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Tae-in-kong-po-chung (fear of social relations). Si-hyung Lee. Ilchogak Seoul 1993

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ANXIETV
258-60 (1996)
TAE-IN-KONG-PO-CHUNG
(FEAR OF SOCIAL
RELATIONS). Si-hyung Lee. Ilchogak, Seoul,
1993.239 pp.
This is a comprehensive work on social phobia in
Korea, a welcome contribution to a small but increasing body of literature on the subject, which goes a
long way in clarifymg some of the questions about the
relation of culture and anxiety and phobia in the social
sphere, especially in East Asian cultural context.
Tae-in-kong-po-chung, which may be abbreviated
as T K C (as taijinkyofusho, the social phobia in Japan,
is TKS [Chang, 1984]),is the Korean pronunciation of
a phrase usually written in five Chinese characters,
standing for: Tae (in relation to), in (person), kong
(fear), PO (fright), chung (syndrome). In other words,
it means social phobia (or anxiety).
For a better perspective on the cultural issues involved, the matter may be put in a larger context.
Anxiety is a prevalent if not universal human predicament, and is experienced in diverse forms and under
varying circumstances. It has been considered a nodal
point in our mental life which can be seen from different perspectives (bio/psycho/social), from which many
problems issue forth, and toward which multitudes of
questions converge (Freud, 1920). Recent advances in
the bio/psychological frontier of anxiety reawakened
our dissipated interest in socio/cultural/psychological dimensions of social anxiety, as summarized, for instance,
in a recent issue of The Bulletin of the Menninger
Clinic (1994).
In Japan, social phobia has been prevalent and extensively discussed since the turn of the century,
though little known to the English-speaking psychiatric community. Social phobia was known in the turn of
the century Europe also (Prince, 1993), but appeared in
the American diagnostic scheme only in 1980 (DSM3).
The reasons for the vicissitudes in our experience
and perception (or imperception) of anxiety in the social sphere as noted above are, first of all, cultural/historical. Since around the time of the introduction of
social phobia into DSM3, an increasing number of
studies on social phobia in Japan (TKS) appeared in
English.
Tanaka-Matsumi (1979) found several DSM2 diagnostic entities in 6 cases of TKS, whereas Prince and
Tseng-LaRoche (1987), Prince (1993), and Kirmayer
(1991) suggested that TKS is comprised of several
DSM3 R entities including avoidant disorder, adjustment disorder, social phobia, paranoia, paranoid personality disorder, borderline personality disorder,
body dysmorphophobic disorder, and schizophrenia.
On the other hand, Russell (1989) was struck, on re0 1996 WILEY-LISS, INC.
viewing recent Japanese literature, by two types of
TKS, an “egocentric,” in which the patient is anxious
about being humiliated or otherwise victimized, and
“allocentric,” in which the patient is anxious lest his/
her shortcomings may distress, even harm others. And
Good and Kleinman (1985) saw an exemplary instance
of “cultural patterning” of anxiety in TKS.
In view of our questions about the nature of the relation between the social anxiety (phobia) in Japan
with its culture, Lee’s work on the social phobia in
Korea, Japan’s immediate neighbor sharing the same
“East Asian” tradition (Reischauer and Fairbank,
1958), is timely, clarifymg as well as posing questions.
Lee’s work under review is based on over 1,000 cases
of social phobia in Korea (TKC) seen at The Korea
General Hospital Neuropsychiatric Department (Seoul),
where he is the Chair, and concludes that TKS is a
single, culturally meaningful entity, and the basic cultural
issues involved are what can be termed as the sociocentric orientation of the culture. These views, it may be
noted, are also the views of Yamashita’s (1977) pioneering
work on Japanese social phobia.
The book is rich in data, comprehensive in bibliographies, and its 11 chapters include: definition, typology, clinical features, symptoms, diagnosis, aetiology,
cultural factors, psychopathology, treatment, course
and prognosis, modern society and social phobia.
Judging from the length assigned, the emphasis in descending order is on symptoms, psychopathology, diagnosis, aetiology, and treatment. Since it is difficult to do
justice to such a book in a brief review I shall focus on
the psycho/socio/cultural sphere, the mainstay of the
book, highlighting those aspects that are directly relevant to the question about the relation between the
symptoms and the Korean culture.
How prevalent is the condition in Korea? It is considerable, and the incidence has been revised upward
as more attention is being paid to the issue, as it has
been observed in the prevalence of social phobia in
America.
A questionnaire survey of 1,473 college students in
Seoul in the 1980s showed 6.6% experienced significant social anxiety, while 2.9% needed clinical help.
Their complaints included the following (in the order
of their frequency): (fear of public) speaking; social
mistake, tremor (or shaking in the presence of others);
physicaVmenta1 tension; (one’s own, too aggressive,
inquisitive, etc.) gaze.
Of those psychiatric patients seen at the clinic for
the 10-year period (1982-1991), 4.5% (838 cases) had
social phobia as the principal diagnosis, while nearly
half of the patients had social phobic symptom as secondary complaints (pp. 3 1-33).
Book Review
Lee considers TKC a single diagnostic entity for the
following reasons. The age of onset (early teens to
twenties); it does not deteriorate; quasidelusional
symptoms (especially in allocentric cases), if present,
are confined to certain types of social relations (with
an intermediate distance) and reality testing is otherwise well preserved; there is no primary affect disturbance. T K C can be classified by the theme of the
complaints, circumstances (in a crowded place, warm
room, etc.), by the nature of the other person (superior, opposite sex, etc.), severity, or the reference
point. The last criteria refer to the question whether
one feels hidherself a victim or victimizer, being offended by or offending other(s). Fifty-four percent
were classified as egocentric, 32 % allocentric, and
14% as mixed.
What comprises the common personality matrix
of TKC? T h e following are common: they are, beneath the veneer of shyness and timidity, competitive, intolerant, envious and hateful, arrogant,
passive/aggressive, secretive and afraid of exposure.
And these clinical impressions are confirmed also by
the Korean version of the MMPI. This profile is
quite similar to the personality patterns of the Japanese social phobia patients (TKS) that emerge from
the description by Takahashi (1976) as well as by
Yamashita (1977).
All these remind this reviewer of various personality
matrices, especially “narcissistic” type. I believe this is
a rich soil where we can find much about the issues
related to personality disorders in the sense of Axis I1
of DSM multiaxial schema.
As to the family background and early childhood
environment of the future phobic, Lee suggests that it
is “average,” “ordinary,” or rather typically “Korean.”
This is interesting, because Yamashita (1977) observes
also that TKS patients tend to come from rather traditional, conservative or typical aapanese) families. A
question is inevitable: if both T K C and TKS come
from “ordinary,” typical, or “average” families, does it
not mean that in that very ordinariness is a pathogenic
factor(s?) eluding even Lee’s and Yamashita’s perception because of its very ordinariness? This is like saying that those observers living in the culture with the
guiding social philosophy of individualism may have
difficulties in perceiving excess and abuse of the philosophy.
Social “harmony” is the social ideal in the traditional East Asian societies (Reischauer and Fairbank,
1958) including Korea, Japan, and China. Deriving
from (or attributable to) this ideal are the various secondary values, practices, and sensibilities that together
give the “East Asian” character to their culture and
personality, with local variations.
To the extent that T K C (or TKS) is contingent
upon the “East Asian” culture we can expect basically similar findings in the patterning of anxiety in
social sphere among Japan, Korea, and China. Lee’s
work affirms this. It might be asked, why has it
59
taken so long to notice such clinical problems in
Korea when they have been observed in its neighbor
since the turn of the century? An answer is again
cultural, or geopolitical and economic: until very recently, in Korea, the immediate physical and material needs were such that they eclipsed “mere”
psychological needs (Chang and E m , 1973). This
reviewer is confident that the situation in China will
turn out to be quite similar.
The “allocentric” subtype of social phobia is manifested earlier, and exhibits more anxiety, but responds
better to psychotherapy, in particular “group” therapy.
This is an intriguing observation since some may
expect the allocentric type to have more severe psychopathology, raising the question of psychosis of
paranoid type, among others. If we recall TKS is
known to better respond to culture-consonant psychotherapy, such as Morita therapy, as suggested for, instance by, Yamashita (1977), primarily because of
congruence if not identity (Chang, 1974) between the
therapeutic approach, symptom and culture at their
basic level, it is probable that there is culturally common element(s) also between Lee’s “group” (therapy)
and the “allocentric” subtype.
To conclude, Korean social phobia is clearly shaped
by the culture, most basically by its sociocentric (holistic, altruistic, or other-centered) orientation. And i t is
a single culturally meaningful entity to the extent
we believe that a “social” dimension is as basic and
primary as is a intrapsychichndividualistic parameter. Altogether, Lee’s work suggests “social phobia”
is a fertile issue from which we can learn much
about the relation between culture, personality and
psychopathology.
REFERENCES
Bulletin of the Menninger Clinic (1994) 58:l-90, Supplement A.
Chang SC (1974) Morita therapy. Am J Psychotherapy 28:208-22 1.
Chang SC, Kim KI (1973) Psychiatry in South Korea. Am J Psychiatry 130667-669.
Chang SC (1984) [Review] Taijinkyofi by Itaru Yamashita 1977.
Transcult Psychiatry Res Rev 21:283-288.
Freud S (1920) A General Introduction to Psychoanalysis. New
York: Boni & Riverright.
Good BJ, Kleinman AM (1985) Culture and anxiety: Crosscultural
evidence for the patterning of anxiety disorders. In Tuma A H
(ed): Anxiety and Anxiety Disorders. Hillsdale, NJ: Lawrence
Earlbaum Associates, Inc., pp. 297-323.
Kirmayer LJ (1991) T h e place of culture in psychiatric nosology:
Taijinkyofusho and DSM3R. J Nervous Mental Disease 179:
19-28.
Prince RH (1993) Culture-bound syndrome: The example of social
phobias. In Ghadirian A-MA (ed): Environment and Psychopathology. Lehmann H.E. pp. 55-72.
Prince RH, Tseng-LaRoche F (1987) Culture bound syndrome
and international disease classifications. Cult Med Psychiatry
11:3-19.
Resiscahuer EO, Fairbank JK (1958) East Asia: The Great Tradition. Boston: Houghton Mifflin.
Russell J G (1989) Anxiety disorders in Japan: A review of Japanese
60
Chang
literature on shinkeishitsu and taijinkyofusho. Cult Med Psychiatry 13:391-403.
Takahashi T (1976) Taijin kyofu. Tokyo: Igakushoin.
Tanaka-Matsumi J (1979) Taijinkyofusho: Diagnostic and cultural
issues in Japanese psychiatry. Cult Med Psychiatry 3:23 1-245.
Yarnashita I (1977) Taijin kyofu. Tokyo: Kanehara. [Its English
translation appeared in 1993: Taijinkyofu or Delusional Social
Phobia. Sapporo: Hokkaido University Press].
Suk C. Chang
Waterbury, Connecticut
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