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 Table of Contents  
Year : 2017  |  Volume : 24  |  Issue : 3  |  Page : 137-142

Pattern and predictors of Brain Fag syndrome among senior secondary school students in Calabar, Nigeria

1 Department of Clinical Services, Federal Neuropsychiatric Hospital, Calabar, Nigeria
2 Department of Psychiatry, University of Calabar Teaching Hospital, Calabar, Nigeria

Date of Web Publication30-Oct-2017

Correspondence Address:
Emmanuel Aniekan Essien
Federal Neuropsychiatric Hospital, 123, Calabar Road, Calabar, Cross River State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_49_17

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Context: Brain Fag syndrome (BFS) is a culture-bound disorder that is quite common among Nigerian students. It is known to be associated with study difficulty, and in severe cases, discontinuation of education. Little is known about its pattern and predictors among secondary school (SS) students in Calabar. Aims: This study aims to determine the pattern and sociodemographic predictors of BFS among SS students in Calabar. Participants and Methods: Stratified sampling was used in this cross-sectional study to recruit 1091 students from ten SSs in Calabar metropolis. The students completed the Brain Fag Syndrome Scale and a sociodemographic questionnaire which were used in the survey. Data was analysed using SPSS software version 21. Results: The prevalence of BFS was 20.4%. Female gender, school type and local government of location, residence type, parental marital status and maternal educational status were found to have statistically significant relationships with the disorder (P ≤ 0.05). Significant predictors of BFS were female gender (odds ratio [OR] = 1.5, 95% confidence interval [CI] = 1.14–2.09) and having parents who were 'not married' (OR = 1.8, 95% CI = 1.24–2.85). Conclusions: We conclude that BFS is highly prevalent amongst SS students in Calabar metropolis albeit at a relatively lower level compared to similar studies and is significantly predicted by female gender and having parents who are unmarried. We recommend that more research should be performed on this much-neglected psychopathology to elucidate it further, with consequent development of appropriate treatment modalities.

Keywords: Adolescent, Brain Fag, psychopathology, somatisation, somatoform, students

How to cite this article:
Essien EA, Okafor CJ, Okegbe J, Udofia O. Pattern and predictors of Brain Fag syndrome among senior secondary school students in Calabar, Nigeria. Niger Postgrad Med J 2017;24:137-42

How to cite this URL:
Essien EA, Okafor CJ, Okegbe J, Udofia O. Pattern and predictors of Brain Fag syndrome among senior secondary school students in Calabar, Nigeria. Niger Postgrad Med J [serial online] 2017 [cited 2021 Oct 17];24:137-42. Available from: https://www.npmj.org/text.asp?2017/24/3/137/217401

  Introduction Top

Brain Fag syndrome (BFS) is a culture-related disorder which was first described by Raymond Prince, a Canadian cultural psychiatrist, during his fieldwork in Nigeria in the 1960s. He reported what he thought was a distinct psychiatric syndrome which occurred among Nigerian students and other 'brain workers'. It was so common that a medical officer at the time once remarked to him that 'If a young man comes in with glasses and European dress, you may be sure that he will complain of burning in the head and inability to read'.[1] These two symptoms are a component of what has been described as a tetrad that characterises the disorder.

BFS was initially considered unique to Nigerian students, but research has proven otherwise. Scanty reports after the first seminal paper by Prince confirmed that it occurs in other African countries such as Liberia, Uganda, Ivory Coast and South Africa. The condition is, however, virtually unreported among Caucasians.[2],[3],[4],[5] Prior to 1990 when Ola et al. finalised the Brain Fag Syndrome Scale (BFSS) which established the minimum criteria for diagnosis, the approach by researchers was inconsistent.[2] Most researchers at the time only studied few Brain Fag symptoms not the more clearly defined 'BFS' and this limits comparability across studies.[2] A study among Ugandans, for example, did not assess or report symptoms such as 'internal heat' or crawling sensation which are now regarded central to the construct.[6]

The tetrad of symptoms currently accepted as part of BFS includes specific somatic complaints, cognitive impairments, sleep-related complaints and other somatic impairments. The specific somatic complaints include crawling, pain or burning sensations around the head and neck region; cognitive complaints include poor concentration, poor retention and inability to grasp the meaning of written and sometimes spoken words; sleep-related complaints include fatigue and sleepiness in spite of adequate rest, other somatic complaints include blurred vision, eye pain or excessive tearing.[2]

A review of studies that are based on the most recent construct of the disorder shows that the prevalence ranges from 22.0% to as high as 40.2%.[2] The overwhelming majority of these studies are Nigerian. This is not surprising considering its origins and psychopathological relevance to the local context. South African studies that investigated Brain Fag symptoms report rates of 17%–25%.[4],[5] Studies from other parts of Africa are mostly case reports and qualitative studies.[2]

Even though the aetiology of BFS is still unresolved, some correlates of this apparently elusive condition have been established. Prince observed that it occurred mostly in males. While some studies confirm this, others report no relationship with gender.[1],[7] This pattern is surprising, in view of the fact that BFS is believed by most researchers to be a form of anxiety or depression, both of which have been established to be more prevalent in females.[2],[8] Prince also found low socioeconomic status to be an important factor and this has been replicated in later studies.[1],[2],[5] Other correlates which have received independent confirmation include neuroticism, faulty study habits, use of psychostimulants, level of cultural orientation as well as physiological factors such as skin conductance and muscle tension.[2]

To the best of our knowledge, only two studies have attempted to determine the predictors of BFS, both conducted among secondary school (SS) students by Ola et al. In summary, they found that poor academic performance and believing one needs to catch up lost sleep significantly predicted BFS. Sociodemographic variables, such as sex, parental marital status or literacy, were not entered into the regression equation.[9],[10]

A number of studies on BFS have been published over the years; however, studies that attempt to determine the predictors of BFS are scarce. Furthermore, Prince believed that, with the evolution of the Nigerian sociocultural structure from a collectivistic to a more individualistic one, this pattern of 'psychoneurosis' as he called it would reduce and eventually disappear.[1] A study by Ayonrinde et al. provided evidence of its diagnostic decline among Nigerian psychiatrists, which possibly signals 'the early extinction of this disorder or nosological metamorphosis from a 'culture-bound' syndrome in West African psychiatric practice'.[11] If a substantial proportion of Nigerian students in reality still suffer from BFS, the neglect of this condition (in research as well as patient management considerations) puts sufferers at a disadvantage as regards clinical care. These considerations in sum provide rationale for our study which revisits BFS more than half a century after it was first described. This study specifically aims to determine the pattern and sociodemographic predictors of BFS among senior SS students in Calabar.

  Participants and Methods Top

Ethical consideration

Ethical approval was obtained from the Research Ethics Committee of the Ministry of Health, Cross River State, on 24th June, 2014 (protocol number: CRS/MH/CGS/E-H/018/VOL II/082). Written approval to conduct the study was also obtained from Cross River State Ministry of Education. Principals of the selected schools were asked to provide permission for participation of their wards. Student participation was strictly voluntary and only students who gave informed consent were recruited. Questionnaire administration was anonymous and strict confidentiality was observed.

Study design and location

This is a cross-sectional descriptive study conducted among SS students in the metropolitan city of Calabar, the capital of Cross River State. Calabar lies on latitude 4°59'36“N and 8°19'05”E and is within the tropical rain forest of Nigeria. It is bounded on the North by Odukpani local government area (LGA), on the West by Calabar River with the Great Qua River on the South and the East.[12],[13] It has two LGAs; Calabar South, the older part of the metropolis where the inner-city slums are located and Calabar Municipality which is the newer, more affluent part of the city. There are eighty government-approved SSs in Calabar. Twenty-two of these are public schools and the rest are privately owned.

Sampling procedure

Schools were selected for participation in the study using the stratified sampling technique. They were first stratified on their location (i.e., Calabar South or Calabar Municipality LGAs) and stratified on the second level based on school type (whether public or privately owned). This approach yielded four groups with 28 private co-educational schools in group 1 (Calabar Municipality), 24 private co-educational schools in group 2 (Calabar South), 14 public co-educational schools in group 3 (Calabar Municipality) and 7 public co-educational schools in group 4 (Calabar South). Simple random sampling was then used to select four schools from group 1, three from group 2, two from group 3 and one from group 4. This made up a total of ten schools, seven privately owned and three public. The higher number of private schools selected reflects their higher number in Calabar Metropolis. Public schools, however, have a considerably larger student population compared to the private schools.

A sample size of 1024 was estimated using the Cochran formula for calculating minimum sample size for a known prevalence rate.[14] Sampling took the secondary school 3 (SS3) population in each school into account (i.e., representation of each school in the final sample was proportionate to the school's total SS3 population). The proportion that each school contributed was calculated by summing the total number of SS3 students in all the ten selected schools and calculating what proportion each school contributed to the sum. The value(s) thus obtained was multiplied by the calculated sample size to give the approximate proportion of students that each school would contribute to the final sample. The number of students each school was to contribute was divided by the number of SS3 arms to get the number to be selected from each arm. Within each arm of the selected SS, simple random sampling through yes or no balloting was used to select the required number of students.

Study instruments

The BFSS was first designed by Prince in the early 1960s to detect the probable cases of BFS. It was later modified by Prince and Morakinyo in 1980 into the current 7-item version.[15] Each question has three possible responses (often, sometimes and never) with scores 2, 1 and 0, respectively. The maximum score obtainable from the scale is 14. To qualify as a case of BFS, the individual must have a minimum total score of 6 and should also have a minimum score of 1 on items 4 and 5 because they are considered central to the construct of the syndrome. Items 4 and 5 assess for the presence of psychosomatic symptoms (such as burning or crawling sensation) and their interference with study, respectively.[9] The instrument is reported to be reliable and has been used in several studies on the BFSS both within and outside Nigeria.[2],[16]

A sociodemographic questionnaire was administered to elicit variables such as age, sex, marital status of parents and educational attainment of parents.

Study procedure

Steps were taken to ensure that questionnaire administration did not interfere with the academic activities of the participants. Before administration of the questionnaires, the aims and objectives of the study were discussed with the students and the voluntariness of the exercise was emphasised. They were also assured of strict confidentiality as regards their participation and any information they would provide. Both questionnaires were administered to the students with the support of a trained research assistant. The filling of the questionnaires was done in their classrooms. Inclusion criterion was (1) senior SS3 students in the selected SSs, while exclusion criteria were (1) students who did not provide consent for participation and (2) students who reported a past history of mental illness. Only students of the most senior class (senior SS3) were recruited because it was expected that they would have a better comprehension of the questionnaires. Data were collected over a period of 2 months. In the end, a total of 1091 students (higher than our estimated sample size by 67) had been successfully recruited for participation in the study. The data were analysed using the Statistical Package for Social Sciences (SPSS) version 21, (IBM Corp, Armonk, New York).[17]

Study hypothesis

Hypotheses (null) formulated to guide interpretation of results were as follows: (1) Gender is not a predictor of BFS, (2) school type is not a predictor of BFS, (3) parental educational level is not a predictor of BFS, (4) parental marital status is not a predictor of BFS and (5) residence type is not a predictor of BFS.

  Results Top

The sample comprised 552 males and 539 females, totalling 1091 students. The mean age of the participants was 15.81 years (±1.35). Respondents from public schools were 604 (55.5%) while those from private schools were 487 (44.6%). Other sociodemographic details are summarised in [Table 1].
Table 1: Sociodemographic variables of all respondents (n=1091)

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A few sociodemographic variables were subsequently dichotomised for simplicity of analysis and presentation. Marital status was dichotomised into 'married' and 'not married'. 'Married' comprised respondents whose parents were married, whether monogamous or polygamous. 'Not married' included respondents whose parents were separated, divorced or never married. The variable which indicated who the participant was living with i.e., residence type was also dichotomised into 'living with parent' and 'others', the latter category being all those who were not living with a parent. Paternal education was dichotomised into 'low education' (i.e., fathers who had no formal education and those who had only primary education) and 'high education' (i.e., those who had only secondary education and those who had tertiary education in addition). The same was done to the maternal educational status.

The prevalence of probable BFS among the respondents was 20.4% (223 out of 1091). It was higher among females, who had 133 cases and a prevalence of 24.7%, compared to males, who had 90 cases (16.3%). This difference was statistically significant (P = 0.001).

BFS was also found to be significantly higher among students from public schools, students schooling in Calabar South, students who were isolated from (i.e., not living with) their parents, students whose parents were 'not married' and students whose mothers had 'low education'. Details are summarised in [Table 2].
Table 2: Sociodemographic correlates of probable Brain Fag syndrome

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A binomial regression [Table 3] was done to determine which sociodemographic factors (independent variables) predict BFS (dependent variable). The logistic regression model was statistically significant, χ2 (5, n = 1091) = 35.59, P = 0.000. The model explained between 3% and 5% of the variance in BFS and correctly classified 79.7% of cases. Females were 1.5 times (95% confidence interval [CI] = 1.14–2.09) more likely to report BFS while students whose parents were not married had a 1.8 times more likelihood to report the condition (95% CI = 1.24–2.85). Other variables entered into the equation were not significant predictors. Hypotheses 1 and 4 are therefore rejected while 2, 3 and 5 are accepted.
Table 3: Logistic regression to determine sociodemographic predictors of Brain Fag syndrome

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  Discussion Top

The prevalence of BFS in this study was quite close to the prevalence reported by some researchers; 22.4%, 22.9% and 25% by Eeguranti, Fatoye and Peltzer, respectively, among SS students.[5],[18],[19] Fatoye in yet another study found a prevalence of 38.9% which was close to the report by Ola and Morakinyo which was 40.2%.[9],[20]

Cultural orientation has been found to be associated with BFS.[1],[2] Our relatively lower prevalence may suggest a low cultural orientation among adolescents in the local population. It is possible that other factors yet unknown, for example, local sociocultural effects may play a role. As Prince predicted, the pattern of the condition in the local population may be changing. We do not hurry to this conclusion, however, because there are no previous studies of BFS in Calabar to demonstrate a reduction in prevalence.

As regards gender, our finding is contrary to previous reports. Early studies conducted in the 1960s and 1970s reported higher rates among males.[2] It has been suggested that this finding was a reflection of the larger population of males in educational institutions at that time.[2] Later studies did not find any difference suggesting that its occurrence among females was rising. To the best of our knowledge, this study is the first to observe a significantly higher prevalence among females. Family pressure and expectation have been linked with BFS, and according to Fatoye, changes in the way the African society views the female child with an increase in family/societal expectations could explain the rise.[20],[21] Gender differences in symptom perception, with females showing a more histrionic response set (leading to over-reporting) and males underreporting, could also play a role.[22]

Research has established that female gender is a risk factor for anxiety and depression, and most researchers link BFS to these disorders.[8],[23] Neki and Marinho, for example, saw it as a somatised form of anxiety or depression. Other important researchers in the field share similar views.[2] If this is indeed the case, then it is expected that female gender should significantly predict BFS as reported in our study. As far as we know, no other study has attempted to determine the predictive effect of gender as regards BFS.

Morakinyo reported that sufferers were more likely to come from socioeconomically deprived backgrounds, which constitutes a threat to achieving their academic objectives in life.[21] School type is a rough indicator of parental socioeconomic status and this could be the reason why the condition was more common among students in public schools.[1],[2] The higher rate of BFS among students in Calabar South is also probably a reflection of the lower average socioeconomic level of people living in this area, which is the older, less affluent part of the city.

It was observed that having parents who were not married (i.e., separated, divorced or single) significantly predicted BFS. To the best of our knowledge, no previous study has attempted to examine this variable in relation to BFS. Psychopathology is widely reported to be higher among children in single-parent families.[24] In cases of divorce, it is thought to be a result of the stress children experience in the family turbulence both before and after separation. Parents possibly get so caught up in their emotional problems to the extent that they neglect their parental duties.[25]

Morakinyo reported that family adversity was an important finding in persons with BFS, after conducting in-depth interviews.[21] It is possible that respondents whose parents are separated, divorced or unmarried experienced more family adversity compared to those whose parents are married. This may play a role in precipitating BFS.

Gerald observed a relationship between isolation from parents and BFS. This is in keeping with our finding as BFS was more common among students who do not live with their parents. It is likely that parents are more likely to bond better with their own biological children and therefore provide better emotional and social support, which has been shown to be a protective factor from mental disorder.[26]

The higher rate of BFS among students whose mothers had lower educational attainment seems to be in agreement with the findings of Prince. He was of the opinion that BFS was more common in students whose parents were lacking in formal education, although a subsequent study by Peltzer did not confirm his observation.[5],[27] It is possible that parents who lack formal education are less westernised (therefore have higher levels of cultural orientation) and are more socioeconomically disadvantaged. These two factors have been theorised to play a role in the aetiology of BFS and could explain our observation.[2]

  Conclusions Top

BFS is highly prevalent among SS students in Calabar. An important change in its pattern of occurrence (higher female prevalence) was reported. Other changes in the syndrome and its associated factors may occur in future due to further evolution in the sociocultural and socioeconomic structure of the society.

In light of its prevalence, clinicians should have a high index of suspicion for identification of the disorder among students to facilitate the provision of needed care. This will lead to reduction in personal suffering and improve academic outcomes.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Ola BA, Morakinyo O, Adewuya AO. Brain Fag Syndrome - A myth or a reality. Afr J Psychiatry (Johannesburg) 2009;12:135-43.  Back to cited text no. 2
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Morakinyo O, Peltzer K. 'Brain fag' symptoms in apprentices in Nigeria. Psychopathology 2002;35:362-6.  Back to cited text no. 4
Peltzer K, Cherian VI, Cherian L. Brain fag symptoms in rural South African secondary school pupils. Psychol Rep 1998;83:1187-96.  Back to cited text no. 5
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IBM SPSS Inc. SPSS Statistics for Windows. IBM Corporation. Ver. 21. IBM Corp, Armonk, New York. Released 2012.  Back to cited text no. 17
Eeguranti A. Stimulant Use and Psychopathology among Secondary School Students in Osogbo, Osun State, Nigeria. Fellowship Thesis. National Postgraduate Medical College of Nigeria; 2006.  Back to cited text no. 18
Fatoye F, Morakinyo O. Study difficulty and the “brain fag” syndrome in South Western Nigeria. J Psychol Afr 2003;13:70-80.  Back to cited text no. 19
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  [Table 1], [Table 2], [Table 3]

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