Predominant psychopathology in a selected population group - adolescents and young adults at school - in a developing country, is described. The highly selective referral to services was supplemented by active case finding in the community over three years. There were 54 cases of somaticised anxiety (brain fag); 22 cases of depressive neurosis characterised by hypochondriasis, cognitive complaints, and culturally determined paranoid ideation; 23 cases of ‘hysteria’ in the form of dissociative states, pseudoseizures and fugues; and 39 cases of brief reactive psychosis which differed from the dissociative states more in duration and intensity than in form. There was a temporal relationship between transient psychosis and the school calendar. Anxiety or depression often predated the florid psychotic reaction which served as a form of help-seeking behaviour or defence in intolerable stress.

In a three-year prospective study of service-based incidence of functional psychoses in Africa, 94 cases of brief reactive psychosis were compared with 56 cases of schizophreniform syndromes, 29 cases of DSM-III schizophrenia and 14 of manic-depressive psychosis. This was supplemented by retrospective study of the same syndromes not in their first episode. Brief reactive psychosis was found to be a composite syndrome. The 50% with preceding depression were a distinct group, in terms of course and demographic features. Of those with intense prodromal anxiety, most were a single episode precipitated by a major life event, a few showed a recurrent long-term pattern. Schizophrenia was heralded, or presented unequivocally months or years later, in 10-20%. The schizophreniform group comprised a range of atypical psychoses intermediate between the transient and major psychoses. The pattern of precipitants and the over-representation of education and paid employment in the acute syndromes, compared with the major psychoses, in a society which was largely first-generation educated, suggested a link with rapid social change.

The profile and prevalence of a syndrome of somaticised anxiety associated with education in Africa was explored by survey of 2040 senior secondary school students in different types of school: rural, urban, and elite. Response to two different screening methods, an open question to elicit symptoms spontaneously, and the SRQ-24, was compared. Symptom prevalence was higher in rural schools, 34%, than periurban, 22%, and elite, 6%, but the central urban school serving a shanty town was also high at 35%. Three categories of the culturally relevant symptoms were identified - somatic, cognitive and ‘spiritual’ - with affective symptoms sparsely represented in the cultural idiom. The SRQ-24 items screening for psychosis were associated with a range of spontaneous symptoms representing anxiety. This ‘spiritual’ expression of neurosis reflects the world views and beliefs of the culture. Intensification under stress could produce the picture of transient reactive psychosis.

The aetiology of psychiatric morbidity associated with education in Africa was explored using two different screening methods (as described in paper III, this supplement). The interactive effect of psychosocial variables was examined by Log linear analysis which demonstrated five independent factors: (a) the financial implications of education which represented the change from subsistence to cash economy; (b) fear of envy and bewitchment which represented the intense cultural response to education; (c) parenting in the pre-school years which was the independent family variable; (d) academic ability; (e) attributes of the school. Age of starting school and birth rank had a marginal effect. Current family adversity in terms of unstable parental union, paternal use of alcohol, polygamy and sibship size operated by interactive or additive effect. Gender and social status had no effect. The brain fag syndrome can be related to the complex social changes during rapid social transition where education is a major agent of change.