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Ofcial journal of the Pacic Rim College of Psychiatrists

Asia-Pacic Psychiatry ISSN 1758-5864

CASE REPORT

Saka, an ancestral possession: Malaysia


Hasanah Che Ismail1 MBBS MPM, Siti Raihan Ishak2 MD MMed, Adil Hussein2 MD MMed & Salmah Win Mar3 MBBS MMed
1 Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia 2 Department of Ophthalmology, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia 3 Department of Radiology, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia

Keywords culture-bound syndrome, Saka, Malaysia Correspondence Hasanah Che Ismail, Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelatan 16150, Malaysia. Tel: 160 12 964 0568 Fax: 160 09 765 9057 Email: hasanah@kb.usm.my Received 1 November 2009 Accepted 7 July 2010 DOI:10.1111/j.1758-5872.2010.00081.x

Abstract This report illustrates a culture-bound disorder known as saka in the local population of Kelantan, as well as other states in Malaysia. It is a form of possession by the spirit of a deceased ancestor who was once a traditional healer or shaman. While in a dissociative state, the patient introduced a 7 34 cm wooden stick precisely into his inferior rectus muscle, in an attempt to identify with a blind ancestor who showed his presence momentarily and specically to the patient. The stick remained hidden to ophthalmologists for 17 days and during this period the patient developed right orbital cellulitis, bilateral cavernous sinus thrombosis and sepsis. The stick was identied after the family took the patient home for cultural healing rites to be performed. The patients altered behavior resolved with the removal of the stick and he returned to his premorbid personality and functioning without psychotropic medication. To date, saka has not been reported in any peer-reviewed medical journal.

Introduction
Spirit possession is common in Malaysia and is incorporated into common beliefs about the causes of altered behaviors or psychiatric illnesses. Shamanism is practiced widely in peninsular Malaysia as well as in east Malaysia. In the Malays, a healer is referred to as a bomoh, otherwise also known as a dukun or a pawang. Malaysians, especially rural people are generally superstitious in their beliefs and many are apprehensive of the shamanist bomohs (witch doctors), believed to be capable of casting maligned ailments. Bomohs practicing within the Islamic tenet are sought for healing most illnesses. Both are regarded as powerful in their own way; the rst is feared, and the latter is referred to as traditional healers are respected. In Malaysia, the consultation of a bomoh or traditional healer has been uniformly reported irrespective of a patients socioeconomic background and level of education. Most researchers in this region are of the opinion that a bomoh would be effective in treating neurotic illness, but results for treating psychotic illness were discouraging (Razali, 2009). Whether Malaysians like it or not, bomohs are their heritage,

and bomohs remain indispensable, even in the modern age of e-medicine (Awang, 2006) Spirit possession commonly refers to the hold exerted over a person by more powerful external forces or entities. These forces may be ancestors or divinities, ghosts of foreign origin, or entities both ontologically and ethnically alien (Frazer, 1922; Boddy, 1994). Locally, ancestral possession is known as saka, an idiom from the Malay word pusaka, which means heritage. Ancestors are classically shamans or traditional healers, and the choice of benefactor is usually unpredictable but retrospectively understandable. Belief in saka is prominent in older generations of people in Kelantan, and in some other states in Malaysia. Kelantan is in the north-east of Malaysia and its people share some cultural values and practices with people in southern Thailand. Saka, or ancestral spirit, is believed to be able to transcend one or more generations. Saka is a special inheritance of healing powers, and upon reception will turn a person into a competent traditional practitioner or healer. Belief in saka is common in north-east Malaysia, as well as in Malays in other states in peninsular Malaysia and east Malaysia. However, many people who claim to be possessed by the

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saka spirit fulll the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria of psychiatric illness. Though found in many societies, the phenomena of possession is expressed and known differently by different cultures; its many forms are recognized as culture-bound syndromes. The American Psychiatric Association (APA) categorized these under Dissociative Disorder Not Otherwise Specied (APA, 2000). Among the local population, spirit possession or inuence is less impressive in its association with physical disorders, probably due to the clear association of cause and effects of the pathology. Rarely is the cause of an accepted physical condition questioned and attributed to spirit possession. However, when a known clinical condition is supplemented with abnormal behavior, then the etiological role is reappraised and the family of the patient will usually insist on a complementary or alternative method of treatment. Cultural explanation of illness is likely to be missed in medical practice as physicians concentrate on identication and removal of pathology. When consultation/liaison psychiatrists assess patients in a medical ward, they frequently miss the sociocultural dynamics behind the patients complaints or abnormal behavior, especially when the family members are not present, thus failing to identify the culture-bound entity. The present case of a patient with saka exemplies cultural belief and healing in a patient with orbital cellulitis with the appearance of inferior ophthalmic vein thrombosis and cavernous sinus thrombosis identied by a computed tomography (CT) scan. Saka has not been previously reported in peer-reviewed psychiatric or medical journals. The current case report adds a locally well-known condition to the list of other accepted culture-bound syndromes. A Medline search resulted in a report of saka trance, a culture-bound syndrome amongst the Taita in Kenya, but which described a different syndrome (Ville, 1997).

scans of the brain, orbit and paranasal sinuses (PNS) were performed. An elongated dense structure with a diameter of 34 mm was seen inside the inferior rectus muscle. The linear density started from the orbital rim and ended in the right cavernous sinus. It was reported as inferior ophthalmic vein thrombosis, which is likely in the presence of cellulitis. On the 4th day of admission, the patient was referred to neuro-medical, medical and psychiatry for assessment of continuing fever, altered sensorium, and tonic movements of the upper and lower limbs. Psychiatric assessment showed a middle-aged man with elective mutism, but who obeyed simple commands to lift specied limbs, with a tendency to go into pseudo seizures and aggressive dissociative states. He was managed with physical restraint, intramuscular midazolam and haloperidol, and oral doses of risperidone 1 mg twice a day. He continued to have convulsions 5 days after treatment with phenytoin. After the patient had been in the ward for 10 days, the source of the eye inammation remained unidentied. In spite of a diagnosis of cavernous sinus thrombosis and an explanation about the patients critical condition, the family insisted on taking the patient home on at own risk (AOR) discharge, to pursue traditional treatment. He was given a follow-up 1 week later, in the ophthalmology clinic. Oral phenytoin and risperidone were not provided on AOR discharge. On review 1 week later, the ophthalmologist on clinical examination noted the end of a wooden stick jutting out from the inferior fornix, located at the medial third region. The stick was removed slowly in a single axis, with minimal bleeding and resistance. The stick measured 7 cm (Figures 1 and 2); the longest foreign body reported in ophthalmology journals was 5.3 cm (Lee & Lee, 2002). Subsequently, the patient was treated in the ophthalmology ward for 15 days. The stay was uneventful, with no dissociative state or convulsion. During his rst admission, diagnoses of delirium, schizophrenia and psychotic depression were

Case report
Clinical presentation and progress A 39-year-old Malay man, single, working in odd jobs, mainly knitting shing nets, was admitted to the ophthalmology ward for right eye orbital cellulitis with bilateral cavernous sinus syndrome. He developed sepsis while the underlying cause of the continuing right eye cellulitis remained unidentied. Ear, nose and throat (ENT) and dental referrals were made to assist identication of the source of infection and CT

Figure 1 The wooden stick which was removed from the patient (7 cm long).

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reinforced the communitys belief that patient was under the control of saka and the cultural healing rites and prayers were considered successful in disengaging the patient from the spirit, thus facilitating the expulsion of the stick, which before the rites was embedded and hidden, and interpreted by a radiologist as inferior ophthalmic vein thrombosis. This belief was further reinforced because the patient returned to his premorbid self and did not need any antiepileptic or psychotropic medications. Mental normality and premorbid functioning was maintained as conrmed by his follow-up visits to the hospital and by a home visit by the psychiatrist 6 months after the patient was discharged from hospital.
Figure 2 A simulated 7 cm stick which demonstrates the possibility of the stick to penetrate the brain.

Discussion
recorded consecutively in his medical notes from three differing psychiatric registrars. The consultant psychiatrist who reviewed the case during the patients second admission gave a diagnosis of culture-bound syndrome; therefore, psychotropic medications were gradually discontinued. Personal and family history The patient completed only lower secondary school because of low intelligence. He had never had a girlfriend, had no close friends and he kept to himself, avoiding social or family gatherings. He preferred solitary activities, like knitting shing nets, and lived with his 85-year-old father, and was responsible for the cooking and looking after their big house. He was the sixth of nine siblings. The patients deceased paternal and maternal grandparents were traditional healers or shamans. The family seemed to share a strong belief that one of the ancestral spirits or saka was trying to integrate into the patient. They believed that he was selected because he was relatively clean of sins that most mortals accumulate through daily dealings and socializing. However, the patients family generally agreed that he should not receive the saka or ancestral spirit, because doing so entails a heavy responsibility and obligation beyond the patients capacity. Cultural intervention During AOR discharge, the patients extended family and neighbors gathered twice for prayer and healing rites, specically conducted to disengage him from the spirit. Two days later, the stick surfaced and was detected by the ophthalmologist. The events After the wooden stick was detected, the radiologist was aware of the unlikelihood of inferior ophthalmic vein thrombosis. Typically, the superior ophthalmic vein is more susceptible to thrombosis. The CT scan could not distinguish it from the appearance of ophthalmic vein thrombosis. The length of the stick could have easily penetrated the brain, (Figure 2), but fortunately did not. The manifestations of saka in the patient fullled criteria 1 and 2 for trance and possession disorder of dissociative disorder not otherwise specied (DDNOS) (Coons, 1992). The patient exhibited trance states characterized by stereotyped behaviors in the form of disorganized aggression and pseudo seizures, and loss of customary sense of identity and narrowing of awareness, which was interpreted by the physician as altered sensorium. The patient and his family believed that he was under the control of an ancestral spirit and the patient could not recall how the foreign body became inserted below his right eye. The patients low intelligence, and poor social and verbal skills may have predisposed him to an atypical presentation of emotional disturbance. He was probably not able to communicate his distress, and out of frustration, poked the stick into his eye. Afraid to admit what he had done, he endured the pain with stoic and obstinate silence. There was no obvious secondary gain, and he recovered as soon as the stick was removed. Trance or possession states are common in different cultures. Coons (1992) claimed that most dissociative disorders diagnosed in non-industrialized nations would probably be DDNOS. Or, as in our patient, the bizarre behavior that led to the physical disorder could easily be labeled as schizophrenia. It was noted that once the diagnosis of schizophrenia was documented

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Culture-bound syndrome

in the patients le the continuation of antipsychotic treatment by subsequent treating doctors followed until culture-bound syndrome was identied by the consultant psychiatrist. To address the issue of mislabeling, psychiatrists should be reminded to apply the Cultural Formulation of the Diagnostic and Statistical Manual for Mental Disorders, 4th ed, Text Revision (DSM-IV-TR) (APA, 2000). The formulation focuses on the patients cultural identity and cultural explanation of illness, including the predominant idioms of distress in the individuals community, perceived causes or explanatory models to explain the illness and any preferences or experiences with professional or popular sources of care. The Cultural Formulation facilitates tolerance toward cultural healing, and for patients best interest, a collaborative culturally appropriate intervention. Eventually, the outcome with or without pharmacotherapy will inuence the diagnostic location of the patients clinical presentation in the established psychiatric nomenclature. The cultural healing rites offered more effective benet to the patient than conventional pharmacotherapy and psychotherapy. Treatment in the form of communal prayers, drinking of and bathing with prayer water, was undertaken in the context of a social event. Families, neighbors and the involved community gathered in prayer, followed by sharing a buffet dinner. If there was social discord, it was immediately repaired, conicts were resolved, and social cohesion and harmony within the family and community was restored and enhanced. The patient was welcomed and integrated back into his community.

The present case exemplies the importance of collaboration and team approach in patient care. Unfortunately, this was only appreciated when it involved a culture-bound disorder, and less so in other types of psychiatric illnesses, which should have a similar holistic approach.

References
American Psychiatric Association. (2000) Diagnostic and Statistical Manual for Mental Disorders, 4th ed, Text Revision (DSM-IV-TR). APA, Washington, DC. Awang H. Bomoh and Malays Are Inseparable, Says Don. Malaysian National News Agency. Available at: http:// www.brudirect.com/DailyInfo/News/Archive/Mar06/ 130306/nite05.htm Accessed March 08, 2006 Boddy J. (1994) Spirit possession revisited: beyond instrumentality. Annu Rev Anthropol. 23, 407434. Coons P.M. (1992) Dissociative disorder not otherwise specied: a clinical investigation of 50 cases with suggestions for typology and treatment. Disassociation. 1, 187195. Frazer J.G. (1922) The Golden Bough: A Study in Magic and Religion (Reprint, abridged ed.) MacMillan, New York. Lee J.A., Lee H.Y. (2002) A case of retained wooden foreign body in orbit. KorJ Ophthalmol. 16, 114118. Razali S.M. (2009) Integrating Malay traditional healers into primary health care services in Malaysia: is it feasible? Int Med J. 16, 1317. Ville J.L. (1997) Possession and its therapeutic interpretation: an unusual system among the Taita of Kenya. Homme. 142, 4967.

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