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More PsychNotes: Policies and Issues in Mental Health

Why Social Anxiety Disorder may be Created by Culture
by Monica A. Frank, PhD

fishing in Asia
Asian cultures have a very low rate of Social Anxiety Disorder (SAD) compared with western cultures, less than 1 percent versus 7+ percent. Why such a difference? The difference in the diagnostic rates may be due to cultural expectations.

For instance, the expectation in the U.S. is that people should be outgoing, independent, and unconcerned about others' perceptions whereas Asian cultures place a greater value on being more reserved, interdependent, and respectful of consequences to others. Asian cultures typically believe that people should be concerned about perceptions (Hofmann, et al., 2010).

The fact that the diagnosis varies so much across cultures shows that the diagnosis is likely based upon the culture's expectations and reactions to the behavior. In other words, because western culture has certain demands regarding extroverted personality features, those who do not fit are often considered defective.

The diagnosis of SAD in children includes the following criteria: prolonged crying or tantrums, becoming physically immobilized, shrinking away from other people, extreme clinging and not being able to speak in social situations. The purpose of a diagnosis is to determine a need for treatment: medication or therapy. Yet, in the case of SAD, it seems that when normal childhood behavior is perceived as bad, the behavior can become worse until it is considered a disorder.

If an introverted child is told from young on that something is wrong with his/her behavior when it is just a different type of personality and are being forced to fit certain societal expectations, it seems that child is likely to develop anxiety as a result. For instance, a shy child may not want to have big birthday parties and may throw a tantrum due to the distress of being forced into such situations. Maybe that wouldn't occur, if instead, that child's preferences were respected.

When a child has been scrutinized and criticized by others, is it unreasonable to develop anxiety? When a child is made to feel less than others because of an introverted personality style, is it unreasonable to be concerned about others' opinions?

So maybe in most cases the problem has more to do with what messages we are giving children about their personalities rather than a true mental disorder. A lot of times these messages are subtle but they come through loud and clear to the children. When I was growing up the outgoing children got more positive attention even though they broke more rules (such as talking in class). I suspect it is still that way. Most likely, in Asian cultures the opposite is true and the introverted, studious children get more positive attention.

The question isn't which is better. Instead, the question is should people be diagnosed with a mental illness and made to feel inferior just because their personality type doesn't fit the norm? How can we value all personality types? How can we help children grow up without forcing them into uncomfortable situations?

I understand the counter-argument is that these children need to live in and participate in our society. Certainly, that is true, and therefore, we may need to teach them the skills to handle different situations. But we don't need to teach them that they are defective because they are uncomfortable. Instead, approaching them with, “This is uncomfortable for a lot of people but this is how we can make it easier” can be more effective than viewing it as a disorder.

Hofmann, S. G., Anu Asnaani, M.A. and Hinton, D. E. (2010), Cultural aspects in social anxiety and social anxiety disorder. Depression and Anxiety, 27, 1117–1127. DOI:10.1002/da.20759

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