Social anxiety disorder (SAD) is characterized by fear of social situations involving performance, social interactions or being observed. In DSM-5, the “generalized” specifier in DSM-IV has been deleted and replaced with a “performance only” specifier. Taijin-kyofu (TK) in Japan is a sufficient criterion for SAD, because the definition of offence of others is added to fear of humiliating or embarrassing oneself. However, it is confusing that the Japanese terms of “jikoshu-kyofu” and “shubo-kyofu” are categorized as other specified obsessive–compulsive disorder and related disorders. The Liebowitz Social Anxiety Scale (LSAS) is a reliable, valid, and widely used scale that is the standard measure of SAD severity. The LSAS-Japanese version (LSAS-J) has been used in the clinical study of SAD in Japan. However, investigation of TK has been hampered by the lack of a measure for the assessment of TK symptoms in the LSAS. We thus developed the Social Anxiety/Taijin-kyoufu Scale (SATS) to rate the severity of the symptoms of SAD and TK.

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Social anxiety disorder (SAD) is a mental disorder characterized by marked fear and anxiety in social or performance situations, and is associated with severe impairment in daily life functions due to the avoidance of such situations. Since the release of DSM-III, a large number of epidemiological studies have been conducted and have reported high morbidity in relation to this disorder. In DSM-IV, in addition to social phobia, “social anxiety disorder” was included in the classification of mental disorders, and this has been reflected in conceptual changes in diagnosis. Comorbidity with other psychiatric disorders has been reported and special attention is needed in cases of major depressive disorders and suicidal behaviors with especially high comorbidity rates. With DSM-5, for the first time, the definition of SAD included anxiety symptoms involving the viewpoint of others, such as “offending to others”, as well as anxiety symptoms from a self-centered viewpoint. This means that SAD and “taijin kyofusho (fear of interpersonal relations)”, a diagnosis particular to Japan, can be regarded as almost the same diagnostic concept. In Japan, SAD has been a “overlooked” disorder which is under-diagnosed and under-treated. Nevertheless, in consideration of Japan’s unique cultural background, health care providers in Japan should be especially aware of SAD with the hope of achieving maximal improvement in these patients.

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The author reviewed recent findings on pharmacotherapy of social anxiety disorder (SAD). Meta-analyses and RCTs have suggested that SSRIs, SNRIs and RIMAs are significantly effective on social anxiety disorder compared with placebo. In Japan, however, RIMA is not available and venlafaxine (an SNRI effective on SAD) is not approved for the treatment of SAD using public health insurance. SSRIs may therefore currently play the most important role in pharmacotherapy of SAD in Japan.

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A recent meta-analysis revealed that cognitive behavioral therapies based on Clark and Wells’ or Heimberg’s models were the most effective for individuals with social anxiety disorder, compared to other pharmacological and psychological treatments. This meta-analysis also suggested that it is important to optimize treatment efficacy because there are patients who could not obtain sufficient effects of the treatment. Cognitive behavioral therapies for social anxiety disorder involve exposure to feared social situations. Significant advances have been made in the field of cognitive neuroscience on fear conditioning and extinction. Craske defined inhibitory learning according to the cognitive neuroscience concepts of extinction learning and emotion regulation. The present paper overviewed the essence of cognitive behavioral therapies for social anxiety disorder in order to enhance treatment efficacy based on Craske’s inhibitory learning and acceptance and commitment therapy perspectives.

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Brain imaging studies of social anxiety disorder (SAD) were reviewed. Structural brain imaging studies of SAD have shown smaller gray matter volumes of amygdala and hippocampus, as well as abnormalities of white matter of uncinate fasciculus in SAD patients. Moreover, functional brain imaging studies of SAD have consistently reported hyperactivity of the amygdala during public speaking and in responses to emotional faces. Furthermore, changes in limbic system and prefrontal cortex (PFC) have been correlated with pharmacotherapy and cognitive behavioral therapy (CBT). Additionally, the predicted outcome of CBT has been associated with pretreatment activities of visual and prefrontal regions (i.e., dosolataral PFC, ventrolateral PFC), and not with amygdala activity. Also, resting state studies have shown dysfunctional connections between amygdala and orbitofrontal cortex (OFC). These studies are suggestive of structural and functional abnormalities of the limbic system (e.g., amygdala, hippocampus, anterior cingulate cortex)—prefrontal regions (e.g., ventromedial PFC), which are neural circuits modulating fear and anxiety.

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Though major depressive disorder, panic disorder and PTSD are twice as common in women as in men in several epidemiologic studies, gender difference in the prevalence of social anxiety disorder (SAD) is not so large. Why not? In the viewpoint of brain science, hypersensitivity of amygdala and dysfunction of prefrontal cortex were known to relate with both depression and anxiety. While chimpanzees are believed to be male dominant in their dominance hierarchy, bonobos are female dominant. In the history of the world, the human society was male dominant, such as patriarchy and military. Recently, Kano et al. (2015) reported that bonobos make more eye contact than chimpanzees. Eye contact is a powerful communication tool. Women may use eye contact better than men. Patients with SAD often avoid eye contact as one of their safety behaviors. In the viewpoint of killing each other on the battlefield, men tend to feel fear of other men in dominance hierarchies in the same way as women. The human nature about fear of other human beings may be a reason for no large gender difference in SAD.

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The present study examined effectiveness of group Acceptance and Commitment Therapy (G-ACT) for psychiatric outpatients. The program of G-ACT was consisted of 8 sessions including exercises and homework about acceptance skills, mindfulness skills, and a modification of behavior. At pre-treatment, post-treatment and 1-month later follow-up period, all patients (N=11) completely STAI, the factor of Reframing from Catastrophic Thinking in the Cognitive Control Scale, and AAQ-II. The results revealed that the post treatment scores and follow-up scores on the all measurement instruments were significantly improved and the each effect sizes were medium or large. These results show that the G-ACT is effective for patients who have anxiety symptoms. The present study might provide the preliminary evidence about the application of G-ACT for patients who have anxiety symptoms.

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The objective of this paper was to examine how child-rearing anxiety of mothers is maintained through a model of metacognitive therapy (MCT). Based on the MCT model, we created a model that containing two processes: metacognitive beliefs about worry enhance worry, and worry enhances child-rearing anxiety. The respondents were 188 mothers whose children (from 3 years to 5 years of age) go to kindergarten or day-care center. The results of a path analysis showed that negative metacognitive beliefs had a strong positive effect on worry, and that worry had a moderately positive effect on child-rearing anxiety. However, worry had a mildly positive effect on child-rearing time which is a factor of child-rearing anxiety. The study therefore suggests that the maintenance process of child-rearing anxiety can be explained by the MCT model.

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Cognitive behavioural model for OCD suggested a theory of compulsive checking, and demonstrated that symptoms of compulsive checking in OCD are exacerbated by three cognitive appraisals (perceived probability of harm, perceived seriousness of harm, perceived responsibility) that ultimately lead to an intrusive thought. In addition, safety behaviors, such as repeated checking, enhance or maintain the cognitive appraisals and OCD symptoms. According to the cognitive behavioural theory of OCD, this case report delineates the effectiveness of cognitive behavioural therapy (CBT) for an OCD patient who exhibited compulsive checking. As a result of CBT, OCD as measured by the Japanese version of the Obsessive Compulsive Inventory were alleviated. In conclusion, CBT was effective for this case. Cognitive intervention for the three cognitive appraisals might have been effective for the symptoms of compulsive checking in this case. In addition, the cognitive intervention may have enhanced exposure and responsive prevention therapy acceptability. In addition, psycho-education using metaphor might facilitate patients’ understanding of CBT concepts.

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