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.

Answer: You are raising a difficult and important question, and one which I can’t answer definitively without knowing more of your situation and symptoms. Feeling “stressed out” because of school and job pressures is fairly common, and – while unpleasant – not usually something requiring professional counseling or psychotherapy. Instead, trying to identify the specific stressors and reducing them as much as possible usually suffices.

For example, can you reduce your job hours at all? Can you find ways to organize your study time more efficiently?(There are many books out on this topic). If you can’t change your job or its hours, can you speak with your supervisor about the nature of the work itself? Are there aspects that could be changed to your liking? Do you have an academic or “peer” advisor who could provide guidance regarding your course load? Should you reconsider your major? etc.

Regarding “self-help” exercises, I assume you have in mind something like self-relaxation or stress reduction. Yes, you can certainly learn these. Herbert Benson’s The Relaxation Response is a good place to start. Various relaxation tapes can be purchased in most good book stores, and certainly can’t do you any harm.

On the other hand, you need to be more concerned if you are actually developing signs and symptoms of a “clinical” depression, or major depressive episode. Symptoms would include, e.g., depressed mood nearly every day for more than 2 weeks; markedly diminished interest or pleasure in most activities, nearly every day; significant weight gain or loss; insomnia or excessive sleep; severe fatigue; feelings of worthlessness or guilt, impaired concentration or inability to make decisions; or thoughts of ending your life, recurrent thoughts about death, etc. More than two or three of these features (or the presence of suicidal ideation alone) should first prompt a visit to your general or family doctor, or school clinic, for a physical exam and routine laboratory studies to rule out medical illness; e.g., low thyroid function, and other underlying physical problems.

If all this is “negative,” you should then consider getting a referral to a mental health professional (psychiatrist, psychologist, psychiatric social worker, or clinical nurse specialist) for psychotherapy and perhaps a trial of antidepressant medication. (Medication can be prescribed only by physicians or, under supervision in some states, clinical nurse specialists and physician assistants).

In the mean time, reading the book Feeling Good by David Burns may be helpful in learning ways of “thinking your way out” of depression. Good luck!

Routledge, Chapman and Hall, London

1989, 196 pages

This useful book is the first in a series on strategies for mental health. Forthcoming titles will include Assertiveness training, Bereavement and loss and Rehabilitation and community care. If these volumes are of the same high standard as this book then they may, as the series title implies, have a positive effect on mental health.

The contents of this book divide into four parts: the first part looks at the research underpinning theories of stress and anxiety, the second describes a wide range of assessment procedures, the third and by far the largest section looks at management strategies, and a final section uses clinical cases to demonstrate the application of the strategies which are described.

The stated aim of the authors is to demystify symptoms and to provide individuals with coping skills. There are skills here in abundance for the general practitioner and other members of the primary health care team. At a personal level there are useful sections on goal planning and time management, and the chapters on self-help techniques, changing client’s lifestyles and running anxiety management groups should further reduce the prescribing of sedatives and tranquillizers.

New York: Oxford University Press; 1997. 236 pp. with index

ISBN 0-19-512120-1 (paper)

“Stress” has become such an overused word that it is now almost a cliché. The Oxford English Dictionary has 10 different meanings for it. Because of these terminological difficulties, some consider that it should be discarded from the medical lexicon altogether. Nevertheless, “stress” has developed a widely understood meaning in common parlance, and it would appear acceptable to use the word technically as long as clear definitions are followed. In the psychosocial and biological sciences it has come to refer to the external events and changes that impinge on an individual and the reaction of the individual to those events. Over the last 50 years a huge volume of psychobiological research has been carried out on stress and its effects on health. It is ironic that, despite mounting clinical, epidemiological and pathophysiological evidence that stress has adverse effects on health, there still are sceptics who doubt the connection or — worse — fail to recognize and assist patients whose clinical problems are caused or aggravated by stress.

A probable reason for the existence of such scepticism is the very real difficulty in measuring stress in a valid and replicable way. This book tackles this problem in a pragmatic and comprehensive manner. Stress is defined as “a process in which environmental demands tax or exceed the adaptive capacity of an organism, resulting in psychological and biological changes that may place persons at risk for disease.” This process is examined from 3 perspectives: environmental, subjective and biological. The “environmental” perspective includes the external life events that impinge on an individual; the “subjective” factors are the psychological and emotional perception and evaluation of those events; and the “biological” factors refer to the physiological responses induced by these environmental and psychological changes. There are helpful introductory and summary chapters to each of the sections.

Two types of tests are used to measure the intensity of environmental events: those that depend on self-report ratings and those that depend on interviewer ratings. Self-report ratings have the major advantage of simplicity and efficiency of administration. However, some environmental events may not be listed in the inventories given to the patient, and earlier stressful events may be poorly remembered and evaluated. Interview methods have the advantages of being able to measure the timing and intensity of life events more accurately, and are also more comprehensive. However, they are much more expensive and time-consuming to administer.

The chapters on psychological response describe the measurement of stress “appraisal” and the measurement of the “affective response.” The book describes a variety of questionnaire-type tests that measure each of these responses. Two final fascinating chapters deal with physiological reactions to stress. These reactions affect 3 systems: the sympathetic-adrenal medullary system, the hypothalamic-pituitary-adrenocortical axis, and the immunological response. Each is important, because each is a likely means by which environmental events cause pathophysiological reactions.

This book is a must-read for those involved or wishing to be involved in stress research. The authors are all actively engaged in experimental research in this area or have helped to develop many of the tests in use. The chapters are comprehensive and well written and referenced. Although the book is expensive, it can be highly recommended as a compendium to those with an interest in this field.