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ROBERTA D. BAER, SUSAN C. WELLER, JAVIER GARCIA DE ALBA GARCIA,


MARK GLAZER, ROBERT TROTTER, LEE PACHTER, AND ROBERT E. KLEIN

A CROSS-CULTURAL APPROACH TO THE STUDY OF THE FOLK


ILLNESS NERVIOS

ABSTRACT. To systematically study and document regional variations in descriptions of


nervios, we undertook a multisite comparative study of the illness among Puerto Ricans,
Mexicans, Mexican Americans, and Guatemalans. We also conducted a parallel study on
susto (Weller et al. 2002, Culture, Medicine and Psychiatry 26(4): 449–472), which allows
for a systematic comparison of these illnesses across sites. The focus of this paper is
inter- and intracultural variations in descriptions in four Latino populations of the causes,
symptoms, and treatments of nervios, as well as similarities and differences between nervios
and susto in these same communities. We found agreement among all four samples on a core
description of nervios, as well as some overlap in aspects of nervios and susto. However,
nervios is a much broader illness, related more to continual stresses. In contrast, susto seems
to be related to a single stressful event.

KEY WORDS: Latino folk illnesses, nervios, susto

INTRODUCTION

Although there have been detailed descriptions of nervios from case reports and
from specific regions, few attempts have been made to compare descriptions of
the illness across cultures. Nervios is often glossed as “nervousness” or “anxiety”
(Trotter 1982), although it is not synonymous with formal definitions of anxiety,
nor is it generally recognized by biomedical practitioners. Low (1985) attempted to
compare published descriptions of nervios in different populations, but found that
methodological differences in how individual studies were conducted made gen-
eralizations difficult. She suggested, however, that the similarity between nervios
and susto (a folk illness glossed as fright or shock) might mean that they were
both expressions of distress, but labeled differently by different segments of the
population. As such, unresolved issues include whether the term nervios means
the same thing in different cultural contexts, and the extent to which nervios and
susto represent similar or distinct illness entities.
Not simply part of the exotica of different cultures, folk illnesses have been
linked to morbidity and mortality. Susto is associated with an increased risk of co-
morbidities and a higher mortality rate (Baer and Bustillo 1993; Baer and Penzell
1993; Rubel et al. 1984) and nervios is now noted in the DSM-IV (American
Psychiatric Association 1994: Appendix 1). The study of these folk illnesses in
relation to physiological symptoms has not been for the purpose of reducing the
Culture, Medicine and Psychiatry 27: 315–337, 2003.
°
C 2003 Kluwer Academic Publishers.
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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 names
for the same problem, nervios sufferers may similarly be at increased health risk.
This paper explores inter- and intracultural variations in descriptions of the
folk illness nervios. Four diverse Latino populations are studied: Puerto Ricans
in Hartford Connecticut, Mexican Americans in South Texas, Mexicans in
Guadalajara, Mexico, and Guatemalans in rural Guatemala. Since a first step is to
understand an illness in its cultural context (Guarnaccia and Rogler 1999:1322)
and then analyze its relationship to co-morbidity, this study first describes nervios
within each of the four populations. One aim is to see if there is a distinct description
of nervios that is shared by culture members—a community explanatory model
of the causes, symptoms, and treatments for nervios. A second aim is to compare
descriptions across the four diverse sites to see the extent to which descriptions are
similar and different in different cultural contexts. Finally, we compare detailed
findings for nervios with those for susto in order to determine if these two folk
illnesses are synonymous or distinct.

BACKGROUND

One problem in our understanding of nervios is that studies have used a variety
of terms for the problem, including “nerves” (Finkler 1989; Krieger 1989; Sluka
1989), “nervousness” (Camino 1989; Koss-Chioino 1989), and “nervios” (Barnett
1989; Finerman 1989; Kay and Portillo 1989; Low 1989). The literature indicates
that the label “nervios” covers a broad range of problems in the mental health
realm, from depression to schizophrenia (Jenkins 1988). In some cultures, the term
nervios may be preferred over the term “mental illness,” and may be interpreted
much more broadly (Baer 1996). The similarity between nervios and susto suggests
that they may both be expressions of distress or stress, but the two different labels
may be used in different contexts (Low 1989).
Nervios has been studied in a variety of locations (including Latin America, the
Mediterranean, northern Europe, and the United States) (Davis and Low 1989).
But among some cultural groups, scholarship about nervios is less well developed
than for many of the other folk illnesses. This is particularly true for Mexican
and Mexican American populations (Trotter 1982). This pattern is curious, in that
Trotter (1982) found that in the lower Rio Grande Valley, nervios was the third
most frequent ailment reported (stomach ache and cough were first and second),
and the most frequent folk illness.
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The folk illness nervios is so widely reported across many contrasting regional,
linguistic, and demographic barriers that it defies description as a “culture-bound
syndrome” (Guarnaccia 1993). Nervios is consistently described as a culturally
approved reaction to overwhelmingly stressful experiences, especially concerning
grief, threat, and family conflict. However, it has been suggested that the way
the illness is experienced and conceptualized may vary across cultural groups
(Guarnaccia 1993).
Guarnaccia et al. (2003) have found that Puerto Ricans differentiate between
categories and experiences of nervios. Ser nervioso (being a nervous person) is
a result of traumatic experiences of suffering, and usually begins in childhood;
the condition lasts the rest of the person’s life and results in more life problems.
Symptoms include unusual amounts of crying, headaches, stomach aches, and
increased anger and violence, particularly in men. Herbal teas and the help of
family members, priests and ministers, and psychologists and psychiatrists were
the recommended treatments. Padecer de los nervios (suffering from nerves) is
more of an illness, and is associated with depression, although the body is also
affected. Life problems, including marital difficulties, are seen as the cause, and it
usually develops in adulthood. This condition is considered to be a form of mental
illness, and the help of physicians, psychologists and psychiatrists is recommended.
Ataques de nervios (nervous attacks) occur as the result of a stressful event, often
in the family setting. Those who are nervous or suffer from nerves are more likely
to suffer from nervous attacks. Due to an event such as the news of the death of a
family member, the person becomes hysterical and “out of control” (Guarnaccia
et al. 2003). This problem is more common in women, although it can occur in
men as well.
In Guatemala, nervios is conceived of and treated as an illness rather than a
symptom, and, according to Low, “is associated with experiencing strong 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-based
concerns in general, and socially manifested expressions of strong emotions in
particular (Low 1989:24). There is also an ethnic dimension in the recognition
and reporting of nervios; most studies have focused on nonindigenous 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
other stressful occurrences (Low 1989:31). Reported symptoms include headaches,
despair, facial pain, trembling, and anger (Low 1989:29). Treatment most com-
monly comes in the form of “nerve pills” bought in local stores or alternative home
remedies (Low 1989: 24). Further, Low suggested that nervios might be the term
used by more urban/ladino populations for what rural/indigenous people call susto
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318 ROBERTA D. BAER ET AL.

(Low 1985) and may reaffirm an “urban, upwardly mobile Ladino identity” (Low
1989:133).
In Mexico, as in Guatemala, there is a higher prevalence of nervios among fe-
males; this is attributed to their inferior social position (Finkler 1991:43). This
is further illustrated by reports that nervios is associated with stressed, harassed,
abused, and/or neglected women in rural Mexico (Davis and Low 1989; Salgado
de Snyder et al. 2000). In Mexican populations, nervios is simultaneously an ex-
planation of illness, a symptom of illness, and a state of illness. However, those
suffering from the symptoms of nervios report a wide variety of symptoms, in-
cluding feelings of desperation, headaches, chest pains, abdominal pains, high and
low blood pressure, and various familial, social, political, and economic concerns
(Finkler 1989; Salgado de Snyder et al. 2000). Patterns of treatment in Mexico in-
clude home remedies, especially herbal teas, frequently used in combination with
physician-prescribed medications (Finkler 1989).
Among Mexican Americans, Jenkins (1988) found that the term nervios is used
to cover everyday problems causing distress, serious family conflict, as well as
schizophrenia. Symptoms associated with nervios included irritability, hopeless-
ness, nervousness, depression, physical effects, and difficulty in functioning in
social or occupational roles. For Mexican and Mexican American farm workers in
Florida, nervios was the label that covered many conditions considered biomedi-
cally to be mental illnesses. However, nervios was not considered to be a mental
illness by the farm workers (Baer 1996). Causes of nervios included money, food
and work problems, and accidents; treatments suggested were talking to some-
one about the problems or getting medical or psychiatric help. Among Mexican
Americans, nervios has been reported as being more common in women (Jenkins
1988). In a study of widows, Kay and Portillo (1989) found that the more bi-
cultural a woman was, the less she was troubled by nervios. Both somatic and
nonsomatic symptoms were reported, but it was primarily the nonsomatic symp-
toms (fear, worry, anguish, anger, separation sorrow, loneliness, disorientation,
feeling empty, confusion, and a feeling of being in the way) that distinguished
nervios.
Although these findings suggest similarities among these populations in their
definitions of nervios, each study used a somewhat different approach and re-
search instrument that limits our ability to tell how similar nervios is among
diverse Latino populations. To systematically study and document regional vari-
ations in descriptions of nervios, we undertook a multisite comparative study of
nervios. Using four distinct geographic and cultural locations, we examined de-
scriptions of nervios to see the degree to which individuals within a community
reported similar causes, symptoms, and treatments for nervios, and then compared
descriptions across sites. We also conducted a parallel study on susto (Weller
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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 Grande
Valley community of Edinburg, Texas. This region is among the poorest metropoli-
tan areas in the United States. Located 15 miles from the US–Mexico border, the
area, although a mixture of urban and rural, is predominantly agricultural. The
population is 80% Mexican American. Hartford, Connecticut, is a medium-sized
city in the northeast United States. While only about one-third of the city’s 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-speaking
mestizos.
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 of nervios’). Additionally, in Edinburg,
respondents had to self-identify as being of Mexican descent, and in Connecticut
they had to self-identify as being of Puerto Rican descent. The preferred respon-
dent in each household was the female head of household, since we assumed
that women have more responsibility for health. Interviews were conducted by
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320 ROBERTA D. BAER ET AL.

bilingual research assistants in the language preferred by the interviewee (English,


Spanish, or a combination).

Questionnaire development
Ten to twenty initial key informant interviews at each of the four Latino sites
were used to develop the questionnaire. We focused on the term nervios, which
is recognized in all of the cultures studied, as opposed to the more extensive
variants of the condition seen among Puerto Ricans (Guarnaccia et al. 2003). Using
open-ended interviews and free listing techniques (Weller and Romney 1988),
qualitative data were gathered on the explanatory model of nervios, including
perceived causes, symptoms, and treatments of nervios (Table I).
In Mexico, respondents were also asked about similarities and differences be-
tween nervios and susto. On the basis of the open-ended interviews (any response
mentioned by at least 10% of the sample), symptoms from the Cornell Medical
Index, and the anthropological literature, a true-false questionnaire was developed.
The final questionnaire1 contained 125 items addressing the causes, symptoms,
and treatments for nervios. The questionnaire also included basic demographic
data on the respondent, as well as questions about experiences with nervios. Fi-
nally the questionnaire was translated into the form of Spanish (or English) spoken
at each particular site being studied.

Data analysis
Our goal was to determine the descriptions of nervios in the four Latino groups
as well as the degree of similarity and difference among the groups. This was
accomplished with a type of data analysis called consensus analysis. Given a set of
related, closed-ended questions, a consensus analysis accomplishes three things.
First, it provides an assessment of the agreement among respondents to see if
there is sufficient agreement to warrant aggregating responses. Then, if there is
sufficient agreement, it provides estimates of how well each person’s responses
correspond to the “group ideas.” Third, it provides estimates of the answers to the
set of questions.
A consensus analysis is an analytic tool that allows one to determine whether
there is group agreement—or consensus—in responses to structured questions.
Identifying or creating a reliable description of community explanatory models
includes an assessment of variability of ideas. If variability is high—that is, if
respondents do not agree with one another and do not seem to have similar ideas—
then it does not make sense nor is it accurate to create a unitary, simple aggrega-
tion of responses. If, however, informants report similar or identical information,
then one is justified in pooling the information to create an overall description of
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TABLE I
Nervios
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Who is Susceptible Causes Symptoms Treatments

Esquintla, Guatemala (n = 20)


10 Adults 6 Por problemas familiares 11 Dolor de cabeza 13 Calmantes
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6 Todos 6 Por enojarse 10 Dolor de muelas 4 Inyeccion (de calmantes)


2 Mujeres 5 Por peleas con las esposas 8 Dolor de cara 2 Aspririna
3 Por causas de accidentes 6 Le molestan los ruidos 2 Pastilla
3 Por falta de vitaminas 5 Enojos 11 Farmacia
3 Por tener susto 3 Brincan 8 Doctor
2 Por recibir noticia de repente 2 Tiemblan 6 En casa
2 Pleitos con los hijos 2 Desesperacion 4 Tiendas
2 Por una impresion (se emociona) 2 IGSS
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11 Se mueren
2 Se puede torcer la boca
2 Se empeora la enfermadad
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Guadalajara, Mexico (n = 20)


10 A la genta mas sensibles 8 Preocupaciones 10 Corajudo 8 Calamarse
5 Debiles de caracter 8 Susto 12 Depresion 9 Home remedies
5 Adultos 6 Problemas familiares 5 Nervios 7 Doctor
4 Ninos 3 Corajes 3 Manchas 6 Medicine
2 Las amas de casa 2 Herencia 3 Dolor de cabeza 5 Psychiatrist
2 A todo tipo de personas 2 A veces no sacan los papas a sus hijos 3 Grita
2 Personas de edad a distraerse; estar platicando con los 2 Sensacion de ahogamiento
2 Personas sin distracciones hijos y llevarlos a pasear 2 Perdida de conocimiento
2 Desesperacion
Edinburg, Texas (n = 20)
8 Anyone 17 Tension; stress; worry 12 Worried, startle easily; jumpy 11 Go to doctor
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5 10 years and older 2 Getting angry; overreacting 7 Very emotional; gets agitated easily 7 Go to Curandera
4 People who are weak 1 An evil spell 5 Pacing, rushing around 7 Relax; rest
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TABLE I
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(Continued)
322

Who is Susceptible Causes Symptoms Treatments

3 People who worry constantly 4 High blood pressure 5 Tea, herbal tea (manzanilla)
MEDI.cls

3 Shaking; chills 4 Counseling; therapy


2 Desperate; uncomfortable feeling 4 Pills
2 No sleep 3 No cure
2 See things that are not there 3 Medication from doctor
2 Rashes 2 Tranquilizers
2 Stomach has gas
2 Loss of appetite
2 Tense
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2 Headache
Hartford, Connecticut (n = 10)
3 Adults 3 Not contagious 2 Loss of control (of one’s nerves) 2 Medication
2 Everyone 1 Being overwhelmed with problems 1 Screaming 2 Pills prescribed by doctor
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1 People with a lot of stress in their lives 1 Problems dealing with life 1 Crying hysterically 2 Tranquilizers
who are unable to cope with problems 1 Depression 1 Not a physical illness; more mental 1 Bring to a doctor
1 Mainly women 1 Anxiety 1 Lots of crying and screaming upon 1 Therapy
1 Weak people who take their problems hearing bad news, especially if 1 Walking
too seriously someone dies 1 Speaking to another person
ROBERTA D. BAER ET AL.

1 Stress, problems 1 Drinking agua de azahar


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ideas in a group. Consistency among respondents’ answers is indicative of shared
knowledge.
Consensus analysis is conducted in a fashion somewhat analogous to factor
analysis. In factor analysis, the structure among a set of variables is described by
classifying items into groups or factors. A single factor solution indicates that all
of the items are “related” in some underlying way. Consensus analysis can be 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 respondent’s concordance
vis-à-vis the group (their cultural knowledge or “competency” score). The analysis
also provides a best estimate of the group’s answers to the questionnaire items,
using a Bayesian posterior probability approach wherein the responses of individ-
uals are weighted based on their relative knowledge vis-à-vis other respondents in
the group. In this study a conservative Bayesian classification rule was used. Items
were classified at the p ≥ 0.999 confidence level.
As with most sample size requirements, sample size determination is a function
of variability. In consensus analysis, the variation is the amount of agreement
among the respondents. For dichotomous response data, using a moderate level of
competency or agreement (0.50), a high confidence level for classifying items as
“true” or “false” (0.999), and a high accuracy for questions to be correctly classified
(0.95), a minimum number of 29 respondents per site are required (Romney et al.
1986; Weller and Romney 1988). To be sure that we had sufficient individuals for
comparative purposes within samples, a sample size of about 40 was obtained at
each site.

RESULTS

The sample
The final sample consisted of 40 respondents in Connecticut, 41 in Texas, 38 in
Mexico, and 40 in Guatemala. Respondents were primarily women (100% in the
Mexican and Texas samples, 90% in Guatemala, and 87% in Connecticut). All
of the informants in the Mexican sample were born in Mexico, and all of the
informants in the Guatemalan sample were born in Guatemala. In the Connecticut
sample, 90% were born in Puerto Rico; 70% of the interviews were conducted
in Spanish, 3% in English, and 28% in combined English and Spanish. In the
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324 ROBERTA D. BAER ET AL.

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 (17–83) 38.5 (20–85) 42.2 (18–81) 37.1 (20–58)
Total children (range) 6.3 (0–14) 4.4 (0–16) 2.8 (1–7) 2.8 (0–12)
Household size (range) 5.4 (1–9) 5.7 (1–11) 3.8 (2–9) 4.1 (1–8)
Education in years (range) 1.8 (0–9) 5.5 (0–13) 11.2 (0–16) 10.3 (0–15)
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 the
response data (the eigenvalue ratios all exceeded the recommended 3:1 ratio: 9.85
in Connecticut, 8.81 in Texas, 6.51 in Mexico, and 5.48 in Guatemala). Responses
were the most homogeneous in the Texas and Connecticut samples, resulting in
the highest levels of sharing (the average cultural knowledge scores were 0.73
in Texas and 0.62 in Connecticut). The Mexican and Guatemalan samples also
exhibited shared ideas, although at a somewhat lower level (0.52 in Mexico and
0.43 in Guatemala). Analysis with all four samples together indicated that they
share a single description of nervios, with about 52% of ideas in common (cultural
knowledge level = 0.52, eigenvalue ratio 6.45). A comparison of knowledge 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, and
r = +0.29, p = 0.07 in Guatemala) or with having had it (r = +0.24, p = 0.13
in Connecticut). Responses were not different ( p > 0.05) between men and women
in the Guatemalan and Connecticut samples, nor were responses different by lan-
guage preference in the Texas and Connecticut samples.
Although the four sites shared a common description of nervios, there was some
variability, as illustrated by a more detailed comparison between the samples. The
highest agreement occurred between the Connecticut and Texas samples with 78%
identical answers, followed by 64% agreement between the Texas and Mexican
samples, and 57% agreement between the Mexican and Guatemalan samples.
Tables III–VI show the questions about nervios that were classified using consensus
analysis by one or more of the samples as having the answer “true” or “yes.” Study
sites are indicated with a “G” for Guatemala, “M” for Mexico, “T” for Texas, or
“C” for Connecticut. Item classification is indicated with a “Y” for “yes” or “true,”
an “N” for “no” or “false,” and a hyphen (“-”) to indicate that the item could not
be classified as either true or false. We first discuss the findings for nervios and
then compare the findings with those for susto.
For susceptibility (Table III, columns 4–7), there was agreement among at least
three of the samples on 10 of the 14 questions (71%), and among all four samples
on 6 of those questions (43%). Nervios is seen in adults and older people, and
though it can occur in anyone, it is more common in sensitive people. The four
sites also agreed that nervios is not a problem among men, and does not occur only
in families who believe in it. Three of the sites also answered that nervios was seen
mainly in women, but also occurs in older children, people with low resistance,
weak people and those of weak character.
For causes of nervios (Table IV, columns 4–7), at least three samples agreed on
27 out of 31 (87%) of the questions, and all four samples agreed on 14 of those
questions (45%). All four samples reported that not eating well, drinking too much,
and using drugs can cause nervios. In addition, a fright (susto) or shock (seeing
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326 ROBERTA D. BAER ET AL.

TABLE III
Susceptibility

Susto Nervios
GMT GMTC

YYY YYYY Adults get it


YYY YYYY Old people get it
– YY YYYY Anyone, regardless of age and gender/sex
YYY YYYY More in sensitive people
NNN NNNN Mainly in men
N –N NNNN Only in families who believe in it
– YN YYNY Mainly in women
YYY – YYY Older children
YYN YYNY Mainly in weak people
YYN YYNY More in people with a weak character
– –N YNYY People with low resistance
YYY N–YY In young children
YYN YNNY In unborn children, if their mother has it
N –N NYNY Relatives of someone with it more susceptible
Y–NN A baby if breast feeding from a mother who has it

someone get killed or being in an accident) can cause nervios. Also important in
causality are strong emotions, anger, worry, family problems, and family fighting.
Nervios is not considered to be contagious. A relationship between susto and
nervios is evident, as susto was considered to be a cause of nervios. In addition,
several situations that are usually cited as producing susto—seeing someone killed,
seeing or being in an accident, or a surprise or shock—were also considered to
be causes of nervios. While the four sites agreed that a cause of nervios might
be not eating well (three sites also thought hunger could cause it), food stuck in
the stomach (usually associated with the folk illness empacho) was not considered
to be a cause of nervios. Three sites also agreed on a lack of hot/cold causality
of nervios. There was also agreement among three sites that witchcraft was not a
cause of nervios, but that the Devil might be.
For the symptoms of nervios (Table V, columns 4–7), there was agreement across
at least three of the samples on 62% of the questions (24 out of 39 questions), and
among all four of the sites on 44% (17 out of 39) of the questions. Symptoms
agreed upon by all four sites included depression or sadness, a feeling of no hope
in life, crying, hysterical crying or crying attacks, and shaking or trembling. Other
symptoms agreed upon by all four sites were headache, a feeling of choking, cold
sweat, weight loss, bad temper, insomnia, and anger caused by small things. There
was also agreement that runny nose, fever, slow healing wounds, and a swollen
stomach were not symptoms of nervios. Additional symptoms agreed upon by
three of the sites included lack of appetite, agitation, and convulsions or seizures.
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TABLE IV
Causes

Susto Nervios
GMT GMTC

NNN YYYY From not eating well


N–N YYYY From drinking too much alcohol
NYN YYYY By using drugs
YYY YYYY Nervios causes susto/fright or susto causes nervios
YYY YYYY By seeing someone get killed
YYY YYYY By seeing or being in an accident
YYY YYYY By a sudden surprise or shock
–YN YYYY By fighting (between spouses or with children)
YYYY By strong emotions (good or bad)
YYYY From anger
YYYY By worrying a lot
YYYY From family problems
N–N YYNY From living in a dirty house
NNN –YYY From hunger
YYN YYNY By the devil
––N YYNY From low resistance
N–N Y–YN By a hard, envious stare
NNN YNNN From cold foods (or drinks)
NNN YNNN By getting wet when you are sweating
YNN YNNN By being exposed to drafts/wind/air
NNN Y–NN By parasites
–YN –YNN By spirits
NNN NNNN From food stuck in the stomach
N–N –NNN By witchcraft
NNN NNNN By using the utensils of someone who has it

For treatments (Table VI, columns 4–7), at least three of the samples agreed
on 73% (30 out of 41) of the questions, and all four samples agreed on 51% (21
out of 41) of the questions. For all four of the sites, over the counter remedies
(such as aspirin, Vicks, cod liver oil, Alka Seltzer), antibiotics, and treatments
used for other folk illnesses (such as barrida, or sweeping with herbs, rubbing
with an egg, a spoonful of oil, pulling the skin of the body until it pops, or binding
the waist) were not indicated for use in the treatment of nervios, nor were the
services of the folk healers, curanderos, or spiritualists. Other treatments rejected
by all groups included spearmint tea, enemas, scaring the affected person, drinking
alcohol, warm towels on the body, and drinking milk. Sedatives, praying, and
trying to relax were the only suggested treatments agreed on by all four samples.
Additionally, three of the sites recommended the use of physicians and psychiatrists
or psychologists, and rejected the use of holy water sprinkled on the body in the
shape of a cross, as well as the use of a pharmacist, herbalist, wise old woman, or
grandmother. Three sites reported that nervios would go away by itself.
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328 ROBERTA D. BAER ET AL.

TABLE V
Symptoms

Susto Nervios
GMT GMTC

YYY YYYY Crying


YYY YYYY Hysterical crying or crying attacks
YYY YYYY Difficulty going to sleep and staying asleep
YYY YYYY Frequent shaking or tembling
YYYY Sadness (and depression)
YYYY A feeling of no hope in life
YYYY Small things cause anger
YYYY A bad temper
Y–N YYYY A headache
N–– YYYY A feeling of choking
–YY YYYY A cold sweat
YYN YYYY Weight loss
YYN Y–YY A lack of appetite
YYY Y–YY Agitation
YYNY A convulsion or seizure
––N YYNN Cloudy or blurred vision
N–Y ––YY Difficulty breathing
N–Y N–YY Stomach pain or stomachache
NYY NNYY Vomiting
NYY NNYY Diarrhea
NNN Y–Y– Itching
YYY –YYN Paleness
––N Y–YN Sleepiness
Y–Y YNY– Chills
YYN YNYN Muscle and body aches/pains
Y–YN Losing consciousness
–NN Y–NN Affected hearing (ringing or buzzing)
N–Y NY–N Frequent urination
NNN –NNY Chest pain
Y–NN Aching teeth
YNNN 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 of nervios, and only they considered face pain to be a symptom and garlic
to be a treatment. It would appear that as far as nervios causality is concerned,
hot–cold explanations are more important in Guatemala than at the other sites. An-
other distinctive pattern occurred in the Mexican and Guatemalan samples, where
untreated nervios was reported to cause a person to become diabetic or the mouth
to become twisted and deformed.
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TABLE VI
Treatments

Susto Nervios
GMT GMTC

NYN YYYY Sedatives


–YY YYYY Trying to relax (keep calm)
YYY YYYY Praying
NYY –YYY Massages
NNN Y–YY Doctor
–YN YY–Y Psychiatrist or psychologist
NNN –NNN Pharmacist
YYN –NNN Herbalist
Y–N –NNN Wise old woman/grandmother
YN– NNNN Curandero
NYN –YNY Tea of orange leaves or orange blossom
YYN YYNN If not treated, person becomes diabetic
YYNN If not treated, mouth becomes deformed and twisted
NNN N–NY Camomile tea
––N Y–NN Vitamins
NNN YNNN Garlic
N–N –YNN Rubbing the back and chest with alcohol
YYY –YN– Treated at home
YYN –YN– Go to church
NNY NNYN Go away by itself
YYN Y–N– If not treated, can one die
Y–N N–NN 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 illnesses—Guatemala,
Mexico, and Texas. The methodology used in both the susto and nervios studies
was the same; in fact, 85 of the questions used in the two studies were 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 older
children can suffer from susto, but this is not the case for nervios which seems to
be more of an adult problem. Nervios is felt to occur mainly in women, while susto
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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 one’s life,
and include family problems and fighting, drugs, alcohol, worry, anger, and strong
emotions (Table IV). Note, however, that susto can cause nervios and that nervios
can cause susto.
A similar pattern is seen with regard to symptoms of nervios and susto, with
overlap in symptoms such as crying, shaking, and difficulty sleeping (Table V).
However, there are many symptoms that are unique to each illness. Paleness may
be more restricted to susto, while headache, a feeling of choking, cold sweat, and
weight loss are associated more with nervios. Neither illness seems to manifest
solely with somatic symptoms. While praying is recommended for both susto
and nervios, the most striking difference between the two illnesses is the use
of Western versus folk treatments. While a doctor or psychologist or 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 nervios
and susto. We found that both sets of interviews contained similar themes: susto is
considered to be briefer than nervios, and nervios is more chronic and is a continual
stress. Susto is caused by an identifiable event—a “susto”—while nervios is caused
by persistent problems.
In summary, there is an overlap in many aspects of these two illnesses. Both
tend to occur more in adults; both are caused by surprising, shocking, or disturbing
occurrences. Both present with symptoms of distress; neither presents solely with
somatic symptoms. However, nervios is a much broader illness, related more to
continual stresses. In contrast, susto seems to be related to a single stressful event.
There are a few broadly recommended treatments for nervios, while those for susto
show more regional variation.
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DISCUSSION AND CONCLUSIONS

The core description of nervios agreed on by all four sites supports the patterns
reported in the literature for these individual populations. Nervios is felt to 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 of susto, mal de
ojo, and caida de la mollera varied by social class. Recognition was highest in the
lower class, intermediate in the working class, and lowest in the middle class. But
unlike other folk illnesses, recognition of nervios in Mexico was not class related.
Similarly, we found no meaningful variation in relevant themes for nervios by
degree of acculturation. In the Texas and Connecticut samples, a very crude index
of acculturation can be estimated by birthplace and language preference. Responses
did not differ significantly on either of these variables.
Nervios and susto are distinct entities. While it has been suggested in the 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 of susto as an illness, unlike that of nervios, may be class
related.
Recognition of susto also varies by region. It is also important to note that
although nervios was considered to be an illness at all four sites, susto was not
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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 of
nervios as well as similarities and differences in that definition among the four
Latino groups studied. The relationship to susto has been clarified, and a link to
diabetes for at least two of the populations studied is suggested as an important
area for further research. While the samples at each site were representative of
the variability in each of those populations, the results cannot be generalized
to, for example, all of Mexico from the Guadalajara sample, or to all Mexican
Americans from the south Texas sample. The similarity in findings across such
diverse samples, however, suggests that the findings would apply to many more
regions than those actually sampled. Because such strong similarities were found
in descriptions from places ranging from rural Guatemala to urban Connecticut,
it is likely that those same themes would be important to Latinos in regions other
than those sampled for this study.
Our approach also demonstrates a number of important directions for the future
study of these conditions. First, this study of nervios demonstrates a way to study
ethnomedical phenomena in their cultural contexts that also allows for 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 yes–no questionnaire) that incorporated
themes from each community’s explanatory model (as well as other items, some
of which had biomedical origin). From this, we were able to determine which
aspects of explanatory models were shared and which were distinct. Our two-step
approach, which incorporated themes from all sites in the interviews, allowed us
to verify whether or not themes mentioned in the open-ended interviews were
important within a community and across communities. The advantage of the
structured interviews was that themes that were mentioned at one particular site
but not at another could also be confirmed. Reliance on the open-ended interviews
alone may have missed some themes relevant across sites. We were also able to
determine similarities and differences between nervios and another folk illness,
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susto. We therefore suggest such an approach as important and appropriate for
cross-cultural ethnomedical research.
We also feel that our approach extends that of Guarnaccia and Rogler (1999).
While they emphasize the importance of describing folk illnesses within their 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 mind–body di-
vision of Western cultures—and of biomedicine—which discounts the relationship
between folk illnesses and physiological disorders. The ethnomedical systems in
which these illnesses are embedded do not recognize a mind–body distinction, and
indeed see a fluid relationship between the physical body and its problems, the
mind, emotions, and the spiritual. If we really want to understand folk illnesses,
we need to allow for the possibility that these categorizations of symptoms may
cross over the neat lines that separate the psychiatric and the physiological in
the biomedical conceptualization. In the case of nervios (and susto as previously
demonstrated by Rubel et al. 1984 and Baer and Penzell 1993), it appears that the
ethnomedical evidence supports a relationship between nervios/susto and physio-
logical as well as psychological problems. Informants’ descriptions of nervios and
susto suggest a connection between nervious and susto and diabetes in two of the
populations studied. The testing of this and other reported relationships between
folk illnesses and biomedical diseases is clearly an important next step in our
understanding of the meaning and implications of these ethnomedical diagnoses.
Biomedicine poorly understands illnesses that transcend the mind–body 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 of nervios, which can only suggest possible factors related to nervios.
For susto, however, there are no comparable epidemiological data. Given that
there is considerable overlap between nervios and susto, mental health surveys
of Latinos should also include susto (although it may or may not exist as an
illness category in specific ethnic groups). The addition of a few questions that
request information on susto would go far in providing population-based 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 of nervios, susto, and other folk illnesses.
Susto (and possibly other folk illnesses) needs to be included on mental health
surveys; nervios (and possibly other folk illnesses) needs to be investigated in terms
of its relationship to stress, depression, physiological symptoms, and mortality. We
cannot continue to assume the separation of the health problems of the mind and
the body when the evidence suggests that such a division may just be an artifact
of our own creation, which obscures rather than illuminates the reality of patterns
and causality of human illnesses.

ACKNOWLEDGMENTS

This project was funded by the National Science Foundation grants BNS-9204555,
SBR-9727322, and BC-0108232 to S. Weller, and SBR-9807373 and 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 Florida
Tampa, FL 33620

Susan C. Weller
Department of Preventive Medicine
University of Texas Medical Branch
Galveston, TX 77555-1153
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Javier Garcia de Alba Garcia


Social Epidemiological and Health Services Research
Unit of IMSS, and Hospital Civil of Guadalajara, J. I.
Menchaca, Guadalajara
Mexico

Mark Glazer
University of Texas Pan American
Edinburg, TX 78539-2997

Robert Trotter
Department of Anthropology
Northern Arizona University
Flagstaff, AZ 86011

Lee Pachter
Department of Pediatrics
University of Connecticut School of Medicine
St. Francis Hospital and Medical Center
Hartford, CT 06105

Robert E. Klein
Medical Entomology Research Training Unit/Guatemala (MERTU/G)
Centers for Disease Control and Prevention