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Cited by 287Mental Health Treatment and AccessMental Health and PsychiatryCultural Competency in Health Care

“Thinking too much”: a systematic review of a common idiom of distress

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Kaiser, Bonnie N., Haroz, Emily E., Kohrt, Brandon A., Bolton, Paul A., Bass, Judith K., Hinton, Devon E.·2015·Social Science & Medicine
DOI 10.1016/j.socscimed.2015.10.044PMC PMC4689615
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Abstract

Idioms of distress communicate suffering via reference to shared ethnopsychologies, and better understanding of idioms of distress can contribute to effective clinical and public health communication. This systematic review is a qualitative synthesis of "thinking too much" idioms globally, to determine their applicability and variability across cultures. We searched eight databases and retained publications if they included empirical quantitative, qualitative, or mixed-methods research regarding a "thinking too much" idiom and were in English. In total, 138 publications from 1979 to 2014 met inclusion criteria. We examined the descriptive epidemiology, phenomenology, etiology, and course of "thinking too much" idioms and compared them to psychiatric constructs. "Thinking too much" idioms typically reference ruminative, intrusive, and anxious thoughts and result in a range of perceived complications, physical and mental illnesses, or even death. These idioms appear to have variable overlap with common psychiatric constructs, including depression, anxiety, and PTSD. However, "thinking too much" idioms reflect aspects of experience, distress, and social positioning not captured by psychiatric diagnoses and often show wide within-cultural variation, in addition to between-cultural differences. Taken together, these findings suggest that "thinking too much" should not be interpreted as a gloss for psychiatric disorder nor assumed to be a unitary symptom or syndrome within a culture. We suggest five key ways in which engagement with "thinking too much" idioms can improve global mental health research and interventions: it (1) incorporates a key idiom of distress into measurement and screening to improve validity of efforts at identifying those in need of services and tracking treatment outcomes; (2) facilitates exploration of ethnopsychology in order to bolster cultural appropriateness of interventions; (3) strengthens public health communication to encourage engagement in treatment; (4) reduces stigma by enhancing understanding, promoting treatment-seeking, and avoiding unintentionally contributing to stigmatization; and (5) identifies a key locally salient treatment target.

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  • A recent systematic review found that 'thinking too much' has often been compared to depression, anxiety, PTSD and psychological distress more broadly, but as a term is stigmatized less.

    “A recent systematic review found that “thinking too much” has often been compared to depression, anxiety, PTSD and psychological distress more broadly, but as a term is stigmatized less.”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [11]

    Results, Aim 3 reports that “thinking too much” was frequently compared with depression, anxiety, PTSD, and general psychological distress. Results, Aim 4 says it was considered less stigmatizing than certain mental disorders in some settings, but was often stigmatized in others. The claim overgeneralizes the stigma finding. Page numbers are not provided in our copy. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • A systematic review found that "thinking too much" is a common idiom of distress that has variable overlap with common mental disorders, but also suggests aspects of experience, distress, and social positioning not captured by psychiatric diagnoses.

    “For example, a systematic review found that “thinking too much” is a common idiom of distress that has variable overlap with common mental disorders, but also suggests aspects of experience, distress, and social positioning not captured by psychiatric diagnoses [11].”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [11]

    Experimental — accuracy not yet measured

  • A recent systematic review has focused on 'thinking too much' as an important idiom of distress in multiple populations.

    “a recent systematic review has focused on ‘thinking too much’ as an important idiom of distress in multiple populations [11].”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [11]

  • 'Thinking too much' has been found to have overlap with common mental disorders such as depression, anxiety, and PTSD, but should not be interpreted as a gloss for psychiatric disorder as it captures aspects of experience, distress, and social positioning not captured by psychiatric diagnoses.

    “It has been found to have overlap with common mental disorders such as depression, anxiety, and PTSD, but should not be interpreted as a gloss for psychiatric disorder as it captures aspects of experience, distress, and social positioning not captured by psychiatric diagnoses [11].”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [11]

  • A wide range of perceived causes of 'thinking too much' has been reported, including past adverse events and ongoing stressors such as economic and structural barriers to meeting basic needs.

    “A wide range of perceived causes has been reported, including past adverse events and ongoing stressors such as economic and structural barriers to meeting basic needs.”

    From Mental health and psychosocial support for South Sudanese refugees in northern Uganda: a needs and resource assessment (2016) · cites this paper as [11]

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Authors
Kaiser, B. N., Haroz, E. E., Kohrt, B. A., Bolton, P. A., Bass, J. K., & Hinton, D. E.
Affiliations
  • Emory University (US)
  • Johns Hopkins University (US)
  • Duke University (US)
  • Harvard University (US)
Corresponding author
Kaiser, Bonnie N.
ORCID
Venue
Social Science & Medicine
Publisher
Elsevier BV
Published
2015-12
Volume
147
Pages
170-183
ISSN
0277-9536 (ISSN-L)
DOI
10.1016/j.socscimed.2015.10.044
PMC
PMC4689615
OpenAlex
W1763471514
Cited by
287
References
145
Citations by year
2026: 16 · 2025: 22 · 2024: 18 · 2023: 42 · 2022: 45 · 2021: 37 · 2020: 34 · 2019: 34 · 2018: 23 · 2017: 10 · 2016: 6
FWCI
2.02
Type
journal article
Language
en
Open access
Licence
Locations
  • Social Science & Medicine (acceptedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • RePEc: Research Papers in Economics (submittedVersion)
  • DukeSpace (Duke University) (submittedVersion, cc-by-nc-nd)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • National Science Foundation (0234618)
  • NIMH (K01MH104310-01)
Topics
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
  • Social Sciences › Sociology and Political Science › Cultural Competency in Health Care
Keywords
idioms of distress, ethnopsychology, ruminative thoughts, intrusive thoughts, anxiety, depression, post-traumatic stress disorder, cross-cultural variation, global mental health, mental health screening, stigma reduction, treatment seeking
MeSH terms
Anxiety, Culture, Depression, Ethnopsychology, Humans, Language, Mental Health, Stress, Psychological, Thinking

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