Abstract
Traumatized Cambodian refugees with PTSD often complain of khyâl attacks. The current study investigates khyâl attacks from multiple perspectives and examines the validity of a model of how khyâl attacks are generated. The study found that khyâl attacks had commonly been experienced in the previous 4 weeks and that their severity was strongly correlated with the severity of PTSD (PTSD Checklist). It was found that khyâl attacks were triggered by various processes—such as worry, trauma recall, standing up, going to a mall—and that khyâl attacks almost always met panic attack criteria. It was also found that during a khyâl attack there was great fear that death might occur from bodily dysfunction. It was likewise found that a complex nosology of khyâl attacks exists that rates the attacks on a scale of severity, that the severity determines how the khyâl attacks should be treated and that those treatments are often complex. As illustrated by the article, khyâl attacks constitute a key aspect of trauma ontology in this group, a culturally specific experiencing of anxiety and trauma-related disorder. The article also contributes to the study of trauma somatics, that is, to the study of how trauma results in specific symptoms in a specific cultural context, showing that a key part of the trauma-somatic reticulum is often a cultural syndrome.
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Notes
PTSD predisposes to generalized anxiety disorder (Ghafori et al. 2009).
Several studies indicate that trauma and PTSD decrease the blood pressure response on standing (Hinton et al. 2009a).
We asked about a feeling of “blacking out” because it is a common complaint in a khyâl attack, but in the DSM panic attack criteria this complaint is joined with “dizziness” and several other complaints.
We asked specifically about cold extremities because it is a key symptom of a khyâl attack, but in the DSM-IV panic attack symptoms, cold extremities and hot flushes are joined in one question.
We asked the two questions about being out of energy (viz., “i” and “j”) because patients differentiate between two levels of exhaustion: simply being “out of energy” versus being “exhausted in the legs and arms” (oh day oh ceung), the latter considered to be an extreme state of energy depletion that is greatly feared.
We asked about reusap reusâl because it is a commonly used term to describe how one feels in a khyâl attack.
These five reduplicatives capture well a feeling that was often experienced in the Pol Pot period: a sense that one has worked beyond one’s energy stores, resulting in dizziness and a feeling of exhaustion. The meaning of the reduplicatives varies slightly: the first one emphasizes more a sense of anxiety and dizziness; the second two, a sense of exhaustion in addition to anxiety and dizziness; and the last two, an added sense of tinnitus, of mental confusion, which is conveyed by sound symbolic means by the repeating “ng” cluster.
Symptoms not typically associated with the pathophysiology of a khyâl attack were much less frequently present: a feeling of choking, derealization/depersonalization and a fear of losing control/going crazy. It is difficult to translate the term derealization/depersonalization into the Cambodia language. However, “de-soulization,” a sense of a body lacking a soul, accompanied by a sense of body lightness and otherness, is a much more common local concept but has a different meaning. Cambodians often complain of such lightness during khyâl attacks. It is as if the excessive khyâl in the body produces this lightness, as well as the lack of energy.
In the same way, an American, if asked whether a panic attack was “untriggered,” might say that it was caused by “stress,” and only careful questioning would show that the attack in question was unexpected at the time it occurred.
Just as there was the sense of being helpless to aid starving and ill relatives during the Pol Pot period, many of whom died, these same feelings are relived in the inability to help relatives in Cambodia at the present time.
Several authors have demonstrated how fear about the negative effects of worry worsen GAD and may result in the worry episode escalating to the point of panic (Wells 2000).
Just as weather-caused panic is often cast in images of the ability to “adjust,” so, too, standing up is thought to involve the ability “to adjust” to standing.
Often, to describe the dizzying effect of these locations, to describe the attention being pulled this way and that, to describe objects and people being here and there, Cambodians use certain expressions: “an jêh an jôh,” literally meaning, “one thing here, one thing there,” but with even more of a sense of shift conveyed in the original Cambodian language version owing to sound symbolism and other means (see Hinton and Good 2009).
Most patients will label a cold with a specific illness term (pdah saay), and so too a flu (pdah saay thom), and they will not consider them to be caused by khyâl. However, sometimes these events may be labeled as khyâl attacks.
Often khyâl attacks begin with a combination of “out of the blue” anxiety, dizziness and fatigue. Such a combination is described by the term reusap reusâl and the other reduplicatives discussed above.
In the DSM and in the panic literature, catastrophic cognitions are often called “triggers” of panic attacks.
This analysis has important implications because currently, to meet DSM-IV panic disorder criteria, the panic attacks must be “out of the blue,” must be untriggered (APA 1994). As this analysis reveals, the definition of these terms (“out of the blue,” “untriggered”) is complex in the case of panic attacks.
It should be noted that there is some overlap in these categories: in the case of both khyâl attacks caused by “people poisoning” and those caused by housework, turning the head may play a causal role. This overlap is especially strong between “thinking a lot” and the categories of worry and trauma recall. One needed to ask further to determine whether it was caused by worry, trauma recall or separation/bereavement issues, or a combination.
But it is more complex because when anxious patients not uncommonly enact malarial episodes as an idiom of distress. In this case, the symptoms of a biomedical illness serve as an idiom of distress.
But in the Pol Pot period there was no khyâl oil or ointment, so water was used for coining, and often there were no coins, so that the skin was pulled by grasping it with the fingers. Of note, khyâl oil and ointment, as well as coins, were readily available before the Pol Pot period (though sometimes, owing to expense, coconut oil was used instead of khyâl oil or ointment); the unavailability of these basic means of self-treatment represented one more aspects of the privations endured during the Pol Pot period.
Some patients do coining with khyâl oil; it has the same ingredients but is an oil rather than an ointment. But khyâl ointment is more popular.
The description of the color as that of pig’s blood comes from the following observation. In Cambodia, most patients have seen pigs or chickens being killed by cutting the neck and collecting the blood. The blood is collected in a container, where it coagulates, and then is cut into cubes to put into soup or other foods. Patients remark that the pig’s blood is bright red upon first flowing out, but as it is exposed to air, it turns a purple color. It is this darker color that is meant when the coining streaks are described as being the color of pig’s blood. Pig’s blood serves as a model of pathophysiology: just as the pig’s blood turns purple when exposed to air, so too does human blood when exposed to khyâl.
Patients do not always attribute anxiety and PTSD symptoms to khyâl attack. Those symptoms may be attributed to other syndromes or simply to fear itself. In many cases, though, fear is attributed to a “khyâl attack.” To give an example, if the patient coins and it does not help at all, the patient may think that it cannot be “khyâl.” In other cases, the patient may have symptoms that lead to alternative diagnosis: if the patient has a sense of inner heat and has certain other symptoms, like great thirst, the anxiety symptoms may be attributed to “inner heat,” for example. Or if the patient has great fear—owing to startle, a nightmare or another cause—it may be attributed to “weak heart” or it may be attributed to simply being afraid. Attributing anxiety symptoms to “khyâl” (versus many other interpretive frames, like heat in the body, fright, soul loss) has certain important consequences, conveys a different set of meanings. For example, in the Cambodian idiom of “hot inside” (kdaw khnong), there is much more the sense that the individual has anger issues in addition to panic attacks.
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Hinton, D.E., Pich, V., Marques, L. et al. Khyâl Attacks: A Key Idiom of Distress Among Traumatized Cambodia Refugees. Cult Med Psychiatry 34, 244–278 (2010). https://doi.org/10.1007/s11013-010-9174-y
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DOI: https://doi.org/10.1007/s11013-010-9174-y