The group of local syndromes defined by severe behavioural disturbances have considerable similarities with ‘psychotic disorders’ (including manic states). Local syndromes that were characterized by sadness and social withdrawal have similarities to what used to be known collectively as ‘neurotic disorders’. However, in the current international psychiatric classifications such as DSM V and ICD-10, these would be characterized as mood disorders, complicated bereavement and/or anxiety disorders.
Conditions related to severe behavioural disturbances
The concept of ‘psychosis’ in psychiatry encompasses five elements: confused thinking, false beliefs, hallucinations, changed emotions and disturbed behaviour. The local concepts identified in this research do not emphasize all these symptoms, but tend to focus on ‘behavioural problems’, particularly violent and chaotic behaviour, and ‘cognitive symptoms’ (‘speaking in a way that people cannot understand’ or ‘saying things that are not real’). Emotional expressions, such as crying and laughing without reason, were found, but these were not considered as typical for severe mental disorders. Hallucinations were not mentioned in any of the settings; however, in all four settings, examples were given of behaviour that could indicate auditory hallucinations, such as ‘speaking when there is no one around’.
Perhaps some elements of popular discourse around psychotic disorders in this study bear witness to prevailing norms and ideals within a particular society. For example, the Luo from Kwajena in South Sudan revere male strength, and see men primarily as warriors. Men are often armed with spears. In their descriptions of moul and wehie arir, they emphasized violent aspects, such as killing people and burning houses. The Burundians in Kibuye stressed the ‘disrespectful behaviour’ of those with mental disorders, which may reflect the importance of harmony and modest, respectful behaviour within their society (as conferred by the local concept of indero). Public displays of emotion are frowned on in Burundi.
Lay descriptions of psychotic disorders in Sub-Saharan Africa emphasize behavioural disturbance and disruption of social norms, yet do not often contain symptoms related to thought disturbance and perceptual symptoms [23–25]. The list of characteristics of people with ‘psychosis’, reported by respondents from four East African ethnic groups in a classical study by Edgerton , included: walking naked, being violent, arson, and talking nonsense. The concepts of moul, mamali, erisire and ibisazi in our study are quite similar and significantly overlap with the psychiatric concept of psychosis. They are, however, less narrowly defined and include categories that in current psychiatric nosology are often separated from psychosis, such as manic episodes and delirium.
The Luo and the Kakwa respondents used separate names for acute, and potentially time limited, states of severe disturbance (wehie arenjo in Kwajena and ngengere in Butembo), with pathology centred on problems with interpersonal behaviour. Professional psychiatric classifications would refer to these acute syndromes as brief reactive psychosis, acute mania, non-affective acute remitting psychosis, ‘bouffée delirante’ or early-stage schizophrenia. Similar distinctions between chronic states of psychosis, and between acute forms characterized by aggression and behavioural disturbance, have been described in other African societies [26–29].
Local aetiologies for conditions related to severe behavioural disturbances
The respondents in this study list a wide range of possible causes for disorders with severe behavioural disturbances, including spiritual, natural and psychosocial factors. In the literature on African causal theories for mental disorders, the role of spiritual aetiology is often emphasized. Indigenous healers in Uganda indicated that the cause of these disorders was not specific to the person, but could be due to any family member or members neglecting cultural practice . However, not all cases of psychotic disorders are attributed to supernatural forces. Edgerton  found that psychosis is not always attributed to witchcraft, and it was often regarded as an illness occurring for no reason or as the ‘natural result of life stress’. In the literature on local aetiological beliefs with regards to psychotic disorders in Africa, a wide range of factors have been described, such as substance misuse , nutritional factors , diseases of the blood , malaria  and ‘ worms in the brain’  In this study, most of these factors were mentioned by the respondents, but there was variance between the settings. Among the Luo (arguably the setting that has been least influenced by monotheistic religions), spiritual causes were more prominent. The Kakwa also mentioned spiritual causes, but more frequently mentioned natural causes (cannabis and alcohol use) and psychosocial causes (‘too much thinking’).
In three of the four settings, respondents indicated that they thought severe mental disorders could not be effectively treated by either traditional healers or in biomedical health facilities. They generally do not seek help in modern health facilities because they are not aware that medications to treat psychotic symptoms may exist. This is quite understandable because, in three of the four locations, there were no health workers who were trained in the diagnosis or management of mental disorders and no psychotropic medication was available in the health facilities. The exception is Butembo, where treatment by Western medication is generally thought to be effective; this may be due to the long-term presence of an active, and highly respected, psychiatric nurse. Respondents were more optimistic about treatment options for acute psychotic conditions. This may be an indication that when psychiatric treatment options for severe mental disorder are made available, people will try them out and continue using them once they experience positive effects.
Conditions related to sadness and social withdrawal
In various African populations, conditions can be found that are assigned to ‘too much worrying’ or ‘too much thinking’ [34–37]. To what extent are these local concepts identical to psychiatric concepts for affective disorder, such as depressive disorders? On first sight, the resemblance is striking. For example, the Luo description of nger yec includes all symptoms of the DSM-IV definition of depression, with the exception of excessive or inappropriate guilt. However, the defining feature cited by the Luo respondents was not the emotional features, but the existence of typical somatic symptoms, in particular pressure on the stomach and diarrhoea.
Ibonge in Burundi also resembles, but is not identical to, depression. Ibonge signifies ‘sadness resulting from a multiple sufferings’ and kurwara akabonge is ‘being sick of sadness’ . In Rwanda, which shares many linguistic and sociocultural features with Burundi, similar local categories were identified. These included agahinda gakabije (with symptoms such as deep sadness, isolation, lack of self-care, loss of mind, not able to work, feeling life is meaningless, not pleased by anything and difficulty in interacting with others) . The features of ibonge and agahinda may seem quite similar to Western concepts of depression, but also reflect a transgression of what is considered ‘good behaviour’. For example, the emphasis that Burundian culture places on harmony and not showing emotions to others.
The conditions identified in this research are not discrete diagnostic categories with a specific set of symptoms, but have fluid boundaries and are applied pragmatically. For example, while the Nande concept alluhire may be associated with features of major depression, it is also a rather idiomatic expression to communicate that a person does ‘not feel well’ and is overwhelmed by the tasks of life. Alluhire should thus not only be understood as a local syndrome, but also as an ‘idiom of distress’: a culturally prescribed way of communicating distress. An idiom of distress may be indicative of psychopathological states that undermine the well-being of a person, but may in other cases better be seen as adaptive reactions to a situation of distress, and thus be a way of coping with distress [9, 40].
Local aetiologies for condition related to sadness and social withdrawal
The local concepts related to sadness and social withdrawal in this assessment are thought to be the consequence of identifiable contextual factors, such as severe loss or adversity that, once removed, will result in improvement. Personality factors (such as being ‘weak’) play a role as well. As elsewhere in Africa, these conditions are less likely to be seen as a medical or mental disorder, but are more likely to be ascribed to social or spiritual problems with poverty, social issues, major life events and ‘thinking too much’ [23, 41–43].
Despite diversity in the symptomatic descriptions, management of conditions related to sadness and social withdrawal is quite similar, especially as these conditions are not seen as medical disorders and therefore treatment is rarely sought in modern health care facilities. People believe the management should be entirely psychosocial and aimed at improving the economic situation, increasing social support and decreasing social isolation and loneliness.
Local African concepts of mental conditions related to ‘traumatic events’ vary considerably from the DSM concept of posttraumatic stress disorder, as demonstrated in Gambia , Rwanda  and among Darfuri refugees in Chad . The latter group distinguished two differing local concepts. The first, hozun, had similarities with depression and some elements of posttraumatic stress disorder. The second, majnun (literally ‘madness’) also contains some posttraumatic stress symptoms similar to major depression, but in general the syndrome is defined by psychotic symptoms mentioned by the Darfuri respondents (such as ‘talking when you are alone’, ‘talking in a way others cannot understand’ and ‘doing things others consider foolish’). In fact, local categories of hozun and majnun would fit well in the dichotomy found in this study, between ‘conditions related to severe behavioural disturbance’ and ‘conditions related to sadness and social withdrawal’. In this assessment, only the Burundian respondents had a concept that referred to trauma related complaints. This syndrome, ihahamuka, is related to the psychological aftermath of terrible events and is characterized by fear and hyperarousal. This is one of the features of posttraumatic stress disorder. Other features, such as traumatic recollections and avoidance or numbing, were not spontaneously mentioned. Yet, according to Hagengimana and Hinton , guhahamuka in Rwanda resembles both posttraumatic stress disorder and panic attacks.
The absence of a local category of trauma-related mental disorders in three of the four settings does, of course, not imply that there is no effect of collective violence on the mental state of the population. As has been shown for Juba in South Sudan violent and traumatic events may have pervasive effects on the general physical and mental health of conflict-affected populations .
Data yielded by FGDs are often influenced by social dynamics within a group and frequently describe what people assume they should think and do, rather than what people actually think and do. Therefore, our data are limited, and cannot shed light on how the illness categories described here actually play out in people’s lives. Moreover, asking nonaffected people about their observations of affected people may favour mentioning phenomena that are easily observable rather than internal cognitive or emotional states, which are less easily observed by outsiders. Another limitation of this study relates to the role of the researcher. By using local research assistants, who were familiar with the language of the participants, the authors tried to reduce the possibility of interviewer bias. However, the presence of an expatriate researcher in some of the FGDs may have still caused bias. The fact that a non-African representing an international organization providing health services shows interest in the phenomena of ‘madness and sadness’ is in itself a social act with some importance that may have induced social desirability in the responses. Alternatively, participants may also have been reluctant to be honest with someone local in the room.
Finally, there was a limitation with the approach used; through the elicitation of how local syndromes are commonly understood, there is a risk of an ‘essentializing’ approach. This sort of approach focuses on what Nichter  calls the ‘whatness’ of particular cultural modes of expressing distress. The authors were aware that local syndromes often have no rigid boundaries, but are used flexibly to interpret illness and misfortune. Yet, this exploratory survey, which identified culturally salient idioms and syndromes, provides a starting point for further, in-depth exploration of how and why specific means of expressing distress, at specific points in time, are being used in concrete situations.
Conclusions and implications for practice
While cultural categories may be closely aligned to mainstream psychiatric categories, it is important to realize they are not identical and to resist reifying them into professional psychiatric classifications. The local terms used by our respondents are heuristic concepts, used pragmatically to bring order to chaotic and disturbing experiences and to assist in the quests for meaning and solutions to end suffering. These concepts are localized and, therefore, show the influence of contextual factors in shaping illness experience.
This assessment has several implications for public mental health interventions. In the first instance, it clearly shows that the population is concerned about conditions characterized by behavioural disturbances. These conditions share many features with psychotic disorders, as identified by Western psychiatry. People see overwhelmingly the need for these conditions to be treated, but do not know how to do so effectively. Treatment by traditional, or religious, healers is primarily not seen as effective. Neither is treatment within the health care sector an option sought very often, as health facilities do not have staff trained in diagnosis and treatment of mental-health conditions and lack effective medicines for treating these conditions. The population is, however, likely to try any treatment option that seems viable once it is made available to them.
Our conclusions are similar to those of a recent study showing that rural Haitians in areas affected by an earthquake do not seek mental health treatment within the formal health sector as this option is not readily available, and not because they do not wish to try it . Moreover, the evidence for the effectiveness of psychiatric interventions for the management of severe mental disorders, such as psychotic syndromes, is relatively strong . Therefore, we advocate that treatment of severe mental disorders should be made a priority for the health care system. Given the extreme shortage of mental health professionals in low-income countries (approximately one psychiatrist per two million people and one psychiatric nurse per 200,000 people), these interventions cannot be implemented simply by specialists . Evidence suggests, however, that mental health care can be delivered effectively within general health care facilities by nonspecialist health providers, with brief training and appropriate supervision by mental health specialists .
Secondly, each population has local categories for states in which a person is overwhelmed by loss or sadness. These conditions are not seen as medical problems or indeed as conditions requiring assistance from the health sector. The interventions considered viable in these instances, by the local population, most often occur within the family and the community. Therefore, the entry point to provide assistance for those who suffer from these conditions would ideally be within the families and the communities. A primary aim for public mental health interventions for these conditions would thus be to empower ‘natural’ social support systems already in place at local levels and to strengthen social cohesion and social capital within communities . However, our respondents also made it clear that the existing mechanisms for healing may fall short or be overwhelmed, particularly in postconflict areas. Local systems of support can be strengthened through capacity building for community-based psychosocial support and by installing services through trained paraprofessional counsellors or community workers [52, 53]. It is important that any approach includes various, overlapping levels of interventions in order to address varying needs for support for problems that range from primarily psychosocial to psychiatric .
One major challenge to the development of such an integrated, multilevelled care systems among populations that are overwhelmed by massive losses and breakdown of social-support structures is how to determine when mild and/or moderate depressive states become psychiatric conditions requiring medical attention [55, 56]. Addressing this problem needs continuous cooperation between health professionals and community resources. Within such a dialogue, it is essential to keep account of how people themselves define what is at stake for their own lives.