Cross-cultural aspects of social anxiety disorder.

Cross-cultural perspectives have much to teach about psychopathology in general and about SAD in particular. The authors accept that the construct of SAD (like that of other anxiety disorders) cannot simply be interpreted as a category fallacy. Universal psychobiological mechanisms are likely important in determining the onset of SAD; empiric, epidemiologic, and neurobiological data provide some support for this argument, and clinical data confirm that patients can experience onset of anxiety disorders in the absence of exposure to cultural narratives about their symptoms. Nevertheless, culture may exert important influences on the experience and expression of anxiety disorders. In the clinic, the authors believe that it is often useful to ask patients about their view of disorders such as SAD and about their opinion of the etiology and optimal treatment of their symptoms. Subsequent negotiation can take place between the clinician's model of the disorder and that of the patient. A shared view of the etiology and treatment is likely to result in the patient feeling more understood and in greater compliance with prescribed treatment. There is an important clinical lesson in the observation that Western scales of anxiety are not always cross-culturally valid. It is also important to recognize that anxiety disorders are not simply the result of culturally influenced interpretations of an underlying disease but rather that anxiety disorders are also disorders of the interpretive process. From the perspective of research, cross-cultural differences in social anxiety disorder suggest a number of interesting leads for further work. Neurobiological and psychopharmacologic investigation of overlap and differences between Western SAD and Eastern TKS may provide helpful new insights. The possible existence of a group of Western SAD patients with poor insight, for example, deserves further scrutiny and research. Women and people with lower socioeconomic status are at greater risk for developing SAD; the mechanisms underlying these associations require further study. Future investigation of the contribution of sociocultural mechanisms to the course of SAD may provide an important avenue toward understanding this complex disorder.