by Michael D. Anestis, M.S.
We have not spent a great deal of time discussing cultural matters on Psychotherapy Brown Bag, so I wanted to take the opportunity today to open up a dialogue on a specific phenomenon listed in the DSM-IV-TR appendix as a culturally bound syndrome: ataques de nervios (ADN). ADN translates in English as "attack of nerves" and is theorized to be a phenomenon similar to but distinct from a panic attack and to occur exclusively in Hispanic culture. Most of my exposure to this phenomenon has been through presentations by a colleague, Meghan Keough, who recently published a study on ADN in Depression and Anxiety along with Kiara Timpano and Brad Schmidt (2009).
Keough and colleagues (2009) provide a thorough description of ADN and I recommend reading the article for a more complete understanding of the phenomenon, but I will summarize their description here. ADN is characterized by a general sense of being "out of control." Common symptoms include uncontrollable shouting, attacks of crying, trembling, and heat in the chest rising into the head. Some individuals also experience dissociative symptoms, suicidal gestures, and either seizures or fainting. Additionally, some individuals report amnesia of the ADN after returning to normal functioning. ADN is theorized to be prompted by the occurrence of distressing events, including conflicts with peers or the death of a loved one.
Keough and her co-authors decided to study this phenomenon in response to the complete lack of data testing the degree to which the basic assumptions underlying its descriptions are true. In other words, despite ADN being listed as a culturally bound syndrome, there is little evidence that it is actually culturally bound. Additionally, although the sense of fear that is a central component of a panic attack is absent in ADN, the degree to which ADN differs from panic attacks has not been tested.
The sample in this study was comprised of 342 undergraduates from a large southeastern university and included 200 Caucasian individuals, 58 African American individuals, 50 Hispanic individuals, 8 Asian individuals, 25 multi-ethnic individuals, and 1 individual who chose not to report his or her race or ethnicity.
In order to ensure that the participants understood the meaning of ADN and panic attacks, they utilized the Panic Attack Questionnaire - Revised (Cox, Norton, & Swinson, 1992), which provides the following description of the two phenomena:
An experience characterized by the sudden onset of intense fear or terror, often associated with feelings of impending doom, which is not a result of real danger. Some of the most common symptoms experienced during an attack are dizziness, shortness of breath, chest pain or discomfort, and trembling or shaking. This experience differs from feelings of fear, anxiety, or worry that build up over time, and also differs from moderate feelings of fear or anxiety. Rather, it involves quick hitting feelings of extreme terror or fear.
Ataques de nervios
An experience of distress characterized by a general sense of being out of control that does not typically involve fear and often occurs following a stressful family event. Some of the most common symptoms experienced are uncontrollable shouting, attacks of crying, trembling, heat in the chest rising into the head, and verbal or physical aggression.
The authors had four primary hypotheses:
- Hispanic participants would exhibit a higher rate of ADN than would African American or Caucasian participants, with the latter two groups showing identical rates relative to one another.
- Hispanic individuals who most closely identified with Hispanic culture (e.g., had lower rates of acculturation) would exhibit higher rates of ADN than would Hispanic individuals who identified less strongly with Hispanic culture.
- ADN would be more closely related to a history of trauma whereas panic attacks would be more strongly associated with anxiety sensitivity, body vigilance, and state and trait anxiety.
- ADN would be less likely than panic attacks to occur out of the blue and would be associated with greater levels of dissociation while taking longer to reach their peak levels.
The findings of this study were fairly surprising. 25% of the sample reported having experienced an episode of ADN in their lifetime, but there was no statistically significant difference between Hispanic, Caucasian, and African American participants in their lifetime rate of ADN. In other words, the evidence did not support the idea that ADN is a culturally bound phenomenon. Instead, ADN appears equally likely to occur across race and ethnicity. Additionally, there was no difference between males and females in their rates of ADN.
The authors' next set of analyses looked at acculturation - the degree to which an individual identifies himself with his own ethnic or racial group as opposed to adopting the culture of his immediate surroundings. Data indicated that Hispanic participants had lower rates of acculturation (e.g., identified with their own heritage rather than their immediate surroundings) than did Caucasian participants, but that degree of acculturation did not predict rates of ADN. In other words, the degree to which Hispanic individuals identify themselves with their Hispanic heritage does not impact the likelihood that they will report having experienced an episode of ADN during the course of their lives. This is important because, without knowing this, a critic could argue that the authors found no difference between Hispanic and non-Hispanic individuals in rates of ADN because the sample was a group of college students in America unlikely to identify with Hispanic culture. The data, however, contradict that criticism and cast doubt on the idea that ADN is culturally bound.
The third set of analyses - those examining the degree to which ADN and panic attacks are related to different predictors, conformed more closely to the authors' hypotheses. Panic attacks were more closely to a history of traumatic experience and the physical sub-factor of anxiety sensitivity than was ADN. This indicates that, although ADN and panic attacks are similar, individuals may become vulnerable to ADN in different ways than they become vulnerable to panic attacks.
The fourth set of analyses - those examining the degree to which the symptoms of ADN differ from the symptoms of panic attacks, were a bit more ambiguous. Panic attacks are characterized by a quick crescendo (they must reach their peak within 10 minutes of the onset of symptoms) and a tendency at times to occur out of the blue rather than being preceded by an environmental stress (this is particularly true in panic disorder). ADN is not theorized to share these characteristics, and yet, the data indicated that ADN and panic attacks did not differ in the degree to which they occurred out of the blue or reached their peak within 10 minutes. Similarly, there were no differences between panic attacks and ADN in dissociative symptoms or dyspnea. Dizziness was more common in panic attacks and ADN was more strongly associated with anger, guilt, fear of causing a scene, uncontrollable shouting, verbal aggression, and the fear of doing something uncontrolled. So, while several symptoms were different between the two, several key characteristics thought to differentiate these two phenomenon actually overlapped.
So what does this tell us? First of all, this study represents one of the few attempts to empirically examine a culturally bound syndrome and test its theorized nature. Considering culture in psychological research is pivotal, but relying on untested assumptions about culture is dangerous. In this case, the data indicates that, although ADN may be distinct from panic attacks, it is not necessarily exclusive or even more common in Hispanic culture.
If you would like to learn more about anxiety in general or panic attacks in particular, we recommend the following resources, all of which are available through our online store:
When Panic Attacks: The New, Drug-Free Anxiety Therapy That Can Change Your Life
Mastery of Your Anxiety and Panic: Workbook
Treatment Plans and Interventions for Depression and Anxiety Disorders
Anxiety Free: Unravel Your Fears Before They Unravel You
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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