DEPRESSION AND ANXIETY 25:230–240 (2008)

Research Article

FEATURES OF THE OFFENSIVE SUBTYPE OFTAIJIN-KYOFU-SHO IN US AND KOREAN PATIENTS

WITH DSM-IV SOCIAL ANXIETY DISORDER

Yujuan Choy, M.D.,1 Franklin R. Schneier, M.D.,1� Richard G. Heimberg, Ph.D.,2 Kang-Seob Oh, M.D.,3

and Michael R. Liebowitz, M.D.1

Taijin– Kyofu– Sho (TKS), an East Asian syndrome of interpersonal fear andavoidance, that has been considered culture-bound, overlaps with social anxietydisorder to an unknown extent. The offensive subtype of TKS is characterized bytwo features considered atypical of social anxiety disorder: the belief that onedisplays physical defects and/or socially inappropriate behaviors (offensive TKSsymptoms) and fear of offending others (allocentric focus), but no studies havesystematically evaluated these two features in patients with social anxietydisorder. The purpose of this study was to assess offensive TKS symptoms andallocentric focus of fear in US (n 5 181) and Korean (n 5 64) patients withDSM-IV social anxiety disorder, using the newly developed TKS Questionnaire.Seventy-five percent of patients with social anxiety disorder in the US and Koreaendorsed at least one of the five offensive TKS symptoms surveyed. The severityof features of offensive TKS was significantly associated with severity of socialanxiety symptoms, depressive symptoms, and disability in both samples. Theseresults suggest that features of the offensive subtype of TKS are not uncommonamong US patients with social anxiety disorder and may not be as culturallyspecific as previously believed. They also suggest that Western clinicians shouldassess patients with social anxiety for features of offensive TKS, and they supportfurther consideration of integrating TKS features into conceptualizationsof social anxiety disorder. Depression and Anxiety 25:230–240, 2008. & 2008

Wiley-Liss, Inc.

Key words: Taijin–Kyofu–Sho; offensive subtype; social anxiety disorder;cross-cultural comparisons; Korea; Taijin–Kyofu–Sho Questionnaire

INTRODUCTIONTaijin–Kyofu–Sho (TKS), literally meaning fear(kyofu) of interpersonal relations (taijin) in Japanese,is a syndrome first described by Morita in the 1930s[Kasahara, 1987; Maeda and Nathan, 1999; Takahashi,1989], and later recognized in Korea, where it is knownas Taein Kong Po [Lee, 1987, 1995]. TKS is oftenconsidered a form of social anxiety that is specific toEast Asian cultures, and it is classified in Appendix Aof DSM-IV as a culture-bound syndrome [APA, 1994].

The TKS syndrome was initially described asexisting on a spectrum of severity level, with fourdistinct forms: (1) a ‘‘transient’’ form of social anxiety

Published online 5 March 2007 in Wiley InterScience (www.

interscience.wiley.com).

DOI 10.1002/da.20295

Received for publication 18 July 2006; Revised 26 October 2006;

Accepted 1 November 2006

�Correspondence to: Franklin R. Schneier, M.D., Anxiety

Disorders Clinic, New York State Psychiatric Institute, and

Department of Psychiatry, College of Physicians and Surgeons,

Columbia University, 1051 Riverside Drive, Unit 69, New York,

New York 10019. E-mail: Fschneier@nyspi.cpmc.columbia.edu

1Anxiety Disorders Clinic, New York State Psychiatric Insti-

tute, and Department of Psychiatry, College of Physicians and

Surgeons, Columbia University, New York, New York2Adult Anxiety Clinic Department of Psychology, Temple

University, Philadelphia, Pennsylvania3Department of Psychiatry, Kangbuk Samsung Hospital,

School of Medicine, Sungkyunkwan University, Seoul, Korea

rr 2008 Wiley-Liss, Inc.

experienced during adolescence, (2) a ‘‘neurosis’’ thatis analogous to DSM-IV’s social anxiety disorder,(3) a ‘‘borderline’’ form of phobia with ideas ofreference, and (4) a ‘‘delusional’’ form with fixed beliefs[Kasahara, 1987]. Others have classified TKS into fourphobic subtypes based on the content of the fears:blushing, deformed body, eye-to-eye contact, and one’sown foul body odor [Suzuki et al., 2003]. A morewidely accepted approach that also reconciles TKSmore closely with DSM-IV describes two subtypes:a ‘‘neurotic’’ or ‘‘typical’’ subtype and an ‘‘offensive’’subtype [Nagata et al., 2006; Seedat and Nagata, 2004;Yamashita, 2002]. The neurotic subtype has manysimilarities to DSM-IV social anxiety disorder (SAD)[Nakao, 1995]. Both are chronic disorders with an earlyage of onset, prominent fear and avoidance of socialsituations, and significant functional impairment. Inboth disorders, the individual fears being embarrassedor humiliated in social or performance situations dueto his/her perceived shortcomings (e.g., difficultymaking small talk) or physical manifestations of anxiety(e.g., blushing, sweating, and tremors).

The offensive subtype of TKS has been described asencompassing the ‘‘borderline’’ and ‘‘delusional’’ formsdescribed by Kasahara. One of the core features ofoffensive subtype is the fear that others will noticesome perceived physical defects, such as blushing ortrembling, having a stiff facial expression or unpleasantbody odor, or that they will exhibit behaviors seenas socially inappropriate or awkward, such as makingtoo much direct eye-to-eye contact or staring at others’body parts in public [Kirmayer, 1991; Lee, 1987;Russell, 1989; Takahashi, 1989; Yamashita, 1993].Some of these symptoms, such as fear of blushing ortrembling, are also common to both the neuroticsubtype of TKS and SAD. Other characteristicsymptoms (e.g. fear of stiff facial expression, unpleasantbody odor) are believed to be relatively specific to theoffensive subtype of TKS, and we will refer to thesesymptoms as ‘‘offensive TKS symptoms.’’

Another hallmark of the offensive subtype of TKS isthat as a result of perceived physical defects orinappropriate behavior, the person fears he or she willembarrass [Seedat and Nagata, 2004], offend, or evenharm others [Chang, 1995, 1997]. This allocentricinterpersonal focus of fear—fear of offending others—is seen as an essential criterion in the diagnosis of theoffensive subtype of TKS [Seedat and Nagata, 2004],and contrasts with the egocentric interpersonal focusof SAD—fear of embarrassing oneself [Chang, 1995,1997]. It should be noted that egocentric fears ofembarrassing oneself are also present in the offensivesubtype of TKS, but that there is a noted absence ofallocentric fears in descriptions of DSM-IV SAD[Kasahara, 1987; Russell, 1989].

The difference in interpersonal focus is widelythought to reflect differences in Eastern and Westerncultures’ conceptualization of the self and others[Kirmayer, 1991; Lee, 1987; Markus and Kitayama,

1991]. For example, Korean children are said to beraised to live peacefully among others, to respect andnot to be in conflict with authority and familymembers, and this regard for others extends to thosein the community [Lee, 1987]. In Japanese culture,interdependence and concern for others is also seen asa virtue, and children are encouraged to be obedient,docile, and to submit to others, and as a result, aremore concerned with how they affect others [Kirmayer,1991]. Thus, East Asian cultures have been noted toemphasize an interdependent self-construal, in whichone views the self as an extension of one’s social group,whereas Western cultures emphasize individualism andview the self as independent from others [Markus andKitayama, 1991].

Some scholars have challenged this distinction[Matsumoto, 1999], however, and recent empiricalfindings in clinical and non-clinical samples alsosuggest that the distinction between SAD and theoffensive subtype of TKS may be less clear-cut thanpreviously believed. Studies in non-clinical samplesfound moderate correlations between social anxiety andfeatures of offensive TKS in healthy volunteers of non-Asian or Japanese descent in the US [Kleinknecht et al.,1994], students in the US and Japan [Kleinknecht et al.,1997], and students in Japan reporting interpersonaldifficulties [Tarumi et al., 2004]. A clinical studyreported that 65.8% of Japanese outpatients withclinically diagnosed TKS also met DSM-III-R criteriafor SAD [Nakamura et al., 2002], although SAD wasmore common among TKS patients characterized by‘‘neurotic’’ symptoms (81.5%) than among those with‘‘delusional’’ symptoms (27.3%). Case reports that havedescribed seven American patients with offensive TKSchallenge the disorder’s cultural exclusivity, suggestingthat offensive TKS does occur, at least sporadically,outside the Far East [Clarvit et al., 1996; McNallyet al., 1990]. These studies suggest that features ofoffensive TKS are associated with features of SAD inboth non-clinical samples and Japanese TKS patientsamples. Among patients diagnosed with SAD, how-ever, the prevalence of offensive TKS features and theirrelationship to SAD features remains unknown. Also,although TKS and its offensive subtype are believedto be common in Korea, there has been little empiricalinvestigation of TKS there.

The goal of this study was to clarify the relationshipof offensive TKS features to SAD features in theUnited States and Korean patients with SAD. Wesystematically assessed the prevalence of (1) character-istic symptoms of the offensive subtype of TKS (bothoffensive TKS symptoms and symptoms believedcommon to SAD and TKS) and (2) allocentricinterpersonal focus, in patients with SAD in the UnitedStates and Korea. Previous studies have not assessedallocentric focus separately from offensive TKS symp-toms. We hypothesized that the allocentric fear ofoffending others would be greater in respect to offensiveTKS symptoms (e.g., stiff facial expression, unpleasant

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body odor) than for symptoms common to both SADand the neurotic subtype of TKS (e.g., blushing andtrembling), whereas the egocentric fear of embarrassingoneself would be greater for the common symptoms.Associations of features of the offensive subtype ofTKS to the overall severity of SAD, scrutiny fears,interpersonal fears, depression, and disability were alsoexplored.

MATERIALS AND METHODSSUBJECTS

Patients in the US were recruited from two sites, theAnxiety Disorders Clinic at the New York StatePsychiatric Institute (NYSPI) in New York City, NewYork (NYC) (n 5 74) and the Adult Anxiety Clinicof Temple University in Philadelphia, Pennsylvania(n 5 107). Patients completed evaluation for a clinicaltrial and received a primary diagnosis of DSM-IV SADas determined by the Structured Clinical Interview ofDSM-IV [First et al., 2002] in NYC or the AnxietyDisorders Interview Schedule for DSM-IV, Lifetimeversion [DiNardo et al., 1994] in Philadelphia,administered by a trained clinician. Patients wereexcluded if they had current major depressive disorder,history of psychotic illness, bipolar disorder or recentsubstance abuse. Patients in South Korea had soughttreatment in the clinic of the Department of Psychiatry,Kangbuk Samsung Hospital in Seoul. Korean patientshad a primary diagnosis of DSM-IV SAD, based onclinical psychiatric interview, but structured interviewswere not performed. In the Korean sample, thepresence of the offensive subtype of TKS wasadditionally diagnosed if the patient had the convictionthat his/her symptoms displeased or offended others.Korean patients were excluded if they met currentcriteria for DSM-IV major depressive disorder,obsessive–compulsive disorder, psychotic illness (otherthan offensive TKS), bipolar disorder or recentsubstance use based on the clinical interview.

Patients participated in the study voluntarily afterinformed consent was obtained and prior to beginningtreatment for SAD. The study was approved by theIRB of the NYSPI and Temple University and by ahuman subjects committee in Korea.

THE TAIJIN KYOFU SHO QUESTIONNAIRE

Because existing measures of TKS symptoms did notallow assessment of offensive TKS symptoms indepen-dently from allocentric interpersonal focus, we devel-oped the TKS Questionnaire (TKSQ, see Appendix A)to assess these features. The TKSQ was not designedto diagnose presence or absence of the syndrome ofTKS. The English version of the TKSQ was translatedinto Korean and back-translated into English toconfirm accuracy.

The TKSQ consists of 30 items. Ten physical/behavioral symptoms characteristic of TKS and/or

SAD are each rated in respect to the severity offear associated with each of three interpersonal foci:(1) embarrassing oneself, (2) making another personuncomfortable, and (3) offending another person. Theintermediate option (i.e. fear of making another personuncomfortable) was included in the TKSQ because wedid not know whether US patients would endorse themore extremely stated fear of causing offense to others.

Five of the 10 symptoms in the TKSQ werehypothesized to be specific to the offensive subtypeof TKS (fears of stiff facial expression, body odor,inappropriate staring, intestinal gas, and physicalappearance), here referred to as offensive TKS symptoms,and the other five were hypothesized to be common toboth SAD and TKS (fears of blushing, body trembling,voice trembling, sweating, and making eye contact),here referred to as common symptoms.

Offensive TKS symptoms were based on the descrip-tions of TKS by Russell [1989], Kasahara [1987],Lee [1987], Takahashi [1989], Yamashita [1993], and onthe diagnostic criteria of TKS proposed by Seedatand Nagata [2004]. For example, Lee [1987] foundfears of body odor and stiff facial expression to be morecommon in delusional and borderline types of TKS.‘‘Inappropriate staring’’ was obtained primarily fromcase reports of inappropriate staring at other’s bodyregions by Yamashita [1993]. ‘‘Physical appearance’’was derived from fears of ‘‘physical deformities’’ asnoted by Lee [1987], Seedat and Nagata [2004] andothers, because we believed the broader term betterreflected this concept.

Common symptoms were based on review of theliterature and the authors’ experience with SAD, andreview of TKS literature as noted above. For ‘‘eye-contact,’’ different terms have been used in the TKSliterature, such as ‘‘line of sight becoming uncontrol-lable’’ [Seedat and Nagata, 2004], ‘‘eye-sight’’ [Lee,1987], or ‘‘fear of side-glancing’’ [Kasahara, 1987].We chose the general term ‘‘eye-to-eye contact withanother person’’ to capture the fear of any eye-contactwith another person, include the fear of direct gazeseen in patients with SAD.

Each of 30 TKSQ items is scored on a four-pointscale: 0 5 not fearful at all, 1 5 mildly fearful, 2 5 mod-erately fearful, and 3 5 extremely fearful. The TKSQitem scores were totaled into six subscores: Fear ofembarrassment to self due to common symptoms(E-CS); Fear of discomfort to others due to commonsymptoms (D-CS); Fear of offense to others due tocommon symptoms (O-CS); Fear of embarrassmentto self due to offensive TKS symptoms (E-TKS);Fear of discomfort to others due to offensive TKSsymptoms (D-TKS); and Fear of offense toothers due to offensive TKS symptoms (O-TKS).Each subscore was the sum of five items (e.g.,E-CS 5 sum of fear of embarrassment scores for thefive common symptoms).

For analyses of prevalence of each physical/behavior-al symptom, a symptom was considered present if the

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respondent reported moderate or extreme fear (a scoreof two or three) in any of the three interpersonalfoci (embarrassment to self, discomfort to others, oroffending others) due to that symptom. The prevalenceof each symptom was also tabulated separately for eachinterpersonal focus of fear.

OTHER ASSESSMENTS

In addition to the TKSQ, all patients completedthree other self-rated scales: (1) the Social Phobia Scale(SPS) [Mattick and Clarke, 1998], a 20-item scale thatassesses fear of being scrutinized by others duringactivities such as eating or writing. Korean subjectscompleted a Korean version that had been translatedand back-translated (2) the Beck Depression Inventory,second edition (BDI-II) [Beck et al., 1996], a 21-itemscale addressing symptoms of depression, and (3) theSheehan Disability Scale (SDS), with three itemsassessing functional impairment in work, family lifeand leisure activities [Sheehan, 1983]. Korean subjectscompleted established Korean versions of the BDIand SDS [Lee and Song, 1991]. The US sample completedtwo additional instruments: (1) the Liebowitz SocialAnxiety Scale (LSAS) [Liebowitz, 1987], a clinician-rated 24-item scale that assesses severity of anxietyand avoidance in social situations and (2) the SocialInteraction Anxiety Scale (SIAS) [Mattick and Clarke,1998], a 20-item self-report scale that rates cognitive,affective and behavioral reactions of anxiety duringsocial interactions.

STATISTICAL ANALYSIS

Statistical analysis was conducted with SPSS 13.0.Continuous measures were analyzed with Student’st-tests or the Mann–Whitney U test and Pearson’sproduct-moment correlation coefficients. Chi-squaretests were applied to comparisons of categorical data.All tests were two-tailed, and P values of .05 wereconsidered statistically significant. Internal consistencywas assessed with Cronbach’s a.

RESULTSDEMOGRAPHIC AND CLINICAL FEATURES

Data for the US sample were obtained from 74patients in NYC and 107 patients in Philadelphia (totaln 5 181) (see Table 1). There were no significantdifferences between the Philadelphia and NYC samplesin age, gender, or marital status. However, the NYCsite had higher proportions of African-American andHispanic patients (25 and 26.4%, respectively) than thePhiladelphia site (15 and 2.8%, respectively) [w2 5 31.4,df 5 4, P 5.0001], and a lower proportion of collegeeducated (79.7% NYC versus 91.4% Philadelphia)[w2 5 5, df 5 1, P 5.026] and employed persons (55.4%NYC versus 75.2% Philadelphia) [w2 5 9.8, df 5 3,P 5.02]. These samples were combined in subsequent

analyses. The US sample included 10 patients of Asiandescent, but excluding these patients did not affectthe outcome of any subsequent analyses, so they wereretained in the US sample.

Data were obtained from 64 patients with SAD inKorea, including 25 diagnosed with the offensivesubtype of TKS. Patients with the offensive subtypewere more likely to be male (88 versus 64.1%)[w2 5 4.5, df 5 1, P 5.04] and married (80 versus54.3%) [w2 5 4.2, df 5 1, P 5.04], but TKS subtypesdid not differ in age, educational level or employmentstatus.

Compared to the US sample, the Korean sampleoverall was younger, more likely to be male, married,and less likely to be employed (see Table 1). Due to themarked differences between the US and Koreansamples in demographics and ascertainment, as wellas potential response bias due to cultural differences,the two groups were not compared directly insubsequent analyses.

The US sample evidenced severity of social anxietysymptoms in the range of generalized SAD [LSAS,SPS, and SIAS, Mennin et al., 2002], mild to moderatedisability [SDS, Sheehan, 1983], and subsyndromallevels of depression [BDI-II, Steer et al., 2001] (seeTable 1).

PSYCHOMETRIC PROPERTIESOF THE TKSQ

The psychometric properties of the TKSQ areshown in Table 2. TKSQ subscores in the US samplewere normally distributed with the exception of theO-CS, which was mildly skewed to the right. Theinternal consistencies of the six subscores weresatisfactory or better. In the Korean sample, E-CSand E-TKS subscores were normally distributed, butthe other subscores were positively skewed. Internalconsistencies were satisfactory or better for thecommon symptom subscores, but lower for theoffensive TKS symptom subscores. In both US andKorean samples, the TKSQ subscores were signifi-cantly correlated with common symptom subscores,social anxiety, depression and disability (Table 3).Outcomes for fear of discomfort to others wereconsistently intermediate to the other two interperso-nal foci of fear, and for clarity of presentation, thesedata were omitted from Table 3 and from Figure 1(described below) but are available on request.

PREVALENCE OF TKS FEATURES

Fear of Embarrassing Oneself and Fear ofOffending Others. The prevalence of fear of em-barrassment and fear of offending others for each of the10 symptoms in the TKSQ are shown in Figure 1 forthe US and Korean patients, respectively. The propor-tion of the US sample endorsing fear of offending othersdue to each of the 10 symptoms ranged from 15.5 to39.2% in the US sample, and from 6.3 to 25.0% in the

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Korean sample. Among Koreans with the offensivesubtype of TKS (not displayed in Fig. 1), theproportion reporting fear of offending others due to eachof the 10 symptoms was as follows: body odor (28%),inappropriate staring (20%), stiff facial expression (44%),intestinal gas (24%), physical appearance (16%), sweating(20%), body trembling (28%), eye contact (28%),blushing (24%), and voice trembling (24%).

Physical/behavioral symptoms. The prevalence ofeach of the 10 TKSQ symptoms due to any of the threeinterpersonal foci of fear was tabulated for US patients, allKorean patients, and the subgroup of Korean patients withoffensive subtype of TKS (see Table 4). In both the USand Korean samples, 75% of the sample endorsed at leastone of the five offensive TKS symptoms. Among Koreanswith the offensive subtype of TKS, 96% endorsed at leastone of the five offensive TKS symptoms.

TKSQ SUBSCORES IN USAND KOREAN SAMPLES

Mean subscores for the US and Korean samples areshown in Table 2. Within the US sample, fear ofembarrassment was greater for the common symptomsthan for the offensive TKS symptoms (E-CS versusE-TKS; t 5 6.3, df 5 180, Po.0001), and the fear ofoffense to others was greater for the offensive TKSsymptoms than for the common symptoms (O-TKSversus O-CS, Z 5 2.3, P 5.02). In addition, embarrass-ment fears were greater than offense fears within boththe common symptoms (E-CS versus O-CS; Z 5 9.7,Po.0001) and the offensive TKS symptoms (E-TKSversus O-TKS; t 5 13, df 5 180, Po.0001).

Similar to the US sample, in the Korean sample,fear of embarrassment was greater for the common

TABLE 1. Demographic and clinical characteristics of the US and Korean samples

US (n 5 181) Korean (n 5 64) Analysis

Variables N (%) N (%) w2 df P

GenderMale 104 (57.5) 47 (73.4) 5.1 1 .02Female 77 (42.5) 17 (26.6)

Marital StatusMarried 35 (19.7) 39 (65.0) 43.0 1 .001Not married 143 (80.3) 21 (35.0)

EducationCollege 151 (86.8) 48 (80.0) 1.6 1 .2High school or less 23 (13.2) 12 (20.0)

EmploymentEmployed (full or part-time) 115 (67.6) 27 (44.3) 14.6 2 .001Homemakers or students 26 (15.3) 23 (37.7)Others 29 (17.1) 11 (18.0)

EthnicityCaucasian 106 (59.2)African-American 34 (19.0)Hispanic 22 (12.3)Asian/Pacific Islander 10 (5.6)Others 7 (3.9)

Mean (SD) Mean (SD) t df P

Age 32.6 (9.6) 29.4 (8.4) 2.4 243 .01SDS-work 5.3 (3.0) 6.5 (3.1)SDS-leisure 7.4 (2.4) 6.6 (3.0)SDS-home 3.2 (2.8) 3.1 (3.0)BDI 13.0 (8.8) 16.9 (10.9)SPS 32.4 (15.9) 50.3 (18.6)LSAS 74.4 (23.7)SIAS 57.7 (14.7)

Employment ‘‘others’’ includes not employed, retired, disabled.Ethnicity: Koreans were all of Korean ethnicity. Groups were not compared in respect to clinical features, due to group differences indemographics, ascertainment, and the potential for culture-based response bias.

234 Choy et al.

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symptoms than for the offensive TKS symptoms (E-CSversus E-TKS; t 5 6.0, df 5 63, Po.0001). Fear ofoffense to others, however, did not differ between thecommon and the offensive TKS symptoms (O-CSversus O-TKS, Z 5 0.3, P 5.77). Embarrassment fearswere greater than offense fears within both thecommon symptoms (E-CS versus O-CS; Z 5 6.4,Po.0001) and the offensive TKS symptoms (E-TKSversus O-TKS; Z 5 5.7, Po.0001).

Comparing the offensive and non-offensive subtypesof the Korean sample, there was no difference inembarrassment due to the common symptoms (meanE-CS 5 7.0 and 6.9, respectively), but offense due tothe common symptoms was greater in the offensivesubtype (mean O-CS 5 4.4) than in the non-offensivesubtype (mean O-CS 5 1.7, Z 5 2.7, Po.01). In addi-tion, the offensive subtype also had greater mean scores

for embarrassment due to offensive TKS symptoms(E-TKS 5 6.0) compared to the non-offensive subtype(E-TKS 5 1.9; Z 5 3.5, P 5.001), as well as greatermean scores for offense due to offensive TKS symptoms(O-TKS 5 4.5 versus O-TKS 5 1.5, respectively, Z 5 5.0,Po.0001).

DISCUSSIONContrary to the prevailing view of TKS symptoms as

limited to East Asian cultures, this first systematicassessment of TKS features in American patientswith DSM-IV SAD found a surprisingly high levelof features of the offensive subtype of TKS. Seventy-fivepercent of the US patients reported moderate-to-severe fear of at least one of the symptoms thatwere thought to be specific to offensive subtype of TKS

TABLE 2. TKSQ subscale scores and psychometric properties of the TKSQ in the US and Korean samples

US (n 5 181) Korean (n 5 64)

TKSQ subscores Mean (SD) Skewness (SE) Kurtosis (SE) a Mean (SD) Skewness (SE) Kurtosis (SE) a

Common symptomsEmbarrassment items

(E-CS)7.3 (3.5) 0.0 (0.2) �0.6 (0.4) .65 7.0 (3.7) 0.3 (0.3) �0.5 (0.6) .74

Discomfort items (D-CS) 5.2 (7.8) 0.6 (0.2) �0.2 (0.4) .76 4.1 (3.8) 1.1 (0.3) 0.8 (0.6) .86Offend items (O-CS) 3.8 (3.7) 1.1 (0.2) 0.7 (0.4) .83 2.7 (3.4) 1.5 (0.3) 2.1 (0.6) .87

Offensive TKS symptomsEmbarrassment items

(E-TKS)5.6 (3.7) 0.6 (0.2) 0.0 (0.4) .76 4.4 (3.0) 1.0 (0.3) 0.8 (0.6) .57

Discomfort items(D-TKS)

4.8 (3.8) 0.8 (0.2) 0.2 (0.4) .79 3.0 (2.7) 1.4 (0.3) 2.2 (0.6) .63

Offend items (O-TKS) 4.3 (4.0) 0.9 (0.2) 0.3 (0.4) .83 2.7 (2.7) 1.2 (0.3) 1.6 (0.6) .63

a5 Cronbach’s a.

TABLE 3. Correlation between TKSQ subscores and standard clinical measures in the US and Korean samples

US Korean

E-CS O-CS E-TKS O-TKS E-CS O-CS E-TKS O-TKS

O-CS .52��� .49���

E-TKS .54��� .55��� .49��� .49���

O-TKS .41��� .72��� .83��� .28� .70��� .80���

SDS-work .20�� .19� .19�� .19� .38�� .36�� .48��� .39���

SDS-leisure .09 .18� .32��� .25��� .41��� .31� .46��� .38��

SDS-home .14 .08 .17� .13 .47��� .40��� .50��� .46���

BDI .21�� .21�� .37��� .37��� .45��� .39�� .50��� .40���

SPS .44��� .43��� .56��� .52��� .65��� .49��� .60��� .46���

LSAS .29��� .29��� .47��� .39���

SIAS .17� .24�� .37��� .33���

�Correlation is significant at 0.05 level; ��Significant at 0.01 level; ���Significant at 0.001 level (two-tailed).E-CS, fear of embarrassing oneself due to common symptoms; O-CS, fear of offending others due to common symptoms; E-TKS, fear ofembarrassing oneself due to offensive TKS symptoms; O-TKS, fear of offending others due to offensive TKS symptoms; SDS, Sheehan DisabilityScale; BDI, Beck Depression Inventory; SPS, Social Phobia Scale; LSAS, Liebowitz Social Anxiety Scale (only in US sample); SIAS, SocialInteraction Anxiety Scale (only in US sample).

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(intestinal gas, stiff facial expression, staring at other’sbody parts, body odor, and physical appearance).In addition, 15.5–39.2% of US patients reportedmoderate-to-severe fear of offending others (as op-posed to only embarrassing oneself) with respect toeach of the symptoms surveyed, including symptomstypical of SAD (blushing, eye contact, sweating, body,

and voice trembling). These estimates were conserva-tive because ratings of ‘‘mild’’ fears (score of 1) werenot considered in our analyses.

Features of offensive TKS were also significantlyassociated with severity of social anxiety in the USsample of patients with SAD, similar to findings innon-clinical samples [Kleinknecht et al., 1997, 1994;

Figure 1. Percentage of US (n 5 181) and Korean (n 5 64) patients with fear of embarrassing oneself and offending others due to eachof the ten symptoms assessed by the TKSQ.

TABLE 4. The percentage of US and Korean patients who endorse the 10 symptoms as a result of any of the threeinterpersonal foci of fear (embarrassment to self, discomfort to others, or offending others)

US (n 5 181) Korean: both subtypes (n 5 64) Korean: offensive subtype(n 5 25)

TKSQ symptoms N (%) N (%) N (%)

Common symptomsBlushing 103 56.9 30 46.9 13 52.0Body trembling 83 46.1 31 48.4 12 48.0Voice trembling 125 69.4 32 50.0 10 40.0Eye contact 85 47.0 32 50.0 15 60.0Sweating 81 45.3 17 26.6 9 36.0

Offensive TKS symptomsStiff facial expression 88 48.9 36 56.3 15 60.0Body odor 57 32.4 12 18.8 8 32.0Inappropriate staring 67 37.2 14 21.9 9 36.0Intestinal gas 80 44.2 17 26.6 10 40.0Physical appearance 68 37.6 11 17.2 9 36.0

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Tarumi et al., 2004]. Our findings are also consistentwith findings of Nakamura et al. [2002], who reporteda high rate of SAD in patients with TKS. UnlikeNakamura et al., however, we did not make a clinicaldiagnosis of the TKS syndrome in the US sample butonly assessed severity of features of the syndrome.

Although US patients endorsed a high degree offeatures of offensive TKS in the TKSQ, this does notimply that the US sample had a high prevalence ofTKS, as presence of the full syndrome of TKS wasnot assessed in this group. Indeed, a post hoc chartreview of 12 cases at the NYC site with the highestoffensive TKS features score [sum of D-CS, O-CS,E-TKS, D-TKS, O-TKS greater than 50 (full rangeof scores 0–75)] found no clinical documentation offeatures of offensive TKS, suggesting that cliniciansdid not inquire about offensive features, and patientsdid not spontaneously report them. It appears that USclinicians did not conceptualize offensive TKS featuresas central to SAD, and US patients may have heldsimilar conceptualizations or may have been embar-rassed to volunteer information about their offensiveTKS symptoms. Future studies that include a clinicalevaluation of the TKS syndrome will be needed toconfirm the clinical significance of TKS features inSAD patients.

Unlike the US sample, the Korean sample had beensystematically assessed for the offensive subtype ofTKS. Korean patients with SAD and the offensivesubtype of TKS had markedly higher scores on fearof offense due to common symptoms, and fear ofembarrassment and fear of offense due to the offensiveTKS symptoms than patients without the offensivesubtype. As expected, there was no difference in fear ofembarrassment due to the common symptoms. Thesefindings support the validity of the TKSQ subscales indiscriminating the clinical features of offensive TKS.This was also one of the first empirical studies of TKSsymptoms in Korea, and it supports clinical impres-sions of similarities to the TKS syndrome describedin Japan [Lee, 1987].

A secondary goal of this study was to explore thestructure of offensive TKS features with respect tothe relationship between focus of fear and typesof symptoms. Fear of embarrassing oneself wasprominent in both US and Korean samples in relationto symptoms that are common to SAD and tosymptoms typically considered to be specific to theoffensive subtype of TKS. This is consistent withJapanese psychiatrists’ observation that embarrassmentand shame to self is also common in patients with TKS[Kasahara, 1987; Russell, 1989]. In the US sample,fear of offending others was greater for offensiveTKS symptoms than common symptoms, and fear ofembarrassing oneself was greater for common symp-toms than offensive TKS symptoms. These findingssupport our hypothesis that offense to others may bemore associated with offensive TKS symptoms, such asconcerns about body odor and releasing intestinal gas,

which are inherently allocentric. It is also notable thatfor each symptom, fear of embarrassment was greaterthan fear of offense, even among Korean patients withthe offensive subtype of TKS. This suggests that thedistinction between allocentric focus of fear in Easternculture versus egocentric focus in Western cultures forSAD is not as clear as others [e.g., Chang, 1997] haveclaimed, and that it may be more accurate to suggestthat both types of fears are present in both cultures.Our results are consistent with a recent analog studyfinding that both independent and interdependenttypes of self-construal exist as a continuum in the sameindividual in both US and Japanese students [Klein-knecht et al., 1997]. Another analog study found thatUS and Japanese participants did not differ in theirinterdependence scores, and regardless of their culturalbackground, individuals who scored higher on inter-dependence scored higher in social phobia symptoms[Dinnel et al., 2002].

Due to marked demographic and ascertainmentdifferences between the US and Korean sample, aswell as the potential for culturally based response bias,we did not directly compare the two groups in respectto features of TKS. Patients may experience andpresent social anxiety symptoms differently in Westernand Eastern cultures. For example, patients from Japantend to present their problems in terms of interperso-nal difficulties (making a diagnosis TKS more likely)whereas patients from the US present their problems inmore general complaints of anxiety or mood symptoms[Tseng et al., 1992]. Reports of low lifetime rates ofSAD in the East Asian countries (including Korea) mayreflect a reluctance to endorse symptoms [Seedatand Nagata, 2004]. Clarification of cross-national andcross-ethnic differences in symptoms will requireadditional studies with a variety of samples andassessment approaches.

Limitations of this study included absence of pre-existing psychometric data on the TKSQ and lackof clinical validation of this self-assessment instrumentin the US sample. Nonetheless, the TKSQ subscalesdemonstrated good internal consistency in the USsample, and in the Korean sample TKSQ findings wereconsistent with clinical TKS subtyping. Diagnosticevaluation of the Korean patients was limited byunstructured clinical assessments of SAD and theoffensive subtype of TKS.

US patients with symptoms of the offensive subtypeof TKS may receive a variety of DSM-IV diagnoses,including anxiety not otherwise specified, a culture-bound syndrome, body dysmorphic disorder, delu-sional disorder, paranoid personality disorder, paranoidschizophrenia [Tanaka-Matsumi, 1979] or avoidantpersonality disorder [Tseng et al., 1992]. Our findingssuggest the need for further study of a broaderconceptualization of SAD that acknowledges somefeatures of the TKS syndrome, including fears ofoffending others as well as classic offensive TKSsymptoms such as fears of stiff facial expression or

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inappropriate staring. Wider assessment of featuresof TKS would enable researchers to better understandtheir relationship to SAD and other disorders, as wellas encourage clinicians to assess features of TKS inpatients who present with complaints of social anxietyand avoidance.

Future studies should determine if the presenceof offensive TKS features in SAD patients predictsresponse to cognitive behavioral therapy or pharma-cotherapy. A chart review of 48 patients with TKSreported a 48% response rate to treatment withclomipramine or fluvoxamine [Matsunaga et al.,2001], and a recent open trial reported that 41% of19 patients diagnosed with the offensive subtype ofTKS (without comorbid disorders) responded toparoxetine [Nagata et al., 2006]. These response ratesare lower than those reported in most controlled trialsof SSRIs for SAD [Blanco et al., 2002]. Clearly,prospective, controlled studies are needed to supportthe preliminary treatment results for TKS.

In summary, our findings that features of theoffensive subtype of TKS are not uncommon inpatients with SAD in both the US and Korea suggestthat offensive TKS features are less specific to EastAsian cultures than previously thought. They suggestthat Western clinicians should assess offensive TKSsymptoms in their patients with SAD and supportfurther consideration of the relationship of TKS toSAD.

Acknowledgments. We thank Andrew Schmidtfor managing the dataset.

Appendix AThe Taijin-Kyofu-Sho Questionnaire (TKSQ)

assesses severity of 10 physical/behavioral symptomsin respect to distress from embarrassment to oneself,discomfort to others, and offense to others (SeeTable A1).

TABLE A1. The Taijin Kyofu Sho Questionnaire(TKSQ)a

PLEASE CIRCLE ONE RESPONSE FOR EACH OF THEFOLLOWING QUESTIONS:How fearful are you that you may blush in front of others,such as turning red when someone asks you a question, and as aresult:1. You will feel embarrassed.

a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

2. You will make another person uncomfortable.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

3. You will offend another person.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

How fearful are you that your facial expressions may stiffen in frontof others, such as not being able to change the expression on yourface, and as a result:

4. You will feel embarrassed.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

5. You will make another person uncomfortable.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

6. You will offend another person.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

How fearful are you that your head, hands, and/or feet will tremblein front of others, and as a result:

7. You will feel embarrassed.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

8. You will make another person uncomfortable.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

9. You will offend another person.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

How fearful are you that your voice will tremble while talking withothers, and as a result:

10. You will feel embarrassed.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

11. You will make another person uncomfortable.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

12. You will offend another person.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

How fearful are you that you will sweat or perspire in front of others,and as a result:

13. You will feel embarrassed.a. Not fearful at allb. Mildly fearfulc. Moderately fearfuld. Extremely fearful

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aThe TKSQ format was presented in one column in the study butdisplayed here in two columns because of space limit.

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