Psychological Medicine, 2007, 37, 1047–1059.

f 2007 Cambridge University Press

doi:10.1017/S0033291707000086 First published online 5 March 2007 Printed in the United Kingdom

The epidemiology of DSM-IV specific phobia in the

USA : results from the National Epidemiologic Survey
on Alcohol and Related Conditions
F R E D E R I C K S. S T I N S O N , D E B O R A H A. D A W S O N , S. P A T R I C I A C H O U ,
S H A R O N S M I T H , R I S E B. G O L D S T E I N , W. J U N E R U A N A N D B R I D G E T F. G R A N T*
Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National
Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human
Services, Bethesda, MD, USA

ABSTRACT
Background. There is a lack of current detailed national data on the prevalence, correlates, dis-
ability and co-morbidity of DSM-IV specific phobia (SP), the prevalence of specific objects and
situations feared, and associations between impairment, treatment and co-morbidity and the
number of specific situations and objects feared, among adults in the USA.
Method. The data were derived from a large (43093) representative sample of the adult population
in the USA.
Results. Prevalences of 12-month and lifetime DSM-IV SP were 7.1 % and 9.4 % respectively.
Being female, young, and low income increased risk, while being Asian or Hispanic decreased risk
(p<0.05). The mean age at onset of SP was 9.7 years, the mean duration of episode was 20.1 years
and only 8.0 % reported treatment specifically for SP. Most specific phobias involved multiple fears,
and an increasing number of fears, regardless of content, was associated with greater disability and
impairment, treatment seeking and co-morbidity with other Axis I and II disorders.
Conclusions. SP is a highly prevalent, disabling and co-morbid disorder in the US adult population.
The early onset of SP and the disorders most strongly associated with it highlights the need for
longitudinal studies beginning in early childhood. Results suggest the existence of a generalized
subtype of SP much like social phobia, which, once revealed, may lead to a classification of SP that
is more etiologically and therapeutically meaningful.

INTRODUCTION disorders (Grant et al. 2004 d; Kessler et al.

2005b) and is associated with substantial im-
Specific phobia (SP) is characterized by a marked
pairment (Wells et al. 2006) and co-morbidity
and persistent and unreasonable fear of discern-
(Sareen et al. 2001; Scott et al. 2006), it has re-
ible, circumscribed objects or situations (APA,
ceived surprisingly little attention in psychiatric
1994 ; Davey, 1998). Despite the fact that SP
epidemiologic studies other than its prevalence
is among the commonest of all psychiatric
(Canino et al. 1987; Boyd et al. 1990 ; Robins &
* Address for correspondence: Bridget F. Grant, Ph.D., Ph.D., Regier, 1991; Stefansson et al. 1991; Merikangas
Laboratory of Epidemiology and Biometry, Room 3077, Division of et al. 1996 ; Bijl et al. 1998; Kringlen et al. 2001).
Intramural Clinical and Biological Research, National Institute on
Alcohol Abuse and Alcoholism, National Institutes of Health, M.S.
Comprehensive and detailed information on SP
9304, 5635 Fishers Lane, Bethesda, MD 20892-9304, USA. is also not available from those epidemiologic
(Email : bgrant@willco.niaaa.nih.gov) studies conducted worldwide using the DSM-IV
The views and opinions expressed in this report are those of the
authors and should not be construed to represent the views of any of criteria (Arnarson et al. 1998; Meyer et al. 2000 ;
the sponsoring organizations, agencies, or the US government. Alonso et al. 2004 ; Kessler et al. 2005a, b) and
1047
1048 F. S. Stinson et al.
only one survey recently conducted in New
Zealand (Wells et al. 2006) has examined im-
pairment associated with this disorder.
In view of the seriousness and chronic unre-
mitting nature (Goisman et al. 1998) of SP,
there is a need for current detailed data on
DSM-IV SP. Currently, several aspects of the
epidemiology of SP are unknown. First, pre-
vious studies had insufficient sample sizes to
characterize race–ethnic differences, age cohort
differences, and co-morbidity patterns defini-
tively (Mueser et al. 1998 ; Swendson &
Merikangas, 2000). These aspects require larger
samples than were previously available (Robins
& Regier, 1991 ; Kessler et al. 1994, 2005 a, b).
Second, no epidemiologic survey has examined
the co-morbidity of SP with Axis II personality
disorders (PDs) other than antisocial PD.
In addition to these methodological limi-
tations, previous epidemiologic surveys using
the Diagnostic Interview Schedule (DIS), such
as the Epidemiologic Catchment Area study
(ECA ; Robins & Regier, 1991), and the
Composite International Diagnostic Interview
(CIDI ; WHO, 2000) and its variants used in the
National Comorbidity Survey (NCS ; Kessler
et al. 1994) and its replication (NCS-R ; Kessler
et al. 2005a) did not differentiate SP from
agoraphobia and panic disorder with agora-
phobia. The key feature differentiating SP
from agoraphobia, including agoraphobia oc-
curring in the context of panic disorder, is that,
in the case of agoraphobia, the fear is due to
anticipated difficulty escaping or getting help
should a panic attack or symptoms occur. In
the case of SP, the fear is due to specific feared
object(s) or situation(s) (Noyes et al. 1986 ;
Friend & Andrews, 1990; Mannuzza et al. 1990 ;
Fyer & Klein, 1992 ; Chapman et al. 1995 ;
Chapman, 1997; Wittchen et al. 1998 ; Sareen
et al. 2001; Andrews & Slade, 2002). Because of
the failure to assess this distinction in these
earlier studies, between 62% and 95% of in-
dividuals diagnosed with agoraphobia (with and
without panic disorder) were rediagnosed with
SP based on subsequent clinical reappraisals
conducted by psychiatrists (Weissman &
Merikangas, 1986 ; Horwath et al. 1993 ;
Wittchen et al. 1996, 1998 ; Andrews & Slade,
2002).
The lack of comprehensive information
about the prevalence, correlates, disability and
co-morbidity of DSM-IV SP and its subtypes
represents a gap in our knowledge in terms of
prevention, intervention, treatment need, and
economic costs. Accordingly, this study was
designed, in part, to address this gap and to
overcome the limitations of previous epidemi-
ologic surveys on SP, especially with regard to
differentiating between SP and agoraphobia.
This survey, the National Epidemiologic Survey
on Alcohol and Related Conditions (NESARC ;
Grant et al. 2003 b, 2004d ), covers specific pho-
bia and major DSM-IV substance use, mood,
and anxiety disorders and seven of the 10 PDs
in a nationally representative US sample of
43 093 respondents. The sample size and excel-
lent response rate of the NESARC allow for
the more precise estimation of rates of SP and
its subtypes (i.e. animal, natural environment,
blood–injection–injury, and situational), exam-
ination of rates of SP in minorities not pre-
viously studied on a national basis, and analysis
of the co-morbidity of SP with other psychiatric
disorders. This study also provides information
on the treatment and impairment associated
with SP and co-morbidity among individuals
with SP as a function of the number of objects
or situations feared.
METHOD
Sample
The 2001–2002 NESARC is a representative
sample of the USA that has been described
in detail elsewhere (Grant et al. 2004 b). The
target population of the NESARC was the
civilian population, 18 years and older, residing
in households and group quarters in the USA,
including Alaska and Hawaii. Face-to-face per-
sonal interviews were conducted with 43 093
respondents. Blacks, Hispanics and young
adults (aged 18–24 years) were oversampled.
The overall survey response rate was 81%.
Data were adjusted to reflect the probability
of selection of primary sampling units (PSUs)
within strata and for the selection of housing
units within sample PSUs. The data were also
adjusted to account for oversampling of young
adults and for non-response at the household
level and person level. The data were then
weighted to be representative of the civilian
population of the USA using the 2000 Census.
Detailed information on the sampling and
 Epidemiology of DSM-IV specific phobia
weighting methodology is available online
(Grant et al. 2003 b).
DSM-IV SP
The diagnostic interview used to generate diag-
noses of SP and all other DSM-IV psychiatric
diagnoses was the Alcohol Use Disorder and
Associated Disabilities Interview Schedule –
DSM-IV version (AUDADIS-IV ; Grant et al.
2001). This diagnostic interview was designed
for experienced lay interviewers.
To arrive at a diagnosis of SP, respondents
were first asked if they ever had such a strong
fear of 12 specific object(s)/situation(s) that they
became very frightened and nervous when con-
fronted with or thinking about such object(s)/
situation(s) or they otherwise tried to avoid
them. The 12 SP objects/situations were selected
based on the DSM-IV SP subtypes, including
animals, the natural environment (heights,
storms, and water), situational (flying, being
in closed spaces, crowds, traveling in buses, cars
or trains), and blood–injection–injury (seeing
blood or getting an injection, going to the den-
tist, and visiting or being in the hospital) with an
additional question asked about other phobic
stimuli not covered by the specific categories.
At least one fear was required to meet all
remaining diagnostic criteria for SP, including:
(1) recognition that the fear was excessive or
unreasonable (respondent was more frightened
or nervous about object(s)/situation(s) than
most people or thought their fear was stronger
than it should have been) ; and (2) significant
restrictions in activity and/or distress and/or
social/occupational impairment (representing
the DSM-IV clinical significance criterion) as
the result of avoidance, anxious anticipation
and/or distress of the feared object/situation.
Social/occupational dysfunction was oper-
ationalized as interference with relationships
with people (arguments, avoidance) or with role
functioning at work, school or home.
Consistent with previous clinical studies
(Lipsitz & Schneier, 2000; Patel et al. 2002;
Schneier et al. 2002 ; Yonkers et al. 2003), the
prevalences of 12-month (0.05%) and lifetime
(0.17 %) agoraphobia without history of panic
disorder were too low to report for co-morbidity
analyses due to precision concerns (Grant et al.
2006). However, co-morbidity results are pre-
sented separately for panic disorder with and
1049
without agoraphobia. The NESARC assess-
ment instrument also included questions to
differentiate SP to specific stimuli from agora-
phobia (in this instance, panic disorder with
agoraphobia), in which fear is due to anticipated
difficulty escaping/getting help should a panic
attack or symptoms occur.
Other DSM-IV psychiatric disorders
Like SP, other anxiety (panic disorder with and
without agoraphobia, social phobia, and gen-
eralized anxiety disorder) and mood (major de-
pressive disorder, dysthymia, bipolar I, bipolar
II) disorders in this report are DSM-IV primary
diagnoses. In DSM-IV, ‘primary ’ excludes
mental disorders that are substance induced or
due to a general medical condition (APA, 1994,
p. 192). All mood and other anxiety disorders
also satisfied the DSM-IV clinical significance
criterion.
AUDADIS-IV questions operationalize
DSM-IV criteria for alcohol and drug-specific
abuse and dependence for 10 drug classes
(Grant et al. 2004 a) (aggregated in this report).
Consistent with DSM-IV, lifetime AUDADIS-
IV diagnoses of alcohol abuse required at least
one of four criteria for abuse either in the 12
months preceding the interview or prior to the
past 12 months. AUDADIS-IV alcohol depen-
dence diagnoses required at least three of seven
DSM-IV criteria for dependence during the past
year. For prior diagnoses of alcohol depen-
dence, at least three criteria must have occurred
within a 1-year period. Drug abuse and depen-
dence and nicotine dependence (Compton et al.
2004; Grant et al. 2004b) diagnoses used the
same algorithms. AUDADIS-IV assessments of
DSM-IV PDs have been described previously
(Grant et al. 2004 c). These included avoid-
ant, dependent, obsessive-compulsive, paranoid,
schizoid, histrionic and antisocial PD.
As reported in detail elsewhere, test–retest
reliability was fair for SP (k=0.48), good to
excellent for substance use disorders (k>0.74),
and fair to good (k=0.40–0.67) for other anxi-
ety, mood and personality disorders (Hasin
et al. 1994, 1997 a, b, 1999, 2003, 2005 ; Grant
et al. 1995, 2003 a, 2004a–d ; Chatterji et al.
1997; Cottler et al. 1997 ; Pull et al. 1997; Ustun
et al. 1997; Vrasti et al. 1997; Canino et al.
1999; Hasin & Paykin, 1999 ; Nelson et al. 1999 ;
Compton et al. 2004). Convergent validity was
1050 F. S. Stinson et al.
good to excellent for other anxiety, mood and
personality disorders (Grant et al. 2004 c,
2005 a, b, 2006), and selected diagnoses show
good agreement (k=0.64–0.68) with psy-
chiatrist reappraisals (Hasin et al. 1997 a, 2005 ;
Canino et al. 1999). Reliability of AUDADIS
diagnoses of SP (k=0.48) are better than those
obtained for other fully structured diagnostic
interviews such as the NCS CIDI (k=0.32)
(Wittchen et al. 1996). Test–retest data do not
exist for the DIS in general population samples
or for the World Mental Health (WMH) CIDI
used in the NCS-R. With respect to commonly
used semi-structured clinical interviews,
AUDADIS diagnoses of SP are better than
those for the Psychiatric Research Interview for
Substance and Mental Disorders (k=0.34)
(Hasin et al. in press) but lower than inter-rater
reliability achieved for the Anxiety Disorder
Interview Schedule – Revised (k=0.63–0.86)
(DiNardo et al. 1993).
Disability/impairment
Disability among SP respondents was deter-
mined using the Mental Component Summary
(MCS) scale of the Short-Form 12, Version 2
(SF-12v2 ; Ware et al. 2002). The SF-12v2 is a
reliable and valid measure of current impair-
ment in psychosocial functioning widely used in
population surveys (Ware et al. 2002). The MCS
included information on mental health, social
functioning, limitations due to emotional prob-
lems, and role and emotional functioning. The
MCS scale is a continuous measure with a mean
of 50 in the general population, and a range of
0–100. Lower scores indicate more disability.
Other measures
Treatment utilization, age at onset of first epi-
sode, age at first treatment, and duration of
only/longest episode were ascertained among re-
spondents with lifetime SP. Treatment specifi-
cally for SP was defined as : (1) visiting a
counselor, therapist, doctor, psychologist, or
similar professional ; (2) being a patient in a hos-
pital for at least one night ; (3) visiting an emerg-
ency room ; or (4) being prescribed medications.
Statistical analyses
Weighted percentages, means, and medians
were computed to derive prevalences and clini-
cal and sociodemographic correlates of SP.
Prevalences of specific fears and subtypes of SP
and distributions of the number of feared ob-
jects and situations were derived for the total
population and among those with lifetime SP.
Logistic regression analyses yielded odds ratios
(ORs) indicating associations between : (1) life-
time SP and sociodemographic correlates ; and
(2) 12-month and lifetime SP and other psychi-
atric disorders, adjusted for sociodemographic
factors. The relationship between 12-month SP
and disability as measured by the SF-12v2 MCS
scale was determined using a multiple linear
regression analysis controlling for socio-
demographic characteristics and all other sub-
stance use, mood, anxiety and personality
disorders. In these analyses, the relative contri-
bution of SP and each of the other psychiatric
disorders to the probability of being disabled is
compared by examining the standardized beta
coefficients. Multinomial logistic regression
analyses were conducted to examine the re-
lationships between distress, impairment, treat-
ment and co-morbidity and the number of
feared objects and situations. This was ac-
complished by categorizing the number of
feared objects/situations reported by the re-
spondents (1 fear, 2–3 fears, 4–5 fears, 6+ fears)
using those who experienced only one fear as the
referent group. Hazard rates reflecting the
cumulative risk of SP onset at specific ages
among the population at risk at those ages were
calculated using standard life table methods
(Lee, 1980). Standard errors and 95 % confi-
dence intervals (CIs) were estimated using
SUDAAN (SUDAAN, 2004), a software program
that adjusts for design effects of the NESARC
(i.e. stratification).
RESULTS
Prevalence and correlates
Lifetime and 12-month estimates of DSM-IV SP
were 9.4 % and 7.1 % respectively (Table 1).
Females showed significantly greater odds of
SP. Among race–ethnic groups, the odds of SP
were significantly lower among Asian and
Hispanic adults than among Whites. Compared
with the oldest age group, the odds of SP were
significantly greater for all other age groups.
The odds of SP were significantly greater among
the three lowest income groups relative to the
highest income group.
 Epidemiology of DSM-IV specific phobia 1051

Table 1. Prevalence of 12-month and lifetime DSM-IV specific phobia and odds
ratios of lifetime specific phobia by sociodemographic characteristics
12-Month (n=3073)a Lifetime (n=4030)

Characteristic %b (S.E.) % (S.E.) OR (95% CI)

Total 7.1 (0.26) 9.4 (0.30)

Sex
Male 4.6 (0.26) 6.2 (0.28) 0.5 (0.43–0.51)
Female 9.5 (0.37) 12.4 (0.41) 1.0
Race–ethnicity
White 7.5 (0.26) 9.9 (0.31) 1.0
Black 7.2 (0.46) 9.1 (0.50) 0.9 (0.81–1.03)
Native American 8.2 (1.14) 12.0 (1.40) 1.2 (0.96–1.61)
Asian 4.1 (0.58) 5.9 (0.82) 0.6 (0.43–0.75)
Hispanic 5.7 (0.52) 7.4 (0.61) 0.7 (0.61–0.87)
Age (years)
18–29 8.0 (0.45) 9.8 (0.49) 1.7 (1.46–1.92)
30–44 7.6 (0.35) 10.1 (0.42) 1.7 (1.54–1.97)
45–64 7.4 (0.33) 10.2 (0.42) 1.8 (1.56–1.98)
65+ 7.5 (0.29) 6.1 (0.32) 1.0
Marital status
Married/living with someone as if married 7.0 (0.29) 9.4 (0.36) 1.0
Widowed/separated/divorced 7.7 (0.35) 10.0 (0.39) 1.1 (0.98–1.18)
Never married 6.9 (0.38) 8.7 (0.42) 0.9 (0.83–1.02)
Education
Less than high school 7.3 (0.48) 9.4 (0.54) 0.9 (0.86–1.11)
High school 7.1 (0.34) 9.0 (0.39) 0.9 (0.85–1.02)
College or higher 7.1 (0.29) 9.6 (0.35) 1.0
Income
$0–$19 999 8.3 (0.34) 10.7 (0.38) 1.8 (1.49–2.09)
$20 000–$34 999 7.0 (0.40) 9.1 (0.49) 1.5 (1.24–1.77)
$35 000–$69 999 5.7 (0.35) 8.1 (0.42) 1.3 (1.09–1.54)
$70 000+ 4.7 (0.40) 6.3 (0.49) 1.0
Urbanicity
Urban 6.9 (0.29) 9.2 (0.35) 0.9 (0.76–1.01)
Rural 8.1 (0.47) 10.3 (0.54) 1.0
Region
Northwest 6.2 (0.49) 8.3 (0.55) 0.8 (0.64–1.04)
Midwest 8.1 (0.47) 10.7 (0.53) 1.1 (0.87–1.34)
South 6.7 (0.39) 8.7 (0.46) 0.9 (0.69–1.07)
West 7.6 (0.70) 10.0 (0.86) 1.0

S.E., Standard error ; OR, odds ratio ; CI, confidence interval.

a
n’s are unweighted figures.
b
Percentages are weighted figures.

Disability (b=x1.4 to x2.0, p<0.0001) and other anxiety

Adjusting for sociodemographic characteristics
and other Axis I and II disorders, 12-month SP
was associated (b=x2.9, p<0.0001) with lower
MCS disability scores, indicating that re-
spondents with SP are significantly more dis-
abled than those who do not have the disorder.
Examination of the standardized regression
coefficients showed that SP contributed less to
disability than mood disorders (b=x6.8 to
x8.6, p<0.00001), but its contribution was
comparable to those of substance use disorders
disorders (b=x2.7 to x4.2, p<0.0001).
Onset, course, and treatment
Mean and median ages at onset of SP were 9.7
and 11.2 years respectively. The hazard rate for
SP showed that the onset of most new cases
is highest at age 5 (including those who
reported having the disorder ‘all of their lives ’).
There was a smaller secondary peak of age at
onset at about 10 years followed by a rapid
decline thereafter. Respondents with lifetime SP
1052 F. S. Stinson et al.

Table 2. 12-Month and lifetime adjusted a odds ratios of DSM-IV specific phobia and other
psychiatric disordersb
Co-morbid disorder 12-month adjusted OR (95 % CI) Lifetime adjusted OR (95% CI)

Any alcohol use disorder 1.8 (1.51–2.08) 2.2 (1.97–2.39)

Alcohol abuse 1.2 (0.97–1.51) 1.2 (1.10–1.36)
Alcohol dependence 2.3 (1.93–2.83) 2.7 (2.41–3.02)
Any drug use disorder 2.3 (1.80–3.00) 2.3 (2.05–2.63)
Any drug abuse 1.6 (1.17–2.33) 1.7 (1.44–1.94)
Any drug dependence 3.8 (2.48–5.84) 3.7 (3.01–4.45)
Nicotine dependence 2.4 (2.18–2.70) 2.5 (2.33–2.78)
Any mood disorder 3.0 (2.67–3.41) 3.4 (3.11–3.78)
Major depressive disorder 2.5 (2.15–2.94) 2.6 (2.36–2.90)
Dysthymia 2.3 (1.65–3.34) 2.3 (1.80–3.13)
Bipolar I 1.8 (1.35–2.52) 2.3 (1.98–2.75)
Bipolar II 4.1 (3.34–4.95) 4.0 (3.44–4.71)
Any other anxiety disorder 6.5 (5.74–7.29) 5.6 (5.09–6.26)
Panic disorder with agoraphobia 14.6 (10.73–19.98) 19.2 (15.16–24.21)
Panic disorder without agoraphobia 3.6 (2.86–4.45) 2.8 (2.37–3.21)
Social phobia 7.9 (6.69–9.34) 6.6 (5.77–7.49)
Generalized anxiety 6.0 (5.06–7.19) 5.4 (4.67–6.14)
Any personality disorder 4.1 (3.66–4.59) 4.2 (3.80–4.63)
Avoidant 5.5 (4.53–6.70) 5.8 (4.78–7.01)
Dependent 5.7 (3.98–8.13) 7.4 (5.11–10.7)
Obsessive-compulsive 3.7 (3.21–4.17) 3.7 (3.26–4.13)
Paranoid 4.9 (4.17–5.65) 5.0 (4.30–5.76)
Schizoid 4.0 (3.38–4.67) 4.3 (3.65–4.97)
Histrionic 5.1 (4.10–6.46) 5.4 (4.32–6.85)
Antisocial 3.2 (2.64–3.89) 3.3 (2.78–3.93)

S.E.,
Standard error ; OR, odds ratio; CI, confidence interval.
a
ORs adjusted for sociodemographic (sex, age, race–ethnicity, marital status, education, income, urbanicity, region of the country) factors.
b
Referent group : respondents with no lifetime specific phobia diagnosis.
Values in boldface are significant.

reported mean and median durations of 20.1
and 22.9 years respectively for their only/longest
episode. Only 8.0% of those with SP reported
treatment specifically for the disorder. Mean
and median ages at first treatment were 31.3 and
29.2 years respectively.
Co-morbidity
The 12-month and lifetime associations between
SP and other psychiatric disorders are shown
in Table 2 in the form of ORs adjusted for
sociodemographic factors. SP was significantly
associated at varying levels with all other dis-
orders except 12-month alcohol abuse. SP was
more strongly related to dependence than abuse
for alcohol and drug disorders. In both time-
frames, bipolar II was the mood disorder most
strongly related to SP. Panic disorder with
agoraphobia was the anxiety disorder most
highly associated with SP. There was little vari-
ation in the associations between specific PDs
and SP for both 12-month and lifetime periods.
Specific phobias and subtypes
Animals and heights were the most prevalent
phobic stimuli among respondents with lifetime
SP and their prevalences in the general popu-
lation were 4.7 % and 4.5% respectively
(Table 3). One-third of respondents with SP
(about 3.0% each of the general population)
reported marked, persistent and unreasonable
fears and/or avoidance of flying or being in
closed spaces. Between 20.8% and 26.0 % of
respondents with SP reported fear and/or
avoidance of storms, water, seeing blood or
getting injections and going to the dentist, with
associated prevalences between 2.0 % and
2.4%. Visiting or being in a hospital, being in a
crowd and traveling in buses, cars or trains were
less frequently reported as phobic stimuli
(7.4–16.5 %), with prevalences ranging between
0.7% and 1.6 %.
With respect to DSM-IV subtypes of SP, 50.3,
62.7, 42.5 and 55.6 % of respondents with
SP specified at least one animal, one natural
 Epidemiology of DSM-IV specific phobia 1053

Table 3. Prevalence and distribution of specific phobias and subtypes

Percentage among
respondents with lifetime Prevalence in the total
Feared situations specific phobia % (S.E.) population % (S.E.)

Type of fear
Insects, snakes, birds or other animals (A) 50.3 (1.10) 4.7 (0.18)
Heights : e.g. tall buildings, bridges or mountains (NE) 47.9 (0.94) 4.5 (0.17)
Storms, thunder or lightning (NE) 20.8 (0.90) 2.0 (0.11)
Being in or on water (NE) 26.0 (0.85) 2.4 (0.11)
Flying (S) 30.7 (0.92) 2.9 (0.12)
Being in closed spaces : e.g. a cave, tunnel or elevator (S) 33.8 (0.93) 3.2 (0.14)
Being in a crowd 16.5 (0.78) 1.6 (0.09)
Traveling in buses, cars or trains (S) 7.4 (0.58) 0.7 (0.06)
Seeing blood or getting an injection (B–I–I) 22.3 (0.79) 2.1 (0.10)
Going to the dentist (B–I–I) 25.1 (0.86) 2.4 (0.11)
Visiting or being in the hospital (B–I–I ) 15.3 (0.77) 1.4 (0.08)
Other specific objects or situations 10.6 (0.62) 1.0 (0.06)
Any animal 50.3 (1.10) 4.7 (0.18)
Any natural environment 62.7 (0.97) 5.9 (0.20)
Any blood–injection–injury 42.5 (0.97) 4.0 (0.16)
Any situational 55.6 (0.99) 5.2 (0.19)
Only animal 9.9 (0.56) 0.9 (0.06)
Only natural environment 9.8 (0.59) 0.9 (0.06)
Only blood–injection–injury 6.5 (0.50) 0.6 (0.05)
Only situational 8.1 (0.49) 0.8 (0.05)
Number of fears
1 28.9 (0.89) 2.7 (0.12)
2 21.2 (0.75) 1.9 (0.10)
3 15.9 (0.68) 1.5 (0.08)
4 11.4 (0.58) 1.1 (0.07)
5 8.1 (0.53) 0.8 (0.05)
6 5.9 (0.43) 0.6 (0.04)
7 3.3 (0.33) 0.3 (0.03)
8 1.9 (0.26) 0.1 (0.03)
9 1.5 (0.29) 0.1 (0.03)
10 0.9 (0.20) 0.1 (0.02)
11 0.6 (0.12) 0.1 (0.02)
12 0.4 (0.11) 0.1 (0.01)

S.E., Standard error ; A, animal; NE, natural environment; S, situational ; B–I–I, blood–injection–injury.

environment, one blood–injection–injury or Number of feared objects and situations

one situational phobic stimulus respectively,
resulting in associated prevalences in the total
sample between 4.0 % and 5.9 %. The percent-
age of respondents with SP reporting only one
subtype of DSM-IV SP was small : less than
10 % for each subtype or less than 1.0 % of the
general population.
The mean number of fears among re-
spondents with SP was 3.1. About one-quarter
of respondents with SP reported fear and
avoidance of only one object or situation,
whereas 21.2 % and 15.9% reported two and
three respectively. The percentages of re-
spondents with lifetime SP reporting four to five
and six or more feared objects or situations were
19.6% and 14.5 % respectively.
The odds of experiencing distress associated
with SP symptoms was no greater among those
with two or more fears compared to those with
only one fear ; over 90 % of the respondents re-
ported distress regardless of number of feared
stimuli reported (Table 4). By contrast, re-
spondents with 2–3, 4–5, and 6+ fears had sig-
nificantly greater odds of social/occupational
dysfunction and restriction of daily usual ac-
tivities due to SP symptoms and treatment than
those with only one fear, with the magnitude of
the association increasing as a function of the
number of fears.
In general, the magnitude of associations
between SP and alcohol and drug use disorders
 1054
Table 4. Distress, impairment, treatment and co-morbidity among individuals with DSM-lifetime specific phobia by number
of feared stimulia
Only 1 fear (n=1085) 2–3 fears (n=1480) 4–5 fears (n=809) 6 or more fears (n=656)

Clinical correlate/co-morbid disorder % (S.E.) OR (95% CI) % (S.E.) OR (95 % CI) % (S.E.) OR (95% CI) % (S.E.) OR (95 % CI)

Clinical correlate
Distress 93.2 (0.89) 1.0 94.7 (0.65) 1.3 (0.89–1.92) 93.4 (1.08) 1.1 (0.71–1.73) 95.1 (1.02) 1.7 (1.01–2.86)
Social/occupational dysfunction 8.6 (1.01) 1.0 11.9 (1.03) 1.4 (1.03–1.99) 19.2 (1.66) 2.4 (1.71–3.48) 30.2 (2.39) 4.2 (2.97–6.03)
Restriction of activities 25.2 (1.64) 1.0 29.9 (1.43) 1.3 (1.02–1.58) 37.5 (2.20) 1.8 (1.38–2.27) 53.5 (2.45) 3.5 (2.61–4.58)
Ever treated 3.9 (0.76) 1.0 7.6 (0.85) 2.1 (1.32–3.47) 9.9 (1.30) 3.1 (1.92–4.96) 14.5 (1.75) 5.2 (3.12–8.56)
Co-morbid disorder
Any alcohol use disorder 44.4 (1.99) 1.0 43.0 (1.72) 1.1 (0.89–1.34) 43.0 (2.52) 1.3 (0.94–1.68) 35.8 (2.63) 1.1 (0.89–1.52)
Alcohol abuse 22.0 (1.55) 1.0 18.5 (1.23) 0.9 (0.68–1.08) 19.4 (1.73) 1.0 (0.78–1.38) 13.3 (1.64) 0.7 (0.50–1.04)
Alcohol dependence 22.4 (1.54) 1.0 24.5 (1.42) 1.3 (1.04–1.67) 23.6 (2.20) 1.3 (0.94–1.81) 22.6 (2.42) 1.5 (1.08–2.20)
Any drug use disorder 17.5 (1.50) 1.0 19.7 (1.35) 1.3 (1.03–1.75) 21.0 (2.20) 1.5 (1.03–2.15) 16.0 (1.92) 1.2 (0.82–1.74)

F. S. Stinson et al.
Any drug abuse 11.7 (1.13) 1.0 12.1 (1.18) 1.2 (0.85–1.61) 12.0 (1.57) 1.2 (0.83–1.86) 8.5 (1.37) 0.9 (0.59–1.49)
Any drug dependence 5.8 (1.02) 1.0 7.7 (0.91) 1.5 (0.97–2.35) 9.0 (1.46) 1.7 (1.01–2.78) 7.5 (1.42) 1.7 (0.94–2.90)
Nicotine dependence 28.6 (1.75) 1.0 33.6 (1.51) 1.3 (1.04–1.71) 37.8 (2.34) 1.6 (1.21–2.04) 35.1 (2.48) 1.5 (1.13–1.97)
Any mood disorder 36.4 (1.80) 1.0 42.9 (1.37) 1.3 (1.10–1.63) 50.0 (2.11) 1.8 (1.45–2.28) 56.7 (2.38) 2.4 (1.87–3.17)
Major depressive disorder 25.6 (1.50) 1.0 29.9 (1.39) 1.2 (1.00–1.49) 30.3 (1.93) 1.3 (0.98–1.63) 30.3 (2.28) 1.3 (0.95–1.71)
Dysthymia 5.9 (0.87) 1.0 6.8 (0.83) 1.1 (0.70–1.65) 7.5 (1.15) 1.2 (0.73–1.91) 12.0 (1.65) 1.9 (1.17–3.22)
Bipolar I 6.3 (0.96) 1.0 8.1 (0.81) 1.4 (0.95–2.05) 14.7 (1.71) 2.6 (1.64–4.09) 19.1 (2.26) 3.6 (2.28–5.75)
Bipolar II 2.1 (0.50) 1.0 2.3 (0.48) 1.1 (0.55–2.04) 2.6 (0.67) 1.2 (0.58–2.48) 4.4 (1.05) 2.0 (0.96–4.33)
Any other anxiety disorder 24.7 (1.56) 1.0 32.1 (1.50) 1.4 (1.13–1.83) 48.9 (2.09) 3.0 (2.32–3.79) 59.9 (2.44) 5.1 (3.80–6.82)
Panic disorder with agoraphobia 3.4 (0.63) 1.0 5.3 (0.79) 1.6 (1.00–2.68) 11.3 (1.42) 3.8 (2.32–6.19) 18.3 (1.89) 7.0 (4.41–11.21)
Panic disorder without agoraphobia 8.0 (0.91) 1.0 8.6 (0.87) 1.0 (0.72–1.44) 13.9 (1.66) 1.7 (1.13–2.61) 14.7 (1.59) 1.7 (1.19–2.56)
Social phobia 9.9 (1.13) 1.0 15.6 (1.12) 1.7 (1.25–2.38) 28.6 (2.05) 3.8 (2.67–5.34) 41.3 (2.63) 7.5 (5.25–10.86)
Generalized anxiety 10.5 (1.25) 1.0 11.6 (1.00) 1.1 (0.77–1.59) 20.5 (1.85) 2.3 (1.56–3.31) 30.7 (2.43) 4.3 (2.94–6.25)
Any personality disorder 26.1 (1.64) 1.0 33.7 (1.57) 1.5 (1.19–1.92) 45.3 (2.25) 2.6 (1.99–3.27) 58.7 (2.56) 4.5 (3.30–6.14)
Avoidant 4.4 (0.82) 1.0 6.1 (0.75) 1.4 (0.87–2.33) 13.6 (1.74) 3.3 (1.98–5.62) 23.7 (2.30) 6.9 (4.15–11.42)
Dependent 0.4 (0.21) 1.0 1.4 (0.36) 3.2 (1.03–9.86) 4.3 (1.05) 8.7 (2.93–26.07) 6.9 (1.39) 16.7 (5.64–49.35)
Obsessive-compulsive 13.6 (1.12) 1.0 18.9 (1.21) 1.6 (1.23–1.99) 25.2 (2.12) 2.4 (1.76–3.13) 34.4 (2.45) 3.8 (2.86–5.10)
Paranoid 7.3 (1.04) 1.0 11.1 (1.03) 1.6 (1.06–2.84) 19.9 (1.70) 2.9 (1.93–4.22) 35.0 (2.63) 5.6 (3.63–8.49)
Schizoid 5.7 (0.96) 1.0 7.7 (0.84) 1.4 (0.88–2.24) 12.5 (1.54) 2.4 (1.42–3.88) 19.4 (1.74) 3.7 (2.32–5.98)
Histrionic 3.1 (0.62) 1.0 6.1 (0.81) 2.3 (1.36–3.80) 9.6 (1.45) 3.7 (2.13–6.51) 12.4 (1.82) 5.6 (3.10–10.01)
Antisocial 6.7 (0.90) 1.0 7.8 (0.91) 1.3 (0.92–1.95) 11.4 (1.53) 2.1 (1.35–3.18) 10.0 (1.72) 1.9 (1.19–3.04)

S.E.,
Standard error; OR, odds ratio ; CI, confidence interval.
a
All models controlled for age, sex, race–ethnicity, marital status, education, income, urbanicity and region of the country.
Values shown in boldface are significant.
 Epidemiology of DSM-IV specific phobia
did not vary as a function of reported fears.
By contrast, the relationship between SP
and nicotine dependence was significantly
greater for each multiple fear category relative
to the group with only one fear. A similar re-
lationship was shown between SP and any
mood disorder. However, this relationship
did not hold for all specific mood disorders ;
associations between SP and dysthymia
and bipolar I disorder were only significantly
greater among respondents reporting 6+
fears relative to those reporting only one.
Associations between SP and each other
anxiety disorder were significantly greater
among respondents reporting 2–3, 4–5 and 6+
fears relative to those reporting only one. The
same pattern of results was generally found for
each specific PD, but the magnitude of the as-
sociations was much greater, especially for
dependent PD.
DISCUSSION
Results indicate that in the USA in 2001–2002,
7.1% of adults experienced SP in the prior 12
months and 9.4% experienced SP during their
lifetimes. These rates are slightly lower than
those (8.7% and 12.5%) recently published
from the 2001–2003 NCS-R study (Kessler et al.
2005 a, b). Failure to exclude substance-induced
cases and to apply the DSM-IV clinical signifi-
cance criteria to diagnoses of SP may have
contributed to the higher rates reported in the
NCS-R. There was little variation in the mag-
nitude of prevalence estimates and co-morbidity
rates of current (12-month) and lifetime SP,
results that underscore the unremitting nature
of the disorder.
The odds of SP were greater among women
than men and highest in the three youngest co-
horts relative to the oldest cohort (65 years and
older), results demonstrated in other surveys
(Kessler et al. 1994, 2005 a; Meyer et al. 2000).
However, the consistency of this finding across
several surveys does not suggest that the in-
creased lifetime odds of SP among younger co-
horts is real. Elevated odds of SP in the youngest
cohorts might occur if this and the other studies
systematically undercounted the disorder in
older cohorts, who have poorer recall of remote
events. Longitudinal surveys are needed to ad-
dress this issue.
1055
Because of its size and oversampling, the
NESARC provides more precise information on
the sociodemographic correlates of SP, es-
pecially race–ethnic differences, than any other
source. The findings disclose lower risk among
Asians and Hispanics. By contrast, the ECA
survey (Robins & Regier, 1991) found higher
rates among Blacks than Whites and the NCS
(Magee et al. 1996) found Hispanics at greater
risk than Whites, results that may be attributed
to sample sizes in these surveys being too small
to analyze rates among these minorities. Thus,
the NESARC findings of lower risk among
Hispanics and Asians provides new information
on race–ethnic differences that can contribute to
health services planning and intervention pro-
grams.
The mean age at onset of SP was 9.1 years,
lower than that observed in other epidemiologic
(mean=15 years) (Magee et al. 1996) and clini-
cal (mean=14 years) studies (Weinshenker et al.
1996–1997 ; Goisman et al. 1998 ; Lipsitz et al.
2002). This may be because individuals with SP
were allowed to report their age at onset as ‘all
of their lives’. The mean duration of episodes
of SP in this general population sample was 19.7
years, similar to the average length of intake
episode (22.4 years) found in the few clinical
studies (Goisman et al. 1998) that have reported
it. The NESARC also indicated a continued
lack of treatment for the majority of individuals
with SP. The impairment associated with SP
shown in this study, which is comparable to
the disability demonstrated by individuals with
other anxiety and substance use disorders, is
avoidable through highly effective pharmaco-
logical and psychological treatments. The fact
that the proportion of treated cases has re-
mained almost unchanged over the past two
decades (Robins & Regier, 1991 ; Magee et al.
1996) suggests that efforts remain to deliver ef-
fective treatments for SP to the many who still
need them. However, the fact that some in-
dividuals may accommodate their phobias to
produce phobia-constricted lifestyles may con-
tribute to the under-recognition of the disorder
by both health professionals and individuals
with the disorder alike.
The results provide new, detailed information
on the co-morbidity of SP and substance abuse
and dependence, including a strong association
of SP with dependence on alcohol, drugs and
1056 F. S. Stinson et al.
nicotine, in contrast to a weak relationship of SP
with substance abuse. This lack of association
may be due to the relatively low reliability of
DSM-IV diagnoses of abuse (Hasin et al. 1999 ;
Grant et al. 2003 a). These results highlight the
importance of not combining abuse with de-
pendence when studying co-morbidity.
Consistent with epidemiologic (Robins &
Regier, 1991 ; Magee et al. 1996; Faravelli et al.
2004 a, b ; Kessler et al. 2005a, b) and clinical
studies (Goisman et al. 1998 ; Brown et al. 2001 a)
concerning co-morbidity, SP was also strongly
associated with other anxiety disorders. The
magnitude ranged from ORs of 2.8 for panic
disorder without agoraphobia to 19.2 for panic
disorder with agoraphobia. It is unlikely that
the strong association between SP and panic
disorder with agoraphobia results from diag-
nostic confusion between these two disorders
for two reasons : (1) the AUDADIS-IV included
questions to establish the reason for the fear in
each disorder; and (2) any fear that was only
related to a fear of experiencing panic symptoms
was not counted toward the SP diagnosis.
With regard to mood disorders, bipolar II
was more strongly related to SP than MDD,
dysthymia and bipolar I, a new finding obscured
in previous surveys, which assessed only manic
episodes and major depressive episodes (as
opposed to MDD and bipolar disorders).
Furthermore, all PDs assessed had strong asso-
ciations with SP, with very little variation in
magnitude. Currently, no theoretical accounts
offer explanations for these observed differ-
ences. Understanding the reasons for these
variations should provide a better understand-
ing of both SP and those disorders that relate
most strongly to it.
Consistent with the very few epidemiologic
(Bourdon et al. 1988; Curtis et al. 1998) and
clinical studies (Goisman et al. 1998; Lipsitz
et al. 2002) that have examined the distribution
of fears among individuals with SP, fears of ani-
mals and heights were the most common, with
50 % of all individuals with SP reporting them.
About 33 % reported each of two situational
phobias, flying and being in closed spaces,
whereas 25 % reported each of four phobias,
including two classified as blood–injection–
injury in the DSM-IV, dental and blood
phobias, and two classified as natural environ-
mental, storms and water phobias. Fewer than
15 % of individuals with SP reported hospital
and crowd phobias. Future epidemiologic
research should collect detailed and separate
information about each fear reported, including
its age at onset, course and co-morbidity.
A major finding of the present study was that
most specific phobias involve multiple fears.
Consistent with clinical studies (Goisman et al.
1998 ; Lipsitz et al. 2002), only 28.9% of in-
dividuals with SP reported only a single specific
fear. Another related finding was that having
more than one fear, regardless of content, was
associated with greater disability and impair-
ment, treatment, and co-morbidity with anxiety
disorders, PDs and nicotine dependence but not
alcohol or drug use or mood disorders relative
to having one fear. One explanation for the
strong associations between the number of fears
and PDs shown in this study and the extremely
early onsets of these disorders is that PDs may
develop in concert with SP as a means of ac-
commodating one’s life to a phobia-constricted
lifestyle. This interpretation is further supported
by the strong associations found between SP
and dependent and avoidant PDs. Taken to-
gether, these findings suggest the existence of a
generalized subtype of specific phobia (similar
to social phobia) that, once elucidated, may lead
to a classification of SP that is more etiologically
and therapeutically meaningful.
Potential study limitations are noted. Similar
to all prior cross-sectional epidemiologic stud-
ies, age at onset and lifetime prevalence and
co-morbidity estimates may be subject to recall
bias. However, this bias is not as relevant to
estimates of 12-month disorders. Most other
psychiatric epidemiology studies have focused
on lifetime prevalence and co-morbidity because
samples were too small for stable 12-month
estimates. However, the large sample size of
the NESARC permitted analyses for 12-month
disorders at the same level of detail as lifetime
disorders. The reliability of AUDADIS-IV SP
diagnoses was only fair. The fact that other
surveys have reported comparable or lower k
values for SP signals a need for more research
on sources of diagnostic unreliability and stra-
tegies for improving inter-rater agreement
and test–retest reliability. Future validation
work directed toward clinical reappraisals of
AUDADIS-IV diagnoses by psychiatrists is
also needed and should complement existing
 Epidemiology of DSM-IV specific phobia
data on the validity of AUDADIS-IV diagnos-
tic measures.
To summarize, this study provides the
most comprehensive information on the epi-
demiology of specific phobia among US adults
to date. SP is associated with the earliest age at
onset of any substance use (20–22 years) (Hasin
et al. 2006 ; Compton et al. in press), mood
(22–30 years) (Grant et al. 2004b ; Hasin et al.
2005) or other anxiety disorder (15.1–33 years)
(Grant et al. 2005 a, b, 2006) assessed in the
NESARC and is associated with significant
distress and impairment and unremitting
course. Most specific phobias involve multiple
fears and are highly co-morbid with other
major Axis I and II disorders. The extensive co-
morbidity highlights the need for comprehen-
sive assessment of other Axis I and II disorders
among individuals with SP. Given the chronic
unremitting nature of SP, the importance of
information on its prevalence, correlates, the
nature and distribution of fears, and psychiatric
co-morbidity cannot be underestimated. This
study provides such information, and a plat-
form for further investigation in a number of
directions.
ACKNOWLEDGMENTS
The National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC) was con-
ducted and funded by the National Institute on
Alcohol Abuse and Alcoholism (NIAAA), with
supplemental support from the National
Institute on Drug Abuse (NIDA). This research
was supported, in part, by the Intramural
Program of the National Institutes of Health,
National Institute on Alcohol Abuse and
Alcoholism.
DECLARATION OF INTEREST
None.
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