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Taijin-kyofu-sho in a black American woman: Behavioral treatment of a “culture-bound” anxiety disorder
Journal o/‘Anriem D8sorderr. Vol. 4. pp. 83-87. Pnnred in the USA. All nghts reserved.
1990 Copyright
0%7-6l85/90 53.00 c .ca C IWJ Pcrgamon Press plc
CASE REPORT
Taijin-kyofu-sho in a Black American Woman: Behavioral Treatment of a “Culture-Bound” Anxiety Disorder RICHARD
J. MCNALLY, University
of Health
PH.D.,
AND KAREN
ScienceslThe
Chicago
JOHN E. CALAMARI. Waukegan
Developmentul
L. CASSIDAY, Medical
B.A.
School
PH.D. Center
Abstract-Taijin-kyofu-sho (TKS) is a common neurotic disorder among psychiatric patients in Japan characterized by “fear of other people.” Unlike social phobics who themselves fear embarrassment, TKS patients avoid social situations for fear of embarrassing or offending others. Because TKS has been reported exclusively among Japanese patients. it is believed to be a culture-bound syndrome. In the present paper, we describe a case of TKS in a black American woman who avoided people because she feared embarrassing them by furtively glancing at their genital areas.
Tuijin-kyofu-sho (TKS) is a common psychiatric syndrome in Japan characterized by “fear of other people” (taijin, in relation to other people; kyofu, fear; she symptom; Prince & Tcheng-Laroche, 1987). Unlike social phobics, who themselves fear humiliation or embarrassment, (DSM-III-R, American Psychiatric Association [APA], 1987), TKS patients are afraid that some aspect of their behavior will embarrass or offend other people. Common fears include embarrassing others by blushing; making others uncomfortable by one’s gaze or by one’s facial expression; or offending others by mumbling one’s thoughts aloud (Prince & Tcheng-Laroche, 1987). TKS is diagnosed in 7% to 36% of Japanese psychiatric patients (Chang, 1984). It occurs most frequently in men in their twenties. Because TKS occurs almost exclusively in Japan, Address correspondence and reprint requests to Richard J. McNally, Department of Psychology, University of Health Sciencesnhe Chicago Medical School, Bldg. 51, North Chicago, IL 60064. 83
83
R. J. MCNALLY,
K. L. CASSIDAY,
AND J. E. CALAMARI
it has been proposed as a culture-bound syndrome (Prince & TchengLaroche, 1987). In this report, we describe a case of TKS in a black American woman who feared embarrassing others by glancing at their genital areas. Although she had never been exposed to Japanese culture, she nevertheless displayed the classic features of this “culture-bound” anxiety disorder. CASE REPORT The patient (Ms. M) is a 34-year-old married, black woman with no children. She graduated from college, and works as an elementary school teacher. She was born in the southern United States and spent the first seven years of her life as an only child on a farm. Her early childhood was uneventful, but her schoolteacher mother was unhappy as the wife of a farmer. She divorced him, moved to Chicago with Ms. M, and remarried. Ms. M was referred to our Anxiety Disorders Clinic for behavioral treatment of obsessive-compulsive disorder (OCD). Although she had some OCD symptoms, her primary complaint was that she avoided people for fear of embarrassing them by furtively glancing at their genital area. She was less anxious around others if her view of their genital area was obstructed. For example, Ms. M experienced less anxiety if the person to whom she was speaking was sitting behind a desk. She feared conversing face-to-face with others because she believed she might glance downward at his or her genital area. She was equally anxious around male and female adults or adolescents, but not around children. She had a fear of speaking before large audiences, but otherwise had no social phobias. There was no evidence of formal thought disorder, emotional blunting, delusions, or hallucinations. She complained of depressive symptoms secondary to TKS. There were no signs of melancholia. Ms. M exhibited a variety of avoidance behaviors. She avoided parties and social activities at church. She avoided returning to school to obtain her master’s degree because she feared she would embarrass her professors by glancing at their genital areas while they lectured. She avoided face-to-face conversations unless she held books or other objects in front of her to prevent her from glancing downward. Ms. M was more comfortable interacting with others while sitting side-by-side on a couch, or sitting across from them at a table. Ms. M interpreted the behavior of others as evidence of the embarrassment they suffered as a result of her gaze. For example, she suspected that people crossed their legs while sitting to obstruct her view of their genital area. She once telephoned a male cousin whom she had not seen for 12 years to ask him whether his former habit of leaving his shirttail untucked was designed to block her view of his genital area. Ordinarily, however, she did not attempt to verify these beliefs. Ms. M developed TKS in 1976 during a stressful period when she was taking care of her father who was dying of cancer. The course of her TKS
TAUIN-KYOFU-SHO
85
has been chronic and unremitting. She developed unrelated minor obsessive-compulsive symptoms in 1986 when her marriage became troubled. She performed a variety of ordering rituals and avoided certain activities to reduce anxiety associated with obsessions about her husband having an extramarital affair. These included performing certain actions in a leftto-right sequence (e.g., putting on eye makeup, putting on shoes), avoiding driving under elevated train tracks, and avoiding using toilet paper purchased in Chicago. She had relatives purchase cases of toilet paper in the southern United States and ship them 800 miles to Chicago. could not realistically prevent She recognized that these “precautions” her husband from having an affair, but she was compelled to perform them nevertheless. (Indeed, her husband was almost certainly involved in sexual relationships with other women.> Finally, she repeatedly checked her bathroom after combing her hair to ensure that no stray hairs had fallen from her brush. This ritual stemmed from a voodoo-related fear that harm would befall her if her hair were to fall into the hands of a potentially malevolent person. Treatment consisted of 10 two-hour sessions of therapist-assisted graduated exposure in vivo conducted over two weeks (Steketee & Foa, 1985). Two hours of self-exposure homework were also completed daily. During therapist-assisted exposure, Ms. M reported her level of anxiety on a 0 to 100 scale every five minutes. As her discomfort diminished, the therapist had her engage in progressively more difficult tasks. Initial exposure for TKS involved MS M conversing with the therapist while maintaining eye contact for progressively longer periods of time. Conversations began with the therapist sitting behind a desk, then sitting by her side, and finally sitting directly in front of her. During subsequent sessions, Ms. M was instructed to glance repeatedly at the therapist’s genital area during extended face-to-face conversations. To confirm that she was glancing in this direction, the therapist would vary the number of fingers resting on his thigh and have her report the number of fingers displayed. Further exposure involved Ms. M maintaining eye contact with strangers while asking them for directions, describing the belt buckles of pedestrians, and trying on shoes in stores. This last task invariably placed the salesperson’s genital area within her range of vision as he assisted her with the shoes. Exposure for her OCD symptoms involved having Ms. M perform tasks “out of order” (e.g., putting on make-up), driving under elevated train tracks, using toilet paper purchased in Chicago, and combing her hair in public lavatories and leaving several strands on the floor. Ms. M’s self-reported anxiety showed both within-session and between-session habituation (Steketee & Foa, 1985). For example, the most difficult exposure tasks near the end of treatment evoked only 30% as much anxiety as when first attempted. Moreover, within-session habituation for these tasks took only 15 rather than 120 minutes to achieve. Questionnaires administered before and two weeks after treatment also indicated the effectiveness of exposure: Fear Questionnaire-Main
86
R. J.
MCNAILY,
K. L.
CASSIDAY.
ANDJ.
E. CALAMARI
Phobia (glancing at the genital area of another person; Marks & Mathews, 1979), pre = 8, post = 2; Fear Questionnaire-Social Phobia, pre = 20, post = 8; Maudsley Obsessive-Compulsive Inventory (Rachman & Hodgson, 1980), pre = 11, post = 6; Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), pre = 29, post = 7. She felt comfortable socializing with others, and no longer found face-to-face conversations difficult. She resolved to terminate her very unsatisfactory marriage. Although follow-up therapy was offered, Ms. M was confident that she did not need further treatment. Unfortunately, during a followup phone call five months posttreatment, Ms. M reported that her TKS-related fears and avoidance behaviors were returning (Main Phobia = 6.3, although she reported no problems with obsessions and compulsions. Significantly, she had not taken steps to divorce her husband. DISCUSSION The present case indicates that TKS is not necessarily a culture-bound syndrome restricted to Japan or to other Asian countries. Although Japanese culture may emphasize the importance of not embarrassing others and thus indirectly promote TKS (Kasahara & Sakamoto, 1970), such cultural mores are evidently not essential for the syndrome to develop. The nosological status of TKS is unclear. Although some Japanese psychopathologists consider it a form of social phobia (Takahashi, 1989), TKS is distinguishable from social phobia as described in DSM-III-R (APA, 1987). Social phobics fear being embarrassed themselves, whereas TKS patients fear embarrassing or offending others. Moreover, social phobics recognize that their fears are excessive or unreasonable, whereas at least some TKS patients do not (Takahashi, 1989). Indeed, some TKS patients are best characterized as suffering from delusional disorder. Finally, some psychopathologists hold that TKS is a form of OCD (Chang, 1984). The fear of embarrassing or offending others resembles the harming obsessions experienced by some OCD patients. The present case also indicates that exposure therapy is as effective for this atypical anxiety disorder as it is for more common phobic and obsessive-compulsive disorders (Marks, 1987). Unfortunately, the benefits of exposure did not persist in this case. REFERENCES American Psychiatric Association. (1987). Diagnosric and statistical manual of mental disorders (3rd ed. rev.). Washington, DC: Author. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Chang, S. C. (1984). Review of 1. Yamashita “Taijin-kyofu.” Transcultural Psychiatric Research
Review.
21, 283-288.
Kasahara, Y., & Sakamoto, K. (1970). Ereuthophobia and allied conditions: A contribution toward the psychopathological and crosscultural study of a borderline state. In S. Arieti
TAIJIN-KYOFU-SHO
87
(Ed.). The world biennial of psychiatry and psychotherapy (Vol. 1, pp. 292-31 I). New York: Basic Books. Marks. I. IM. (1987). Fenrs. phobias, and rituals. New York: Oxford University Press. Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research
and Therapy,
17, 263-267.
Prince. R.. & Tcheng-Laroche. F. (1987). Culture-bound syndromes and international disease classification. Culture, Medicine and Psych&p, 11, 3- 19. Rachman, S. .I., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall. Steketee, G. & Foa, E. B. (1985). Obsessive-compulsive disorder. In D. H. Barlow (Ed.), Clinical handbook ofpsychologiccd disorders (pp. 69- 144). New York: Guilford. Takahashi, T. (1989). Social phobia syndrome in Japan. Comprehensive Psychiatry, 30, 45-52.
1990 Copyright
0%7-6l85/90 53.00 c .ca C IWJ Pcrgamon Press plc
CASE REPORT
Taijin-kyofu-sho in a Black American Woman: Behavioral Treatment of a “Culture-Bound” Anxiety Disorder RICHARD
J. MCNALLY, University
of Health
PH.D.,
AND KAREN
ScienceslThe
Chicago
JOHN E. CALAMARI. Waukegan
Developmentul
L. CASSIDAY, Medical
B.A.
School
PH.D. Center
Abstract-Taijin-kyofu-sho (TKS) is a common neurotic disorder among psychiatric patients in Japan characterized by “fear of other people.” Unlike social phobics who themselves fear embarrassment, TKS patients avoid social situations for fear of embarrassing or offending others. Because TKS has been reported exclusively among Japanese patients. it is believed to be a culture-bound syndrome. In the present paper, we describe a case of TKS in a black American woman who avoided people because she feared embarrassing them by furtively glancing at their genital areas.
Tuijin-kyofu-sho (TKS) is a common psychiatric syndrome in Japan characterized by “fear of other people” (taijin, in relation to other people; kyofu, fear; she symptom; Prince & Tcheng-Laroche, 1987). Unlike social phobics, who themselves fear humiliation or embarrassment, (DSM-III-R, American Psychiatric Association [APA], 1987), TKS patients are afraid that some aspect of their behavior will embarrass or offend other people. Common fears include embarrassing others by blushing; making others uncomfortable by one’s gaze or by one’s facial expression; or offending others by mumbling one’s thoughts aloud (Prince & Tcheng-Laroche, 1987). TKS is diagnosed in 7% to 36% of Japanese psychiatric patients (Chang, 1984). It occurs most frequently in men in their twenties. Because TKS occurs almost exclusively in Japan, Address correspondence and reprint requests to Richard J. McNally, Department of Psychology, University of Health Sciencesnhe Chicago Medical School, Bldg. 51, North Chicago, IL 60064. 83
83
R. J. MCNALLY,
K. L. CASSIDAY,
AND J. E. CALAMARI
it has been proposed as a culture-bound syndrome (Prince & TchengLaroche, 1987). In this report, we describe a case of TKS in a black American woman who feared embarrassing others by glancing at their genital areas. Although she had never been exposed to Japanese culture, she nevertheless displayed the classic features of this “culture-bound” anxiety disorder. CASE REPORT The patient (Ms. M) is a 34-year-old married, black woman with no children. She graduated from college, and works as an elementary school teacher. She was born in the southern United States and spent the first seven years of her life as an only child on a farm. Her early childhood was uneventful, but her schoolteacher mother was unhappy as the wife of a farmer. She divorced him, moved to Chicago with Ms. M, and remarried. Ms. M was referred to our Anxiety Disorders Clinic for behavioral treatment of obsessive-compulsive disorder (OCD). Although she had some OCD symptoms, her primary complaint was that she avoided people for fear of embarrassing them by furtively glancing at their genital area. She was less anxious around others if her view of their genital area was obstructed. For example, Ms. M experienced less anxiety if the person to whom she was speaking was sitting behind a desk. She feared conversing face-to-face with others because she believed she might glance downward at his or her genital area. She was equally anxious around male and female adults or adolescents, but not around children. She had a fear of speaking before large audiences, but otherwise had no social phobias. There was no evidence of formal thought disorder, emotional blunting, delusions, or hallucinations. She complained of depressive symptoms secondary to TKS. There were no signs of melancholia. Ms. M exhibited a variety of avoidance behaviors. She avoided parties and social activities at church. She avoided returning to school to obtain her master’s degree because she feared she would embarrass her professors by glancing at their genital areas while they lectured. She avoided face-to-face conversations unless she held books or other objects in front of her to prevent her from glancing downward. Ms. M was more comfortable interacting with others while sitting side-by-side on a couch, or sitting across from them at a table. Ms. M interpreted the behavior of others as evidence of the embarrassment they suffered as a result of her gaze. For example, she suspected that people crossed their legs while sitting to obstruct her view of their genital area. She once telephoned a male cousin whom she had not seen for 12 years to ask him whether his former habit of leaving his shirttail untucked was designed to block her view of his genital area. Ordinarily, however, she did not attempt to verify these beliefs. Ms. M developed TKS in 1976 during a stressful period when she was taking care of her father who was dying of cancer. The course of her TKS
TAUIN-KYOFU-SHO
85
has been chronic and unremitting. She developed unrelated minor obsessive-compulsive symptoms in 1986 when her marriage became troubled. She performed a variety of ordering rituals and avoided certain activities to reduce anxiety associated with obsessions about her husband having an extramarital affair. These included performing certain actions in a leftto-right sequence (e.g., putting on eye makeup, putting on shoes), avoiding driving under elevated train tracks, and avoiding using toilet paper purchased in Chicago. She had relatives purchase cases of toilet paper in the southern United States and ship them 800 miles to Chicago. could not realistically prevent She recognized that these “precautions” her husband from having an affair, but she was compelled to perform them nevertheless. (Indeed, her husband was almost certainly involved in sexual relationships with other women.> Finally, she repeatedly checked her bathroom after combing her hair to ensure that no stray hairs had fallen from her brush. This ritual stemmed from a voodoo-related fear that harm would befall her if her hair were to fall into the hands of a potentially malevolent person. Treatment consisted of 10 two-hour sessions of therapist-assisted graduated exposure in vivo conducted over two weeks (Steketee & Foa, 1985). Two hours of self-exposure homework were also completed daily. During therapist-assisted exposure, Ms. M reported her level of anxiety on a 0 to 100 scale every five minutes. As her discomfort diminished, the therapist had her engage in progressively more difficult tasks. Initial exposure for TKS involved MS M conversing with the therapist while maintaining eye contact for progressively longer periods of time. Conversations began with the therapist sitting behind a desk, then sitting by her side, and finally sitting directly in front of her. During subsequent sessions, Ms. M was instructed to glance repeatedly at the therapist’s genital area during extended face-to-face conversations. To confirm that she was glancing in this direction, the therapist would vary the number of fingers resting on his thigh and have her report the number of fingers displayed. Further exposure involved Ms. M maintaining eye contact with strangers while asking them for directions, describing the belt buckles of pedestrians, and trying on shoes in stores. This last task invariably placed the salesperson’s genital area within her range of vision as he assisted her with the shoes. Exposure for her OCD symptoms involved having Ms. M perform tasks “out of order” (e.g., putting on make-up), driving under elevated train tracks, using toilet paper purchased in Chicago, and combing her hair in public lavatories and leaving several strands on the floor. Ms. M’s self-reported anxiety showed both within-session and between-session habituation (Steketee & Foa, 1985). For example, the most difficult exposure tasks near the end of treatment evoked only 30% as much anxiety as when first attempted. Moreover, within-session habituation for these tasks took only 15 rather than 120 minutes to achieve. Questionnaires administered before and two weeks after treatment also indicated the effectiveness of exposure: Fear Questionnaire-Main
86
R. J.
MCNAILY,
K. L.
CASSIDAY.
ANDJ.
E. CALAMARI
Phobia (glancing at the genital area of another person; Marks & Mathews, 1979), pre = 8, post = 2; Fear Questionnaire-Social Phobia, pre = 20, post = 8; Maudsley Obsessive-Compulsive Inventory (Rachman & Hodgson, 1980), pre = 11, post = 6; Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), pre = 29, post = 7. She felt comfortable socializing with others, and no longer found face-to-face conversations difficult. She resolved to terminate her very unsatisfactory marriage. Although follow-up therapy was offered, Ms. M was confident that she did not need further treatment. Unfortunately, during a followup phone call five months posttreatment, Ms. M reported that her TKS-related fears and avoidance behaviors were returning (Main Phobia = 6.3, although she reported no problems with obsessions and compulsions. Significantly, she had not taken steps to divorce her husband. DISCUSSION The present case indicates that TKS is not necessarily a culture-bound syndrome restricted to Japan or to other Asian countries. Although Japanese culture may emphasize the importance of not embarrassing others and thus indirectly promote TKS (Kasahara & Sakamoto, 1970), such cultural mores are evidently not essential for the syndrome to develop. The nosological status of TKS is unclear. Although some Japanese psychopathologists consider it a form of social phobia (Takahashi, 1989), TKS is distinguishable from social phobia as described in DSM-III-R (APA, 1987). Social phobics fear being embarrassed themselves, whereas TKS patients fear embarrassing or offending others. Moreover, social phobics recognize that their fears are excessive or unreasonable, whereas at least some TKS patients do not (Takahashi, 1989). Indeed, some TKS patients are best characterized as suffering from delusional disorder. Finally, some psychopathologists hold that TKS is a form of OCD (Chang, 1984). The fear of embarrassing or offending others resembles the harming obsessions experienced by some OCD patients. The present case also indicates that exposure therapy is as effective for this atypical anxiety disorder as it is for more common phobic and obsessive-compulsive disorders (Marks, 1987). Unfortunately, the benefits of exposure did not persist in this case. REFERENCES American Psychiatric Association. (1987). Diagnosric and statistical manual of mental disorders (3rd ed. rev.). Washington, DC: Author. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Chang, S. C. (1984). Review of 1. Yamashita “Taijin-kyofu.” Transcultural Psychiatric Research
Review.
21, 283-288.
Kasahara, Y., & Sakamoto, K. (1970). Ereuthophobia and allied conditions: A contribution toward the psychopathological and crosscultural study of a borderline state. In S. Arieti
TAIJIN-KYOFU-SHO
87
(Ed.). The world biennial of psychiatry and psychotherapy (Vol. 1, pp. 292-31 I). New York: Basic Books. Marks. I. IM. (1987). Fenrs. phobias, and rituals. New York: Oxford University Press. Marks, I. M., & Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behaviour Research
and Therapy,
17, 263-267.
Prince. R.. & Tcheng-Laroche. F. (1987). Culture-bound syndromes and international disease classification. Culture, Medicine and Psych&p, 11, 3- 19. Rachman, S. .I., & Hodgson, R. J. (1980). Obsessions and compulsions. Englewood Cliffs, NJ: Prentice-Hall. Steketee, G. & Foa, E. B. (1985). Obsessive-compulsive disorder. In D. H. Barlow (Ed.), Clinical handbook ofpsychologiccd disorders (pp. 69- 144). New York: Guilford. Takahashi, T. (1989). Social phobia syndrome in Japan. Comprehensive Psychiatry, 30, 45-52.