The defining feature of social anxiety disorder (SAD) is the fear of negative evaluation by others. Therefore, SAD is directly linked to social standards and role expectations, which are culture dependent. Recognizing the intricate interplay between culture and social anxiety, some research has focused on psychopathologic manifestations of SAD across cultures [1], while in other studies the focus has been on comparing disorder-typical symptoms across cultures [2]. It should be noted that most of the studies on cultural differences in SAD have examined Eastern (especially Japanese, Korean, and Chinese) and Western (US American and European) samples.

The following is a review of the evidence pertaining to the validity of the DSM-IV-TR criteria for social anxiety disorder (SAD) as it relates to culture, race, and ethnicity. We use the term “race” when we refer to broad differentiations based on physiognomy (e.g., White), “ethnicity” when we refer to “common descent” and affiliation with a historically continuous community (e.g., Latino), and “culture” when we refer to social groups with specific or homogenous attributes. We particularly concentrate on culture as a source for the nosological revisions to explore whether certain cognitive/ behavioral elements (e.g., interpretations of illness; patterned reactions to stressors) affect the development or expression of psychiatric syndromes.

The search methods for the current review entailed a thorough computer search using the Pubmed and PsychInfo databases for articles published since the publication of the DSM-IV in 1994. Specifically, key words relevant to SAD (i.e., “social phobia” or “social anxiety disorder”) were combined with the terms “culture”, “ethnic*”, and “race”. This approach yielded 602 articles, which were evaluated for relevance to the present topic. Finally, bibliographies of key articles were inspected, as well as references from 1965–1994 (as appropriate), to augment the final reference list.

In this review, we first discuss cultural differences in rates of SAD, in the form that SAD takes (emphasizing the well-researched case of TKS), and in treatment response. The final section examines key factors that generate SAD and affect its presentation, and discusses how these key mechanism may be influenced by culture. We end with a discussion of the implications of the review.

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Cultural Aspects in Social Anxiety and Social Anxiety Disorder

To examine race-ethnic differences in the lifetime prevalence rates of common anxiety disorders, we examined data from the Collaborative Psychiatric Epidemiology Studies. The samples included 6870 White Americans, 4598 African Americans, 3615 Hispanic Americans, and 1628 Asian Americans. White Americans were more likely to be diagnosed with social anxiety disorder, generalized anxiety disorder, and panic disorder than African Americans, Hispanic Americans, and Asian Americans. African Americans more frequently met criteria for post-traumatic stress disorder (PTSD) than White Americans, Hispanic Americans, and Asian Americans. Asian Americans were also less likely to meet the diagnoses for generalized anxiety disorder and PTSD than Hispanic Americans, and were less likely to receive social anxiety disorder, generalized anxiety disorder, panic disorder, and PTSD diagnoses than White Americans. The results suggest that race and ethnicity need to be considered when assigning an anxiety disorder diagnosis. Possible reasons for the observed differences in prevalence rates between racial groups are discussed.

A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders.

The etiology of social anxiety disorder: An evidence-based model.

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children’s relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent–child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.

Integrating etiological models of social anxiety and depression in youth: Evidence for a cumulative interpersonal risk model.

Background: The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM-IV-TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent “over-specification” of disorders, the post-DSM-III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross-cultural limitations in DSM-IV-TR anxiety disorder criteria. Methods: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity-related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders. Results: Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10-minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM-V validators that could help clarify the cross-cultural applicability of criteria. Conclusions :O n the basis of the available data, options and preliminary recommendations for DSM-V are put forth that should be further evaluated and tested. (This Article is being co-published by Depression & Anxiety and the American Psychiatric Association. This Article first appeared in

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Lynn A. Alden

Papers

Cultural differences in perceived social norms and social anxiety.