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.REFERENCES1.Kendler K.S., Neale M.C., Kessler R.C., Heath A.C., Eaves L.J.(1992) The genetic epidemiology of phobias in women: the interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia.Arch.Gen.Psychiatry, 49: 273–281.2.Kendler K.S., Jyers J., Prescott C.A., Neale M.C.(2001) The genetic epidemiology of irrational fears and phobias in men.Arch.Gen.Psychiatry, 58: 257–265.3.Stein M.B., Chartier M.J., Hazen A.L., Kozak M.V., Tancer M.E., Lander S.,Furer P., Chubaty D., Walker, J.R.(1998) A direct-interview family study of generalized social phobia.Am.J.Psychiatry, 155: 90–97.1.7Clusters, Comorbidity and Context in Classification of Phobic DisordersJoshua D.Lipsitz1Current DSM-IV and ICD-10 phobia classifications bear a strikingresemblance to the categories proposed by Marks in 1970 [1].The diagnosesof agoraphobia and social phobia have become generally accepted as valid1 Anxiety Clinic, Unit 69, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA48 ____________________________________________________________________________________________ PHOBIASand are widely appreciated for their clinical utility.Both diagnosticcategories have generated large independent bodies of research and havebeen the focus of specified treatment approaches.However, it is equallystriking that the past three decades have generated relatively little in the way of progress toward further refinements in phobia classification.Because the third phobia category, specific phobia, was created throughsubtraction, it was not surprising to find that specific phobias differed from one another along a variety of dimensions.These include some of thosedimensions outlined by Marks and Mataix-Cols as a potential basis fortaxonomy.Clinical features such as focus of fear, presence of unexpectedpanic attacks and distinct physiological response have been taken asevidence of phobia heterogeneity in some studies [2].However, otherstudies have failed to replicate findings of clinical difference [3].Several limitations may be responsible for a lack of progress in refiningthe residual category of specific phobia.One problem is that research hasfocused on phobia heterogeneity but not on the extent to which phobiaswithin each proposed subcategory cluster.To show that new diagnosticcategories are valid, it is not sufficient to show that phobias in one category differ from those in another category.It must also be the case that different phobias within the same category are more similar to each other along thesame dimensions.This type of analysis would require very large sampleswith a range of representative phobias from each proposed category.Instead, most studies have attempted to draw conclusions from a singlerepresentative group (e.g.spider phobia for animal category) as contrasted with another representative group.In addition, most studies to date have failed to control for the impactof comorbidity.Clinical samples comprised of patients seeking treatmentfor a specific type of phobia may also have a variety of other phobias [4] as well as other comorbid anxiety disorders [5] such as panic disorder.Thesemay quietly influence observed clinical features (e.g.presence of panicattacks) attributed to specific phobias in these samples.However, sincerelatively few patients with pure (non-comorbid) specific phobia seektreatment, it is challenging to obtain pure samples of sufficient size forstudy.Finally, studies of specific phobia have taken observations at face valueand do not consider the role that external context might play in observedpatterns.While all medical and psychological disorders occur within anexternal context, phobias, like allergies, are entirely defined by their context.A large majority of phobias are direct responses to an external object orsituation.However, even for those phobias in which the focus of fear isinternal (e.g.fear of vomiting, choking or falling), it is typically through the external context that the fear becomes relevant and clinically meaningful(e.g.eating a certain type of food or walking on an icy pavement).As such,DIAGNOSIS AND CLASSIFICATION OF PHOBIAS: COMMENTARIES ____________ 49phobias are only partially a function of the individual and his or hersymptoms.Equally important to diagnosis, impairment and treatmentseeking are incidental characteristics of the external context.Consider, for example, the interpretation of observed differences in age of onset across phobias [6].Marks and Mataix-Cols point out, for example,that fear of falling (space phobia) has onset in advanced years.They present this as a feature that distinguishes this phobia from others.However, it is an open question whether this late age of onset is intrinsic and informativeabout the phobic reaction or whether it is a function of external factors in the individual’s context (e.g.increased potential for injury as one gets older, if a fall takes place).Social phobia of dating typically precedes a social phobia of speaking up at parent–teacher meetings, but we would not seethis incidental sequence as evidence that the two fears reflect distinctsyndromes.Similarly, Antony et al.[3] question the implications of later age of onset of situational fears in a sample of individuals with driving phobias: since most people do not have an opportunity to drive prior to 16 or 17, this‘‘feature’’ is incidental to the phobia.Observed differences in gender distribution across phobias may also beattributable to context.The finding of a roughly even gender distributionfor height phobias [7] appears to distinguish this phobia from other specific phobias in which distribution is skewed toward female gender.However, itis possible that height phobias are reported with high frequency in menbecause cultural norms demand that men experience much higher levels ofexposure to heights.Finally, phobia classification efforts to date may have been overlyambitious.The previous, more deliberate model of identifying a singleprominent phobic syndrome (such as social phobia) and keeping theremaining phobias in a residual status for the time being has beenabandoned.Comprehensive subtype systems have been advanced andevaluated in an all-or-nothing approach to categorize nearly all of theremaining common phobias.Unfortunately, empirical research is not yetsufficient to inform a comprehensive classification of specific phobias.REFERENCES1.Marks I.(1970) The classification of phobic disorders.Br.J.Psychiatry, 116: 377–386.2.Craske M.G., Zarate R., Burton T., Barlow D.H.(1998) The boundary betweensimple phobia and agoraphobia: a survey of clinical and nonclinical samples.In DSM-IV Sourcebook, vol.4 (Eds T.A.Widiger, A.J.Frances, H.A.Pincus, R.Ross, M.B.First, W.Davis, M.Kline), pp.217–244.American Psychiatric Association, Washington, DC.3.Antony M., Brown T.A., Barlow D.H.(1997) Heterogeneity among specificphobia types in DSM-IV.Behav.Res.Ther., 35: 1089–1100 [ Pobierz całość w formacie PDF ]
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.REFERENCES1.Kendler K.S., Neale M.C., Kessler R.C., Heath A.C., Eaves L.J.(1992) The genetic epidemiology of phobias in women: the interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia.Arch.Gen.Psychiatry, 49: 273–281.2.Kendler K.S., Jyers J., Prescott C.A., Neale M.C.(2001) The genetic epidemiology of irrational fears and phobias in men.Arch.Gen.Psychiatry, 58: 257–265.3.Stein M.B., Chartier M.J., Hazen A.L., Kozak M.V., Tancer M.E., Lander S.,Furer P., Chubaty D., Walker, J.R.(1998) A direct-interview family study of generalized social phobia.Am.J.Psychiatry, 155: 90–97.1.7Clusters, Comorbidity and Context in Classification of Phobic DisordersJoshua D.Lipsitz1Current DSM-IV and ICD-10 phobia classifications bear a strikingresemblance to the categories proposed by Marks in 1970 [1].The diagnosesof agoraphobia and social phobia have become generally accepted as valid1 Anxiety Clinic, Unit 69, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA48 ____________________________________________________________________________________________ PHOBIASand are widely appreciated for their clinical utility.Both diagnosticcategories have generated large independent bodies of research and havebeen the focus of specified treatment approaches.However, it is equallystriking that the past three decades have generated relatively little in the way of progress toward further refinements in phobia classification.Because the third phobia category, specific phobia, was created throughsubtraction, it was not surprising to find that specific phobias differed from one another along a variety of dimensions.These include some of thosedimensions outlined by Marks and Mataix-Cols as a potential basis fortaxonomy.Clinical features such as focus of fear, presence of unexpectedpanic attacks and distinct physiological response have been taken asevidence of phobia heterogeneity in some studies [2].However, otherstudies have failed to replicate findings of clinical difference [3].Several limitations may be responsible for a lack of progress in refiningthe residual category of specific phobia.One problem is that research hasfocused on phobia heterogeneity but not on the extent to which phobiaswithin each proposed subcategory cluster.To show that new diagnosticcategories are valid, it is not sufficient to show that phobias in one category differ from those in another category.It must also be the case that different phobias within the same category are more similar to each other along thesame dimensions.This type of analysis would require very large sampleswith a range of representative phobias from each proposed category.Instead, most studies have attempted to draw conclusions from a singlerepresentative group (e.g.spider phobia for animal category) as contrasted with another representative group.In addition, most studies to date have failed to control for the impactof comorbidity.Clinical samples comprised of patients seeking treatmentfor a specific type of phobia may also have a variety of other phobias [4] as well as other comorbid anxiety disorders [5] such as panic disorder.Thesemay quietly influence observed clinical features (e.g.presence of panicattacks) attributed to specific phobias in these samples.However, sincerelatively few patients with pure (non-comorbid) specific phobia seektreatment, it is challenging to obtain pure samples of sufficient size forstudy.Finally, studies of specific phobia have taken observations at face valueand do not consider the role that external context might play in observedpatterns.While all medical and psychological disorders occur within anexternal context, phobias, like allergies, are entirely defined by their context.A large majority of phobias are direct responses to an external object orsituation.However, even for those phobias in which the focus of fear isinternal (e.g.fear of vomiting, choking or falling), it is typically through the external context that the fear becomes relevant and clinically meaningful(e.g.eating a certain type of food or walking on an icy pavement).As such,DIAGNOSIS AND CLASSIFICATION OF PHOBIAS: COMMENTARIES ____________ 49phobias are only partially a function of the individual and his or hersymptoms.Equally important to diagnosis, impairment and treatmentseeking are incidental characteristics of the external context.Consider, for example, the interpretation of observed differences in age of onset across phobias [6].Marks and Mataix-Cols point out, for example,that fear of falling (space phobia) has onset in advanced years.They present this as a feature that distinguishes this phobia from others.However, it is an open question whether this late age of onset is intrinsic and informativeabout the phobic reaction or whether it is a function of external factors in the individual’s context (e.g.increased potential for injury as one gets older, if a fall takes place).Social phobia of dating typically precedes a social phobia of speaking up at parent–teacher meetings, but we would not seethis incidental sequence as evidence that the two fears reflect distinctsyndromes.Similarly, Antony et al.[3] question the implications of later age of onset of situational fears in a sample of individuals with driving phobias: since most people do not have an opportunity to drive prior to 16 or 17, this‘‘feature’’ is incidental to the phobia.Observed differences in gender distribution across phobias may also beattributable to context.The finding of a roughly even gender distributionfor height phobias [7] appears to distinguish this phobia from other specific phobias in which distribution is skewed toward female gender.However, itis possible that height phobias are reported with high frequency in menbecause cultural norms demand that men experience much higher levels ofexposure to heights.Finally, phobia classification efforts to date may have been overlyambitious.The previous, more deliberate model of identifying a singleprominent phobic syndrome (such as social phobia) and keeping theremaining phobias in a residual status for the time being has beenabandoned.Comprehensive subtype systems have been advanced andevaluated in an all-or-nothing approach to categorize nearly all of theremaining common phobias.Unfortunately, empirical research is not yetsufficient to inform a comprehensive classification of specific phobias.REFERENCES1.Marks I.(1970) The classification of phobic disorders.Br.J.Psychiatry, 116: 377–386.2.Craske M.G., Zarate R., Burton T., Barlow D.H.(1998) The boundary betweensimple phobia and agoraphobia: a survey of clinical and nonclinical samples.In DSM-IV Sourcebook, vol.4 (Eds T.A.Widiger, A.J.Frances, H.A.Pincus, R.Ross, M.B.First, W.Davis, M.Kline), pp.217–244.American Psychiatric Association, Washington, DC.3.Antony M., Brown T.A., Barlow D.H.(1997) Heterogeneity among specificphobia types in DSM-IV.Behav.Res.Ther., 35: 1089–1100 [ Pobierz całość w formacie PDF ]