Soc. Sci. Med. Vol. 40, No. 9, pp.

1291-1298, 1995
Pergamon ElsevierScienceLtd. Printedin Great Britain
0277-9536(94)00231-2

EXPLANATORY MODELS OF MENTAL ILLNESS IN

SUB-SAHARAN AFRICA
VIKRAMPATEL
Section of Epidemiologyand General Practice, Institute of Psychiatry, London, England and Department
of Psychiatry, University of Zimbabwe Medical School, P.O. Box A178, Avondale, Harare, Zimbabwe

A~traet--Knowledgeof explanatory modelsof illnesscan be used to conduct cross-culturalepidemiological

studies which, while being culturally sensitive,are also comparable with other studies. This paper reviews
studies from sub-Saharan Africa which examine beliefs relating to mental illness. There is a rich diversity
of beliefs, but within this diversity are a number of shared concepts. Thus, many African cultures do
distinguish between the mind and body. The mind is cited as residing in the head as well as the heart or
abdominal region. Spiritual causes are frequent explanations for mental illness. Though there are some
similaritieswith biomedicalconcepts of mental illness,there are also significantvariations. Psychotic illness
is often recognized as 'madness' though emphasis is on behavioural symptoms rather than delusions;
neurotic presentations are much more varied, often somatically defined and may not be considered to be
mental illnessesat all. Emic psychiatric instruments need to be developedif future cross-cultural psychiatric
research is to be both comparable and culturally valid.

Key words--explanatory models, cross-cultural psychiatry, sub-Saharan Africa, medical anthropology

INTRODUCTION Kleinman [4] to denote the "notions about an episode

Cross-cultural psychiatric research has polarized into
two schools of thought; the etic approach advocates
the universality of mental illness while the emic
approach argues that mental illness categories need to
be generated from within cultures. The former
approach assumes that mental illness is similar
throughout the world and that psychiatric tax-
onomies, their measuring instruments and models of
health care designed in the West are globally
applicable. The WHO multinational studies [l] are an
example of this approach. On the other hand, the emic
approach evaluates phenomena from within a culture
and its context, aiming to understand its significance
and relationship with other intra-cultural elements.
Anthropological studies of community attitudes and
illness behaviour are examples of this approach.
Neither of these approaches are supported by
cross-cultural research; for example, purely etic studies
tend to exclude a significant number of persons who
may be mentally ill but do not fit predetermined
external diagnostic criteria whilst purely emic
studies are unable to provide data which can
be compared across cultures. It is increasingly
accepted that their integration is essential for the
development of the "new cross-cultural psychiatry"
[2, 3]. Thus, equal value needs to be ascribed to folk
beliefs about mental illness and its categorization as to
the Western biomedical system of psychiatry.
Essential to this process is an investigation of the
explanatory models of mental illness held by patients
and care providers.
Explanatory models (EMs) is a term coined by
of sickness and its treatment that are employed by all
those engaged in the clinical process". EMs are formed
from a variable cluster of cultural symbols,
experiences and expectations associated with a
particular category of illness. EMs reveal sickness
labelling and cultural idioms for expressing the
experiences of illness and have been shown to influence
health seeking behaviour and health service utilization
[5]. Whilst the concept of an EM is broad and
encompasses several features of illness related
behaviour and ideas, this review focuses on the EMs
of mental illness, specifically on the concepts,
classification, phenomenology and models of causality
in sub-Saharan African (SSA) cultures. Many authors
have noted the significant similarities in beliefs relating
to traditional religion and health in SSA cultures [6, 7].
By exploring the diversity of EMs of mental illness, this
review aims to determine common threads that run
through these diverse health beliefs. Such common
threads could then be incorporated in future
cross-cultural epidemiological studies of mental
illness.
This review does not aim to be comprehensive; there
is a bias in covering articles by biomedical health
professionals, reflecting the orientation and training of
the author; material written by sociologists, medical
geographers and anthropologists is also reviewed.
Included in this review is a recent study conducted by
the author in Zimbabwe [8]. The literature covers data
from I l SSA nations, viz. Nigeria, Senegal, Uganda,
Zimbabwe, Botswana, Ethiopia, Ghana, Swaziland,
South Africa, Guinea-Bissau and Kenya. To keep the

SSM40/9-1 1291
1292 VIKRAMPATEL
article contemporarily relevant, all but one of the
studies reviewed have been published after 1970.
CONCEPTS OF THE MIND
In any study of EMs of mental illness, two
fundamental issues need to be considered at the outset;
first, do the cultures in question have a concept of the
mind and body; i.e. is mental illness seen as being
distinct from somatic illness? And second, what are the
determinants of the concept of mind? Although it is
often assumed that traditional African concepts of
health view illness in a holistic way (i.e. the mind-soma
dichotomy is not as distinct as in Euro-American
society), the evidence suggests that such a holistic view
incorporates a distinction between mind and body.
Studies in Guinea showed that major mental disorders
such as psychosis, mental retardation and convulsive
disorders (often percieved to be related to mental
illness) are differentiated from somatic illness [6]. In
Zimbabwe, Gelfand recognized the importance of
traditional categories of illness well before terms such
as explanatory models had become fashionable. In an
early paper [7], he found that the conception of disease
amongst the Shona was not very different from that of
most Southern African tribes. The Shona have a good
idea of what constitutes madness and the description
is similar to European concepts of acute psychotic
illness. Beiser et al.'s studies amongst the Serer peoples
of Senegal elicited seven important "illnesses of the
spirit" which the authors concluded were analogous to
mental illness [9]. These categories were based on
symptomatic descriptions and are discussed later;
what matters at this stage, is that 'illnesses of the spirit'
were similar in phenomenology to Euro-American
ideas of mental illness, and that the Serer people
distinguished these from somatic illness. Beiser et al.
examined those persons in the community identified as
suffering from illnesses of the spirit using Western
psychiatric interviews and found that there was an
'encouraging' goodness-of-fit between the Serer
category and Euro-American concepts of mental
illness. The existence of traditional healers who
specialize in the diagnosis and treatment of mental
illness in several nations including Zimbabwe, Kenya,
Botswana and Nigeria [10-13] bears testimony to the
existence of a distinction between somatic and mental
illness. In Kenya and Zimbabwe, traditional healers
clearly identified mental disorder as a condition that
they were especially skilled at treating [10, 14].
Personal and social adjustment problems, which may
be presumed to include psychological distress, was the
most frequent reason for consultation with traditional
healers in Kenya, while psychosomatic problems
accounted for 40% of all consultations with healers in
Bostwana [13].
Thus, one can conclude that SSA cultures do
distinguish between the mind and the body, at least as
far as illness experiences are concerned. What, then, is
the nature of the mind? What are its functions, where
in the body is it located and so on? Focus group
discussions with primary care providers in Harare
found that most agreed that though the mind resided
in the head region, the heart or moyo was closely
connected with it. Thus "when someone thinks a lot,
the heart becomes heavy" and when someone steals "it
is the heart which decides it, and the brains work out
how to do it" [8]. The Baganda peoples of Uganda
believe that both the heart and the brain think;
according to Orley, the concept of a thinking function
for the brain is itself introduced by Western influence
since the idea of attributing any function to the brain
as opposed to the head as a whole is probably new [15].
The heart is the centre of emotions such as fear, anger,
joy and jealousy. The Baganda distinguish between
permanent and temporary changes affecting the head;
thus temporary changes such as those resulting from
intoxication with beer or spirit possession which catch
a person on the head are distinguished from more
permanent strangeness which is present in the head.
Studies with the AmaXhosa people of Southern Africa
suggest that the soul is considered to be the seat of
feelings and resides in the blood and heart. The mind
is located in the brain and is "the initiator of action and
required for health" [16]. Unlike European concepts
which emphasize the cognitive component of mental
life, the AmaXhosa emphasize the behavioural and, to
a lesser extent, the emotional components.
The Akan people of Ghana have a complex concept
of selfhood, which can be simplified into consisting of
three finely balanced components: onipadua, the
physical-mortal part; sunsum which is akin to
personality; and okra which is an intellectual,
nonpersonal life force. Good health is dependent on a
fine balance of these three components [17]. The brain
or adwene resides in the head or tiri. Some illnesses are
identified as being purely physical, the central concept
being that the abdominal organs are not functioning
properly and that constipation is the root of the
trouble. By contrast, illness afflicting sunsum or okra
are not readily located, not so susceptible to treatment
and are usually chronic. Mental illnesses may be
categorized under these groups. Mutambirwa has
likened the Shona concepts of mankind to the three
components of the Freudian model of parts of the
personality [18]: muviri or n y a m a represents the body
or flesh, and like the Freudian id, is incapable of doing
anything without the direction of the second
component, the mind-soul which is immortal and is
the system of cognitive process that is the thinking,
percieving and deciding part of mankind. It is this part
which continues to function after death by becoming
a mudzimu, the ancestor spirit. Thus, while the body
component is visible to the naked eye, the mind-soul
is not. Like the Freudian ego, the mind-soul is the
internal mediator between the desires of the body and
those of conscience. The third part is the m w e y a or
spirit, which lives in eternal health through its moral
and just function. Like the Freudian superego, the
spirit forms the conscience part of mankind and is the
 Explanatory models of mental illness in SSA
inhibiting and restraining force which perfects and
purifies a person's behaviour.
CLASSIFICATIONAND AETIOLOGICALMODELS OF
MENTAL ILLNESS
The concepts of disease causation and classification
are intimately related to traditional religious beliefs
and to some extent are shared by many African
peoples. Underlying these attitudes and beliefs are
three fundamental ideas concerning causality [6]: first,
all things which exist or which happen have a cause,
which possesses more power than the effect and thus
possesses greater 'rights' or privileges; second,
occurrences which seriously affect human beings, such
as birth, puberty, drought and so on, are also
intentionally caused; and third, the cause of any
occurrence can be ascertained through divination,
memory, reason and empirical judgement. In essence,
there is a general belief that both physical and mental
illness originates from various external causes [19].
Closely related to these beliefs is the idea of continuity
between the living and dead. Thus, after death, though
the body may disintegrate, the spirit lives on and plays
an important role in maintaining the wellbeing of its
living descendants. Spirits can be of different types,
such as family, community ancestors, alien and evil.
The first two are usually associated with maintainance
of good health, although, if they are upset such as if
a social taboo is broken, they may cause illness and
misfortune. The latter two spirits are more likely to
cause illness in a random and malicious manner, often
unrelated to the daily actions of the victim [5].
Witchcraft is a widely held belief', and despite legal
sanctions in several nations, continues to be seen as an
important cause of illness and misfortune. Unlike
spiritual causation, the witch is often a living person
with evil powers.
Illness is classified both on aetiological and
phenomenological grounds. In rural Kenya, Good
found that many afflictions such as mental illness tend
to be initially attributed to a human agency, such as
witchcraft. It is only later, when the illness becomes
chronic and is perceived to be incurable that it is said
to be in God's hands [l 0]. Traditional healers classified
illness into several aetiological categories, which, in
order of importance include: 'God-given', witchcraft,
curse, seasonality, hereditary, spirit possession,
poisoning, broken taboos, infections, evil eye and
sorcery. Madness was caused by anaemia, blood
'boils', bewitchment, curse from parents, excessive
thinking, complications of malaria, drug use, jealousy,
natural causes, studying too much and so on. Good
notes that, in actual practice, the assignment of cause
of illness is subject to broad interpretation. He also
observed that urban traditional healers placed much
less emphasis on spirit-caused illness relative to rural
healers citing the diminishing concern with ancestral
spirits among the more sophisticated urban popu-
lation as a possible reason.
1293
The Baganda classify diseases of the brain into 4
groups which have close equivalents in Western
medicine: eddalu or violent madness; ensimbu or
epilepsy; obusiru or foolishness which may be either
congential or acquired; and kantalooze or dizziness.
The heart is believed to be the seat of emotions and two
conditions similar to neurotic disorder are recognized:
emmeme etyemuka referring to a pounding of the heart
with fright; and emmeme egwa which manifests as a
general weakness of the body and a failure to eat.
Other conditions of relevance to mental health include
amakiro which afflicts women a few days postpartum,
akawango characterized by a persistent headache,
enjoka referring to stomach aches, and a variety of
terms referring to concerns regarding sexual function
and potency. Mental illness can also be classifed by
aetiology according to three dichotomies: those that
come by themselves and those sent or caused by
witchcraft; strong and weak; and Kiganda and
non-Kiganda (referring to illness already known to the
Baganda before the advent of Europeans) [15].
Two studies with traditional healers in Nigeria
revealed that mental illness was classified on both
aetiological and phenomenological grounds [20, 2l].
Thus, three major phenomenological categories of
mental illness were identified; one resembling
psychotic illness, a less severe disorder with somatic
symptoms and mental retardation. Aetiologically,
mental illness could be induced by enemies, brought
upon oneself by drug and alcohol abuse or
supernatural forces, hereditary influences, epilepsy,
breaking of social taboos, being breast-fed fed by a
mentally ill woman, severe fever, head injuries and
infections.
Kortmann identified more than 15 types of mental
problems in Ethiopia; some of these represent
individual phenomena such asfirhat which denotes a
fear of certain objects, some are aetiological categories
such as abishu which denotes behavioural disturbances
associated with intoxication, and the rest represent
behavioural syndromes such as ibd in which there is
seriously disturbed behaviour with wandering naked,
using unintelligible and obscene language and talking
to one self [22]. Supernatural spirits, the evil eye
possessed by witches, sorcery, poisoning and thinking
too much are recognized as important causes.
The people of Berekuso in Ghana classify illness
into the broad categories of natural and supernatural
on the basis of the attributed cause [5]. The former
category includes causes such as worms, rapid changes
in climate, improper diet and so on, whilst the latter
includes two sub-groups, viz. the benign supernatural
agent who is usually an ancestral god or diety and the
evil forces unleashed by witches and sorcerers. The
Akan people in Ghana believe that a child inherits the
mother's blood or mogya. It is suggested that the
concept of genetically transmitted mental disorder is
well developed, since it is used as one of the criteria
for selecting a future spouse in that one ensures
that there is no mentally ill person in the family of
1294 VIKRAM PATEL
one's future spouse (anonymous referee, personal
communication).
The AmaXhosa of Southern Africa recognize a
range of mental illness, but only a few are regarded to
be due to constitutional abnormalities of the brain
[16]. All other categories are attributed to external
causes including: failure to propitiate the ancestors
with the necessary sacrifices or rituals; non-observance
of taboos and consequent ancestral displeasure;
bewitchment; intrusion of evil spirits sent by sorcerers;
and excessive worry over matters 'which have been
kept to himself'. Although hereditary illness is
recognized, these are often in a spiritual context.
A study in Botswana presented case descriptions of
tuberculosis, epilepsy and psychosis to villagers,
nursing personnel and general medical outpatients
[23]. Although villagers who believed witchcraft was
the main cause of psychosis and ancestral spirit
disturbance was the main cause of epilepsy were more
likely to choose indigenous treatment for these
vignettes, there were no consistent relationships
between aetiological models and treatment preference
for the other groups of respondents. The most
important causative factor for psychosis was identified
as alcohol abuse by nurses, blood impurities by
patients and witchcraft by villagers. Illness could be
classified into the broad categories of 'natural' and
'unnatural' illness; the former refers to disorders which
come on their own for no reasons and the latter refers
to illness which was deliberately sent by others.
Four studies in Zimbabwe have provided a detailed
description of the aetiology and types of illness
amongst the Shona peoples [7, 8, 18, 24]. Illnesses such
as colds and mild fevers are classified as being 'normal'
since they occurred from time to time in the life of
individuals and were of a fleeting nature. However,
when this complaint persisted for a long time, or if the
quality of the complaint was different, then the illness
was 'abnormal' and required further explanation.
These included angry spirits, most commonly, the
vadzimu or ancestor spirits, ngozi or spirits of those
who died unnaturally, mashave or alien spirits and
witches. Most illness is conceptualized as being natural
in the initial stages, and patients consult either
traditional or Western medical care; once an abnormal
aetiology is considered, traditional medicine is
preferred [24]. A related dichotomy is that of bad airs
or mamhepo. When marnhepo is associated with
natural, minor or normal illness, the airs emanate from
the environment and its source could be natural
phenomena such as decaying matter and seasonal
changes. They are not viewed with alarm and no
spiritual significance is attached to them. The second
category is when bad airs are associated with
unnatural or serious health problems and these can
affect the body, spiritual and social health. These are
believed to originate from evil powers associated with
physical or earthly aspects of life, but not with the
Creator [18]. The term mamhepo is also used in relation
to mental disorder to describe a sudden bizarre
behavioural disturbance which has been likened to
hysteria [8, 14]. A recent study by the author replicated
the prominent role of spirits and witchcraft in the
causal models of mental illness, but also revealed that
several biomedical concepts were incorporated,
including drug abuse, old age, AIDS, poverty,
unemployment and marital discord [8]. A variety of
types of mental illnesses are recognized by traditional
healers in Zimbabwe [7, 8]. Some disorders are
identified according to phenomenology. Kupenga
kwechitsiko resembles an anxiety state or hysterical
disorder and is characterized by the display of a mental
imbalance in the presence of people, which goes away
when the person is away from them. Other categories
include the eating of mud or other 'dirty' matter, and
continuous repetitive behaviour or movements such as
a drummer who cannot stop drumming (likened by
Gelfand to compulsive behaviour). In ebebzi, the
person suddenly starts talking nonsense or performs
senseless tasks but is normal in lucid intervals; in
zuwanda, a person may commit crimes such as theft,
and imagines that something is continually moving
over his body; in mamhepo, a person may behave like
an animal and may become very agitated, often
requiring restraint. Mental illness caused by a witch is
beleived to be far more serious than that caused by
ancestral spirits. Some disorders can also be classifed
on aetiological grounds: thus, rema signifies a mentally
handicapped child, born handicapped because of an
angry spirit; kutanda botse is when a person wanders
in a dishevelled state, wearing only rags, moving from
village to village and is due to angry spirits. The Shona
recognize that strain can also result in mental
breakdown. Thus, a person who has stolen something
and continues to worry that he may be discovered
could have a mental breakdown. Hearing voices is
often a sign of mental disorder and is believed to be the
result of ghosts. Ghosts also cause an affliction in
which a person suddenly disappears every now and
then (masaramusi). Recent studies have replicated
many of these categories, and added the category of
'thinking too much' or kufungisisa which may be
related to the biomedical constructs of depression and
anxiety [8, 25].
PHENOMENOLOGY OF MENTAL ILLNESS
Most studies on mental illness in SSA have tended
to use biomedical diagnostic systems as a comparative
model. In the biomedical model, mental illness is
broadly classified into organic and functional
categories; functional illness constitutes the bulk of
mental illness and is characterized by the lack of
discernable pathological findings. Functional dis-
orders are further classified into the broad groups of
psychotic and neurotic illness. Psychotic illnesses are
the 'major' mental disorders, and include schizo-
phrenia and bipolar affective disorder; neurotic
disorders constitute the bulk of mental illness in
primary care and consists of several categories with
 Explanatory models of mental illness in SSA
blurred boundaries. It is worth noting that there is no
unanimous agreement on the classification of mental
illness, especially neurotic disorders and some authors
have suggested the use of a dimensional model of
classifying common mental disorder [26].
Many studies describing phenomenology of mental
illness in SSA describe illnesses with marked
behavioural disturbance bearing close similarity to
acute psychotic illness. In Kenya, Good asked
traditional healers to describe the "visible physical, or
emotional signs" of various illnesses [10]. Madness was
associated with the following phenomena: first,
behavioural disturbances such as jumping, tearing
clothes, singing and running around, beating other
people, fierceness, laughing and talking to oneself,
becoming wild, restless and stronger than normal,
collecting rubbish and wearing it; second, cognitive
and speech disturbances such as loss of memory,
confusion, talking nonsense and saying bizarre things
such as 'an animal is eating me'; third, general
appearance includes reddened or yellowish eyes,
swaying of the head and twitching and shifting eyes.
In Zimbabwe, behavioural changes and impaired
self-care are cited as the core features of mental illness,
which is typically associated with kupenga or severe
madness [8]. The Serer of Senegal recognize seven
illnesses of the spirit on phenomenological grounds: o
bodah is when a person has no ideas in his head, is
unable to understand, talk to himself, thinks like a
child and is easily influenced; o dof occurs when
behaviour is hostile, overly excited and destructive.
The person may speak to himself in an unintelligible
fashion; pobouh lang designates a person who eats
earth but specifically excludes pregnant mothers and
children prior to weaning; mbefedin literally mean
those who swoon and its sufferers are prone to periodic
fits characterized by fainting, convulsions, foaming at
the mouth, tongue bite and incontinence; o yome
signifies impotence; hon haft"and song nakh are both
the result of spirit possession and have protean
manifestations including aching in the joints and
episodes of palpitations [9]. The latter two categories
may be related to neurotic illnesses. Studies with the
AmaXhosa have identified symptomatology associ-
ated with mental illness which mirrors the classic
categories of mental illness in the West. Thus, case
descriptions of three major categories of disturbed
behaviour reveal similarities with behavioural disturb-
ances associated with acute psychoses (e.g. agitation,
disrobing, sleeping less, aggressive behaviour, unpre-
dictable behaviour, suspiciousness), major depression
(e.g. not eating, becoming very lazy, crying because the
heart is sore, becoming thin) and a category with more
diffuse boundaries called isifo esimhlophe which is an
indication that the sufferer is being called to become
a spirit medium or healer or headman, and begins with
sensations of palpitations, throbbing, epigastric
discomfort and is often accompanied by psychotic
behaviour, hallucinations which inevitably involve the
ancestors guiding the patient to becoming a medium.
1295
Cognitive disorders such as obsessional states are
rarely recognized, and the authors suggest that these
can only be determined according to Xhosa value
systems. Similarly, perceptual phenomena such as
hallucinations appear to have a status value, and even
when they are associated with florid psychotic states,
seem to have less diagnostic importance than
behavioural and affective disturbances [16].
'Neurotic' symptoms are generally more difficult to
identify cross culturally. It is often stated that mental
illness in Africa, especially neurotic illness, tends to
present with somatic symptoms. Ebigbo states that for
Africans, the body is the mind, and the mind is the
body, and physical images are often used to describe
feelings of the mind, and dispositions of an external
mind (as in witchcraft) are attributed to the body [19].
He reports on the phenomenology of patients treated
in a Nigerian psychiatric hospital and given
biomedical diagnoses [27]. Sixty five somatic and other
symptoms relating to the head and body were included
in a rating scale which effectively distinguished
psychiatric patients from normals. Whilst many of the
symptoms bear close similarity to biomedical
phenomena such as insomnia, loss of apetite,
headache, fearful thoughts, palpitations, dizziness,
suicidal wishes, aggressiveness, excessive talkative-
ness, hypersomnia, restlessness, bodily pains and so
on, there were several symptoms which appear to be
unique including heat and crawling sensation in the
head, heat inside the body, neck stiffness and rigidity,
feeling as if the tongue was trembling, a turning
sensation in the head, a sensation of the heart wanting
to fly out and so on. The significance of these somatic
symptoms in relation to mental illness remains
unclear; thus, many symptoms have no equivalent in
the Euro-American systems, and there is evidence that
patients with somatic symptoms do not respond as
well to physical treatments [28]. Cognitive features
such as guilt are much less emphasized in Nigerian
patients, giving credence to the traditional belief that
depression represents an attack from the outside, such
as through witchcraft and spirit aggression [19]. In
another study, at least three neurotic-like illnesses
were identified by Nigerian traditional healers [12]: ode
ori which signifies heat in the head and tension
headaches; innu which denotes fearful feelings,
palpitations and insomnia; and were ironu is mental
illness due to excessive thinking on an unresolved
problem. In Zimbabwe, phenomena such as thinking
too much, pressure or heat on the head, the sensation
of something moving under the skin, dizziness, body
aches and palpitations may be equivalent to neurotic
phenomena [8, 29].
There are some conditions which either have no
corollary in biomedical classifications, such the 'brain
fag syndrome', or are described as occuring with much
greater frequency in Africa, such as the brief reactive
psychoses. Despite the fact that the brain fag
syndrome has been described in a number of SSA
cultures for over 30 years, it does not find a mention
1296 VIKRAMPATEL
in the latest W H O classification of mental disorder,
reflecting the dominance of the Euro-American model
of psychiatry [30]. The condition is typically reported
in students. Recent studies in Swaziland [31] reported
that the syndrome appears to resemble a neurotic
illness associated with the stress of education. Somatic
symptoms are prominent and include headaches,
crawling sensations and hot fluid in the scalp,
abdominal and chest pains, fatigue, palpitations,
dizziness and faintness. Behavioural features included
falling asleep in class which was a characteristic feature
of the syndrome. Cognitive features such as poor
concentration, the mind going blank, thinking too
much and the mind feeling boiling hot were also
frequent. Depression was diagnosed on the basis of
etic phenomena such as impaired apetite and sleep,
social withdrawal, anhedonia and suicidal ideas.
Although the students rarely admitted depressed
mood, they did admit occasionally to feeling that the
heart was sinking or was sore, that the soul was ebbing
away and that bad news was imminent. Intensification
of the original somatic symptoms, confusion in terms
of forgetfulness and inefficient thinking and feelings of
being possessed or haunted were also volunteered.
Occasionally, patients would exhibit a behavioural
disturbance akin to a hysterical disassociative state
characterized by sudden onset of disinhibited
behaviour with vivid hallucinations. Typically,
neurotic disorder was attributed to high blood
pressure by patients and clinic staff.
Brief reactive psychosis are characterized by the
sudden onset of intense overarousal, restlessness,
aggressive behaviour, stripping naked, bizarre be-
haviour such as smearing faeces and pressured speech.
The psychotic episode usually lasts less than a month
and there is complete recovery. It has been suggested
that the frequent presentations of such psychoses may
account for the apparently better prognosis of
schizophrenia in Africa [32]. In Zimbabwe, a brief
behavioural disturbance akin to this biomedical
category is recognized by traditional healers [8].
DISCUSSION
This paper reviewed studies on mental illness from
11 SSA nations and extracted information relating to
explanatory models. Several questions can be posed
whose answers are contained in this review.
- - Do SSA cultures differentiate between the mind
and body?
- - Is this concept of mind shared by the different
cultures?
- - H o w does it relate to the Euro-American
concepts?
One can firmly conclude that virtually all the
cultures reported differentiate between the mind and
the body and the concepts relating to the mind are
shared to some extent by the different cultures. The
existence of traditional healers who specialize in the
management of mental illness adds concept validity to
the existence of a mind-body differentiation. There are
striking similarities to Euro-American concepts,
evidenced by reports of a 'goodness-of-fit' between the
two systems' identification of mental illness, and the
attempts by some authors to compare traditional
concepts about the parts of man to Euro-American
ideas, such as Freudian theories about the personality.
But there are also significant variations from
biomedical concepts in relation to concepts of the
mind, its functions and localization. Thus, in many
SSA cultures, the soul and spirit is concerned with
mental life and emotions, and some authors suggest
that illnesses of the 'spirit' and of the 'soul' are
probably analogous to mental illness. The somatic
localization of the soul and mind is in the head, chest
and/or abdominal regions. The finding that a
'thinking' function is increasingly ascribed to the head
is probably the result of syncretization of Euro-Amer-
ican influence with traditional beliefs. As Ebigbo has
stated, the localization of the mind to somatic
structures may explain the phenomenon of somatic
presentations of many nonpsychotic mental illnesses
[19]. Thus, what is perceived by British patients as
being palpitations associated with anxiety due to
neurochemical imbalance in the brain, may be
perceived by some SSA patients as palpitations due to
imbalance in the function of the heart.
How do the different models of classification of
mental illness relate to each other? A number of
common threads can be identified in the diversity of
taxonomies and aetiological models: first, though
there is a common assumption that classification is
often solely on aetiological grounds, there is evidence
that phenomenological classifications are also import-
ant. Thus, the type and severity of behavioural
disturbance is often used to classify broad categories
of mental illness; it is within these categories that
aetiological models are used for further classification.
Secondly, the classifications used are flexible and
patient-dependent; thus, even though phenomenology
may be used by a healer to understand the nature of
the illness, an aetiological model is almost always
provided since it gives the illness experience meaning
for the patient. Thirdly, there is a general classification
of illness into the two categories of 'normal' and
'abnormal' illness; these have clear implications on
health service utilization, since the former category
may be percieved as being equally well treated by both
biomedical and traditional modes, whereas the latter
is seen to be related to traditional beliefs of misfortune
and illness and is thus brought principally to
traditional healers. Natural causes include a range of
external environmental factors including climactic
changes, infections and substance abuse. Mental
illness can be inherited either due to spiritual or genetic
factors. A further classification of unnatural causes is
the three way model of supernatural forces, illness
caused by other human beings, and illness caused by
the behaviour of an individual or his family [6].
 Explanatory models of mental illness in SSA
Murdock's models ofaetiology, based on a worldwide
survey of illness also classified illness into two basic
groups viz. natural causation, such as infections and
accidents, and supernatural causation, which included
mystical causes (e.g. fate, ominous sensations,
contagion, mystical retribution), animistic causes (e.g.
soul loss, spirit aggression) and magical causes (e.g.
witchcraft and sorcery) [33]. Fourthly, the role of
spirits is prominent in the causation of illness, and
though witchcraft is outlawed in most of SSA, this
category continues to be used as an important way of
explaining misfortune. Finally, there is evidence that
with the influence of colonization and change, views
about illness are also changing. Thus a recent study
involving psychiatric outpatients in Nigeria found that
less than half the patients held a supernatural cause as
the source of their problem; neurotic illness was more
likely to be ascribed to supernatural causes than
psychotic illness [34]. Similarly, the diminishing
importance of spiritual causal models in urban settings
was noted by Good in Kenya [10].
Do the broad biomedical categories of psychotic
and neurotic illness have equivalent concepts in SSA?
Ben-Tovim, in a review of the literature on mental
illness in Africa concluded that not only did
psychiatric diseases as first identified in Europe also
exist in Africa, but that, at least as far as neurotic
disorders were concerned, they were as common [35].
However, most of the studies he reviewed used etic
diagnostic interviews and it was not clear whether the
patients and local people felt that those diagnosed as
suffering a neurotic disorder were suffering from a
mental illness. This review suggests that most
commonly, EMs of mental illness in Africa equate
them with psychotic disorders. Thus, in many studies,
when healers or key informants are asked open
questions to describe mental illness, they most often
describe behavioural features related to psychotic
illness. It is only when there is more detailed inquiry,
or the presentation of case vignettes, that the extended
ramifications of the concepts and classification of
mental illness which include neurotic-like disorders are
elicited. Kortmann's finding that though there existed
a general and 'neutral' Amharic term to denote mental
illness in Ethiopia, this excluded many less severe
forms of psychiatric disturbance which were not
considered as being illnesses [22] has echoes in many
studies of other African cultures; thus, in Zimbabwe,
although case vignettes of depression, agoraphobia
and somatization were recognized by a range of
primary care providers, they were often considered to
be social problems as opposed to 'mental' disorders [8].
Indeed, the view that traditional healers may not be
able to distinguish neurotic and psychotic disorders [7]
may be largely due to the fact that they do not
recognize the former as being related in any way to the
latter.
Do the various mental disorders as recognized by
etic and emic criteria present with phenomenology
that relates across cultures and to Euro-American
1297
concepts? As far as acute and severe psychotic illness
is concerned, there is a striking similarity in the
behavioural symptoms across cultures, with some
behaviours such as incoherent speech, talking to
oneself, disrobing, wandering and aggression being
particularly common. A behaviour such as disrobing
is rarely reported in Euro-American literature, and it
is tempting to hypothesize that this is evidence of the
direct contribution of sociocultural norms to the
symptoms of even the most severe of mental illness.
Although such patients would be identified as suffering
from a psychotic illness by etic criteria, there is much
less emphasis on cognitive features such as delusions
which are central to the diagnosis in the biomedical
model. As would be expected, there is much greater
variation in phenomenology of neurotic disorders,
further confirming the important role that sociocul-
tural factors play in the genesis and expression of these
disorders. Disorders resembling the neuroses (this
category has now been replaced by new categories in
ICD-10, many of which are not validated in SSA),
though often not percieved to be mental disorders, are
still recognized by local people and traditional healers
as being sources of illness, suffering and misfortune.
Somatic features predominate, and there are some
symptoms with no obvious biomedical equivalent such
as the experience of crawling under the skin and
uncomfortable sensations originating in the region of
the heart and abdomen. A number of cognitive
features such as fearful feelings, thinking too much
and the mind going blank are also identified, though
they are less emphasized. Finally, there are several
phenomena that bear close similarity to biomedical
anxiety and depression, such as insomnia, palpita-
tions, headache and anorexia. Even though, in general,
no distinctions are made between the various
categories of neurotic disorder, some studies involving
detailed questioning of traditional healers have
uncovered a number of sub-categories which bear
similarities with biomedical categories; perhaps the
most frequently reported groups are those resembling
hysterical disorders and panic disorders. Obsessive
complusive disorders and phobias are rarely differenti-
ated from other conditions. In contrast, the brain
fag syndrome and brief reactive psychoses are
frequently reported but only rarely encountered in
Euro-American settings.
CONCLUSIONS
The various studies of EMs of mental illness in SSA
reviewed in this paper reveal a rich diversity of beliefs.
Within this diversity are a number of shared ideas.
Most cultures distinguish between the mind and body,
and share some concepts of mental illness with
Euro-American concepts. Whilst psychotic illness is
often recognized as 'madness', neurotic presentations
are more varied, often somatically defined and may
not be considered to be mental disorders at all.
Cognitive features of mental illness are much Tess
1298 VIKRAMPATEL
emphasized, as compared to behavioural and somatic
features. The implications for future research are clear.
Etic case finding instruments such as the Self Report
Questionnaire have been found to lack validity in
Africa [36] and some reasons for this can be
understood from this review; thus, the emphasis on
behavioural features of psychotic illness and somatic
features and unique cognitive features of neurotic
illness are far removed from the Euro-American
idioms of distress. A future strategy would envisage
the development of an emic case finding instrument
consisting of symptoms described by patients who are
considered to suffer from a mental illness by local
care-providers. Comparisons of patients identified by
emic and etic criteria may allow a clearer understand-
ing o f the similarities and differences between the
concepts of mental illness between two cultures. Only
then can cross-cultural research be comparable,
culturally valid and meaningful to the communities
and care providers in SSA.
Acknowledgements--VP is supported by the Beit Medical
Trust to conduct a study on mental illness and traditional
medicine in primary care in Harare. I am grateful to Keith
Lloyd for introducing me to the literature of medical
anthropology.
REFERENCES
1. American Psychiatric Association. Task Force on
Nomenclature and Statistics, DSM-III-R. APA Press,
Washington, 1985.
2. Littlewood R. From categories to contexts : a decade of
the 'new cross-cultural psychiatry'. Br. J. Psychiat. 156,
308, 1990.
3. Left J. The 'new cross-cultural psychiatry' a case of the
baby and the bathwater. Br. J. Psychiat. 156, 305, 1990.
4. Kleinman A. Patients and Healers in the Context of
Culture. University of California Press, Berkeley, 1980.
5. Fosu G.B. Disease classification in rural Ghana:
framework and implications for health behaviour. Soc.
Sci. Med. 15B, 471, 1981.
6. de Jong J.T.V.M. A Descent into African Psychiatry.
Royal Tropical Institute, The Netherlands, 1987.
7. Gelfand M. Psychiatric disorders as recognized by the
Shona. Central Aft. J. Med. 13, 39, 1967.
8. Patel V., Musara T., Maramba P. and Butau T. Concepts
of mental illness and medical pluralism in Harare.
Psychol. Med. in press, 1994.
9. Beiser M., Ravel J., Collomb H. and Egelhoff C.
Assessing psychiatric disorder among the Serer of
Senegal. J. Nerv. Mental Dis. 154, 141, 1972.
10. Good C.M. Ethnomedical Systems in Africa : Patterns of
Traditional Medicine in Rural and Urban Kenya. Guilford
Press, London, 1987.
11. Gelfand M., Mavi C.S., Drummond R.B. and Ndemera
B. The Traditional Medical Practitioner in Zimbabwe.
Mambo Press, Gweru, 1985.
12. Odejide A.O., Olatawura M., Sanda A. and Oyenye A.
Traditional healers and mental illness in the city of
Ibadan. Aft. J. Psychiat. 3, 99, 1977.
13. Staugard F. Traditional Medicine in Botswana: Tra-
ditional Healers. Ipelegeng Publishers, Gaborone, 1985.
14. Fanuel N. Knowledge, attitudes and practices of
traditional healers in Gutu District. Directory of
Socio-Behavioural Research on H I V Infection and AIDS
in Zimbabwe, pp. 51-52 (Abstract), 1992.
15. Orley J. Culture and Mental Illness: A Study from
Uganda. East African Publishing House, Nairobi,
Kenya, 1970.
16. Cheetham R.W.S. and Cheetham R.J. Concepts of
mental illness amongst the rural Xhosa people in South
Africa. Aust. N. Zeal. J. Psychiat. 10, 39, 1976.
17. Brautigam W. and Osei Y. Psychosomatic illness concept
and psychotherapy among the Akan of Ghana. Can. J.
Psychiat. 24, 451, 1979.
18. Mutambirwa J. Health problems in rural communities,
Zimbabwe. Soc. Sci. Med. 29, 927, 1989.
19. Ebigbo P.O. The mind, the body, and society: an African
perspective. Advances; Inst. Adv. Hlth, 3, 45, 1986.
20. Dhadphale M., Cooper G. and Cartwright-Taylor L.
Prevalence and presentation of depressive illness in a
Primary Health Care setting in Kenya. Am. J. Psychiat.
146, 659, 1989.
21. Left J. Culture and differentiation of emotional states.
Br. J. Psychiat. 123, 299, 1973.
22. Kortmann F. Popular, traditional, and professional
mental health care in Ethiopia. Transcult. Psychiat. Res.
Rev. 24, 255, 1987.
23. Dale J.R. and Ben-Tovim D.I. Modem or traditional? A
study of treatment preference for neuropsychiatric
disorders in Botswana. Br. J. Psychiat. 145, 187, 1984.
24. Chavunduka G.L. Traditional Healers and the Shona
Patient. Mambo Press, Gwelo, 1978.
25. Abas M., Broadhead J., Mbape P. and Khumalo-
Sakatukwa G. Defeating depression in the developing
world: a Zimbabwean model. Br. J. Psychiat. 164, 293,
1994.
26. Goldberg D. and Huxley P. Common Mental Dis-
orders: A Biosocial Model. Tavistock/Routledge,
London, 1992.
27. Ebigbo P.O. Development of a culture specific (Nigeria)
screening scale of somatic complaints indicating
psychiatric disturbance. Cult. Med. Psychiat. 6, 29, 1982.
28. Odejide A.O., Oyewunmi L.K. and Ohaeri J.U.
Psychiatry in Africa: an overview. Am. J. Psychiat. 146,
708, 1989.
29. Chikara G. and Manley M.R.S. Psychiatry in
Zimbabwe. Hosp. Commun. Psychiat. 42, 943, 1991.
30. Patel V. and Winston M. The "universality" of mental
disorder revisited: assumptions, artefacts and new
directions. Br. J. Psychiat. in press, 1994.
31. Guinness E.A. Patterns of mental illness in the early
stages of urbanisation. Br. J. Psychiat. 160, Supplement
16, 1992.
32. StevensJ. Briefpsychoses: do they contribute to the good
prognosis and equal prevalence of schizophrenia in
developing countries? Br. J. Psychiat. 151, 393, 1987.
33. Murdock G.P., Wilson S.F. and Frederick V. World
distribution of theories of illness. Transcult. Psychiat.
Res. Rev. 17, 37, 1980.
34. Ilechukwu S.T. Inter-relationships of beliefs about
mental illness, psychiatric diagnoses and mental health
care delivery among Africans. Int. J. Soc. Psychiat. 34,
200, 1988.
35. Ben-Tovim D.I. Development Psychiatry: Mental Health
and Primary Health Care in Botswana. Tavistock
Publications, London, 1987.
36. Kortmann F. Psychiatric case finding in Ethiopia:
shortcomings of the Self Report Questionnaire. Cult.
Med. Ps.vchiat. 14, 381, 1990.