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Saka - An Ancestral Possession

Saka - An Ancestral Possession

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Published by Ahmad Cendana
Official journal of the Pacific Rim College of Psychiatrists

Asia-Pacific 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
Official journal of the Pacific Rim College of Psychiatrists

Asia-Pacific 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

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CASE REPORT
Saka, an ancestral possession: Malaysia
Hasanah Che Ismail
1
MBBS MPM, Siti Raihan Ishak
2
MD MMed, Adil Hussein
2
MD MMed &Salmah Win Mar
3
MBBS MMed
1 Department of Psychiatry, School of Medical Sciences, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia2 Department of Ophthalmology, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia3 Department of Radiology, Universiti Sains Malaysia, Khota Bharu, Kelatan, Malaysia
Keywords
culture-bound syndrome, Saka,Malaysia
Correspondence
Hasanah Che Ismail, Department ofPsychiatry, School of Medical Sciences,Universiti Sains Malaysia, Kota Bharu,Kelatan 16150, Malaysia.Tel:
1
60 12 964 0568Fax:
1
60 09 765 9057Email:hasanah@kb.usm.myReceived 1 November 2009Accepted 7 July 2010DOI:10.1111/j.1758-5872.2010.00081.x
Abstract
Thisreportillustratesaculture-bounddisorderknownas‘saka’inthelocalpopulation of Kelantan, as well as other states in Malaysia. It is a form ofpossession by the spirit of a deceased ancestor who was once a traditionalhealer or shaman. While in a dissociative state, the patient introduced a7
Â
3–4cm wooden stick precisely into his inferior rectus muscle, in anattempt to identify with a blind ancestor who showed his presence mo-mentarily and specifically to the patient. The stick remained hidden toophthalmologists for 17 days and during this period the patient developedright orbital cellulitis, bilateral cavernous sinus thrombosis and sepsis. Thestick was identified after the family took the patient home for culturalhealing rites to be performed. The patient’s altered behavior resolved withthe removal of the stick and he returned to his premorbid personality andfunctioning without psychotropic medication. To date, saka has not beenreported in any peer-reviewed medical journal.
Introduction
Spirit possession is common in Malaysia and is incor-porated into common beliefs about the causes ofaltered behaviors or psychiatric illnesses. Shamanismis practiced widely in peninsular Malaysia as well as ineast 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 generallysuperstitious in their beliefs and many are apprehen-sive of the
shamanist bomohs
(witch doctors), believedto be capable of casting maligned ailments.
Bomohs
practicing within the Islamic tenet are sought forhealing most illnesses. Both are regarded as powerfulin their own way; the first is feared, and the latter isreferred to as traditional healers are respected.In Malaysia, the consultation of a
bomoh
or tradi-tional healer has been uniformly reported irrespectiveof a patients’ socioeconomic background and level ofeducation. Most researchers in this region are of theopinion that a
bomoh
would be effective in treat-ing neurotic illness, but results for treating psychoticillness were discouraging (Razali, 2009). WhetherMalaysians 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 orentities. These forces may be ancestors or divinities,ghosts of foreign origin, or entities both ontologicallyand ethnically alien (Frazer, 1922; Boddy, 1994).Locally, ancestral possession is known as ‘‘saka’’,an idiom fromthe Malayword ‘‘pusaka’’, which meansheritage. Ancestors are classically shamans or tradi-tional healers, and the choice of benefactor is usuallyunpredictable but retrospectively understandable. Be-lief in saka is prominent in older generations of peoplein Kelantan, and in some other states in Malaysia.Kelantanisinthenorth-eastofMalaysiaanditspeoplesharesomeculturalvaluesandpracticeswithpeopleinsouthern Thailand. Saka, or ancestral spirit, is believedto be able to transcend one or more generations. Sakais a special inheritance of healing powers, and uponreception will turn a person into a competent tradi-tional practitioner or healer. Belief in saka is commonin north-east Malaysia, as well as in Malays in otherstates 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 Copyrightc
2010 Blackwell Publishing Asia Pty Ltd
Asia-Pacific Psychiatry ISSN 1758-5864
Official journal of thePacific Rim College of Psychiatrists
 
saka spirit fulfill the Diagnostic and Statistical Manualof Mental Disorders (DSM-IV) criteria of psychiatricillness.Though found in many societies, the phenomenaof possession is expressed and known differently bydifferent cultures; its many forms are recognized asculture-bound syndromes. The American PsychiatricAssociation(APA)categorizedtheseunderDissociativeDisorder Not Otherwise Specified (APA, 2000).Among the local population, spirit possession orinfluence is less impressive in its association withphysical disorders, probably due to the clear associa-tion of cause and effects of the pathology. Rarely is thecause of an accepted physical condition questionedand attributed to spirit possession. However, when aknown clinical condition is supplemented with abnor-mal behavior, then the etiological role is reappraisedand the family of the patient will usually insist on acomplementary or alternative method of treatment.Cultural explanation of illness is likely to bemissed in medical practice as physicians concentrateon identification and removal of pathology. Whenconsultation/liaison psychiatrists assess patients in amedical ward, they frequently miss the socioculturaldynamics behind the patients’ complaints or abnormal behavior, especially when the family members are notpresent, thus failing to identify the culture-boundentity.The present case of a patient with saka exemplifiescultural belief and healing in a patient with orbitalcellulitis with the appearance of inferior ophthalmicvein thrombosis and cavernous sinus thrombosis iden-tified by a computed tomography (CT) scan. Saka hasnot been previously reported in peer-reviewed psy-chiatric or medical journals. The current case reportadds a locally well-known condition to the list of otheraccepted culture-bound syndromes. A Medline searchresulted in a report of saka trance, a culture-boundsyndrome amongst the Taita in Kenya, but whichdescribed 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 theophthalmologywardforrighteyeorbitalcellulitiswith bilateral cavernous sinus syndrome. He developedsepsis while the underlying cause of the continuingright eye cellulitis remained unidentified. Ear, noseand throat (ENT) and dental referrals were made toassist identification of the source of infection and CTscans of the brain, orbit and paranasal sinuses (PNS)were performed. An elongated dense structure with adiameter of 3–4mm was seen inside the inferior rectusmuscle. The linear density started from the orbital rimandendedintherightcavernoussinus.Itwasreportedas inferior ophthalmic vein thrombosis, which is likelyin 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 upperand lower limbs.Psychiatricassessmentshowed amiddle-agedmanwith elective mutism, but who obeyed simple com-mandstoliftspecifiedlimbs,withatendencytogointopseudo seizures and aggressive dissociative states. Hewas managed with physical restraint, intramuscularmidazolam and haloperidol, and oral doses of risper-idone 1mg 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 criticalcondition, the family insisted on taking the patienthome on ‘at own risk’(AOR) discharge, to pursuetraditionaltreatment.Hewasgivenafollow-up1weeklater, in the ophthalmology clinic. Oral phenytoin andrisperidone were not provided on AOR discharge.On review 1 week later, the ophthalmologist onclinical examination noted the end of a wooden stick jutting out from the inferior fornix, located at themedial third region. The stick was removed slowly ina single axis, with minimal bleeding and resistance.The stick measured 7cm (Figures 1 and 2); the longestforeign body reported in ophthalmology journals was5.3cm (Lee & Lee, 2002). Subsequently, the patientwas treated in the ophthalmology ward for 15 days.The stay was uneventful, with no dissociative state orconvulsion. During his first admission, diagnoses ofdelirium,schizophreniaandpsychoticdepressionwere
Figure 1
The wooden stick which was removed from the patient (7 cmlong).
 Asia-Pacific Psychiatry
2 (2010) 166–169 Copyrightc
2010 Blackwell Publishing Asia Pty Ltd
167
H.C. Ismail
et al
. Culture-bound syndrome
 
recorded consecutively in his medical notes from threediffering psychiatric registrars. The consultant psychia-trist who reviewed thecase during thepatient’s secondadmission 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 agirlfriend, had no close friends and he kept to himself,avoiding social or family gatherings. He preferredsolitary activities, like knitting fishing nets, and livedwithhis85-year-oldfather,andwasresponsibleforthecooking and looking after their big house. He was thesixth of nine siblings.The patient’s deceased paternal and maternalgrandparents were traditional healers or shamans.The family seemed to share a strong belief that one ofthe ancestral spirits or saka was trying to integrate intothepatient.Theybelievedthathewasselectedbecausehe was relatively clean of sins that most mortalsaccumulate through daily dealings and socializing.However, the patient’s family generally agreed that heshould not receive the saka or ancestral spirit, becausedoing so entails a heavy responsibility and obligation beyond the patient’s capacity.
Cultural intervention
During AOR discharge, the patient’s extended familyand neighbors gathered twice for prayer and healingrites, specifically conducted to disengage him fromthe spirit. Two days later, the stick surfaced andwas detected by the ophthalmologist. The eventsreinforced the communitys belief that patient wasunder the control of saka and the cultural healing ritesand prayers were considered successful in disengagingthe patient from the spirit, thus facilitating the expul-sion of the stick, which before the rites was embeddedand hidden, and interpreted by a radiologist as inferiorophthalmic vein thrombosis. This belief was furtherreinforced because the patient returned to his premor- bid self and did not need any antiepileptic or psycho-tropic medications. Mental normality and premorbidfunctioning was maintained as confirmed by his fol-low-up visits to the hospital and by a home visit by thepsychiatrist 6 months after the patient was dischargedfrom hospital.
Discussion
After the wooden stick was detected, the radiologistwas aware of the unlikelihood of inferior ophthalmicvein thrombosis. Typically, the superior ophthalmicvein is more susceptible to thrombosis. The CT scancould not distinguish it from the appearance ofophthalmic vein thrombosis. The length of the stickcould have easily penetrated the brain, (Figure 2), butfortunately did not. The manifestations of saka in thepatient fulfilled criteria 1 and 2 for trance and posses-sion disorder of dissociative disorder not otherwisespecified (DDNOS) (Coons, 1992). The patient exhib-ited trance states characterized by stereotyped beha-viors in the form of disorganized aggression andpseudoseizures,andlossofcustomarysenseofidentityandnarrowingofawareness,whichwasinterpretedbythe physician as alteredsensorium. The patient and hisfamily believed that he was under the control of anancestralspiritandthepatientcouldnotrecallhowtheforeign body became inserted below his right eye.The patient’s low intelligence, and poor social andverbal skills may have predisposed him to an atypicalpresentation of emotional disturbance. He was prob-ably not able to communicate his distress, and out offrustration,pokedthestickintohiseye.Afraidtoadmitwhat he had done, he endured the pain with stoic andobstinate silence. There was no obvious secondarygain, and he recovered as soon as the stick wasremoved.Trance or possession states are common in differ-ent cultures. Coons (1992) claimed that most dissocia-tive disorders diagnosed in non-industrialized nationswould probably be DDNOS. Or, as in our patient, the bizarre behavior that led to the physical disorder couldeasily be labeled as schizophrenia. It was noted thatonce the diagnosis of schizophrenia was documented
Figure 2
A simulated 7 cm stick which demonstrates the possibility ofthe stick to penetrate the brain.
168
Asia-Pacific Psychiatry
2 (2010) 166–169 Copyrightc
2010 Blackwell Publishing Asia Pty Ltd
H.C. Ismail
et al
.Culture-bound syndrome

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Shamsul Anuar added this note
an eye opener for the fusion between traditional and cultural beliefs and treatment with the modern medical development.
Hasanah Che Ismail added this note
Thank you Ahmad Cendana for uploading.
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