Culture and Mental Health Project (Outline and Paper): Students will complete a culture and mental health research project for the course. This project will involve choosing a mental health condition that has a culturally specific manifestation (idiom of distress or culture bound syndrome) or a mental health condition (broadly defined) that develops from, or is shaped by, a social/cultural/behavioral process. Students will complete a detailed outline of their paper and complete a final paper on their chosen topic. The outline and paper will reflect a detailed review of the literature focused on the mental health problem, a review of culturally-specific aspects of the problem, and potential (culturally appropriate) methods of addressing the problem. Example titles of projects are Globalization and farmer suicides among rural Kenyan men, The legacy of colonialism on substance abuse in the Caribbean, or Suicide among Information Technology workers in Bangalore, India.Paper Outline is due April 27th at 11:59pm via Canvas online submission. The Outline should be 4-5 pages in length, single spaced, and contain a references list with at least 5 relevant peer review articles or books to be discussed in the presentation and final paper. This assignment will be used to evaluate the adequacy of the topic area and if alterations need to be made. Instructors will provide feedback on the topics and suggest changes if needed. Completing the Outline is worth 15% of your overall grade. In order to receive credit, the outline must sufficiently meet the assignment requirements outlined in the syllabus and reviewed in class.Please use the Journal of the American Medical Association (JAMA) citation style. A guide for JAMA style can be found here: AmericanMedicalAssociationStyleJAMA.pdf
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G H 456
Final Project Outline
Investigation of Taijin Kyofusho in South East Asia
Introduction (1 page)
a. What is Tajin Kyofusho?
i. Literal translation: fear (kyofu) of interpersonal relations (taijin)
ii. Abbreviated to TKS in English
iii. Exact definition varies slightly between the DSM, ICD-10, and health
iv. Prevalence in general population of Japan or South Korea unknown
v. In Japanese clinical settings, as many as 38% of patients diagnosed
with TKS (Matsunaga 2001: 231)
b. Area of inquiry: South East Asia
i. In DSM, defined as culture-bound syndrome of Japan and South Korea
ii. Majority of research is from Japan
? Related to fact that South Korea didnt experience rapid
industrialization and economic growth until the 1960s?
? Complexity of cross-cultural diagnosis
iii. Evidence that TKS may be applicable to other South East Asian
? Dependent on definition of TKS?
c. Goal of paper
i. To review current definitions and research on TKS
ii. To access whether TKS is specific to Japan and Korea or applicable to
other South East Asian cultures, and in doing so gain insight into TKS
iii. To determine if there is any association between TKS and the high
suicide rates in Japan and South Korea
iv. To suggest areas for future research
Overview of TKS (3-4 pages)
a. HistoryKey events defining TKS in Japan
i. Not long after Western psychiatry was brought to Japan, TKS
symptoms were documented in 1907 by Tazawa Hidesaburo
ii. 1st psychotherapy of TKS documented by Morita Shoma in 1934
(termed Morita therapy)
iii. Yamashita surveyed 100 patients of TKS at the Neuropsychiatric
Department of Hokkaido University Hospital from 1960s to 1970s,
reporting clinical symptoms
? Many patients were from more traditional families, characterized
by maternal overprotection and control
? Despite being around so long, the diagnostic criteria was not
established until 1995
i. DSM-IV: culture bound form of social anxiety
? Persistent and excessive fear of offending others in social
circumstances due to physical characteristics
o Body Odor
ii. ICD-10: anthropophobia under social phobia
? Fear of social situations and of contracting diseases as well as
iii. Other descriptions
? Fear of gaze, emitting odors, creating tension in social
? Belief that attitude, behavior, and physical characteristics are
not good enough in social circumstances, resulting in shame,
embarrassment, anxiety and fear
? Belief that specific body part is defective, whether it be eyes,
body, odor, or appearance, which consequently makes other
? Besides ICD-10, sources emphasize that key element of TKS is the
fear of offending others.
c. Debate whether TKS should be classified as a social phobia in DSM
i. Difference in situations in which TKS or social phobia expressed
? Anxiety from TKS most often occurs in settings where one is
surrounded by acquaintances
o Strong anxiety at school, work, during commute, etc.
? For other social phobias, anxiety occurs around strangers or
close friends/family members
ii. Difference in symptom topography
? TKS patients display symptoms unique to other social phobia,
specifically hypersensitivity to particular body parts
iii. Similarity in that both involve avoidance of social situations
iv. Similarity in that both involve fear of being negatively evaluated by
? Is TKS a specific culture-bound illness or a variant of social anxiety
d. Other inconsistencies in classification of TKS
i. Previously thought that males suffered more from TKS, based on
Yamashita survey. More recent studies suggest that females have a
higher prevalence of TKS in clinical setting.
Related to women entering the workforce and increased gender
ii. Recent studies suggest that TKS is more common during young
adulthood. Debate whether TKS is transient, rarely continuing into
adulthood or whether prevalence differences are a result of
? Change in Japanese family environment due to social changes
established under the Civil Law in 1948
? But, development also a sensitive period in which peer
relationships are prioritized
iii. Documentation of fear of blushing less frequent as used to be. Now,
fear of body odor, appearance, and gaze more common.
? Need for a universal classification, especially within the same country
(majority of the evidence for TKS comes from Japan)
Affected population (3-4 pages)
a. Elements of Japanese culture associated with TKS
i. TKS theorized to arise from aspects of Japanese culture that extend to
other South East Asian societies
? Child-rearing practices
o More controlling and physical as well as emphasis on
dependence, compliance, and passivity
? Social ideals
o Greater concern for others thoughts and feelings
? Norms of social interactions
ii. Another study suggests that TKS is unrelated to child-rearing
practices. Biased by methodologies of study and narrow target
population? (Essau 2010: 219)
iii. Interdependent self-construal vs. independent self-construal
? Interdependent self-construal: prioritize social roles and
? Independent self-construal: prioritize individual autonomy
iv. TKS more common in Japan (interdependent) than England
(Dependent) (Essau 2010: 219)
? TKS found to be positively associated with interdependent selfconstrual and negatively associated with independent self-construal
? From this perspective, TKS is a by-product of culture. Yet, this
conclusion needs more supporting evidence.
b. Extension of TKS to other South Asian countries
i. If TKS arises from collectivistic cultures, supports why so far
predominantly observed in Japan and Korea
ii. One study conducted in Indonesia found that Indonesians associate
with an interdependent self-construal and found evidence suggesting
that TKS is not only present but common in the country (Vriends 2013:
iii. Rare cases of TKS in other locations worldwide (even in Australia).
TKS diagnoses possibly applicable worldwide? Then social anxiety
Consequences of TKS (1-2 pages)
a. Range in severity of TKS
i. On clinical level, severity ranged form neurosis to psychosis
ii. In adolescents, TKS linked to conduct problems, emotional symptoms,
hyperactivity-inattention, and peer problems
b. Limitations of treatment
i. Morita therapy traditional treatment in Japan
? Based on idea that individual with hypochondriacal
temperament undergoes chance event, becoming overly
? Therapy involves hospitalization and consists of many stages
from isolated bed-rest to gradual increase in work load and
amount of social interaction
? Mention of neo-Morita therapy?
? One study demonstrated positive response to treatment in
77.6% of patients (Kitanishi 1992: 14)
ii. Attempts of giving TKS patients serotonin reuptake inhibitors
? Only initial studies done and believed to be most effective in
TKS patients based on social anxiety disorder criteria
? Research on treatment options is very limited and no established
treatment outside of Japan. Effectiveness of Morita therapy only
supported by one study. Not sure how widely Morita therapy is
practiced throughout Japan.
c. Connection of TKS to suicide?
i. Suicide rates are extremely high in Japan and Korea, the two countries
in which TKS is predominately reported
ii. It is possible that the more severe cases of TKS contribute to these
countries high suicide rates, especially since the current treatment for
TKS is limited. Also, both TKS and suicide rates are associated with
? This has yet to be investigated, probably due to the fact that the
suicide rates are highest in the middle age group of the two
populations, while TKS is most prominent during early
adulthood (at least in Japan).
Conclusions (1 page)
a. Summarize findings
i. Strong need to establish consensus whether or not TKS is a culture
bound syndrome or SAD variant.
TKS is most likely not limited to Japan and Korea but applicable
to other South East Asian cultures that are also collectivistic.
? Other evidence that TKS could also be applied to individuals
with interdependent self-construal. Possibly change DSM
definition of social phobia?
? Demonstrates need for more research worldwide
ii. Once TKS is better understood and more widely acknowledged, may
be able to establish more standardized treatment, but will most likely
be on a country be country basis.
iii. Future research determining if there is a connection between TKS and
Ben PB, Lester D. Social integration and suicide in South Korea. Crisis, 2006; 27:4850.
Chang SC. Social anxiety (phobia) and East Asian culture. Depression and Anxiety.
Essau CA, Sasagawa S, Ishikawa S, Okajima I, O’Callaghan J, Bray D. A Japanese
form of social anxiety (taijin kyofusho): frequency and correlates in two generations
of the same family. The International Journal of Social Psychiatry, 2012;58:635-42.
Kitanishi K, Miyake Y, Kwang IK, Liu X. A Comparative Study of Taijin Kyofusho
(TKS) Tendencies among College Students in Japan, Korea, and the Peoples’s
Republic of China. Jikeikai Medical Journal. 1995;42:231.
Lester D. Size of youth cohort and suicide rate in Japan. Perceptual and Motor
Maeda F, Nathan JH. Understanding taijin kyofusho through its treatment, Morita
therapy. Journal of Psychosomatic Research, 1999;46:525-30.
Vriends N, Pfaltz, MC, Novianti P, Hadiyono, J. Taijin kyofusho and social anxiety
and their clinical relevance in indonesia and Switzerland. Frontiers in Psychology,
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