1.1 - Taijin Kyofusho: from Cultural Bound Syndromes to Idiom of Distress
DSM-5 defines “Taijin Kyofusho” as a “cultural syndrome characterised by anxiety about and avoidance of interpersonal situations due to the thought, feeling, or conviction that one's appearance and actions in social interactions are inadequate or offensive to others” (APA 2013, 837). Individuals diagnosed with Taijin Kyofusho tend to focus on the impact they can have on other people, believing that they may be a threat to the group's cohesiveness by causing them discomfort (Bhardway, Shekhawat, and Viju 2021). Major concerns are facial blushing, having an offensive body odour, inappropriate gaze or body deformity (APA 2013). The symptomatology of this syndrome is very close to the one of “social phobia” (Essau et al. 2012): both “social phobia” and “taijin kyofusho” refer to a form of distress connected with social situations. What distinguishes the first from the latter is that individuals with “social phobia” are afraid to embarrass themselves, while individuals diagnosed with taijin kyofusho fear that they may offend others, bringing shame upon to their social or familiar group (Essau et al. 2012). Furthermore, taijin kyofusho symptoms tend to be more exacerbated in social situations with acquaintances, such as talking to colleagues, and less so when interacting with strangers or intimate friends and family. Fear symptoms of social phobia, instead, are related to being in social or performance situations, in which the person is exposed to unfamiliar people or exposed to possible scrutiny by others (Essau et al. 2012).
The distinctive symptoms of taijin kyofusho occur especially in Japan (in japanese taijin means “in relation to others” and kyofusho “fear or phobia”; namely “fear of others” (Zhang et al. 2001)), but also Korea, Australia, New Zealand and USA (APA 2013). For these reasons, as can also be seen from the definition reported above, DSM-5 conceptualises Taijin Kyofusho as a “cultural syndrome”, meaning that it occurs especially in specific cultural contexts.
The concept of “Culture-bound Syndrome” (CBS from now on) first appeared in the DSM nosography in 1994, with the fourth version of the manual. The introduction of this concept aimed to understand culture not as a merely confounding factor of the diagnostic process, but as a different worldview with impact on illness experience (Kirmayer 2006). Culture-bound Syndrome helped to draw the attention to the contingent dimension of mental disorders, showing how they are constructed and related to political, social and economic dimensions (Kleinmann 1977; Kaiser and Weaver 2019). However, with the introduction of this term, some criticism arose among the scientific community. The concern was related to an “uncritical and static” presentation of these syndromes, reifying them through a detachment process from the interactive and “vital” context of origin that produces them (Kaiser and Weaver 2019). Other issues of CBS are related to: finding of patterns of “cultural-symptoms” in different cultural contexts, lack of a cohesive presentation of symptoms characterising CBS, diversity in aetiological attributions, vulnerability groups and symptoms that risk to influence the cultural label (Kohrt et al. 2014).
To take over these limitations, the construct of “Idiom of Distress” was introduced. The main idea was to explore how people experience distress through an analysis of what they say and do about it (Kaiser and Weaver 2019), focusing on the social and personal meaning of these words: this has been used to identify collective and individual areas of coping, social support, and intervention (Lewis-Fernandez and Kyrmayer 2019). This construct is due to the work of Mark Nichter (1981; see also Nichter 2010) and it gained rapidly large consensus among the scientific community, as the amount of work made with it testifies (for a review see Kaiser and Weaver, 2019; Kohrt et al. 2014; Cork, Kaiser and White 2019). Other attempts to overcome the use of the term CBS have been made through the constructs of “cultural syndrome”, “popular category of distress” and “explanatory model” (Kohrt et al. 2014; APA 2013). To aggregate these different constructs, DSM-5 used the term “cultural concept of distress” (CCD) to refer to the “ways cultural groups experience, understand and communicate suffering behavioural problems, or troubling thoughts and emotions” (APA 2013, 758) stating in addition, that “all forms of distress are locally shaped, including DSM disorders” (APA 2013, 758). The appearance of CCD in the DSM-5 marks the interest and attention of the scientific community towards the ways in which the cultural background shapes the expression of distress.
Therefore, on the one hand, it is possible to observe an increasing interest in the study of how people use the language to express their distress. On the other hand, recent reviews highlighted some criticalities in the methods adopted to study, compare and use the CCD (for a review see Cork, Kaiser and White 2019; Kohrt et al. 2014). Deepening these criticalities, it is possible to observe how the core issue in the scientific observation of CCD is translation, which “permeates” the entire field of study of CCD (Cork Kaiser and White 2019): from information gathering, to the ways idioms are translated and contextualised in terms of local meaning and used during the intervention. For example, a possible issue, as the works of Cassaniti (2019) et al. (2019) show, is that the same idiom of distress can be used to describe a wide range of different experiences, highlighting the polysemic dimension of these words to be understood in relation to the specific communicative contexts in which they are used. Moreover, idioms of distress are embedded in a dense web of interactions between local and global meanings, making specific ethnographic analysis necessary to understand the particular meaning attributed to the studied term (Mendenhall et al. 2019; Lewis-Fernandez and Laurence 2019). In the last years, scholars have tried to deal with these issues in many innovative and different ways, however there’s still a lack of a common guideline for the study of idioms of distress (Weaver, Krupp and Madhivanan 2022).
Consequently, since what has been said so far, Taijin Kyofusho can be understood as a content used by people living in specific areas of the world to express, communicate and generate their experience of suffering. Introducing the construct of idiom of distress, we highlighted some issues connected to the content analysis of these words. Therefore, in continuity with the work inaugurated by Richter, we present an approach that, focusing on the processual use of language by speakers, aims to offer an innovative contribution to the study on how people generate, through language, their experience of distress.
1.2 - From content to process analysis of language through Dialogical Science
Dialogic Science (Turchi and Orrù 2014; Turchi et al. 2021) is a research program that, thanks to the formalisation of the use of natural language, allows the study and the analysis of how speakers interact and generate their reality of sense through language; i.e. how they create different “Discursive Configurations” (for a definition of this construct see Turchi et al. 2014; Turchi and Orrù 2014; Turchi et al., 2021). We emphasise how the object of Dialogic Science is the language as theorised by Wittgenstein (2009), making it necessary to distinguish language from the different local idioms. In fact, the first refers to a feature of humankind that allows humans to interact using a system of symbols and a set of rules of use of these symbols. The latter refers instead to the local “shapes” that language can assume: French, Swahili, Italian, Japanese and all the other idioms and dialects used around the world. In other words, it is possible to state that the language is what all idioms have in common (Turchi and Orrù 2014).
Moreover, Dialogic Science focuses on the ostensible property of language, i.e. the property of language to assume a different value every time the symbolic unit is used (Turchi 2009). More specifically, Dialogic Science uses a formalised language to describe the ways in which natural language is used to interact; each one of these ways is conceptualised as a specific rule of use of natural language (Turchi and Orrù 2014). To date, this research program conceptualized 24 rules of language use, to which correspond 24 “Discursive Repertories” (for a definition of this construct, see Turchi et al. 2014a; Turchi and Orrù 2014; for a deeper understanding of the different Discursive Repertories and the discursive-interactive framework they generate, see the paragraph 2, and the attached materials in Turchi et al. 2021).
Focusing on the usage value of language allows the researcher to overcome the content differences that characterise each idiom and to observe the interactive scenario that the use of these contents generates. Hence, if the comparative research usually focuses on the content brought by the respondents (Hoffman, Anu Asnaani and Hinton 2010; Vriends et al. 2013), distinguishing, for example, between individualistic and collectivistic contents, independent and interdependent self-construal’s content (for a review see Hoffman, Anu Asnaani and Hinton 2010), the focus on processual dimension allows the researcher to observe and measure also how all these contents are used to generate a reality of sense and interact with others (Turchi and Vendramini 2016; Turchi et al. 2021).
To clarify the difference between a content analysis (of meaning) and a processual one (rule of use), here are some examples:
1. a) “Being patient is not always the best behaviour”; b)“I’m a patient of my doctor”
2. a) “All the patients are sick”; b) “Yesterday, during lunch, I saw some patients waiting outside the doctor’s office”.
In the first case (1) it is possible to distinguish two different meanings of the same word “patient”. In the second couple of sentences (2), the word “patient” has always the same meaning, however it is used in two different ways: in the first case (a) to state an absolute and certain reality, with a lack of common references and thus allowing no other possible scenario; conversely, in the second case (b), the language is used to describe a fact, a situation, providing the interlocutor with shareable references, thus opening to the interaction and so to the generation of other different reality of sense.
Finally, the aim of this explorative research is to describe and compare the modalities through which people with different cultural backgrounds use the idiom of distress of “social phobia” and “taijin kyofusho”, to interact, configure and give shape to a reality of sense. In doing so, our aim is to contribute to the research program on the idiom of distress, providing transcultural and “transidiomatic” scientific data on how people use language when they talk about distress experiences. Moreover, these data, thanks to the measures provided by Dialogic Science, can be used to anticipate the interactive scenario that specific rules of use of the language make more possible (see the next section for further details on this last aspect and the discussions for some examples).