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

feasible? Int Med J. 16, 13–17.

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