International Society for Traumatic Stress Studies

Diversity and Trauma Cultural Expressions of Distress Following Trauma: Ataques de Nervios

Posted 31 March 2015 in StressPoints by Erika Felix, PhD and Sonia Rubens, PhD

Mental health screening and intervention efforts following a traumatic event must attend to issues of cultural diversity by being sensitive to cultural expressions of distress. Ataques de nervios (attacks of the nerves; hereafter, ataques) are a cultural idiom of distress common among many Latino groups (Guarnaccia et al., 2010).

Ataques are often precipitated by actual or threatened loss, grief, or family conflicts (Febo San Miguel et al., 2006; Guarnaccia et al. 1993). Prior research in Puerto Rico found a 9 percent prevalence rate of ataques in youth age 4-17 years, and a 26 percent rate in a clinical sample (Guarnaccia et al., 2005).

Another study comparing Puerto Rican children (5-13 years) in Puerto Rico and in New York found prevalence rates of 5 percent and 4 percent respectively (Lopez et al., 2009). Among adults, an epidemiological study found a 7-15 percent prevalence rate across different groups of Latino adults residing in the US (Guarnaccia et al., 2010), whereas a clinical sample in the US found a 70 percent prevalence rate (Liebowitz et al., 1994).

Description of Ataques de Nervios

Ataques include a number of internalizing and externalizing symptoms (Febo San Miguel et al., 2006; Guarnaccia et al., 1993, 2005). These include (1) emotional expressions, such as crying spells, screaming, and feeling anguish, anxious, or depressed; (2) physical sensations, such as trembling, chest pain, heart palpitations, breathlessness, headaches, stomachaches, weakness, loss of sensation in part of the body, convulsion, and seizures; (3) changes in feelings of consciousness, such as fainting, amnesia, dizziness, increased thoughts and memories, and possibly hallucinations or a sense of “going crazy”; and (4) actions, such as suicidal ideation or attempts and self-injurious behavior (Guarnaccia et al., 1993). If a person loses a sense of consciousness, they often regain it quickly and may not remember the ataque (Gaurnaccia et al., 1993). Ataques often occur in the presence of others, and brings forth social support from the afflicted person’s social network (Guarnaccia et al., 1993).

Ataques are comorbid with a range of psychiatric disorders in both adolescent and adult studies (Lopez et al., 2009), particularly anxiety and depressive disorders (Guarnaccia et al. 1993, 2005; Rubens, Felix, Vernberg, & Canino, in press), but also substance use disorders (Guarnaccia et al., 2010), somatic complaints (Lopez, Ramirez, Guarnaccia, Canino, & Bird, 2011), disruptive behavior disorders (Guarnaccia et al., 2005), and global impairment in functioning (Lopez et al., 2009). Ataques can be distinguished from panic disorder due to the clear precipitating event (Lewis-Fern├índez et al., 2002). Guarnaccia and colleagues (1993) note that ataques “could not be treated as simply a culturally shaped version of a specific psychiatric disorder.” (p. 161)

Ataques Following Disaster

Although ataques can occur after a variety of distressing events, clinicians working with Latino populations should consider screening for ataques following disaster. A disaster, with its acute, intense disruption to normal life; threat or loss of life and property; potential for missing loved ones; and increased familial stress during the recovery period can trigger episodes of ataques among Latino survivors (Guarnaccia et al., 1993, Felix, You, & Canino, in press).

Indeed, in a representative sample of adults following a mudslide disaster in Puerto Rico in 1985, a prevalence rate of 13.8 percent for ataques was found, making it one of the most common syndromes found post-disaster in this group (Guarnaccia et al., 1993). Along with disaster exposure, characteristics of peer and family relationships can confer additional risk for ataques (Felix et al., in press; Rubens et al., in press).

For example, hurricane exposure was significantly related to a lifetime experience of an ataque among adolescents who did not report associating with violent peers; but, for those that did, hurricane exposure did not increase risk (Rubens et al., in press). Another study found that for children, hurricane exposure directly increased risk for ataques; whereas for adolescents, the increased risk for ataques post-disaster was indirect, through the impact of the disaster on the parent-child relationship and quality of discipline (Felix et al., in press).

Given the prevalence of ataques among Latino populations, and the association between disaster exposure and ataques, mental health professionals should assess for culturally influenced expressions of distress and contextual factors to improve the cultural sensitivity of post-disaster interventions.

About the Authors

Erika Felix, PhD, is an assistant professor in the Department of Counseling, Clinical and School Psychology at the University of California, Santa Barbara (UCSB). Her research focuses on promoting adaptive recovery for youth following disaster or terrorism, youth victimization and its consequences, and research and evaluation to improve community-based services.

Sonia Rubens, PhD, is a postdoctoral fellow at Dana-Farber Cancer Institute and Boston Children’s Hospital. She received her doctorate in clinical child psychology from the University of Kansas. Sonia’s research focuses on promoting resilience among diverse youth exposed to acute and chronic trauma, including identifying factors that may protect against or exacerbate the relation between exposure to trauma and mental health outcomes in youth.


Febo San Miguel, V.E., Guarnaccia, P.J., Shrout, P.E., Lewis-Fernandez, R., Canino, G., Ramirez, R.R. (2006). A quantitative analysis of Ataques de Nervios in Puerto Rico: Further examination of a cultural syndrome. Hispanic Journal of Behavioral Sciences, 28, 313-330.

Felix, E.D., You, S., & Canino, G. (In Press). Family influences on the relationship between hurricane exposure and Ataques de Nervios. Journal of Child and Family Studies.

Guarnaccia, P.J., Canino, G., Rubio-Stipec, M., & Bravo, M. (1993). The prevalence of Ataques de Nervios in the Puerto Rico disaster study: The role of culture in psychiatric epidemiology. The Journal of Nervous and Mental Disease, 181, 157-165.

Guarnaccia, P.J., Lewis-Fernandez, R., Pincay, I.M., Shrout, P., Guo, J., Torres, M., Canino, G., & Alegria, M. (2010). Ataques de Nervios as a marker of social and psychiatric vulnerability: Results from the NLAAS. International Journal of Social Psychiatry, 56, 298-309.

Guarnaccia, P.J., Martinez, I., Ramirez, R., & Canino, G. (2005). Are Ataques de Nervios in Puerto Rican children associated with psychiatric disorder? Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1184-1192.

Lewis-Fernandez, R., Guarnaccia, P., Martinez, I.E., Salman, E., Schmidt, A. & Liebowitz, M. (2002). Compartive phenomenology of Ataques de Nervios, panic attacks, and panic disorder. Cultural, Medical Psychiatry, 26, 199-223.

Liebowitz, M.R., Salman, E., Jusino, C.M., Garfinkel, R., Street, L., Cardenas, D.L., et al., (1994). Ataques de Nervios and panic disorder. American Journal of Psychiatry, 151, 871-875.

Lopez, I., Ramirez, R., Guarnaccia, P., Canino, G., & Bird, H. (2011). Ataques de Nervios and somatic complaints among Island and mainland Puerto Rican children. CNS Neuroscience & Therapeutics, 17, 158-166.

Lopez, I., Rivera, F., Ramirez, R., Guarnaccia, P.J., Canino, G., & Bird, H. (2009). Ataques de Nervios and their psychiatric correlates in Puerto Rican children from two different contexts. Journal of Nervous and Mental Disease, 197, 923-929.

Rubens, S.L., Felix, E.D., Vernberg, E.M., & Canino, G. (In Press). The role of peers in the relation between hurricane exposure and Ataques de Nervios in Puerto Rican adolescents. Psychological Trauma: Theory, Research, Practice, and Policy.doi: 10.1037/a0036701