24 October 2022: Articles
Educational Purpose (only if useful for a systematic review or synthesis), Rare coexistence of disease or pathologyMohamad Faris Rusydi Rusly1ABEF, Mazapuspavina Md Yasin1AE, Khairatul Nainey Kamaruddin1CDE*, Nik Munirah Nik Mohd Nasir1E, Khariah Mat Nor2DE
Am J Case Rep 2022; 23:e937633
BACKGROUND: Charm needle, otherwise known as susuk, is a needle-shaped pin inserted subcutaneously into various body parts. It is most commonly inserted by shamans in the orofacial region to grant magical powers to the wearer, such as health, wealth, beauty, and other benefits. These talismans are prevalent among women in South-East Asia countries.
CASE REPORT: A 75-year-old woman presented with recurrent musculoskeletal symptoms over multiple sites, but physical assessment only revealed mild tenderness over the right hip joint. A plain pelvic radiograph showed incidental findings of susuk around the genital regions, with older skull and pelvic radiograph displaying similar findings. The patient had a susuk insertion more than 20 years ago for marriage stability and beauty. After this incidental discovery, the patient had repeated visits to the clinic to request more imaging to determine whether the susuk were still present after the shaman’s attempted mystical removal. She also developed persistent preoccupation, worry, and guilt related to the susuk presence and was referred to psychiatry for further assessment. She was diagnosed with generalized anxiety disorder. She was then started on psychotherapy and pharmacological treatment, with simultaneous spiritual therapy.
CONCLUSIONS: This case report describes the link between susuk implantation and psychological illness. Even though there are no reports that specifically correlate susuk with generalized anxiety disorder, it has been established that guilt and shame have a strong relationship with anxiety.
Keywords: Foreign Bodies, Needles, Physicians, Primary Care
A susuk, also known as a charm needle or charm pin, is a needle-shaped talisman measuring 0.5–1.0 mm in diameter and 0.5–1.0 cm in length, usually made of gold or silver, with 1 sharp end and 1 blunt end . The susuk is implanted subcutaneously by a shaman under the skin . During the insertion, the shaman casts a spell to make it effective .
Wearing a talisman is regarded to be traditionally common for a variety of reasons. Body piercing, scarification, tattooing, and implants were among the techniques. The practice of susuk is suspected to be long-established among the Malay community; however, it has been observed that this practice is also common to the varied religion and ethnicity in South-East Asia, especially Malaysia, Indonesia, Brunei, and Singapore . The first published report regarding the radiographic image of susuk was discovered by a Burmese physician in 1928 .
Susuk is used for various reasons. It is believed to improve health, amplify beauty, protect from harm, achieve career success, and even cure illness . The most typical site for susuk insertion is in the face and other body parts, including the chest, breast, lower back, and limbs . The bearer of this susuk will keep their susuk insertion as a secret only known to themselves. This can be due to the taboos surrounding the practice of susuk insertion, and by telling other people of this talisman, it will make the susuk lose its power .
This case report presents a case of susuk discovery in a patient who then developed persistent preoccupation, worry, and guilt related to the susuk presence. This case also highlights an uncommon site for susuk insertion, which is over the genital area, that was diagnosed incidentally from a pelvic radio-graph. Issues of diagnosis, treatment, prognosis, psychological effects, somatization, and physical complications are discussed.
A 75-year-old Malay woman with underlying type 2 diabetes mellitus, hypertension, dyslipidemia, and stage 1 adenocarcinoma of the right breast had multiple visits to the primary care clinic in 2021, with somatic symptoms of recurrent right hip, buttock, and pelvic pain. Physical examination showed mild tenderness over the right hip joint, but no other remarkable findings. Plain radiographs of the right hip, pelvis, and lower lumbar spine were done (Figure 1). There was an incidental finding of 4 linear hyper-density areas projected within the anterior pelvic soft tissue region, near the genital area, suggestive of foreign bodies; the impression of the appearance was typical of charm needles or susuk. The imaging also reported degenerative changes in the right hip joint, with multilevel lumbar spondylosis worst at L4/L5. The presence of popcorn calcification in the pelvis is characteristic of a calcified fibroid.
Upon the findings of the susuk, the patient’s previous radio-graphs were traced back, and multiple plain radiographs that were done in 2017 were found. There were pelvic radiographs (Figure 2) that showed similar findings as in Figure 1. The patient also underwent chest radiography, which was normal, but the facial/skull radiographs showed 10 fine linear density (needle-like) foreign bodies over the maxillofacial area (Figure 3).
The needles were not visible or palpable on gross physical examination of the areas.
The patient stated she had susuk insertion more than 20 years ago for beauty and marriage stability. The materials used were gold; 10 needles were inserted around the maxillofacial area and 4 at the labia. The patient felt ashamed of the incidental findings and started to develop preoccupied thoughts about it. She previously went to her shaman to have the susuk removed, and she had been told that it had been removed mystically. There is no surgical procedure done to remove the susuk. The susuk, however, were still intact according to the most recent radiographs.
Since this incidental discovery, the patient has had recurrent visits to the primary care clinic with the same symptoms and asking for repeat imaging to see if the susuk were still there after her repeated attempts to remove them. However, the requested imaging was not granted as there is no clear indication. The patient was also not interested in having surgery to remove the susuk as she was worried about potential complications. She continued to be preoccupied with the susuk, with constant worrying and guilt about her previous decision to insert susuk in the first place.
She was referred to the psychiatry team for further psychological assessment in view of these persistent preoccupations, worry, and guilt. She was then diagnosed with generalized anxiety disorder and was started on psychotherapy, pharmacological treatment, and spiritual therapy. Her condition has now improved after treatment.
The practice of inserting foreign bodies has been established for decades. Susuk is a well-known ancient mystical practice in South-East Asia. It is a cultural practice in which tiny metallic needles are implanted into the subcutaneous tissue by a shaman, in which during the insertion of susuk, a ritual ceremony is conducted accompanied by a specific enchanting mantra . Susuk is used for various reasons, including maintaining beauty, gaining charm, preventing spousal infidelity, achieving business success, and protecting oneself from danger .
Susuk can be implanted anywhere around the body, the commonest being over the facial area . The other documented sites for susuk insertion include the knee and lumbosacral area , pelvic region and left flank area , neck and chest , and leg and foot . A case report by Umesan et al summarized the site of susuk insertion and found a similar finding that the orofacial region was the most prevalent, while the least frequent insertion sites were the wrist, hip, and breast . Our case report is among the first to report the findings of susuk insertion in the genital region, a site rarely reported in previous case reports . The genital area is an uncommon site for susuk insertion, and the reason for its specific function depends on the wearer’s wish. The function can be related to sexuality, but it can be a taboo topic to discuss. Our patient was silent about the reasons when asked for its function, perhaps due to shame and guilt.
To maintain its potency, susuk wearers must follow a set of rules. The shaman admonishes wearers to keep the talismans hidden because telling others about their presence is thought to diminish their special abilities . In this case, the diagnosis of susuk was clear as the patient was willing to share the history of charm needle insertion during her younger years after its discovery from the plain radiograph. However, this incidental discovery sparked preoccupation, guilt, and shame in this patient, leading to her diagnosis of generalized anxiety disorder.
There is currently no report or journal that specifically links susuk with anxiety from our extensive search on online databases. Nonetheless, a study by Fergus et al revealed a significant relationship between generalized anxiety disorder symptoms and shame-proneness after adjusting for other anxiety disorder symptoms, depressive symptoms, and guilt-proneness .
A meta-analysis by Cândea and Szentagotai-Tătar discovered that shame and guilt were substantially related with anxiety, with shame-proneness being found to be more strongly associated with anxiety symptoms than guilt-proneness .
In terms of management options for susuk removal, surgery intervention is possible; however, pinpointing the exact position of the susuk is difficult. Only when patients show signs and symptoms of pain or infection, or if the existence of charm needles poses a risk to the patient, should intervention or surgical removal of charm needles be considered . These small and fine needles are typically not apparent clinically or palpable on physical examination. The needle itself is usually easy to remove surgically, but identifying its location is difficult . A case study by Wen Tay et al reported that surgical removal of susuk was done after the patient reported pain near the insertion site in the orofacial region. Cone beam computed tomography (CBCT) imaging, which involves higher radiation exposure, was performed to aid in the localization of the susuk. The patient also requested another susuk removal over his upper limb, but was counselled against it as he had no symptoms .
Unfortunately, few studies on the possible adverse consequences or complications of susuk have been reported. A susuk is a foreign body, insertion techniques are not sterile, and insertion site hygiene may be poor. According to a case study, there was tissue infection in the region of the susuk, but whether the susuk were the primary source of the infection is unknown . Another case study reported pain over the susuk insertion area, in which the susuk was removed; however, it was not concluded whether the susuk was the cause of the pain . There is also the possibility of penetration or dislodgement into other structures, potentially causing injury to crucial organs or nearby neurovascular structures .
Susuk generally remains in situ for many years, but there is a possibility that they might break into smaller pieces owing to material corrosion and muscle contractions. Unless they cause symptoms or complications, it is recommended that they be left alone.
This case report describes the link between susuk implantation and generalized anxiety disorder. There are currently no reports or journals that specifically establish the correlation between susuk with anxiety; nonetheless, it has been discovered that guilt and shame have a strong relationship with anxiety. Our patient had an uncommon placement of susuk insertion in the genital, as opposed to the typical susuk location over the facial region.
FiguresFigure 1.. Antero-posterior view of the pelvic radiograph taken in 2021 shows 4 linear hyper-density materials projected within the anterior pelvic soft tissue region (red arrow). There is also a popcorn calcification in the pelvis, characteristic of a calcified fibroid (black arrow). Figure 2.. Antero-posterior view of a pelvic radiograph taken in 2017, shows similar findings as described in Figure 1. Figure 3.. Antero-posterior view of a skull radiograph taken in 2017, shows 10 fine linear density needle-like foreign bodies over the maxillofacial area (red arrow).
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