Cultural psychopathology: uncovering the social world of mental illness.

We review cultural psychopathology research since Kleinman's (1988) important review with the goals of updating past reviews, evaluating current conceptualizations and methods, and identifying emerging substantive trends. Conceptual advances are noted, particularly developments in the definition of culture and the examination of both culture-specific and cultural-general processes. The contributions of the Culture and Diagnosis Task Force for DSM-IV and the World Mental Health Report are reviewed and contrasted. Selected research on anxiety, schizophrenia, and childhood disorders is examined, with particular attention given to the study of ataque de nervios, social factors affecting the course of schizophrenia, and cross-national differences in internalizing and externalizing problems in children. Within the last ten years, cultural psychopathology research has become a significant force. Its focus on the social world holds promise to make significant inroads in reducing suffering and improving people's everyday lives.

Research on culture-bound syndromes: new directions.

The unprecedented inclusion of culture-bound syndromes in DSM-IV provides the opportunity for highlighting the need to study such syndromes and the occasion for developing a research agenda to study them. The growing ethnic and cultural diversity of the U.S. population presents a challenge to the mental health field to develop truly cross-cultural approaches to mental health research and services. In this article, the authors provide a critique of previous analyses of the relationship between culture-bound syndromes and psychiatric diagnoses. They highlight the problems in previous classificatory exercises, which tend to focus on subsuming the culture-bound syndromes into psychiatric categories and fail to fully investigate these syndromes on their own terms. A detailed research program based on four key questions is presented both to understand culture-bound syndromes within their cultural context and to analyze the relationship between these syndromes and psychiatric disorders. Results of over a decade of research on ataques de nervios, a Latino-Caribbean cultural syndrome, are used to illustrate this research program. The four questions focus on the nature of the phenomenon, the social-cultural location of sufferers, the relationship of culture-bound syndromes to psychiatric disorders, and the social and psychiatric history of the syndrome in the life course of the sufferer.

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.

Multicultural experiences of family caregiving: a study of African American, European American, and Hispanic American Families.

There is growing attention to the roles of families as caregivers of relatives with serious mental illness. This chapter examines the experiences of family caregivers in diverse cultures and discusses the implications of these experiences for the goal of supporting families in these roles.

The mental health and adjustment of immigrant and refugee children.

Although parents may make decisions to leave their homes, either willingly in the hope of improving their lives or involuntarily to escape danger and seek safety for themselves and their families, it is never a voluntary decision for the child. The economic, political, social, and other contextual issues associated with migration are as significant in predicting the child's adjustment to his or her new circumstances as his or her physical and psychological endowment. This article addresses these issues and suggests that particular consideration be given to children whose migration was punctuated by life-threatening danger or whose families were overwhelmed by the stresses of migratory experiences. Child and adolescent psychiatrists and other well-trained mental health professionals can further the understanding of the interactions among the child, family, and new community, which can promote or hinder the process of adaptation to the new setting.

The experiences of ataques de nervios: towards an anthropology of emotions in Puerto Rico.

Ataques de nervios are an idiom of distress used by Puerto Ricans and other Latinos to express dislocations in the social world of the family. This paper contributes to the growing study of the "anthropology of the emotions". Through detailed interviews with 121 people in Puerto Rico, 78 of whom had had an ataque de nervios, we are developing a thick description of both the prototypical models for ataques de nervios and the varied individual experiences of ataques. The interview used in this study is a version of the Explanatory Model Interview Catalogue specifically adapted for use in a community study of ataques de nervios in Puerto Rico. Responses to questions on the experience of ataque de nervios were analyzed using a team of reviewers who represented differing knowledge and experience with Puerto Rican culture and mental health practice. The experience of ataques de nervios involves a loss of control in several important domains of experience: emotional expressions, bodily sensations, action dimensions and alterations in consciousness. That loss of control is closely linked to important social contexts relating to major life problems and the experience of suffering.

Ethnicity, social status, and families' experiences of caring for a mentally ill family member.

There is growing attention to the role of families nas caregivers of family members with serious mental illness. This paper presents presents data from a multicultural sample of 90 family caregivers from diverse ethnic backgrounds. The paper examines families' experiences with mental health services; their support networks and family burdens; and their conceptions of mental illness. The paper both provides one of the first comparative studies of family caregivers from different ethnic groups and suggests an agenda for future research in this area.

Ataques de nervios in Puerto Rico: culture-bound syndrome or popular illness?

Ataque de nervious is a popular illness category among Puerto Ricans and other Latinos written about in anthropological and psychiatric literature for over thirty years. This paper discusses the issue of categorizing ataque de nervios as a "culture-bound syndrome" using data from the first community-based study of this phenomena using epidemiological methods. The paper summarizes the social and psychological correlates of ataques de nervios and provides a preliminary overview of the situations which provoke ataques and the symptoms people experience. The paper critically examines the use of the "culture-bound syndrome" framework analyzing ataques de nervios and suggests that the term "popular illness" is a more effective label for categorizing this syndrome.

The prevalence of ataques de nervios in the Puerto Rico disaster study. The role of culture in psychiatric epidemiology.

This paper presents one of the few epidemiological studies of a popular category of distress, ataques de nervios (attacks of nerves), in the cross-cultural psychiatric literature. As part of a major study of the psychological consequences of the 1985 floods and mudslides which caused considerable damage and death in Puerto Rico, a question was added to the Diagnostic Interview Schedule/Disaster Supplement concerning ataques de nervios. This additional item provided the opportunity to carry out the first study of this important Puerto Rican popular category of distress using a representative, community-based sample. This paper addresses several key questions about ataques de nervios which come from previous psychiatric and anthropological literatures concerning the social correlates of who experiences an ataque de nervios and the relationship of ataques to social distress and psychiatric disorder. People who reported an ataque de nervios were more likely to be female, older, less educated, and formerly married. They were also more likely to meet criteria for anxiety and depressive disorders than those who had not experienced an ataque. The picture that emerges from our analyses is that those who suffer from a combination of social disadvantage, psychiatric disorder, and poor perceived health are more likely to experience an ataque de nervios.

The societal and organizational contexts of culturally sensitive mental health services: findings from an evaluation of bilingual/bicultural psychiatric programs.

The Hispanic mental health literature focuses mostly on cultural and clinical issues. This paper argues that researchers and practitioners concerned with mental health services for Hispanics and other minority groups need to pay more attention to the societal and organizational contexts that facilitate or impede the development of effective culturally sensitive psychiatric programs. Utilizing data from an evaluation of three New York psychiatric programs for seriously mentally ill (SMI) Hispanic patients, the paper discusses societal and organizational factors that influenced the programs' development. Among societal forces were the significance of Hispanics as a voting bloc, the political organization of Hispanic mental health professionals, the philosophy of ethnic assimilation in American society, prevailing views about the place of cultural knowledge in psychiatric treatment, and fiscal crises, and the shortage of Hispanic mental health professionals. Among organizational factors, hospital administrative support and program leadership mediated the effects of societal forces upon the programs, while ethnic competition and lack of coordination between the program and other organizational units acted as barriers to the programs' development. The findings are relevant to any innovative mental health service in an organizational setting.

Si dios quiere: Hispanic families' experiences of caring for a seriously mentally ill family member.

Among Hispanics, the family is viewed as the primary care giver for seriously mentally ill family members. This paper reports on a study of minority families' conceptions of serious mental illness, of their interaction with mental health resources, and on the burdens experienced by families in caring for a seriously mentally ill family member. The focus of this paper is on Hispanic families in New Jersey, with some comparative data from other ethnic group families. Families' conceptions of serious mental illness are explored and analyzed to demonstrate the importance of concepts of nervios and fallo mental in shaping families' responses to their ill family member. Social support systems for families are also explored with particular attention to the role of religious institutions and religious healing as a major source of solace.

[The role of culture in psychiatric epidemiology: an examination of research on Latin American mental health]. / Le rôle de la culture en épidémiologie psychiatrique: examen de la recherche sur la santé mentale des Latino-Américains.

In psychiatric epidemiology, culture has often been treated in one of two ways: as a confounding variable to be controlled or as an explanation for unexpected findings. In cases where culture is presented as an explanation, there is often little detailed examination of how culture shapes responses to psychiatric interviews. In this paper, I will argue that culture plays a central role in influencing responses to psychiatric interviews in at least three ways: culture affects the way people respond to psychiatric interviews; culture influences the valuation of specific symptom items; and cultural categories are embedded in responses to psychiatric interviews. Through a review of research on the mental health of Latino populations, I will examine the roles of cultural categories in shaping responses to psychiatric epidemiology studies and will outline an alternative research approach to simultaneously exploring psychiatric diagnostic categories and cultural idioms of distress.

A critical review of epidemiological studies of Puerto Rican mental health.

Through a review of the epidemiological literature on the mental health of Puerto Ricans and other Hispanics, the authors argue that lack of attention to cultural issues in epidemiological studies leaves many questions unanswered and raises concerns about the validity of studies in this area. The authors point out that the mental health status of Puerto Ricans in New York City is still poorly understood after 30 years of research. The roles of cultural response styles and of culturally meaningful expressions of distress in shaping responses to research interviews should be central concerns in developing research in cross-cultural psychiatry.

Ataques de nervios in the Puerto Rican Diagnostic Interview Schedule: the impact of cultural categories on psychiatric epidemiology.

This paper examines the effect of the cultural category ataques de nervios on responses to the Puerto Rican Diagnostic Interview Schedule (DIS), a Spanish version of structured psychiatric diagnostic interview developed for the NIMH Epidemiologic Catchment Area study. An ataque de nervios scale was created from the Somatization items of the DIS to explore the effect of this culturally meaningful category of distress on responses to a standard psychiatric interview. Analysis of 1,513 cases from a representative sample of the island of Puerto Rico indicated that people reporting ataque symptoms fit the social characteristics described for ataques sufferers in the ethnographic literature. Qualitative data indicated that Puerto Ricans were reporting ataques de nervios in the panic section of the DIS. Questions are raised about the validity of the somatization and panic sections of the DIS in cross-cultural research with Hispanics.