08 Ono (dm/d) 9/11/01 12:18 pm Page 506

transcultural
psychiatry
December
2001

ARTICLE

Taijin Kyofusho in a Japanese Community

Population

YUTAKA ONO
Keio University School of Medicine

KIMIO YOSHIMURA
National Cancer Center Research Institute

KEITA YAMAUCHI, MASAHIRO ASAI, AND JEROME YOUNG

Keio University School of Medicine

SHIGEKI FUJUHARA
Yamazumi Hospital

TOSHINORI KITAMURA
Kumamoto University Medical School

Abstract We report the first community epidemiological study of taijin

kyofusho in Japan. A total of 132 inhabitants in a small community in the
city of Kofu, Japan, was interviewed by trained interviewers using a semi-
structured interview, and completed self-report questionnaires. Of these
respondents, nine (6.8%) reported ‘taijin kyofu’ symptoms, eight of whom
reported having specific concerns about strong body odor although the
‘taijin kyofu’ symptoms were not serious enough to meet the criteria of a

Vol 38(4): 506–514[1363–4615(200112)38:4;506–514;020117]

Copyright © 2001 McGill University

506
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 507

Ono et al.: Taijin Kyofusho in Japan

mental disorder. Although taijin kyofusho has traditionally been viewed as a

disorder of young males, our cases were older and predominantly female.
Although this sample was small and drawn from only one community, and
we had no control group, our findings seem to support the view that some
psychiatric symptoms are influenced by socio-cultural factors and that the
symptoms of taijin kyofu are likely to be found in the general population of
Japan.
Key words body odor • community • socio-cultural • taijin kyofusho

Introduction
Taijin kyofusho, usually translated as ‘anthropophobia’ or ‘phobia of inter-
personal relations,’ is a syndrome characterized by an excessive sensitivity
to interpersonal relations. The psychopathology of taijin kyofusho was first
described by Shoma Morita in the 1920s (Fujita, 1986). Taijin kyofusho is
a type of shinkeishitsu (anxiety disorder) in which patients feel extremely
anxious whenever they are in the presence of other people. Patients suffer-
ing from this syndrome experience a variety of symptoms including fear
of eye-to-eye contact, fear of blushing, fear of an imagined ugliness and
fear that their body smells offensive to others. Morita characterized the
personality of these patients as introverted. Excessive introspective focus
on the self leads the patient to become preoccupied with his bodily and
mental condition, including both his social self-presentation and his sense
of what he considers appropriate social behavior. This preoccupation is the
basis of the patient’s hypochondriacal temperament and leads to manifold
phobic symptoms.
As one of the essential features of taijin kyofusho is phobic avoidance of
interpersonal relationships, it superficially resembles social phobia in
DSM-IV (American Psychiatric Association, 1994). However, taijin
kyofusho is a broader concept. Yamashita (1982), for example, pointed out
the overlap between the psychological structure of taijin kyofusho and that
of hypochondriasis. Kirmayer (1991, 1995) has argued that some patients
diagnosed with taijin kyofusho could be diagnosed as having body dys-
morphic disorder. Other studies (Nakamura, 1994; Narita, 1988) have
suggested that certain types of taijin kyofusho may be diagnosed as un-
differentiated somatoform disorder. Phillips, McElroy, Kecker, Pope, and
Hudson (1993) suggested that in the case of dysmorphophobia, taijin
kyofusho encompasses both psychotic and non-psychotic conditions.
In addition to being broader in scope than the DSM definition of social
phobia, taijin kyofusho differs in the emphasis placed on specific symptoms
in the definition. Whereas the DSM emphasizes the fear of embarrassment
in social situations, taijin kyofusho is marked by a persistent concern about
disturbing others. This difference points to socio-cultural factors in the

507
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 508

Transcultural Psychiatry 38(4)

presentation of self. Kirmayer (1991) discussed some of the cultural factors

that might account for the Japanese emphasis on the group over and above
the individual. This sensitivity toward others and the group is so great that,
as with social phobia, a person afflicted with this disorder is afraid of and
even avoids interpersonal situations. Patients with taijin kyofusho,
however, typically withdraw from interpersonal situations due to a strong
concern that others might look down upon them, or that they might make
others feel uncomfortable. Such fear is thought to be due to individuals’
belief that their blushing, eye-to-eye contact, an imagined ugliness, or
body odor is disturbing to others, and not primarily because they are
embarrassed.
One other significant aspect of taijin kyofusho, which distances it from
DSM social phobia and points to an important socio-cultural element of
the disorder, is the fact that it has been a psychiatric diagnostic category in
Japan for nearly 80 years, whereas social phobia was only introduced into
the third edition of DSM in 1980. This suggests that socio-cultural factors
have played an important role in the recognition of psychiatric symptoms
(Edgerton, 1969; Kleinman, 1978). In Japan, where there is an emphasis on
the proper relationship of the self to the group, there was recognition early
in the last century of a type of obsessive neurosis which has only been
recognized in the West (albeit with a narrower focus and different
emphasis) over the last 30 years.
The medical community’s understanding of taijin kyofusho has been
based on studies of patients in medical settings. Although taijin kyofusho
has been seen commonly in clinical settings in Japan and its characteristics
have been discussed from a cultural point of view (Kirmayer, 1991;
Scheper-Hughes & Lock, 1987), no epidemiological study on ‘taijin kyofu’
symptoms has been carried out in the general population to determine the
presence of ‘benign’ (subclinical) forms of the symptoms. By looking at a
non-patient population it is possible to gain insight into the role of culture
in the presentation of self and mental illness. To our knowledge, this is the
first study of its kind in Japan using a semi-structured interview.

Methods
In this article, we report the results from a study carried out in town A in
the City of Kofu, the capital of Yamanashi Prefecture, during the summer
of 1993. The details of this study are described elsewhere (Ono et al., 2000).
All inhabitants aged 18 years or older (N = 508) were invited to take part
in an interview survey, and 132 (26%) agreed to participate. All partici-
pants were given self-report questionnaires and were interviewed by
trained psychiatrists or psychologists who used an ad hoc semi-structured
interview schedule, the Time-Ordered Stress and Health Interview

508
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 509

Ono et al.: Taijin Kyofusho in Japan

(Kitamura, 1992). Results using this interview have been reported else-
where (Aoki, Fujihara, & Kitamura, 1994; Fujihara & Kitamura, 1993).
In addition to questions to assess mood, anxiety, and other psychiatric
disorders, this interview schedule included five specific questions dealing
with ‘taijin kyofu’ (fear of interpersonal relations). Two questions
concerned sensitivity to personal body odor: ‘Do you ever notice an un-
pleasant body odor coming out of your own body?’ and ‘Do you think that
people around you notice your body odor?’ Two questions focused on a
preoccupation with an imagined defect in the person’s appearance: ‘Do you
think that some parts of your body are different from those of others?’ and
‘Do you think that other people notice that some parts of your body are
different from those of others?’ Finally, one question addressed concerns
about eye-to-eye contact: ‘Do you think that your eyes sometimes make the
person you are looking at feel uncomfortable?’ The interviewers were
instructed not only to score the presence or absence of these symptoms but
also to write down the participants’ answers verbatim. One of the authors
(YO) reviewed all the descriptions of ‘taijin kyofu’ symptoms.

Results
Of the 132 participants interviewed, nine (6.8%) reported ‘taijin kyofu’
symptoms (Table 1). The nine participants consisted of seven women and
two men. Of these nine people, only two were diagnosed with any kind of
mental illness. One participant was diagnosed with simple phobia, and
another one was diagnosed with a combination of obsessive–compulsive
disorder, panic disorder, and simple phobia. None of them, however, was
diagnosed with taijin kyofusho per se because the symptoms were not
serious enough to warrant the diagnosis.

TABLE 1
Subjects with subclinical ‘taijin kyofu’ symptoms
Location of Eye-to-
Locations of imagined eye
Age Sex Odor odor Dysmorphic deficits contact

Case 1 36 F + axilla
Case 2 45 F + leg
Case 3 70 F + axilla
Case 4 70 F + mouth
Case 5 73 F + whole body
Case 6 45 M + axilla + eye
Case 7 66 F + mouth, axilla + head, eye, nose
Case 8 64 F + axilla +
Case 9 55 M +

509
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 510

Transcultural Psychiatry 38(4)

These participants did, however, express a ‘benign’ (subclinical) concern

about their body odor, their physical appearance and/or eye-to-eye
contact. Two of the participants reported feeling uncomfortable with
eye-to-eye contact, and two others reported imagined defects in their
bodies. The location of the imagined defects was the face (in one case the
eyes, and in the other case the head, eyes, and nose). The most interesting
result of our study related to concerns about unpleasant body odor. Eight
of the nine participants (seven of whom were women) who reported taijin
kyofu symptoms were fearful that their bodies gave off unpleasant odors.
Four participants reported that they were concerned that they had bad
breath; four complained that the odors came from their axilla; one thought
the odors came from her legs, and another believed that the odors came
from her whole body. Of these eight participants, six said they were
conscious of their own body odor but that other people neither noticed
nor complained about it. The other two participants, however, complained
that others noticed their body odors.

Discussion
It has been pointed out that taijin kyofusho is a culture-bound syndrome
(Kasahara, 1975; Kirmayer, 1991; Tseng, Asai, Kitanishi, McLaughlin, &
Kyomen, 1992) and a considerable amount of literature concerning this
issue has been published (Kirmayer & Robbins, 1991; Tanaka-Matsumi,
1979). Although the presence of taijin kyofu symptoms in our participants
was not severe enough for a diagnosis of a mental disorder, our data lend
credence to the view that taijin kyofu symptoms are culture bound.
Traditionally, taijin kyofusho has been thought of as an illness afflicting only
young people between the ages of 14–29 (Kasahara, 1975, 1986; Russell,
1989), but all nine participants who reported taijin kyofu symptoms were
older.
In our study, the most frequently reported symptom was fear of bodily
odor. Fear of bodily odors is among the most frequent symptoms of taijin
kyofusho and eight of our nine participants (seven of whom were women)
reported concerns about giving off offensive odors. They reported that the
odors came from sites where people usually emit odor; namely, the mouth
(four cases) and axilla (four cases). This fear of bodily odor may reflect the
socio-cultural context and interpersonal schema of the individual because
most of the participants reported that other people had not noticed any
odor. Our participants seemed to be more concerned with their self-
presentation, i.e., with their own awareness of their body odor, than with
an actual perception of any odor by others. This suggests that the partici-
pants place more emphasis on their internal image of their interpersonal
relationships than their actual external experiences.

510
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 511

Ono et al.: Taijin Kyofusho in Japan

Usually, taijin kyofusho is thought of as a predominantly male disorder

(Russell, 1989). Interestingly, in our study, of the nine participants who
reported taijin kyofusho symptoms, seven were women. One possible
explanation for this might be that the traditional expectation for Japanese
women to stay at home and be less assertive in society makes them more
self-conscious (Ono et al., 1996). Moreover, as our women participants
were older, they might be more influenced by these traditional values
which emphasize self-appearance and appropriate social behavior. These
women probably monitor their normal bodily sensations more, scrutin-
izing trivial and transitory symptoms, and react to these perceptions with
fear and alarm. This attitude is similar that of patients with hypochon-
driasis, which Barsky and Klerman (1983) conceptualize using the concept
of an ‘amplifying somatic style.’ Patients with hypochondriasis amplify
minor changes in their bodily sensations and become excessively worried
about their health. Likewise, older Japanese women may amplify their
experiences of body odor, eye-to-eye contact, and imagined bodily defects
and may misinterpret them according to the socio-cultural values with
which they are accustomed. This may explain why they are afraid of
offending others or making them feel uncomfortable.
Although our findings must be viewed with caution because of the small
sample size and the low rate of participation, it is nonetheless noteworthy
that 6.8% of our community sample reported ‘taijin kyofu’ symptoms.
Although the prevalence of these symptoms in other societies is unknown,
we suspect that they are more common among Japanese. Socio-cultural
factors probably play some role in the development of this psychiatric
disorder and might explain why our participants were predominantly
female. Further epidemiological studies are needed for comparison to
examine the gender distribution and to determine to what extent the
symptoms are socially or culturally determined. Cross-cultural studies,
such as the World Health Organization International Study of Somatoform
Disorders (Janca, Isaac, & Costa e Silva, 1995; Ono & Janca, 1999) are
important in order to clarify how such symptoms are influenced by
psychosocial factors.

Acknowledgements
This project was supported partly by Research Grant 3A-3 for Nervous and Mental
Disorders from the Ministry of Health and Welfare, a Research Grant from Uehara
Memorial Foundation, a Grant from Mental Health Services Research Fund
Ministry of Health and Welfare 1993, and a Research Grant from Nakatomi Foun-
dation. The authors would like to thank the co-workers of the projects: N. Takashi,
K. Watanabe, M. Watanabe, M. Aoki, M. Fujino, N. Takara, C. Ura, Y. Kaibori, T.
Kitahara, M. L. Chiou, T. Koizumi, K. Hiyama, H. Oga, N. Kawakami, T. Tanigawa,

511
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 512

Transcultural Psychiatry 38(4)

N. Hirashima, T. Yamazoe, N. Iwata, R. Yasumiya, E, Tanaka, T. Sumiyama, T.

Tomoda, and S. Sakamoto. The authors also thank Douglas Berger for helpful
support and comments.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of
mental disorders (4th ed.) Washington, DC: American Psychiatric Press.
Aoki, K., Fujihara, S., & Kitamura, T. (1994). Panic attacks and panic disorder in
a Japanese non-patient population: Epidemiology and psychosocial corre-
lates. Journal of Affective Disorders, 32, 51–59.
Barsky, A. J., & Klerman, G. L. (1983). Overview: Hypochondriasis, body
complaints, and somatic styles. American Journal of Psychiatry, 140, 273–283.
Edgerton, R. B. (1969). On the recognition of mental illness. In S. C. Plog & R. B.
Edgerton (Eds.), Changing perspectives in mental illness (pp. 49–72). New
York: Holt, Rinehart & Winston.
Fujihara, S., & Kitamura, T. (1993). The epidemiological survey of psychiatric
disorders in town A of Kofu City. Japanese Journal of Medicine, 3618, 47–50
(in Japanese).
Fujita, C. (1986). Morita therapy: A psychotherapeutic system for neurosis. Tokyo:
Igaku-shoin.
Janca, A., Isaac, M., & Costa e Silva, J. A. (1995). World Health Organization inter-
national study of somatoform disorders – background and rationale.
European Journal of Psychiatry, 9, 100–110.
Kasahara, Y. (1975). Social phobia in Japan. In Social phobia in Japan and Korea,
Proceedings of the first cultural psychiatry symposium between Japan and Korea.
Seoul: The East Asian Academy of Cultural Psychiatry.
Kasahara, Y. (1986). Fear of eye-to-eye confrontation among neurotic patients in
Japan. In T. S. Lebra & W. P. Lebra (Eds.), Japanese culture and behavior
(pp. 379–387). Honolulu: University of Hawaii Press.
Kirmayer, L. J. (1991). The place of culture in psychiatric nosology: Taijin kyofusho
and DSM-III-R. Journal of Nervous and Mental Disease, 179, 19–28.
Kirmayer, L. J. (1995). The cultural context of anxiety disorders. Psychiatric Clinics
of North America, 18, 503–521.
Kirmayer, L. J., & Robbins, J. M. (1991). Conclusion: Prospects for research and
clinical practice. In L. J. Kirmayer & J. M. Robbins (Eds.), Current concepts of
somatization: Research and clinical perspectives (pp. 201–225). Washington,
DC: American Psychiatric Press.
Kitamura, T. (1992). Time ordered stress and health interview. Ichikawa: Depart-
ment of Sociocultural Environmental Research, National Institute of Mental
Health.
Kleinman, A. (1978). Clinical relevance of anthropological and cross-cultural
research: Concepts and strategies. American Journal of Psychiatry, 135,
427–431.
Nakamura, K. (1994). Social phobia and taijin kyofusho – Preliminary reports.
Psychiatry (Seisinigaku) 36, 131–139 (in Japanese).

512
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 513

Ono et al.: Taijin Kyofusho in Japan

Narita, Y. (1988). Taijin kyofusho – recent perspectives. In K. Kaketa (Ed.), New

encyclopedia of psychiatry (Gendaiseishinigakutaikei) (‘88A) (pp. 171–185).
Tokyo: Nakayamashoten. (in Japanese).
Ono, Y., & Janca, A. (1999). Rethinking somatoform disorders. Journal of Psycho-
somatic Research, 46(6) 537–539.
Ono, Y., Yoshimura, K., Sueoka, R., Yamauchi, K., Mizushima, H., Momose, T.,
Nakamura, K., Okonogi, K., & Asai. M. (1996). Avoidant personality disorder
and taijin kyoufu: Sociocultural implications of the WHO/ADAMHA Inter-
national Study of Personality Disorders in Japan. Acta Psychiatrica Scandi-
navica, 93, 172–176.
Ono, Y., Yoshimura, K., Yamauchi, K., Asai, M., Young, J., Fujihara, S., & Kitamura,
T. (2000). Somatoform symptoms in a Japanese community population:
Prevalence and association with personality characteristics. Transcultural
Psychiatry, 37(2), 217–228.
Phillips, K. A., McElroy, S. L., Kecker, P. E. Jr, Pope, H. G. Jr, & Hudson J. I. (1993).
Body dysmorphic disorder: 30 cases of imagined ugliness. American Journal
of Psychiatry, 150, 302–308.
Russell, J. G. (1989). Anxiety disorders in Japan: a review of the Japanese literature
on shinkeishitsu and taijinkyofusho. Culture, Medicine and Psychiatry, 13,
391–403.
Scheper-Hughes, N., & Lock, M. (1987). The mindful body: a prolegomenon to
future work in medical anthropology. Medical Anthropology, 1, 6–41.
Tanaka-Matsumi, J. (1979). Taijin kyofusho: Diagnostic and cultural issues in
Japanese psychiatry. Culture, Medicine and Psychiatry, 3, 231–245.
Tseng, W. S., Asai, M., Kitanishi, K., McLaughlin, D. G., & Kyomen, H. (1992).
Diagnostic patterns of social phobia: Comparison in Tokyo and Hawaii.
Journal of Nervous and Mental Disease, 180, 380–385.
Yamashita, I. (1982). Japanese diagnosis of neurosis and DSM-III. Clinical
Psychiatry (Rinshoseishinigaku), 11, 205–212 (in Japanese).

YUTAKA ONO, MD, graduated from Keio University School of Medicine in 1978.
He is an Assistant Professor in the Department of Neuropsychiatry at Keio
University and a distinguished fellow of the American Psychiatric Association.
Address: Department of Neuropsychiatry, Keio University School of Medicine, 35
Shinanomachi, Shinjuku-ku, Tokyo 160–8582, Japan. [E-mail: yutakaon@med.
keio.ac.jp]

KIMIO YOSHIMURA, MD, graduated from Keio University School of Medicine in

1992. He is a Research Fellow in the Cancer Information and Epidemiology
Division of the National Cancer Center Research Institute.

KEITA YAMAUCHI, MD, graduated from Keio University School of Medicine in 1991.
He is an Assistant in the Department of Health Policy and Management of Keio
University School of Medicine. Address: Keio University School of Medicine, 35
Shinanomachi, Shinjuku-ku, Tokyo, 157–8582, Japan.

513
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015
08 Ono (dm/d) 9/11/01 12:18 pm Page 514

Transcultural Psychiatry 38(4)

MASAHIRO ASAI, MD, graduated from Keio University School of Medicine in 1962.
He is Professor and Chairman of the Department of Neuropsychiatry at Keio
University School of Medicine. Address: Keio University School of Medicine, 35
Shinanomachi, Shinjuku-ku, Tokyo, 157–8582, Japan.

JEROME YOUNG, MA (PHIL), received his Master’s degree from Temple University.
He is a Foreign Lecturer at Keio University SFD, Faculty of Environmental Infor-
mation, and a postgraduate student in the Philosophy and Ethics of Mental Health
Program at the University of Warwick, UK.

SHIGEKI FUJUHARA, MD, graduated from Nippon Medical School in 1981. He is an

Associate Director at Yamazumi Hospital in Japan.

TOSHINORI KITAMURA, FRCPSYCH, graduated from Keio University School of

Medicine in 1972. He is Professor and Chairman of the Department of Neuro-
psychiatry, Kumamoto University Medical School.

514
Downloaded from tps.sagepub.com at GEORGIAN COURT UNIV on May 1, 2015