Anxiety Disorders: Among Ethnic Minority Groups

Gayle Y Iwamasa & Shilpa M Pai. Handbook of Racial & Ethnic Minority Psychology. Editor: Guillermo Bernai. Sage Publications. 2003.

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994), anxiety disorders involve conditions in which an individual experiences anxiety, fear, apprehension, increased arousal, and avoidance behavior to the extent that it interferes with daily functioning. Although the DSM-IV does include sections on “Specific Culture, Age, and Gender Features” for each anxiety disorder, the information provided is very general (except for the mention of taijin-kyofu-sho, which is discussed later in this chapter). Thus, clinicians are not provided with specific information or resources in the consideration of anxiety symptoms among various cultural groups.

Good and Kleinman (1985) reviewed the cross-cultural literature on anxiety disorders and concluded that although different terminology may be used, anxiety disorders are universal. However, they did point out that the expression of anxiety symptoms is influenced by culture-specific factors. For example, some cultures may have disorders of the “nerves,” “fright disorders,” or “neurasthenia,” which all include anxiety symptoms. Comparability of these disorders with the DSM-IV diagnostic classification is often difficult because although some symptoms may overlap, others do not.

The purpose of this chapter is to briefly summarize the existing research on anxiety disorders among the four major ethnic minority groups in the United States. Treatment will briefly be discussed, but readers are encouraged to refer to Part 6 of this book, as treatment issues are discussed in more depth than they can be in this chapter. As may be expected, the amount of research on the mental health of ethnic minorities is woefully inadequate. Thus, when appropriate, brief summaries of research on anxiety disorders from a more broad-based cultural perspective will be provided, as it is possible that such culture-specific disorders may be seen among U.S. ethnic minorities, particularly among immigrants. Indeed, some of the disorders discussed in this chapter have already been documented in the U.S. mental health literature.

Prevalence of Anxiety Disorders Among Ethnic Minorities

Guarnaccia (1997) reviewed the prevalence of anxiety disorders among selected ethnic minority groups based on the Epidemiologic Catchment Area (ECA) studies (Reiger et al., 1984). Guarnaccia cited data from the Los Angeles ECA site, which, unfortunately, only included information comparing Mexican Americans born in Mexico and the United States (Karno et al., 1989). Those results indicated that U.S.-born Mexican Americans had higher rates of anxiety disorders as compared to those born in Mexico. Guarnaccia also presented comparison data from the Baltimore and St. Louis ECA sites (Brown, Eaton, & Sussman, 1990) between Black and White Americans. At both sites, Black Americans had higher prevalence rates of phobias as compared to White Americans.

Guarnaccia (1997) noted that cultural differences in the prevalence of anxiety disorders are difficult to explain because it is possible that the range of experiences and, perhaps, the diagnostic criteria of anxiety disorders are culturally bound and may need modification. For example, DSM definitions emphasize excessive worry and apprehension and lack emphasis on somatic symptoms. Clearly, more epidemiological data on the prevalence of anxiety symptomatology and disorders among ethnic minority individuals are needed.

The Conceptualization of Anxiety

The influence of culture on the conceptualization of disease and illness has been addressed in the work of Kleinman, Eisenberg, and Good (1978). Their explanatory model of illness (EMI) specifically addresses the influence of culture on help-seeking behavior. The EMI defines disease as a Western concept of biological malfunctioning, whereas illness is a personal or cultural reaction to disease. Therefore, illness is shaped by how culture influences the perception, labeling, experience, and coping with disease. As a result, Kleinman et al. hypothesized that culture will influence the presentation of symptoms, which therefore influences one’s expectations for treatment and thus help seeking. The implication, as suggested by Kleinman et al.’s EMI, is that mental health providers and other health care workers will provide inappropriate treatment, or no treatment at all, without knowledge of their patients’ conceptualization of illness. In addition, compliance with treatment recommendations is likely to be diminished if the patient and health care provider have differing EMIs of the patient’s difficulties. Related to anxiety, a clinician who is not aware of how his or her EMI may differ from that of the client will likely not be able to develop a culturally sensitive treatment plan and thus will not adequately explain the rationale for whatever treatment recommendations he or she may have. It is reasonable to assume that clients will not follow treatment recommendations that they do not see as being helpful.

The issue of how one conceptualizes anxiety and anxiety disorder symptoms is particularly important for ethnic minority individuals. Unfortunately, this issue has received little attention in the empirical literature, and as a result, not much is known about how various ethnic minority groups experience and express psychological distress in general and anxiety specifically. Culturally appropriate clinical assessment of anxiety is apt to be challenging, yet mental health professionals must be aware of those challenges and adjust their assessment methods accordingly.

Assessment Issues

Although Part IV of this book covers issues related to diagnosis and assessment, a few comments will be made here due to their importance. Factors such as language, cultural and motivational differences, and interpersonal expectations may complicate the assessment process, and special considerations may be necessary to provide appropriate assessment and diagnosis of ethnic minority individuals (Butcher, Nezami, & Exner, 1998).

Dana (1993) conducted comprehensive reviews of a variety of assessment measures used with multicultural populations. He outlined the use of both etic assessment (assumption of universality of constructs) and entic assessment (culture specific) with ethnic minorities and emphasized that a combination of a general with a more individualized approach to assessment is often needed and provides more comprehensive and important information. In addition to the domains discussed by Butcher et al. (1998), Dana also discussed the need to consider the issues of differing worldviews (i.e., one’s group identity, individual identity, beliefs, and values), ethnic identity, and racism in conducting assessment.

Use of Translators in Assessment

To address the needs of individuals for whom English is not their first language, some mental health professionals have turned to using translators. Although the use of translators in psychological assessment grew in the 1990s, clinicians must be aware of the potential problems using translators may cause. Unless the translator is a mental health worker familiar with diagnostic classification systems, symptomatology, and certain cultural expressions, the risk of misinterpretation and inaccurate information is very high.

Given the lack of staff who are fluent in a variety of languages, many agencies resort to using family members as translators—often the client’s child or even grandchild. This mode of assessment may not only be in direct opposition to specific cultural roles family members have but may actually violate such roles. For example, in many cultures, elder family members are held in high regard and viewed as wise and knowing. Thus, placing a child or grandchild in the position of having to question an elder regarding symptoms of psychological distress and to also provide the recommendations of the mental health professional is likely to be disrespectful, shameful, and embarrassing to the older adult. This influences the increased likelihood of a poor client-provider relationship, the gathering of inaccurate information, inappropriate treatment recommendations, and poor compliance with treatment.

Factors Influencing the Development of Anxiety Among Ethnic Minorities

Although specific ethnic group issues in the expression and experience of anxiety will be covered in this chapter, a number of general factors likely influence the development of anxiety symptoms among ethnic minority individuals. First, the impact of racism and discrimination experienced by many ethnic minorities is likely to be an influential factor and thus should be assessed as a potential risk factor for the development of anxiety symptoms. When assessing an individual’s anxiety symptoms, clinicians not only would benefit from acknowledging the possibility that such experiences might contribute to anxiety but also should inquire about any specific experiences or perceptions of racism and/or discrimination an ethnic minority client may have. This assessment should also include inquiry about parental and other familial experiences of racism and discrimination that the client may have vicariously experienced. Indeed, transgenerational effects of trauma have been documented by international scholars in children of Holocaust survivors (Solomon, 1998) and Aboriginal people in Australia (Rafael, Swan, & Martinek, 1998). In the United States, Sorscher and Cohen (1997) have documented transgenerational trauma in children of Holocaust survivors, and Nagata (1991) documented the transgenerational impact of the internment of Japanese Americans during World War II. Given the history of racism and discrimination of many ethnic minority groups, it is reasonable to believe that many ethnic minority individuals have experienced the transgenerational transmission of racism and discrimination, and this may serve as a risk factor in the development of anxiety symptoms and disorders.

In assessing anxiety among ethnic minority individuals, mental health professionals must recognize the great heterogeneity among each ethnic minority group. Among Asian Americans, Latinos, and Black/African Americans, there exists a vast array of nationalities, ethnicities, languages, religious/spiritual beliefs and practices, generational status, and so on. Among American Indians, there are numerous tribes, each with different values, languages, practices, and so on (Bigfoot & Braden, 1998; John, 1998; McDonald, 2000). For newer immigrants, huge differences may exist in terms of reasons for immigrating to the United States, their familiarity with American values and customs, the immigration process, and adaptation experiences once arriving in the United States, which all may influence the development of anxiety. For example, refugees from Cambodia, Haiti, and certain Central American countries are likely to be at higher risk for the development of anxiety as compared to immigrants who left their countries during relatively peaceful periods (e.g., Korean immigrants). A thorough review of these issues is beyond the scope of this chapter. Thus, readers are referred to Iwamasa’s (1997) summary of the literature related to increased anxiety symptoms among Asian immigrants, which are likely to be applicable to other ethnic minority immigrants as well.

Acculturation level and ethnic and racial identity are additional personal characteristics on which ethnic minorities will vary. Although frequently related to generational status (Iwamasa, Pai, Hilliard, & Lin, 1998; Suinn, Rickard-Figueroa, Lew, & Vigil, 1987), acculturation level may vary across generations and, among first-generation individuals, may be affected by length of residence in the United States. In addition, mental health researchers have increasingly examined the role of ethnic and racial identity and its relation to various psychological concepts (Casas & Pytluk, 1995; Choney, Berryhill-Paapke, & Robbins, 1995; Cross, 1995; Marsella, Johnson, Johnson, & Brennan, 1998; Sodowsky, Kwan, & Pannu, 1995; White & Parham, 1990; Yamada, Marsella, & Yamada, 1998). Some of the research on the relationship of these processes and identities, as well as the development of psychological distress in general and anxiety disorders in particular, has been equivocal. For example, as discussed later in this chapter, McNeil, Kee, and Zvolensky (1998) found that ethnic identity was related either to decreases or increases in anxiety, depending on the context. In addition, Christensen (1999) examined the influence of ethnic identity and family relationships on the psychological well-being of Native American elders. The results revealed that a stronger familial support was related to fewer anxiety and psychosomatic symptoms. However, ethnic identity was not found to significantly relate to psychological well-being.

In addition, the huge, increasing number of biethnic/biracial individuals also must be considered. Root (1992, 1998, 1999) and LaFromboise and colleagues (LaFromboise, Coleman, & Gerton, 1993; LaFromboise, Heyle, & Ozer, 1999), among others, have discussed the difficulties with ethnic identity development that some racially mixed individuals may face, such as feeling ostracized and discriminated by members of both ethnic groups, which might also increase the risk of developing psychological distress. Again, issues related to the development of identity among these individuals have increasingly been associated with various psychological concepts and processes (Kerwin & Ponterotto, 1995).

These are just a few of the shared risk factors among ethnic minority groups that should be included in any assessment of anxiety symptoms. Clinicians should be familiar with these issues as well as with ethnic-specific issues and should integrate questions about them in the assessment process.

State-Trait Anxiety Inventory

Specific to anxiety, in his review, the only assessment device Dana (1993) discussed was the multicultural application of the State-Trait Anxiety Inventory (STAI) (Spielberger, 1976). According to Spielberger (1989), the STAI has been translated into more than 40 different languages and dialects, generally following an idiomatic rather than literal equivalence approach. Idiomatic translation may be a more accurate reflection of the underlying meaning of a phrase as compared to a literal translation. Unfortunately, psychometric data were not provided, thus making it difficult to ascertain the utility of these translated versions. Dana’s evaluation of the STAI’s Spanish versions indicated that these versions are useful tools in assessing anxiety symptoms among Spanish-speaking adults. However, he did emphasize that clinicians must consider “local” and community norms in the interpretation of scores. For example, age, gender, socioeconomic status, and nationality will vary among Latinos and thus should be considered in interpreting level of distress.

Developed in 1986 for use in Hong Kong, the Chinese version of the ST AI (C-STAI) revealed high item-total correlations and alpha coefficients (Chan, 1990). Shek’s (1993) comparison of the C-STAI to other psychological measures (i.e., Beck Depression Inventory [BDI], General Health Questionnaire, Leeds Scales for the Self-Assessment of Anxiety and Depression) revealed concurrent validity and a significant correlation between A-State and A-Trait.

Clinician Self-Assessment

In addition to the client factors discussed above, a brief discussion of clinician factors must be made. Mental health professionals must begin to acknowledge the role of their own worldview, knowledge base and experience with other cultural groups, possible biases, and stereotypes and prejudices that might influence the process of assessment. In addition to didactic knowledge, mental health professionals must take some responsibility for acquiring the skills needed to provide culturally appropriate assessment. Minimally, this would include the clinician’s own self-assessment of thoughts and feelings related to people of different cultural backgrounds. In addition, mental health professionals should also strive to understand the context in which ethnic minorities live. For example, clinicians could consider what it might be like for a potential client to face lifelong discrimination and racism through a combination of personal experience and vicarious, observed experiences. Indeed, the need for emphasis on multicultural competence among mental health professionals not only is warranted but is an ethical obligation (Sue, Bingham, Porche-Burke, & Vasquez, 1999).

Asian Americans / Pacific Islanders

The November 1, 1999, U.S. census population estimates indicated that approximately 4% of the population was Asian American/ Pacific Islander (U.S. Bureau of the Census, 2000). The Census Bureau also reported that as a collective group, Asian Americans are one of the fastest-growing ethnic and cultural groups in the United States. Indeed, the population estimates of Asian Americans and Pacific Islanders increased by .4% in just AVi years. As mentioned previously, Asian Americans/Pacific Islanders (AA/PIs) are a very heterogeneous group comprising more than 25 ethnic groups collapsed into one category based on their common heritage in Asia and the Pacific Islands, similar appearance, and cultural values.

As indicated earlier, prevalence data on anxiety disorders among AA/PI individuals do not exist. Thus, the extent of anxiety problems among AA/PIs is unknown. In a review of the literature on depression and anxiety among Asian American older adults, Iwamasa and Hilliard (1999) found only two studies that focused on anxiety and Asian American older adults, and both focused on Japanese Americans. Yamamoto et al.’s (1985) study found that among Japanese American elders, anxiety disorders were less frequent as compared to other disorders such as depression and organic brain disorder. Nine percent of their participants met criteria for panic disorder. Iwamasa, Hilliard, and Osato (1998) conducted interviews with Japanese American elders and found that although many individuals defined anxiety and depression similar to the diagnostic criteria of DSM, some of the participants conceptualized anxiety using depressive symptoms and vice versa. These results highlight the notion that how AA/PIs conceptualize anxiety may be different from other ethnic groups’ conceptualization. For some AA/PI individuals, they may describe a person as being anxious using depressive symptoms and a depressed person as someone with anxiety symptoms.

Culture-Specific Considerations

In the assessment of anxiety symptoms among AA/PI individuals, clinicians should consider the following issues in terms of the roles they may play in mediating anxiety: focus on family, focus on community, respect for elders, communication style, interpersonal harmony and cooperation (collectivistic orientation), sex roles, ethnic identity, language, acculturation, generational status, immigration status, religiosity/spirituality, age, education level, occupational status, socioeconomic status (SES), and access to health care. Some of these values/behaviors may actually serve as protective factors against the development of some anxiety symptoms. For example, Lin, Ensel, Simeone, and Kuo (1979) found that social support was significantly and negatively related to illness symptoms in a Chinese American sample in Washington, D.C. Similarly, Viswanathan, Shah, and Ahad (1997) revealed that family involvement and social support may facilitate the therapeutic process but also may produce additional anxiety (e.g., disagreeing with an authority figure). Given that family and community are important Asian cultural values, this may actually work to decrease the development of anxiety and other distress symptoms in Asian Americans. This highlights one of the resources available to health care providers—using family and community to support treatment.

However, some aspects about traditional Asian values might also increase the likelihood of the development of an anxiety disorder. For example, values within the Asian Indian culture such as dependency, unassertiveness, and submissiveness may contribute to social phobias, especially within the American culture, which promotes assertiveness and less rigid social boundaries (Viswanathan et al., 1997).

Culture-Specific Disorders

Dhat. Evidence of dhat syndrome, a sexual neurosis, has been found within the Indian subcontinent (Viswanathan et al., 1997). This syndrome is characterized by a fear of losing semen {dhat) through urine, which leads to a loss of physical and mental energy. Individuals present with several somatic symptoms such as weakness, fatigue, palpitations, sleeplessness, and physical and mental exhaustion (Bhatia & Malik, 1991). Although not technically an anxiety disorder, dhat syndrome is included here because of its psychological sequelae. Treatment includes sexual counseling and treatment of the associated disorders. Research and evidence of this syndrome have primarily occurred in India. Thus, mental health providers in the United States may observe dhat syndrome only in first-generation Asian Indians.

Hwa-Byung. Lin (1983) described three cases of hwa-byung, a Korean folk illness experienced by patients and their families to be a physical affliction, despite the fact that its manifestations include both physiological and psychological symptoms. From a Western perspective, hwa-byung appears to be a mixture of depression and anxiety. In addition, the patient often recognizes interpersonal conflicts and anger as precipitating factors to the somatic complaints. Each patient described by Lin also identified an epigastric mass that was not identified on physical examination. Symptoms of the disorder included (a) repressed or suppressed anger of long duration; (b) various somatic complaints (e.g., panic attacks, psychomotor retardation, tiredness, loss of appetite, weight loss, indigestion, dizziness, insomnia); (c) feelings of helplessness, resentfulness, and guilt; (d) tension; (e) pressure or compression in the epigastrium; and (f) fear of impending death despite medical reassurance. With these patients, antidepressants were prescribed, and with two of the patients, supportive psychotherapy also was used. Lin reported these treatments as being effective in treating the symptoms. A follow-up study of 109 Korean Americans, ages 18 years and older, in the metropolitan Los Angeles area, found that 11.9% reported having suffered from hwa-byung (Lin et al, 1992). Thus, it appears that the incidence of hwa-byung may increase as the population of Korean Americans increases and as clinicians become more aware of the symptoms. See Iwamasa (1997) for a more thorough review of this disorder.

Koro. This syndrome, documented in Chinese and Asian Indian cultures, is characterized by an intense fear that the penis will shrink or disappear into the abdomen as a punishment for sins (Al-Issa & Oudji, 1998; Viswanathan et al., 1997). Symptoms include anxiety related to sexual functioning of organs, heart palpitations, sweating, vertigo, fear of death, and guilt and shame associated with masturbation and sexual activity. Among the Chinese, koro is referred to as shuk (dwindling/withdrawal) yang (male genitals) (Al-Issa & Oudji, 1998). Treatment of koro in India and China includes psychotherapy and tranquilizers (Viswanathan et al., 1997). Although not yet documented in the United States, this disorder may exist in first-generation Indian and Chinese men.

Taijin-Kyofu-Sho. Taijin-kyofu-sho (TKS) has been described by Kirmayer (1991) as the Japanese equivalent to social phobia. DSM-IV describes social phobia as marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or scrutiny by others. The individual fears he or she will act in a humiliating or embarrassing way, and exposure to the feared social situation provokes anxiety; thus, the situation is avoided.

TKS is described in Japan as a neurotic disorder of extraordinary intense anxiety and tension in social settings, in which people have a fear of being looked down upon, making others feel unpleasant, and being disliked, such that it leads to withdrawal or avoidance of social relations (Tseng, Asai, Kitanishi, McLaughlin, & Kyomen, 1992). Behaviors that might lead to the intense anxiety include blushing, concerns about emitting offensive odors, staring inappropriately, and improper facial expressions. An individual might not actually be doing these behaviors, but instead, the anxiety is a result of the fear that others perceive that he or she is engaging in the behaviors. In most incidences, individuals often describe a single circumscribed fear. The four subtypes of TKS are (a) transient type (temporary, usually occurs in adolescents); (b) neurotic type; (c) severe type, which often includes delusions or ideas of reference; and (d) secondary type, which is a phobia that occurs concomitantly with schizophrenia.

Kleinknecht, Dinnel, Tanouye-Wilson, and Lonner (1994) described the major difference between social phobia and TKS as being the focus of the social anxiety. With social phobia, anxiety is due to concern that the person will embarrass himself or herself. With TKS, the concern is that the person will do something that will offend or embarrass others. As discussed earlier, traditional Asian cultural values emphasize the importance of the group over the individual. One can see how the emphasis on interpersonal relations among the Japanese could result in intense anxiety in those who may lack adequate coping skills or who have low levels of self-confidence. Thus, one might experience anxiety symptoms as a result of the cultural emphasis on interpersonal harmony. A more thorough discussion of TKS may be found in Iwamasa (1997).

Blacks and African Americans

The November 1, 1999, U.S. census population estimates indicated that approximately 12.8% of the population was Black/African American (U.S. Bureau of the Census, 2000). As with AA/PIs, the population of Blacks/ African Americans is increasing, albeit at a slower rate of .2% in the past AVi years. Although they comprise a significant portion of the U.S. population, unfortunately, the anxiety literature on the prevalence, expression, and help-seeking patterns of this population is quite limited (Heurtin-Roberts, Snowden, & Miller, 1997).

The prevalence rates of anxiety disorders have been reported to be higher in African Americans than in other populations. For example, African Americans are three times more likely to have simple phobias than Caucasians, experience panic disorders more than other populations, and have higher comorbidity rates with anxiety and other illnesses (Snowden, 1999). African American children also experience more general fears and reality-based fears than other children (Heurtin-Roberts et al., 1997).

Culture-Specific Considerations

Historically, African Americans have been misdiagnosed and mistreated by the mental health professional (Neal-Barnett & Smith, 1997). As such, active help seeking among African Americans is quite limited. Thus, mental health professionals should be aware of the potential distrust of the field that many African Americans may have toward them and consider those issues in conducting assessment and treatment. Neal-Barnett and Smith (1997) also discussed the need to inform and educate African Americans on the signs and symptoms of anxiety disorders.

As with other ethnic minority groups, it has been suggested that the presentation of anxiety symptoms differs in African Americans because it is influenced by culture. For example, a cultural theme related to a blood imbalance (e.g., thickening or thinning of blood) that leads to emotional distress has been reported (Heurtin-Roberts et al., 1997). Anxiety folk disorders related to this blood imbalance include falling-out, “high-pertension,” high blood, and nerves. Evidence for this cultural expression of anxiety has been found in the United States, the Caribbean, and South America. Panic disorder also appears to co-occur frequently with diagnoses of hypertension among African Americans (Neal, Nagle-Rich, & Smucker, 1994; Neal & Turner, 1991). Other culturally related anxiety symptoms may include hallucinations and delusions, and themes of victimization, violence, and paranoia have been found (Heurtin-Roberts et al, 1997).

Kleinman et al.’s (1978) warning that inappropriate treatment will occur without knowledge of a patient’s conceptualization is quite salient given that the misdiagnosis of African Americans has led to high rates of hospitalization and prescription of antipsychotic medications (Al-Issa & Oudji, 1998). Snowden (1999) also reported that African Americans express somatic complaints (i.e., headaches, dizziness, weakness, pounding heart, hot flashes, and chills) that are believed to be symptoms of underlying disorders and contribute to the overall distress level. Following this presentation of somatic symptoms, research has revealed that African Americans are more likely to use medical services rather than mental health services (Heurtin-Roberts et al, 1997).

With regard to specific anxiety disorders, Neal-Barnett and Smith (1997) found that in general, African Americans seldom endorse generalized anxiety disorder symptoms. In one study of African American women, Neal-Barnett and Smith discovered that although some symptoms were exhibited, diagnostic criteria for generalized anxiety disorder were not met. The authors hypothesized that Africans Americans may experience life as full of generalized anxiety and thus learn to cope with it. In addition, concerning social anxiety disorder, Neal-Barnett and Smith reported that African Americans are more likely to experience social anxiety in the presence of other Blacks than with Caucasians. This heightened anxiety may be due to a fear of not attaining an African American “standard” or fitting in with the African American culture. For African Americans who experience social anxiety in the presence of Caucasians, the authors suggested that racism may play a role.

As previously mentioned, African Americans experiencing anxiety symptoms are more likely to present to medical services. African Americans experiencing obsessive-compulsive disorder commonly present to dermatology clinics (Neal-Barnett & Smith, 1997). Despite this help-seeking pattern, the authors noted that the presentation of obsessive-compulsive disorder is similar to the DSM-IV diagnosis. To provide appropriate diagnosis and treatment, Neal-Barnett and Smith suggested modifying structured interviews to include information on extended family, spirituality, victimization, exposure to violence, and sleep paralysis. In general, limited information exists on the presentation, conceptualization, and treatment of anxiety disorders with African Americans.

For Caribbean Americans, Gopaul-McNichol and Brice-Baker (1997) discussed the difficulties inherent in assessing anxiety symptoms, as Caribbean Americans are likely to be resistant to mental health intervention. Specifically, the concept of time (“anytime is Caribbean time”) and the need to keep “secrets” within the family (and resolve problems within the family) were discussed as major impediments to traditional therapy. Gopaul-McNichol and Brice-Baker also discussed potential risk factors for the development of anxiety symptoms and disorders among Caribbean Americans, such as immigration experiences, racism, and witchcraft. Although practice of voodoo, espiritismo, and santería are often viewed as protective factors, fear of evil spirits or being the target of an evil spell may precipitate panic attacks.

Culture-Specific Disorders

Brain-Fag Syndrome. Prince first defined this syndrome in 1960, and its existence was confirmed in several regions of Africa (Al-Issa & Oudji, 1998). The basis of this disorder is an intense fear of failure as educational achievement is highly valued within the African family. This syndrome was observed in university students in Africa after intense study periods. Symptoms included (a) pain in the back of the neck, (b) frontal headache, (c) burning sensations of the scalp and head, (d) difficulty in attention and thinking, and (e) inability to understand what one reads and amnesia of what has just been studied. More recently, Prince (1985) attributed the brain-fag syndrome to “the forbidden knowledge theory.” He reported that African students attending Western schools perceived themselves as betraying their ancestors (they reported dreams of their ancestors beating them). Prince noted that these individuals were less acculturated into Western society. Thus, this disorder may be more likely to be documented among immigrant African Americans. More research is necessary to further investigate this syndrome.

Isolated Sleep Paralysis. Bell, Hildreth, Jenkins, and Carter (1988) described isolated sleep paralysis among African Americans as a recurrent condition often referred to as “the witch is riding you,” which occurs upon awakening or when falling asleep. Individuals report being unable to move and may experience hallucinations or feelings of impending danger. When the paralysis subsides, individuals often report panic symptoms. The relationship of isolated sleep paralysis to panic disorder is not yet clear, but some believe it serves as a precursor to the development of panic disorder (Neal et al., 1994).

Native Americans

The November 1, 1999, U.S. census population estimates indicated that approximately .9% of the population was American Indian, Eskimo, and Aleut (U.S. Bureau of the Census, 2000). In addition to the aforementioned ethnic groups, Bigfoot and Braden (1998) suggested that the Native American population also include Native Alaskans and Native Hawaiians.

American Indians share a history of oppression, depression, anxiety, and shame (Bigfoot & Braden, 1998). Yet McNeil et al. (1998) noted the paucity of empirical information on the nature, assessment, and impact of anxiety on American Indians. This information is salient given that anxiety is associated with poor health and substance abuse. Tribal surveys have revealed that more than 50% of participants reported anxiety problems followed by substance abuse and depression. In addition, many Native American children and adolescents have also been found to meet criteria for an anxiety disorder (McNeil, Porter, Zvolensky, Chaney, & Kee, 2000).

Culture-Specific Considerations

Forty-eight percent of the American Indian/Eskimo/Aleut population continues to reside in the most rural areas of the United States as compared to other ethnic minority groups, who are more likely to live in urban areas. This population is characterized as younger, less educated, and poorer than the general population. Approximately 31.6% of American Indians live below the poverty line as compared to a national average of 13.1% (Bigfoot & Braden, 1998). Limited access to medical facilities, medical professions, and funding sources have also contributed to the poor health of American Indians. For example, tuberculosis, diabetes, and fetal alcohol syndrome are higher in Native Americans than in other populations. Native Americans may also be characterized by their adherence to traditional culture, language, family structure, social functions, and health practices (Norton & Manson, 1996). Again, provided that this population is very heterogeneous, the information presented in this section is intended to serve as general guidelines and is not necessarily applicable to all Native Americans.

Researchers have highlighted the importance of examining anxiety, as the cultural abuses (i.e., forced relocation, genocide) suffered by American Indians may have led to culturally related anxiety. For example, McNeil et al.’s (1998) study of Navajo college students examined the relationship between ethnic identity (self-concept related to social group membership and emotional response to the membership) and culturally related anxiety. A strong ethnic identity may decrease the development of anxiety as an individual has more access to tribal support systems. However, a strong ethnic identity may also contribute to the development of anxiety due to culturally related anxiety and interacting with the majority culture. No significant relationship between ethnic identity and anxiety was found. In addition, no gender differences were revealed with respect to culturally related anxiety.

More recently, McNeil et al. (2000) developed the Native American Cultural Involvement and Detachment Anxiety Questionnaire (CIDAQ), a 20-item culturally related anxiety measure. The CIDAQ includes three subscales: Social Involvement With Native Americans and Alaska Natives, Economic Issues, and Social Involvement With the Majority (Caucasian) Culture. The measure, which was normed on a pan-Indian sample and a homogeneous sample (Navajo), had good internal consistency and appeared to tap into culturally related anxiety. The authors reported that future research should continue to assess the psychometric properties of the CIDAQ.

With regard to help seeking and treatment, research has revealed that compared to other Americans, American Indians are less aware of available psychological services. For those aware of services, they fail to pursue therapy due to cultural and ethnic differences (LaFromboise, 1988). This may be because American Indians’ view of therapy significantly differs from the dominant culture (LaFromboise, Trimble, & Mohatt, 1990). Specifically, expectations, goals, and attitudes toward therapy may differ. These differences include but are not limited to a spiritual and holistic view of mental health, inclusion of the Indian community, attribution of psychological problems to weakness or lack of discipline to maintain cultural values, ceremonial rituals, and consultation with medicine men.

American Indians may also fear that therapists will attempt to change values rather than problem solve or suggest treatments in conflict with American Indian culture. In addition, the historical mistreatment of American Indians and racism also may provide a barrier in developing trust in therapy (LaFromboise et al., 1990). For successful therapy, LaFromboise et al. (1990) recommended increasing access to traditional treatments and integrating traditional healing methods into culturally appropriate therapy. The authors specifically noted the merits of using a skills-training paradigm (social learning theory) or a network approach (inclusion of clan, family, and friends) in working with American Indians.

Bigfoot-Sipes, Dauphinais, LaFromboise, and Bennett (1992) investigated help-seeking patterns with a high school sample of American Indians and Metis (mixed Indian and Caucasian ancestry). Research revealed that American Indians with a strong adherence to their culture preferred counselors of the same ethnicity and sex. American Indian girls appeared to prefer female American Indian counselors. In addition, the nature of the problem (personal vs. academic) also influenced therapist preference. For personal problems, same-sex counselors were preferred, whereas similar age and education were preferred for academic problems. Similar to other ethnic groups, this research highlights the importance of assessing acculturation level in working with American Indians.

Culture-Specific Disorders

Kayak-Angst. This syndrome, characterized as an acute panic state, has been evidenced among the Inuit. Symptoms include vertigo, dazed feelings, spatial disorientation, “violent vegetative reaction,” and “panic-stricken anguish.” Al-Issa and Oudji (1998) reported that kayak-angst has been observed while Inuit seal hunters wait (immobile) in a boat for hours. The symptoms appear to be relieved when an affected individual is assisted and surrounded by others. The limited information on this culture-specific syndrome clearly warrants future research.


The November 1,1999, U.S. census population estimates indicated that approximately 11.6% of the population was of Hispanic origin (of any race) (U.S. Bureau of the Census, 2000). According to census projections, this population is the fastest-growing ethnic minority group in the United States, with a 2.6% increase in just 9 years. As discussed earlier, this population is highly heterogeneous, composed of individuals collapsed into one category based on their common heritage in South and Central America, Puerto Rico and Cuba, and Spain.

Culture-Specific Considerations

The underutilization of mental health services by Hispanic Americans has been associated with language and cultural differences. Research has revealed that Hispanics’ reliance on family, religion, and folk remedies may account for the limited utilization of mental health services (Salman, Diamond, Jusino, Sanchez-LaCay, & Liebowitz, 1997). In addition, Hispanics have culturally defined labels for behaviors that also contribute to the limited use of mental health services. Due to this underutilization of mental health services, the family may serve as the primary caregiver and buffer individuals from the embarrassment and stigma associated with mental illness. In addition, as with AA/PIs, some of these cultural values may actually serve as protective factors in the development of anxiety. However, use of mental health facilities was found to increase when bilingual individuals were available to work with Hispanic clients (Salman et al., 1997).

Glover, Pumariega, Holzer, Wise, and Rodriguez’s (1999) study revealed that anxiety disorders are more prevalent in Mexican American adults than in other populations. They also noted a high prevalence rate (13.8%-21%) among Mexican American adolescents. The researchers noted that a relationship between culture and symptomatic expression may exist. Based on their research, Glover et al. hypothesized that Mexican American adolescents with higher levels of anxiety may be attempting to balance two cultures. They specifically noted that female adolescents may be attempting to balance gender roles and experience more internal emotional distress and somatic symptoms. Applicable to other ethnic minority groups, Glover et al. noted the importance of examining the relationship between acculturation and anxiety.

Tran (1997) investigated the effects of ethnic identification and gender with respect to several social stress variables, including anxiety. Participants were Cuban American, Mexican American, and Puerto Rican American older adults. Results revealed that a high percentage of these three groups experienced anxiety. Results also revealed that individuals with lower SES, increased physical difficulties, and poorer health experienced more anxiety than their counterparts. With regard to gender, across the three groups, more women (46.2%) reported anxiety than men (33.8%). In examining within-group gender differences, Puerto Rican men experienced more anxiety than both Cuban and Mexican American men. In contrast, Puerto Rican women experienced less anxiety than both Cuban and Mexican American women. The results of Tran’s study demonstrate the importance of examining both ethnicity and gender when researching psychological disorders with ethnic minority populations.

Culture-Specific Disorders

Ataques de Nervios. Ataques de nervios was reported in 1955, as observed in Puerto Rican army recruits. Since then, ataques de nervios also has been documented in the general Puerto Rican adult population, among Caribbean Hispanics, and also in areas of Latin America (Guarnaccia, 1997). Ataques is viewed as a normative stress-related reaction that commonly occurs at funerals, accidents, and familial conflicts. Symptoms of this disorder include crying, shaking, palpitations, numbness, shouting, swearing, striking others, and falling to the ground with convulsive body movements (Al-Issa & Oudji, 1998; Salman et al., 1997). Guarnaccia, Rivera, Franco, and Neighbors (1996) have also highlighted the role of strong anger, loss of impulse control, and dissociative features as significant features of the phenomenology of ataques.

Salman et al. (1997) referred to this syndrome as a folk label used to describe a loss of emotional control. In their clinical sample, the authors discovered that some of these ataques were diagnosable anxiety and affective disorders. They also noted subtypes of ataques, each possessing a specific symptom pattern and correlating with a psychological disorder. Thus, Salman et al. reported that ataques may be helpful clinical markers for identifying psychological disorders.

Nervios. The Hispanic population has referred to nervios as a level of distress related to physical symptoms, emotional conditions, and familial changes. As compared to ataques, nervios are more chronic, low grade, and transient (Salman et al., 1997). Symptoms include headache, insomnia, lack of appetite, trembling, and disorientation (Al-Issa & Oudji, 1998). Recent studies have revealed that left untreated, nervios may develop into diagnosable psychological disorders.

Treatment Issues

Part VI of this book focuses on clinical interventions in depth. However, some treatment issues are discussed here as they relate specifically to anxiety symptoms. As discussed earlier, Kleinman et al.’s (1978) construct of EMI will likely influence treatment. Thus, as few ethnic minority individuals are likely to seek out traditional mental health services when experiencing anxiety problems, the possibility that they will seek informal or medical sources of help are fairly high (Cheung, 1991; Dinges & Cherry, 1995).


In the medical field, ethnic differences with regard to psychopharmacology have been noted, yet concern still exists as to whether those who prescribe medications take culture and ethnicity into consideration in prescribing medications, both type and dosage (Lawson, 1996, 1999; Sramek, 1996). Although ethnic differences in response to psychotropic medications have been documented and discussed in the psychopharmacology literature (Lin, 1986, 1995; Ramirez, 1996), little information on the use of psychiatric medications among ethnic minorities is available in the multicultural mental health literature. What little research exists demonstrates the need for caution in the use of medications among ethnic minority populations (Al-Issa & Oudji, 1998). For example, some studies have revealed that African Americans are more sensitive to several psychotropic drugs than Caucasians. African Americans have also been found to have a quicker reaction to tricyclic antidepressants than Caucasians. Finally, Asian Americans are generally prescribed smaller dosages (one half to two thirds less) of benzodiazapines as compared to Caucasians. More information on the use of psychotropic medications for anxiety among ethnic minorities must be provided in the mental health literature.

Incorporation of Spirituality, Religion, and Healing Practices

As stated in this chapter and throughout this book, for many ethnic minorities, seeking help from professional mental health professionals is not the first-line approach when experiencing psychological distress. Many ethnic minority individuals have strong spiritual or religious beliefs and may turn to their spiritual and religious leaders when seeking help. For example, Bigfoot and Braden (1998) noted that American Indians may conduct ceremonies and rituals for healing, and prayers may be offered to assist families. In general, American Indians maintain their cultural traditions (e.g., respect for elderly, role of extended family, traditional gatherings), and thus the mental health professional must be made aware to provide culturally appropriate assessment and treatment of this population. This specific example demonstrates the need to consider ethnic minority individuals’ social support networks and the context of their lives in the development of culturally appropriate treatment plans. Readers are encouraged to consult Koss-Chioino (1995), who provides an excellent review of traditional and folk approaches to psychological distress and suggestions on incorporating such practices into traditional psychotherapy.

Future Directions

This chapter has provided a brief summary of the existing research on anxiety disorders among ethnic minority populations. Clearly, more research is needed to help mental professionals fully understand the experiences of ethnic minority individuals in psychological distress. More epidemiological data on anxiety disorders (and other mental disorders, in general) are needed on all ethnic minority groups. Health care providers and mental health professionals must also begin to consider the applicability of the culture-specific disorders contained in this chapter for immigrant individuals. As has been noted, some of these disorders have already been documented in the United States, and thus it is quite possible that the other disorders likely exist as well; but because health care providers lack knowledge about them, they are left unidentified and untreated, resulting in unnecessary psychological distress. In conducting this research, further data are needed on the effects of factors specific to ethnic minorities such as racism and discrimination, accessibility to services, language barriers, and culture-specific conceptualizations of anxiety. Finally, in the research on anxiety among ethnic minorities, within-group differences such as ethnic identity, acculturation, generational status, and sex and gender roles must be examined to further assist us in understanding the complex issues faced by ethnic minority people.

Concluding Comments

Anxiety disorders are thought to be some of the most common psychological disorders among the general population of the United States. However, given the lack of epidemiological and empirical data on ethnic minority people in the United States, the extent of anxiety disorders among ethnic minorities is unclear. It is hoped that this brief summary of the mental health literature, demonstration of the lack of research on anxiety disorders among ethnic minorities, and presentation of the unique cultural issues among ethnic minority populations will serve as a wake-up call to researchers. Much more research is needed to provide culturally appropriate and effective services to this increasing and very diverse population.