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 of nervios, we undertook a multisite comparative study of the illness among Puerto Ricans, Mexicans, Mexican Americans, and Guatemalans. We also conducted a parallel study on susto (Weller et al. 2002, Culture, Medicine and Psychiatry 26(4): 449–472), which allows for 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 of nervios, as well as similarities and differences between nervios and susto in these same communities. We found agreement among all four samples on a core description 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 seems to 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 of nervios 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 nervios and 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 (American Psychiatric 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: 315–337, 2003. C 2003 Kluwer Academic Publishers.
Transcript
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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 FOLKILLNESSNERVIOS
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): 449–472), which allowsfor a systematic comparison of these illnesses across sites. The focus of this paper isinter- and intracultural variations in descriptions in four Latino populations of the causes,symptoms, and treatments ofnervios, as well as similarities and differences betweennerviosandsustoin these same communities. We found agreement among all four samples on a coredescription ofnervios, as well as some overlap in aspects ofnerviosandsusto. However,nerviosis a much broader illness, related more to continual stresses. In contrast,sustoseemsto be related to a single stressful event.
KEY WORDS: Latino folk illnesses,nervios, susto
INTRODUCTION
Although there have been detailed descriptions ofnerviosfrom case reports andfrom specific regions, few attempts have been made to compare descriptions ofthe illness across cultures.Nerviosis 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 tocompare published descriptions ofnerviosin different populations, but found thatmethodological differences in how individual studies were conducted made gen-eralizations difficult. She suggested, however, that the similarity betweennerviosandsusto(a folk illness glossed as fright or shock) might mean that they wereboth expressions of distress, but labeled differently by different segments of thepopulation. As such, unresolved issues include whether the termnerviosmeansthe same thing in different cultural contexts, and the extent to whichnerviosandsustorepresent similar or distinct illness entities.
Not simply part of the exotica of different cultures, folk illnesses have beenlinked to morbidity and mortality.Sustois associated with an increased risk of co-morbidities and a higher mortality rate (Baer and Bustillo 1993; Baer and Penzell1993; Rubel et al. 1984) andnervios is now noted in the DSM-IV (AmericanPsychiatric Association 1994: Appendix 1). The study of these folk illnesses inrelation to physiological symptoms has not been for the purpose of reducing the
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316 ROBERTA D. BAER ET AL.
folk illnesses to their biomedical equivalents, but rather to understand the meaningof these ethnomedical diagnoses for increasing risk of morbidity and mortality.Sincesustohas been linked with increased morbidity (Baer and Penzell 1993) andmortality (Rubel et al. 1984), ifnerviosandsustoare really just different namesfor the same problem,nerviossufferers may similarly be at increased health risk.
This paper explores inter- and intracultural variations in descriptions of thefolk illness nervios. Four diverse Latino populations are studied: Puerto Ricansin Hartford Connecticut, Mexican Americans in South Texas, Mexicans inGuadalajara, Mexico, and Guatemalans in rural Guatemala. Since a first step is tounderstand an illness in its cultural context (Guarnaccia and Rogler 1999:1322)and then analyze its relationship to co-morbidity, this study first describesnervioswithin each of the four populations. One aim is to see if there is a distinct descriptionof nerviosthat is shared by culture members—a community explanatory modelof the causes, symptoms, and treatments fornervios. A second aim is to comparedescriptions across the four diverse sites to see the extent to which descriptions aresimilar and different in different cultural contexts. Finally, we compare detailedfindings fornervioswith those forsustoin order to determine if these two folkillnesses are synonymous or distinct.
BACKGROUND
One problem in our understanding ofnerviosis that studies have used a varietyof terms for the problem, including “nerves” (Finkler 1989; Krieger 1989; Sluka1989), “nervousness” (Camino 1989; Koss-Chioino 1989), and “nervios” (Barnett1989; Finerman 1989; Kay and Portillo 1989; Low 1989). The literature indicatesthat the label “nervios” covers a broad range of problems in the mental healthrealm, from depression to schizophrenia (Jenkins 1988). In some cultures, the termnerviosmay be preferred over the term “mental illness,” and may be interpretedmuch more broadly (Baer 1996). The similarity betweennerviosandsustosuggeststhat they may both be expressions of distress or stress, but the two different labelsmay be used in different contexts (Low 1989).
Nervioshas been studied in a variety of locations (including Latin America, theMediterranean, northern Europe, and the United States) (Davis and Low 1989).But among some cultural groups, scholarship aboutnerviosis less well developedthan for many of the other folk illnesses. This is particularly true for Mexicanand Mexican American populations (Trotter 1982). This pattern is curious, in thatTrotter (1982) found that in the lower Rio Grande Valley,nervioswas the thirdmost 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 ILLNESSNERVIOS317
The folk illnessnerviosis so widely reported across many contrasting regional,linguistic, and demographic barriers that it defies description as a “culture-boundsyndrome” (Guarnaccia 1993).Nerviosis consistently described as a culturallyapproved reaction to overwhelmingly stressful experiences, especially concerninggrief, threat, and family conflict. However, it has been suggested that the waythe illness is experienced and conceptualized may vary across cultural groups(Guarnaccia 1993).
Guarnaccia et al. (2003) have found that Puerto Ricans differentiate betweencategories and experiences ofnervios. Ser nervioso(being a nervous person) isa result of traumatic experiences of suffering, and usually begins in childhood;the condition lasts the rest of the person’s life and results in more life problems.Symptoms include unusual amounts of crying, headaches, stomach aches, andincreased anger and violence, particularly in men. Herbal teas and the help offamily members, priests and ministers, and psychologists and psychiatrists werethe recommended treatments.Padecer de los nervios(suffering from nerves) ismore of an illness, and is associated with depression, although the body is alsoaffected. Life problems, including marital difficulties, are seen as the cause, and itusually develops in adulthood. This condition is considered to be a form of mentalillness, and the help of physicians, psychologists and psychiatrists is recommended.Ataques de nervios(nervous attacks) occur as the result of a stressful event, oftenin the family setting. Those who are nervous or suffer from nerves are more likelyto suffer from nervous attacks. Due to an event such as the news of the death of afamily member, the person becomes hysterical and “out of control” (Guarnacciaet al. 2003). This problem is more common in women, although it can occur inmen as well.
In Guatemala,nervios is conceived of and treated as an illness rather than asymptom, 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 toreportnerviosthan men, which suggests that the illness is related to gender-basedconcerns in general, and socially manifested expressions of strong emotions inparticular (Low 1989:24). There is also an ethnic dimension in the recognitionand reporting ofnervios; most studies have focused on nonindigenous Spanish-speaking populations (ladinos). Causality ofnerviosis attributed to anger, grief,birth control pills, other illnesses, the birth of a child, anxiety, problems,susto, andother stressful 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 homeremedies (Low 1989: 24). Further, Low suggested thatnerviosmight be the termused by more urban/ladino populations for what rural/indigenous people callsusto
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318 ROBERTA D. BAER ET AL.
(Low 1985) and may reaffirm an “urban, upwardly mobile Ladino identity” (Low1989:133).
In Mexico, as in Guatemala, there is a higher prevalence ofnerviosamong fe-males; this is attributed to their inferior social position (Finkler 1991:43). Thisis further illustrated by reports thatnerviosis associated with stressed, harassed,abused, and/or neglected women in rural Mexico (Davis and Low 1989; Salgadode Snyder et al. 2000). In Mexican populations,nerviosis simultaneously an ex-planation of illness, a symptom of illness, and a state of illness. However, thosesuffering from the symptoms ofnerviosreport a wide variety of symptoms, in-cluding feelings of desperation, headaches, chest pains, abdominal pains, high andlow blood pressure, and various familial, social, political, and economic concerns(Finkler 1989; Salgado de Snyder et al. 2000). Patterns of treatment in Mexico in-clude home remedies, especially herbal teas, frequently used in combination withphysician-prescribed medications (Finkler 1989).
Among Mexican Americans, Jenkins (1988) found that the termnerviosis usedto cover everyday problems causing distress, serious family conflict, as well asschizophrenia. Symptoms associated withnerviosincluded irritability, hopeless-ness, nervousness, depression, physical effects, and difficulty in functioning insocial or occupational roles. For Mexican and Mexican American farm workers inFlorida,nervioswas the label that covered many conditions considered biomedi-cally to be mental illnesses. However,nervioswas not considered to be a mentalillness by the farm workers (Baer 1996). Causes ofnerviosincluded money, foodand work problems, and accidents; treatments suggested were talking to some-one about the problems or getting medical or psychiatric help. Among MexicanAmericans,nervioshas been reported as being more common in women (Jenkins1988). In a study of widows, Kay and Portillo (1989) found that the more bi-cultural a woman was, the less she was troubled bynervios. Both somatic andnonsomatic symptoms were reported, but it was primarily the nonsomatic symp-toms (fear, worry, anguish, anger, separation sorrow, loneliness, disorientation,feeling empty, confusion, and a feeling of being in the way) that distinguishednervios.
Although these findings suggest similarities among these populations in theirdefinitions ofnervios, each study used a somewhat different approach and re-search instrument that limits our ability to tell how similarnervios is amongdiverse Latino populations. To systematically study and document regional vari-ations in descriptions ofnervios, we undertook a multisite comparative study ofnervios. Using four distinct geographic and cultural locations, we examined de-scriptions ofnerviosto see the degree to which individuals within a communityreported similar causes, symptoms, and treatments fornervios, and then compareddescriptions across sites. We also conducted a parallel study onsusto(Weller
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESSNERVIOS319
et al. 2002), which allowed for a systematic comparison of these illnesses acrosssites.
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 mainlandPuerto Rican community in Hartford, Connecticut. The other two research loca-tions were the rural ladino community of Esquintla, Guatemala, and the urbanMexican 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 US–Mexico border, thearea, although a mixture of urban and rural, is predominantly agricultural. Thepopulation is 80% Mexican American. Hartford, Connecticut, is a medium-sizedcity in the northeast United States. While only about one-third of the city’s pop-ulation is Hispanic, children of Puerto Rican descent make up 47% of those inthe public school system. The interviews for this study were conducted in thetwo census tracts that have the majority of the Puerto Rican population. TheGuatemalan interviews were conducted in the department of Esquintla, locatedon the Pacific coast. This area is agricultural; primarily cotton and sugar caneare grown. The population sample was Spanish-speaking ladinos in four ruralvillages, each of which had a population of about five hundred. The Mexicansample was drawn from the modern industrial city Guadalajara, which has apopulation of approximately three million. Predominantly mestizo, residents ofGuadalajara are from both rural and urban backgrounds. In order to capture thevariation 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 waschosen, and then blocks and households were selected. The inclusion criteria werethat the respondent be an adult and recognizenerviosas 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 Connecticutthey 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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320 ROBERTA D. BAER ET AL.
bilingual research assistants in the language preferred by the interviewee (English,Spanish, or a combination).
Questionnaire development
Ten to twenty initial key informant interviews at each of the four Latino siteswere used to develop the questionnaire. We focused on the termnervios, whichis recognized in all of the cultures studied, as opposed to the more extensivevariants of the condition seen among Puerto Ricans (Guarnaccia et al. 2003). Usingopen-ended interviews and free listing techniques (Weller and Romney 1988),qualitative data were gathered on the explanatory model ofnervios, includingperceived causes, symptoms, and treatments ofnervios(Table I).
In Mexico, respondents were also asked about similarities and differences be-tweennerviosandsusto. On the basis of the open-ended interviews (any responsementioned by at least 10% of the sample), symptoms from the Cornell MedicalIndex, and the anthropological literature, a true-false questionnaire was developed.The final questionnaire1 contained 125 items addressing the causes, symptoms,and treatments fornervios. The questionnaire also included basic demographicdata on the respondent, as well as questions about experiences withnervios. Fi-nally the questionnaire was translated into the form of Spanish (or English) spokenat each particular site being studied.
Data analysis
Our goal was to determine the descriptions ofnerviosin the four Latino groupsas well as the degree of similarity and difference among the groups. This wasaccomplished with a type of data analysis called consensus analysis. Given a set ofrelated, closed-ended questions, a consensus analysis accomplishes three things.First, it provides an assessment of the agreement among respondents to see ifthere is sufficient agreement to warrant aggregating responses. Then, if there issufficient agreement, it provides estimates of how well each person’s responsescorrespond to the “group ideas.” Third, it provides estimates of the answers to theset of questions.
A consensus analysis is an analytic tool that allows one to determine whetherthere is group agreement—or consensus—in responses to structured questions.Identifying or creating a reliable description of community explanatory modelsincludes an assessment of variability of ideas. If variability is high—that is, ifrespondents do not agree with one another and do not seem to have similar ideas—then it does not make sense nor is it accurate to create a unitary, simple aggrega-tion of responses. If, however, informants report similar or identical information,then one is justified in pooling the information to create an overall description of
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESSNERVIOS321TA
BLE
IN
ervi
os
Who
isS
usce
ptib
leC
ause
sS
ympt
oms
Tre
atm
ents
Esq
uint
la,G
uate
mal
a(
n=
20)
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6P
orpr
oble
mas
fam
iliar
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orde
cabe
za13
Cal
man
tes
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dos
6P
oren
ojar
se10
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orde
mue
las
4In
yecc
ion
(de
calm
ante
s)2
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eres
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orpe
leas
con
las
espo
sas
8D
olor
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ririn
a3
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caus
asde
acci
dent
es6
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oles
tan
los
ruid
os2
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tilla
3P
orfa
ltade
vita
min
as5
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jos
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arm
acia
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ner
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o3
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can
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r2
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reci
bir
notic
iade
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nte
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iem
blan
6E
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sa2
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itos
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los
hijo
s2
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espe
raci
on4
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ndas
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orun
aim
pres
ion
(se
emoc
iona
)2
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S11
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mue
ren
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ede
torc
erla
boca
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eem
peor
ala
enfe
rmad
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ra,M
exic
o(n=
20)
10A
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nta
mas
sens
ible
s8
Pre
ocup
acio
nes
10C
oraj
udo
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alam
arse
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ebile
sde
cara
cter
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sion
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ome
rem
edie
s5
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ltos
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emas
fam
iliar
es5
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vios
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octo
r4
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os3
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ajes
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anch
as6
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icin
e2
Las
amas
deca
sa2
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enci
a3
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orde
cabe
za5
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chia
tris
t2
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dotip
ode
pers
onas
2A
vece
sno
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nlo
spa
pas
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rita
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deed
ada
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ican
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amie
nto
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nas
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ar2
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dida
deco
noci
mie
nto
2D
eses
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cion
Edi
nbur
g,Te
xas
(n=
20)
8A
nyon
e17
Tens
ion;
stre
ss;w
orry
12W
orrie
d,st
artle
easi
ly;j
umpy
11G
oto
doct
or5
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ars
and
olde
r2
Get
ting
angr
y;ov
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actin
g7
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emot
iona
l;ge
tsag
itate
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oto
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ple
who
are
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ing
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nd7
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ax;r
est
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322 ROBERTA D. BAER ET AL.
TAB
LEI
(Co
ntin
ue
d)
Who
isS
usce
ptib
leC
ause
sS
ympt
oms
Tre
atm
ents
3P
eopl
ew
how
orry
cons
tant
ly4
Hig
hbl
ood
pres
sure
5Te
a,he
rbal
tea
(man
zani
lla)
3S
haki
ng;c
hills
4C
ouns
elin
g;th
erap
y2
Des
pera
te;u
ncom
fort
able
feel
ing
4P
ills
2N
osl
eep
3N
ocu
re2
See
thin
gsth
atar
eno
tthe
re3
Med
icat
ion
from
doct
or2
Ras
hes
2T
ranq
uiliz
ers
2S
tom
ach
has
gas
2Lo
ssof
appe
tite
2Te
nse
2H
eada
che
Har
tford
,Con
nect
icut
(n=
10)
3A
dults
3N
otco
ntag
ious
2Lo
ssof
cont
rol(
ofon
e’s
nerv
es)
2M
edic
atio
n2
Eve
ryon
e1
Bei
ngov
erw
helm
edw
ithpr
oble
ms
1S
crea
min
g2
Pill
spr
escr
ibed
bydo
ctor
1P
eopl
ew
itha
loto
fstr
ess
inth
eir
lives
1P
robl
ems
deal
ing
with
life
1C
ryin
ghy
ster
ical
ly2
Tra
nqui
lizer
sw
hoar
eun
able
toco
pew
ithpr
oble
ms
1D
epre
ssio
n1
Not
aph
ysic
alill
ness
;mor
em
enta
l1
Brin
gto
ado
ctor
1M
ainl
yw
omen
1A
nxie
ty1
Lots
ofcr
ying
and
scre
amin
gup
on1
The
rapy
1W
eak
peop
lew
hota
keth
eir
prob
lem
she
arin
gba
dne
ws,
espe
cial
lyif
1W
alki
ngto
ose
rious
lyso
meo
nedi
es1
Spe
akin
gto
anot
her
pers
on1
Str
ess,
prob
lem
s1
Drin
king
agua
deaz
ahar
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESSNERVIOS323
ideas in a group. Consistency among respondents’ answers is indicative of sharedknowledge.
Consensus analysis is conducted in a fashion somewhat analogous to factoranalysis. In factor analysis, the structure among a set of variables is described byclassifying items into groups or factors. A single factor solution indicates that allof 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 howstandard factor analysis groups individual items in a questionnaire. A single factorsolution indicates homogeneous responses among a single group of respondents,i.e., consensus. In this study, consensus analysis is used to determine whether theaggregate responses to the yes/no questions on thenerviosquestionnaire indicateunderlying group agreement (consensus) at each site and between sites regardingthe domain of study (nerviossusceptibility, causes, symptoms, and treatments).
Consensus analysis also provides an estimate of each respondent’s concordancevis-a-vis the group (their cultural knowledge or “competency” score). The analysisalso provides a best estimate of the group’s 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 inthe group. In this study a conservative Bayesian classification rule was used. Itemswere classified at thep ≥ 0.999 confidence level.
As with most sample size requirements, sample size determination is a functionof variability. In consensus analysis, the variation is the amount of agreementamong the respondents. For dichotomous response data, using a moderate level ofcompetency 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 forcomparative purposes within samples, a sample size of about 40 was obtained ateach site.
RESULTS
The sample
The final sample consisted of 40 respondents in Connecticut, 41 in Texas, 38 inMexico, and 40 in Guatemala. Respondents were primarily women (100% in theMexican and Texas samples, 90% in Guatemala, and 87% in Connecticut). Allof the informants in the Mexican sample were born in Mexico, and all of theinformants in the Guatemalan sample were born in Guatemala. In the Connecticutsample, 90% were born in Puerto Rico; 70% of the interviews were conductedin Spanish, 3% in English, and 28% in combined English and Spanish. In the
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Texas sample, 95% of the respondents were born in the U.S., and 66% of theinterviews were in English, 7% in Spanish, and 27% in combined English andSpanish. Respondents’ educational levels varied significantly between samples,reflecting normative rates for each region: 1.8 years in Guatemala, 5.5 years inMexico, 11.2 years in Texas, and 10.3 years in Connecticut (Table II).
Actual experience withnerviosvaried somewhat by community. Most respon-dents knew someone withnervios(95% in Guatemala, 90% in Connecticut andTexas, 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 experiencednervios 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, andtreatments fornerviosrevealed that asingle, shared system of knowledge aboutnervios exists for each sample of respondents. The cultural consensus model fits theresponse data (the eigenvalue ratios all exceeded the recommended 3:1 ratio: 9.85in Connecticut, 8.81 in Texas, 6.51 in Mexico, and 5.48 in Guatemala). Responseswere the most homogeneous in the Texas and Connecticut samples, resulting inthe highest levels of sharing (the average cultural knowledge scores were 0.73in Texas and 0.62 in Connecticut). The Mexican and Guatemalan samples alsoexhibited shared ideas, although at a somewhat lower level (0.52 in Mexico and0.43 in Guatemala). Analysis with all four samples together indicated that theyshare a single description ofnervios, with about 52% of ideas in common (culturalknowledge level= 0.52, eigenvalue ratio 6.45). A comparison of knowledge lev-els across samples indicated that there was a greater degree of shared responsesin Texas than in Connecticut, significantly greater sharing in Connecticut than
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Mexico, and significantly greater sharing in Mexico than Guatemala (ANOVAp ≤ 0.00005; Scheffe comparisonp ≤ 0.005).
The distribution of cultural knowledge within each sample was more stronglyrelated 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 aboutnervios. Similarly, in Texas, households with fewer people inthem were associated with greater knowledge aboutnervios (r = −0.42, p =0.01). In Guatemala, a larger household was associated with more knowledge(r = +0.29, p = 0.07). Personal experience withnervios(knowing someone withit or having had it) was associated with greater cultural knowledge, althoughthe associations were not significant. Greater cultural knowledge was corre-lated with knowing someone withnervios(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 = 0.13in Connecticut). Responses were not different (p > 0.05) between men and womenin 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 somevariability, as illustrated by a more detailed comparison between the samples. Thehighest agreement occurred between the Connecticut and Texas samples with 78%identical answers, followed by 64% agreement between the Texas and Mexicansamples, and 57% agreement between the Mexican and Guatemalan samples.Tables III–VI show the questions aboutnerviosthat were classified using consensusanalysis by one or more of the samples as having the answer “true” or “yes.” Studysites 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 notbe classified as either true or false. We first discuss the findings fornerviosandthen compare the findings with those forsusto.
For susceptibility (Table III, columns 4–7), there was agreement among at leastthree of the samples on 10 of the 14 questions (71%), and among all four sampleson 6 of those questions (43%).Nervios is seen in adults and older people, andthough it can occur in anyone, it is more common in sensitive people. The foursites also agreed thatnerviosis not a problem among men, and does not occur onlyin families who believe in it. Three of the sites also answered thatnervioswas seenmainly 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 4–7), at least three samples agreed on27 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 causenervios. In addition, a fright (susto) or shock (seeing
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TABLE IIISusceptibility
Susto NerviosG M T G M T C
Y Y Y Y Y Y Y Adults get itY Y Y Y Y Y Y Old people get it– Y Y Y Y Y Y An yone, regardless of age and gender/sexY Y Y Y Y Y Y More in sensitive peopleN N N N N N N Mainly in menN – N N N N N Only in families who believe in it
– Y N Y Y N Y Mainly in womenY Y Y – Y Y Y Older childrenY Y N Y Y N Y Mainly in weak peopleY 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 childrenY Y N Y N N Y In unborn children, if their mother has itN – 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 causenervios. Also important incausality are strong emotions, anger, worry, family problems, and family fighting.Nervios is not considered to be contagious. A relationship betweensustoandnerviosis evident, assustowas considered to be a cause ofnervios. In addition,several situations that are usually cited as producingsusto—seeing someone killed,seeing or being in an accident, or a surprise or shock—were also considered tobe causes ofnervios. While the four sites agreed that a cause ofnerviosmightbe not eating well (three sites also thought hunger could cause it), food stuck inthe stomach (usually associated with the folk illnessempacho) was not consideredto be a cause ofnervios. Three sites also agreed on a lack of hot/cold causalityof nervios. 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 4–7), there was agreement acrossat least three of the samples on 62% of the questions (24 out of 39 questions), andamong all four of the sites on 44% (17 out of 39) of the questions. Symptomsagreed upon by all four sites included depression or sadness, a feeling of no hopein life, crying, hysterical crying or crying attacks, and shaking or trembling. Othersymptoms agreed upon by all four sites were headache, a feeling of choking, coldsweat, weight loss, bad temper, insomnia, and anger caused by small things. Therewas also agreement that runny nose, fever, slow healing wounds, and a swollenstomach were not symptoms ofnervios. Additional symptoms agreed upon bythree of the sites included lack of appetite, agitation, and convulsions or seizures.
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TABLE IVCauses
Susto NerviosG M T G M T C
N N N Y Y Y Y From not eating wellN – N Y Y Y Y From drinking too much alcoholN Y N Y Y Y Y By using drugsY Y Y Y Y Y Y Nervioscausessusto/fright or sustocausesnerviosY Y Y Y Y Y Y By seeing someone get killedY Y Y Y Y Y Y By seeing or being in an accidentY 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 angerY Y Y Y By w orrying a lotY Y Y Y From family problems
N – N Y Y N Y From living in a dirty houseN N N – Y Y Y From hungerY Y N Y Y N Y By the devil– – N Y Y N Y From low resistanceN – N Y – Y N By ahard, envious stareN N N Y N N N From cold foods (or drinks)N N N Y N N N By getting wet when you are sweatingY N N Y N N N By being exposed to drafts/wind/airN 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 stomachN – N – N N N BywitchcraftN N N N N N N By using the utensils of someone who has it
For treatments (Table VI, columns 4–7), at least three of the samples agreedon 73% (30 out of 41) of the questions, and all four samples agreed on 51% (21out 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 asbarrida, or sweeping with herbs, rubbingwith an egg, a spoonful of oil, pulling the skin of the body until it pops, or bindingthe waist) were not indicated for use in the treatment ofnervios, nor were theservices of the folk healers,curanderos, or spiritualists. Other treatments rejectedby all groups included spearmint tea, enemas, scaring the affected person, drinkingalcohol, warm towels on the body, and drinking milk. Sedatives, praying, andtrying to relax were the only suggested treatments agreed on by all four samples.Additionally, three of the sites recommended the use of physicians and psychiatristsor 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, orgrandmother. Three sites reported thatnervioswould go away by itself.
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TABLE VSymptoms
Susto NerviosG M T G M T C
Y Y Y Y Y Y Y CryingY Y Y Y Y Y Y Hysterical crying or crying attacksY Y Y Y Y Y Y Dif ficulty going to sleep and staying asleepY 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 lifeY Y Y Y Small things cause angerY Y Y Y A bad temper
Y – N Y Y Y Y A headacheN – – Y Y Y Y A feeling of choking– Y Y Y Y Y Y A cold sweatY Y N Y Y Y Y W eight loss
Y Y N Y – Y Y A lack of appetiteY Y Y Y – Y Y Agitation
Y Y N Y A convulsion or seizure
– – N Y Y N N Cloudy or blurred visionN – Y – – Y Y Difficulty breathingN – Y N – Y Y Stomach pain or stomachacheN Y Y N N Y Y V omitingN Y Y N N Y Y DiarrheaN N N Y – Y – ItchingY Y Y – Y Y N Paleness– – N Y – Y N SleepinessY – Y Y N Y – ChillsY 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 urinationN N N – N N Y Chest pain
Y – N N Aching teethY N N N Facepain
Differences between sites
There were, however, some interesting differences between the sites. OnlyGuatemalans reported eating cold foods or getting wet while sweating or drafts ascauses ofnervios, and only they considered face pain to be a symptom and garlicto be a treatment. It would appear that as far asnervioscausality is concerned,hot–cold explanations are more important in Guatemala than at the other sites. An-other distinctive pattern occurred in the Mexican and Guatemalan samples, whereuntreatednervioswas reported to cause a person to become diabetic or the mouthto become twisted and deformed.
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TABLE VITreatments
Susto NerviosG M T G M T C
N Y N Y Y Y Y Sedatives– Y Y Y Y Y Y T rying to relax (keep calm)Y Y Y Y Y Y Y Praying
N Y Y – Y Y Y MassagesN N N Y – Y Y Doctor– Y N Y Y – Y Psychiatrist or psychologistN N N – N N N PharmacistY Y N – N N N HerbalistY – N – N N N Wise old woman/grandmotherY N – N N N N Curandero
N Y N – Y N Y Tea oforange leaves or orange blossomY 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 VitaminsN N N Y N N N GarlicN – N – Y N N Rubbing the back and chest with alcoholY Y Y – Y N – Treated at homeY Y N – Y N – Go tochurchN N Y N N Y N Go away byitselfY 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 betweennerviosandsusto. We conducted another study similar to our investigations ofnerviosexploring regional variations in beliefs aboutsusto(Weller et al. 2002). Thesustostudy was originally planned for the same four sites wherenervioswas studied;howeversustowas not found to exist as an illness among the Puerto Rican pop-ulation in Hartford, Connecticut. As a result, the discussion below compares theresults from the three sites that recognized both of these illnesses—Guatemala,Mexico, and Texas. The methodology used in both thesustoandnerviosstudieswas the same; in fact, 85 of the questions used in the two studies were iden-tical. While the actual respondents for thenerviosand sustostudies were notidentical, each sample was representative of the community from which it wasdrawn.
Susceptibility is broader forsustothan fornervios(Table III). Younger and olderchildren can suffer fromsusto, but this is not the case fornervioswhich seems tobe more of an adult problem.Nerviosis felt to occur mainly in women, whilesusto
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is not as closely linked to gender. While there is some overlap in causes ofsustoandnervios(including seeing someone get killed, seeing or being in an accident,and a sudden surprise or shock),sustoseems more related to a particular incidentor accident. In contrast, causes ofnerviosare of a continual nature in one’s life,and include family problems and fighting, drugs, alcohol, worry, anger, and strongemotions (Table IV). Note, however, thatsustocan causenerviosand thatnervioscan causesusto.
A similar pattern is seen with regard to symptoms ofnerviosandsusto, withoverlap in symptoms such as crying, shaking, and difficulty sleeping (Table V).However, there are many symptoms that are unique to each illness. Paleness maybe more restricted tosusto, while headache, a feeling of choking, cold sweat, andweight loss are associated more withnervios. Neither illness seems to manifestsolely with somatic symptoms. While praying is recommended for bothsustoand nervios, the most striking difference between the two illnesses is the useof Western versus folk treatments. While a doctor or psychologist or psychi-atrist is recommended fornervios, they are not considered effective forsusto(Table VI). In fact, home treatment and folk healers are used more often forsusto.
Patterns of regional variation similar to those found fornerviosalso appearfor similarities and differences betweensustoandnervios. Only the Mexican andGuatemalan samples report that weak people and people with a weak characterare more likely to get either illness (the Texas sample did not) and that the Devilcould cause bothsustoandnervios. Similarly, these two sites saw diabetes as apossible outcome of both untreatedsustoand untreatednervios. Guatemala wasthe only site to feel that drafts were a cause of these illnesses. Finally, only theTexas sample reported that bothnerviosandsustowould go away by themselves.
We also compared the differences betweennerviosandsustowhich emergedfrom the analysis of the structured questionnaire data to those differences reportedin the initial open-ended interviews in Mexico. In those open-ended interviews,respondents were asked about the similarities and differences betweennerviosandsusto. We found that both sets of interviews contained similar themes:sustoisconsidered to be briefer thannervios, andnerviosis more chronic and is a continualstress.Sustois caused by an identifiable event—a “susto”—while nerviosis causedby persistent problems.
In summary, there is an overlap in many aspects of these two illnesses. Bothtend to occur more in adults; both are caused by surprising, shocking, or disturbingoccurrences. Both present with symptoms of distress; neither presents solely withsomatic symptoms. However,nerviosis a much broader illness, related more tocontinual stresses. In contrast,sustoseems to be related to a single stressful event.There are a few broadly recommended treatments fornervios, while those forsustoshow more regional variation.
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DISCUSSION AND CONCLUSIONS
The core description ofnerviosagreed on by all four sites supports the patternsreported in the literature for these individual populations.Nerviosis felt to oc-cur more often in women. It is caused by emotion and interpersonal problems; itssymptoms are primarily nonsomatic. Interestingly, although treatment by psychol-ogists and doctors is recommended, the most broadly recommended treatment isneither biomedical nor folk, but spiritual, i.e., praying. However, at all four sites,nervioscovered a broad range of mental health conditions. It would seem of greatimportance for mental health professionals working with these populations to un-derstand the way the termnerviosis used and the types of conditions it covers.It should be noted, however, that the literature suggests thatnerviosmay not beconsidered a “mental illness” by these populations (Baer 1996).
Almost everyone approached to be interviewed for this study considerednerviosto be an illness. Thus, there is an interesting contrast in prevalence betweennerviosand other common Latino folk illnesses. We have carried out parallel studies tothose described here forsustoandnerviosfor the folk illnessescaida de la mollera(fallen fontanelle) andmal de ojo(evil eye) (Weller 1997; Weller and Baer 2001).These studies indicated that in the Mexican sample, in which 100% of respondentsconsiderednerviosto be an illness, recognition ofsustowas 87%,caida de lamollera85%, and formal de ojoonly 63% However, recognition ofsusto, mal deojo, andcaida de la molleravaried by social class. Recognition was highest in thelower class, intermediate in the working class, and lowest in the middle class. Butunlike other folk illnesses, recognition ofnerviosin Mexico was not class related.Similarly, we found no meaningful variation in relevant themes fornerviosbydegree of acculturation. In the Texas and Connecticut samples, a very crude indexof acculturation can be estimated by birthplace and language preference. Responsesdid not differ significantly on either of these variables.
Nerviosandsustoare distinct entities. While it has been suggested in the liter-ature thatnerviosmay 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,sustois also an illness category,and it can be distinguished fromnervios. The two illnesses appear to overlap, butnerviosis a much broader illness and is widely recognized. People in the samecommunities recognize both illnesses, andnerviosappears to transcend socialclass. Specific research would be necessary with indigenous groups to determinewhether the same pattern holds in those populations. However, in Mexico it ap-pears that the recognition ofsustoas an illness, unlike that ofnervios, may be classrelated.
Recognition ofsustoalso varies by region. It is also important to note thatalthoughnervioswas considered to be an illness at all four sites,sustowasnot
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recognized as an illness by Puerto Ricans in Connecticut. During the initial stagesof this project (when descriptive, open ended interviews were conducted to elicitindividual explanatory models), Puerto Rican respondents indicated that they con-sideredsustoto be a symptom, a feeling, but not an illness.
Finally, at least for the Mexican and Guatemalan populations,nervios(andsusto;Weller et al. 2002) is implicated in the causality of diabetes. While diabetes is nota 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. InMexico, the diabetic mortality rate for people older than 65 is several times greaterthan that in the United States (PAHO 1986). Bothnerviosandsustoneed furtherstudy exploring their possible relation to diabetes.
This study demonstrates the usefulness of cross-cultural research onnerviosand of a systematic comparison withsusto. We determined a core description ofnerviosas well as similarities and differences in that definition among the fourLatino groups studied. The relationship tosustohas been clarified, and a link todiabetes for at least two of the populations studied is suggested as an importantarea for further research. While the samples at each site were representative ofthe variability in each of those populations, the results cannot be generalizedto, for example, all of Mexico from the Guadalajara sample, or to all MexicanAmericans from the south Texas sample. The similarity in findings across suchdiverse samples, however, suggests that the findings would apply to many moreregions than those actually sampled. Because such strong similarities were foundin descriptions from places ranging from rural Guatemala to urban Connecticut,it is likely that those same themes would be important to Latinos in regions otherthan those sampled for this study.
Our approach also demonstrates a number of important directions for the futurestudy of these conditions. First, this study ofnerviosdemonstrates a way to studyethnomedical phenomena in their cultural contexts that also allows for cross-cultural comparisons. In this research, we used free listing to elicit the explanatorymodel (Kleinman et al. 1978) ofnerviosin each population being studied. Next,we developed a structured interview (a yes–no questionnaire) that incorporatedthemes from each community’s explanatory model (as well as other items, someof which had biomedical origin). From this, we were able to determine whichaspects of explanatory models were shared and which were distinct. Our two-stepapproach, which incorporated themes from all sites in the interviews, allowed usto verify whether or not themes mentioned in the open-ended interviews wereimportant within a community and across communities. The advantage of thestructured interviews was that themes that were mentioned at one particular sitebut 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 todetermine similarities and differences betweennerviosand another folk illness,
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susto. We therefore suggest such an approach as important and appropriate forcross-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 determinehow these illnesses are related to psychiatric disorders (Guarnaccia and Rogler1999). Our work expands the relationship to include both mental and physicaldisorders. In doing so we stress the importance of questioning the mind–body di-vision of Western cultures—and of biomedicine—which discounts the relationshipbetween folk illnesses and physiological disorders. The ethnomedical systems inwhich these illnesses are embedded do not recognize a mind–body distinction, andindeed see a fluid relationship between the physical body and its problems, themind, emotions, and the spiritual. If we really want to understand folk illnesses,we need to allow for the possibility that these categorizations of symptoms maycross over the neat lines that separate the psychiatric and the physiological inthe biomedical conceptualization. In the case ofnervios(andsustoas previouslydemonstrated by Rubel et al. 1984 and Baer and Penzell 1993), it appears that theethnomedical evidence supports a relationship betweennervios/sustoand physio-logical as well as psychological problems. Informants’ descriptions ofnerviosandsustosuggest a connection between nervious andsustoand diabetes in two of thepopulations studied. The testing of this and other reported relationships betweenfolk illnesses and biomedical diseases is clearly an important next step in ourunderstanding of the meaning and implications of these ethnomedical diagnoses.Biomedicine poorly understands illnesses that transcend the mind–body distinc-tion. Developing an understanding of the ethnomedical systems and diagnosesthat recognize and understand these connections may be important in augmentingthe biomedical understanding of the full dimensions and causes of human healthproblems.
To do so will require a broad and interdisciplinary approach. Due to the ef-forts of Guarnaccia and colleagues,nervioshas been included in large-scale men-tal health surveys. This has allowed an estimation of the prevalence ofnerviosand made possible comparisons between genders and social classes in the oc-currence ofnervios. These data are critical, as they supplement the descriptivecase reports ofnervios, which can only suggest possible factors related tonervios.For susto, however, there are no comparable epidemiological data. Given thatthere is considerable overlap betweennerviosandsusto, mental health surveysof Latinos should also includesusto(although it may or may not exist as anillness category in specific ethnic groups). The addition of a few questions thatrequest information onsustowould go far in providing population-based infor-mation on the prevalence ofsustoand its distribution across social classes andgenders.
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However, the reliance on mental health surveys for data onnervios haslimited 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 betweensustoand stress, depression, physio-logical symptoms, and mortality. They found that althoughsustois associatedwith psychological symptoms, it is also associated with physiological out-comes. The overlap betweensusto and nervios suggests that more needsto be understood about the relationship betweennervios and physiologicaloutcomes.
In conclusion, we see the need for collaboration between anthropologists andpsychiatric epidemiologists in the study ofnervios, susto, and other folk illnesses.Susto(and possibly other folk illnesses) needs to be included on mental healthsurveys;nervios(and possibly other folk illnesses) needs to be investigated in termsof its relationship to stress, depression, physiological symptoms, and mortality. Wecannot continue to assume the separation of the health problems of the mind andthe body when the evidence suggests that such a division may just be an artifactof our own creation, which obscures rather than illuminates the reality of patternsand 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.
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Roberta D. BaerDepartment of AnthropolotyUniversity of South FloridaTampa, FL 33620
Susan C. WellerDepartment of Preventive MedicineUniversity of Texas Medical BranchGalveston, TX 77555-1153
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESSNERVIOS337
Javier Garcia de Alba GarciaSocial Epidemiological and Health Services ResearchUnit of IMSS, and Hospital Civil of Guadalajara, J. I.Menchaca, GuadalajaraMexico
Mark GlazerUniversity of Texas Pan AmericanEdinburg, TX 78539-2997
Robert TrotterDepartment of AnthropologyNorthern Arizona UniversityFlagstaff, AZ 86011
Lee PachterDepartment of PediatricsUniversity of Connecticut School of MedicineSt. Francis Hospital and Medical CenterHartford, CT 06105
Robert E. KleinMedical Entomology Research Training Unit/Guatemala (MERTU/G)Centers for Disease Control and Prevention
