Anxiety Across Cultures

RUNNING HEAD: DEPTH PAPER ANXIETY 2












Depth Paper: Anxiety Across Cultures

Ethan Snyder
Fielding Graduate University









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.


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 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 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 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 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 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 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, 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 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 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, 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
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 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 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 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).
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
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.

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