Are suicide attempts by young Latinas a cultural idiom of distress?

Abstract

The high rates of suicide attempts among adolescent Hispanic females in the United States have been well established by epidemiological and clinical studies. In this paper, we review the research history of Latina suicide attempts and their characteristics. Then we apply multifaceted conceptual and empirical criteria found in the anthropological and psychiatric literature about cultural idioms of distress to the suicide attempts of young Latinas. We contrast the suicide-attempt phenomenon to the well-known ataque de nervios and propose that the phenomenon may reflect a developmental or cultural variant of the ataque. The attempt-as-idiom proposition is intended to invite discussion that can deepen our understanding of the cultural roots of the suicide attempts and their possible designation as cultural idiom. Establishing the meaning of suicide attempts within a cultural perspective can assist psychological and psychiatric research and clinical interventions.

Epidemiological surveys of United States’ high school students have established that adolescent Hispanic females, or Latinas,¹ report the highest rates of suicide ideation, planning and attempts of any youth group, ranging from one in five Latinas to one in seven (U.S. Centers for Disease Control and Prevention [CDC], 1996, 2008; Zayas, Lester, Cabassa, & Fortuna, 2005). Since the CDC initiated its Youth Risk Behavior Surveillance System (YRBSS) in 1991, its ten biennial YRBSS surveys have consistently shown that young Latinas in the 14- to 18-year-old group are from 1.5 to 2 times as likely as non-Hispanic White or African American females or males to consider, plan or attempt suicide. Other national and regional surveys, which incorporate data from younger and older youth in school and community settings, have reported similar findings during the same two-decade span (Garcia, Skay, Sieving, Naughton, & Bearinger, 2008; Garofalo, Wolf, Wissow, Woods, & Goodman, 1999; Peña et al., 2008; Substance Abuse and Mental Health Services Administration, 2003). These surveys add verity to smaller studies and anecdotal reports that young Latinas are at higher risk for suicidal behaviors than other females in their age group, grade level, neighbor hoods, and communities (e.g., Friedman, Asnis, Boeck, & Difiore, 1987; Ng, 1996; Roberts & Chen, 1995; Robles, 1995; Smith, Mercy, & Warren, 1985; Vega, Gil, Zimmerman, & Warheit, 1993). The higher rates do not reflect the influence of just one Hispanic group; the phenomenon has been documented across most Hispanic groups, including Cuban, Dominican, Mexican, Nicaraguan, Ecuadoran, and other Latin American heritages (Ng, 1996; Roberts & Chen, 1995; Robles, 1995; Vega et al., 1993).

In spite of the relatively stable findings from year to year and study to study, one question remains: Why do Latinas attempt suicide so often despite very low rates of death by suicide? In this paper, we explore the possibility that suicide attempts by U.S. Latinas represent a cultural idiom of distress. We have found that descriptions of suicide attempts by young Latinas have characteristics similar to those of ataques de nervios (nervous attacks), widely recognized idioms of distress experienced by Caribbean, Mexican, and Central American women (Davis & Low, 1989). To date, the relationship between ataques de nervios and suicidal behavior remains unclear. Suicidal gestures frequently accompany an ataque, suggesting the Latina teen suicide attempts may have roots in this idiom of distress. Suicide attempts among young Latinas may represent an adolescent expression of the ataque, or it may represent a cultural variant. To develop a comparative description of suicide attempts and ataques, we critically examine the current body of literature on each of these behaviors, drawing attention to the parallels between them. In doing so, we hope to add conceptual clarity to the suicide attempts of young Latinas and high light the need for further research to inform diagnostic and clinical practice.

Suicide attempts of U.S. Latinas

The earliest accounts of suicide attempts by Hispanic immigrants in the U.S. were by Trautman (1961a, 1961b), who identified the “suicidal fit” among young adult women of Puerto Rican heritage living in the South Bronx of New York City in the late 1950s. Working in the emergency room of Lincoln Hospital, Trautman became interested in the apparently frequent appearance of young Hispanic women, mostly Puerto Rican, who had attempted suicide. Trautman described these attempts as impulsive escapes from stressful situations, often manifested by ingesting pills or household cleansers. He found that a key characteristic of the suicide attempt was a strong association with disturbances in family relations, typically with a spouse or mother. The women in Trautman’s sample reported that they did not recall having thoughts of death at the time of the attempt, and in fact, most women were not aware of their thoughts during the attempt. On psychiatric evaluation, the women showed little evidence of psychotic symptomatology. Trautman surmised that the stress of immigration and subsequent acculturation contributed significantly to the “suicidal fit.”

After Trautman’s initial reports, there was little in the literature on this phenomenon until the late 1980s and then again in the 1990s when research and empirical analyses of Latina suicidality reemerged (Friedman et al., 1987; Razin et al., 1999). These later reports indicated that suicide attempts were not limited to Puerto Ricans, but occurred across many Latino groups adding empirical evidence that Latinas were at higher risk than other youth. Reports on suicidal behavior revealed an increasing number of cases among adolescent females of Cuban, Dominican, Mexican, Nicaraguan, and other Hispanic sub-groups (Ng, 1996; Roberts & Chen, 1995; Robles, 1995; Vega et al., 1993b).

To some extent, this changing profile reflected the shifting demographic trends in the U.S. Hispanic population. Since 1990, the number of Hispanics has increased from about 21 million to 33 million, a 57% growth compared to 11% for the total U.S. population (U.S. Bureau of the Census, 2000). This growth has been accompanied by an expansion in Hispanic national-origin diversity. In 1980, for instance, Puerto Ricans in New York City comprised over 61% of the Hispanic population, and Dominicans only 9%. In 1990, Puerto Ricans receded to less than 50% and Dominicans rose to more than 20% of all New York City Hispanics. Large increases in the numbers of Colombians, Ecuadorans, Mexicans, and other Central and South Americans have also taken place in New York City.

Although demographic shifts help to account for broad changes in patterns of suicidal behavior over time, the persistent elevated rate of suicide attempts among Latina youth has led researchers to look for differences in the underlying psychology of Hispanic girls. The general adolescent suicide literature demonstrates that psychological risk factors most often found among female suicide attempters include depression and dysthymic disorders, histories of physical and sexual abuse, low self-esteem, poor coping strategies, hopelessness, and deficient anger management (Campbell, Milling, Laughlin, & Bush, 1993; Donaldson, Spirito, & Farnett, 2000; Goldston et al., 2001; Rotheram-Borus, 1990; Spirito, Sterling, Donaldson, & Arrigan, 1996; Wagner & Cohen, 1994; Wagner, Cole, & Schwartzman, 1995). Clinicians serving Hispanic women have found similar psychological characteristics, including problems in the regulation of emotions and impulsivity that are known to be related to suicidality (Brent et al., 1997; Corruble, Damy, & Guelfi, 1999; Mann, Oquendo, Underwood, & Arango, 1999). Studies indicated that suicidal adolescents—both Hispanic and non- Hispanic—were more likely to use social withdrawal, wishful thinking, and blame as key coping strategies when compared to non-attempting adolescents who were more likely to engage in problem-solving and behaviors that drew social support to them (Spirito et al., 1996; Turner, Kaplan, Zayas, & Ross, 2000).

This scholarship suggests that the psychological profiles between Latina adolescents and other teenagers are similar, and thus, cannot account for significant differences in rates of suicide attempts. Zayas (1987, 1989) theorized that socio- economic disadvantage, traditional gender-role socialization, acculturation, ethnic identity, and adolescent-parental conflict converged to influence the suicidal behavior of adolescent Hispanic females. Research suggests that family-related stresses seem to play a greater role in the onset of suicidal behavior than is seen among non-Hispanic adolescents (Berne, 1983; Kobus & Reyes, 2000; Ng, 1996; Razin et al., 1991; Zayas, 1987; Zayas, Gulbas, Fedoravicius, & Cabassa, 2010; Zimmerman & Zayas, 1995). This scholarship touches on the complex relation ship among individual psychology, developmental trajectory, and socio-cultural milieu in shaping the etiology of suicidal behavior among Latina teens. To gain deeper insight into this complexity, we posit that Latina teen suicide attempts may represent a cultural idiom of distress; that is, that the suicide attempt represents a way of articulating emotional suffering in culturally meaningful ways.

Definitions of cultural idioms of distress in the literature

To advance our thesis that suicide attempts of Latinas represent a cultural idiom of distress, we first turn to a broader literature that has focused on how different cultures categorize locally-defined abnormal behaviors. In this area, researchers have developed a number of terms to identify and characterize such behaviors, ranging from explanatory models and folk illnesses to culture-bound syndromes and idioms of distress (Lewis-Fernández, Guarnaccia, & Ruiz, 2009). We restrict this discussion to an examination of the terms culture-bound syndromes and idioms of distress due to the fact that these concepts are used interchangeably, often resulting in conceptual confusion. Our aim is to clarify the subtle, yet significant, differences between these concepts, and to outline how suicidal behavior can be appropriately investigated as an idiom of distress.

Research on culture-bound syndromes emerged as a way to describe the perceived uniqueness of specific illness experiences within given cultural groups (Hahn, 1996). The concept is used most widely “to describe forms of psychopathology on whose emergence, manifestation, or course local cultural factors exert an especially strong influence” (Lewis-Fernandez et al., 2009, p. 2519). The DSM-IV (American Psychiatric Association, 2000) defines culture-bound syndromes as those “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category” (p. 844). The aberrant behaviors are usually linked to specific societies or cultures, and are folk diagnostic categories. They give coherence and meaning to the repetition of troubling experiences.

The incorporation of culture-bound syndromes within the DSM-IV represents a significant interpretive development—the acknowledgement that culture shapes the manifestation of psychological illness (Rebhun, 2004)—and the concept remains important to the disciplines of cultural psychology and psychiatry. At the same time, the proliferation of research on culture-bound syndromes has stimulated debate over terminology and theoretical issues, particularly regarding the concept of culture (Lewis-Fernández et al., 2009). To date, there is little consensus across disciplines regarding the types of illnesses or syndromes that should be classified as culture-bound syndromes. Some scholars, particularly anthropologists, have questioned the conceptual and pragmatic utility of the concept because it reifies culture as a bounded, localized, and discrete system (Hahn, 1996; Lewis-Fernández et al., 2009; Rebhun, 2004), an approach to culture that has been abandoned in anthropology in recent decades (Ware & Kleinman, 1992). Conceptualizations of culture have developed considerably and have “given way to a view of cultural worlds as temporary, ever-changing constructions that emerge from interactions between individuals, communities, and larger ideologies and institutional practices” (Kirmayer, 2001, p. 22). As concepts of culture have become more nuanced, much of the research on culture-bound syndromes has revealed that many of the so-called syndromes are not syndromes at all, but rather local explanatory models for the etiological origins of illness that could be used to convey a variety of different psychosomatic experiences (Kirmayer & Sartorius, 2007).

To move beyond the conceptual shortcomings associated with the term “culture-bound syndromes,” many scholars have redirected their focus onto cultural responses to various psychosocial problems. Mark Nichter (1981) advocated such a shift in his seminal piece on idioms of distress, arguing that many illnesses did not represent distinct entities with recognizable signs and symptoms, but rather local reactions to certain kinds of distress. Rather than constituting illness complexes or discrete syndromes per se, idioms of distress are conceptually useful for investigating cultural factors shaping individual responses to distress (whether originating in illness or psychosocial issues) and revealing what distress conveys about the broader socio-cultural world order (Kirmayer & Sartorius, 2007). In this sense, an idiom of distress may overlap with a given illness complex, but the aim of analysis is directed more broadly to understand how the experiential nature of distress is interpreted through the lens of culture, and thus becomes interpreted as illness in the first place. As Kleinman points out, “The peculiar expression of misery as depression, anxiety, backache or fear of being possessed results from the particular cultural apparatus of language, perceptual schema, and symbolic categories which constitute distress in one or other mode” (1991, p. 70).

In this way, an idiom of distress comprises a broad spectrum of emotional, physical, and cultural responses to embodied suffering (Hollan, 2004). More importantly, idioms of distress communicate something: they indicate to others in the individual’s social world that something is amiss. Although this may function to assuage distress—for example, by releasing that individual from prescribed social responsibilities (Dabbagh, 2005)—the expression of an idiom does not always result in positive social outcomes. As Hollan (2004) puts it,

There has been a tendency in the anthropological, psychiatric, and psychoanalytic literature, I think, to exaggerate the ease with which idioms of distress are deployed and the success of those using or enacting them to alleviate or transform their symptoms of suffering … The use and enactment of idioms of distress to cope with suffering is often mobilized by feelings of fear, anxiety, ambivalence, and uncertainty, but their use and enactment may engender such feelings as well. (pp. 75–76)

By placing individual experiences of distress into a more nuanced social context, we can address the deeper significance of how particular idioms are deployed, as well as compare the idiomatic nature of various responses of distress, such as suicide attempts. We assert that suicide attempts among young Latinas may be better understood as an idiom of distress because to fully understand the phenomenon necessitates a focus on the specific meanings, intentions, experiences, and sociocultural influences associated with the attempt. The potential for such analysis is great for it may help to reveal how the particular suffering felt by the young Latina led her to communicate that distress through suicidal behavior rather than to enact a different idiom. Ultimately, this calls for an in-depth investigation of the distribution of the behaviors and meanings used by individuals in the expression of their distress. To this end, we turn to a more direct comparison of the idiomatic nature of ataques and suicide attempts among young Latinas, following the guidelines established by Guarnaccia and Rogler (1999) and Lewis-Fernández and colleagues (2009) to carry out such an exercise. This exercise stipulates that the fundamental elements that shape idioms of distress include the phenomenological characteristics of distress, the broader social context, and the presence of co-morbid psychiatric disorders.

The idiomatic nature of ataques de nervios and suicide attempts

Suicidal gestures sometimes configure prominently in ataques, underscoring the importance of the relationship between ataques and suicidal behavior within Hispanic populations. Ataques de nervios (nervous attacks) are widely recognized and experienced by individuals throughout Latin America, commonly representing responses to interpersonal crises (Guarnaccia, Rivera, Franco, & Neighbors, 1996). Suicide attempts, on the other hand, are not bound to any specific geographic region. However, Trautmann (1961b) did note that the typical suicide attempt among Latinas is sudden, unplanned, and often occurs at home with someone nearby. The attempt is usually carried out through non-lethal methods, such as the ingestion of medicine or slicing a body part with a sharp instrument. Many attempters recall feeling ambivalent about the underlying goal of the attempt—it is rarely to kill oneself, and instead reflects a broader desire to escape. Nevertheless, the attempt is still described by Latinas as a suicide attempt (intento de suicidio) (Zayas et al., 2010).² Because suicide attempts sometimes occur alongside ataques, this suggests that suicidality and ataques de nervios may be linked. To date, this relationship remains incompletely understood. We now examine the extent to which suicide attempts and ataques represent conceptually distinct idioms by looking at differences in phenomenology, the social context, and relation to psychopathology.

The phenomenology of ataques and suicide attempts

A phenomenological description of an idiom focuses on the subjective experience of distress in order to uncover the essential structure of that experience across individuals (Ayres, Kavanaugh, & Knafl, 2003; Guarnaccia & Rogler, 1999). Guarnaccia and colleagues (1996) have found four dimensions that appear salient to the experience of an ataque: emotional expressions, alterations in consciousness, bodily sensations, and actions. Emotional expressions associated with ataques are varied and may include nervousness, fear, feeling a sense of loss of control, sadness, hopelessness, anger, irritability, and suicidal thoughts. Altered states of consciousness range from perceptions of unreality to loss of consciousness, usually through fainting. Bodily sensations encompass blurred vision, shaking, and trembling; and often, sufferers of ataques become verbally or physically aggressive, sometimes engaging in screaming or crying fits (Guarnaccia et al., 1996). Suicidal behavior may sometimes present during a severe ataque (Guarnaccia, Lewis-Fernández, & Marano, 2003).

This patterning is supported by studies in other Hispanic sub-groups, including Mexicans (Finkler 1989), Guatemalans (Low, 1989), and Latinos living in the United States (Jenkins 1988). It should be noted, however, that there is some regional variation in experiences of ataques, most notably in the expression of particular bodily sensations. For example, Baer and colleagues (2003) found that vomiting, diarrhea, and stomach pains are indicative of ataques among Latinos living in the United States, but are not experienced among individuals living in Mexico or Guatemala. Ataques may also be accompanied by sleeplessness, headaches, cold sweats, and weight loss. This suggests that the degree of somatization in ataques may vary greatly.

Similar to ataques, there seems to be consistency in the phenomenological characteristics of suicidal behavior among young Latinas, particularly across time. Latinas in the mid-20th century and those in the early 21st century (Trautman, 1961a, 1961b; Zayas et al., 2010) show remarkable similarity in descriptions of their experiences of attempting suicide. Like ataques, the phenomenology of suicide attempts can be characterized according to emotional expressions, alterations in consciousness, bodily sensations and actions. Of particular importance is the fact that a number of girls express overwhelming, often contradictory, emotions at the time of the attempt. Many attempters describe an urgent need to escape—usually due to the intense, rush of emotions that wash over them—and the attempt is often viewed as a way to actualize that need. Feelings range from intense anger or rage, to hopelessness and despair, sadness, feelings of being trapped, and intense guilt. Yet at the same time, girls report feelings of numbness and ambivalence. During the attempt, they are feeling everything and nothing at once (Zayas et al., 2010). Young Latinas also describe the experience of the attempt in a way that suggests altered states of consciousness, possibly fugue-like moments. This is often accompanied by bodily sensations that include trembling, shaking, and physical numbness. In addition to the actual attempt, young Latinas report both internalizing and externalizing behaviors, ranging from intense crying fits to screaming to the destruction of personal property. The consistency in their similarities and in the telling of the subjective experience by a cultural minority group suggests the idiomatic nature of the expression.

Evidently, phenomenological similarities exist between ataques and suicide attempts, including feelings of anger, hopelessness, sadness, altered states of consciousness, trembling, shaking, crying fits, and aggressive behavior. Yet decisions to engage in suicidal behavior are marked by overwhelming feelings of being trapped and needing to escape. This difference can be understood more clearly upon an investigation of the different social contexts between sufferers of ataques and young Latinas who attempt suicide.

The social context of ataques and suicide attempts

Idioms of distress communicate suffering in culturally salient ways, thus requiring an examination of the broader socio-cultural context within which specific idioms manifest (Nichter, 2010). The majority of research on ataques de nervios focuses on the significance of this idiom within Hispanics from the Caribbean, namely Puerto Ricans (Guarnaccia, 1993; Guarnaccia et al., 2003) and Dominicans (Liebowitz et al., 1994). Yet ataques have been reported in regions throughout Latin America, including Mexico, El Salvador, and Argentina (Davis & Low, 1989; Molina & Luxardo, 2004; Norris et al., 2001). Although the prevalence of this idiom spans a significant geographic region, the demographic profile of women who have experienced an ataque reveals striking continuity. Sufferers are typically over the age of 45, unemployed, divorced or separated, with little more than a high-school education (Guarnaccia & Rogler, 1999; Guarnaccia, Canino, Rubio-Stipec, & Bravo, 1993; Lewis-Fernández et al., 2010).

The likelihood of having an ataque is strongly correlated to the experience of specific life events. Marital disruption and the death of a family member are particularly significant life events that may trigger ataques. Recent research reveals that an individual is at higher risk of suffering an ataque after exposure to interpersonal trauma, and trauma that occurs during childhood has been shown to be highly related to the experience of an ataque later in life (Lewis-Fernández et al., 2010). In general, it appears that ataques stem from a sudden disruption in the person’s familial, personal, or social network, compounded with a sociocultural context of social oppression and disadvantage with few social means to express powerlessness, anger and dysphoria (Guarnaccia & Farias, 1988). Salgado de Snyder and colleagues (2000) note that the greater presence of ataques among low-income women sheds light on the interpersonal struggles within an environment of “strict gender role differentiation, [wherein women] additionally face many responsibilities and obligations in a context of poverty and scarcity” (p. 454). Ataques de nervios among women appear to be a coping strategy that reduces the demands and expectations that family and spouses put on them, thus providing an opportunity for women to regain their psychological, emotional and social equilibrium (Finerman, 1989; Guarnaccia & Farias, 1988; Salgado de Snyder et al., 2000).

In comparison to ataques, the high rates of suicide attempts among adolescents in the United States seem to manifest predominantly among Hispanic females. While the first known publication about the phenomenon appeared in 1960, clinical observations (Zayas, 1987, 1989) and subsequent small-scale studies in the 1980s continued to suggest that rates of suicidal behavior were higher-than-average among Latinas. Starting in the early 1990s, this was confirmed by epidemiological surveys. The high rates, frequency, and consistent patterning suggest a unique context of suicide attempts in the experience of young Latinas in the United States.

Suicidal behavior in Latina adolescents often arises after experience of a painful or distressing event in the family. Research indicates that a disruption in family structure, due to migration, divorce, or death—or by intense conflicts among family members—may trigger suicidal behavior (Gulbas et al., 2011). Additionally, many attempters report being a witness to or victim of physical or sexual assault, often committed by a parent or extended kin member (see Zayas et al., 2010). This particular event, or trigger, should be understood as part of a context of similar events that insult the girl’s emotional status. With persistent patterns of instability, tension, conflicts, and victimization, the Latina feels vulnerable, feeling misunderstood, trivialized, unsupported, and unprotected, and possibly violated physically, psychologically, and emotionally. A trigger event that reminds her of or revives her emotional agony may evoke suicidal behavior at a moment when she was primed by an emotionally fragile state.

This suggests that interpersonal dynamics between the adolescent attempter and her parents figure prominently in the onset of suicidal behavior. We find that the intense, often prolonged, teenager–parent conflict stems from recurrent patterns of disagreements about autonomy-centered issues (e.g., having a boyfriend, parental discovery of the adolescent’s sexual activity, recurrent conflicts with parents, especially the mother). Research shows that the suicide attempts among Latinas seem to originate during a key developmental life transition: the adolescent struggle between autonomy and relatedness or connection to parents and family in which she feels disempowered, misunderstood, excluded, and relegated because of her gender to an inferior social position (Zayas et al., 2010). Adolescence is a period in human development of rapid physical, cognitive, and emotional growth and maturation, an epoch that is challenging not just for the adolescent but the adults around her (Blos, 1967; Erikson, 1950; Steinberg, 1990, 2007). Early adolescence—corresponding to the years between 12 and 15—is a time of major psychological and emotional awakening and physical maturation. The typical period for Latina suicide attempts is between the ages of 14 and 16 years (Peña et al., 2008), suggesting that the period of transition that accompanies adolescence plays a salient role in the emergence of suicidal behavior, particularly because it may be at odds with both the familial and broader American cultural prescriptions of female development.

Adolescence, as experienced by the attempter, reflects the contradictory nature of the lives of Latina youth growing up in the United States. Their daily lives embody contradictions imposed on them by U.S. norms and expectations, on one hand, and those of their Hispanic parents, on the other hand. For example, in many Hispanic families, the emphasis on restrictive, authoritarian parenting, especially for females, may clash with the emphasis on autonomy and individuation that is so prevalent in mainstream U.S. culture (Lester, 2007). Among Latina teen suicide attempters, the experience of marginalization and alienation is central: young women may be caught between two or more life-ways that are not congruous and finds little help from those around her in negotiating the resultant tensions. Suicide attempts may communicate their reaction to this conflicting experience and their need to escape that existence. In the aftermath of the suicide attempt, the message may be received and understood by those closest to the girl. Although many attempters express fear that they will be stigmatized as “crazy” in the school system and among their American peers, many attempters describe the attempt as an event that brought their families together, opening up channels of communication that were previously shut down (Zayas et al., 2010).

The similarity between the social history of ataques de nervios and Latina teen suicide attempts is noteworthy. In both cases, perceived threats to the integrity of the woman’s social world, especially that of her family, appear to be central. Yet, the interpersonal stress of the intense, often prolonged, adolescent-parent conflict may be the principal area of distinction between adolescent suicide attempters and sufferers of ataques. Whereas a woman suffers an ataque within her prescribed social role as mother or wife, the young suicide attempter experiences her distress in her role as daughter and woman.

Relationship to psychiatric disorder

Idioms of distress do not necessarily imply underlying psychopathology, although co-morbidity with psychiatric disorders is not uncommon (Guarnaccia & Rogler, 1999). Ataques de nervios have been demonstrated to co-occur with depression, anxiety and other mental disorders. Although ataques appear to have some overlap with panic disorders and dissociative disorders not otherwise specified, a direct one- to-one correspondence has not been found (Lewis-Fernández et al., 2010; Liebowitz et al., 1994).

Similarly, anxiety, depression, and problems in emotional regulation are often found among the girls who make suicide attempts. More research is needed to answer the co-morbidity question of Latina suicide attempts by developing a fuller symptom picture of the suicide attempt experience and the diagnostic qualities of the young Latina attempters.

Reconsidering the relationship between ataques and Latina teen suicide attempts

Framing Latina teen suicide attempts as an idiom of distress, reveals similarities to ataques de nervios (see Table 1). Given that suicidal gestures sometimes present during an ataque, this suggests that suicide attempts may have roots in idioms of distress that are seen mostly in women from societies with strict gender roles and obligations, who occupy low social status, and have very little access to sources of power and advancement or expression of their dysphoria (Guarnaccia & Farias, 1988; Salgado de Snyder et al., 2000). The most severe cases of ataques, during which a sufferer may attempt suicide, seem to emerge from the desolation or hopelessness experienced after a major disruption to the family unit (Guarnaccia et al., 2003). Research indicates that threats to the integrity of family life strongly influence suicidality among Hispanics (Ungemack & Guarnaccia, 1998). This reveals a particularly noteworthy connection: younger women suffering ataques also experience higher rates of suicidal behavior (Fortuna, Perez, Canino, Sribney, & Alegria, 2007; Ungemack & Guarnaccia, 1998).

Table 1.

A comparison of key idiomatic elements in ataque de nervios and suicide attempts

Idiom	Ataque de nervios	Suicide attempts
Phenomenology	Anger, hopelessness, nervousness, fear, feeling a loss of control, crying fits, possible suicidal gestures	Anger, hopelessness, sadness, feelings of being trapped/needing to escape, guilt, numbness
Social context	Ubiquitous across Latin America, primarily occurs among adult women	Ubiquitous across Latin America, higher rates in the US, primarily adolescents
Social history	Disruption in familial or social network, interpersonal trauma	Disruption in familial or social network, interpersonal trauma (sexual, physical abuse)
Relationship to psychiatric diagnosis	Overlap with panic disorders and dissociative disorders not otherwise specified	Possible overlap with depression, and anxiety disorder

Like sufferers of ataques, suicidal behavior seems to be most prevalent among individuals with few means for expressing their feelings of anger, frustration, depression, dysphoria, and desperation (Guarnaccia & Farias, 1988; Salgado de Snyder et al., 2000). Across time, we see that the suicide attempt is often part of an emotionally deteriorating process that weakens the young Latina’s ability to deal with the intense, protracted interpersonal stresses that derive from family conflict, disruption, or fracture. The suicidal behavior indicates a strong desire to end recurrent and painful family trauma. These family-related conflicts and tensions trigger non-lethal, impulsive acts of self-injury. Viewing suicide attempts as a cultural idiom of distress, sheds light on how this behavior is culturally meaningful.

Of particular importance is the fact that suicide attempts seem to manifest at a higher rate among Latina adolescents, whereas ataques are usually experienced by adult women. Adolescence represents the onset of emotional and behavioral autonomy, as a young woman shifts cathexis from family to others. This transition is met with a parallel shift in the social realm, in which social structures, particularly schools, reward youth with much more autonomous functioning. The psychological experience of adolescence parallels the American cultural emphasis on individualism, enhancing the young Latina’s sense of discontinuity between herself and her family. A young Latina may find that she is ill-equipped to deal with the resultant sense of fragmentation, and the suicide attempt expresses her predicament.

Ultimately, the emotional suffering caused by such distress is experienced and interpreted in distinct ways. While the manifestation of an ataque may enable a Hispanic woman to cope with the suffering caused by perceived threats to her social world, suicidal behavior may intensify or worsen emotional distress. Recurring cycles of abuse and parent–adolescent conflict may encourage future suicide attempts, particularly if the dynamics that contributed to the onset of suicidal behavior are not resolved through the enactment of the idiom (Gulbas et al., 2011). If we are to conclude that suicide attempts are an idiom of distress—and we encourage colleagues to engage in a critical dialogue to advance this proposition—then we need to refine our designation of this particular idiom. It is possible that suicide attempts are a variant of ataques de nervios, or perhaps a developmental variation of this particular idiom. Further research is warranted, particularly regarding the possibility that suicide attempts may act as a precursor to suffering from ataques de nervios during adulthood and later life.

Conclusion

We have argued that some suicide attempts among U.S. Hispanic female adolescents may represent a cultural idiom of distress, and more specifically, a developmental or cultural variant of the widely recognized idiom of ataque de nervios. Suicide attempts are recurrent among young females, primarily, girls who occupy a marginal position in mainstream U.S. society and within their cultural group. Like many idioms of distress, suicide attempts are a response to social and interpersonal turmoil, in which the person or her important social networks—family, marriage, children, friendships—are threatened. Recognizing suicidal behavior of young Hispanic females as an idiom of distress can provide conceptual clarity and a vantage point from which to better understand suicidal behavior. Distinguishing between an idiom of distress and a psychiatric disorder (including a major depression that can result in death by suicide) can improve diagnostic assessment and inform how clinicians approach the young Latina and her treatment.

Biographies

Luis H. Zayas, PhD, is dean of the School of Social Work at The University of Texas at Austin. Dr. Zayas focuses on human behavior, parenting, and family functioning. He has studied the childrearing values of low-income Hispanic mothers, effects of ethnicity on the psychiatric diagnostic process, and more recently how undocumented parents’ deportation affects the mental health of citizen-children.

Lauren E. Gulbas, PhD, is a Research Assistant Professor in the Department of Anthropology at Dartmouth College. She also holds an adjunct position in the Women’s and Gender Studies Program. Her research focuses on mental health issues, primarily within Hispanic populations in Latin America and the United States.