Why do Asian-Americans (especially university students) appear to suffer from higher levels of symptoms of social anxiety than white Americans, yet their high symptom reports are not accompanied by behavioral signs of social anxiety? Is this discrepancy due to culturally determined display rules or biased assessment by those who are culturally different? How does this discrepancy make it difficult for clinicians to accurately assess the severity of social anxiety among Asian-Americans?
Transcultural psychiatry and ethnic minority mental health research have made significant gains toward our understanding of mental health problems among Asian-Americans (e.g., Kurasaki et al., 2002). However, relatively little is known about the manifestation of social anxiety and social phobia among Asian-Americans. This article summarizes the available empirical literature on social anxiety and social phobia in this population group and highlights clinical implications.
Symptoms Versus Diagnosis
Cumulative evidence suggests that compared to their white American counterparts, Asian-Americans report higher distress on various measures of social anxiety and social phobia (Norasakkunkit and Kalick, 2002; Okazaki, 2002, 2000, 1997; Okazaki et al., 2002; Sue et al., 1990, 1983). Only one study to date has failed to find this pattern: Leung et al. (1994) found no differences between Chinese-American and non-Chinese-American community residents on measures of social anxiety, social phobia, shyness and public self-consciousness. It should be noted that Chinese-American community residents in this sample were screened for the absence of psychopathology and counseling experience. Moreover, unlike the other studies cited, the subjects were non-college students; studies with Asian-American student populations indicate higher reports of social anxiety.
These findings of elevated social anxiety reports among Asian-Americans mirror the cross-cultural differences between East Asians and North Americans on a variety of self-report measures of personality, well-being, self-esteem and psychopathology. However, the interpretation that Asian-Americans are more socially anxious than white Americans, based on symptom report measures, runs counter to the available evidence regarding the low prevalence of social phobia in Asian-American and East Asian populations.
A review of psychiatric epidemiologic studies of social phobia suggested that the lifetime prevalence of social phobia in Western countries is between 7% and 13% (Furmark, 2002). However, the estimates in this study varied widely depending on the diagnostic criteria, assessment methods and population. Estimates of social phobia in East Asia are much lower than those in the West, with estimated lifetime prevalence in Korea of 0.5% (Lee et al., 1990) and in Taiwan of 0.6% (Hwu et al., 1989).
Another cross-national epidemiologic study also indicated that the lifetime prevalence of social phobia was much lower in Korea than in the United States (Weissman et al., 1996). There has only been one psychiatric epidemiologic study of Asian-Americans published to date (Takeuchi et al., 1998). Using data from approximately 1,700 Chinese-Americans in Los Angeles County, the Chinese American Psychiatric Epidemiologic Study (CAPES) estimated the lifetime prevalence of social phobia in this population to be 1.2% (Chang, 2002).
Analyses of psychiatric epidemiological data have shown that in the United States, people with social phobia seldom seek professional treatment unless they also suffer from some other comorbid disorder (Kessler et al., 1999). No data exist on treatment-seeking among Asian-Americans with social anxiety disorder. However, an analysis of the CAPES data indicated that only 3.6% of 1,503 Chinese-American community residents reported seeking treatment for emotional problems in the previous 12 months, a rate lower than the 5% to 7% range for help-seeking in the general population (Abe-Kim et al., 2002). Other studies have also shown that Asian-Americans tend to underutilize both inpatient and outpatient mental health care services (Snowden and Cheung, 1990; Ying and Hu, 1994). It is likely, then, that few Asian-Americans seek treatment specifically for social phobia, although they may be suffering from social anxiety symptoms.
An experimental study examined whether Asian-Americans and white Americans would show differential patterns of reporting depressive and social anxiety symptoms depending on the method of reporting (written questionnaire versus face-to-face interview) (Okazaki, 2000). The results showed that Asian-Americans reported higher levels of social anxiety than white Americans in both interview and written conditions. The findings suggested that the method of reporting does not differentially affect Asian-Americans; there are persistent ethnic differences between Asian-Americans and white Americans in the types and levels of distress they report.
Another methodological criticism that has been leveled against the use of symptom questionnaires is that they are single-occasion global measures. Studies have shown that there are more cultural variations in global reports of well-being than in momentary reports, with white Americans tending to present a rosier global picture of themselves than Asians and Asian-Americans (Oishi, 2002).
To address this concern, a study of social anxiety with Asian-Americans and white Americans was conducted using experience sampling methods, which gather multiple momentary reports of anxiety in the natural environments of the respondents over an extended period of time (M.R. Lee, B.A., and S. Okazaki, Ph.D., unpublished data, August 2002). Results from a two-week, event-contingent diary study suggested that Asian-Americans reported higher intensity, but not greater frequency, of social anxiety than white Americans. However, the types of social contexts (e.g., ethnicity, gender and number of people in the social setting) did not differentially impact the intensity of distress across ethnicity. The results of these studies suggested that Asian-white differences in social anxiety symptom reports are not driven by differential responses to interpersonal contexts in either experimental or natural settings.
An unresolved question surrounding higher reports of distress by Asian-Americans is whether the self-reported social anxiety also manifests in dysfunctional behavior. Studies comparing Asian-Americans and white Americans on behavioral aspects of social anxiety have not found ethnic differences.
For example, when asked to role-play (with either an Asian or white experimenter) 13 hypothetical situations that require assertive responding, the same Chinese-American men who had reported higher social anxiety on trait measures demonstrated just as much assertiveness as white American men in their verbal behavior (Sue et al., 1983). The ethnicity of the experimenter did not affect levels of assertive responding. These results were replicated with Chinese-American and white American women (Sue et al., 1990). In another study, Zane et al. (1991) showed that Asian-Americans and white Americans did not differ in the assertiveness of their responses to hypothetical scenarios that concerned acquaintances or significant people in their lives. However, Asian-Americans reported that they expected to feel anxious and guilty after assertive responding to a greater extent than did white Americans.
In a laboratory-based experiment, Okazaki et al. (2002) examined whether differences between Asian-Americans and white Americans on self-report of social anxiety extend to observed behavior and reports of anxiety-related emotions during a brief social performance task. Asian-American and white American participants completed a social phobia questionnaire and rated their distress while anticipating the task and immediately following the task. Trained evaluators rated their videotaped behavior using behavioral codes. Results indicated that Asian-Americans reported more social anxiety than white Americans not just on the global measure of social anxiety but also during the experiment. However, Asian-Americans and white Americans did not differ substantially on behavioral indices of anxiety, as rated by trained observers. Moreover, the self-report and behavioral measures of social anxiety converged moderately for white Americans but not among Asian-Americans.
The laboratory finding of a discrepancy between Asian-Americans' subjective reports versus their behavior was replicated in a naturalistic setting. Okazaki (2002) examined the correspondence between self-report and informant ratings of depression and social anxiety among Asian-American and white American university students. Friends and acquaintances served as independent informants. On average, Asian-Americans' levels of distress were underestimated by their informants to a greater extent than white Americans' levels of distress. Moreover, white American peers underestimated the subjective social anxiety of their Asian-American friends to a greater extent than did the Asian-American peers who rated the social anxiety of their Asian-American friends.
To summarize, studies of social anxiety in Asian-American college students suggest that there is a greater discrepancy between how socially anxious they feel and how they exhibit their anxiety to others, particularly to others of a different ethnic background. These findings have significant implications. First, chronic underestimation of distress in Asian-Americans may lead to delay in their help-seeking. Next, there is a greater potential for disagreement over the severity of distress associated with social anxiety when clinicians and clients are of different ethnic backgrounds.
Another relevant line of research on social phobia in Asian individuals revolves around the notion of the Japanese (and other East Asian) culture as a "pseudo-sociophobic culture" that promotes the sense of shame, "or one's awareness and sensitivity to the shame experienced by oneself or others" (Okano, 1994). Taijin-kyofu-sho (TKS) is a social phobia-like condition first described in the 1930s by Japanese psychiatrist Masatake Morita. In particular, the delusional subtype of TKS--in which individuals avoid interpersonal situations because they are convinced that they have a particular bodily defect that is offensive or harmful to others--has attracted much clinical and scholarly attention as exemplifying the collectivistic cultural emphasis on shame and humility. While TKS is often thought of as unique to Japan, the offensive subtype has been reported as being prevalent among Koreans (Lee and Oh, 1999), and individual cases of non-Asians with TKS in the United States have also been reported (Clarvit et al., 1996; McNally et al., 1990). A recent cross-cultural comparison showed that TKS-like symptoms (e.g., fear of offending others) were more likely to be reported by Japanese university students than by their American counterparts (Dinnel et al., 2002).
In an interesting test of the hypothesis that features of East Asian cultures promote the development of social anxiety and social phobia, Leung et al. (1994) compared social anxiety among American patients with social phobia with those of Chinese-American and non-Chinese community residents. Previously, emotionally distant and controlling attitude and behavior in child-rearing were shown to play a role in the development of social phobia in American and European patients. Leung and colleagues noted that East Asian parenting styles had also been characterized as emphasizing emotional control. The Chinese-American community residents and non-Chinese-Americans with social phobia in the study reported that their parents had discouraged sociability, used shaming tactics and were highly concerned with others' opinion. However, Chinese-Americans did not report elevated levels of social anxiety or social phobia. In fact, the association between restrictive parenting practices and the adult children's level of social anxiety was much greater for non-Chinese-Americans than for Chinese-Americans. Thus, cultural parenting styles were not strongly associated with social anxiety.
Summary and Implications
Although inconclusive, the evidence to date suggests that Asian-Americans tend to report higher social anxiety than white Americans, yet they may be no more likely to manifest dysfunctional levels of social anxiety (that meet the diagnostic criteria of social phobia) or exhibit behavior that others view as social anxiety. It is not clear if this discrepancy between subjective distress versus assessed function is due to culturally determined display rules or biased assessment by those who are culturally different, but the discrepancy may make it difficult for clinicians to accurately assess the severity of social anxiety among Asian-Americans.
It should be noted that many of these tentative conclusions are based on studies conducted largely on Asian-American college students, who tend to be more acculturated to the U.S. mainstream than the general Asian-American adult population. A significant factor that has not received scholarly attention is the possibility that subjective distress in social contexts among Asian-Americans may be heightened by their status as visible ethnic minorities, many of whom are immigrants or non-native English speakers striving to adjust to a culturally different environment and behavioral standards.
Abe-Kim J, Takeuchi D, Hwang WC (2002), Predictors of help seeking for emotional distress among Chinese Americans: family matters. J Consult Clin Psychol 70(5):1186-1190.
Chang DF (2002), Understanding the rates and distribution of mental disorders. In: Asian-American Mental Health: Assessment Theories and Methods, Kurasaki KS, Sue S, Okazaki S, eds. New York: Kluwer Academic/Plenum Publishers, pp9-27.
Clarvit SR, Schneier FR, Liebowitz MR (1996), The offensive subtype of Taijin-kyofu-sho in New York City: the phenomenology and treatment of a social anxiety disorder. J Clin Psychiatry 57(11):523-527.
Dinnel DL, Kleinknecht RA, Tanaka-Matsumi J (2002), A cross-cultural comparison of social phobia symptoms. Journal of Psychopathology and Behavioral Assessment 24(2):75-84.
Furmark T (2002), Social phobia: overview of community surveys. Acta Psychiatr Scand 105(2):84-93.
Hwu HG, Yeh EK, Chang LY (1989), Prevalence of psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatr Scand 79(2):136-147.
Kessler RC, Stang P, Wittchen HU et al. (1999), Lifetime comorbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med 29(3):555-567.
Kurasaki KS, Sue S, Okazaki S, eds. (2002), Asian-American Mental Health: AssessmentTheories and Methods. New York: Kluwer Academic/Plenum Publishers.
Lee CK, Kwak YS, Yamamoto J et al. (1990), Psychiatric epidemiology in Korea. Part I: Gender and age differences in Seoul. J Nerv Ment Dis 178(4):242-246.
Lee SH, Oh KS (1999), Offensive type of social phobia: cross-cultural perspectives. International Medical Journal 6:271-279.
Leung AW, Heimberg RG, Holt CS, Bruch MA (1994), Social anxiety and perception of early parenting among American, Chinese American, and social phobic samples. Anxiety 1(2):80-89.
McNally RJ, Cassiday KL, Calamari JE (1990), Taijin-kyofu-sho in a black American woman: behavioral treatment of a "culture-bound" anxiety disorder. J Anxiety Disord 4(1):83-87.
Norasakkunkit V, Kalick SM (2002), Culture, ethnicity, and emotional distress measures: the role of self-construal and self-enhancement. Journal of Cross-Cultural Psychology 33(1):56-70.
Oishi S (2002), The experiencing and remembering of well-being: a cross-cultural analysis. Personality and Social Psychology Bulletin 28(10):1398-1406.
Okano K (1994), Shame and social phobia: a trans cultural viewpoint. Bull Menninger Clin 58(3):323-338.
Okazaki S (1997), Sources of ethnic differences between Asian American and White American college students on measures of depression and social anxiety. J Abnorm Psychol 106(1):52-60.
Okazaki S (2000), Asian American and White American differences on affective distress symptoms. Do symptom reports differ across reporting methods? Journal of Cross-Cultural Psychology 31(5):603-625.
Okazaki S (2002), Self-other agreement on affective distress scales in Asian Americans and White Americans. Journal of Counseling Psychology 49(4):428-437.
Okazaki S, Liu JF, Longworth SL, Minn JY (2002), Asian American-white American differences in expressions of social anxiety: a replication and extension. Cultur Divers Ethnic Minor Psychol 8(3):234-247.
Snowden LR, Cheung FK (1990), Use of inpatient mental health services by members of ethnic minority groups. Am Psychol 45(3):347-355.
Sue D, Ino S, Sue DM (1983), Nonassertiveness of Asian Americans: an inaccurate assumption? Journal of Counseling Psychology 30:581-588.
Sue D, Sue DM, Ino S (1990), Assertiveness and social anxiety in Chinese-American women. J Psychol 124(2):155-163.
Takeuchi DT, Chung RC, Lin KM et al. (1998), Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. Am J Psychiatry 155(10):1407-1414.
Weissman MM, Bland RC, Canino GJ et al. (1996), The cross-national epidemiology of social phobia: a preliminary report. Int Clin Psychopharm 11(suppl 3):9-14.
Ying Y, Hu LT (1994), Public outpatient mental health services: use and outcome among Asian Americans. Am J Orthopsychiatry 64(3):448-455.
Zane N, Sue S, Hu L, Kwon J (1991), Asian-American assertion: a social learning analysis of cultural differences. Journal of Counseling Psychology 38(1):63-70.