Abstract
Brain fag was originally described as a culture-bound syndrome among West African students. The term “brain fag” literally means “brain fatigue.” Available literature indicates that brain fag symptoms usually present in formal academic settings when African students are required to transit to a reliance on written literature (as opposed to more traditional oral forms of information transmission) and to adapt to westernized, individualistic systems of education that, at times, oppose the values of relatively collectivistic African societies. Based on detailed observation of two typical and two nontypical cases of brain fag, the authors suggest that the syndrome may not be solely related to tensions in the academic sphere, but may function more generally as an expression of psychological distress that results from societal pressures that exceed the coping capacity of the individual. The brain fag symptoms, including lack of concentration, sensations of internal heat in the head and body, heaviness, and multiple somatic complaints, may constitute a defensive process which helps prevent a full-fledged decompensation.
Keywords
Introduction
The processes of coping and adjusting to everyday hassles and stresses, as well as the challenges posed by rapid social change, economic recession, educational demands, technological advances, and globalization, call for innovative and constantly evolving responses from individuals and communities (Bhugra & Mastrogianni, 2004; Bolger, DeLongis, Kessler, & Schilling, 1989; Brod, 1984; Fisher, 1996; Harper, 2000; Selye, 1974, 1976). For many West Africans, approaches to coping and adjustment are influenced by distinctive cultural, spiritual or religious ideas and practices. One example of a culture-informed response to stress that emerged in the 20th century is the brain fag syndrome.
Brain fag is an expression of psychological distress that was first described in Nigeria by Raymond Prince (1959, 1960, 1962, 1989). Locally believed to be a result of brain fatigue, the main features of brain fag include: unpleasant feelings in the head (pain, burning, crawling sensations, vacancy), visual disturbances (dimness of vision, pain in the eyes, and tearing), cognitive impairment (inability to grasp the meaning of written and sometimes spoken words, inability to concentrate, poor retention), and a variety of other symptoms such as weakness, dizziness, writer’s cramp and migrating pains (Prince, 1959, 1960, 1989). Notably, all these symptoms occur or are exacerbated while reading or, occasionally, while listening to lectures. Onset is quite gradual, with somatic symptoms in the head commencing before intellectual impairment. The patient notices the burning in the head while reading, and later symptoms occur with intellectual activity of any kind. Finally, the symptoms may be present continually and the patient may withdraw from intellectual activity altogether (Prince, 1989). These symptoms also have been documented by Minde (1974), Morakinyo (1985), and Ola and Igbokwe (2011). Ola, Morakinyo, and Adewuya (2009) further elaborated that the diagnosis of brain fag syndrome should be made based not only on the symptoms but also on the presence of two associated conditions: (a) unpleasant sensations around the head/neck and (b) difficulty studying. 1
Though initially observed among Yoruba, Igbo, and other ethnic groups in southern Nigeria (Prince, 1959, 1960), brain fag has since been identified in several other countries including Uganda (German & Arya, 1969; German & Assael, 1971; Minde, 1974), Liberia (Thebaund & Rigamer, 1976; Wintrob, 1971), the Ivory Coast (Lehmann, 1972; Parin, 1984), and Malawi (Peltzer, 1987). Symptoms of brain fag have also been reported among African students studying in Britain (N. Malleson, 1973, personal communication cited in Minde, 1974). Brain fag has been reported to be more common among males than females (Boroffka & Marinho, 1963; German & Arya, 1969; German, Assael, & Muhangi, 1970; Neki & Marinho, 1968; Prince, 1960), but Ola et al. (2009) suggest that this male preponderance may simply have reflected the lower numbers of females in postsecondary educational institutions.
Brain fag has been described as a somatization reaction to studying (Prince, 1960). Somatization may constitute a defensive process in which psychological distress is expressed in somatic complaints. In line with Nichter’s (1981) observation that somatization symptoms may function as “idioms of distress” that are understandable within the culture of manifestation, Ebigbo and Ihezue (1981a, 1981b, 1981c; see also Ebigbo, 1996) and Obiako and Ebigbo (1982) explored the local meaning of some of the somatic complaints that accompany brain fag. For example, sensations of crawling and heat in the head and body, difficulty sleeping, headaches, and other somatic complaints are not exclusive to brain fag but rather occur in other social contexts and psychiatric syndromes. It is important to note that the diagnosis of somatization should be made after a proper medical examination has been carried out in order to rule out a biological basis for the somatic complaints.
This paper aims to update the literature on brain fag syndrome by describing the clinical manifestations of its symptoms in cases seen several decades after it was first described in Nigeria. We consider the etiology of brain fag based in part on a review of cases manifesting outside academic settings. Finally, we discuss therapeutic interventions that may be applied in treating brain fag.
Methods
This paper summarizes the findings of a multiple-case study. All four cases presented here were subjected to institutional review board (IRB) and federal wide assurance (FWA) ethical clearance by the ethics committee of the UNTH. Details have been disguised to protect patient anonymity.
Setting and Sample
This study was based in the Department of Psychological Medicine of the University of Nigeria Teaching Hospital (UNTH) in Ituku/Ozalla Enugu, Nigeria. The UNTH serves as a tertiary-level referral centre for hospitals and health facilities in the southeastern states of Nigeria. 2 A total of 273 cases were referred to the Psychological Medicine Unit of the UNTH from December 2011 to May 2012. During this period, 10 cases were referred to the Psychological Medicine Clinic from the university’s counseling unit for students, of which eight had been diagnosed with brain fag. Within the same period four other cases of brain fag were referred from other units of the hospital, making a total of 12 cases. Brain fag cases (n = 12) comprised 3% of all referrals to the Psychological Medicine Clinic but 80% of referrals from the students’ counseling unit. While these data may not reflect the true prevalence of brain fag in the general population, they do indicate that the syndrome persists both in academic and nonacademic settings. Two of the cases reported in this paper were referred from the counseling committee, and the other two, a carpenter and a pastor, were seen within the same period at the same clinic but referred from other consultants within the teaching hospital. Although two of the four cases we discuss involve medical students, cases from other disciplines were also seen.
Measures and Procedure
Each client was evaluated by a clinician familiar with the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). In addition, several psychometric instruments were used to assess clients: the Test Anxiety Inventory (TAI), Eysenck Personality Questionnaire (EPQ), Symptom Checklist (SCL-90), Neurotic Illness Questionnaire (NIQ), Enugu Somatization Scale (ESS), and the Cosmogram. All of the psychometric tests are norm-referenced.
The Test Anxiety Inventory (TAI) was developed by Spielberger (1980) and was validated for use in Nigeria by Omoluabi (1993). The test measures three components of test anxiety: worry, emotionality, and anxiety. The Eysenck Personality Questionnaire (EPQ), developed by Eysenck and Eysenck (1975), was validated for use in Nigeria by Omoluabi (1997). The EPQ measures four personality domains: neuroticism, psychoticism, extraversion, and introversion. The Symptom Checklist-90 (SCL-90) measures 10 dimensions of psychological distresses: somatization, obsessive-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism, and neuroticism (Derogatis, Lipman, & Covi, 1977). The Neurotic Illness Questionnaire was developed by Janakiramaiah and Kolkar (1981) to measure somatization, anxiety, and depression. It was validated in Nigeria by Ebigbo, Janakiramaiah, and Kumaraswamy (1989). The Enugu Somatization Scale (ESS) was developed in Nigeria by Ebigbo (1982) to measure somatic complaints indicative of psychiatric disturbance. It consists of two sections assessing head and body symptoms. Items are scored on dichotomous responses. The Cosmogram (Figure 1) is an assessment method based on harmony restoration theory (HRT), which asserts that, in many African societies, health or ill health is conceptualized as a state of harmony or disharmony in one’s world of relationships (cosmos; Ebigbo, 1995; Ebigbo, Elekwachi, Eze, Nweze, & Innocent, 2013: Ebigbo, Oluka, Ezenwa, Obidigbo, & Okwaraji, 1995). According to the theory, functional relationships within one’s cosmos foster health while dysfunctional ones foster ill health. Relationships are divided into three areas: endocosm (mind and body relationship), mesocosm (relationship with significant others), and exocosm (relationship with God, gods, deities, customs, religion, etc.). The cosmogram is used to map out functional and dysfunctional relationships, thereby facilitating a treatment plan. The primary aim of the tool is to reveal the area(s) where there is lack of harmony in order to restore it. This may be achieved through using functional relationships in a salutogenic effort to foster well-being (Anthonowsky, 1993) or by repairing existing dysfunctional (pathogenic) relationships to restore harmony. Thus, in a broader sense, harmony restoration provides a framework within which a variety of psychotherapeutic interventions can be applied.
The cosmogram: A method of mapping relationships in harmony restoration therapy. The cosmogram is a clinical method of mapping functional and dysfunctional relationships based on harmony restoration theory (HRT; Ebigbo et al., 1995). The aim of psychotherapy is then to restore harmony by repairing dysfunctional relationships and/or using functional relationships to foster well-being.
When using a cosmogram in a clinical setting, all the relationships that are important to the individual are mapped out through an in-depth psychological interview that attends to common values in African societies, for example, harmony or discord in relationships with immediate and extended family members as well as the individual’s religion or belief system. At the end of the interview, which may also involve eliciting information from some key relations of the client, a fairly developed picture of the individual’s relational world should emerge. The cosmogram may also be helpful in screening for somatic complaints of psychological origin, as well as paranoid complaints; for example, the client may attribute symptoms to the covetous gaze or evil eye of another community member. The clinician may explore who would want to curse the client or wish him dead, or who has charmed or bewitched him.
Case examples
Case 1
Mr. A. was a 19-year-old male medical student referred to the clinic by one of his supervisors. He described his main complaints in the following terms: Recently I have been having poor concentration, weak memory and heat sensation in my head. This has led to having low scores in my exams. When I noticed that this has persisted, I went home to my parents. My mother then quickly took me to a prayer house where they gave me some prayers and they told me that some people, who did not want me to be relevant (helpful) to my parents, were responsible for my low performance in school.
Mr. A. reported that about a year earlier he had been performing reasonably well in school exams. The problem started with the approaching of his second professional examinations, which required extensive reading. He was the second son of three male siblings. His other siblings were also students and doing well. He described his relationship with his mother and father as cordial. Both parents were well educated. As the second child in his family, he felt he ought to be successful in his academic work in order to help the family. More exploration showed he had heard frightful stories about how tough the mock second professional exams were. He was therefore afraid to look at all the questions at a glance during exams, and would instead cover all questions other than the one he was currently answering. In the process of doing this, his mind would go totally blank (“blackout”). When results came out, he had performed poorly. At this point he became suspicious of what was happening to him and returned home.
Mr. A’s medical examination was normal. The clinical presentation was consistent with the description of brain fag in the DSM-IV-TR glossary. His TAI results indicated a tendency to worry about examinations, although this was not significant enough to affect overall emotional and behavioral response. His SCL-90 scores were only significant for an elevation on the Paranoid Ideation subscale. The EPQ showed elevations on introversion and neuroticism. The cosmogram indicated that Mr. A had good relationships with his two siblings and parents but lacked confidence in himself, was fearful about the outcome of the exams and lacked skills to express his feelings. Assertiveness training to build up his self-esteem was indicated.
The client was provided with information on brain fag syndrome. His medical examination results were also used as evidence to show him that he was medically fit. He was told to lower his high expectations on himself, and to read during his peak concentration period (established through conversation with the client during the sessions). He gained confidence in himself through cognitive restructuring and assertiveness assignments, which began by having him list 10 positive statements about himself and reading them to himself in the morning and at night before he slept. He strengthened his functional relationships with his parents and siblings. On a practical level he was encouraged to increase his contact with his parents and siblings through more frequent telephone calls. The client was able to continue his academic work and reported general improvement and high motivation to pass his examinations, based on the reading plan made during therapy.
In this case there was perceived family pressure to succeed on the part of the client. This was attributed to the fact that his parents were senior and successful scholars with successful children—the client’s two brothers were also students in the university and doing well. When he heard stories of how difficult the examinations usually were, he became fearful and lacked confidence. The need to succeed and the perceived challenge became overwhelming. Cognitive behavioral interventions were sufficient to reduce symptoms and improve functioning so that he was able to continue his studies without interruption.
Case 2
Mr. B. was a 22-year-old, single, Nigerian medical student. He was referred to our clinic by the head of his program who had requested he withdraw from medical school to attend to his ailment. The client complained of continuous fatigue, and loss of intellectual power, interest in reading books, and fluency in speech (difficulties with pronunciation). Furthermore, he reported loss of memory and concentration, heat sensations all over his head and body, pain in the heart, and that, “Sometimes I feel my brain has become void.”
Mr. B’s ailment started about four years earlier while preparing for the entrance exam to medical school. Although he had a number of symptoms, he managed to gain admission into the university. After passing the exams his symptoms intensified, making him sometimes go blank and “lose the power of reasoning.”
He was from a monogamous Catholic family. His father was about 60 years old and his mother was about 40 and both were farmers. He had six siblings (three male and three female) and was the third born. Socioeconomically, he described his family as “poor but surviving.” There was no history of mental illness in his immediate or extended family. Academically, he had been among the best students in his class all through primary, secondary, and tertiary levels. He had his first sexual experience when he was 18 but currently did not have a girlfriend because he consciously deprived himself of certain pleasures (such as playing football and having sex) for religious reasons. He felt that denying himself these pleasures would serve as a form of mortification that might make God hear his cry about his ailment and come to his rescue.
His personal explanation of his condition was as follows: [E]ach time I eat in a dream, the problem escalates. I think it is spiritual and I suspect some of my envious relatives in the village are responsible. Even when I take medications and get better, once I eat in the dream, the problem will come back.
The client said that he was the only hope his family had because he was the only one among his siblings studying at university. The client’s elder brother refused to go to school, and his parents then used all the money they had to start up a business for him. Unfortunately, the business collapsed and his brother was now pursuing vocational skills. His elder sister had just graduated from a school for the hearing-impaired, and his younger sister was struggling to complete secondary school. His parents and siblings looked up to him and this made the client resolve to be industrious and perform well in his studies.
The ESS test indicated a high level of somatic complaints related to anxiety and goal frustration. On the SCL-90, the client had significantly elevated scores on 10 subscales of the test, indicating serious psychological distress; on the NIQ, he had high scores on all three domains of somatization, anxiety, and depression. The EPQ indicated an introverted personality with psychotic and neurotic thoughts. The cosmogram suggested that he lacked confidence in himself, and that he was fearful of relatives who he felt might be involved in some evil machination against him. The cosmogram also showed he had a functional relationship with his God.
This client came from a poor family that invested much in him because he was perceived as their last hope in terms of social mobility. As a result, the client decided to succeed academically in order not to fail his parents. He had low self-esteem, which made him feel unable to cope with the barrage of academic requirements and led him to judge that he was unable to meet familial and educational expectations. Brain fag, in this case, appeared to function as a kind of avoidance reaction or a face-saving outlet that relieved him of the heavy burden imposed by his overwhelming situation. The cosmogram identified the problem to be mainly located in the client’s relationship with himself. Although he felt his problem might have come from his relatives, he reported good relationships with each of them.
Treatment for this client was aimed at building self-esteem, providing an atmosphere of unconditional positive regard, empathy, and genuineness. This encouraged him to initiate his own deep internal exploration to identify ways of cognitively and behaviorally reducing the overwhelming burden of expectations he had internalized. Cognitive therapy was also aimed at restructuring faulty thinking that the client’s relatives might be remotely influencing his life. He developed a daily reading timetable, based on his peak periods of concentration. This was aimed at discouraging long hours of reading with low concentration, which might have been reinforcing feelings of poor memory capacity. Based on the suggested idiomatic interpretation of heat in the head as a result of goal frustration (Ebigbo, 1986), the client was encouraged to set more realistic goals. These included reading less than he was accustomed to and accepting a grade of “B” instead of an “A.” The client also was referred to a psychiatrist who felt that the client was depressed and prescribed antidepressant medication, which resulted in improvement.
At the sixth session, the client reported better psychological well-being. He had started playing football once again, which he had denied himself for many years. He was observed to be better groomed and no longer complained of excessive heat. He was ready to reapply to return to medical school to continue his studies.
Case 3
Mr. C. was a 25-year-old male, single, Igbo Nigerian, who by profession was a carpenter. He was referred to our clinic by a medical doctor after he presented with several psychosomatic complaints. About three years ago, the client started noticing some crawling sensations around his brain and hands. He also felt like hot water had been poured into his brain. He had feelings that his eyes expanded and contracted. When these symptoms started he began to feel easily distracted from his work and became less articulate. Before going anywhere, he would have to calculate his route at home. Around the time the symptoms started, he noticed that he could no longer talk and work at the same time, something he could do easily before. As the years passed he felt his brain was becoming weak, especially during mental work involving calculation. These symptoms made him become easily irritable, self-conscious, and more paranoid. When he started noticing these symptoms he received a diagnosis of malaria and typhoid and was treated with only marginal relief from the symptoms.
Mr. C was born in an African country outside Nigeria and spent most of his childhood there. He came from a monogamous Christian family of seven siblings, of which he was the fifth. He described his family as poor. According to the client, his father, also an artisan, was an alcoholic and highly irresponsible; he frequently wasted all his money drinking in the bar and would sometimes even sleep there.
Mr. C’s primary education was cut short due to financial constraints. Consequently he was sent to various “masters” as hired help, where he worked in exchange for food and shelter. His childhood was difficult; as household servant, he had to take on more responsibilities than he could carry. At age 17, he came back to Nigeria with his sister, where he trained as a trader and later as a carpenter.
The client had a cordial relationship with his mother but dysfunctional relationships with his father and siblings. Though he had not seen his father and elder brothers for over 10 years because they were still outside Nigeria, he felt it was his duty to go and visit them abroad and, if possible, bring them back to Nigeria. To achieve this, he felt he ought to first build a house in the village where they all could stay and save enough money to travel outside the country to escort them back. These have not been easy goals to achieve because his business as a carpenter has not flourished.
Given Mr. C’s symptoms, DSM-IV-TR indicated brain fag. He was assessed using only the Enugu Somatization Scale translated into Igbo because of his level of education. The scale showed a high level of somatization, which is indicative of a high level of psychological distress. The cosmogram showed he was deeply unhappy with himself and that he had been unable to save up enough money to build a house and travel outside the country to bring back his father and siblings. Moreover, even though he hoped to bring his family members back, he described having a troubled relationship with them. In particular, his tendency to become easily irritable and suspicious affected his relationships with others.
The cosmogram revealed a problematic relationship between Mr. C and his father. The client felt that it was his responsibility to bring his father and elder siblings back to Nigeria and had been struggling to save money to this end, but was unable to achieve this goal because his business as a carpenter had not flourished. For the past 3 years he had tried to build a house in the village without success. It was within these 3 years that he developed the symptoms of brain fag. In this case, Mr. C’s symptoms can be traced more to interpersonal and financial difficulties than to a failure to adjust to an educational environment. Indeed, he had only received informal training in carpentry and was not studying at the time of onset. This raises questions about the etiology of brain fag and its relationship with the academic milieu.
The core therapeutic process with Mr. C involved first explaining what brain fag was, and then helping him to realize that he had imposed heavy burdens on himself that exceeded his capacity to meet them (cognitive restructuring). A warm therapeutic atmosphere, characterized by empathy, genuineness, and unconditional positive regard, was cultivated in order to enable the client to express the burdens he experienced. Mr. C was then encouraged to address these burdens using a problem-solving approach (de Shazer, 1985), which was deemed appropriate considering his level of education. The problem-solving approach consisted of taking up a problem and finding a way or ways of solving it or creating alternative attainable goals, especially when the goals were overwhelming. Today, Mr. C has resumed contact with his parents through letters and telephone calls. This brought new information that their economic condition has improved, lessening the burden on him. Therapy is currently ongoing, and includes an emphasis on restoring harmony in his relationships with his parents and siblings, among other aims.
Case 4
Mr. D is a 47-year-old Igbo Nigerian. He is married and is a Protestant clergyman. He recently had an appendectomy, and, although postsurgery recovery appeared to progress normally, he continued presenting some psychosomatic complaints to his doctor. This prompted a referral from the Surgical Out-Patient (SOP) Department to the Department of Medicine first and then to the Department of Psychological Medicine.
Mr. D presented with the following complaints: I have constant and severe headache. For some time now I have been feeling very dizzy. I have a feeling that something is blocking my throat. My shoulder is as heavy as if I were carrying a heavy load. I recently have been having poor concentration while preparing for messages to preach in church.
Mr. D comes from a polygamous family; his father had two wives. The client’s mother gave birth to him and a sister, and his step-mother gave birth to five children (two male and three female). Both his father and the step-mother are now dead. While they were alive, the client got along with them well, and he continues to have a very cordial relationship with his mother.
Early in life—around age 15—Mr. D was sent to learn a trade. His master did not treat him fairly. However, when he was due to set out on his own, his master suggested they go into partnership, to which he agreed. This partnership continued until he was 30 years old. The business was not profitable and he had to struggle to survive. It was during this difficult time that he experienced a calling to become a pastor.
The client had five children, all of whom were female. Although he desired male children, his wife had reached menopause and the adoption process for a male child that he started had not yielded a result. He could not remarry because of religious restrictions. Financially the client was unable to take care of his children because his work as a clergyman did not bring in enough income. There were many things he desired to accomplish, including building his own house, driving a car, training his children in good schools, and building his own church. At the time of consultation, these goals had become overwhelming. The fear of not having a male child to bear his name—an important tradition in Igbo culture—added to his feelings of incapacitation.
An analysis of Mr. D’s symptoms based on the DSM-IV-TR indicated a diagnosis of brain fag. The Enugu Somatization Scale (ESS), Symptom Distress Checklist, and Eysenck Personality Questionnaire indicated psychological distress expressed as somatization, anxiety, depression, and neuroticism. The cosmogram showed that he was unhappy with himself because things had not turned out the way he had wanted; he did not have a male child and his poor income was not enough to meet his family needs. His relationship to his wife and children appeared to have grown tense, affected by this feeling of failure.
Mr. D had experienced a number of salient stressors over the course of his life. At a young age, he went to learn a trade that supported him through most of his youth. However, when he formed a partnership with his former boss, life became very difficult. His current occupation as a clergyman also failed to bring enough income into the family, putting financial strain on him and his wife. Mr. D’s inability to produce a male child was an additional source of distress, as male children are highly valued in his society as bearers of the family name. Given his age of 47 years, a time of mid-life transition (Baron, 1992; Levinson, 1986), he felt overwhelmed by his failure to meet perceived expectations. Taken together, these facts compose a picture of overwhelming self-imposed pressure as the source of Mr. D’s brain fag.
With regard to treatment, we recommended assertiveness training to increase self-esteem, followed by cognitive behavioral therapy with an emphasis on gaining perspective and setting realizable goals. We have also begun efforts at harmony restoration between Mr. D and his wife, who will be crucial in helping him reduce his overwhelming self-imposed expectations.
Discussion
In all four cases discussed here, patients presented with classical brain fag syndrome as defined in the DSM-IV-TR. Moreover, while these cases developed both within and outside formal educational settings, all participants described intense pressure associated with expectations of their family, society, and themselves to achieve a high level of success and improve their economic and social standing. These expectations were perceived as overwhelming, or exceeding the individuals’ capacity to cope, and were imposed both externally by the demands of challenging environments and internally by the individuals who set very high standards for themselves. These unrealistic standards and the failure to meet them appeared to lead inadvertently to demobilization of the instrument of goal achievement (i.e. the brain). Loss of concentration, weak memory, loss of interest in learning and, very often, somatization, anxiety, and depression ensued.
In light of these commonalities, we propose that brain fag functions as a culturally shaped and socially legitimate coping response to an overwhelming situation. These cases illustrate the ability of the human mind to prevent total derailment or collapse by enabling a temporary withdrawal from achievement pressure through the adoption of a socially acceptable sick role. In contrast with previous scholarship, we further assert that this mechanism may function in contexts other than formal education. In Case 3, for example, the client was a carpenter, but likewise experienced a lack of concentration and “demobilization” of the brain typical of brain fag in students. In Case 4, the client was a pastor who lacked the concentration to preach, disrupting his ability to achieve the many goals he had set for himself, and which had become overwhelming. Based on these cases, we posit that the distinctive psychological condition of brain fag is not that of being a student unprepared for the rigors of academic life, but rather being overwhelmed by responsibilities and expectations of high achievement—academic or other—that may contribute to the material success and social status of the family.
Our findings may also help to elaborate the characteristics of brain fag as it presents most commonly today. Several of our cases showed symptoms of anxiety and depression, which led to a diagnosis of depression by the psychiatrist in Case 2. This is concordant with the DSM-IV-TR criteria, which note that symptoms of brain fag may resemble depression or anxiety. Our findings also support earlier evidence that when brain fag symptoms are treated with antianxiety or antidepressant drugs, patients may recover (Neki & Marihno, 1968; Prince, 1989).
The cases presented further confirm that brain fag entails multiple somatic symptoms, usually around the head, including crawling sensations in the head or body, a lump in the throat, a feeling of heaviness in the head or body, and dizziness. These symptoms have been previously described by Ebigbo (1982), who observed that mentally ill patients in Nigeria and elsewhere in West Africa often present with psychosomatic complaints, regardless of their diagnosis and whether or not their illness is very acute. Prince (1989) has pointed out that in the practice of psychiatry in Africa, diagnoses are often constituted by a combination of somatic complaints and other symptoms. For example, a patient who presents somatic complaints accompanied by tearfulness or suicidal ideas may be diagnosed as suffering from depression; alternatively, burning and crawling sensations, if accompanied by palpitations and tension, may be diagnosed as anxiety. Prince’s (1989) work also suggests that somatic symptoms often precede the development of full-fledged disorders; symptoms such as burning and crawling may function as early signs of distress, while if distressing circumstances persist or are excessive, other types of symptoms (depression, hallucinations, etc.) emerge from the common somatic complaint matrix (Ebigbo & Ihezue, 1981b). Thus, the somatic complaints that accompany brain fag may function as early signals of distress in the development of the syndrome, and recognizing and attending to these signals when they appear may lead to better treatment outcomes.
Our results also point to personality factors that may play a role in the development of brain fag. The self-esteem of the patients in our cases was low, making them feel unworthy or incapable of mastering the new demanding or adjustment situation. In Cases 2 and 4, EPQ results also highlighted neuroticism and mild psychoticism. The authors’ interpretation of these findings is that unstable personality characteristics like neuroticism and psychoticism may predispose an individual to developing brain fag syndrome. This hypothesis is also supported by the work of Morakinyo (1980a, 1980b, 1985), who found that students suffering from brain fag tended to score high in neuroticism on the Eysenck Personality Inventory. Morakinyo’s participants also showed a high achievement orientation, came from economically deprived social backgrounds, and frequently suffered from sleep deprivation, relying on substances like amphetamines or coffee to sustain themselves. At this point, it is important to note that individuals with unstable personality traits, for example, neuroticism, appear to be more likely to fail when confronted with demanding situations (Morakinyo, 1980b); this may represent one mechanism through which neuroticism contributes to the development of brain fag, although further research is needed on this subject.
Regarding causal attribution, participants in Cases 1, 2, and 3 attributed their symptoms, in part, to supernatural influences or malignant magic. In many parts of Africa, there exists a widespread belief that both physical and mental illnesses originate from various external causes: the breach of taboos or customs, disturbances in social relations, hostile ancestral spirits, spirit possession, evil machination and intrusion of objects, evil eye, sorcery, natural causes, and affliction by God or gods (Baasher, 1975). Moreover, given a context of traditional friendliness to strangers and high suspicion of close family relations (Ebigbo, 2001; Ebigbo & Onuora, 1987), as soon as the feelings of anxiety, depression, or somatization are experienced, a Nigerian/West African may begin to look for who, among their close family members, has caused them. These beliefs undoubtedly influence the manifestation of brain fag as well as individuals’ efforts to seek help. For example, although the parents in Case 1 were educated, they believed in the power of jealous people and sent the student to a prayer house priest for help. In Case 2, the patient’s dreams of eating made his problem escalate and fueled his belief that his envious relatives were after him spiritually. The notion that eating in dreams is dangerous is a relatively popular cultural belief among Nigerians; Ilechukwu (1985) has pointed out that this belief cuts across gender and social class lines in Nigeria, and that those who feel closer to “traditional” culture see eating in dreams as dangerous to life or health. Ebigbo and Anyaegbuna (1989) have also noted that food is an important dream content among psychiatrically ill patients in Nigeria. Likewise it is seen as a source of initiation into the “pathological” mermaid cult known as “Ogbanje” (Ebigbo & Anyaegbuna, 1989).
Yet while beliefs of this nature are widespread in the broader cultural context under study, their frequency and association here with brain fag are noteworthy as they may pose challenges to diagnosis and treatment. For example, an inexperienced practitioner might easily misdiagnose brain fag syndrome as paranoia based on the fears and accusations the symptoms often raise. An experienced practitioner, however, should recognize that fears of supernatural intervention by jealous friends or relatives is common in the presentation of brain fag and does not necessarily represent a discrete disorder. This is consistent with earlier research by Guiness (1992), who named fear of envy and bewitchment as one of five factors linked to the etiology of brain fag.
In addition to its roots in “traditional” belief systems, brain fag may also reflect the rapid influx of Western culture and values in West Africa. The contemporary Nigerian social and cultural context is rapidly changing. This is occasioned by globalization, urbanization, and modernization, creating a need for acculturation. In a developing country like Nigeria, many grapple with the desire to attain better social, political, and economic well-being, leading to rural–urban migration and a consequent sense of upheaval. In order to better understand the implications of these shifts in the field of psychiatry, Ebigbo and Ihezue (1981d) have categorized hospital patients into three groups: (a) the traditional type of patient tends to have been raised in the village and to have lived his or her formative years in a rural environment, and has migrated to the city relatively late in life. The person’s cognitive system is analogical, magical, and pictorial. Prior to being admitted to the psychiatric hospital, the person had effectively used the skills of rural, traditional healers in meeting his or her treatment needs. (b) The Western type has often been born and raised in an urban environment. The person is invariably educated, and may come from a monogamous family structure. From childhood s/he may have received treatment in hospitals, and may never have chosen prior consultation with a traditional healer. (c) The mixed or transitional type constitutes the majority of patients seen in hospitals. The patient may have been born and raised in the village but spent his or her adult working life in the city, or else was raised in a city while retaining strong social and affective ties with the village. The person is the outcome and carrier of a “confused mixture” of cultural systems and is liable to utilize treatment modalities derived from both.
Based on this study, it appears that the sense of upheaval described above is experienced most acutely by the mixed or transitional type. Arriving in their new environment, these individuals have to cope with the demands of modern economic and social life as well as uncertainty in the social, political, and economic systems in which they find themselves, all while balancing the demands and expectations of their families. This may become the preparatory ground for some individuals to break down. In other words, globalization, acculturative stress, and bicultural adaptations may all contribute to the development of brain fag.
These factors are evident in all four cases presented above. Cases 1 and 2 are classical cases of brain fag in which students must juggle demands from home, usually economic problems in the family, while trying to meet a high standard of achievement in school. It appears that the overwhelming aspect of their situations came from being the first in the family to become a student and the first in one’s clan or town to enter university. In Cases 3 and 4, participants likewise viewed themselves as primarily responsible for providing for their families, the families’ “only hope,” and therefore experienced intense pressure to excel in their professional lives. Thus, it appears that when the self-concept of the individual cannot bear this special status and associated expectations, brain fag may represent an attempt to withdraw from the double demands of the situation. Given that low socioeconomic status individuals may feel they have no excuse for withdrawal other than something as serious and widely recognized as physical illness, “brain weakness” functions as a socially accepted physical complaint that relieves an individual from his role and the achievement expectation associated with it.
Conclusion
In conclusion, brain fag is a syndrome heavily influenced by both traditional and contemporary culture in West Africa. In full bloom, it can manifest as lack of concentration, weak memory, loss of interest in studies and mental activities, in addition to other idioms of distress (such as “brain weakness” and culturally informed somatic symptoms that indicate stress). This study confirms the relevance of the brain fag phenomenon in Nigeria more than 40 years after its first description by Prince (1959). At the same time, the cases presented challenge the presumed association with academic settings, portraying brain fag as a more general phenomenon emerging at the crux of family and environmental pressures. This being the case, there is a need for more research on brain fag to determine its actual prevalence in both clinical and community samples in West Africa and possibly beyond. Longitudinal and cross-sectional studies are needed to contribute to the debate on whether brain fag is a culture-bound syndrome found exclusively in West Africa, or a phenomenon that exists in other places and remains undocumented for lack of attention. The presence of brain fag among Black Africans outside West Africa and even in diaspora (Minde, 1974) suggests a need for further research at the global scale. Only after more attention is given to the syndrome can we begin to address questions about diagnostic validity and reliability.
In closing, we note that the cases presented here underscore the relationship between somatization and brain fag. If somatic complaints of psychological origin are truly indicative of unbearable social and psychological pressure, then more studies on the possible meaning and sociocultural etiological conditions of somatization are warranted. We believe that future research of this nature will help to illuminate the origins of brain fag. Indeed, the syndrome of brain fag may one day lose relevance as we become able to interpret the meaning of clusters of somatic symptoms more precisely.
Footnotes
Acknowledgements
We wish to acknowledge the department of Medicine, University of Nigeria Teaching Hospital (UNTH) for providing an office for our psychotherapy clinic. Also we thank Frau Marie Louise Sulzer for funding the foundation of the International Federation for Psychotherapy Centre, which encouraged research in indigenous methods of psychotherapy.