Toward a Puerto Rican Popular Nosology: Nervios and Ataque de Nervios

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´ PETER J. GUARNACCIA, ROBERTO LEWIS-FERNANDEZ, AND MELISSA RIVERA MARANO

TOWARD A PUERTO RICAN POPULAR NOSOLOGY: NERVIOS AND ATAQUE DE NERVIOS

ABSTRACT. This paper is about naming illnesses—about who determines what categories are used and the implications of these determinations. The central concerns of medical/psychiatric anthropology have been to understand popular categories of and systems for classification of illness, to examine the relationship of illness categories to cultural understandings of the body, and to interpret the role of categories of illness in mediating between the personal and social spheres. At the same time, the paper also discusses the interplay of popular categories and psychiatric diagnoses. This paper examines the multiple experiences of nervios among Puerto Ricans in Puerto Rico and New York City. Our contention is that nervios is more than a diffuse idiom of distress, and that there are different categories and experiences of nervios which provide insights into how distress is experienced and expressed by Puerto Ricans and point to different social sources of suffering. The data in this paper come from the responses to a series of open-ended questions which tapped into people’s general conceptions of nervios and ataques de nervios. These questions were incorporated into follow-up interviews to an epidemiological study of the mental health of adults in Puerto Rico. The results suggest ways to incorporate these different categories of nervios into future research and clinical work with different Latino groups in the United States and in their home countries. KEY WORDS: ataques de nervios, culture and diagnosis, nervios, Puerto Ricans, social sources of suffering

All men have the stars, . . . but they are not the same things for different people. For some, who are travelers, the stars are guides. For others, they are no more than little lights in the sky. For others, who are scholars, they are problems. For my businessman they were wealth. But all these stars are silent. The Little Prince, Antoine de Saint Exup´ery, 1971 (104). This paper is about naming illnesses—about who determines what categories are used and the implications of these determinations. The central concerns of medical/psychiatric anthropology have been to understand popular categories of and systems for classification of illness, to examine the relationship of illness categories to cultural understandings of the body, and to interpret the role of categories of illness in mediating between the personal and social spheres (Scheper-Hughes and Lock 1987; Good 1994). Medical anthropologists have examined the relationship between popular categories of illness and biomedical categories of disease, both in terms of the different understandings of experience incorporated in these different Culture, Medicine and Psychiatry 27: 339–366, 2003. ° C 2003 Kluwer Academic Publishers.

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kinds of category systems and in terms of the different social consequences of understanding distress and suffering through these different schemata (Kleinman 1988; Rubel et al. 1984). In this paper, we examine the multiple experiences of nervios among Puerto Ricans in Puerto Rico and New York City. Although we are concerned about delineating the specificity of these experiences of nervios, we also contend that our approach is applicable across syndromes and cultural groups. Our contention is that nervios is more than a diffuse idiom of distress; that there are different categories and experiences of nervios which provide insights into how distress is experienced and expressed by Puerto Ricans and point to different social sources of suffering (Kleinman et al. 1997). We propose that these different ways of talking about nervios are systematized, not into discrete Linnaean classification schemata, but rather into “fuzzy sets” (White 1982:74–75). We propose calling this schema a “popular nosology of suffering,” for we contend that this kind of schema is not just important for analytic purposes, but may also provide the basis for alternative praxis in mental health and other social arenas to alleviate the distress of those who experience nervios in its varied forms. We also want to clarify that the experiences of nervios we discuss are not uniquely Puerto Rican, but are shared among many Latin American cultures. At the same time, there may be particular inflections to nervios among Puerto Ricans and other Latinos from the Caribbean, which distinguish them from the experiences of nervios among Mexicans and Central and South Americans (Guarnaccia and Far´ıas 1988). However, as we illustrate with our discussion of the emergence of the term “Puerto Rican Syndrome” in the psychiatric literature of the 1960s, not all attempts to identify cultural issues in mental health are benign. Our purpose in this paper is to propose a popular nosology based on our research among Puerto Ricans which could serve as a model for cross-cultural mental health research and practice. The study of how cultural groups categorize illness has long been a central concern in anthropology (Evans-Pritchard 1937; Frake 1961). There is a widespread human tendency to use classification systems as a way to both understand and act in the world. Our work was influenced by Geertz’s argument that a major goal of anthropology is to describe experience from “the native’s point of view” (Geertz 1983). We see our research as contributing to the development of a Puerto Rican ethnopsychiatry. We draw methodological support from Gaines’ (1992) cultural constructivist approach to studying folk/popular and professional psychiatries which argues that all these systems are equally cultural and should be considered equivalent “ethnopsychiatries.” Given that no system has an inherent claim to greater ontological reality, Gaines argues that the focus of analysis should be on experience-near realities in experience-near terms such as suffering. In addition, each ethnopsychiatry is understood to express its respective culture. In

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this view, ethnopsychiatric nosologies are products of cultural processes which change over time as human interactions create and recreate ethnopsychiatric realities. More specifically, our approach takes Good’s (1994) interpretive and critical approach to studying illness categories across cultures as its starting point. [I]llness categories can be understood as images which condense fields of experience, particularly of stressful experience. And they can be understood as core symbols in a semantic network, a network of words, situations, symptoms, and feelings which are associated with an illness and give it meaning for the sufferer. The meaning of an illness term is generated socially as it is used by individuals to articulate their experiences of conflict and stress, thus becoming linked to typical syndromes of stresses in the society. (Good 1977:39–40)

In analyzing these categories of nervios, we start with experience-near descriptions of these categories and then discuss the larger frameworks of social and cultural meanings which surround them. We utilize the frameworks provided by Good and Gaines to propose a way of linking Puerto Rican popular terms for emotional distress into a schema that can inform anthropology and mental health practice. PREVIOUS WORK ON LATINO ILLNESS CLASSIFICATION

The development of a Puerto Rican popular nosology builds on previous work on Latino cultural models of mental health problems. Over twenty years ago, Newton (1978) proposed a Mexican-American emic model of mental illness based on qualitative interviews with 23 subjects who were part of a larger study to investigate Mexican Americans’ underutilization of mental health services. Newton systematized the families’ understandings of mental illness into a model (see Table I). He argued that the first major distinction was between an emotional problem, where emotional control and the persistence of problems are key factors, and a mental problem, where mental functioning and violent behavior determine the degrees of severity of the problem. Problems of nervios figured prominently on both sides of this divide. Unfortunately, the model was never developed further on larger or more diverse Latino samples, nor were the clinical implications of using this system with Mexican American clients developed. However, this schema provides a useful reference point for our work. Harwood (1977) provided another schema for diagnosis within the framework of espiritismo, a form of religious healing and practice among Puerto Ricans both on the Island and the mainland (see also Garrison 1977). Harwood’s study of espiritismo in New York City was explicitly carried out under the sponsorship of a community health center whose directors sought to make the center responsive to the needs of the surrounding Latino community. Thus, the development of ethnopsychiatric knowledge was directly relevant to the clinical practice of

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TABLE I Mexican American Emic Model of Mental Illness Condition

Degree Minor: temporary, can be endured, can be handled

Emotional Problem (Problema Emocional)

Serious: persistent pervasive cannot solve alone Mentally ill

Mental Disorder (Problema Mental) Insane

Symptoms

Treatment

Worries, hurt feelings, tensions

Self-help

Nervous (nervioso) worried, jittery mildly depressed

Seek help; talk it out with a relative, friend, maybe a physician

severe depression, desperation (desesperado), or hysteria No emotional control cannot cope, feel like exploding

See a physician, perhaps then a psychotherapist

Mind “snaps/clicks,” suicide attempt, “nervous crisis” (crisis nerviosa) “attack of nerves” (ataque de nervios)

“Mental help” psychotherapist

Crazy (loco) harmless

Psychotherapist medication; partial cure Institutionalization; no hope of cure

Violent, bizarre, homicidal behavior complete withdrawal

Note: N = 23 Mexican Americans. Adapted from: Newton, Frank. 1978. The Mexican American Emic System of Mental Illness: An Exploratory Study. In Family and Mental Health in the Mexican American Community (Monograph 7), J.M. Casas and S.E. Keefe, eds., p. 82. Los Angeles: Spanish Speaking Mental Health Research Center.

providers at the center. Of particular relevance to our paper is Harwood’s delineation of the etiological categories of Spiritist diagnosis (see Table II). In contrast to the kinds of diagnostic categories presented by the MexicanAmerican informants which describe certain kinds of feelings and behaviors, the Spiritist categories are based on different spiritual causes of illness. Comparing these two nosological systems provides several insights. Whereas some diagnostic categories are based on certain core symptoms and are descriptive of particular types of experiences, others are based on shared causes of illness and

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TABLE II Etiological Categories in Spiritist Diagnosis Etiological Category 1. Envidia (envy) 2. Brujer´ıa (sorcery) 3. Mala influencia (evil influence) 4. Facultades (faculties) 5. Prueba (test or trial)

6. Cadena (chain) 7. Castigo (punishment)

Implied Spiritual Cause The unexpressed envy of incarnate spirits in close association with the victim A disembodied spirit sent to harm the victim by an enemy working in league with a spiritist A disembodied spirit of low rank seeking to be “given light” Spirits of various ranks who possess the body of a person insufficiently trained in controlling such seizures a. Protective spirits who test a person while he or she is developing faculties b. God-predestined trials in a person’s life The spirit of a deceased relative or other associate from the past who has done some misdeed Misguided spirits allowed to beset a victim who has neglected his relationship with his spiritual protectors

From: Harwood, Alan. 1977. Rx: Spiritist as Needed. p. 94. New York: Wiley-Interscience

are etiological in nature (Guimera 1978; Bibeau 1981; Good and Good 1982). Some diagnoses focus on internal experiences of the person, whereas others mark the interactions between the person and important others in the society or with the spiritual world. Some ethnopsychiatric categories reflect reactions to stressful experiences which can be resolved by the person him/herself or with the help of close others, whereas other experiences are more enduring and less controllable (see also Rogler and Hollingshead 1985; Koss-Chioino 1992). These dimensions are useful in thinking about different kinds of nervios and in understanding their relationship to biomedical categories and we refer to them in our discussions of our own study. The Spiritist diagnostic framework also reminds us that even within a cultural group such as Puerto Ricans, there are multiple popular nosologies which exist in relation to each other and to the frameworks of biomedicine. THE MISUSE OF POPULAR CATEGORIES: THE CASE OF THE “PUERTO RICAN SYNDROME”

The use of popular categories does not always provide a more culturally meaningful perspective on illness and suffering in a culture. The history of the discussion of ataques de nervios in the psychiatric literature illustrates this point. Early in the writing on ataques de nervios the label of “Puerto Rican Syndrome” was used to refer to these phenomena, usually by military psychiatrists attached to US Army recruiting and training stations in Puerto Rico (Roberts de Ram´ırez de Arellano et al. 1954; Rubio et al. 1955). Puerto Rican and American psychiatrists

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responding to the growing professional use of the label in the 1960s reached diverse opinions about its appropriateness. But the majority concluded that these expressions of distress denoted something uniquely Puerto Rican, which rendered them worthy of serious attention (Fern´andez-Marina 1961; Rothenberg 1964). The more disturbing implication of this label, however, was that there was some defect in Puerto Rican character which led Puerto Ricans to express distress in this fashion (De la Cancela et al. 1986). Unfortunately, both the label and the focus on the problem lying in Puerto Rican character have continued to the present in the responses of medical personnel in urban US contexts to these expressions of distress by Puerto Ricans and other Latinos, as well as in the informal diagnostic practice of some psychiatrists and psychologists in Puerto Rico. Ironically, one setting where the label seems to survive today is among mental health professionals on the Island, in the form of the spoken acronym “PRS,” invariably pronounced in English—“pea are ess”—even when speaking in Spanish. This expression is especially popular among residents in psychiatry training programs in Puerto Rico, but it is also employed by some established psychiatrists and psychologists, whose use of the term sanctions it for the next generation of clinicians. The settings in which it emerges are strictly informal, verbal and extra-official. The expression signals the existence of a kind of conspiratorial familiarity among participants, an understanding that formal categories have been transcended and more basic understandings are being discussed which perhaps do not conform to strict professional standards. Although superficially derogatory and condemning, the label is not infrequently applied with some degree of affection for the behavior referred to, and even a sense of kinship, especially when the speaker is also Puerto Rican. Implied is the notion of a shared weakness between the labeler and the one labeled, which the latter has had the misfortune, ignorance, mischievousness, or obduracy to succumb to, a meaning highlighted by the tone of irony or humor that typically underlines the comment. An accompanying notion is that the behavior denoted is somehow inevitable, in that there is something about being Puerto Rican that predisposes one to the appearance of “el PRS.” Additionally, the term can even evoke a judgment of the behavior as maliciously funny, constituting a kind of resistance against an overly serious and ordered view of the world. We would argue that these labels say more about the reactions of the labelers to behavior from which they seek to divorce themselves (with poignant ambivalence in the case of the Puerto Rican clinicians), than they do to help to explain the phenomena they describe on their own terms or in relation to biomedical categories. The use of the term “Puerto Rican Syndrome” and its modern equivalent “PRS” has impeded development of an understanding of these phenomena by researchers and health professionals and has led to a justifiable defensiveness among many Puerto Ricans concerning studies which explore the differences in the ways Puerto

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Ricans and other Latinos express distress compared to Anglo populations on the mainland. For the Puerto Rican clinicians who employ it, the term unfortunately signals the additional burden of having to struggle with an internalization of the notion of defective Puerto Rican character, which tars them with the same brush as their patients. As such, the label and its use constitute part of the colonial domination of the Island by the United States, as evidenced by the fact that the original formulation of the concept of “Puerto Rican Syndrome” occurred in the context of the forced incorporation of young Puerto Rican men into the US military, and that the label is in English and has no Spanish equivalent. The early psychiatric writings on ataque de nervios, and the clinical labels that resulted from them, clearly fit what Thompson (1995) characterizes as the “othering” of Puerto Ricans. Turning ataques into the “Puerto Rican Syndrome” effected a transformation from the anger and resistance implicit in the experiences of the young Puerto Rican army recruits who invoked this idiom of distress into a proposed defective feature of Puerto Ricanness. In fact, the culturally appropriate labels of ataque de nervios and mal de pelea (“fighting sickness,” denoting ataques particularly characterized by outwardly aggressive behavior) are nearly absent from the initial descriptions of the phenomenon (for a notable exception, see Roberts de Ram´ırez de Arellano et al. 1954). One of the goals of this paper is to start from the categories people in Puerto Rico use to communicate their emotional distress and build a nosological system from them, rather than imposing or inventing categories. We seek to take seriously both the local categorizations of emotion and the social experiences which produce them. METHODS OF ANALYSIS

The genesis of the research on different experiences of nervios reported in this paper began with the inclusion of a single question identifying those who had experienced an ataque de nervios in an epidemiological study of the mental health of the Puerto Rican population. The details of this study and the inclusion of the question on ataques de nervios are provided in a previous paper by Guarnaccia and colleagues (1993). Briefly, after preliminary work on ataques de nervios with the Behavioral Sciences Research Institute at the University of Puerto Rico Medical School, we added a question to identify people who had experienced an ataque de nervios to the Diagnostic Interview Schedule (DIS), a standardized psychiatric diagnostic interview (Robins et al. 1981) being used in the Puerto Rico Disaster Study (Canino et al. 1987). The question was added to the Somatization section of the DIS, and people were asked whether they had experienced an ataque, and if they had, to briefly describe the symptoms and context to the interviewer. This study was based on a sampling frame which included the entire population of Puerto Rico, thus making it representative of the Island. Of the 912 people interviewed,

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TABLE III Relationship Between Reports of ataque de nervios and Socio-demographic Variables Demographic Variables

No Ataque

Ataque de Nervios

N = 912 Sex Male Female Age 17–24 25–44 45–68 Education < High school High school + Marital Status Married Formerly married Never married Employment Status Out of Labor Force Unemployed Employed

767 (84%)

145 (16%)

348 (45%) 419 (55)

41 (28%)∗∗ 104 (72)

189 (25%) 344 (45) 234 (30)

22 (15%)∗∗ 61 (42) 62 (43)

372 (48%) 395 (52)

96 (66%)∗∗ 49 (34)

379 (49%) 134 (18) 254 (33)

67 (46%)∗∗ 43 (30) 35 (25)

392 (52%) 140 (18) 225 (30)

91 (63%)∗ 26 (18) 28 (19)

Chi-square was used to establish if differences were significant for each demographic variable. ∗ p < 0.05. ∗∗ p < 0.01.

145 people, or 16 percent, reported having had an ataque de nervios during their lifetime (see Table III). Experiencing an ataque de nervios was strongly associated with meeting criteria for a range of anxiety and depression diagnoses (Guarnaccia et al. 1993) (see Table IV). Given the large number of people who reported an ataque de nervios and the representative nature of the sample, we saw this as a valuable opportunity to explore the experiences of ataques and nervios more broadly and thoroughly. We developed a detailed follow-up interview (structured on the Explanatory Model Interview Catalogue [EMIC] designed by Weiss and colleagues [1992] on the basis of Kleinman’s [1980] Explanatory Model framework) to explore the experiences of ataque de nervios among Puerto Ricans. This follow-up interview contained sections which discussed general ideas about various forms of nervios (being a nervous person, suffering from nerves, and having an ataque de nervios). We had already identified these ways of talking about nervios in clinical ethnographic work that Guarnaccia and Lewis-Fern´andez had previously carried out in community mental health programs in the Boston area. The follow-up interview also collected descriptions of specific experiences of ataques de nervios, help-seeking

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TABLE IV Relationship Between Reports of ataque de nervios and Psychiatric Diagnoses Psychiatric Diagnoses

No Ataque

Ataque de Nervios

Odds Ratio

N = 912 Depression (5%) Dysthymia (12%) Generalized Anxiety (18%) Panic Disorder (2%) Posttraumatic Stress Disorder (6%) Any Affective Disorder Any Anxiety Disorder Any DIS Disorder

767 (84%) 19 (2%) 67 (9%) 108 (14%) 3 (0.4%) 29 (4%) 49 (6%) 109 (14%) 214 (28%)

145 (16%) 29 (20%) 40 (28%) 55 (38%) 13 (9%) 25 (17%) 43 (30%) 58 (40%) 91 (63%)

9.84 3.63 3.73 25.08 5.30 6.18 4.02 4.35

for ataques, evaluations of the severity of ataques, and perceived causes of these experiences (Guarnaccia et al. 1996). In the follow-up study, we attempted to interview all of the people who had reported an ataque de nervios in the Puerto Rico Disaster Study (N = 145). We also added a comparison sample which consisted of either people who had experienced a panic attack but not an ataque de nervios (N = 17) or people who had not had either of these experiences (N = 13). The follow-up sample included people from the entire island of Puerto Rico, both from large cities and small towns. Given the social characteristics of those experiencing ataques de nervios, the follow-up sample over-represented women over 45 with less than a high school education who were divorced or widowed (Guarnaccia et al. 1993). We interviewed 121 people in the follow-up study, 79 of whom reported having experienced at least one ataque de nervios and 42 who reported not having this experience (see Table V). The data in this paper come from the responses to a series of open-ended questions which tapped into people’s general conceptions of nervios and ataques de nervios. These questions are detailed in Appendix A in Spanish, followed by their English equivalents. The interview was developed in Spanish by the first two authors of this paper and their collaborators at the Behavioral Sciences Research Institute. The interview team included the first author and three Puerto Rican interviewers with long research experience in community studies of mental health. The questions focus on three categories of nervios which we had identified as important through preliminary clinical ethnography (Guarnaccia et al. 1989; Lewis-Fern´andez 1995): ser nervioso (being a nervous person); padecer de los nervios (suffering from nerves); and tener ataques de nervios (having nervous attacks). We consistently asked all respondents, both those with and without ataques, to describe a person who fit these categories, to speculate on the causes of these experiences, and to discuss what kinds of help a person with these experiences might receive.

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TABLE V Social Characteristics of ataque de nervios Study Sample Social Characteristics N = 121 Sex Male Female Age < 29 30–49 > 50 Education < High School High School

No Ataque

Ataque

N = 42

N = 79

15 (36%) 27 (64)

65 (20%)∗∗ 63 (80)

11 (25%) 19 (43) 12 (32)

9 (12%)∗∗ 31 (40) 39 (48)

19 (46%) 23 (54)

48 (61%)∗∗ 31 (39)

Chi-square was used to establish if differences were significant for each demographic variable. ∗ p < 0.05. ∗∗ p < 0.01.

Responses to these questions were grouped according to the different categories of nervios using a text analysis package. These were read by two trained, bilingual/bicultural research assistants (including the third author), who provided summaries of the responses for all respondents, for men and women separately, and for those who had and had not had an ataque de nervios. Thus we were able to look at overall understanding of nervios as well as examine differences in understandings of these categories by gender and by degree of experience with nervios. WAYS OF BEING NERVOUS: EXPERIENCES OF NERVIOS AND ATAQUE DE NERVIOS

The different kinds of nervios represent complex physical, emotional, and social experiences that occur simultaneously on multiple levels. Nervios occur in response to stressful social events and are commentaries on a social world out of control. Although much of this section focuses on distinguishing among “being a nervous person,” “suffering from nerves,” and having “nervous attacks,” there are also key similarities among these experiences. No one feature of any of these experiences uniquely defines it; rather it is the sum total of the experience which distinguishes it from other experiences. Whereas these kinds of “somatopsychosocial” experiences occur throughout the world in different forms, the particular configuration of experiences makes them fit within specific sociocultural contexts. These expressions and the experiences which they describe are not universal in Puerto Rico. They are powerful idioms invoked much more frequently by working class and poor individuals, although they are familiar to most Puerto Ricans. They are also particularly prominent forms of expression for the generation of Puerto

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Ricans who lived through the transition from an agrarian to an industrial society and who came of age in the post-World War II period. This is also the generation that migrated in large numbers to New York City. We will return to these issues after describing the different forms of nervios and identifying the social sources of these experiences. These experiences of nervios also span the range from expected responses to upsetting life events, to signs of vulnerability to emotional problems, to expressions of mental illness. The terms “normal” and “abnormal” complicate as much as they illuminate this discussion. It is clear that these terms are relative ones that must be understood within their cultural context, and that they carry strong moral judgments as well (Benedict 1934; Good 1994). These different expressions of nervios are often responses to significant pain, suffering, and social loss—in this sense they are responses to extreme and exceptional occurrences. But that does not necessarily make them “abnormal,” because these responses may be the way one should respond to suffering within the culture. What could be considered abnormal instead, for example, may be controlling one’s emotions in the face of tragedy or death. The “normality” or appropriateness of these expressions has always been contested within Puerto Rican culture according to the positions taken by participants around issues of class, gender roles, and the influence of education on behavior. What may be considered normal in a working class woman in her rural barrio— such as, prototypically, having an ataque de nervios during her husband’s funeral— may be judged as the sign of impending mental imbalance in a wealthy man from a prominent family in a similar setting of acute grief. Given the particular social expectations determining such a person’s behavior, the dramatic expressiveness of the ataque may appear quite outside the normal. What seems to us more important is how to judge when the suffering marked by different types of nervios is beyond the expected or “normative,” which may serve as a better term here. One measure may be when the pain is significant enough that it requires outside help, particularly professional help. Even this determination is as much social as clinical, as the growing literature on the increasing medicalization of social life indicates. “BEING A NERVOUS PERSON” (SER NERVIOSO)

“Being a nervous person” (ser nervioso) usually starts in childhood, sometimes as a result of suffering or traumatic experiences, or as an inherited vulnerability that makes the person more prone to being affected by the normal stresses of everyday life. In this latter sense, nervousness can run in families or is said to be hereditary, and the affected child is said to “llevarlo en la sangre” (“carry it in the blood”) or to “ser nervioso de naci´on” (“be nervous by constitution,” lit. nation, race). This

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explanation is especially evoked in the absence of any clearly identifiable social precipitants for nervousness in a child and the presence of other family members suffering from some form of nervios. Respondents reported that severe family traumas, such as deaths in the family or abusive parents, could cause someone to become nervioso. Some felt that nervousness could develop in the womb, even in the absence of affected relatives. Although people often referred to this as “hereditary,” what they described was that if the mother suffered physical or emotional abuse while she was pregnant, drank excessively, or used drugs, or experienced severe nutritional deprivation, this could result in the child becoming a “nervous person.” Once someone is nervioso they tend to remain so for the rest of their lives, although most people can control this condition with the help and support of family members and others. However, people who are nervioso are vulnerable to upsetting events and more likely to respond to them in severe ways. People who are nervioso have more life problems, what Finkler (1994) has referred to as “life’s lesions,” than others, and often have great difficulty in solving their problems. They worry more than others. The common symptoms that go along with “being a nervous person” include trembling and crying more than others, talking and moving one’s hands rapidly, and biting one’s nails a lot. People who are nervioso are more prone to headaches and stomachaches. They startle more easily than others and are also quicker to lose their tempers. Men were more likely than women to see someone who is nervioso as more prone to anger and violence. Men also associated becoming nervioso with the traumas of war. Women were more apt to see serious family and economic problems as sources of becoming nervioso in adulthood. Family members were seen as the primary source of help for someone who is nervioso, but it was also clear that “being a nervous person” has become medicalized in Puerto Rico. The key thing family members can do is to help the person lead a calm life (una vida tranquila), which is highly valued in Puerto Rico (Lewis-Fern´andez 1998). The major gender difference in help-seeking was that women knew and recommended a wide range of home remedies, particularly herbal teas, which men did not report at all. Spiritual help was also viewed as useful, again because it aided the person in finding tranquility. Interestingly, respondents both recommended and sought help more from priests and ministers than from espiritistas or santeros, who have received much more anthropological attention in studying spiritual healing in Puerto Rico (Garrison 1977; Harwood 1977; Koss-Chioino 1992). People strongly recommended professional help and felt that therapy and counseling from psychologists or psychiatrists would be valuable. They also felt that medications would be helpful. People who suffered from some kind of nervios were even more likely to recommend professional help.

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In general, “being a nervous person” is viewed as a chronic condition that either one is born with or that occurs as the result of childhood traumas. Although being nervioso is difficult to control, it can be controlled through family support and outside help. However, people who are nervioso are more vulnerable to stressful life events and more likely to break down under the weight of accumulating life problems. It is this enhanced vulnerability that is a critical aspect of “being a nervous person.” “SUFFERING FROM NERVES” (PADECER DE LOS NERVIOS)

Padecer de los nervios is more of an illness than ser nervioso, and was most frequently associated with depression by our respondents. It affects the body and mind and is seen as more debilitating. Whereas “suffering from nerves” is more likely to develop in adulthood as the result of an overburdening series of “life’s lesions,” many respondents felt that the vulnerability to suffering from nerves was hereditary or congenital, much in the same way that people described “being a nervous person.” People who suffer from nerves experience a sense of having too many thoughts that overwhelm them. They cannot stay still and are always moving and trembling, and they talk very fast. Their personalities are affected as well; people who suffer from nerves are described as erratic, very sensitive to stressors, often nervous and fearful, and more prone to explosive anger. This constellation of experiences shares features with the evolving psychiatric diagnosis of atypical depression (Liebowitz et al. 1984). In many ways, the causes of padecer de los nervios are similar to ser nervioso. The differences are that the stressful events occur more in adulthood, are more severe, and particularly come together in an overwhelming way. The feeling that one cannot find a solution to one’s problems was also a key aspect of suffering from nerves. Women prominently mentioned marital difficulties, as well as concerns about and conflicts with children. Men and women both mentioned the effects of war, although for men it was more often the effects of having gone to war and for women concerns over a family member serving in the military. Instead of being able to “control” their reactions to life’s lesions, a valued attitude of equanimity in most Puerto Rican communities (Lewis-Fern´andez 1998), nervios sufferers felt frequently “out of control” when faced with significant stressors, displaying more than the normal share of irritability, sadness, or anxiety. The seriousness of padecer de los nervios is reflected in the kinds of help respondents recommended for someone who suffers from nerves. Whereas respondents saw support from close family and friends as helpful, the overwhelming majority thought that someone who suffered from nerves should get professional help. Doctors can help with the physical damage to the nerves, whereas a psychologist

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or psychiatrist can provide therapy and medication to deal with the psychological problems. Respondents also recommended that activities which occupied the person would be helpful to keep them from worrying and thinking too much. Suffering nerves is very difficult to control on one’s own; it requires outside help to manage one’s nervios. These recommendations indicate that once someone “suffers from nerves,” he or she has crossed over into the realm of mental illness; in Newton’s (1978) terms, they have crossed the line from an emotional to a mental disorder. “NERVOUS ATTACKS” (ATAQUES DE NERVIOS)

Ataques de nervios are acute, dramatic episodes which occur as the result of a major stressful event, particularly in the family sphere (for a fuller discussion of ataques de nervios see Guarnaccia et al. 1996 and Lewis-Fern´andez 1996). Ataques can happen to anyone who experiences a stressful enough event, although people who are nervous or suffer from nerves are more prone to experience an ataque. Although women are more likely to experience an ataque de nervios, men do have them in the face of upsetting or frightening situations. Ataques usually occur directly in response to an upsetting situation and begin with uncontrollable crying and screaming; people become “hysterical.” Sufferers may throw things or strike out at others; at this point they are seen as “out of control” both in terms of the intentionality of their behavior and their actual actions. The ataque also reflects a social world out of control. During the ataque de nervios, sufferers may fall to the ground and lie there “as if dead,” or shake as if experiencing a seizure. The whole episode is relatively brief, with a rapid return to the pre-ataque state, although a period of post-ataque exhaustion or depression is not uncommon. Afterwards, the person frequently reports little memory of what happened during the ataque. In severe cases, people may contemplate or even attempt suicide during the ataque in response to the despair they feel as a result of the event that provoked the episode. The classic event which provokes an ataque is unexpected news of the death of a family member. Both the tragedy of the death and the unexpected nature of the news are seen to have a physical as well as emotional force within Puerto Rican ethnopsychology. Other events include conflicts between spouses, particularly when they threaten divorce, and conflicts between parents and older children, particularly when the children no longer share the same values of family relations as their parents. In severe cases, the dramatic nature of the ataque reflects violence in the relationship. The appropriate source of help depends greatly on the cause of the ataque de nervios and the class and religious characteristics of the person’s social network. When an ataque occurs at a rural Catholic funeral, the appropriate helpers are family members, who will protect the person when she falls and then pray over her and

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rub her face with alcoholado (alcohol with herbs) to bring her back to consciousness. When family conflicts are the source of ataques, both religious counseling and mental health treatments are seen as useful by many Puerto Ricans. If the ataques are thought to have a spiritual cause, several help options are available. An espiritista may be consulted to mediate with the spirit of a deceased relative who is bothering the person. Alternatively, in Pentecostal circles the episode may be seen as a demonic intrusion, and rebuking of the spirit (reprender) in the name of Jesus Christ may be the preferred course of action. If the ataque marks the worsening of a more chronic problem of nervios, the person may seek or be brought to mental health treatment. For both assessing the relation of the ataque de nervios to mental illness and for deciding on appropriate helpers, social context is critical.

THE SOCIAL SOURCES OF NERVIOS

All the forms of nervios are powerful idioms employed primarily by working class and poor Puerto Rican women and men to express personal distress, crises in the family, and social deprivation. Describing someone as suffering from the various types of “nerves” simultaneously recognizes bodily pain, interpersonal tensions, and social dislocation. Using the different categories of nervios is not only a way to label certain illnesses in Puerto Rico, it is also a way to talk about certain kinds of persons, their social relationships, and their place in society. People’s discussions of nervios make clear their recognition of the social sources of these conditions while acknowledging the interaction between life experience and bodily vulnerability. Although the language of heredity is often invoked in talking about the sources of nervios, it signifies equally a recognition of a social inheritance as of the influence of genes. Puerto Ricans recognize that physical and emotional deprivation of the developing child takes its toll in a number of ways, including the development of nervios. The language of nervios also recognizes the emotional and physical force of social relations to alter one’s nervous system. At another level, people recognize that many of life’s lesions, such as family losses, abusive and violent family relationships, lack of economic resources, and the traumas of sending loved one’s off to or going to war, can produce major alterations in one’s nervios (Finkler 1994). When one talks about one’s nervios, one is talking as much about one’s life circumstances and need for help as about bodily pains and emotional distress. Nervios have also become a potent form of commentary for a generation of Puerto Ricans who have lived through major social transformations of the Island from a more agrarian and rural society to a more industrial and urban one. Much of this transformation occurred starting in the late 1940s, during Operation Bootstrap.

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Operation Bootstrap was the major program of rapid industrialization of the Island in the interests of American corporations and Puerto Rican elites, associated with a far-reaching populist campaign of “modernization” (Lewis 1968). The resultant destruction of the agricultural base of Puerto Rican society led to massive migration to the cities of San Juan and New York. On breaking the communicative ties which served him as a means of orientation in the country, the migrant dwelling in the slums of San Juan or the ghettos of New York finds himself without points of references for the orientation of his behavior. The result is the phenomenon of alienation: a feeling of impotence and fatalism in the face of the surrounding world. (Maldonado-Denis 1972:161)

Operation Bootstrap also significantly altered the shape and function of the Puerto Rican family. Although the authors do not want to overly romanticize the traditional Puerto Rican family, the traditional rural family provided important complementary resources to its members, both emotional and instrumental. The destruction of those social networks by the dual processes of industrialization and migration led to the increase of family dissolution and family violence. One avenue for this generation’s expression of their losses and crises was the various forms of nervios, which continues as a potent idiom of distress for working class and poor Puerto Ricans now in their fifties, sixties, and seventies. This generation also lived through the significant involvement of Puerto Rican men in both the Korean War and the Vietnam War, in which Puerto Ricans served in much higher proportions than their percentage of the US population. Both the direct experiences of participation in these wars and the fears for family members sent overseas to fight were expressed through people’s nervios. Thus the various forms of nervios have emerged as multivocal idioms of distress for a generation of Puerto Ricans affected by particular historical events and transformations, both on the Island and more globally. Clearly, not all Puerto Ricans of this generation, not even those who are working class or poor, experienced nervios as a result of these major social changes. Nervios serve to mark a constellation of vulnerabilities—physical, emotional, social, economic, and political. AN EXPLORATION OF THE POPULAR NOSOLOGY APPROACH

We illustrate the benefits of linking popular and medical/psychiatric nosologies in two case histories of nervios from clinical research at the Hispanic Treatment Program of the Anxiety Disorder Clinic at the New York State Psychiatric Institute. The Hispanic Treatment Program started in 1990 to serve the large and growing Latino community which surrounds the Psychiatric Institute in northern Manhattan. Previous studies by Liebowitz and colleagues (Leibowitz et al. 1994; Salm´an et al. 1998) of the interplay among cultural syndromes, psychiatric disorder

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and important life experiences had already made clear that leaving any one of these aspects out of clinical work distorts understanding significantly. This particular research project provided a unique opportunity to look at the complex and interwoven nature of these experiences in a systematic fashion. It provides the best evidence to date of incorporating perspectives from a popular nosology into clinical work. We developed these case histories from a series of interviews that were part of the research program of the Hispanic Treatment Program. The study was designed to provide a multi-dimensional perspective on the experience of ataques de nervios and its relationship to anxiety disorders. Subjects were recruited from persons seeking treatment in the Hispanic Treatment Program for anxiety and/or depression who were then screened for having had an ataque de nervios. New subjects were also recruited specifically for help with their ataques de nervios; recruitment was done through fliers and through referrals from other mental health and medical services within the large Columbia University medical system that surrounds the Psychiatric Institute. Overall there were 92 subjects recruited into the study, of whom 66 reported having had at least one ataque de nervios. Of this group, 48 (70 percent) were Dominican and 18 (30 percent) Puerto Rican, reflecting the changing Latino mix of Washington Heights (see Lewis-Fern´andez et al. 2002 for more detail on the sample). The results of three different interviews were used to assess the experiences of nervios and develop the profiles we present below. The first was the Explanatory Model Interview Catalogue (EMIC), which the authors adapted specifically for this study of the broad range of nervios among Puerto Ricans and other Latinos. The second interview was the Structured Clinical Interview for Diagnosis (SCID). The SCID is a structured clinical interview designed to standardize clinicians’ psychiatric assessments of patients according to DSM criteria. The interviewers who conducted the EMIC and the SCID were blind to the results of each other’s assessments. The final interview was an integrative interview which took the results of both the EMIC and SCID, developed the sequencing and interaction of the cultural experiences with the episodes of psychiatric disorder, and placed them in the context of important events in the person’s life. The first case history is of a 31-year-old Puerto Rican woman who had a history of nervios, ataques de nervios, and anxiety disorders (see Figure 1). She described herself as “nervous since childhood” because of shyness and because her mother forbade her to play with other children. This cultural identification of nerviosa desde chiquita appears to signal vulnerability to later traumas and mental health problems. Her ataques began in adolescence as the result of beatings from her mother. Her anxiety problems emerged in early adulthood, first appearing as social phobia during her university studies and then as panic attacks after the birth of her first child at age 21. She was quite clear about the differences between her ataques de nervios and panic attacks.

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Figure 1. Histories of Nervios.

This case illustrates the important role of early life traumas in setting the stage for later problems of nervios and psychiatric disorders. This woman clearly understood her first experiences of distress in cultural terms. At the same time, this characterization of being nerviosa desde chiquita appears in several interviews as a vulnerability factor for the development of more severe and enduring mental health problems. The case demonstrates ways that cultural syndromes and psychiatric disorders emerge at key life transitions when new stressful experiences are encountered. The second case history concerns a 45-year-old Puerto Rican woman with a series of more serious life traumas and a concomitantly more complex history of nervios, ataques de nervios, and psychiatric problems (see Figure 2). Again, she described herself as being “nervous since childhood,” but with no clear traumatic history in her early years, and experienced the onset of social phobia in her later school years. She reported a history of severely abusive relationships with men in adulthood resulting in posttraumatic stress disorder. These episodes of abuse were marked by ataques de nervios. Subsequent violent attacks by her son, who was involved with drugs, also provoked several ataques. The onset of depression at age 35 and the worsening of depressive symptoms later in life, when her son was jailed and her husband became fanatically involved in religion, provide poignant examples of the cumulative impact of life’s lesions.

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Figure 2. Histories of Nervios.

This case illustrates the important role of ataques de nervios in highlighting episodes of severe distress and trauma within key social relationships. These ataques need to be recognized as clear cries for help in a social world that is progressively spiraling out of control (Guarnaccia et al. 1996; Lewis-Fernandez 1998). Surrounding both of these case histories are larger clusters of social adversities which many Puerto Rican and other Latino migrants to New York City face: discrimination, poverty, neighborhood violence, unstable employment, and housing. These broader problems linked to the biographies of these women create the context for these histories of nervios and psychiatric problems. As a result of our research and clinical experience, we have expanded our understanding of the different experiences of nervios into the following categories reflected in the questions in Appendix B. “Being a nervous person since childhood” (ser nervioso desde chiquito) has emerged in a number of the clinical research cases as signaling a particular vulnerability to social distress and psychiatric disorder later in life. Thus we have added the qualifier “since childhood” to the original category of “being a nervous person” (ser nervioso). We have also distinguished between “suffering from nerves” (padecer de los nervios) as a more chronic experience and “being sick from nerves” (estar enfermo de los nervios) as a more acute and more serious condition. As an example, these distinctions would parallel the psychiatric distinction between dysthymia, a chronic and lower intensity form of depression lasting two years or longer, and major depressive episode, an acute and

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intense depressive episode occurring over a two-week period of intense sadness and disability. Finally, we have distinguished between ataques de nervios, which occur once or twice in a person’s life, taking place during funerals or other culturally appropriate events, and ataques which happen frequently. The first kind of ataque, while marking a period of intense suffering, is much less likely to be associated with psychiatric disorder. Frequent ataques, particularly when accompanied by dissociative experiences and/or suicidal gestures, are much more likely signs of psychiatric disorder and people suffering them may benefit significantly from clinical intervention. This refinement of our proposal for a popular nosology of nervios grows out of the interaction between epidemiological, clinical and anthropological research and direct clinical work with people who seek help from the suffering expressed through their nervios. At the same time, we want to emphasize that this is a preliminary proposal for further research both to continue to develop this popular nosology of nervios and to test its clinical applicability. TOWARD A PUERTO RICAN POPULAR NOSOLOGY

I have serious reason to believe that the planet from which the little prince came is the asteroid known as B-612. This asteroid has only once been seen through the telescope. That was by a Turkish astronomer, in 1909. On making his discovery, the astronomer had presented it to the International Astronomical Congress in a great demonstration. But he was in Turkish costume, and so nobody would believe what he said. . . . Fortunately, however for the reputation of Asteroid B-612, a Turkish dictator made a law that his subjects, under pain of death, should change to European costume. So in 1920 the astronomer gave his demonstration all over again, dressed with impressive style and elegance. And this time everybody accepted his report. The Little Prince, Antoine de Saint Exup´ery, 1971 (15–16). In a time when biological psychiatry continues to outpace psychotherapy as a form of clinical practice and social psychiatry as the focus of research, developing an alternative mental health nosology built on cultural idioms of distress may be a quixotic proposal. Yet our research and clinical experiences make clear that these various forms of nervios are still widely used by some people in Puerto Rican to express a range of personal and social suffering. Much of this suffering is healed in the family context and is most appropriately handled in that realm. However, because of the multiple strains on families, both internally and externally produced, some significant portion of nervios sufferers need

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the help of people outside the family. Religious help, within mainstream Catholic and Protestant churches, in the newer charismatic and Pentecostal churches, and from those with spiritual faculties who practice as espiritistas and santeros, serves as one broad set of resources. Medical and mental health professionals are another set of resources widely consulted by and seen as relevant for help with nervios by a wide range of Puerto Ricans. We want to end this paper with several arguments for the value of a popular nosology of nervios both for clinical practice and for mental health research. One argument for a Puerto Rican popular nosology is that it more closely reflects the “local knowledge” (Geertz 1983) of those who seek care and provides for a form of communication about suffering more immediate to their concerns than psychiatric diagnoses. By developing and elucidating this popular nosology, researchers and clinicians can more accurately and effectively translate between these cultural idioms of distress and medical/psychiatric diagnoses which guide clinical action and intervention (for a fuller discussion of an approach to examining the interface between cultural idioms and psychiatric diagnoses, see Guarnaccia and Rogler 1999). In particular, “psycho-educational” approaches, geared at providing patients with information about their diagnoses and treatments in order to maximize treatment adherence, would clearly benefit from knowledge about local categories of distress. A corollary of this improved understanding of the translation process between the popular and professional classification systems is a potential reduction in the misdiagnosis of Puerto Rican and other Latino patients presenting with nervios and ataques to mainstream medical services. Ataques in particular, due to their seizurelike character, can be confused with various medical conditions with paroxysmic presentations, such as syncope (loss of consciousness brought on by various causes, including cardiac conduction abnormalities) or epilepsy. In addition, the distinction between ataque and the psychiatric diagnosis of panic disorder can be subtle— involving clarification of the exact phenomenology of the episode and the issue of whether the attack was or was not precipitated—but essential to the proper management of either condition (Liebowitz et al. 1994; Lewis-Fern´andez et al. 2002). Finally, nervios and ataques can be associated with reports of perceptual distortions (such as hearing one’s name being called when alone or experiencing presences), which are common non-psychotic experiences among Puerto Ricans but which can become more frequent and distressing in the context of nervios conditions. These distortions can be easily misdiagnosed by clinicians as psychotic processes requiring unnecessarily drastic interventions, such as intramuscular medication or psychiatric hospitalization (Lewis-Fern´andez 1996). Another value of the popular nosology is that it expands therapeutic concerns from a narrow focus on lesions in organ systems to a broader focus on life’s lesions in their personal and social context. Medications and individual therapy can often be quite useful in helping people cope with the pains and sorrows reflected in

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different experiences of nervios. By paying attention to nervios in the ways we have defined and described here, it becomes immediately clear that internal and individual interventions will not suffice, but that clinical interventions will also need to deal with the social sources of suffering, and particularly with the ways these are mediated through family relationships and interactions. This links clinical work to social and community practice on the one hand, and to family interventions on the other. These links are often theoretically recognized but less frequently implemented in practice. A comprehensive therapeutic model for nervios and ataques should ideally have access to a wide range of interventions that can be implemented in diverse combinations and sequences. A final value of developing a popular nosology is that it stands as a challenge to a narrow medical/psychiatric model (Kleinman 1988). Popular nosologies are one strategy for challenging the medical/psychiatric hegemony which has developed for naming and healing human suffering. In contrast to current dominant medical nosologies, which focus attention on the internal and biological sources of distress, popular nosologies focus on the interpersonal, social, political, economic, and spiritual sources of distress. They present a dynamic, contextual alternative to the highly bounded, descriptive medical approach. A key characteristic of the Puerto Rican popular nosology we have described is that it defines the realms of health and pathology in the interaction between the coping skills of the person and the amount of suffering endured, as lying in the borderland between resilience, support, and stress. The full concept of nervios encapsulates this tension, playing out its thematic variations in the subtleties of the classification system we have outlined. This basic contextuality enables a popular nosology such as the one we have proposed for Puerto Rican mental health to provide an alternative language and framework for understanding human suffering and thereby suggest different forms of intervention to alleviate that suffering. APPENDIX A

Questions on Nervios and Ataque de Nervios from the EMIC CREENCIAS GENERALES SOBRE NERVIOS Y ATAQUES DE NERVIOS (GENERAL CONCEPTIONS OF “NERVES” AND “NERVOUS ATTACKS”)

1. Para Ud., ¿cu´al es la diferencia entre ser nerviosa(o), tener ataques de nervios, y padecer de los nervios? For you, what is the difference between being “nervous,” having “nervous attacks,” and “suffering from nerves”? a. ser nerviosa(o)/ being “nervous” b. tener ataques de nervios/having “nervous attacks” c. padecer de los nervios/suffering from “nerves”

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2. ¿C´omo describir´ıa Ud. a la persona que . . . How would you describe a person that . . . a. es nerviosa? is “nervous”? b. tiene un ataque de nervios? has a “nervous attack”? c. padece de los nervios? suffers from “nerves”? 3. ¿Cu´al piensa Ud. que es la causa m´as probable de . . . What do you think is the most probable cause of . . . a. ser nervioso? being “nervous”? b. tener un ataque de nervios? having a “nervous attack”? c. padecer de los nervios? suffering from “nerves”? 9. ¿Una persona que . . . deber´ıa recibir alg´un tipo de atenci´on? SI DICE SI, ¿Qu´e tipo de ayuda debe recibir? Should a person that . . . receive some type of help? IF THEY SAY YES, What type of help should be received? a. es nerviosa/is “nervous” b. tiene un ataque de nervios/has “nervous attacks” c. padece de los nervios/suffers from “nerves” 10. ¿Un doctor, un psiquiatra, un psic´ologo, u otro profesional de salud puede ayudar a una persona que . . . Can a doctor, a psychiatrist, a psychologist, or other health professional help a person that . . . a. es nerviosa? is “nervous”? b. tiene un ataque de nervios? has “nervous attacks”? c. padece de los nervios? suffers from “nerves”? APPENDIX B

Proposed Questions for Assessing Nervios and Ataques de Nervios in Clinical and Research Settings 1. ¿Ha sido usted una persona nervioso(a) desde ni˜no(a)? Have you been “nervous” since childhood? 2. ¿Es usted una persona nerviosa? Are you a “nervous” person? 3. ¿Ha padecido de los nervios alguna vez en la vida? Have you ever suffered from “nervios” in your life? 3a. SI DICE S´I: ¿Padece de los nervios todav´ıa? IF YES: Do you still suffer from “nervios” now? 4. ¿Ha tenido alguna vez un ataque de nervios? Have you ever had an “ataque de nervios”?

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4a. ¿Cu´antos ataques de nervios ha tenido en su vida? How many “ataques de nervios” have you had in your life? Especifique el n´umero de ataques de nervios: Specify the number of “ataques de nervios” [77 = “too many to count”; 88 = don’t know; 99 =denied, refused] ´ 5. Ultimamente, ¿ha estado enfermo(a) de los nervios? Recently, have you been “ill with nervios”? (Developed by Roberto Lewis-Fern´andez for use in clinical practice and research.) ACKNOWLEDGMENTS

The research for this paper was supported by a FIRST Award to Dr. Guarnaccia from the Division of Biometry and Epidemiology of the National Institute of Mental Health [MH45789]. Dr. Guarnaccia was a Visiting Scholar at the Russell Sage Foundation, New York, NY, during the conceptual development of this paper. Dr. Lewis-Fern´andez was supported by grants from the MacArthur Foundation MindBody Network and the Nathan Cummings Foundation. Dr. Rivera was supported by Project L/EARN at the Institute for Health, Health Care Policy and Aging Research and by a Supplement for Underrepresented Minorities in Biomedical and Behavioral Research from the National Institute of Mental Health. The authors would like to thank Angel Lopez, Project L/EARN intern, for his help in coding the data for this paper. The cases in this paper come from interviews carried out by Dr. Michael Liebowitz, Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons, and Director, Anxiety Disorders Clinic, New York State Psychiatric Institute. REFERENCES

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Peter J. Guarnaccia Institute for Health, Health Care Policy, and Aging Research 30 College Avenue Rutgers University New Brunswick, NJ 08901-1293 Roberto Lewis-Fern´andez Anxiety Disorders Clinic and Hispanic Treatment Program New York State Psychiatric Institute and Columbia University New York, NY

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Melissa Rivera Marano Graduate School of Applied and Professional Psychology, and Institute for Health, Health Care Policy, and Aging Research Rutgers University New Brunswick, NJ