The relationship of severity of agoraphobia to associated psychopathology

Behor REJ. Tkr. Vol. 23. No. 3. pp. 305-310. 1985 Printed m Grear Bntam. All rights reserved

THE

Copyght

0005-7967:X5 S3.00 + O.Ml ‘c: 19X5 Pergamon Press Ltd

RELATIONSHIP OF SEVERITY OF AGORAPHOBIA TO ASSOCIATED PSYCHOPATHOLOGY DIANNE

Agoraphobia

and

Anxtety

Program.

(Received Summary-The psychopathology and treatment

L.

CHAMBLESS*

Department Philadelphia,

of Psychiatry, Penn., U.S.A. IO October

relationships of avoidance behavior and in a large sample of agoraphobic outpatients discussed.

Temple

University

Medical

School.

1984) panic frequency with other are examined and implications

measures of for research

INTRODUCTION

Agoraphobics are consistently found to suffer from a range of psychological problems beyond the phobia itself and the associated panic attacks. These include chronic anxiety (Buglass, Clarke, Henderson, Kreitman and Presley, 1977; Marks, 1967, 1970; Snaith. 1968) depression (Buglass et al., 1977: Jasin. 1981) neuroticism (Goldstein and Chambless, 1978; Marks, 1967), social phobia (Chambless, Hunter and Jackson. 1982; Goldstein and Chambless. 1978; Marks, 1967) deficits in assertion (Chambless ef al., 1982; Goldstein and Chambless, 1978). sexual dysfunction (Buglass et al., 1977; Webster, 1953) hypochondriasis (Buglass EI al., 1977; Jasin. 1981). and, for male agoraphobics, hysteria (Jasin, 1981). The incidence or intensity of these problems has been found to distinguish agoraphobics from a variety of normal and psychiatric control groups. With few exceptions, however, investigators have not examined the relationship between the severity of agoraphobia and these associated forms of psychopathology, although it is quite likely that these additional problems may affect the agoraphobic’s ability to benefit from behavior therapy. For example. Zitrin, Klein and Woerner (1980) found agoraphobics with higher levels of depression improved less with group in vim exposure, even with the addition of antidepressant, presumably antipanic. medication (imipramine). Emmelkamp and Cohen-Kettenis (1975) found depression in agoraphobics to be highly correlated (0.57) to general phobic severity, as measured by a total Fear Survey Schedule (FSS) score; severity of agoraphobia per se was not measured. In a second Dutch investigation, Arrindell (1980) obtained responses to an FSS and the Symptom Checklist-90 from over 700 members of a phobia society. Scores on the agoraphobia factor of the FSS were found to correlate significantly with those on the social phobia factor (0.31) the blood and injury factor (0.43). the fear of sexual and aggressive displays factor (0.26) and the fear of animals factor (0.18). In addition the agoraphobia factor correlated significantly with the neuroticism factor (0.31) the somatization factor (0.47) and the hostility factor (0.22) of the SCL-90. The finding on hostility has been replicated with very similar results by Hafner and Ross (1984). The results of these studies indicate that agoraphobia is interwoven with various other forms of psychopathology and that these relationships warrant further investigation. For the present study, 378 diagnosed agoraphobic outpatients completed self-report questionnaires selected to measure problems reported to be common in agoraphobics in clinical reports or in prior investigations. These included depression, chronic anxiety, assertiveness, social anxiety. marital dissatisfaction. fear of fear (catastrophic cognitions about the effects of anxiety and fear of body sensations indicating anxiety or autonomic arousal) and panic intensity. Also collected was information on demographic/biographic variables some of which have been found to be important correlates in other neurotic disorders such as depression (e.g. Brown. Bhrolcain and Harris, 1975): marital status, age. duration of agoraphobia, number of children living at home under the age of

*Present address: Department DC 20016. U.S.A.

of Psychology.

The American

305

University

4400 Massachusetts

Avenue

NW. Washington.

306

DIANNE L. CHAMBLESS

14 (a variable related to depression in the Brown et al. study, perhaps because of the strain and isolation women experience when restricted by the care of young children) and socioeconomic status. Of these variables only age has been considered in past research: Arrindell (1980) found no significant relationship between age and agoraphobic severity. The psychopathology and biographical variables were correlated to the severity of agoraphobia as measured by two central features of that syndrome: the frequency of panic attacks and the severity of avoidance behavior. Of secondary interest was the relationship of agoraphobics’ depression to the obtained measures. Depression and anxiety are so commonly intertwined that some investigators consider anxiety problems such as agoraphobia to be secondary to depression (e.g. Bowen and Kohout. 1979). METHOD Subjects Subjects were 64 men and 3 14 women who applied for treatment at the Agoraphobia and Anxiety Program of Temple University Medical School from 1979-1984 and who received a diagnosis of agoraphobia with panic attacks according to the DSM-III criteria (APA, 1980). Of these clients. 52p/, were married, 27’4 never married and 21”/, separated or divorced. A wide range of social classes was represented. According to the Hollingshead categories 1 Is,, were in Class I, 1So,, in Class II, 32% in Class III, 25% in Class IV and 129; in Class V. Clients averaged 35.19 yr in age (SD = 10.16 yr) and had been agoraphobic for an average of 9.17 yr (SD = 9.03 yr). Measures Agoraphobic Cognitions Questionnaire (ACQ ) and BOL+ Sensations Questionnuire (BSQ ). These companion questionnaires are designed to measure fear of fear among agoraphobics (Chambless. Caputo, Bright and Gallagher, 1984). On l-5 scales clients rate how much they fear signs of autonomic arousal such as rapid heart beat and how often they think, when anxious, maladaptive fear of self-statements such as, ‘I’ll die’, or ‘I’ll go crazy’. The ACQ has two factors: social/behavioral consequences of anxiety and fe’ar of the physical consequences. Analyses are reported for the total score as well as for the separate factors. The reliability and construct validity of these scales have been confirmed in a series of studies. Scale scores are expressed as item averages. Assertion Inventory (AI). Constructed by Gambrill and Richey (1975). this inventory contains 40 items which are rated twice: once for discomfort in responding assertively, and once for the probability of behaving assertively. Higher scores (range 40-200) indicate greater problems with assertion. Test-retest reliability is high, and initial data supportive of the scale’s validity have been reported. Beck Depression Inventory (BDZ). This scale is a widely used and well-validated self-report inventory for measuring the severity of depression (Beck, Ward. Mendelson, Mock and Erbaugh. 1961). Biographical Data Sheet. Information collected on this sheet included sex. age, marital status. number of children at home under age 14, education and occupation of both self and. where appropriate. spouse (parental data were requested for those still living with their parents) and duration of agoraphobic symptoms. Education and occupation were used to compute social class according to the Hollingshead (1957) Two-factor Index of Social Position. For data analyses the Index was used as a continuous measure ranging from 1 l-77 with the latter indicating lowest status. whereas for sample description the traditional class breakdowns are reported. Eysenck Personality Questionnaire (EPQ). This questionnaire (Eysenck and Eysenck, 1975) is an extension of the previous Eysenck Personality Inventory to which a Psychoticism scale has been added. This scale appears to tap psychotic deterioration, criminality, aggression and hostility. Preliminary validity data have been gathered on this scale, and the Neuroticism scale has been extensively validated and widely used. In addition there is a Lie scale to measure dissimulation. Scores on the Psychoticism scale were used in the present study as a measure of method variance advisable because all assessment procedures were self-report. Fear of Negative Evaluation (FNE) and Social Avoidance and Distress (SAD) Questionnaires. These self-report questionnaires were devised by Watson and Friend (1969) to measure separable

Severity

of agoraphobia

307

but overlapping dimensions of social evaluative anxiety. The 30 items on the FNE and the 28 on the SAD are in true/false format, and the scores are expressed as sums of responses indicating greater anxiety or avoidance. The reliability and validity of these scales have been confirmed in a series of experimental investigations. Marital Dissatisjkction Questionnaire (MDQ). On this measure, five items are rated twice: once to describe the spouse as he/she is, and once to describe the spouse as the client would ideally like him/her to be. The items, set in a semantic differential format, were taken from Bland and Hallam (1981) who found them to predict treatment outcome with agoraphobics. Test-retest reliability in our clinic with an agoraphobic sample of 31 has been found to be 0.77 over a median 25-day interval. Mobility Inventory. This inventory contains four measures: Avoidance Alone, Avoidance Accompanied. Panic Frequency and Panic Intensity (Chambless, Caputo. Jasin, Gracely and Williams, 1985a). Twenty-six situations agoraphobics commonly avoid are rated on l-5 scales of avoidance. Separate anxiety ratings are not obtained, since anxiety and avoidance have been shown to be highly correlated at all stages of treatment. Scores are an average of the item responses. The two avoidance scales were averaged for the purposes of this investigation to reduce the number of analyses conducted, and therefore the possibility of Type I error. Panic Frequency is a report of the number of panic attacks experienced in the past 7 days, so devised to be useful in short-term treatment; however, 7-day frequency is highly correlated with that in a longer time period (i.e. 21 days. 7 = 0.80. n = 35). The avoidance scales are highly reliable, while the Panic Frequency measure is moderately so. The construct validity and discriminative efficiency of these measures have been demonstrated in a series of studies. The use of Panic Intensity has not been previously reported. This is a l-5 rating scale measuring self-reported intensity of panic attacks. With data collected on a sample of 11 agoraphobics, the test-retest reliability for a median of 25 days was 0.70. State-Trait Anxiety Inventory-Trait Form (STAZ). Devised by Spielberger, Gorsuch and Lushene (1970) this measure of chronic anxiety has repeatedly been shown to be reliable and valid. Procedure

When Ss reported for intake, each was given a packet of questionnaires in randomized order. Subsequently clients had a diagnostic interview with a psychologist specializing in agoraphobia. Only those receiving that diagnosis were retained in the data set. Since there were changes made in the packet over time, not all questionnaires were completed by the entire sample. RESULTS Table 1 contains the means and standard deviations for the various measures. These indicate that. compared to the scale norms, on the average agoraphobic outpatients are moderately depressed, highly socially anxious, somewhat unassertive, highly chronically anxious (75th percentile for neuropsychiatric patients). and neurotic (about average for neurotic patients). The relationships between measures of avoidance behavior and other variables were, on the whole, assessed with Perason product-moment correlations. Those with panic frequency were analyzed with Kendall r nonparametric correlations because of the extreme skewedness of this measure. The relationship of marital status to agoraphobic symptoms was analyzed with parametric and nonparametric (Kruskal-Wallis) ANOVAs. Results of the correlational analyses may be found in Table 2.

Table

I

Means

Measltre

and standard

devmtions

___..Avoidance 01 = 331) Al-Discomfort 01 = 308) BDI Irt = 318) EPQ-Lie ,n = 283) EPQ-Psychotmm ,,I = 283) Panx Frequency (medmn) (n = 300) SAD (n = 321)

K _____ 2.82 106.85 19.57 1.73

2.76 2.1 I 14.86

for agoraphobic SD 0.83 26.13 9.93 3.97 2.33 8.37

outpatients

on measures

of psychopathology

Measure ACQ (n = 231) AI-Probability (n = 305) BSQ (n = 232) EPQ-Neurotictsm (n = 283) FNE (n = 337) Pamc Intensity (n = 156) STAI-Trait Anxiety (n = 314)

R ._~___~~_.~ 2.42 112.47 3.05 17.90 20.43 3.18 55.45

SD 0.63 19.72 0.85 4 14 7.81 0.99 10.85

DIANBT L. CHAMBLESS

308

Table 2. Correlatmns of reventv of awxdance ~Pearson’s) and freauencv of panic attacks ,Kendall r) with othe; measures of psychopathology and bibgradhxal varmbles for agoraphobic clients Avoidance

Age

-0.02 0.41*** 0.23* 0 ‘5’ 0.;9** 0.35*** 0.3 I*** O.AO*** 0.01 0.15** 0.08 0.10 0.30*** -0.10 0.14*** 0.22** -0.05 0.34”’ 0.42-9’ 0.33***

ACQ-Total ACQ-Soclal/Behavloral ACQ-Physical AI-Probability AI-Discomfort

BSQ BDI Duration of Agoraphobia FNE EPQ-Lie MDQ EPQ-Neurotictsm No. of Young Children Panic Frequency Panic Intensity EPQ-Psychotmm Social Class Social Phobia STAI-Trait Annietv ‘P < 0.05: **p < 0.01: ***p

Pam

303 7’7 __96 87 270 273 212 7n7 5;3 300 277 74 277 293 280 152 277 ‘75 286 305

Frequency

-0.12**

0.13” 0 17’ 0.35** 0 06 0.06 0.15” 0.20** -0.07 0.07 0 00 -0.10 0.10’ 0.01 0.20*** -004 0.0 I 0.10* 0 ?I***

359 I85 64 65 331 234 I81 366 236 258 236 I08 236

251 I48 236 233 250 x2

-c 0.001

Correlations between the agoraphobic severity measures and the EPQ Lie scale indicate that the clients’ responses were not significantly shaped by social desirability: both were not significant. Moreover, the correlations with the EPQ Psychoticism scale were also not significant. This would suggest that other correlations obtained among measures of psychopathology do not reflect a simple tendency for those with higher levels of agoraphobic distress to report globally and indiscriminantly higher levels of disturbance. Both the frequency of panic attacks and the severity of avoidance behavior were higher when clients reported being more depressed, more chronically anxious, more neurotic on the EPQ. and higher on fear of fear and on the intensity of panic attacks. On the two factors of the ACQ, the fear of physical consequences (e.g. heart attack) was more strongly related to panic frequency than was the fear of social/behavioral consequences; this was not the case for avoidance behavior. Avoidance behavior was more extensive when clients reported being more fearful of negative evaluation, less assertive (whether measured by a low probability of behaving assertively or by discomfort in being assertive), and more introverted on the EPQ. Neither measure was related to marital satisfaction. Analyses of the biographical variables indicated that neither marital status (for avoidance. F = 0.74, df'= 3.290.P = 0.53; for panic frequency, x2 = 1.15, P = 0.76) nor duration of the agoraphobia was related to severity, whereas increasing age was modestly associated with decreasing frequency of panic attacks. Decreasing socioeconomic status was associated with increasing levels of avoidance behavior. It will be noted that, on the whole, correlations with panic frequency were low compared to those with avoidance behavior. There are at least two possible reasons for this. Nonparametric correlations are generally lower than parametric correlations, and in addition the range on the panic measure is rather restricted. Twenty-four percent of the clients reported having no panics during the 7-day period before assessment. and many spontaneously wrote on the questionnaire that they avoided all situations that might lead to panic and so rarely had them anymore. Thus the fact that one has had panic and continues to feel vulnerable to their recurrence may be more important than current episodes. Correlations with BDI are reported in Table 3. Clients who are more depressed are more likely to be socially anxious, fearful of criticism, unassertive and chronically anxious. They have a higher frequency of panic. greater panic intensity and are more fearful of fear. They tend to be younger. of lower socioeconomic status and to have been agoraphobic for a shorter period of time. Depression was not, however. related to marital status, marital dissatisfaction or to the number of young children in the home.

Table

3. Correlations

Severity

of

of the BDI

with

MeCNlre

I

ACQ Al-Discomfort Durauon

of Agoraphobia

MDQ I\io.

of Young lntenslty

Socml

Phobia

Children

“A : nonparametric ‘P

< 0.05:

***P

corrclatlon

other

measures

for agoraphobic

MCWIK

n

chentq r

)I

0 40***

320

Al-Probability

0.25***

284

0.42***

287

BSQ

0.33”’

225

284

FNE

0 36***

314

EPQ-Neuroticism

0.57”’

278

-0.14’

0.00

Pamc

agoraphobta

-0.06

71 306

Pamc

Frequency”

0.20***

266

0.31***

162

Social

Class

0.23’8’

288

0.37***

300

STAI-Trart

0.72’**

323

Anxiety

was used for this measure

< 0.001.

DISCUSSION The data from the present study. containing the largest number of clinical Ss analyzed in research to date. yield several suggestions for researchers in the field of agoraphobia. First. agoraphobics are often referred to as ‘housebound housewives’, and investigations are sometimes limited to married. female agoraphobics (e.g. Barlow, O’Brien and Last, 1984; Buglass et af., 1977). From the description of this sample it should be clear that over half of agoraphobic clients do not fit this category. and that inquiries limited to married women may reduce S variance at the expense of generalization. Second, socioeconomic status is an important variable to consider in S assignment and description in future research. In addition to their having more severe phobias initially, clinical observation in our center would suggest that poverty-level clients are more likely to drop out of treatment or attend erratically, thus diminishing the impact of treatment. The latter finding is congruent with data from epidemiological research indicating that agoraphobia is twice as likely to occur in the poorly educated (reviewed by Weissman, 1983), and from a study with a clinical sample by Rock and Goldberger (1978) in which agoraphobics were found to have lower educational attainment than simple phobics. Thus the popular myth among agoraphobic self-help groups in the U.S.A., to the effect that agoraphobia occurs mostly in those who are highly intelligent and imaginative would seem to be just that: a myth. Similarly to depression (e.g. Brown et ul., 1975), agoraphobia is most likely to plague the disadvantaged, although our sample does indicate agoraphobia exists at all social statuses. Unlike the case of depression. however. marital status. the number of young children in the home, and age (a replication of Arrindell, 1980) were not significant variables for severity of agoraphobia. Third. these data indicate that depression, social anxiety, fear of fear and chronic anxiety are significant, interrelated features of the agoraphobic syndrome. Consequently, attention should be given to these problems in treating agoraphobics. hloreover, in the case of depression, these findings demonstrate that investigators who eliminate depressed agoraphobics (e.g. Buglass et al.. 1977; Zitrin et al.. 1980) are excluding the more severe agoraphobics and are thus risk biasing their findings in significant ways. Consistent with the study by Arrindell (1980). these data indicate that severe agoraphobia is associated with a broad array of neurotic problems. Fourth, these results are consistent with those of Milton and Hafner (1979) and Bland and Hallam (198 1) in demonstrating that marital dissatisfaction is not related to pretreatment levels of agoraphobic severity, although in the prior investigations pretreatment level of marital dissatisfaction was related to lack of improvement on agoraphobia in the long run. Thus the contribution of marital distress to the problem of agoraphobia noted by many writers (e.g. Goldstein and Chambless. 1978: Hafner, 1982) is not a simple one with direct effects on symptom severity. Rather. data by Barlow et al. (1984) would suggest that lack of support from the spouse may undermine the maritally distressed agoraphobic’s ability to change. By extension, the lack of social support may be related to greater susceptibility to a stress problem such as panic. but not necessarily to a more severe phobia than that experienced by those with more positive marital relationships. Fifth. the patterns of relationships between depression and the other measures would indicate that depression among agoraphobics is rather different from that in the general population. Typically the separated and divorced are more depressed than the married (reviewed by Weissman and Klerman. 1979). and larger numbers of young children and greater marital dissatisfaction are associated with higher levels of depression The substantial-to-very-high correlations of depression

310

DIANX

L. CHAMBLESS

to various measures of anxiety and phobia are consistent with the hypothesis that depression among agoraphobics is secondary to the anxiety. perhaps as a result of the demoralization associated with the low sense of self-efficacy in relation to the phobias. anxiety and panic. This hypothesis is buttressed by data indicating that depression is radically altered by treatment for agoraphobia (Chambless et al., 1984). Finally, the relationship between panic frequency and panic intensity in this investigation was low. though positive. This would indicate that combining these two variables into one rating (e.g. Watson and Marks. 1971) may reduce the validity of the measure. .4cknoi~lerlgements-The author wishes to thank Priscilla Bright. Craig Caputo. Richard Gallagher. Z&ma Kennedy, Beth McAllister. Christme Williams and Diane Zimmerman for their assistance in data collection. and Ed Gracely for stattstical consultation. Requests for reprmts should be addressed to Dianne L. Chambless. Ph.D., Department of Psychology. The ,American University. 4400 Massachusetts Avenue, NW. Washington. DC 20016. USA.

REFERENCES Arrindell W. A. { 1980) Dimensional structure and psychopathology correlates of the Fear Survey Schedule (FSS-III) in a phobic population: a factorial definition of agoraphobia. Behar. Res. T/w. 18, 229-242. Barlow D. H., O’Brien G. T. and Last C. G. (1984) Couples treatment of agoraphobia. Behar. T/w. 15. Ai-58. Beck A. T.. Ward C. H.. Mendelson M.. Mock .I. and Erbaugh J. (1961) An inventory for measuring depression. .-frch.i ge’en. Ps.&riuf. 4. 561-571. Bland K. and Hallam R. S. (1981) Relationship between response to graded exposure and marital satisfaction. Behar. Rrv. Ther. 19, 335-338. Bowen R. C. and Kohout J. (1979) The reiattonship between agoraphobia and primary affective disorder. Cun. /. P.s.rchWr. 24, 317-321. Brown G. W.. Bhrolcain X4. and Harris T. (1975) Social class and psychiatric disturbance among women in an urban population. Sociofogy 9. 225-254. Buglass D., Clarke J.. Henderson A. S.. Kreitman N. and Persley A. S. (1977) A study agoraphobichousewiv,es. fs~~~/tol. :Llrd 7, 73-86. Chambless D. L.. Hunter K. and Jackson A. (1982) Social anxiety and assertiveness in normal and phobic populations. Behac. Res. Thu. 20, 403-404. Chambless D. L.. Caputo G. C.. Bright P. and Gallagher R. ( 1984) The assessment of fear of fear in agoraphobtcs: the Body Sensations Questionnaire and the Agoraphobic Cognitions Questionnaire. J. consult. c/in. Psychoi. 52, 1090- 1097. Chambless D. L.. Caputo G. C.. Jasin S.. Gracely E. and Williams C. (1985a) The Mobility Inventory for Agoraphobta. Behat,. Res. Thu. 23, 35-44. Chambless D. L.. Goldstein A. J.. Gallagher R. and Bright P. (1985b) Integrating behavior therapy and psychotherapy in the treatment of agoraphobia. Psvchofherapy. In press. Emmelkamp P. M. G. and Cohen-Kettenis P. T. (1975) Relationship of locus of control to phobic anxtety and depression. P.ychof. Rep. 36, 390. Eysenck H. J. and Eysenck S. B. G. (1975) Eysenck Personulirv Quesrionnuire. EdITS, San Diego. Calif. Gambrill E. D. and Richev C. A. (1975) An assertion inventorv for use in assessment and research. Behar. Thu. 6. 550-561. Goldstein A. J. and Chambless D. L. (1978) A reanalysis of agoraphobia. Behur. Ther. 9. 47-59. Hafner R. J. (I 982) The marital context of the agoraphobic syndrome. In Agoraphohu: ztfu/riplc Puspecritrs on Theor? and Treufment (Edited by Chambless D. L. and Goldstein A. J.). pp. 77-l 17. Wiley, New York. Hafner R. J. and Ross M. W. (1984) Agoraphobia in women: factor anaiysts of symptoms and personality correlates of factor scores in a clinical population. Behau. Res. Ther. 22. 441-444. Hollingshead A. B. (1957) Two Factor Index of Social Position. Unpublished document available from the author at I65 Yale Station. New Haven. Conn. Jasin S. (1981) A comparison of agoraphobics, anxiety neurotics, and depressives using the MMPI and the Beck Depression Inventory. Unpublished Doctoral Dissertation. Temple Univ.. Philadelphia. Penn. Marks I. M. (1967) Components and correlates of psychiatric questionnaires. Br. J. rneti. fs)cizoi. a. X--272. Marks I. M. (1970) The origins of phobic states. Am. J. P$yclzofi?er. 24, 657-657. Milton F. and Hafner R. J. The outcome of behavior therapy for agoraphobia in relation to marilal adJustment. .Arc/t.r qen. P.syhiur. 36, 807-X I L, Rock M. H. and Goldberger L. ( 1978) Relationship between agoraphobia and field dependence. J. riert‘. men!. nis. i66( 1I). 78 l-786. Snatth R. P. (1968) A clinical investigation of phobias. Br. J. f’sychiar. 114, h73-697. Sptelberger C., Gorsuch A. and Lushene R. ( 1970) The Starr-Trair Anxiety hrenrory. Consulttng Psychologists Press. Palo Alto. Calif. Watson D. and Friend R. ( 1969) Measurement of social-evaluative anxiety. J. consulf. clin. P.s?-c/ml. 33, 448357. Watson J. P. and Marks I. M. (1971) Relevant and irrelevant fear in flooding: a cross-over study of phobic patients. Be/ru?. Tkr. 2. 275-293. Webster A. S. (1953) The development of phobias in married women. P.Tw/~o(. .Mc~nc>,qr. NO. 67. Weissman M. M. (1983) The epidemtology of anxiety disorders: rates. risks. and familial patterns. Paper presented at the .VIMH-.v~~or~.sor~~~ Con/. otf An.\-iery cmd Anxiery Di.sordw.s. Tuxedo. N .Y. Weissman M. M. and Klcrman G. ( 1979) Sex ditferences and the cpidemology of depression. In GrnJrr mttf IXsordered B&wior (Edited by Gomberg E. S. and Franks V.). pp. 383~425. Brunner:Mazel. New York. Zitrln C. M.. Kletn D. F. and Woerner M. (1980) Treatment of agoraphobia with group exposure m r’h>o and imipramine. ,-lrch.v ,~n~. Puvchirrt. 37, 63-72.

of