Culture, Medicine, and Psychiatry

, Volume 34, Issue 2, pp 219–243 | Cite as

Association of Trauma-Related Disorders and Dissociation with Four Idioms of Distress Among Latino Psychiatric Outpatients

  • Roberto Lewis-FernándezEmail author
  • Magdaliz Gorritz
  • Greer A. Raggio
  • Clara Peláez
  • Henian Chen
  • Peter J. Guarnaccia
Original Paper


Past research on idioms of distress among U.S. Latinos has revealed that ataque de nervios and altered perceptions, such as hearing and seeing things when alone, are independent markers of higher morbidity and mental health utilization despite having no one-to-one relationships with any single psychiatric diagnosis. It has been proposed that the idioms exert this effect because they are signs of distressing dissociative capacity associated with traumatic exposure. This study examines the relationships in an ethnically diverse Latino psychiatric outpatient sample (N = 230) among interpersonal trauma, posttraumatic stress disorder (PTSD), major depressive disorder, dissociative capacity and four cultural idioms of distress associated with the popular overall category of nervios. We particularly explore how these relationships change with varied measures of traumatic exposure, including trauma severity and timing or persistence of trauma. A series of adjusted bivariate regressions assessed the matrix of associations between the idioms and the clinical variables. In this highly traumatized population, we identified a strong ‘nexus’ of associations between dissociation and three of the idioms: currently being ill with nerves, ataque de nervios and altered perceptions. These idioms were largely independent from PTSD and depression and were associated with trauma persistence and severity. A fourth idiom, being nervous since childhood, was not associated with any other variable and may represent a personality trait rather than a diagnosable condition. Our results validate the clinical utility of the construct of nervios as a set of specific idioms associated with dissociation that are useful markers of mental health need among Latinos independently of their association with clinical diagnoses.


Idioms of distress Ataque de nervios Dissociation Trauma Posttraumatic stress disorder Altered perceptions Latinos 



The authors wish to thank Ivan Balán, Gabriel Pantol, Lynne Matte, José Hernández, Paula Yáñez, Ashley Henderson, Michelle Bell and Melissa Rosario for their help conducting the study. This study was supported in part by the National Alliance for Research on Schizophrenia and Depression (NARSAD) and by institutional funds from the New York State Psychiatric Institute.


  1. Allison, Paul D. 2001 Missing Data. Thousand Oaks, CA: Sage.Google Scholar
  2. American Psychiatric Association (APA) 2000 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychiatric Association.Google Scholar
  3. Bremner, J. Douglas, Steven Southwick, Elizabeth Brett, Alan Fontana, Robert Rosenheck, and Dennis S. Charney 1992 Dissociation and Posttraumatic Stress Disorder in Vietnam Combat Veterans. American Journal of Psychiatry 149(3):328–332.Google Scholar
  4. Briere, John, Catherine Scott, and Frank Weathers 2005 Peritraumatic and Persistent Dissociation in the Presumed Etiology of PTSD. American Journal of Psychiatry 162(12):2295–2301.CrossRefGoogle Scholar
  5. Brown, Richard J., Etzel Cardeña, Ellert Nijenhuis, Vedat Sar, and Onno van der Hart 2007 Should Conversion Disorder Be Reclassified as a Dissociative Disorder in DSM-V? Psychosomatics 48(5):369–378.CrossRefGoogle Scholar
  6. Bryant, Richard A. 2007 Does Dissociation Further Our Understanding of PTSD? Journal of Anxiety Disorders 21:183–191.CrossRefGoogle Scholar
  7. Carlson, Eve B., and Rhonda Rosser-Hogan 1991 Trauma Experiences, Posttraumatic Stress, Dissociation, and Depression in Cambodian Refugees. American Journal of Psychiatry 148(11):1548–1551.Google Scholar
  8. Chang, Doris F., Hector F. Myers, Albert Yeung, Yalin Zhang, Jingping Zhao, and Shunying Yu 2005 Shenjing Shuairuo and the DSM-IV: Diagnosis, Distress, and Disability in a Chinese Primary Care Setting. Transcultural Psychiatry 42(2):204–218.CrossRefGoogle Scholar
  9. Chu, James A. and Diana L. Dill 1990 Dissociative Symptoms in Relation to Childhood Physical and Sexual Abuse. American Journal of Psychiatry 147(7):887–892.Google Scholar
  10. Clark, David M. 1986 A Cognitive Approach to Panic. Behaviour Research and Therapy 24(4):461–470.CrossRefGoogle Scholar
  11. Dancu, Constance V., David S. Riggs, Diana Hearst-Ikeda, Beth G. Shoyer, and Edna B. Foa 1996 Dissociative Experiences and Posttraumatic Stress Disorder Among Female Victims of Criminal Assault and Rape. Journal of Traumatic Stress 9(2):253–267.CrossRefGoogle Scholar
  12. David, Daniella, Gary S. Kutcher, Elizabeth I. Jackson, and Thomas A. Mellman 1999 Psychotic Symptoms in Combat-Related Posttraumatic Stress Disorder. Journal of Clinical Psychiatry 60(1):29–32.Google Scholar
  13. First, Michael B., Robert L. Spitzer, Miriam Gibbon, and Janet B. W. Williams 1996 Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinician Version, User’s Guide. Washington, DC: American Psychiatric Association.Google Scholar
  14. Guarnaccia, Peter J., Luz M. Guevara-Ramos, Gloria Gonzáles, Glorisa J. Canino, and Héctor Bird 1992 Cross-Cultural Aspects of Psychotic Symptoms in Puerto Rico. Research in Community and Mental Health 7:99–110.Google Scholar
  15. Guarnaccia, Peter J., Glorisa Canino, Maritza Rubio-Stipec, and Milagros Bravo 1993 The Prevalence of Ataques de Nervios in the Puerto Rico Disaster Study: The Role of Culture in Psychiatric Epidemiology. Journal of Nervous and Mental Disease 181(3):157–165.CrossRefGoogle Scholar
  16. Guarnaccia, Peter J., Melissa Rivera, Felipe Franco, and Charlie Neighbors 1996 The Experiences of Ataques de Nervios: Towards an Anthropology of Emotions in Puerto Rico. Culture, Medicine, and Psychiatry 20:343–367.CrossRefGoogle Scholar
  17. Guarnaccia, Peter J., Roberto Lewis-Fernández, and Melissa Rivera Marano 2003 Towards a Puerto Rican Popular Nosology: Nervios and Ataques de Nervios. Culture, Medicine, and Psychiatry 27:339–366.CrossRefGoogle Scholar
  18. Guarnaccia, Peter J., Igda Martínez, Rafael Ramírez, and Gloria Canino 2005 Are Ataques de Nervios in Puerto Rican Children Associated with Psychiatric Disorder? Journal of the American Academy of Child and Adolescent Psychiatry 44(11):1184–1192.CrossRefGoogle Scholar
  19. Guarnaccia, Peter J., Roberto Lewis-Fernández, Igda Martínez Pincay, Patrick E. Shrout, Jing Guo, Maria Torres, Glorisa Canino, and Margarita Alegría 2010 Ataque de Nervios as a Marker of Social and Psychiatric Vulnerability: Results from the NLAAS. International Journal of Social Psychiatry. In press.Google Scholar
  20. Hinton, Devon E., and Roberto Lewis-Fernández 2010a The Cross-Cultural Validity of Posttraumatic Stress Disorder: Implications for DSM-V. Depression and Anxiety. Under review.Google Scholar
  21. Hinton, Devon E., and Roberto Lewis-Fernández 2010b “Idioms of Distress” (Culturally Salient Indicators of Distress) and Anxiety Disorders. In Anxiety Disorders: Theory, Research, and Clinical Perspectives. Helen B. Simpson, Yuval Neria, Roberto Lewis-Fernández, and Frank S. Schneier, eds. Cambridge: Cambridge University Press.Google Scholar
  22. Hinton, Devon, Khin Um, and Phalnarith Ba 2001 Kyol Goeu (“Wind Overload”) Part II: Prevalence, Characteristics, and Mechanisms of Kyol Goeu and Near- Kyol Goeu Episodes of Khmer Patients Attending a Psychiatric Clinic. Transcultural Psychiatry 38(4):433–460.CrossRefGoogle Scholar
  23. Hinton, Devon E., Vuth Pich, Steven A. Safren, Mark H. Pollack, and Richard J. McNally 2006 Anxiety Sensitivity Among Cambodian Refugees with Panic Disorder: A Factor Analytic Investigation. Journal of Anxiety Disorders 20(3):281–295.CrossRefGoogle Scholar
  24. Hinton, Devon E., Roberto Chong, Mark H. Pollack, David H. Barlow, and Richard J. McNally 2008a Ataque de Nervios: Relationship to Anxiety Sensitivity and Dissociation Predisposition. Depression and Anxiety 25(5): 489–495.Google Scholar
  25. Hinton, Devon E., Stefan G. Hofmann, Roger K. Pitman, Mark H. Pollack, and David H. Barlow 2008b The Panic Attack-Posttraumatic Stress Disorder Model: Applicability to Orthostatic Panic Among Cambodian Refugees. Cognitive Behavior Therapy 37(2): 101–116.Google Scholar
  26. Hinton, Devon E., Roberto Lewis-Fernández, and Mark H. Pollack 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.CrossRefGoogle Scholar
  27. Johnson, Dawn M., Julie L. Pike, and Kathleen M. Chard. 2001 Factors Predicting PTSD, Depression, and Dissociative Severity in Female Treatment-Seeking Childhood Sexual Abuse Survivors. Child Abuse and Neglect 25(1):179–198.CrossRefGoogle Scholar
  28. Johnson, Jeffrey G., Patricia Cohen, Stephanie Kasen, and Judith S. Brook 2006 Dissociative Disorders Among Adults in the Community, Impaired Functioning, and Axis I and II Comorbidity. Journal of Psychiatric Research 40(2):131–140.CrossRefGoogle Scholar
  29. Liebowitz, Michael R., Ester Salmán, Carlos M. Jusino, Robin Garfinkel, Linda Street, Dora L. Cárdenas, Joao Silvestre, Abby J. Fyer, José L. Carrasco, Sharon Davies, Peter Guarnaccia, and Donald F. Klein 1994 Ataque de Nervios and Panic Disorder. American Journal of Psychiatry 151(6):871–875.Google Scholar
  30. Lewis-Fernández, Roberto 1994 A Comparison About Ataque de Nervios Among Puerto Ricans and Possession Syndrome in India. Pp. 123–171 in Dissociation, Culture, Mind and Body. David Spiegel, ed., pp. 123–171. Washington, DC: American Psychiatric Press.Google Scholar
  31. Lewis-Fernández, Roberto 1996 Cultural Formulation of Psychiatric Diagnosis. Case No. 02. Diagnosis and Treatment of Nervios and Ataques in a Female Puerto Rican Migrant. Culture, Medicine, and Psychiatry 20:155–163.CrossRefGoogle Scholar
  32. Lewis-Fernández, Roberto 1998 Eso No Estaba en Mí… No Pude Controlarme: El Control, la Identidad y las Emociones en Comunidades Puertorriqueñas That Was Not in Me… I Could Not Control Myself: Control, Identity, and Emotion in Puerto Rican Communities. Revista de Ciencias Sociales Puerto Rico 4:268–299Google Scholar
  33. Lewis-Fernández, Roberto, Pedro Garrido-Castillo, Mari Carmen Bennasar, Elsie M. Parrilla, Amaro J. Laria, Guoguang Ma, and Eva Petkova 2002 Dissociation, Childhood Trauma, and Ataque de Nervios Among Puerto Rican Psychiatric Outpatients. American Journal of Psychiatry 159(9):1603–1605.CrossRefGoogle Scholar
  34. Lewis-Fernández, Roberto, Peter J. Guarnaccia, Sapana Patel, Dana Lizardi and Naelys Diaz 2005 Ataque de Nervios: Anthropological, Epidemiological and Clinical Dimensions of a Cultural Syndrome. Pp. 63–85 in Perspectives in Cross-Cultural Psychiatry. A. M. Georgiopoulos and J. F. Rosenbaum, eds. Philadelphia: Lippincott Williams and Wilkins.Google Scholar
  35. Lewis-Fernández, Roberto, Alfonso Martínez-Taboas, Vedat Sar, Sapana Patel, and Adeline Boatin 2007 The Cross-Cultural Assessment of Dissociation. Pp. 279–319 in The Cross-Cultural Assessment of Psychological Trauma and PTSD. J. P. Wilson and C. So-Kum Tang, eds. New York: SpringerCrossRefGoogle Scholar
  36. Lewis-Fernández, Roberto, Marcela Horvitz-Lennon, Carlos Blanco, Peter J. Guarnaccia, Zhun Cao, and Margarita Alegría 2009 Significance of Endorsement of Psychotic Symptoms by US Latinos. Journal of Nervous and Mental Disease 197(5):337–347.CrossRefGoogle Scholar
  37. Little, Roderick J. A. and Donald B. Rubin 2002 Statistical Analysis with Missing Data. New York: John Wiley & Sons.Google Scholar
  38. Low, Setha M. 1981 The Meaning of Nervios: A Sociocultural Analysis of Symptom Presentation in San Jose, Costa Rica. Culture, Medicine, and Psychiatry 5:25–47.CrossRefGoogle Scholar
  39. Marsella, Anthony J., Matthew J. Friedman, Ellen T. Gerrity, and Raymond M. Surfield 1996 Ethnocultural Aspects of PTSD: Some Closing Thoughts. Pp. 529–538 in Ethnocultural Aspects of Posttraumatic Stress Disorder: Issues, Research, and Clinical Applications. A. J. Marsella, M. J. Friedman, E.T. Gerrity, and R. M. Scurfield, eds. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  40. Marshall, Grant M., and Terry L. Schell 2002 Reappraising the Link Between Peritraumatic Dissociation and PTSD Symptom Severity: Evidence from a Longitudinal Study of Community Violence Survivors. Journal of Abnormal Psychology 111(4):626–636.CrossRefGoogle Scholar
  41. Marshall, Randall D., Franklin R. Schneier, Brian A. Fallon, Charles B.G. Knight, Linda A. Abbate, Deborah Goetz, Raphael Campeas, and Michael R. Liebowitz. 1998 An Open Trial of Paroxetine in Patients with Non-Combat-Related, Chronic Posttraumatic Stress Disorder. Journal of Clinical Psychopharmacology 18(1):10–18.CrossRefGoogle Scholar
  42. Martínez-Taboas, Alfonso 1995 The Use of the Dissociative Experiences Scale in Puerto Rico. Dissociation 8(1):14–23.Google Scholar
  43. Martínez-Taboas, Alfonso, Roberto Lewis-Fernández, Vedat Sar, and Arun Lata Agarwal 2001 Cultural Aspects of Psychogenic Nonepileptic Seizures. Pp. 121–130 in Gates and Rowan’s Nonepileptic Seizures. 3rd ed. Steven C. Schachter and W. Curt LaFrance, eds. Cambridge, UK: Cambridge University Press.Google Scholar
  44. Mueser, Kim T., and Robert W. Butler 1987 Auditory Hallucinations in Combat-Related Chronic Posttraumatic Stress Disorder. American Journal of Psychiatry 144(3):299–302.Google Scholar
  45. Murray, James, Anke Ehlers, and Richard A. Mayou 2002 Dissociation and Post-traumatic Stress Disorder: Two Prospective Studies of Road Traffic Accident Survivors. British Journal of Psychiatry 180:363–368.CrossRefGoogle Scholar
  46. Nichter, Mark 1981 Idioms of Distress: Alternatives in the Expression of Psychosocial Distress: A Case Study from South India. Culture, Medicine, and Psychiatry 5:379–408.CrossRefGoogle Scholar
  47. Olfson, Mark, Roberto Lewis-Fernández, Myrna M. Weissman, Adriana Feder, Marc J. Gemeroff, Daniel Pilowsky, and Milton Fuentes 2002 Psychotic Symptoms in an Urban General Medicine Practice. American Journal of Psychiatry 159(8):1412–1419.CrossRefGoogle Scholar
  48. Ozer, Emily J., Suzanne R. Best, Tami L. Lipsey, and Daniel S. Weiss 2003 Predictors of Posttraumatic Stress Disorder and Symptoms in Adults: A Meta-Analysis. Psychological Bulletin 129(1):52–73.CrossRefGoogle Scholar
  49. Realmuto, George M., Ann Masten, Linda Flies Carole, Jon Hubbard, Andrea Groteluschen, and Bunchean Chhun 1992 Adolescent Survivors of Massive Childhood Trauma in Cambodia: Life Events and Current Symptoms. Journal of Traumatic Stress 5(4):589–599.CrossRefGoogle Scholar
  50. Peirce, Jessica M., Christopher K. Burke, Kenneth B. Stoller, Karin J. Neufeld, and Robert K. Brooner 2009 Assessing Traumatic Event Exposure: Comparing the Traumatic Life Events Questionnaire to the Structured Clinical Interview for DSMIV. Psychological Assessment 21(2): 210–218.CrossRefGoogle Scholar
  51. Posternak, Michael A., and Mark Zimmerman 2005 Elevated Rates of Psychosis Among Treatment-Seeking Hispanic Patients with Major Depression. Journal of Nervous and Mental Disease 193(1):66–69.CrossRefGoogle Scholar
  52. Putnam, Frank W., Eve B. Carlson, Colin A. Ross, Geri Anderson, Patti Clark, Moshe Torem, Elizabeth S. Bowman, Philip Coons, James A. Chu, Diana L. Dill, Richard J. Loewenstein, and Bennett G. Braun 1996 Patterns of Dissociation in Clinical and Nonclinical Samples. Journal of Nervous and Mental Disease 194(11):673–679.CrossRefGoogle Scholar
  53. Salgado De Snyder, V. Nelly, De Jesús Díaz-Pérez, and Victoria D. Ojeda 2000 The Prevalence of Nervios and Associated Symptomatology hmong Inhabitants of Mexican Rural Communities. Culture, Medicine, and Psychiatry 24:453–470.CrossRefGoogle Scholar
  54. Salmán, Ester, Michael R. Liebowitz, Peter J. Guarnaccia, Carlos M. Jusino, Robin Garfinkel, Linda Street, Dora L. Cárdenas, João Silvestre, Abby J. Fyer, José L. Carrasco, Sharon O. Davies, and Donald F. Klein 1998 Subtypes of Ataques de Nervios: The Influence of Coexisting Psychiatric Diagnosis. Culture, Medicine, and Psychiatry 22:231–244.CrossRefGoogle Scholar
  55. Schafer, Joseph L. 1997 Analysis of Incomplete Multivariate Data. London: Chapman & Hall.Google Scholar
  56. Schechter, Daniel S., Randall Marshall, Ester Salmán, Deborah Goetz, Sharon Davies, and Michael R. Liebowitz 2000 Ataque de Nervios and History of Childhood Trauma. Journal of Traumatic Stress 13(3):529–534.CrossRefGoogle Scholar
  57. Takeuchi, David T, Chi-Ah Chun, Fang Gong, Haikang Shen 2002 Cultural Expressions of Distress. Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine 6(2):221–235Google Scholar
  58. van Ijzendoorn, Marinus H., and Carlo Schuengel 1996 The Measurement of Dissociation in Normal and Clinical Populations: Meta-analytic Validation of the Dissociative Experiences Scale (DES). Clinical Psychological Review 16(5):365–382.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Roberto Lewis-Fernández
    • 1
    • 2
    Email author
  • Magdaliz Gorritz
    • 1
  • Greer A. Raggio
    • 1
  • Clara Peláez
    • 3
  • Henian Chen
    • 4
  • Peter J. Guarnaccia
    • 5
  1. 1.New York State Psychiatric InstituteNew YorkUSA
  2. 2.Department of PsychiatryColumbia College of Physicians & SurgeonsNew YorkUSA
  3. 3.Hospital Puerta de HierroMadridSpain
  4. 4.Department of BiostatisticsWinthrop University Hospital, Stony Brook University Medical SchoolStony BrookUSA
  5. 5.Institute for Health, Health Care Policy & Aging ResearchRutgers UniversityNew BrunswickUSA

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