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CulturalAspectsofSocialAnxietyDisorderAQualitativeAnalysisofAnxietyofAnxietyExperiencesandInterpretation.pdf

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Cultural Aspects of Social Anxiety Disorder: A Qualitative Analysis of Anxiety Experiences and Interpretation

Abolafzl Mohammadi 1 , Imaneh Abasi

2 *, Mehdi Soleimani

1 , Seyed Tayeb Moradian

3 , Taha Yahyavi

4 ,

Mostafa Zarean 5

Abstract Objective: Anxiety is a complex phenomenon on which culture has a prominent influence. The present study aimed to

investigate the cultural aspects of social anxiety disorder (SAD) in an Iranian population. Method: A qualitative content analysis research was done to answer the study question. A total of 16 individuals with

social anxiety disorder (six men and 10 women) were selected using purposeful sampling method (M = 24.43, SD = 4.56). The study was conducted in Tehran, Urmia, and Sanandaj- Iran. Participants were from different ethnic backgrounds (LOR, FARS, TURK, and KURD). Data were analyzed by thematic analysis using an inductive method. Results: Analysis of participants’ records yielded five distinct categories with some subcategories, which are as follow:

(1) anxiety experiences; (2) core beliefs; (3) reasons of being anxious; (4) effects of SAD on life aspects; and (5) coping strategies. Conclusion: It seems that symptoms of social anxiety and its underlying beliefs, causes and effects and coping

strategies are almost experienced and interpreted in a way that could be the same as DSM-5 clinical presentation of social anxiety, with the exception that somatic symptoms are experienced by almost all participants.

Key words: Anxiety; Culture; Qualitative Research; Social Anxiety Disorder

Anxiety disorders are the most prevalent psychiatric disorders (1). They affect various aspects of life,

including social, financial, educational, relationship, and

quality of life. Anxiety disorders are the result of

genetic, environmental, familial, mental, and cultural

factors (2, 3). Anxiety disorders are affected by cultural

features (4, 5); and symptoms and variation in

prevalence of anxiety disorders could be transformed

across ethnicities and cultures (6, 7).

Cultural values and beliefs may put individuals at risk

and they may also act as a buffer against anxiety

problems (8). Culture plays an important role in

awareness toward problem severity and its consequences

and health care searching behaviors (9).

In line with cultural influences on anxiety disorders, a

review showed that unexpectedness and 10-minute

crescendo criteria in panic disorder, definition of social

anxiety and social reference group in social anxiety

disorder, and the preference given to psychological

symptoms of worry in generalized anxiety disorder are

phenomenological expressions in different cultures (10).

Individualism vs. collectivism nature of countries may

be related to social anxiety differently (11). Furthermore,

khyâl cap (wind attacks), taijin kyofusho, and ataques de

nervios are three main examples of culture-specific

expressions of anxiety disorders, which have been

included in DSM-V as distress concepts (12).

Iran J Psychiatry 2019; 14: 1: 33-39

Original Article

1. Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

2. Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

3. Atherosclerosis Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.

4. Department of Psychiatry, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

5. Department of Psychology, School of Education and Psychology, Tabriz University, Tabriz, Iran.

*Corresponding Author:

Address: Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, kodakyar Avenue, Daneshjo

Boulevard, Evin, Tehran, Iran. Postal Code: 1985713834

Tel: 98-2122180045, Fax: 98-2122180045, Email: [email protected]

Article Information:

Received Date: 2018/04/11, Revised Date: 2018/08/18, Accepted Date: 2018/09/16

Mohammadi, Abasi, Soleimani, et al.

Iranian J Psychiatry 14: 1, January 2019 ijps.tums.ac.ir 34

A study on anxiety and its cultural complexities in Iran

showed that individuals with Azeri ethnicity (one of

several Iranian ethnicities) suffering from emotional

disorders reported 11 main themes as avoidance,

dysfunction, arousal, disorganized personality,

repetition, somatization, problematic behavior,

maladaptive cognition, awareness, and positive and

negative emotionality, among which somatization had

the highest frequency (13). There is strong evidence that

individuals from non-Western cultures significantly

report more somatic rather than psychological symptoms

(14, 15).

In this study, we used the term culture and ethnicity

interchangeably to refer to common heritage, shared

beliefs, and norms of a unit or a group of people. Iran is

a country with different cultural and ethnical

background, and this may be responsible for various

psychological manifestations. Moreover, there is no

adequate information about cultural aspects of anxiety in

Iranian population and because of the prominence of

cultural effects on anxiety symptoms (8, 9 and 12) and

culture-gene interactions (16, 17), studying the cultural

nature of anxiety disorders in Iranian population is of

utmost importance. Furthermore, the anxiety

phenomenon is extremely complex and passing of time

makes it even more complex in some ways, so the best

way to clarify a content-based phenomenon is to conduct

a qualitative research.

The qualitative method can illuminate some phenomena

which could not be reached out through qualitative

methods. Moreover, it can also help understand different

perspectives and contribute to mental health policy (18).

The main objective of this research was to study the

cultural aspects of anxiety, mainly social anxiety, in four

ethnic groups (LOR, FARS, TURK, and KURD) in Iran,

who were diagnosed with social anxiety disorder. Thus,

generalization is possible. Specific aims in this research

were as follow: describing anxiety experience among

people suffering from anxiety disorders; evaluating

awareness and experience of anxiety among general

people; determining the causes of perceived anxiety

among participants in the study; describing the

participants’ opinions towards prognoses and

consequences of anxiety, describing the participants’

opinions towards prevention and treatment of anxiety

disorders.

Materials and Methods The study design is a qualitative content analysis

research. Study conducted in the cities of Tehran, Urmia,

and Sanandaj- Iran. A total of 16 individuals with social

anxiety disorders (six men and 10 women) were selected

via purposeful sampling method (M = 24.43, SD = 4.56).

With respect to education level, nine participants had

high school diploma, one had a bachelor’s degree, and

six had a master’s degree. With respect to ethnicity, one

participant was identified as Lor, two as Fars, six as

Turk, and seven as Kurd. Patients were selected

according to some inclusion and exclusion criteria and

were recruited from counseling centers in

aforementioned cities. Main inclusion criteria were

age>18 and primary diagnosis of social anxiety disorder.

Main exclusion criteria were as follow: comorbid with

any debilitating mental illness like schizophrenia,

bipolar disorder, substance abuse, and mental

retardation; comorbid with debilitating physical illness.

The study was done during 2016-2017. All individuals

were interviewed by a psychiatrist and were diagnosed

as social anxiety disorder. Then, they were informed

about the purpose of study, and informed consent was

obtained from all of them. All voluntary participants

were asked open ended questions by a clinical

psychologist (MS.c.) through an in-depth and semi-

structured interview. Answers were audio recorded and

lasted 30 to 60 minutes. Questions were categorized into

three main groups: (1) personal experiences and

perception about anxiety; (2) factors causing anxiety;

and (3) coping strategies when feeling anxious. Ethical

approval was obtained from the National Institute for

Medical Research Development. Informed consent was

obtained before interviewing. Participants were assured

about the confidentiality of their information and were

debriefed about the purpose of the study .

Analysis

Results of the interview with each participant were

recorded, coded, and categorized. Overall, the

interviewed data were processed through thematic

analysis. An inductive method was used for data analysis

(19).

Results Participants’ description of their experiences and beliefs

about coping consequences of anxiety, SAD reasons,

and coping strategies when facing anxiety were

categorized in the following categories (Table 1).

1 .Symptoms of Anxiety

1.1 Emotional

Anxiety was experienced mainly in public (feeling

anxious when speaking, asking questions, and

commenting) and in classroom (anxiety when

presenting, providing training courses, asking questions,

speaking, and commenting).

Example

Participant 1: I am afraid of speaking in public because I

feel I am not good at it .

1.2 .Cognitive

Cognitive aspect of anxiety was categorized into two

main categories as pre event rumination (thinking of

making a mistake and thinking of being humiliated,

thinking of being mocked, and thinking of not being able

to handle the situation) and post event rumination

(thinking of making mistakes, thinking of being

humiliated, and thinking of being mocked).

Example

Cultural Aspects of Social Anxiety Disorder

Iranian J Psychiatry 14: 1, January 2019 ijps.tums.ac.ir 35

Participant 2. I am afraid of making mistakes and

classmates laugh at me because of it.

1.3 Behavioral

Behavioral aspect was categorized into 3 main sections

as avoidance (avoiding stressful situations), surrender

(inability of movement and inability to speak), and

safety behaviors (talking fast).

Example

Participant 5: When I am in stressful situations I can’t

speak or move, it is like I am in a cage .

1.4 Physical

Physical aspect consisted of several symptoms including

increasing heartbeat, feeling cold, feeling pressure on the

head, sweating, hoarseness, inability to swallow saliva,

suffocation, body weakness, lowering the pressure of the

body, blushing, feeling hot in the body, difficulty

sleeping, feeling of losing balance, flushing, and

lowering the tone of voice .

Example

Participant 9: when I am anxious, I feel flushed, I feel I

am losing balance, and I feel hot in my body.

2 .Core Beliefs

Profound beliefs related to social anxiety experienced by

participants were categorized in following categories:

2.1 Fear of negative evaluation: Being neglected by

others, rejected, mocked by others, loss of pride, loss of

popularity, and feeling ashamed.

Example

Participant 10: When I want to give presentation in class,

I feel like everybody is looking at me, they are making

fun of me, and they think I am not good at it .

2.2 Unworthiness: Not being worthy, not being satisfied

with oneself .

Example

Participant 12: I think something makes me most

vulnerable in these situations and that is I don’t feel

worthy enough.

2.3 Incompetency: loss, failure.

Example

Participant 7: When I think of my SAD symptoms, I

think about my previous failures.

3 .Reasons of Being Anxious

3.1 Familial factors: Family tension, parental

punishment, parental harshness, incorrect parenting

systems, and emotional deprivation.

Example

Participant 13: I was raised in a family full of tension

and stress that were beyond my ability to manage .

3.2 Fear: Fear of negative evaluation, fear of being

rejected, and losing loved ones .

Example

Participant 13: I think fear of other`s views about us and

fear of being rejected by them can make us anxious.

3.3 Core beliefs: Unworthiness and incompetency.

Example

Participant 16: In an anxious situation, I really feel like I

can’t help myself and this may be the reason of my

anxiety.

3.3 Society: Poverty and school (poor education and

inappropriate laws).

Example

Participant 15: I have been faced with poverty and other

stresses several times and since then I have been so

tensed and anxious.

4 .Effects of SAD on Life Aspects

4.1 .Social dysfunction (inability to speak in front of

others, inability to connect with others, inability to make

friends, inability to go out alone, losing job

opportunities, avoiding social relationships, and failure

to establish a relationship with the opposite sex).

4.2 .Emotional dysfunction (worry, lowering fear

threshold, and feeling disappointed)

Example

Participant 14: Social anxiety has ruined my life. I am

always worried about social situations .

4.3 .Behavioral Dysfunction (poor quality of life,

avoiding stressful situations)

Example

Participant 11: I don’t take part in social situations

where I am not acquainted.

5 .Coping Mechanisms

Participant’s explanation about strategies for handling

their anxiety was categorized in following sections:

5.1 .Treatment (psychotherapy and pharmacotherapy)

Example

Participant 12: A psychologist or a psychiatrist may be

helpful .

5.2 .Emotion-based mechanisms (watching movies,

overeating, sleeping, avoiding stressful situations,

praying, talking to others, drinking, smoking, listening to

music, and relaxing)

Example

Participant 11: When I am worried or anxious, I eat and

sometimes I listen to music.

5.3 .Problem-based strategies (studying psychological

books, practicing for presentation or speaking, studying