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transcultural
psychiatry
December
2001

COMMENTARY

Kyol Goeu in Cambodia

EDVARD HAUFF
University of Oslo

Introduction
The point of departure for this comment on Hinton et al.’s interesting
articles in this issue of the Journal, is their limited discussion of the
generalizability of their findings. They have studied exiled psychiatric
patients with primarily a rural background and low education in one
refugee clinic in the US.
Obviously, such cultural syndromes may change over time, and also
develop differently in different geographical locations. Is their description
of kyol goeu and near-kyol goeu valid only for older patients with a rural
background, who have left their country many years ago? Or, is it still a
relevant emic illness category for modern Khmer persons living in urban
settings in Cambodia today?
As part of the international assistance regarding rehabilitation and
reconstruction of the healthcare system in the country, a systematic psychi-
atric educational programme for Cambodian physicians and nurses, has
been implemented since 1994, as a collaboration between the Ministry of
Health, the University of Oslo and International Organization for
Migration (IOM) (Hauff, 1996, 1997). As part of this programme, the first
psychiatric out-patient department in the capital Phnom Penh was estab-
lished in 1994. This is the main psychiatric clinic in the country and is
located in the largest teaching hospital in Cambodia, the Preah Norodom

Vol 38(4): 468–473[1363–4615(200112)38:4;468–473;020113]

Copyright © 2001 McGill University

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Sihanouk Hospital. The author is now an advisor to the programme, the

Cambodian Mental Health Development Program (CMHDP). This situ-
ation provided an opportunity to obtain information about the experience
with kyol goeu among patients and clinicians in this clinic.
This commentary addresses the following questions:
1. Is this syndrome known among Cambodia physicians practising
psychiatry in Cambodia at present, and what are their own attitudes
and personal experiences with the condition?
2. How common do kyol goeu and near-kyol goeu appear to be among
patients attending a psychiatric out-patient clinic in Cambodia at
present?

Methods
Sample
The sample consisted of two groups, 10 psychiatric residents and 12 psychi-
atric out-patients in Cambodia.

The Residents. The group of clinicians consisted of 10 psychiatric residents

in their final, third, year of the Cambodian psychiatric specialization
programme, and they constitute all Cambodians being trained as
psychiatrists in the country at present. None of them had ever been refugees
in the West. Two of them were female. The average age was 35.6 years
(range: 29–42 years). They came from different provinces in Cambodia.

The Patients. Twelve consecutive psychiatric non-psychotic, non-

emergency out-patients received at the PNSH psychiatric out-patient clinic
in March 2001 were included. The patients came from different provinces in
Cambodia; two-thirds lived in urban areas, whereas one-third lived in rural
areas. The mean age was 30.6 years (range 19–43 years). Seventy-five percent
were female, and 82% were literate; the mean duration of formal education
was 5.6 years (range: 0–12 years). Most of the patients suffered from a
depressive condition (ICD-10: F32.2) or a condition of mixed anxiety and
depression (ICD-10: F41.2). None had been refugees in the West.

Procedure
A focus group discussion was conducted by the author with the residents.
They were asked to describe kyol goeu and near-kyol goeu conditions, their
own experiences with them, the different treatments they knew about, the
consequences if the condition was not treated and possible explanations
for the condition.

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Transcultural Psychiatry 38(4)

The residents were then asked to interview up to four consecutive non-

psychotic, non-emergency patients about their experience with kyol goeu
and near-kyol goeu during the subsequent week. Because of a large number
of emergency patients and the associated time constraints only 12 reports
were obtained during the designated time.

Results
The psychiatric residents were obviously familiar with the condition, and
immediately proceeded to describe the symptoms and signs, about which
there was no major disagreement. They transcribed it kyol kor (instead of
kyol goeu used by Hinton et al.) and called the less severe condition kyol
chabb (Hinton et al: kyol cap). They emphasized that this was only a
phenomenon seen not only among the rural or older segments of the
population, but also among young and educated persons.
They described that the sufferer of kyol goeu suddenly becomes uncon-
scious, falls to the ground and the body becomes pale and the sufferer starts
to sweat. The extremities become cold, and sometimes the body becomes
stiff. The sufferer is still breathing and the heart is still beating.
Two of the residents reported that they had suffered from the condition
themselves, whereas seven of them had seen others having an attack. One
male resident described that he suffered an attack of kyol kor a few years
previously when he was travelling to the capital on a ferry. He thought that
he woke up after 2–5 minutes, when his uncle was coining him. He had
blurred vision and felt tired afterwards, but had recovered the next day.
However, he emphasized that ‘old people said that I might have died if I
had not been treated.’ Another male resident had experienced kyol goeu
when he was 18 years old. He was also treated by coining, by his mother
and siblings, in order to wake him up.
They described the prodromal symptoms as insomnia, exhaustion, ‘cold
extremities’ (a frequent presenting complaint among the patients in the
clinic). Some emphasized that one might develop kyol goeu if one had not
coined for a long time, and if one had neglected to treat kyol cap. Their
descriptions of possible causes included hypoglycaemia, cardiac illness,
hyperventilation, emotional stress, and disturbances of the autonomic
nervous system.
They also emphasized the psychological aspects of the condition, and
that it is often related to emotional stress. They emphasized that the
phenomenon often occurred in a public place, sometimes when people are
waiting to see ‘a high-ranking person, like the King or the Prime Minister,’
and that it often, but not always, could be described as a panic attack.
Regarding treatment, they would first check the vital signs and start
resuscitation if necessary. If the vital signs were intact, their first treatment

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method would be coining (n = 7) and pinching (n = 3). They frowned at

the idea of biting the ankles, as described by Hinton et al. The majority
(n = 8) would use coining themselves if they suffered from kyol cap.
The consequences of untreated kyol goeu were considered to be grave by
four of the residents, who believed that the sufferer may die from it. Four
stated that it was impossible to die from it, whereas two differentiated
between a cardiac type, which might be lethal, and a psychological type,
which was non-lethal.
They also expressed their ambivalence regarding believing in such
traditional illness categories, but still discussed the syndrome as an illness
category with personal relevance for them, and not only a more distant
phenomenon observed among their patients.
All the patients were also familiar with the concept of kyol goeu and three
of them (25%), all females, had experienced it themselves at some time in
their lives. Ten patients (83%) had suffered an attack of near-kyol goeu
during the last six months.
None of the residents or the patients spontaneously associated the
syndrome with their experiences during the Khmer Rouge regime.

Discussion
This commentary is an example of ‘instant research’ as a response to
Hinton et al.’s articles. The small clinical sample was different from their
sample in several dimensions: they were younger and were non-refugees
without western experience. They were also primarily living in urban
settings and were mostly literate, whereas the American sample were
farmers and mostly illiterate. Obviously, the psychiatric residents were even
more different from Hinton’s sample regarding educational background,
but they were more similar in age, and all had lived through the Pol Pot
time in Cambodia. They participated in an internationally oriented
training programme, but were also accustomed to discussing cultural
meaning and variation. Still, our findings were basically in agreement with
those of Hinton and colleagues. However, the clinicians did not uniformly
associate the syndrome with panic attacks, although this was one of the
conditions mentioned.
To some extent, the authors relate the kyol goeu syndrome to the suffer-
ers’ experiences during the Khmer Rouge regime. They may be right in their
hypothesis that ‘most likely the extreme frequency of kyol goeu in this popu-
lation relates to privations in the Pol Pot regime,’ but that remains to be
shown. In the US and other western countries, mental health professionals
are usually aware of the atrocities of this regime. They often seem to
attribute emotional suffering among their Khmer patients in exile to their
experiences during this regime. But, based on my experiences of working

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Transcultural Psychiatry 38(4)

off and on in Cambodia since 1993, I would like to emphasize the extensive
uncertainty, insecurity and danger which this population has experienced
for decades, both before and since the Khmer Rouge regime. This is related
to the war with the extensive bombing of the country, the civil war and also
to subsequent repression and socio-cultural disintegration. To understand
the complex relationships between the socio-political contexts and
emotional and social suffering in the Khmer population, we need to study
these relationships more carefully as well.
The authors’ careful description of this cultural syndrome and its con-
sequences is likely to be useful for clinicians working with Cambodian
patients both in exile and inside Cambodia. Wind illness is also a well-known
phenomenon in other Southeast Asian countries (e.g., Eisenbruch,
1983; Muecke, 1980), and this extensive mapping and discussion of a
cultural syndrome, contributing to the cultural phenomenology of illness
experience, should also be of interest to clinicians and academics in
general.

Conclusion
Our small study of kyol kor in contemporary Cambodia among psychiatric
out-patients and psychiatric residents support the findings among the
Cambodian refugees reported in this issue of the Journal. There appears to
be little difference in the description of kyol kor in the two locations. The
syndrome and the traditional methods to treat it appear to be well known
both among psychiatric patients, also in the younger age groups, and
among physicians. The physicians are also familiar with the condition from
their own personal experiences, and not only as medical practitioners. The
relationship between kyol goeu and the socio-political context in which it
is experienced requires further study.

Acknowledgements
The author would like to thank the psychiatric residents in the Cambodian Mental
Health Development Program (CMHDP) for their interest and ability to discuss
this issue in such an open way. He would also like to thank the patients in the Preah
Norodom Sihanouk Hospital in Phnom Penh who participated in the study.

References
Eisenbruch, M. (1983). ‘Wind illness’ or somatic depression? A case study in
psychiatric anthropology. British Journal of Psychiatry, 143, 323–326.
Hauff, E. (1996). The Cambodian mental health training programme. Australasian
Psychiatry, 4(4), 187–188.

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Hauff: Kyol Goeu in Cambodia

Hauff, E. (1997). Establishing mental health services after massive destruction:

Experiences from Cambodia. WAPR Bulletin, 9(2), 6–8.
Muecke, M. (1980) Wind illness in Northern Thailand. Culture, Medicine and
Psychiatry, 4, 267–290.

EDVARD HAUFF, MD, PHD, did his medical studies at Royal College of Surgeons in
Ireland. He specialized in psychiatry in Norway, and received his PhD from the
University of Oslo. At present, he is Consultant Psychiatrist at Ullevaal University
Hospital (Dept. of Psychiatric Research and Education, and Holmlia Community
Mental Health Centre) and Professor of Transcultural Psychiatry at the University
of Oslo. He also has a part-time private practice in psychotherapy, and functions
as an advisor to the Cambodian Mental Health Development Program (CMHDP).
Address: Department of Psychiatric Research, Ullevaal University Hospital, 0407
Oslo, Norway. [E-mail: edvardh@psykiatri.uio.no]

World Congress on Psychosomatic Medicine

The 17th World Congress on Psychosomatic Medicine will be held

August 23–28, 2003 in Waikoloa, Hawaii, USA. This meeting
occurs biennially under the auspices of the International College of
Psychosomatic Medicine to promote education and research in the
biopsychosocial aspects of health and disease.

Contact Information:

Jon Streltzer, M.D., Chair Organizing Committee,

17th World Congress on Psychosomatic Medicine,
Queen’s Office of Continuing Medical Education, Harkness 117
1301 Punchbowl Street, Honolulu, Hawaii 96813, USA
Tel: 808-537-7009
Fax: 808-547-4031
E-mail: icpm2003@aol.com
Website: www.hawaiiresidency.org/icpm2003

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