This excerpt from a 1999 U.S. Surgeon General's Mental Health Report summarizes the definitions and incidences in the U.S. population of agoraphobia; specific phobias (such as fear of snakes, spiders, heights, etc.); and social phobias (such as fear of public speaking or performance).
Mental Health: A Report of the Surgeon General (1999)
(excerpt from Chapter 4, “Anxiety Disorders”)
The ancient term agoraphobia is translated from Greek as fear of an open marketplace. Agoraphobia today describes severe and pervasive anxiety about being in situations from which escape might be difficult or avoidance of situations such as being alone outside of the home, traveling in a car, bus, or airplane, or being in a crowded area (DSM-IV).
Most people who present to mental health specialists develop agoraphobia after the onset of panic disorder (American Psychiatric Association, 1998). Agoraphobia is best understood as an adverse behavioral outcome of repeated panic attacks and the subsequent worry, preoccupation, and avoidance (Barlow, 1988). Thus, the formal diagnosis of panic disorder with agoraphobia was established. However, for those people in communities or clinical settings who do not meet full criteria for panic disorder, the formal diagnosis of agoraphobia without history of panic disorder is used (DSM-IV).
The 1-year prevalence of agoraphobia is about 5 percent (Table 4-1). Agoraphobia occurs about two times more commonly among women than men (Magee et al., 1996). The gender difference may be attributable to social-cultural factors that encourage, or permit, the greater expression of avoidant coping strategies by women (DSM-IV), although other explanations are possible.
These common conditions are characterized by marked fear of specific objects or situations (DSM-IV). Exposure to the object of the phobia, either in real life or via imagination or video, invariably elicits intense anxiety, which may include a (situationally bound) panic attack. Adults generally recognize that this intense fear is irrational. Nevertheless, they typically avoid the phobic stimulus or endure exposure with great difficulty. The most common specific phobias include the following feared stimuli or situations: animals (especially snakes, rodents, birds, and dogs); insects (especially spiders and bees or hornets); heights; elevators; flying; automobile driving; water; storms; and blood or injections.
Approximately 8 percent of the adult population suffers from one or more specific phobias in 1 year (Table 4-1). Much higher rates would be recorded if less rigorous diagnostic requirements for avoidance or functional impairment were employed. Typically, the specific phobias begin in childhood, although there is a second “peak” of onset in the middle 20s of adulthood (DSM-IV). Most phobias persist for years or even decades, and relatively few remit spontaneously or without treatment.
The specific phobias generally do not result from exposure to a single traumatic event (i.e., being bitten by a dog or nearly drowning) (Marks, 1969). Rather, there is evidence of phobia in other family members and social or vicarious learning of phobias (Cook & Mineka, 1989). Spontaneous, unexpected panic attacks also appear to play a role in the development of specific phobia, although the particular pattern of avoidance is much more focal and circumscribed.
Social phobia, also known as social anxiety disorder, describes people with marked and persistent anxiety in social situations, including performances and public speaking (Ballenger et al., 1998). The critical element of the fearfulness is the possibility of embarrassment or ridicule. Like specific phobias, the fear is recognized by adults as excessive or unreasonable, but the dreaded social situation is avoided or is tolerated with great discomfort. Many people with social phobia are preoccupied with concerns that others will see their anxiety symptoms (i.e., trembling, sweating, or blushing); or notice their halting or rapid speech; or judge them to be weak, stupid, or “crazy.” Fears of fainting, losing control of bowel or bladder function, or having one’s mind going blank are also not uncommon. Social phobias generally are associated with significant anticipatory anxiety for days or weeks before the dreaded event, which in turn may further handicap performance and heighten embarrassment.
The 1-year prevalence of social phobia ranges from 2 to 7 percent (Table 4-1), although the lower figure probably better captures the number of people who experience significant impairment and distress. Social phobia is more common in women (Wells et al., 1994). Social phobia typically begins in childhood or adolescence and, for many, it is associated with the traits of shyness and social inhibition (Kagan et al., 1988). A public humiliation, severe embarrassment, or other stressful experience may provoke an intensification of difficulties (Barlow, 1988). Once the disorder is established, complete remissions are uncommon without treatment. More commonly, the severity of symptoms and impairments tends to fluctuate in relation to vocational demands and the stability of social relationships. Preliminary data suggest social phobia to be familial (Rush et al., 1998).
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