The role of cultural factors in paranoid psychosis among the Yoruba tribe

Transcultural Psychiatry: Cultural Difference, Universalism and Social Psychiatry in the Age of Decolonisation

In the mid-twentieth century, in the aftermath of WWII and the Nazi atrocities and in the midst of decolonisation, a new discipline of transcultural psychiatry was being established and institutionalised. This was part and parcel of a global political project in the course of which Western psychiatry attempted to leave behind its colonial legacies and entanglements, and lay the foundation for a more inclusive, egalitarian communication between Western and non-Western concepts of mental illness and healing. In this period, the infrastructure of post-colonial global and transcultural psychiatry was set up, and leading psychiatric figures across the world embarked on identifying, debating and sometimes critiquing the universal psychological characteristics and psychopathological mechanisms supposedly shared among all cultures and civilisations. The article will explore how this psychiatric, social and cultural search for a new definition of 'common humanity' was influenced and shaped by the concurrent global rise of social psychiatry. In the early phases of transcultural psychiatry, a large number of psychiatrists were very keen to determine how cultural and social environments shaped the basic traits of human psychology, and 'psy' practitioners and anthropologist from all over the world sought to re-define the relationship between culture, race and individual psyche. Most of them worked within the universalist framework, which posited that cultural differences merely formed a veneer of symptoms and expressions while the universal core of mental illness remained the same across all cultures. The article will argue that, even in this context, which explicitly challenged the hierarchical and racist paradigms of colonial psychiatry, the founding generations of transcultural psychiatrists from Western Europe and North America tended to conceive of broader environmental determinants of mental health and pathology in the decolonising world in fairly reductionist terms-focusing almost exclusively on 'cultural difference' and cultural, racial and ethnic 'traditions', essentialising and reifying them in the process, and failing to establish some common sociological or economic categories of analysis of Western and non-Western 'mentalities'. On the other hand, it was African and Asian psychiatrists as well as Marxist psychiatrists from Eastern Europe who insisted on applying those broader social psychiatry concepts-such as social class, occupation, socio-economic change, political and group pressures and relations etc.-which were quickly becoming central to mental health research in the West but were largely missing from Western psychiatrists' engagement with the decolonising world. In this way, some of the leading non-Western psychiatrists relied on social psychiatry to establish the limits of psychiatric universalism, and challenge some of its Eurocentric and essentialising tendencies. Even though they still subscribed to the predominant universalist framework, these practitioners invoked social psychiatry to draw attention to universalism's internal incoherence, and sought to revise the lingering evolutionary thinking in transcultural psychiatry. They also contributed to re-imagining cross-cultural encounters and exchanges as potentially creative and progressive (whereas early Western transcultural psychiatry primarily viewed the cross-cultural through the prism of pathogenic and traumatic 'cultural clash'). Therefore, the article will explore the complex politics of the shifting and overlapping definitions of 'social' and 'cultural' factors in mid-twentieth century transcultural psychiatry, and aims to recover the revolutionary voices of non-Western psychiatrists and their contributions to the global re-drawing of the boundaries of humanity in the second half of the twentieth century.

The politics and practice of Thomas Adeoye Lambo: towards a post-colonial history of transcultural psychiatry

This article traces the career of Thomas Adeoye Lambo, the first European-trained psychiatrist of indigenous Nigerian (Yoruba) background and one of the key contributors to the international development of transcultural psychiatry from the 1950s to the 1980s. The focus on Lambo provides some political, cultural and geographical balance to the broader history of transcultural psychiatry by emphasizing the contributions to transcultural psychiatric knowledge that have emerged from a particular non-western context. At the same time, an examination of Lambo's legacy allows historians to see the limitations of transcultural psychiatry's influence over time. Ultimately, this article concludes that the history of transcultural psychiatry might have more to tell us about the politics of the 'transcultural' than the practice of 'psychiatry' in post-colonial contexts.

A social and clinical study of delusions in schizophrenia

Many studies show that incidence and prevalence rates of schizophrenia are related to the social characteristics of the patient's environment; hypotheses—such as that of social isolation—have been invoked to account for the association, but for the most part remain unconfirmed. That the symptoms of schizophrenia or that the clinical form of the illness may also be affected by environmental factors is less clearly established. Nevertheless, some interesting observations have been made, by Benedict and Jacks (1954) and by Yap (1951) for example. Sherman and Sherman's (1934) study of delusions in a mixed American population is probably the most detailed investigation of this kind. They found that American men formulated their grandiose delusions in terms of wealth; foreign-born males did so more often in terms of literary or artistic abilities; and in negroes a religious component tended to predominate. White women were less grandiose and more paranoid than men; but in negro women the reverse was found. Hallucinations were more common in women than in men, and far more common among negroes than whites. Somatic delusions were found more frequently in white than in negro families.

Malignant Anxiety

This is an attempt to describe a clinical syndrome which has hitherto received very little attention. It is widespread in Africa and has important medicolegal implications.

The “Brain Fag” Syndrome in Nigerian Students

There has recently been a good deal of concern expressed in the Press, both of Nigeria and Ghana, over the high incidence of psychiatric disturbance among West African students in the United Kingdom. Whether the incidence of such disturbances is in fact greater among Africans than among other foreign students in the British Isles is not known; nor has it been determined whether the African student abroad is more prone to illness than his counterpart studying at home. Relevant to the latter question, it is clear that a high proportion of the cases seen in the psychiatric clinics both at Aro Hospital, Abeokuta and at the University College Hospital, Ibadan, are students, teachers and other “brain workers” who have never left Nigeria.

The Symptomatology of Mental Disease Among Refugees in Norway

In an earlier investigation the author (1959) raised the question regarding whether a higher incidence of psychiatric disorders could be observed among refugees who remained in, or came to Norway after World War II. Through a personal investigation of all the (sixty) refugees who were admitted to Norwegian mental hospitals and psychiatric departments during the period 1 January, 1946–31 December, 1955, it has been possible to answer this question in the affirmative and without any shadow of doubt. The author could also show that the incidence of psychoses among refugees in Norway is, for all diagnoses, five times higher than could be expected when compared with a matched Norwegian population. For schizophrenia alone the incidence is less than five times higher, while for reactive psychoses it lies far above this number.

The Yoruba Image of the Witch

Witchcraft, the extra-natural interference in the welfare of the community by women, has long since ceased to be a source of major concern in Western society. In many other areas of the world, however, the witch remains a very active and vital image in the consciousness of the people, This is certainly true for the Yoruba*—a negro group occupying large areas of Nigeria, Dahomey and Togoland along the north-west coast of Africa. With the Yoruba (irrespective of his social level, religion or education), belief in the witch and in her powers is all but universal.

Sociocultural Antecedents of Magical Thinking in a Modernizing African Society

Despite the consensual adherence to a magico-mythical orientation in Africa, it was hypothesized that a deeper fear of bewitchment is likely to exist among persons with low as opposed to those who enjoy high levels of social functioning. A community survey involving 771 adult respondents in an urban and a rural area in Western Nigeria was under-taken. Socioeconomic background data and indices of the social functioning level of the respondents were collected. The index for level of social functioning was derived on the basis of recognized Yoruba normative patterns. Stepwise regression analysis was used to investigate the predictive factors of the fear of bewitchment. A deeper fear of bewitchment appears to exist in the urban but not in the rural subgroup. Some of the items which constitute the social functioning index also appear to predict the fear of bewitchment.

Shall we really say goodbye to first rank symptoms?

BACKGROUND

First rank symptoms (FRS) of schizophrenia have been used for decades for diagnostic purposes. In the new version of the DSM-5, the American Psychiatric Association (APA) has abolished any further reference to FRS of schizophrenia and treats them like any other "criterion A" symptom (e.g. any kind of hallucination or delusion) with regard to their diagnostic implication. The ICD-10 is currently under revision and may follow suit. In this review, we discuss central points of criticism that are directed against the continuous use of first rank symptoms (FRS) to diagnose schizophrenia.

METHODS

We describe the specific circumstances in which Schneider articulated his approach to schizophrenia diagnosis and discuss the relevance of his approach today. Further, we discuss anthropological and phenomenological aspects of FRS and highlight the importance of self-disorder (as part of FRS) for the diagnosis of schizophrenia. Finally, we will conclude by suggesting that the theory and rationale behind the definition of FRS is still important for psychopathological as well as neurobiological approaches today.

RESULTS

Results of a pivotal meta-analysis and other studies show relatively poor sensitivity, yet relatively high specificity for FRS as diagnostic marker for schizophrenia. Several methodological issues impede a systematic assessment of the usefulness of FRS in the diagnosis of schizophrenia. However, there is good evidence that FRS may still be useful to differentiate schizophrenia from somatic causes of psychotic states. This may be particularly important in countries or situations with little access to other diagnostic tests. FRS may thus still represent a useful aid for clinicians in the diagnostic process.

CONCLUSION

In conclusion, we suggest to continue a tradition of careful clinical observation and fine-grained psychopathological assessment, including a focus on symptoms regarding self-disorders, which reflects a key aspect of psychosis. We suggest that the importance of FRS may indeed be scaled down to a degree that the occurrence of a single FRS alone should not suffice to diagnose schizophrenia, but, on the other hand, absence of FRS should be regarded as a warning sign that the diagnosis of schizophrenia or schizoaffective disorder is not warranted and requires specific care to rule out other causes, particularly neurological and other somatic disorders. With respect to the current stage of the development of ICD-11, we appreciate the fact that self-disorders are explicitly mentioned (and distinguished from delusions) in the list of mandatory symptoms but still feel that delusional perceptions and complex hallucinations as defined by Schneider should be distinguished from delusions or hallucinations of "any kind". Finally, we encourage future research to explore the psychopathological context and the neurobiological correlates of self-disorders as a potential phenotypic trait marker of schizophrenia.

Traumatic pasts and the historical imagination: Symptoms of loss, postcolonial suffering, and counter-memories among African migrants

This work aims to rethink the relationship between anthropology and cultural psychiatry from a historical perspective, through reflections on the dynamics of forgetting and remembering in the context of migration. While migrants' symptoms often bear cultural hallmarks of suffering, they also reveal images of a traumatic history, which resurface in moments of danger, uncertainty, and crisis. I claim these symptoms are allegories of a dispossessed past, and can be interpreted as counter-memories, as "palimpsests" of an eclipsed script. Trauma symptoms keep returning to a collective past, and thus can be considered a particular form of historical consciousness. Psychiatric diagnoses may obscure these counter-memories. In particular, the diagnostic category of posttraumatic stress disorder that is commonly attached to traumatic experiences in current clinical practice recognizes the truth of individual traumatic events, but at the same time contributes to concealing the political, racial, and historical roots of suffering.

Clinical symptoms of psychotic episodes and 25-hydroxy vitamin D serum levels in black first-generation immigrants

OBJECTIVE

Dark-skinned immigrants have a higher risk for schizophrenia and other psychoses than other immigrants. The first British studies reported that first-generation immigrants (FGIs) from the Caribbean presented atypical psychoses. This study examines the characteristics of psychotic episodes in black FGIs to Canada.

METHOD

The charts of 18 FGIs from Africa and Haiti, extracted from a series of 20 black patients consecutively admitted to Psychiatry, were retrospectively reviewed regarding clinical features, diagnoses and vitamin D levels.

RESULTS

Young FGIs presented acute psychotic episodes with abrupt onset, florid positive symptoms, few negative symptoms and good evolution. The onset was more insidious in older FGIs. Overall, catatonia was very frequent (28%), and mood symptoms still more frequent (44%). No cognitive decline was observed during follow-up. Serum levels of 25-hydroxy vitamin D were in the insufficiency range. Supplementation at 1000 IU/day did not restore normal levels.

CONCLUSION

The clinical features of psychotic episodes in black FGIs are similar to those reported in dark-skinned FGIs to other countries. They are also observed in other immigrants and in non-immigrants. These atypical psychoses are possibly related to a recent vitamin D deficit. This hypothesis should be tested by clinical trials of sufficient vitamin D supplementation.

The deployment of ethnographic sciences and psychological warfare during the suppression of the Mau Mau rebellion

This essay provides readers with a critical analysis of the ethnographic sciences and the psychological warfare used by the British and Kenyan colonial regimes during the suppression of the Mau Mau rebellion. In recent years, several survivors of several detention camps set up for Mau Mau suspects during the 1950s have brought cases in British courts, seeking apologies and funds to help those who argue about systematic abuse during the times of "emergency." The author illustrates that the difficulties confronting Ndiku Mutua and other claimants stem from the historical and contemporary resonance of characterizations of the Mau Mau as devilish figures with deranged minds. The author also argues that while many journalists today have commented on the recovery of "lost" colonial archives and the denials of former colonial administrators, what gets forgotten are the polysemic ways that Carothers, Leakey, and other social agents co-produced all of these pejorative characterizations. Kenyan settlers, administrators, novelists, filmmakers and journalists have helped circulate the commentaries on the "Mau Mau" mind that continue to influence contemporary debates about past injustices.

Explanatory models and concepts of West African Malian patients with psychotic symptoms

BACKGROUND

Subjective explanations of illness concepts and disease can differ from culture to culture. We examined explanatory models of West African patients with schizophrenia in a community-centred department of psychiatry in Mali, West Africa.

METHODS

Patients and experts volunteered to be interviewed in the Department of Psychiatry of the University Hospital, Pont G, in Bamako, the capital of Mali. We used semi-structured interviews to explore key psychotic symptoms and explanatory models of psychosis in five experts and fifteen patients with schizophrenia. All interviews were analysed using computer assisted content-analysis with the program Atlas.ti.

RESULTS

African patients displayed key symptoms of schizophrenia such as commenting and imperative voices, inserted thoughts and other phenomena of alien control, which were often subjectively explained as obsession by witches or jinns. Explanatory models differed depending on occidental migration experience and age. The involvement of family members in the treatment-setting facilitates inclusion and recovery. Experts emphasized the need to integrate traditional and ethno-pharmacological approaches and modern medicine to treat their patients in a culture sensitive manner.

DISCUSSION

Our data suggests a strong influence of illness concepts on the experience of psychotic symptoms, treatment expectations and health-related behaviour.

Autoenucleation--a culture-specific phenomenon: a case series and review

Cases of autoenucleation may provide a good example of the pathoplastic effects of culture. To further characterize this phenomenon, the author reviewed the medical literature and conducted a retrospective search of the local psychiatric hospital records. Medline search did not show a single case of autoenucleation in the non-European Christian culture. Descriptive accounts of the identified seven patients show they were all psychotic at the time of the act, and five had a history of prior drug abuse. Most were religiously preoccupied before the act and displayed prominent affective symptoms, and they all interpreted the Biblical text literally. The association of sight and the concept of sin is discussed in a wider cultural context, and it is proposed that autoenucleation may be unique to the Christian West.

Psychiatry's culture

Culture remains an ambiguous concept for psychiatry: deprecated by the assumption that it is secondary to biomedical reality, yet at the same time some notion of 'culture' has served to represent the modern against the primitive. Contemporary clinical understandings of culture derive from imperial medicine which had applied the accepted distinction between the biological form and the cultural content of psychopathology to local illnesses which could not easily be fitted into the European nosology. The later concept of culture-bound pathology, like the psychoanalysts' 'modal personality', only imperfectly escaped from evaluative assumptions of 'development', but it is difficult to argue that psychiatry provided British colonial administrations with any significant ideological justification.

Interventions with families of people with schizophrenia in India

Although families have traditionally been the caregivers for mentally ill relatives in India, this situation is changing, creating a need for more structured interventions with families. Interventions appropriate to families in India are discussed here.

Psychiatric disorders of old age in Enugu, Nigeria. Sociodemographic and clinical characteristics

A retrospective study of the demographic and clinical characteristics of 73 consecutive patients aged 60 years and over admitted for the first time into a psychiatric hospital in Nigeria shows that they constituted about 5% of all admissions over a 2-year period. While the majority (58%) were aged below 70 years, 8% were aged over 80 years, with more females than males living to the older age groups. Single status, separation and divorce were more common among males; widowhood was more common among the females. A high illiteracy rate of 86% was recorded, with more males than females being literate. More than 84% belonged to the 2 lowest socioeconomic classes. There was a significant difference in the distribution of diagnostic categories, with senile dementia, affective psychosis, neurotic disorders and paranoid states more common among the females, while arteriosclerotic dementia and schizophrenia were diagnosed more often among the males. Functional psychosis (49%) was the largest diagnostic category, followed by organic psychosis (30%), while neurotic disorders (10%) ranked third. Within the functional psychoses, paranoid states (30%) predominated, followed by affective disorders (14%) consisting mainly of depressive symptoms; 6% presented with schizophrenic illness; and 11% presented with physical illness with associated psychiatric manifestations. There was a long delay before referral to hospital, associated with use of alternative medical facilities (traditional and spiritual healers). The probable sociocultural antecedents and medical and social implications of these findings are discussed.

'Bhanamati' sorcery and psychopathology in south India. A clinical study

We describe the patterns of illness attributed to sorcery among 209 patients who attended a special clinic in south India. Somatisation and conversion disorders accounted for the majority of patients, although several other psychiatric and medical disorders were also seen. Aspects of treatment of such patients in the sociocultural context are discussed.

On the expression of psychosis in different cultures: schizophrenia in an Indian and in a Nigerian community

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and "self-centered" orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

Clinical anxiety in Nigeria

Two hundred patients clinically certified as suffering from anxiety state were investigated with a view to understanding the clinical manifestation of the condition in Nigeria. We found that 67 symptoms were manifested by those patients, but only 15 symptoms were presented by about 10% of the sample. These common symptoms were: frequent headaches, difficulty in falling asleep, flushing, difficulty in concentrating, rapid or irregular heart beating, weakness, hot flashes, dizziness, feeling of something crawling in the head, heaviness of the head, nervousness, poor appetite, poor sight, nightmares, and chest pain. The five major precipitating factors were physical ailments, studying and examinations, use of drugs, psychological phenomona, pregnancy and childbirth, in decreasing order of magnitude. The most vulnerable age group was between 18 and 23 years old. The first born children account for the highest number of anxiety patients, but as the number of siblings increases, the vulnerability of the last-born increases. Anxiety neurosis as seen here is predominantly a problem of single males and females with secondary school education.

Mental health in Africa: II. The nature of mental disorder in Africa today. Some clinical observations

Aspects of clinical psychiatric syndromes described in Africa which are discussed include the issue of schizophrenic disorders having a better prognosis in developing countries; controversy over this is by no means at an end. There is an increasing realisation as to the frequency of affective disorders in Africa; while somatisation is common, cherished beliefs, such as the absence of guilt, have not been confirmed by more recent research. Nor is suicide as infrequent as has been suggested. The relationship of background physiological abnormalities of cerebral functioning may be relevant to some of the clinical issues that are currently under discussion in African psychiatry.

Mental illness among immigrant minorities in the United Kingdom

Cross-cultural studies on immigrants from Pakistan and the New Commonwealth are reviewed, with emphasis on epidemiology and differences in clinical presentation. Their referral to the psychiatric service is also examined and deficiencies are noted. Awareness of transcultural issues among health professionals need to be increased in order to achieve diagnosis and improvements in health care.

Paranoid disorder--environmental, cultural or constitutional phenomenon?

At a London hospital the prevalence and types of recorded paranoid disorders, and their characteristics were extracted from the files of in-patients of various cultural groups. It was found that West Indians and Africans had more paranoid colouring in their psychiatric illness than any other group. Other immigrant groups had less paranoid features than the English group. The self or a family member was the commonest focus of intended harm in all the cultural groups. Supernatural modes of injury were common in the West Indians and Africans. It is argued that in immigrants paranoid disorder is not merely due to discrimination consequent on their migrant status, but that cultural factors inherent in the immigrants are also of etiological importance.

Content of grandiose phenomenology across cultures

The content of grandiose ideas and delusions in patients of various cultural groups admitted to a London psychiatric hospital were compared. There were no overall differences but certain trends were apparent. It was found that religion was the commonest content of grandiose symptoms in all the groups. Its frequency was higher in the African and Jamaican groups, an observation that can be understood from the cultural background of these groups. The other types of content, namely royals, identity and ability were less frequent in all groups.

The interrelationship of tropical disease and mental disorder: conceptual framework and literature review (Part I--Malaria)

Substantial interactions between tropical diseases and psychiatric illness have long been recognized, but the impact of biological factors in the field of cross-cultural psychiatry has been less well studied than psychosocial factors. In reviewing the literature at the intersection of tropical medicine and psychiatry in order to summarize the existing data base in this field, a generalized interactive model informed by the theoretical contributions of George Engel, the WHO Scientific Working Group on Social and Economic Research, Arthur Kleinman, P. M. Yap, Edward Sapir and others has been developed to serve as a conceptual framework for this analysis of the literature and to guide further research. The clinical literature of tropical medicine and psychiatry which recognizes the significance of concurrent tropical disease and mental disorders is reviewed along with the more specific literature on malaria and concomitant psychiatric illness. Many authors have focused on the role of organic mental disorders, especially in connection with cerebral malaria, but several have also addressed psychosocial parameters through which the interrelationship between malaria and a full range of mental disorders is also mediated. The effects of malaria may serve as biological, psychological or social stressors operating in a cultural context which precipitate or shape features of psychiatric symptomatology. Psychiatric illness may likewise precipitate an episode of malaria with typical symptoms in a patient with a previously subclinical infection. Implications of the literature and this generalized interactive model are considered as they apply to clinical practice, public health and the application of social science theory in medicine.

Frequency and clinical significance of delusions across cultures

The pattern of delusions in a cross-cultural hospital population was studied. It was found that there were cultural differences in persecutory, grandiose and religious, and sexual and fantastic delusions, accounted for mainly by the relatively higher frequencies in the African and West Indian cultural groups. These phenomena can be understood in terms of the cultural backgrounds of these groups. It is further argued that similarly defined persecutory delusions have a wide clinical significance that goes beyond schizophrenia in some cultural groups.

Some social and phenomenological characteristics of psychotic immigrants

Various studies have shown: (i) increased rates of psychoses in immigrants to Britain, and a particularly high rate of schizophrenia in the West Indian- and West African-born; and (ii) a greater proportion of atypical psychoses in immigrants. A retrospective study of psychotic inpatients from a London psychiatric unit demonstrated increased rates of schizophrenia in patients from the Caribbean and West Africa. These patients included a high proportion of those with paranoid and religious phenomenology, those with frequent changes of diagnosis, formal admissions, and married women. The West Indian-born had been in Britain for nearly 10 years before first seeing a psychiatrist and, if they had an illness with religious symptomatology, were likely to have been in hospital for only 3 weeks. Rates of schizophrenia without paranoid phenomenology were similar in each ethnic group. It is suggested that the increase in the diagnosis of schizophrenia in the West Indian-born, and possibly in the West African-born, may be due in part to the occurrence of acute psychotic reactions which are diagnosed as schizophrenia.

Acute psychotic reactions in Caribbean-born patients

A prospective study of patients with religious delusions identified 24 West Indian and West African patients. Those who had none of Schneider's first-rank symptoms of schizophrenia (principally West Indians) differed from those who did by virtue of early religious commitment, life-long religious experiences, an acute admission precipitated by social events, a greater chance of having their diagnosis changed, less than 10 different PSE syndromes, the absence of 'twentieth-century' delusions, and the presentation of malevolent witchcraft as the sole explanation of the episode. It is suggested that this group can usefully be considered as demonstrating an acute psychotic reaction of the type previously described in Africa and the Caribbean.

Nigerian psychiatry in perspective

The history of Nigerian psychiatry is reviewed, and the main features and leading figures identified. The author then proceeds to discuss future directions to be taken by Nigerian psychiatry, if it is to effectively meet the challenges involved, the most prominent being to provide service for a large but growing population living in rapidly changing times.

Differential use of psychiatric services by West Indians, West Africans and English in London

Two hundred and ninety West Indian and 73 West African patients were identified and matched against 204 and 53 English patients respectively. Significantly more migrant patients were: not referred to hospital by their GPs, showed disturbed behaviour prior to psychiatric contact, and were admitted formally. Studying consecutive attendances or admissions to one hospital may lead to an unrepresentative sample.

Psychiatric morbidity among West Africans and West Indians living in London

All west Africans and West Indians living in Camberwell who made a psychiatric contact between 1 January 1965 and 31 December 1968 were selected using the Camberwell Psychiatric Register as a sampling frame. Inception rates of psychiatric illness were then calculated using the 1966 10% census figures for West Africans and West Indians in Camberwell. The rates found were compared to those among the British living in Camberwell. For each major diagnostic caterogy, with the exception of reactive depression and paranoid states, the inception rates are significantly higher among West Africans than West Indians. They are also significantly higher among West Indians than British. However, the differences in inception rates are generally greater between West Africans and West Indians than between the latter and the British.

Cultural aspects of delusions: a psychiatric study of Egypt

This paper deals with the cultural elements of the delusions of a sample of Egyptian psychiatric patients. After examination of clinical records, interviewing psychiatrists and reviewing literature, the author reaches the conclusion that the content of the patient's delusion varies directly in relation to his social class. For most of the low class men and women, the delusional symptoms, either megalomaniac or persecutory were fantasied in terms of the cultural religious institutions. Middle and upper class patients, however, much more frequently "secularized" their restitutive narcissistic and self esteem delusions in terms of science and class conception of power.

Aspects of clinical psychiatry in Sub-Saharan Africa

Baan was referring to the underdeveloped world, or the ‘third world’ as it is often called. This review is concerned with psychiatry in a small part of it—Sub-Saharan Africa—that part of the African continent inhabited by black Africans. At the time of writing, the term is used more specifically to describe independent black Africa, excluding South Africa—hence a bloc of cultures and sub-cultures with ethnic, economic, religious and customary patterns very different from those of the continents of Europe and North America where the bulk of current data and theory about psychiatric disorders has been obtained and expanded. In view of such major differences in factors long thought to influence the occurrence and nature of psychiatric illnesses, the patterns of these disorders in Sub-Saharan Africa are important in clarifying theories about psychiatric disease despite the paucity of adequate research carried out to date.

Preliminary psychiatric observations in Egypt

In the following paper a short clinical, descriptive account is given of the first 1,000 patients attending Ain Shams University Psychiatric Clinic from the beginning of 1966. Although the clinic is in the centre of Cairo, its catchment area extends all over Egypt. Patients are referred through three channels; either general practitioners send them for a psychiatric opinion or they come from other medical out-patient clinics at the University. The third group represents those who come independently and ask for psychiatric examination. Usually these are patients from the countryside who have tried lay therapy in their villages but without improvement. This group represents a deficit in the organization of referral, as many of them, having been examined at the psychiatric clinic may have to be referred to another medical out-patient clinic because of a non-psychiatric organic pathology.

Mentally ill West Indian immigrants

At present there exist in the literature numerous references to mental illness in different cultures; these vary from consideration of disorders peculiar to certain cultures, e.g. Koro, Latah, Amok, Wihtigo, etc., well reviewed by Yap (Yap, 51) to the problems of acculturation and mental illness. Examples of the latter include the studies of Tooth and Carothers, the latter suggesting that Westernization and detribalization increased the incidence of psychosis in Africans (Carothers, 2; Tooth, 45). Slotkin (42) pointed to the paranoid schizophrenia phenomena among acculturated Menomini. Hallowell (14, 15) found significant Rorschach differences between acculturated and unacculturated Salteaux.

Beliefs and delusions of West Indian immigrants to London

Psychiatrists have for long paid attention to mental illness in different communities and cultures. In Java, Kraepelin noted that melancholia and mania were rare and that depressive reactions rarely contained elements of sinfulness (9). Later, Bleuler commented upon differences between English and Irish patients and between Bavarian and Saxon patients (2). Others have described various “culture-bound” syndromes such as amok, the windigo psychosis of the Cree, Salteaux and Ojibwa, latah and Arctic hysteria (23, 5, 8, 11, 26). More recently Tooth has described a special category of “delusional” states in West Africans while Carothers has reported on “ill-defined” states and “primitive” psychoses among the West Africans (22, 4). Other workers have stressed the significance of cultural factors in the distribution of mental illness. Seligman noted in 1929 that confusional states were more common than systematized insanities among the Papuans of New Guinea and could not find any cases of manic depressive illness (17). Berne noted that toxic confusional psychoses rather than the schizophrenias were the predominant illness among hospitalized Malay (1). Carothers related Westernization to an increase in manifest paranoid behaviour among patients in Kenya (4). Similarly Spiro noted that the Ifaluk in the Carolines had violent paranoid outbursts only after Japanese occupation and Slotkin emphasized the paranoid schizophrenia phenomena among acculturated Menomini (20, 19). Opler found that lower class Filipinos had a high proportion of affective disorders and catatonic confusional states among the Hawaiian hospitalized, while Carothers and Tooth in Africa both found statistically low incidences of depression and suicidal states with relatively high rates of confusional states among African natives (13, 4, 22).

Mental maladjustment in the East African

Relatively little is yet known of the incidence or nature of mental disorder in Africans. The literature on African psychiatry is not extensive and, although a wealth of anthropological and sociological work has given us an idea of the cultural and physical background of the African, we are still much in the dark as to how these factors influence his personality and what bearing they may have upon mental illness. A number of studies of patients in African Mental Hospitals have been made by various writers and diagnostic classifications have been attempted. Most writers agree that it is rare to find any great degree of similarity between the various types of mental disorder in Africa and those found in the higher developed western countries. Most of the work in this field has been summarized by Carothers (1954).

My aim in this paper is to give a rough idea of the African background, to speculate on various aspects of the African personality in the light of present knowledge, and to try and reflect these speculations by description of the various types of insanity that are encountered in a mental hospital in Tanganyika. Some of the differences in the nature and aetiology of these disorders, compared with those most common in the home country, will be discussed. My remarks are, of course, confined to Tanganyika and if I inadvertently use the term “the African” I refer to the native of Tanganyika whom I have studied for the past eight years and who compose the bulk of the patients in hospital.