SETHA M. LOW
T H E M E A N I N G O F N E R V I O S : A S O C I O C U L T U R A L A N A L Y S I S
O F S Y M P T O M P R E S E N T A T I O N I N S A N J O S E , C O S T A R I C A
ABSTRACT. The foundation of the symbolic tradition in medical anthropology is the examination of a patient's experience of a category of illness. The interpretation of folk explanations of etiology and nosology provides insight into the cultural definition of what constitutes an illness, how and why an illness is labeled, and how the afflicted individual should be treated. Further, the analysis of sociocultural meaning emerges as a critical the- oretical contribution to our understanding of health and culture.
Alien Young in his article "Some Implications of Medical Beliefs and Practices for Social Anthropology" suggests " . . . that if we want to learn the social meaning of sickness, we must understand that 'signs,' whatever their genesis, become 'symptoms' because they are expressed, elicited, and perceived in socially acquired ways" (1976: 14). He further states that some categories of sickness are particularly interesting in that they enable people to organize the illness event into an episode that has form and meaning (1976: 19-20).
Nervios is an example of a symptom that has acquired a special sociocultural pattern of expression, elicitation and perception in San Josg, Costa Rica. The empirical study of symptom presentation in general medicine and psychiatric outpatient clinics describes the patients who present the symptom and their associated attributes and explanations of the symptom's occurrence. The meaning of nervios is then discussed within a social interac- tional and symbolic framework.
I N T R O D U C T I O N
In Costa R i c a the s y m p t o m o f nervios (nerves) is e m p l o y e d in a v a r i e t y o f settings
t o signal p s y c h o s o c i a l distress. I t is a c u l t u r a l l y a p p r o p r i a t e s y m p t o m in t h a t its
pervasive use is p r i m a r i l y w i t h i n Costa Rica; persons o f all social statuses, age
and sex use t h e t e r m ; and its use elicits w h a t is c o n s i d e r e d t h e socially a p p r o p r i -
ate response o f e x p r e s s e d c o n c e r n and a t t e n t i o n . Nervios is e t i o l o g i c a l l y l i n k e d
t o f a m i l y d i s r u p t i o n and a b r e a k d o w n in f a m i l y r e l a t i o n s h i p s , p r o v i d i n g a socially
a c c e p t a b l e c a t e g o r y o f p h y s i c a l a n d m e n t a l d i s t u r b a n c e for t h e s y m p t o m s o f
being ' o u t o f c o n t r o l ' , g e n e r a t e d b y d i f f i c u l t f a m i l y r e l a t i o n s . The e x a m i n a t i o n
o f p a t i e n t p r e s e n t a t i o n o f nervios is illustrative o f h o w a s y m p t o m links an in-
d i v i d u a l ' s p e r s o n a l e x p e r i e n c e w i t h t h e social i n s t i t u t i o n s o f f a m i l y a n d h e a l t h
care in a c u l t u r a l l y m e a n i n g f u l w a y .
The t h e o r y and d a t a e m p l o y e d t o analyze t h e m e a n i n g o f n e r v i o s are o r g a n i z e d
in a research r e p o r t f o r m a t . The research p r o b l e m is first p r e s e n t e d i n c l u d i n g
a review o f references t o nervios in t h e m e d i c a l a n t h r o p o l o g i c a l l i t e r a t u r e a n d a
c l a r i f i c a t i o n o f t h e p r o b l e m . The s e c o n d s e c t i o n describes the r e l e v a n t research
s e t t i n g , m e t h o d and sample. A d a t a s e c t i o n follows w h i c h discusses o u t p a t i e n t
s y m p t o m p r e s e n t a t i o n , t h e c h a r a c t e r i s t i c s o f p a t i e n t s p r e s e n t i n g nervios, and
Culture, Medicine and Psychiatry 5 (1981) 25-47. 0165-005X/81/0051-0025 $02.30. Copyright © 1981 by D. R eidel Publishing Co., Dordrecht, Holland, and Boston, U.S.A.
26 SETHA M. LOW
doctor diagnosis and treatment of those patients. Finally, a theoretical and concluding section explores the psychological, social and cultural meaning of
Health to a Costa Rican is expressed as well-being (bienestar) or to be sound, whole, or complete (estar sano). To achieve and maintain this well-being requires that one must vivir tranquilo, that is live calmly, tranquilly, in balance with oneself and one's physical, social, and psychological environment. Nervios, or "nerves", the focus of this paper, appears as a counterpart to the expressed ideal state, signifying an interruption in the individual's ability to vivir tranquilo.
values, ideals, and culture. The relationship of health and culture is illuminated through the symbolic
and psychophysiological expression of cultural rules in body image and body experience. The examination of one symptom therefore can decode a much larger cultural matrix of beliefs and ideals. An in-depth analysis of the attached meanings, social context and interpersonal manipulation of nervios will provide insights to the individuals' response to a changing world.
The interpretation of symptoms as sociocultural phenomena has traditionally been an area of concern for medical anthropologists and has included studies of communication problems in public health assistance programs in Latin America (Simmons 1955; Wellin 1955; Foster 1962, 1969; Erasmus 1952, 1968), studies of ethnic disorders or culture-bound syndromes (Honigman 1967; Kiev 1964, 1968; deReuck and Porter 1965; Foulks 1972; McDaniel 1972; Yap 1969; Cawte 1976; Weidman 1979; Bilu 1980), and epidemiological and theoretical analyses of folk illness (Fabrega and Metzger 1968; Rubel 1964; Foster 1953; Frake 1961; Currier 1966; Ingham 1970; O'Neil and Selby 1968; Scott 1973; Uzzell 1974). These perspectives, however, have limited applicability and can be theoretically restrictive when dealing with symptoms whose physical and behavioral characteristics are diffuse and difficult to define. Recent theoretical approaches to symptom interpretation therefore have employed semantic analysis (Good 1977; Kay 1979), symbolic analysis (Moerman 1979; Tousignant 1979), cultural role recruitment (Townsend and Carbone 1980), and models of clinical explanation (Gaines 1979; Blumhagen 1980; Kleinman 1980) to more effec- tively identify the sociocultural meaning of symptoms.
The initial literature search for references to nervios revealed few mentions of the term and provided minimal explanation for its usage. A reference from a village in Mexico indicates that "such items as bad blood, cramps, colds, arthritis, indigestion, and nerves actually subsume a large number of disorders" for the
THE MEANING OF NER VIOS 27
local curer (Brown 1963: 101). Among working class Mexican psychiatric out-
patients, "a few persons mentioned nerves" as the problem for which they were seeking help; and in response to a question on the cause o f their disorder, 70% agreed nervios was involved, women tending to agree more than men (Fabrega 1967: 706). A woman in Fabrega's sample also stated that she needed to "dom-
inate her nerves" in order to get better (Fabrega 1967: 706), a comment often heard outside the medical consultation in San Jos6. Puerto Ricans in the United States "seek the help of Spiritists when they have . . . problems with their 'nerves'" (Garrison 1972: 3). North American references to nerves include a
study undertaken in North Carolina where patients receiving public health nursing care frequently complained o f "nerves" and/or nervousness (Leighton
1968: 39) and a Nova Scotia study population reporting minor psychiatric symptoms sometimes described as "nerves" (Schuchat 1975).
Historically, a book o f Nicaraguan folk medical terms reports two varieties o f nervios which are recorded from early Nicaraguan studies: nervios regados in which a person is nervous, easily excitable, manifesting punctuated muscle pain and insomnia; and nervios resentidos in which a person who is not able to get rid o f his troubles suffers pain, anger, passion and melancholy (Miranda 1967: 235). Mexican medical folklore identifies nervousness (nerviosismo) as an anxious reaction which accompanies susto characterized b y sensation in the m o u t h o f the stomach, bones or chest, however nervios as a distinct symptom is not mentioned (Padron 1956). Francisco Escobar, a Costa Rican sociologist, suggests that nervios is related to an old folk notion o f calbagar, a term used to excuse one from fulfillment o f normal duties because o f a personal crisis
such as loss o f a loved one, economic disaster, or insult to one's pride (personal communication); however, no published reference to this concept was found.
Recent references to nervios have increased with the publication o f new
medical anthropological studies from Latin American and Galenic influenced cultures. Nervios in Colombia is related to mental disorder and debilidad (de- bility) (Langdon and MacLennan 1979). Researchers from Iran report "nerves"
as a women's problem (Good 1980) and as a location o f distress (Good 1977). Finkler (1980), Sandoval (1979), Garrison (1977) and Harwood (1 9 7 7 )refer to "nerves" in relation to symptom presentation for spiritualist treatment. Spicer's (1977) collection o f Southwest medical ethnographics reports the occurrence o f "nerves" in various border cultures.
The literature establishes that nervios is present in Mexico, Colombia, Ni- caragua and the Southwestern United States, while "nerves" and "nervousness" have a broader distribution; however, because the references are brief and fo- cused on other topics it is difficult to ascertain whether the reported symptoms are the same as nervios in Costa Rica. In other words, it is not clear from the literature that nervios is a phenomenon particular to each situation or whether
28 SETHA M. LOW
it has cross-cultural significance. This question requires extensive further re- search. For the purposes of this paper, nervios refers to the symptom as it occurs only in Costa Rica. The special relationship o f nervios to Costa Rican cultural themes, the frequent presentation o f the symptom in the physician's office, and the widespread use of nervios in conversation in a variety o f social settings suggest that the meaning of nervios in Costa Rica is framed by the cultural
The research data upon which this paper is based were collected in San Jos6, the capital of Costa Rica, located on the Meseta Central of this small Central American republic. With a metropolitan population o f over 460,000, one-fourth of the national total, San Jos6 is a primate city representing 53% of the country's total urban population (Morse 1971 ; Ministerio de Economia 1974). Costa Rica, like many developing countries, is experiencing rapid urbanization in which a large proportion o f the rural population has moved to the capital straining social services and physical resources. The resulting unemployment, poor housing conditions and increasing social disorder has disrupted traditional patterns o f family structure and community organization (Low 1977).
Costa Rican family structure emphasizes independence and self-sufficiency historically attributed to the subsistence agricultural economy. Life is family- centered in the sense that significant personal relations usually lie within family boundaries. When asked about friendships outside the family a Costa Rican denies having close (intima) friends; friendship is suspect as it suggests non- familiar alliances and an unwillingness to fulfill family obligations.
Internally, family functions segregate into duties and responsibilities appro- priate to a member's age or sexual status. Husband and wife maintain segregated conjugal networks, reinforcing ties with their own consanguineal families through labor exchange, visiting, and residential proximity. Any deviation from the ideal family pattern increases one's susceptibility to disequilibrium in the form o f dependence on friends rather than family, need for institutional assistance or intervention, and social sanction by avoidance, gossip or restricted interaction. Institutions are only for the very sick and senile - when the children cannot care for them. Even then an informant responds that she "cries all day to think of an old lady alone. If the children do not live with their parents then they should at least visit every day."
Costa Rican society, both structurally and conceptually, reflects a preoccupa- tion with health. One is struck by the abundance of medical offices and related
THE MEANING OF NER VIOS 29
laboratories, clinics and pharmacies. The national budget for 1973 allotted more money for health than for defense and internal security (La Repfiblica 1973: 12); and the proportion o f public expenses corresponding to the health sector has increased from 9.0% in 1960 to 14.9% in 1972 (Bermudez and G6mez 1974: 22). The semi-autonomous Caja Costarficense de Seguro Social is the the major internal money lender to the national government. In either o f the major daily
newspapers La Nabion or La Reptiblica there are lengthy articles reporting health hazards, health directives or information announcing the opening o f a new clinic or medical program. Richardson and Bode (1971) report from field- work in Puntarenas, Costa Rica that 66% o f their sample worry more about their health than about their economic state.
M e t h o d
The major portion o f the research was undertaken in outpatient clinics o f four hospitals within the two principal Costa Rican health care delivery systems: Hospital Calder6n Guardia and Hospital M~xico o f the Caja Costarricense de Seguro Social, and Hospital San Juan de Dios and psychiatric Hospital Manuel
Antonio Chapui of the Ministry of Public Health. The Caja Costarricense de Seguro Social is a semi-autonomous nationalized health, disability, and retire- ment program, which at the time o f the study enrolled salaried employees and their families, some 60% of the total population (Caja Costarricense de Seguro Social 1974). The Ministry o f Public Health is part o f the executive branch o f the central government, and operates a lottery-supported system providing free or low cost inpatient and outpatient care to those not covered b y the Seguro Social. Additional field work was conducted with herbalists in the central market, pharmacists in their boticas, and with a range o f paramedical practi- tioners in their offices and homes. Extensive ethnographic data were collected
while living as a participant-observer in a transitional suburb o f San Jos~ where the researcher had informant contact through everyday situations and personal interaction.
The methods employed varied according to the setting and sequence within the overall research design. The initial phase o f research was focused on observa-
tion o f doctor-patient interaction in the consultation office. Between consulta- tions doctors, nurses, social workers and other auxiliary clinic personnel were interviewed with reference to their perceptions o f patient behavior and clinic function. The second phase began after having established the pattern o f con- sultation interaction; a structured interview covering patient perception o f their illness and treatment was administered by a research assistant in the waiting room before and after the observed medical consultation. Finally, a sample o f the interviewed patients were selected for a home visit during which the researcher
30 SETHA M. LOW
and her assistant conducted an open-ended family interview which emphasized personal and family health histories, geneological and family network material,
health utilization patterns and general questions o f values, preferences and health beliefs.
Observation o f doctor-patient interaction was chosen as a means o f most economically describing Costa Rican disease types, the variety o f symptoms and their cultural expression, and doctor-patient interaction in terms o f function
and outcome. Consultations were recorded in notes taken in diary form and
included relevant material on the situational context. The two major hospital
outpatient clinics o f b o t h the Public Health hospital, San Juan de Dios, and the
Social Security hospital, Calderon Guardia, were selected to represent general
medicine services in San Jos6. Two psychiatric clinics and one psychosomatic
clinic were added to gain greater breadth o f information on patients with nervios
(Figure 1). The observed patient sample was obtained b y working alternate hours
Ministry of public Health (201)
San Juan de Dios (151)
Extempor- aneous (101)
Psychiatric HospRal Chapui (50)
I General Medicine Outpatien (50)
Psychiatry Outpatient (5 o)
System. Total Sample = 457
General Medicine Services (305)
Psychiatric Services (152)
Social Security Fund System (256)
Calderon Guardia (206)
Extempor- aneous (51)
I Hospital Mexico (50)
I General Medicine Outpatient (103)
I Psychiatry Outpatient (52)
Psychosomatic Outpatient (50)
Fig. 1. Distribution of patient samples by system, hospitals and services
and days o f the week with as m a n y different doctors as possible; in this manner an attempt was made to randomize patient attendance patterns. Approximately 1 2 - 2 0 patients were observed with each doctor depending on their case load. All patients who entered the office during the observation period were recorded to minimize selection bias.
THE MEANING OF NER VIOS 31
A total of 305 observations of doctor-patient interaction in general medicine were recorded in addition to 50 and 52 observations in each of the psychiatric outpatient facilities and another 50 in the psychosomatic clinic (Figure 1). The resulting data on symptom presentation, patient history, family and per- sonality variables were coded and analyzed with computer assistance. The 117 before-and-after consultation interviews which analyzed patient expectations, satisfaction, and concepts of causation and treatment of disease were collected during a two week period of consecutive interviewing for one full day in each clinic setting. The sample of 12 patients selected for team-conducted family interviews was made up of interviewed patients who agreed to a home visit by the research team. These intensive family sessions generated theories o f symp- tom formation.
The sample is made up of 305 cases in general medicine clinics and 152 patients in three psychiatry clinics selected as noted above. The general characteristics of the research sample include a predominance of women: 70% of patients in general medicine and 63% in psychiatric clinics were female. The mean age of the sample was 33.5 years with no significant differences between general medicine and psychiatry clinics or between Public Health or Social Security medical systems.
PATIENT PRESENTATION OF NER VIOS
S y m p t o m Presentation
Symptom presentation in the medical setting indicates both the kinds of distur- bances commonly experienced by Costa Ricans and the culturally available verbal and behavioral repertoire for the expression o f psychosocial distress. Outpatients present a wide variety of physical and emotional statements ranging from headaches, body pain and respiratory complaints to worries, depression, and disorientation. The analysis of symptoms by general medicine and psychiatric outpatient clinics provides ranked frequencies distinguishing the two medical services. Of sixty-five possible coded symptoms, general medicine patients most often experience, in order o f decreasing frequency, head pain, stomach pain, nervios, itching, side and back pain, lack of appetite, cough, fever, sore throat, chest pain, hip and leg pain, runny eyes, fatigue, vomiting, and congestion
32 SETHA M. LOW
(Table I). P s y c h i a t r i c p a t i e n t s have m o r e e m o t i o n a l c o m p l a i n t s a n d p r e s e n t
nervios m o s t f r e q u e n t l y , f o l l o w e d b y h e a d p a i n , d e p r e s s i o n , i n s o m n i a , anger or
b a d c h a r a c t e r , l a c k o f a p p e t i t e , fears or susto, f a t i g u e , t r e m b l i n g , a l t e r e d p e r c e p -
t i o n s o r t e m p o r a r y b l i n d n e s s .
TABLE I Symptom frequency by patient subgroups
Rank order and percent of patients presenting symptom
General medicine (N=305) Psychiatry (N=152) Nervios (N=122) 1
Symptoms % Symptoms % Symptoms %
1. Head pain, 17.1 1. Nervios 50.0 1. Nervios 100.0 stomach pain
2. Nervios 15.1 2. Head pain 29.5 2. Head pain 36.9 3. Itching 12.4 3. Depression 28.9 3. Insomnia 26.2 4. Sideand 11.5 4. Insomnia 25.0 4. Lack of appetite 24.6
back pain 5. Lack of 10.0 5. Angry or bad 20.4 5. Depression 23.0
appetite character 6. Cough, fever 9.9 6. Lack of appetite 18.5 6. Fears, Susto 19.7 7. Sorethroat 9.5 7. Fears, Susto 17.1 7. A n g r y o r b a d 18.0
character 8. Chest pain 9.2 8. Fatigue, trembling, 16.5 8. Trembling, 15.6
descomposiciones descornposiciones 9. Leg andhip 8.5 9. Altered perception 15.8 9. Disorientations 12.3
pain or temporary blindness
10. Fatigue 10. Rurmyeyes 8.3 10. Disorientations 13.8
1 The n=122 was based on the total number of patients reporting nervios, 46 (15.1% of the 305) from general medicine clinics, and 76 (50% of 152) from pyschiatric clinics.
Costa R i c a n disease s t a t e m e n t s are a c o m b i n a t i o n o f b i o l o g i c a l and s o c i o p s y -
chological s y m p t o m s a n d reflect t h e absence o f a m i n d / b o d y dualism r e p o r t e d
for L a d i n o c u l t u r e . T h e f o l l o w i n g dialogue r e p o r t e d b y F a b r e g a for L a d i n o s in
I am having the pain of X . . . It is the pain of my liver located here, which was brought on by doing Y after having experienced Z, and the pain is like someone squeezing me inside, and the vomiting and headache that I am also having is part of the same malady. (1973: 231)
applies t o t h e Costa R i c a n m e d i c a l c o n s u l t a t i o n w i t h s u b s t i t u t i o n o f t h e h e a d ,
THE MEANING OF NER VIOS 33
stomach, or back for the referent organ. Pain descriptions also resemble the
Chiapas Ladino format: "Physical and social metaphors abound in attempts to elaborate about the pain associated with various conditions which may be seen as focused in discrete anatomical parts" (Fabrega 1973: 223). In this fashion, a Costa Rican patient complains of a "wind" in the heart, coming on very fast, causing agitation; or a pain that starts high on the hip, moving to the front, then to the testicles. Pain is often expressed as "beating" or "hitting" the patient, or as an itching or cramp. Most Costa Rican disease statements include some pain description.
Many Costa Rican symptoms can be explained by examining the biocultural context. Symptoms related to bronchitis - chest pain, breathing difficulties, coughing - common in the older rural population, are partially caused by the traditional use of open woodburning stoves, a synergistic combination o f cultural choice and a biophysical medical problem (Rawson 1974). Another example of a medical problem arising from the interaction o f cultural beliefs and the biological determinants o f disease is the Costa Rican emphasis on appetite loss as a sign o f illness; that is, to be slightly heavy or fat is considered attractive, and to eat heartily at all times is considered imperative to maintain one's energy
and vigor. A patient who is hypertensive or diabetic and dangerously overweight will not agree to any decrease in food intake, even when therapeutically induced by the doctor. "Brainache", a folk category o f headache, is thought o f as a syndrome o f debilidad del cerebro (debility of the brain), caused b y a lack o f alimento, vitamins or healthy food (Cosminsky 1975). In this case the folk bio- cultural categroy corresponds to the medical explanation o f the disease in that brainache signals improper nutrition and is treated b y physicians with vitamin injections. Nervios, however, does not have a folk biocultural explanation and does not appear to be the result o f a cultural belief interacting directly with an underlying biological process.
Of the 457 patients in the sample, 122 complained o f nervios. These patients exhibited an interesting pattern of other symptoms: headache, insomnia, lack of appetite, depression, fears or susto, anger or bad character, trembling, disori- entation and temporary blindness, fatigue, itching, altered perceptions, profuse sweating, lifelessness, vomiting and hot sensations (Table I). The common at- tribute o f these symptoms seems to be that the patient is " o u t o f control", or separated from body and self. The patient complains that these sensations are not part o f their normal behavior, but are experienced as undesirable b o d y responses over which they have no control. The b o d y is seemingly objectified
3 4 S E T H A M. L O W
b y t h e p a t i e n t ; t h e p a t i e n t v i e w s t h e s e l f as f e e l i n g a n d a c t i n g i n a p p r o p r i a t e l y .
E t h n o g r a p h i c d a t a c o r r o b o r a t e s t h i s i m p r e s s i o n :
Maria is eighteen years old and came in with her older sister. Her family is from the coun- tryside (campo), a six hour bus ride south o f San Jos6. There are six boys and four girls in her family. The mother is "mentally" ill and mistreats her daughter, so the sister has brought Maria to live with her. The sister hopes to help her " i f there is time". Maria says that she has nervios. Four times she has become unconscious, "lifeless" and without feeling in her body. She has been this way for the past six months. Maria says she feels like crying, sleeps all the time even though she has a boyfriend who is handsome. Her sister says that Maria is crazy not to get well for her handsome boyfriend. The sister sleeps with Maria so that she can watch her at night. Maria says that when she has these periods o f unconscious- ness her hand falls asleep, and her tongue and body feel strange. She feels everyone is very far away and doesn't speak. "Does it scare you?" asks the doctor. "Yes", replies Maria. Her appetite is good. She says she often feels angry. The sister comments that she feels that the anger is from the same nervios as in Maria's system. Maria called her attacks descomposiciones.
T h e i n t e r p r e t a t i o n t h a t t h e p a t i e n t is " o u t o f c o n t r o l " is f u r t h e r r e i n f o r c e d
f r o m d a t a c o l l e c t e d i n t h e s t r u c t u r e d i n t e r v i e w s h e l d b e f o r e a n d a f t e r c o n s u l t a -
t i o n w i t h 117 p a t i e n t s , T h e s e r e s p o n s e s w e r e e l i c i t e d b y asking " W h a t d o y o u
h a v e ? W h a t d o y o u t h i n k i t is c a u s e d b y ? " .
A 24 year old male from the rural highlands complained o f a noise in his head, constant dizziness, sweats, fear, nervios, pressures and neck pain. " I lost control," the patient told the interviewer, "and blacked out twice". He thinks that it could be caused by getting wet in the afternoon, or that he worked under a plastic roof.
A woman from a poor neighborhood in San Jos6 complains o f nervios accompanied by descomposiciones, a fear to leave the house and go on the street. It's "a terrible complex", she complained, in which her head hurt, and she can't eat, and sometimes she can't talk. She says that this comes from her husband who tried to kill her ten years ago. "But now my nervios is worse," she says. She thinks that her nervios is caused by anger (colera) and possibly by her liver.
A 32 year old woman, with nine living children from the southern valley o f Costa Rica, complains o f headache, dizziness, crying, temporary blindness. A week before she had an attack of nervios, a derrarne de cerebro or stroke, during which she was unconscious for two hours. She thought it might be family worries.
A single man from a working-class neighborhood employed in a laboratory department o f a large hospital complains o f nervios, anxiety, desperation, and being disoriented to self; he is not sure o f his acts or words. He says that he has an impersonal attitude, superficial affect, and doesn't feel himself. He reports that his problems come from his family, who do not appreciate him and stay apart from him. His work is "very alone". He feels guilty because the family stays away from him because o f his problems.
W h e n nervios p a t i e n t s are c o m p a r e d t o t h e t o t a l p a t i e n t s a m p l e t h e d i s t r i b …