KORO, LATAH AND RUNNING AMOK

KORO

Koro is a mental disorder found in Malaysia (similar to other disorders found elsewhere in East Asia) characterized by intense anxiety that one’s sexual organs will recede into the body. Some afflicted with it become so obsessed with the delusion they mutilate themselves, in some cases causing death. There are occasional epidemics of the disorder. One in Singapore in the 1960s was quite famous. [Source: Cultural Mental Illness: Diagnostic and Statistical Manual of Mental Disorders by American Psychology Association.]

Professor Kua Ee Heok of the Department of Psychological Medicine, National University of Singapore, wrote in Transcultural Psychiatry: “Koro refers to a syndrome, which has for its central theme a fear of death due to the person’s conviction that his penis is shrinking into the abdomen. The panic-stricken man often clutches on to his penis with bewildered spouse and relatives assisting. The term koro is thought to derive from the Malay word kura which means “tortoise” – the symbolic meaning is that the penile retraction is compared with the retraction of the head of the tortoise into its shell. The syndrome in traditional Chinese medicine is known as suo-yang, which literally means shrinkage of the male sexual organ. In women it may take the form of retraction of the vulval labia or nipple.

“Koro is often viewed as a form of panic disorder with the symptom-complex of fear of penile retraction and impending death, palpitations, sweating, breathlessness and paraesthesia. The factors, which contribute to the occurrence of koro, include beliefs and attitudes pertaining to sexuality. A common Chinese belief is that the loss of semen weakens the body, and loss of yang occurs with masturbation and nocturnal emission. The loss of semen through sexual excesses is thought in traditional Chinese belief to lead to fatal ill-health. Personality traits associated with koro have been described as nervous temperament, suggestibility, sensitivity and immaturity.” [Ibid]

In the Singapore Medical Journal (1963, 4, 119-121), Dr. Gwee AL, describes a Koro case involving a male Chinese aged 34, seen on 24 March 1956: “He was at a cinema show when he felt the need to micturate. He went out to the latrine in the foyer and, as he was easing himself, he felt a sudden loss of feeling in the genital region, and straightaway, the thought occurred to him that he was going to get penile retraction. Sure enough, he soon noticed that he penis was getting shorter. Intensely alarmed, he held on to his penis with his right hand and shouted for help, which however was not forthcoming as the latrine was deserted during the show. He felt cold in the limbs, and was weak all over, and his legs gave way under him. So he sat down on the floor, all this time holding on to his penis. About half an hour later, the attack abated.”

Koro is very rare these days. But a new mental disease has appeared among the Chinese. Known to the Chinese as wi han zheng, it is a “fear of being cold.” Those afflicted with the disorder put gloves, wool hats and coats even when the weather is sweltering.

Koro and Chinese Ideas About Health

Nearly all the who suffered from koro have been Chinese men. Some sources cite a role in Chinese metaphysical beliefs, where abnormal sexual acts (visiting prostitutes, masturbation or nocturnal emissions) disturb the yin-yang balance, leading to a loss of the yang (or male) force with accompanying consequences on key organs.

Ng Beng Yeong, an expert in culture-bound syndromes at the Woodbridge Hospital and Institute of Mental Health in Singapore and author of a seminal 1991 paper on koro, told the New York Times: "What struck me with koro is that here was a mental disease that was directly caused by the traditional Chinese conception of health. It came from inside the culture. Nearly all the men who suffered from koro were ethnic Chinese." In a conceptual system, he explains, which emphasizes opposing male and female "energies" -- think yin and yang -- men tend to be obsessed with their masculinity, which they fear can be sapped from them. A koro-like affliction, Ng explains, appears in ancient Chinese medical texts, where it is known as suo-yang. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

"In ancient China, castration was the most feared punishment," Yeong said, "So when you felt anxious or unwell, you would often become obsessed with your penis." But in 1967, he goes on, there was an added factor contributing to the koro epidemic on the Malaysian peninsula. Racial tensions between Muslim Malays and non-Muslim Chinese were running high, and among the Chinese there was a virulent rumor that the Malays had poisoned their pork. The atmosphere was primed for hysteria. "Koro was like a collective anxiety attack," Ng concludes. "It was the manifestation of social unease." ++

Lawrence Osborne wrote in the New York Times magazine, “ In recent years, koro has almost disappeared from the Chinese diaspora in the Malacca Straits and Singapore. "It's almost as if changing social conditions produce changing syndromes," the Yeong said. But it has been replaced by equally strange phenomena: a condition that the Chinese call wei han zheng, or "fear of being cold." Ng calls it frigophobia. Patients bundle up in the steamy Singapore heat, wearing wool hats and gloves. Like koro, he explains, frigophobia seems to stem from Chinese cultural beliefs about the spiritual qualities of heat and cold. "I don't really know," he laughs. "Maybe it's just a reaction to mass air-conditioning. Frigophobia is so new, it doesn't even exist in the psychiatric literature. So far, it's unique to Singapore. I'm as perplexed by it as anyone else. I wonder if it will be in D.S.M.-V." ++

"One thing I've noticed," Yeong said, "is that modern psychiatry is essentially a Western import." In the East, Ng continues, patients tend not to distinguish between mind and body. "Our patients rarely talk about their moods per se, the way people in the West do," he explains. So even with mental afflictions that appear to have a clear biological basis -- like schizophrenia -- people's ways of expressing them are shaped by culture. ++

Great Koro Epidemic of 1967

7In 1967 there was an outbreak of koro following press reports of Koro cases due to the consumption of pork from a pig that had been inoculated against swine fever. The epidemic struck in October 1967 for about ten days. Newspapers initially reported that some people developed koro after eating the meat of pigs inoculated with anti-swine-flu vaccine. A headline from the Straits Times on November 5, 1967 read: “A Strange Malady Hits Singapore Men.” Rumours relating eating pork and koro spread after a further report of an inoculated pig dying from penile retraction. The cases reported amounted to 97 in a single hospital unit within one day, at five days after the original news report. Government and medical officials alleviated the outbreak only by public announcements over television and in the newspapers. [Source: The annotated budak, , May 14, 2006, Wikipedia]

Dr. Gwee authored a study (in the Singapore Medical Journal 1969, 10, 234-242) about the 1967 epidemic, which affected over 500 persons. He wrote: “ …before the outbreak of the epidemic, there was concern about chickens being injected with oestrogen to increase their growth. Some men were afraid that the oestrogen in the chicken would cause gynaecomastia and avoided chicken meat. At about the same time, there was a rumour that contaminated pork was being sold on the market and that diseased pigs were being inoculated against swine fever. This triggered off the epidemic and a possible explanation of the outbreak is that the inoculation of the pigs was seen to be similar to the injection of chickens with oestrogen." His report also noted that the epidemic “subsided rapidly after ressurance and explanation from the doctors through television, radio and newspaper.”

Chris Buckle of the University of Ottawa wrote in his study “A Conceptual History of Koro”: “In July 1967, all swine in the country were inoculated with an anti-swine fever vaccine. It was an event that brought much public concern and considerable media attention. On October 29, 1967, rumors began to circulate that the consumption of this inoculated pork was causing men’s genitalia to retract. It is unknown how, why or where in Singapore the rumors began. However, there is some evidence that the kosher Malays were blamed for the event, an accusation in line with the background of racial tension that plagued Singapore in the nineteen sixties. While this idea was not described in the government controlled Chinese or English language media, personal accounts do give it credence.

“On October 30th a small Chinese language paper reported that “people developed koro after eating the meat of pigs inoculated with anti-swine fever vaccine”. A few days later, the same paper reported that an inoculated pig had died from penile retraction.” Within the week, public hospitals were seeing hundreds of koro patients, and Buckle notes that no statistics exist for the presumably high number of individuals who were treated by family or traditional Chinese physicians. It was reported that "men resorted to clamps, pegs, and even weights to ensure that their tackle remained in its rightful place."

“An alarmed Ministry of National Development issued an immediate statement claiming that ‘no one in Singapore need worry over the safety of pork from pigs slaughtered at the government abattoir where every carcass is carefully examined and stamped as fit for human consumption before they are released to the market’”. The outbreak subsided after press statements by the Singapore Medical Association that “koro is a culturally determined form of emotional ill-health affecting primarily the Chinese…the present incidence of koro is essentially due to fear and rumors which have no foundation”. Meanwhile, advertisements for Australian pork began to appear in the papers. The Chinese-language Nanyang also reported that a man in the ministry of production had apologised for comments about the link between the swine vaccine and koro. The final nail on koro’s coffin came with the televised statement of the Deputy Director of Medical Services, Dr. Lim Guan Ho, who stressed that koro “is only a disease of the mind and the victim requires no medical treatment at all.”

Running Amok

In Malaysia and Indonesia there is mental disorder called amok, experienced mostly by men, characterized by brooding and violent outburst from an otherwise normal person caused by a slight or insult. Sometimes the outburst can be so violent that the inflicted person can kill anyone who crosses his path. The colonial British were quite familiar with the disease and gave birth to the expression “running amok.” Sometimes people running amok kill those in his To this day, cases of amok are reported in Malaysian newspapers.

In his paper “Running Amok: A Modern Perspective on a Culture-Bound Syndrome,” Manuel L. Saint Martin, M.D. wrote: “Running amok is considered a rare culture-bound syndrome by current psychiatric classification systems, but there is evidence that it occurs frequently in modern industrialized societies. The general public and the medical profession are familiar with the term running amok, the common usage of which refers to an irrational-acting individual who causes havoc. The term also describes the homicidal and subsequent suicidal behavior of mentally unstable individuals that results in multiple fatalities and injuries to others. Except for psychiatrists, few in the medical community realize that running amok is a bona fide, albeit antiquated, psychiatric condition. Although episodes of multiple homicides and suicide by individuals with presumed or known mental disorders occur with alarming regularity today, there are virtually no recent discussions in the medical literature about the recognition and treatment of these individuals before their suicidal and homicidal behavior occurs. [Source: Running Amok: A Modern Perspective on a Culture-Bound Syndrome by Manuel L. Saint Martin, M.D., J.D., Primary Care Companion to the Journal of Clinical Psychiatry, June 1999; 1(3): 66–70 /=/]

“The psychiatric literature classifies amok as a culture-bound syndrome based on its discovery 2 centuries ago in remote primitive island tribes where culture was considered the predominant factor in its pathogenesis. The primitive groups' geographic isolation and spiritual beliefs were thought to produce a mental illness not observed elsewhere in the world. DSM-IV,1 which is the current consensus opinion on psychiatric diagnosis, depicts amok as a cultural phenomenon that rarely occurs today. However, characterizing amok as a culture-bound syndrome ignores the fact that similar behavior has been observed in virtually all Western and Eastern cultures, having no geographical isolation. Furthermore, the belief that amok rarely occurs today is contrary to evidence that similar episodes of violent behavior are more common in modern societies than they were in the primitive cultures where amok was first observed.” /=/

In the abstract to “Running Amok” (Int J Soc Psychiatry. 1977;23(4):264-74) the authors Schmidt K, Hill L, Guthrie G. wrote: “This study examines twenty-four cases of amok, believed the largest number of cases ever collected. They were observed in Sarawak, East Malaysia. They occurred in all indigenous groups in Sarawak, excluding the Chinese, such as Malay, Sea Dayak, Land Dayak, Kayan, Punan and Melanau at frequencies more or less following the proportion of these groups in the total population.

“No differences were found according to religion, the Malay being Muslim and the other groups either predominantly Christian like the Iban or animistic. Only slight diminution in the frequency was observed from 1954 to 1968. The education level of the amok runners was much lower than that of the average population. The weapons used were those immediately at hand be it parang (short sword), ax, sticks, knives, guns, bare hands or a lorry. The classical four stages were largely present: (a) brooding and withdrawal, (b) homicidal paroxysm, (c) continuation of homicidal behaviour until killed, restrained or falling into stupor of exhaustion, (d) complete or partial amnesia. While in 14 no motive could be ascertained, insult, jealousy and paranoid ideation was present in the others. Both family history of mental illness and personal psychiatric history were predominant. All cases fell into accepted diagnostic categories from organic and endogenous psychosis to neurosis and behaviour disorder.

History of Running Amok

In his paper “Running Amok: A Modern Perspective on a Culture-Bound Syndrome,” Manuel L. Saint Martin, M.D. wrote: “Amok, or running amok, is derived from the Malay word mengamok, which means to make a furious and desperate charge. Captain Cook is credited with making the first outside observations and recordings of amok in the Malay tribesmen in 1770 during his around-the-world voyage. He described the affected individuals as behaving violently without apparent cause and indiscriminately killing or maiming villagers and animals in a frenzied attack. Amok attacks involved an average of 10 victims and ended when the individual was subdued or “put down” by his fellow tribesmen, and frequently killed in the process. According to Malay mythology, running amok was an involuntary behavior caused by the “hantu belian,” or evil tiger spirit entering a person's body and compelling him or her to behave violently without conscious awareness. Because of their spiritual beliefs, those in the Malay culture tolerated running amok despite its devastating effects on the tribe. [Source: Running Amok: A Modern Perspective on a Culture-Bound Syndrome by Manuel L. Saint Martin, M.D., J.D., Primary Care Companion to the Journal of Clinical Psychiatry, June 1999; 1(3): 66–70 /=/]

“Shortly after Captain Cook's report, anthropologic and psychiatric researchers observed amok in primitive tribes located in the Philippines, Laos, Papua New Guinea, and Puerto Rico. These observers reinforced the belief that cultural factors unique to the primitive tribes caused amok, making culture the accepted explanation for its pathogenesis in these geographically isolated and culturally diverse people. Over the next 2 centuries, occurrences of amok and interest in it as a psychiatric condition waned. The decreasing incidence of amok was attributed to Western civilization's influence on the primitive tribes, thereby eliminating the cultural factors thought to cause the violent behavior. Modern occurrences of amok in the remaining tribes are almost unheard of, and reports in the psychiatric literature ceased around the mid-20th century. Inexplicably, while the frequency of and interest in amok among primitive tribes were decreasing, similar occurrences of violence in industrial societies were increasing. However, since the belief that amok is culturally induced had become deeply entrenched, its connection with modern day episodes of mass violence went unnoticed. /=/

“The following cases reports illustrate the typical violent behavior reported in amok episodes in Malay tribes: 1) In 1846, in the province of Penang, Malaysia, a respectable elderly Malay man suddenly shot and killed 3 villagers and wounded 10 others. He was captured and brought to trial where evidence revealed that he had suddenly lost his wife and only child, and after his bereavement, he became mentally disturbed. 2) In 1901, in the province of Phang, Malaysia, a 23-year-old Muslim man who was formerly a member of the police force stole a Malay sword and attacked 5 individuals while they were sleeping or smoking opium. He killed 3, almost decapitating 1 victim, and he seriously wounded the others. /=/

Early travelers in Asia sometimes describe a kind of military amok, in which soldiers apparently facing inevitable defeat suddenly burst into a frenzy of violence which so startled their enemies that it either delivered victory or at least ensured what the soldier in that culture considered an honourable death. In contemporary Indonesia, the term amok (amuk) generally refers not to individual violence, but to frenzied violence by mobs. [Source: Wikipedia]

Indonesians now commonly use the term 'gelap mata' (literally 'darkened eyes') to refer to individual amok. Laurens van der Post experienced the phenomenon in the East Indies and wrote in 1955: 'Gelap mata', the Dark Eye, is an expression used in Sumatra and Java to describe a curious and disturbing social phenomenon. Socially speaking, the Malays, Sumatrans and Javanese are the best behaved people I have ever encountered. On the surface they are an extremely gentle, refined, submissive people. In fact the word 'Malay' comes from 'malu', 'gentle', and gentleness is a quality prized above all others among the Malays and their neighbours. In their family life, in their submission to traditional and parental authority, in their communal duties, they are among the most obedient people on earth. But every now and then something very disturbing happens. A man who has behaved in this obliging manner all his life and who has always done his duty by the outside world to perfection, suddenly finds it impossible to keep doing so. Overnight he revolts against goodness and dutifulness.

Saint Martin wrote: “Contemporary descriptions of multiple homicides by individuals are comparable to the case reports of amok. In the majority of contemporary cases, the slayings are sudden and unprovoked and committed by individuals with a history of mental illness. News media, witnesses, and police reports describe the attackers as being odd or angry persons, suggesting personality pathology or a paranoid disorder; or brooding and suffering from an acute loss, indicating a possible depressive disorder. The number of victims in modern episodes is similar to the number in amok despite the fact that handguns and rifles are used in contrast to the Malay swords of 2 centuries ago. The outcome for the attacker is also analogous to amok, being death, suicide, and less commonly, apprehension. /=/

“The following report demonstrates the resemblance between amok and contemporary violent behavior: “In 1998 in Los Angeles, Ronald Taylor, aged 46, killed 4 of his family members and a friend, and then jumped to his death from a freeway overpass. The police discovered Taylor's victims when they went to his home to inform them of his death. Court records revealed that Taylor was experiencing financial problems, was filing for bankruptcy, and had debts of more than $64,000, including a $21,302 personal loan from his employer and a $5,547 Sears credit card debt. /=/

“Amok was first classified as a psychiatric condition around 1849 on the basis of anecdotal reports and case studies revealing that most individuals who ran amok were mentally ill. Prior to that time, amok was studied and reported as an anthropological curiosity. Historically, observers described 2 forms of amok, but DSM-IV does not differentiate between them. The more common form, beramok, was associated with a personal loss and preceded by a period of depressed mood and brooding; while the infrequent form, amok, was associated with rage, a perceived insult, or vendetta preceding the attack. Based on these early case reports, beramok is plausibly linked to a depressive or mood disorder, while amok appears to be related to psychosis, personality disorders, or a delusional disorder. /=/

“The early case reports suggest that amok in all likelihood is not a psychiatric condition, but simply a description of violent behavior resulting from another mental illness. The multiple homicides and injuries that occur in amok may represent an unusual manifestation of a depressive condition, a psychotic illness, or a severe personality disorder. It is also probable that certain individuals are predisposed to exhibiting extremely violent behavior when they are suffering from mood disorders or personality disorders.”

Contemporary Explanations of Amok

In his paper “Running Amok: A Modern Perspective on a Culture-Bound Syndrome,” Manuel L. Saint Martin, M.D. wrote: “From a modern perspective, amok should not be considered a culture-bound syndrome, because the only role that culture plays is in how the violent behavior is manifested. An individual's behavior is influenced by environment and culture even in situations where those actions are the product of a mental illness. Thus, the behavior observed in amok 200 years ago in the primitive tribes will necessarily differ from that seen in contemporary cases of violent behavior. Characterizing the violent behavior in amok as the product of another mental illness dispenses with its culture-bound origins and reconciles it with the violent behavior observed in contemporary cases. [Source: Running Amok: A Modern Perspective on a Culture-Bound Syndrome by Manuel L. Saint Martin, M.D., J.D., Primary Care Companion to the Journal of Clinical Psychiatry, June 1999; 1(3): 66–70 /=/]

“Previous psychiatric investigators also questioned the culture-bound classification of amok, indicating disagreement with the consensus opinion that was developing circa the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pow Meng Yap, a psychiatrist for the Hong Kong Government, wrote in 1951 that amok behavior was preceded by a period of brooding, and if the attacker was not killed in the process, it ended when the individual became exhausted and collapsed (and frequently had amnesia for the event). Yap's description of amok suggests a psychotic type of depressive disorder or a dissociative disorder. By the time of Yap's comments, violent behavior similar to amok had been observed in most countries. For a condition to truly be culture bound, it could not be found in other distinct cultures, and culture must be indispensable to its pathogenesis. This has never been the case with amok, or for that matter, with most other psychiatric conditions./=/

“Jin-Inn Teoh, a professor of psychiatry at the University of Aberdeen in London, reported in 1972 that amok behavior existed in all countries, differing only in the methods and weapons used in the attacks. According to Teoh, culture was a modulating factor that determined how amok was manifested, but not whether or not it occurred. The individual's culture and the weapons available naturally influenced the method of the attack. Teoh's report of amok was one of the last in the psychiatric literature. In the subsequent quarter century, the incidence of violent behavior similar to amok has increased dramatically in industrialized countries, surpassing its incidence in primitive cultures. This increase may be the result of better case reporting and heightened public awareness and interest in violence, combined with an increase in the psychopathology responsible for amok. Teoh's findings and the increase in violent behavior in industrialized societies are further evidence against characterizing amok as a culture-bound syndrome.

“Amok was thought to be related to suicide, a violent behavior that has never been considered a culturally bound psychiatric condition. In fact, suicide and suicidal behavior are not considered psychiatric conditions at all under present psychiatric classification systems. Suicide is a self-destructive behavior that can occur in a variety of psychopathologic states such as psychotic depression, personality disorders, and schizophrenia. In 1934, John Cooper, a professor of anthropology at Catholic University in Washington, D.C., analogized amok to suicide in an attempt to disprove its classification as a culture-bound syndrome.6 Cooper stated that neither racial, ethnic, nor environmental factors played a role in the pathogenesis of mental diseases and that amok had the same etiology in primitive and industrialized people. Cooper postulated that running amok in primitive tribes was an indirect means of committing suicide.6 Suicide was a rare occurrence in primitive cultures as opposed to industrialized societies. He thought that the same psychosocial stressors leading an industrialized European to commit suicide caused amok in the Malay tribesman. /=/

“However, Cooper's conceptualization of amok as an expression of suicidal urges does not explain why violent behavior similar to amok is so common in Western cultures like the United States, where societal prohibitions against suicide are not strong. Cooper's theory also implies that suicide and amok are alternate phenomena where culture determines which behavior the individual will manifest. Thus, Cooper's characterization of amok makes culture a necessary factor in its pathogenesis, which is the premise he was attempting to disprove. Suicide and amok share common features and risk factors, but they are nevertheless distinct behaviors.” /=/

Treating and Preventing Amok

In his paper “Running Amok: A Modern Perspective on a Culture-Bound Syndrome,” Manuel L. Saint Martin, M.D. wrote: “Running amok should no longer be considered an archaic culture-bound syndrome. A more useful and modern approach is that amok represents an extreme form of violent behavior occurring as a result of a mental disorder, personality pathology, and psychosocial stressors. Early recognition of the risk factors for amok and prompt treatment of the underlying psychiatric condition or personality disorder offer the best chance of preventing it. [Source: Running Amok: A Modern Perspective on a Culture-Bound Syndrome by Manuel L. Saint Martin, M.D., J.D., Primary Care Companion to the Journal of Clinical Psychiatry, June 1999; 1(3): 66–70 /=/]

“Today, amok should be viewed as one possible outcome of an individual's undiagnosed and/or untreated psychiatric condition with psychosis or severe personality pathology. Considering the large number of individuals who have psychotic psychiatric conditions, mood disorders, and personality disorders, amok is still a statistically uncommon occurrence. Nevertheless, the emotional damage that it causes to the victims, their families, and communities goes beyond its small numbers and has an enduring effect. Since it is virtually impossible to stop an amok attack without risking one's life or limb, prevention is the only method of avoiding the damage that it causes. Viewing amok from this new perspective dispels the commonly held perception that episodes of mass violence are random and unpredictable, and thus not preventable. Characterizing amok as the end result of a psychiatric condition reveals that, like suicidal behavior, there are risk factors that can be used to assess a patient's potential for amok and for planning treatment. /=/

“Preventing episodes of amok requires early recognition of susceptible individuals and prompt treatment of the underlying psychopathologic condition. Medical intervention is virtually impossible once an individual is running amok, and the outcome of his or her violent behavior is no different today than it was 200 years ago before the advent of modern psychiatric diagnosis and treatment. The first step in intervention is identifying those individuals whose psychiatric conditions or psychosocial stressors predispose them to running amok. Identification entails assessing patients for risk factors that are known to be related to violent behavior. /=/

“The second step in intervention is treating the patient's underlying psychiatric condition or personality disorder so that running amok never occurs. A primary care practitioner can initiate medical intervention in patients who are susceptible to running amok, but it should be supplemented with a prompt referral for psychiatric or psychological evaluation and treatment, because these patients pose complicated and challenging clinical management cases. The treatment can also be initiated by a nonmedical source through a referral to an employee assistance program, the patient's health insurance provider, or a community mental health clinic. Involuntary psychiatric hospitalization is an option for those patients who are imminently suicidal or homicidal as a result of their mental condition, but patients whose risk factors do not include a major mental illnesses may not qualify for involuntary treatment. This is typically the case with patients who have personality disorders. /=/

“Proper treatment of the patient at risk for running amok requires that the clinician make an accurate diagnosis that can be used to determine which treatment modalities are best suited for each patient. To date, there is no medication that has been proven to specifically treat violent behavior, and since violence results from multiple factors, it is unlikely that any such medication will be developed in the near future. The mass violence observed in running amok may be caused by a variety of psychiatric conditions, and medical treatment should therefore be aimed at a diagnosable mental disorder or a personality disorder. In general, depressive disorders can be treated with antidepressants and supportive psychotherapy. Antidepressants are effective in alleviating depressive symptoms and depressive disorders in 85 percent of cases. Antidepressants should be started in therapeutic doses, and the patient should be monitored for symptom improvement within 6 to 8 weeks. The selective serotonin reuptake inhibitors should be the first-line treatment choice because of their rapid therapeutic response as compared with tricyclic antidepressants and evidence that serotonin depletion plays a role in suicidal and violent behavior.8 The supportive psychotherapeutic goal is to prevent violent behavior, and the clinician should take an active role in the therapy and enlist the help of the patient's family and social support network. If the patient has signs of psychosis along with the depressive disorder, then an initial treatment period with antipsychotic medications may be necessary until the antidepressant's mood-elevating effect is achieved. While most patients can be managed in outpatient settings, those with severe psychotic symptoms or with homicidal or suicidal urges occurring during their depressive illness may require hospitalization. /=/

“Patients who have psychotic disorders such as paranoid schizophrenia or delusional disorder should be treated with antipsychotic medications. Antipsychotic agents are effective in reducing the thought disorder, hallucinations, and delusions in schizophrenia, mania, and nonspecific psychotic disorders.9 The antipsychotic agents are only modestly effective in controlling violent behavior resulting from nonpsychotic conditions such as borderline personality and antisocial personality disorders.10 Anticonvulsants have been used and found effective to control violent behavior in limited series of patients.11 However, their use, like that of the other medications discussed for treating violent behavior, is still considered experimental and off-label.12 The only exception to the general statement regarding off-label usage is when anticonvulsants such as valproate or carbamazepine are used to treat violent behavior associated with mania. The antimanic agent lithium is still the first line of treatment for bipolar disorder and mania. Hospitalization may be necessary to prevent these patients from harming themselves or others, and most state laws provide for involuntary commitments. After hospitalization, or if the symptoms do not warrant it, partial hospitalization and day treatment programs are useful as a means of monitoring patients' behavior and adjusting their medications in response to it.” /=/

Latah

Latah is a mental disorder found in Malaysia, Indonesia Japan and Thailand characterized nonsense mimicking others and trancelike behavior experienced after a sudden fright. People who have latah experiences are called latahs. Most are women. Latahs often do bizarre dances and obey commands, even to take off all their clothes, from people around them. Sometimes they sweat profusely while in the trace and often claim they have no memory of what they have done after they break out of the trance. Rather than being ostracized as outcasts they are often embraced as celebrities and their outburst became the object of playful practical jokes.

The New York Times magazine described one woman with the disease. When her husband would suddenly clap his hands she began shrieking: “Grasshopper! Grasshopper! Grasshopper! Grasshopper!,” and go into a trance and do a little dance while sweating profusely and laughing hysterically with her teeth bared. The woman developed the disease 35 years after being repeatedly poked. Cats often set her off. When that happened she often shouted the Malaysian slang word for penis.

Lawrence Osborne wrote in the New York Times magazine, “The little house looks like most of the others in the Malaysian jungle hamlet of Kampung Sebiris. The louvered windows are trimmed with heavy curtains, the tiled floor is immaculate and cushioned chairs line the walls. Even though it is over 90 degrees, there is no fan; outside, humid forest spreads out beneath a mist-wrapped mountain. As in many rural Malay homes, in the front room there is an ornate display cabinet filled with knickknacks: teapots, wooden pineapples, gaudy silk flowers. The jungle comes right up to the glass slats, and the whistling of insects is deafening.” [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

“But this is no typical home. Sitting on a woven mat in the center of the room is a gray-haired woman named Dibuk ak Suut. Wrapped in a pale green sarong, the slender 59-year-old matriarch is comfortably surrounded by her husband, daughter and grandchildren -- but her eyes flash nervously from side to side. Her husband, Sujang, has just served us cups of weak hot chocolate. He is in a playful mood. "Watch this," he whispers to me in Malay. Standing up, he suddenly claps his hands. Dibuk gives a start, shudders and leaps to her feet. Everyone roars with laughter. Dibuk's delicate, slightly lopsided face goes into a glassy trance. She begins shrieking: "Grasshopper! Grasshopper! GRASSHOPPER!" ++

“Sujang then winks like Popeye, and Dibuk does the same. The family howls in merriment. Sujang goes into a comical dance, shaking his shoulders slinkily and wiggling his hips. Still locked in her seeming trance, Dibuk does likewise. She waves her hands in front of her face and mops her cheeks with a small cloth. She sweats profusely and bares her teeth in hysterical laughter. After a few minutes, Sujang goes up to her and taps her firmly on the shoulder. The mimic-trance is over. Dibuk sits down and mops her face. "Are you O.K.?" her daughter, Catherine, asks. "Was I talking nonsense again?" Dibuk asks. "Not too bad this time," Catherine says. "You didn't say anything obscene." ++

“The family recomposes itself, and we drink our lukewarm chocolate. Then, a few minutes later, a cat creeps up to Dibuk from behind. Suddenly noticing it, she gives another violent start and begins pawing the air in front of her. "Cat," she cries. "Cat! Cat!" She then starts screaming a Malay slang word for penis. Sujang leans over to me. "It's cats that get her the most," he murmurs. "They make her more latah than anything." ++

“The Suuts are farmers living in the hills behind the tiny trading town of Lundu in Sarawak, the Malaysian side of Borneo. The kampungs, or villages, here are incredibly isolated, connected by a solitary road winding through plots of coconuts and pineapples. Outsiders rarely visit. Yet in recent years, Western scholars have become intrigued by women like Dibuk. She is a latah, suffering from an intriguing mental disturbance known in the West as hyperstartle syndrome. ++

Similarities of Latah to Other Mental Disorders

Lawrence Osborne wrote in the New York Times magazine, “The startle reflex is a universal one. When we are jolted by surprise, we tend to scream, shout obscenities or make involuntary gestures. And some of us are a lot jumpier than others. But with latahs, as sufferers are known, these reactions become prolonged to an extreme degree. In Malay village life, people who are susceptible to such exaggerated reactions are deliberately provoked further -- through furtive pokes in the ribs or tin pots thrown behind their backs -- to induce a frenzied startle-trance. Over time, latahs become so sensitive that trances can be triggered by a falling coconut. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

“Latahs tend to blurt out offensive phrases, much like sufferers of Tourette's syndrome. (Indeed, Georges Gilles de la Tourette, the French discoverer of the syndrome in the 1880's, explicitly compared it to latah.) Latahs also often mimic the actions of people around them or obey commands, including requests to take off their clothes. Afterward, latahs often claim to have no memory of what they said or did. While latahs experience profuse sweating and an increased heart rate while in a trance, there is no clear physiognomic source for the condition. What is clear, however, is that in Malaysia, interaction with latahs has become a complex form of social play. Instead of being shunned, latahs are accepted, even celebrated, for their oddity. ++

“In 1994, the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M.-IV, recognized latah for the first time as a member of a new category of psychiatric illnesses known as culture-bound syndromes -- that is, mental disorders induced primarily by culture and not by any bodily pathology. Culture-bound syndromes are not only rare and exotic; they're also controversial, for they raise intriguing and profound questions about the very nature of mental illness. At the heart of these questions are age-old debates about the conflicting roles of nature and nurture.” ++

Social and Hysterical Aspects of Latah

Lawrence Osborne wrote in the New York Times magazine, “One puzzling characteristic of culture-bound syndromes is that they often take the form of social epidemics....In other words, instead of being physiologically rooted in every afflicted individual, some syndromes can be infectious in a purely mental way. But what starts the chain of infection? In the case of latah, no scholar can say for sure. It may be that, at one time, a neurological disorder produced exaggerated startle reactions in some Malaysian women -- and that over time, as awareness of the affliction permeated the culture, the disease spread through social mimicry. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

“This does not mean, of course, that modern latah sufferers are consciously faking their afflictions. After all, American girls desperate to resemble their skinny peers aren't faking obsessions with food. As Kleinman writes in "Rethinking Psychiatry," his groundbreaking 1987 book, "mental illnesses are real; but like other forms of the real world, they are the outcome of the creation of experience by physical stuff interacting with symbolic meanings." Malaysians themselves seem well aware of latah's social component. "Latah is highly infectious," Dibuk responds when I ask if she knows any other women who are afflicted. "A woman named Duyik, who lives in Kampung Tebaro, has it. We caught it from each other." ++

“Curious to see for myself, I hitch a ride down to Kampung Tebaro. It's a neat cluster of wood houses at the edge of the forest, and there Duyik Anak Gagang lives with her grandchildren and her son. Jolly and roly-poly, she breaks into a crooked smile as she shakes my hand. Then she chops her hand playfully at her teenage grandson, Jasni. "That one, he's always poking my ribs," she croaks. "Then I start dancing, I can't help it." Jasni concurs. "I just clap my hands behind her back, and she starts throwing stuff around the room," he says. Although she is 69, Duyik becomes surprisingly agile while latah. She has been known to dance wildly for 30 minutes straight. ++

“Duyik claims her condition can be traced to the trauma of childbirth. "I became latah when my first son was born," Duyik explains to me matter-of-factly. "It was such a big shock for me. You see, it's only women who are latah. We don't know why. It's just the way it is." "That's right," Jasni says. "I'll never be latah, I hope." The family nods silently. Latah is indeed a condition that mostly strikes women, usually middle-aged or older. ++

“I ask Duyik what kinds of things she does while in a trance state. "I just mimic everything I see around me," she says. "Even the TV. While I'm latah, I apparently imitate everything I see on TV." "Doesn't that make it a little dangerous?" I ask. "Well," Duyik titters, holding a hand over her mouth to hide her teeth, "I try not to watch too much wrestling." ++

Urban, Social Latah

Lawrence Osborne wrote in the New York Times magazine, “Kuching lies on a bend of the Sarawak River on Borneo's northern coast. It's a bustling river town of peeling Chinese godowns, genteel English colonnades and pell-mell Malay markets that have not yet ceded ground to the air-conditioned malls of the Asian boom. The city's population is a microcosm of modern Malaysia: a polyglottal confusion of immigrant Chinese, Indians, Malays, Dyaks and Ibans.” Peter Kedit, a local anthropologist, says over the years “latah has spread from Malaysia's rural backwaters to its urban centers. "Here in Kuching, latah has become a kind of social rebellion," Kedit explains. "Some people are more hard-core latah than others, and they kind of lead on the rest. Then it turns into a subversive game. Some ham it up, but others truly can't help themselves." Most latahs in Kuching are women, Kedit says, but not all. He notes that some of the more baroque cases of latah can be found among the city's homosexual and transvestite populations. This may be because for many Malaysians, the malady has become firmly associated with femininity. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

“Across the river from the town center lies the sprawling suburb of Petra Jaya. Here, Iban and Dyak villages have begun sprouted up among the posh houses of Muslim ministers and Chinese businessmen, creating an incongruous patchwork of marble villas and wooden shacks. In this neighborhood, a pair of old ladies have become known in the markets of Kuching for their latah antics. One of them is Serai, a frail 75-year-old. She welcomes me inside her son-in-law's house, with its sweltering front room of gaudy pink couches. Thirty-five years ago, Serai explains, she was invited to join a woodchopping team of women in the forests outside Kuching. The work was arduous, and the other women constantly teased their inexperienced companion. "They poked and poked me," she recalls a little mournfully, "and I became latah." ++

“Over the years, Serai says, she has gotten used to her affliction. And she is comforted by the fact that her close friend Amin Anak Jantan has developed the condition as well. "We're latah together," she says, wiggling her hips as if to demonstrate. Serai sends me to a home nearby to meet her friend. Amin sits in a room brimming with fake silk flowers; as I sit with her, I notice a long line of ants crawling up the wall next to me. Amin somberly tells me that she became latah in 1957, when her fifth son died of leukemia. "I nearly went insane," she whispers. "It was the grief that made me latah. I was completely traumatized. I fainted all the time." ++

“I then ask what Amin gets up to with Serai in the Kuching markets. "We go shopping together," she says, drying her tears quickly. "But sometimes when we do, certain things will set us off, like cats or cars backfiring. We'll start imitating people for no reason. If we see this hunchback man who lives in the Chinese neighborhood, we'll both start imitating his hump." She gets up and demonstrates, theatrically rolling her shoulders forward. "Everyone thinks it's very funny, but it's not funny for us." ++

“How can latah consistently strike two people at the exact same moment? It seems that Serai and Amin must have some control, even if they are unable to acknowledge it, over their affliction. And if they can remember what happens to them while in a trance state, then is it really latah? Is Michael Kenny right -- that latah is more of a ritual than an illness? ++

“Latah is, in the end, a very slippery phenomenon. While some sufferers may simply be imitating trance behaviors in a bid for attention, others may well be predisposed to exaggerated startles for physiological reasons. Making things even more complex, every latah seems to have a unique explanation for her malady. Amin, for example, grew up in a traditional rural village called Banting, but she doesn't remember any latahs when she was a child. "There were none in my village," she says. "I only see latahs where people from different villages are thrown together, like here in Kuching. Mixing people together is what causes latah." ++

“There is one thing that remains constant for all latah sufferers. Upon becoming afflicted, latahs become permanently sensitive to startling. It is a lifetime condition. Scholars have only encountered a few latahs who have overcome their symptoms. Even if latah is spread primarily by culture, then, it is a potent virus. ++

“Indeed, the power of culture to propagate mental illness has become a subject of increasing fascination in the West. In recent years, scholars have seen mysterious maladies proliferate in a way that echoes the spread of latah. Multiple-personality disorder, for example, flourished among white, middle-class American women in the 1980's. And more recently, American and European psychologists have begun tracking apotemnophilia -- a new, disturbing condition in which sufferers desire to amputate one of their own limbs. The Internet, medical anthropologists say, is helping spread the condition globally. As with latah, there is no cure.

Indeed, the latahs of Petra Jaya tell me that they are at a loss to know what to do about their debilitating propensity to startle. For them, latah is not something they've made up in their minds. It is something beyond their control. "I'd go to my doctor," Amin says seriously, her eyelids flickering as she mops her face again. "But there's nothing they can do."

Film and Research About Latah

Lawrence Osborne wrote in the New York Times magazine, “In 1968, the anthropologist Hildred Geertz wrote a paper called "Latah in Java: A Theoretical Paradox," in which she argued that the raucous behavior of latah could be understood only in the context of the courtly emotional restraint that is the cultural norm in Malaysia and Indonesia. This highly decorous culture provided very few outlets for intense emotion -- and latah had become one of them. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001 ++]

“Yet here was the paradox: syndromes very like latah, Geertz reported, existed in several other cultures as well. In rural parts of the Philippines, for instance, a nearly identical condition known as mali-mali is widespread. In Siberia, there is a hyperstartle complex known as myriachit, while in Thailand it is known as baah-ji and in Japan, imu. In the 1930's, scholars made a curious film about hyperstartling among the Ainu, an ethnic minority in northern Japan. The faded reels show Ainu women being startled, waving their arms like windmills and running around in a frenzy. A form of latah has even been recorded among French loggers in Canada. (Perhaps they are startled by falling trees?) Sufferers are known in medical literature, rather improbably, as the Jumping Frenchmen of Maine. Were these all hyperstartle complexes different forms of latah, Geertz asked, or were they all unique syndromes? ++

“After Geertz's paper appeared, a psychiatrist named Ronald C. Simons made a research trip to the oceanside hamlet of Padang Kemunting in West Malaysia. There he found a village in which latah was common. Now a professor emeritus at Michigan State, Simons was immediately convinced that latah was more significant than most Western researchers were prepared to admit at the time. In 1978, Simons made a short documentary film about Padang Kemunting, in which latahs and their relatives were interviewed. One woman, Layut Binti Ali, describes her condition thus: "One sees a centipede, or a snake, or a coconut leaf falls, and one is startled. Then someone sees what happens. Later, when he sees me again, perhaps he'll poke me in the ribs." Pawang Lamun, an indigenous healer, is asked if ordinary people can become latah. He explains: "If we keep poking a normal person like that, she'll become a latah. It doesn't take long. Five days poking over and over, little by little, a person becomes quite flustered." ++

“Throughout the film, an atmosphere of good humor prevails. When an august matriarch is startled and blurts out obscenities, everyone splits his sides. Nevertheless, latah is clearly a debilitating condition. The worst sufferers appear to be extremely anxious. And for the village's few male sufferers, latah -- seen by many locals as a feminine affliction -- is a source of deep shame. ++

“In the years after making his film, Simons puzzled over Geertz's paradox. Was latah a universal pathology or a cultural oddity? In a 1996 book, "Boo! Culture, Experience and the Startle Reflex," Simons argues that latah-like syndromes exist in many cultures because the startle response is itself physiologically universal. It's just that some cultures are more fascinated (and amused) by the startle response than others, making people who are easily frightened objects of attention.

Treating Latah

"Is there a cure for it?" Duyik asks me with sudden urgency. "Is there a drug I can take to help me?" "I don't know," I say. Would a little Prozac -- the West's current cure-all -- make Duyik less nervous, and less prone to latah? Perhaps, but here in remote Borneo, pharmacological therapy is not a very realistic option. [Source: Lawrence Osborne, New York Times magazine, May 6, 2001]

Lawrence Osborne wrote in the New York Times magazine, “ Simons also points out that doctors in the West have identified a rare disease known as hyperexplexia -- a hereditary neurological disorder that causes violent and attenuated startle responses (but no trance). Hyperexplexia, scientists have learned, is caused by a genetic alteration affecting glycine receptors in the brain and is treated by American doctors with the drug Clonazepam. Could Clonazepam, Simons asks, be used to treat latahs? "So far, no treatment has been offered to latahs at all," he notes. "There have been no drug studies whatsoever. That seems highly unsatisfactory to me, because many of these women really suffer from their condition." ++

“Other researchers have strongly disagreed with Simons's suggestion that latah might be treated with drugs. Michael Kenny, an anthropologist at Simon Fraser University in British Columbia, has argued that latah has been unduly medicalized by the D.S.M.-IV. Latah is an elaborate cultural ritual, he argues, and nothing more. He says it is ethnocentric to call latah an organic illness. "All this psychiatrizing is another form of colonialism," Kenny says. "Latahs aren't bothered by being latahs. Nor is anyone around them. Why, then, is it a so-called syndrome?" Such criticisms make Simons impatient. "If that's true," he says in response, "then why do latahs themselves ask if they can be cured?"

Image Sources:

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Malaysia Tourism Promotion Board, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Foreign Policy, Wikipedia, BBC, CNN, and various books, websites and other publications.

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© 2008 Jeffrey Hays

Last updated June 2015

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