The effect of culture on anxiety is similar to that on depression, especially since cross-cultural studies have shown a marked ten-dency for anxiety and depression to overlap (American Psychi-atric Association, 1994). Cultural factors affect the precipitants, symptom presentations, pathological thresholds and specific syndrome criteria of the anxiety disorders (Good and Kleinman, 1985). For example, the cross-cultural validity of criterion A for the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) generalized anxiety disor-der (GAD) has been challenged because it restricts the diagnosis of chronic pathological anxiety to a disturbance stemming from undue worry in the absence of actual stressors or excessive worry after minor stress. This leaves out the much larger group of pa-tients in developing societies and devalued minorities in the West who experience chronic pathological anxiety as a result of recur-rent stress (Lewis-Fernández and Kleinman, 1995).
Cultural and ethnic elements have been invoked to explain local differences in anxiety disorder prevalence that persist af-ter controlling for other social factors. For example, the higher rate of simple phobia social phobia and agoraphobia among the African-Americans, as compared with whites (Neal and Turner, 1991), has been attributed to the stress resulting from racial dis-crimination (Brown et al., 1990). In fact, the cross-cultural epi-demiological literature reveals a complex pattern of similarities and differences with regard to the anxiety disorders, and opin-ions differ as to the role of culture in this process (Guarnaccia and Kirmayer, in press). For example, it is presently unclear why the Mexicans born in Mexico, when compared with those born in the USA, show a markedly lower rate of anxiety and other disorders. Suggested explanations include selective migrations, different thresholds for perceiving and reporting a disorder stem-ming from distinct cultural interpretations of what constitutes a “hard life’’ and acceptable suffering, and a combination of both explanations (Shrout et al., 1992).
Multiple cross-cultural studies point to the coappearance of anxiety, depression, somatoform complaints and dissociative symptoms among the nonWestern groups. A markedly somatic idiom predominates, often in the form of culturally specific symp-toms (Ebigbo, 1982). These often coalesce distinctively as cul-ture-bound syndromes characterized also by specific etiological factors, demographics, patterns of impairment and help-seek-ing choices (Hughes et al., in press). It is far from clear that this represents the comorbidity of the Western disorders rather than a different organization of pathological experience (Maser and Dinges, 1992). Examples include ataque de nervios among the Latinos, koro in the Asian communities and taijin kyofusho among the Japanese (Guarnaccia and Kirmayer, in press). Each of these disorders exhibits significant differences that prevent simple one-to-one correlations with the established Western cat-egories (Weiss, 1996).