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 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 generalizations 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 comorbidities 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.

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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 names for 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 members—a community explanatory model of 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 suggests that 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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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 concerning grief, 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 person’s 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 of family 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 emotions, particularly anger and grief or sorrow, and with problems related to reproduction 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-based concerns 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 Spanishspeaking populations (ladinos). Causality of nervios is attributed to anger, grief, birth control pills, other illnesses, the birth of a child, anxiety, problems, susto, and other stressful occurrences (Low 1989:31). Reported symptoms include headaches, despair, facial pain, trembling, and anger (Low 1989:29). Treatment most commonly 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 term used by more urban/ladino populations for what rural/indigenous people call susto

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(Low 1985) and may reaffirm an “urban, upwardly mobile Ladino identity” (Low 1989:133). In Mexico, as in Guatemala, there is a higher prevalence of nervios among females; this is attributed to their inferior social position (Finkler 1991:43). This is further illustrated by reports that nervios is associated with stressed, harassed, abused, and/or neglected women in rural Mexico (Davis and Low 1989; Salgado de Snyder et al. 2000). In Mexican populations, nervios is simultaneously an explanation of illness, a symptom of illness, and a state of illness. However, those suffering from the symptoms of nervios report a wide variety of symptoms, including feelings of desperation, headaches, chest pains, abdominal pains, high and low blood pressure, and various familial, social, political, and economic concerns (Finkler 1989; Salgado de Snyder et al. 2000). Patterns of treatment in Mexico include home remedies, especially herbal teas, frequently used in combination with physician-prescribed medications (Finkler 1989). Among Mexican Americans, Jenkins (1988) found that the term nervios is used to cover everyday problems causing distress, serious family conflict, as well as schizophrenia. Symptoms associated with nervios included irritability, hopelessness, nervousness, depression, physical effects, and difficulty in functioning in social or occupational roles. For Mexican and Mexican American farm workers in Florida, nervios was the label that covered many conditions considered biomedically to be mental illnesses. However, nervios was not considered to be a mental illness by the farm workers (Baer 1996). Causes of nervios included money, food and work problems, and accidents; treatments suggested were talking to someone about the problems or getting medical or psychiatric help. Among Mexican Americans, nervios has been reported as being more common in women (Jenkins 1988). In a study of widows, Kay and Portillo (1989) found that the more bicultural a woman was, the less she was troubled by nervios. Both somatic and nonsomatic symptoms were reported, but it was primarily the nonsomatic symptoms (fear, worry, anguish, anger, separation sorrow, loneliness, disorientation, feeling empty, confusion, and a feeling of being in the way) that distinguished nervios. Although these findings suggest similarities among these populations in their definitions of nervios, each study used a somewhat different approach and research instrument that limits our ability to tell how similar nervios is among diverse Latino populations. To systematically study and document regional variations in descriptions of nervios, we undertook a multisite comparative study of nervios. Using four distinct geographic and cultural locations, we examined descriptions of nervios to see the degree to which individuals within a community reported similar causes, symptoms, and treatments for nervios, and then compared descriptions across sites. We also conducted a parallel study on susto (Weller

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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 interviewed in the Mexican American community of Edinburg, Texas, and the mainland Puerto Rican community in Hartford, Connecticut. The other two research locations 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 Grande Valley community of Edinburg, Texas. This region is among the poorest metropolitan areas in the United States. Located 15 miles from the US–Mexico 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 city’s population 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-speaking mestizos. To ensure representative samples in each community, a two-stage random sampling 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 (respondents were asked simply if they ‘had heard of nervios’). 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 respondent in each household was the female head of household, since we assumed that women have more responsibility for health. Interviews were conducted by

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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 sites were used to develop the questionnaire. We focused on the term nervios, which is recognized in all of the cultures studied, as opposed to the more extensive variants of the condition seen among Puerto Ricans (Guarnaccia et al. 2003). Using open-ended interviews and free listing techniques (Weller and Romney 1988), qualitative data were gathered on the explanatory model of nervios, including perceived causes, symptoms, and treatments of nervios (Table I). In Mexico, respondents were also asked about similarities and differences between nervios and susto. On the basis of the open-ended interviews (any response mentioned by at least 10% of the sample), symptoms from the Cornell Medical Index, and the anthropological literature, a true-false questionnaire was developed. The final questionnaire1 contained 125 items addressing the causes, symptoms, and treatments for nervios. The questionnaire also included basic demographic data on the respondent, as well as questions about experiences with nervios. Finally the questionnaire was translated into the form of Spanish (or English) spoken at each particular site being studied. Data analysis Our goal was to determine the descriptions of nervios in the four Latino groups as well as the degree of similarity and difference among the groups. This was accomplished with a type of data analysis called consensus analysis. Given a set of related, closed-ended questions, a consensus analysis accomplishes three things. First, it provides an assessment of the agreement among respondents to see if there is sufficient agreement to warrant aggregating responses. Then, if there is sufficient agreement, it provides estimates of how well each person’s responses correspond to the “group ideas.” Third, it provides estimates of the answers to the set of questions. A consensus analysis is an analytic tool that allows one to determine whether there is group agreement—or consensus—in responses to structured questions. Identifying or creating a reliable description of community explanatory models includes an assessment of variability of ideas. If variability is high—that is, if respondents 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 aggregation of responses. If, however, informants report similar or identical information, then one is justified in pooling the information to create an overall description of

17 Tension; stress; worry 2 Getting angry; overreacting 1 An evil spell

Edinburg, Texas (n = 20) 8 Anyone 5 10 years and older 4 People who are weak

12 Worried, startle easily; jumpy 7 Very emotional; gets agitated easily 5 Pacing, rushing around

10 Corajudo 12 Depresion 5 Nervios 3 Manchas 3 Dolor de cabeza 3 Grita 2 Sensacion de ahogamiento 2 Perdida de conocimiento 2 Desesperacion

11 Dolor de cabeza 10 Dolor de muelas 8 Dolor de cara 6 Le molestan los ruidos 5 Enojos 3 Brincan 2 Tiemblan 2 Desesperacion

Symptoms

11 Go to doctor 7 Go to Curandera 7 Relax; rest

8 Calamarse 9 Home remedies 7 Doctor 6 Medicine 5 Psychiatrist

13 Calmantes 4 Inyeccion (de calmantes) 2 Aspririna 2 Pastilla 11 Farmacia 8 Doctor 6 En casa 4 Tiendas 2 IGSS 11 Se mueren 2 Se puede torcer la boca 2 Se empeora la enfermadad

Treatments

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8 Preocupaciones 8 Susto 6 Problemas familiares 3 Corajes 2 Herencia 2 A veces no sacan los papas a sus hijos a distraerse; estar platicando con los hijos y llevarlos a pasear

6 Por problemas familiares 6 Por enojarse 5 Por peleas con las esposas 3 Por causas de accidentes 3 Por falta de vitaminas 3 Por tener susto 2 Por recibir noticia de repente 2 Pleitos con los hijos 2 Por una impresion (se emociona)

Causes

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Guadalajara, Mexico (n = 20) 10 A la genta mas sensibles 5 Debiles de caracter 5 Adultos 4 Ninos 2 Las amas de casa 2 A todo tipo de personas 2 Personas de edad 2 Personas sin distracciones

Esquintla, Guatemala (n = 20) 10 Adults 6 Todos 2 Mujeres

Who is Susceptible

Nervios

TABLE I

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3 Not contagious 1 Being overwhelmed with problems 1 Problems dealing with life 1 Depression 1 Anxiety 1 Weak people who take their problems too seriously 1 Stress, problems

Causes

322 2 Medication 2 Pills prescribed by doctor 2 Tranquilizers 1 Bring to a doctor 1 Therapy 1 Walking 1 Speaking to another person 1 Drinking agua de azahar

5 Tea, herbal tea (manzanilla) 4 Counseling; therapy 4 Pills 3 No cure 3 Medication from doctor 2 Tranquilizers

Treatments

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2 Loss of control (of one’s nerves) 1 Screaming 1 Crying hysterically 1 Not a physical illness; more mental 1 Lots of crying and screaming upon hearing bad news, especially if someone dies

4 High blood pressure 3 Shaking; chills 2 Desperate; uncomfortable feeling 2 No sleep 2 See things that are not there 2 Rashes 2 Stomach has gas 2 Loss of appetite 2 Tense 2 Headache

Symptoms

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Hartford, Connecticut (n = 10) 3 Adults 2 Everyone 1 People with a lot of stress in their lives who are unable to cope with problems 1 Mainly women

3 People who worry constantly

Who is Susceptible

TABLE I (Continued)

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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 by classifying 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 conceptually 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 respondent’s concordance vis-`a-vis the group (their cultural knowledge or “competency” score). The analysis also provides a best estimate of the group’s answers to the questionnaire items, using a Bayesian posterior probability approach wherein the responses of individuals 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 Connecticut sample, 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

Sample size % female Age in years (range) Total children (range) Household size (range) Education in years (range) Knows someone with nervios Family member had nervios Respondent had/has nervios

Guatemala

Mexico

Texas

Connecticut

40 90 42.9 (17–83) 6.3 (0–14) 5.4 (1–9) 1.8 (0–9) 95% 88% 65%

38 100 38.5 (20–85) 4.4 (0–16) 5.7 (1–11) 5.5 (0–13) 82% 74% 63%

40 100 42.2 (18–81) 2.8 (1–7) 3.8 (2–9) 11.2 (0–16) 90% 71% 46%

40 87 37.1 (20–58) 2.8 (0–12) 4.1 (1–8) 10.3 (0–15) 90% 80% 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 respondents 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 twothirds 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 the response 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 of nervios, with about 52% of ideas in common (cultural knowledge level = 0.52, eigenvalue ratio 6.45). A comparison of knowledge levels 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 correlated with knowing someone with nervios (r = +0.22, p = 0.18 in Texas, and r = +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 language preference in the Texas and Connecticut samples. Although the four sites shared a common description of nervios, 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 III–VI 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 4–7), there was agreement among at least three 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 of nervios (Table IV, columns 4–7), at least three samples agreed on 27 out of 31 (87%) of the questions, and all four samples agreed on 14 of those questions (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 GMT

Nervios GMTC

YYY YYY – YY YYY NNN N –N

YYYY YYYY YYYY YYYY NNNN NNNN

Adults get it Old people get it Anyone, regardless of age and gender/sex More in sensitive people Mainly in men Only in families who believe in it

– YN YYY YYN YYN – –N

YYNY – YYY YYNY YYNY YNYY

Mainly in women Older children Mainly in weak people More in people with a weak character People with low resistance

YYY YYN N –N

N–YY YNNY NYNY

In young children In unborn children, if their mother has it Relatives of someone with it more susceptible

Y–NN

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 susto—seeing someone killed, seeing or being in an accident, or a surprise or shock—were 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 of nervios. There was also agreement among three sites that witchcraft was not a cause of nervios, but that the Devil might be. For the symptoms of nervios (Table V, columns 4–7), 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 swollen stomach 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 GMT

Nervios GMTC

NNN N–N NYN YYY YYY YYY YYY –YN

YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY

From not eating well From drinking too much alcohol By using drugs Nervios causes susto/fright or susto causes nervios By seeing someone get killed By seeing or being in an accident By a sudden surprise or shock By fighting (between spouses or with children) By strong emotions (good or bad) From anger By worrying a lot From family problems

N–N NNN YYN ––N N–N NNN NNN YNN NNN –YN NNN N–N NNN

YYNY –YYY YYNY YYNY Y–YN YNNN YNNN YNNN Y–NN –YNN NNNN –NNN NNNN

From living in a dirty house From hunger By the devil From low resistance By a hard, envious stare From cold foods (or drinks) By getting wet when you are sweating By being exposed to drafts/wind/air By parasites By spirits From food stuck in the stomach By witchcraft By using the utensils of someone who has it

For treatments (Table VI, columns 4–7), 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 treatments used 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 and psychiatrists or psychologists, and rejected the use of holy water sprinkled on the body in the shape 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 GMT

Nervios GMTC

YYY YYY YYY YYY

YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY YYYY

Crying Hysterical crying or crying attacks Difficulty going to sleep and staying asleep Frequent shaking or tembling Sadness (and depression) A feeling of no hope in life Small things cause anger A bad temper A headache A feeling of choking A cold sweat Weight loss

YYN YYY

Y–YY Y–YY YYNY

A lack of appetite Agitation A convulsion or seizure

––N N–Y N–Y NYY NYY NNN YYY ––N Y–Y YYN

YYNN ––YY N–YY NNYY NNYY Y–Y– –YYN Y–YN YNY– YNYN Y–YN

Cloudy or blurred vision Difficulty breathing Stomach pain or stomachache Vomiting Diarrhea Itching Paleness Sleepiness Chills Muscle and body aches/pains Losing consciousness

–NN N–Y NNN

Y–NN NY–N –NNY Y–NN YNNN

Affected hearing (ringing or buzzing) Frequent urination Chest pain Aching teeth Face pain

Y–N N–– –YY YYN

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 of nervios, 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, hot–cold explanations are more important in Guatemala than at the other sites. Another distinctive pattern occurred in the Mexican and Guatemalan samples, where untreated 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 GMT

Nervios GMTC

NYN –YY YYY

YYYY YYYY YYYY

Sedatives Trying to relax (keep calm) Praying

NYY NNN –YN NNN YYN Y–N YN–

–YYY Y–YY YY–Y –NNN –NNN –NNN NNNN

Massages Doctor Psychiatrist or psychologist Pharmacist Herbalist Wise old woman/grandmother Curandero

NYN YYN

–YNY YYNN YYNN

Tea of orange leaves or orange blossom If not treated, person becomes diabetic If not treated, mouth becomes deformed and twisted

NNN ––N NNN N–N YYY YYN NNY YYN Y–N

N–NY Y–NN YNNN –YNN –YN– –YN– NNYN Y–N– N–NN

Camomile tea Vitamins Garlic Rubbing the back and chest with alcohol Treated at home Go to church Go away by itself If not treated, can one die 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 population in Hartford, Connecticut. As a result, the discussion below compares the results from the three sites that recognized both of these illnesses—Guatemala, 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 identical. 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 older children 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 one’s 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 susto and nervios, the most striking difference between the two illnesses is the use of Western versus folk treatments. While a doctor or psychologist or psychiatrist 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 nervios and 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 event—a “susto”—while 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 occur more often in women. It is caused by emotion and interpersonal problems; its symptoms are primarily nonsomatic. Interestingly, although treatment by psychologists 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 understand 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 of susto, 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 of nervios 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 can be estimated by 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 literature 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 appears that the recognition of susto as an illness, unlike that of nervios, 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 considered 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 of nervios 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 of nervios demonstrates a way to study ethnomedical phenomena in their cultural contexts that also allows for crosscultural 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 yes–no questionnaire) that incorporated themes from each community’s 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 interviews alone 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 cultural 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 mind–body division of Western cultures—and of biomedicine—which discounts the relationship between folk illnesses and physiological disorders. The ethnomedical systems in which these illnesses are embedded do not recognize a mind–body 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 physiological as well as psychological problems. Informants’ descriptions of nervios 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 mind–body distinction. 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 efforts of Guarnaccia and colleagues, nervios has been included in large-scale mental health surveys. This has allowed an estimation of the prevalence of nervios and made possible comparisons between genders and social classes in the occurrence of nervios. These data are critical, as they supplement the descriptive case reports of nervios, 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 information 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, physiological symptoms, and mortality. They found that although susto is associated with psychological symptoms, it is also associated with physiological outcomes. 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 of nervios, 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 terms of 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 BCS0108228 to R. Baer.

NOTES

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

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Roberta D. Baer Department of Anthropoloty University of South Florida Tampa, FL 33620 Susan C. Weller Department of Preventive Medicine University of Texas Medical Branch Galveston, TX 77555-1153

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Javier Garcia de Alba Garcia Social Epidemiological and Health Services Research Unit of IMSS, and Hospital Civil of Guadalajara, J. I. Menchaca, Guadalajara Mexico Mark Glazer University of Texas Pan American Edinburg, TX 78539-2997 Robert Trotter Department of Anthropology Northern Arizona University Flagstaff, AZ 86011 Lee Pachter Department of Pediatrics University of Connecticut School of Medicine St. Francis Hospital and Medical Center Hartford, CT 06105 Robert E. Klein Medical Entomology Research Training Unit/Guatemala (MERTU/G) Centers for Disease Control and Prevention

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