Ataques de Nervios

In European and American mental health, mental disorders are defined by symptom checklists in the Diagnostic Statistical Manual (DSM) or the International Classification of Diseases (ICD) (Fernando, 2010). When a set of symptoms beyond a Western country does not fall in DSM or ICD’s checklists, the symptom cluster is called a culture-bound syndrome (CBS). These take into account the cultural and social aspect of mental health that DSM fails to account for. Mental disorders lack the biological diagnostic tools and diagnosis instead depends on culturally based markers that may decrease the validity of diagnosis (Nogueira, Maria, Razzouk, 2015).

Commonly found in Puerto Rico and the Dominican Republic, the CBS named Ataques de Nervios shares many similarities to anxiety disorders and was recently noted as "idioms of distress" (Hofmann & Hinton, 2014). This syndrome is “considered normal by many Latinos” and has affected up to 13.8 percent of people in Puerto Rico. Ataques implies disruptive behavior triggered by emotional stressful event while Nervios was characterized by chronic dysphoric mood states. Patients with the Ataques de Nervios commonly suffer from feeling the heat within their bodies, loss of control, chest tightness, palpitations, arm or leg shaking, a feeling of impending fainting, a fear of dying or losing control because of the bodily symptoms, and dissociation symptoms such as amnesia, identity alteration, and depersonalization (Lewis-Fernández et al., 2002). Guarnaccia describes the syndrome as “anger episodes or grief reactions.” (Guarnaccia et al., 1993).

The syndrome typically develops when the person experiences negative event, such as a trigger to a traumatic memory or terrible news about a loved one (Lewis-Fernández et al., 2002). If the distress or anxiety escalates, then the person may experience Ataques symptoms and even an attack. In places such as Puerto Rico and Dominican Republic, and among many US Latinos, this mental health illness is viewed as culturally acceptable behavior secondary to the stress and individual experiences. Symptoms often cease with an increase in an individual’s social support system. Individuals will turn to family, friends, and folk healers; however, among many Hispanic Americans there is increased medical seeking – psychiatrist or psychologist – as a treatment for Ataques de Nervios (Durà-Vilà, Hodes, 2012). This difference could be attributed to difference in acceptable cultural behavior and diagnosis of mental disorder across culture and countries.

Despite the syndrome’s prevalence, due to the DSM and ICD’s criteria for panic disorders, dissociative disorders, and culture-bound syndromes, patients in Latin American countries on occasion self-diagnose themselves with Ataques de Nervios but do not meet the diagnosis standards set by European and American institutions and qualify for psychiatric treatment (Fernando, 2010; Lewis-Fernández, 2002). Still, among the patients who do report an attack, they were more likely to be female, older, less educated, previously married, and be diagnosed with anxiety or depressive disorders (Guarnaccia et al., 1993).

Ataques de Nervios patients have been studied to be often diagnosed with other disorders. In a study of 29 patients who experienced Ataques de Nervios confirmed under the 3rd edition of the DSM (a version with less CBS comprehension than the current DSM-V) there was a high rate of post-traumatic stress disorder (Lewis-Fernández et al., 2002). Another study of 2,554 Latinos primarily from Mexico, Cuba, and Puerto Rico found that patients who reported to have Ataques had higher rates of anxiety and substance abuse disorders (Guarnaccia et al., 2010).

The statistics behind Ataques de Nervios reveal a common theme of European bias in the DSM and ICD. There are very few studies concerning European bias in mental health diagnosis, but Frederick Hickling’s report on African Caribbean and British studies may shed light on the racism Latin Americans face in similar situations. The rate for reported schizophrenia in Jamaica is less than one tenth of the rate reported for British African Caribbean immigrants and less than one third of Caucasians in Britain. Studies suggest this is partly due to racism, and perhaps European cultures foster schizophrenia (Hickling, 2005). Many Latin American immigrants face racism, especially in the US. Likely, Latin Americans may face new mental health challenges in different countries. Particularly, Dominicans and Puerto Ricans are at high risk for experiencing racism and developing Ataques de Nervios if they emigrate to one of the previously imperial and colonizing countries.

The diagnostic comparison study concluded that the diagnostic agreement between the Jamaican and British psychiatrists in the study was more reliable for white patients than black patients. This suggests the current diagnostic standards, the American DSM and the ICD, are better suited for American and European psychiatry. Rooted in history, today’s mental disorder standards do not appear to fully reflect the psychiatry of the rest of the world. Likely, Latin American mental health is not well reflected in current biomedical psychiatry, as codified in the DSM and ICD. Regrettably, there is scant research on the intersection between Latin American mental health and European psychiatric diagnostics, as well as Ataques de Nervios, to further investigate this (Hickling, 2005).

Related Articles

• Health and Haitian Migrants to the Dominican Republic
• Health and Migration along the US-Mexico Border
• Healthcare in Puerto Rico
• Mental Health in Indigenous Populations

Additional Resources

Hinton, D. E., Lewis-Fernández, R., & Pollack, M. H. (2009). A Model of the Generation of Ataque de Nervios: The Role of Fear of Negative Affect and Fear of Arousal Symptoms. CNS Neuroscience & Therapeutics, 15(3), 264-275.

Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. (2001). PsycEXTRA Dataset.

References

Durà-Vilà, G., & Hodes, M. (2012). Cross-cultural study of idioms of distress among Spanish nationals and Hispanic American migrants: susto, nervios and ataque de nervios. Social psychiatry and psychiatric epidemiology, 47(10), 1627-1637.

Fernando, S. (2010). Mental health, race and culture (3rd ed.). Basingstoke: Palgrave Macmillan. 36.

Guarnaccia, P. J., Canino, G., Rubio-Stipec, M., & Bravo, M. (1993). The Prevalence of Ataques De Nervios in the Puerto Rico Disaster Study. The Journal of Nervous and Mental Disease, 181(3), 157-165.

Guarnaccia, P. J., Lewis-Fernandez, R., Martinez-Pincay, I., Shrout, P., Guo, J., Torres, M., . . . Alegria, M. (2010). Ataque de Nervios as a Marker of Social and Psychiatric Vulnerability: Results from the NLAAS. International Journal of Social Psychiatry, 56(3), 298-309.

Hickling, F. W. (2005). The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean. Revista Panamericana De Salud Pública, 18(4-5), 256-262.

Hofmann, S. G., & Hinton, D. E. (2014). Cross-Cultural Aspects of Anxiety Disorders. Current Psychiatry Reports, 16(6).

Lewis-Fernández, R., Garrido-Castillo, P., Bennasar, M. C., Parrilla, E. M., Laria, A. J., Ma, G., & Petkova, E. (2002). Dissociation, Childhood Trauma, and Ataque De Nervios Among Puerto Rican Psychiatric Outpatients. American Journal of Psychiatry, 159(9), 1603-1605.

Lewis-Fernández, R., Hinton, D. E., Laria, A. J., Patterson, E. H., Hofmann, S. G., Craske, M. G., . . . Liao, B. (2010). Culture and the anxiety disorders: Recommendations for DSM-V. Depression and Anxiety, 27(2), 212-229.

Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. (2001). PsycEXTRA Dataset.

Nogueira, B. L., Mari, J. D. J., & Razzouk, D. (2015). Culture-bound syndromes in Spanish speaking Latin America: the case of Nervios, Susto and Ataques de Nervios. Archives of Clinical Psychiatry (São Paulo), 42(6), 171-178.