Anxiety Across Cultures

RUNNING HEAD: DEPTH PAPER ANXIETY1

Depth Paper: Anxiety Across Cultures

Ethan Snyder

Fielding Graduate University

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I affirm that this my original work and has not been copied or plagiarized from any other sources, nor has it been previously submitted for academic credit. This electronic message counts as my signature: Ethan Snyder

Abstract

This paper discusses the causes, manifestations and

treatments of anxiety across several cultural groups. The groups

particularly focused on are Asians, Hispanics, African-American

and Native Americans.

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Anxiety is defined as a mood state characterized by thoughts

of worry and apprehension, which generally occur with physical

symptoms (Draguns, 1988). Anxiety most often occurs when an

individual anticipates impending danger, catastrophe, or

misfortune whether the threat is real or imaginary (Draguns,

1988). Physically, anxiety is often characterized by muscle

tensing, fast or difficult breathing, a rapid heartbeat, sweating

and dizziness. Anxiety may be distinguished from real fear both

conceptually and physiologically, although the two terms are

often mistakenly used interchangeably in everyday language

(American Psychiatric Association, 2013). This anxious reaction

is associated with a number of psychological issues, such as

acute anxiety, anticipatory anxiety, generalized anxiety

disorder, separation anxiety, agoraphobia and social anxiety

(American Psychiatric Association, 2013). Though anxiety

reactions may have a biological basis, this paper will focus on

external variables that may contribute to these reactions.

Anxiety may be considered a universal occurrence, but its causes

and manifestations vary across cultures (Draguns, 1988). This

also means diagnosis and treatment of an anxiety disorder may

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http://psychologydictionary.org/apprehension/


need to include interventions relevant to the culture of the

sufferer. Anxiety is a complex physical and psychiatric issue

that needs to be explored for cultural variations.

National Comorbidity Survey Replication (NCS-R) show that

the 12-month prevalence rate of anxiety disorders among US adults

is 7.1–7.9% (Baxter, 2014). nSimilar rates have been found in

other cultural groups: 6.4% in Chile and 9.1% in Brazil (Baxter,

2014). In contrast, the 12-month prevalence rate from East Asian

surveys, although less studied, has been reported to be much

lower, in the range of 0.4% in Taiwan,0.2–0.6% in Korea, 0.2% in

China, and 0.8% in Japan (Baxter, 2014). The prevalence rates in

several other populations have been found to be similarly low,

such as in epidemiological surveys found rates of anxiety to be

1.7% Mexico, 0.3 % Nigeria, 1.9% South Africa, and 0.8% Europe

(Baxter, 2014).

Causes

The triggers of anxiety can be different across cultures,

this not only includes national, racial and ethnic cultures, but

age and gender as well (Sue, 2008). External stimuli can cause

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an increase in feelings of worry, anxiousness and apprehensions

(Lewis-Fernández, 2010). In Americans, work, relationships,

money and media overload are some of the top reported causes of

anxiety (Carter, 2012). In Asian individuals, health, family and

personal achievement are prevalent external stressors that

trigger anxiety within individuals (Chang, 2006). Health and

money are reported as likely stressors for Hispanic individuals

(Carter, 2012). For African- Americans and Native Americans,

being part of a minority culture is a leading cause of anxiety

(White, 1998; Neal-Barnett, 2011).

There are a number of studies focused on being a member of a

minority culture within the American culture and the anxiety this

can cause (White, 1998; Neal-Barnett, 2011; Carter, 2012).

African-American, Native American and Hispanic/Latino individuals

have all demonstrated higher levels of anxiety associated with

being part of a minority culture (Carter, 2012; Draguns, 1988;

Eshun, 1999). Asians also show greater levels of anxiety when

living in a foreign country (Sue, 2008). In particular,

adolescents seem to suffer more than adults from anxiety

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associated with minority culture membership (Carter, 2012). This

anxiety, if unaddressed, can lead to clinical depression and

substance abuse (White, 1998, Rieckmann, 2004). Clinicians,

educators and leaders from multiple groups have suggested that a

conflict of cultural identity in the minority culture youth is

related to anxiety and depression (White, 1998). Trying to

reconcile both the dominant and minority cultural identities

seems create stress that can lead to maladaptive behaviors and

thinking that manifests as anxiety and depression (Rieckmann,

2004). In African-Americans this conflict of cultures has been

demonstrated to cause Trichotillomania in a large population of

African-Americans (Neal-Barnett, 2011). In Native Americans,

substance abuse and suicide have been linked to this stressor

(White, 1998)

One cause of anxiety recognized by many practitioners across

cultures is irrational beliefs, but the types of beliefs may vary

culturally (Chang, 2006). Irrational beliefs are thoughts that

run counter to reality, sometimes referred to cognitive

distortion (Baxter, 2014). Cognitive therapy tradition maintains

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that there is a strong correlation between irrational beliefs and

mental health problems such as anxiety (Eshun, 2009). Cultural

study of irrational beliefs have shown that certain cultures may

engender these thoughts more than others. Vandervoort (1999)

conducted research that demonstrated irrational beliefs occurred

across cultures, but were not necessarily the same irrational

beliefs. These researchers found that Asian were more anxious

and have more irrational beliefs than Caucasian or multi-cultural

individuals (Vandervoort, 1999). Results showed Asian culture

seems to place more emphasis on perfectionism and personal

achievement (Vandervoort, 1999). This emphasis causes Asian

individuals to focus on irrational thoughts of potential failure,

causing anxiety. Asian culture also tends to view such emotional

reactions as a weakness, which means suggests a sufferers may

become overwhelmed by stressors and feelings of being unable to

cope effectively which, in turn, increases anxiety levels

(Vandervoort, 1999, Chang, 2006; Sue, 2008). Japanese

individuals seem to suffer this irrational thinking the most,

with Chinese individuals showing less prevalence (Baxter, 2008).

Statistics show the U.S. has a higher rate of anxiety disorders

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than Japan, though research shows Japanese individuals suffer

higher levels of anxiety (Baxter, 2014). This is likely due to

cultural differences in how anxiety is viewed and treated.

Japanese individuals often seek treatment not for anxiety, but

rather for the physical ailments associated with it, a common

occurrence among Asian cultures (Change, 2006). Therefore, the

reported numbers of anxiety disorders are likely to be lower as

sufferers may be treated for physical ailments related to anxiety

rather than the mental issue (Eshun, 2009; Baxter, 2008).

Another consideration when looking at anxiety across

cultures is that what passes for an anxiety disorder in one

culture may not be considered one by another. Agoraphobia, for

example, is often considered an anxiety disorder because one

experiences panic attacks in places or situations from which

escape might be difficult (or embarrassing) or in which help

might not be available (American Psychiatric Association, 2013).

Individuals suffering agoraphobia often become housebound and

experience anxiety at the prospect of leaving the place where

they feel comfortable (Eshun, 1999). This definition is largely

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based on Western culture. As Eshun (1999) points out, “being

bound to the home, which is a sign of severe agoraphobia in the

West, is a sign of virtue in a Muslim housewife” (p. 200). In

Muslim culture, agoraphobia among women is reported to occur much

less than in other groups because it is not viewed as abnormal

(Eshun, 1999).

Manifestations

The signs and symptoms of anxiety can be different depending

on the culture of the sufferer (Eshun, 2009). Anxiety generally

has two forms, mental and physical. The mental form refers to

thoughts, feeling and pains reported by the sufferer. Physical

symptoms are related to the body that may observed by others

(Dragun, 1988). Acute reactions, such as associated with panic

attacks include shortness of breath, dizziness, heart

palpitations and sweating (Carter, 2012). Chronic signs and

symptoms like pain, fatigue, headaches and hypertension can occur

if anxiety is present for a long period of time (Carter, 2012).

Many cultures in Africa and Asia teach that “thinking too

much” can lead to brain damage (American Psychiatric Association,

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2013). This form of anxiety appears to mean an individual is

perseverating on a topic of distress. This problem, sometimes

referred to as Kufunisisa, has been linked to stomach ailments,

dizziness, difficulty breathing and/or “feelings of heat or

crawling sensations in the head” (American Psychiatric

Association, 2013, p. 834)

As mentioned earlier, some cultures view mental anxiety as a

personal weakness and individuals may be unlikely to seek

treatment for it (Sue, 2008). However, sufferers maybe willing

to seek medical treatment for physical symptoms (Sue, 2008). In

addition to having higher levels of anxiety, research has shown

that Asians tend to somaticize stress and anxiety which makes

them more likely to seek medical treatment for psychological

problems (Eshun, 2009; Sue, 2008). In Asian cultures there is

stigmatization against individuals with a mental illness and it

is seen as a sign of emotional weakness (Chang, 2006). This may,

in part, be the reason depression occurs more in Asians than

Caucasians (Chang, 2006). Americans have a higher occurrence of

anxiety treatment, but Asians tend to wait longer before getting

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treatment, meaning what begins as anxiety develops into

depression (Chang, 2006). Anxiety in Asians is more likely to

manifest as pain, particularly in the neck and back,

hypertension, crying and lethargy (Change, 2006). Shenjing

shuairuo is a Chinese culture bound syndrome similar to General

Anxiety Disorder, which translates to “weakness of nerves”

(Change, 2006). This Disorder is associated with physical or

mental fatigue, irritability, excitability, headaches or other

pains, and sleep disturbances (Chang, 2006). Other

amnifestations include dizziness, concentration and memory

difficulties, gastrointestinal problems, and sexual dysfunction

(Change, 2006). Cambodia, Japan and India have similar culture

bound syndromes (Change, 2006).

A similar negative cultural view of mental health treatment

in the African-American community leads many to seek medical

treatment over psychiatric treatment (Bulatao, 2004). This group

of anxiety sufferers is more likely to use a medical emergency

room to seek treatment than a mental health professional

(Friedman, 1995; Bulatao, 2004). Part of this may be due to the

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fact that African-Americans are more likely to be placed in

psychiatric hospitlizations than Caucasian Americans with the

same presenting manifestations (Friedman, 1995). One symptom of

anxiety that tends to be reported more by African-Americans than

other groups is repetitive episodes of isolated sleep paralysis

(Friedman, 1995). An African-American male with an anxiety

disorder is almost 10 times more likely to suffer isolated sleep

paralysis than his counterpart in any other cultural group

(Friedman, 1995). African-Americans, especially those at the low

end of the economic spectrum, report not only a great number of

stressful life events but also stronger responses to them, or

greater distress, than other groups in a variety of domains

(Bulatao, 2004). In some studies, African-Americans reacted with

greater psychological and physiological distress than whites to

unpleasant events (Bulatao, 2004). These reactions may include

aches, pains, heart palpitations, crying, sweating and/or

screaming (Bulatao, 2004)

Hispanic individuals tend to experience anxiety as bodily

aches and pains, like stomach aches, backaches or headaches,

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which persist despite medical treatment (Carter, 2012). Anxiety

and subsequent depression are often described by Hispanics as

causing a feeling nervousness or fatigue (Lewis-Fernández, 2010).

Other symptoms of depression include changes in sleeping or

eating patterns, restlessness or irritability, and difficulty

concentrating or remembering (Lewis-Fernández, 2010; Eshun,

2009). Culture-bound syndromes related to anxiety seen in

Hispanic Americans include susto (fright), nervios (nerves), mal

de ojo (evil eye), and ataque de nervios (American Psychiatric

Association, 2013). Symptoms of an ataque may include screaming

uncontrollably, crying, trembling, verbal or physical aggression,

dissociative experiences, seizure-like or fainting episodes, and

suicidal gestures (Lewis-Fernández, 2010). Hispanic culture does

not view emotional issues as a weakness, in the same manner

others do, however, Hispanic individuals are more likely to seek

help from religious figures rather than mental health providers

(Carter, 2012).

Treatment

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The primary treatment for anxiety is medication (Eshun,

2009). This addresses the physiological issues, but not

necessarily the environmental triggers for anxiety. Some

cultures hold beliefs about the causes of mental illness and

expect treatment that falls in line with those beliefs (Sue,

2008). Therefore, even if cultural beliefs do not fit with the

clinical model of treatment, these beliefs should not be

discounted to the sufferer (Sue, 2008; Carter, 2012). Cultural

beliefs should be respected and incorporated along with clinical

treatment. Doing this has shown greater participation by clients

and better treatment outcomes (Carter, 2012). Researchers have

shown that treatment by a therapist of same or similar culture

increases likeliness of sufferers to follow and complete

treatment as well as increasing positive treatment outcomes

(Carter, 2012; Sue, 2008).

Traditional Chinese culture explain mental health issues

like anxiety as being caused by an imbalance in cosmic forces,

the yin and yang (Sue, 2008). Tradition teaches to restore the

balance through exercise or diet (Chang, 2006). Other East Asian

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cultures attribute feelings of anxiety to evil spirits, angry

ancestors or religious experiences. As mental healthcare

professionals who work with individuals from East Asian cultures

point out, it is important not to alienate clients by discounting

these beliefs (Sue, 2012). Therapists often have to convince

clients that getting help in both a mental health and traditional

setting is important (Carter, 2012; Sue, 2008). Asian clients

may see a psychologist and conduct traditional rituals with a

religious figure to alleviate anxiety (Carter, 2012). Because

family is important in Asian culture, family members are also

encouraged to provide help and support for anxiety sufferers and

participate in treatment if possible (Carter, 2012). Research

shows that traditional Cognitive Behavioral Treatment (CBT) for

anxiety can be affective for Asian when therapists are culturally

sensitive (Carter, 2012). This may include changing some aspects

of the traditional therapy to reflect the Asian culture of the

client (carter, 2012).

African-Americans seem to make little progress using CBT for

anxiety in the clinical setting even when treatment is tailored

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for their cultural group (Carter, 2012). There is also evidence

that African Americans drop out of treatment with greater

frequency than other groups (Bulatao, 2004). Attempts to alter

traditional CBT to better reflect African-American culture has

shown only minimal improvement in treatment outcome (Carter,

2012). Some practitioner have theorized, based on client self-

reports, that African-American clients have an unrealistic

expectation of treatment, believing improvement in their anxiety

levels should begin sooner than is realistically likely occur

(Bulatao, 2004; Friedman, 1995). When these expectations are not

met, individuals are quick to abandon treatment or not fully

participate (Bulatao, 2004; Friedman, 1995). Though there are

calls for improvement in the culture sensitivity of CBT for

African-American clients, no one has yet to find specific changes

to CBT that significantly improve the likely positive outcomes

for African-American anxiety sufferers (Carter, 2012).

Researchers have found that African-American women respond

positively to what has been termed “sister circles,” which are

support groups for women (Neal-Barnett, 2011). While they are

largely educational, Neal-Barnett (2011) and colleagues found

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African-American women were willing to use cultural support

groups as a potential mechanism to learn about anxiety and to

receive empirically supported strategies for managing anxiety.

Despite the absence of empirical studies on the treatment of

anxiety disorders among Native Americans, it is typically

recommended to use culturally appropriate methods with this

population (Carter, 2012). For example, research suggests that

when working with Native Americans one be aware of culture and

the meaningful nature of human experience, something Native

Americans focus on (Carter, 2012) Treatment should be done

collaboratively with medicine persons or ritual leaders if the

client feels he or she will benefit from their involvement

(Carter, 2012). Researchers suggest attending to external

stressor and understanding any obstacles encountered in the

context of therapy, such as miscommunication (Carter, 2012).

Native Americans have shown higher likelihood of improvement in

symptoms when working with therapists that are from the same

tribe (White, 2008).

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Similar to how the word Asian is used as an umbrella for

numerous cultures, so too is the label Hispanic. Different

cultures within the Hispanic population each have their own

perception of psychological illnesses as well as what is

considered a reasonable option for management of those issues

(Carter, 2012; Sue 2008). Even certain language uses varies

among Hispanic cultures, therefore seeking treatment for anxiety

difficult (carter, 2012). However, where other groups have shown

fewer positive treatment outcomes from traditional Western based

anxiety interventions, Hispanic groups have shown similar

treatment outcomes to Caucasians (Carter, 2012). Traditional

forms of CBT appear to help Hispanic groups even when it has not

been tailored to be culturally relevant to the sufferer (Carter,

2012). However, communication is key to improvement, and, as

noted, certain Hispanic groups have found it difficult to find

therapists capable of providing effective communication (Carter,

2012).

Conclusions

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Despite the progress that has been made in the field of

anxiety disorder research, relatively little consideration has

been given to the way in which anxiety and the anxiety disorders

are influenced by culture (Eshun, 2009). While depression and

schizophrenia have been researched among various cultures by

institution such as the World Health Organization, it’s only been

within the last 15 years that anxiety has been closely studied

across cultures (Eshun, 2009). Previous research often referred

to the term “culture-bound syndrome” which was intended to

describe forms of commonly recognized mental illnesses, like

anxiety, that are rendered unusual because of the influence of

culture (Eshun, 2009). However, close examination by scholar led

to the conclusion that many of the “culture-bound” syndromes are

in fact found in multiple cultures and have some common symptoms

seem different because they are “nonwestern” (Eshun, 2009).

There is no doubt more research on individual cultural groups

needs to be conducted and provided to therapists.

References

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Anxiety Across Cultures