E. K. TAN AND JOHN E.

C A R R

PSYCHIATRIC SEQUELAE OF AMOK

ABSTRACT. The authors present evidence of an indigenous diagnostic system by which

Malay culture defines Amok, and of the disparate relations between individual conceptualiz-
ation, behavior, and tradition which contributes to the labeling process.
Amok is viewed as a cultural prescription for violent behavior in response to a given set
of conditions. It is not a disease but rather a behavioral sequence, perceived as illness, that
may be precipitated by various etiological factors.
Finally, evidence is presented to support the hypothesis that traditional forms of Amok
are being replaced by new variants in which psychopathology is increasingly evident.

1. I N T R O D U C T I O N

Amok has been defined by Yap (1951) as an acute outburst of unrestrained

violence associated with homicidal attacks, preceded by a period of brooding
and ending with exhaustion and amnesia. The fury of the patient may be quite
undirected and he may strike down animals and humans indiscriminately in his
path. Medically, it has been ascribed to epilepsy, liver disorders, infection,
confusion from malaria or cerebral lesions, hashish poisoning, sunstroke,
schizophrenia, organic brain syndrome, and mania. Socioculturally, it is a
phenomenon of the Malay Archipeligo, a standardized form of intense emotional
release, accepted by the community and expected of any male individual who is
placed for some reason or other in an intolerably embarrassing or shameful
situation. The indiscriminate killings are considered a continuation of revengeful
feelings but within the context of saving face in the closely-knit kampong
community. The Amok must reestablish himself in the eye~ of his fellow man
and proceeds to do so by a "violent assertion of his power" - the only court of
appeal known to his fathers for countless generations (Van Loon 1927;
Galloway 1923; Fitzgerald 1923; Van Wulfften-Palthe 1933).
Yap (1969) has argued that Amok is one of the 'culture bound reactive
syndromes', forms of psychopathology produced by certain systems of implicit
values, social structure, and obviously shared beliefs indigenous to certain areas.
Although social and cultural factors may produce special forms of mental illness,
Yap viewed these as only atypical variants of generally distributed psychogenic
disorders.
The few clinical studies of Amok reported in the literature suggest support
for this view. Zaguirre (1957) examined 25 military cases of Amok in .the
Philippines and diagnosed 17 in terms of common psychiatric disorders. Tan
(1965) studied five cases of Amok in West Malaysia and found all five consistent

Culture, Medicine and Psychiatry 1 (1977) 59-67. All Rights Reserved.

Copyright © 19 77by D. Reidel Publishing Company, Dordrecbt-Holland.
60 E. K. TAN AND JOHN E. CARR

with Bleuler's definition of schizophrenia. Schmidt et al. (1977) described an

intensive study of 24 cases in East Malaysia and concluded that all 24 cases met
the criteria for traditional diagnostic categories.
A major shortcoming of such studies is that ex post facto diagnoses on the
basis of second hand report are of questionable validity. An alternative approach
to the problem would be to examine the outcome of treatment as a means of
cross-validating the diagnosis. If Amok is but an atypical variant of common
psychiatric disorders, then once the particular disorder is diagnosed, the
treatment course for any patient should be consistent with the predicted course
for that disorder. Any variation from the expected sequelae for a specific
disorder would argue against support of Yap's hypothesis and suggest, instead,
that Amok has not only unique clinical features, but having differentiable
sequelae, is indeed a unique clinical entity as well.

2. MATERIAL FOR STUDY

In Hospital Bahagia, Ulu Kinta, West Malaysia, there were 134 patients in the
male security ward at the time of this study. Of these, 21 were labeled 'Amok'
when first brought in for admission. These cases were on indefinite detention in
the Security Ward of the hospital 'under the Ruler's pleasure' after being
pronounced guilty but insane in Court (Criminal Procedure Code 1971). They
had been in the ward for varying periods of time ranging from 1 to 29 years and
had received varying forms of treatment. Case files were thoroughly reviewed.
The identifying data, sociocultural background, the nature of the amok attack,
the post-amok state, and the mental status on admission were recorded. All
patients were then interviewed in their native tongues and questioned regarding
their view of amok. Ten patients were familiar with the concept of Amok
(sophisticated), six had never heard of Amok (naive), and five were still
psychotic and non-communicative.
The ten cases who were familiar with the concept were all male Malays, from
rural areas, illiterate, and padi-planters, rubber-tappers, labourers, or unem-
ployed. They consistently defined Amok as an illness characterized by sudden
acute violence against any living thing using 'anything handy' as a weapon. It is
caused by spirits, magic, threat, fever, or God and is precipitated by anger,
anxiety, or disturbed thoughts. The patient is always unconscious and, therefore,
not responsible. Multiple victims are usually the case, but death of the victim
need not occur. Following Amok, the patient claims amnesia for the entire event
and is exhausted for a prolonged period. The family response was generally one
of sympathy, mixed with fear, shame, and sadness. The community response
tended to be one of fearful respect or notoriety mixed with some anger.
In important respects the defining characteristics provided by our subjects
 PSYCHIATRIC SEQUELAE OF AMOK 61

were more general than the classic definitions reported in the literature. First,
our subjects insisted the 'illness' was no respector of race, sex, or age. The
traditional view is that the Amok is a middle-aged male Malay. Second, our
subjects defined weapons as 'anything handy'. The traditional view is that the
kris (jagged dagger), parang (machete), or spear are the traditional weapons o f
choice. Third, our informants were agreed the illness was recurrent, yet none o f
the patients had had a recurrent attack, nor did they know o f any case in which
this had occurred. This relates to a fourth difference, namely, that while our
Amoks reported cessation occurs through force, spontaneous recovery, or appeal
to reason, classic reports uniformly emphasized force (usually resulting in death)
as the only successful means of termination.
Interestingly, the actual acts o f violence committed by these ten patients
were more consistent with the traditional view of Amok than with their own
definition o f the phenomenon (a point to which we shall return in our
discussion). Hence, we have called these ten patients the 'true' Amok in that
their behavior, cultural background, and demographic descriptors were consistent
with the classical definition of Amok (Shaw 1972).
The six patients who were naive regarding Amok were Chinese or Indian
males, from urban centers, and were employed in mercantile occupations, e.g.,
shop clerks or hawkers. They committed murder (by their own description) in a
fit of rage, had fewer victims (2.2 versus 4.3 by the true Amok), and used a
variety of weapons, none o f which are associated with traditional Amok (e.g.,
guns, scissors, meat cleavers, hoes, etc.) They had no consistent cultural
explanation for their crimes (only personal explanations), and were totally
unfamiliar with the one that had somehow been apparently imposed upon them
by the civil system.
The remaining five cases were severely psychotic at the time o f the study,
were incoherent, and totally incommunicative. Since they could not be
interviewed, their familiarity with the concept o f Amok, and their own account
o f their behavior could not be determined. Their records revealed, however, that
all had histories o f marginal psychological and economic adjustment prior to
hospitalization and had been psychotic throughout their hospital course.

3. THE INDIGENOUS DIAGNOSTIC SYSTEM

Confronted with the problem o f explaining (a) why some 'Amoks' did not know
they were Amoks while others did, and (b) why the Amok came to be located in
the mental hospital, we intensively reviewed civil records of the original assault
and subsequent events. The labeling appeared to be a function o f the cultural
background o f the arresting officer - all were Malays! This explained why some
62 E.K. TAN AND JOHN E. CARR

of the patients (Chinese and Indian), unfamiliar with the concept, were so
labeled.
The routing to the mental hospital, while complex, followed from this initial
labeling. In Malay culture Amok is seen as 'mental illness' and it is apparent from
the review of official records that this basic assumption influenced all
subsequent judicial and medical decisions regarding the Amok - i.e., they were
pronounced 'guilty by reason of insanity' and removed to the mental hospital.
There they came under observation by trained psychiatrists for the first time.
(Cart and Tan 1976).

4. METHODOLOGY

This paper is concerned with the course of events that followed after the amok
patient had been admitted.
The progress of the amok cases can be studied in detail since they have all
been inpatients in the security ward. Throughout their stay they have been
exposed to the same ward environment. Hence, differences in their psychiatric
sequelae should reflect the intrinsic or endogenous qualities of their 'illness'
rather than differential psychosocial factors found in the outside community.
For purposes of analysis the age of onset of the amok incident, the duration
of the initial 'psychotic' or abnormal behavior in the ward, the total duration of
hospitalization, the type of treatment, and the outcome of treatment were
examined as a function of (A) relapse, and (B) sophistication with respect to
Amok.

5. FINDINGS

Of the ten 'sophisticated' Amoks, eight were diagnosed as schizophrenic. One

was a case of manic-depressive pyschosis with a history of previous admission for
a manic episode. Prior to his second admission he committed murder, but he has
stayed in the hospital for five years and has had no relapses of abnormal
behavior. The tenth case was diagnosed as general paresis after laboratory
confirmatory evidence. It was presumed he committed murder during a
psychotic episode due to his organic brain disease, but the patient had been
symtom free during his hospitalization for the past 24 years. All of the six
'naive' Amoks were diagnosed as schizophrenic.

6. 'SOPHISTICATED'AMOKS

The average age at the time of admission of the relapse group was 29.3 years
versus 32.3 years for the 'non-relapsers'. Among the relapsers, the duration of
 PSYCHIATRIC SEQUELAE OF AMOK 63

their first episode of abnormal behavior was about 2.2 months. For the
non-relapsers, the duration of their first and only episode of abnormal behavior
was 4.9 months. Three out of four relapse patients were treated with oral
phenothiazine whereas only one non-relapse patient had phenothiazine. How-
ever, the prescribing of phenothiazine did not alter the progress of the patients
in the terms of relapses. Of four patients admitted in the pre-phenothiazine era,
three remained symptom-free after their initial psychosis for 23, 24, and 29
years, whereas the fourth experienced about seven relapses over a period of 18
years' hospitalization.
Amongst the relapsers, the average number of relapses per patient was four.
In terms of their progress in the ward, one patient was socializing well while the
other three cases, although not overtly psychotic, were considered as abnormal
in behavior much of the time they were on the ward. Two were physically
aggressive, attempting to assault staff members or fellow patients during relapses,
and one patient became episodically withdrawn. In contrast, all the non-relapsers
socialized well and took an active part in the rehabilitative programs within the
ward.
The total length of stay in the ward averaged 8.7 years for the relapsers and
15.6 years for the non-relapsers. Obviously, increased frequency of relapse is not
the result of time spent within the security ward.

7. 'NAIVE'AMOKS

As can be seen in Table I, there is little difference in hospital course between

sophisticated versus naive amoks with the exception of type of treatment
offered. While the majority of patients in the other groups tended to receive
essentially a phenothiazine-oriented program, the non-relapsing 'sophisticated'
amok group was unique in that only one-sixth received phenothiazine treatment.

8. DISCUSSION
While there is overlap in the groups, there are distinctive characteristics worthy
of note. The relapsers tended to be younger at the time of Amok, were from a
more recent cohort, had more recent admissions, and were clearly of the
phenotherazine era, which may account in part for their more rapid recovery
from the initial episode.
The non-relapsers were of an older age and cohort. Although fewer received
phenothiazine treatment, they did not relapse following the initial episode
which, in fact, was longer than in the relapsing patients. Despite the fact that
almost all of the patients had the same diagnosis, there were clearly two
differentiable groups based on sequelae. It seems likely that the relapsing
patients are, indeed, cases of severe chronic psychopathology, who during their
64 E. K. TAN AND JOHN E. C A R R

TABLE I
Hospital course of 16 Amok patients

Duration
1 st Duration
Age at "psychotic" Treat- hospital
Race* Amok Year episode ment** # Relapses stay

RELAPSING PATIENTS
"Sophisticated" A m o k s
M 35 1951 3 mo. obs. 7+ 18 yr.
M 26 1966 5 mo. P 4 9 yr.
M 35 1972 0 mo. P 3 2 yr.
M 21 t974 0.8 mo. P 2 1 yr.
MEAN 29.3 51-74 2.2 3P/1 obs. 4 7.5
'Naive' A rnoks
C 38 1963 2 mo. P 20+ 12 yr.
C 30 1965 12 mo. P 1 10 yr.
MEAN 34 7 2P 10.5 11
Total Mean Score 30.8 3.8 too. 5P/1 obs. 6.2 8.7

NON-RELAPSING PATIENTS
'Sophisticated" A m o k s
M 42 1946 8 mo. obs. 0 28 yr.
M 40 1949 1 mo. obs. 0 24 yr.
M 23 1952 9 mo. obs. 0 23 yr.
M 31 1955 8 mo. obs/P-'59 0 19.3 yr.
M 35 1968 3 mo. obs. 0 4.5 yr.
M 23 1973 0.5 mo. obs. 0 1.5 yr.
MEAN 32.3 46-73 4.9 5 obs/1P 0 16.7
'Naive' A mo ks
C 34 1951 13 mo. P? 0 23 yr.
C 42 1956 2 mo. obs. 0 19 yr.
C 40 1962 3 mo. P 0 12 yr.
C 43 1973 3 mo. P 0 2 yr.
MEAN 39.8 5.3 3P/1 obs. !0 14.0
Total Mean Score 35.3 5.1 6 obs/4P 0 15.6

* M = Malay: C = Chinese.
** obs. = observation: P = phenothiazine.

acute p s y c h o t i c e p i s o d e c o m m i t t e d m u r d e r o r injured o t h e r s in a m a n n e r
c o n s i s t e n t w i t h t h e A m o k t r a d i t i o n , and, t h e r e f o r e , were ' d i a g n o s e d ' ' A m o k ' b y
the Malay police w h o a p p r e h e n d e d t h e m . Their progress in the h o s p i t a l suggests
that subsequent relapses (assaultive b e h a v i o r ) were r e p e t i t i o n s o f earlier
p s y c h o t i c episodes. In c o n t r a s t , t h e r e is ample reason t o q u e s t i o n w h e t h e r t h e
n o n - r e l a p s i n g , s o p h i s t i c a t e d g r o u p o f A m o k is (or ever was) p s y c h o t i c . These
p a t i e n t s m o r e closely a p p r o x i m a t e t h e classical A m o k since t h e y s p o n t a n e o u s l y
r e c o v e r e d f r o m t h e i m m e d i a t e p o s t - a m o k state and a d j u s t e d well t o t h e life o f
 PSYCHIATRIC SEQUELAE OF AMOK 65

the security ward, showing none of the abnormal behavior or sequelae that
would be consistent with untreated severe chronic psychopathology, for up to
28 years.
While these 21 patients came from diverse races and backgrounds, had
differing etiologies and treatments, and varied outcomes, they were all labeled
'Amok'. Apparently, this common 'diagnosis' derived from sharing in common
the following:
(1) they engaged in violently assaultive behavior;
(2) they were apprehended by a Malay policeman who was
(3) utilizing defining criteria sufficiently general to allow incorporation of
the diverse behavioral and background dimensions.
We noted earlier a peculiar disparity between how the patient defined the
concept (more general) versus how the patient behaved (more specific), which,
in turn, was more consistent with the traditional view of Amok reported
throughout the literature by non-Malay observers (more specific). We have noted
in other contexts the propensity of the Malay for precise and highly predictable
behavior, while tolerating a remarkable degree of ambiguity and indefiniteness in
their conceptualization and language (Che'Asmah 1968; Endicott 1970). We
would conclude that it is this process which accounts for the 'indigenous
diagnostic system' whereby naive as well as sophisticated amoks are defined.
The results further suggest that while the majority of cases labeled 'Amok' are
indeed variants of more familiar psychiatric disorders, there is a small cohort of
older patients who evidence post-morbid sequelae consistent with 'classical
Amok'. Thus, our findings appear to support Murphy's (1973) thesis that, when
viewed as an epidemiological phenomenon, Amok has undergone a number of
changes, both in incidence as well as nature over the past several centuries.
Specifically, the traditional form of the behavior (seen in older cohorts) is being
replaced by a new variant in which a variety of psychopathological processes are
increasingly evident. Put another way, Amok is a culturally (Malay) prescribed
form of violent behavior, sanctioned by tradition as an appropriate response to a
given set of conditions. It is not, per se, a disease, but a behavioral sequence that
may be precipitated by any number of etiological factors, among them physical,
psychological, and socio-cultural determinants.

9. SUMMARY

Sixteen cases of Amok were intensively studied and interviewed in the Security
Ward of Hospital Bahagia, Ulu Kinta, Malaysia. Their psychiatric sequelae were
studied in terms o f duration of hospitalization, relapse rate, progress on the
ward, and sophistication regarding the concept of Amok. There was little
difference in the hospital course of sophisticated (knowledgeable about Amok)
66 E. K. TAN AND JOHN E. CARR

versus naive patients. It was found that some patients followed the course of a
chronic relapsing schizophrenic illness despite phenothiazine medication, whereas
a group remained sympton-free over an average of sixteen years' hospitalization,
and in the case of sophisticated patients, without medication. It is postulated
that the latter group represents a decreasing cohort of classical cases of Amok, a
culture-bound syndrome of some degree of specificity in its etiology, nature of
attack, and sequelae, which is being replaced by variant forms in which
psychopathology has increasingly intruded

ACKNOV~'LEDGMENTS

We wish to thank Dr. Edward Tan, Director of Hospital Bahagia, Ulu Kinta,
Perak and Professor Eng Seong Tan, former Head of the Department of
Psychological Medicine, University of Malaya for their encouragement and kind
assistance in the preparation of this paper. Thanks are also due to Mr. Kwek
(Hospital Assistant of the Security Ward of Hospital Bahagia) and his staff
members who helped during the interviews and data collection.

University of Malaya
University of Washington

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(Received 1 July, 1976)