Friday, August 14, 2015

Susto: Fright and Soul Loss in the Spanish-Speaking World

Susto: Fright and Soul Loss in the Spanish-Speaking World

Brendan Bombaci

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            Susto is a both a culture bound syndrome and an idiom of distress with many variations around a consensus fundamental core set of symptoms – mostly somatic but some psychological – caused mostly by fright and stress.  It is found mostly in Central and South America, but also among Mexican American populations, and to a lesser degree in Spain; it does not occur throughout the whole Spanish-speaking world.  The DSM IV only lists susto in Appendix I and relates it to Major Depressive Disorder (MDD), Post Traumatic Stress Disorder (PTSD), and lastly to Somatoform Disorders (SD) which have no apparent medical cause.  Anthropologically, it has been studied for associations to physiological symptoms via biomarker analyses, with positive correlations, but also reported by some populations to be a causal factor in major debilitating illness (mostly diabetes, but also cancer) and even death, where research has provided tentative evidence that neither is the case.  Analyzed by surveys and narrative, it is dissimilar to Western cases of anxiety and depression, even though it paradoxically is correlated with increased risk for depression and has been traditionally treated with anxiolytic (anti-anxiety) plant medicines.  For some populations, susto is overtly known to have individual-scale effects symbolic of and in outcry to colonialism and resource loss.  However dramatic, it is rectified easily and quickly via praying, family counsel, physical touch, and both indigenous and Western forms of talk therapy with their respective healing practitioners.  The DSM may only be credited with any helpful, albeit partial, treatment by way of self-reports that the psychological and somatic complaints are alleviated by talk therapy; but, this may rather be due to the building of a patient/clinician relationship more than “repair” of the unconscious mind.  In regards to all of this, in some cases it appears to be a runaway neurosis caused by expectations from trigger events and then symptom exacerbation through catastrophic cognition or looping, and/or in other cases it is an idiom of distress, consciously or unconsciously enacted, but in no way does it resemble a neurobiological disorder.  There is still the future possibility for (1) cultural congruency study to see if social status and syncretism increase risk for susto and (2) culturally sensitive psychiatric interviews and cultural consonance study based in grounded theory, for the purposes of differentiating between the two forms and determining exactly how the social responses to the idiom of distress returns power to the sufferer and/or the community.  Between these methods, and that of culturally sensitive psychiatry when a susto patient seeks Western help (in order to determine if their seemingly somatic symptoms are actually from preexisting organic maladies), the knowledge base on this illness/idiom can be greatly enhanced.

Background and Symptomatology

            Susto is “prevalent among some Latinos in the United States and [mostly] among people in Mexico, Central America, and South America” (APA 1994:848, emphasis added) as well as Spain (Weller et al. 2002) but perhaps to a much lesser degree.  Its lack of occurrence in places like Puerto Rico “may be due to whether the beliefs originated in Spain or had an indigenous origin” (Weller et al. 2002:468).  However it may be that the term susto has been appropriated to describe otherwise spiritually-relative precolonial illnesses (although transmitted to other cultures) for some ethnic groups (Gonzales 2012:29-30) and which is perceived to result “in the loss of vital substance or force, and may be regarded as the separation of the soul from the body” (Durà Vilà and Hodes 2012:1628).  For others, it may be a simple case of prolonged fright from scare or startle (Baer et al. 2012:340, Durà-Vilà and Hodes 2012:1628, Uzzell 1974, Weller et al. 2008), an outcome of fear and anger (Baer and Bustillo 1993:91), or a politically focused rite of retaliation against postcolonial stress (Burman 2010, Gonzales 2012:37-38).  In a non-cognitive/spiritual explanatory model, some Florida farmworkers have even blamed pesticide exposure for their own experiences of susto (Baer and Bustillo 1993).  In as much, it is unique among illnesses of the world.  It is an idiom of distress – which I will explain later – but also a culture-bound syndrome in that its distinctiveness arises “from cultural influences on the mechanisms of disease causation or pathogenesis, or on the shaping of symptoms, illness experience, and the temporal course of the disorder” (Hinton and Good 2009:39).  The American Psychiatric Association (APA) is respectful in noting that
“[t]here is seldom a one-to-one equivalence of any culture-bound syndrome with a DSM diagnostic entity. Aberrant behavior that might be sorted by a diagnostician using DSM-IV into several categories may be included in a single folk category, and presentations that might be considered by a diagnostician using DSM-IV as belonging to a single category may be sorted into several by an indigenous clinician. Moreover, some conditions and disorders have been conceptualized as culture-bound syndromes specific to industrialized culture (e.g., Anorexia Nervosa, Dissociative Identity Disorder) given their apparent rarity or absence in other cultures.” [APA 1994:844].
This is reified in the case of susto as it is seen to arise from a variety of circumstances, and is located in time and place.

            Symptoms of susto are many and somewhat diverse, so cultural consensus needs to be understood to address it.  Susan Weller is a leader in this methodology (2007).  In practice, consensus analysis
“determines whether the responses of a group of individuals have a sufficient degree of homogeneity to describe them as a single set of “shared beliefs” [...,] estimates individual respondents’ level of cultural knowledge about the questions [..., and] estimates the culturally “correct” answers to the questions (the normative cultural responses) and provides a probabilistic confidence level for the estimation of answers to the questions.” [Weller et al. 2002:458]
Using this analysis method, her team discovered variances in the expression of susto (in Guatemala, Texas, and Mexico) but that there are mostly core symptoms.  Symptoms for (1) all locations include agitation, crying and hysterical crying, bad dreams, difficulty sleeping, fear of strange people, frequent shaking and trembling, tossing and screaming during sleep, paleness, and nerves; for (2) only Guatemala include lack of appetite and weight loss, fever, lack of animation, and muscle/body aches; and for (3) only Texas include cold sweat, vomiting, and diarrhea (Weller et al. 2002:464).  Then there are the outliers, the more possession-relative symptoms.  For the Aymara of Peru, susto can occur even without the aforementioned “loss of soul,” where a strange invading spirit takes over the body and mind instead and “starts to influence the person, and makes him think, speak, act, and feel in “strange” ways” (Burman 2010:464).  This concept has coursed through early Mesoamerican cultures as well (Gonzales 2012:29).  Causes of susto being what they are, seeming to be illogically related to the physiological symptom set, it should be warned that labeling them as solely psychological projections is ethnocentrically assumptive.
“[S]omatization – the theory that ego converts unexpressed emotions into bodily experiences – is an equally inadequate construct inasmuch as it artificially separates bodily and psychological symptoms that patients experience as a unified whole. The Chinese experience of depression [i.e.] suggests that the existential core of depression is bodily.” [Lee et al. 2007:5]
Not only are these experiences legitimately unique ways of experiencing psychiatric stress (Kirmayer 2012:9), but they can also be products of or causal factors for measurable physiological disease.

Medical Assays

            Baer et al. (2012) studied the relationship between diabetes and susto, as susto has been blamed by Mexican and Mexican American patients as causal to their diagnoses of diabetes (Baer et al. 2012:340-341).  They chose to study 239 diabetes I patients and 200 non-diabetic control patients at the family practice clinic at the Instituto Mexicano de Seguro Social (IMSS) in Guadalajara, Mexico (choosing the same treatment population that Weller et al. [2008] decided to use, but focusing on diabetics that Weller et. al excluded due to nascent research that they cited which asserted that the two were not correlated).  Baer et al. noted that “because those who had diabetes for a longer period of time may have experienced a folk illness after the onset of diabetes, we limited the sample to those who were recently diagnosed,” increasing “the likelihood that the folk illness was experienced at or before the diagnosis of diabetes” (Baer et al. 2012:342).  They
“found that the prevalence of susto among those with a recent diagnosis of diabetes (63%) was not higher than that among controls without a diagnosis of diabetes (69%). Furthermore, the prevalence of susto among those with undiagnosed diabetes (55%) was not higher than that among those without undiagnosed diabetes (72%).” [Baer et al. 2012:344]
Forced choice questions were also asked, with curious results: “fifty-one percent said susto caused diabetes, 20 percent said it might, and 29 percent said it did not cause diabetes. When asked if susto caused your diabetes, however, the pattern of responses reversed: 29 percent said yes, 13 percent said it might have, and 58 percent said no” (Baer et al. 2012:342).  If both diagnostic correlations and personal responses such as these exist beyond Guadalajara, and results are publicized widely, the resulting psychosomatic behavior relating susto to diabetes could be dissolved, possibly alleviating some of the panic associated to susto.  Also, cancer has been a narratively reported outcome of susto by some Mexican elders (Gonzales 2012:32), but a Web of Science search for co-occurring terms “susto” and “cancer” revealed no such biocultural or clinical study either supporting or refuting such an association.

One biomedical study stands out as having some promise in explaining the psychological reaction that is susto.  Awad et al. (2009) regard susto as simply being a cultural explanation of anxiety, because of beneficial neurological responses that hypothetically occur in the afflicted when they consume traditional Q’eqchi’ Maya healing herbs (recognized as containing anxiolytic [anti-anxiety] chemicals) utilized to treat susto.  There may be some validity to this corroborated by similar Western folk medicine practices.  If, for example, a susto patient is experiencing listlessness (a common symptom), and such plants do efficiently treat their ails, chamomile may also help them sleep and thereby remove a symptom-compounding aspect of susto.  This is not because it is a sedative, as commonly imagined in the West, but because it is actually an anxiolytic agent (like the Mayan plants referred to) with actions clinically proven to be similar to pharmaceutical benzodiazapenes (Viola et al. 1995).  Lack of sleep is associated with a variety of health problems, both psychiatric and somatic; losing sleep alone could cause a person to lose their rationality and to focus on, and even create, other symptoms and thereby categorize themselves as having susto, a behavior in many illness situations known as looping (Kirmayer 2012:8-9, Kirmayer and Sartorius 2007:836).  They may also experience catastrophic cognitions about their somatic symptoms that lead them to experience debilitating panic or obsessive stress, amplifying or making a conscious rather than subconscious symptom set from that fright which originated their ailment to begin with (Hinton and Good 2009:14-15).  Both related behaviors should be made of primary importance in Western psychiatric diagnostic criteria if we are to be labeling as similar the illnesses that occur from culture to culture (Kirmayer and Sartorius 2007:838-839), because this would help to accentuate the ways that different worldviews and norms shape mental illness.

Being that such stress can compromise the immune system (Sapolsky 1998:144-185), a biocultural viewpoint of susto is necessary to fully comprehend what it is and how successful treatment occurs.  “[D]isease in the Western medical paradigm is malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual; whereas illness represents personal, interpersonal, and cultural reactions to disease or discomfort” (Kleinman, Eisenberg, and Good 1978:252).  From the available ethnographic evidence, it is most probable that discomfort is the main cause of susto, meaning that it is primarily an illness - an experience of lingering “fright” or stress that cannot be cured, but can be healed.  It can apparently have physiological repercussions if left unchecked, however.  These can be signified “by temperature changes, stress hormones, and biological functions” (Gonzales 2012:31).  It could even be that chronic susto, or cases untreatable and enduring, could elevate diabetes risk (Sapolsky 1998), making the research of Baer et al. (2012) only time-and-place specific.  Furthermore, anxiety and stress are well known to be associated to depression (APA 1994:623, Gonzales 2012:32, Sapolsky 1998:56, 291-296), which may be a culture bound syndrome and/or idiom of distress in and of itself (Bracken et al. 2012) and has implications for metabolic syndromes and suicide risk.

Weller et al. (2008) interviewed 200 non-diabetic patients from the Family Medicine Clinic at the IMSS in Guadalajara, Mexico.  Weller et al. aimed to learn about susto conceptualization and experience as relative to stress and depression.  They correlated structured interview responses to survey responses from the Zung depression scale, patients’ demographic information, and Cohen’s Perceived Stress Scale (PSS) – a questionable instrument due to the fact that it was designed for use with people who have at least a junior high school education (less than 35.7% of respondents) and is arguably only purported in usefulness for people of any population (Cohen, Kamarck, and Mermelstein 1983:387-388).  Those reporting past susto experiences “were 1.8 (95% CI: 0.8, 4.3) times more likely to be depressed and women were 2.5 (95% CI: 10.0,6.8) times more likely to be depressed than men” (Weller et al. 2008:415).  But a paradox appeared whereby
“those who are depressed are likely to report past experiences with susto and/or nervios, but that the majority of those who suffer from susto and/or nervios may not be depressed, suggests an interesting area for future study. It is possible that the culturally accepted diagnosis of a folk illness may provide the necessary timeout and social support from roles and responsibilities so that some people with such folk diagnoses do not go on to develop depression.” [Weller et al. 2008:417]
It might also be assumed that some people simply have a susceptibility to said illness, but I will address this in the next section. 

Although there are narrative reports of susto being so wracking as to directly cause death (Gonzales 2012:36, Uzzell 1974:369), this is disputable (Uzzell 1974:373) because such fatality would more likely be the cause of a chronic course of susto symptoms, both those already mentioned as well as some physiological ones that either predicate symptom reporting or are caused by otherwise enduring susto suffering.  Rubel et al. (1984)
tested for differences between [Mestizos, Chinantecs, and Zapotecs] with susto and those without it in terms of social stress (defined as the difference between expected and perceived role performance in three different cultural settings), as well as physical/organic disease and emotional/psychiatric impairment.  They found that susto was associated with greater stress and a greater likelihood of parasitic infections and anemia, and [...], follow-up of the original sample after seven years indicated a significantly higher mortality rate among those who had had susto.” [Weller et al. 2008:409, emphases added].
Zapotecs complaining of susto have also been noted to have amebic colitis and hepato amebiasis (Uzzell 1974:370).  It is no conjecture to connect these instances and aver that social support can prevent fright-and-stress caused biomedical maladies in Mexican populations.  It remains to be understood, however, what number of susto patients are experiencing stress and fright from the recognition of bodily reactions to already existing physiological disease.  Having the many symptoms of susto as a result of this circumstance is another probable example of catastrophic cognition and looping.

The Subjective Burdens and Healing Powers of Social Roles and Interaction

            There is further evidence to corroborate role stress as causal to susto, suggesting that, because not all people get susto either immediately or after an experience of fright or stress, those who do are commanding psychosocial attention and/or agency.  In one study of Hispanic and Spanish people in Spain, the youngest, the unemployed, the least educated, the non-home-owners, the infrequent churchgoers, and the Hispanic (more than the native Spaniards) were more apt to get susto or use the concept in describing others with illness (Durà Vilà and Hodes 2012:1635).  These people may represent those with less status and agency over self and others.  “A failure to fulfill critical aspects of social roles and expectations may play an essential role in understanding the occurrence of this idiom” (Durà Vilà and Hodes 2012:1628).  This phenomenon may be similar to that in an example of a Brazilian population that was studied for cultural consonance (individual embodiment of the cultural consensus) in living up to economic status standards as relative to blood pressure biomarkers (a proxy for stress).  They experienced worse mental health and increased arterial blood pressure as consonance decreased (Dressler, Balieiro, and dos Santos 1998).  Corroborating my prior statements about catastrophic cognition and looping effects, it is also the case with people in this population that the perception of stress intensity can mediate the way that cultural consonance levels associate with depression (Balieiro et al. 2011).  With the Whitehall study of British civil servants, not economic status per se, but rank – a profound stressor even for baboons (Sapolsky 1998:355-358) – was associated to dramatic differences in lifespan between people (Marmot 2006:2083).  In a gendered form of role stress, in the Whitehall II study, rates of heart disease and mental illness increased for women with decreased control at home (Marmot 2006:2088).  There may be a draw between this sort of outcome and that of women in Oaxaca who experience more stress and susto than men (Uzzell 1974:369-370, 374), although this may be location and/or time specific, as such gender variation is not as significant in other research findings.  I would suggest that those with increased consonance and/or with less susceptibility to become obsessive or worrisome about stressors or social status are far less likely to get susto.

As mentioned before, there is a question of whether or not susto originated with Central and South American cultures or with the Spanish.  The Durà Vilà and Hodes (2012) study would lead us to believe the former, because Spanish people were less likely to use the idiom and more likely to use biomedical and psychiatric explanations for illness.  This was one study, so there is need for further relative research with other Spaniard population groups, but it offers a tentative proof.  Still, the effects of Spanish acculturation/collaboration to unified European scientific worldviews (Westernization) would need to be accounted for. 

There is evidence that susto is not just relative to cultural consonance or rank/status stress, but that can also be an idiom of distress and/or a political statement.
“Idioms of distress communicate experiential states that lie on a trajectory from the mildly stressful to depths of suffering that render individuals and groups incapable of functioning as productive members of society. In some cases, idioms of distress are culturally and interpersonally effective ways of expressing and coping with distress, and in other cases, they are indicative of psychopathological states that undermine individual and collective states of well-being. When experienced along with significant pathology, idioms of distress express personal and interpersonal distress beyond that associated with universal disease processes.” [Nichter 2010:405]
They can be a legitimized way to “act out” in manners that are culturally abnormal or uncalled for, dramatic at least, in order to garner support for empowerment or to retaliate against oppressive forces, and, being legitimized through social contract, they are working systems.  Those who are asustado or who have susto may show a range of outward physical symptoms, but are known to be cured of susto when they begin acting normally with others again, whether or not other physical symptoms still exist (Uzzell 1974:372). 
This virtually assures that some kind of episode will be available to everybody, but more than that it gives enough latitude for the asustado to find a kind of episode that fits his overall personal fiction [...] It appears reasonable, then, to think of the playing of the role of asustado by one participant in an interaction in such a way that his co-participants recognize that he is playing that role, as establishing a context in which the asustado's otherwise deviant acts not only become nondeviant, but are even required for maintenance of the interaction” (Uzzell 1974:373).  
In some cases, idioms such as susto “may be viewed not as health problems but as personal challenges or moral issues or as consequences of disharmony in family or community” (Kirmayer 2012:7).  Such behavior could be considered justified for many Central American peoples suffering trauma from intergenerationally transmitted blood memory (Gonzales 2012:37) and for Aymara peoples experiencing soul-manipulation, all of this from past and present colonialization/“modernization” and resource loss (Burman 2010:464-466), when they are expected amongst themselves, with pride and resilience intact, to be strong in the face of perpetual adversity.  This is a very objective way to undergo what for those in the Western world might be subjective PTSD.  That it is a culture-specific idiom is evident in the dearth of Spanish utilization instances, and also in the example that “well-adjusted” Mexican Americans in Texas (but not Guatemalans or Mexicans) list “will just go away by itself” (Weller et al. 2002:464) as a treatment option.

            Derek Summerfield has an argument for the way in which the Western psychiatric framework tries to medicalize the world of experience.
“Can psychi­atric approaches honed in relatively well resourced and stable societies distinguish mental disorder from normal responses to a social world that is no longer coherent or functional? The danger of the medicali­sation of everyday life is that it deflects attention from what millions of people worldwide might cite as the basis of their distress, for example, poverty and lack of rights.” [Summerfield 2008:993]
Poverty (low SES and education, and housing situation) and lack of rights have already been listed as issues correlated with susto.  Perhaps, instead of going into a location – like Samoa, as McDade (2002) did – and biomedically diagnosing all of the seemingly random youth who appear to have symptom sets indicative of Western psychiatric disorders (depression with suicidal ideation, e.g.), a more holistic course of action would be to see if culture puts seemingly obscure order into the phenomenon.  McDade realized, with a method similar to cultural consonance survey, that in a heavily syncretizing (Westernizing) social climate, people who weren’t solely high in traditional social status and weren’t solely assimilative to Western ways – that is, both those majorly with and majorly without bicultural power – were those culturally congruent individuals who experienced far less biomarker-proven physiological stress and health risks.  Those who had power in either culture exclusive to the other were those with negatively impacted immune systems from stress (their Eppstein-Barr Virus antibodies were elevated).  If this methodology were used in the Central and South American settings to study susto, a similar image might appear; it could very well be that both those who (1) deeply resent Westernization and those who (2) try too hard to Westernize (when they are still embedded in their traditional setting, in contrast to the “well-adjusted” Texas setting or Spain), are those who experience sub/conscious idiomatic susto at some point.  There is, however, a possibility that susto will be increasingly on the move, either spreading this phenomenon as it is or altering it even further in place and time.  The vast number of migrating Hispanic and Spanish people, to each opposite’s respective countries of origin and elsewhere, “means that the idioms of distress will not only be encountered in the countries where they were first recognized but also it would be beneficial to understand their distribution for improved health care delivery” (Durà Vilà and Hodes 2012:1628).

            This latter prospect may sound imposing, even negating Summerfield’s advice, but indeed some asustado people seek psychiatric and other Western medical treatment.  It would then behoove the medical establishment to appreciate the cultural implications of its development and course.  In the Spain study with 223 Spanish and 54 Hispanic respondents, 83.8% and 64.3% respectively reported they would use relatives and friends to resolve susto, 62.8% and 70.2% respectively reported they would use psychotherapy (with only 2.3% and 4.8% reporting they would use medications), with use of priests at 31.2% and 27.4% and then “wise, respected person(s)” thereafter at 12% and 9.5% (Durà Vilà and Hodes 2012:5).  Understanding what makes treatment preference percentages significantly similar in this case between family/friends and psychologists/psychiatrists is key for psychological anthropologists and for transcultural psychiatrists to help treat susto or just to understand it better, especially sbecause it is situational.  This Western medical preference is not ubiquitous.  Weller et al. (2002) found that praying and treating at home were top preferences shared between Guatemalans, Mexicans, and Mexican Americans in Texas, followed by herbalism (bolstering the antianxiety correlation mentioned earlier) for the first two groups, and then psychotherapy far down the line for the Mexican group only.  With each following preference respective to those locations, going to church, relaxing or keeping calm, and getting a massage are also curative.  For Guatemalans, seeing a wise woman or a curandero, for magical healing rituals, are options.  Being that the latter is the norm in Zautla, and can be quite inexpensive for such circumstances (Uzzell 1974:372), it is not to be considered a unilateral last-resort choice due to economy.  Seeing a maestro, a culturally unique healer but analogous to a curandero/a, is of prime utility for the Aymara as well (Burman 2010).  Widely used by a variety of Central American cultures and among the Aymara are limpias (or limpiezas) or barridas, which are therapeutic “cleansings” or sweeping ceremonies, utilizing herb brushes on the body and ambient incense (Burman 2010, Gonzales 2012, Weller et al. 2002).  An important point to make is that (1) even though there is wide variation in remedial action for susto, these are all relatively self-affirmative and transpersonal healing methods, whether or not susto is being experienced as a genuine culture bound syndrome or an idiom of distress, and that (2) there appears to be no neurobiological cause for susto in as much.  It would appear that the remedy is a meaning response (Moerman and Jonas 2002), a psychological reaction to expectation, intention, symbolism, and sensations either real or imagined but often only indirectly or metaphorically associated with the source of symtoms (Eisenberg and Kaptchuk 2002:819-820) – a nonstigmatizing and analytical explanation for the placebo effect that ascribes real healing power to ritual itself (Kirmayer 2012:10-11).  And at least for people experiencing culture bound syndromes, transpersonal healing methods may work simply because a comfortable or trusting and therapy-modeled relationship is established (Bracken et al. 2012:431).

Conclusion: Insight for Psychiatrists and Anthropologists

Being that symptoms such as those experienced in the solely culture bound syndrome form of susto can be much more than somatoform disorders, it is important that Western psychotherapists recognize when they frame a patient as having a culture bound syndrome that any “diagnosis of a somatoform disorder [therein] conveys psychiatric stigma, perplexes patients because it implies their problems are mental rather than physical, and justifies therapeutic nihilism on the part of clinicians” (Kirmayer 2007:838).  Being that susto can be caused by fright or stress due to physiological sensations or symptoms stemming from actual organic maladies, this only serves to promote missteps in treatment, failing to cure that which may be physiologically detrimental to their health, and perpetuating “neocolonial missionizing, cultural proselytizing or imposing frames of interpretation and practices of dubious benefit that may also serve to undermine local expertise and competence” (Kirmayer 2012:6).  In areas of Mexico and Central America that are increasingly being Westernized, it is critical that this is recognized.  Focused interviews with asustado people could incorporate Kleinman, Eisenberg, and Good’s (1978) Clinical Strategy for Applying Social Science Concepts, to elicit each individual’s explanatory model.  This would firstly help to differentiate between those who are experiencing susto as a culture bound syndrome and those experiencing an idiom of distress, and secondly assist the practitioner in determining whether or not the susto is a response to stress or startle or if it is from fright caused by already existing symptoms (which they can then assess and treat).  Such a practice would be just as good for applied medical anthropologists seeking to do community service for the impoverished and underrepresented.

As one half of susto appears to be an idiom of distress, the alleviation of a person’s stress from rumination upon and life impacting effects from postcolonial strife must come about as a result of the social responses to their actions.  Not yet detailed are deep firsthand narratives of how such sub/conscious resolution works to empower the asustado (or at least what aspects of their life it affects).  We see a community interaction, restoration of health and return from social deviance, and otherwise seemingly no change to their actual postcolonial situation.  But susto and the various Central American etiologies synonymous with it,
“[...] are not “magical” illnesses and carry their own internal logic as part of coherent meaning systems with expansive concepts of the body, nature, spirit and place. They help to explain how Indigenous peoples understand their vulnerabilities to illnesses and diseases. These frameworks are often invisible or hidden from providers of allopathic medicine.” [Gonzales 2012:38]
There is much yet to be studied in these regards.  If it is an idiom being experienced, extensive grounded theory (Corbin and Strauss 2007) put into practice, perhaps with the McGill Illness Narrative Interview (Groleau, Young, and Kirmayer 2006) as a template, could produce a wealth of schematic information relative to that form of susto – what makes it come on, what makes it recur if it does at all, and what currently inconspicuous parts of lifestyle, intention, and community are enduringly affected (or will be in the future) by its treatment.  Common coded themes between interviews could be used for multi-community cultural consonance surveys that would demonstrate the degree of variation in how this idiom works in removed social contexts.

Whether or not susto is experienced as a set of symptoms in reaction to fright or stress or if it is a subconscious or overt idiom of distress, it can be traced to cultural circumstance.
“There is increasing recognition that social determinants of health, and mental health specifically, are among the most powerful factors influencing the risk, onset and course of mental illness. [...These] include poverty and social inequality, social integration and support, and racism and discrimination. The conditions of social life have powerful effects on wellbeing in part because they determine basic physical conditions like nutrition, exposure to infectious agents, toxins or other environmental hazards, and provision of other essential needs. These needs include a meaningful and coherent social world. We are fundamentally social beings and depend on stable interpersonal bonds, reliable care giving during development, social solidarity and esteem to give our lives meaning and coherence.” [Kirmayer 2012:5]
From family interaction to visitation from a priest, taking tea, getting a massage, getting a limpia or barrida from a curandero/a, or otherwise, the ethnopsychiatry of susto is more complex than (1) that which Western medicine can currently provide for, assuming it always to be merely a somatoform disorder (APA 1994:848-849), and (2) that which medical anthropology has described thus far, not detailing the social outcomes ushered by the asustado’s restoration to health when susto is experienced as an idiom of distress.  It is clear that there is much work to be done to fully understand this illness/idiom, in order to better recognize and empathize with people whose culture incorporates it, and to better assist them when they choose to be healed by Western practitioners.


            Throughout this paper I have not described how susto is generally diagnosed more in children than in adults.  I obviated this information because in the literature wherein this is revealed, it is duly noted that such diagnoses are contentious because the children do not display the cultural artefacts of susto which come with learning, and are likely afflicted with physiological symptoms from biological maladies that will self-limit or require other treatments.  Adults may be perpetuating the folk illness model in this way (Uzzell 1974:369), as children cannot verify such diagnostic claims, and because grown children who are told by the elders whom they trust that they have had susto in the past will likely carry on the tradition in this way, furthering the idea that it cannot be controlled and perpetuating the circumstances under which biopsychosocial looping occurs.


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