Running head: RECOMMENDATIONS TO INCLUDE EAST ASIANS
Recommendations to Include East Asians in the Diagnostic Criteria of
Social Anxiety Disorder
Josie Boehlert
University of Virginia
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Recommendations to Include East Asians in the Diagnostic Criteria of
Social Anxiety Disorder
Social anxiety disorder (SAD) is a condition that can significantly affect all areas
of functioning. The fear of social situations that is characteristic of SAD often inhibits
performance in social, emotional, academic, and occupational arenas. Information on
prevalence rates of SAD included in the most recent edition of the American
Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (5th
ed., DSM-V; American Psychiatric Association, 2013a) has indicated that the disorder is
diagnosed more commonly in Caucasian individuals and less often in the East Asian
population. However, symptoms of SAD are commonly found in East Asian individuals
(Essau et al., 2011). It is hypothesized that the disorder may appear through different
presentations in cultures around the world. Manifestations of SAD in East Asian cultures
may include taijin kyofusho and hikikomori. The purpose of this paper is to consider
potential reasons that SAD is diagnosed less frequently in the East Asian population
despite the presence of SAD symptoms. After surveying possible manifestations of SAD
in the East Asian population, this paper will provide recommendations for improved
diagnostic procedures.
Social Anxiety Disorder
The DSM-V has classified SAD as a disorder in which individuals fear social
situations that may expose them to scrutiny. Affected individuals specifically fear that
they will act in ways that will show their anxiety and therefore will be negatively
evaluated. A recent change in the DSM has included the fear of offending others in this
criterion. Individuals with SAD avoid social situations or endure them with anxiety. The
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anxiety is out of proportion with threat posed by the situation and with the sociocultural
context. The symptoms must last longer than 6 months and they must impair functioning.
SAD cannot be diagnosed if the symptoms are caused by a substance or another medical
condition, or if the symptoms can be better explained by another mental disorder.
Statistics in the DSM-V have indicated that SAD in the United States has a
prevalence rate of approximately 7%. Lower prevalence rates are seen around the world
using the DSM-V criteria. East Asians in particular are less often diagnosed with SAD.
Although rates of SAD diagnosis are lower for East Asians, a few studies have
found that many individuals in these cultures experience considerable social anxiety.
Schreier, Heinrichs, Alden, Rapee, Hofmann, Chen, Oh, and Bogels (2010) conducted a
study that compared social anxiety levels between people in individualistic and
collectivistic cultures. University students from both types of cultures completed selfreport questionnaires and Social Interaction Anxiety scales. The researchers found that
East Asians displayed significantly higher rates of social anxiety than those from Western
cultures.
The findings of this study have not been adequately represented in rates of SAD
diagnosis. One reason that East Asians have been overlooked in the diagnosis of SAD
may be the different presentation of their social anxiety symptoms. In other words, SAD
may manifest itself differently in East Asian individuals. A condition known as taijin
kyofusho may be one way that social anxiety is expressed in East Asian individuals.
Taijin Kyofusho
Taijin kyofusho was first described in the 1930’s and translates into English as, “a
fear of interpersonal relations” (Choy, Schneier, Heimberg, Kang-Seob, & Liebowitz,
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2008). Researchers have suggested that prevalence rates in clinical settings may be as
high as 38% (Essau et al., 2011). No known research has been done to discover
prevalence rates in the general population.
Two subtypes have been described in the literature on taijin kyofusho. In the
“neurotic” or “sensitive” subtype, individuals experience many of the symptoms that are
characteristic of SAD (Choy at al., 2008). Individuals fear being embarrassed in social
situations because of the physical symptoms of their anxiety. The “offensive” type is
characterized by a fear of offending others. Individuals may fear that perceived
imperfections such as physical defects, body odor, blushing, eye contact, and trembling
will offend or displease others.
Relation to SAD
The sensitive subtype of taijin kyofusho has many similarities to SAD. In both
conditions, individuals are afraid of being embarrassed in social situations because of
their anxiety symptoms (Choy et al., 2008). Both deal with egocentric concerns of
becoming embarrassed. The offensive type differs slightly in the content of the anxiety
producing cognitions. Individuals with this condition are not as concerned with their own
embarrassment, but are more focused on the wellbeing of others. The thought of
offending others invokes feelings of anxiety.
Taijin Kyofusho in the DSM-V
Authors of the DSM-V have taken a few steps to include East Asian symptoms of
social anxiety in the diagnostic criteria for SAD. In response to the requests of many
researchers, the authors of the DSM-V changed the second criterion of SAD (the fear of
being negatively evaluated) to include a fear of offending others (5th ed.; DSM-V;
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American Psychiatric Association, 2013a). The DSM-V has also included taijin kyofusho
in the Glossary of Culture-Related Diagnostic Issues. The short description explains that
taijin kyofusho often includes symptoms that go beyond the criteria of SAD (5th ed.;
DSM-V; American Psychiatric Association, 2013b). It states that additional symptoms
that may be experienced in taijin kyofusho often resemble the diagnostic criteria for body
dysmorphic disorder and delusional disorder. It is therefore possible that individuals with
taijin kyofusho may be diagnosed with SAD and other comorbid disorders according to
the existing DSM-V criteria.
Cultural Considerations
Much of the existing literature has regarded taijin kyofusho as a culturally bound
condition that is specific only to East Asian individuals (Tarumi et al., 2004). Many
theorize that the collective nature of Asian cultures gives rise to taijin kyofusho. The
DSM-V appendix affirms that the symptoms occur in specific cultural contexts, but it also
points out that taijin kyofusho has been described in other countries including the United
States, Australia, and New Zealand. It can therefore be theorized that taijin kyofusho is
not a culturally bound condition.
A research study conducted by Choy, Schneier, Heimberg, Oh, and Liebowitz
(2008) affirmed that taijin kyofusho is not confined strictly to East Asian cultures. The
researchers collected data from Koreans and United States citizens through
questionnaires that measured taijin kyofusho and social phobia. The results showed that
participants in the United States reported experiencing symptoms of taijin kyofusho, and
that in both samples, higher rates of taijin kyofusho correlated with severity of social
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anxiety symptoms. The findings indicate that taijin kyofusho is not specific to East Asian
cultures and that Westerns clinicians should give more consideration to the condition.
Need for Increased Attention
In order to affectively diagnose and treat disorders of social anxiety, more
attention must be given to taijin kyofusho. Essau, Sasagawa, Ishikawa, Okajima,
O’Callaghan, and Bray (2011) compared rates of taijin kyofusho in adolescents to rates in
adults in Japan. The researchers found that rates of taijin kyofusho and social anxiety
symptoms were much higher in the adolescents than in the adults. It is possible that the
adolescents in the study experienced more social anxiety because of their developmental
stage. However, the authors theorized that rates of taijin kyofusho are increasing because
of societal changes. If this is the case, it is more important than ever to give serious
consideration to the symptoms of taijin kyofusho and to include them fully in the
diagnostic criteria for SAD in the DSM-V.
Manifestations of social anxiety in East Asian cultures have been largely ignored
in diagnostic criteria and in treatment. An article by Tarumi, Ichimiya, Yamada, Umesue,
and Kuroki (2004) may have contributed to this neglect through the statements that most
individuals with taijin kyofusho are able to function adequately socially, and that people
with taijin kyofusho only meet standards for sub-clinical levels of SAD. It is important to
keep in mind that the participants in their study comprised only of university students.
Individuals with taijin kyofusho who were unable to function socially and had clinical
levels of SAD may not have been present in the sample because their symptoms
prevented them from attending a university. It is possible that the individuals who suffer
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the most from taijin kyofusho and possible SAD are being overlooked in research and
literature.
Common East Asian manifestations of social anxiety have not been included in
the literature and as a result, neglected in the DSM-V. Many researchers have concluded
that social anxiety as experienced by East Asians is not significant because their studies
have been based upon samples that do not include individuals with more severe cases. It
can be argued that the tendency of researchers and clinicians to ignore East Asian
presentations of social anxiety has contributed to the phenomenon of hikikomori, which
severely inhibits the lives of affected individuals.
Hikikomori
Hikikomori has been translated as the “abnormal avoidance of social contact” and
it was first described in 1998 (Tateno, Tae Woo, Kato, Umene-Nakano, & Saito, 2012).
Since that time, the prevalence of the condition has grown substantially. The Japanese
government estimated that around 236,000 individuals in 2010 were experiencing
hikikomori. No agreed upon definition is in existence, but the Japanese government’s
guidelines state that individuals with hikikomori become recluses in their own homes and
avoid social situations for at least 6 months.
Little research has been conducted on hikikomori and the underlying causes of the
condition are still unknown. Tateno, Park, Kato, Umene-Nakano, and Saito (2012)
investigated the causes of hikikomori by sending questionnaires to psychiatrists,
pediatricians, nurses, psychologists, and medical students in Japan. The researchers noted
50% of pediatricians cited stress-related disorders including SAD as the underlying cause
of hikikomori.
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Another study sought to determine the relationship between SAD and hikikomori
(Nagata et al., 2011). The researchers tested participants in a Japanese clinical setting for
SAD, hikikomori, and other conditions including bipolar disorder, depressive disorders,
obsessive-compulsive disorder, and an array of personality disorders by using interviews
and screening instruments. The results indicated that the other mental disorders did not
account for hikikomori and the researchers concluded that hikikomori is a severe form of
SAD.
Discussion
It has been argued that East Asian presentations of social anxiety do not fit the
criteria for SAD because the social phobia is socially acceptable in East Asian society
(Schreier et al., 2010). The DSM-V has specified that in order to be diagnosed with SAD,
the anxiety experienced must be out of proportion to the sociocultural context (5th ed.;
DSM-V; American Psychiatric Association, 2013a). Because East Asian cultures have a
greater acceptance of socially withdrawn behaviors and avoidant tendencies, the same
levels of social anxiety that may be considered a disorder in a Western country may not
meet the same criteria in an East Asian country (Schreier et al., 2010).
Social Anxiety as it is experienced by East Asians is being overlooked because it
is “socially acceptable.” It can be argued that by ignoring East Asian manifestations of
SAD, the psychiatric community is allowing prevalence rates to rise and more severe
forms of the disorder to take form. It is important to note that throughout history in East
Asian cultures, even suicide has been accepted and possibly even encouraged in some
situations. It seems obvious that most clinicians would not ignore a client’s suicidal
ideation because it is accepted in his culture. Cultural acceptability, therefore, is not a
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valid reason for researchers or clinicians to ignore the symptoms of clients who are
suffering because of a mental disorder.
In all expressions of social anxiety, individuals are negatively affected. The
social, emotional, academic, and occupational functioning is significantly impaired. The
psychological community has done a disservice to East Asians by trivializing their
conditions and their expressions of social anxiety. In order to help those who are affected
by social anxiety, the authors of the DSM-V must continue to take steps that include East
Asian presentations of social anxiety in diagnostic criteria. Clinicians must seriously
consider that social anxiety may manifest itself differently in cultures around the world.
Suggestions for the DSM-V
The authors of the DSM-V have taken measures to include East Asian
presentations of social anxiety by acknowledging the fear of offending others as a
possible symptom of SAD. Future editions should continue improvement by considering
more fully incorporating the symptoms of taijin kyofusho in the diagnostic criteria for
SAD. The explanation of taijin kyofusho in the appendix of the DSM-V indicates that the
condition has been seen in individuals from cultures around the world. The symptoms of
taijin kyofusho should therefore not be confined only to the Glossary of Cultural
Concepts of Distress.
No editions of the DSM have included information about hikikomori. There is a
need for the global psychiatric community to agree upon a definition of the condition and
specify diagnostic criteria. Related disorders that are at the root of hikikomori need to be
better identified. After hikikomori is more fully understood, information about
differential diagnoses should be provided to help clinicians discern each disorder.
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Suggestions for Clinicians
It is of utmost importance that clinicians keep in mind that social anxiety may
appear through different presentations depending on the cultural context. It is common
for unique presentations of any disorder to stray slightly from the specific guidelines
delineated by the DSM-V. As always, clinicians should keep an open mind and rely upon
their clinical expertise to fully consider the source and severity of a client’s symptoms.
An individual’s case should not be disregarded or trivialized because it does not fit neatly
within the DSM-V criteria.
Clinicians should look for signs and symptoms of taijin kyofusho and hikikomori
specifically in East Asian clients and in Asian-American clients. However, they should be
aware that these conditions have been seen even in Western cultures, and they should
keep them in mind when encountering any client with social anxiety symptoms. They
should ask questions that inquire whether clients are inhibited by a fear of offending
others. They should also consider SAD and hikikomori when presented with clients who
display reclusive tendencies.
Remaining Questions
Future research needs to determine the prevalence rate of taijin kyofusho within
the general population. More research must be conducted to study hikikomori and to find
an agreed-upon definition and diagnostic criteria. The true prevalence rate needs to be
determined and hikikomori’s relationship with other mental disorders needs to be more
fully investigated. After this research has been conducted, more studies need to be carried
out to determine a more accurate prevalence rate of SAD within East Asian populations.
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Commonly accepted statistics that have shown East Asian populations to have a
low prevalence rate of SAD may not take into account unique cultural manifestations of
social anxiety. East Asians may experience and express social anxiety through taijin
kyofusho and hikikomori. In order to identify and treat individuals who are negatively
affected by social anxiety, the authors of the DSM-V should consider incorporating
symptoms that may occur in other cultures in the diagnostic criteria for SAD. Clinicians
should keep in mind that disorders may present differently in cultures around the world,
and they should grant serious consideration and respect to each individual client. By
taking these measures, the psychological community can better identify, diagnose, and
treat individuals around the world who are negatively affected by social anxiety.
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Resources
American Psychiatric Association. (2013a). Diagnostic and statistical manual of mental
disorders (5th ed.). doi:10.1176/appi.books.9780890425596.257491
American Psychiatric Association. (2013b). Appendix III: Glossary of cultural concepts
of distress. In Diagnostic and statistical manual of mental disorders (5th ed.).
doi:10.1176/appi.books.9780890425596.223986
Choy, Y., Schneier, F. R., Heimberg, R. G., Kang-Seob, O., & Liebowitz, M. R. (2008).
Features of the offensive subtype of taijin-kyofu-sho in US and Korean patients
with DSM-IV social anxiety disorder. Depression & Anxiety (1091-4269), 25(3),
230-240. doi:10.1002/da.20295
Essau, C. A., Sasagawa, S., Ishikawa, S., Okajima, I., O’Callaghan, J., & Bray, D.
(2012). A Japanese form of social anxiety (taijin kyofusho): Frequency and
correlates in two generations of the same family. International Journal Of Social
Psychiatry, 58(6), 635-642. doi:10.1177/0020764011421099
Nagata, T., Yamada, H., Teo, A. R., Yoshimura, C., Nakajima, T., & van Vliet, I. (2013).
Comorbid social withdrawal (hikikomori) in outpatients with social anxiety
disorder: Clinical characteristics and treatment response in a case series.
International Journal Of Social Psychiatry, 59(1), 73-78.
doi:10.1177/0020764011423184
Schreier, S., Heinrichs, N., Alden, L., Rapee, R. M., Hofmann, S. G., Chen, J., & ...
Bögels, S. (2010). Social anxiety and social norms in individualistic and
collectivistic countries. Depression & Anxiety (1091-4269), 27(12), 1128-1134.
doi:10.1002/da.20746
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Tarumi, S., Ichimiya, A., Yamada, S., Umesue, M., & Kuroki, T. (2004). Taijin kyofusho
in university students: Patterns of fear and predispositions to the offensive variant.
Transcultural Psychiatry, 41(4), 533-546. doi:10.1177/1363461504047933
Tateno, M., Tae Woo, P., Kato, T. A., Umene-Nakano, W., & Saito, T. (2012).
Hikikomori as a possible clinical term in psychiatry: A questionnaire survey.
BMC Psychiatry, 12(1), 169-175. doi:10.1186/1471-244X-12-169