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Current Medical Research and Opinion
Vol. 3, No. 6, 1975
Treatment of ‘brain fag’ syndrome
A. Anumonye,*M.D.
Curr. med. Res. Opin., (1 975). 3,367.
Lagos University Teaching Hospital, Lagos, Nigeria
Received: 17th May 1975
Summary Sixtjj male Nigerian students suffering from ‘brainfag’ syndrome who had faired to respond satisfactorily to 4 to 8 weeks’ treatment with other benzodiazepines were treated with J to 2 mg. lorazepam t.i.d. There was marked improvement in symptoms il? over 80% of the patients by the end of the second week of Iorazepam treatment. Side-effects were considerably less frequent or incapacitating than with the previous therap).. Key words: Lorazepam - tranquillizing agents - neuroses, anxiety - depression ‘brainfag’ s.vndrome
Introduction ‘Brain fag’ was described in 1960 by Princeg as a psychiatric syndrome occurring in young, unmarried, male Nigerian students. The symptoms are remarkably similar to those of depressive illness with somatisation secondary to anxiety. Intellectual and sensory impairment, anxiety, sleep disturbances, a burning sensation in the head and neck, in addition to other symptoms which militate against the students’ ability to study, predominate. There is also a tense facial expression and a characteristic gesture, that of passing the hand over the surface of the scalp and of rubbing the vortex of the skull during a period of intense concentration. While these are undoubtedly neurotic symptoms, not essentially dissimilar to those manifested in anxious and depressed patients of European cultures, their clinical features are culturally influenced and are peculiar to the male Nigerian student, possibly as a reaction to the imposition of European learning techniques, to academic pressures, or to both. In the treatment of symptom complexes such as are found in this syndrome, lorazepam, one of the newer anxiolytic benzodiazepines, has shown considerable promise. Lorazepam possesses dose-related anxiolytic and sedative-hypnotic properties2.4 and has been proved effective in decreasing anxiety and tension in many emotional and physical illnesses.’ p 3 . 5 , 6 - * , 1 0 - 1 2 Like most agents used in psychiatry, lorazepam is used as an adjunct to psychotherapy, to help the patient integrate his defenses against intra- and interpersonal challenges. The possibility that lorazepam might offer advantages in the treatment of ‘brain fag’ syndrome *Professor of Psychiatry
367
Treatment of ‘brain fag’ syndrome
I
Curr Med Res Opin Downloaded from informahealthcare.com by Washington University Library on 12/26/14 For personal use only.
was investigated in this limited open study. A major objective was to determine the efficacy of lorazepam in improving the emotional status of the patient.
Methods and materials Sixty male students between the ages of 13 and 30 attending the out-patient psychiatric clinic of the Lagos University Teaching Hospital were admitted to the study. All had a diagnosis of ‘brain fag’ syndrome and all had failed to respond satisfactorily after 4 to 8 weeks of treatment with other benzodiazepines, (chlordiazepoxide and diazepam). Diagnosis of ‘brain fag’ syndrome was made on the basis of symptomatology described by Prince9 and included those symptoms shown in Table 1. Table I. Symptomatologyof ‘brain fag’ syndrome
Intellectual dificulties Poor concentration Difficulty in comprehension Poor memory Slowed Inability to read for long Difficulty in manipulating figures Difficulty in expression
Sleep disturbances Difficulty in going off t o sleep Early morning wakening Sleep unsatisfying Excessive sleep Excessive dreaming
Disturbance of afect Sadness/tense expression Feeling of sadness Fed up’ feeling Agitation/nervousness Manifest anxiety Irritability Phobias
Physiological disturbances Loss of weight Tremor Excessive perspiration Abdominal discomfort Breathing difficulties
Sensory disturbances ( a ) Somaesthetic Localised in headlneck Heat o r ‘peppery’ feeling Tension Heaviness Crawling sensation Headaches Pain Numbness Eye pain Itching sensation Emptiness Fluid’ inside head
(b) Special senses Visual Blurring Dimness of vision Auditory Tinnitus Vestibular Dizziness Tendency to fall
Generalised Heat and ‘peppery’ feeling Lightness Weaknesslweariness Biting/itcbing
The presence and severity of these symptoms were recorded for each patient prior to and after treatment with lorazepam and served as a basis for a clinical global evaluation. Severity of symptoms was rated on a scale of 0 (none) to 3 (severe). Clinical improvement was rated on a scale of 0 (none) to 3 (marked). After a washout period of 1 week during which no medication was permitted, lorazepam was administered to each patient, 1 or 2 mg. t.i.d. Each of the patients was told that certain side-effects, such as dry mouth or drowsiness, might occur but should not be allowed to interrupt the routine intake of medication. Patients were instructed to report these and other side-effects at their weekly visits to the clinic. 368
A. Anumonye
Curr Med Res Opin Downloaded from informahealthcare.com by Washington University Library on 12/26/14 For personal use only.
Results and discussion A steady decrease in the severity of symptoms from pre-treatment levels was noted in more than 80 % of the patients, becoming quite evident by the end of the second week. By the end of the study, therapeutic gains were readily apparent. Improvement of symptoms was marked in 51 patients (84%), moderate in 7 (12%), and mild in 1. Symptoms in the remaining patient were unaffected. These results contrast sharply with those of previous studies with chlordiazepoxide and diazepam, in which only mild or no improvement was noted (Table 11). Table 11. Response to lorazepam and other benzodiazepines
Patient improvement ~
~~~
Lorazepam % improved
% side-effects
Chlordiazepoxide/Diazepam % improved % side-effects
~
Marked Moderate Mild Unchanged
84 12 2
14 18 5
2
56 44
66
2
Those symptoms which responded most rapidly to treatment with lorazepam included difficulty in concentrating, sleep disturbances, and somatic discomfort referrable to the eye and head. Dizziness, which can have devastating effects in an ambulant patient population, was notably absent during treatment with lorazepam. By contrast, dizziness was a concomitant of treatment with the other benzodiazepines in 35 % of the patients. Adverse effects were no problem during treatment with lorazepam. Such effects, which consisted for the most part of mild and transient dry mouth (20 patients) and drowsiness (2 patients), were well tolerated as treatment continued. Findings from previous studies with chlordiazepoxide and diazepam (Table 111) showed a comparable incidence of dry mouth, a higher incidence of drowsiness, and an unusually high incidence of dizziness, which limited the usefulness of these agents, particularly since all of these patients need to be fully ambulatory. Table 111. Adverse effects during treatment with lorazepam and other benzodiazepines
Side-effect Dizziness Dryness ofmouth Drowsiness Weight loss Depression Tremor Dystonic symptoms Akathisia Excitement Apathy Nausea
No. patients reporting Lorazepam
Chlordiazepoxide/Diazepam
20
35 30
2
10
5
10 5 5 4 4 2 2 2
1
369
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Treatment of ‘brain fag’ syndrome
The most frequently used dose of lorazepam was 1 mg. t.i.d. In some patients an occasional temporary increase to 2 mg. t.i.d. was necessary when symptoms were exacerbated by unusual stress. Most patients reported that this treatment was the most effective they had ever used. Some, however, complained that the cost was prohibitive. References 1. Abry, M., Piante, M., Grossetete, J. L., Daly, J. P., and Laurant, J., (1971). Study of a new benzodiazepine derivative, lorazepam, in gastroenterology. Lyon mkd., 226,581. 2. Appel, P., Berger, I., and Harrer, G., (1971). Erfahrungen mit Wy 4036, einem neuen Tranquilizer aus der Benzodiazepin-Reihe. Arzneim.-forsch., 21,1083. 3. Eaves, D., Jain, V. K., and Swinson, R. P., (1973). A double-blind controlled trial of lorazepam and diazepam in the treatment of anxiety. Curr. med. Res. Opin., 1,265. 4. Elliott, H. W., Nomof, N., Navarro, G., Ruelius, H. W., Knowles, J. A., and Comer, W. H., (1971). Central nervous system and cardiovascular effects of lorazepam in man. Clin. pharm. Therup., 12,468. 5. Guthy, H., Hildgren, J., and Brinkmann, G., (1971). Die Behandlung des Zielsymptoms Angst bei Neurosen, abnormen Erlebnisreaktionen, neuro-vegetativen psychosomatischen Storungen und Depressionen. Arzneim. -forsch., 21,109. 6. Haider, I., (1971). Evaluation of a new tranquilizer - Wy 4036 - in the treatment of anxiety. Brit. J. Psychiat., 119,597. 7 . Haider, I., (1971). Comparative trial of lorazepam and diazepam. Brit. J . Psychiut., 119,599. 8. Meusert, W., (1971). Priifung von Lorazepam (Wy 4036) in der nervenartzlichen Praxis. Arzneim. -forsch., 21,1087. 9. Prince, R., (1960). The ‘brain fag’syndrome in Nigerian students. J. meni. Sci.,106,559. 10. Schrappe, O., (1971). Klinische Untersuchungen mit Wy 4036 (lorazepam) einem neuartigen Tranquilizer. Arzneim. -forsch., 21,1079. 11. Sherliker, J., (1973). A comparison of lorazepam and diazepam in general practice. Curr. med. Res. Opin., 1,269. 12. Soubeyroux, B., Monges, H., and Poilroux, B., (1972). Interest in lorazepam, a new benzodiazepine derivative, in gastroenterological therapy. Corse-Mediterunt!emid., 208,118.
370
Current Medical Research and Opinion
Vol. 3, No. 6, 1975
Treatment of ‘brain fag’ syndrome
A. Anumonye,*M.D.
Curr. med. Res. Opin., (1 975). 3,367.
Lagos University Teaching Hospital, Lagos, Nigeria
Received: 17th May 1975
Summary Sixtjj male Nigerian students suffering from ‘brainfag’ syndrome who had faired to respond satisfactorily to 4 to 8 weeks’ treatment with other benzodiazepines were treated with J to 2 mg. lorazepam t.i.d. There was marked improvement in symptoms il? over 80% of the patients by the end of the second week of Iorazepam treatment. Side-effects were considerably less frequent or incapacitating than with the previous therap).. Key words: Lorazepam - tranquillizing agents - neuroses, anxiety - depression ‘brainfag’ s.vndrome
Introduction ‘Brain fag’ was described in 1960 by Princeg as a psychiatric syndrome occurring in young, unmarried, male Nigerian students. The symptoms are remarkably similar to those of depressive illness with somatisation secondary to anxiety. Intellectual and sensory impairment, anxiety, sleep disturbances, a burning sensation in the head and neck, in addition to other symptoms which militate against the students’ ability to study, predominate. There is also a tense facial expression and a characteristic gesture, that of passing the hand over the surface of the scalp and of rubbing the vortex of the skull during a period of intense concentration. While these are undoubtedly neurotic symptoms, not essentially dissimilar to those manifested in anxious and depressed patients of European cultures, their clinical features are culturally influenced and are peculiar to the male Nigerian student, possibly as a reaction to the imposition of European learning techniques, to academic pressures, or to both. In the treatment of symptom complexes such as are found in this syndrome, lorazepam, one of the newer anxiolytic benzodiazepines, has shown considerable promise. Lorazepam possesses dose-related anxiolytic and sedative-hypnotic properties2.4 and has been proved effective in decreasing anxiety and tension in many emotional and physical illnesses.’ p 3 . 5 , 6 - * , 1 0 - 1 2 Like most agents used in psychiatry, lorazepam is used as an adjunct to psychotherapy, to help the patient integrate his defenses against intra- and interpersonal challenges. The possibility that lorazepam might offer advantages in the treatment of ‘brain fag’ syndrome *Professor of Psychiatry
367
Treatment of ‘brain fag’ syndrome
I
Curr Med Res Opin Downloaded from informahealthcare.com by Washington University Library on 12/26/14 For personal use only.
was investigated in this limited open study. A major objective was to determine the efficacy of lorazepam in improving the emotional status of the patient.
Methods and materials Sixty male students between the ages of 13 and 30 attending the out-patient psychiatric clinic of the Lagos University Teaching Hospital were admitted to the study. All had a diagnosis of ‘brain fag’ syndrome and all had failed to respond satisfactorily after 4 to 8 weeks of treatment with other benzodiazepines, (chlordiazepoxide and diazepam). Diagnosis of ‘brain fag’ syndrome was made on the basis of symptomatology described by Prince9 and included those symptoms shown in Table 1. Table I. Symptomatologyof ‘brain fag’ syndrome
Intellectual dificulties Poor concentration Difficulty in comprehension Poor memory Slowed Inability to read for long Difficulty in manipulating figures Difficulty in expression
Sleep disturbances Difficulty in going off t o sleep Early morning wakening Sleep unsatisfying Excessive sleep Excessive dreaming
Disturbance of afect Sadness/tense expression Feeling of sadness Fed up’ feeling Agitation/nervousness Manifest anxiety Irritability Phobias
Physiological disturbances Loss of weight Tremor Excessive perspiration Abdominal discomfort Breathing difficulties
Sensory disturbances ( a ) Somaesthetic Localised in headlneck Heat o r ‘peppery’ feeling Tension Heaviness Crawling sensation Headaches Pain Numbness Eye pain Itching sensation Emptiness Fluid’ inside head
(b) Special senses Visual Blurring Dimness of vision Auditory Tinnitus Vestibular Dizziness Tendency to fall
Generalised Heat and ‘peppery’ feeling Lightness Weaknesslweariness Biting/itcbing
The presence and severity of these symptoms were recorded for each patient prior to and after treatment with lorazepam and served as a basis for a clinical global evaluation. Severity of symptoms was rated on a scale of 0 (none) to 3 (severe). Clinical improvement was rated on a scale of 0 (none) to 3 (marked). After a washout period of 1 week during which no medication was permitted, lorazepam was administered to each patient, 1 or 2 mg. t.i.d. Each of the patients was told that certain side-effects, such as dry mouth or drowsiness, might occur but should not be allowed to interrupt the routine intake of medication. Patients were instructed to report these and other side-effects at their weekly visits to the clinic. 368
A. Anumonye
Curr Med Res Opin Downloaded from informahealthcare.com by Washington University Library on 12/26/14 For personal use only.
Results and discussion A steady decrease in the severity of symptoms from pre-treatment levels was noted in more than 80 % of the patients, becoming quite evident by the end of the second week. By the end of the study, therapeutic gains were readily apparent. Improvement of symptoms was marked in 51 patients (84%), moderate in 7 (12%), and mild in 1. Symptoms in the remaining patient were unaffected. These results contrast sharply with those of previous studies with chlordiazepoxide and diazepam, in which only mild or no improvement was noted (Table 11). Table 11. Response to lorazepam and other benzodiazepines
Patient improvement ~
~~~
Lorazepam % improved
% side-effects
Chlordiazepoxide/Diazepam % improved % side-effects
~
Marked Moderate Mild Unchanged
84 12 2
14 18 5
2
56 44
66
2
Those symptoms which responded most rapidly to treatment with lorazepam included difficulty in concentrating, sleep disturbances, and somatic discomfort referrable to the eye and head. Dizziness, which can have devastating effects in an ambulant patient population, was notably absent during treatment with lorazepam. By contrast, dizziness was a concomitant of treatment with the other benzodiazepines in 35 % of the patients. Adverse effects were no problem during treatment with lorazepam. Such effects, which consisted for the most part of mild and transient dry mouth (20 patients) and drowsiness (2 patients), were well tolerated as treatment continued. Findings from previous studies with chlordiazepoxide and diazepam (Table 111) showed a comparable incidence of dry mouth, a higher incidence of drowsiness, and an unusually high incidence of dizziness, which limited the usefulness of these agents, particularly since all of these patients need to be fully ambulatory. Table 111. Adverse effects during treatment with lorazepam and other benzodiazepines
Side-effect Dizziness Dryness ofmouth Drowsiness Weight loss Depression Tremor Dystonic symptoms Akathisia Excitement Apathy Nausea
No. patients reporting Lorazepam
Chlordiazepoxide/Diazepam
20
35 30
2
10
5
10 5 5 4 4 2 2 2
1
369
Curr Med Res Opin Downloaded from informahealthcare.com by Washington University Library on 12/26/14 For personal use only.
Treatment of ‘brain fag’ syndrome
The most frequently used dose of lorazepam was 1 mg. t.i.d. In some patients an occasional temporary increase to 2 mg. t.i.d. was necessary when symptoms were exacerbated by unusual stress. Most patients reported that this treatment was the most effective they had ever used. Some, however, complained that the cost was prohibitive. References 1. Abry, M., Piante, M., Grossetete, J. L., Daly, J. P., and Laurant, J., (1971). Study of a new benzodiazepine derivative, lorazepam, in gastroenterology. Lyon mkd., 226,581. 2. Appel, P., Berger, I., and Harrer, G., (1971). Erfahrungen mit Wy 4036, einem neuen Tranquilizer aus der Benzodiazepin-Reihe. Arzneim.-forsch., 21,1083. 3. Eaves, D., Jain, V. K., and Swinson, R. P., (1973). A double-blind controlled trial of lorazepam and diazepam in the treatment of anxiety. Curr. med. Res. Opin., 1,265. 4. Elliott, H. W., Nomof, N., Navarro, G., Ruelius, H. W., Knowles, J. A., and Comer, W. H., (1971). Central nervous system and cardiovascular effects of lorazepam in man. Clin. pharm. Therup., 12,468. 5. Guthy, H., Hildgren, J., and Brinkmann, G., (1971). Die Behandlung des Zielsymptoms Angst bei Neurosen, abnormen Erlebnisreaktionen, neuro-vegetativen psychosomatischen Storungen und Depressionen. Arzneim. -forsch., 21,109. 6. Haider, I., (1971). Evaluation of a new tranquilizer - Wy 4036 - in the treatment of anxiety. Brit. J. Psychiat., 119,597. 7 . Haider, I., (1971). Comparative trial of lorazepam and diazepam. Brit. J . Psychiut., 119,599. 8. Meusert, W., (1971). Priifung von Lorazepam (Wy 4036) in der nervenartzlichen Praxis. Arzneim. -forsch., 21,1087. 9. Prince, R., (1960). The ‘brain fag’syndrome in Nigerian students. J. meni. Sci.,106,559. 10. Schrappe, O., (1971). Klinische Untersuchungen mit Wy 4036 (lorazepam) einem neuartigen Tranquilizer. Arzneim. -forsch., 21,1079. 11. Sherliker, J., (1973). A comparison of lorazepam and diazepam in general practice. Curr. med. Res. Opin., 1,269. 12. Soubeyroux, B., Monges, H., and Poilroux, B., (1972). Interest in lorazepam, a new benzodiazepine derivative, in gastroenterological therapy. Corse-Mediterunt!emid., 208,118.
370
