phobia in a five year old boy – S Freud – 1909. 

Reference 13: Obsessions and phobias: Their psychical mechanism and their aetiology – S Freud – 1895.

Reference 14: Little Hans: The dramaturgy of phobia: On Freud's couch – Johan Norman – 1998/2020. One source of the opening snap. Provenance of the text uncertain.