Susto as a cultural conceptualization of distress: Existing research and aspects to consider for future investigations

Abstract

Among the cultural conceptualizations of distress, susto is defined in the DSM-5 as “a cultural explanation of distress and misfortune in Latin America that refers to an illness attributed to a terrifying event that causes the soul to leave the body and leads to unhappiness and illness, as well as difficulties in performing key social functions” (American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: APA, p. 836). Thus, susto represents a cultural explanation that encompasses the symptoms of various mental disorders and physical diseases. We analyzed the descriptions of susto from different scientific fields and related them to definitions of DSM-5 syndromes. Three syndromic subtypes of susto show a symptomatic overlap with depression, post-traumatic stress disorder (PTSD) and somatic disorder. However, linguistic metaphors describing symptoms and perceived causes that are specific for Latin American culture support the concept of susto as a specific idiom of distress (e.g., loss of soul, shadow or ajayu; sunken, closed or white eyes; jumping and screaming in the night; being thrown to the ground). In addition, if diagnostic criteria are met for mental disorders, then susto describes a perceived cause of psychopathological states (e.g., depressive disorder, PTSD, somatic disorder, panic disorder, generalized anxiety disorder). Future research with people who have experienced susto is needed to clarify whether susto precedes the onset of other mental disorders (perceived cause) or whether it is a way of designating distress (idiom of distress).

Introduction

Historically, the influence of cultural factors on mental illness, its symptoms, causes and treatments, and on other forms of expressing distress, has been widely studied (Kaiser & Weaver, 2019). These studies have led to the denomination of syndromes linked to their cultural context as culture-bound syndromes (APA, 1994; Pagani et al., 2017; Roldán-Chicano et al., 2017; Weller et al., 2002). As one of the culture-bound syndromes, susto (“fright”) was introduced in the DSM-4 (APA, 1994) as a “folk illness attributed to a terrifying event that causes the soul to leave the body and leads to unhappiness and illness” (p. 903). In the DSM-5 (APA, 2013) the term culture-bound syndrome was replaced by three concepts: cultural syndromes, idioms of distress, and explanatory models or perceived causes. Cultural syndromes are clusters of symptoms that usually occur in individuals from the same cultural context and can be considered “coherent patterns of experience” (APA, 2013, p. 758); idioms of distress are “shared ways of experiencing and talking about personal or social concerns” but “may not involve specific symptoms or syndromes” (p. 758); and explanatory models/perceived causes are culturally recognized attributions for symptoms, illness or distress (APA, 2013).

Susto is a “cultural explanation for distress” among Latinas/Latinos (APA, 2013). It is highly prevalent among people in Mexico, Central America, and South America, as well as among some Latinos in the United States, with lifetime prevalence rates ranging from 37%, in Guatemala, to 59%, among Mexican Americans in Texas (Weller et al., 2008). Although data are largely lacking, it is suggested that susto is not adequately addressed in health care and interferes with treatment compliance if not well understood by the healthcare provider (Moreira et al., 2018). However, assessment and treatment of susto is complicated by a broad definition that may be inappropriate for use in health care (Waldram & Hatala, 2022). Specifically, three syndromic types of susto have been applied: one related to depression, another related to somatic disorder, and the last related to post-traumatic stress disorder (PTSD) (APA, 2013). These three syndromic forms of susto respond to specific predominant symptoms and perceived causes.

In addition to the psychiatric definition, susto has also been studied from specific perspectives of health sciences and social sciences. The aim of this study is to analyze the descriptions of susto from different scientific fields and to compare these descriptions with those of the DSM-5. The principal scope of our analysis is the question of whether definitions of susto and descriptions of symptoms from other scientific fields, such as anthropology, sociology and ethnology, are consistent with the psychiatric definition and can therefore be characterized as a generally accepted category. To carry out this systematic investigation, we analyzed four relevant aspects: definition, symptoms, perceived causes and management of susto. We conducted a systematic search for articles of all scientific fields and classified information on susto into categories.

Method

A search for articles on susto was carried out using the keyword “susto” in the PubMed and SciELO databases. To reduce the likelihood of bias in the results, no other search terms were entered. PubMed is a biomedical and life sciences database, and SciELO is an online scientific electronic library supported by the Latin American and Caribbean Center for Health Sciences Information. Articles were obtained from international and Latin American scientific journals and from various health and social science disciplines. The inclusion criterion was that the articles included a definition of susto, its symptoms, causes and management, or that at most one of these aspects was missing. Thus, 18 articles were included (Table 1): 8 from PubMed and 10 from SciELO. A further 45 articles on susto were rejected for not fulfilling the criterion. Nevertheless, 23 of these 45 articles had punctual information about one or two criteria which were then used in the discussion as complementary data if pertinent.

Table 1.

Research that summarizes the definitions, perceived causes, symptoms and management associated with susto.

Author	Field of investigation	Population and location	Definition of susto	Perceived causes of susto	Symptoms of susto	Management of susto
Armijos et al. (2014)	Ethnobiology and ethnomedicine	Saraguro indigenous healers from southern Ecuador	Susto is a supernatural disorder	The negative energy of a person or place	Nervousness, lack of appetite, sleep loss	Cleaning the patient's body with medicinal plants and praying
Ávila-Testa and Idoyaga-Molina (2013)	Anthropology	Peruvian emigrants in Argentina	An emotional imbalance caused by traumatic or panic experiences. As a consequence, the soul of the person leaves the body	Natural (accidents, electric shocks, bad news) or supernatural causes (ghosts)	States of anguish, restlessness, sleeping difficulties, crying, headache or feeling pain in an organ	Calling the lost soul, cleansing the patient's body with an egg or a guinea pig (which can absorb the patient's illness) and praying
Bianchetti (2014)	History, ethnography	Analysis of cultural diseases in northwest Argentina	Frequent psychosomatic affection caused by an emotional shock. As a result of it, the soul of the person leaves the body	Natural (external like falls or emotional like states of fear) and supernatural causes (ghosts, devil)	Decay, nausea, vomiting, tachycardia, headache, high fever, confusion, embarrassment and irritation. Nocturnal delirium, nervous disorders and death in extreme cases	The healer is in charge of reintegrating the soul to the body
Brooks (2016)	Biocultural, medical anthropology	Highlanders from Peru	Susto is a cultural syndrome associated with fright which is common in many parts of Latin America	Car accidents, being chased by animals	“Loss of appetite, jumping in the night, and feeling like you are being absorbed by the earth.” (p. 111)	—
Burman (2010)	Anthropology	Aymara indigenous people from El Alto (Bolivia)	Susto is a spiritual disorder in which the person loses some component of their being (ajayu)	—	Fever, pain, skin rashes, asocial behavior and strange manners. Crying and sleep problems in children	Calling the lost being with some food the affected person likes, a patient's clothes or a woolen thread and removing strange influences from the patient's body (p. 466)
Cepeda-Chamorro et al. (2018)	Cross-cultural nursing, ethnography	Mothers of children under one year of the Guambiana ethnicity from Colombia	Susto refers to the workings of a fantastic entity, which occupies the body of a child causing sickness (deduced)	Susto in children is caused by the possession of a supernatural entity	Vomiting, diarrhea, sunken or rounded eyes, crying, closed eyes, and variations in the pulse rate. In severe cases developmental problems and death	There are different healing methods. One of them is the use of medicinal plants
Estrada-Reyes et al. (2014)	Ethnopharmacology	Analysis of the effects of traditional medicinal plants in mice	Susto is a cultural affiliation syndrome in Latin America	Susto appears when a person is suddenly frightened and their soul and body separate	Weakness, apathy, fever, sadness, headaches, and nightmares	With rituals and prayers invoking good spirits and asking for the return of the lost soul. Medicinal plants acting as anxiolytic, tranquilizer and sedative agents are also used in the form of teas and infusions
Muñoz-Morán (2011)	Anthropology, ethnography	Indigenous people of the Sevina community (Michoacán, Mexico)	Susto or espanto is a disease arising from unusual experiences, whether natural or supernatural, which cause a strong impression on the person	Encounter with the devil, who punishes people who display socially inappropriate behavior	The affected person spends many days in bed, in a state of semi-unconsciousness, with a feverish process. In extreme cases death	The person must show good behavior being with their family and at home praying to God
Otero et al. (2012)	Psychiatry	Latin America	“Very diverse chronic somatic conditions attributed to a loss of spirits induced by intense fear.” (p. 381)	Unforeseen situations in places where supernatural beings supposedly inhabit. As a consequence, body and soul separate	Agitation, anorexia, insomnia, fever, diarrhea, general confusion, apathy, depression, introversion, headaches, nausea, vomiting, palpitations, death. In the Andean region also delusions and hallucinations	—
Pagani et al. (2017)	Ethnopharmacology	Mestizo inhabitants of Brazilian Amazonia	Espante (a native variation of susto) is a culture-bound syndrome in Brazil	Frightening events or having the soul (shadow) stolen by animals or supernatural forces	Fever, agitation, dizziness, crying and scared face, sleep problems, hunger and weight loss. Espante may be a milder ailment than susto	Prayers, blessings, magic and medicinal plants. A mixture of plant leaves may have antidepressant and anxiolytic effects
Remorini and Palermo (2016)	Ethnography	Mothers in Salta (Argentina)	Susto is a cultural affiliation syndrome produced by the loss of the person's soul	Natural and supernatural stimuli that cause a strong impression. Transmission from pregnant mothers to their babies	“Being mean, whiny, upset, nagging, being annoyed, sad, angry.” (p. 91). Diarrhea, vomiting	Medicinal plants are used in the form of infusions or for rubbing the child's body
Roldán-Chicano et al. (2017)	Transcultural nursing	Bolivian immigrants in Spain	Susto is a culture-bound syndrome. Participants considered susto a disease in which the soul of the person gets lost	Unexpected frightening events that cause the separation of the soul from the body	One participant reported apathy and headache. Another said that her daughter woke up at night screaming. Also red stains on the body and crying	With offering rituals called “white tables” and ingesting medicinal plants
Rösing (1993)	Anthropology	Traditional Kallawaya healers of Bolivia	Susto is one of the most frequent causes of illness in the kallawaya region (Bautista Saavedra province of La Paz, Bolivia)	Frightening events or debt to supernatural beings (good and bad spirits). As a consequence, soul and body separate	Almost any symptoms. Sometimes insomnia, nightmares, restlessness, boredom, and apathy	1. Diagnosis by reading coca leaves or cards 2. Calling the lost soul at night burning incense and sugar 3. Expelling evil spirits with offering tables with live animals
Rubel (1964)	Ethnology	Epidemiological study of susto as a folk illness	Susto is a folk illness in Latin America, which encompasses a particular set of symptoms and its attendant beliefs and behaviors	For Indians: capture of the soul by spirit guardians of earth, rivers, forest or animals. For non-Indians: unexpected accidents	Restlessness, listlessness, depression, introversion, body pain, diarrhea, fever. Also, loss of appetite, hygiene and strength	Both Indians and non-Indians call the lost soul and show it the way back to the patient’s body. The patient's body is also rubbed with a guinea pig, an egg or medicinal plants to remove the illness from their body
Thomas et al. (2009)	Medical anthropology	Indigenous people from Trinitario (Bolivia)	Susto is a Latin American folk syndrome classified as a culture-bound syndrome and characterized by soul loss	Capture of the soul by supernatural beings (spiritual owners of natural elements or animals) or lose of the soul by negative action of a person	Fever, weakness, vomiting, diarrhea, “white eyes”, crying, excessive thirst, inability to urinate, restless sleep and, in some cases, edema	Taking smoke baths produced by the burning of animal tissues or hair/nails of the person who caused susto. Also, calling the lost soul
Urióstegui-Flores (2015)	Public health, sociocultural epidemiology	Traditional healers from Taxco (Mexico)	Susto is a cultural affiliation syndrome in Latin America	Concussions, falls, strong impressions, see how a person suffers a strong fall	Trauma, loss of appetite, weight loss, continued discomfort, diabetes, insomnia, and death	With medicinal plants and prayers
Vega (2008)	Sociology	Bolivian Aymara immigrants in Buenos Aires, Argentina	Susto is a polymorphic taxon that includes organic and psychological disorders	Some psychic entity of the person is lost as a result of a traumatic supernatural situation	Listlessness, loss of appetite and sleep, “sunken white eyes”, diarrhea, general boredom, laziness, madness	Calling the lost soul at night with clothing and a meal that they like
Weller et al. (2002)	Cross-cultural research, psychiatry	Mestizo sample of Guatemala, Mexico and Texas	Susto is a culture-bound syndrome linked to major depressive disorders, post-traumatic stress disorder, and somatoform disorders in the DSM-4	Frightening experiences. In Mexico and Guatemala also supernatural causes	Agitation, shaking, nervousness, crying, sleeping difficulty, bad dreams, fear of unfamiliar people and places, tossing and screaming during sleep, and paleness	Praying and keeping calm. In Texas susto is believed to go away by itself, but in Mexico and Guatemala it must be treated. There are also differences between the three samples in the specific rituals and symbolic elements used

Results

Definitions of susto

Nine of the 18 articles in Table 1 define susto as a culture-bound syndrome, a culture affiliation syndrome or a folk syndrome. Therefore, there is apparent agreement among researchers from different disciplines that susto is a syndrome that appears only in certain cultures, specifically in Latin America. Other authors (Armijos et al., 2014; Burman, 2010; Cepeda-Chamorro et al., 2018; Muñoz-Morán, 2011) build on this definition and characterize susto as a supernatural or spiritual disorder, referring to the fact that when a person is frightened, one of their souls is trapped or stolen by a spirit. Susto could therefore be considered a cultural syndrome related to supernatural actions or events.

However, we also find other definitions, such as emotional imbalance (Ávila-Testa & Idoyaga-Molina, 2013) and a polymorphic taxon that includes organic and psychological disorders (Vega, 2008). These definitions show that susto can be related to different signs and symptoms, both psychological and physical. Furthermore, two authors define susto as a psychosomatic or somatic condition (Bianchetti, 2014; Otero et al., 2012). This coincides with one of the types of susto that appear in the DSM-5. Only one author considers susto a cause of various illnesses, as it is defined in the DSM-5 (Rösing, 1993).

Perceived causes of susto

The perceived causes of susto are included in Table 1. Most authors concur in pointing out natural and supernatural perceived causes. Natural causes would be, for example, severe accidents, violent episodes (Armijos et al., 2014), falls, concussions, startling noises (Bianchetti, 2014), witnessing dramatic situations, or being attacked by an animal (Remorini & Palermo, 2016). Supernatural causes refer to encounters with ghosts, the souls of dead people, or the devil (Bianchetti, 2014); the anger of deities for not giving enough in ritual offerings (Rösing, 1993; Rubel, 1964); or walking around sacred places inhabited by deities (Thomas et al., 2009; Vega, 2008).

Patients believe that one or more of these stimuli cause a state of fright in which the soul leaves the body provoking the symptoms. These cultural beliefs are expressed in the form of linguistic metaphors, which should be understood as idioms of distress. When the cause is supernatural, an entity “steals” or “grabs” the soul. Many of the linguistic metaphors encountered refer to this dynamic: “the soul has been grabbed by water, air, hill, earth, deceased person, or an evil one” (Bianchetti, 2014, p. 159). Patients believe that after the soul–body separation, a foreign spirit could enter the “soulless” person’s body and cause different symptoms.

Symptoms associated with susto

According to the DSM-5 (APA, 2013), there are no specific defining symptoms for susto. Rather, a wide variety of both psychological and somatic symptoms may appear (Table 1). The different symptoms can be gathered in sets that represent:

1. somatic disorder,

2. depressive disorder,

3. PTSD,

4. panic disorder and/or generalized anxiety disorder (GAD),

5. infection,

6. symptoms not otherwise specified.

A full differential diagnosis cannot be conducted due to the lack of information about symptomatic time criterion and severity.

In general, somatic symptoms were cited more often than psychological ones. These were headache, sleeping problems, body pain, weakness, stomachache, nausea, diarrhea, vomiting, skin rashes, difficulty breathing, and frequent urination (set 1). Set 2 symptoms consisting of loss of motivation, apathy, crying, restlessness, introversion, decay, sadness, lack of appetite, sleeping problems, and delusions and hallucinations in severe forms could link susto to major depressive disorder. Furthermore, a group of symptoms (set 3) comprising nervousness, confusion, nightmares, agitation, states of anguish, embarrassment, irritation, continued discomfort, fear of unknown people and places, feeling easily startled at night and sleeping difficulty may show a link with PTSD.

However, set 4 comprising a state of semi-unconsciousness, breathing problems, nausea, stomachache, palpitations, sweat, shaking and fear of unknown people and places, could also be associated with panic disorder. If we add the symptoms nervousness, tendency to be startled, body pain, irritability, and problems falling asleep, there would be a link to generalized anxiety disorder. Set 5 comprising fever, cold sweat, body pain, headache, stomachache, weakness, weight loss, swelling, diarrhea, nausea, vomiting, paleness, excessive thirst, frequent urination, shaking and difficulty breathing could also indicate the presence of an infection. Lastly, a group of symptoms not directly related to other mental or physical health disorders was found (set 6). This set comprises linguistic metaphors that should indicate distress in a patient. These are specific to a region or culture and, cannot usually be medically or scientifically proven. This set can be identified as idioms of distress. Table 2 shows these grouped according to different themes. Various culture-related explanations are also provided.

Table 2.

Idioms of distress associated with susto and possible culture-related explanations.

Theme	Idioms of distress	Possible culture-related explanations
Loss of morale or spiritual decay	“Sensation that the body is out of spirits” (Bianchetti, 2014, p. 156) “Being thrown to the ground” (Brooks, 2016, p. 107) “Feeling like you are being absorbed by the earth” (Brooks, 2016, p. 111) “Separation of one’s soul from the body” (Brooks, 2016, p. 110) “The fright … is like being separated from the spirit at that moment” (Roldán-Chicano et al., 2017, p. 5) “Loss of the shadow” (Rubel, 1964, p. 270) “Susto is caused by the loss of a vital substance or force” (Weller et al., 2002, p. 451) “Children fall on the ground unexpectedly without any apparent reason (they got grabbed by the earth)” (Thomas et al., 2009, p. 303)	According to the Andean religion, there are different souls (also called psychic entities or shadows) which contain various aspects of a person's character, temperament, and vitality. These souls are dynamic and can leave and re-enter the body. They can get lost or be stolen by other entities (foreign spirits). The symptoms vary depending on the cause of loss. Andean (Aymara) societies believe health to be the result of the harmony or balance between: ○ the higher plane or celestial world (alajpacha), related to the gods; ○ the earthly, intermediate plane, the here and now (akapacha or urake), inhabited by human beings, flora and fauna; ○ the lower plane or subsoil (mankhapacha), the place of Mother Earth (Pachamama), death and life (López, 2011, p. 42)
Physiological changes	“Cadaver-like appearance” because of fat loss. Sad, dull expression in the eyes (Bianchetti, 2014, p. 135) Closed, sunken or rounded eyes (Cepeda-Chamorro et al., 2018, pp. 183–185); “white eyes” (Thomas et al., 2009, p. 303; Vega, 2008, p. 5); “in small children the sclera (white of the eyes) gets larger” (Thomas et al., 2009, p. 310) “Eyes burn and sting and can't stand the light” (Rösing, 1993, p. 181) “Sternum sinking and asymmetry when measuring the feet” (Bianchetti, 2014, p. 156) “Weak, bounding, or asymmetrical pulse in children” (Cepeda-Chamorro et al., 2018, p. 184); “bad blood pressure” (Weller et al., 2002, p. 452) “Swelling of the body or body parts” (Thomas et al., 2009, p. 310); “swelling of the hands and face, hair loss, paleness/ yellowface (palidez/cara amarilla)” (Weller et al., 2002, pp. 452–456)	Some of the idioms can hardly be scientifically proven since measurements are not usually taken. This is also bound to subjectivity because the limit between normal and pathological depends on the observer. Changes in the eyes are a repetitive theme. Some Andean cultures believe the eyes to be the representation of the vitality and the wisdom of the person. Eyes are also the symbol of a higher plane of existence (alajpacha), which could be interpreted as heaven (Paz-Esquerre, 2015). Asymmetries are also a recurrent theme in the symptoms. Because Andean cultures believe that symmetry or balance is the key to health, asymmetries denote illness.
Sleep disturbance	“When you sleep, you jump” (Ávila-Testa & Idoyaga-Molina, 2013, p. 63); “jumping in the night” (Brooks, 2016, p. 111); “they jump, cry and scream when they are asleep” (Weller et al., 2002, Table 1, p. 456) “Nocturnal shaking and agitation during sleep” (Bianchetti, 2014, p. 134); “tossing and screaming during sleep” (Weller et al., 2002, p. 463) Nocturnal delirium (Bianchetti, 2014, p. 134) “Sleep fitfully and talking aloud during sleep” (Rubel, 1964, p. 273). “Scared of the dark, afraid of being alone” (Weller et al., 2002, Table 1, p. 456)	Traditional Andean societies believe that at nighttime the soul is especially vulnerable because it can voluntarily leave the body during sleep and return to the body when the person awakens. During this time foreign spirits may grab the soul, causing susto (Bianchetti, 2014; Rubel, 1964). Perhaps the allusion to jumping during sleep refers to the departure of the soul from the body. The devil may appear after midnight to those people walking outside because it is considered a “bad hour” (la mala hora) (Muñoz-Morán, 2011). Nocturnal apparitions (visual hallucinations) or dreams can also cause susto (Rösing, 1993, p. 169).

The linguistic metaphors “feeling thrown to the ground” (Brooks, 2016, p. 107) and “unexpectedly falling on the ground” (Thomas et al., 2009, p. 303) are idioms of the symptoms, which in turn relate directly to the idioms of the perceived cause “being grabbed by the earth” (see the previous section ‘Perceived causes of susto’). If the cause was a foreign entity inhabiting the person's body, the person may have the symptom “behave strangely” (Vega, 2008, p. 5).

Furthermore, there are some idioms of distress that are recurrently mentioned by several authors. These linguistic metaphors are cited more frequently, which may indicate that their use is more widespread or they are more prototypical of susto. These are:

• loss of soul, shadow or ajayu (Bianchetti, 2014; Brooks, 2016; Roldán-Chicano et al., 2017; Rösing, 1993; Rubel, 1964; Vega, 2008; Weller et al., 2002);

• sunken, closed or white eyes (above all in babies and children) (Bianchetti, 2014; Cepeda-Chamorro et al., 2018; Rösing, 1993; Thomas et al., 2009; Vega, 2008);

• jumping and screaming in the night (Ávila-Testa & Idoyaga-Molina, 2013; Bianchetti, 2014; Brooks, 2016; Rubel, 1964; Weller et al., 2002);

• loss of speech (in severe cases) (Bianchetti, 2014; Onofre-Mamani, 2013; Vega, 2008).

Management of susto

As seen in Table 1, various procedures and elements can be used to manage susto. Eight articles mention the use of medicinal plants, either by ingestion or to cleanse the patient's body (rubbing). The specification of cleansing the patient's body of foreign spirits or removing the illness from their body were cited in four articles. Seven articles noted praying. A further six articles noted unspecified rituals that involve magic, offerings, and smoke baths. Six articles mentioned specifically calling of the lost soul. One article (Bianchetti, 2014) did not specify how susto is managed. The presence of family members is also mentioned in the articles, both directly calling for the lost soul, and indirectly offering emotional support to the patient (Table 1).

It should be noted that management is adapted to the perceived cause of susto and to the specific patient. If the perceived cause of susto relates to losing a soul in a specific location or to a deity of a location, the healer, patient and company (in most cases family) must travel to said place to perform the ritual. The calling of the lost soul is made by calling the name of the patient while showing something of they own or like, for example a piece of clothing or their favorite dish.

Discussion

This article aims to summarize and analyze the data provided by 18 articles on susto in terms of its definition, associated symptoms, perceived causes, and management.

As expected, the definitions of susto were varied: nine defined susto as a culture-bound syndrome (or similar), four as a supernatural syndrome, two as a somatic condition, and three single definitions as emotional imbalance, polymorphic taxon, and cultural cause of illness. Nine authors define it as a culture-bound syndrome, matching the old DSM-4 (APA, 1994) definition. It is possible that there is still insufficient research to support the current notion of susto as a cultural explanation for symptoms, illness or distress and that the authors rely on previous research for their definitions. The variety of definitions of susto from other fields differs from the psychiatric definition. Therefore, the psychiatric definition of susto is not a generally accepted category.

For the analysis we gathered the symptoms described in the articles into five sets of disorders described in DSM-5 (APA, 2013): three sets related to depression, PTSD, and somatic disorder, matching the definition of susto of DSM-5 as a perceived cause for other disorders. Here we must consider that Latin American populations are more prone to somatization (Tófoli et al., 2011) which could explain the results of the susto type linked to somatic disorder.

Other sets of symptoms, associated with panic disorder and/or generalized anxiety disorder (GAD) and infections were also found. The link with panic disorder and/or GAD was described in pharmacological research (outside the criterion filling articles), which found fear-suppressing, tranquilizing and anxiolytic effects of some medicinal plants used in the management of susto (Cárdenas et al., 2017; Gonzales de la Cruz et al., 2014; Jenks & Seung-Chul, 2013; Mullally et al., 2016; Picard et al., 2014). The association with infections is also supported by research, particularly viral infections (Pagani et al., 2017) and respiratory tract infections (Larson et al., 2009). Other investigations relate it generally to gastrointestinal disorders (Ospina-Lozano, 2018) and unspecified organic diseases (Otero et al., 2012).

There is also a broad line of research that links susto to a heightened probability of developing diabetes (Concha et al., 2016; Moreira et al., 2018; Page-Pliego, 2015; Palmquist et al., 2012; Sullivan et al., 2010). Some research considers susto a strong emotional trauma that can trigger diabetes (Flaskerud & Ruiz-Calvillo, 2007; García de Alba-García et al., 2015; García Reza et al., 2014; Montesi, 2017). Other research suggests that having experienced susto also increases the chances of developing other diseases (Lemley & Spies, 2015; Pagani et al., 2017).

The link between susto and a wide variety of mental disorders and physical health diseases in all these articles would support its current definition as a cultural explanation/perceived cause of other disorders/ diseases. Nevertheless, to consider susto a perceived cause of other disorders/ diseases, it is necessary to verify that people who have had it meet the diagnostic criteria for the said disorders. These include the presence of certain symptoms (required symptoms), severity levels and specific periods of symptom occurrence. Most articles do not mention this information explicitly. In relation to severity levels, only Brooks (2016) states that susto can be mild, moderate, or severe, depending on the number of symptoms; other authors simply mention the fact that susto can end with the death of the person. As for the time frame, only Rösing (1993) mentions that the symptoms can appear immediately after the fright, but also weeks, months or years later. A formal and complete diagnosis procedure is impossible without this information and is a limitation of this investigation. This indicates the need to analyze required symptoms, severity levels, and the temporal period of susto in future research.

Furthermore, the DSM-5 (APA, 2013) states, in cultural formulation, that the same cultural term frequently denotes more than one type of cultural concept. These are cultural syndromes, idioms of distress and cultural explanations/perceived causes of other disorders. Taking this into account, we can define another group of symptoms not otherwise specified (set 6 above) as idioms of distress (Table 2). When the description of susto focuses on these linguistic metaphors, susto should be defined as an idiom of distress, defined in the DMS-5 as “widely varying forms of suffering without mapping onto a discrete set of symptoms, syndrome, or disorder” (APA, 2013, p. 758). In other cases, when susto is used to explain the occurrence of other diseases and the diagnostic criteria for other diseases are met, susto may be a cultural explanation/perceived cause of other diseases. Thus, depending on the predominant symptoms and causes, susto can be a perceived cause of other disorders/ diseases and an idiom of distress.

The perceived causes of susto can be grouped into natural and supernatural factors, both categories having numerous possible originating stimuli. Some stimuli described in the articles can be interpreted as traumatic experiences that lead to PTSD, making susto a cause of PTSD based on supernatural ideas. Yet, because of the variability of susto-provoking stimuli and the multifactorial etiology of mental disorders, no links with other disorders can be established. It would be necessary to analyze each case to draw accurate conclusions. This task is left for future research.

Susto is usually managed using medicinal plants combined with praying and the ritual calling of the lost soul. Medicinal plants can be ingested or rubbed on the patient's body. When ingested, they have fear-suppressing, anxiolytic, and tranquilizing effects. Rubbing can be considered a cultural expression, “cleansing the person’s body”, which refers to a cultural belief in which the spirits that cause illness can be expelled from the person's body. The use of rituals, such as calling the lost soul, serves to manage the perceived cause of susto. For example, if the perceived cause of susto relates to losing one’s soul in a specific place or to a deity of a location, the healer, patient and company (in most cases family) must travel to said place to perform the ritual. The presence of family members throughout the process is noteworthy, both directly, calling for the lost soul, and indirectly, offering emotional support to the patient.

When analyzing the factors related to the effectiveness of traditional susto management, we found first of all, that the intake of medicinal plants has fear-suppressing, anxiolytic, and calming effects, similar to the psychiatric treatment of panic disorder and GAD. Healing rituals, such as calling of the lost soul, can be effective through symbolic actions. These actions can heal through non-verbal communication, inducing positive psychological states (Hinton & Kirmayer, 2017). Other healing factors may be the strengthening of interpersonal relationships by involving the patient's relatives in the healing rituals (Rösing, 1993) and adapting the language and expressions used to the patient (Cork et al., 2019; Heim & Kohrt, 2019; Kaiser & Weaver, 2019), offering them the chance to use the idioms of distress that best explain their symptoms.

These healing factors can be considered nonspecific and, in Western societies, are also used in psychological and psychiatric therapies for mental disorders. For this reason, according to Hinton and Patel (2017), Western therapies can be adapted to the use of cultural concepts of distress, such as idioms of distress. The therapist can address the patient's concerns (e.g., considering oneself an incomplete person because one's soul has been stolen), modify catastrophic cognitions (e.g., a person without a soul can die suddenly) and somatic symptoms (e.g., a trauma-related nightmare is a spiritual attack), and use culturally accepted imagery and metaphors, among others. In addition, the clinician should ask about idioms of distress to increase treatment adherence, because these expressions are part of everyday interactions, “sharing in a typically unquestioned normativity” (Hinton & Lewis-Fernández, 2010, p. 211). These investigations aim to compromise the “Western” understanding of disorders with the cultural variations of each patient. We find that further guidelines into this sort of treatment would be beneficial and should be done in future research.

After analyzing the causes and management of susto, we believe that a third possibility would be to consider it a clinical chain of psycho-socio-cultural events: a natural or supernatural stimulus causes a fright. Upon frightening, the person soul is lost or robbed. This loss weakens the person, making it easier for them to become ill. The term “falling ill” does not distinguish between psychological disorders or physical diseases; hence the symptoms can be highly varied, both psychological and somatic, and their severity can be variable. This would explain why idioms or linguistic metaphors were found to reflect the different sections of this research (causes, symptoms and management of susto). From this perspective, susto would be a psycho-socio-cultural phenomenon not reducible to the DSM-5 (APA, 2013) definitions.

This research has a number of limitations. First, the only search term used was the word “susto”, thus reducing the possibility of finding other criterion fitting articles. Other expressions that could have been used included the English word “fright”, and other synonyms such as espanto, ajayu, sombra or “soul loss” (Bianchetti, 2014; Brooks, 2016; Roldán-Chicano et al., 2017; Rösing, 1993; Rubel, 1964; Vega, 2008; Weller et al., 2002). Second, when comparing descriptions of susto from different fields, little cohesion is found in the terms used, forcing interpretations. Some articles used cultural expressions to define susto, such as “supernatural illness” (Muñoz-Morán, 2011) or “spiritual disorder” (Burman, 2010), whereas others used the more widespread term “culture-bound syndrome” (Brooks, 2016; Estrada-Reyes et al., 2014; Pagani et al., 2017; Remorini & Palermo, 2016; Roldán-Chicano et al., 2017; Rubel, 1964; Thomas et al., 2009; Urióstegui-Flores, 2015; Weller et al., 2008). Moreover, the aims of each article were different, with some focusing on a description of rituals to call the lost soul (Rösing, 1993), whereas others described in detail the symptoms (Weller et al., 2008) or the causes (Thomas et al., 2009). Third, the studies come from different countries, which may bias the results. It is possible that some expressions, such as ajayu, as well as some beliefs about the origin of susto and the elements used in the rituals for the call of the lost soul are more specific to a particular region and not generalizable to all Latin America. For example, the research of Thomas et al. (2009) focused on the analysis of the capture of the soul by supernatural entities in the Trinitario society (Bolivia), and we do not know whether the belief in these supernatural entities is extended to other regions. To clarify this aspect, it would be necessary to conduct research on susto in different regions of Latin America and compare the results. Finally, when comparing descriptions with the DSM-5, there may be a bias towards consistency, which may have led to misinterpretations.

All things considered, and keeping the limitations in mind, this is the first study that compares current definitions of susto between different research fields taking into account descriptions of its symptoms, causes, and traditional treatments. This study finds that the syndromic types provided about susto in DSM-5 (APA, 2013) concur with the symptomatology described in articles from different fields. However, there is the constant presence of other sets of symptoms; especially those that involve linguistic metaphors, which should make researchers consider defining susto as an idiom of distress, in addition to the current definition as a cultural explanation/perceived cause.

Conclusion

This research has focused on comparison of the definition of susto in the DSM-5 (APA, 2013) with its descriptions from other research areas, such as anthropology, sociology and ethnology. Diverse definitions have been found; hence the DSM-5 definition is not universally accepted. Analysis of the symptoms has, on the one hand, corroborated the three DSM-5 syndromic subtypes of susto, related to depression, somatic disorder and PTSD, although other subtypes related to panic disorder/GAD and infections have also been found. In addition, we have collected other symptoms that appear as cultural expressions for distress, which leads us to think that susto may also be an idiom of distress. Future research will need to analyze and compare the definitions and descriptions of susto in different regions of Latin America to clarify this question.

Biography

Fanny Beatriz Martínez-Radl started her academic career studying psychology at the Goethe University of Frankfurt and the University of Santiago de Compostela (Spain) concurrently, and graduated as Diplom Psychologin and Licenciada respectively. She worked for several years in Germany in clinical branch of psychology. Afterwards she researched culture-bound syndromes in Bolivia for 3 years and is currently writing her PhD at the Goethe University of Frankfurt. At the same time, she is finishing her master's degree in general health psychology at the University of Santiago de Compostela (Spain).

Devon Emerson Hinton, MD, PhD, is an anthropologist and psychiatrist, and a professor of psychiatry at Massachusetts General Hospital and in the Department of Global Health and Social Medicine, Harvard Medical School. He has researched in cross-cultural perspective idioms of distress, somatic symptoms, sleep paralysis, panic attacks, panic disorder, and PTSD, with a focus on Southeast Asian populations, particularly Cambodian and Vietnamese refugees, as well as Latino populations. He has written extensively on culturally sensitive cognitive behavioral therapy. He is fluent in several languages including Cambodian, Spanish, and Thai.

Ulrich Stangier, PhD, is Professor for Clinical Psychology and Psychotherapy, University of Frankfurt. His main research areas are cognitive therapy for depression and social anxiety, and the cultural adaptation of psychological treatments for refugees.