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ROBERTA D. BAER, SUSAN C. WELLER, JAVIER GARCIA DE ALBA GARCIA,
MARK GLAZER, ROBERT TROTTER, LEE PACHTER, AND ROBERT E. KLEIN
A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK
ILLNESS NERVIOS
ABSTRACT. To systematically study and document regional variations in descriptions ofnervios, we undertook a multisite comparative study of the illness among Puerto Ricans,Mexicans, Mexican Americans, and Guatemalans. We also conducted a parallel study onsusto (Weller et al. 2002, Culture, Medicine and Psychiatry 26(4): 449472), which allowsfor a systematic comparison of these illnesses across sites. The focus of this paper is
inter- and intracultural variations in descriptions in four Latino populations of the causes,symptoms, and treatments ofnervios, as well as similarities and differences between nerviosand susto in these same communities. We found agreement among all four samples on a coredescription of nervios, as well as some overlap in aspects of nervios and susto. However,nervios is a much broader illness, related more to continual stresses. In contrast, susto seemsto be related to a single stressful event.
KEY WORDS: Latino folk illnesses, nervios, susto
INTRODUCTION
Although there have been detailed descriptions of nervios from case reports and
from specific regions, few attempts have been made to compare descriptions of
the illness across cultures. Nervios is often glossed as nervousness or anxiety
(Trotter 1982), although it is not synonymous with formal definitions of anxiety,
nor is it generally recognized by biomedical practitioners. Low (1985) attempted to
compare published descriptions ofnervios in different populations, but found that
methodological differences in how individual studies were conducted made gen-
eralizations difficult. She suggested, however, that the similarity between nerviosand susto (a folk illness glossed as fright or shock) might mean that they were
both expressions of distress, but labeled differently by different segments of the
population. As such, unresolved issues include whether the term nervios means
the same thing in different cultural contexts, and the extent to which nervios and
susto represent similar or distinct illness entities.
Not simply part of the exotica of different cultures, folk illnesses have been
linked to morbidity and mortality. Susto is associated with an increased risk of co-
morbidities and a higher mortality rate (Baer and Bustillo 1993; Baer and Penzell
1993; Rubel et al. 1984) and nervios is now noted in the DSM-IV (AmericanPsychiatric Association 1994: Appendix 1). The study of these folk illnesses in
relation to physiological symptoms has not been for the purpose of reducing the
Culture, Medicine and Psychiatry 27: 315337, 2003.
C 2003 Kluwer Academic Publishers.
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316 ROBERTA D. BAER ET AL.
folk illnesses to their biomedical equivalents, but rather to understand the meaning
of these ethnomedical diagnoses for increasing risk of morbidity and mortality.
Since susto has been linked with increased morbidity (Baer and Penzell 1993) and
mortality (Rubel et al. 1984), if nervios and susto are really just different namesfor the same problem, nervios sufferers may similarly be at increased health risk.
This paper explores inter- and intracultural variations in descriptions of the
folk illness nervios. Four diverse Latino populations are studied: Puerto Ricans
in Hartford Connecticut, Mexican Americans in South Texas, Mexicans in
Guadalajara, Mexico, and Guatemalans in rural Guatemala. Since a first step is to
understand an illness in its cultural context (Guarnaccia and Rogler 1999:1322)
and then analyze its relationship to co-morbidity, this study first describes nervios
within each of the four populations. One aim is to see if there is a distinct description
of nervios that is shared by culture membersa community explanatory modelof the causes, symptoms, and treatments for nervios. A second aim is to compare
descriptions across the four diverse sites to see the extent to which descriptions are
similar and different in different cultural contexts. Finally, we compare detailed
findings for nervios with those for susto in order to determine if these two folk
illnesses are synonymous or distinct.
BACKGROUND
One problem in our understanding of nervios is that studies have used a variety
of terms for the problem, including nerves (Finkler 1989; Krieger 1989; Sluka
1989), nervousness (Camino 1989; Koss-Chioino 1989), and nervios (Barnett
1989; Finerman 1989; Kay and Portillo 1989; Low 1989). The literature indicates
that the label nervios covers a broad range of problems in the mental health
realm, from depression to schizophrenia (Jenkins 1988). In some cultures, the term
nervios may be preferred over the term mental illness, and may be interpreted
much more broadly (Baer 1996). The similarity between nervios and susto suggeststhat they may both be expressions of distress or stress, but the two different labels
may be used in different contexts (Low 1989).
Nervios has been studied in a variety of locations (including Latin America, the
Mediterranean, northern Europe, and the United States) (Davis and Low 1989).
But among some cultural groups, scholarship about nervios is less well developed
than for many of the other folk illnesses. This is particularly true for Mexican
and Mexican American populations (Trotter 1982). This pattern is curious, in that
Trotter (1982) found that in the lower Rio Grande Valley, nervios was the third
most frequent ailment reported (stomach ache and cough were first and second),and the most frequent folk illness.
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 317
The folk illness nervios is so widely reported across many contrasting regional,
linguistic, and demographic barriers that it defies description as a culture-bound
syndrome (Guarnaccia 1993). Nervios is consistently described as a culturally
approved reaction to overwhelmingly stressful experiences, especially concerninggrief, threat, and family conflict. However, it has been suggested that the way
the illness is experienced and conceptualized may vary across cultural groups
(Guarnaccia 1993).
Guarnaccia et al. (2003) have found that Puerto Ricans differentiate between
categories and experiences of nervios. Ser nervioso (being a nervous person) is
a result of traumatic experiences of suffering, and usually begins in childhood;
the condition lasts the rest of the persons life and results in more life problems.
Symptoms include unusual amounts of crying, headaches, stomach aches, and
increased anger and violence, particularly in men. Herbal teas and the help offamily members, priests and ministers, and psychologists and psychiatrists were
the recommended treatments. Padecer de los nervios (suffering from nerves) is
more of an illness, and is associated with depression, although the body is also
affected. Life problems, including marital difficulties, are seen as the cause, and it
usually develops in adulthood. This condition is considered to be a form of mental
illness, and the help of physicians, psychologists and psychiatrists is recommended.
Ataques de nervios (nervous attacks) occur as the result of a stressful event, often
in the family setting. Those who are nervous or suffer from nerves are more likely
to suffer from nervous attacks. Due to an event such as the news of the death of a
family member, the person becomes hysterical and out of control (Guarnaccia
et al. 2003). This problem is more common in women, although it can occur in
men as well.
In Guatemala, nervios is conceived of and treated as an illness rather than a
symptom, and, according to Low, is associated with experiencing strong emo-
tions, particularly anger and grief or sorrow, and with problems related to repro-
duction and child rearing (Low 1989:24). Women are significantly more likely to
report nervios than men, which suggests that the illness is related to gender-basedconcerns in general, and socially manifested expressions of strong emotions in
particular (Low 1989:24). There is also an ethnic dimension in the recognition
and reporting of nervios; most studies have focused on nonindigenous Spanish-
speaking populations (ladinos). Causality of nervios is attributed to anger, grief,
birth control pills, other illnesses, the birth of a child, anxiety, problems, susto, and
otherstressful occurrences (Low 1989:31). Reported symptoms include headaches,
despair, facial pain, trembling, and anger (Low 1989:29). Treatment most com-
monly comes in the form of nerve pills bought in local stores or alternative home
remedies (Low 1989: 24). Further, Low suggested that nervios might be the termused by more urban/ladino populations for what rural/indigenous people call susto
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 319
et al. 2002), which allowed for a systematic comparison of these illnesses across
sites.
METHODS
Data collection
Four Latino populations were sampled. In the United States, people were inter-
viewed in the Mexican American community of Edinburg, Texas, and the mainland
Puerto Rican community in Hartford, Connecticut. The other two research loca-
tions were the rural ladino community of Esquintla, Guatemala, and the urban
Mexican community of Guadalajara.
The Mexican American interviews were conducted in the lower Rio GrandeValley community of Edinburg, Texas. This region is among the poorest metropoli-
tan areas in the United States. Located 15 miles from the USMexico border, the
area, although a mixture of urban and rural, is predominantly agricultural. The
population is 80% Mexican American. Hartford, Connecticut, is a medium-sized
city in the northeast United States. While only about one-third of the citys pop-
ulation is Hispanic, children of Puerto Rican descent make up 47% of those in
the public school system. The interviews for this study were conducted in the
two census tracts that have the majority of the Puerto Rican population. The
Guatemalan interviews were conducted in the department of Esquintla, located
on the Pacific coast. This area is agricultural; primarily cotton and sugar cane
are grown. The population sample was Spanish-speaking ladinos in four rural
villages, each of which had a population of about five hundred. The Mexican
sample was drawn from the modern industrial city Guadalajara, which has a
population of approximately three million. Predominantly mestizo, residents of
Guadalajara are from both rural and urban backgrounds. In order to capture the
variation present in the city, three neighborhoods were sampled, one middle class,
one working class, and one poor; all of those interviewed were Spanish-speakingmestizos.
To ensure representative samples in each community, a two-stage random sam-
pling design was employed. First, a village, neighborhood, or census tract was
chosen, and then blocks and households were selected. The inclusion criteria were
that the respondent be an adult and recognize nervios as an illness entity (respon-
dents were asked simply if they had heard ofnervios). Additionally, in Edinburg,
respondents had to self-identify as being of Mexican descent, and in Connecticut
they had to self-identify as being of Puerto Rican descent. The preferred respon-
dent in each household was the female head of household, since we assumedthat women have more responsibility for health. Interviews were conducted by
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 321
TABLEI
Ne
rvios
WhoisSusceptible
Causes
Symptoms
Treatments
Esquintla,Guatemala(n=
20)
10Adults
6Porproblemasfamiliares
11Dolordecabeza
13Calmantes
6Tod
os
6Porenojarse
10Dolordemuelas
4Inyeccion(decalm
antes)
2Mu
jeres
5Porpeleasconlasesposas
8Dolordecara
2Aspririna
3Porcausasdeaccidentes
6Lemolestanlosruidos
2Pastilla
3Porfaltadevitaminas
5Enojos
11Farmacia
3Portenersusto
3Brincan
8Doctor
2Porrecibirnoticiaderepente
2Tiemblan
6Encasa
2Pleitosconloshijos
2Desesperacion
4Tiendas
2Porunaimpresion(seemociona)
2IGSS
11Semueren
2Sepuedetorcerla
boca
2Seempeoralaenfermadad
Guadalajara,Mexico(n=
20)
10A
lagentamassensibles
8Preocupaciones
10Corajudo
8Calamarse
5Debilesdecaracter
8Susto
12Depresion
9Homeremedies
5Adultos
6Problemasfamiliares
5Nervios
7Doctor
4Nin
os
3Corajes
3Manchas
6Medicine
2Las
amasdecasa
2Herencia
3Dolordecabeza
5Psychiatrist
2Atodotipodepersonas
2Avecesnosacanlospapasasushijos
3Grita
2Personasdeedad
adistraerse;estarplaticandoconlo
s
2Sensaciondeahogamiento
2Personassindistracciones
hijosyllevarlosapasear
2Perdidadeconocimiento
2Desesperacion
Edinburg,Texas(n=
20)
8Anyone
17
Tension;stress;worry
12Worried,startleeasily;jumpy
11Gotodoctor
510yearsandolder
2Gettingangry;overreacting
7Veryemotional;getsagitatedeasily
7GotoCurandera
4Peo
plewhoareweak
1Anevilspell
5Pacing,rushingaround
7Relax;rest
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322 ROBERTA D. BAER ET AL.
TABLEI
(Continued)
WhoisSusceptible
Causes
Symptoms
Treatmen
ts
3Peoplewhoworryconstantly
4Highbloodpressure
5Tea,herbaltea(m
anzanilla)
3Shaking;chills
4Counseling;therapy
2Desperate;uncomfortablefeeling
4Pills
2Nosleep
3Nocure
2Seethingsthatarenotthere
3Medicationfrom
doctor
2Rashes
2Tranquilizers
2Stomachhasgas
2Lossofappetite
2Tense
2Headache
Hartford,
Connecticut(n=
10)
3Adults
3Notcontagious
2Lossofcontrol(ofon
esnerves)
2Medication
2Everyone
1Beingoverwhelmedwithpro
blems
1Screaming
2Pillsprescribedb
ydoctor
1Peoplewithalotofstressintheirlives
1Problemsdealingwithlife
1Cryinghysterically
2Tranquilizers
who
areunabletocopewithproblems
1Depression
1Notaphysicalillness;moremental
1Bringtoadoctor
1Mainlywomen
1Anxiety
1Lotsofcryingandscreamingupon
1Therapy
1Weakpeoplewhotaketheirp
roblems
hearingbadnews,especiallyif
1Walking
tooseriously
someonedies
1Speakingtoanot
herperson
1Stress,problems
1Drinkingaguadeazahar
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 323
ideas in a group. Consistency among respondents answers is indicative of shared
knowledge.
Consensus analysis is conducted in a fashion somewhat analogous to factor
analysis. In factor analysis, the structure among a set of variables is described byclassifying items into groups or factors. A single factor solution indicates that all
of the items are related in some underlying way. Consensus analysis can be con-
ceptually thought of as a factor analysis of individuals in a sample, much like how
standard factor analysis groups individual items in a questionnaire. A single factor
solution indicates homogeneous responses among a single group of respondents,
i.e., consensus. In this study, consensus analysis is used to determine whether the
aggregate responses to the yes/no questions on the nervios questionnaire indicate
underlying group agreement (consensus) at each site and between sites regarding
the domain of study (nervios susceptibility, causes, symptoms, and treatments).Consensus analysis also provides an estimate of each respondents concordance
vis-a-vis the group (their cultural knowledge or competency score). The analysis
also provides a best estimate of the groups answers to the questionnaire items,
using a Bayesian posterior probability approach wherein the responses of individ-
uals are weighted based on their relative knowledge vis-a-vis other respondents in
the group. In this study a conservative Bayesian classification rule was used. Items
were classified at the p 0.999 confidence level.
As with most sample size requirements, sample size determination is a function
of variability. In consensus analysis, the variation is the amount of agreement
among the respondents. For dichotomous response data, using a moderate level of
competency or agreement (0.50), a high confidence level for classifying items as
true or false (0.999), and a high accuracy for questions to be correctly classified
(0.95), a minimum number of 29 respondents per site are required (Romney et al.
1986; Weller and Romney 1988). To be sure that we had sufficient individuals for
comparative purposes within samples, a sample size of about 40 was obtained at
each site.
RESULTS
The sample
The final sample consisted of 40 respondents in Connecticut, 41 in Texas, 38 in
Mexico, and 40 in Guatemala. Respondents were primarily women (100% in the
Mexican and Texas samples, 90% in Guatemala, and 87% in Connecticut). All
of the informants in the Mexican sample were born in Mexico, and all of the
informants in the Guatemalan sample were born in Guatemala. In the Connecticutsample, 90% were born in Puerto Rico; 70% of the interviews were conducted
in Spanish, 3% in English, and 28% in combined English and Spanish. In the
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TABLE II
Sample Demographics
Guatemala Mexico Texas Connecticut
Sample size 40 38 40 40
% female 90 100 100 87
Age in years (range) 42.9 (1783) 38.5 (2085) 42.2 (1881) 37.1 (2058)
Total children (range) 6.3 (014) 4.4 (016) 2.8 (17) 2.8 (012)
Household size (range) 5.4 (19) 5.7 (111) 3.8 (29) 4.1 (18)
Education in years (range) 1.8 (09) 5.5 (013) 11.2 (016) 10.3 (015)
Knows someone with nervios 95% 82% 90% 90%
Family member had nervios 88% 74% 71% 80%
Respondent had/has nervios 65% 63% 46% 52%
Texas sample, 95% of the respondents were born in the U.S., and 66% of the
interviews were in English, 7% in Spanish, and 27% in combined English and
Spanish. Respondents educational levels varied significantly between samples,
reflecting normative rates for each region: 1.8 years in Guatemala, 5.5 years in
Mexico, 11.2 years in Texas, and 10.3 years in Connecticut (Table II).
Actual experience with nervios varied somewhat by community. Most respon-
dents knew someone with nervios (95% in Guatemala, 90% in Connecticut and
Texas, and 82% in Mexico) and had experienced it in their family (88% Guatemala,
80% Connecticut, 74% Mexico, and 71% Texas). Of our respondents, about two-
thirds of those in Guatemala and Mexico had experienced nervios themselves;
46% of those in Texas and 52% of those in Connecticut also reported it.
Descriptions of nervios
Analysis of responses to the 125 items concerning the causes, symptoms, and
treatments for nervios revealed that a single, shared system of knowledge about
nervios exists for each sample of respondents. The cultural consensus model fits theresponse data (the eigenvalue ratios all exceeded the recommended 3:1 ratio: 9.85
in Connecticut, 8.81 in Texas, 6.51 in Mexico, and 5.48 in Guatemala). Responses
were the most homogeneous in the Texas and Connecticut samples, resulting in
the highest levels of sharing (the average cultural knowledge scores were 0.73
in Texas and 0.62 in Connecticut). The Mexican and Guatemalan samples also
exhibited shared ideas, although at a somewhat lower level (0.52 in Mexico and
0.43 in Guatemala). Analysis with all four samples together indicated that they
share a single description ofnervios, with about 52% of ideas in common (cultural
knowledge level = 0.52, eigenvalue ratio 6.45). A comparison of knowledge lev-els across samples indicated that there was a greater degree of shared responses
in Texas than in Connecticut, significantly greater sharing in Connecticut than
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 325
Mexico, and significantly greater sharing in Mexico than Guatemala (ANOVA
p 0.00005; Scheffe comparison p 0.005).
The distribution of cultural knowledge within each sample was more strongly
related to demographic characteristics than to personal experience. In Mexico,those with fewer children (r= 0.37, p = 0.02), fewer people in the household
(r= 0.32, p = 0.05), and a higher educational level (r= +0.29, p = 0.09)
knew more about nervios. Similarly, in Texas, households with fewer people in
them were associated with greater knowledge about nervios (r= 0.42, p =
0.01). In Guatemala, a larger household was associated with more knowledge
(r= +0.29, p = 0.07). Personal experience with nervios (knowing someone with
it or having had it) was associated with greater cultural knowledge, although
the associations were not significant. Greater cultural knowledge was corre-
lated with knowing someone with nervios (r= +0.22, p = 0.18 in Texas, andr= +0.29, p = 0.07 in Guatemala) or with having had it (r= +0.24, p = 0.13
in Connecticut). Responses were not different (p > 0.05) between men and women
in the Guatemalan and Connecticut samples, nor were responses different by lan-
guage preference in the Texas and Connecticut samples.
Although the four sites shared a common description ofnervios, there was some
variability, as illustrated by a more detailed comparison between the samples. The
highest agreement occurred between the Connecticut and Texas samples with 78%
identical answers, followed by 64% agreement between the Texas and Mexican
samples, and 57% agreement between the Mexican and Guatemalan samples.
Tables IIIVI show the questions about nervios that were classified using consensus
analysis by one or more of the samples as having the answer true or yes. Study
sites are indicated with a G for Guatemala, M for Mexico, T for Texas, or
C for Connecticut. Item classification is indicated with a Y for yes or true,
an N for no or false, and a hyphen (-) to indicate that the item could not
be classified as either true or false. We first discuss the findings for nervios and
then compare the findings with those for susto.
For susceptibility (Table III, columns 47), there was agreement among at leastthree of the samples on 10 of the 14 questions (71%), and among all four samples
on 6 of those questions (43%). Nervios is seen in adults and older people, and
though it can occur in anyone, it is more common in sensitive people. The four
sites also agreed that nervios is not a problem among men, and does not occur only
in families who believe in it. Three of the sites also answered that nervios was seen
mainly in women, but also occurs in older children, people with low resistance,
weak people and those of weak character.
For causes ofnervios (Table IV, columns 47), at least three samples agreed on
27 out of 31 (87%) of the questions, and all four samples agreed on 14 of thosequestions (45%). All four samples reported that not eating well, drinking too much,
and using drugs can cause nervios. In addition, a fright (susto) or shock (seeing
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TABLE III
Susceptibility
Susto Nervios
G M T G M T C
Y Y Y Y Y Y Y Adults get it
Y Y Y Y Y Y Y Old people get it
Y Y Y Y Y Y Anyone, regardless of age and gender/sex
Y Y Y Y Y Y Y More in sensitive people
N N N N N N N Mainly in men
N N N N N N Only in families who believe in it
Y N Y Y N Y Mainly in women
Y Y Y Y Y Y Older children
Y Y N Y Y N Y Mainly in weak people
Y Y N Y Y N Y More in people with a weak character
N Y N Y Y People with low resistance
Y Y Y N Y Y In young children
Y Y N Y N N Y In unborn children, if their mother has it
N N N Y N Y Relatives of someone with it more susceptible
Y N N A baby if breast feeding from a mother who has it
someone get killed or being in an accident) can cause nervios. Also important in
causality are strong emotions, anger, worry, family problems, and family fighting.
Nervios is not considered to be contagious. A relationship between susto and
nervios is evident, as susto was considered to be a cause of nervios. In addition,
several situations that are usually cited as producing sustoseeing someone killed,
seeing or being in an accident, or a surprise or shockwere also considered to
be causes of nervios. While the four sites agreed that a cause of nervios might
be not eating well (three sites also thought hunger could cause it), food stuck in
the stomach (usually associated with the folk illness empacho) was not considered
to be a cause of nervios. Three sites also agreed on a lack of hot/cold causality
ofnervios. There was also agreement among three sites that witchcraft was not acause ofnervios, but that the Devil might be.
For the symptoms ofnervios (Table V, columns 47), there was agreement across
at least three of the samples on 62% of the questions (24 out of 39 questions), and
among all four of the sites on 44% (17 out of 39) of the questions. Symptoms
agreed upon by all four sites included depression or sadness, a feeling of no hope
in life, crying, hysterical crying or crying attacks, and shaking or trembling. Other
symptoms agreed upon by all four sites were headache, a feeling of choking, cold
sweat, weight loss, bad temper, insomnia, and anger caused by small things. There
was also agreement that runny nose, fever, slow healing wounds, and a swollenstomach were not symptoms of nervios. Additional symptoms agreed upon by
three of the sites included lack of appetite, agitation, and convulsions or seizures.
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TABLE IV
Causes
Susto Nervios
G M T G M T C
N N N Y Y Y Y From not eating well
N N Y Y Y Y From drinking too much alcohol
N Y N Y Y Y Y By using drugs
Y Y Y Y Y Y Y Nervios causes susto/fright or susto causes nervios
Y Y Y Y Y Y Y By seeing someone get killed
Y Y Y Y Y Y Y By seeing or being in an accident
Y Y Y Y Y Y Y By a sudden surprise or shock
Y N Y Y Y Y By fighting (between spouses or with children)
Y Y Y Y By strong emotions (good or bad)
Y Y Y Y From anger
Y Y Y Y By worrying a lotY Y Y Y From family problems
N N Y Y N Y From living in a dirty house
N N N Y Y Y From hunger
Y Y N Y Y N Y By the devil
N Y Y N Y From low resistance
N N Y Y N By a hard, envious stare
N N N Y N N N From cold foods (or drinks)
N N N Y N N N By getting wet when you are sweating
Y N N Y N N N By being exposed to drafts/wind/air
N N N Y N N By parasites
Y N Y N N By spiritsN N N N N N N From food stuck in the stomach
N N N N N By witchcraft
N N N N N N N By using the utensils of someone who has it
For treatments (Table VI, columns 47), at least three of the samples agreed
on 73% (30 out of 41) of the questions, and all four samples agreed on 51% (21
out of 41) of the questions. For all four of the sites, over the counter remedies
(such as aspirin, Vicks, cod liver oil, Alka Seltzer), antibiotics, and treatmentsused for other folk illnesses (such as barrida, or sweeping with herbs, rubbing
with an egg, a spoonful of oil, pulling the skin of the body until it pops, or binding
the waist) were not indicated for use in the treatment of nervios, nor were the
services of the folk healers, curanderos, or spiritualists. Other treatments rejected
by all groups included spearmint tea, enemas, scaring the affected person, drinking
alcohol, warm towels on the body, and drinking milk. Sedatives, praying, and
trying to relax were the only suggested treatments agreed on by all four samples.
Additionally, three of the sites recommended the use of physicians andpsychiatrists
or psychologists, and rejected the use of holy water sprinkled on the body in theshape of a cross, as well as the use of a pharmacist, herbalist, wise old woman, or
grandmother. Three sites reported that nervios would go away by itself.
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TABLE V
Symptoms
Susto Nervios
G M T G M T C
Y Y Y Y Y Y Y Crying
Y Y Y Y Y Y Y Hysterical crying or crying attacks
Y Y Y Y Y Y Y Difficulty going to sleep and staying asleep
Y Y Y Y Y Y Y Frequent shaking or tembling
Y Y Y Y Sadness (and depression)
Y Y Y Y A feeling of no hope in life
Y Y Y Y Small things cause anger
Y Y Y Y A bad temper
Y N Y Y Y Y A headache
N Y Y Y Y A feeling of choking
Y Y Y Y Y Y A cold sweatY Y N Y Y Y Y Weight loss
Y Y N Y Y Y A lack of appetite
Y Y Y Y Y Y Agitation
Y Y N Y A convulsion or seizure
N Y Y N N Cloudy or blurred vision
N Y Y Y Difficulty breathing
N Y N Y Y Stomach pain or stomachache
N Y Y N N Y Y Vomiting
N Y Y N N Y Y Diarrhea
N N N Y Y Itching
Y Y Y Y Y N Paleness
N Y Y N Sleepiness
Y Y Y N Y Chills
Y Y N Y N Y N Muscle and body aches/pains
Y Y N Losing consciousness
N N Y N N Affected hearing (ringing or buzzing)
N Y N Y N Frequent urination
N N N N N Y Chest pain
Y N N Aching teeth
Y N N N Face pain
Differences between sites
There were, however, some interesting differences between the sites. Only
Guatemalans reported eating cold foods or getting wet while sweating or drafts as
causes ofnervios, and only they considered face pain to be a symptom and garlic
to be a treatment. It would appear that as far as nervios causality is concerned,
hotcold explanations are more important in Guatemala than at the other sites. An-
other distinctive pattern occurred in the Mexican and Guatemalan samples, whereuntreated nervios was reported to cause a person to become diabetic or the mouth
to become twisted and deformed.
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 329
TABLE VI
Treatments
Susto Nervios
G M T G M T C
N Y N Y Y Y Y Sedatives
Y Y Y Y Y Y Trying to relax (keep calm)
Y Y Y Y Y Y Y Praying
N Y Y Y Y Y Massages
N N N Y Y Y Doctor
Y N Y Y Y Psychiatrist or psychologist
N N N N N N Pharmacist
Y Y N N N N Herbalist
Y N N N N Wise old woman/grandmother
Y N N N N N Curandero
N Y N Y N Y Tea of orange leaves or orange blossom
Y Y N Y Y N N If not treated, person becomes diabetic
Y Y N N If not treated, mouth becomes deformed and twisted
N N N N N Y Camomile tea
N Y N N Vitamins
N N N Y N N N Garlic
N N Y N N Rubbing the back and chest with alcohol
Y Y Y Y N Treated at home
Y Y N Y N Go to church
N N Y N N Y N Go away by itself
Y Y N Y N If not treated, can one dieY N N N N Holy water on body in shape of a cross
Comparisons with Susto
The next issue we address is that of similarities and differences between nervios
and susto. We conducted another study similar to our investigations of nervios
exploring regional variations in beliefs about susto (Weller et al. 2002). The susto
study was originally planned for the same four sites where nervios was studied;however susto was not found to exist as an illness among the Puerto Rican pop-
ulation in Hartford, Connecticut. As a result, the discussion below compares the
results from the three sites that recognized both of these illnessesGuatemala,
Mexico, and Texas. The methodology used in both the susto and nervios studies
was the same; in fact, 85 of the questions used in the two studies were iden-
tical. While the actual respondents for the nervios and susto studies were not
identical, each sample was representative of the community from which it was
drawn.
Susceptibility is broader for susto than for nervios (Table III). Younger and olderchildren can suffer from susto, but this is not the case for nervios which seems to
be more of an adult problem.Nervios is felt to occur mainly in women, while susto
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330 ROBERTA D. BAER ET AL.
is not as closely linked to gender. While there is some overlap in causes of susto
and nervios (including seeing someone get killed, seeing or being in an accident,
and a sudden surprise or shock), susto seems more related to a particular incident
or accident. In contrast, causes of nervios are of a continual nature in ones life,and include family problems and fighting, drugs, alcohol, worry, anger, and strong
emotions (Table IV). Note, however, that susto can cause nervios and that nervios
can cause susto.
A similar pattern is seen with regard to symptoms of nervios and susto, with
overlap in symptoms such as crying, shaking, and difficulty sleeping (Table V).
However, there are many symptoms that are unique to each illness. Paleness may
be more restricted to susto, while headache, a feeling of choking, cold sweat, and
weight loss are associated more with nervios. Neither illness seems to manifest
solely with somatic symptoms. While praying is recommended for both sustoand nervios, the most striking difference between the two illnesses is the use
of Western versus folk treatments. While a doctor or psychologist or psychi-
atrist is recommended for nervios, they are not considered effective for susto
(Table VI). In fact, home treatment and folk healers are used more often for
susto.
Patterns of regional variation similar to those found for nervios also appear
for similarities and differences between susto and nervios. Only the Mexican and
Guatemalan samples report that weak people and people with a weak character
are more likely to get either illness (the Texas sample did not) and that the Devil
could cause both susto and nervios. Similarly, these two sites saw diabetes as a
possible outcome of both untreated susto and untreated nervios. Guatemala was
the only site to feel that drafts were a cause of these illnesses. Finally, only the
Texas sample reported that both nervios and susto would go away by themselves.
We also compared the differences between nervios and susto which emerged
from the analysis of the structured questionnaire data to those differences reported
in the initial open-ended interviews in Mexico. In those open-ended interviews,
respondents were asked about the similarities and differences between nerviosand susto. We found that both sets of interviews contained similar themes: susto is
considered to be briefer than nervios, and nervios is more chronic and is a continual
stress. Susto is caused by an identifiable eventa sustowhile nervios is caused
by persistent problems.
In summary, there is an overlap in many aspects of these two illnesses. Both
tend to occur more in adults; both are caused by surprising, shocking, or disturbing
occurrences. Both present with symptoms of distress; neither presents solely with
somatic symptoms. However, nervios is a much broader illness, related more to
continual stresses. In contrast, susto seems to be related to a single stressful event.There are a few broadly recommended treatments for nervios, while those for susto
show more regional variation.
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 331
DISCUSSION AND CONCLUSIONS
The core description of nervios agreed on by all four sites supports the patterns
reported in the literature for these individual populations. Nervios is felt to oc-cur more often in women. It is caused by emotion and interpersonal problems; its
symptoms are primarily nonsomatic. Interestingly, although treatment by psychol-
ogists and doctors is recommended, the most broadly recommended treatment is
neither biomedical nor folk, but spiritual, i.e., praying. However, at all four sites,
nervios covered a broad range of mental health conditions. It would seem of great
importance for mental health professionals working with these populations to un-
derstand the way the term nervios is used and the types of conditions it covers.
It should be noted, however, that the literature suggests that nervios may not be
considered a mental illness by these populations (Baer 1996).Almost everyone approached to be interviewed for this study considered nervios
to be an illness. Thus, there is an interesting contrast in prevalence between nervios
and other common Latino folk illnesses. We have carried out parallel studies to
those described here for susto and nervios for the folk illnesses caida de la mollera
(fallen fontanelle) and mal de ojo (evil eye) (Weller 1997; Weller and Baer 2001).
These studies indicated that in the Mexican sample, in which 100% of respondents
considered nervios to be an illness, recognition of susto was 87%, caida de la
mollera 85%, and for mal de ojo only 63% However, recognition ofsusto, mal de
ojo, and caida de la mollera varied by social class. Recognition was highest in the
lower class, intermediate in the working class, and lowest in the middle class. But
unlike other folk illnesses, recognition ofnervios in Mexico was not class related.
Similarly, we found no meaningful variation in relevant themes for nervios by
degree of acculturation. In the Texas and Connecticut samples, a very crude index
of acculturation canbe estimatedby birthplace and language preference. Responses
did not differ significantly on either of these variables.
Nervios and susto are distinct entities. While it has been suggested in the liter-
ature that nervios may be the illness of choice among ladinos (Low 1989:133)for expressing stress or distress, our data do not totally support this hypothesis.
Among the ladino/mestizo populations we studied, susto is also an illness category,
and it can be distinguished from nervios. The two illnesses appear to overlap, but
nervios is a much broader illness and is widely recognized. People in the same
communities recognize both illnesses, and nervios appears to transcend social
class. Specific research would be necessary with indigenous groups to determine
whether the same pattern holds in those populations. However, in Mexico it ap-
pears that the recognition ofsusto as an illness, unlike that ofnervios, may be class
related.Recognition of susto also varies by region. It is also important to note that
although nervios was considered to be an illness at all four sites, susto was not
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332 ROBERTA D. BAER ET AL.
recognized as an illness by Puerto Ricans in Connecticut. During the initial stages
of this project (when descriptive, open ended interviews were conducted to elicit
individual explanatory models), Puerto Rican respondents indicated that they con-
sidered susto to be a symptom, a feeling, but not an illness.Finally, at least for the Mexican and Guatemalan populations, nervios (and susto;
Weller et al. 2002) is implicated in the causality of diabetes. While diabetes is not
a great problem at this time in Guatemala, possibly due to widespread malnutrition
(which reduces the prevalence of obesity), this is not the situation in Mexico. In
Mexico, the diabetic mortality rate for people older than 65 is several times greater
than that in the United States (PAHO 1986). Both nervios and susto need further
study exploring their possible relation to diabetes.
This study demonstrates the usefulness of cross-cultural research on nervios
and of a systematic comparison with susto. We determined a core description ofnervios as well as similarities and differences in that definition among the four
Latino groups studied. The relationship to susto has been clarified, and a link to
diabetes for at least two of the populations studied is suggested as an important
area for further research. While the samples at each site were representative of
the variability in each of those populations, the results cannot be generalized
to, for example, all of Mexico from the Guadalajara sample, or to all Mexican
Americans from the south Texas sample. The similarity in findings across such
diverse samples, however, suggests that the findings would apply to many more
regions than those actually sampled. Because such strong similarities were found
in descriptions from places ranging from rural Guatemala to urban Connecticut,
it is likely that those same themes would be important to Latinos in regions other
than those sampled for this study.
Our approach also demonstrates a number of important directions for the future
study of these conditions. First, this study ofnervios demonstrates a way to study
ethnomedical phenomena in their cultural contexts that also allows for cross-
cultural comparisons. In this research, we used free listing to elicit the explanatory
model (Kleinman et al. 1978) of nervios in each population being studied. Next,we developed a structured interview (a yesno questionnaire) that incorporated
themes from each communitys explanatory model (as well as other items, some
of which had biomedical origin). From this, we were able to determine which
aspects of explanatory models were shared and which were distinct. Our two-step
approach, which incorporated themes from all sites in the interviews, allowed us
to verify whether or not themes mentioned in the open-ended interviews were
important within a community and across communities. The advantage of the
structured interviews was that themes that were mentioned at one particular site
but not at another could also be confirmed. Reliance on the open-ended interviewsalone may have missed some themes relevant across sites. We were also able to
determine similarities and differences between nervios and another folk illness,
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A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK ILLNESS NERVIOS 333
susto. We therefore suggest such an approach as important and appropriate for
cross-cultural ethnomedical research.
We also feel that our approach extends that of Guarnaccia and Rogler (1999).
While they emphasize the importance of describing folk illnesses within their cul-tural contexts, they particularly stress the need for anthropologists to determine
how these illnesses are related to psychiatric disorders (Guarnaccia and Rogler
1999). Our work expands the relationship to include both mental and physical
disorders. In doing so we stress the importance of questioning the mindbody di-
vision of Western culturesand of biomedicinewhich discounts the relationship
between folk illnesses and physiological disorders. The ethnomedical systems in
which these illnesses are embedded do not recognize a mindbody distinction, and
indeed see a fluid relationship between the physical body and its problems, the
mind, emotions, and the spiritual. If we really want to understand folk illnesses,we need to allow for the possibility that these categorizations of symptoms may
cross over the neat lines that separate the psychiatric and the physiological in
the biomedical conceptualization. In the case of nervios (and susto as previously
demonstrated by Rubel et al. 1984 and Baer and Penzell 1993), it appears that the
ethnomedical evidence supports a relationship between nervios/susto and physio-
logical as well as psychological problems. Informants descriptions ofnervios and
susto suggest a connection between nervious and susto and diabetes in two of the
populations studied. The testing of this and other reported relationships between
folk illnesses and biomedical diseases is clearly an important next step in our
understanding of the meaning and implications of these ethnomedical diagnoses.
Biomedicine poorly understands illnesses that transcend the mindbody distinc-
tion. Developing an understanding of the ethnomedical systems and diagnoses
that recognize and understand these connections may be important in augmenting
the biomedical understanding of the full dimensions and causes of human health
problems.
To do so will require a broad and interdisciplinary approach. Due to the ef-
forts of Guarnaccia and colleagues, nervios has been included in large-scale men-tal health surveys. This has allowed an estimation of the prevalence of nervios
and made possible comparisons between genders and social classes in the oc-
currence of nervios. These data are critical, as they supplement the descriptive
case reports ofnervios, which can only suggest possible factors related to nervios.
For susto, however, there are no comparable epidemiological data. Given that
there is considerable overlap between nervios and susto, mental health surveys
of Latinos should also include susto (although it may or may not exist as an
illness category in specific ethnic groups). The addition of a few questions that
request information on susto would go far in providing population-based infor-mation on the prevalence of susto and its distribution across social classes and
genders.
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334 ROBERTA D. BAER ET AL.
However, the reliance on mental health surveys for data on nervios has
limited the type of information that is available on that illness. In contrast,
for susto there has been an explicit exploration by Rubel and colleagues
(1984) of the possible relation between susto and stress, depression, physio-logical symptoms, and mortality. They found that although susto is associated
with psychological symptoms, it is also associated with physiological out-
comes. The overlap between susto and nervios suggests that more needs
to be understood about the relationship between nervios and physiological
outcomes.
In conclusion, we see the need for collaboration between anthropologists and
psychiatric epidemiologists in the study ofnervios, susto, and other folk illnesses.
Susto (and possibly other folk illnesses) needs to be included on mental health
surveys; nervios (and possibly other folk illnesses) needs to be investigated in termsof its relationship to stress, depression, physiological symptoms, and mortality. We
cannot continue to assume the separation of the health problems of the mind and
the body when the evidence suggests that such a division may just be an artifact
of our own creation, which obscures rather than illuminates the reality of patterns
and causality of human illnesses.
ACKNOWLEDGMENTS
This project was funded by the National Science Foundation grants BNS-9204555,
SBR-9727322, and BC-0108232 to S. Weller, and SBR-9807373 and BCS-
0108228 to R. Baer.
NOTES
1. The final questionnaire is available from the authors RDB or SCW upon request.
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Roberta D. Baer
Department of Anthropoloty
University of South FloridaTampa, FL 33620
Susan C. Weller
Department of Preventive Medicine
University of Texas Medical Branch
Galveston, TX 77555-1153
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