medical anthropology - bbaeretal-2003

8/14/2019 Medical Anthropology - Bbaeretal-2003

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ROBERTA D. BAER, SUSAN C. WELLER, JAVIER GARCIA DE ALBA GARCIA,

MARK GLAZER, ROBERT TROTTER, LEE PACHTER, AND ROBERT E. KLEIN

A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK

ILLNESS NERVIOS

ABSTRACT. To systematically study and document regional variations in descriptions ofnervios, we undertook a multisite comparative study of the illness among Puerto Ricans,Mexicans, Mexican Americans, and Guatemalans. We also conducted a parallel study onsusto (Weller et al. 2002, Culture, Medicine and Psychiatry 26(4): 449472), which allowsfor a systematic comparison of these illnesses across sites. The focus of this paper is

inter- and intracultural variations in descriptions in four Latino populations of the causes,symptoms, and treatments ofnervios, as well as similarities and differences between nerviosand susto in these same communities. We found agreement among all four samples on a coredescription of nervios, as well as some overlap in aspects of nervios and susto. However,nervios is a much broader illness, related more to continual stresses. In contrast, susto seemsto be related to a single stressful event.

KEY WORDS: Latino folk illnesses, nervios, susto

INTRODUCTION

Although there have been detailed descriptions of nervios from case reports and

from specific regions, few attempts have been made to compare descriptions of

the illness across cultures. Nervios is often glossed as nervousness or anxiety

(Trotter 1982), although it is not synonymous with formal definitions of anxiety,

nor is it generally recognized by biomedical practitioners. Low (1985) attempted to

compare published descriptions ofnervios in different populations, but found that

methodological differences in how individual studies were conducted made gen-

eralizations difficult. She suggested, however, that the similarity between nerviosand susto (a folk illness glossed as fright or shock) might mean that they were

both expressions of distress, but labeled differently by different segments of the

population. As such, unresolved issues include whether the term nervios means

the same thing in different cultural contexts, and the extent to which nervios and

susto represent similar or distinct illness entities.

Not simply part of the exotica of different cultures, folk illnesses have been

linked to morbidity and mortality. Susto is associated with an increased risk of co-

morbidities and a higher mortality rate (Baer and Bustillo 1993; Baer and Penzell

1993; Rubel et al. 1984) and nervios is now noted in the DSM-IV (AmericanPsychiatric Association 1994: Appendix 1). The study of these folk illnesses in

relation to physiological symptoms has not been for the purpose of reducing the

Culture, Medicine and Psychiatry 27: 315337, 2003.

C 2003 Kluwer Academic Publishers.


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316 ROBERTA D. BAER ET AL.

folk illnesses to their biomedical equivalents, but rather to understand the meaning

of these ethnomedical diagnoses for increasing risk of morbidity and mortality.

Since susto has been linked with increased morbidity (Baer and Penzell 1993) and

mortality (Rubel et al. 1984), if nervios and susto are really just different namesfor the same problem, nervios sufferers may similarly be at increased health risk.

This paper explores inter- and intracultural variations in descriptions of the

folk illness nervios. Four diverse Latino populations are studied: Puerto Ricans

in Hartford Connecticut, Mexican Americans in South Texas, Mexicans in

Guadalajara, Mexico, and Guatemalans in rural Guatemala. Since a first step is to

understand an illness in its cultural context (Guarnaccia and Rogler 1999:1322)

and then analyze its relationship to co-morbidity, this study first describes nervios

within each of the four populations. One aim is to see if there is a distinct description

of nervios that is shared by culture membersa community explanatory modelof the causes, symptoms, and treatments for nervios. A second aim is to compare

descriptions across the four diverse sites to see the extent to which descriptions are

similar and different in different cultural contexts. Finally, we compare detailed

findings for nervios with those for susto in order to determine if these two folk

illnesses are synonymous or distinct.

BACKGROUND

One problem in our understanding of nervios is that studies have used a variety

of terms for the problem, including nerves (Finkler 1989; Krieger 1989; Sluka

1989), nervousness (Camino 1989; Koss-Chioino 1989), and nervios (Barnett

1989; Finerman 1989; Kay and Portillo 1989; Low 1989). The literature indicates

that the label nervios covers a broad range of problems in the mental health

realm, from depression to schizophrenia (Jenkins 1988). In some cultures, the term

nervios may be preferred over the term mental illness, and may be interpreted

much more broadly (Baer 1996). The similarity between nervios and susto suggeststhat they may both be expressions of distress or stress, but the two different labels

may be used in different contexts (Low 1989).

Nervios has been studied in a variety of locations (including Latin America, the

Mediterranean, northern Europe, and the United States) (Davis and Low 1989).

But among some cultural groups, scholarship about nervios is less well developed

than for many of the other folk illnesses. This is particularly true for Mexican

and Mexican American populations (Trotter 1982). This pattern is curious, in that

Trotter (1982) found that in the lower Rio Grande Valley, nervios was the third

most frequent ailment reported (stomach ache and cough were first and second),and the most frequent folk illness.


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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 317

The folk illness nervios is so widely reported across many contrasting regional,

linguistic, and demographic barriers that it defies description as a culture-bound

syndrome (Guarnaccia 1993). Nervios is consistently described as a culturally

approved reaction to overwhelmingly stressful experiences, especially concerninggrief, threat, and family conflict. However, it has been suggested that the way

the illness is experienced and conceptualized may vary across cultural groups

(Guarnaccia 1993).

Guarnaccia et al. (2003) have found that Puerto Ricans differentiate between

categories and experiences of nervios. Ser nervioso (being a nervous person) is

a result of traumatic experiences of suffering, and usually begins in childhood;

the condition lasts the rest of the persons life and results in more life problems.

Symptoms include unusual amounts of crying, headaches, stomach aches, and

increased anger and violence, particularly in men. Herbal teas and the help offamily members, priests and ministers, and psychologists and psychiatrists were

the recommended treatments. Padecer de los nervios (suffering from nerves) is

more of an illness, and is associated with depression, although the body is also

affected. Life problems, including marital difficulties, are seen as the cause, and it

usually develops in adulthood. This condition is considered to be a form of mental

illness, and the help of physicians, psychologists and psychiatrists is recommended.

Ataques de nervios (nervous attacks) occur as the result of a stressful event, often

in the family setting. Those who are nervous or suffer from nerves are more likely

to suffer from nervous attacks. Due to an event such as the news of the death of a

family member, the person becomes hysterical and out of control (Guarnaccia

et al. 2003). This problem is more common in women, although it can occur in

men as well.

In Guatemala, nervios is conceived of and treated as an illness rather than a

symptom, and, according to Low, is associated with experiencing strong emo-

tions, particularly anger and grief or sorrow, and with problems related to repro-

duction and child rearing (Low 1989:24). Women are significantly more likely to

report nervios than men, which suggests that the illness is related to gender-basedconcerns in general, and socially manifested expressions of strong emotions in

particular (Low 1989:24). There is also an ethnic dimension in the recognition

and reporting of nervios; most studies have focused on nonindigenous Spanish-

speaking populations (ladinos). Causality of nervios is attributed to anger, grief,

birth control pills, other illnesses, the birth of a child, anxiety, problems, susto, and

otherstressful occurrences (Low 1989:31). Reported symptoms include headaches,

despair, facial pain, trembling, and anger (Low 1989:29). Treatment most com-

monly comes in the form of nerve pills bought in local stores or alternative home

remedies (Low 1989: 24). Further, Low suggested that nervios might be the termused by more urban/ladino populations for what rural/indigenous people call susto


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et al. 2002), which allowed for a systematic comparison of these illnesses across

sites.

METHODS

Data collection

Four Latino populations were sampled. In the United States, people were inter-

viewed in the Mexican American community of Edinburg, Texas, and the mainland

Puerto Rican community in Hartford, Connecticut. The other two research loca-

tions were the rural ladino community of Esquintla, Guatemala, and the urban

Mexican community of Guadalajara.

The Mexican American interviews were conducted in the lower Rio GrandeValley community of Edinburg, Texas. This region is among the poorest metropoli-

tan areas in the United States. Located 15 miles from the USMexico border, the

area, although a mixture of urban and rural, is predominantly agricultural. The

population is 80% Mexican American. Hartford, Connecticut, is a medium-sized

city in the northeast United States. While only about one-third of the citys pop-

ulation is Hispanic, children of Puerto Rican descent make up 47% of those in

the public school system. The interviews for this study were conducted in the

two census tracts that have the majority of the Puerto Rican population. The

Guatemalan interviews were conducted in the department of Esquintla, located

on the Pacific coast. This area is agricultural; primarily cotton and sugar cane

are grown. The population sample was Spanish-speaking ladinos in four rural

villages, each of which had a population of about five hundred. The Mexican

sample was drawn from the modern industrial city Guadalajara, which has a

population of approximately three million. Predominantly mestizo, residents of

Guadalajara are from both rural and urban backgrounds. In order to capture the

variation present in the city, three neighborhoods were sampled, one middle class,

one working class, and one poor; all of those interviewed were Spanish-speakingmestizos.

To ensure representative samples in each community, a two-stage random sam-

pling design was employed. First, a village, neighborhood, or census tract was

chosen, and then blocks and households were selected. The inclusion criteria were

that the respondent be an adult and recognize nervios as an illness entity (respon-

dents were asked simply if they had heard ofnervios). Additionally, in Edinburg,

respondents had to self-identify as being of Mexican descent, and in Connecticut

they had to self-identify as being of Puerto Rican descent. The preferred respon-

dent in each household was the female head of household, since we assumedthat women have more responsibility for health. Interviews were conducted by


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TABLEI

Ne

rvios

WhoisSusceptible

Causes

Symptoms

Treatments

Esquintla,Guatemala(n=

20)

10Adults

6Porproblemasfamiliares

11Dolordecabeza

13Calmantes

6Tod

os

6Porenojarse

10Dolordemuelas

4Inyeccion(decalm

antes)

2Mu

jeres

5Porpeleasconlasesposas

8Dolordecara

2Aspririna

3Porcausasdeaccidentes

6Lemolestanlosruidos

2Pastilla

3Porfaltadevitaminas

5Enojos

11Farmacia

3Portenersusto

3Brincan

8Doctor

2Porrecibirnoticiaderepente

2Tiemblan

6Encasa

2Pleitosconloshijos

2Desesperacion

4Tiendas

2Porunaimpresion(seemociona)

2IGSS

11Semueren

2Sepuedetorcerla

boca

2Seempeoralaenfermadad

Guadalajara,Mexico(n=

20)

10A

lagentamassensibles

8Preocupaciones

10Corajudo

8Calamarse

5Debilesdecaracter

8Susto

12Depresion

9Homeremedies

5Adultos

6Problemasfamiliares

5Nervios

7Doctor

4Nin

os

3Corajes

3Manchas

6Medicine

2Las

amasdecasa

2Herencia

3Dolordecabeza

5Psychiatrist

2Atodotipodepersonas

2Avecesnosacanlospapasasushijos

3Grita

2Personasdeedad

adistraerse;estarplaticandoconlo

s

2Sensaciondeahogamiento

2Personassindistracciones

hijosyllevarlosapasear

2Perdidadeconocimiento

2Desesperacion

Edinburg,Texas(n=

20)

8Anyone

17

Tension;stress;worry

12Worried,startleeasily;jumpy

11Gotodoctor

510yearsandolder

2Gettingangry;overreacting

7Veryemotional;getsagitatedeasily

7GotoCurandera

4Peo

plewhoareweak

1Anevilspell

5Pacing,rushingaround

7Relax;rest


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TABLEI

(Continued)

WhoisSusceptible

Causes

Symptoms

Treatmen

ts

3Peoplewhoworryconstantly

4Highbloodpressure

5Tea,herbaltea(m

anzanilla)

3Shaking;chills

4Counseling;therapy

2Desperate;uncomfortablefeeling

4Pills

2Nosleep

3Nocure

2Seethingsthatarenotthere

3Medicationfrom

doctor

2Rashes

2Tranquilizers

2Stomachhasgas

2Lossofappetite

2Tense

2Headache

Hartford,

Connecticut(n=

10)

3Adults

3Notcontagious

2Lossofcontrol(ofon

esnerves)

2Medication

2Everyone

1Beingoverwhelmedwithpro

blems

1Screaming

2Pillsprescribedb

ydoctor

1Peoplewithalotofstressintheirlives

1Problemsdealingwithlife

1Cryinghysterically

2Tranquilizers

who

areunabletocopewithproblems

1Depression

1Notaphysicalillness;moremental

1Bringtoadoctor

1Mainlywomen

1Anxiety

1Lotsofcryingandscreamingupon

1Therapy

1Weakpeoplewhotaketheirp

roblems

hearingbadnews,especiallyif

1Walking

tooseriously

someonedies

1Speakingtoanot

herperson

1Stress,problems

1Drinkingaguadeazahar


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ideas in a group. Consistency among respondents answers is indicative of shared

knowledge.

Consensus analysis is conducted in a fashion somewhat analogous to factor

analysis. In factor analysis, the structure among a set of variables is described byclassifying items into groups or factors. A single factor solution indicates that all

of the items are related in some underlying way. Consensus analysis can be con-

ceptually thought of as a factor analysis of individuals in a sample, much like how

standard factor analysis groups individual items in a questionnaire. A single factor

solution indicates homogeneous responses among a single group of respondents,

i.e., consensus. In this study, consensus analysis is used to determine whether the

aggregate responses to the yes/no questions on the nervios questionnaire indicate

underlying group agreement (consensus) at each site and between sites regarding

the domain of study (nervios susceptibility, causes, symptoms, and treatments).Consensus analysis also provides an estimate of each respondents concordance

vis-a-vis the group (their cultural knowledge or competency score). The analysis

also provides a best estimate of the groups answers to the questionnaire items,

using a Bayesian posterior probability approach wherein the responses of individ-

uals are weighted based on their relative knowledge vis-a-vis other respondents in

the group. In this study a conservative Bayesian classification rule was used. Items

were classified at the p 0.999 confidence level.

As with most sample size requirements, sample size determination is a function

of variability. In consensus analysis, the variation is the amount of agreement

among the respondents. For dichotomous response data, using a moderate level of

competency or agreement (0.50), a high confidence level for classifying items as

true or false (0.999), and a high accuracy for questions to be correctly classified

(0.95), a minimum number of 29 respondents per site are required (Romney et al.

1986; Weller and Romney 1988). To be sure that we had sufficient individuals for

comparative purposes within samples, a sample size of about 40 was obtained at

each site.

RESULTS

The sample

The final sample consisted of 40 respondents in Connecticut, 41 in Texas, 38 in

Mexico, and 40 in Guatemala. Respondents were primarily women (100% in the

Mexican and Texas samples, 90% in Guatemala, and 87% in Connecticut). All

of the informants in the Mexican sample were born in Mexico, and all of the

informants in the Guatemalan sample were born in Guatemala. In the Connecticutsample, 90% were born in Puerto Rico; 70% of the interviews were conducted

in Spanish, 3% in English, and 28% in combined English and Spanish. In the


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TABLE II

Sample Demographics

Guatemala Mexico Texas Connecticut

Sample size 40 38 40 40

% female 90 100 100 87

Age in years (range) 42.9 (1783) 38.5 (2085) 42.2 (1881) 37.1 (2058)

Total children (range) 6.3 (014) 4.4 (016) 2.8 (17) 2.8 (012)

Household size (range) 5.4 (19) 5.7 (111) 3.8 (29) 4.1 (18)

Education in years (range) 1.8 (09) 5.5 (013) 11.2 (016) 10.3 (015)

Knows someone with nervios 95% 82% 90% 90%

Family member had nervios 88% 74% 71% 80%

Respondent had/has nervios 65% 63% 46% 52%

Texas sample, 95% of the respondents were born in the U.S., and 66% of the

interviews were in English, 7% in Spanish, and 27% in combined English and

Spanish. Respondents educational levels varied significantly between samples,

reflecting normative rates for each region: 1.8 years in Guatemala, 5.5 years in

Mexico, 11.2 years in Texas, and 10.3 years in Connecticut (Table II).

Actual experience with nervios varied somewhat by community. Most respon-

dents knew someone with nervios (95% in Guatemala, 90% in Connecticut and

Texas, and 82% in Mexico) and had experienced it in their family (88% Guatemala,

80% Connecticut, 74% Mexico, and 71% Texas). Of our respondents, about two-

thirds of those in Guatemala and Mexico had experienced nervios themselves;

46% of those in Texas and 52% of those in Connecticut also reported it.

Descriptions of nervios

Analysis of responses to the 125 items concerning the causes, symptoms, and

treatments for nervios revealed that a single, shared system of knowledge about

nervios exists for each sample of respondents. The cultural consensus model fits theresponse data (the eigenvalue ratios all exceeded the recommended 3:1 ratio: 9.85

in Connecticut, 8.81 in Texas, 6.51 in Mexico, and 5.48 in Guatemala). Responses

were the most homogeneous in the Texas and Connecticut samples, resulting in

the highest levels of sharing (the average cultural knowledge scores were 0.73

in Texas and 0.62 in Connecticut). The Mexican and Guatemalan samples also

exhibited shared ideas, although at a somewhat lower level (0.52 in Mexico and

0.43 in Guatemala). Analysis with all four samples together indicated that they

share a single description ofnervios, with about 52% of ideas in common (cultural

knowledge level = 0.52, eigenvalue ratio 6.45). A comparison of knowledge lev-els across samples indicated that there was a greater degree of shared responses

in Texas than in Connecticut, significantly greater sharing in Connecticut than


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Mexico, and significantly greater sharing in Mexico than Guatemala (ANOVA

p 0.00005; Scheffe comparison p 0.005).

The distribution of cultural knowledge within each sample was more strongly

related to demographic characteristics than to personal experience. In Mexico,those with fewer children (r= 0.37, p = 0.02), fewer people in the household

(r= 0.32, p = 0.05), and a higher educational level (r= +0.29, p = 0.09)

knew more about nervios. Similarly, in Texas, households with fewer people in

them were associated with greater knowledge about nervios (r= 0.42, p =

0.01). In Guatemala, a larger household was associated with more knowledge

(r= +0.29, p = 0.07). Personal experience with nervios (knowing someone with

it or having had it) was associated with greater cultural knowledge, although

the associations were not significant. Greater cultural knowledge was corre-

lated with knowing someone with nervios (r= +0.22, p = 0.18 in Texas, andr= +0.29, p = 0.07 in Guatemala) or with having had it (r= +0.24, p = 0.13

in Connecticut). Responses were not different (p > 0.05) between men and women

in the Guatemalan and Connecticut samples, nor were responses different by lan-

guage preference in the Texas and Connecticut samples.

Although the four sites shared a common description ofnervios, there was some

variability, as illustrated by a more detailed comparison between the samples. The

highest agreement occurred between the Connecticut and Texas samples with 78%

identical answers, followed by 64% agreement between the Texas and Mexican

samples, and 57% agreement between the Mexican and Guatemalan samples.

Tables IIIVI show the questions about nervios that were classified using consensus

analysis by one or more of the samples as having the answer true or yes. Study

sites are indicated with a G for Guatemala, M for Mexico, T for Texas, or

C for Connecticut. Item classification is indicated with a Y for yes or true,

an N for no or false, and a hyphen (-) to indicate that the item could not

be classified as either true or false. We first discuss the findings for nervios and

then compare the findings with those for susto.

For susceptibility (Table III, columns 47), there was agreement among at leastthree of the samples on 10 of the 14 questions (71%), and among all four samples

on 6 of those questions (43%). Nervios is seen in adults and older people, and

though it can occur in anyone, it is more common in sensitive people. The four

sites also agreed that nervios is not a problem among men, and does not occur only

in families who believe in it. Three of the sites also answered that nervios was seen

mainly in women, but also occurs in older children, people with low resistance,

weak people and those of weak character.

For causes ofnervios (Table IV, columns 47), at least three samples agreed on

27 out of 31 (87%) of the questions, and all four samples agreed on 14 of thosequestions (45%). All four samples reported that not eating well, drinking too much,

and using drugs can cause nervios. In addition, a fright (susto) or shock (seeing


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TABLE III

Susceptibility

Susto Nervios

G M T G M T C

Y Y Y Y Y Y Y Adults get it

Y Y Y Y Y Y Y Old people get it

Y Y Y Y Y Y Anyone, regardless of age and gender/sex

Y Y Y Y Y Y Y More in sensitive people

N N N N N N N Mainly in men

N N N N N N Only in families who believe in it

Y N Y Y N Y Mainly in women

Y Y Y Y Y Y Older children

Y Y N Y Y N Y Mainly in weak people

Y Y N Y Y N Y More in people with a weak character

N Y N Y Y People with low resistance

Y Y Y N Y Y In young children

Y Y N Y N N Y In unborn children, if their mother has it

N N N Y N Y Relatives of someone with it more susceptible

Y N N A baby if breast feeding from a mother who has it

someone get killed or being in an accident) can cause nervios. Also important in

causality are strong emotions, anger, worry, family problems, and family fighting.

Nervios is not considered to be contagious. A relationship between susto and

nervios is evident, as susto was considered to be a cause of nervios. In addition,

several situations that are usually cited as producing sustoseeing someone killed,

seeing or being in an accident, or a surprise or shockwere also considered to

be causes of nervios. While the four sites agreed that a cause of nervios might

be not eating well (three sites also thought hunger could cause it), food stuck in

the stomach (usually associated with the folk illness empacho) was not considered

to be a cause of nervios. Three sites also agreed on a lack of hot/cold causality

ofnervios. There was also agreement among three sites that witchcraft was not acause ofnervios, but that the Devil might be.

For the symptoms ofnervios (Table V, columns 47), there was agreement across

at least three of the samples on 62% of the questions (24 out of 39 questions), and

among all four of the sites on 44% (17 out of 39) of the questions. Symptoms

agreed upon by all four sites included depression or sadness, a feeling of no hope

in life, crying, hysterical crying or crying attacks, and shaking or trembling. Other

symptoms agreed upon by all four sites were headache, a feeling of choking, cold

sweat, weight loss, bad temper, insomnia, and anger caused by small things. There

was also agreement that runny nose, fever, slow healing wounds, and a swollenstomach were not symptoms of nervios. Additional symptoms agreed upon by

three of the sites included lack of appetite, agitation, and convulsions or seizures.


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TABLE IV

Causes

Susto Nervios

G M T G M T C

N N N Y Y Y Y From not eating well

N N Y Y Y Y From drinking too much alcohol

N Y N Y Y Y Y By using drugs

Y Y Y Y Y Y Y Nervios causes susto/fright or susto causes nervios

Y Y Y Y Y Y Y By seeing someone get killed

Y Y Y Y Y Y Y By seeing or being in an accident

Y Y Y Y Y Y Y By a sudden surprise or shock

Y N Y Y Y Y By fighting (between spouses or with children)

Y Y Y Y By strong emotions (good or bad)

Y Y Y Y From anger

Y Y Y Y By worrying a lotY Y Y Y From family problems

N N Y Y N Y From living in a dirty house

N N N Y Y Y From hunger

Y Y N Y Y N Y By the devil

N Y Y N Y From low resistance

N N Y Y N By a hard, envious stare

N N N Y N N N From cold foods (or drinks)

N N N Y N N N By getting wet when you are sweating

Y N N Y N N N By being exposed to drafts/wind/air

N N N Y N N By parasites

Y N Y N N By spiritsN N N N N N N From food stuck in the stomach

N N N N N By witchcraft

N N N N N N N By using the utensils of someone who has it

For treatments (Table VI, columns 47), at least three of the samples agreed

on 73% (30 out of 41) of the questions, and all four samples agreed on 51% (21

out of 41) of the questions. For all four of the sites, over the counter remedies

(such as aspirin, Vicks, cod liver oil, Alka Seltzer), antibiotics, and treatmentsused for other folk illnesses (such as barrida, or sweeping with herbs, rubbing

with an egg, a spoonful of oil, pulling the skin of the body until it pops, or binding

the waist) were not indicated for use in the treatment of nervios, nor were the

services of the folk healers, curanderos, or spiritualists. Other treatments rejected

by all groups included spearmint tea, enemas, scaring the affected person, drinking

alcohol, warm towels on the body, and drinking milk. Sedatives, praying, and

trying to relax were the only suggested treatments agreed on by all four samples.

Additionally, three of the sites recommended the use of physicians andpsychiatrists

or psychologists, and rejected the use of holy water sprinkled on the body in theshape of a cross, as well as the use of a pharmacist, herbalist, wise old woman, or

grandmother. Three sites reported that nervios would go away by itself.


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TABLE V

Symptoms

Susto Nervios

G M T G M T C

Y Y Y Y Y Y Y Crying

Y Y Y Y Y Y Y Hysterical crying or crying attacks

Y Y Y Y Y Y Y Difficulty going to sleep and staying asleep

Y Y Y Y Y Y Y Frequent shaking or tembling

Y Y Y Y Sadness (and depression)

Y Y Y Y A feeling of no hope in life

Y Y Y Y Small things cause anger

Y Y Y Y A bad temper

Y N Y Y Y Y A headache

N Y Y Y Y A feeling of choking

Y Y Y Y Y Y A cold sweatY Y N Y Y Y Y Weight loss

Y Y N Y Y Y A lack of appetite

Y Y Y Y Y Y Agitation

Y Y N Y A convulsion or seizure

N Y Y N N Cloudy or blurred vision

N Y Y Y Difficulty breathing

N Y N Y Y Stomach pain or stomachache

N Y Y N N Y Y Vomiting

N Y Y N N Y Y Diarrhea

N N N Y Y Itching

Y Y Y Y Y N Paleness

N Y Y N Sleepiness

Y Y Y N Y Chills

Y Y N Y N Y N Muscle and body aches/pains

Y Y N Losing consciousness

N N Y N N Affected hearing (ringing or buzzing)

N Y N Y N Frequent urination

N N N N N Y Chest pain

Y N N Aching teeth

Y N N N Face pain

Differences between sites

There were, however, some interesting differences between the sites. Only

Guatemalans reported eating cold foods or getting wet while sweating or drafts as

causes ofnervios, and only they considered face pain to be a symptom and garlic

to be a treatment. It would appear that as far as nervios causality is concerned,

hotcold explanations are more important in Guatemala than at the other sites. An-

other distinctive pattern occurred in the Mexican and Guatemalan samples, whereuntreated nervios was reported to cause a person to become diabetic or the mouth

to become twisted and deformed.


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TABLE VI

Treatments

Susto Nervios

G M T G M T C

N Y N Y Y Y Y Sedatives

Y Y Y Y Y Y Trying to relax (keep calm)

Y Y Y Y Y Y Y Praying

N Y Y Y Y Y Massages

N N N Y Y Y Doctor

Y N Y Y Y Psychiatrist or psychologist

N N N N N N Pharmacist

Y Y N N N N Herbalist

Y N N N N Wise old woman/grandmother

Y N N N N N Curandero

N Y N Y N Y Tea of orange leaves or orange blossom

Y Y N Y Y N N If not treated, person becomes diabetic

Y Y N N If not treated, mouth becomes deformed and twisted

N N N N N Y Camomile tea

N Y N N Vitamins

N N N Y N N N Garlic

N N Y N N Rubbing the back and chest with alcohol

Y Y Y Y N Treated at home

Y Y N Y N Go to church

N N Y N N Y N Go away by itself

Y Y N Y N If not treated, can one dieY N N N N Holy water on body in shape of a cross

Comparisons with Susto

The next issue we address is that of similarities and differences between nervios

and susto. We conducted another study similar to our investigations of nervios

exploring regional variations in beliefs about susto (Weller et al. 2002). The susto

study was originally planned for the same four sites where nervios was studied;however susto was not found to exist as an illness among the Puerto Rican pop-

ulation in Hartford, Connecticut. As a result, the discussion below compares the

results from the three sites that recognized both of these illnessesGuatemala,

Mexico, and Texas. The methodology used in both the susto and nervios studies

was the same; in fact, 85 of the questions used in the two studies were iden-

tical. While the actual respondents for the nervios and susto studies were not

identical, each sample was representative of the community from which it was

drawn.

Susceptibility is broader for susto than for nervios (Table III). Younger and olderchildren can suffer from susto, but this is not the case for nervios which seems to

be more of an adult problem.Nervios is felt to occur mainly in women, while susto


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is not as closely linked to gender. While there is some overlap in causes of susto

and nervios (including seeing someone get killed, seeing or being in an accident,

and a sudden surprise or shock), susto seems more related to a particular incident

or accident. In contrast, causes of nervios are of a continual nature in ones life,and include family problems and fighting, drugs, alcohol, worry, anger, and strong

emotions (Table IV). Note, however, that susto can cause nervios and that nervios

can cause susto.

A similar pattern is seen with regard to symptoms of nervios and susto, with

overlap in symptoms such as crying, shaking, and difficulty sleeping (Table V).

However, there are many symptoms that are unique to each illness. Paleness may

be more restricted to susto, while headache, a feeling of choking, cold sweat, and

weight loss are associated more with nervios. Neither illness seems to manifest

solely with somatic symptoms. While praying is recommended for both sustoand nervios, the most striking difference between the two illnesses is the use

of Western versus folk treatments. While a doctor or psychologist or psychi-

atrist is recommended for nervios, they are not considered effective for susto

(Table VI). In fact, home treatment and folk healers are used more often for

susto.

Patterns of regional variation similar to those found for nervios also appear

for similarities and differences between susto and nervios. Only the Mexican and

Guatemalan samples report that weak people and people with a weak character

are more likely to get either illness (the Texas sample did not) and that the Devil

could cause both susto and nervios. Similarly, these two sites saw diabetes as a

possible outcome of both untreated susto and untreated nervios. Guatemala was

the only site to feel that drafts were a cause of these illnesses. Finally, only the

Texas sample reported that both nervios and susto would go away by themselves.

We also compared the differences between nervios and susto which emerged

from the analysis of the structured questionnaire data to those differences reported

in the initial open-ended interviews in Mexico. In those open-ended interviews,

respondents were asked about the similarities and differences between nerviosand susto. We found that both sets of interviews contained similar themes: susto is

considered to be briefer than nervios, and nervios is more chronic and is a continual

stress. Susto is caused by an identifiable eventa sustowhile nervios is caused

by persistent problems.

In summary, there is an overlap in many aspects of these two illnesses. Both

tend to occur more in adults; both are caused by surprising, shocking, or disturbing

occurrences. Both present with symptoms of distress; neither presents solely with

somatic symptoms. However, nervios is a much broader illness, related more to

continual stresses. In contrast, susto seems to be related to a single stressful event.There are a few broadly recommended treatments for nervios, while those for susto

show more regional variation.


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DISCUSSION AND CONCLUSIONS

The core description of nervios agreed on by all four sites supports the patterns

reported in the literature for these individual populations. Nervios is felt to oc-cur more often in women. It is caused by emotion and interpersonal problems; its

symptoms are primarily nonsomatic. Interestingly, although treatment by psychol-

ogists and doctors is recommended, the most broadly recommended treatment is

neither biomedical nor folk, but spiritual, i.e., praying. However, at all four sites,

nervios covered a broad range of mental health conditions. It would seem of great

importance for mental health professionals working with these populations to un-

derstand the way the term nervios is used and the types of conditions it covers.

It should be noted, however, that the literature suggests that nervios may not be

considered a mental illness by these populations (Baer 1996).Almost everyone approached to be interviewed for this study considered nervios

to be an illness. Thus, there is an interesting contrast in prevalence between nervios

and other common Latino folk illnesses. We have carried out parallel studies to

those described here for susto and nervios for the folk illnesses caida de la mollera

(fallen fontanelle) and mal de ojo (evil eye) (Weller 1997; Weller and Baer 2001).

These studies indicated that in the Mexican sample, in which 100% of respondents

considered nervios to be an illness, recognition of susto was 87%, caida de la

mollera 85%, and for mal de ojo only 63% However, recognition ofsusto, mal de

ojo, and caida de la mollera varied by social class. Recognition was highest in the

lower class, intermediate in the working class, and lowest in the middle class. But

unlike other folk illnesses, recognition ofnervios in Mexico was not class related.

Similarly, we found no meaningful variation in relevant themes for nervios by

degree of acculturation. In the Texas and Connecticut samples, a very crude index

of acculturation canbe estimatedby birthplace and language preference. Responses

did not differ significantly on either of these variables.

Nervios and susto are distinct entities. While it has been suggested in the liter-

ature that nervios may be the illness of choice among ladinos (Low 1989:133)for expressing stress or distress, our data do not totally support this hypothesis.

Among the ladino/mestizo populations we studied, susto is also an illness category,

and it can be distinguished from nervios. The two illnesses appear to overlap, but

nervios is a much broader illness and is widely recognized. People in the same

communities recognize both illnesses, and nervios appears to transcend social

class. Specific research would be necessary with indigenous groups to determine

whether the same pattern holds in those populations. However, in Mexico it ap-

pears that the recognition ofsusto as an illness, unlike that ofnervios, may be class

related.Recognition of susto also varies by region. It is also important to note that

although nervios was considered to be an illness at all four sites, susto was not


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recognized as an illness by Puerto Ricans in Connecticut. During the initial stages

of this project (when descriptive, open ended interviews were conducted to elicit

individual explanatory models), Puerto Rican respondents indicated that they con-

sidered susto to be a symptom, a feeling, but not an illness.Finally, at least for the Mexican and Guatemalan populations, nervios (and susto;

Weller et al. 2002) is implicated in the causality of diabetes. While diabetes is not

a great problem at this time in Guatemala, possibly due to widespread malnutrition

(which reduces the prevalence of obesity), this is not the situation in Mexico. In

Mexico, the diabetic mortality rate for people older than 65 is several times greater

than that in the United States (PAHO 1986). Both nervios and susto need further

study exploring their possible relation to diabetes.

This study demonstrates the usefulness of cross-cultural research on nervios

and of a systematic comparison with susto. We determined a core description ofnervios as well as similarities and differences in that definition among the four

Latino groups studied. The relationship to susto has been clarified, and a link to

diabetes for at least two of the populations studied is suggested as an important

area for further research. While the samples at each site were representative of

the variability in each of those populations, the results cannot be generalized

to, for example, all of Mexico from the Guadalajara sample, or to all Mexican

Americans from the south Texas sample. The similarity in findings across such

diverse samples, however, suggests that the findings would apply to many more

regions than those actually sampled. Because such strong similarities were found

in descriptions from places ranging from rural Guatemala to urban Connecticut,

it is likely that those same themes would be important to Latinos in regions other

than those sampled for this study.

Our approach also demonstrates a number of important directions for the future

study of these conditions. First, this study ofnervios demonstrates a way to study

ethnomedical phenomena in their cultural contexts that also allows for cross-

cultural comparisons. In this research, we used free listing to elicit the explanatory

model (Kleinman et al. 1978) of nervios in each population being studied. Next,we developed a structured interview (a yesno questionnaire) that incorporated

themes from each communitys explanatory model (as well as other items, some

of which had biomedical origin). From this, we were able to determine which

aspects of explanatory models were shared and which were distinct. Our two-step

approach, which incorporated themes from all sites in the interviews, allowed us

to verify whether or not themes mentioned in the open-ended interviews were

important within a community and across communities. The advantage of the

structured interviews was that themes that were mentioned at one particular site

but not at another could also be confirmed. Reliance on the open-ended interviewsalone may have missed some themes relevant across sites. We were also able to

determine similarities and differences between nervios and another folk illness,


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susto. We therefore suggest such an approach as important and appropriate for

cross-cultural ethnomedical research.

We also feel that our approach extends that of Guarnaccia and Rogler (1999).

While they emphasize the importance of describing folk illnesses within their cul-tural contexts, they particularly stress the need for anthropologists to determine

how these illnesses are related to psychiatric disorders (Guarnaccia and Rogler

1999). Our work expands the relationship to include both mental and physical

disorders. In doing so we stress the importance of questioning the mindbody di-

vision of Western culturesand of biomedicinewhich discounts the relationship

between folk illnesses and physiological disorders. The ethnomedical systems in

which these illnesses are embedded do not recognize a mindbody distinction, and

indeed see a fluid relationship between the physical body and its problems, the

mind, emotions, and the spiritual. If we really want to understand folk illnesses,we need to allow for the possibility that these categorizations of symptoms may

cross over the neat lines that separate the psychiatric and the physiological in

the biomedical conceptualization. In the case of nervios (and susto as previously

demonstrated by Rubel et al. 1984 and Baer and Penzell 1993), it appears that the

ethnomedical evidence supports a relationship between nervios/susto and physio-

logical as well as psychological problems. Informants descriptions ofnervios and

susto suggest a connection between nervious and susto and diabetes in two of the

populations studied. The testing of this and other reported relationships between

folk illnesses and biomedical diseases is clearly an important next step in our

understanding of the meaning and implications of these ethnomedical diagnoses.

Biomedicine poorly understands illnesses that transcend the mindbody distinc-

tion. Developing an understanding of the ethnomedical systems and diagnoses

that recognize and understand these connections may be important in augmenting

the biomedical understanding of the full dimensions and causes of human health

problems.

To do so will require a broad and interdisciplinary approach. Due to the ef-

forts of Guarnaccia and colleagues, nervios has been included in large-scale men-tal health surveys. This has allowed an estimation of the prevalence of nervios

and made possible comparisons between genders and social classes in the oc-

currence of nervios. These data are critical, as they supplement the descriptive

case reports ofnervios, which can only suggest possible factors related to nervios.

For susto, however, there are no comparable epidemiological data. Given that

there is considerable overlap between nervios and susto, mental health surveys

of Latinos should also include susto (although it may or may not exist as an

illness category in specific ethnic groups). The addition of a few questions that

request information on susto would go far in providing population-based infor-mation on the prevalence of susto and its distribution across social classes and

genders.


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However, the reliance on mental health surveys for data on nervios has

limited the type of information that is available on that illness. In contrast,

for susto there has been an explicit exploration by Rubel and colleagues

(1984) of the possible relation between susto and stress, depression, physio-logical symptoms, and mortality. They found that although susto is associated

with psychological symptoms, it is also associated with physiological out-

comes. The overlap between susto and nervios suggests that more needs

to be understood about the relationship between nervios and physiological

outcomes.

In conclusion, we see the need for collaboration between anthropologists and

psychiatric epidemiologists in the study ofnervios, susto, and other folk illnesses.

Susto (and possibly other folk illnesses) needs to be included on mental health

surveys; nervios (and possibly other folk illnesses) needs to be investigated in termsof its relationship to stress, depression, physiological symptoms, and mortality. We

cannot continue to assume the separation of the health problems of the mind and

the body when the evidence suggests that such a division may just be an artifact

of our own creation, which obscures rather than illuminates the reality of patterns

and causality of human illnesses.

ACKNOWLEDGMENTS

This project was funded by the National Science Foundation grants BNS-9204555,

SBR-9727322, and BC-0108232 to S. Weller, and SBR-9807373 and BCS-

0108228 to R. Baer.

NOTES

1. The final questionnaire is available from the authors RDB or SCW upon request.

REFERENCES

American Psychiatric Association1994 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington,

DC: American Psychiatric Association.Baer, Roberta

1996 Health and Mental Health Among Mexican American Migrant Workers: Implica-tions for Survey Research. Human Organization 55: 5866.

Baer, Roberta, and Martha Bustillo1993 Susto and Mal de Ojo Among Florida Farm Workers: Emic and Etic Perspectives.

Medical Anthropology Quarterly 17(1): 90100.Baer, Roberta, and Dennis Penzell


21/23


1993 Susto and Pesticide Poisoning Among Florida Farm Workers. Culture, Medicineand Psychiatry 17(3): 321327.

Barnett, Elyse A.1989 Notes on Nervios: A Disorder of Menopause. In Gender, Health, and Illness: The

Case Of Nerves. D.L. Davis and S.M. Low, eds., pp. 6777. New York: HemispherePublishing Co.

Camino, Linda A.1989 Nerves, Worriation, and Black Women. In Gender, Health, and Illness: The Case

Of Nerves. D.L. Davis and S.M. Low, eds., pp. 203222. New York: HemispherePublishing Co.

Davis, Dona L., and Setha M. Low1989 Gender, Health and Illness: The Case of Nerves. New York: Hemisphere Publishing

Co.Finerman, Ruthbeth

1989 The Burden of Responsibility: Duty, Depression, and Nervios in Andean Ecuador.

In Gender, Health, and Illness: The Case Of Nerves. D.L. Davis and S.M. Low,eds., pp. 4965. New York: Hemisphere Publishing Co.Finkler, Kaja

1989 The Universality of Nerves. In Gender, Health, and Illness: The Case Of Nerves.D.L. Davis and S.M. Low eds., pp.7987. New York: Hemisphere Publishing Co.

1991 Physicians at Work, Patients in Pain. Boulder: Westview Press.Guarnaccia, Peter J.

1993 Ataques de Nervios in Puerto Rico: Culture-Bound Syndrome or Popular Illness.Medical Anthropology 15: 157165.

Guarnaccia, Peter J., Roberto Lewis-Fernandez, and Melissa Rivera Marano2003 Toward a Puerto Rican Popular Nosology:Nervios and Ataques de Nervios. Culture,

Medicine and Psychiatry 27(3): 339366.Guarnaccia, Peter J., and Lloyd H. Rogler

1999 Research on Culture-Bound Syndromes: New Directions. The American Journalof Psychiatry 156: 13221327.

Jenkins, Janis H.1988 Conceptions of Schizophrenia as a Problem of Nerves: A Cross-Cultural Compar-

ison of Mexican Americans and Anglo-Americans. Social Science and Medicine26(12): 12331243.

Kay, Margarita, and Carmen Portillo1989 Nervios and Dysphoria in Mexican American Widows. In Gender, Health and Ill-

ness: The Case Of Nerves. D.L. Davis and S.M. Low, eds., pp. 181201. New York:Hemisphere Publishing Co.

Kleinman, Arthur, Leon Eisenberg and Byron Good1978 Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural

Research. Annals of Internal Medicine 88: 251258.Koss-Chioino, Joan D.

1989 Experience of Nervousness and Anxiety Disorders in Puerto Rican Women: Psychi-atric and Ethnopsychological perspectives.In Gender, Health, and Illness: The CaseOf Nerves. D.L. Davis and S.M. Low, eds., pp. 153180. New York: HemispherePublishing Co.

Krieger, Laurie1989 Nerves and Psychosomatic Illness: The Case of Um Ramadan. In Gender, Health,

and Illness: The Case Of Nerves. D.L. Davis and S.M. Low, eds., pp. 89101. New

York: Hemisphere Publishing Co.Low, Setha

1985 Culturally Interpreted Symptoms of Culture-Bound Syndromes: A Cross-CulturalReview of Nerves. Social Science and Medicine 21(2): 187196.


22/23


1989 Gender, Emotion, and Nervios in Urban Guatemala. In Gender, Health, and Ill-ness: The Case Of Nerves. D.L. Davis and S.M. Low, eds., pp. 115[23]140[48].New York: Hemisphere Publishing Co.

Pan American Health Organization (PAHO)

1986 Health Conditions in the Americas, 19811984. Washington, DC: Pan AmericanHealth Organization.

Romney, A. Kimball, Susan C. Weller, and William Batchelder1986 Culture and Consensus: A Theory of Culture and Informant Accuracy. American

Anthropologist 88: 313351.Rubel, Arthur, Carl W. ONell, and Rolando Collado-Ardon

1984 Susto, a Folk Illness. Berkeley: University of California Press.Salgado de Snyder, V. Nelly, Maria de Jesus Diaz-Perez, and Victoria D. Ojeda

2000 The Prevalence of Nervios and Associated Symptomatology among Inhabitants ofMexican Rural Communities. Culture, Medicine and Psychiatry 24(4): 453470.

Sluka, Jeffrey A.

1989 Living on their Nerves: Nervous Debility in Northern Ireland. In Gender, Health,and Illness: The Case Of Nerves. D.L. Davis and S.M. Low, eds., pp. 127151.New York: Hemisphere Publishing Co.

Trotter, Robert, II1982 Susto: The Context of Community Morbidity Patterns. Ethnology 21: 215226.

Weller, Susan1997 Latino Beliefs about Mollera Caida. Paper presented at the meetings of the Society

for Applied Anthropology, March, Seattle, WA.Weller, Susan, and Roberta Baer

2001 Intra- and Intercultural Variation in the Definition of Five Illnesses: AIDS, Diabetes,the Common Cold, Empacho, andMal de Ojo. Cross-Cultural Research 35(2): 201226.

Weller, Susan, and A. Kimball Romney1988 Systematic Data Collection. Newbury Park, CA: Sage Publications.

Weller, Susan C., Roberta D. Baer, Javier Garcia de Alba Garcia, Mark Glazer,Robert Trotter, Lee Pachter, and Robert E. Klein

2002 Regional Variation in Latino Descriptions ofSusto. Culture, Medicine and Psychi-atry 26(4): 449472.

Roberta D. Baer

Department of Anthropoloty

University of South FloridaTampa, FL 33620

Susan C. Weller

Department of Preventive Medicine

University of Texas Medical Branch

Galveston, TX 77555-1153


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