Fear of Offending Others

That inversion runs all the way through. The avoidance is the same, the racing heart and breathlessness and panic and trembling are the same, and the dread on being around people is the same. Only the direction of the concern is reversed, from harm to self to harm to others.

Which subtypes the Japanese system names

The official Japanese diagnostic system divides it four ways, by what the person believes is offending:

• sekimen-kyofu, the phobia of blushing
• shubo-kyofu, the phobia of having a deformed body, close to body dysmorphic disorder
• jikoshisen-kyofu, the phobia of one's own gaze, meaning eye contact
• jikoshu-kyofu, the phobia of giving off a foul body odour, which elsewhere carries the names olfactory reference syndrome, osmophobia and bromidrosiphobia

Roughly 17 per cent of people with the condition fear producing an offensive smell.

Japanese psychologists add a second axis, by severity. The transient type is short-lived and moderately severe, appearing most often in the teens though it can arrive at any age. The delusional type is the most common and the closest to social phobia, usually chronic, usually starting before thirty, and ranging from moderate to severe. The third is not really a phobia at all, being taijin kyofusho as a manifestation of schizophrenic symptoms.

The DSM-5 declined to file it with the social anxiety disorders. It appears instead under Other Specified Obsessive-Compulsive and Related Disorder, at 300.3, with shubo-kyofu and jikoshu-kyofu named as its variants. The revised edition then split the condition itself in two: a sensitive subtype, which subdivides again into a classical type afraid of being judged for visible anxiety such as sweating and tremor and an avoidant type, and an offensive subtype, for people who believe something about them is offensive, whether odour, gas, too much or too little eye contact, or blushing. In the Japanese literature it is also treated as a subtype of shinkeishitsu, the anxiety disorder.

Who the condition appears in

Lifetime prevalence is put between 3 and 13 per cent, with severity changing over a lifetime. It is usually preceded by a childhood history of shyness and social inhibition, and can follow a humiliating experience or simply surface after years of being present. Temperament matters: people who develop it tend toward the hypochondriacal, weighted more to introversion than extroversion, and the inward focus on their own weaknesses feeds the anxiety and the depression both.

The sex ratio inverts as well. Clinical data show more men than women with the condition, even though women score higher on social phobia scales and report a greater proclivity to embarrassment. In Western societies the prevalence of social phobia runs somewhat higher in women, and studies also find this condition common in older generations. Symptoms of it are not at all unusual in Japan, whether or not they get diagnosed.

What Morita therapy involves

The standard Japanese treatment is Morita therapy, developed by Shoma Morita in the 1910s specifically for taijin kyofusho and shinkeishitsu. The original regimen was severe: isolation, enforced bed rest, diary writing, manual labour, and lectures on self-acceptance and positive endeavour. Since the 1930s it has been adapted for outpatient and group work, and the modified form is called neo-Morita therapy.

Medication has since gained acceptance. Milnacipran, a serotonin-norepinephrine reuptake inhibitor, is in current use and has proved effective for the related social anxiety disorder. Systematic desensitisation and relaxation skills are used alongside, and the primary work of treatment is getting patients to turn their attention onto their own body parts and sensations.