Social anxiety disorder, as defined in the DSM 5 (12), is characterized by a fear of being judged, negatively evaluated, or rejected in social situations or during a per- formance. As with other anxiety disorders, such symptoms must be distressing, impairing, and not attributable to other conditions to fulfill criteria for SAD. As social anxiety stems from fear of social evaluation, it is necessarily shaped by broader cultural influences that dictate appropriate social behaviors and the conse- quences for violating the same. Indeed, the cultural norms guiding social interac- tions have been found to influence the presentation, and recognition, of social anxiety because cultures differ in how much they emphasize social cohesion and the costs of violating social norms (52). There is some support for the hypothesis that the mismatch between an individual’s cultural orientation and the broader societal values is associated with greater severity of SAD (53).
While Asian Americans are consistently diagnosed with SAD more often than their Caucasian counterparts (54) and collectivistic cultures tend to have a greater fear of blushing, collectivistic cultures also tend to accept socially reticent behaviors more than individualistic cultures (55). These seemingly contradictory findings indicate that social reticence and associated features, such as fear of negative evalu- ation, may be more tolerated and considered less pathological in collectivistic cul- tures that value obedience to social norms.
A framework to conceptualize culturally specific presentations of SAD is sum- marized by Hofmann and Hinton (2014), who support an interactionist perspective of individual and environmental factors shaping culturally distinct SAD presenta- tions (56). Specifically, the cultural views on ethnophysiology (i.e., local ideas of
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mind–body relations) interact with contextual factors (i.e., social rules). The distinct presentation of SAD is well illustrated among the Japanese and Koreans, who report a local syndrome, taijin kyofusho. This syndrome overlaps with SAD in that it is also characterized by fear of social situations. While the social-evaluative concerns of taijin kyofusho fulfill criteria for SAD, the fears are also qualitatively distinct from SAD. The focal point of the concern in social situations for a Japanese or Korean individual with taijin kyofusho is about making others uncomfortable. The DSM 5 provides the example of a client with taijin kyofusho possibly reporting a complaint such as “My gaze upsets people so they look away and avoid me” (12).
The Japanese diagnostic system further subclassifies this syndrome into four types reviewed by Hofmann and colleagues (57): sekimen-kyofu (characterized by a fear of blushing), shubo-kyofu (characterized by a fear of a deformed body), jikoshisen- kyofu (characterized by a fear of eye-to-eye contact), and jikoshu-kyofu (character- ized by a fear of one’s own foul body odor). While the first two overlap with SAD, the last two share features with body dysmorphic disorder as conceptualized in the DSM 5 (57). These examples demonstrate how fears related to social evaluation actually stem from offending others. Applying the interactionist framework to understanding taijin kyofusho, Hofmann and Hinton (2014) observe “[‘Taijin kyo- fusho’] is an example of a culture-specific form of an anxiety disorder in which contextual factors predominate” (54p4).
There is a limited literature that comprehensively integrates cognitive, affective, and somatic mechanisms that underlie SAD, let alone taijin kyofusho. The sparse literature that does exist emphasizes the role of repetitive negative thinking in gen- eral, and rumination in particular, in the maintenance of social anxiety symptoms.
Individuals who experience high anxiety during social situations are likelier to engage in post-event rumination (58). Although rumination is a transdiagnostic and transcultural factor seen among many anxiety disorders and cultural groups, the content of rumination is unique for individuals who experience SAD. Typically, rumination in SAD is related to self-evaluations of one’s performance in the situa- tion. However, there is limited literature examining whether ruminating about one’s anxiety symptoms in general can also impact post-event rumination following spe- cific social situations.
A study sought to examine whether this general propensity to ruminate over one’s anxiety symptoms and other established constructs, such as anxiety sensitiv- ity, are associated with post-event rumination in SAD. This study on Canadian col- lege students found that social anxiety and anxious rumination were significantly predictive of how much participants ruminated about the anxiety-provoking social event following the experience. Interestingly, anxiety sensitivity was not related to post-event rumination (59). These findings suggest that the cognitive mechanism of
“thinking a lot” – specifically rumination-type thoughts – influences the mainte- nance of SAD symptoms. “Thinking a lot” can also be applied to future worries in SAD. For instance, individuals with SAD-like symptoms often report anticipatory anxiety for future social situations (60).
The maintenance of SAD via “thinking a lot” can be explained in three ways.
First, when individuals engage in post-event rumination, they might sustain the
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experience of dysphoria by dwelling upon their experience and strengthening their beliefs as socially inept individuals. Second, the aversive experiences associ- ated with social interactions may lead individuals to avoid future social interac- tions. This avoidance is negatively reinforced by limiting the aversive consequences (e.g., dysphoria and rumination) in the short term but strengthening other aversive consequences in the long term (e.g., isolation). Third, anticipating negative evalu- ation is likely to increase state anxiety in a social situation, contributing to poorer social interactions and objectively negative evaluations by others. Thus, “thinking a lot” about future social interacts can inadvertently cause true negative outcomes, which can continue to negatively reinforce future avoidance behaviors.
While cognitive theories of SAD have been tested experimentally among Anglo- European or other Westernized populations, little literature examines the relevance of cognitive mechanisms among individuals who predominantly report taijin kyo- fusho. Experimental studies that test these hypotheses with diverse groups, includ- ing those with only taijin kyofusho and those with comorbid taijin kyofusho and SAD, can enhance the knowledge base on the transcultural applicability of cogni- tive theories of SAD.
Cultural Considerations for Generalized Anxiety Disorder (GAD) Across Cultures
Generalized anxiety disorder, as defined in the DSM 5, refers to a pattern of exces- sive worrying accompanied by irritability, muscle tension, and sleep and concentra- tion difficulties that endure for over 6 months, cause distress or impairment, and are not attributable to other causes (e.g., substance withdrawal, medical condition, or another anxiety disorder) (12). The symptom profile of GAD can vary widely across cultures, such that some individuals may present with predominantly somatic symp- toms, whereas others may have a mixed symptom profile. However, the putative hallmark symptom of GAD is excessive worry (6, 12).
The variability in symptom profile of GAD is documented across cultures. For example, one study elicited typical symptom presentations corresponding with anx- iety from eight countries through descriptive interviews with psychiatrists in Asia, Latin America, North Africa, and Eastern Europe (42). Psychiatrists from India and Chile reported that clients presented with and subjectively complained of worry, tension, and “thinking a lot,” which are considered characteristic of GAD as con- ceptualized by the DSM 5 (12). However, the vast majority of these cultural groups reported somatic symptoms that were treated as expressions of generalized dyspho- ria rather than concrete diagnostic entities that corresponded with DSM or ICD criteria. Somatic symptoms similar to those seen in GAD, yet expressed in unique idioms, included “heart rushing” (Brazil), “[going] to the bathroom frequently”
(Peru), “cannot swallow” (Venezuela, Brazil), “something [blocking] the chest,”
and “heart stop” (Brazil, Peru, Morocco). Such differences in the symptom profile and the prominence of somatic discomfort during general anxiety warrant assess-
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ment of transdiagnostic and transcultural processes. Such assessments may better explain cultural variations of GAD compared to symptom checklists that assess symptoms that do not have cross-cultural equivalence.
The centrality of “thinking a lot” is easily identified in the etiology and mainte- nance of GAD, given that excessive worry is an essential diagnostic marker of GAD. What is likely to differ between cultural groups are the worry domains.
According to work conducted with Cambodian refugees, multiple worry domains include the following: finances for themselves and relatives in Cambodia, safety related to living in poor areas with ongoing violence, health concerns, catastrophic interpretations of somatic symptoms, and spiritual status of relatives who may be believed to be suffering because of culturally inappropriate burial due to missed opportunities for completing culturally indicated bereavement rites (61).
Aside from unique worry domains, Cambodians also attribute the consequences of worry in a culturally distinct manner. For instance, Cambodians have multiple concerns following a worry episode. Some examples of the feared impact of worry include the following: mental agitation, overheated and potentially damaged brain, and weakened mind and body. Further adverse consequences of worrying include poor memory, dizziness, propensity for khyâl attacks, cardiac arrest, stroke, and insanity (62). These feared consequences have emerged as linking factors between worry episodes and more severe psychopathology. Specifically, worry was associ- ated with posttraumatic stress disorder (PTSD) as suggested by a path analysis study exploring mechanisms that explain feared consequences of khyâl attacks (61).
This relationship between khyâl attacks and PTSD was explained by worry-induced somatic arousal, worry-induced catastrophic cognitions, worry-induced trauma recall, inability to stop worry, and irritability. Findings from this work suggest that all three transcultural and transdiagnostic mechanisms proposed in this chapter – i.e., “thinking a lot” (by way of worry and associated catastrophic cognitions), anxi- ety sensitivity (by way of worry-induced somatic arousal), and somatization (by way of discomfort from multiple interacting somatic sensations) – explained GAD- like symptoms and its association with more severe psychopathology such as PTSD.
A final consideration in conceptualizing GAD across cultures relates to the role of the socioeconomic and safety context a client is in. Specifically, it is essential to assess current stressors because they might be compounding worry and impacting the chronicity of its course. For cultural groups living in contexts of ongoing vio- lence, poverty, or structural inequities, assessing worry as “excessive” (a qualifier needed to diagnose GAD) may be more difficult as their worry could be adaptive for addressing true safety threats.