Take a walk down any street and out of every 10 people you pass, one will probably be afflicted by social phobia at some point in their life. Phobias may vary drastically in terms of their prevalence and severity, but they are rather more common than we realise.
There are two known mechanisms that allow phobias to develop. The first is simply personal experience – so people who have been bitten by a dog, for example, learn to associate dogs with fear and danger.
The second is the global media. Before the advent of the internet and rolling 24-hour news coverage, the only information about a tragedy would come from print newspapers, evening television news reports and hearsay. Nowadays, the coverage of events such as the two Malaysia Airlines disasters earlier this year is so immersive, it can instil sustained anxiety or trauma in some viewers, even if their own experiences of flying have been positive.
For around one third of phobia sufferers, however, the cause is unknown.
While there is currently no evidence that this occurs in humans, research involving animal models suggests the effect of traumatic experiences can be passed from the brain to the genome and inherited by future generations. Scientists found that the offspring of mice conditioned to experience fear when exposed to a particular odour became fearful when they were exposed to the same smell.
It may not always be clear what causes phobias, but we do understand how they are maintained: the problem is avoidance. In the 1950s, the South African psychologist James Taylor developed “graduated exposure therapy” or “systematic desensitisation” to treat pathological fears. He conducted a variety of experiments on his patients, including exposing compulsive hand washers to situations that would elicit anxiety, and then prevented them from washing.
The idea is to progressively teach the limbic system – the emotional part of the brain – that the object of your fear is not associated with any real threat.
“Phobics know that when they see a little spider on the counter, they shouldn’t be panicking because technically it’s not dangerous,” says Stéphane Bouchard, a psychologist at the University of Quebec. “They’ll tell you, ‘I know this is crazy.’ But because they keep avoiding, their limbic system keeps associating spiders with danger or extreme disgust and they never undergo that corrective experience.”
For many types of phobia, however, traditional exposure therapy is not feasible. Crippling fears of public speaking or flying, for example, can be difficult to tackle practically. Over the past 10 years the solution has increasingly been the virtual world, utilising some of the technologies that brought us 3D cinema.
“We have these immersive rooms, known as ‘caves’ where we can create 3D projections which float in front of the patient just like in the movie theatre,” Bouchard explains. “But there you can always remember you’re not on the planet Avatar because you can see the surrounding people. In the cave, there are six sides and images are coming from all of them. So you have no point of reference with the physical reality as the only thing you notice is the visual stimuli.”
This allows the therapist to provide careful guidance while retaining full control over everything that takes place, pacing the intensity of the therapy according to the individual needs of the patient. If the phobia is public speaking, then with a few clicks of a mouse a talk in front of an audience of thousands can be arranged – an appreciative audience who will laugh and applaud everything the patient says.
For those who have never experienced a phobia, it may be difficult to imagine how such a virtual world can ever realistically replicate the experience of confronting the real thing. After all, on close inspection even the finest virtual spiders do not resemble the real-life arachnids that menace bedrooms and bathrooms around the world.
However, virtual reality therapy works because of a neurological trick scientists uncovered by comparing the brain pathways activated in phobics and non-phobics in the virtual environment. Non-phobics are quickly able to pick up the subtle details telling them the object is not real, such as the way the spider moves and reacts or the lack of motion in the virtual aeroplane. Phobics, however, instantly look for the cues they perceive to be relevant to their survival. The mere presence of the spider’s legs and motion in their direction is enough to trigger a strong emotional response – sufficient to initiate the corrective learning experience.
Scans show that, once treatment is complete, the brain’s threat mechanism returns to normal functioning. In particular, there is a vastly diminished response in two regions: the insula and the amygdala.
“If you have a phobia about talking in public and I tell you you’re going to give a speech in a minute, you start being apprehensive, over-thinking and then physically you find that your heart’s beating [faster],” Bouchard says. “This is due to the insula, which is telling you something wrong is happening and recruiting consciousness.
“Because you’re perceiving danger the amygdala will kick in and this partially links to the hippocampus where the memories are stored of how you coped in the past. If you ran away every time, that will be triggered.”
This whole sequence lasts 12-15 milliseconds and is followed by a second pathway whereby information is reanalysed by the prefrontal areas, the logical part of the brain. This sequence of neural events is why virtual reality works. “Even though the situation is not real, your emotions have already kicked into gear before you consider it logically,” he says. “But after therapy this emotional response is much less.”
The only slight downside of virtual reality becomes apparent if the patient has a very specific phobia about a particular location, for example delivering a presentation in their office. They are now able to speak confidently to a vast auditorium in the virtual world, but standing up at work still reduces them to a quivering wreck.
Google Glass and similar technologies have led to the emergence of a new therapeutic strategy that might get around this – augmented reality. This time the patient can see the physical reality, but the virtual stimuli have been added on top, enabling them to practise delivering their talk in their actual office to a virtual audience.
This can save time for the people developing such simulations. “It’s a short cut for us because we only need to develop the stimuli, not the whole surroundings,” Bouchard says. “But it only works with things like objects or a few people. If you’re afraid of flying you need to think you’re in an aeroplane so I would need to replace the whole physical reality by the virtual reality.”
Virtual reality training programs have also began to be trialled as a new therapy for youngsters with autism spectrum disorder, for whom anxiety and social phobias are extremely common. The results of a series of trials at Newcastle University were highly successful.
“For some people with autism, it can difficult for them to imagine being in certain situations and that’s where this treatment has been very useful because it’s allowed them to find themselves in a replica of that situation and visualize things rather than just talking about them,” says Jeremy Parr, a paediatrician specializing in neurodisability. “Parents are also able to observe their child working with a therapist via a videolink and learn techniques for helping them deal with that environment.”
The technology is likely to become ever more sophisticated, driven by a growing need. Approximately 10 million people in the UK are believed to have some sort of phobia and the vast majority will never consider seeking treatment. But with phobias and social anxieties becoming increasingly common, especially amongst the young, the increasing ease with which these therapeutic techniques can tackle the most complex of problems may encourage more to confront their fears.
