|February 2001||Book Reviews|
not included in the nosological system of the DSM-IV. Increasing the sensitivity of clinicians to cultural issues would seem timely; it is estimated that by the year 2050 (as cited in the Preface), the near majority of the US population will be either Hispanic, African American, or Asian American.
This book comprises a collection of scholarly chapters by prominent cross-cultural psychologists and psychiatrists, including Laurence Kirmayer, Michael Liebowitz, and Myrna Weissman (to name a few), that were presented as part of a 1-day symposium on treating anxiety disorders across cultures held in New York in 1995. While the book might now be considered in some ways dated, the authors review then-current epidemiological data and offer clinical strategies that are entirely relevant to current clinical practice. I found each chapter to be written in a clear and concise fashion, and the chapters hold together very well despite the breadth of research and clinical issues covered.
The book is divided into 3 sections, with the first focusing on what we know about the frequency of anxiety disorders worldwide and what differences there are in symptom patterns. It also provides an introduction into culture-specific syndromes. In contrast to psychiatric disorders such as schizophrenia and depression, there has never been a World Health Organization (WHO) study of the anxiety disorders. This text reviews cultural differences in the anxiety disorders—including panic disorder, agoraphobia, social phobia, generalized anxiety disorder, and obsessive–compulsive disorder—based on the findings from the National Comorbidity Study (NCS) and the Epidemiological Catchment Area (ECA) study. The authors highlight the significant differences in the way anxiety is described and experienced among nations (NCS) and by different cultural groups within the US (ECA). In addition to discussing prevalence rates across cultural groups, they
review the risk factors for anxiety disorders. Perhaps most striking is the consistent role of sex, social economic status, and education in shaping the anxiety disorders across cultures. In relation to vulnerability and maintenance models of anxiety disorders, they also discuss the unique stresses associated with immigration and acculturation.
Further, they describe and evaluate cultural syndromes outside the framework of the DSM in relation to current nosology. For example, there is a syndrome not infrequently reported in Puerto Rico and other areas of Latin America that is known as ataques de nervios and is characterized by “screaming uncontrollably” and “attacks of crying.” While resembling to some extent the description of a DSM-IV–defined panic attack, other aspects of this syndrome include affective and somatization features, as well as difficulties with anger and impulse control. Another disorder reported in several Asian cultural groups is koro, described as acute anxiety with the fear of genital retraction into the abdomen resulting in death. This disorder has been described for centuries in medical texts but is rarely diagnosed accurately without the support of the person’s family or representatives of the cultural group.
Section 2 comprises 6 chapters on the treatment of anxiety in different cultural and ethnic groups: Hispanic Americans, Caribbean Americans, Asian Americans, Orthodox Jews, African Americans and Asian-Indian Americans. These chapters examine how each group experiences and applies meaning to anxiety symptoms. It also describes in detail how group members view traditional psychiatric services and offers specific suggestions for making an accurate diagnosis and fostering the treatment alliance.
One theme that emerges across all groups is the comparative underuse of community mental health services,
despite the high base rates of anxiety disorders in these communities. In most, the family acts as the primary caregiver, and psychiatric difficulties are framed within the perspective of a “family problem.” In addition, language barriers and greater investment in traditional folk remedies lead to underuse. Other factors discussed by some authors include poor doctor–patient relationships and the important issues of stigma and personal shame associated with psychiatric illness. The authors provide culturally sensitive and truly culture-specific recommendations for building trust and engagement. They discuss the cultural meaning of symptoms (for example, “being bound to the home, which is a sign of severe agoraphobia in the West, is a sign of virtue in a Muslim housewife”), and the personal style required from the therapist (for example, the need to be active and directive with Caribbean American clients), as well as the tasks of therapy (for example, careful planning of in vivo exposures for the Orthodox Jew so as not to create conflict with religious beliefs or affect his or her standing in the community) and compliance with treatment (for example, overcoming poor compliance with antidepressant medications among Hispanic Americans by recognizing and working with their emphasis on the somatic aspects of anxiety and depression).
Section 3 comprises 2 chapters that highlight recent trends and future directions in cross-cultural research on anxiety. One chapter gives a fascinating overview of the role of ethnicity and culture in regard to response to pharmacological treatment, while the final chapter synthesizes the role of culture in the anxiety disorders.
This scholarly book will serve as an excellent reference on the subject of culture and anxiety. It will also be an invaluable resource to practising clinicians who work in ethnically diverse treatment settings. Even though the book focuses on the different cultural