saka - an ancestral possession
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C A S E R E P O R T
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
AbstractThis 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� 3–4 cm wooden stick precisely into his inferior rectus muscle, in an
attempt to identify with a blind ancestor who showed his presence mo-
mentarily and specifically 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 identified after the family took the patient home for cultural
healing rites to be performed. The patient’s 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 incor-
porated 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 apprehen-
sive 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 first is feared, and the latter is
referred to as traditional healers are respected.
In Malaysia, the consultation of a bomoh or tradi-
tional 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 treat-
ing 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 mod-
ern age of e-medicine (Awang, 2006)
Spirit possession commonly refers to the hold exer-
ted 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 tradi-
tional healers, and the choice of benefactor is usually
unpredictable but retrospectively understandable. Be-
lief 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 tradi-
tional 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. How-
ever, many people who claim to be possessed by the
166 Asia-Pacific Psychiatry 2 (2010) 166–169 Copyright c� 2010 Blackwell Publishing Asia Pty Ltd
Asia-Pacific Psychiatry ISSN 1758-5864
Offi cial journal of thePacifi c Rim College of Psychiatrists
saka spirit fulfill 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 Specified (APA, 2000).
Among the local population, spirit possession or
influence is less impressive in its association with
physical disorders, probably due to the clear associa-
tion 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 abnor-
mal 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 identification 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 exemplifies
cultural belief and healing in a patient with orbital
cellulitis with the appearance of inferior ophthalmic
vein thrombosis and cavernous sinus thrombosis iden-
tified by a computed tomography (CT) scan. Saka has
not been previously reported in peer-reviewed psy-
chiatric 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).
Case report
Clinical presentation and progress
A 39-year-old Malay man, single, working in odd jobs,
mainly knitting fishing 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 unidentified. Ear, nose
and throat (ENT) and dental referrals were made to
assist identification of the source of infection and CT
scans of the brain, orbit and paranasal sinuses (PNS)
were performed. An elongated dense structure with a
diameter of 3–4 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 admis-
sion, the patient was referred to neuro-medical, med-
ical 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 com-
mands to lift specified 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 risper-
idone 1 mg twice a day. He continued to have convul-
sions 5 days after treatment with phenytoin.
After the patient had been in the ward for 10 days,
the source of the eye inflammation remained uniden-
tified. In spite of a diagnosis of cavernous sinus throm-
bosis and an explanation about the patient’s 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 first admission, diagnoses of
delirium, schizophrenia and psychotic depression were
Figure 1 The wooden stick which was removed from the patient (7 cm
long).
Asia-Pacific Psychiatry 2 (2010) 166–169 Copyright c� 2010 Blackwell Publishing Asia Pty Ltd 167
H.C. Ismail et al. Culture-bound syndrome
recorded consecutively in his medical notes from three
differing psychiatric registrars. The consultant psychia-
trist who reviewed the case during the patient’s second
admission gave a diagnosis of culture-bound syn-
drome; therefore, psychotropic medications were gra-
dually 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 fishing 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 patient’s 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 patient’s family generally agreed that he
should not receive the saka or ancestral spirit, because
doing so entails a heavy responsibility and obligation
beyond the patient’s capacity.
Cultural intervention
During AOR discharge, the patient’s extended family
and neighbors gathered twice for prayer and healing
rites, specifically conducted to disengage him from
the spirit. Two days later, the stick surfaced and
was detected by the ophthalmologist. The events
reinforced the community’s 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 expul-
sion 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 premor-
bid self and did not need any antiepileptic or psycho-
tropic medications. Mental normality and premorbid
functioning was maintained as confirmed by his fol-
low-up visits to the hospital and by a home visit by the
psychiatrist 6 months after the patient was discharged
from hospital.
Discussion
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 fulfilled criteria 1 and 2 for trance and posses-
sion disorder of dissociative disorder not otherwise
specified (DDNOS) (Coons, 1992). The patient exhib-
ited trance states characterized by stereotyped beha-
viors 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 patient’s low intelligence, and poor social and
verbal skills may have predisposed him to an atypical
presentation of emotional disturbance. He was prob-
ably 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 differ-
ent cultures. Coons (1992) claimed that most dissocia-
tive 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
Figure 2 A simulated 7 cm stick which demonstrates the possibility of
the stick to penetrate the brain.
168 Asia-Pacific Psychiatry 2 (2010) 166–169 Copyright c� 2010 Blackwell Publishing Asia Pty Ltd
H.C. Ismail et al.Culture-bound syndrome
in the patient’s file the continuation of antipsychotic
treatment by subsequent treating doctors followed
until culture-bound syndrome was identified 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 patient’s cultur-
al identity and cultural explanation of illness, includ-
ing the predominant idioms of distress in the
individual’s community, perceived causes or explana-
tory 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 patient’s best interest,
a collaborative culturally appropriate intervention.
Eventually, the outcome with or without pharma-
cotherapy will influence the diagnostic location of the
patient’s clinical presentation in the established psy-
chiatric nomenclature. The cultural healing rites of-
fered more effective benefit 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, conflicts 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 exemplifies the importance of
collaboration and team approach in patient care. Un-
fortunately, 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, 407–434.
Coons P.M. (1992) Dissociative disorder not otherwise
specified: a clinical investigation of 50 cases with
suggestions for typology and treatment. Disassociation.
1, 187–195.
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, 114–118.
Razali S.M. (2009) Integrating Malay traditional healers
into primary health care services in Malaysia: is it
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Ville J.L. (1997) Possession and its therapeutic
interpretation: an unusual system among the Taita of
Kenya. Homme. 142, 49–67.
Asia-Pacific Psychiatry 2 (2010) 166–169 Copyright c� 2010 Blackwell Publishing Asia Pty Ltd 169
H.C. Ismail et al. Culture-bound syndrome
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