In the spirit of not letting mental illness define yourself or how you see other people. Diagnosis isn’t a label or an identity. That is what 2016 taught me.
Ever heard of a culture-bound syndrome? Apart from known psychiatric and psychological disorders, there are certain disorders which are closely associated with a certain population and require cultural context to understand its diagnostic dimensions and treatment methods. The occurrence of these disorders really draw attention to the role of cultural factors in the onset and prevalence of various disorders.
One particular culture-bound disorder I found out about is called taijin kyofusho (TKS) which is a social anxiety or phobia manifested in the Japanese cultural context. TKS patients suffer from an intense fear that his or her body or its parts will offend, humiliate or displease other people. This form of anxiety is characterised by a fear of social contact, extreme self-consciousness in terms o body odour, blushing and physical appearance and the contraction of disease.
Feelings of emotional distress in the form of shame, embarrassment, fear and tense feelings when in social conditions are characteristic symptoms of TKS. Those who worry about the maintenance of healthy interpersonal relationships can also be diagnosed with the disorder. Its somatic symptoms include insomnia, fatigue, head, body and stomach aches. Physical symptoms include blushing, inappropriate eye contact & facial expressions, shaking of the hands, gastrointestinal distress, profuse sweating, body odour and dishevelled appearance.
Cultural influences play an integral role in the development of taijin kyofusho which explains why this disorder occurs in Japanese populations. As an Eastern collectivistic society, people in Japan are concerned with adherence to group norms, family loyalty and harmonious social relations. Emphasis lies in the promotion of selflessness and putting others needs, such as family or community, ahead of one’s own needs. It is encouraged to behave in a way that betters society. Individualistic societies typically seen in the West, are by contrast, concerned with personal identity with the individuals needs put before the one’s of others.
The fundamental differences among these cultures explains the distinction that can be made between social phobia disorder (SAD) and taijin kyofusho (TKS).
At first glance it may seem that social phobia and TKS are similar but there exists an essential difference between the two. Not to be mistaken or grouped under social anxiety which is the fear of embarrassment in the presence of others, those suffering from taijin kyofusho fear that others will be embarrassed in his or her presence. Primarily, social phobia disorder (SAD) is based on an individual’s reactions while taijin kyofusho is based on the perceived reactions of a group of others. This explains why the former commonly occurs in Western individualistic cultures and the latter commonly occurs in the Japanese collectivistic culture.
Furthermore, self reliance in the case of collectivistic cultures is viewed as not being a burden to others. This explains why the Japanese do not wish to humiliate others with their presence and the induced fear that this can bring shame to their loved ones i.e family and friends.
Socialisation of children is also another perspective from which this syndrome can be viewed. Children learn about the norms, values, beliefs and attitudes of their culture through this process yet it can have adverse negative effects in extremes. According to the ICD-10, Japanese cultural values encourage “over-socialisation” of some children which could lead to the development of feelings of inferiority and anxiety when in social situations.
Also, one of the phobias comprised of TKS called Jikoshisen-kyofu can be explained in a cultural context in the sense that Japanese children are taught that making direct eye contact with another person is considered rude whereas by contrast, in the West it is not. The fear of direct eye contact offending others may stem from such an embedded expectation within Japanese culture. Shame is culturally pervasive and has well defined norms for which the violations are instantly recognised and together with embarrassment is conceptualised as haji. For the Japanase, gaze is seen as a stressor that can result in physiological reactions. Japanese feel stress when subjected to gaze and this in turn is processed into haji. Even imaginary gaze is sufficient to generate the same response. The tendency for this to occur lies in the fact that the Japanese have allocentric empathy which allows them to take on the role of the audience and view their actions as a spectator. This explains why TKS patients feel so concerned about the embarrassment of others rather than of their own selves and why they may have a phobia of eye-to-eye contact.
Also, perfectionism is a common trait of TKS patients and that is because of the high standards of self presentation that exist within Japanese culture. What is known as exposure sensitivity makes Japanese individuals feel as if they are actors on a stage and hence feel the need to display perfection which involves impeccable self presentation. Codes of formal communication both verbal and nonverbal are meant to facilitate this self presentation such as extremely conventional forms of greetings and facial expressions, gestures, postures that are occasion appropriate, coordinated group activities like sports and singing. Japanese readily conform to these rigid codes. The Japanese tea ceremony is an example of a formal art that reflects the cultures embedded perfectionism. The participant of this ceremony must follow elaborate rules in preparing the tea, utilising utensils and dressing accordingly etc.
Hence, perfectionism on display and exposure sensitivity can cause a morbid fear of self-exposure wherein the self is considered to be localised in different body parts like the face, eyes and mouth. This self-exposure fear can manifest as what is called hitomishiri which is the Japanese conception of stranger anxiety. Hitomishiri has been attributed to the Japanese characteristic of shyness. This abounds from the clear line that is drawn between two domains i.e the socially internal domain referred to as uchi and the external domain called soto. In other words, there is a dilemma in which the individual fears self exposure to the audience and thus tends to become socially withdrawn but is aware of the fact that this behaviour is odd. Knowing this, he or she feels driven to overcome this tendency and present him or herself in a perfectionist way. Hence TKS can be viewed as a part of the shame complex or conflict.
Together, all of these factors can explain why a culture bound social anxiety such as TKS has developed among the Japanese population. However, a case of Jikoshisen-kyofu has been reported in Korea which a study suggests as meaning that TKS is not only specific to the Japanese culture but also to those countries with similar cultures. It has been found that China, Korea and Japan in East Asia give a great deal of importance to social etiquette and appropriate interpersonal relations so it is possible that Jikoshisen-kyofu may not necessarily be ‘bound’ to Japan but can be viewed as an East Asian specific syndrome. Further research exploring TKS in the broader East Asian cultural context can shed light on this matter as there is still so much left to investigate. (Iwata et. al).
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