Major depression and phobias: the genetic and environmental sources of comorbidity

In a population based sample of 2163 personally interviewed female twins, substantial comorbidity was observed between DSM-III-R defined major depression (MD) and 4 subtypes of phobia: agoraphobia, social phobia, animal phobia and situational phobia. However, the level of comorbidity of MD with agoraphobia was much greater than that found with the other phobic subtypes. We concluded bivariate twin analyses to decompose the genetic and environmental sources of comorbidity between MD and the phobias. Our results suggest that a modest proportion of the genetic vulnerability to MD also influences the risk for all phobic subtypes, with the possible exception of situational phobias. Furthermore, the magnitude of comorbidity resulting from this shared genetic vulnerability is similar across the phobic subtypes. By contrast, the non-familial environmental experiences which predispose to depression substantially increase the vulnerability to agoraphobia, have a modest impact on the risk for social and situational phobias and no effect on the risk for animal phobias. The increased comorbidity between MD and agoraphobia results, nearly entirely, from individual-specific environmental risk factors for MD which also increase the risk for agoraphobia but not for other phobias.     

Blood-injury-injection phobia and dental phobia

The present study was carried out to explore the relation between BII phobia and dental phobia. An additional aim was to determine the fainting tendency of dental phobics and BII phobics during an invasive treatment procedure. Participants were 63 patients undergoing treatment in a dental fear clinic, and 173 patients undergoing dental surgery in a university hospital. They completed measures on fears of particular medical and dental stimuli, fainting history, general trait anxiety, dental anxiety, BII anxiety, BII avoidance, and a questionnaire aimed to define a phobia based on DSM-IV criteria. Immediately after treatment information was obtained on exposures to blood or injections, state anxiety, and feelings of faintness during treatment. The results did not indicate any significant relationship between measures of dental anxiety and BII anxiety or BII avoidance. However, 57% of the dental phobic patients could also be classified as BII phobic. The proportion of dental phobics who reported fainting episodes in their past was similar to that of the BII phobics (37%), but none of the participants fainted during treatment. It is concluded that, albeit the level of co-occurrence for both types of phobias is high, dental phobia should be considered as a specific phobia, independent for the BII subtype within DSM-IV. Further, the findings are inconsistent with the notion that individuals with BII phobia have a remarkably high tendency to faint in the presence of their phobic stimuli.     

Current approaches to etiology and pathophysiology of specific phobia

Specific phobia is a common, heterogeneous disorder whose central feature is persistent, unreasonable fear of a circumscribed object or situation. This article reviews current etiological theories and empirical data that seem likely to be important in investigating the pathophysiology of this disorder. These include conditioning, modified conditioning, and nonassociative models of phobia development, physiological response to the phobic stimulus, neuroimaging, primate, and biological challenge studies. Pathophysiological hypotheses suggested by recent research on the neurocircuitry of conditioned fear are also discussed. Though specific phobias have been of less public health and clinical interest than other anxiety disorders, their circumscribed nature and possible relationship to conditioned fear may make them a productive subject for research into basic pathophysiology.     

Disgust and disgust sensitivity in blood-injection-injury and spider phobia

Blood-injection-injury (BII) phobics and spider phobics show markedly different cognitive, psychophysiological, and motoric reactions to activating stimuli. These observations have led theorists to question whether the emotion of fear mediates both phobias. The present study examined the role of disgust and disgust sensitivity in these subtypes of specific phobia. BII phobics, spider phobics, and nonphobics completed questionnaires and rated pictures of specific objects on fear and disgust scales. Questionnaire data indicated that phobic participants were higher than nonphobics on fear, and also on disgust sensitivity. The reaction of BII phobics to pictures of medical stimuli was one of disgust, rather than fear. The reaction of spider phobics to pictures of spiders was a combination of fear and disgust, though fear appeared to predominate. Results are discussed in view of current theories of emotional factors in specific phobia.     

The etiology of childhood spider phobia

Twenty-six girls with a clinical spider phobia and 26 matched control girls were interviewed about conditioning, modeling, and negative information experiences in connection with spiders. In addition, parents of the phobic girls were independently interviewed about the origins of their child's phobia. Phobic children more often reported aversive conditioning experiences with spiders than did control children. Also, in a number of cases, conditioning events described by the phobic children were confirmed by their parents, a result that replicates the findings of Merckelbach, Muris and Schouten (1996; Behaviour Research and Therapy, 34, 935-938). Taken together, the results contradict a strong version of the non-associative account of phobias and suggest that in at least some cases, conditioning events may contribute to the development of (childhood) spider phobia.     

Social phobia: A comparison of specific and generalized subtypes and avoidant personality disorder.

The validity of the social phobia subtype distinction was examined in a large sample of carefully diagnosed social phobics (N?=?89). Generalized and specific subtypes were diagnosed reliably, and the generalized subtype showed a consistent pattern of greater symptom severity than did the specific subtype. In addition, generalized social phobics with and without avoidant personality disorder were compared, and a difference was found for only 1 of 4 parameters. The results are discussed in terms of the validity of subtyping in social phobia and the diagnostic boundary between social phobia and avoidant personality disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia: An analysis of possible developmental factors.

Sixty-eight individuals with specific or generalized social phobia and 25 normal controls were assessed for presence of a family history of anxiety, childhood shyness, traumatic conditioning experiences, neuroticism, and extraversion. Subtype differences emerged, including significantly greater neuroticism and a more frequent history of shyness in the generalized subtype. Those with the generalized subtype also had significantly lower extraversion scores, and those with the specific subtype had a significantly higher frequency of traumatic conditioning episodes. Together, traumatic conditioning and childhood shyness predicted the presence of social phobia, although other unidentified factors also appeared to be relevant. The results are discussed in terms of potentially different modes of onset for the subtypes of social phobia and the role of neuroticism and introversion in the development of the disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia, avoidant personality disorder and atypical depression: co-occurrence and clinical implications

BACKGROUND: Increasing attention has been directed in recent years to the detection and treatment of psychiatric co-morbidity among depressed individuals. The overlap of social phobia (SP) and avoidant personality disorder (APD) has been well recognized and a relationship between these disorders and depression has been suggested. METHODS: The pattern and clinical implications of co-morbidity of SP and APD with major depressive disorder (MDD), diagnosed by DSM-III-R criteria, were studied among 243 out-patients presenting with depression. RESULTS: Overall, 26.7% of adults in our sample with MDD met criteria for SP and 28.4% for APD. Almost two-thirds of depressed adults meeting criteria for social phobia or avoidant personality disorder met criteria for both (SP+APD). Depressed adults who met criteria for both SP+APD exhibited a significantly higher proportion of atypical depression (54.8%) compared with those with neither SP nor APD (31.1%). Among depressed patients, the co-occurrence of SP with APD was also associated with an earlier age of onset of MDD, a greater number of comorbid Axis I diagnoses, and greater impairment of social adjustment and assertiveness. CONCLUSIONS: Results confirm the overlap of SP and APD in a depressed population and the high prevalence of these disorders in MDD. They suggest that depressed individuals with both SP and APD but not SP alone are at particularly high risk for atypical depression and for social dysfunction in excess of that caused by a current major depression.     

A clinical study of a case of phobia.

Describes a 41-yr-old unmarried woman with a plethora of phobia-like symptoms and panic attacks. Symptoms include sensations of unreality, wildness, confusion, visualizations of convulsion, fear of insanity, fear of death, and fear of railway trains. The phobia of insanity and death is seen to be at the root of S's other phobias and attacks. (0 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A psychodynamic theory for dental phobia

Dentists recognise various degrees of dental anxiety in their patients. There are those who are relaxed, those who are anxious and those who are dentally phobic. The question remains why should disagreeable dental experiences result in dental anxiety in one patient, have little effect upon another and cause dental phobia in a third? The aim of this paper is to propose a psychodynamic theory for dental phobia based upon the ideas of false connections and displacement.     

Blood and injection phobia: Background and cognitive, physiological, and behavioral variables.

Blood-phobic (n?=?81) and injection-phobic (n?=?59) patients fulfilling the Diagnostic and Statistical Manual of Mental Disorders-III—Revised (DSM-III—R) criteria for simple phobia were compared on a number of variables. There were no differences between the samples in age at onset, age at treatment, marital and occupational status, history of fainting in the phobic situation, and impairment. Higher proportions of blood-phobic Ss than of injection-phobic Ss reported having 1st-degree relatives with the same phobia (61 vs 29%) and reported fearing that they were going to faint in the phobic situation (77 vs 48%). In both samples, these proportions were higher in the subgroup with a history of fainting. Injection-phobic Ss rated 2 of 11 physiological items higher than did blood-phobic Ss, but the groups did not differ on behavioral variables. Overall, the similarities were more marked than the differences, and it is suggested that these two specific phobias should be regarded as one diagnostic entity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders

BACKGROUND: The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity. METHOD: Cross-sectional and prospective data on 20,291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period. RESULTS: Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder. CONCLUSIONS: Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.     

Psychopathology of social phobia and comparison to avoidant personality disorder.

Studied the clinical manifestations of social phobia in a diagnosed sample of 21 social phobics (aged 21–53 yrs). Social phobia was found to be a chronic and pervasive condition affecting a variety of life areas and producing significant emotional distress. In a 2nd study, individuals with a diagnosis of social phobia or avoidant personality disorder were compared using a subsample of 10 socially phobic Ss and a sample of 8 Ss with avoidant personality disorder (aged 30–60 yrs). Although physiological reactivity and cognitive content were essentially the same for both groups in a number of situational tasks, those Ss with a diagnosis of avoidant personality disorder were found to be more sensitive interpersonally, and exhibited significantly poorer social skill than did the social phobic Ss. Results are discussed in relation to Diagnostic and Statistical Manual of Mental Disorders (DSM-III) criteria for social phobia, the significance of social phobia as a clinical syndrome, and the research and treatment implications of the difference found between individuals with a diagnosis of social phobia and those with avoidant personality disorders. (19 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Validity of the distinction between generalized social phobia and avoidant personality disorder.

Disorders of pervasive social anxiety and inhibition are divided into 2 categories: generalized social phobia (GSP) and avoidant personality disorder (APD). The authors explored the discriminative validity of this categorization by examining the comorbidity of GSP and APD and by comparing these groups on anxiety level, social skills, dysfunctional cognitions, impairment in functioning, and presence of concurrent disorders. Results from 23 Ss showed high comorbidity of the 2 diagnoses: All Ss who met criteria for APD also met criteria for GSP. APD was associated with greater social anxiety, impairment in functioning, and comorbidity with other psychopathology, but no differences in social skills or performance on an impromptu speech. GSP and APD seem to represent quantitatively different variants of the same spectrum of psychopathology rather than qualitatively distinct disorders. The authors also investigated a proposed social phobia subtyping scheme. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emotional imagery in simple and social phobia: Fear versus anxiety.

In a 1st study, 60 phobic volunteer Ss reacted psychophysiologically with greater vigor to imagery of their own phobic content than to other fearful or nonaffective images. Imagery heart rate responses were largest in Ss with multiple phobias. For simple (dental) phobics, cardiac reactivity was positively correlated with reports of imagery vividness and concordant with reports of affective distress; these relationships were not observed for social (speech) phobics. In a 2nd study, these phobic volunteers were shown to be similar on most measures to an outpatient clinically phobic sample. In an analysis of the combined samples, fearful and socially anxious subtypes were defined by questionnaires. Only the fearful subtype showed a significant covariation among physiological responses, imagery vividness, and severity of phobic disorder. This fearful–anxious distinction seems to cut across diagnostic categories, providing a heuristic perspective from which to view anxiety disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An investigation of gender differences in social phobia

The present study was an exploratory investigation of gender differences in a large sample of persons with social phobia. Potential differences in demographic characteristics, comorbidity, severity of fear, and situations feared were examined. No differences were found on history of social phobia, social phobia subtype, or comorbidity of additional anxiety disorders, mood disorders, or avoidant personality disorder. However, women exhibited more severe social fears as indexed by several assessment instruments. Some differences between men and women also emerged in their report of severity of fear in specific situations. Women reported significantly greater fear than men while talking to authority, acting/performing/giving a talk in front of an audience, working while being observed, entering a room when others are already seated, being the center of attention, speaking up at a meeting, expressing disagreement or disapproval to people they do not know very well, giving a report to a group, and giving a party. Men reported significantly more fear than women regarding urinating in public bathrooms and returning goods to a store. Additionally, there were some differences in the proportion of men and women reporting fear in different situations. Specifically, more women than men reported fear of going to a party, and more men than women reported fear of urinating in a public restroom. Gender differences among patients with social phobia are discussed in the context of traditional sex-role expectations.     

Age of onset in different phobias.

The age of onset, other background data, and measures from behavioral avoidance tests were studied in 370 phobic patients. They belonged to six different categories: agoraphobia (n?=?100), social phobia (n?=?80), claustrophobia (n?=?40), animal phobia (n?=?50), blood phobia (n?=?40), and dental phobia (n?=?60). Results showed that animal phobia had the earliest onset age (7 years), followed by blood phobia (9 years), dental phobia (12 years), social phobia (16 years), claustrophobia (20 years), and agoraphobia (28 years). The groups also differed in marital and occupational status, heart rate, anxiety experiences during the behavioral test, and general fearfulness. On the whole, agoraphobia and animal phobia stood out as the extremes on many measures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorders and features in social phobia and panic disorder.

The hypothesis that there is a specific relationship between social phobia (SP) and avoidant personality disorder (APD) was investigated. Using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) Personality Disorders, 32 patients with SP and 85 patients with panic disorder (PD) for the presence of personality disorders were screened. Avoidant features were found significantly more often in SP than in PD, although the diagnosis of APD could not be established significantly more often. On the item level, APD Criterion 6 (fears being embarrassed) discriminated the strongest. Social phobics appeared to be more disturbed on Axis II than PD patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sleep Deprivation in social phobia and generalized anxiety disorder

BACKGROUND: Sleep deprivation has been shown to improve depressive symptoms in some patients with major depressive disorder, but it has not been tested in patients with generalized anxiety disorder (GAD) or social phobia (SP). METHODS: To determine if sleep deprivation altered anxiety or depressive symptoms in patients with GAD (n = 7) or SP (n = 8), we sleep deprived patients and normal controls (n = 18) for one night. RESULTS: On one measure of anxiety, GAD patients improved compared with controls, but there were otherwise no significant change differences between controls and SP or GAD patients. CONCLUSIONS: The lack of benefit is consistent with previous findings that sleep deprivation provides no benefit to patients with other anxiety disorders. Sleep deprivation may be a biological intervention that distinguishes anxiety from affective disorders.     

The formation and persistence of a dental treatment phobia

The anxiety which accompanies dental care may in some cases represent a disabling handicap. The authors have outlined the characteristics of this type of dental anxiety and describe the typical pattern with which "odontophobia" is formed and persists over time. This enables them to understand the "attempted solutions" used to overcome this phobia, opening the way to the study of psychological interventions which may prove efficacious and effective.