Anxiety: A Common but Multifaceted Condition 13
tures is complicated by the fact that our standard diagnostic classification system, DSM-
IV-TR (APA, 2000), is based on American conceptualizations and experiences of anxiety
that may not have hig h diag nostic validit y in other cultu res (van Om meren, 20 02). Cross-
cultural generalizability is not necessarily improved by using the WHO’s classification of
anxiety disorders, the International Classification of Diseases—Tenth Revision (ICD-10),
because of the dominance of the European- influenced Western experience (World Health
Organization, 1992). Thus our standard diagnostic and assessment approaches to anxiety
may overemphasize aspects of anxiety that are prominent in the European Western expe-
rience and omit significant expressions of anxiety that are more culture- specific.
Barlow (2002) concluded in his review that apprehension, worry, fear, and somatic
arousal are common in all cultures. For example, a large community survey of 35,014
adult Iranians found that 20.8% had anxiety symptoms (Noorbala, Bagheri-Yazdi,
Yasamy, & Mohammad, 2004). Even in remote rural or mountainous regions of develop-
ing countries where modern industrial amenities and pressures are minimal, the occur-
rence of anxiety and panic disorders is similar to rates reported in Western community
surveys (Mumford, Nazir, Jilani, & Yar Baig, 1996). Nevertheless, countries do appear
to have different population rates of the anxiety disorders. The WHO World Mental
Health Surveys found that 1-year prevalence of DSM-IV anxiety disorders ranged from
a low of 2.4%, 3.2%, and 3.3% in Shanghai, Beijing, and Nigeria, respectively, to
11.2%, 12%, and 18.2% in Lebanon, France, and the United States, respectively (WHO
World Mental Health Survey Consortium, 2004). This broad variability in prevalence
rates raises the possibility that culture may influence the actual rate of anxiety disorders
across countries, although methodological differences across sites cannot be ruled out
as an alternative explanation for the differences.
There is substantial evidence that culture does play a significant role in the expres-
sion of anxious symptoms. Barlow (2002) noted that somatic symptoms appear more
prominent in emotional disorders in most countries other than those of the European-
influenced West. Table 1.2 presents a select number of culture-bound syndromes with a
significant anxiety component.
Clinician Guideline 1.6
Assessment for anxiety should include a consideration of the individual’s culture and social/
familial environment and their inf luence on the development and subjective experience of
a n x ie t y.Persistence and Course
In contrast to major depression, anxiety disorders are often chronic over many years
with relatively low remission but more variable rates of relapse after complete recovery
(Barlow, 2002). The Harvard–Brown Anxiety Disorder Research Program (HARP), an
8-year prospective study, found that only one-third to one-half of patients with social
phobia, GAD, or panic disorder achieved full remission (Yonkers, Bruce, Dyck, & Keller,
2003).^1 The Zurich Cohort Study found that nearly 50% of individuals with an initial
(^1) Although these remission rates are very low, especially for social phobia and panic disorder, they probably
overestimate the true remission rates for the anxiety disorders since 80% of the subjects had some form of
pharmacological treatment over the 8-year follow-up.