New York, London: The Guilford Press; 1997. 261 pp. with index

ISBN 1-57230-237-2

Anxiety is a profound human experience. Anxiety disorders are universal in human societies, although the diagnostic patterns vary over time and from one place to another. This volume describes some culturally bound anxiety syndromes, but dwells on the diagnostic categories of the Diagnostic and Statistical Manual of Mental Disorders, third (DSM-III), third revised (DSM-III-R) and fourth (DSM-IV) editions. This manual provides diagnostic criteria for panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder and the generalized anxiety disorder. Twenty-seven prominent psychiatrists, psychologists and experts from related fields contributed to this volume, offering guidelines for diagnosis and culturally informed treatment.

The first part of the book deals with general issues in the cross-cultural treatment of anxiety disorders. The second part of the volume deals with the treatment of specific ethnic groups in the US, including Hispanic-, Caribbean-, Asian- and African-Americans, as well as Orthodox Jews, and Asian-Indian-Americans. The third part of the book examines the relations between psychopharmacology and ethnicity, and modern aspects of the clinical and research agenda in culture and anxiety.

P.J. Guarnaccia addresses risk factors, symptoms of distress, and the diagnosis of post-traumatic stress disorder (PTSD) among refugee groups from Southeast Asia and Central America. PTSD occurs with depressive disorders, and its prevalence rates vary in populations of trauma victims. E. Horwath and M.M. Weissman analyze epidemiological data on anxiety based on DSM-III and DSM-III-R criteria, comparing prevalence rates from the United States with data from other countries. The lifetime prevalence rates of panic disorder are remarkably consistent across community studies and ethnic boundaries. Data on agoraphobia show more variation across studies and cross-culturally.

The chapters in the second part of the book are organized around common themes. These include a description of the culture of the group, its view of mental illness and anxiety, treatment expectations, the possibilities of a therapeutic alliance and family involvement. E. Salman and colleagues examine anxiety disorders of Hispanic-Americans. The authors analyze the culturally bound syndrome of “ataque de nervios,” which is a folk label for loss of control, often with anxiety. The authors stress the need to reconcile the folk diagnoses with the DSM-IV framework.

S.-A. Gopaul-McNicol and J. Brice-Baker compare indigenous and western treatments of anxiety disorders in the Caribbean. G.Y. Iwamasa analyzes demographic and clinical variables in Asian-Americans, who tend to underuse both outpatient and inpatient mental health services. The author points out that, in many Asian ethnic groups, the needs of the family take precedence over those of the individual, that and religion and spirituality are important in everyday family life. CM. Paradis and her colleagues focus on the cognitive-behavioural treatment of anxiety disorders and emotional problems of Orthodox Jews, a minority in their own community. Confidentiality is important in this culture, and mental illness often has to be concealed. The assessment and treatment of patients with strong religious beliefs remain a mental health challenge.

There is still limited information on anxiety disorders in African-Americans. A.M. Neal-Barnett and J. Smith argue that the African-Americans have been targets of misdiagnosis. The authors discuss the clinical importance of spirituality, of the extended family and the therapeutic alliance in the treatment. R. Viswanathan and colleagues stress the fact that some attitudes of patients from the Indian subcontinent tend to be sociocentric rather than egocentric. Family and neighbours are valued, gender and hierarchical roles are rule-bound, and behaviour is influenced by the concept of shame.

In the third part of the volume, I.M. Lesser and colleagues provide a valuable overview of the clinical research on psychopharmacology and ethnicity, mechanism of drug effects and response to treatment. The authors highlight the interplay of ethnic background and genetics, but many of the important variables and relations need more research. In his closing chapter, L.J. Kirmayer reflects on the role of culture in emotional experience, considering the variations of anxiety symptoms in an increasingly ethnically diverse society.

The authors offer an updated and deep insight into factors inherent in the development, manifestation and treatment of anxiety in subjects from different cultures and ethnic groups. The book is well structured and clearly written, though the anxietynculture relations are complex and the evidence is still fragmented. This useful book will interest students and scholars in transcultural psychiatry/psychology and mental health professionals working with patients from ethnic groups.

Post-traumatic Stress Disorder (PTSD) has become much more recognized and appreciated following the traumatic events of September 11th. The estimated lifetime prevalence for PTSD is almost 8%. This anxiety disorder centers on a person re-experiencing an extremely traumatic event, such as a natural disaster, war, crime, rape, or abuse, whether the abuse is physical, mental or sexual in nature. Because of this experience, a person may have recurrent thoughts about the event or actually re-experience some of the same feelings and reactions that occurred during the initial exposure. A person with Post-traumatic Stress Disorder (PTSD) will try to avoid activities or thoughts associated with the initial traumatic event. In addition, the person will usually experience autonomic arousal or panic symptoms when encountering or thinking about the triggering situation.

Social Phobia (SP)

Social phobia affects between 3% and 13% of the adult population and can occur in patients as young as in early childhood. Social phobia is not about being shy, bashful, or not liking people; instead it is a disorder in which patients experience intense feelings of humiliation and/or scrutiny when in a social situation. This situation can be specific, such as giving a talk in a class, or generalized to almost every encounter with any person throughout the day, whether this involves one person or many people. Social phobia is a chronic, unremitting anxiety disorder that has a significant genetic component and a biological basis. Social Phobia (SP) has high comorbidity with other anxiety disorders, as well as depression and alcohol and substance use disorders. The impairment can have extreme ramifications, ranging from not ever applying for a job or a school to quickly quitting because of the intense discomfort experienced when the patient is forced to talk or interact with others. Common symptoms include flushing, blushing, tachycardia, sweating, stuttering, and tremor. In essence, the patient has panic-attack symptoms when he or she is only placed in social situations. The person can experience either limited symptoms or a full-blown attack that affects every body system. TABLE 4 lists some situations in which people with social phobia experience extreme anxiety and thus make every effort to avoid.

* note: social anxiety disorder is characterized by the fear of being observed or evaluated by others; sufferers report an overwhelming fear of embarrassment in social and performance situations.
* researchers at the University of Southampton conducted a 12-week, multi-centre, double-blind, placebo-controlled clinical trial to compare the efficacy of Paxil (20-50 mg daily) to placebo, in 290 patients with social anxiety disorder.
* found a statistically significant symptom improvement in patients treated with Paxil within as little as four weeks of treatment onset, as measured by the Liebowitz Social Anxiety Scale (LSAS), which provides an assessment of a patient’s level of fear and avoidance of performance and/or social situations.
* the researchers say that Paxil was associated with a definitive reduction in symptoms of social anxiety disorder, increased participation in social activity, as well as a significant improvement in overall well being.
* Paxil (paroxetine), from SmithKline Beecham Pharma Canada, has been approved in 82 countries for the treatment of depression, obsessive-compulsive disorder and panic disorder in patients over the age of 18 and is indicated for the treatment of generalized social anxiety disorder in 35 countries, including the U.S.