Agoraphobia, Simple Phobia, and Social Phobia in the National Comorbidity Survey

William J. Magee, PhD; William W. Eaton, PhD; Hans-Ulrich Wittchen, PhD; Katherine A. McGonagle, PhD; Ronald C. Kessler, PhD

prevalences, correlates, comorbidities, pairments associated with DSM-III-R phobias.

lation

Background: Data are presented on the general popuand im-

Methods: Analysis is based on the National Comorbidity Survey. Phobias were assessed with a revised version of the Composite International Diagnostic Interview. Results: Lifetime (and 30-day) prevalence estimates are 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia. Increasing lifetime prevalences are found in recent cohorts. Earlier median ages at illness onset are found for simple (15 years of age) and social (16 years of age) pho-

bias than for agoraphobia (29 years of age). Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment. Conclusions: Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated. Focused research is needed to investigate barriers to help seeking.

(Arch Gen Psychiatry. 1996;53:159-168)

ally representative data on the general population de scriptive epidemiology of DSM--R agoraphobia (with or without panic), social phobia, and simple phobia from the National Comor bidity Survey (NCS).1 The focus is on prevalence, sociodemographic corre lates, comorbidity, impairment, and pro fessional help seeking.
RESULTS

THIS

ARTICLE presents nation

P<.05).

though still statistically significant (z 3.4,

=

Lifetime prevalence estimates gener ally decline with age, as shown in Table 1, suggesting the possible existence of co hort effects. Analysis of age-at-onset curves, shown in Figure 1, Figure 2, and Figure 3, documents that these cohort differences are significant for all three pho bias and most pronounced for agorapho
bia. Despite the apparent sex difference in the age effect in Table 1, none of the co hort effects in the Figures 1 through 3 dif fers significantly by sex. Intercohort dif ferences emerge quite early in life for agoraphobia and, while most pro nounced for the difference between the most recent (ages 15 to 24 years at inter view) vs earlier (ages 25 to 54 years at in terview) cohorts, are also shown in Fig ure 1 to be statistically significant within the three later cohorts. Intercohort differ ences in simple and social phobias are con-

Department of Psychiatry, The University

From the

of Wisconsin, Madison (Dr Magee); the Department of Mental Hygiene, The Johns Hopkins University, Baltimore,
Md (Dr Eaton); the Department of Clinical Psychology, The Max Planck
Institute

PREVALENCE

Institute, Munich, Germany (Dr Wittchen); and the

of Psychiatry\p=m-\Clinical

Institute for Social Research

Ann Arbor.

McGonagle and Kessler) Department of Sociology (Dr Kessler), The University of Michigan,
and the

(Drs

30-day prevalence esti presented in Table I. As re ported previously,1 lifetime prevalence es timates are 6.7% for agoraphobia, 11.3% for simple phobia, and 13.3% for social phobia. The prevalence estimates for ago raphobia and simple phobia are over twice as high among women as among men, with female-male prevalence ratios of 2.2:1.0 for agoraphobia (z 5.7, P-C05) and 2.3:1.0 for simple phobia (z 7.4, P<.05). The female-male prevalence ratio for social phobia is considerably lower (1.4:1.0), alLifetime and
mates are
=
=

METHODS
SAMPLE

As described in
in the

more
area

detail in
NCS

administered to a strati probability sample of 8098 respon dents (age range, 15 to 54 years) selected from the noninstitutionalized household population of the coterminous United States and to a supplemental sample of students in campus group housing. The survey was fielded between Sep tember 1990 and March 1992. The response rate was 82.4%. The data were weighted for differential probabilities of se lection and differential nonresponse and to adjust the sample to approximate the cross-classification of the population dis tribution on a range of sociodemographic characteristics. These weights are described in more detail elsewhere. '
was

Archives,1"' the

previous articles published

fied, multistage

(with or without panic), simple phobia, or social phobia. Short-term test-retest reliabilities of the diagnoses gener ated from these structured questions were assessed in the WHO-CIDI Field Trials. Values of were .68 for agora phobia, .59 for simple phobia, and .64 for social phobia.6 Although disorder-specific validity estimates have not been reported, a comparison of CIDI diagnoses and clinical di agnoses made by one of two psychiatrists in the CIDI Field Trials documented good concordance ( .76) for the anxi ety and phobic disorders as a whole.6 The psychiatrists in this concordance study were either observers of the CIDI interviews or, on a small number of occasions, adminis tered the CIDI. The psychiatrists were then allowed to ask whatever additional questions they wished to complete a DSM--R criteria checklist as the basis for clinical diag=

ANALYSIS PROCEDURES Estimates of disorder prevalences,

DIAGNOSTIC ASSESSMENT

The NCS diagnoses are based on a modified version of the World Health Organization's Composite International Di agnostic Interview (WHO-CIDI),4 a structured interview designed to be administered by trained interviewers who are not clinicians. Phobias were assessed by asking respon dents whether there was ever a time in their life when any of 19 potentially phobic situations always made them so afraid that they either tried to avoid it or felt very uncom fortable in the situation. These situational descriptors were presented in three lists (five situations for agoraphobia, eight for simple phobia, and six for social phobia). The main change in the version of the CIDI developed at The Uni versity of Michigan, Ann Arbor, for the NCS (UM-CIDI) was that respondents were asked to review these lists vi sually as the interviewer read the stem questions in an ef fort to focus memory search and reduce chances of induc ing the "no" response set that has been documented to occur when "yes-no" questions are presented in lists of this sort.5 Respondents who endorsed one or more situational descriptors were then administered the structured CIDI questions that assessed DSM-II-R criteria for agoraphobia

were ob tained by calculating means for dichotomous outcomes us ing the PSRATIO program in the OSIRIS software package.7 Age-at-onset curves were calculated using the SURVIVAL procedure in the SPSS software package.8 Cross-sectional estimates of sociodemographic correlates and bivariate comorbidities were obtained by estimating odds ratios (ORs) based on logistic regression models with dichotomous pre dictor variables using the LOGISTIC procedure in the SAS software package.9 Owing to the complex sample design and weighting of the NCS, special analysis procedures were required to obtain unbiased estimates of SEs of parameter estimates. The Taylor series linearization method10 was used to ad just SEMs. The method of Balanced Repeated Replica tions,11 operationalized in a SAS MACRO,9 was used to ad just SEs of ORs. Odds ratios for bivariate models are reported below, with 95% confidence intervals (CIs) adjusted for de sign effects (ie, the effects of weighting and clustering of observations). All statistical tests were evaluated at the .05 level of significance, using two-tailed tests and designbased SEs.

ing, and proportions of cases with impairment

professional help seek

fined to cases with disease onsets after age 16 years. While the cohort effect for social phobia in Figure 3 is largely owing to relatively early age at onset among the most re cent cohort, intercohort differences are statistically sig nificant both between the most recent and earlier co horts and within the earlier cohorts. It is also noteworthy that simple and social phobias generally have earlier es timated ages at onset than agoraphobia, based on retro spective self-reports. Median ages at onset in the oldest cohort, where years of risk are greatest, are 15 years for simple phobia, 16 years for social phobia, and 29 years for agoraphobia. Thirty-day prevalence estimates are 2.3% for agora phobia, 5.5% for simple phobia, and 4.5% for social pho bia. The estimates for agoraphobia and simple phobia are substantially higher among women than among men, with prevalence ratios of 2.2:1.0 for agoraphobia (z 3.4, P<.05) and 3.8:1.0 for simple phobia (z 7.2, P<. 05). The femalemale prevalence ratio for social phobia is much smaller
=

Age differences (which could also be interpreted as co hort differences) are generally not significant, although there is a fairly consistent trend for 30-day prevalence es timates to be highest in the youngest cohort.
SOCIODEMOGRAPHIC CORRELATES
Bivariate associations between

(1.4:1.0), but still statistically significant (2=2.2, P<.05).

ables and 30-day phobias are presented in Table 2 as a way of providing descriptive information on the social distribution of phobias. Thirty-day agoraphobia is nega tively related to income and education and is signifi cantly elevated among blacks; homemakers; persons who are neither working, nor students, nor homemakers; and those who live with someone other than a spouse. Thirtyday simple phobia is negatively related to education but not income, and it is significantly elevated among Hispanics, all persons who are not employed (including stu-

sociodemographic vari

Ages 15-24 y at Interview. Born 1966-1975 Ages

35-44 y at Interview, Born 1946-1955

Ages 25-34 y at Interview, Born 1956-1965

Ages 45-54 y at Interview, Born 1936-1945

2(3)=59.1, <.05 2 (2)=5.2, P<.05 for the Most Recent vs Earlier Cohorts 2 (2)=23.3, P<.05 Excluding the Most Recent Cohort
m-f6
| | | | | |

10

12

14

16

18

20

|-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1-1 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 at

Onset, y

Figure

1. Cumulative lifetime

prevalence of agoraphobia by cohort. Numbers in parentheses indicate degrees of freedom.

dents, homemakers, and others), and those who live with

their parents. Thirty-day social phobia is negatively re lated to education and income and significantly el evated among the never married; students; persons who are neither working, nor students, nor homemakers; and

those who live with their parents. None of the phobias is meaningfully associated with either region of the coun

try or urbanicity. Multivariate relationships were also ex amined and found to be quite similar to those reported in Table 2. (The results of these and other analyses that

Ages 15-24 y at Interview, Born 1966-1975

Ages
35-44 y at Interview, Born 1946-1955

Ages 25-34 y at Interview, Born 1956-1965 Ages 45-54 y at Interview, Born 1936-1945

.10-

.08

04

02

2 (3)=5.8, NS, for Total Sample 2(3)=1.2, NS, for Ages 0-15 y 2(3)=29.3, P<.05,forAges16+y 2 (1 )=0.7, NS, for the Most Recent vs Earlier Cohorts, for Ages 16+ y 2 (2)=13.6. P<.05, Excluding the Most Recent Cohort, tor Ages 16+ y
~~r~ ~1~

12

14

16

22

34

36

38

42

44

46

50

52

54

Age at Onset, y

Figure

2. Cumulative lifetime prevalence of simple

phobia by cohort. NS indicates not significant; numbers in parentheses, degrees of freedom.

Ages 15-24 y at Interview, Born 1966-1975

A Ages 35-44 y at Interview, Born 1946-1955

Ages 25-34 y at Interview, Born 1956-1965 Ages 45-54 y at Interview, Born 1936-1945

<3

'

.02

2 (3)=21.8. P<.05, for Total Sample 2 (3)=5.8, NS, for Ages 0-15 y 2(3)=12.6, P<.05, for Ages 16+y 2 (1 )=6.7, P<.05, for the Most Recent Cohort vs Earlier Cohorts, for Ages 16+ y 2 (2)=9.9, P<.05, Excluding the Most Recent Cohort, for Ages 16+ y
"1 20
I ~1 ~1 ~1 "I-

18

30

32

34

38

42

46

50

52

Age at

Onset,

Figure 3. Cumulative lifetime prevalence of social phobia by cohort. NS indicates not significant; numbers in parentheses, degrees of freedom.

*0R indicates odds ratio; CI, confidence interval. -[Significant at the .05 level, two-tailed test. {students excluded from education and income analyses.

described in the text without the presentation of re sults can be obtained from the public-access Internet file described in the acknowledgments.) Correlates of 30day prevalence among lifetime cases controlling for age at onset and time since onset were also examined and found to be largely nonsignificant, suggesting indirectly that the persistence of phobias is unrelated to these sociodemographic variables.
are

4.8

COMORBIDITY
As shown in Table 3, the
sons

vast

phobia (87.6% of persons with agoraphobia, 83.4% of per

majority of persons with

with simple phobia, and 81.0% of persons with so cial phobia) reported at least one other lifetime DSM--R/ NCS disorder. These proportions are significantly higher than those found among the subsample of NCS respon dents who reported never having a phobia, with bivari ate ORs of 6.8 (agoraphobia), 5.3 (simple phobia), and

significantly comorbid with either alcohol or drug dependence (OR range, 0.9 to 1.2). The OR single largest in the data is between panic disorder and agoraphobia (11.9), a result observed because ago raphobia with panic and agoraphobia without panic were not distinguished in defining agoraphobia. There is also a very large OR between mania and simple phobia ( 10.0). It is noteworthy that only a minority (35.8%) of the re spondents diagnosed in the UM-CIDI as having lifetime agoraphobia reported ever having an unexpected panic attack (including 21.6% with panic disorder and an ad
are not

(social phobia). Disorder-specific ORs show that life strongly comorbid with each other (OR range, 7.1 to 8.7), with other anxiety disorders (OR range, 2.7 to 11.9), and with affective disorders (OR range, 3.1 to 10.0). Phobias are more weakly comorbid with alco hol and drug dependence (OR range, 1.7 to 2.9), and they
time phobias are

abuse without

ditional 14.6% with panic attacks but not panic disor der) despite the high panic-agoraphobia OR.

^Excluding

*NSC indicates National Comorbidity Survey; ORs, odds ratios; CI, confidence interval; and PTSD, [Significant at the .05 level, two-tailed test. With or without panic disorder. the relevant phobia(s).

posttraumatic stress disorder.

As shown in Table 4, comorbid agoraphobia is usu ally secondary (55.4% of comorbid cases) in the sense of agoraphobia onset occurring at a later age than at least one other comorbid condition. Comorbid simple pho bia and social phobia, in comparison, are usually tem porally primary (56.8% for simple phobia and 52.6% for social phobia). These results are consistent with the ear lier observation that the retrospectively reported me dian ages at onset of simple and social phobias are dur ing the adolescent years (15 to 16 years) compared with a median age at onset of 29 years for agoraphobia.

IMPAIRMENT AND PROFESSIONAL HELP SEEKING

The proportions of persons with lifetime phobia who per ceived themselves to ever have significant role impairment (as operationalized by a report that the phobia interfered "a lot," rather than "some," "a little," or "not at all," with their life and activities), who sought professional help, or who took medication more than once for their phobias are presented in Table 5. All three of these severity indica tors are consistently more prevalent among comorbid than pure cases and, within the subsample of comorbid cases, more prevalent among those with a lifetime history of panic. Perceived role impairment is significantly less preva lent overall among persons with agoraphobia (26.5%) than among persons with either simple (34.2%, 2.4, P<.05)
=

2.4, P<.05) phobias. However, there significant difference across types of phobia in the prevalence of perceived role impairment in the subsample of those with panic attacks. A higher proportion of persons with agoraphobia (41.0%) sought profes sional help for their phobias at some time in their life than those with either simple (30.2%, 3.1, P< .05) or social z 4, (19.0%, P<.05) phobias. Furthermore, a higher pro of with agoraphobia reported lifetime use persons portion of medications for their phobias (21.6%) than those with either simple (8.0%, 5.9, P.05) or social (6.2%, 7.5, P<.05) phobias. Overall, approximately half of persons with agoraphobia, simple phobia, and social phobia re ported at least one outcome indicative of severity at some time in their life (either a lot of interference, professional help seeking, or use of medications more than once).
or
=

social (33.5%,

is

no

The opposite-sign pattern seen in Table 5, ie, a lower proportion of persons with agoraphobia who reported im pairment but higher proportions of those who reported help seeking and use of medication, implies that the re lationship between perceived impairment and treat
ment

differs by type of phobia. This is examined di rectly in Table 6, where it is shown that the probabilities of professional help seeking and use of medication among the persons with agoraphobia at a given level of per ceived role impairment are generally higher than among the persons with simple or social phobias who reported the
same

levels of role

impairment.

* This phobia is the respondent's only lifetime National Comorbidity Survey (NCS) DSM-III-R disorder. \This phobia was at an earlier age of onset (based on retrospective self-reports) than any other disorder and was followed by the onset of at

least

one

same

disorder were at the ages of onset, which were earlier than those of any other disorder. At least one other /CS/DSM-III-R disorder occurred at an earlier age than this phobia.

$This phobia and at least one other WCS/DSM-III-R

other CS/DSM-III-R disorder.

done by estimating logistic regression equations, in which measures of 30-day agoraphobia, simple phobia, and social phobia were used to predict various measures of cur rent role impairment, controlling for sociodemographic variables (age, sex, education, marital status, number of preschool-aged children in the home, and interactions be tween sex and marital status and between sex and pre schoolers), and comorbid disorders. The analyses showed that agoraphobia and simple phobia, but not social pho bia, are associated with significantly increased work ab sence among employed men (equivalent to 1.1 days per month for persons with agoraphobia and 0.7 day per month for persons with simple phobias [z 6.7 and 6.1, respec tively] compared with a nonsignificant 0.05 days per month for persons with social phobia [z 0.1]) but not among employed women. In addition, simple and social phobias, but not agoraphobia, are associated with low so cial support (defined as the lowest decile in the sample), with ORs of 1.92 (95% CI, 1.11 to 3.35) for simple pho bia and 1.74 (95% CI, 1.03 to 2.95) for social phobia, com pared with a nonsignificant OR of 1.08 (95% Cl, 0.23 to 5.04) for agoraphobia. None of the phobias was signifi cantly related to financial adversity, as defined by either low family income in the total sample or low earnings in the subsample of the employed.
was
= , =

Given that the finding of less role impairment among persons with agoraphobia than among those with other phobias is inconsistent with prior research,1217 an analy sis of more objective role impairment was conducted. This

ria, as defined in the Diagnostic Interview Schedule.18 The

NCS agoraphobia lifetime prevalence estimate of 6.7% is at the upper end of the range of these earlier surveys (2.9% to 6.9%),19M while the NCS simple phobia life time prevalence estimate of 11.3% is in the middle of the range in earlier surveys (6.5% to 21.6%).21 The NCS so cial phobia lifetime prevalence estimate of 13.3%, in com parison, is far above the range in earlier surveys (1.6%

3.2%),2022 although lower than in a recent European community epidemiologie survey (16.0%) that used DSMto

-R criteria and made

thermore, a recent epidemiologie survey of a Canadian community, based on DSM--R criteria, reported a pe riod prevalence of social phobia (7.1%)24 that is quite simi
lar
to

diagnoses with the CIDI.23 Fur

the NCS 12-month

A blind clinical

respondents who endorsed the stem question for social phobia found that 100% of CIDI cases were confirmed
as cases

prevalence estimate of 7.9%.] reappraisal of a subsample of NCS

noncases were

and 84% of

confirmed

as non-

But how can this

cases,25 documenting that the higher prevalence in the NCS than in earlier surveys is not owing to invalidity.

COMMENT

PREVALENCE Previous studies of phobias in North American commu nity samples have largely been based on DSM- crite-

high prevalence be explained? At least three factors appear to be involved. First, the phobia stem questions in the NCS are based on DSM--R, which requires either avoidance or dis tress on exposure, rather than the narrower DSM-I re quirement of avoidance. This has a much larger effect on the prevalence of social phobia than other phobias, be cause it is much more difficult to avoid social situations than the situations associated with simple phobia or ago raphobia.
Second, while the NCS descriptors for simple pho

bia and

agoraphobia were similar in number and word-

AGE AT ONSET

analysis is that the NCS asked respondents to date their age at first onset of their unrealistic fear, not the age when they first developed a full phobic syndrome. Nonetheless, the estimated me dian ages at onset of 15 years for simple phobia, 16 years for social phobia, and 29 years for agoraphobia are quite similar to those obtained by Ost26 in a review of clinical studies (between 7 and 20 years for separate simple pho bias, 16 years for social phobia, and 28 years for agora
A limitation of the age-at-onset

phobia).

COHORT EFFECTS
The significant intercohort difference in lifetime phobia prevalence was found to be more pronounced for ago raphobia than for the other phobias and only to appear for later-onset cases of simple and social phobias. These specifications could explain why Burke et al,27 who ex

Seeking help for the fear from a nonpsychiatric medical doctor, a specialist, or any other professional (eg, priest, minister, rabbi, counselor, or nurse). t Taking medication more than once because of the fear. {.Percentage of subjects with lifetime agoraphobia who sought any help in the subsample of those who reported "a lot" of role impairment due to the phobia.
*

mental health

ing to those used in the Epidemiologie Catchment Area (ECA) there was an expansion from three social phobia

dorsed by 29.1%). Third, the estimated prevalence of social phobia is more sensitive than those of simple phobia or agorapho bia to changes in diagnostic criteria, as documented by the fact that the prevalence estimates for agoraphobia and simple phobia did not change very much when the di agnostic criteria were changed from DSM--R to DSM111 (from 6.7% to 5.5% for agoraphobia and from 11.3% to 10.9% for simple phobia). The prevalence estimate for social phobia, in comparison, changes substantially, from 13.3% to 8.3%, with this change in diagnostic criteria. When diagnosis was further restricted to the NCS re spondents who endorsed one of the situational descrip tors most comparable to those used in the Diagnostic In terview Schedule-DSM-III surveys, the lifetime social phobia prevalence dropped to 4.8%, which is close to the estimates in the earlier surveys.

fied in tbe NCS to delete the words "you know," with an increase in the prevalence of endorsement to 14.6%. The new questions added to the NCS all tapped highprevalence social-phobic fears: of having to use the toi let when away from home (endorsed by 6.3%), of writ ing when someone watches (endorsed by 6.1%), of talking to people and not having anything to say or sounding fool ish (endorsed by 13.5%), and of speaking in public (en

descriptors in the earlier surveys to six in the NCS. The ECA asked about low-prevalence social-phobic fears: of eating in public (endorsed by 2.7% of ECA respondents and 2.7% of NCS respondents), of speaking to new ac quaintances (endorsed by 4.7% of ECA respondents and not included in the NCS), and of speaking in front of a small group of people you know (endorsed by 6.5% of ECA respondents). The third of these questions was modi

amined cohort differences in onset distributions of total phobia in the ECA (not distinguishing among agorapho bia, simple phobia, and social phobia) up to age 29 years, failed to document consistent evidence for increasing prevalences in more recent cohorts. Although it is conceivable that evidence for increas ing prevalences of phobias in more recent cohorts could be owing to a methodological artifact involving either greater recall failure among older respondents or greater exclusion from the sample of older phobies, neither of these possibilities can explain the fact that the signifi cant cohort differences in lifetime simple and social pho bias are confined to later-onset cases. This specification raises the possibility that there is heterogeneity in the causes of simple and social phobias depending on age at onset. More precise assessment of this possibility, how ever, will require analysis of longitudinal data to distin guish a true cohort effect from a methodological arti fact.
SOCIODEMOGRAPHIC CORRELATES

The finding that agoraphobia and simple phobia are ap proximately twice as prevalent among women as among men while there is a much smaller sex difference in so cial phobia is consistent with the results of several pre vious studies.192028"32 The strong and negative associa tion of at least one indicator of socioeconomic status (education or income) with all three phobias is also con sistent with previous research.33 34 The inconsistency of the associations between phobias and other sociodemographic correlates mirrors inconsistencies found in ear lier epidemiologie studies.1420212326"283536
COMORBIDITY

The NCS finding of significant comorbidities between phobias and other disorders are consistent with prior clini cal studies37"39 and community epidemiologie sur veys.122240 The strongest of the NCS comorbidities is that between panic and agoraphobia (OR 11.9), a result con sistent with prior research41"43 and owing to the fact that
=

bias,43 a result that is consistent with the fact that ago raphobia without a history of panic is very rare in clinical

did not distinguish agoraphobia with panic from ago raphobia without panic in the definition of agorapho bia. Despite this very high OR, however, only about one third of NCS agoraphobic respondents reported ever hav ing an unexpected panic attack, a result also found in the ECA Study.44 Subsequent clinical reanalysis of ECA cases found that many of those classified as agoraphobic with out panic had, in fact, misdiagnosed simple or social pho
we

of role functioning have generally found that the rank ordering of the different phobias in terms of im pairment varies depending on the way impairment is as sessed,1415 a result that is consistent with our analysis of the impairments associated with current phobias. More detailed assessment of functional impairments is needed in future epidemiologie research on this issue.
sessments

PROFESSIONAL HELP SEEKING

bid with substance use disorders than with other anxiety disorders or affective disorders. This result is consistent with a comprehensive review of the literature by Schuckit and Hesselbrock, who concluded that "the available data, while imperfect, do not prove a close relationship between life long anxiety disorders and alcohol dependence."48 Finally, the NCS result that comorbid simple and social phobias are usually temporally primary while co morbid agoraphobia is usually temporally secondary is consistent with previous results of both clinical and epi demiologie studies.14224950 However, it is important to remember that both the NCS and many of the previous studies that examined temporal priority between pho bias and other disorders dated the age at onset of the first fear of phobic situations rather than of first meeting full diagnostic criteria. It is possible that an assessment of the latter would lead to different conclusions concerning tem poral priorities between phobias and comorbid disor ders. Although clinical studies might be expected to pro vide valid data of this sort, such studies often rely on retrospective patient reports that are subject to the same sort of bias.35 The only rigorous way to obtain unequivo cal data on this issue is to use longitudinal general popu lation data. Data of this sort document that anxiety dis orders generally occur before comorbid affective disorders, but are less clear that anxiety disorders predict the sub sequent onset of substance use disorders.51"33
IMPAIRMENT

samples.46,47 More detailed analysis of the NCS data is cur rently under way to discriminate persons with agora phobia who deny ever having simple or social phobic fears from those with such fears (who could have misdiag nosed simple or social phobias) in an effort to evaluate the possibility that a similar diagnostic confusion under lies the appearance that agoraphobia without panic is more common than agoraphobia with panic in the NCS. Another important result concerning comorbidity is that all the phobias were found to be more weakly comor

The NCS results are consistent with earlier community sur veys in finding that only a minority of individuals with pho bia ever seek professional help,152454 as well as in finding that persons with agoraphobia are more likely than are those with other phobias to obtain treatment.54 While it has pre viously been assumed that the higher prevalence of help seeking among persons with agoraphobia is an effect of their greater impairment, the NCS results suggest that this might not be the case, as this association persists after control ling for perceived impairment. One plausible interpreta tion of this result is that subjects with agoraphobia are more likely than are those with other phobias to interpret their symptoms in mental health terms. This could occur be cause the symptoms of agoraphobia first occur much later than the symptoms of other phobias and, because of this, are more readily seen as deviations from some prior stan dard of behavior, rather than the way things have always been. Or it could be that fears of agoraphobic situations are more readily interpreted as pathological than fears of simple phobic situations (which might be interpreted as caused cautiousness rather than mental disorder) or so cial phobic situations (which might be interpreted as caused by shyness rather than mental disorder). Whatever the case may be, the objective role impairments, barriers associ ated with problem recognition, and subsequent help seek ing among individuals with simple and social phobias need to be studied more seriously in future research.

by

The NCS results concerning perceived role impair odds with most other clinical and commu nity studies in finding that a somewhat smaller propor tion of persons with agoraphobia (26.5%) than those with either simple (34.2%) or social (33.5%) phobias re ported that their phobia "interfered a lot" with their "life and activities." This might be caused by imprecision in the single self-reported question used to assess per ceived role impairment, which could miss the fact that avoidance of public places impairs ability to work much more than does avoidance of harmless animals or avoid ance of social situations. More detailed and objective asments are at

Accepted for publication September 7, 1995. The National Comorbidity Survey (NCS) is a col laborative epidemiologie investigation of the prevalence, causes, and consequences of psychiatric morbidity and comorbidity in the United States, supported by the National 46376 and Institute of Mental Health (grants ROI ROI MH49098) and the National Institute of Drug Abuse (through a supplement to RO MH/DA46376), Rockville, Md, and the W. T. Grant Foundation, New York, NY (grant 90135190; Dr Kessler, Principal Investigator). Prepara tion of this report was also supported by Research Scien tist Award K05 MH00507 and by Training grants T32 MH14641 and T32 MH16806 from the National Institute of Mental Health. Collaborating NCS sites and investiga
The Addiction Research Foundation, Toronto, On (Robin Room, PhD); Duke University Medical Cen ter, Durham, NC (Dan Blazer, MD, PhD, and Marvin Swartz, MD); The fohns Hopkins University, Baltimore, Md (fames Anthony, MD, William Eaton, PhD, and Philip Leaf, PhD); the Max Planck Institute of PsychiatryClinical Institute, Munich, Germany (Hans-Ulrich Wittchen, PhD); the Medical College of Virginia, Richmond (Ken neth Kendler, MD); The University of Michigan, Ann Ar bor (Lloyd Johnston, PhD, and Ronald Kessler, PhD); New
tors are

tario

University, New York (Patrick Shrout, PhD); SUNY Stony Brook (Evelyn Bromet, PhD); the University of Mi ami, Miami, Fla (R. Jay Turner, PhD); and Washington University School of Medicine, St Louis, Mo (Linda Cot
York

24. Stein MB, Walker JR, Forde DR. Setting diagnostic thresholds for social phobia: considerations from a community survey of social anxiety. Am J Psychia-

complete list of NCS publications can be obtained NCS Study Coordinator, Room 1006, Institute the from Social Research, The University of Michigan, Box 1248, for Ann Arbor, MI 48106-1248. The text of this and other NCS publications, working papers, and the raw data from the NCS can also be obtained from the NCS home page by using the URL: http://www.umich.edu/~ncsum/. We appreciate the thoughtful comments of Murray Stein and the anonymous reviewers. Reprint requests to Survey Research Center, The Uni versity of Michigan, 426 Thompson St, PO Box 1248, Ann
A

tier, PhD).

25. Wittchen, H-U, Zhao, S, Abelson, JM, Abelson, JL, Kessler, RC. Reliability and procedural validity of UM-CIDI DSM-III-R phobic disorders. Psychol Med. In press. 26. Ost L-G. Age of onset of different phobias. J Abnorm Psychol. 1987;96:223\x=req-\ 229. 27. Burke KC, Burke JD, Rae DS, Regier DA. Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations. Arch Gen Psychiatry. 1991;48:789-795. 28. Boyd JH, Rea DS, Thompson JW, Burns BJ, Bourdon K, Locke BZ, Regier DA. Phobia: prevalence and risk factors. Soc Psychiatry Psychiatr Epidemiol. 1990; 25:314-323. 29. Chen C, Wong J, Lee N, Chan-Ho M, Lau JT, Fung M. The Shatin Community Mental Health Survey in Hong Kong, II: major findings. Arch Gen Psychiatry. 30. Hwu HG, Yeh EK, Chang LY. Prevalence of psychiatric disorders in Taiwan as defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatr Scand.

try. 1994;151:408-412.

1993;50:125-133. 1989;79:136-147.

Arbor,

Ml 48106-1248

(Dr Kessler).

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