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Social Anxiety and the Fear of Causing Discomfort to Others: Conceptualization and Treatment
Abstract
The current diagnostic description and cognitive conceptualization of social phobia gives prominence to fears pertaining to negative evaluation and embarrassment in the etiology and maintenance of the disorder. Patients with social phobia also report concerns that their symptoms of anxiety will adversely affect the comfort and performance of others in the shared environment, a fear dimension that we have previously labeled "Social Anxiety - Fear of Causing Discomfort to Others" (SA-DOS; Rector, Kocovski, & Ryder, 2006). In this article, we outline how fears focused on causing others discomfort as a result of the display of anxious symptoms contribute to the person's experienced anxiety in the anticipation, performance, and post-event phases of social interaction. We also attempt to trace the developmental, cultural, and social components of these interpersonal fear appraisals. Finally, we discuss refinements to current first-line psychological treatments for social phobia so that greater attention to SA-DOS concerns can occur in the assessment and treatment of the disorder. This is important given that these fears are not routinely targeted in manual-based cognitive-behavioral therapy (CBT) treatments.
... Identifying pre-treatment predictors of treatment outcome is vital to help elucidate specific patient populations that respond well or poorly to conventional treatment strategies and improve treatment outcomes. One factor that has not been traditionally conceptualized within contemporary CBT models or SAD treatment, and is uniquely associated with IPES (Laposa et al., 2010), is the fear of causing discomfort to others (Rector et al., 2006a(Rector et al., , 2006b. Specifically, some individuals with SAD report fears distinct from fear of negative evaluation of oneself, also reporting fear content relating to the perceived aversive repercussions of their anxiety for others in the social environment (Nishikawa et al., 2017;Rector et al., 2006aRector et al., , 2006bZhu et al., 2014). ...
... One factor that has not been traditionally conceptualized within contemporary CBT models or SAD treatment, and is uniquely associated with IPES (Laposa et al., 2010), is the fear of causing discomfort to others (Rector et al., 2006a(Rector et al., , 2006b. Specifically, some individuals with SAD report fears distinct from fear of negative evaluation of oneself, also reporting fear content relating to the perceived aversive repercussions of their anxiety for others in the social environment (Nishikawa et al., 2017;Rector et al., 2006aRector et al., , 2006bZhu et al., 2014). Although these fears share a focus on the interpersonal aspects of social anxiety amongst individuals with Taijin-Kyofu-Sho (TKS; Takahashi, 1989), TKS fear content primarily focuses on the fear of offending or embarrassing others through one's bodily characteristics (vs. ...
... Previous studies have demonstrated that fear of causing discomfort to others (Nishikawa et al., 2017) and IU (Mahoney & McEvoy, 2012a, 2012b) decrease during CBT for SAD. In the case of fear of causing discomfort to others, for example, the opportunities to disconfirm catastrophic beliefs regarding the impact of one's anxiety on the well-being of others during CBT (McManus et al., 2008;Rector et al., 2006aRector et al., , 2006b) may have reduced negative interpretations of positive social events. With regard to IU, Katz et al. (2017) found that although higher pretreatment IU predicted greater symptoms severity at the end of treatment, it did not moderate the rate of symptom change across treatment. ...
Background
Individuals with social anxiety disorder (SAD) report interpreting social events negatively regardless of valence. Fear of causing discomfort to others and intolerance of uncertainty (IU) are associated with negative interpretations of positive social situations. However, no studies have examined whether these negative interpretations change over CBT for SAD, nor predictors of such changes. This study examined if: negative interpretations of positive social events improve during CBT for SAD; these negative interpretations correlate with social anxiety symptom severity, fear of causing discomfort to others, and IU at the start of treatment; and fear of causing discomfort to others, IU and its subfactors at the start of treatment predict changes in these negative interpretations over treatment.
Methods
Eighty-five treatment-seeking DSM diagnosed individuals with primary SAD completed measures of the tendency to interpret positive events negatively pre-post CBT, and IU and fears of causing discomfort to others at pre-treatment.
Results
Results demonstrated significant pre-post decreases after CBT for SAD in negative interpretations of positive social events. All measures were significantly correlated with each other. None of the pre-treatment variables significantly predicted decreases in negative interpretations of positive social events over treatment.
Conclusions
CBT may be effective in reducing these negative interpretations.
... Two domains of negative appraisal that have recently emerged in social phobia are fear of causing discomfort to others, and negative interpretation of positive social events. Interpersonal fears, namely the affective and behavioural ramifications of their embarrassment or anxiety for others, are present in some individuals with social phobia (Rector, Kocovski, & Ryder, 2006a, 2006b). Many individuals with social phobia are concerned that their anxiety will render others uncomfortable, anxious, and/or annoyed with them. ...
... During social situations these fears are thought to augment self-focus, anticipated danger, and fixation on autonomic arousal symptoms. Rector et al. (2006b) suggested that fear of causing discomfort to others contributes to PEP following social situations, but this remains to be tested. Individuals may be afraid that their discomfort in the video will be evident, and may make others uncomfortable, thus contributing to more PEP. ...
... This is consistent with finding that interaction social situations tend to result in more PEP than performance situations (e.g., Fehm, Schneider, & Hoyer, 2007). Fear of discomfort to others is thought to increase fixation on interoceptive cues (Rector et al., 2006b). In the present study, this self focus likely increased the severity of the negative self-representation of how they thought others would perceive them the following week. ...
Following social events, individuals with social phobia engage in post-event processing (PEP), namely a post-mortem detailed analysis of a social situation. This study aimed to examine cognitive and symptom correlates of PEP, as well as stability of PEP, in the context of videotaped exposures that occurred during treatment at sessions four and eight. Before treatment, 75 individuals with DSM-IV diagnosed social phobia completed measures of social anxiety, anxious rumination, fear of causing discomfort to others, and negative interpretation of positive social events. They rated their peak anxiety during the taped exposure. Then, they completed a measure of PEP one week after each videotaped exposure exercise. Results revealed that baseline social anxiety symptoms, state anxiety during the videotaping, anxious rumination, fear of causing discomfort to others, and negative interpretation of positive social events were all positively associated with PEP for the first taped exposure. Regression analyses demonstrated that unique predictors of PEP over and above baseline social anxiety were state social anxiety during the exposure, and anxious coping-focused rumination. This was largely replicated in the second taped exposure. In addition, PEP following two videotaped exposures separated by four weeks showed a moderate-to-large positive correlation. These findings highlight symptom and cognitive correlates of PEP, and underscore importance of state anxiety in social situations, as well as general anxiety focused rumination in social phobia.
... The principal source of anxiety in social phobia is the fear of negative evaluation (Turner, Beidel, & Townsley, 1992), which can be thought of as a largely intra-personal process. However, some individuals with social anxiety also report fears related to interpersonal processes, namely the perceived affective and behavioral consequences of their anxiety or embarrassment for others (Rector, Kocovski, & Ryder, 2006a, 2006b. Individuals with GSP often report concerns that their anxiety will cause others to feel anxious, uncomfortable, and/or annoyed with them. ...
... Rector et al. (2006a) demonstrated that fear of causing discomfort to others is elevated in individuals with GSP in comparison to those with panic disorder and student controls. These fears enhance anticipated danger, self-focus, and preoccupation with autonomic arousal symptoms during social situations, as well as PEP following social situations (Rector et al., 2006b). Fear of causing discomfort to others reflects an interpersonal vulnerability that is elevated in individuals with GSP, and is thought to enhance other cognitive dimensions of importance in theories of GSP. ...
... Individuals who fear causing discomfort to others worry not only that others will notice their symptoms of anxiety, but also that their anxiety will make others uncomfortable. Rector et al. (2006b) theorized that this fear may arise in part due to the tendency to catastrophize the impact of one's arousal symptoms for the wellbeing of others. Individuals with this fear may interpret positive social cues as others attempting to make them feel comfortable because they see how anxious the individual with GSP is. ...
Research suggests that individuals with social phobia fear positive social events and interpret them in a negative fashion that serves to maintain anxiety. To better elucidate the nature and role of interpretation of positive events in social phobia, two studies were conducted. Study 1 examined symptom and cognitive correlates of negative interpretation of positive social events. Participants with DSM-IV diagnosed generalized social phobia (GSP) completed a measure of interpretation of positive social events (IPES) in relation to a range of symptom and cognition measures of social anxiety. Results indicated that perfectionism and a measure tapping interpersonal fears associated with social anxiety were significantly predictive of IPES scores. Study 2 examined IPES scores in clinical participants with GSP, obsessive compulsive disorder (OCD), panic disorder with or without agoraphobia (PD/A), generalized anxiety disorder (GAD), and non-anxious controls. Results indicated that individuals with GSP scored higher on the IPES than those with PD/A, GAD and controls, but did not differ from OCD. These findings suggest that negative interpretation of positive events is a distinct and characteristic feature of social phobia with significant associations with other cognitive risk factors for the disorder.
... In addition, 5.6% of the Australian respondents scored 42 standard deviations above the mean of the total sample of respondents pointing to the existence of individuals with extreme scores on TK offensive symptoms, even in Western populations. A few recent studies have also reported that scores on the Social Phobia Scale (SPS) and Social Interaction and Anxiety Scale (SIAS) in patients with social phobia were significantly correlated with scores on the measures of TK offensive symptoms [Choy et al., 2007] or fear of causing discomfort to others [Rector et al., 2006]. These results suggest that TK offensive type might well exist in the West. ...
... In addition, it was reported from Korea that cognitive behavioural group therapy was most effective for treating TK offensive type while pharmacotherapy was less effective [Lee and Oh, 1999]. However, one recent study has failed to demonstrate a significant reduction in levels of fear of causing discomfort to others in a sample of patients with social phobia after successful cognitive behavioural group therapy [Rector et al., 2006]. Reasons for these discrepant results are not clear but may partly be a result of different measures across studies. ...
... These results are consistent with a suggestion that social phobia and TK offensive type may represent two subtypes of a single higher order entity [Choy et al., 2007;Lee and Oh, 1999;Nagata et al., 2006;Nakamura et al., 2002]. However, another recent study by Rector et al. [2006] has failed to find a significant reduction in levels of fear of causing discomfort to others in patients with social phobia after completion of successful cognitive behavioural group therapy. The discrepancy may have been caused by the different measures used in the studies. ...
This study investigated the culture specificity of Taijin-Kyofusho (TK) offensive type by examining whether symptoms of the disorder covary with social phobia and determining the proportion of those who meet criteria for a diagnosis of TK offensive type among Australian socially phobic individuals. The study included a total of 94 participants who met the DSM-IV criteria for social phobia and 39 normal controls who did not meet criteria for any mental disorder. All participants were born in Western countries and resided in Australia. Results showed that levels of offensive worry were significantly elevated in socially phobic individuals and decreased after treatment of their social phobia, pointing to a close relationship between symptoms of TK offensive type and social anxiety. Correlational analysis indicated that TK offensive type and social phobia appear to represent distinct constructs, although the two constructs were clearly strongly related. However, diagnostic examination revealed that the prevalence of reported offensive symptoms (eight out of 94; 8.5%) was extremely low among participants with social phobia in Australia and none of them met the full criteria for TK offensive type. The mixed findings relevant to the existence of TK offensive type among an Australian sample with social phobia are discussed in relation to cultural influences on life interference, referral behaviors, and diagnostic customs.
... – Self Construal Scale (SCS ; Singelis, 1994) – Brief Fear of Negative Evaluation Scale (BFNE ; Leary, 1983) – Social Interaction Anxiety Scale (SIAS ; Mattick & Clarke, 1998) – Social Anxiety – Causing Discomfort to Others (SADOS ; Rector, Kocovski, & Ryder, 2006) – Taijin Kyofusho Scale (TKS ; Kleinknecht, Dinnel, Kleinknecht, Hiruma, & Harada, 1997) – Modified version of Taijin-Kyofu-Sho Questionnaire (Modified TKSQ ; Choy, Schneier, Heimberg, 16. Si mon frère ou ma soeur échoue, je me sens respon- sable. ...
... – Self Construal Scale (SCS ;Singelis, 1994)– Brief Fear of Negative Evaluation Scale (BFNE ;Leary, 1983)– Social Interaction Anxiety Scale (SIAS ;Mattick & Clarke, 1998)– Social Anxiety – Causing Discomfort to Others (SADOS ;Rector, Kocovski, & Ryder, 2006)– Taijin Kyofusho Scale (TKS ;Kleinknecht, Dinnel, Kleinknecht, Hiruma, & Harada, 1997)– Modified version of Taijin-Kyofu-Sho Questionnaire (Modified TKSQ ; Choy, Schneier, Heimberg, Oh, & Liebowitz,16. Si mon frère ou ma soeur échoue, je me sens responsable.1 2 3 4 5 616. ...
This document contains 6 in-house translated scales (in French) that are related to social anxiety and Taijin Kyofusho. These translated scales are: Self Construal Scale (30 items), Brief Fear of Negative Evaluation Scale (12 items), Social Interaction Anxiety Scale (20 items), Social Anxiety - Causing Discomfort to Others (26 items), Taijin Kyofusho Scale (31 items), Modified version of Taijin Kyofusho Questionnaire (40 items).
To access the full text, please go to HAL open access repository: https://hal.archives-ouvertes.fr/hal-01138044
... Por otra parte, Rector, Kocovski y Ryder (2006) en su artículo «Ansiedad social y el miedo de causar inconformidad en los otros: conceptualización y tratamiento» plantean cómo para el paciente el miedo es la causa de que los otros se sientan disconformes en la interacción social. El miedo no se focaliza en su propia evaluación negativa que hace el paciente sobre su actuación sino que se centra en las consecuencias que causa su ansiedad en la incomodidad y ofensa en la interacción con los otros. ...
... Por ejemplo, hay culturas en donde el contacto visual es una ofensa porque refleja insensibilidad hacia los otros e irrespeto para el establecimiento de las estructuras sociales. Por consiguiente, Rector et al., (2006) sugieren para el tratamiento de este trastorno la utilización de estrategias dirigidas a consultar a los «otros» como observaron las conductas de ansiedad. El terapeuta le sugiere al paciente que le pregunte a sus familiares sobre lo que pasaría si él se pone ansioso en una situación social familiar y cómo ellos responderían, ejemplo que ofrece una nueva forma para abordar este trastorno desde las interrelaciones. ...
... Selain ketergantungan pada teman yang memperkuat ketidakpercayaan diri siswa, karena siswa mengalami kegelisahan saat teman-teman yang lain sudah menyelesaikan masalah yang di ujikan, sedangkan durasi waktu pengerjaan akan berakhir. Hal tersebut berdasarkan penelitian yang relevan bahwa terdapat hubungan pertemanan dengan kecemasan (Rodebaugh, Lim, Shumaker, Levinson, & Thompson, 2015;Rector, Kocovski & Ryder, 2006). ...
Fenomena kecemasan dalam penyelesaian matematika dikalangan siswa kerap terjadi, namun penyelesaian permasalahan tersebut belum banyak menjadi perhatian para guru matematika. Penelitian ini bertujuan mengatasi kecemasan siswa dalam menyelesaikan masalah matematika dengan menerapkan terapi behavioral menggunakan teknik desensitisasi sistematis sebagai upaya penangananya. Metode yang digunakan dalam penelitian ini adalah kualitatif dengan desain penelitian studi kasus. Adapun instrumen yang digunakan dalam penelitian ini yakni skala kecemasan menggunakan skala T-MAS, wawancara dan dokumentasi. Penelitian dilakukan pada 25 siswa kelas X AKL-1 SMK Islamic Centre Cirebon. Tiga tahapan analsisi data yang terdiri reduction, display dan conclusion drawing atau verification dilakukan dalam penelitian ini. Adapun hasil penelitian ini mendapati 3 siswa yang tidak mengalami kecemasan, 5 siswa yang mengalami kecemasan ringan, 12 siswa mengalami kecemasan sedang, 4 siswa mengalami kecemasan berat dan 1 siswa mengalami kecemasan panik. Sedangkan terdapat 9 tahapan dalam terapi yakni pengkondisian, rasionalisasi, latihan relaksasi, menyusun hierarki, diskusi gambaran hal yang menyenangkan bagi konseli, relaksasi, memunculkan hierarki kecemasan dan mengamatinya serta melakukan evaluasi tindakan. Selanjutnya, berpedoman pada standar uji perilaku tingkat keberhasilan penerapan terapi behavioral dengan teknik desensitisasi sistematis menunjukkan persentase 66% gejala tidak pernah dilakukan seperti posisi duduk yang gelisah dan tangan yang berkeringat dimana 60% < x < 75% dikategorikan cukup berhasil. Sehingga terapi behavioral dengan teknik teknik desensitisasi sistematis berimplikasi dalam menurunkan tingkat kecemasan siswa dalam penyelesain matematika.
... However, cultural context, namely Japanese vs. American, UNPACKING CULTURAL VARIATIONS 6 accounted for additional variability in TKS symptoms, with Japanese participants scoring higher. Clinical research, meanwhile, has shown that the TKS-specific fear of offending others or making others uncomfortable could be identified among North American patients with European heritage (e.g.,Choy et al., 2008;Clarvit, Schneier, & Liebowitz, 1996;Rector, Kocovski, & Ryder, 2006). In addition, the occurrence of TKS symptoms is not strongly related to interdependent self-construal among Japanese students (Dinnel et al., 2002;Kleinknecht et al., 1997). ...
This article presents two studies that aim to unpack cultural variations in general social anxiety (SA) and the offensive-type of Taijin Kyofusho (OTKS)a type of SA characterized by the extreme fear of offending others. Cultural variations in the expression and manifestation of SA are well established; however, the mechanisms underpinning this relation are unclear. The present studies use the Parallel Multiple Mediation Model to study how SA and OTKS are jointly shaped by self-construal and intolerance of uncertainty (IU). Study 1 compared Euro-Canadians and Chinese migrants in Canada. Results showed a mean group difference in OTKS, but not SA, with the difference mediated by IU. Study 2 tested this pattern of multiple mediations in Japanese, Chinese, and Euro-Canadian cultural contexts. Results showed significant differences among these three cultural groups on both SA and OTKS via multiple mediators (e.g., independent vs. interdependent self-construals and IU). Findings in both studies revealed that OTKS seems to be a psychopathology that is not specific to Japanese participants. The underlying mechanisms and processes of OTKS are also significantly different from SA. Significant cultural variations in SA and OTKS between Chinese versus Japanese cultural contexts were observed in Study 2. These studies demonstrate the conceptual and empirical advantages of using more complex models to unpack the psychological mechanisms shaping cultural variations in SA and OTKS. "To access the full text, please go to HAL open access repository: https://hal.archives-ouvertes.fr/hal-01104640"
... In fact, a similar concept, 'Fear of causing discomfort to others' (SA-DOS), was also found in social phobia. Rector et al. (2006) described some social phobic patients expressed concern that their display of anxiety symptoms would adversely affect the comfort and performance of others in the shared environment. Another condition, taijin kyofusho ('taijin' means 'vis-à-vis other people', 'kyofu' means 'fear', 'sho' means 'syndrome'), roughly corresponding to social phobia in Western society, has been widely recognized in Japan since the early 1930s. ...
Objectives: The aim of this study was to explore and describe the subjective experiences of agoraphobia in Hong Kong Chinese.
Method: This was a cross-sectional descriptive study, using a combined qualitative–quantitative approach. In the qualitative part, two focus groups were held with nine participants suffering from DSM-IV panic disorder with agoraphobia, followed up in a regional hospital in Hong Kong. The audiotaped material was transcribed and analysed into four main categories and 13 subcategories based on a grounded theory approach. One subcategory (‘Fear of making others worried and being a burden to others’) was identified as a novel, culture-specific concept in agoraphobia that was not reported in Western literature. In the quantitative part, this subcategory was redefined and measured by a two-item, self-rated questionnaire survey in another 35 participants suffering from DSM-IV defined panic disorder with agoraphobia.
Results: Qualitative data showed that the clinical manifestations of agoraphobia were specifically related to the underlying corresponding catastrophic cognitions. An individual’s agoraphobic cognitions and symptoms were highly related to the identity of the surrounding people during panic attacks in agoraphobic situations, which reflected the characteristic structure of the Chinese interpersonal network. Participants preferred reliance on self to cope with the anxiety first, then turned to their family members for help due to higher interpersonal trust. Participants also expressed fear of affecting others due to their illness. A new sub-theme of agoraphobia (‘Fear of making others worried and being a burden to others’) was extracted from the qualitative data. Its validity was confirmed by the quantitative description of this new theme using a self-rated questionnaire as a methodological triangulation.
Conclusions: The central theme to emerge from the qualitative data was that agoraphobia is a clinical condition that has a close relationship to Chinese cultural factors. ‘Fear of making others worried and being a burden to others’ is a new concept in agoraphobia worthy of further study.
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Moving abroad as international students would changes the social environment due to language, food, people and cultural diversity in a foreign country. This condition may cause the feeling of social anxiety in their new daily life. At worst, social anxiety might increase problems in cognitive, affective, and behavioral areas. This study aims to describe more about social anxiety among international students of Sultan Idris Education University according to the mother tongue, and gender as additional analysis. Research was designed by quantitative approach using descriptive, t-test and anova analyses. There were 117 International Students who completed the survey using Social Interactions Anxiety Scale (SIAS) for university students. The Anova test result reported, there is a significant difference in social anxiety among international students according to their mother tongue, p= 0.03 (p<0.05) and F = 2.326. International students who have mother tongue, English, seem had the lowest score of social anxiety (mean=2.12), followed by Indonesian (mean=2.54), followed by Korean (mean=2.57), and followed by Chinese (mean= 2.75). This study revealed international language, English, become as one factor that effected social anxiety problems among international students in the university.
Revisioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience, and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice; • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts; • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems; • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Background:
Patients with social anxiety disorder (SAD) report fear content relating to the perceived aversive consequences of their anxiety for others in their social environment. However, no studies to date have examined the diagnostic specificity of these fears to SAD as well as predictors to treatment response of these fears.
Aims:
To examine relative specificity of fears related to causing discomfort to others, as measured by Social Anxiety-Fear of Causing Discomfort to Others (SA-DOS), among patients with anxiety disorders, obsessive compulsive disorder (OCD) and major depressive disorder (MDD), in addition to relation between dysfunctional attitudes and treatment response among patients with SAD.
Method:
In study 1, a large (n=745) sample of DSM diagnosed OCD, MDD and anxiety disorder participants completed the SA-DOS. In study 2, patient participants with SAD (n=186) participated in cognitive behavioural group therapy (CBGT) and completed measures of social anxiety symptoms and dysfunctional attitudes.
Results:
In study 1, the SAD group demonstrated significantly elevated SA-DOS scores compared with participants with generalized anxiety disorder (GAD), OCD and panic disorder with or without agoraphobia (PD/A), but not the MDD group. In study 2, CBGT treatment was found to lead to significant reductions in SA-DOS scores. Need for approval (NFA) but not perfectionism, predicted treatment response to fears related to causing discomfort to others, with greater change in NFA relating to greater change in SA-DOS scores.
Conclusions:
These findings extend previous research linking allocentric fears to the phenomenology and treatment of SAD.
The title of this chapter evokes the common ground between anthropology and psychiatry, and by extension suggests Edward Sapir’s (1932) enduringly astute essay on this topic, written already eighty years ago, as a starting point for defining a cultural phenomenology of psychiatric illness. Sapir was a close collaborator of Harry Stack Sullivan, based in part on the concordance of Sullivan’s interpersonal psychiatry and Sapir’s anthropological understanding that the locus of culture is in the interaction of specific individuals. Sapir begins by observing that cultural anthropology emphasizes the group and its traditions, and the testimony of discrete individuals is of interest only insofar as they can be assumed typical of their community. Despite the presence in ethnography of "a kaleidoscopic picture of varying degrees of generality" from the broadly shared to the idiosyncratic, the individual note creates "disquieting interruptions to the impersonality of his [the anthropologist’s] thinking" (1932, p. 230). Psychiatry’s concern for individual pathology tends to be dominated by a need to magnify the biological approach in order to maintain legitimacy in the medical profession, even though "attempts to explain a morbid suspiciousness of one’s companions or delusion as to one’s status in society by some organically definable weakness of the nervous system or of the functioning of endocrine glands may be no more to the point than to explain the habit of swearing by the absence of a few teeth or by a poorly shaped mouth" (1932, p. 232). Psychiatric morbidity is "not a morbidity of organic segments or even organic functions but of experience itself," and it is unrealistic to "assume that ll experience is but the mechanical sum of physiological processes lodged in isolated individuals" (1932, p. 232). Sapir’s argument, perhaps ironically, is that anthropology and psychiatry most fruitfully overlap precisely at their respective blind spots: he individual for anthropology, experience for psychiatry. Culture as "superorganic" or abstracted from individual experience is a deterrent to "the more dynamic study of… cultural patterns because these cannot be disconnected from those organizations of ideas and feelings which constitute the individual" (1932, p. 233).
What do psychiatrists encounter when they encounter psychopathological experience in their patients? How should we interpret such experiences? In this chapter, we contrast a checklist approach to diagnosis, which is standard today and which treats psychiatric symptoms and signs (i.e., "the psychiatric object", Marková & Berrios, 2009; see also Chapter 2, this volume) as readily operationalizable object-like entities, with a nonstandard phenomenological approach that emphasizes the importance of a specific kind of interpretive interview. The descriptive methods of today’s psychiatry perpetuate what has been called psychiatry’s "problem of description" (Spitzer, 1988) because these methods are not adequately tailored to the ontological nature of the "psychiatric object." The psychiatric object is typically portrayed as an objective, thinglike entity, unproblematically graspable as it exists "in itself" through a behaviorist third-person perspective and as being indicative of a specific and modular physiological dysfunction. We will propose a different epistemological approach, considering the nature of mental disorders to be primarily constituted by the patient’s anomalies of experience, expression, and existence that typically involve suffering and dysfunction (Parnas, Sass, & Zahavi, 2013). Introduction: Is There a Problem in Contemporary Psychiatry?. More than thirty years ago, psychiatry, attempting to match somatic medicine in its scientific-biological foundations, underwent an "operational revolution," introducing criteria-based diagnoses and "operational definitions" of such criteria (American Psychiatric Association [APA], 1980). The operational project radically abridged, simplified, and condensed the then existing corpus of clinical knowledge into diagnostic manuals accessible to the grand publique because they are written in lay language and stripped of theoretical and psychopathological reflection. These manuals have long been the main source of clinical knowledge for psychiatrists in training (Andreasen, 2007). Moreover, it is assumed that a structured interview, that is, an interview in which a psychiatrist asks the patient a series of preformulated questions in a fixed sequence, is an adequate methodology for obtaining psychodiagnostic information. We will argue that this is a mistaken assumption.
The descriptions of psychiatric disorders in DSM-5 (APA, 2013) represent only some of the diverse forms of clinical presentations worldwide and throughout history. Cultural variation may help explain why current DSM diagnoses only partially map onto their putative biological substrates at the genetic or neurocircuitry level. It is more likely that these biological domains constitute dimensional vulnerability factors that pattern disorder expression more generally (e.g., mood dysregulation), and that specific syndromes arise from the interaction of this general vulnerability with other contextual factors, including culturally patterned illness expressions. This hypothesis raises several questions: How can research on cultural variation help elucidate the full range of underlying mechanisms that culminate in a given illness prototype? What cultural-contextual information can help clarify the relationship between related but diverse presentations of psychopathology? How can cultural variation be included in a universalistic nosology, such as DSM-5? This chapter presents a model of interdisciplinary triangulation that suggests how combining findings from sociocultural contextual analysis, neurobiological substrates of mental illness, and psychological dimensions can identify the substrates of illness phenomenology. The model will first be illustrated through an example of research on language, and then applied to a cultural syndrome included in the DSM-5 Appendix: ataque de nervios (attack of nerves). The chapter concludes by discussing how this model helped the DSM-5 revision process and by suggesting areas for future research. Psychopathology is experienced, expressed, and interpreted around the world with considerable cultural variation. To date, no blueprint exists that can untangle the contributions to this variation from neurobiological, psychological, and cultural levels of analysis (Kendler, 2008). As a result, classification systems of psychopathology rely almost exclusively on phenomenological description - in its simplest sense of that which is apparent to an external observer (Andreasen, 2007; Hyman, 2010) and with only the barest attention to other aspects of illness phenomenology, such as the sufferer’s own subjective description of lived experience and an accounting of the sociocultural environment that helps pattern illness expression (Csordas, Chapter 5, this volume; Heidegger, 1962 /1927; Merleau-Ponty, 1996 /1945; Parnas & Gallagher, Chapter 3, this volume).
Introduction In this chapter, we propose a model to describe the various ways in which biological mechanisms of anxiety and their psychological correlates are embedded in, shape, and are shaped by particular cultural contexts. Our approach focuses on a set of processes, including attentional looping, catastrophic cognitions, and interpretive biases, and uses several versions of our "multiplex model" in order to illustrate the profound effects of culture on panic attacks, panic disorder, worry/generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), anxiety symptoms, and somatization more generally. In doing so, we illustrate how local conceptualizations of the body alter the experience of somatic and panic-related symptoms. Our illustrations come mainly from research and clinical work with traumatized Cambodian refugees. The multiplex models illustrate the importance of a dimensional approach to psychopathology - such as catastrophic cognitions, panic, somatic sensations, trauma associations, biology of trauma (e.g., amygdala reactivity) - in line with NIMH’s RDoC initiative (Morris & Cuthbert, 2012; Sanislow et al., 2010; see also Kirmayer & Crafa, 2014, for critique); the models also provide insights into how a biocultural phenomenology of mental disorders may be advanced. More specifically, the multiplex models demonstrate how certain somatic symptoms may be subject to "bioattentional" looping, a positive feedback effect whereby interpretation of the symptoms in terms of the local ethnophysiology, ethnopsychology, and ethnospirituality may "loop back" and amplify their physiological effects, creating a vicious circle (for a review, see Hinton & Good, 2009; Hinton & Hinton, 2002; Hinton, Hinton, Eng, & Choung, 2012; Hinton & Kirmayer, 2013; Kirmayer & Blake, 2009; Kirmayer & Sartorius, 2007). As conceptualized in the multiplex models, trauma associations and metaphor associations also may play a role in the generation and escalation of the somatic symptoms and general distress. Furthermore, the multiplex models are nested in that they involve core processes embedded within the matrices of other processes, including coping, treatment, and interpersonal contexts (e.g., Kleinman & Becker, 1998), what we refer here to as sociocultural pragmatics. Altogether, the models demonstrate how anxiety ontologies can vary greatly across cultures, with important implications for assessment and treatment.
After a two-centuries-long alliance with medicine, psychiatry (its structure, objects, language, and praxis) remains as opaque as ever. Explaining why this is the case should be the task of the epistemology of psychiatry (EP). Surprisingly enough, until recently psychiatry lacked an epistemology to explore the nature and legitimacy of psychiatric knowledge. Instead, its problems have been addressed in part by the general epistemology of medicine (Berrios, 2006; Wulff, Pedersen, & Rosenberg, 1986) and in part by work in the philosophy of psychiatry, which began to appear after World War II (see, e.g., Blanc, 1998; Griffiths, 1994; Kehrer, 1951;Lanteri-Laura, 1963; Lewis, 1967; Natanson, 1969; Palem, 2010; Palmer, 1952; Reznek, 1991; Siegler & Osmond, 1974; Spiegelberg, 1972; Spitzer & Maher, 1990; Strauss, 1958; and others). In the hands of Anglo-American writers (such as Fulford, Thornton, & Graham, 2006; Radden, 2004) the philosophy of psychiatry has now become a voluminous industry. Given its bias in the direction of analytical philosophy, a great deal of this work has been openly justificatory of the neurosciences in general and of biological psychiatry in particular (Bolton & Hill, 2003; Kendler & Parnas, 2008; Murphy, 2006; more on this later). This predictable state of affairs throws into relief the urgent need for a dedicated epistemology that may act as an independent auditor of all psychiatric narratives, past and present, and that conceives of psychiatry as a sui generis discipline, broader than the conventional sciences, language-bound, and closely dependent on its historical period. This chapter will present a sketch of a new EP along these lines. We are using the concept of "EP" to refer to the discipline of examining the various sources of knowledge underlying psychiatry and its objects in order to further develop understanding concerning their nature and stability. Because we feel that philosophy of psychiatry, while pursuing a similar aim, is too constraining in its methods and sources of knowledge, we have adopted the broader term of "epistemology" to widen the field. Within EP, there will naturally be many approaches and ways of tackling the questions, but as far as the discipline is concerned we are talking about a single general epistemology rather than many epistemologies of psychiatry.
Introduction Every year more than eight hundred thousand people die by suicide, and more than twenty times that number attempt suicide (World Health Organization [WHO], 2014). In addition to the confusion and pain generated by the loss of a beloved family member or friend, suicide has major consequences for society. The WHO estimates the actual burden of suicide to be twenty million life-years and predicts that, by 2020, suicide could be responsible for 2.4 percent of the total burden of disease (WHO, 2006). These statistics not only clearly show the importance suicide has on society but also highlight our inability to properly implement prevention strategies. Suicide represents the extreme of a behavioral continuum comprising different forms and severities of self-injurious behaviors (van Heeringen, 2001). It is generally assumed that suicide is a complex behavior resulting from the interaction of different distal and proximal risk factors. Distal risk factors such as familial history of suicide, genetic and epigenetic factors, early life adversity, and personality traits confer vulnerability to suicide, while proximal risk factors like psychopathology, recent life events, hopelessness, and acute substance intoxication are better understood as precipitants of the suicidal crisis. The presence of comorbid major depressive disorder (MDD) and substance abuse are among the strongest proximal risk factors. Indeed, studies suggest that 50 to 70 percent of suicide completers die during an episode of MDD (Arsenault-Lapierre, Kim, & Turecki, 2004; Cavanagh, Carson, Sharpe, & Lawrie, 2003), although most individuals who are affected by MDD and other mood disorders will not die by suicide (F. Angst, Stassen, Clayton, & Angst, 2002; J. Angst, Angst, & Stassen, 1999; J. Angst, Degonda, & Ernst, 1992; Blair-West, Cantor, Mellsop, & Eyeson-Annan, 1999). Age and other sociodemographic factors such as educational level, employment, and income moderate the impact of proximal factors on suicide risk (Brezo, Paris, Tremblay, et al., 2007; Brezo, Paris, & Turecki, 2006; van den Bos, Harteveld, & Stoop, 2009). Among risk factors influencing suicide more distally are personality traits and familial history of suicidal behavior, both considered strong predictors of suicide (Hawton & van Heeringen, 2009; Suominen et al., 2004).
Introduction A few short weeks before the long-awaited publication of DSM-5, Thomas Insel, director of the National Institute of Mental Health (NIMH), stated that the manual suffers from a "lack of validity" (Insel, 2013). To remedy this problem, he envisaged a new direction for psychiatry whereby clinicians and researchers classify disorders based on underlying neurobiological causes rather than on highly variable symptoms. The anticipation of DSM-5 and professional efforts surrounding it generated unprecedented questioning from both consumers and practitioners. The public, advocacy groups, and even senior members of the psychiatric community raised questions, not only regarding decisions to include or exclude specific types of problems from the revised manual but also concerning the scientific foundation of the whole enterprise. Many of these criticisms were based on recognizing the limited advances that have been made in the biological understanding and treatment of mental disorders. Psychiatry aims to link behavioral science to underlying mechanisms, using the techniques of neuroscience. Yet decades of work on cognitive, molecular, and systems neuroscience have taught most scientists a lesson in humility: despite an enormous investment in research with an emphasis on the neural correlates of typical and atypical behavioral "phenotypes," breakthroughs are sorely lacking. In spite of the global efforts and the accumulation of a large body of findings, the lack of clinical advances has undermined many working assumptions concerning the neurobiological basis of psychiatric distress. The genetic and neuroimaging revolutions - which seemed poised to elucidate and ultimately explain conditions categorized as psychopathologies and psychiatric disorders - have produced modest results that speak only obliquely to the vast, complex dynamics revealed by behavioral science. Many scholars are disillusioned with imaging studies of the living human brain, and further recognize that genetic polymorphisms putatively appearing to increase risk of schizophrenia in one person may actually predispose another to bipolar disorder (Bilder, 2011). Furthermore, some scientists argue that the therapeutic effects of drugs that comprise the backbone of modern psychiatry - antidepressants and atypical antipsychotics - are largely indistinguishable from placebos in common clinical situations (Raz & Harris, in press). These findings challenge the extent to which the study of pharmaceutical drugs contributes to our understanding of psychological conditions.
Introduction to the Problem WHO [World Health Organization] is making a simple statement: mental health - neglected for far too long - is crucial to the well-being of individuals, societies and countries and must be universally regarded in a new light. (WHO, 2001, p. ix) WHO has received an increasing number of requests from countries for assistance and country-specific action. The need for - and relevance of - an economic perspective in planning, provision, and assessment of services, and for scaling up care for MNS [Mental, Neurological and Substance use] disorders is another reason to revise the focus of the mental health strategy. Moreover, a comprehensive programme for action can inspire stakeholders and accelerate progress by bringing together partners with a common purpose. (WHO Mental Health Gap Action Programme, 2008, p. 9) How does a term such as "global mental health" become a normative object of medical and epidemiological evaluation and estimation to the degree that remedial strategies can be deployed toward its improvement? When WHO reports that, worldwide, "Depression is the leading cause of disability as measured by YLDs [years lost due to disability]" and that "by the year 2020, depression is projected to reach 2nd place of the ranking of DALYs [disability adjusted life years] calculated for all ages, both sexes," how does WHO wish us to understand the object so as to act on it? We move closer to the intended object with the WHO estimate that the treatment gap for mental, neurological, and substance abuse disorders is greater than 75 percent (Barbui et al., 2010), and through comorbidities is linked further, as cause and consequence, to primary health concerns in those locales (Prince et al., 2007, p. 1). The opening quote from WHO frames their engagement with global mental health as a response to pleas for help from low- and middle-income countries (LMICs). In a podcast interview of three of the founders of the new global mental health movement, including Shekhar Saxena, coordinator for mental health at WHO, Graham Thornicroft estimated that every year a quarter of all adults will have a mental illness, with a lifetime prevalence of 50 percent.
Introduction: At the center of psychiatry as a clinical discipline is the human encounter between patient and clinician. Although we can imagine forms of psychiatry in the future that might eliminate this relationship in favor of self-management or interactions with artificial intelligence, there are arguments for insisting that the interaction of two human beings allows unique forms of communication, understanding, and intervention. What is distinctive about this embodied encounter are the dynamics of interpersonal interaction, which include processes of empathy, identification, and emotional connection based on similarity, but also the recognition of difference, otherness, or alterity. In some ways, the construct of empathy stands in for larger questions about the nature of the relationship between patient and clinician. Of course, this relationship involves much more than empathy, but thinking about empathy provides a way to begin to explore the phenomenology and dynamics of the clinical encounter. Contemporary mental health practitioners rely on empathy to understand patients’ experiences and to maintain the interpersonal relatedness that facilitates helping and healing. Various forms of psychopathology, unusual or extreme experiences, and differences in cultural background or social position all present challenges to clinicians’ ability to empathize. Failures of empathy may undermine the working alliance, but they may also convey diagnostic information about psychopathological processes or the status of the clinician-patient relationship. When empathy reaches its limits, the other may be experienced as alien, uncanny, and unknown. Theories of psychopathology, which may include structural models and causal mechanisms, offer alternative ways to explain alien or inaccessible experience (Glover, 2014). Clinicians learn to use these models to guide their response to patients, and, in some circumstances, such technical models or explanations may enhance or restore empathy. But cultural difference also demands that we learn to use our imagination in disciplined ways to build bridges between different worlds of experience and to respect the limits of our understanding of the other. Forms of Knowledge in the Clinical Encounter Clinical understanding demands attention to multiple sources of knowledge, each with its own epistemology and methods of inquiry (McHugh & Slavney, 1998).
Introduction The ability to effectively process and regulate emotional information is a crucial social skill that undergoes important developmental changes from childhood through adolescence and adulthood. Clinical studies indicate that individuals diagnosed with psychiatric disorders, in particular anxiety and mood disorders, exhibit abnormalities in emotion processing and regulation (Phillips, Ladouceur, & Drevets, 2008). Evidence from epidemiological, genetic, and neuroimaging studies suggests that abnormalities in neural connectivity within and between regions of the brain implicated in emotion processing and regulation may play an important role in the neuropathophysiology of these disorders (Almeida & Phillips, 2012; Hajek, Carrey, & Alda, 2005; Leibenluft, Charney, & Pine, 2003; Merikangas et al., 2011; Phillips et al., 2008; Versace et al., 2015). Collectively, these neural connections, or networks, constitute the Brain’s "connectome" (Hagmann, 2005; Sporns, Tononi, & Kötter, 2005). It is possible that altered development of these neural networks might contribute to the developmental trajectories of these disorders in vulnerable youth or youth at familial risk for these disorders. In this chapter, we will focus particularly on bipolar disorder (BD), a serious and recurrent neuropsychiatric illness that affects 2-5 percent of the population (Merikangas et al., 2007) and ranks as one of the top ten leading causes of disability in the world (WHO, 2001). One of the chief clinical features of BD is the difficulty in regulating a range of emotions. In particular, BD is characterized by a pervasive mood disturbance that involves rapid fluctuations and changes in the valence and intensity of emotional states ranging from episodes of sadness, irritability, and anger to episodes of extreme happiness, elation, increased activity, and risky behavior. he emergence of BD in children and adolescents is of particular concern because early onset of BD has been associated with severe presentation and course, including high rates of hospitalization, psychosis, suicidal behavior, substance abuse, and other psychosocial problems (Birmaher et al., 2006; Geller et al., 2002; Perlis et al., 2004). Moreover, evidence from adoption, twin, high-risk, and family studies indicate that BD is highly heritable (Birmaher et al., 2009; DelBello & Geller, 2001; Goodwin & Jamison, 2007; Tsai, Lee, & CC, 1999; Tsuang & Faraone, 1990).
In 1918, Victor Tausk - a lawyer who, under the influence of Freud, had turned to psychoanalysis - read a paper to the Vienna Psychoanalytic Society entitled "On the Origin of the ‘Influencing Machine’ in Schizophrenia" (published as Tausk 1919 and, in English translation, as Tausk 1933). Tausk reports on a thirty-one-year-old patient Natalija A. who had formed the belief that she, her mother, and her friends were being manipulated by a machine located in Berlin. Although she is uncertain about the nature of the machine, she suspects that it functions by means of telepathy. In a strange coincidence, a version of the influencing machine delusion also appears in the very first extended description in English of what psychiatry would come to call "schizophrenia. " James Tilly Matthews, an inmate in Bethlem at the turn of the nineteenth century, was the subject of a detailed case history by his doctor John Haslam (Haslam, 1988; see also Jay, 2012, and Porter, 1985). In the years before being committed to Bethlem, Haslam had been living in Paris when Franz Mesmer was making the rounds of Parisian salons and demonstrating the new force he believed he had discovered and which he called "animal magnetism. " Once in Bedlam, Matthews came to believe that a gang of villains was operating outside the walls of the hospital and using a machine - the "Air Loom" - to torment him with magnetic waves. Tausk notes that as new technologies enter popular culture, they creep into patients’ delusions. In the twentieth century (Linn, 1958) the influencing machine is conceived of as a robot; in the twenty-first, it is replete with contemporary tropes: manipulation by Marilyn Manson; persecutors projecting pornography into a patient’s eyes by "laser radiation", Muslims and Russians monitoring a patient’s sexual activities; and airport security tracking someone by means of a computer chip inserted into his neck (Hirjak & Fuchs, 2010). The chapters in this section provide a variety of arguments for the claim that trying to understand psychiatric disorders or symptoms outside of the appropriate cultural context is deeply problematic. The influencing machine delusion provides a particularly clear illustration of one more way in which the study of culture can serve a revisioned psychiatry.
Re-Visioning Psychiatry explores new theories and models from cultural psychiatry and psychology, philosophy, neuroscience and anthropology that clarify how mental health problems emerge in specific contexts and points toward future integration of these perspectives. Taken together, the contributions point to the need for fundamental shifts in psychiatric theory and practice: • Restoring phenomenology to its rightful place in research and practice • Advancing the social and cultural neuroscience of brain-person-environment systems over time and across social contexts • Understanding how self-awareness, interpersonal interactions, and larger social processes give rise to vicious circles that constitute mental health problems • Locating efforts to help and heal within the local and global social, economic, and political contexts that influence how we frame problems and imagine solutions. In advancing ecosystemic models of mental disorders, contributors challenge reductionistic models and culture-bound perspectives and highlight possibilities for a more transdisciplinary, integrated approach to research, mental health policy, and clinical practice.
Given considerable evidence that culture profoundly shapes both normative social behaviors and psychopathology, we argue that social anxiety disorder cannot be properly understood in the absence of cultural context. In particular, there is evidence that Chinese cultural contexts foster concern for whether one is making other people uncomfortable. We examined these concerns in 175 Han Chinese depressed psychiatric outpatients in Changsha, China and 104 Euro-Canadian depressed psychiatric outpatients in Toronto, Canada. As anticipated, anxiety about causing discomfort to others was related to but distinct from social interaction anxiety, with a stronger relation in the Han Chinese sample. Also as anticipated, anxiety about causing discomfort to others was higher in the Han Chinese sample compared to the Euro-Canadian sample, especially in outpatients who acknowledged anxiety in social situations. These findings can be understood in light of research demonstrating that Chinese cultural contexts foster particular concerns for the maintenance of social harmony. We discuss implications of these findings for assessment and treatment of social anxiety disorder.
This document contains 9 in-house translated scales (in Simplified Chinese) that are related to social anxiety, Taijin Kyofusho and intolerance of uncertainty. These translated scales are: Self Construal Scale (30 items), Intolerance of Uncertainty Scale (27 items), Brief Fear of Negative Evaluation Scale (12 items), Fear of Positive Evaluation Scales (10 items), Modified version of Taijin Kyofusho Questionnaire (40 items), Social Anxiety - Causing Discomfort to Others (26 items), Taijin Kyofusho Scale (31 items), Social Interaction Anxiety Scale (20 items) and the Revision of Self-Monitoring Scale (13 items). "To access the full text, please go to HAL open access repository: https://hal.archives-ouvertes.fr/hal-01132783"
Interoception can be broadly defined as the sense of signals originating within the body. As such, interoception is critical for our sense of embodiment, motivation, and well-being. And yet, despite its importance, interoception remains poorly understood within modern science. This paper reviews interdisciplinary perspectives on interoception, with the goal of presenting a unified perspective from diverse fields such as neuroscience, clinical practice, and contemplative studies. It is hoped that this integrative effort will advance our understanding of how interoception determines well-being, and identify the central challenges to such understanding. To this end, we introduce an expanded taxonomy of interoceptive processes, arguing that many of these processes can be understood through an emerging predictive coding model for mind–body integration. The model, which describes the tension between expected and felt body sensation, parallels contemplative theories, and implicates interoception in a variety of affective and psychosomatic disorders. We conclude that maladaptive construal of bodily sensations may lie at the heart of many contemporary maladies, and that contemplative practices may attenuate these interpretative biases, restoring a person’s sense of presence and agency in the world.
Rector, Kocovski, and Ryder (2006, this issue) suggest that fear of causing discomfort to others is a unique form of social anxiety and that focusing on this concern may be clinically helpful. We argue that the fear of causing discomfort to others is dependent upon fear of negative evaluation, and provide evidence from the domains of evolutionary psychology, personality psychology, self-regulation theory, and our own clinical experience that support this argument. Given that fear of causing discomfort to others is dependent upon fear of negative evaluation, it is well addressed by current empirically supported cognitive behavioral interventions. Thus, although fear of causing discomfort to others may ultimately prove to be a useful construct, further evidence is required to demonstrate that it provides unique insights regarding social anxiety or social anxiety disorder.
Social anxiety is a devastating and persistent condition that is characterized by a fear of social interactions (Luterek, 2006). Emotional expressivity is the tendency to express emotions nonverbally, such as through actions, facial expressions, tone of voice, and posture (Barchard & Matsumoto, in prep). Because social anxiety and emotional expressivity are both related to social interactions, there may be a negative correlation between them. In this study, 508 participants were recruited from the Psychology Subject Pool; they completed the Liebowitz (1987) Social Anxiety Scale and six measures of emotional expressivity (happiness, amusement, affection, sadness, anger, and fear). There was a moderate negative correlation between social anxiety and the expression of affection. However, social anxiety did not correlate with the expression of the remaining five emotions. Perhaps the expression of these other emotions did not have significant correlations with social anxiety because they do not always involve social interactions, the way that affection does. This research suggests that affection may have a different relationship with social anxiety than other emotions do. Future research could explore whether social anxiety can be reduced by increasing patient's expression of affection. Introduction Social Anxiety is a debilitating and chronic condition which is characterized by a persistent fear of interacting or performing in social situations. This fear is caused by concerns of embarrassment, humiliation, or negative evaluations by others (Luterek, 2006). Segrin (1992) argued that social skills are based on three things: ability, performance, and perceptions of outcomes. His study suggests that people who suffer from social anxiety often feel unmotivated to engage in social interactions. Socially anxious persons feel they will inhibit their communication and others around them will perceive their nervousness. Social Anxiety includes both fear and avoidance (Balon, 2007). Because of these fears, those with social anxiety often avoid social interactions altogether. Emotional expressivity refers to the expression of emotions in nonverbal ways, such as through actions, expressions of the face, tone of voice, and posture (Barchard, & Matsumoto, in prep). In the past, emotional expressivity was often measured uni-dimensionally, which meant that researchers assumed that people who cry a lot are also the ones who laugh a lot. However, Barchard and Matsumoto found that emotional expressivity is best measured using a higher-order model. This model states that the expression of each emotion has only a small relationship with the expression of other emotions. They divide emotional expressivity into six dimensions: happiness, affection, amusement, anger, fear, and sadness. Both Barchard and Matsumoto (in prep) and others have found that these scales have differential validity. Barchard and Matsumoto (in prep) found that the expression of happiness, affection, and amusement had a positive moderate correlations with Extraversion and very small correlations with Neuroticism; whereas the expression of anger, fear, and sadness generally had smaller correlations with Extraversion. Suveg, Mary, and Maine (2004) also found that each of these factors has different connections with both personality and behavior. We hypothesize that people with social anxiety will be less emotionally expressive. Luterek (2006) hypothesized that since social anxiety is the fear of being embarrassed or humiliated by others, by definition, social anxiety would hinder or change one's ability to be fully expressive. Relationships of socially anxious individuals are often restricted and controlled by these fears. After examining both socially anxious and non-anxious persons, Luterek found that the emotionally anxious persons showed a noticeable difference in facial expressivity overall. On the other hand, Heerey and Kring (2007) found that people with social anxiety were more likely than non-socially anxious people to use anger-, fear-, and sadness-laden emotion words when engaged in social situations. The purpose of this research will be to examine the relationship between social anxiety and emotional expressivity, to resolve this apparent conflict. A link between social anxiety and emotional expressivity is also apparent in research with children. Suveg, Zeman, Flannery-Schroeder, and Cassano (2005) examined the relationship between the emotional expressivity of mothers with social anxiety and their children's emotional expressivity. They found that mothers of children with anxiety disorders spoke less often than their children, and were more likely to discourage their children from being emotional (Suveg, Zeman, & Flannery-Schroeder, et al. 2005). This study demonstrated how adults with social anxiety might develop problems with emotional expressivity during childhood. Shipman and Zeman (1998) also studied how social factors can affect emotional expressivity in children. They found that socially anxious children limited their emotional expressions (not showing they are sad, happy, etc.) so they won't be teased or judged by their peers. Thus, these studies show that relationships between emotional expressivity and social anxiety may span all ages and, if links are found, they will be important for all generations. To test our hypothesis we will correlate social anxiety with emotion-specific measures of emotional expressivity. We expect negative relationships for each of the emotional expressivity scales. Method Participants A total of 508 (209 male, 299 female) students participated for course credit. Ages ranged from 18 to 50 (mean 19.78, SD 3.17). Participants identified themselves as 57.1% Caucasian, 12.8% Hispanic, 11.4% Asian, 7.9% African American, 6.3% Pacific Islander, 4% Native American, and 4.1% other. Measures The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 2002) is a commonly used self-report measure of social anxiety. The LSAS consists of 24 items, each depicting different a social situation. For each situation, the person rates their level of fear (where 0 indicates no fear and 3 indicates severe fear) and avoidance (0 indicates they never avoid a particular situation and 3 indicates they usually avoid that situation). The items are divided into two subscales: social interaction and performance situations. The overall score is based on six additional scores: total fear, fear of social interaction, fear of performance situations, total avoidance, avoidance of social interaction, and avoidance of performance situations (Baker, Heinrichs, Hofmann, & Hyo-Jin, 2002). In our study, we used total scores on the LSAS.
Patients with social phobia frequently report fearing that their symptoms of anxiety will adversely affect the comfort and performance of others, but these fears are not typically included in traditional measures. In Study 1, an initial 26-item pool was developed to assess this fear dimension and then administered in conjunction with measures of social phobia, anxiety and depression, to undergraduate students (n=277), patients with social phobia (n=101) and patients with panic disorder (n=25). A unidimensional scale, the Social Anxiety—Discomfort to Others Scale (SA-DOS), was derived based on exploratory factor analyses and item-response theory. The unitary structure of the SA-DOS was replicated in a second sample of patients with social phobia (n=100). In Study 2, participants with social phobia were found to have significantly higher SA-DOS scores than patients with panic disorder and student controls. Further, the SA-DOS was found to possess convergent and divergent validity in relation to validated measures assessing fear of negative evaluation and psychopathological constructs from the cross-cultural literature. In Study 3, baseline SA-DOS scores were found to be associated with poorer treatment response in a sample of patients with social phobia (n=55) receiving Cognitive-Behavioral Group Therapy. These preliminary findings suggest that fear of causing discomfort to others is a related but distinct fear dimension of social phobia requiring greater attention in the conceptualization and treatment of the disorder.
Gathers evidence from biology and psychology bearing on the issue of whether altruism is part of human nature. The traditional views of both evolutionary biology and psychology left little room for altruism. Current variants of the Darwinian model—group selection, kin selection, reciprocal altruism, and inclusive fitness—point to the acquisition of altruistic as well as egoistic structures in humans. Psychological research is also compatible with this view. There may be a general human tendency to help others in distress that has properties analogous to egoistic motivation and yet comes into play independently of egoistic motivation. The theory of inclusive fitness also requires that mediators of altruistic action be selected (rather than altruistic action itself), because this would provide the necessary flexibility. Evidence is presented suggesting that empathy may fit the evolutionary requirements of such a mediator: It is reliably aroused in humans in response to misfortune in others, it predisposes the individual toward helping action and yet is amenable to perceptual and cognitive control, and it appears to have a neural base that may have been present early in human evolution. (80 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Western psychologies have traditionally given greater importance to self-development than to interpersonal relatedness, stressing the development of autonomy independence, and identity as central factors in the mature personality. In contrast, women, many minority groups, and non-Western societies have generally placed greater emphasis on issues of relatedness. This article traces the individualistic bias and recent challenges to this view. It is proposed that evolutionary pressures of natural selection result in 2 basic developmental lines: interpersonal relatedness and self-definition, which interact in a dialectical fashion. An increasingly mature sense of self is contingent on interpersonal relationships: conversely, the continued development of increasingly mature interpersonal relationships is contingent on mature self-definition. Conclusions include implications for social policy and for facilitating more balanced development of both dimensions in all members of society. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
People in different cultures have strikingly different construals of the self, of others, and of the interdependence of the 2. These construals can influence, and in many cases determine, the very nature of individual experience, including cognition, emotion, and motivation. Many Asian cultures have distinct conceptions of individuality that insist on the fundamental relatedness of individuals to each other. The emphasis is on attending to others, fitting in, and harmonious interdependence with them. American culture neither assumes nor values such an overt connectedness among individuals. In contrast, individuals seek to maintain their independence from others by attending to the self and by discovering and expressing their unique inner attributes. As proposed herein, these construals are even more powerful than previously imagined. Theories of the self from both psychology and anthropology are integrated to define in detail the difference between a construal of the self as independent and a construal of the self as interdependent. Each of these divergent construals should have a set of specific consequences for cognition, emotion, and motivation; these consequences are proposed and relevant empirical literature is reviewed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study examined two forms of social anxiety or phobia, social phobia as defined by DSM-IV and Taijin Kyofusho (TKS, a Japanese form of social anxiety), in relation to their respective culturally prescribed self-construals as independent and interdependent. Japanese university students (N = 124) and U.S. university students (N = 123) were administered the Social Interaction Anxiety Scale, the Social Phobia Scale, the TKS Scale, and the Self-Construal Scale. From the results of a hierarchical regression analysis, TKS symptoms are more likely to be expressed by individuals who are Japanese and individuals who construe themselves low on independence but high on interdependence. In addition, social phobia symptoms are more likely to be expressed by individuals who construe themselves low on independence but high on interdependence irrespective of culture. Implications for therapists from each culture who have clients who present social anxiety or phobia symptoms are discussed.
Clinical evidence suggests that components of perfectionism may have special relevance to social phobia. This study examines this relationship by comparing 61 patients with social phobia and 39 community volunteers with no anxiety disorder on Frost, Marten, Lahart and Rosenblate's (1990) Multidimensional Perfectionism Scale (MPS). Social phobia patients scored higher on subscales assessing concern over mistakes, doubts about actions, and perceived parental criticism. Community volunteers scored higher on the organization subscale. It was further hypothesized that, for the social phobia patients, perfectionism would be associated with greater symptom severity. Correlational analysis confirmed that the Concern over Mistakes and Doubts about Actions subscales of the MPS were consistently associated with greater social anxiety, trait anxiety, and general psychopathology. Implications for the treatment of social phobia patients are considered.
Recent experimental research has revealed forms of human behavior involving interaction among unrelated individuals that have proven difficult to explain in terms of kin or reciprocal altruism. One such trait, strong reciprocity is a predisposition to cooperate with others and to punish those who violate the norms of cooperation, at personal cost, even when it is implausible to expect that these costs will be repaid. We present evidence supporting strong reciprocity as a schema for predicting and understanding altruism in humans. We show that under conditions plausibly characteristic of the early stages of human evolution, a small number of strong reciprocators could invade a population of self-regarding types, and strong reciprocity is an evolutionary stable strategy. Although most of the evidence we report is based on behavioral experiments, the same behaviors are regularly described in everyday life, for example, in wage setting by firms, tax compliance, and cooperation in the protection of local environmental public goods.
The validity of the social phobia subtype distinction was examined in a large sample of carefully diagnosed social phobics (N = 89). Generalized and specific subtypes were diagnosed reliably, and the generalized subtype showed a consistent pattern of greater symptom severity than did the specific subtype. In addition, generalized social phobics with and without avoidant personality disorder were compared, and a difference was found for only 1 of 4 parameters. The results are discussed in terms of the validity of subtyping in social phobia and the diagnostic boundary between social phobia and avoidant personality disorder.
To explore the role of perfectionism across anxiety disorders, 175 patients with either panic disorder (PD), obsessive compulsive disorder (OCD), social phobia, or specific phobia, as well as 49 nonclinical volunteers, completed two measures [Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R., (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14, 449-468; Hewitt, P. L., & Flett, G. L., (1991). Perfectionism in the self and social contexts: Conceptualization, assessment and association with psychopathology. Journal of Personality and Social Psychology, 60, 456-470.] that assess a total of nine different dimensions of perfectionism. Relative to the other groups, social phobia was associated with greater concern about mistakes (CM), doubts about actions (DA), and parental criticism (PC) on one measure and more socially prescribed perfectionism (SP) on the other measure. OCD was associated with elevated DA scores relative to the other groups. PD was associated with moderate elevations on the CM and DA subscales. The remaining dimensions of perfectionism failed to differentiate among groups. The clinical implications of these findings are discussed.
Empirical studies of the behavioral or cognitive—behavioral treatment of social phobia have appeared with increasing frequency over the last decade, and there is reason for cautious optimism in the evaluation of treatment effectiveness. However, few studies have reported systematic followup data, and there is little information available about the durability of change in treated social phobics. We report on the followup evaluation of cognitive—behavioral group therapy (CBGT) for social phobia. Patients who received CBGT or a credible alternative treatment were recontacted after a period of 4.5 to 6.25 years and completed a battery of self-report questionnaires, an individualized behavioral test, and a structured interview with an independent assessor. Patients who received CBGT remained more improved than alternative treatment patients on measures from all assessment modalities. However, due to the long followup period, only a portion of the original study sample could be assessed, and these patients may have been less severely impaired than patients who did not participate in the long-term followup. Limitations of the current study and issues of sample attrition in the conduct of long-term followup studies are discussed.
Patients with social phobia frequently report fearing that their symptoms of anxiety will adversely affect the comfort and performance of others, but these fears are not typically included in traditional measures. In Study 1, an initial 26-item pool was developed to assess this fear dimension and then administered in conjunction with measures of social phobia, anxiety and depression, to undergraduate students (n=277), patients with social phobia (n=101) and patients with panic disorder (n=25). A unidimensional scale, the Social Anxiety—Discomfort to Others Scale (SA-DOS), was derived based on exploratory factor analyses and item-response theory. The unitary structure of the SA-DOS was replicated in a second sample of patients with social phobia (n=100). In Study 2, participants with social phobia were found to have significantly higher SA-DOS scores than patients with panic disorder and student controls. Further, the SA-DOS was found to possess convergent and divergent validity in relation to validated measures assessing fear of negative evaluation and psychopathological constructs from the cross-cultural literature. In Study 3, baseline SA-DOS scores were found to be associated with poorer treatment response in a sample of patients with social phobia (n=55) receiving Cognitive-Behavioral Group Therapy. These preliminary findings suggest that fear of causing discomfort to others is a related but distinct fear dimension of social phobia requiring greater attention in the conceptualization and treatment of the disorder.
The place of culture in psychiatric nosology is explored through the example of taijin kyofusho (TKS), a common Japanese psychiatric disorder characterized by a fear of offending or hurting others through one's awkward social behavior or an imagined physical defect. Although variants of this disorder have been described in other cultures (e.g., dysmorphobia), the full spectrum appears to be confined to Japan. TKS can be understood as a pathological amplification of culture-specific concerns about the social presentation of self and the impact of improper conduct on the well-being of others. Both social interaction and constitutional vulnerability may contribute to the cognitive processes that underlie TKS. The salience of cultural differences for psychiatric nosology then depends on whether the clinical focus is on disordered biology, individual psychology and experience, or the social context of behavior. Any attempt to include cultural variation in psychiatric diagnoses must begin by making explicit the intended use of the classification because different social contexts and clinical goals demand alternative diagnostic schemes.
Within the framework of neo-Darwinism, with its focus on fitness, it has been hard to account for altruism behavior that reduces the fitness of the altruist but increases average fitness in society. Many population biologists argue that, except for altruism to close relatives, human behavior that appears to be altruistic amounts to reciprocal altruism, behavior undertaken with an expectation of reciprocation, hence incurring no net cost to fitness. Herein is proposed a simple and robust mechanism, based on human docility and bounded rationality that can account for the evolutionary success of genuinely altruistic behavior. Because docility-receptivity to social influence-contributes greatly to fitness in the human species, it will be positively selected. As a consequence, society can impose a "tax" on the gross benefits gained by individuals from docility by inducing docile individuals to engage in altruistic behaviors. Limits on rationality in the face of environmental complexity prevent the individual from avoiding this "tax." An upper bound is imposed on altruism by the condition that there must remain a net fitness advantage for docile behavior after the cost to the individual of altruism has been deducted.
A genetical mathematical model is described which allows for interactions between relatives on one another's fitness. Making use of Wright's Coefficient of Relationship as the measure of the proportion of replica genes in a relative, a quantity is found which incorporates the maximizing property of Darwinian fitness. This quantity is named “inclusive fitness”. Species following the model should tend to evolve behaviour such that each organism appears to be attempting to maximize its inclusive fitness. This implies a limited restraint on selfish competitive behaviour and possibility of limited self-sacrifices.
Special cases of the model are used to show (a) that selection in the social situations newly covered tends to be slower than classical selection, (b) how in populations of rather non-dispersive organisms the model may apply to genes affecting dispersion, and (c) how it may apply approximately to competition between relatives, for example, within sibships. Some artificialities of the model are discussed.
The purpose of this paper is to consider the possible origins of an inflated sense of responsibility which occupies an important place in the cognitive theory of obsessive compulsive disorder (Rachman, S. (1993). Obsessions, responsibility, and guilt. Behaviour Research and Therapy, 31, 149-154. Salkovskis, P. M. (1985). Obsessional-compulsive Problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23 (5), 571-583). Clinical experience and consideration of current cognitive conceptualisations of obsessions and obsessive compulsive disorder suggest a number of possibilities, each of which is described after a brief introduction to the concept itself. While there are reasons to believe that some general patterns can be identified, the origins of obsessional problems are best understood in terms of complex interactions specific to each individual.
Anthropophobia, a subtype of social phobia, is prevalent in Chinese and Japanese societies. This study investigated sociocultural influences on the course of this culturally specific mental disorder.
One hundred and fifty subjects, including 50 anthropophobic, 50 neurasthenic, and 50 community subjects, were interviewed in Beijing, China for the assessment of their early life experiences (child-parent relationships and sexual experiences), collectivism disposition, sexual attitudes, and communication behaviors. Logistic and linear regression analyses were performed to examine significant predictors of the occurrence and the symptom level of anthropophobia.
Regression models explained 69% of variance in the diagnosis and 57% of variance in the symptom level of anthropophobia among anthropophobic and community subjects. They also explained 48% and 47% of variance respectively in the diagnosis and the level of symptoms among anthropophobic and neurasthenic subjects. Anthropophobic subjects had more problematic relationships with parents than did community and neurasthenic subjects. They also exhibited significantly stronger characteristics of collectivism than did community subjects. Sexual contact with a non-family member prior to age 19 and a feeling of discomfort when interacting with the opposite sex were significantly associated with the diagnosis and symptom level of anthropophobia.
It was concluded that anthropophobic subjects' early sexual experiences and need for parental approval shaped their conformity to social norms and negative sexual attitudes, which were reinforced by the collective-orientated cultural environment, and contributed to the development of anthropophobia.