'Nerves': folk idiom for anxiety and depression?

Blood, Sweat, and/or Tears: Comparing Nervios Symptom Descriptions in Honduras

With the aim of advancing the cross-cultural investigation of the folk illness nervios, I conducted a dual-sited comparative study of symptom descriptions among two diverse research settings in Honduras. Baer et al. (Cult Med Psychiatry 27(3):315-337, 2003) used cultural consensus modeling (CCM) to confirm a core description of nervios among four Latino groups in the US, Mexico, and Guatemala, but observed that overall agreement and average competence in a shared illness model decreased along a gradient from presumably more-to-less economically developed sites. This has left unresolved whether such variation extends to other Latin American regions. This paper is an exploratory analysis of inter- and intracultural variation in nervios symptom descriptions by 50 Hondurans from the market town of Copán Ruinas (n = 25) and city of San Pedro Sula (n = 25). I performed CCM using a combination of free-listing, pile-sorting, and rating activities to establish if respondents across sites share a single model of nervios. I found consensus for the San Pedro Sula subsample, but not for Copán Ruinas or for the overall sample. Results suggest nervios is constitutive of differing forms of distress ranging from chronic illness to acute suffering, as well as anger- and panic-based manifestations that overlap with biomedical ideas about depression, anxiety, and panic disorder. This variation derives in part from demographic factors such as age, gender, and residence, but may also result from ethnic and regional diversity among subsamples. However, consensus only being present among San Pedro Sula respondents suggests their greater awareness of cultural distinctions between biomedical and folk medical knowledge, which is likely due to their exposure to manifold health frameworks in those settings.

Dangerous sadness: nervoza among first and second generation Macedonian immigrants to Australia

OBJECTIVE

Nervoza is a commonly-used illness category among Macedonian Australians. Although nervoza belongs broadly to the category of 'nerve illnesses' little is known of its meaning among Macedonian immigrants, and whether there is intergenerational attrition in its meaning and use. We aimed to explore how nervoza and its treatment are perceived by members of the Macedonian community in Australia.

DESIGN

In-depth interviews in Macedonian with 18 participants from the Macedonian community in Melbourne, Australia.

RESULTS

Nervoza is a layered concept relating shame, emotional experience and nerves, used as an idiom of distress and sadness in the presence of acute and chronic stressors. Nervoza develops in both the social world (through poverty, grief or the loss of war), and in the psyche of distressed and isolated people. It is viewed as dangerous on many levels: to physical health, as a 'gateway condition' to long-term psychological illnesses such as depression and schizophrenia, and to the person's social well-being. The normalised treatment for nervoza in Macedonia - benzodiazepines - is the subject of significant medical control in Australia.

CONCLUSION

For sufferers of nervoza, the social self is both medicalized and stigmatised. Health services in Australia are often considered marginal in the management of nervoza. Second generation Macedonians viewed the concept as unhelpful, and possibly increasing the stigmatisation of mental illnesses. The lack of knowledge about, and underutilisation of, mental health services and support groups in the Macedonian Australian community should be the focus of community-based inter-generational health literacy initiatives.

Obeah-illness versus psychiatric entities among jamaican immigrants: cultural and clinical perspectives for psychiatric mental health professionals

In order to provide culturally authentic healthcare, psychiatric-mental health nurses and other professionals must familiarize themselves with the culture-specific syndromes, idioms of distress, beliefs and practices that may present among the diverse patient groups with whom they work. Psychiatric conditions relating to the Jamaican belief in "Obeah" are specific, culturally-interpreted phenomena that psychiatric nurses may encounter among Jamaican patients. This paper describes the phenomenon of Obeah and its influences on the worldview of life, health, illness; psychiatric conditions in the form of culture-bound syndromes; and help-seeking behaviors throughout Jamaican cultural communities. Inability to understand the obeah-illness concept from a culturally-interpreted perspective may be constrictive and result in less-than-optimal care. Armed with the knowledge of the concept of Obeah from a core belief perspective, how it influences psychiatric presentations, and embracing its significance to the Jamaican health belief model will assist in building a workable, caring, best-practice framework aimed toward a clinical and practice paradigm for this unique folk-health belief system.

Explanations of illness experiences among community mental health patients: an argument for the use of an ethnographic interview method in routine clinical care

Cultural variations in perceptions of mental distress are important issues for healthcare. They can affect communication between patients and professionals and may be a root cause for misdiagnosis, patient disengagement, and disparities in access, outcomes and overall experiences of treatment by patients. Taking into account patients' explanatory models (EMs) of mental distress is fundamental to patient-centred care, and improved outcomes. This paper reports on the outcomes from the Cultural Consultation Service, commissioned in an inner-city London borough. We used a narrative-based ethnographic method of assessment, in which community mental health patients referred for a cultural consultation were interviewed using Barts Explanatory Model Inventory and Checklist (BEMI) to assess the EMs of their mental distress. Patients mainly attributed the causes and consequences of their mental distress to emotional and psychological factors, which were inextricably linked to existing social concerns and interpersonal issues. Desired solutions mainly focused on treatment, social, and systemic interventions. We found that using BEMI could contribute to a comprehensive assessment in routine care and can be used by professionals within a short timeframe and with minimal training. Ethnographic assessment method captures patients' EMs and illness experiences, opening the way for patient-centred interventions and potentially better outcomes and experiences.

Bridging Psychiatric and Anthropological Approaches: The Case of "Nerves" in the United States

Psychiatrists and anthropologists have taken distinct analytic approaches when confronted with differences between emic and etic models for distress: psychiatrists have translated folk models into diagnostic categories whereas anthropologists have emphasized culture-specific meanings of illness. The rift between psychiatric and anthropological research keeps "individual disease" and "culture" disconnected and thus hinders the study of interrelationships between mental health and culture. In this article we bridge psychiatric and anthropological approaches by using cultural models to explore the experience of nerves among 27 older primary care patients from Baltimore, Maryland. We suggest that cultural models of distress arise in response to personal experiences, and in turn, shape those experiences. Shifting research from a focus on comparing content of emic and etic concepts, to examining how these social realities and concepts are coconstructed, may resolve epistemological and ontological debates surrounding differences between emic and etic concepts, and improve understanding of the interrelationships between culture and health.

Nerves as embodied metaphor in the Canada/Mexico seasonal agricultural workers program

This article examines nerves among participants in the Canada/Mexico Seasonal Agricultural Workers Program (C/MSAWP). Based on in-depth interviews with 30 Mexican farm workers in southwestern Ontario, we demonstrate that nerves embodies the distress of economic need, relative powerlessness, and the contradictions inherent in the C/MSAWP that result in various life's lesions. We also explore their use of the nerves idiom as an embodied metaphor for their awareness of the breakdown in self/society relations and, in certain cases, of the lack of control over even themselves. This article contributes to that body of literature that locates nerves at the "normal" end of the "normal/abnormal" continuum of popular illness categories because, despite the similarities in symptoms of nerves among Mexican farm workers and those of anxiety and/or mood disorders, medicalization has not occurred. If nerves has not been medicalized among Mexican farm workers, neither has it given rise to resistance to their relative powerlessness as migrant farm workers. Nonetheless, nerves does serve as an effective vehicle for expressing their distress within the context of the C/MSAWP.

Lives in isolation: stories and struggles of low-income African American women with panic disorder

Research evidence points to the existence of racial-ethnic disparities in both access to and quality of mental health services for African Americans with panic disorder. Current panic disorder evaluation and treatment paradigms are not responsive to the needs of many African Americans. The primary individual, social, and health-care system factors that limit African Americans' access to care and response to treatment are not well understood. Low-income African American women with panic disorder participated in a series of focus-group sessions designed to elicit (1) their perspectives regarding access and treatment barriers and (2) their recommendations for designing a culturally consistent panic treatment program. Fear of confiding to others about panic symptoms, fear of social stigma, and lack of information about panic disorder were major individual barriers. Within their social networks, stigmatizing attitudes toward mental illness and the mentally ill, discouragement about the use of psychiatric medication, and perceptions that symptoms were the result of personal or spiritual weakness had all interfered with the participants' treatment seeking efforts and contributed to a common experience of severe social isolation. None of the focus-group members had developed fully effective therapeutic relationships with either medical or mental health providers. They described an unmet need for more interactive and culturally authentic relationships with treatment providers. Although the focus-group sessions were not intended to be therapeutic, the women reported that participation in the meetings had been an emotionally powerful and beneficial experience. They expressed a strong preference for the utilization of female-only, panic disorder peer-support groups as an initial step in the treatment/recovery process. Peer-support groups for low-income African American women with panic disorder could address many of the identified access and treatment barriers.

Susto and nervios: expressions for stress and depression

Folk illnesses that are cultural constructions of psychological distress offer a vehicle for the cross-cultural study of stress and stress-related morbidity. This study explores the relationship between the Latin American folk illnesses susto and nervios and mental health. We hypothesize that these folk illnesses are distinct and that there is a stronger association between current levels of stress and depressive symptoms with past experience of nervios than with susto, because the cultural constructions of these folk illnesses reflect chronic and acute concepts of distress, respectively. Interviews were conducted in Guadalajara, Mexico, where participants responded to questions about their socio-demographic characteristics, stress, depressive symptoms, and whether they had experienced susto or nervios. Susto and nervios are very prevalent and occur across sociodemographic subgroups, with the exception that nervios occurred more often in women (p < 0.05). Susto was significantly associated with stress and depressive symptoms (p < 0.05), but nervios had a much stronger association (p < 0.0001), even after controlling for gender. Susto and nervios were expressions of psychological distress; most of those with depression reported susto and/or nervios. This study validates the link between these folk illnesses and stress and depression and may, ultimately, facilitate cross-cultural research on stress.

Diagnostic validity of two instruments for assessing anxiety and depression among pregnant women in Hyderabad, Pakistan

The objective of this study was to compare the diagnostic validity of two measures, the Aga Khan University Anxiety and Depression Scale (AKUADS) and the How I Feel scale, for assessing anxiety and depression among pregnant women in Pakistan. The sample included 200 pregnant women in Hyderabad, Pakistan. Using psychiatrist-administered Diagnostic and Statistical Manual of Mental Disorders-fourth edition (DSM-IV) criteria, 71 (36%) of the women were diagnosed with depression or anxiety or both. Receiver operating characteristic (ROC) analyses indicated that the two scales had similar levels of discrimination. This study represents an important initial step in developing measures to assess the psychological well-being of Pakistani pregnant women. Additional research is needed, however, to improve the sensitivity and specificity of these scales by removing items that do not function well in this population.

Social support and distress among Q'eqchi' refugee women in Maya Tecún, Mexico

This article addresses issues of vulnerability and distress through an analysis of the relationship between social support networks and traumatic stress in a Q'eqchi' refugee community in southern Mexico. The sociopolitical violence, forced displacement, and encampment of Guatemalan Mayan populations resulted in the breakdown and dispersal of kin and community groups, leaving many Q'eqchi' women with weakened social support networks. Research involving testimonial interviews and traumatic stress and social support questionnaires revealed that Q'eqchi' refugee women with weak natal kin social support networks reported greater feelings of distress and symptoms of traumatic stress than did women with strong networks. In particular, a condition identified as muchkej emerged as one of the most significant symptoms reported by women with weak natal kin support networks. I critically consider muchkej as an idiom of distress and argue that aid organizations should consider the relationship between social support and traumatic stress, as expressed through such idioms, when attempting to identify vulnerable members of a refugee population.

Maternal cognitions about distress and anxiety in young Latino children with disruptive behaviors

This study was undertaken to describe how Caribbean Latina mothers understand distress in children, the behaviors that they attribute to it, and the labels that they use to express their cognitions. Findings from 62 mothers of young children with disruptive behaviors indicated that mothers made attributions about anxiety in 40% of the children with a high likelihood of clinical anxiety. Hyperactive and restless behavior, but not children's fears, was understood by mothers to reflect anxiety. References to 'nervios' could be categorized into: an illness condition, a crisis condition, and a temperament type. Only temperament usage was applied to children.

No comfort in the rural South: women living depressed

Despite the widespread notion of the bucolic life in the country, major depressive disorder (MDD) is common among impoverished women in the rural South. Women with MDD seldom get treated because of the paucity of treatment available, the inability to pay for services because of no insurance, and the distance they must travel to reach care. Even if treatment was available, impoverished rural Southern women are unlikely to seek services because of cultural and social prohibitions. These include incongruence between the biomedical model of MDD and sociocultural explanations for its causes and manifestations, stigma, and traditional viewpoints of women that keep them isolated and invisible. Innovative treatment strategies must be devised for these women that are based on local views of MDD and its treatment, and people and monetary resources available in poor rural economies. Needed research with this population include ethnographic studies to gain understanding of the cultural factors associated with MDD and its treatment and evaluation of outreach, and other novel paradigms of rural service delivery including the use of nonprofessional personnel. Although the problems of treatment and research with this population are daunting, there is an opportunity for imagination, innovation, and creativity in devising local solutions to local problems.

From illness narratives to social commentary: a Pirandellian approach to "nerves"

The concept of "nerves" is an integral component of the language of distress found in a number of societies. Individuals, however, often extend its meaning well beyond the realm of suffering. In this article, I examine some Sicilian-Canadian uses of "nerves" from a Pirandellian perspective. This, I believe, gives us an insight into how people (1) make use of illness narratives to give meaning to their life experiences, and (2) attempt to influence the thought and behavior of significant others. In the process, I address the question how do we move away from anthropological definitions and explanations that tend to simplify or mask some of the rich complexities surrounding the meaning(s) of "folk" concepts?

Travelling with "excess baggage": health problems of refugee women in Western Australia

Refugee women face problems during resettlement in host countries that are often worse than those faced by voluntary migrants. Although these problems are generally thought to be related to previous traumatic experiences, this may not always be the case; there are many refugee women who may not have personally experienced torture or trauma but who nonetheless express needs that suggest a perception of profound marginalisation from the mainstream society. This paper summarises the health problems identified in a needs assessment of refugee women from Latin America resident in Perth, Western Australia and discusses some of the issues that create "excess baggage" for refugee women.

Subtypes of ataques de nervios: the influence of coexisting psychiatric diagnosis

The current study assesses the relationship between presenting symptomatology of the self-labeled Hispanic popular diagnosis of ataques de nervios and the specific co-morbid psychiatric diagnoses. Hispanic subjects seeking treatment at an anxiety disorders clinic (n = 156) were assessed with a specially designed self-report instrument for both traditional ataque de nervios and panic symptoms, and with structured or semistructured psychiatric interviews for Axis-I disorders. This report focuses on 102 subjects with ataque de nervios who also met criteria for panic disorder, other anxiety disorders, or an affective disorder. Distinct ataque symptom patterns correlated with co-existing panic disorder, affective disorders, or other anxiety disorders. Individuals with both ataque and panic disorder reported the most asphyxia, fear of dying, and increased fear during their ataques. People with ataques who also met criteria for affective disorder reported the most anger, screaming, becoming aggressive, and breaking things during ataques. Ataque positive subjects with other anxiety disorders were less salient for both panic-like and emotional-anger symptoms. The findings suggest that (a) ataque de nervios is a popular label referring to several distinct patterns of loss of emotional control, (b) the type of loss of emotional control is influenced by the associated psychiatric disorder, and (c) ataque symptom patterns may be a useful clinical marker for detecting psychiatric disorders. Further study is needed to examine the relationship between ataque de nervios and psychiatric disorders, as well as the relationship to cultural, demographic, environmental, and personality factors.

Expressions of anxiety in African Americans: ethnography and the epidemiological catchment area studies

High levels of anxiety have long been reported for African Americans. Recent analyses of Epidemiological Catchment Area (ECA) data have failed to support this, although contemporary ethnographies have discussed important African American folk idioms of anxiety. This study compares ethnographically reported symptoms of anxiety in African Americans to those reported in the ECA data. A multivariate analysis of female African American and European American differences in comparable ECA and ethnographic symptoms was performed. Significant differences were found not in ethnicity but in education levels. Alternative interpretations are discussed. Methodological problems are discussed highlighting limitations of both household survey research, such as the ECA project, and ethnography.

Gender, emotion, and physical distress: the Sicilian-Canadian "nerves" complex

Researchers identify "nerves" as an idiom of distress, an illness category, a metaphorical device capable of communicating social distress, and a technique for impression management. Much of the literature, however, links "nerves" to women. In this paper, I address two aspects of the phenomenon which have received limited attention. First, I discuss "nerves" within the context of Sicilian-Canadian conceptions of anatomy and physiology. Sicilian-Canadians regard "nerves" as essential components of the human anatomy which, in some cases, may be linked to both physical and psychic distress. Second, I build on this discussion to examine how Sicilian-Canadian males make use of the "nerves" idiom. The implications of my work include the need to: (1) modify our definition of "nerves" to recognize formally that we are dealing with a dynamic complex consisting of multiple, variable, and ambiguous meanings--meanings that enable people to confront or cope with a variety of situations; (2) direct greater attention to "nerves" as an idiom of physical distress; and, (3) examine further the role of physical "nerves" in the social construction of gender.

Professional constructions of a 'lay' illness: 'nerves' in a rural 'coloured' community in South Africa

As part of a larger study, medical practitioners working in Mamre, a 'coloured' village close to Cape Town, South Africa, were interviewed concerning their use of the term 'nerves' in interaction with their patients. Contrary to the initial perception of researchers and some clinicians, the term is not simply a folk category. It does, however, represent a medium through which psychosocial issues are discussed in the clinical encounter. Differences in the usage of the term by different practitioners seemed to indicate different attitudes towards patient care. The data are presented and discussed in the context of debates concerning the development of more accessible and responsive health services in a future South Africa, and the information gleaned has implications for future training of clinicians.

The child's disease (Doença de criança): popular paradigm of persistent diarrhea?

According to popular report, the folk illness, Doença de criança (The Child's Disease) is the leading cause of infant and childhood death in Northeast Brazil; most health professionals, however, are unaware it exists. Doença de criança is described based on ethnographic interviews with 50 traditional healers and 50 bereaved mothers whose children have died from the condition. Doença de criança is a sociocultural label developed by the popular medical system and applied to the end stages of severe childhood infectious diseases and malnutrition against a background of grinding poverty. Doença de criança is discussed as an analog to persistent diarrhea. Practical treatment and management implications of this relationship are presented. Doença de criança, most importantly, offers a new, holistic paradigm for the future study of persistent diarrhea.

Nervios and dysphoria in Mexican American widows

One hundred widows participating in experimental research entitled Efficacy of Support Groups for Mexican American Widows were studied to learn how they express the loss of their husbands. Mourning practices, acknowledged symptoms of dysphoria, and somatic reactions were studied to learn if the syndrome of nervios subsumes their reaction to bereavement. In addition, their responses to instruments designed to measure depression, the Spanish version of the Beck Depression Inventory and the Center for Epidemiologic Studies Depression Scale, were examined for correlation with nervios and relationships to Mexican American acculturation. Nervios seems to be a manifestation of dysphoria rather than a specific syndrome for these women.

Nerves, worriation, and Black women: a community study in the American south

The experience of nerves among women in a low-income Black neighborhood was examined. Research conducted in the neighborhood revealed nerves as a formal classification of folk illness linked with life stress, yet in-depth interviews with a purposeful sample of 24 residents showed that a greater manifestation of nerves among women contributes to tendencies among family members to ignore the severity of its symptoms and to equate experiences of nerves with life conditions deemed inevitable for women. Lack of support for nerves among female sufferers was also evident among friends and physicians. These findings are analyzed against a background of gender-specific concepts of nerves and "worriation" operating in the neighborhood. Residents aver that women's "naturally" weaker constitutions and a moral imperative to worry places them at greater risk for nerves. Implications for clinical care of low-income Black women with nerves are discussed, and specific recommendations for culturally appropriate interventions are outlined.