Simple phobia as a comorbid anxiety disorder

DEPRESSION AND ANXIETY 7:105–112 (1998)

SIMPLE PHOBIA AS A COMORBID ANXIETY DISORDER Robert M. Goisman, M.D.,1,2* Jenifer Allsworth, B.A.,3 Malcolm P. Rogers, M.D.,2,4 Meredith G. Warshaw, M.S.S., M.A.3 Idell Goldenberg, Psy.D., M.A.,3 Russell G. Vasile, M.D.,2,5 Fernando Rodriguez-Villa, M.D.,2,6 Gopinath Mallya, M.D.,2,7 and Martin B. Keller, M.D.3,8 This study sought to describe clinical and demographic characteristics differentiating patients with DSM-III-R simple phobias comorbid with one or more of five DSM-III-R index anxiety disorders as compared with those with the index diagnoses alone. From 711 subjects participating in a multicenter, longitudinal, naturalistic study of anxiety disorders, 115 subjects with comorbid simple phobias were compared with 596 subjects without simple phobias in terms of demographic data, comorbidity with other disorders, somatic and psychosocial treatment received, and quality of life. In addition, episode characteristics, types of simple phobias found, and course of illness were specified. Subjects with simple phobias had more additional comorbid anxiety disorders by history than did those without. Mean length of intake episode was 22.43 years and severity was typically moderate. Fears of heights and animals were the most commonly represented simple phobias. Subjects with uncomplicated panic disorder were less likely to have comorbid simple phobias than were subjects with other index diagnoses, and subjects with simple phobia were more likely to have comorbid posttraumatic stress disorder than were those without simple phobia. Subjects with and without simple phobias did not differ by somatic or psychosocial treatment received or in terms of quality of life. Simple phobia appeared in this study to be a chronic illness of moderate severity for which behavioral treatment methods of recognized efficacy were not being frequently utilized. Uncomplicated panic disorder may reflect some type of resistance to phobia development. Depression and Anxiety 7:105–112, 1998. © 1998 Wiley-Liss, Inc. Key words: phobia; anxiety; comorbidity

S

INTRODUCTION

imple phobia is an anxiety disorder with a venerable history of psychiatric interest. It is a common diagnosis, with the National Comorbidity Survey (Kessler et al., 1994) reporting a lifetime prevalence of 6.7% for males and 15.7% for females using DSM-III-R criteria (APA, 1987) and the Epidemiologic Catchment Area (ECA) study (Robins et al., 1984) reporting lifetime prevalences at three sites of 3.8–14.5% for males and 8.5–25.9% for females using DSM-III criteria (APA, 1980). Despite its history and frequency, however, there is a relative lack of data about this disorder, especially regarding comorbidity, treatment, and course. In this paper, after a brief review of relevant recent literature, we report on descriptive and clinical characteristics of patients with DSM-III-R simple phobia comorbid with one or more anxiety diagnoses. In so doing, we hope to identify characteristics specific for simple phobia in this population and to clarify the additional burden of illness which simple phobias contribute to patients with anxiety disorders. DSM-III-R (APA, 1987) identified three types of © 1998 WILEY-LISS, INC.

1

Massachusetts Mental Health Center, Boston, Massachusetts Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 3 Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island 4 Division of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts 5 Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts 6 Department of Psychiatry, Cambridge Hospital, Cambridge, Massachusetts 7 McLean Hospital, Belmont, Massachusetts 8 Butler Hospital, Providence, Rhode Island 2

Contract grant sponsor: Upjohn Company; Contract grant sponsor: NIMH; Contract grant number: MH51415. *Correspondence to: Robert M. Goisman, M.D., Massachusetts Mental Health Center, 74 Fenwood Road, Boston, MA 02115. Received for publication 2 July 1997; Accepted 15 October 1997

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simple phobias: fears of animals or insects, of blood or injury, or of situations (e.g., heights, air travel, or closed spaces; Himle et al., 1989). Some investigators have added other categories to these, e.g., claustrophobia (Ost, 1987), choking or vomiting (Himle et al., 1989), and dental work (Ost, 1987). DSM-IV re-categorized these types as those of animals, natural environment, blood-injection-injury, situations, or other (APA, 1994), also renaming the category “specific phobia” rather than “simple phobia” but not otherwise substantively altering the criteria for the diagnosis (Fyer et al., 1995). Investigators have examined the age of onset of simple phobia symptoms in DSM-III and in DSM-IIIR. Ost (1987) studied 190 patients with DSM-III simple phobias of closed spaces (i.e., claustrophobia), animals, blood, and dental work, and found that animal phobias had the earliest age of onset (7 years), followed by those of blood (9 years), dental work (12 years), and closed spaces (20 years). Craske et al. (1993) studied 95 patients meeting DSM-III-R anxiety disorder criteria and found animal phobias to again have the earliest age of onset, closed places the latest, and blood/injury in between. Kendler et al. (1992) also found DSM-III animal phobias to have earlier onset and situational phobias later onset in their study of 2163 adult female twins from a population-based (i.e., not clinical) twin registry study. In a group of 88 DSM-III simple phobics Himle et al. (1989) similarly found the mean age of onset to be greatest for patients with situational phobias at 27.3 years, least for bloodinjury (12.4) and animal-insect phobics (14.9), and intermediate for choking-vomit phobics (20.6 years). Patterns of comorbidity involving simple phobia patients have also been investigated. Kendler et al. (1992) found situational and animal phobias to have lower rates of comorbidity with major depression, generalized anxiety disorder, panic disorder, alcoholism, and eating disorders compared to agoraphobia or social phobia. Brawman-Mintzer et al. (1993) found simple phobia to be a common comorbid diagnosis in their group of DSM-III-R generalized anxiety disorder patients (21%, or 23/109 subjects); this finding is similar to that of Borkovec et al. (1995), who found simple phobia in 40% of 55 patients with DSM-III-R generalized anxiety. Judd (1994) reported a lifetime comorbidity for simple phobia of 59% among patients with social phobia. Sanderson et al. (1994) found simple phobia to be the anxiety disorder least often comorbid with a personality disorder (12% of 123 patients with comorbid anxiety and personality disorders). Fyer et al. (1995) found the majority of cases of simple phobia among family members of patients with simple phobia to be without comorbid anxiety disorders, although it should be noted that in this study no simple phobia probands had comorbid anxiety disorders (p. 568). In an earlier report of the comorbidity of anxiety disorders observed within the larger Harvard/Brown

Anxiety Disorders Research Program (HARP), from which the present paper emanates, Goisman et al. (1995) found that simple phobia most commonly accompanied agoraphobia without history of panic disorder (AWOPD) among the five HARP index diagnoses (20% lifetime and current) and least often accompanied uncomplicated panic (9% lifetime, 8% current). These studies all address certain aspects of the phenomenology and comorbidity of simple phobias, but none of them present longitudinal data regarding the course and treatments received by a clinical study group of anxiety disorder patients all of whom had simple phobias as comorbid disorders. The HARP study, with its large study group size, 5 year length of follow-up, and rigorous assessment and monitoring instruments, particularly lends itself to addressing some of these gaps in the literature.

METHODS This paper draws upon data collected in the Harvard/ Brown Anxiety Disorders Research Program. This prospective, naturalistic, longitudinal study of adults with present or past anxiety disorders consists of 711 subjects from 11 sites. The methods are described in detail elsewhere (Massion et al., 1993). Patients were recruited for this study if they had at least one of the following current or past DSM-III-R index anxiety diagnoses: panic disorder (with or without agoraphobia), agoraphobia without a history of panic disorder (AWOPD), generalized anxiety disorder (GAD), or social phobia. A small number (n = 19) of subjects with obsessive-compulsive disorder (OCD) but without other past or present comorbid index diagnoses were admitted as well for a small substudy comparing primary OCD with OCD as a comorbid anxiety disorder. Insufficient for inclusion, but frequently seen as comorbid conditions, were DSM-IIIR diagnoses of simple phobia, posttraumatic stress disorder, obsessive-compulsive disorder (except as described above), or anxiety disorder not otherwise specified. Subjects had to be at least 18 years of age and willing to voluntarily participate in the study and sign a consent form. Exclusion criteria were the presence of an organic brain syndrome, a history of schizophrenia, or current psychosis. This protocol allowed for multiple diagnoses among the index disorders as well as all other DSM-III-R psychiatric diagnoses. Treatment was monitored but not otherwise influenced, as is customary in naturalistic designs. The initial comprehensive evaluation assessed demographic characteristics and lifetime history of mental disorders by using selected items from the Personal History of Depressive Disorders (Hogarty et al., 1980), the Structured Clinical Interview for the DSM-III-R Non-Affective Disorders-Patient Version (SCID-P; Spitzer et al., 1988), the Medical History Form-II (Scheftner and Endicott, 1984), and the Research Diagnostic Criteria (RDC) Schedule for Af-

Research Article: Simple Phobia as a Comorbid Anxiety Disorder

fective Disorders-Lifetime (SADS-L; Endicott and Spitzer, 1978). Items of the SCID-P and SADS-L were combined to create the SCALUP (Keller et al., 1987b), a single intake instrument used to diagnose all HARP subjects. Follow-ups were conducted at 6 month intervals for the first 2 years and annually thereafter. Follow-up assessments were based on the Longitudinal Interval Follow-Up Evaluation-Upjohn (LIFE-UP; Keller et al., 1987a), which collects detailed information on the course of illness, severity of symptoms, somatic treatment, and psychosocial functioning using a “change point” method to anchor weekly symptom ratings from birthdays, holidays, and other relevant life events (Warshaw et al., 1994). Reliability data for the LIFEUP are described in Warshaw et al. (1994). Personality assessment was conducted using the Personality Disorder Examination (PDE; Loranger et al., 1987) and the Personality Diagnostic Questionnaire-Revised (PDQ), a self-report measure (Hyler et al., 1990); in this paper data from the PDE collected at the 1 year follow-up assessment were used. Psychosocial treatment received was assessed using the Psychosocial Treatments Interview (PTI), the construction and psychometric properties of which are described elsewhere (Steketee et al., 1997; Goisman et al., 1993). The LIFE-UP method used was based on that originally used in the NIMH Collaborative Depression Study (Keller et al., 1987a; Warshaw et al., 1994), with Psychiatric Status Ratings (PSR’s) created for the DSM-III-R anxiety disorders being followed in this study. Warshaw et al. (1994) discuss the reliability of these PSR’s; in particular, intra-class correlation for the simple phobia PSR’s was .98. Individual PSR’s were assigned for each week of follow-up, as shown in Table 1. In this article we refer to sustained decreases in seTABLE 1. Psychiatric status scale for simple phobia Code

Definition

6

Meets full DSM-III-R criteria for Simple Phobia and phobic avoidance grossly interferes with the person’s normal routine, or with usual social activities, or relationships with others. Meets full criteria for Simple Phobia without gross interference in functioning. Meets all criteria for Simple Phobia excluding criterion D (interference or marked distress about having the fear). Meets criterion A (fear) and criterion F (exclusionaries). Fails at least two, but not all criteria B, C, D, and E. Meets criterion A (fear) and criterion F (exclusionaries) only. Fails all other criteria for DSM-III-R Simple Phobia. None of the above. Weekly status ratings prior to the introduction of a new diagnosis (used, when a subject has had the onset of a new disorder between follow-up interviews, to denote the period within that interval before the onset of the new diagnosis).

5 4 3 2 1 0

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verity and number of symptoms as “remissions.” We have adopted this convention because the severity and length of the symptom-free period necessary to constitute a “recovery” is not known (Frank et al., 1991). Remission in the HARP study was defined a priori as a PSR of 2 or less for 8 consecutive weeks. Subjects who met this definition were virtually asymptomatic for 2 consecutive months at some point during the follow-up. All statistical analyses were conducted in SAS, Version 6.07 (SAS, 1990). Comparisons between the simple phobia and non-simple phobia groups were made for sociodemographic variables, Global Assessment Scores (GAS), history of suicidality and psychiatric hospitalization, and comorbidity with anxiety, affective, and personality disorders. We did not control for possible differences in prevalences of other anxiety disorders in the two groups (simple phobia vs. non-simple phobia). Statistical comparisons of distributions on categorical variables were calculated using chi-square tests or Fisher’s exact test (PROC FREQ), while those for continuous variables were calculated by T-test (PROC TTEST). Longitudinal data were analyzed using standard survival analysis techniques (Kalbfleish and Prentice, 1980). All survival analyses were conducted using PROC LIFETEST and PROC PHREG. Due to the exploratory nature of this paper many analyses were conducted, which could increase the likelihood of spurious findings. All P-values are two-tailed.

RESULTS Demographic data are displayed in Table 2. The 115 subjects in episode of simple phobia at intake tended to be more likely female than the 596 without it. Also, they were marginally more likely to be married and slightly older. Subjects with simple phobia had significantly more additional comorbid anxiety disorders by history (index disorder with simple phobia X = 2.03 vs. index disorder with no simple phobia X = 1.73, t = –3.19, df = 146.3, P = .002). The mean length of intake episodes was 22.43 years. Mean age at onset of simple phobia symptoms was 14.36 years ± 10.8. There were no significant differences between subjects with vs. without comorbid simple phobia regarding work status, financial assistance, education, GAS score at intake, history of pre-intake suicidal gestures or attempts, history of psychiatric hospitalization, or number of comorbid psychiatric illnesses other than anxiety disorders. Types of simple phobias found among HARP subjects are presented in Table 3. Fear of heights was the most commonly represented single type of simple phobia, followed by those of animals, spaces, and blood, but the difference between fear of heights and of animals was not statistically significant. Almost half of the subjects had one or more of 16 simple phobias not covered by the above typology,

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TABLE 2. Subject characteristics

TABLE 4. Rate of simple phobia in the presence of index anxiety disorders

No simple phobia Simple phobia n (% of 596) n (% of 115)

Simple phobia n (row %)

a

Gender Female Male Works full-time Receives financial assistance Marrieda Education Graduate College graduate Partial college High school < High school Age at intake (Mean ± S.D.)b GAS at intake (Mean ± S.D.) Suicide gestures or attempts before intake Ever hospitalized — Phychiatric # anxiety disordersc,d (Mean ± S.D.) # non-anxiety disorders (Mean ± S.D.) Mean length of intake episodes (Mean years ± S.D.)

383 (64) 213 (36) 252 (42) 147 (25) 296 (50)

88 (77) 27 (23) 49 (43) 31 (27) 72 (63)

91 (15) 149 (25) 172 (29) 141 (24) 41 (7) 40.1 ± 12.6 60.1 ± 11.5 60 (10)

17 (15) 18 (16) 35 (30) 31 (27) 14 (12) 43.2 ± 12.7 59.7 ± 10.8 11 (10)

204 (34) 1.73 ± 0.80

40 (35) 2.03 ± 0.96

0.77 ± 0.90

0.87 ± 1.01

—

22.43 ± 15.05

a

X2 = 6.5; df = 1, P = .01. t = 2.44; df = 709; P = .01. c t = –3.19; df = 146.3; P = .002. d Not including simple phobias. b

e.g., flying, water, crowds, or loud noises. One third had more than one type of phobia. There was no difference in age of onset between these types of phobias (i.e., animals or insects, blood or injury, or heights or situations). Comorbidity of simple phobia with HARP index diagnoses is presented in Table 4. Subjects with uncomplicated panic disorder were less likely to have comorbid simple phobia than were subjects with other HARP index diagnoses. All tests compared presence vs. absence of the disorder. The comorbidity of simple phobia with other psychiatric disorders is presented in Table 5. Subjects with simple phobia were more likely to have comorbid post-traumatic stress disorder (PTSD) than were those without simple phobia. Rates of ob-

Uncomplicated panica (n=81) Panic w/agorb (n=357) AWOPD (n=30) GAD (n=180) Social phobia (n=176) Any of the above disorders (n=606) a

X2 = 5.18; df = 1; P = .02. X2 = 6.23; df = 1; P = .01.

b

sessive-compulsive disorder (OCD), various forms of depression, histories of alcoholism or other substance abuse, or any of 11 personality disorders (data not shown) were not statistically significantly different for HARP subjects with or without simple phobia. As in Table 4, all tests compared presence vs. absence of the disorder. Treatment data are presented in Table 6. The presence or absence of simple phobia did not change the likelihood that psychotropic medication would be prescribed nor the class of medication selected. Further, there was no significant difference between subjects with and without simple phobias in the number of psychotropic medications prescribed (mean number of medications prescribed was 1.48 for subjects without simple phobia and 1.38 for those with simple phobia). Similarly, the likelihood that any particular psychotherapy would be received, chiefly referring to behavioral, cognitive, supportive, or dynamic forms of therapy, did not vary with the presence or absence of simple phobia. Course data up to 5 years were available for 112 of the 115 subjects with simple phobia (see Table 7). All disorders were categorized as yes/no in episode (see Methods). The probability of remission of simple phobia symptoms was low at all times, with 5% having achieved remission at 6 months and only 20% having achieved remission at 5 years. All other subjects still met either partial or full criteria and thus were still in TABLE 5. Rates of comorbid diagnoses in presence or absence of simple phobia

TABLE 3. Types of phobias

No simple phobia n (% of 596) n (% of 115)a

Animal Heights Spaces Blood Other More than one type of phobia a

6 (7) 70 (20) 7 (23) 34 (19) 36 (20) 103 (17)

37 (32) 47 (41) 19 (17) 8 (7) 50 (44) 38 (33)

Percentages add up to >100 because categories are not mutually exclusive.

OCD (n=113) PTSDa (n=54) Major depression (n=192) Minor depression (n=41) IDD (n=109) History of alcohol abuse (n=198) History of substance abuse (n=119) a

X2 = 5.80; df = 1; P = .02.

101 (17) 39 (7) 161 (27) 38 (6) 89 (15) 164 (28) 98 (16)

Simple phobia n (% of 115) 12 (10) 15 (13) 31 (27) 3 (3) 20 (17) 34 (30) 21 (18)

Research Article: Simple Phobia as a Comorbid Anxiety Disorder

TABLE 6. Treatment

Somatic treatment Any medication Benzodiazepine SSRI MAOI Tricyclic Psychosocial treatment at 6 month follow-up Behavioral Cognitive Dynamic

No simple phobia

Simple phobia

n (% of 553) 457 (84) 346 (630 121 (22) 26 (5) 137 (25) n (% of 445)

n (% of 112) 88 (79) 69 (62) 24 (21) 3 (3) 31 (28) n (% of 90)

82 (18) 63 (14) 147 (33)

15 (17) 15 (17) 30 (33)

episode. Two subjects (out of 20) achieved remission but later relapsed to full criteria. The probability of remission did not vary with the number of comorbid disorders at intake, number of phobias, types of phobias, gender, or history of major depressive disorder. We cannot make inferences about the relationship between treatment status and likelihood of remission, as HARP is a naturalistic study and all HARP subjects were referred into the study from clinical practitioners during the course of treatment. All 115 subjects were in episode of simple phobia at intake. Of the 112 subjects for whom course data are available, 71 (63%) met full DSM-III-R criteria (i.e., PSR ≥ 5) at week 1 of follow-up, although only one of these subjects had PSR = 6 (gross interference; see Table 1 for PSR definitions). Thirty-eight subjects (34%) met partial DSM-III-R criteria (PSR = 3 or 4) at week 1 of follow-up, and only 3 (3%) had minimal or no symptoms, i.e., had PSR ≤ 2. There were no significant differences between patients with and without simple phobia regarding a number of subject-rated quality of life measures (Katz et al., 1979; Stewart et al., 1988). These included relationships with family and friends, emotional health, levels of nervousness, and others.

DISCUSSION One finding of immediate significance is the length of the typical episode of simple phobia within our TABLE 7. Kaplan-Meier estimates of probability of remission of simple phobia

6 months 1 year 2 years 3 years 4 years 5 years

n at risk

Cumulative probability

n remissions in interval

112 100 94 83 60 41

.05 .11 .14 .17 .20 .20

6 6 3 3 2 0

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sample, which was 22.43 years (Table 2). Given this time span and the low probability of remission as shown in Table 7, the impact of these disorders may not be trivial. On the other hand, 63% of the subjects met full criteria but only one experienced “gross interference” from these symptoms, possibly signifying only a moderate effect of the symptoms upon subjects’ lives. A brief look at two of our subjects’ narrative descriptions of their symptoms and courses may be illustrative here. One 50-year-old subject with social phobia and a history of major depression further described simple phobic avoidance of birds and of water since age 10, predating the onset of any other psychiatric symptoms; this woman cannot go to restaurants with her family because of the prevalence of pigeons and other birds nearby, nor can she take part in waterfront sports or other activities with her family in the summertime. Another woman, age 40, has had a clear simple phobia of bees since age 7, in addition to panic disorder with agoraphobia and major depression of much later onset; she has had times in which she would stay in her house for prolonged time periods unrelated to exacerbations of her other two disorders just because bees were prevalent then. Another possibility for the appearance of only a moderate degree of impact is that subjects’ expectations of what constituted normal life for themselves may have been revised to accommodate the phobias. Given the already established chronicity of these disorders and the tendency of some phobic patients to arrange their lives so as to diminish the likelihood of contact with their phobic stimuli (Marks, 1987), it may be that the impact of these symptoms has been lost and does not register because subjects may now be defining their phobia-constricted lifestyle as “normal.” As described above (Tables 4 and 5), subjects with uncomplicated panic were less likely to have comorbid simple phobia than were other HARP subjects, and those with simple phobia were more likely to have additional comorbid PTSD than were those without simple phobia. Posttraumatic stress disorder frequently has phobic avoidance as part of its symptomatology, demonstrating some phenomenologic commonality with simple phobias. These findings, and those of Table 2 in which the number of comorbid anxiety disorders is increased among those with simple phobia, suggest that certain disorders may reflect or confer vulnerability to “phobicness,” i.e., a phobic diathesis, while others may reflect some degree of resistance to phobia development, e.g., uncomplicated panic disorder. Himle et al. (1989) similarly observed that patients with panic disorder did not have a heightened likelihood of developing animal or blood-injury phobias, a finding compatible with our own. Thus, simple phobias may represent a phenomenologic “marker” for one’s de-

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gree of vulnerability to the development of other, more severe anxiety disorders which are defined by more widespread avoidance. Alternatively, the overlap among these disorders could be looked at as an artifact of the way in which these diagnostic categories have been constructed. We have commented elsewhere on the degree to which the extensive comorbidity of generalized anxiety disorder (GAD) with other HARP diagnoses might be taken as a call to re-evaluate the usefulness of GAD as an independent diagnostic category (Goisman et al., 1995), and others have explored the same issue regarding agoraphobia without history of panic disorder (Horwath et al., 1993). Similarly, the present data may call into question the validity of our nosology for simple phobia. Almost half of our subjects had phobic stimuli not fitting into the DSM-III-R category system, so that there may be problems with the subcategories within the simple phobia construct as well as with the broader definition of simple phobia itself. (All subjects when reanalyzed using DSM-IV criteria still met criteria for specific phobia.) In contrast to the studies cited earlier, our subjects with animal phobias did not share the earlier age of onset described by other writers (Ost, 1987; Kendler et al., 1992; Craske et al., 1993). Furthermore, the mean age of onset of all of our subjects at 14.36 years is older than all those described earlier by Ost (1987). One potential cause for these discrepancies might be related to our subjects’ phobias occurring only as comorbid with other anxiety disorders, as compared with other investigations which observed simple phobia as a primary or sole diagnosis. In addition, the literature is not unanimous in its findings in this area, with Himle et al. (1989) finding a mean age of onset for animal phobias of 12.8 years (excluding one outlying case) and Thyer et al. (1985) reporting a mean age of onset of 16.1 years for mixed animal and specific phobias. Thus, it is not clear whether the present data represent a deviation from previous findings or simply a new set of findings in an area in which previous data have not always agreed. Remarkably, the presence or absence of comorbid simple phobia did not affect the type or even quantity of treatment received, either somatic or psychosocial. As no medication is currently indicated for the treatment of simple phobia, this finding may not be of great significance from a pharmacologic standpoint. However, there is no dearth of data justifying the use of behavioral methods as specific treatment for simple phobia (e.g., Marks, 1987), so that the relative absence of behavior therapy as a modality used in the treatment of simple phobic HARP subjects is significant. We have written elsewhere about the relative underutilization of behavioral treatment within the HARP study (Goisman et al., 1993); this may be yet another manifestation of the same problem. Thus, HARP subjects with comorbid simple phobias did not receive more somatic or psychosocial

treatment or have more impairment of quality of life than did those without simple phobias. It must be kept in mind that simple phobia was not an index diagnosis for HARP recruitment, so that subjects specifically requesting treatment for simple phobia would have been excluded from this study group unless they had a comorbid index disorder. Therefore our data may reflect characteristics of simple phobia only when it is comorbid and not primary, and therefore not be generalizable to patients with self-identified distressing simple phobia seeking treatment in other settings (see Chapman et al., 1993 for more on this point). Similarly, due to the inclusion criteria for this study there could not be a “simple phobia only” group with which to make comparisons. What cannot therefore be determined is the degree to which undertreatment of simple phobic symptoms is a serious problem. It is reasonable to suspect that the long episode lengths and chronic, non-remitting course experienced by HARP subjects would be similar to the episode length and course of simple phobia treatment-seekers elsewhere; the latter group might more likely have quality of life impairment than did members of our study group. In this regard we note the work of Chapman et al. (1993), who compared 25 DSM-III-R treated simple phobia patients with 58 untreated simple phobics and found the treated group to have more “functionally impairing” phobias (p. 817), the presence of more than one distinct phobia, and the presence of panic symptoms when in contact with the phobic stimulus. It may be that index disorder symptomatology diminishes the salience to clinicians of these persistent but potentially very treatable disorders, and our study methodology precludes our learning the degree to which referring clinicians were aware of the simple phobia diagnosis or offered treatment targeted to it. But the long course and lack of successful treatment found here for simple phobias should impel us to examine our treatment methods in order to determine whether or not we are doing the best we can to help alleviate the suffering undergone by patients with anxiety disorders. Acknowledgments. The Harvard/Brown Anxiety Disorders Research Program is conducted with the participation of the following investigators: P. Alexander, M.D., A. Gordon, M.D., M.B. Keller, M.D. (Chairperson), S. Rasmussen, M.D., R. Stout, Ph.D. (Butler Hospital—Brown University School of Medicine); M.G. Warshaw, M.S.S., M.A. (Brown University School of Medicine); T. Shea, Ph.D. (Veterans Administration Medical Center, Providence—Brown University School of Medicine); J. Cole, M.D., G. Mallya, M.D. (McLean Hospital—Harvard Medical School); E. Fierman, M.D.; F. Rodriguez-Villa, M.D. (Cambridge Hospital—Harvard Medical School); M.P. Rogers, M.D. (Brigham and Women’s Hospital—Harvard Medical School); R.M. Goisman, M.D. (Massachusetts Mental Health Center—Harvard Medi-

Research Article: Simple Phobia as a Comorbid Anxiety Disorder

cal School); N. Weinshenker, M.D. (University of Medicine and Dentistry—New Jersey Medical School); R. Vasile, M.D. (Beth Israel Deaconess Medical Center— Harvard Medical School); J. Ellison, M.D., M.P.H. (Harvard Pilgrim Health Care and Cambridge Hospital—Harvard Medical School); A. Massion, M.D. (University of Massachusetts Medical School); G. Steketee, Ph.D. (Boston University School of Social Work); K. Yonkers, M.D. (University of Texas—Southwestern Medical Center). Additional contributions from: J. Curran, M.D.; I. Goldenberg, Psy.D.; R. Hirschfeld, M.D. (University of Texas Medical Branch, Galveston); J. Hooley, D. Phil. (Harvard University); P. Lavori, Ph.D. (Stanford University); J. Perry, M.D. (Jewish General Hospital—McGill University School of Medicine, Montreal); L. Peterson, M.D. (Veterans Administration Hospital, Togus, Maine); J. Reich, M.D. M.P.H.; J. Rice, Ph.D. (Renard Hospital—Washington University School of Medicine, St. Louis); H. Samuelson, M.A. (Brigham and Women’s Hospital); D. Shera, M.S.; M. Weissman, Ph.D. (Columbia University); K. White, M.D. (St. Elizabeth’s Hospital, Brighton, MA). This investigation was supported in part by the Upjohn Company. This study was supported by NIMH Grant # MH51415. The Quintiles Corporation provided valuable consultation services to this project. This manuscript has been reviewed by the Publications Committee of the Harvard/Brown Anxiety Disorders Research Program and has its endorsement.

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