Journal of Psychosomatic Research, Vol. 46, No. 6, pp.

525530, 1999
Copyright 1999 Elsevier Science Inc.
All rights reserved.
0022-3999/99 $see front matter

S0022-3999(98)00113-5

EDITORIAL

UNDERSTANDING TAIJIN KYOFUSHO THROUGH

ITS TREATMENT, MORITA THERAPY

FUMIKO MAEDA* and JEFFREY H. NATHAN

AbstractThis article presents a brief review of the definition, nosology, history, clinical features, and
etiology of taijin kyofusho. Special attention is also given to Morita therapy for taijin kyofusho. The term
taijin kyofusho literally means the disorder (sho) of fear (kyofu) of interpersonal relations (taijin). Mor-
ita therapy was developed by Masatake Morita in the 1910s to treat the Japanese mental disorders called
shinkeishitsu and taijin kyofusho. It is suggested that taijin kyofusho is an excellent example of a mental
disorder in which understanding its treatment is an integral part of its conceptualization. 1999 Elsevier
Science Inc.

Keywords: Anthropophobia; Morita therapy; Psychotherapy; Taijin kyofusho.

INTRODUCTION

Taijin kyofusho (anthropophobia; included in social phobia in ICD-10 [1]) is a men-

tal disorder, which has been frequently considered from a cultural perspective.
However, in this study, taijin kyofusho is used as an example of understanding mental
disorders from the way in which they are treated. By discussing the Morita therapy
treatment of taijin kyofusho, it will be seen that the treatment of a mental disorder
is integral to its conceptualization.

DEFINITION, NOSOLOGY AND HISTORY OF TAIJIN KYOFUSHO

The term taijin kyofusho literally means the disorder (sho) of fear (kyofu) of
interpersonal relations (taijin) [2]. Taijin kyofusho was originally described by
Masatake Morita (also known as Shoma Morita) in the 1930s as a manifestation of
shinkeishitsu (nervous character or temperament) [2]. Taijin kyofusho is considered
to be the core type of shinkeishitsu and it has, to some extent, come to be used syn-
onymously with the term shinkeishitsu. It is now so widely known in Japan that pa-
tients sometimes come to mental health professionals with comments such as, I
have taijin kyofusho. I want to do something about it.
The diagnostic term, taijin kyofusho, has been used for more than half a century
and there has been much discussion about its etiology, subtype, and relation to Jap-
anese cultural, social, and religious phenomena [3]. Nevertheless, diagnostic criteria

* Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School,
Boston, USA.
Department of Psychology, University of Hawaii at Manoa, Honolulu, Hawaii, USA.
Address correspondence to: Dr. Fumiko Maeda, Department of Neurology, BIDMC, 330 Brookline
Ave., KS452, MA 02215, USA, Tel: 1-617-667-0203.

525
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Table I.Diagnostic criteria of taijin kyofusho [4]

All of the following criteria should be met:

1. The feeling that his/her own attitudes, behavior, and physical characteristics are inadequate
in social situations.
2. The persistent suffering (caused by condition 1) from emotional reactions such as shame,
embarrassment, anxiety, fear, and tense feelings in social situations.
3. Worrying that he/she is unable to maintain healthy relationships with others (feeling
unaccepted, despised, and avoided) due to conditions 1 and 2.
4. Avoids painful social and interpersonal situations, while reluctant to do so.

Supplementary items:
A diagnosis of delusional taijin kyofusho should be made when the following criteria are met:
1. Certainty that he/she has a defect in a particular part of body or physical sensations, such
as eyes, body odor, and appearance.
2. Delusional conviction that he/she harms other people or gives others unpleasant feelings
because of condition 1.
3. Delusional conviction that others always avoid him/her due to conditions 1 and 2.

have not been established until recently: provisional diagnostic criteria were drawn
up in 1995 [4] (see Table I). These criteria will be helpful for future epidemiological
and statistical studies.

CLINICAL FEATURES OF TAIJIN KYOFUSHO

Taijin kyofusho is an obsession of shame and anxiety. It is characterized by fears

of offending others by blushing, stuttering, emitting offensive odors, staring inap-
propriately, presenting improper facial expressions, blemishes, and/or physical de-
formity [5, 6]. Strong anxiety is usually not experienced in the presence of very
closely related people, or, conversely, complete strangers. Rather, it is in settings
where other people are to a certain degree familiar, but not intimate, that individu-
als with taijin kyofusho suffer the most anxiety. Such settings include the places
most frequented by sufferers (e.g., school, work, commuter trains, etc.). Males pre-
dominate in clinical presentation by a ratio of approximately 3:2 [5]. The course
may be transient, but is more often chronic. It is rare, however, for taijin kyofusho
to continue into middle age.
Japanese mental health professionals conceptualize taijin kyofusho as varying on
a continuum of severity ranging from (a) the highly prevalent but transient adoles-
cent social anxiety to (b) delusional disorders. Kasahara [7] has described four types
of taijin kyofusho by the topography of clinical presentation: (a) transient type; (b)
phobic type (most typical); (c) delusional type (most severe); and (d) phobic disor-
der, accompanied by schizophrenia, arising as a prodrome of schizophrenia or as a
postpsychotic syndrome. For simplicity, taijin kyofusho has been divided into two
types: (a) mild/neurotic; and (b) severe/delusional [8].
Although taijin kyofusho is included in social phobia in ICD-10, many profession-
als believe it to be separate from social phobia. The primary difference between tai-
jin kyofusho and social phobia involves symptom topography and situations in
which the disorder is expressed. In taijin kyofusho, the symptoms often involve a
hypersensitivity to certain body parts such as the eyes or a body deformity. This is
not as prominent in social phobia. Additionally, the symptoms of taijin kyofusho
 Editorial 527
Table II.Moritas theory of taijin kyofusho [12, 13]

[Occurence of taijin kyofusho] 5 [Temperament] 3 [Chance Event] 3 [Pathogenic Factor]

Temperament: Hypochondriacal Basic Tone
A personality characteristic relating to the taijin kyofusho condition
Introversion: introspective, self-punitive, vigilant, prudent, shy, wavering
Extroversion: positive, self-centered, aggressive, stubborn, ambitious
Pathogenic Factor: Psychic Interaction
A mental process in which attention is concentrated on a certain sensation; this sensation
becomes hypersensitized; this condition of hypersensitivity fixates attention; the
hypersensitized sensation and the fixation of attention mutually interact to increasingly
intensify the sensitivity of the sensation. (Morita)

become the most exacerbated in social situations with acquaintances. In social situa-
tions with strangers or intimate friends and family, the symptoms tend to be less.
This is not the case in social phobia.
Recent studies have revealed that the clinical features of taijin kyofusho may be
changing. Findings indicate that: (a) the percentage of female patients is increasing
[9]; (b) the exemplary fear of blushing has been decreasing while the more severe
types of fears, such as fears of eye-to-eye confrontation, body odor, and body defor-
mity, are increasing [10]; (c) avoidant and withdrawal tendencies are increasing [9];
(d) a change from feeling shame toward others to fear occurring from being with
others [11]; and (e) complaints of anxiety and fear are becoming more vague [12].

ETIOLOGY OF TAIJIN KYOFUSHO ACCORDING TO MORITA THERAPY

The psychopathology of taijin kyofusho was first explained by Morita utilizing the
terms hypochondriacal temperament and psychic interaction [12]. Hypochon-
driacal temperament is a temperamental characteristic, which, according to Morita
[12], needs to be given the highest priority in understanding of the process of the
onset of taijin kyofusho (see Table II). That is, individuals who are prone to develop
taijin kyofusho have a temperamental characteristic of being hypochondriacal. Fur-
thermore, the balance between introversion and extroversion in hypochondriacal
temperament is inclined toward introversion. In Moritas understanding, those with
an introverted attitude have a tendency to fixate on their weak points and become
anxious and depressed [13]. The specific weak points can include their own staring,
blushing, facial expression, stuttering, bodily odors, blemishes, and/or body deformity.
Morita explained the mental mechanisms that trigger the onset of taijin kyofusho
with an equation (see Table II). In the development of taijin kyofusho, an individual
starts with a hypochondriacal temperament. An accidental experience results in the
individual becoming highly sensitized. The tendency to impose an oversensitive in-
terpretation of the events in the individuals internal and interpersonal life is rein-
forced. This leads to a further intensification of sensations, and attention becomes
more and more focused on these sensations and fears of interpersonal situations.
This process of increased attention and sensation is what Morita called psychic in-
teraction and this ultimately sets up a vicious circle of attention and sensation [13,
14] (see Fig. 1). The feelings of fear of interpersonal situations and sensitivity to
bodily sensations and weak points are intensified, and the criteria for the disorder
of taijin kyofusho are met.
528 Editorial

Fig. 1. With an accidental experience, an individual with a hypochondriacal temperament becomes

highly sensitized, and a vicious circle of attention and sensation is created. This is how it develops to taijin
kyofusho.

MORITA THERAPY OF TAIJIN KYOFUSHO

Morita therapy was developed by Morita in the 1910s [5]. The goal of Morita
therapy is to restore the patients mind to its condition before it was caught up in
psychic interaction. In Moritist terms, the goal is to restore the mind to an aruga-
mama (things as they are) condition [15, 16]. In the arugamama mind, sensations
are experienced in a flow, and the patients actual living situation is accepted as
they are.
The procedure of Morita therapy consists of experiential guidance in the accep-
tance of the patients specific symptoms. Morita therapy seeks to direct the individ-
uals energy from their previous concerns, such as somatic symptoms, to the here
and now [12] (see Fig. 2).

Fig. 2. This process of pathogenesis in this figure is also described in Fig. 1. The process of cure is the
voluntary and involuntary acceptance of previous concerns.
 Editorial 529

Morita therapy originally treated shinkeishitsu patients by rest and discipline [17].
An ideal course of therapy begins with hospitalization. The first stage consists of iso-
lated bed-rest. Patients are not allowed to have visitors or to engage in any reading
or conversation. They stay in bed all day except when they eat or go to the toilet.
They may, at this time, worry and preoccupy themselves with their problems. At
this stage they learn that anguish eventually leads to deliverance (hanmonsokuge-
datsu) [18]. The second stage is more active. They are out of bed, engaging in light
work, and are assigned single chores. They are still in an isolated environment and
are not permitted to speak to others. From the second day of this stage, they write
diaries under the therapists guidance. They engage in reading such things as classi-
cal poems out loud in the morning and before sleep. In the third stage, they are as-
signed heavy work with minimum guidance. They may read light literature but are
still prohibited from taking free walks or engaging in other entertainment. In the
fourth stage, they attend lectures and meetings and are exposed to persuasive argu-
ments toward accepting themselves and their symptoms and toward engaging in
constructive activities. The total period of this treatment was originally 40 days [16,
17]; however, variations were incorporated considering the length of treatment,
boundaries of each stage, and content [17, 19].
Since the 1930s, Morita therapy has been modified and is now conducted on an
out-patient basis and in groups. The protocol including the modified methods is
called neo-Morita therapy. In addition, a greater numbers of patients are now con-
sidered candidates for Morita therapy. Although Morita therapy was originally ap-
plied only to neurotic disorders (e.g., shinkeishitsu and taijin kyofusho), it is now
administered to a variety of disorders such as depression, schizophrenia, borderline
personality disorder, and alcohol dependence [16, 20]. One study found that, in a
treatment group with many atypical cases, the positive treatment response was
77.6% [21]. It has also been reported that when treatment protocols are followed
more strictly, 93.3% of Morita therapy patients had favorable outcomes [22].

IMPORTANCE OF TREATMENT OF TAIJIN KYOFUSHO IN ITS

CONCEPTUALIZATION AS MENTAL DISORDER

Taijin kyofusho is an excellent example of a mental disorder in which the concep-

tualization of its treatment is an important aspect in the understanding of the disorder
itself. Historically, the development of the treatment of taijin kyofusho proceeded
along with the development of ideas in regard to its definition, etiology, and mainte-
nance. Additionally, conceptualization of these ideas and the treatment of taijin
kyofusho were promoted primarily by one individual, Masatake Morita.
It is quite probable that the formation of ideas about the treatment of taijin kyo-
fusho influenced its definition, perception, expression, etiology, maintenance, clini-
cal features, and epidemiology. When Morita therapists defined the problem of
taijin kyofusho and then focused scientific and nonscientific attention on the symp-
toms of taijin kyofusho, the tendency for those symptoms to be noticed by individu-
als with a hypochondriacal temperament may have increased. While an individuals
hypochondriacal temperament may have an underlying temperamental etiology,
the tendency to become caught in the psychic interaction may have been influenced
by media coverage of the symptoms of taijin kyofusho. An individual may become
more aware that the symptoms they experience are part of taijin kyofusho, because
530 Editorial

of the nature of the disorder is involved in attention. That is, a primary aspect of
taijin kyofusho is the focusing of attention on bodily parts and sensations. The per-
sons attention becomes fixated on those body parts and sensations. Thus, ideas
about the treatment of taijin kyofusho probably influence manifestation of the dis-
order. In the future, as the treatment of the disorder changes, its clinical features
may also change.

AcknowledgmentsThe authors thank Dr. Kenji Kitanishi, Dr. Masahiro Asai, and Dr. Joichiro Shira-
hase for their helpful comments.

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