Assessing Social Anxiety in Japanese and Japanese-Americans in the United States

A Social Anxiety Scale designed to assess culture-specific symptoms in Japanese clients was assessed for face validity data. Taijin-Kyofusho is a culture-bound syndrome specific to Japanese culture in the DSM-5. A Social Anxiety Scale (SAS) was designed by the first author from existing Western social anxiety scales and a Taijin-Kyofusho scale. A demographic form yielded information about culturallyknowledgeable clinician respondents, and a questionnaire was used to get feedback on the SAS. Responses were obtained from 27 mental health professionals who worked clinically with Japanese legal residents in the United States and Japanese Americans, regarding culturally appropriate social anxiety assessment. Participants perceived the SAS as comprehensive and applicable to Japanese residents and Japanese Americans. Regarding Taijin-Kyofusho, most agreed that it should be assessed in Japanese residents but were undecided about its clarity and applicability to Japanese Americans. Several concerns were expressed about the validity of Western social anxiety scales for these populations. Most stressed the need for contextualization of social anxiety scales, differences in stigma against mental disorders across ethnicities, and the need for sensitivity of mental health professions to LGBTQ members in these populations. This is the first study on the views of clinicians working with these populations about Taijin-Kyofusho and how to assess anxiety. Nuances between Japanese residents and Japanese Americans were noted. We urge incorporation of cultural differences in manifestations of distress and specifically on Taijin-Kyofusho in training for mental health professionals. The purpose of this paper is to report on the first step in development of a culturally appropriate social anxiety scale for Japanese and Japanese-Americans living in the United States (U.S.). We first review the literature on differences in anxiety presentation across U.S. and Japanese cultures. We then report on feedback from culturally knowledgeable clinicians of the new scale, and specifically on the question of whether Taijin-Kyofusho symptoms should be included.


INTRODUCTION Psychopathology and culture
Scholars have increasingly directed research efforts toward clarifying cultural influences on manifestations of psychopathology and diagnostic assessment, both of which vary based on race, ethnicity, and culture [1][2][3][4][5]. Social anxiety is a disorder that is highly subject to cultural differences [6][7][8][9][10][11][12][13]. For instance, Asian Americans tend to describe more somatic symptoms related to anxiety compared with European Americans [1,2]. In a study conducted in China, approximately 60% of all cases of DSM-IV anxiety disorders were diagnosed as belonging to the "Not Otherwise Specified" category based on the use of clinician-administered diagnostic instruments. Although instrument issues could account for this finding, "the DSM criteria embedded in the diagnostic instrument do not capture key aspects of Chinese pathological anxiety" [3]. In fact, in a study that applied the Composite International Diagnostic Interview (CIDI) in Beijing and Shanghai, researchers discovered that the CIDI, which is based on the concept of psychopathology in the DSM-IV, could not match the criteria of Chinese pathological symptoms of anxiety. The DSM-IV's definition of anxiety has placed emphasis on psychological symptoms more than somatic symptoms [3], which partially accounts for this discrepancy. The DSM-5 applies greater cultural sensitivity to its updated diagnostic criteria to reflect aspects of culture as "dynamic systems that undergo continuous changes over time" [14]. Furthermore, the DSM-5 modified culturally determined criteria and made them more inclusive and applicable across diverse cultures in the United States. For instance, the criteria for social anxiety disorder include the fear of "offending others," so as to reflect clinical manifestations that are seen in a Japanese cultural context [14].
Since expression of social anxiety is highly influenced by cultural norms and clients' cultural backgrounds, these are important considerations when conducting psychological assessments. Some research on social anxiety has reported its association with self-construal (i.e., independence vs. interdependence) and/or cultural factures (i.e., individualistic vs. collectivistic). There are positive correlations between higher levels of social anxiety and interdependence self-construal, and between higher levels of social anxiety and coming from a collectivistic culture [3,6,7,[15][16][17][18][19].
The threshold for typical behaviors versus pathological symptoms also is influenced by culture. A higher threshold exists for social anxiety symptoms as psychopathology in collectivistic societies, and a lower threshold in individualistic societies. In individualistic countries, social withdrawal and shyness are regarded as interfering with quality of life and are labeled as problematic. As a result, children in these countries are more likely to learn to modify their shyness. On the other hand, social reticence can be interpreted positively in collectivistic countries; therefore, introverted behavior may be understood and supported during development. As a byproduct of these different developmental trajectories, people in collectivistic countries are likely to manifest more social anxiety symptoms compared to people in individualistic countries. However, there is a lower prevalence of social phobia diagnoses in collectivistic countries, despite having higher levels of symptomatology. This may not be due to underdiagnosis, but rather because social withdrawal does not result in interpersonal difficulties (e.g., criticism or dislike) and thus is not labeled as pathological [7].

Cultural considerations in the diagnostic criteria for social anxiety
The diagnostic criteria for social anxiety were constructed based on Western cultural norms, and these norms are codified in social anxiety scales. Yet there are ethnic differences in individuals' experiencing of social anxiety, such as East Asian Americans and immigrants exhibiting higher levels of social anxiety in assessments compared to their White counterparts [9,10,12,17,20]. However, it is debatable whether this means East Asian Americans actually experience more distress in social situations or if some of their behaviors encouraged by their cultural norms are misconstrued as social anxiety symptoms in Western cultural norms. In fact, higher levels of social anxiety in East Asian populations (in Canada) might not reflect their " functional impairment or distress " [17]. The researchers delineated differences of personality traits that are encouraged in Western versus Eastern cultures [17]. Specifically, they determined that individualistic cultural norms encourage an independent view of the self, (i.e., an independent selfconstrual), the consistency of personal attributes across situations, and self-confidence. In contrast, collectivistic cultural norms enhance an interdependent view of the self (i.e., an interdependent self-construal), reflective identity of social situations and self-criticism [17]. In a collectivistic society, adjusting to one ' s environment and integrating situational attributes into one's own thoughts and actions are important skills necessary to thrive. Therefore, a changeable self-image that functions across social situations and self-criticism that is applied "to identify and adjust negative personal attributes that threaten the success of a group interaction" [17] are strengths and virtues in East Asian cultures, while these personality traits can be perceived as weaknesses and a feature of psychopathology in Western cultures. From the perspective of evolutionary psychology, the behaviors that manifest as social anxiety reflect "naturally occurring reactions that can be adaptive under certain circumstances" [12]. The concept of social anxiety was developed based on these perspectives of individualism and is ingrained in Western social anxiety scales, which perceive and detect some traits of collectivism as social anxiety symptomatology in East Asians [17].
There are arguments in favor of the need to contextualize social relationship variables in social anxiety assessments of Asian Americans and immigrants. Rapee and Spence [12] delineated biological/genetic, psychological and environmental factors that can cause social anxiety in individuals. For instance, social contextual issues (such as racial discrimination and microaggressions) which Asian Americans and immigrants of Asian descent are exposed to can cause distress in social situations and lead to social anxiety [12]. Another study investigated the social anxiety of first-generation Chinese immigrants across different social contexts [20]. They focused on the social situations in which these Chinese immigrants interacted with European Americans and with other Chinese from a perspective of social anxiety levels. Context included three cultural factors (acculturation, enculturation, and English proficiency), one environmental stressor (perceived racial discrimination), and two personality traits (neuroticism and extraversion). They found that less extraversion and the experiencing of more discrimination were significant, unique predictors for social anxiety when interacting with other Chinese as well as with European Americans. In addition, more neuroticism and less acculturation significantly contributed to social anxiety levels in a European American context [20]. Their findings suggested that the racial discrimination people perceived influenced their social anxiety across contexts.
More attention has recently been directed toward the heterogeneity of the Asian American population in terms of differences concerning race/ethnicity, culture, socioeconomic status, nativity status, immigration history, educational attainment, English proficiency level, and regional variability. Whereas "Asian cultures" have the cultural values of Buddhism and Confucian philosophy in common, some studies found empirical evidence of racial/ethnic differences among Asian races/ethnicities [4,21]. For instance, one study showed different levels of adherence to six values-collectivism, conformity to norms, emotional self-control, family recognition through achievement, filial piety, and humility-among Chinese American, Filipino-American, Japanese-American, and Korean-American students [22]. Filipino culture, which is influenced by Catholicism and American language and culture (due to Spanish colonization) in addition to Buddhism and Confucian philosophy demonstrated lower adherence to these six values [21]. Moreover, Chinese, Japanese, and Korean American students demonstrated various levels of adherence to values (e.g., Japanese showed significantly higher adherence to selfcontrol dimension compared to others) and held a unique configuration for Asian cultural values. Thus Kim [21] identified " the need to understand within-ethnic-group differences to provide the most culturally sensitive psychological services to ethnic minorities" (p. 358), as do the new APA Multicultural Guidelines [23,24].

Cultural idioms of distress -Taijin-Kyofusho
The DSM-5 replaced the DSM-IV term culture-bound syndromes with "cultural concepts of distress" [14], and it has been defined as "ways cultural groups experience, understand, communicate suffering behavioral problems, or troubling thoughts and emotions" [13]. These cultural concepts also have been called " idioms of distress, " which may be manifested differently than Western expressions.
Ethnopsychology/ethnophysiology factors have a cultural influence on individuals' conceptualizations of how the mind and body function and relate and the ways in which distress is manifest. Cultural idioms of distress are unique manifestation of distress that results from individuals ' cultural perceptions of psychological/physiological functions and their cultural norms [24].
Taijin-Kyofusho is a phobia that is culturally specific to East Asia countries such as Japan and Korea. In the DSM-5, taein kong po in Korea is considered similar to the condition of Taijin-Kyofusho [14]. Taijin-kyofusho refers to the "fear of interpersonal relations" [25]. Masatake Morita, who invented Morita therapy in 1919, first delineated it in the 1930s as the core manifestation of shinkeishitsu, which resembles neurasthenia, described as a combination of anxious, depressive, and somatic symptoms [26]. Later, Taijin-Kyofusho became " synonymous with the term shinkeishitsu" [27].

Etiology of Taijin-Kyofusho in Morita therapy
Morita found the shared mechanism of symptom formation across the various shinkeishitsu types of neurosis, which is called " toraware " and means " to be bound as by some intense preoccupation" [28]. Morita also described shinkeishitsu as "a nervous-prone personality with a hypochondriacal base" [28]. Based on Morita ' s theory, individuals who have a hypochondriacal temperament will develop Taijin-Kyofusho after experiencing an accidental event and becoming highly sensitized [27]. Reinforced by their tendency to partake in an oversensitive interpretation of such an event, they become more affected by sensations and more focused on these sensations and fears of interpersonal situations, which Morita called " psychic interaction " and described as causing a " vicious circle of attention and sensation" [27]. In Morita therapy, the unfolding of toraware and the alleviating of shinkeishitsu are fundamentally associated; clients with shinkeishitsu or Taijin-Kyofusho need to go through the recovery process arugamama, which means to "accept reality as it is and lead a constructive life" [28].
In the Japanese cultural context, shame has been associated with the symptomatology of Taijin-Kyofusho, and it has been called "an obsession of shame and anxiety" [27] and a "phobia of being ashamed " [29]. Clinical manifestations are " an excessive sensitivity to interpersonal relations" [30] and include symptoms such as feeling anxious in the presence of others, blushing, subjective disfigurement, the fear of eye contact, and the fear of emitting unpleasant body odors.
People with Taijin-Kyofusho suffer from certain fears, including being embarrassed in the presence of others, offending others, and/or making others feel uncomfortable, which causes them to avoid social situations and interactions. Despite a dearth of epidemiological studies regarding the prevalence of social phobia in Japan or taijin-kyofusho in the general population in Japan [31], initial research indicates that up to 38% of patients have been diagnosed with Taijin-Kyofusho in Japanese clinical settings [32].

Taijin-Kyofusho diagnostic criteria
Although it has been more than several decades since Morita coined Taijin-Kyofusho in Japan, Maeda and Nathan ' s formal diagnostic criteria were not established until 1995 [26]. Each researcher formed his/her own nomenclature of Taijin-Kyofusho and its classification [32]. Based on its symptomatology, shinkeishitsu was sub-grouped into obsession (being obsessed with ideas), ordinary shinkeishitsu (being obsessed with somatic symptoms), and paroxysmal neurosis (being obsessed with anxiety attacks and anxiety) [28]. Kasahara redefined Taijin-Kyofusho as a type of neurosis that includes excessive anxiety and tension in social situations and withdrawing from interactions with others [33]. Nagata later developed diagnostic criteria for Taijin-Kyofusho, which consist of the tension (fear of being looked at by others) and offensive (fear of offending or embarrassing others) subtypes [34]. Two sets of diagnostic criteria [27,34] are listed in Table 1.

Taijin-Kyofusho and western psychopathology
Although some research has demonstrated similarities between the subtypes of Taijin-Kyofusho and Western psychopathological entities (e.g., sekimen-kyofu and social anxiety, shubo-kyofu and body dysmorphic disorder, jikoshu-kyofu and olfactory reference syndrome), the offensive subtype of Taijin-Kyofusho is thought to be foreign to Western social anxiety. Even in DSM-5, which includes taijin-kyofusho's offensive symptoms in the definition of social anxiety [14], Taijin-Kyofusho remains one of the cultural idioms of distress syndromes in the DSM-5. On the other hand, research findings have thus far indicated that the offensive subtype may not be as specific to Japanese culture as was previously thought [16,29,[35][36][37]. Nonetheless, it is notable that Taijin-Kyofusho exhibits some characteristics of Japanese thought processes pertaining to social anxiety. We believe, therefore, that Taijin-Kyofusho symptomatology should be considered in assessments for populations in which Japanese cultural and social values are prevalent.
Social anxiety assessment should involve examinations of cultures, individuals ' cultural background, and the cultural norms of their environment. In particular, immigrants require specific assessments that are tailored to examine their own issues. The purpose of this study was to create a culturallyappropriate social anxiety scale for Japanese and Japanese Americans in the United States. The first step in the development of a new scale was to have it assessed for face validity by mental health professionals knowledgeable about Japanese and/or Japanese American clients with anxiety.

Maeda & Nathan [27]
Nagata et al. [34] A. All of the following criteria should be met: (A1) The feeling that his/her own attitudes, behavior, and physical characteristics are inadequate in social situations.
(A2) The persistent suffering (caused by condition 1) from emotional reactions such shame, embarrassment, anxiety, fear, and tense feelings in social situations. (A3) Worrying that he/she is unable to maintain healthy relationships with others (feeling unaccepted, despised, and avoided) due to conditions 1 and 2.
(A4) Avoiding painful social and interpersonal situations, while reluctant to do so.

B. Supplementary items:
(B1) Certainty that he/she has a defect or issue related to a particular part of the body, such as the eyes, body odor, and his/her general appearance.
(B2) Delusional conviction that he/she harms other people or gives others unpleasant feelings because of condition 1.
(B3) Delusional conviction that others always avoid him/her due to conditions 1 and 2.
A. At least one of the following features:

Research questions
• To what degree do culturally-knowledgeable clinicians perceive this social anxiety scale as effective for assessing social anxiety in Japanese and Japanese Americans in the U.S.? • How clear and applicable is each item of the social anxiety scale? • Should symptoms be included when assessing social anxiety in these populations? • How might the social anxiety scale be improved? • Which social anxiety scales are professionals currently using for these target populations?

Participants and recruitment
Participants were 27 licensed mental health professionals with clinical experience in treating Japanese and/or Japanese Americans in the U.S. All were licensed psychologists (n=10), marriage and family therapists (9), clinical social workers (5) (70.4%), and 22.2% were native English speakers (and 7.4% were neither but had formal education in English in their home countries). All but one rated their English proficiency as 'good' or 'primary language,' and 23 rated their Japanese proficiency as 'good' or 'primary language.'

MEASURES Social Anxiety Scale (SAS)
Social Anxiety Scale is a 43-question self-report scale, with fivelevel Likert multiple-choice items, that was created for this study by the first author. The content of the scale was designed with reference to prevalent social anxiety scales used in the United States (e.g., the Liebowitz Social Anxiety Scale, the Social Avoidance and Distress Scale, the Social Interaction Anxiety Scale, and the Social Phobia Inventory), as well as items assessing Taijin-Kyofusho symptoms (from the Social Anxiety/Taijin-Kyofusho Scale; SATS). One item ("I believe my abilities offend others") was not originally from the SATS but created to modify the scale for the situations of Japanese and Japanese Americans in the U.S. Because some users of the scale might have concerns about their English proficiency and/or accents, the definition of taijin kyofusho's was expanded ("fears of offending others by blushing, stuttering, emitting offensive odors, staring inappropriately, presenting improper facial expressions, blemishes, and/or physical deformity") and included "abilities" in general.

Demographic questionnaire
The demographic questionnaire was designed for this study and was used to gain descriptive information about the respondents. The first six questions pertained to licensure and clinical experience. The next two questions were for participants' selfassessment of English proficiency, rated using four-levels (1=Poor; 2=Fair; 3=Good; 4=Primary language), and Japanese language proficiency rated using five levels (1=N/A; 2=Poor; 3=Fair; 4=Good; 5=Primary language).

Survey questionnaire
The survey questionnaire was designed for this study and was used to gain opinions about the SAS. Six levels were available for responses (0=N/A; 1=Strongly disagree; 2=Disagree; 3=Neutral; 4=Agree; 5=Strongly agree). The first question sought to examine the overall social anxiety scale: (a) Can it assess social anxiety in Japanese clients? (b) Can it assess social anxiety in Japanese American clients?
The clarity and applicability of each of the 43 items also were assessed. One question was included to gather opinions of whether items regarding Taijin-Kyofusho symptoms should be assessed in these populations. The last four items were openended questions, which were asked to obtain participants ' clinical experience with these populations, the existing social anxiety scales they presently use, and general opinions about how to improve the proposed social anxiety scale.

Procedures
The survey website provided information about the purpose of the study and the procedures to complete the evaluation survey. The following were included: (a) A self-report of English proficiency, (b) The Social Anxiety Scale, (c) An evaluation surveys.
After including a check mark in the designated box to indicate having read the consent form, participants were shown the SAS and asked to complete an evaluation questionnaire. Participants were able to choose the language version (i.e., English or Japanese) they examined based on the primary language of their clients. When participants were bilingual in English and Japanese, they were encouraged to examine both versions. The anxiety scale items were repeated on the questionnaire so that respondents did not have to scroll back to the anxiety scale items. All answers were anonymous, and participants were taken to a separate page to enter a lottery for three $50 gift-cards. They had the option of requesting the study results and/or some of the literature review.

Research questions
The scale for responses to each research question was 1=Strongly disagree; 2=Disagree; 3=Neutral; 4=Agree; 5=Strongly agree. Also included was 0=not applicable.

Research question 1:
To what degree do professionals perceive this social anxiety scale as effective for assessing social anxiety in Japanese residents and Japanese Americans?
For the three versions of the scale (English version for Japanese; English version for Japanese Americans, and Japanese version for Japanese) the mean of responses were 3.76 (SD=.70), 3.54 (SD=.81) and 3.80 (SD=.63), respectively.
For the English version of the scale, nine participants wrote comments. Four participants explained the reasons of their endorsements of "Agree" or "Strongly agree," such as "It covers most social scenarios." For those who endorsed 'Neutral' or ' Disagree, ' there were four comments. For example, one comment read as "I think many items are right on. However, some items are not clear whether they describe social anxiety symptomatology or behaviors that are against Japanese cultural norms" (translated into English by the first author) ( Table 3). "The contents of some of the questions are culturally appropriate behaviors for Japanese to some extent, such as not keeping the eye contact, and feeling uncomfortable disagreeing with others, etc." "I think many items are right on. However, some items are not clear whether they describe social anxiety symptomatology or behaviors that are against Japanese cultural norms" (translated into English by the author). " People with social anxiety are typically observed to have issues in a middle distance of relational proximity such as a relationship with acquaintances wherein they are neither friends nor strangers. In this social anxiety scale, there are not many items that describe situations in such a middle distance of relational proximity" (translated into English by the author).
Regarding "Speaking in front of an audience," "Expressing disagreement with someone," "Talking to people with more authority," "Making eye contact when talking to someone," "Making phone calls to persons with whom one is not very well acquainted," "Being in the center of attention," "Returning goods to a store," "Make an important judgment for a group you are involved in") "In Japanese culture, one is expected to not stand out, to be considerate of others/worry about what others would think of you, and to avoid conflicts/obvious disagreement with others. Those items (…) wouldn't be appropriate to assess social anxiety Japanese clients/some Japanese Americans because those behaviors are overall discouraged or not valued in Japanese culture." "Some second-generation of Japanese Americans with both Japanese parents may have held more Japanese cultural values, while third-generation of Japanese Americans or even second-generation of Japanese Americans whose one of parents are not Japanese are likely to hold more American cultural values." (translated into English by the author).
(Regarding "Talking to people of the opposite sex") "If you mean 'people of sexual attraction' by 'people of the opposite sex', the wording should be thoughtfully considered in terms of LGBTQ inclusion." (translated into English by the author).
(Regarding "Returning goods to a store") "I am wondering this is not applicable to Japanese Americans since this custom is the norm in this country." (Regarding "Returning goods to a store") It doesn't refer to social anxiety symptoms in Japanese cultural context." (Regarding "Going to a party) "Japanese do not have may parties in Japan. If there is, there is usually "kanji" type people who is good at doing it take care of it, so not too many Japanese experience giving a party. Also, those questions are kind of overlapping with (A-)6, 8, 9, 10, 13 that are more specific in nature. I wonder why party situation is singled out." (Regarding "Giving a party") "(It is) culturally acceptable (if Japanese get anxious throwing a party). Also, other reasons can be concerned." Taijin

Taijin-Kyofusho for Japanese residents
Some participants ' comments focused on how its cultural specificity can have an influence on this population and thus can factor into the reason for selecting "Agree." For instance, "This is a very culturally-specific issue and it is important that any therapist working with this population be versed in the subject." One participant, who indicated "Disagree," stated the following: "In my experience, I have rarely seen people with Taijin-Kyofusho, nor have I diagnosed anybody with it. As for anxiety disorders, I have only had clients with general anxiety and PTSD " (translated into English by the first author). Only two participants reported clinical experiences in working with clients with Taijin-Kyofusho.

Taijin-Kyofusho for Japanese Americans
Some participants agreed that taijin-kyofusho should be assessed in Japanese Americans due to Japanese cultural influences. An example was "Japanese Americans who hold Japanese cultural values need to be assessed." In comparison, participants who disagreed or were undecided expressed concerns about its applicability to Japanese Americans. As one participant noted, "Taijin-Kyofusho symptoms are developed in the Japanese cultural environment. I think that Japanese Americans who live in this country are unlikely to manifest its symptoms " (translated into English by the first author).

Other Questions for Mental Health Professionals
We asked the professionals what scales they currently used, if any ( Table 4). The DSM-5 criteria were the most commonly used. However, seven professionals used no scales with Japanese Americans clients and eight used no scales with Japanese clients.
We asked how the SAS could be improved and received twelve comments. In general, the comments were about needing highly nuanced assessment. One participant made a distinction between the east and west coasts of the U.S. English proficiency, acculturation, and interlocutor were also raised as issues that could affect social anxiety.
For example, a professional wrote that "one thing I notice is anxiety around syntax and accent. Being afraid that someone might misunderstand them and that what they say may have an unintentionally embarrassing meaning." Changing cut-off scores for anxiety threshold was another suggestion.

DISCUSSION
Most participants indicated that both the English and Japanese versions of the Social Anxiety Scale would be effective for assessing social anxiety in their Japanese resident and Japanese American clients. Interestingly, there were various levels of awareness about Taijin-Kyofusho among participants. Even some participants who were raised in Japan had never seen clients with Taijin-Kyofusho nor received any training in it. Given the lack of formal diagnostic criteria for Taijin-Kyofusho before 1995 and a history of the use of various operational definitions of the diagnostic subtypes in Japan [26], it is comprehensible that even Japanese clinicians demonstrated varied levels of understanding of Taijin-Kyofusho. Also, there was disagreement among participants regarding the necessity of Taijin-Kyofusho assessment for Japanese residents. Specifically, one participant pointed out that some Japanese clients with Taijin-Kyofusho deteriorated after moved to the United States, while other participants questioned whether Japanese clients who decided to emigrate from Japan on their own develop taijin-kyofusho in the United States. Since there is no study about the prevalence of taijin-kyofusho and social anxiety in Japanese residents in the United States, we cannot predict the likelihood of working with Japanese clients with Taijin-Kyofusho. Nonetheless we believe it is important to hold knowledge of Taijin-Kyofusho for mental health professionals who are working and may work with Japanese residents and Japanese Americans.
A number of participants stated that certain items describe situations and behaviors that are not indicative of social anxiety symptoms in the Japanese cultural context. When a behavior is considered as disrespectful or impolite in Japanese society, it should not necessarily count as a symptom when assessing anxiety. Such behaviors include "speaking up at a meeting," "expressing disagreement with someone," and "talking to people with more authority." For instance, speaking up at a meeting without permission from a person with authority can be regarded as impolite and inappropriate.
This behavior can be considered to be standing out or to be inconsiderate in a group, which is not encouraged in Japanese culture. This point of view is consistent with previous research findings.
Foreign-born East Asians are found to report higher social anxiety than those born in the United States, which can result from Western social anxiety scales that were developed based on Western constructs of social anxiety that regard interdependence and collectivistic attitudes as psychopathology [17]. As Hong and Woody [17] suggested, what Western social anxiety measures detect in East Asians may not be equivalent to subjective distress and the avoidance of social situations in Westerners.
Participants pointed out the need to contextualize social anxiety assessment to consider sociocultural, political, and racial factors that are relevant to Japanese residents and Japanese Americans. Assessing social and environmental stressors should not be underestimated to understand social anxiety symptoms experienced by people of color and people with different cultural backgrounds. Previous research findings also indicated that environmental distress plays an important role in the onset and maintenance of social anxiety [19,20,38]. As diathesis-stress paradigm posits that psychopathology, especially social anxiety, corresponds with environmental, biological/genetic, and psychological factors [20] and should be assessed with scales that are tailored for each population. Cultural specificity that can contribute to the development and maintenance of social anxiety in Japanese residents includes language/communication abilities and collectivistic/interdependent tendency, which reflects individuals' acculturation processes as well.
Some participants did not view unfamiliar situations or behaviors that can provoke anxiety as indications of social anxiety, while others regarded normal situations or behaviors as ineffective question items to detect social anxiety. For instance, four participants expressed that items such as "returning goods to a store" for Japanese residents are not culturally appropriate since this behavior is not considered to be normal in Japanese society and does not occur regularly. In comparison, two participants regarded the same item for Japanese Americans as not culturally appropriate and thus, ineffective because this behavior is normal and " not referenced as being rude and disrespectful. " These perspectives of adequateness are quite contradictory to each other. This argument reflects a point that requires further investigation in a future study: balance between contextualization and generalization to tailor the specificity of social anxiety in Japanese residents and Japanese Americans. This incorporation of each individual's cultural background is necessary to avoid over-pathologizing individuals.
On the other hand, we need to refrain from being so overly attentive to cultural factors that we lose sight of individual distress. Cross-cultural social anxiety assessments involve both cultures; a cultural context of physical place wherein an individual resides and interacts with others, and a cultural context of the individual holds of. As mental health professionals we are required to strike a balance among multiple cultures pertaining to our clients. For instance, a number of participants expressed concerns about the applicability of items such as "going to a party" and "giving a party," as well as "returning goods to a store." Socialization in the United States does not necessarily correspond to that in Japan; social functions at work and at school in the United States play a more important role than in Japan. Thus, Japanese residents are particularly at risk of experiencing distress on social occasions. Additionally, some Japanese residents face challenges on social functions due to language issues and lack of American social skills that are required to function socially in the United States, which can interfere with their socialization. Therefore, we have to detect possible causation of distress leading to social anxiety. Specifically, avoidant behaviors in some situations (e.g., "not participating in a party " ) can lead to racial labeling and discrimination, which may affect social and/or vocational functioning negatively. For instance, Asian students are viewed as hard workers and good students who do not get the point of talking to strangers at a party and drinking when they could be studying. As previous research findings indicated, sensing the discrepancy between social expectations and one's self-view can cause distress in social situations and can lead to social anxiety [12,17]. Moreover, after a certain period of time, we can expect resilience to allow adjustment to a new environment. If not, we should consider adequate treatment plans for rigidity-a factor that can lead individuals to social anxiety. We should detect anxious behaviors that are provoked by unfamiliar customs to immigrants ' cultural background in a new environment and check up on their transformation over time. Otherwise, they may eventually develop social anxiety.
As for Taijin-Kyofusho, most participants were undecided as to whether Taijin-Kyofusho should be assessed in Japanese Americans. Some participants expressed that Japanese Americans are unlikely to express Taijin-Kyofusho symptoms because Japanese Americans who were raised in the United States as Americans are unlikely to express Taijin-Kyofusho symptomatology that is a culturally-specific expression of distress. On the other hand, most participants agreed that Taijin-Kyofusho should be assessed in Japanese residents (even though only two respondents each reported one case of taijin-kyofusho). The findings are congruent with some of the previous research and consensus on taijin-kyofusho in the United States [6,30]. However, other research findings have indicated that Taijin-Kyofusho might not be as specific to Japanese culture as was previously thought [16,29,39]. Given the variability of responses, we suggest using the DSM-5 cultural formulation interview [14] protocol.
This interview allows clinicians to be more specific and nuanced in their understanding of a client's culture and its role in the client's mental health. Additionally, we need to consider the effects of current globalization which weakens existing boundaries across cultures, geographic locations, and expressions of psychological distress [13,40].
Some participants expressed concerns about prominent stigma against mental health disorders in Japanese residents and Japanese Americans. This point is consistent with previous findings that Asian immigrants and Asian Americans tend to be resistant toward mental health services, which causes a delay in seeking treatments from professionals [41][42][43][44][45].

CONCLUSION
In particular, this study presented a new perspective about ethnic differences of mental health stigma in a minority community, which requires further investigation in a future study. An important addition to the DSM-5 was a cultural formulation interview protocol. This interview allows clinicians to be more specific and nuanced in their understanding of a client's culture and its role in the client's mental health. A few participants commented on the wording of one item (A-5) from a perspective of LGBTQ inclusion. This item asks about fear of approaching an opposite sex person to whom one is romantically attracted and needs to be reworded to allow for same-sex attractions. This intersectionality would be an important consideration in future work with the current measure.