E. Sonmez

Common Factors in Psychotherapy

Many meta-analyses and research study reviews affirm the comparable effectiveness of psychotherapies in adult patients. This points to common (or core) factors in diverse schools of psychotherapy.

Taijin kyofusho: A culture-bound diagnosis discussed by Japanese and international early career psychiatrists

F ROM THE 1930S, Japanese psychiatrist Morita characterized Taijin kyofusho (TKS) as phobia of blushing and being ashamed. Kasahara redefined TKS as a type of neurosis that includes excessive anxiety and tension in social situations and withdrawing from interpersonal relationships. He also reported that there can be severe, almost delusional cases. Nagata later developed diagnostic criteria for TKS differentiating the tension (fear of being looked at by others) and offensive (fear of offending or embarrassing others) subtypes. In 1980, the DSM-III adopted social phobia encompassing fear of scrutiny by others, fear of humiliation and embarrassment, and fear of offending others. The criteria were close to the classification of TKS, as social phobia is diagnosed in 66% of TKS cases. In 1994, under DSM-IV, social anxiety disorder (SAD) was listed as equivalent to social phobia, and TKS was added in ‘culture-bound syndromes.’ Fears of offending others in certain cultures (e.g., Japan and Korea) were first mentioned as associated features of SAD. DSM-5 recently included offending others as one of the main fears in SAD, although differences remain between TKS and SAD, as some symptoms of TKS, shubo-kyofu (similar to body dysmorphic disorder) and jikoshu-kyofu (similar to olfactory reference syndrome), are categorized as other specified obsessive– compulsive disorder and related disorders. Still, TKS appears to be changing under cross-border cultural influences. In the Fellowship Award Symposium at the 112th annual meeting of the Japanese Society of Psychiatry and Neurology (JSPN), a TKS case vignette was discussed. Awardees (including some of the co-authors of this letter) chose SAD as a diagnosis, while others suggested body dysmorphic disorder or delusional disorder. In the discussion, we were reminded that diagnostic practices may be culture-bound and may evolve over time, even though DSM is an internationally accepted diagnostic standard. Professor Malcolm John Hopwood of the Royal Australian and New Zealand College of Psychiatrists pointed out the importance of thinking about the purpose of diagnostics and the differences of prognosis and intervention for SAD, TKS, and other diagnoses. Reflection on the diagnostic principles and purposes is crucial for early career psychiatrists. The discussion among international colleagues at the JSPN fellowship award symposium was extremely valuable.