Culture, Medicine, and Psychiatry

, Volume 40, Issue 4, pp 570–619 | Cite as

A Transcultural Model of the Centrality of “Thinking a Lot” in Psychopathologies Across the Globe and the Process of Localization: A Cambodian Refugee Example

  • Devon E. HintonEmail author
  • David H. Barlow
  • Ria Reis
  • Joop de Jong
Original Paper


We present a general model of why “thinking a lot” is a key presentation of distress in many cultures and examine how “thinking a lot” plays out in the Cambodian cultural context. We argue that the complaint of “thinking a lot” indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining “thinking a lot” in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of “thinking a lot” begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and “zoning out”) and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of “thinking a lot” and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of “thinking a lot,” or on what might be called the “thinking a lot” causal network.


“Thinking too much” “Thinking a lot” Rumination Idioms of distress Cross-cultural psychiatry Cultural concepts of distress 


Compliance with Ethical Standards

Conflict of interest

The author has no conflict of interest

Informed consent

Informed consent was obtained from all participants, and the study was conducted as per in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


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Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Devon E. Hinton
    • 1
    Email author
  • David H. Barlow
    • 2
  • Ria Reis
    • 3
    • 4
    • 5
  • Joop de Jong
    • 4
    • 6
  1. 1.Center for Anxiety and Traumatic, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  2. 2.Center for Anxiety and Related DisordersBoston UniversityBostonUSA
  3. 3.Leiden University Medical CenterLeidenThe Netherlands
  4. 4.Amsterdam Institute for Social Science ResearchUniversity of AmsterdamAmsterdamThe Netherlands
  5. 5.The Children’s Institute, School of Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
  6. 6.Boston University School of MedicineBostonUSA

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