Abstract
Taijin-kyofusho (taijin, interpersonal; kyofu, fear;sho, syndrome) was originally defined by Morita [1]. Patients with taijin-kyofusho have the obsession that they might displease or embarrass others due to somatic symptoms such as blushing, a defect in the appearance of the face or body, staring inappropriately, or emitting a foul odour [2]. Because of these perceived problems, people with these symptoms fear being unaccepted and avoided by others.
Although there is no specific diagnostic criterion of taijin-kyofusho (fear of interpersonal relations), the fear of somatic symptoms mentioned above is clinically regarded as taijin-kyofusho only when the fear is seen with no other obvious mental symptom, or in the course of schizophrenia or depressive disorder. However, individuals with fear of interpersonal relations may secondarily develop depression due to worry about the symptoms of fear of interpersonal relations, or may become schizophrenic later. The frequency of occurrence of depression among patients with fear of interpersonal relations remains unknown, and it is also unclear which fear of interpersonal relations subtypes are predisposed to depression. According to the content of the fear, fear of interpersonal relations has been classified into four subtypes: sekimen-kyofu (the phobia of blushing), shubo-kyofu (the phobia of having a deformed face/body), jiko-shu-kyofu (the phobia of one's own foul body odour), and jiko-shisen-kyofu (the phobia of one's own glance) [2–4]. It has been pointed out that phobia of one's own foul body odour is the subtype that most often results in schizophrenia [3]. Patients with fear of interpersonal relations usually have only one of these subtypes at a time, rather than multiple subtypes. Fear of interpersonal relations typically begins in adolescence. However, the detailed natural course of the illness has not been clarified. Phobia of blushing spontaneously remits by age and few patients with this subtype receive physicians’ treatments. Phobia of one's own foul body odour responds to SSRIs and antipsychotics [5], but which treatment is more effective has not been determined. The others, phobia of one's own glance and phobia of a deformed face/body, have symptoms that fluctuate between remission and exacerbation, and there is no effective treatment for either of these conditions.
Although fear of interpersonal relations has been considered as a culture-bound syndrome [6–11], it can also be classified under existing categories in the DSM-IV-TR [12]; cases meeting the definition of some of these subtypes have, in fact, been reported in the west [13]. For instance, phobia of blushing, a subtype that is most often observed in patients with fear of interpersonal relations, can reasonably be included under the category of social phobia according to the DSM-IV, since a fear of blushing is a common symptom among people with social phobia. In addition, phobia of a deformed face/body fulfils the criteria for body dysmorphic disorder, which is classified as a somatoform disorder according to the DSM-IV. Therefore, the notion that fear of interpersonal relations is purely a culture-bound syndrome does not hold true under scrutiny. Although phobia of one's own foul body odour cannot be adequately assigned to any of the diagnoses in the DSM-IV system, a similar condition does exist in the literature in the west (i.e. olfactory reference syndrome) [13,14]. The remaining subtype, jiko-shisen-kyofu (jiko, self; shisen, glance; kyofu, fear), is the condition in which patients convince themselves of hurting others and displeasing them because of their own sharp-eyed and displeasing glance. The concept of, jiko-shisen-kyofu, phobia of one's own glance, is also clearly different from that of shisen-kyofu, which is a term clinically used by physicians in Japan and corresponds to a fear of being observed by others or a fear of direct eye contact.
To the best of our knowledge, only a single case closely resembling phobia of one's own glance has been reported thus far in a western country. McNally et al. [15] described an American woman who feared embarrassing others by glancing at their genital areas, and she was given a diagnosis of fear of interpersonal relations. However, that report did not elaborate upon whether the source of the fear of displeasing others was due to the patient's glance itself or whether the fear was, instead, related to being seen staring at the genital area in particular. If the latter were the case, that patient would not have been diagnosed as having phobia of one's own glance according to the strict classification system used in Japan. On the basis of the Japanese diagnostic system, phobia of one's own glance is characterized as a fear of uncontrollably glancing at people in the vicinity [3]. It is likely that the broader concepts of fear of interpersonal relations have been misunderstood in the west, since these concepts have not been adequately introduced into western society [16,17]. To make matters worse, the concept of phobia of one's own glance has never been introduced in the west. Therefore, better characterization of this condition is still needed. In this report, we present four Japanese cases in the hope of providing a clear picture of jiko-shisen-kyofu (phobia of one's own glance), and discuss whether or not this condition is a culture-bound unique entity.
Report of cases
Case 1
A 27-year-old male farmer presented with the persistent preoccupation that his glance was harmful to other people. When he was a 16-year-old high school student, he first had the fear that his glance at women was causing them discomfort. After graduating from high school, he started to work at a restaurant. However, because he persistently felt embarrassed by the belief that the expression in his eyes was disturbing customers at the restaurant, and because his job involved working closely with others, he resigned from the job. Subsequently he changed jobs, repeatedly turned down promotions, and eventually took up running a dairy farm because he thought that by doing so, he could avoid seeing other people. Nevertheless, when he was 27 years old, he developed a much more severe fear of the possibility that his peculiar glance could hurt everyone near him. Accordingly, he became progressively depressed and socially withdrawn, and then ultimately visited our clinic. He reported that his conviction of offending others with his glance made him feel uneasy and often irritable, although he acknowledged that his fear was excessive and unreasonable. He was treated with various anxiolytics, but no improvement was observed. Thus, the patient was advised to be admitted to a hospital to receive treatment with Morita therapy, which was developed in the 1920s in Japan. Morita therapy has recently been re-evaluated as a type of cognitive-behavioural therapy, and is currently used in clinical practice in Japan [18]; this approach has proven effective for the treatment of fear of interpersonal relations [19]. However, in this case, the patient turned down the offer and sought treatment elsewhere.
Case 2
A 21-year-old female student presented with the fear that her glance was a nuisance to others. Since childhood she had been abused by her father. At age 13, her parents were divorced. When she was 15 years old and in high school, she began to worry that she annoyed others with her glance. She perceived objects in her surroundings as flat, i.e. as having only two dimensions. She thus consulted an ophthalmologist, but no abnormalities were found. As her grades worsened, she left school without completing her coursework. The patient reported an avoidance of seeing other people, and she finished high school by completing correspondence courses; after completion of that course, she enrolled at a university. At the age of 21, she was admitted to our hospital. She complained that her eyes made people in her immediate vicinity uncomfortable. To avoid glancing at others, she looked downward at all times and often closed her eyes, even at mealtimes. Nonetheless, she felt that her field of vision had expanded. She felt restless because she was unable to keep from glancing at someone near her, in spite of her efforts not to do so. She also presented with anxiety, agitation, labile affect, and suicidal ideation. Daily administration of both alprazolam at a dose of 1.2 mg and risperidone at 1 mg ameliorated these symptoms, except for the fear of offending others with her glance. She admitted that her idea that her eyes made others uncomfortable was excessive. The patient confessed that even after her parents’ divorce, her father remained living close to her and her mother's house, and that he continued to abuse her physically. This necessitated an intervention, and the father was warned against seeing his daughter, which in turn was found to reduce, to a remarkable extent, the patient's worries about her own glance. After discharge, she succeeded in obtaining a part-time job in a bakery.
Case 3
A 50-year-old male taxi driver presented with the persistent preoccupation with the idea that his glance rendered his customers embarrassed. The problem that his own glance embarrassed others started when he was 20 years old. He gradually became depressed and withdrew from all social situations into his home. At age 22, he was treated with an antidepressant, which improved his depressive symptoms but the fear of his own glance remained. When he consulted a physician for a fever at the age of 25 he was referred to our clinic due to irritability and sleep disturbance. The patient reported that when he met people, he always felt that they were disdainful and condemned him. He feared glancing at others uncontrollably and also being stared at by others and interpreted others’ attitudes as evidence of their displeasure with him. The patient did not demonstrate any insight regarding his irrational thoughts. However, his worries were ameliorated, to some degree, during the subsequent 25 year follow-up period with 3–6 mg /day of pimozide. Despite the administration of other types of antipsychotics aimed at treating the delusional nature of a patient's preoccupation, this patient's belief that his glance embarrassed others remained basically unchanged. However, the patient has been able to continue to work as a taxi driver, although he continues to change the direction of the rear-view mirror such that his glance does not meet the customer's eyes.
Case 4
A 52-year-old female presented with the chief complaint of being disturbed by her own glance. She had become depressed with suicidal ideations during almost every autumn since the age of 48, and she was treated with antidepressants during each episode. At age 52, she began to be concerned that her own glance made others, including her husband and close friends, feel unpleasant and caused them discomfort. She visited our clinic a few months later. She believed that her eyes were assuming an offensive expression. She was convinced that her eyes led others to feel uncomfortable, even though she acknowledged that her idea was somewhat ludicrous. The fear of her own glance was not concomitant with any depressive symptom. In this case, the problem responded well to a combination of 30 mg/day of maprotiline and 6 mg/day of bromazepam, an anxiolytic. After administration of this combination treatment, she reported only rare feelings of embarrassment due to this problem. Four months after her initial contact with our clinic, the patient discontinued the treatment and did not re-visit our clinic.
Discussion
On the basis of the Japanese diagnostic system, phobia of one's own glance is characterized by a fear of one's own glance, which they believe assumes an offensive nature and is uncontrollably directed at persons near them [3]. Individuals with phobia of one's own glance believe that their glance brings others discomfort, and people with this diagnosis convince themselves of the accuracy of their belief by interpreting the trivial behaviour of others (e.g. coughing, laughing, sniffing, sneezing, head turning, etc.) as evidence for this belief. Such patients feel deeply ashamed, demeaned, and unaccepted, and many eventually avoid social situations [20]. A diagnosis of phobia of one's own glance is not contingent upon whether or not a patient considers his or her thoughts to be excessive [3]; therefore, neither the presence nor a lack of insight is essential for the diagnosis. The fear of one's own glance in cases of phobia of one's own glance is clearly different from the fear of being observed by others or a fear of eye-to-eye contact, which is often seen in patients with social phobia; it is also markedly different from the fear of being watched by others in a delusional context (e.g. delusion of reference) in schizophrenia.
The patient described in Case 1 had no apparent psychotic symptoms other than jiko-shisen-kyofu (phobia of one's own glance). The patient had only a single prominent symptom, i.e. the fear of one's own glance itself, and both patients demonstrated good insight regarding their irrational thoughts. In Japan, such patients represent typical and pure phobia of one's own glance sufferers, and these people are often seen by non-physicians in a variety of private treatment settings [5]. Although Case 2 was also a typical case of phobia of one's own glance, this patient exhibited depersonalization, anxiety, and depression in the course of her illness. These symptoms seemed to co-occur secondary to her distress over the phobia of her own glance. There are some cases in which patients show characteristics other than those of phobia of one's own glance alone, as described in Cases 3 and 4. In Case 3, the patient believed that attitudes and gestures of others had personal significance for him, and he had no insight into the pathological level of the belief. In this regard, his belief could be regarded as delusional. In fact, a diagnosis of delusional disorder could be assigned to this case, according to the DSM-IV. As regards Case 4, the patient suffered from a recurrent type of depression, and her phobia of her own glance first appeared four years after the onset of depression, but was not concomitant with the depressive episode. In this case, the phobia of her own glance and depression are likely to be independent. On the other hand, an antidepressant was found to be an effective treatment for her phobia of her own glance. Most patients with phobia of one's own glance have been reported as being resistant to treatment with antidepressants [3]. Additionally, her condition had an exceptionally late onset. Because of these findings, the appearance of phobia of one's own glance in Case 4 may be considered to reflect depressive symptoms.
As mentioned earlier, only a single case has been reported in the west that seems to resemble phobia of one's own glance [15]. In Asian countries other than Japan, one Korean case was thought to reflect phobia of one's own glance [21]. As judged from the description of that case, the Korean patient described as a case of ‘fear of gaze’ in the report appears to have had a feature characteristic of phobia of one's own glance, i.e. the fear of discomforting others with patient's own glance. This is therefore the only non-Japanese case that fulfils the definition of jiko-shisen-kyofu (phobia of one's own glance) as used in Japan. No other unequivocal reports of cases of phobia of one's own glance have been published to date.
Although each of the four subtypes of fear of interpersonal relations differs as regards the content of the fear as described earlier, they have a common feature, which is the sense of being ashamed, unaccepted, and avoided by others [1–3]. Fear of interpersonal relations is, in effect, used broadly as a term for describing subjects with this common feature in Japan. Such a concept of fear of interpersonal relations seems to have been erroneously recognized as a single symptomatic entity among western psychiatrists. This confusion may have arisen from an imprecision in, or inadequacy of, the introduction of this concept into the western world. We have recently reported that three of the four subtypes of fear of interpersonal relations, taijin-kyofusho, with the exception of jiko-shisen-kyofu (phobia of one's own glance), can be adequately classified under certain categories in the DSM-IV [12]. Furthermore, patients who have characteristics of each of these three subtypes have been reported in the west [14]. Therefore, although in the DSM-IV fear of interpersonal relations, taijin-kyofusho, has been described as a culturally distinct syndrome in Japan, this conceptualization of the disorder is untenable. Nevertheless, jiko-shisen-kyofu (phobia of one's own glance), a subtype of taijin-kyofusho (fear of interpersonal relations), may be a unique entity and culture-bound syndrome, since no case with phobia of one's own glance has been reported in western countries. A single case resembling phobia of one's own glance was reported in Korea, and that report, combined with the fact that Korea and Japan have similar cultures [20], indicates that this condition may exist in countries with cultures similar to that of Japan. In east Asia, including Japan, Korea, and also China, there is a cultural emphasis on proper social etiquette and an over-concern about interpersonal relations with intermediately surrounding persons. Therefore, phobia of one's own glance is not a condition ‘bound’ to the Japanese culture; rather, it should be described as an east Asian culture-related specific syndrome [22].
To clarify this issue, further studies will be needed; for example, population-based studies should be conducted in various countries in order to determine whether the condition of phobia of one's own glance is virtually non-existent in western countries, and also to determine whether or not phobia of one's own glance is an east Asian culture-related specific syndrome.
Footnotes
Acknowledgements