Social anxiety disorder in the West and in the East
Department of Psychiatry, University of Cape Town, Cape Town, South Africa, Mt. Sinai School of Medicine, New York, NY, USA
BACKGROUND: Although social anxiety disorder (SAD) is one of the most prevalent psychiatric disorders in epidemiological surveys, concepts of social anxiety have varied from time to time and place to place. In recent years, however, similar assessments and treatments have been utilized across the world.
METHODS: In this paper, current concepts of SAD in the West and the partially related condition known as taijin kyofusho (TKS) in the East are summarized, and trials of selective serotonin reuptake inhibitors (SSRIs) that have been undertaken in both the United States/Europe and in Japan for social anxiety symptoms are reviewed.
RESULTS: Despite differences in the conceptualization of SAD and TKS, social anxiety is a prevalent symptom in many parts of the world. Fluvoxamine is more effective than placebo in randomized controlled trials of SAD in the West and the East.
CONCLUSIONS: Patients suffering from SAD in different parts of the world share many features in common, and certain SSRIs are an effective treatment for this condition globally.
KEYWORDS: social anxiety disorder, taijin kyofusho, cultural concepts, selective serotonin reuptake inhibitors
ANNALS OF CLINICAL PSYCHIATRY 2009;21(2):109–117
Social anxiety disorder (SAD) is one of the most prevalent psychiatric disorders in systematic epidemiological surveys. The National Comorbidity Survey1 found an estimated lifetime prevalence rate of 13.3% of DSM-IIIR SAD, whereas the National Comorbidity Survey Replication estimated lifetime prevalence rates of 12.1% of DSM-IV SAD. A review of a range of European epidemiological surveys found a median lifetime prevalence rate of 6.6%.2
Such surveys, as well as clinical research on patients with SAD, consistently emphasize that SAD is a chronic disorder accompanied by substantial comorbidity and significant disability.2,3 Age of SAD onset is typically in adolescence, whereas major depression, other anxiety disorders, and substance abuse disorders often appear at a later stage. Disability findings in SAD include lower grades and higher dropout rates from school, lower salaries, higher rates of unemployment, and lower marriage rates.
Nevertheless, rates of SAD diagnosis and treatment are low in many parts of the world.2,3 There is some evidence that awareness of SAD has increased in the West. However, many continue to view social anxiety as a normative response that is different in some way from more typical medical disorders.4 Screening rates for SAD in primary care practices are low, and the majority of those who have this condition go untreated.2,3
One reason for varying rates of diagnosis and treatment of SAD around the world may be different constructs of social anxiety. Although social anxiety has long been recognized by clinicians, descriptions of this condition have varied. In the West, constructs for conceptualizing social anxiety have included shyness, avoidant personality traits, and social phobia,5 whereas in the East, the category taijin kyofusho (TKS) has been applied.6-8
This article summarizes current concepts of SAD in the West and TKS in the East, and reviews trials of selective serotonin reuptake inhibitors (SSRIs) from the United States/Europe and Japan.
Phenomenology of SAD and TKS
Social Anxiety Disorder. DSM-IV defines SAD as a disorder characterized by excessive and persistent fear and avoidance of social or performance situations.9 Exposure to such situations provokes an anxiety response, which includes feelings of self-consciousness, embarrassment, and difficulty speaking coupled with symptoms such as blushing, sweating, trembling, and palpitations. Marked anticipatory anxiety may precede a social event, and as a consequence, patients may withdraw from social situations they fear, resulting in impaired social and occupational functioning. Typically, patients with SAD have good insight into the excessiveness of their anxiety, but are nevertheless unable to quell it.
The diagnostic criteria for SAD in DSM-IV and ICD-10 differ slightly. In ICD-10, public speaking to a large audience is not considered a phobic condition, as its criteria note that the fear of scrutiny should be related to small groups of people. DSM-IV specifies that the disorder must place a socioeconomic burden on the patient in terms of academic or occupational impairment, whereas ICD-10 does not. ICD-10 recognizes the importance of specific physical symptoms such as blushing, tremor, or nausea, whereas DSM-IV refers only to anxiety symptoms that may take the form of a panic attack. Using DSM-III-R criteria, the lifetime prevalence of SAD in a general population in Basel, Switzerland was 16%, whereas it was 9.5% using the more stringent criteria of ICD-10.10
In the generalized subtype of SAD, patients experience the disorder in most situations. Compared with nongeneralized SAD, the generalized subtype is associated with earlier onset, greater severity, longer duration, and more disability. There is evidence that generalized SAD is more likely to have a familial component. Some authors have suggested a spectrum of social anxiety symptoms ranging from shyness through SAD and on to selective mutism in children and avoidant personality disorder in adults.5,11 Behavioral inhibition has been associated with subsequent risk for SAD and may serve as an endophenotype for understanding this disorder.
Taijin kyofusho. TKS, also known as anthropophobia (fear of people), literally means a fear of interpersonal relations. Patients present with fear of offending or embarrassing others.12 Like SAD, TKS usually is not experienced in the presence of intimate friends and family or complete strangers. Rather, it is associated with settings in which other people are familiar but not intimate, eg, at school or work or on commuter trains. Patients are anxious about blushing, inappropriate eye contact, improper facial expressions, physical deformity, or body odor that may be offensive to others. The fear of being unfairly judged or disliked by others, or making people feel uncomfortable or offending them, may lead to withdrawal or avoidance of social situations.
TKS was described by Shoma Morita, a Japanese psychiatrist who studied under Emil Kraepelin and later developed a specific psychotherapeutic system to treat this condition. TKS has been recognized in Japan as a distinct diagnostic entity since the early 1930s and is included in the DSM-IV and ICD-10 as a culture-bound variation of SAD that is specific to Japan. Diagnostic criteria have been provided by various authors (TABLE).13,14 Different types of TKS have been proposed, including transient (mild social concerns), phobic neurosis, inordinate concern about bodily features, and delusional disorder, in extreme cases.
TKS appears to differ from SAD in that:
it is characterized more by fear of offending others than fear of embarrassing oneself
the specific symptoms often focus on concerns about one’s having an offensive odor, gaze, or appearance
poor insight appears to characterize one type of TKS.
Therefore, TKS has been described as an allocentric, or other-orientated, disorder and SAD as an egocentric, or self-orientated, disorder.15
TKS is common in Japan; clinical prevalence rates vary from 7.8% of patients with neuroses seen in a university general psychiatric outpatient clinic to 45.5% of patients with neuroses seen at a clinic offering TKS-specific therapy.16 However, there are few epidemiological data on the prevalence of this condition in the general population of Japan.17 Individuals who present with clinical symptoms of TKS are predominantly male, although the percentage of female patients in Japan who present with this disorder is rising. Onset of TKS in Japan typically occurs during adolescence and affects the individual’s ability to form interpersonal relationships as well as impeding personal growth and development. Patients with TKS frequently have comorbid psychiatric disorders.
Diagnostic criteria for social anxiety disorder and taijin kyofusho
Social anxiety disorder
Persistent distress from emotional reactions such as shame, embarrassment, anxiety, and fear in social situations
Worry that one is unaccepted, despised, and avoided by others, and inability to maintain healthy relationships
Psychobiology of SAD and TKS
In the 1980s, social phobia was described as a disorder neglected by psychiatry.18 Two decades later, although SAD continues to be comparatively under-studied, a growing database of psychobiological studies supports the hypothesis that discrete neuronal circuits and associated molecules mediate symptoms of this condition.19 Advances in functional brain imaging and neurogenetics have provided a particularly important impetus for studies of SAD’s psychobiology. There has been relatively little work, however, on the psychobiology of TKS, although pharmacotherapy studies do shed some light on which systems are likely to be involved (see next section).
Animal models have allowed investigation of the neurocircuitry—including monoamine neurotransmitters and neuropeptides—that mediates dominance/subordination and social interaction. Human models have emphasized that behavioral inhibition is a heritable temperament that is underpinned by specific neuroanatomical and neurochemical pathways.20,21 A range of studies have suggested that limbic and striatal regions involved in emotional and social processing, including serotonergic and dopaminergic receptors, play an important role in SAD.22,23
Whereas psychobiological research focuses on the proximal mechanisms mediating social anxiety, evolutionary theorists have speculated about the distal mechanisms that underlie vulnerability to medical and psychiatric disorders.24 Darwin wrote extensively about the evolutionary origins of human blushing,25 and more recent authors have suggested that blushing is similar to an appeasement display in animals.26 Therefore, the argument is that SAD is characterized by a “false alarm,” in which appeasement displays are cued inappropriately.27
Pharmacotherapy of SAD and TKS
Early clinical trials demonstrated the value of monoamine oxidase inhibitors (MAOIs) in the pharmacotherapy of SAD.28 However, irreversible MAOIs are associated with significant safety and tolerability issues. Similarly, although there are some positive data regarding benzodiazepines for treating SAD,29 these agents are not effective for the comorbid depressive symptoms that are often present, are contraindicated in the many patients with comorbid substance abuse, and have a somewhat worrisome safety profile.
The introduction of SSRIs for SAD treatment was a potentially important step forward. Early trials of fluvoxamine were positive,30,31 and subsequent trials with paroxetine,32-34 sertraline,35,36 and escitalopram37,38 have also shown efficacy in SAD. The serotonin-noradrenaline reuptake inhibitor (SNRI) venlafaxine is also effective for SAD.39
Meta-analyses confirm the efficacy and tolerability of these agents for SAD.40-42 The few long-term studies of SAD pharmacotherapy that have been conducted support the value of ongoing maintenance.38,43,44 Other areas in which relatively less research has been done include the pharmacotherapy of patients with SAD and comorbid disorders,45 the pharmacotherapy of children and adolescents with SAD,46 studies in primary care and other “real-world” contexts,47 and combined pharmacotherapy and psychotherapy.48 Expert consensus recommends trials of SSRIs/SNRIs for 12 weeks, with continued treatment for at least 1 year.3,49
In Japan, tricyclic antidepressants (TCAs) and benzodiazepines are the most commonly prescribed pharmacotherapies for depression and anxiety disorders. SSRIs have recently become available in Japan to treat depression and anxiety, with fluvoxamine approved for depression and obsessive-compulsive disorder (OCD) and paroxetine for depression and panic disorder. Milnacipran is the only SNRI approved for use in Japan. The introduction of SSRIs to Japan has provided an opportunity to use fluvoxamine and other modern antidepressants to treat SAD and TKS.
Matsunaga et al6 found that when outpatients with TKS were treated with a TCA (clomipramine) or an SSRI (fluvoxamine) for at least 6 months, 48% (16 of 33) on either drug were categorized as responders by a Clinical Global Impressions-Improvement (CGI-I) rating of “very much” or “much improved.” Although this study was open-label, these data support the use of SSRIs for this condition. Similarly, in a retrospective chart review, Shindo et al50 found that fluvoxamine was effective for the treatment of SAD in Japan. The possible efficacy of paroxetine and milnacipran for TKS has also been suggested in small case series or open-label trials.51-53
More recently, a randomized placebo-controlled trial demonstrated the efficacy of fluvoxamine in patients with SAD in Japan.54 Patients meeting DSM-IV criteria for generalized SAD were randomized to receive treatment with fluvoxamine (50 to 300 mg/d) or placebo for 10 weeks. The primary efficacy outcome was mean change from baseline on the Liebowitz Social Anxiety Scale-Japanese Version (LSAS-J) total score. In this study, 176 fluvoxamine-treated patients and 89 placebo-treated patients were eligible for the efficacy analysis. Fluvoxamine-treated patients had a significantly greater reduction in the LSAS-J total score compared with placebo-treated patients (P=.02), with significantly more fluvoxamine recipients being at least “much improved” on the CGI-I scale compared with placebo-treated patients (P=.02). Fluvoxamine-treated patients also had better responses on the Sheehan Disability Scale (P=.02).
It is interesting to compare the demographics and clinical features of patients who participated in the fluvoxamine trials of SAD in the West and in the East. Although males predominated in both sets of trials, this was particularly apparent in the Japanese trial. In that trial, the mean age of participants was 38, with onset at mean age 20. On the basis of CGI-I scores at week 10, in the Japanese study, 45.1% of patients in the fluvoxamine group responded, which was comparable to the percentage of patients (42.9%) treated with flexible doses of fluvoxamine in a multicenter, randomized, double-blind, placebo-controlled study of SAD treatment in the United States.31
Psychotherapy of TKS and SAD
Growing evidence indicates that cognitive-behavioral treatment (CBT) is effective for SAD.19 Although medication may work more quickly, CBT may have more lasting effects.55 The combination of pharmacotherapy and psychotherapy is not necessarily more effective than either modality alone,47 with the possible exception of D-cycloserine augmentation of exposure therapy,48 but CBT may be useful in allowing patients to discontinue benzodiazepine treatment.
Components of CBT may include psychoeducation, video feedback, exposure therapy (conditioning patients to the situation they fear), cognitive restructuring (patients examine their thoughts about feared situations and the reasons that may underlie them), relaxation training (patients learn to control the degree of physiological arousal experienced during or in anticipation of feared events), and social skills training (based on the idea that patients with SAD have behavioral deficiencies). The question of which component of CBT is the most effective remains controversial.
Morita psychotherapy has been used in Japan for many years to treat TKS.13,56 The intensive “inpatient isolation” format that was originally used was modified in the 1930s, and neo-Morita therapy is now conducted on an outpatient basis in groups. Present day Morita therapy consists of 2 phases: intensive psychotherapy for several months, followed by a working-through process at an outpatient clinic. The goal is not symptom relief per se but, rather, improved functioning.
Morita therapy includes aspects of CBT, such as exposure exercises. Anecdotal results from Morita therapy suggest that approximately 80% of TKS patients recovered or were much improved at 2 months to 8 years after treatment. However, few controlled studies have been performed.
Cross-cultural approaches to SAD and TKS
How do we best conceptualize the differences between SAD in the West and TKS in the East? It may be useful to consider 3 approaches: clinical, anthropological, and integrated. Although these approaches to a complex literature on cross-cultural aspects of psychiatry are simplified, they nevertheless provide a useful heuristic framework.57-59
A clinical approach is informed by a positivist philosophy of science that emphasizes the objectivity of the scientific method. It argues that psychiatric disorders are similar in different parts of the world, although the precise content of symptoms may vary. Kraepelin, the father of contemporary psychiatric nosology, pioneered this approach in his work on psychotic patients in Java, arguing that psychosis has a universal form, with social factors contributing only to the diverse content of symptoms. Indeed, some cross-cultural psychiatrists have argued that relatively minor alterations in modern nosological systems would result in a truly international classification of diseases.60
An anthropological position, on the other hand, is informed by a hermeneutic philosophy that emphasizes the subjectivity of our understanding of humans and counters that psychiatric classification is a product of society. Once again, this approach has a long history. Boas, a pioneering figure in American anthropology, wrote that, “If it is our serious purpose to understand the thoughts of a people, the whole analysis of experience must be based on their concepts, not ours.”61 Within this approach the concept of “culture-bound” disorders has been highlighted, and contemporary psychiatric nosology has been criticized for committing a “category fallacy” in which Western classifications are incorrectly reified as universal natural kinds.
An integrated approach attempts to synthesize aspects of both the clinical and anthropological approaches. It is informed by a philosophical perspective, which notes that although psychiatric science is a human activity involving subjective understanding of others, it is able to identify real mechanisms and provide objective explanations. Although psychiatric classifications potentially have scientific validity, social constructs of disorder also affect our expression and experience of mental disorders.
Increasing evidence suggests that SAD is found worldwide and is mediated by similar psychobiological mechanisms. However, it may be that in the West, constructs of social anxiety are embedded in our concerns with individual performance, whereas in the East, the expression and experience of social anxiety are more likely to reflect social concerns about disrupting harmony. Some have argued that these differences mirror the Eastern emphasis on social cohesion. The individual is not so concerned with his or her own performance but, rather, with disrupting social harmony, and the fear is less likely to be about public situations than it is about being with small groups of acquaintances.
Similarly, in some cultures the person experiencing embarrassment is likely to laugh, whereas in others embarrassment is more commonly accompanied by being quiet. In many cultures, women are expected to be modest and retiring, and indeed deference and shyness may be highly prized in some groups. Women from such cultures may experience distress when placed in situations—for example, after immigration—in which they are expected to play a more socially dominant role. Other aspects of the immigrant experience also may contribute to social anxiety. For example, having to master different social norms and having to use a second language may contribute significantly to performance anxiety.
The distinction between “disease” and “illness” may be helpful in illustrating the differences among the clinical, anthropological, and integrative approaches. Disease refers to biomedical disorders that are present across cultures (eg, high blood pressure, social anxiety), whereas illness refers to the subjective perception and experience of such disorders.62 The clinical perspective focuses primarily on disease; problems are conceptualized in terms of biomedical dysfunction, and intervention is based primarily on this model. An anthropological perspective asserts that the perception of a disorder can affect its course and outcome, and optimal clinical intervention requires a relationship in which the patient’s experience is understood. From an integrative perspective, although there appear to be universal disease processes, cross-cultural factors result in different experiences and expressions of psychopathological phenomena. It is important to understand and research both disease and illness.
Spectrums of social anxiety: SAD vs TKS
The phenomenology of both Western SAD and Eastern TKS can be described in terms of fear of social situations and subsequent avoidance behaviors. However, in the West the fear is more often of embarrassing oneself, whereas in the East the fear is more often of offending others.
Nevertheless, in the West:
SAD patients may demonstrate concerns about offending others
socially anxious patients may present with primary concerns regarding body odor (olfactory reference syndrome [ORS]) and appearance (body dysmorphic disorder [BDD])
there is a range of insight into symptoms that is particularly well documented in OCD, ORS, and BDD.63,64
Conversely, patients with TKS may have typical SAD fears (embarrassing themselves) and concerns (worrying about blushing, sweating, or trembling), and may meet diagnostic criteria for SAD, particularly in the nondelusional variant, or for ORS.6,65,66
One study assessing the symptoms and behavioral patterns seen in SAD and TKS by comparing case histories for American and Japanese students found that cultural variables mediated the expression of SAD or TKS, but both disorders could be found in each sample of students.12 Conversely, in a retrospective study, SAD was the most common comorbid disorder in patients with TKS, and TKS patients who were treated with serotonin reuptake inhibitors invariably met SAD diagnostic criteria that were modified to focus on fear of offending or embarrassing others.6 Data from other studies are consistent with the idea that social anxiety symptoms, including offensive ones, are seen worldwide.67-70
Both SAD and TKS begin in early childhood and middle adolescence. The early age of onset for both disorders contributes to impairment in interpersonal relationships and disruption in personal growth and development. In a European general population study, the lifetime prevalence rate of SAD was higher in females (7%) than in males (4%), although the prevalence rate of SAD symptoms was similar (23% to 24%) in males and females.10 Epidemiological data for the general population show that the gender distribution of TKS differs from that of SAD, with TKS being more prevalent in males. However, as more females enter the workplace in Japan, treatment-seeking may increase in this population.13 Patients with both SAD and TKS may also meet criteria for avoidant personality disorder.71
Kleinknecht12 has argued that social harmony is paramount in Japan and other Far Eastern cultures, whereas Western culture is more focused on the individual. Eastern individuals with TKS feel that they upset social harmony by offending others through inappropriate gazes or unpleasant body odors. In contrast, in the West, patients with SAD fear negative evaluation by others in social or performance situations. Nevertheless, it is hard to generalize about societies, and in today’s world, there seem to be increasing cultural similarities, perhaps accounting for the overlap between these disorders.
Subtle differences between SAD and TKS may possibly be explained by differences in sociocultural mechanisms. The rules of social gaze, for example, differ across cultures. In some cultures it is rude not to maintain eye contact—the Western-oriented Liebowitz Social Anxiety Scale includes an item on fear of maintaining eye gaze—whereas in others it is rude to stare too intently; certainly this is the case in a number of Eastern cultures. Interestingly, there is a growing base of literature on the neurobiology of gaze, which has been hypothesized to be dysfunctional in a several psychiatric disorders, including schizophrenia and autism.72
Furthermore, just as SSRIs are effective in SAD, so Eastern TKS responds to clomipramine and fluvoxamine, particularly when patients do not meet criteria for delusional disorder. ORS and BDD—even when accompanied by poor insight—also respond to SSRIs,73,74 and some Western patients with TKS symptoms also appear to respond to MAOIs.69 In addition, some aspects of Morita therapy overlap closely with those of behavioral therapy.
Other psychobiological mechanisms may play an important role in the development of SAD/TKS. We have noted the possibility that different social expectations can increase the perceived distress of shyness. In countries where shyness is viewed positively, socially anxious individuals may have less objective occupational impairment. Alternatively, in families where parents are less accommodating of behavioral inhibition, exposure therapy has been suggested as a means of altering this temperament.
Both TKS and SAD might be considered almost part of an individual’s personality or culture rather than a medical illness, and this may be one reason for the under-recognition of these disorders. SAD and TKS might not be recognized because some medical professionals misinterpret these disorders as mere shyness or because patients believe they have a condition that cannot be treated. Unfortunately, patients often present only after developing a depressive disorder or alcohol dependence or when they seek treatment for distressing physical symptoms, such as blushing or sweating.
The patient-physician relationship can play an important role in improving the recognition and treatment of psychiatric disorders. Physicians, perhaps more so in Japan, may be reluctant to refer patients to a psychiatrist or ask probing questions about social anxiety for fear of offending them. However, such questioning is particularly important precisely when patients are less inclined to discuss their symptoms. Furthermore, it is useful to ask patients about their view of disorders such as SAD and their opinion of the etiology and optimal treatment for their symptoms. Subsequent negotiation can take place between the clinician’s and the patient’s model of the disorder. A shared view of etiology and treatment is likely to result in the patient feeling more understood and in greater adherence to treatment.
The data suggest that patients in different parts of the world who experience SAD share many common features. Certainly, increasing evidence shows that specific neuronal circuitry and molecules underlie social anxiety symptoms. Although the expression and experience of anxiety disorders may vary from time to time and place to place, there are universal psychobiological mechanisms that underlie these conditions. Still, we can learn a great deal from investigating differences in social anxiety across cultures. The possible existence of a group of Western SAD patients with offensive symptoms or poor insight, for example, deserves further scrutiny and research.67
Although rating scales currently used internationally for SAD often have not been formally validated in different cultures, the LSAS has appeared to be robust in differentiating medication and placebo responses in multinational studies in the West. The Composite International Diagnostic Interview does not include questions about causing offense or about body dysmorphic symptoms. If such criteria were included, a higher worldwide prevalence of SAD might be reported.
Fortunately, a number of SSRIs effectively treat this condition, both in the West and in the East. CBT has also demonstrated effectiveness in treating SAD. Given the disability associated with SAD and TKS and the availability of effective treatments, it is important to encourage early diagnosis and intervention. The similarities between the 2 disorders and the high degree of symptom overlap suggest that SSRIs may also provide an effective treatment for patients with TKS.
DISCLOSURE: Dr. Stein has received research grants and/or consultancy honoraria from AstraZeneca, Eli Lilly and Company, GlaxoSmithKline, Johnson and Johnson, Lundbeck, Orion, Pfizer Inc, Pharmacia, Roche, Servier, Solvay, Sumitomo, Takeda, Tikvah, and Wyeth Pharmaceuticals.
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CORRESPONDENCE: Dan J. Stein, MD, PhD Department of Psychiatry University of Cape Town Groote Schuur Hospital (J-2) Anzio Rd., Observatory 7925 Cape Town, South Africa. E-MAIL: firstname.lastname@example.org
Annals of Clinical Psychiatry ©2009 American Academy of Clinical Psychiatrists