MARIA OQUENDO, EWALD HORWATH, AND ABIGAIL MARTINEZ

ATAQUES DE NERVIOS: PROPOSED DIAGNOSTIC CRITERIA FOR A CULTURE SPECIFIC SYNDROME ABSTRACT. The authors propose a set of diagnostic criteria and report two cases of ataque de nervios, a syndrome of brief duration seen primarily in Spanish-speaking people of the Caribbean. Following a psychosocial stressor, the afflicted person demonstrates impulsivity, dissociation and communication and perceptual disturbances. The symptoms often begin in the presence of the family, allow a temporary relinquishing of social roles, and result in the mobilization of the social network in support of the person. Further research is needed to improve our understanding of this culture specific syndrome and its relationship to psychiatric disorder. Ataque de nervios is a syndrome seen in people of the Spanish-speaking Caribbean (Cuba, Dominican Republic, Puerto Rico). Among the early reports were those of U.S. Armed Forces psychiatrists evaluating Puerto Rican recruits in the 1950's (Mehlman 1961). Since then, it has been observed in the Hispanic Caribbean population in their native countries and in those who have immigrated to the U.S. Yet, its epidemiology, symptomatology and treatment have never been studied systematically. Ataque de nervios may occur in the absence of another mental disorder or concurrently with psychiatric disorders, ranging from schizophrenia to personality disorders. Its coexistence with such a wide gamut of psychiatric disorders has made it difficult to clarify the phenomenology of this culture specific syndrome. Reflecting this, there have been differing portrayals of the syndrome throughout the literature. For instance, Rothenberg characterizes ataque de nervios as a sudden onset of violence, uncommunicativeness and hyperkinesis (1984). He adds that swearing and striking out at others is common. Guarnaccia et al. and Grace describe how the afflicted person may fall to the floor and either convulse, or act as if dead (Guamaccia et al. 1989; Grace 1959). Similarly, Thomas and Garrison describe a case presenting with unresponsiveness, hyperventilation, and tonic clinic movements (Thomas and Garrison 1975). Trautman describes another version of ataque de nervios, "the suicidal fit" (1961). The fit has two phases; one during which the patient flees a stressful scene and the other during which suicide is impulsively attempted (Trautman 1961). Though superficially distinct, these descriptions have important common denominators, namely the suddenness of onset, the disruption in ability to communicate and the action-oriented result. The ataque de nervios usually begins at a funeral, at the scene of an accident or family fight, or at other times when strong emotional expression is culturally sanctioned. Among Spanish-speaking people of the Caribbean, it is considered an acceptable way of displaying distress. Culture, Medicine and Psychiatry 16: 367-376, 1992. © 1992Kluwer Academic Publishers. Printed in the Netherlands.

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Another prominent feature of ataque, which has rarely been noted, is its effect on the social support network. The ataque mobilizes the person's family and friends, all of whom come together and attempt to alleviate the stress as best as they can (Guarnaccia et al. 1989). This in itself may lead to symptom remission. As currently constituted, DSM-III and DSM-III-R are not equally applicable across cultures. The absence of descriptions of culture specific syndromes such as ataque de nervios, limits the clinical utility of DSM-III and DSM-I/I-R in the rather large United States Hispanic population. In order to clarify the phenomenology of ataque, we propose a description and a set of diagnostic criteria for this syndrome. This would represent an important step towards a standardized definition of ataque de nervios. The use of diagnostic criteria would also foster research to refine the diagnosis of ataque de nervios and to clarify its relationship to other psychiatric disorders. The following description is a synthesis of our own clinical experience and published accounts of ataque de nervios. The cases reported herein were seen on an acute inpatient unit serving northern Manhattan. The catchment area of our psychiatric service has a large Hispanic population, a significant portion of which is recently immigrated to New York City from the Dominican Republic, Puerto Rico, Cuba and other Latin American countries. This is reflected in the composition of the inpatient population, which is 60 to 70% Hispanic. The average length of stay is thirty days.

DESCRIPTION AND DIAGNOSTIC CRITERIA Essential Features This syndrome is seen in persons from the Spanish-speaking islands of the Caribbean. The essential feature is a sudden, though transient, change in behavior that occurs after a major stress. The stress may range from a break-up with a boyfriend or girlfriend to the death of a child. Though it is usually in the interpersonal arena, it is not invariably so. Following the stress, psychotic symptoms may ensue, most frequently incoherence or auditory hallucinations of the voice of a loved one. Dissociative experiences are common and include changes in the level of consciousness and amnesia. Sudden or impulsive behavior such as suicide attempts, falling to the floor, assanltiveness and seizure-like activity may bring the person to medical attention. Episodes of ataque occur along a wide spectrum of severity. Cases that come to medical attention may represent only the most severe end of that spectrum.

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Associated Features The sociocultural context of ataque de nervios is crucial to the diagnosis. The syndrome usually begins in the presence of family members, often at home. Through this culturally condoned coping mechanism, the afflicted member relinquishes his or her social roles. The family then mobilizes to provide support and, if possible, to remove the stressor. For example, if the stressor is a separation, there may be a transient reconciliation.

Age at onset. An ataque may occur at any age, ranging from adolescence to adulthood, but may occur more frequently in people over 45 (Guamaccia et al. 1989).

Course. Duration varies from a few hours up to a week and is followed by a retum to baseline functioning. The frequency of recurrence is unknown.

Impairment. Impairment may be moderate to severe during the ataque but does not persist after its resolution.

Complications. Self-injury may occur in some cases. Predisposing factors. Ataque always follows a psychosocial stressor, and may occur more frequently in persons of lower socioeconomic status and educational level.

Prevalence.

Because many cases may not come to medical attention, it is difficult to estimate the prevalence in the general population. No systematic study of the prevalence has been done in the United States.

Sex ratio. The disorder appears to be more common in women, but the exact ratio is unknown (Guarnaccia et al. 1989).

Familialpattern. Not known. Differential diagnosis.

Because ataque de nervios can occur among persons with a wide range of psychopathology, the diagnosis may be difficult. Mild cases of ataque in which the symptoms last for only a few hours may not come to medical attention or present a problem in differential diagnosis. More severe cases presenting with psychotomimetic symptoms may meet criteria for the diagnosis of brief reactive psychosis. The sudden onset of perceptual and communication disturbances, abrupt change in behavior, or dissociative experiences should suggest the diagnosis of ataque de nervios when seen in a Hispanic person from the Caribbean islands.

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In cases presenting with a change in level of consciousness, mutism, incoherence, or amnesia, the differential diagnosis should include organic mental disorder. A toxicology screen may point toward substance-induced organic mental disorder. A diagnosis of dissociative disorder should be made when dissociative symptoms occur in the absence of other symptoms of ataque. Ataque de nervios may be diagnosed in the presence of borderline personality disorder and, in fact, may become a recurrent pattern behavior. Factitious disorder with psychological symptoms may be difficult to rule out. In general, the symptoms of ataque are not thought to be intentionally produced, or under the affected person's conscious control. The diagnosis of adjustment disorder with disturbance of emotions and conduct may be made when dissociative experiences, communication disturbance, or psychotic symptoms are not present. The proposed diagnostic criteria for ataque are shown in the table.

CASE REPORTS The following two cases illustrate our own experience with this syndrome. They constitute two of three cases admitted in which no Axis I or Axis II Diagnosis could be made. This is of interest because both our Emergency Services psychiatrists and the psychiatrist who screens admissions are sensitive to the manifestation of ataques. The majority of the cases that present to the Emergency Room are "treated" there with family interventions. We do not have statistics on the total number of cases of ataques de nervios seen in the Emergency Room.

CASE I A. is an 18 year old single Dominican woman who was brought to the emergency room by her family after a suicide attempt. Both she and her family denied any previous psychiatric history. She functioned normally until recently, when she became estranged from her family because of their objection to her boyfriend. She moved out of her sister's home and soon thereafter her boyfriend left her. The patient was distraught and tried unsuccessfully to get back with him. On the day of her suicide attempt, she went to her boyfriend's apartment and threatened to kill herself. Back on the street, she bought a half gram of cocaine and went to her sister's home, where she ingested vitamin pills. A. then took a nail polish container, smashed the glass and mixed the glass and nail polish with

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the cocaine, dish detergent, and soda. After drinking this mixture, she felt ill and became frightened. She told her sister and immediately fainted. She was brought to the emergency room where she was found to be unresponsive to pain, but easily aroused with ammonium salts. The toxicology screen was positive for cocaine only. Initially, she would not answer questions despite being alert and awake. A. became more communicative by the following morning, but because of her inappropriate affect, her lack of insight, and her refusal of psychiatric follow up, she was admitted for further assessment. While on the ward, the patient described auditory hallucinations prior to her suicide attempts. She stated she heard the voice of her father, who was dead, telling her she should leave her boyfriend. However, she experienced no hallucinations while in the hospital. Her family visited her regularly on the ward and in a family meeting, offered to have her return to live with her sister. The patient readily accepted. She agreed to psychiatric follow-up and was discharged on no medications with full recovery of her baseline functioning. This case illustrates one of the forms that ataque may take. The patient, who was from the Dominican Republic, suffered the breakup of an amorous relationship. She proceeded to experience brief psychotic symptoms and a change in her ability to communicate. A. then made a suicide attempt and was brought to the emergency room by her sister. The total duration of her ataque was approximately 4 days. The diagnosis of ataque was strongly supported by the cultural context, the patient's prompt improvement without medication and her positive response to family support. In this case, the severity of the psychosocial stressor would not meet the criteria for brief reactive psychosis. Although toxic psychosis might be considered, the dose and route of ingestion of the cocaine would not usually result in psychotic symptoms.

CASEH

B. is a 35 year old divorced Dominican woman who was brought to the emergency room by her family because of facial pain. A week prior to admission, the patient heard that her ex-husband had remarried in the Dominican Republic. During the next few days, she became increasingly agitated and developed insomnia and anorexia. She moved into her mother's home with her two children and that day developed severe left-sided facial pain. Her mother and brother brought her to the emergency room, where the patient became increasingly agitated and started screaming during her medical evaluation.

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The psychiatric consultant found her to be alternately mute and mumbling unintelligibly in Spanish and English. She was given small doses of lorazepam and later haloperidol with no response. Because of her behavior she was admitted to the psychiatric ward for further evaluation. On the ward, the patient exhibited agitation, stereotyped movements, and behavioral outbursts. She would suddenly snatch another patient's purse or grab at gold chains around a male patient's neck. At one point, she ate plastic flowers from a vase. She appeared sad, frightened and dishevelled. She reported ideas of reference and command auditory hallucinations of her daughter's voice telling her to kill herself. She received haloperidol up to 60 mg/day. Though there was some decrease in her agitation, she continued to have psychotic symptoms with intermittent episodes of bizarre behavior. A family meeting was held with the patient, her mother, daughter, and son. There, the patient's concerns about her financial situation were explored. The patient was able to express anxiety about her ex-husband's possible decreased interest in her and her children now that he had remarried. A meeting was scheduled with her ex-husband to discuss these issues. After this meeting, there was a pronounced change in the patient. Her psychotic symptoms resolved and her intermittent episodes of agitation stopped. Her dose of haloperidol was tapered and discontinued without recurrence of symptoms and she was discharged having returned to her previous level of functioning. In this case, after her ex-husband remarried, this Dominican woman developed agitation, a change in ability to communicate, and incoherence alternating with mutism. On the ward, she had psychotic symptoms and bizarre behavior. Her ataque began in her mother's home and resulted in a mobilization of the family to care for her children and bring her to medical attention. The cultural context, the communication disturbance, and the bizarre behaviors, along with the patient's response to family intervention strongly suggest a diagnosis of ataque.

DISCUSSION As currently conceived, DSM-HI-R is lacking in an explicit recognition of psychocultural categories. Cultural factors can play an important role in symptom formation, in the reaction to psychosocial stressors, and in the family's response to an ill member. By not including culture specific syndromes, DSMIII-R limits the understanding of cultural factors as they influence a variety of clinical syndromes, including, but not limited to, syndromes such as ataque. The experience of hallucinations and the degree of reality testing surrounding perceptual experiences are strongly influenced by culturally condoned beliefs (Andrade et al. 1988; Hirsch and Hollender 1969; Al-Issa 1977; Andrade and

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Srinath 1986). Andrade argues that, in India, where the majority of the population accepts paranormal phenomena such as mystical trances and demonic possession, hearing voices or seeing visions has a cultural sanction (Andrade et al. 1988). Al-Issa suggests that certain cultural attitudes may increase the tendency to give reality status to visual and auditory hallucinations (Al-Issa 1977). Likewise, Rock reports that in Asian women, the most common cause of hallucinations is not schizophrenia, but hysteria (Rock 1982). Similarly, among Hispanics, culturally sanctioned beliefs such as Espiritismo (Bird and Canino 1981) or Santeria (Sandoval 1977) may influence both the experience and the interpretation of hallucinatory perceptions. Skodol, in a discussion of culturebound syndromes, notes that culture exerts a powerful pathoplastic influence on the expression of symptoms (Skodol 1989). These observations suggest that spiritual beliefs and other cultural influences play an important role in symptom formation and the interpretation of perceptual experiences. Cultural factors also strongly influence a person's response to severe stress. Guamaccia and associates argue that the ataque is an expression of anger and grief resulting from the disruption of family systems, the process of migration, and concerns about family members in the country of origin (Guamaccia et al. 1989). Garrison suggests that, among certain groups of Puerto Rican immigrants to the United States, some form of ataque may be expected of a "good woman" at the death of a close relative or when witnessing violence within the family (Garrison 1977). In the latter instance, the ataque may bring the violence to a halt. Trautman describes the "suicidal fit" as a culturally influenced response to a severe psychosocial stressor, such as the breakup of an important relationship (Trautman 1961). He reports that, of 69 Puerto Rican women, 43 gave as the immediate cause of their action a fight with husband or lover; 14 had quarreled with their mothers; and 12 described severe financial trouble, homesickness or chronic illnes (Trautman 1961). In our own cases, estrangement from the family, rupture of a romantic involvement, or bad news regarding an ex-husband each played some role in precipitating the ataque. Among these women, the ataque represents a condoned, perhaps even expected, pattern of behavior in response to stress. Cultural factors are also important determinants of the family's response to distress in one of its members. Where the precipitating stress is a threatened rift in an intimate relationship, the family may facilitate a reconciliation. Trautman describes the dramatic effect of the "suicidal fit" on the patient's family and intimate friends (Trautman 1961). Invariably, the fit causes a major upheaval in the family, eliciting strong guilt feelings and a show of attention and affection toward the patient. In our cases the ataque moved the families into action and the episodes resolved when threatened relationships were reconciled. This clinical observation strongly suggests the need for therapeutic family interventions in such cases.

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The consistent observation of cultural influences on symptom formation, stress related behavior, and family response suggests a need to explicitly describe identifiable culture specific syndromes in a reliable way. DSM-III and DSM-HI-R already include at least one syndrome which may be considered culture specific. Westermeyer (1985) suggests that bulimia is predominantly a syndrome of North American females "bound" to our culture. With this in mind, the diagnostic categories included in DSM-HI and DSM-III-R would be more useful internationally if syndromes such as ataque were included. The explicit recognition of psychocultural categories would also add flexibility to a diagnostic system intended for a culturally diverse country such as the United States (Alarcon 1983). Indeed, the rapid growth of the immigrant Spanish-speaking population may make the recognition of such categories a clinical necessity. We agree with Wig (1983) that more systematic scientific data needs to be gathered on culture specific syndromes. This objective would best be attained by the drafting of complete descriptions, including diagnostic criteria, and their inclusion in diagnostic classifications, such as DSM-IV. The use of diagnostic criteria would facilitate research into the cultural determinants of perceptual disturbances and other processes of symptom formation. The reliable recognition of this syndrome would also have important therapeutic implications. Early recognition would lead to family interventions and, in some cases, might obviate the need for medications or hospitalization.

College of Physicians and Surgeons Columbia University 722 West 168th Street New York, NY 10032 U.S.A.

ACKNOWLEDGEMENT The authors wish to acknowledge the advice and assistance of Francine Cournos, M.D., Andrew Skodol, M.D. and Janet Williams, D.S.W. REFERENCES Al-Issa, A. 1977 Social and Cultural Aspects of Hallucinations. Psychological Bulletin 84:570-587. Alarcon, R.D. 1983 A Latin-American Perspective on DSM-III, In Case Studies in Spirit Possession. V. Crapanzano and V. Garrison, eds. New York: John Wiley and Sons. Andrade, C., and S. Srinath 1986 True Auditory Hallucinations as a Conversion Symptom. British Journal of

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Psychiatry 148:100-102. Andrade, C., S. Srinath, and A.C. Andrade 1988 True Hallucinations as a Culturally Sanctioned Experience. British Journal of Psychiatry 152:838-839. Bird, H., and I. Canino 1981 The Sociopsychiatry of Espiritismo. Journal of the American Academy of Child Psychiatry 20:725-740. Garrison, V. 1977 The Puerto Rican Syndrome in Psychiatry and Espiritismo. In Case Studies in Spirit Possession. V. Crapanzano and V. Garrison, eds. New York: John Wiley and Sons. Grace, W.J. 1959 Ataque. New York Medicine 15:12-13. Guarnaccia, P.J., V. DeLaCancela, and E. Carrillo 1989 The Multiple Meanings of Ataques de Nervios in the Latino Community. Medical Anthropology 2:47-62. Guarnaccia, P.J., M. Rubio-Stipec, and G. Canino 1989 Ataques de Nervios in the Puerto Rico Diagnostic Interview Schedule: The Impact of Cultural Categories on Psychiatric Epidemiology. Culture, Medicine and Psychiatry 13:275-295. Hirsch, S.J., and M.H. Hollender 1969 Hysterical Psychosis: Clarification of the Concept. American Journal of Psychiatry 125:909-915. Mehlman, R.D. 1961 The Puerto Rican Syndrome. American Journal of Psychiatry 118:322-328. Rock, P. 1982 Race, Culture and Mental Disorder. London and New York: Tavistock Publications. Rothenberg, A. 1964 Puerto Rico and Aggression. American Journal of Psychiatry 120:962-970. Sandoval, M. 1977 Afrocuban Concepts of Disease and its Treatment in Miami. Journal of Operational Psychiatry 8:52-63. Skodol, A.E. 1989 Problems in Differential Diagnosis: From DSM-III to DSM-III-R in Clinical Practice. Washington, D.C.: American Psychiatric Press. Thomas, C.S., and V. Garrison 1975 A General Systems View of Community Mental Health. In Progress in Community Mental Health, Vol. III. L. Bellak and H. Barten, eds. New York: Brunner/Mazel. Trautman, E.C. 1961 The Suicidal Fit. Archives of General Psychiatry 5:98-105. Westermeyer, J. 1985 Psychiatric Diagnosis Across Cultural Boundaries. American Journal of Psychiatry 142:798-805. Wig, N.N. 1983 DSM-III: A Perspective from the Third World. In International Perspectives on DSM-III. R.L. Spitzer, J.B.W. Williams and A.E. Skodol, eds. Washington D.C.: American Psychiatric Press.

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Criteria for culture specific syndrome of ataque de nervios A. Seen in Spanish speaking people of the Caribbean Islands (Cuba, Dominican Republic, Puerto Rico). B. Onset within one week after a severe psychosocial stressor. C. A severe and sudden change in behavior characterized by two or more of the following features: 1. Sudden or impulsive behaviors, such as suicide attempt, falling to the floor, seizure-like movements, assaultiveness, posturing or agitation. 2. Dissociative experiences (a or b). a) Change in level of consciousness. e.g., Failure to respond to verbal stimuli, decreased response to pain. b) Localized or selective amnesia. e.g., Patient cannot recall a circumscribed period of time and/or behaviors following stressor. 3. Disturbance in communication (a, b, c, or d). a) Mutism. b) Neologisms (e.g., speaking in tongues). c) Incoherence. d) Screaming. 4. Brief psychotic symptoms (a or b). a) Auditory hallucinations. b) Visual hallucinations. D. Duration. The syndrome may last hours to days, but no longer than one week, and is followed by a return to baseline functioning.

Ataques de nervios: proposed diagnostic criteria for a culture specific syndrome.

The authors propose a set of diagnostic criteria and report two cases of ataque de nervios, a syndrome of brief duration seen primarily in Spanish-spe...
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