In some cultures, social demands may lead to symptoms of Social Phobia. For example, in Japan and Korea an individual may develop persistent and excessive fears of giving offense to others in social situations, instead of being embarrassed (DSM-IV, 1994, p. 413). These fears may be expressed in terms of extreme anxiety resulting from the belief that one's body odor, facial expression, or eye contact will be offensive to others. In Table I, these symptoms resemble taijin kyofusho (DSM-IV 1994, p. 849).
Behaviors that are culturally prescribed should be differentiated from Obsessive-Compulsive Disorder (OCD), unless these culturally sanctioned behaviors exceed cultural norms, occur at times and places judged inappropriate by other members of the same culture, and interfere with social role functioning (DSM-IV, 1994, p. 420). Religious rituals such as repetitive washing, checking and ordering objects, praying, and repetition of words or phrases silently are expected in many cultures (Castillo, 1997; Kirmayer et al., 1995). For example, compulsive praying (e.g., praying five times per day) associated with obsessive rules (e.g., repetition of some words many times during pray) are expected among strict Egyptian Moslems (Bernstein, 1997; Castillo, 1997). These rituals would be considered pathological by clinicians unfamiliar with this culture. Examples of other cultures in which similar OCD behaviors have been observed include Israel, India, Taiwan, and Latin American countries (e.g., Puerto Rico, Dominican Republic, Cuba, Colombia, Venezuela, etc.).
e. posttraumatic stress disorder and Acute Stress Disorder
Immigrants from countries with a high frequency of social unrest, wars, and civil conflicts may show high rates of Posttraumatic Stress Disorder (PTSD) (Boehnlein & Kinzie, 1995). These immigrants may be particularly reluctant to divulge experience of torture and trauma because of their political immigrant status (DSM-IV, 1994, p. 426). In the specific case of practitioners providing mental health services to American Indians and Alaska Natives, McNeil, Kee, and Zvolensky (1999) suggested an assessment of historical events leading to cultural abuses and discrimination against these groups (see Paniagua, 1998, pp. 77-81) and how these historical (aversive) events "may lead to intergen-erational Posttraumatic Stress Disorder [among members of these groups]" (McNeil et al., 1999, p. 62). In the case of Acute Stress Disorder, the severity of this disorder may be determined by cultural differences in the implications of loss. Coping behaviors may also be culturally determined. For example, many clients from Latin American countries are expected to show symptoms resembling Acute Stress Disorder when they are exposed to stressful events associated with the family (e.g., the death of a close relative, separation and divorce, etc.). Symptoms involving TSD and Acute Stress Disorder may resemble "ataques de nervios" and "susto" in Table I (Castillo, 1997; DSM-IV 1994, p. 849.
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