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The place of culture in psychiatric nosology is explored through the example of taijin kyofusho (TKS), a common Japanese psychiatric disorder characterized by a fear of offending or hurting others through one's awkward social behavior or an imagined physical defect. Although variants of this disorder have been described in other cultures (e.g., dysmorphophobia), the full spectrum appears to be confined to Japan. TKS can be understood as a pathological amplification of culture-specific concerns about the social presentation of self and the impact of improper conduct on the well-being of others. Both social interaction and constitutional vulnerability may contribute to the cognitive processes that underlie TKS. The salience of cultural differences for psychiatric nosology then depends on whether the clinical focus is on disordered biology, individual psychology and experience, or the social context of behavior. Any attempt to include cultural variation in psychiatric diagnoses must begin by making explicit the intended use of the classification because different social contexts and clinical goals demand alternative diagnostic schemes.