DEPRESSION AND ANXIETY 25:230–240 (2008)
Research Article
FEATURES OF THE OFFENSIVE SUBTYPE OF
TAIJIN-KYOFU-SHO IN US AND KOREAN PATIENTS
WITH DSM-IV SOCIAL ANXIETY DISORDER
Yujuan Choy, M.D.,1 Franklin R. Schneier, M.D.,1 Richard G. Heimberg, Ph.D.,2 Kang-Seob Oh, M.D.,3
and Michael R. Liebowitz, M.D.1
Taijin– Kyofu– Sho (TKS), an East Asian syndrome of interpersonal fear and
avoidance, that has been considered culture-bound, overlaps with social anxiety
disorder to an unknown extent. The offensive subtype of TKS is characterized by
two features considered atypical of social anxiety disorder: the belief that one
displays physical defects and/or socially inappropriate behaviors (offensive TKS
symptoms) and fear of offending others (allocentric focus), but no studies have
systematically evaluated these two features in patients with social anxiety
disorder. The purpose of this study was to assess offensive TKS symptoms and
allocentric focus of fear in US (n 5 181) and Korean (n 5 64) patients with
DSM-IV social anxiety disorder, using the newly developed TKS Questionnaire.
Seventy-five percent of patients with social anxiety disorder in the US and Korea
endorsed at least one of the five offensive TKS symptoms surveyed. The severity
of features of offensive TKS was significantly associated with severity of social
anxiety symptoms, depressive symptoms, and disability in both samples. These
results suggest that features of the offensive subtype of TKS are not uncommon
among US patients with social anxiety disorder and may not be as culturally
specific as previously believed. They also suggest that Western clinicians should
assess patients with social anxiety for features of offensive TKS, and they support
further consideration of integrating TKS features into conceptualizations
of social anxiety disorder. Depression and Anxiety 25:230–240, 2008.
& 2008
Wiley-Liss, Inc.
Key words: Taijin–Kyofu–Sho; offensive subtype; social anxiety disorder;
cross-cultural comparisons; Korea; Taijin–Kyofu–Sho Questionnaire
INTRODUCTION
Taijin–Kyofu–Sho (TKS), literally meaning fear
(kyofu) of interpersonal relations (taijin) in Japanese,
is a syndrome first described by Morita in the 1930s
[Kasahara, 1987; Maeda and Nathan, 1999; Takahashi,
1989], and later recognized in Korea, where it is known
as Taein Kong Po [Lee, 1987, 1995]. TKS is often
considered a form of social anxiety that is specific to
East Asian cultures, and it is classified in Appendix A
of DSM-IV as a culture-bound syndrome [APA, 1994].
The TKS syndrome was initially described as
existing on a spectrum of severity level, with four
distinct forms: (1) a ‘‘transient’’ form of social anxiety
r 2008 Wiley-Liss, Inc.
1
Anxiety Disorders Clinic, New York State Psychiatric Institute, and Department of Psychiatry, College of Physicians and
Surgeons, Columbia University, New York, New York
2
Adult Anxiety Clinic Department of Psychology, Temple
University, Philadelphia, Pennsylvania
3
Department of Psychiatry, Kangbuk Samsung Hospital,
School of Medicine, Sungkyunkwan University, Seoul, Korea
Correspondence to: Franklin R. Schneier, M.D., Anxiety
Disorders Clinic, New York State Psychiatric Institute, and
Department of Psychiatry, College of Physicians and Surgeons,
Columbia University, 1051 Riverside Drive, Unit 69, New York,
New York 10019. E-mail: Fschneier@nyspi.cpmc.columbia.edu
Received for publication 18 July 2006; Revised 26 October 2006;
Accepted 1 November 2006
DOI 10.1002/da.20295
Published online 5 March 2007 in Wiley InterScience (www.
interscience.wiley.com).
Research Article: Taijin-Kyofu-Sho
experienced during adolescence, (2) a ‘‘neurosis’’ that
is analogous to DSM-IV’s social anxiety disorder,
(3) a ‘‘borderline’’ form of phobia with ideas of
reference, and (4) a ‘‘delusional’’ form with fixed beliefs
[Kasahara, 1987]. Others have classified TKS into four
phobic subtypes based on the content of the fears:
blushing, deformed body, eye-to-eye contact, and one’s
own foul body odor [Suzuki et al., 2003]. A more
widely accepted approach that also reconciles TKS
more closely with DSM-IV describes two subtypes:
a ‘‘neurotic’’ or ‘‘typical’’ subtype and an ‘‘offensive’’
subtype [Nagata et al., 2006; Seedat and Nagata, 2004;
Yamashita, 2002]. The neurotic subtype has many
similarities to DSM-IV social anxiety disorder (SAD)
[Nakao, 1995]. Both are chronic disorders with an early
age of onset, prominent fear and avoidance of social
situations, and significant functional impairment. In
both disorders, the individual fears being embarrassed
or humiliated in social or performance situations due
to his/her perceived shortcomings (e.g., difficulty
making small talk) or physical manifestations of anxiety
(e.g., blushing, sweating, and tremors).
The offensive subtype of TKS has been described as
encompassing the ‘‘borderline’’ and ‘‘delusional’’ forms
described by Kasahara. One of the core features of
offensive subtype is the fear that others will notice
some perceived physical defects, such as blushing or
trembling, having a stiff facial expression or unpleasant
body odor, or that they will exhibit behaviors seen
as socially inappropriate or awkward, such as making
too much direct eye-to-eye contact or staring at others’
body parts in public [Kirmayer, 1991; Lee, 1987;
Russell, 1989; Takahashi, 1989; Yamashita, 1993].
Some of these symptoms, such as fear of blushing or
trembling, are also common to both the neurotic
subtype of TKS and SAD. Other characteristic
symptoms (e.g. fear of stiff facial expression, unpleasant
body odor) are believed to be relatively specific to the
offensive subtype of TKS, and we will refer to these
symptoms as ‘‘offensive TKS symptoms.’’
Another hallmark of the offensive subtype of TKS is
that as a result of perceived physical defects or
inappropriate behavior, the person fears he or she will
embarrass [Seedat and Nagata, 2004], offend, or even
harm others [Chang, 1995, 1997]. This allocentric
interpersonal focus of fear—fear of offending others—
is seen as an essential criterion in the diagnosis of the
offensive subtype of TKS [Seedat and Nagata, 2004],
and contrasts with the egocentric interpersonal focus
of SAD—fear of embarrassing oneself [Chang, 1995,
1997]. It should be noted that egocentric fears of
embarrassing oneself are also present in the offensive
subtype of TKS, but that there is a noted absence of
allocentric fears in descriptions of DSM-IV SAD
[Kasahara, 1987; Russell, 1989].
The difference in interpersonal focus is widely
thought to reflect differences in Eastern and Western
cultures’ conceptualization of the self and others
[Kirmayer, 1991; Lee, 1987; Markus and Kitayama,
231
1991]. For example, Korean children are said to be
raised to live peacefully among others, to respect and
not to be in conflict with authority and family
members, and this regard for others extends to those
in the community [Lee, 1987]. In Japanese culture,
interdependence and concern for others is also seen as
a virtue, and children are encouraged to be obedient,
docile, and to submit to others, and as a result, are
more concerned with how they affect others [Kirmayer,
1991]. Thus, East Asian cultures have been noted to
emphasize an interdependent self-construal, in which
one views the self as an extension of one’s social group,
whereas Western cultures emphasize individualism and
view the self as independent from others [Markus and
Kitayama, 1991].
Some scholars have challenged this distinction
[Matsumoto, 1999], however, and recent empirical
findings in clinical and non-clinical samples also
suggest that the distinction between SAD and the
offensive subtype of TKS may be less clear-cut than
previously believed. Studies in non-clinical samples
found moderate correlations between social anxiety and
features of offensive TKS in healthy volunteers of nonAsian or Japanese descent in the US [Kleinknecht et al.,
1994], students in the US and Japan [Kleinknecht et al.,
1997], and students in Japan reporting interpersonal
difficulties [Tarumi et al., 2004]. A clinical study
reported that 65.8% of Japanese outpatients with
clinically diagnosed TKS also met DSM-III-R criteria
for SAD [Nakamura et al., 2002], although SAD was
more common among TKS patients characterized by
‘‘neurotic’’ symptoms (81.5%) than among those with
‘‘delusional’’ symptoms (27.3%). Case reports that have
described seven American patients with offensive TKS
challenge the disorder’s cultural exclusivity, suggesting
that offensive TKS does occur, at least sporadically,
outside the Far East [Clarvit et al., 1996; McNally
et al., 1990]. These studies suggest that features of
offensive TKS are associated with features of SAD in
both non-clinical samples and Japanese TKS patient
samples. Among patients diagnosed with SAD, however, the prevalence of offensive TKS features and their
relationship to SAD features remains unknown. Also,
although TKS and its offensive subtype are believed
to be common in Korea, there has been little empirical
investigation of TKS there.
The goal of this study was to clarify the relationship
of offensive TKS features to SAD features in the
United States and Korean patients with SAD. We
systematically assessed the prevalence of (1) characteristic symptoms of the offensive subtype of TKS (both
offensive TKS symptoms and symptoms believed
common to SAD and TKS) and (2) allocentric
interpersonal focus, in patients with SAD in the United
States and Korea. Previous studies have not assessed
allocentric focus separately from offensive TKS symptoms. We hypothesized that the allocentric fear of
offending others would be greater in respect to offensive
TKS symptoms (e.g., stiff facial expression, unpleasant
Depression and Anxiety
232
Choy et al.
body odor) than for symptoms common to both SAD
and the neurotic subtype of TKS (e.g., blushing and
trembling), whereas the egocentric fear of embarrassing
oneself would be greater for the common symptoms.
Associations of features of the offensive subtype of
TKS to the overall severity of SAD, scrutiny fears,
interpersonal fears, depression, and disability were also
explored.
MATERIALS AND METHODS
SUBJECTS
Patients in the US were recruited from two sites, the
Anxiety Disorders Clinic at the New York State
Psychiatric Institute (NYSPI) in New York City, New
York (NYC) (n 5 74) and the Adult Anxiety Clinic
of Temple University in Philadelphia, Pennsylvania
(n 5 107). Patients completed evaluation for a clinical
trial and received a primary diagnosis of DSM-IV SAD
as determined by the Structured Clinical Interview of
DSM-IV [First et al., 2002] in NYC or the Anxiety
Disorders Interview Schedule for DSM-IV, Lifetime
version [DiNardo et al., 1994] in Philadelphia,
administered by a trained clinician. Patients were
excluded if they had current major depressive disorder,
history of psychotic illness, bipolar disorder or recent
substance abuse. Patients in South Korea had sought
treatment in the clinic of the Department of Psychiatry,
Kangbuk Samsung Hospital in Seoul. Korean patients
had a primary diagnosis of DSM-IV SAD, based on
clinical psychiatric interview, but structured interviews
were not performed. In the Korean sample, the
presence of the offensive subtype of TKS was
additionally diagnosed if the patient had the conviction
that his/her symptoms displeased or offended others.
Korean patients were excluded if they met current
criteria for DSM-IV major depressive disorder,
obsessive–compulsive disorder, psychotic illness (other
than offensive TKS), bipolar disorder or recent
substance use based on the clinical interview.
Patients participated in the study voluntarily after
informed consent was obtained and prior to beginning
treatment for SAD. The study was approved by the
IRB of the NYSPI and Temple University and by a
human subjects committee in Korea.
THE TAIJIN KYOFU SHO QUESTIONNAIRE
Because existing measures of TKS symptoms did not
allow assessment of offensive TKS symptoms independently from allocentric interpersonal focus, we developed the TKS Questionnaire (TKSQ, see Appendix A)
to assess these features. The TKSQ was not designed
to diagnose presence or absence of the syndrome of
TKS. The English version of the TKSQ was translated
into Korean and back-translated into English to
confirm accuracy.
The TKSQ consists of 30 items. Ten physical/
behavioral symptoms characteristic of TKS and/or
Depression and Anxiety
SAD are each rated in respect to the severity of
fear associated with each of three interpersonal foci:
(1) embarrassing oneself, (2) making another person
uncomfortable, and (3) offending another person. The
intermediate option (i.e. fear of making another person
uncomfortable) was included in the TKSQ because we
did not know whether US patients would endorse the
more extremely stated fear of causing offense to others.
Five of the 10 symptoms in the TKSQ were
hypothesized to be specific to the offensive subtype
of TKS (fears of stiff facial expression, body odor,
inappropriate staring, intestinal gas, and physical
appearance), here referred to as offensive TKS symptoms,
and the other five were hypothesized to be common to
both SAD and TKS (fears of blushing, body trembling,
voice trembling, sweating, and making eye contact),
here referred to as common symptoms.
Offensive TKS symptoms were based on the descriptions of TKS by Russell [1989], Kasahara [1987],
Lee [1987], Takahashi [1989], Yamashita [1993], and on
the diagnostic criteria of TKS proposed by Seedat
and Nagata [2004]. For example, Lee [1987] found
fears of body odor and stiff facial expression to be more
common in delusional and borderline types of TKS.
‘‘Inappropriate staring’’ was obtained primarily from
case reports of inappropriate staring at other’s body
regions by Yamashita [1993]. ‘‘Physical appearance’’
was derived from fears of ‘‘physical deformities’’ as
noted by Lee [1987], Seedat and Nagata [2004] and
others, because we believed the broader term better
reflected this concept.
Common symptoms were based on review of the
literature and the authors’ experience with SAD, and
review of TKS literature as noted above. For ‘‘eyecontact,’’ different terms have been used in the TKS
literature, such as ‘‘line of sight becoming uncontrollable’’ [Seedat and Nagata, 2004], ‘‘eye-sight’’ [Lee,
1987], or ‘‘fear of side-glancing’’ [Kasahara, 1987].
We chose the general term ‘‘eye-to-eye contact with
another person’’ to capture the fear of any eye-contact
with another person, include the fear of direct gaze
seen in patients with SAD.
Each of 30 TKSQ items is scored on a four-point
scale: 0 5 not fearful at all, 1 5 mildly fearful, 2 5 moderately fearful, and 3 5 extremely fearful. The TKSQ
item scores were totaled into six subscores: Fear of
embarrassment to self due to common symptoms
(E-CS); Fear of discomfort to others due to common
symptoms (D-CS); Fear of offense to others due to
common symptoms (O-CS); Fear of embarrassment
to self due to offensive TKS symptoms (E-TKS);
Fear of discomfort to others due to offensive TKS
symptoms (D-TKS); and Fear of offense to
others due to offensive TKS symptoms (O-TKS).
Each subscore was the sum of five items (e.g.,
E-CS 5 sum of fear of embarrassment scores for the
five common symptoms).
For analyses of prevalence of each physical/behavioral symptom, a symptom was considered present if the
Research Article: Taijin-Kyofu-Sho
respondent reported moderate or extreme fear (a score
of two or three) in any of the three interpersonal
foci (embarrassment to self, discomfort to others, or
offending others) due to that symptom. The prevalence
of each symptom was also tabulated separately for each
interpersonal focus of fear.
OTHER ASSESSMENTS
In addition to the TKSQ, all patients completed
three other self-rated scales: (1) the Social Phobia Scale
(SPS) [Mattick and Clarke, 1998], a 20-item scale that
assesses fear of being scrutinized by others during
activities such as eating or writing. Korean subjects
completed a Korean version that had been translated
and back-translated (2) the Beck Depression Inventory,
second edition (BDI-II) [Beck et al., 1996], a 21-item
scale addressing symptoms of depression, and (3) the
Sheehan Disability Scale (SDS), with three items
assessing functional impairment in work, family life
and leisure activities [Sheehan, 1983]. Korean subjects
completed established Korean versions of the BDI
and SDS [Lee and Song, 1991]. The US sample completed
two additional instruments: (1) the Liebowitz Social
Anxiety Scale (LSAS) [Liebowitz, 1987], a clinicianrated 24-item scale that assesses severity of anxiety
and avoidance in social situations and (2) the Social
Interaction Anxiety Scale (SIAS) [Mattick and Clarke,
1998], a 20-item self-report scale that rates cognitive,
affective and behavioral reactions of anxiety during
social interactions.
STATISTICAL ANALYSIS
Statistical analysis was conducted with SPSS 13.0.
Continuous measures were analyzed with Student’s
t-tests or the Mann–Whitney U test and Pearson’s
product-moment correlation coefficients. Chi-square
tests were applied to comparisons of categorical data.
All tests were two-tailed, and P values of .05 were
considered statistically significant. Internal consistency
was assessed with Cronbach’s a.
RESULTS
DEMOGRAPHIC AND CLINICAL FEATURES
Data for the US sample were obtained from 74
patients in NYC and 107 patients in Philadelphia (total
n 5 181) (see Table 1). There were no significant
differences between the Philadelphia and NYC samples
in age, gender, or marital status. However, the NYC
site had higher proportions of African-American and
Hispanic patients (25 and 26.4%, respectively) than the
Philadelphia site (15 and 2.8%, respectively) [w2 5 31.4,
df 5 4, P 5.0001], and a lower proportion of college
educated (79.7% NYC versus 91.4% Philadelphia)
[w2 5 5, df 5 1, P 5.026] and employed persons (55.4%
NYC versus 75.2% Philadelphia) [w2 5 9.8, df 5 3,
P 5.02]. These samples were combined in subsequent
233
analyses. The US sample included 10 patients of Asian
descent, but excluding these patients did not affect
the outcome of any subsequent analyses, so they were
retained in the US sample.
Data were obtained from 64 patients with SAD in
Korea, including 25 diagnosed with the offensive
subtype of TKS. Patients with the offensive subtype
were more likely to be male (88 versus 64.1%)
[w2 5 4.5, df 5 1, P 5.04] and married (80 versus
54.3%) [w2 5 4.2, df 5 1, P 5.04], but TKS subtypes
did not differ in age, educational level or employment
status.
Compared to the US sample, the Korean sample
overall was younger, more likely to be male, married,
and less likely to be employed (see Table 1). Due to the
marked differences between the US and Korean
samples in demographics and ascertainment, as well
as potential response bias due to cultural differences,
the two groups were not compared directly in
subsequent analyses.
The US sample evidenced severity of social anxiety
symptoms in the range of generalized SAD [LSAS,
SPS, and SIAS, Mennin et al., 2002], mild to moderate
disability [SDS, Sheehan, 1983], and subsyndromal
levels of depression [BDI-II, Steer et al., 2001] (see
Table 1).
PSYCHOMETRIC PROPERTIES
OF THE TKSQ
The psychometric properties of the TKSQ are
shown in Table 2. TKSQ subscores in the US sample
were normally distributed with the exception of the
O-CS, which was mildly skewed to the right. The
internal consistencies of the six subscores were
satisfactory or better. In the Korean sample, E-CS
and E-TKS subscores were normally distributed, but
the other subscores were positively skewed. Internal
consistencies were satisfactory or better for the
common symptom subscores, but lower for the
offensive TKS symptom subscores. In both US and
Korean samples, the TKSQ subscores were significantly correlated with common symptom subscores,
social anxiety, depression and disability (Table 3).
Outcomes for fear of discomfort to others were
consistently intermediate to the other two interpersonal foci of fear, and for clarity of presentation, these
data were omitted from Table 3 and from Figure 1
(described below) but are available on request.
PREVALENCE OF TKS FEATURES
Fear of Embarrassing Oneself and Fear of
Offending Others. The prevalence of fear of embarrassment and fear of offending others for each of the
10 symptoms in the TKSQ are shown in Figure 1 for
the US and Korean patients, respectively. The proportion of the US sample endorsing fear of offending others
due to each of the 10 symptoms ranged from 15.5 to
39.2% in the US sample, and from 6.3 to 25.0% in the
Depression and Anxiety
234
Choy et al.
TABLE 1. Demographic and clinical characteristics of the US and Korean samples
US (n 5 181)
Korean (n 5 64)
Analysis
Variables
N
(%)
N
(%)
w2
df
P
Gender
Male
Female
104
77
(57.5)
(42.5)
47
17
(73.4)
(26.6)
5.1
1
.02
Marital Status
Married
Not married
35
143
(19.7)
(80.3)
39
21
(65.0)
(35.0)
43.0
1
.001
Education
College
High school or less
151
23
(86.8)
(13.2)
48
12
(80.0)
(20.0)
1.6
1
.2
Employment
Employed (full or part-time)
Homemakers or students
Others
115
26
29
(67.6)
(15.3)
(17.1)
27
23
11
(44.3)
(37.7)
(18.0)
14.6
2
.001
Ethnicity
Caucasian
African-American
Hispanic
Asian/Pacific Islander
Others
106
34
22
10
7
(59.2)
(19.0)
(12.3)
(5.6)
(3.9)
Mean
(SD)
Mean
(SD)
t
df
P
32.6
5.3
7.4
3.2
13.0
32.4
74.4
57.7
(9.6)
(3.0)
(2.4)
(2.8)
(8.8)
(15.9)
(23.7)
(14.7)
29.4
6.5
6.6
3.1
16.9
50.3
(8.4)
(3.1)
(3.0)
(3.0)
(10.9)
(18.6)
2.4
243
.01
Age
SDS-work
SDS-leisure
SDS-home
BDI
SPS
LSAS
SIAS
Employment ‘‘others’’ includes not employed, retired, disabled.
Ethnicity: Koreans were all of Korean ethnicity. Groups were not compared in respect to clinical features, due to group differences in
demographics, ascertainment, and the potential for culture-based response bias.
Korean sample. Among Koreans with the offensive
subtype of TKS (not displayed in Fig. 1), the
proportion reporting fear of offending others due to each
of the 10 symptoms was as follows: body odor (28%),
inappropriate staring (20%), stiff facial expression (44%),
intestinal gas (24%), physical appearance (16%), sweating
(20%), body trembling (28%), eye contact (28%),
blushing (24%), and voice trembling (24%).
Physical/behavioral symptoms. The prevalence of
each of the 10 TKSQ symptoms due to any of the three
interpersonal foci of fear was tabulated for US patients, all
Korean patients, and the subgroup of Korean patients with
offensive subtype of TKS (see Table 4). In both the US
and Korean samples, 75% of the sample endorsed at least
one of the five offensive TKS symptoms. Among Koreans
with the offensive subtype of TKS, 96% endorsed at least
one of the five offensive TKS symptoms.
Depression and Anxiety
TKSQ SUBSCORES IN US
AND KOREAN SAMPLES
Mean subscores for the US and Korean samples are
shown in Table 2. Within the US sample, fear of
embarrassment was greater for the common symptoms
than for the offensive TKS symptoms (E-CS versus
E-TKS; t 5 6.3, df 5 180, Po.0001), and the fear of
offense to others was greater for the offensive TKS
symptoms than for the common symptoms (O-TKS
versus O-CS, Z 5 2.3, P 5.02). In addition, embarrassment fears were greater than offense fears within both
the common symptoms (E-CS versus O-CS; Z 5 9.7,
Po.0001) and the offensive TKS symptoms (E-TKS
versus O-TKS; t 5 13, df 5 180, Po.0001).
Similar to the US sample, in the Korean sample,
fear of embarrassment was greater for the common
Research Article: Taijin-Kyofu-Sho
235
TABLE 2. TKSQ subscale scores and psychometric properties of the TKSQ in the US and Korean samples
US (n 5 181)
TKSQ subscores
Mean (SD) Skewness (SE)
Common symptoms
Embarrassment items
7.3
(E-CS)
Discomfort items (D-CS) 5.2
Offend items (O-CS)
3.8
Offensive TKS symptoms
Embarrassment items
(E-TKS)
Discomfort items
(D-TKS)
Offend items (O-TKS)
Korean (n 5 64)
Kurtosis
(SE)
a
Mean (SD) Skewness
(SE)
Kurtosis
(SE)
a
(3.5)
0.0
(0.2)
0.6
(0.4)
.65
7.0
(3.7)
0.3
(0.3)
0.5
(0.6)
.74
(7.8)
(3.7)
0.6
1.1
(0.2)
(0.2)
0.2
0.7
(0.4)
(0.4)
.76
.83
4.1
2.7
(3.8)
(3.4)
1.1
1.5
(0.3)
(0.3)
0.8
2.1
(0.6)
(0.6)
.86
.87
5.6
(3.7)
0.6
(0.2)
0.0
(0.4)
.76
4.4
(3.0)
1.0
(0.3)
0.8
(0.6)
.57
4.8
(3.8)
0.8
(0.2)
0.2
(0.4)
.79
3.0
(2.7)
1.4
(0.3)
2.2
(0.6)
.63
4.3
(4.0)
0.9
(0.2)
0.3
(0.4)
.83
2.7
(2.7)
1.2
(0.3)
1.6
(0.6)
.63
a 5 Cronbach’s a.
TABLE 3. Correlation between TKSQ subscores and standard clinical measures in the US and Korean samples
US
O-CS
E-TKS
O-TKS
SDS-work
SDS-leisure
SDS-home
BDI
SPS
LSAS
SIAS
E-CS
O-CS
.52
.54
.41
.20
.09
.14
.21
.44
.29
.17
.55
.72
.19
.18
.08
.21
.43
.29
.24
Korean
E-TKS
O-TKS
.83
.19
.32
.17
.37
.56
.47
.37
.19
.25
.13
.37
.52
.39
.33
E-CS
O-CS
E-TKS
O-TKS
.49
.49
.28
.38
.41
.47
.45
.65
.49
.70
.36
.31
.40
.39
.49
.80
.48
.46
.50
.50
.60
.39
.38
.46
.40
.46
Correlation is significant at 0.05 level; Significant at 0.01 level; Significant at 0.001 level (two-tailed).
E-CS, fear of embarrassing oneself due to common symptoms; O-CS, fear of offending others due to common symptoms; E-TKS, fear of
embarrassing oneself due to offensive TKS symptoms; O-TKS, fear of offending others due to offensive TKS symptoms; SDS, Sheehan Disability
Scale; BDI, Beck Depression Inventory; SPS, Social Phobia Scale; LSAS, Liebowitz Social Anxiety Scale (only in US sample); SIAS, Social
Interaction Anxiety Scale (only in US sample).
symptoms than for the offensive TKS symptoms (E-CS
versus E-TKS; t 5 6.0, df 5 63, Po.0001). Fear of
offense to others, however, did not differ between the
common and the offensive TKS symptoms (O-CS
versus O-TKS, Z 5 0.3, P 5.77). Embarrassment fears
were greater than offense fears within both the
common symptoms (E-CS versus O-CS; Z 5 6.4,
Po.0001) and the offensive TKS symptoms (E-TKS
versus O-TKS; Z 5 5.7, Po.0001).
Comparing the offensive and non-offensive subtypes
of the Korean sample, there was no difference in
embarrassment due to the common symptoms (mean
E-CS 5 7.0 and 6.9, respectively), but offense due to
the common symptoms was greater in the offensive
subtype (mean O-CS 5 4.4) than in the non-offensive
subtype (mean O-CS 5 1.7, Z 5 2.7, Po.01). In addition, the offensive subtype also had greater mean scores
for embarrassment due to offensive TKS symptoms
(E-TKS 5 6.0) compared to the non-offensive subtype
(E-TKS 5 1.9; Z 5 3.5, P 5.001), as well as greater
mean scores for offense due to offensive TKS symptoms
(O-TKS 5 4.5 versus O-TKS 5 1.5, respectively, Z 5 5.0,
Po.0001).
DISCUSSION
Contrary to the prevailing view of TKS symptoms as
limited to East Asian cultures, this first systematic
assessment of TKS features in American patients
with DSM-IV SAD found a surprisingly high level
of features of the offensive subtype of TKS. Seventy-five
percent of the US patients reported moderateto-severe fear of at least one of the symptoms that
were thought to be specific to offensive subtype of TKS
Depression and Anxiety
236
Choy et al.
Figure 1. Percentage of US (n 5 181) and Korean (n 5 64) patients with fear of embarrassing oneself and offending others due to each
of the ten symptoms assessed by the TKSQ.
TABLE 4. The percentage of US and Korean patients who endorse the 10 symptoms as a result of any of the three
interpersonal foci of fear (embarrassment to self, discomfort to others, or offending others)
US (n 5 181)
Korean: both subtypes (n 5 64)
Korean: offensive subtype
(n 5 25)
TKSQ symptoms
N
(%)
N
(%)
N
(%)
Common symptoms
Blushing
Body trembling
Voice trembling
Eye contact
Sweating
103
83
125
85
81
56.9
46.1
69.4
47.0
45.3
30
31
32
32
17
46.9
48.4
50.0
50.0
26.6
13
12
10
15
9
52.0
48.0
40.0
60.0
36.0
Offensive TKS symptoms
Stiff facial expression
Body odor
Inappropriate staring
Intestinal gas
Physical appearance
88
57
67
80
68
48.9
32.4
37.2
44.2
37.6
36
12
14
17
11
56.3
18.8
21.9
26.6
17.2
15
8
9
10
9
60.0
32.0
36.0
40.0
36.0
(intestinal gas, stiff facial expression, staring at other’s
body parts, body odor, and physical appearance).
In addition, 15.5–39.2% of US patients reported
moderate-to-severe fear of offending others (as opposed to only embarrassing oneself) with respect to
each of the symptoms surveyed, including symptoms
typical of SAD (blushing, eye contact, sweating, body,
Depression and Anxiety
and voice trembling). These estimates were conservative because ratings of ‘‘mild’’ fears (score of 1) were
not considered in our analyses.
Features of offensive TKS were also significantly
associated with severity of social anxiety in the US
sample of patients with SAD, similar to findings in
non-clinical samples [Kleinknecht et al., 1997, 1994;
Research Article: Taijin-Kyofu-Sho
Tarumi et al., 2004]. Our findings are also consistent
with findings of Nakamura et al. [2002], who reported
a high rate of SAD in patients with TKS. Unlike
Nakamura et al., however, we did not make a clinical
diagnosis of the TKS syndrome in the US sample but
only assessed severity of features of the syndrome.
Although US patients endorsed a high degree of
features of offensive TKS in the TKSQ, this does not
imply that the US sample had a high prevalence of
TKS, as presence of the full syndrome of TKS was
not assessed in this group. Indeed, a post hoc chart
review of 12 cases at the NYC site with the highest
offensive TKS features score [sum of D-CS, O-CS,
E-TKS, D-TKS, O-TKS greater than 50 (full range
of scores 0–75)] found no clinical documentation of
features of offensive TKS, suggesting that clinicians
did not inquire about offensive features, and patients
did not spontaneously report them. It appears that US
clinicians did not conceptualize offensive TKS features
as central to SAD, and US patients may have held
similar conceptualizations or may have been embarrassed to volunteer information about their offensive
TKS symptoms. Future studies that include a clinical
evaluation of the TKS syndrome will be needed to
confirm the clinical significance of TKS features in
SAD patients.
Unlike the US sample, the Korean sample had been
systematically assessed for the offensive subtype of
TKS. Korean patients with SAD and the offensive
subtype of TKS had markedly higher scores on fear
of offense due to common symptoms, and fear of
embarrassment and fear of offense due to the offensive
TKS symptoms than patients without the offensive
subtype. As expected, there was no difference in fear of
embarrassment due to the common symptoms. These
findings support the validity of the TKSQ subscales in
discriminating the clinical features of offensive TKS.
This was also one of the first empirical studies of TKS
symptoms in Korea, and it supports clinical impressions of similarities to the TKS syndrome described
in Japan [Lee, 1987].
A secondary goal of this study was to explore the
structure of offensive TKS features with respect to
the relationship between focus of fear and types
of symptoms. Fear of embarrassing oneself was
prominent in both US and Korean samples in relation
to symptoms that are common to SAD and to
symptoms typically considered to be specific to the
offensive subtype of TKS. This is consistent with
Japanese psychiatrists’ observation that embarrassment
and shame to self is also common in patients with TKS
[Kasahara, 1987; Russell, 1989]. In the US sample,
fear of offending others was greater for offensive
TKS symptoms than common symptoms, and fear of
embarrassing oneself was greater for common symptoms than offensive TKS symptoms. These findings
support our hypothesis that offense to others may be
more associated with offensive TKS symptoms, such as
concerns about body odor and releasing intestinal gas,
237
which are inherently allocentric. It is also notable that
for each symptom, fear of embarrassment was greater
than fear of offense, even among Korean patients with
the offensive subtype of TKS. This suggests that the
distinction between allocentric focus of fear in Eastern
culture versus egocentric focus in Western cultures for
SAD is not as clear as others [e.g., Chang, 1997] have
claimed, and that it may be more accurate to suggest
that both types of fears are present in both cultures.
Our results are consistent with a recent analog study
finding that both independent and interdependent
types of self-construal exist as a continuum in the same
individual in both US and Japanese students [Kleinknecht et al., 1997]. Another analog study found that
US and Japanese participants did not differ in their
interdependence scores, and regardless of their cultural
background, individuals who scored higher on interdependence scored higher in social phobia symptoms
[Dinnel et al., 2002].
Due to marked demographic and ascertainment
differences between the US and Korean sample, as
well as the potential for culturally based response bias,
we did not directly compare the two groups in respect
to features of TKS. Patients may experience and
present social anxiety symptoms differently in Western
and Eastern cultures. For example, patients from Japan
tend to present their problems in terms of interpersonal difficulties (making a diagnosis TKS more likely)
whereas patients from the US present their problems in
more general complaints of anxiety or mood symptoms
[Tseng et al., 1992]. Reports of low lifetime rates of
SAD in the East Asian countries (including Korea) may
reflect a reluctance to endorse symptoms [Seedat
and Nagata, 2004]. Clarification of cross-national and
cross-ethnic differences in symptoms will require
additional studies with a variety of samples and
assessment approaches.
Limitations of this study included absence of preexisting psychometric data on the TKSQ and lack
of clinical validation of this self-assessment instrument
in the US sample. Nonetheless, the TKSQ subscales
demonstrated good internal consistency in the US
sample, and in the Korean sample TKSQ findings were
consistent with clinical TKS subtyping. Diagnostic
evaluation of the Korean patients was limited by
unstructured clinical assessments of SAD and the
offensive subtype of TKS.
US patients with symptoms of the offensive subtype
of TKS may receive a variety of DSM-IV diagnoses,
including anxiety not otherwise specified, a culturebound syndrome, body dysmorphic disorder, delusional disorder, paranoid personality disorder, paranoid
schizophrenia [Tanaka-Matsumi, 1979] or avoidant
personality disorder [Tseng et al., 1992]. Our findings
suggest the need for further study of a broader
conceptualization of SAD that acknowledges some
features of the TKS syndrome, including fears of
offending others as well as classic offensive TKS
symptoms such as fears of stiff facial expression or
Depression and Anxiety
238
Choy et al.
inappropriate staring. Wider assessment of features
of TKS would enable researchers to better understand
their relationship to SAD and other disorders, as well
as encourage clinicians to assess features of TKS in
patients who present with complaints of social anxiety
and avoidance.
Future studies should determine if the presence
of offensive TKS features in SAD patients predicts
response to cognitive behavioral therapy or pharmacotherapy. A chart review of 48 patients with TKS
reported a 48% response rate to treatment with
clomipramine or fluvoxamine [Matsunaga et al.,
2001], and a recent open trial reported that 41% of
19 patients diagnosed with the offensive subtype of
TKS (without comorbid disorders) responded to
paroxetine [Nagata et al., 2006]. These response rates
are lower than those reported in most controlled trials
of SSRIs for SAD [Blanco et al., 2002]. Clearly,
prospective, controlled studies are needed to support
the preliminary treatment results for TKS.
In summary, our findings that features of the
offensive subtype of TKS are not uncommon in
patients with SAD in both the US and Korea suggest
that offensive TKS features are less specific to East
Asian cultures than previously thought. They suggest
that Western clinicians should assess offensive TKS
symptoms in their patients with SAD and support
further consideration of the relationship of TKS to
SAD.
Acknowledgments. We thank Andrew Schmidt
for managing the dataset.
Appendix A
The Taijin-Kyofu-Sho Questionnaire (TKSQ)
assesses severity of 10 physical/behavioral symptoms
in respect to distress from embarrassment to oneself,
discomfort to others, and offense to others (See
Table A1).
TABLE A1. The Taijin Kyofu Sho Questionnaire
(TKSQ)a
PLEASE CIRCLE ONE RESPONSE FOR EACH OF THE
FOLLOWING QUESTIONS:
How fearful are you that you may blush in front of others,
such as turning red when someone asks you a question, and as a
result:
1. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
2. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
Depression and Anxiety
3. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that your facial expressions may stiffen in front
of others, such as not being able to change the expression on your
face, and as a result:
4. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
5. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
6. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that your head, hands, and/or feet will tremble
in front of others, and as a result:
7. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
8. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
9. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that your voice will tremble while talking with
others, and as a result:
10. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
11. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
12. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that you will sweat or perspire in front of others,
and as a result:
13. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
Research Article: Taijin-Kyofu-Sho
14. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
15. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that you will have body
odors around others, and as a result:
16. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
17. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
18. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that you will stare
at parts of other persons’ bodies,
and as a result:
19. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
20. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
21. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that you will release
intestinal gas in the presence of others,
and as a result:
22. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
23. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
24. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that you will make eye-to-eye contact with
another person, and as a result:
239
25. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
26. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
27. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
How fearful are you that due to your physical appearance to others:
28. You will feel embarrassed.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
29. You will make another person uncomfortable.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
30. You will offend another person.
a. Not fearful at all
b. Mildly fearful
c. Moderately fearful
d. Extremely fearful
a
The TKSQ format was presented in one column in the study but
displayed here in two columns because of space limit.
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