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Melissa Chan
Professor Deepa Rao
GH 456, Section B
Final Paper
June 3, 2016

Culturally-Distinct but Not Culturally-Bound: Grisi Siknis in Nicaragua

Introduction

In 2003, the Commission of Health for Regional Advice declared a state of epidemic

crisis in Nicaraguas northeastern states.1 The small village of Raiti, remotely located near the

Rio Coco river along the Nicaragua-Honduras border was suffering one of the largest and most

violent outbreaks of grisi siknis to date. 1 Almost 140 villagers were affected. 1 The medical team

could find no evidence of pathogens or drugs in the communitys blood samples or drinking

water, and the phenomena was spreading rapidly to other villages. 1 Desperate to contain the

outbreak, the Commission asked the Institute of Traditional Medicine for assistance (Wedel

2012, 307). A traditional curandero healer was sent, and within one week every patient was

cured. 1

Grisi sikinis translates to crazy sickness. 1 Dr. Philip Dennis, an anthropologist at Texas

Tech University, spent two years in the 1970s studying the condition and describes it as a

dramatic culture-bound syndrome affecting the Miskito people of northeastern Nicaragua. 2

Symptoms are characterized by convulsions and loss of consciousness, followed by frightening

visions of spirits that often cause victims to act out violently towards themselves and others in a

trance-like state. 1 Additionally, the condition usually affects small groups of young women from

remote or disadvantaged neighborhoods, and is highly contagious. 1

Documented cases of grisi siknis date back to the 1800s, but outbreaks in the last decade

have exhibited more extreme violence, spread faster, and affected a broader demographic. 1 The
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2003 Raiti outbreak demonstrated the syndromes unresponsiveness to Western medical

interventions, and it has therefore become a regional health concern. 1 However, in light of this,

further studies of the conditions epidemiology have begun to question grisi siknis as a solely

Miskito, culturally-bound syndrome. Dr. Johan Wedel, an anthropologist at the University of

Gothenburg, posits that although the condition seems to be cured only by culturally-specific

methods, the victims circumstances, environments, and demographics reveal cross-cultural

comparisons. 1 Wedel suggests that grisi siknis is really just the Miskito form of involuntary

mass spirit possession, a multi-symptomatic syndrome found in many other cultures.

The goal of this paper is to review current research on grisi siknis and its modern idioms

of distress within the socioeconomic contexts of recent major outbreaks. This will enable a

holistic comparison of grisi siknis with the cross-cultural disorder involuntary mass spirit

possession in order to assess whether grisi siknis can be considered merely a Miskito form of it.

Finally, the conclusion of this paper will serve to suggest preventative measures that take into

account the socioeconomic contexts of vulnerable populations, as well as promote therapeutic

dualism through an alliance between the traditional and medical ontologies.

Modern Idioms of Distress

In addition to the generalized progression from convulsions and loss of consciousness to

visions and violence, victims of grisi siknis also report initial feelings of anxiety, irritation, and

dizziness before the onset of the attack. 1 The visions are often characterized by spirits

threatening the victim with bloody weapons while trying to abduct them. 1 But particularly when

the victim is an adolescent girl, she will usually describe a dream of being raped by the devil. 1

During the subsequent trance-like state, reports depict victims running around with machetes to
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destroy property, and some later claim that a sorcerer magically introduced stones, insects, or

small pieces of metal into their bodies. 1 Following each episode, victims usually have amnesia

about the entire ordeal. 1

These idioms of distress are largely focused around broader themes of anxiety and

mysticism. Looking at the demographics and socioeconomic circumstances around outbreaks,

investigators believe that these idioms are rooted in traditional Miskito culture and historical

conflicts.

Factors from Miskito Culture and Religion

The Miskito are considered a colonial tribe because their existence as a distinct ethnic

group came about in the mid 17th century from contact between indigenous populations, British

settlers, and African slaves on the Atlantic coast. 3 Strong ties with the British resulted in an

amalgamation of indigenous and Moravian Protestant ideologies that make up the modern

Miskito religion. 1

Even today, the Miskito people are very connected to their spirit world, which includes

both animistic deities and human sorcerers. 1 Both reverence for and fear of these spirits is

instilled from an early age through childrens stories about how the spirits work to protect the

land and punish humans for bad deeds. 1 Consequently, the Miskito believe that illness is caused

by angry spirits or human sorcerers with evil intentions. 1 The strength of their connection to this

cultural cosmology may underscore the intense spiritual focus of the grisi siknis visions, as well

as help explain why only traditional healing methods involving spiritual rituals seem to provide

relief.
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Additionally, several theories about sociocultural factors contributing to the

symptomology of grisi siknis were developed considering how the original scope of the

outbreaks affected small groups of young females. After spending two years studying Miskito

culture, Philip Dennis observed that strong expressions of emotion and displays of emotional

behavior are commonplace in everyday interactions. 1 In a culture where hysterical behavioris

a normal way to express frustration and stress, Dennis proposed that grisi siknis is a culturally

derived form of extreme emotional expressiveness. 1 Building off of this, Mark Jamieson, an

anthropologist at Durham University, proposed a theory to explain the disproportionate number

of adolescent females affected. He described grisi siknis as a manifestation of frustration at the

cultural sentiments around a girls transition into womanhood. 4 Young girls, or tiara, grow up

under strong attitudes of protection and repression, which translate into conflicting behavioral

expectations during adolescence. 4 Marriage and childbirth are the pillars of adulthood for

women and grant them acceptance as full members of society. 4 During their courtship years,

tiara are expected to be sexually continent and demonstrate shame until a suitable groom is

foundhowever, they are [also] expected to use their sexual skills to secure husbands of whom

their parents approve. 4 This along with strict courtship customs results in an extremely stressful

and pressured time period within a culture that is comfortable with expressions of emotional

outlets. Jamieson therefore suggests that grisi siknis is a tiaras expression of anxieties towards

entering womanhood, brought about by a culture-specific constellation of representations and

beliefs around sexual maturation. 4

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Historical Incidents, Societal Contexts, and Recent Developments

While the Dennis and Jamieson theories consider how core aspects of Miskito culture and

ideology contribute to the grisi siknis phenomenon, the focus of their studies on early outbreaks

and the young women affected does not explain the change in characteristics of more recent

incidents. As in the 2003 Raiti outbreak, both women and men of all ages were affected, the

spread was not isolated to that one village, and the behavior of the victims was reportedly more

violent than previous descriptions. 1 In response to this, Johan Wedel suggests that an extended

analysis of Miskito culture within the broader context of historical events and time periods of

socioeconomic tensions is necessary to explain these changes. 1

Looking back at the major documented outbreaks, Wedel found that many coincided with

or occurred shortly after historical events that threatened the Miskito community. As a colonial

tribe, the Miskito were closely connected with the British trading empire, particularly as wage

laborers for rubber extraction. 1 One of the first recorded grisi siknis outbreaks happened in 1879

following the rubber boom in the Amazon basin. 1 Success in the Amazon caused a sharp drop

in rubber prices for all other extraction sites, and consequently threatened Miskito wage laborers

income and livelihoods. 1 Continuing through the first half of the 20th century, outbreaks were

reported from notably poor neighborhoods and remote villages within the Miskito territory. 1

Most of the outbreaks during this time still characteristically affected small groups of young

women.

However, after the 1979 Sandinistas Revolution, life for the Miskito changed

dramatically. Under the previous Somoza dictatorship, they had mostly been left alone, but the

new Sandinista government implemented relocation and integration policies affecting all

indigenous peoples. 5 Having historically been affiliated with the British, the Miskito spoke
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English as their second language and had adopted pro-Western values. 5 They therefore were

strongly against integration into the Spanish-speaking, socialist society the Sandinistas were

forcing upon them. 5 Resistance was met with military violence, and many Miskito fled to

refugee camps on the Honduras side of the border. 5 It was during and after this time period that

grisi siknis outbreaks became more violent and widespread. Documented cases from the 1980s

and 90s affected both men and women of all ages. Two notable cases occurred in the Wasla

military camp in 1981 and among the Lamlaya canal workers in 1996. 1 Both groups were

comprised of young Miskito men who had been relocated from their communities to work for

extended periods of time. 1 An additional series of attacks hit the Puerto Cabezas boarding school

in the early 2000s, affecting students of Miskito origin who had been sent there for schooling. 1

The continued oppression and marginalization of the Miskito people was paralleled by

the increased severity and scope of grisi siknis outbreaks. Mass incidents like the 2003 Raiti

outbreak have brought grisi siknis to national attention, but additionally both concerning and

insightful is the recent spread of the condition to affect non-Miskito populations. Starting in the

early 2000s, neighboring Mayangna and Mestizo communities, who were also subject to

relocation and integration under the Sandinistas, reported grisi siknis-like attacks. 1 Perhaps the

spread of the condition to peoples with different cultures but similar circumstances concretely

speaks to Wedels argument that grisi siknis is not strictly a culture-bound syndrome.

Comparison to Involuntary Mass Spirit Possession

Globally, involuntary mass spirit possession is broadly characterized by panic-like or

malaise symptoms preceding a temporary absence of conscious agency, and is later attributed

to a spiritual entity consistent with the victims cultural and religious practices. 1 Incidences of
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possession seem to take place among cultures that highly revere belief in a spirit world, and

occur in response to stress, anxiety, and social tension. 1

Examples exhibiting similarities to the symptoms and circumstances surrounding grisi

siknis include a 1990 possession of school children in Madagascar. The young victims were

described as running around screaming and behaving aggressively in an altered state of

consciousness. 1 This outbreak occurred within the context of a mass rural to urban migration that

created tension between village and town life. 1 This tension seems analogous to the anxiety

surrounding threats to traditional ways of life for the Miskito. A number of examples have also

been reported from Malaysian factories, where outbreaks of similar symptomology have affected

female workers. These episodes are locally explained as punishments by evil spirits against

women for transgressing traditional moral gender codes, but are also often set within

exploitative working conditions. 1

Comparisons between victim accounts and circumstantial factors of grisi siknis and

involuntary mass spirit possession seem to support Wedels proposal that grisi sikinis is not

entirely culturally-bound to just the Miskito. However, the importance of Wedels argument is

not in the syndromes label, but in its implications for treatment and prevention. As Wedel states,

to consider a phenomenon as culture-bound precludes cross-cultural comparison and suggests

that the causative issue lies within some backwards element of the culture itself. 1 It is necessary

to consider cultural idiosyncrasies in order to explain symptom manifestations and to create

respectful treatment plans. But approaching an investigation into underlying triggers of the

condition would benefit from a comparative perspective. Removing the label of culturally-bound

enables an analysis of the contextual similarities between analogous cases that can better inform

the scope for treatment and prevention measures.

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Current Treatment Approaches

Today, regional authorities and healthcare personnel recognize that grisi siknis is

undetectable via Western medical techniques and responds only to traditional healing methods.

However, the tensions this creates between biomedical and traditional healers complicates the

current treatment processes.

It is important to clarify that the Miskito people do not completely reject all Western

medicine, and instead just differentiate which illnesses require treatment from a traditional healer

versus a Western biomedical doctor. 3 A Miskito patient will often go to a health outpost when

injured or feeling ill, and then see the local healer afterwards if the doctor was not able to help

them because this is interpreted as a sign that the malady has been caused by spirits. 6 This does

however create a conflict between treatment plans, as a biomedical doctor might recognize the

presentation of risks for grisi siknis and prescribe Western psychiatric medications that conflict

with the traditional healers methods. 6

In 2004, the Commission of Health instituted the National Health Plan to try to encourage

cooperation between traditional healers and biomedical professionals in indigenous

communities.6 This partnership was meant to use a mutual referral system that would enable

biomedical doctors to treat biological and pathological problems while traditional healers

addressed spiritual needs in tandem. 6 But so far the referrals have been largely one-sided. 6

Traditional healers readily refer patients to the health outposts when they deem the problem to be

biomedical, but there has been resistance from physicians refusing to acknowledge the validity

of traditional healing. 6 This disregard and ridicule for traditional practices is frankly

disrespectful to Miskito patients, and ultimately just results in patient non-compliance, further

marginalization, and the persistence of inadequately addressed health problems.

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Treatment and Prevention Suggestions

If grisi siknis is considered a form of involuntary mass spirit possession with roots as a

response to external pressures on traditional ways of life, then the discord between the national

health system and traditional healers that only further exacerbates these pressures is not helping

the current situation. The 2004 National Health Plan made steps towards a more cooperative

system, but productive collaboration cannot exist if one party believes the other to be inherently

inferior. Part of the issue most likely stems from the lack of everyday interaction between

indigenous Miskito and broader Nicaraguan population, and as a result Miskito culture is viewed

as backwards and exotic. As one medical doctor with Miskito origins puts it, Most of the

doctors come from the Pacific [side of Nicaragua]. This is an isolated and abandoned place[so]

they come with negative expectationsand there exists little understanding of Miskito illness

beliefs among [these] medical personnel. 6 The job of a healthcare professional, regardless of

ontological origin, is to care for the wellbeing of a community. There are many ways to go about

this, but part of caring for a person is respecting how they want to be treated. In order to truly

address the physical and mental health needs of the Miskito population, interventions are needed

to help biomedical professionals understand the legitimacy and necessity of including traditional

healers in the treatment plans for Miskito patients. Perhaps a place to start would be with Patrick

Corrigans approach of targeted, continuous contact.7 Regularly immersing Pacific side

medical doctors in Miskito cultures alongside traditional healers may help reshape their

judgements and foster a more collaborative environment for medical dualism.

Additionally, prevention strategies for grisi siknis could largely benefit from both cross-

cultural comparisons to involuntary mass spirit possession and a dualistic alliance between

traditional healers and Western mental health professionals. As seen in the noted examples of
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possession outbreaks, many have roots in economic crisis, traumatic experiences in war, and

oppression of marginalized peoples. 1 While setting out to prevent global conflicts may not be

very feasible as a mental health prevention strategy, collaborators can take advantage of this

contextual pattern to identify at-risk populations. For the Miskito people, an effective

intervention may be to train local advocates to identity warning signs specific to their culture. To

address the Dennis theory of grisi siknis causation, advocates would be on alert for signs of

elevated emotional expressions, especially during and after stressful events. Those identified to

be at risk would be offered integrated treatment with both a medical mental health professional

and traditional healer, so as to gain the most benefit from different perspectives. Furthermore,

interventions could address the Jamieson theory by providing alternative means for youth to

express their frustrations. This might be accomplished through cognitive behavioral therapy talk

sessions; however, thorough studies would have to be conducted beforehand in order to

determine what methods of counseling would be most culturally appropriate. Interventions

would have to be careful to avoid villainizing cultural traditions, so collaboration with local

youth and community leaders is absolutely necessary.

Conclusion

In conclusion, grisi siknis should be contextualized as a culturally-distinct Miskito

syndrome for the purposes of targeted prevention and treatment plans. The outbreaks manifest as

extreme emotional and visceral responses to adverse social conditions that threaten tradition;

however, those causative adverse conditions and general idioms of distress are comparable to

global cases of involuntary mass spirit possession. It would therefore be remiss to confine grisi

siknis by the label of culturally-bound, as this prevents productive comparisons that could better
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inform the scope of targeted preventions and treatments. Additionally, a review of current

treatment systems suggests a dire need for interventions addressing therapeutic dualism so that

the culturally-appropriate treatment victims need can be more easily and effectively accessible.

Ultimately, the treatment of grisi siknis symptoms must be culturally-sensitive, but the premise

of preventative interventions must address broader social contexts.

REFERENCES
1. Wedel J. Involuntary mass spirit possession among the Miskitu. Anthropol Med.
2012;19(3):303-314. doi:10.1080/13648470.2012.692356.
2. Dennis P. The Culture-Bound Syndromes: Folk Illnesses of Psychiatric and Anthropological
Interest. In: Simons RC, Hughes CC, eds. Dordrecht: Springer Netherlands; 1985:289-306.
doi:10.1007/978-94-009-5251-5_27.

3. Edgardo R. Cultural politics and health: the development of intercultural health policies in
the Atlantic coast of Nicaragua. Universidad de Puerto Rico. 2006.

4. Jamieson M. Masks and madness: ritual expression of the transition to adulthood among
Miskitu adolescents. 2001;(1981):257-272. doi:10.1017/S0964028201000209.
5. Bonner R. Miskito Indians are focus of debate. New York Times.
http://www.nytimes.com/1982/08/13/world/miskito-indians-are-focus-of-debate.html.
Updated August 13, 1982. Accessed June 1, 2016.

6. Wedel J. Bridging the Gap between Western and Indigenous Medicine in Eastern Nicaragua.
Anthropol Notebooks. 2009;15:49-64.
7. Corrigan P. Best practices: Strategic stigma change (SSC): five principles for social
marketing campaigns to reduce stigma. Psychiatr Serv. 2011;62(8):4-6.
doi:10.1176/appi.ps.62.8.824.