SETHA M.

LOW

THE MEANING OF NERVIOS: A SOCIOCULTURAL ANALYSIS

OF SYMPTOM PRESENTATION IN S A N J O S E , C O S T A R I C A

ABSTRACT. The foundation of the symbolic tradition in medical anthropology is the

examination of a patient's experience of a category of illness. The interpretation of folk
explanations of etiology and nosology provides insight into the cultural definition of what
constitutes an illness, how and why an illness is labeled, and how the afflicted individual
should be treated. Further, the analysis of sociocultural meaning emerges as a critical the-
oretical contribution to our understanding of health and culture.
Alien Young in his article "Some Implications of Medical Beliefs and Practices for Social
Anthropology" suggests " . . . that if we want to learn the social meaning of sickness, we
must understand that 'signs,' whatever their genesis, become 'symptoms' because they are
expressed, elicited, and perceived in socially acquired ways" (1976: 14). He further states
that some categories of sickness are particularly interesting in that they enable people to
organize the illness event into an episode that has form and meaning (1976: 19-20).
Nervios is an example of a symptom that has acquired a special sociocultural pattern of
expression, elicitation and perception in San Josg, Costa Rica. The empirical study of
symptom presentation in general medicine and psychiatric outpatient clinics describes the
patients who present the symptom and their associated attributes and explanations of the
symptom's occurrence. The meaning of nervios is then discussed within a social interac-
tional and symbolic framework.

INTRODUCTION

In Costa Rica the s y m p t o m of nervios (nerves) is employed in a variety o f settings

to signal psychosocial distress. It is a culturally appropriate s y m p t o m in that its
pervasive use is primarily within Costa Rica; persons o f all social statuses, age
and sex use the term; and its use elicits what is considered the socially appropri-
ate response o f expressed concern and attention. Nervios is etiologically linked
to family disruption and a breakdown in family relationships, providing a socially
acceptable category o f physical and mental disturbance for the symptoms o f
being 'out of control', generated by difficult family relations. The examination
of patient presentation of nervios is illustrative o f how a s y m p t o m links an in-
dividual's personal experience with the social institutions of family and health
care in a culturally meaningful way.
The theory and data employed to analyze the meaning ofnervios are organized
in a research report format. The research problem is first presented including
a review of references to nervios in the medical anthropological literature and a
clarification o f the problem. The second section describes the relevant research
setting, m e t h o d and sample. A data section follows which discusses outpatient
symptom presentation, the characteristics of patients presenting nervios, and

Culture, Medicine and Psychiatry 5 (1981) 25-47. 0165-005X/81/0051-0025 $02.30.

Copyright © 1981 by D. R eidel Publishing Co., Dordrecht, Holland, and Boston, U.S.A.
26 SETHA M. LOW

doctor diagnosis and treatment of those patients. Finally, a theoretical and

concluding section explores the psychological, social and cultural meaning of
nervios.

RESEARCH PROBLEM

Health to a Costa Rican is expressed as well-being (bienestar) or to be sound,

whole, or complete (estar sano). To achieve and maintain this well-being requires
that one must vivir tranquilo, that is live calmly, tranquilly, in balance with
oneself and one's physical, social, and psychological environment. Nervios, or
"nerves", the focus of this paper, appears as a counterpart to the expressed ideal
state, signifying an interruption in the individual's ability to vivir tranquilo.

values, ideals, and culture.

The relationship of health and culture is illuminated through the symbolic
and psychophysiological expression of cultural rules in body image and body
experience. The examination of one symptom therefore can decode a much
larger cultural matrix of beliefs and ideals. An in-depth analysis of the attached
meanings, social context and interpersonal manipulation of nervios will provide
insights to the individuals' response to a changing world.
The interpretation of symptoms as sociocultural phenomena has traditionally
been an area of concern for medical anthropologists and has included studies of
communication problems in public health assistance programs in Latin America
(Simmons 1955; Wellin 1955; Foster 1962, 1969; Erasmus 1952, 1968), studies
of ethnic disorders or culture-bound syndromes (Honigman 1967; Kiev 1964,
1968; deReuck and Porter 1965; Foulks 1972; McDaniel 1972; Yap 1969;
Cawte 1976; Weidman 1979; Bilu 1980), and epidemiological and theoretical
analyses of folk illness (Fabrega and Metzger 1968; Rubel 1964; Foster 1953;
Frake 1961; Currier 1966; Ingham 1970; O'Neil and Selby 1968; Scott 1973;
Uzzell 1974). These perspectives, however, have limited applicability and can
be theoretically restrictive when dealing with symptoms whose physical and
behavioral characteristics are diffuse and difficult to define. Recent theoretical
approaches to symptom interpretation therefore have employed semantic analysis
(Good 1977; Kay 1979), symbolic analysis (Moerman 1979; Tousignant 1979),
cultural role recruitment (Townsend and Carbone 1980), and models of clinical
explanation (Gaines 1979; Blumhagen 1980; Kleinman 1980) to more effec-
tively identify the sociocultural meaning of symptoms.
The initial literature search for references to nervios revealed few mentions
of the term and provided minimal explanation for its usage. A reference from a
village in Mexico indicates that "such items as bad blood, cramps, colds, arthritis,
indigestion, and nerves actually subsume a large number of disorders" for the
 THE MEANING OF NER VIOS 27

local curer (Brown 1963: 101). Among working class Mexican psychiatric out-
patients, "a few persons mentioned nerves" as the problem for which they were
seeking help; and in response to a question on the cause of their disorder, 70%
agreed nervios was involved, women tending to agree more than men (Fabrega
1967: 706). A woman in Fabrega's sample also stated that she needed to "dom-
inate her nerves" in order to get better (Fabrega 1967: 706), a comment often
heard outside the medical consultation in San Jos6. Puerto Ricans in the United
States "seek the help of Spiritists when they have . . . problems with their
'nerves'" (Garrison 1972: 3). North American references to nerves include a
study undertaken in North Carolina where patients receiving public health
nursing care frequently complained of "nerves" and/or nervousness (Leighton
1968: 39) and a Nova Scotia study population reporting minor psychiatric
symptoms sometimes described as "nerves" (Schuchat 1975).
Historically, a book of Nicaraguan folk medical terms reports two varieties
of nervios which are recorded from early Nicaraguan studies: nervios regados
in which a person is nervous, easily excitable, manifesting punctuated muscle
pain and insomnia; and nervios resentidos in which a person who is not able to
get rid of his troubles suffers pain, anger, passion and melancholy (Miranda
1967: 235). Mexican medical folklore identifies nervousness (nerviosismo) as
an anxious reaction which accompanies susto characterized by sensation in the
mouth of the stomach, bones or chest, however nervios as a distinct symptom
is not mentioned (Padron 1956). Francisco Escobar, a Costa Rican sociologist,
suggests that nervios is related to an old folk notion of calbagar, a term used
to excuse one from fulfillment of normal duties because of a personal crisis
such as loss of a loved one, economic disaster, or insult to one's pride (personal
communication); however, no published reference to this concept was found.
Recent references to nervios have increased with the publication of new
medical anthropological studies from Latin American and Galenic influenced
cultures. Nervios in Colombia is related to mental disorder and debilidad (de-
bility) (Langdon and MacLennan 1979). Researchers from Iran report "nerves"
as a women's problem (Good 1980) and as a location of distress (Good 1977).
Finkler (1980), Sandoval (1979), Garrison (1977) and Harwood (1977)refer to
"nerves" in relation to symptom presentation for spiritualist treatment. Spicer's
(1977) collection of Southwest medical ethnographics reports the occurrence of
"nerves" in various border cultures.
The literature establishes that nervios is present in Mexico, Colombia, Ni-
caragua and the Southwestern United States, while "nerves" and "nervousness"
have a broader distribution; however, because the references are brief and fo-
cused on other topics it is difficult to ascertain whether the reported symptoms
are the same as nervios in Costa Rica. In other words, it is not clear from the
literature that nervios is a phenomenon particular to each situation or whether
28 SETHA M. LOW

it has cross-cultural significance. This question requires extensive further re-

search. For the purposes of this paper, nervios refers to the symptom as it occurs
only in Costa Rica. The special relationship of nervios to Costa Rican cultural
themes, the frequent presentation of the symptom in the physician's office,
and the widespread use of nervios in conversation in a variety of social settings
suggest that the meaning of nervios in Costa Rica is framed by the cultural
context.

RESEARCH METHODOLOGY

Setting

The research data upon which this paper is based were collected in San Jos6,
the capital of Costa Rica, located on the Meseta Central of this small Central
American republic. With a metropolitan population of over 460,000, one-fourth
of the national total, San Jos6 is a primate city representing 53% of the country's
total urban population (Morse 1971 ; Ministerio de Economia 1974). Costa Rica,
like many developing countries, is experiencing rapid urbanization in which a
large proportion of the rural population has moved to the capital straining social
services and physical resources. The resulting unemployment, poor housing
conditions and increasing social disorder has disrupted traditional patterns of
family structure and community organization (Low 1977).
Costa Rican family structure emphasizes independence and self-sufficiency
historically attributed to the subsistence agricultural economy. Life is family-
centered in the sense that significant personal relations usually lie within family
boundaries. When asked about friendships outside the family a Costa Rican
denies having close (intima) friends; friendship is suspect as it suggests non-
familiar alliances and an unwillingness to fulfill family obligations.
Internally, family functions segregate into duties and responsibilities appro-
priate to a member's age or sexual status. Husband and wife maintain segregated
conjugal networks, reinforcing ties with their own consanguineal families through
labor exchange, visiting, and residential proximity. Any deviation from the ideal
family pattern increases one's susceptibility to disequilibrium in the form of
dependence on friends rather than family, need for institutional assistance or
intervention, and social sanction by avoidance, gossip or restricted interaction.
Institutions are only for the very sick and senile - when the children cannot
care for them. Even then an informant responds that she "cries all day to think
of an old lady alone. If the children do not live with their parents then they
should at least visit every day."
Costa Rican society, both structurally and conceptually, reflects a preoccupa-
tion with health. One is struck by the abundance of medical offices and related
 THE MEANING OF NER VIOS 29

laboratories, clinics and pharmacies. The national budget for 1973 allotted more
money for health than for defense and internal security (La Repfiblica 1973:
12); and the proportion of public expenses corresponding to the health sector
has increased from 9.0% in 1960 to 14.9% in 1972 (Bermudez and G6mez 1974:
22). The semi-autonomous Caja Costarficense de Seguro Social is the the major
internal money lender to the national government. In either of the major daily
newspapers La Nabion or La Reptiblica there are lengthy articles reporting
health hazards, health directives or information announcing the opening of a
new clinic or medical program. Richardson and Bode (1971) report from field-
work in Puntarenas, Costa Rica that 66% of their sample worry more about their
health than about their economic state.

Method

The major portion of the research was undertaken in outpatient clinics of four
hospitals within the two principal Costa Rican health care delivery systems:
Hospital Calder6n Guardia and Hospital M~xico of the Caja Costarricense de
Seguro Social, and Hospital San Juan de Dios and psychiatric Hospital Manuel
Antonio Chapui of the Ministry of Public Health. The Caja Costarricense de
Seguro Social is a semi-autonomous nationalized health, disability, and retire-
ment program, which at the time of the study enrolled salaried employees and
their families, some 60% of the total population (Caja Costarricense de Seguro
Social 1974). The Ministry of Public Health is part of the executive branch of
the central government, and operates a lottery-supported system providing
free or low cost inpatient and outpatient care to those not covered by the
Seguro Social. Additional field work was conducted with herbalists in the central
market, pharmacists in their boticas, and with a range of paramedical practi-
tioners in their offices and homes. Extensive ethnographic data were collected
while living as a participant-observer in a transitional suburb of San Jos~ where
the researcher had informant contact through everyday situations and personal
interaction.
The methods employed varied according to the setting and sequence within
the overall research design. The initial phase of research was focused on observa-
tion of doctor-patient interaction in the consultation office. Between consulta-
tions doctors, nurses, social workers and other auxiliary clinic personnel were
interviewed with reference to their perceptions of patient behavior and clinic
function. The second phase began after having established the pattern of con-
sultation interaction; a structured interview covering patient perception of their
illness and treatment was administered by a research assistant in the waiting
room before and after the observed medical consultation. Finally, a sample of the
interviewed patients were selected for a home visit during which the researcher
30 SETHA M. LOW

and her assistant conducted an open-ended family interview which emphasized

personal and family health histories, geneological and family network material,
health utilization patterns and general questions of values, preferences and
health beliefs.
Observation of doctor-patient interaction was chosen as a means of most
economically describing Costa Rican disease types, the variety of symptoms and
their cultural expression, and doctor-patient interaction in terms of function
and outcome. Consultations were recorded in notes taken in diary form and
included relevant material on the situational context. The two major hospital
outpatient clinics of both the Public Health hospital, San Juan de Dios, and the
Social Security hospital, Calderon Guardia, were selected to represent general
medicine services in San Jos6. Two psychiatric clinics and one psychosomatic
clinic were added to gain greater breadth of information on patients with nervios
(Figure 1). The observed patient sample was obtained by working alternate hours

Ministry of System. Total Social Security

public Health (201) Sample = 457 Fund System (256)
I
I I
1 I
Psychiatric Calderon Hospital
San Juan
de Dios (151)

I
I
I
HospRal
Chapui (50)
Hospitals Guardia
(206)

I
I
Mexico
(50)

I
l
Extempor- General General Extempor- General
aneous Medicine Medicine aneous Medicine
(101) Outpatien Services (305) (51) Outpatient
(50) (103)

I
Psychiatry Psychiatric Psychiatry Psychosomatic
Outpatient Services (152) Outpatient Outpatient
(5 o) (52) (50)

Fig. 1. Distribution of patient samples by system, hospitals and services

and days of the week with as many different doctors as possible; in this manner
an attempt was made to randomize patient attendance patterns. Approximately
1 2 - 2 0 patients were observed with each doctor depending on their case load.
All patients who entered the office during the observation period were recorded
to minimize selection bias.
 THE MEANING OF NER VIOS 31

A total of 305 observations of doctor-patient interaction in general medicine

were recorded in addition to 50 and 52 observations in each of the psychiatric
outpatient facilities and another 50 in the psychosomatic clinic (Figure 1).
The resulting data on symptom presentation, patient history, family and per-
sonality variables were coded and analyzed with computer assistance. The 117
before-and-after consultation interviews which analyzed patient expectations,
satisfaction, and concepts of causation and treatment of disease were collected
during a two week period of consecutive interviewing for one full day in each
clinic setting. The sample of 12 patients selected for team-conducted family
interviews was made up of interviewed patients who agreed to a home visit by
the research team. These intensive family sessions generated theories of symp-
tom formation.

Sample

The sample is made up of 305 cases in general medicine clinics and 152 patients
in three psychiatry clinics selected as noted above. The general characteristics
of the research sample include a predominance of women: 70% of patients
in general medicine and 63% in psychiatric clinics were female. The mean age
of the sample was 33.5 years with no significant differences between general
medicine and psychiatry clinics or between Public Health or Social Security
medical systems.

PATIENT PRESENTATION OF NER VIOS

Symptom Presentation

Symptom presentation in the medical setting indicates both the kinds of distur-
bances commonly experienced by Costa Ricans and the culturally available
verbal and behavioral repertoire for the expression of psychosocial distress.
Outpatients present a wide variety of physical and emotional statements ranging
from headaches, body pain and respiratory complaints to worries, depression,
and disorientation. The analysis of symptoms by general medicine and psychiatric
outpatient clinics provides ranked frequencies distinguishing the two medical
services. Of sixty-five possible coded symptoms, general medicine patients most
often experience, in order of decreasing frequency, head pain, stomach pain,
nervios, itching, side and back pain, lack of appetite, cough, fever, sore throat,
chest pain, hip and leg pain, runny eyes, fatigue, vomiting, and congestion
32 SETHA M. LOW

(Table I). Psychiatric patients have more emotional complaints and present
nervios most frequently, followed by head pain, depression, insomnia, anger or
bad character, lack of appetite, fears or susto, fatigue, trembling, altered percep-
tions or temporary blindness.

TABLE I
Symptom frequency by patient subgroups

Rank order and percent of patients presenting symptom

General medicine (N=305) Psychiatry (N=152) Nervios (N=122) 1

Symptoms % Symptoms % Symptoms %

1. Head pain, 17.1 1. Nervios 50.0 1. Nervios 100.0

stomach
pain
2. Nervios 15.1 2. Head pain 29.5 2. Head pain 36.9
3. Itching 12.4 3. Depression 28.9 3. Insomnia 26.2
4. Sideand 11.5 4. Insomnia 25.0 4. Lack of appetite 24.6
back pain
5. Lack of 10.0 5. Angry or bad 20.4 5. Depression 23.0
appetite character
6. Cough, fever 9.9 6. Lack of appetite 18.5 6. Fears, Susto 19.7
7. Sorethroat 9.5 7. Fears, Susto 17.1 7. Angryorbad 18.0
character
8. Chest pain 9.2 8. Fatigue, trembling, 16.5 8. Trembling, 15.6
descomposiciones descornposiciones
9. Leg andhip 8.5 9. Altered perception 15.8 9. Disorientations 12.3
pain or temporary
blindness
10. Rurmyeyes 8.3 10. Disorientations 13.8 10. Fatigue

1 The n=122 was based on the total number of patients reporting nervios, 46 (15.1% of the
305) from general medicine clinics, and 76 (50% of 152) from pyschiatric clinics.

Costa Rican disease statements are a combination o f biological and sociopsy-

chological symptoms and reflect the absence o f a m i n d / b o d y dualism reported
for Ladino culture. The following dialogue reported by Fabrega for Ladinos in
Chiapas, Mexico:

I am having the pain of X . . . It is the pain of my liver located here, which was brought
on by doing Y after having experienced Z, and the pain is like someone squeezing me
inside, and the vomiting and headache that I am also having is part of the same malady.
(1973: 231)

applies to the Costa Rican medical consultation with substitution o f the head,
 THE MEANING OF NER VIOS 33

stomach, or back for the referent organ. Pain descriptions also resemble the
Chiapas Ladino format: "Physical and social metaphors abound in attempts to
elaborate about the pain associated with various conditions which may be seen
as focused in discrete anatomical parts" (Fabrega 1973: 223). In this fashion, a
Costa Rican patient complains of a "wind" in the heart, coming on very fast,
causing agitation; or a pain that starts high on the hip, moving to the front, then
to the testicles. Pain is often expressed as "beating" or "hitting" the patient, or
as an itching or cramp. Most Costa Rican disease statements include some pain
description.
Many Costa Rican symptoms can be explained by examining the biocultural
context. Symptoms related to bronchitis - chest pain, breathing difficulties,
coughing - common in the older rural population, are partially caused by the
traditional use of open woodburning stoves, a synergistic combination of cultural
choice and a biophysical medical problem (Rawson 1974). Another example
of a medical problem arising from the interaction of cultural beliefs and the
biological determinants of disease is the Costa Rican emphasis on appetite loss
as a sign of illness; that is, to be slightly heavy or fat is considered attractive,
and to eat heartily at all times is considered imperative to maintain one's energy
and vigor. A patient who is hypertensive or diabetic and dangerously overweight
will not agree to any decrease in food intake, even when therapeutically induced
by the doctor. "Brainache", a folk category of headache, is thought of as a
syndrome of debilidad del cerebro (debility of the brain), caused by a lack of
alimento, vitamins or healthy food (Cosminsky 1975). In this case the folk bio-
cultural categroy corresponds to the medical explanation of the disease in that
brainache signals improper nutrition and is treated by physicians with vitamin
injections. Nervios, however, does not have a folk biocultural explanation and
does not appear to be the result of a cultural belief interacting directly with an
underlying biological process.

Nervios Patients

Of the 457 patients in the sample, 122 complained of nervios. These patients
exhibited an interesting pattern of other symptoms: headache, insomnia, lack
of appetite, depression, fears or susto, anger or bad character, trembling, disori-
entation and temporary blindness, fatigue, itching, altered perceptions, profuse
sweating, lifelessness, vomiting and hot sensations (Table I). The common at-
tribute of these symptoms seems to be that the patient is "out of control", or
separated from body and self. The patient complains that these sensations are
not part of their normal behavior, but are experienced as undesirable body
responses over which they have no control. The body is seemingly objectified
34 SETHA M. LOW

b y the patient; the patient views the self as feeling and acting inappropriately.
Ethnographic data corroborates this impression:

Maria is eighteen years old and came in with her older sister. Her family is from the coun-
tryside (campo), a six hour bus ride south of San Jos6. There are six boys and four girls
in her family. The mother is "mentally" ill and mistreats her daughter, so the sister has
brought Maria to live with her. The sister hopes to help her "if there is time". Maria says
that she has nervios. Four times she has become unconscious, "lifeless" and without feeling
in her body. She has been this way for the past six months. Maria says she feels like crying,
sleeps all the time even though she has a boyfriend who is handsome. Her sister says that
Maria is crazy not to get well for her handsome boyfriend. The sister sleeps with Maria so
that she can watch her at night. Maria says that when she has these periods of unconscious-
ness her hand falls asleep, and her tongue and body feel strange. She feels everyone is
very far away and doesn't speak. "Does it scare you?" asks the doctor. "Yes", replies
Maria. Her appetite is good. She says she often feels angry. The sister comments that she
feels that the anger is from the same nervios as in Maria's system. Maria called her attacks
descomposiciones.

The i n t e r p r e t a t i o n that the patient is " o u t o f c o n t r o l " is further reinforced

f r o m data collected in the structured interviews held b e f o r e and after consulta-
tion w i t h 117 patients, These responses were elicited b y asking " W h a t do y o u
have? What do y o u t h i n k it is caused b y ? " .

A 24 year old male from the rural highlands complained of a noise in his head, constant
dizziness, sweats, fear, nervios, pressures and neck pain. "I lost control," the patient told
the interviewer, "and blacked out twice". He thinks that it could be caused by getting wet
in the afternoon, or that he worked under a plastic roof.

A woman from a poor neighborhood in San Jos6 complains of nervios accompanied by

descomposiciones, a fear to leave the house and go on the street. It's "a terrible complex",
she complained, in which her head hurt, and she can't eat, and sometimes she can't talk.
She says that this comes from her husband who tried to kill her ten years ago. "But now
my nervios is worse," she says. She thinks that her nervios is caused by anger (colera) and
possibly by her liver.

A 32 year old woman, with nine living children from the southern valley of Costa Rica,
complains of headache, dizziness, crying, temporary blindness. A week before she had an
attack of nervios, a derrarne de cerebro or stroke, during which she was unconscious for
two hours. She thought it might be family worries.

A single man from a working-class neighborhood employed in a laboratory department of

a large hospital complains of nervios, anxiety, desperation, and being disoriented to self;
he is not sure of his acts or words. He says that he has an impersonal attitude, superficial
affect, and doesn't feel himself. He reports that his problems come from his family, who
do not appreciate him and stay apart from him. His work is "very alone". He feels guilty
because the family stays away from him because of his problems.

When nervios patients are c o m p a r e d to the total patient sample the distribution
o f sex, age, residence, medical system utilization, and s o c i o e c o n o m i c factors
is statistically comparable. In o t h e r ways, nervios patients differ f r o m the general
medical sample: t h e y experience m o r e family disruption; are m o r e o f t e n single,
 THE MEANING OF NER VIOS 35

separated, or widowed; and more frequently mention family or spouse abandon-

ment, death, or abuse in relation to their symptom.
The relationship of family function and illness has been well documented for
folk illnesses such as the bilious attacks middle-aged wives experience from quar-
reling with their husbands in Chinautla, Guatemala (Reina 1966) and colera
(rage) precipitated by marital tensions and miscounduct (Redfiled 1940). Clas-
sical psychosomatic disease such as duodenal ulcer (Goldberg 1958), ulcerative
colitis (Jackson and Yalom 1966) and stress-induced diseases (Croog 1970;
Titchener, Riskin and Emerson 1960) appear to include family conflict in their
etiology. In the Costa Rican data there is considerable evidence, both analytically
and from the point of view of the informant, that family problems often create
physical and mental distress, frequently in the symptomatic form of nervios.
There are a variety of family disturbances to which nervios is attributed by the
12 family interview informants:

(1) A crisis of nervios is said to be the result of the marriage of a son to

a socially undesirable woman.
(2) A woman reported getting sick with nen, ios when her illegitimate
child was born.
(3) A child is thought to have nervios because her unmarried mother
was very upset during the pregnancy, didn't go out of the house,
and didn't want to see people.
(4) A man has nervios and blames a traumatic childhood of poverty
and an alcoholic father.
(5) Nervios and bronchial asthma resulted when a husband didn't come
home on time.
(6) A mother had a derrame (a stroke) when one of her grandchildren
was killed by a car and ten days later another was born yellow. The
one born yellow is now said to have nervios.
(7) A young woman has nervios believed to be caused by having an
alcoholic father who fights with her and because of the economic
problems his drinking creates.

Nervios appears as a symptom of family interaction discord (examples 5

and 7), disruption of family structure (examples 1, 2, and 6), and past family
disturbance (3 and 4). As further evidence of the etioligical link between
family disruption and nervios, it was found that in the clinic sample, patients
who present nervios differ from those who do not in attributing the cause
of their symptoms more often to family, social, reproductive or sex-related
factors.
36 SETHA M. LOW

Doctor Diagnosis and Treatment

Doctors accept nervios as a valid symptom and respond positively to the patient's
request for an explanation of their illness. The presentation of nervios influences
the interaction by eliciting physician concern and attention with regard to the
development of the patient's complaint. Doctors state that nervios frequently
reflects family or economic factors, female reaction to husband inattention
or abandonment, an attempt to obtain affection from individuals outside the
family network, a reaction to hostility or guilt created by overdependency,
"boredom" in the countryside, or sexual problems. The acceptance of the
symptom and the variation of labels applied to it suggest that for doctors nervios
is highly negotiable and may have many interpretations and designations
(Edgerton 1969).
Doctors record the incidence of nervios on patient charts usually with a
diagnosis of anxiety, anxious depression or conversion reaction. Treatment
often includes a prescription of Valium (sedative) or Tofranil (antidepressant).
To the patient, however, the physician uses the symptom nervios for diagnosis
and discussion; he refrains from using a psychiatric label for what the patient
perceives as a general problem.
In summary, the evidence from the clinic sample shows nervios to be a wide-
spread symptom presented frequently among Costa Rican general medicine and
psychiatric patients, accompanied by a broad range of associated symptoms
expressing a feeling of being "out of control" or separated from body or self.
Nervios incidence does not vary by sex, age, residence, or socioeconomic status;
it is, however, associated with family disruption. Patients and doctors attribute
its occurrence to a range of causal factors, primarily social in nature. Lastly,
nervios, accepted as a valid symptom by doctors, enhances the interaction of the
doctor and the patient during the consultation by directing attention towards
the social circumstances of its development.

THE MEANING OF NERVIOS

The cultural anthropologist may, if he chooses, advance from his relatively technical prob-
lems of cultural definition, distribution, organization and history to more intimate problems
of cultural meaning, both for individuals and for significantlydefinable groups of individual.
(Sapir 1939)

The description of nervios derived from observation, interview and ethnographic

data suggests that a complex set of meanings are operative in patient symptom
presentation. At the individual and psychosocial level nervios refers to a disturbed
body perception of being "out of control" and is etiologically linked to family
 THE MEANING OF NER VIOS 37

disruption. A second, social level of meaning is implied by the enhanced atten-

tion elicited from doctors when patients present nervios. The third level of
meaning includes the symbolic and cultural aspects of the symptom as nervios
represents the antithesis of the healthy, family-based life prescribed by Costa
Pican values and ideal family structure.

Body Perception, Identity and Family Disruption

The body is valued for its appearance and functioning, and persons tend to
identify with it (Goffman 1961 : 342). In Costa Pica body concern is expressed
through a constant monitoring of internal cycles and external signs to ensure
balance and continuity of function. A Costa Rican woman carefully tracks her
menstrual cycle, and a Costa Pican man is acutely aware of any changes in his
physical strength or sexual potency. Changes in body shape or size influence
role performance, self-perception and identity in relation to cultural stereotypes
of physical attractiveness or strength, and signs of intelligence or personality.
This identification of self with body often takes the form of an individual's
definition of body boundaries (Turner 1971) which is limited by controls exerted
from the social system (Douglas 1973). Hall (1973) illustrates this relationship
by describing how a schizophrenic having discarded social reality and social
controls experiences an expansion of body boundaries which may include an
entire room or encompass a landscape, confusing self-perception and identity.
In the same sense the symptoms associated with nervios emphasize a temporary
breakdown of perceived body boundaries. The individual is "out of control",
experiences dissociative and alien sensations, pain or temperature change with-
out environmental influence, disorientation, unconsciousness, altered percep-
tions, temporary blindness and fears of commonplace situations or places. The
social system controls appear to have been disrupted and perception of self
distorted.
The family in Costa Pica is the basis of an individual's self-concept and soci-
etal identification. In order to locate a person within the national social system
in terms of status, wealth or morality, an individual's combined patrilineal and
matrilineal surnames, apeIlidos, are elicited. The family is the dominant social
institution whose functions include behavior regulation and social accessibility:

Familial organization is the base of social order ... consideration of family controls the
behavior of people because the main source of individual identity lies within the family
rank. (Youssef 1973: 329)

Costa Ricans in fact are said to be too dependent on their families such that in-
dividual motivation is restricted and destructive emotional bonds are perpetuated.
Proper behavior is expected of family members and restrictions are imposed;
38 SETHA M. LOW

if the deviation is considered serious enough, a person m a y be excluded from the

family group and membership.

If a person is declassed . . . . changes political allegiances, becomes impoverished, marries

across factions, or otherwise misbehaves in terms offamilia (family) norms, he is ostracized
and loses his status as a pariente (relative). (Hunt 1969: 26)

An example from the field research iUustrates this kind o f family rejection:

The doctor immediately points out to me the patient's surnames as very important as
this patient is from a good family. The woman, 44, was jailed for robbing a store, lost
her memory and became lifeless (sin anima). The patient said that the doctors told her
that her nervios is due to a problem with her glands; she has had two operations and was
intoxicated by a drug given to her for treatment. She was living very happily, but not now,
because with no medicine she feels terrible. She begins to talk of the robbery and of her
house and how she lost all her clothes. Crying, she tells a story of her poverty and down-
fall. She can't work because she feels like her legs are paralyzed. The doctor asks about
her family names and why her family doesn't help. She answers that she married a poor
man and the family abandoned her. Since then she has separated from him and now is
all alone.

Corroborating evidence is found in Costa Rican Civil Law which states that
the definition of political person or marriage is null and void if the person
is mentally incapable or interned in a public institution (Vincenzi 1972: I0).
If such laws reflect social ideology, then the very essence of civil status and
maintenance o f family (idealized in the concept o f marriage) depends upon
control o f public behavior so as not to be labeled as incapable.
The feeling o f being " o u t o f control" expressed b y nervios patients' dis-
turbed perception of b o d y boundaries refers specifically to family control
in that the family is the source o f Costa Rican self-identity. Family disrup-
tion breaks down normal patterns of behavior and relationships. Nervios, how-
ever, acts as a socially acceptable label for being " o u t of control" and is used
to socially include the person, rather than exclude him in a deviant or men-
tally impaired category. The psychosocial function o f nervios is to maintain
social control b y reinforcing family relationships thereby enhancing family
cohesion.
Nervios m a y in fact be a cultural adjustment in identity, a reworking o f
relations and feelings about self in order to reintegrate into the social group;
but at no time is the individual's total social role endangered. Mental illness,
however, may be an identity change that does affect role performance and an
individual's ability to function in a socially acceptable manner. When a person
is threatened with losing one's social person, through an inability to fulfill basic
social roles, the episode is labeled mental illness rather than nervios.
 THE MEANING OF NER VIOS 39

Communication and Social Interaction

In the medical setting nervios enhances the possibility of a positive doctor-

patient interaction. The statement "I have nerves" elicits a response from the
receiver, transmits a command sensitive to the social context, and places the
symptom presentation in the realm of a culturally relevant communication.
Communication models such as the one proposed by Weakland (1969)emphasize
the communicative value of a symptom, particularly across status differentials,
and clarify otherwise enigmatic elements of the Costa Rican data.
Weakland (1969) identifies four criteria for symbolic communication: (1)
that the communication focuses on exchanges in certain social situations;
(2) that the communication is important in stimulating and shaping individual
behavior and social interaction; (3) that messages involve systems of codifica-
tion; and (4) that communication always involves a multiplicity of interrelated
message and social contexts, each of which qualifies the others significance.
These criteria can be applied to nervios by examining how the symptom as a
symbolic message functions within each of a variety of social contexts.
The communication approach focuses on exchanges of messages in certain
social situations. The statement "I have nerves" occurs within the medical
setting as part of a therapeutic encounter. The resolution sought through the
exchange of symptom presentation for symptom validation is an explanation
of the etiology and a reaffirmation of identity. In the familial context the
message is exchanged for expressions of personal concern and understanding.
Communication is important in stimulating and shaping individual behavior
and social interaction as is manifested in the positive influence of the nervios
statement. The nervios message works in two ways during the consultation:
it involves the physician, and directs his involvement to an examination of
the symptom through the request for explanation. The impact of the nervios
communication within the family and social network is even more extensive
in that it redirects attention to the individual and any related problems such
that behavior can be changed through social support or group sanction.
Nervios as a system of codification reflects social constraints symbolically
expressed in body processes. Nervios functions symbolically in the therapeutic
setting by expressing in a coded form information which would be otherwise
culturally inappropriate or difficult to present. Within the consultation the
patient is initially hesitant to directly discuss "private" family data, and the
physician capable of misunderstanding; nervios provides a medium by which
social and emotional issues can be explored. Within the wider social world of
the patient, nervios expresses social distress in a psychophysical symptom which
can be discussed and examined without focusing on the socially unacceptable
40 SETHA M. LOW

aspects of symptom etiology. A person can signal social "disease" encoded

through a culturally acceptable body disturbance.
Communication always involves a multiplicity of interrelated message and
social contexts, each of which qualifies the other's significance. When nervios is
presented an association is made by the physician that the complaint is related
to other problems. Patient discussion and physician questioning moves to
personal and familial topics. At another level nervios is interpreted as soliciting
attention or signaling a need for affection to which the physician responds by
being more interpretative and amiable. The entire complex of meaning encoded
by nervios is a sociocultural set, and this set reflects a portion of the cultural
system of meaning.

Cultural Symbols, Values and Ideals

Nervios is an appropriate symbol for social structural disturbance as it contrasts

comceptuaUy to tranquilidad, a cultural value which connotes independence,
individualism, and balance - the elements of a sano or healthy life. A person
is not tranquilo nor independent in terms of social acceptability necessary for
unhindered social access without a family. An example of this proposition is
that children of unwed and unaccompanied women often have nervios. When
the woman continues to live with her parents, the child is embarrassed or abused
because of the mother's "uncontrolled" behavior and his own lack of a father,
i.e., the child does not have a "family" in the sense of the cultural ideal.
According to Geertz:

Culture... denotes an historically transmitted pattern of meanings and symbols, a system

of inherited conceptions expressed in symbolic forms by means of which men communicate,
perpetuate, and develop their knowledge about and attitudes toward life. (1973: 89)

Nervios, at the level of cultural meaning, indicates an inability to fulfill the

cultural ideal in terms of maintaining the proper attitude towards life and be-
having in culturally acceptable patterns. Some people are born with nervios,
it is said, and from birth are physiologically or social structurally unable to ful-
fill cultural expectations; others are only temporarily afflicted through family
disturbance and express sensations of dissociation. The cultural content of
nervios is expressed somatically and communicates to socially significant others
the need for acceptance and identity affirmation in a culturally meaningful way.
The individual's symbolic signaling of a need for acceptance when he can no
longer fulfill his culturally appropriate role is best illustrated by a case of an old
man whose niece wants to place him in a public home for the aged:

The patient is 71 years old, married with two children. He is separated from his wife and
lives in a room with his niece and nephew; the niece has accompanied him. He is full of
 THE MEANING OF N E R VIOS 41

nervios - before he had none - and has had headaches for the past half year. He had an
operation for cataract and practically can't see. He doesn't s!eep much. Doctor takes his
pulse. Patient goes on to say that he is not sad but is "without defenses"; he forgets things,
thinks of the past all the time. The niece says that the patient is hard to manage now that
he can't see. He was a gardener, but can't work now. The responsibility for his care has
fallen on her. She would like to put him in an old person's home, but when she suggests
it his nervios gets worse. She asks the doctor if he would recommend a home for the old
man. The niece says that she must suffer for him out of her patience.

The cultural content o f nervios in this example is two-fold; first, the man is
expected to work as part o f his culturally determined sex role, but he can no
longer see well enough to perform his tasks; and second, the niece is expected
to continue to care for him in her home, but she is unwilling to fulfill her cul-
tural obligation. The occurrence of nervios in this situation somatically expresses
b o t h the old man's inability to conform to the cultural ideal - he can't live the
independent, healthy, tranquilo life that is so culturally desirable - and at the
same time reinforces the cultural expectation that the niece will affirm his iden-
tity as a family member b y responding to his nervios with concern and keeping
him at home. The symptom effectively communicates a culturally appropriate
message that releases the old man from his role expectations, while still main-
taining his position in the family.
Nervios as a s y m p t o m works to reaffirm a person's linkage to the social
system b y encouraging culturally appropriate behavior and adherence to cultural
norms. Individuals who experience delinquency, divorce, widowhood, old age,
illegitimacy as well as periodic episodes o f other socially unacceptable conduct
- alcoholism, crime, drug addiction or chronic illness - r i s k family exclusion
and have transgressed by not living tranquilo. Nervios provides a cultural me-
chanism for the social realignment o f the individual through the symbolic process
of symptom presentation and treatment. The symbolic analysis of the cultural
meaning of nervios adds a final dimension to the power of this s y m p t o m to
effect both interpersonal and sociocultural change.

CONCLUSION

Nervios can be interpreted as a communication about self and self's relation to

the social system expressed through a disturbance, or "discontinuity" of the
b o d y perception. The importance of the s y m p t o m is that it reflects both the
individual's relations in the social system and represents cultural participation;
it is a help-seeking behavior o f individuals or families attempting to reestablish
a balanced sociocultural state.

Some illness is interpreted as related to a derangement or imbalance in human relations...

The ailment has positive social function in that it provides a stimulus for the restoration of
social equilibrium. (Clark 1970: 202-203)
42 SETHA M. LOW

Nervios provides for a retum to social equilibrium through its symbolic ability
to somatically signal weakened family boundaries in a society where family is
the primary source of social identity. The individual presents nervios first to
family members, friends, and neighbors in an effort to reconfirm identity. If
the immediate community does not provide adequate support the individual
may then turn to the medical care system. Within the medical institution the
symptom is presented to a physician who responds positively to the patient
through acceptance and treatment of the symptom. The validation of the symp-
tom and the discussion of its social etiology suggests that nervios is an effective
and culturally acceptable manifestation and communication of a socially un-
acceptable reality.

ACKNOWLEDGEMENTS

The research data were collected over a period of twenty months from October
1972 through July 1974 supported in part by a National Institute of Mental
Health Combination Research Fellowship, number 1 FO1 MH 54060-01. Sup-
plemental funds were provided by a Special Career Fellowship in the Social
Sciences and Humanities and a Center for Latin American Studies Fellowship
from the University of California, Berkeley.
I would like to thank the doctors, staff and patients of Hospital San Juan
de Dios, Hospital Calderon Guardia, Hospital Mexico and Hospital Psiqiatrico
Manuel Antonio Chapui for their assistance and participation.

Department of Landscape Architecture and

Regional Planning, Graduate School
of Fine Arts
University of Pennsylvannia
Philadelphia, Pennsylvannia 19104

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