2 The Genealogy of Social Phobia If something can be said to exist formally and definitively only when it acquires an official name, social phobia came into the world fully formed with the publication of the DSM-III in 1980. The notion designated by the name, however, is much older; the fearful self-protective pattern itself is likely as old as humanity. The dual purposes of this chapter are to trace the intellectual history of the term, and to establish whether and how it has evolved. In carrying out this overview I shall rely mostly on the invaluable historical survey of Pelissolo & Le ´ pine (1995) concerning social phobia as such as well as the broader overviews of the conceptual history of anxiety disorders by Berrios (1999) and Glas (1996). Before embarking on the historical survey, it is well to consider what perspective regarding the nature of social phobia would serve our pur- pose best. In principle, on a continuum of the nature of psychopathology, two seemingly contradictory positions face off. On the one hand, social phobia might be envisaged as a distinct entity occurring in nature and obtaining universally that went unrecognized until discovered. On the other hand, social phobia could be taken for a linguistic construction denoting several ambiguous phenomena (lending themselves to numer- ous readings) lumped together. This construction is a cultural product of various social forces embedded in a particular way of life. On that view, as the factors sustaining its use fluctuate, social phobia might fall into disuse, could be replaced (e.g. ‘‘social anxiety disorder’’) so as to better serve the purposes of those who advocate the change, or find its meaning transformed with reversals in circumstances. These two À admittedly extreme À perspectives would likely give rise to quite different histories. I shall take an intermediate position, one that attempts to reconcile the apparent contradictions. From the ‘‘naturalis- tic’’ perspective one could argue that the core of social phobia is fear (or anxiety, I use the terms interchangeably À see chapter 3) evoked by interpersonal transactions and their social/cultural contexts. Fear, like emotion in general, is a loosely linked cluster of responses incorporating 16 feelings, thoughts, behaviors and physiological activation, in this case geared towards self-protection. Thus, fear is incorporated and visceral, associated with a fairly well-defined physiological and endocrinological pattern of responses coordinated by various systems in the brain involved in emotional regulation (Misslin, 2003; Marks, 1987, pp. 177À227). Furthermore, social phobia relates to one of four classes of common (i.e. normal) fears reproduced in numerous surveys (Ohman, 2000, p. 575). These are of: (1) interpersonal strife, criticism, rejection; (2) death, disease, injuries, pain; (3) animals; (4) being alone and/or trapped or amidst strangers far from a secure and familiar base. Social phobia is obviously linked to the interpersonal cluster of fears, as the fear-evoking situations triggering it are predominantly social. From the ‘‘constructivist’’ perspective it could be said that the social experiences, interpersonal behaviors and patterns of behavior generated under the state of fear as well as the manner they are construed are largely malleable, and as such indeterminate. Although tending to clus- ter, they nonetheless vary among individuals, across cultures and social practices. Bearing these considerations in mind I shall proceed with the histor- ical review. Background The term phobia derives from the Greek word phobos (attendant and son of Ares À the god of war) denoting fear, terror, panic. Its source is the worship of Phobos, who had the power to instill terror in enemies of ancient Greeks. The deity was often depicted on weapons, especially shields. The term phobia only reappears in the literature in the mid-nineteenth century, after an absence of 1,300 years. In the intervening period, irrational fears combined with glum mood and much else went under the heading of melancholia (black bile). For according to Hippocrates ‘‘temporary fears and terrors are due to overheating of the brain and are associated with an expansion and preponderance of bile in that structure’’ (Errera, 1962, p. 327). In European culture before the eighteenth century, anxiety was mostly linked to spiritual anguish, of interest to theologians and philosophers. A common Christian belief for example was that such fear resulted from sin. In this view timidity reflected an insufficient faith (in god) and shyness expressed insufficient love (charity) for one’s neighbor. With the secularization of life, the eighteenth century witnessed the beginning of the medicalization of the abnormal experiences of fear. The Genealogy of Social Phobia 17 Thus, medical treatises dedicated to the gut and the heart, for example, described what today would be regarded as anxious complaints (e.g. abdominal cramps, dry mouth, oppressive feeling in the chest: Berrios, 1999, p. 84). Palpitations, for instance, were described as symp- toms of heart disease and hyperventilation a disease of the lungs (1999, p. 84). While the process of medicalization reached its peak in the first half of the nineteenth century, a process of psychologization (e.g. Freud) got under way in the second half. What in the former era were regarded as symptoms of independent disease, in the latter period become facets of putative entities (e.g. neurasthenia, anxiety-neurosis). Launched in the USA and later adopted in Europe, neurasthenia was conceived as a new disease category induced by ‘‘modern life.’’ As defined, it involved fatigue and a vast range of depressive and anxious manifestations. Anxiety-neurosis as proposed by Freud narrowed the field to encompass an anxious state of distress combined with a ‘‘nervous over-excitement’’ involving flushes, sweat, tremors, diarrhea, etc. Both neurasthenia and anxiety-neurosis were considered by their proponents diseases of the nervous system, the putative sexual etiology of the latter notwithstanding. The continued failure however to find any neurological or other cause accounting for ‘‘nervous disorders’’ during the nineteenth century, cleared the way for psychological theories. The Notion of Social Phobia The term ‘‘social phobia’’ originated with Janet (1903). While the label is roughly 100 years old, the pattern of behavior it denotes has been noticed and described since antiquity. Burton (1621, quoted in Marks, 1987, p. 362) for example set forth a state of fear that ‘‘amazeth many men that are to speak, or show themselves in public assemblies, or before some great personages, as Tully confessed of himself, that he trembled still at the beginning of his speech; and Demosthenes that great orator of Greece, before Phillipus.’’ Burton gave further the exam- ple of Hippocrates who ‘‘through bashfulness, suspicion, and timor- ousness, will not be seen abroad; loves darkness as life, and cannot endure the light, or to sit in lightsome places; his hat still in his eyes, he will neither see nor be seen by his good will. He dare not come in company, for fear he should be misused, disgraced, overshoot himself in gestures or speeches or be sick; he thinks every man observes him’’ (1987, p. 362). Systematic and mostly medical interest in the phenomena clustered around the construct of social phobia crystallized late in nineteenth- century France. There were several strands to this trend. 18 What is Social Phobia? First, it was construed as a phobia. Within the context of a classifi- catory scheme Janet (1903) conceived of four types of phobias: situational, bodily, of objects, and of ideas. Situational phobias were further subdivided into those related to places (open À agoraphobia; enclosed À claustrophobia) and those related to social occasions. Janet emphasized repeatedly the social nature of the phobic fear. This arises only in response to having to act in public or interact with someone, for such individuals do not fear shaking or blushing when alone, for instance. Janet proposed the term social phobia or phobia of society to stress this point. He conceived social phobia broadly as ranging over fear of blushing, of intimacy (and sex), public speaking and acting from a position of authority, among others. Second, several detailed descriptions of cases of ereutophobia (blushing phobia) and discussions of related conceptual issues were published. Notable is a Swiss psychologist, Claparede’s (1902), contribution. Although narrowly conceived as concerning only blushing, the social and the phobic aspects were emphasized. Neither was necessarily recog- nized as such by all authorities; some construed the morbid dread of blushing as an obsession; others of a more traditional medical bent, a cardiovascular problem. Attempts at treatment are mentioned: alcohol, and opium among others, but also hypnosis and psychotherapy. In a refractory case, leeches were applied, followed by a sham operation designed to simulate a ligature of the carotid arteries. Improvement was short-lived. Thirdly, Dugas (1898), and especially Hartenberg (first published in 1901; I have used the available 4th edition of 1921) approached the crippling fears of the social phobic pattern of behavior as an exacerbation of a common dimension of personality À namely shyness (‘‘social anxi- ety’’ in modern parlance) À rather than as a putative abnormal entity, as did Janet and Claparede. Philosophically, Hartenberg considered himself a positivist psychologist ‘‘more interested in behavior than in the soul’’ and believed in ‘‘the predominance of the affective life and in the JamesÀLange theory of emotions’’ (Berios, 1999, p. 90). Both Dugas and Hartenberg trained under Ribot and with him ‘‘believed that both in psychiatry and in education the emotions were more important than the intellect’’ (1999, p. 91). Hartenberg (1921) emphasized the situational nature of social anxiety. Furthermore, he conceived of social anxiety as an admixture of two basic emotions: fear and shame. He related primarily the somatic experi- ences (e.g. palpitations, tremor, sweating), but also the experience of dread À to fear. Self-consciousness, a heightened sense of propriety and blushing were expressions of shame. Social anxiety is evoked socially The Genealogy of Social Phobia 19 by engaging with others and thereby submitting to their scrutiny. It is generated through the dread of falling short of expectations or of appear- ing inferior or ridiculous. Hartenberg (1921, pp. 21À40) gave a most comprehensive and detailed description of a paroxysm of social anxiety (acces de timidite). This involves, among others: (1) cardiovascular reactions (e.g. palpita- tions and due to peripheral vaso-constriction, cool extremities, and pallor); (2) respiratory difficulties; (3) gastro-intestinal and bladder muscle malfunctioning giving rise to vomiting, cramps, and alternating diarrhea and constipation and the urge to urinate; (4) muscle tension in the face, trembling and incoordination of the hands; (5) speech difficul- ties due to troubled breathing and incoordination of muscles involved in articulation; and (6) mentally: blunted perceptiveness, diminished responsiveness (e.g. ability to concentrate), and confusion. An indirect testimony to the social nature of such anxiety is the almost universal tendency to dissimulate its manifestations (1921, p. 83). Hartenberg’s (1921, pp. 157À182) dimensional conception of social anxiety is in evidence in his singling out several occupations whose practitioners are at risk of what might be termed stage fright or perfor- mance anxiety (‘‘le trac’’). Namely, these are stage actors, musicians, lecturers, preachers and trial lawyers. Were they not bound to perform in front of an attentive (and possibly critical) audience, there would be no fear. To Hartenberg (1921, pp. 183À184), common social anxiety becomes morbid when it is exaggerated, becomes over-generalized and chronic. Anxiety however is embedded in a personality constellation characterizing the shy. Interpersonally, these tend to sensitivity, propri- ety, dissembling, passivity, isolation, pessimism, and suppressed resent- ment among others (1921, pp. 47À100). As a man of his time, Hartenberg (1921, p. 217) was unequivocal about the main cause of morbid social anxiety: predisposing inherited constitutional defects. His analysis of causality however also included determinant causes (e.g. physical, psychological) or social defects (real or imagined) as well as occasional (i.e. situational) causes. As to the latter, he commends English education for its emphasis on physical exercise and the encouragement of freedom and initiative as the key to its success in producing the least shy individuals. His approach to treatment was reassurance and a behavioral therapy. In today’s terminology this would include exposure in vivo, role- rehearsal for public speaking and modification of posture and other non-verbal elements of social behavior. For fear of reading in public, for example, he recommended graduated exercises of reading in the classroom. First it was to be done in unison with the whole class, 20 What is Social Phobia? followed by reading with a diminishing number of other participants ending with reading by the socially phobic individual alone. Treatment also included self-administered tasks to be performed in between sessions (1921, pp. 222À250). Over the next 50 years interest in social phobia À the hypothetical construct À waned while the name fell into disuse. Myerson’s (1945) description of social anxiety neurosis is striking in its resemblance to social phobia with an emphasis on chronic physiological over-activation and an intense concern with related bodily sensations. Myerson pointed to some similarities between social anxiety neurosis and certain forms of schizophrenia. First, there is the common tendency towards withdrawal. Second, certain features of social phobia taken in isolation might appear delusional (ideas of reference) such as a sense of being closely watched or taken advantage of. A similar dual focus on the physical aspect of fear and its interpersonal consequences is also manifest in a Japanese version of an entity remi- niscent of social phobia. Characterized by vivid social fears and labeled tai-jin kyofu by Morita in 1930 (Takahashi, 1989), it consists of a dread of the negative reactions of others to the bodily manifestation of fear (shaking, sweating, blushing, being inappropriate). Such conspicuous displays are considered disgraceful. The years after World War II see the rise of psychology and the appli- cation of its psychometric methods to the study of social phobia. The first scale for the measurement of social anxiety À the psychological construct at the heart of social phobia À is devised and put to the test by Dixon, De Monchaux & Sandler (1957). A factor analysis extracts a large factor of social anxiety with small factors denoting fears of losing control of bodily functions, fears of draw- ing attention to oneself and appearing inferior. Marks & Gelder (1966) resurrected the term social phobia by provid- ing, for the first time, some supporting evidence of its validity. Social phobia is distinguishable from agoraphobia and specific phobias on the basis of age of onset. Subsequent work (Marks, 1987, pp. 362À371) refined the identifying features of the construct by singling out anxious distress evoked by social activities, a tendency to avoid them and as a result, impaired functioning. In essence these indicators were adopted by the DSM-III in 1980 and the ICD-10 in 1990. While the ICD used specific descriptors, the DSM opted for abstract definitions (see chapter 5). Consequently, social phobia in the ICD is more narrowly defined. This was the culmination of descriptive work carried out over a century, enshrining social phobia as a putative entity or a psychopathological pattern of behavior. The Genealogy of Social Phobia 21 An attempt to reduce the heterogeneity of the vast expanse of psycho- logical content encompassed by social phobia led to the creation of two subtypes in DSM-III-R, hypothetically distinguished by the number of situations evocative of social anxiety. This proved an impetus to research, that overall disconfirmed the contention that generalized and ‘‘specific’’ social phobia are distinct sub-entities. Rather, (as can be seen in chapter 5) most available evidence is consistent with the view that the putative subtypes, together with avoidant personality disorder, are degrees of severity of social phobia. Recently, social phobia found itself in a process of ‘‘rebranding’’ as social anxiety disorder. This label was first proposed as an alternative by the DSM-IV taskforce on anxiety disorders, aligning it semantically with the other ‘‘anxiety disorders.’’ Subsequently, the desirability of a change in name was justified by the image it projects; social anxiety disorder, it is argued, ‘‘connotes a more severe and impairing disorder than implied by the label social phobia’’ (Liebowitz, Heimberg, Fresco, Travers, & Stein, 2000). The appropriateness of labeling social phobia a phobia may be quer- ied on more substantive grounds, for a phobia ought by definition to be a highly specific response to a concrete stimulus. The wide-ranging and at times diffuse social anxiety experienced by most social phobic individ- uals fits with strain the narrow definition of a phobia. However that may be, the proposed new name À social anxiety disorder À while perhaps striking a more ominous note, does not call into question the construct of social phobia as such. That has remained consistent since its inception. Discussion Anxiety-related experiences and behaviors were well known before the nineteenth century. Palpitations, dizziness, intestinal cramps, and other somatic manifestations, however, were taken to be expressions of separate diseases. There was a major conceptual shift when these phenomena began to be considered as neuroses (i.e. resulting from disorders of the autonomic nervous system). Against this background, gradually social phobia, agoraphobia, depersonalization, and paroxys- mal surges of anxiety were described. Perhaps the emergence of these constructs may be related to the process of psychologization that set in with the failure to find any support for considering them neurological diseases. The construct of social phobia began to emerge with the realization that this pattern stands out among other anxiety-linked problems for 22 What is Social Phobia? having a dual locus. As in all such disorders, the anxious response is all-pervasive and largely incorporated (i.e. somatic). In social phobia uniquely, it is integrated into interpersonal behavior (e.g. dissembling) in response to social circumstances. It is Hartenberg’s, Dugas’, and Janet’s valuable contribution to have emphasized this in their formulations. Both Hartenberg and Claparede saw poor heredity (‘‘congenital taint’’) as the main cause of social phobia, relegating environmental circumstances to a triggering role. Such views prefigure a certain bio- medical outlook prevalent today. Then as now there was a tendency to see in agglomerations of social phobia in some families, support for genetic transmission. Claparede reported ‘‘family antecedents’’ in 83% of his sample. Few of these, however, might be described as social phobic individuals as many were labeled alcoholic, hysteric, neur- asthenic and nervous. However that may be, preponderance of social phobia or even social anxiety (a more vast category) in the family cannot be taken by itself as proof of genetic inheritance; social anxiety might be transmitted and maintained in the family through psychological pro- cesses. Environments are inherited as much as genes. ‘‘Congenital taint’’ notwithstanding, social phobia was from the outset considered as amenable to treatment. Early psychopharmacotherapy included alcohol and opium À both sound ‘‘anxiolytics’’ with some undesirable ‘‘side effects.’’ Although no longer prescribed, these are still widely consumed in social phobic circles today. A sophisticated use was made of medical placebos: leeches were applied and mock operations performed. Attesting to the power of such procedures, the results, although short-lived, were not negligible. Psychological approaches specifically devised for social phobia were pioneered applying many of the principles that were subsequently refined and in use today; namely exposure, role practice, and cognitive restructuring. The outcomes of the various treatments, however, were not systematically assessed and reported. Two outlooks, the categorical and the dimensional, were put forward in the initial attempts to formulate social phobia. The categorical (e.g. Janet, 1903) treated social phobia in Kraeplinian fashion (Roelcke, 1997) as an entity sharply distinguished from both normality and other hypothetical entities of psychopathology. Underlying it is the assumption that social phobia is a morbid manifestation due to a break- down in normal processes. In that sense it is similar to social phobia as conceived in DSM-III and onwards. The dimensional (e.g. Hartenberg, 1921) envisaged social phobia in continuity with normal social anxiety. From that perspective, the anxious response differs from the normal The Genealogy of Social Phobia 23 not in kind but in degree. In comparison to the normal, the social phobic response is exaggerated, over-generalized, and chronic. The issues raised by these incompatible points of view attending the inception of the notion of social phobia are as relevant now as they were then; they are as controversial and not anywhere near being settled. 24 What is Social Phobia? . With the secularization of life, the eighteenth century witnessed the beginning of the medicalization of the abnormal experiences of fear. The Genealogy of. chronic. The issues raised by these incompatible points of view attending the inception of the notion of social phobia are as relevant now as they were then; they