Taijin Kyofusho: Social Anxiety

A Culture-Bound Syndrome

The essential feature of a social phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur, and there are many different forms of this condition which manifest uniquely in different environments. One type of social phobia, occurring primarily in Japanese culture, is called Taijin Kyofusho and is translated as "the disorder of fear." Understanding this disorder is clearly important to the many whom suffer from it, but this cultural-bound syndrome is also an important aid in understanding the differences between Western society and other areas of the globe.

Taijin Kyofusho is a specific type of social anxiety which finds its origins in Japan. It is seen as an individual's intense fear that his or her body, its parts or its functions, displease, embarrass or are offensive to other people in appearance, odor, facial expressions, or movements. Taijin kyofusho, centers on concerns about embarrassing others with one's presence, rather than embarrassing one's self in the presence of others. TKS is believed to emerge out of a childhood history of social inhibition and shyness. The disorder may abruptly follow a stressful or humiliating experience or its onset could be more subtle in nature with the lifetime course of the disorder usually existing on a continuum.

Taijin Kyofusho is a disease foreign to Western society. Americans tend to be individualistic and see the pursuit of personal goals as a sign of psychological health. However, most cultures are collectivist, meaning that group goals are superordiante to the individual. In cultures where the group is seen as more important than its individual parts, social anxiety disorders manifest differently as people often become increasingly distressed about how they may affect others.

Symptoms of Taijin Kyofusho

A person may be diagnosed with Taijin Kyofusho (TKS), if they feel as if their attitudes, behavior, and physical characteristics are inadequate in social situations. As a result of these feelings, they also experience persistent suffering in the form of emotional distress through shame, embarrassment, anxiety, fear, and other tense feelings when confronted with social circumstances. In addition, individuals also worry about being unable to maintain healthy relationships with others. When it comes to socializing, TKS sufferers avoid painful social and interpersonal situations, while simultaneously being averse to doing so.

In the official Japanese diagnostic system, Taijin Kyofusho is subdivided into the following categories:

• Sekimen-kyofu: the phobia of blushing
• Shubo-kyofu: the phobia of a deformed body (similar to body dysmorphic disorder)
• Jikoshisen-kyofu: the phobia of eye-to-eye contact
• Jikoshu-kyofu: the phobia of having foul body odor (similar to olfactory reference syndrome)

Although TKS is primarily a mental disorder, like most anxiety disorders, there are also varied, related physical symptoms. These include blushing, improper (rigid) facial expressions, inappropriate eye contact, offensive body odors, appearing disheveled, sweating copiously, trembling hands, voice, feet, and uncontainable flatulence.

Prevalence

Typically diagnosed in adolescence or early adulthood, taijin kyofusho affects 10-20% of the Japanese population. Clinical data indicates that more males have the condition than females despite the fact that females scored higher on a social phobia scale and report higher scores on embarrassibility than their male counterparts. This differs from Western society where the prevalence of females with social phobias is to some extent greater than that of males. The lifetime prevalence of the disorder falls anywhere between 3% and 13% with changes in severity occurring throughout one's lifetime.

Treatment for Taijin Kyofusho

Psychological treatments for TKS include elements common to cognitive behavioral therapy, including relaxation training, systematic desensitization, cognitive restructuring, rehearsal, and skills training. Central to these is the idea that the conceptualization of treatment is a key element in the understanding of the disorder itself.

Morita therapy was developed by Masatake Morita in the 1910's. The procedure includes pragmatic guidance in the acceptance of the patient's specific symptoms and an attempt to direct the individual's energy from their previous concerns, such as somatic symptoms, to the present. The first stage consists of isolated bed rest, where the patient is not allowed to have visitors, read, or have conversation and helps them learn that anguish eventually leads to deliverance. The second stage is more active in that the patient can engage in light work and is assigned simple chores like writing in a diary under a therapist's supervision. In this stage, the patient is also allowed to engage in reading such things as classical poetry; however, they still are not permitted to speak to others. In the third stage, the patient is given heavy work with minimal guidance while being prohibited to take free walks or engage in other forms of entertainment. The fourth stage consists of attending lectures and meetings where they are exposed to persuasive arguments toward learning to accept themselves and their symptoms in an attempt to move toward engaging in constructive activities. Morita treatment has since been modified to include out-patient and group treatments. The modified version is known as neo-Morita therapy. After completion of this process, depending on how closely the protocol is followed, treatment response has been noted anywhere from 78-93%, which shows that sometimes the answer to a problem is simply critically thinking about it.

Medications are also used to treat TKS. One study indicated that milnacipran may be helpful in the treatment of the disorder. Milnacipran is the first in a new class of anti-depressants, that boosts serotonin and noradrenaline levels, however, more studies must be done to verify its efficacy. Another study involving paroxetine (Paxil) and psycho-education was effective in reducing offensive social anxiety as well as also improving patient insight into their fears regarding offending others due to their particular physical functions and appearance.

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Disclaimer: This information should not be considered medical advice and should not substitute the judgment of a competent psychiatrist.

Credits: Article written by Dustin Saunders; reviewed, edited and revised by M. Williams, Ph.D.