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“Thinking too much”: A systematic review of a common idiom of distress
Open accessAbstract
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.”
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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“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]
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“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]
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“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]
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“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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“However, the review’s authors caution to equate “thinking too much” with psychiatric disorders as classified in international diagnostic systems, given the potential for idioms of distress to range from non-pathological states to disordered states, their heterogeneous presentation, and for the idiom to communicate social ruptures and processes [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]
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“These characteristics might have an influence in the establishment of relationship and trust on the study outcomes”
From Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: Systematic review and meta-analysis (2019) · cites this paper as Kaiser et al., 2015
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“Metaphors such as 'low spirits' 3 or 'sadness and dejection' 4 have been used throughout human history to describe the experience of depression.”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [4]
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“A meta-analysis examining the association of these concepts with ICD/DSM depression categories observed that persons endorsing these idioms had 7·55 greater odds than others of meeting the ICD/DSM depression criteria. 4”
From Time for united action on depression: a Lancet–World Psychiatric Association Commission (2022) · cites this paper as [4]
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The Place of Inter-Rater Reliability in Qualitative Research: An Empirical Study
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The Illness Narratives: Suffering, Healing, and the Human Condition
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Time for united action on depression: a Lancet–World Psychiatric Association Commission
Herrman, H., Patel, V., Kieling, C., Berk, M., Buchweitz, C., Cuijpers, P., Furukawa, T. A., Kessler, R. C., Kohrt, B. A., Maj, M., et al. (2022) · The Lancet · doi:10.1016/s0140-6736(21)02141-3 · Cited by 1,104
Self-citationHow is depression experienced around the world? A systematic review of qualitative literature
Haroz, E. E., Ritchey, M., Bass, J. K., Kohrt, B. A., Augustinavicius, J., Michalopoulos, L., Burkey, M. D., & Bolton, P. (2017) · Social Science & Medicine · doi:10.1016/j.socscimed.2016.12.030 · Cited by 292
Self-citationTurrini, G., Purgato, M., Acarturk, C., Anttila, M., Au, T., Ballette, F., Bird, M., Carswell, K., Churchill, R., Cuijpers, P., et al. (2019) · Epidemiology and Psychiatric Sciences · doi:10.1017/s2045796019000027 · Cited by 258
“These characteristics might have an influence in the establishment of relationship and trust on the study outcomes (Kaiser et al., 2015; Haroz et al., 2017).”
BackgroundKohrt, B. A., Luitel, N. P., Acharya, P., & Jordans, M. J. D. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-0768-y · Cited by 250
Self-citationPurgato, M., Gastaldon, C., Papola, D., van Ommeren, M., Barbui, C., & Tol, W. A. (2018) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011849.pub2 · Cited by 215
Metadata
- 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.
- Venue
- Social Science & Medicine
- Publisher
- Elsevier BV
- Published
- 2015-12
- Volume
- 147
- Pages
- 170-183
- ISSN
- 0277-9536 (ISSN-L)
- 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
- bronze
- doi.org
- 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
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › 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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