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Historical background of Cambodian population
The Communist Party of Kampuchea, known as the Khmer Rouge, emerged from the Cambodia's striving to get free from the French colonization and it took control of the country in 1975. The Khmer Rouge was leaded by Pol Pot, who was one of the world’s most infamous dictators and responsible for the Cambodian genocide. During the Khmer Rouge rule (1975-1979), it is estimated that approximately two million people of Cambodia’s 7.9 million population died. , People were executed, tortured, they went through starvation, slave labour (from up to 20 hours per day) while starving (they were fed with a few grains of rice per day) and they died because of untreated illnesses. Many of them were held in prisons, where they were first interrogated, tortured and then executed. The most important prison in Cambodia held approximately 14.000 prisoners, but only twelve people survived. People lived with a constant threat of death.

After the genocide, Cambodians who survived became refugees and most of them moved to the USA and Australia. , Due to the severe trauma most of the Cambodian refugees developed Post-traumatic stress disorder (PTSD) and they often complained of khyal attacks.

Cambodian perception of khyal attack
According to the Cambodian perception, khyâl is a windlike substance that flows through the body beside blood, and it is considered as a potentially pathogenetic element. It is believed that an abnormality of this ‘’wind flow’’ (khyal flow) might result in the presence of various somatic symptoms. A similar perception about this pathological characteristic of khyal, of the windlike substance, has been noticed in other Asian cultures too. Specifically, according to the Cambodian culture, when the human body is in a healthy condition, it allows the regular flow of khyal (the windlike substance) through the body alongside blood which then exits the body by following different routes, either by passing through the hands, the feet, or by exiting through the skin pores. However, it is assumed that sometimes the normal flow of khyal through the body suddenly becomes disturbed and causes the khyal to surge towards the head, often alongside blood and results in occurrence of many somatic symptoms and bodily disasters. This is a possible description of Cambodian’s perception of ‘khyal attack’. Consequently, it has been revealed that the trauma ontology of Cambodian refugees is mainly composed of khyâl attacks, which cause a trauma-related disorder with precise symptoms and route.

Khyal attack: culture-bound syndrome or subtype of panic attack?
Khyal attacks have been recognised as a Cultural Concept of Distress in the Diagnostic and Statistical Manual of Mental Disorders-5 (2013). However, it has been found that khyal attacks constitute a subtype of panic attack, and they have been characterised as ‘‘khyal attack’’-type panic attacks. Hinton et al. (2010) examined traumatised Cambodian refugees who often complained of khyal attacks and revealed that almost every khyal attack met panic attack criteria mentioned in the Diagnostic and Statistical Manual of Mental Disorders-5 (2013). Patients with khyal attack displayed all panic attack symptoms, including dizziness, nausea, trembling, numbness or tingling, chest pain, irregular heartbeat, shortness of breath, choking, sweating, derealisation, flushes or chills, they were very afraid of losing control and also dying, with the most common symptom being dizziness. However, Hinton et al. (2010) found that patients with khyal attack suffered from additional symptoms too, not mentioned in the Diagnostic and Statistical Manual of Mental Disorders-5 (2013) panic attack criteria. These symptoms included, anxiousness, tinnitus, headache, cold hands and feet, blurry vision, black out, sore neck and jaw, hypersalivation, feeling dizzy, tired, exhausted, sleepy, and having weak arms and legs. From these extra non Diagnostic and Statistical Manual of Mental Disorders symptoms, the one that occurred more often was the feeling of dizziness, tiredness and exhaustion.

Brain Activity
Nevertheless brain activity during khyal attack has not been examined yet, it is expected, since khyal attack has been characterised as a sub-type of panic attack, to affect the brain in the same way as panic attacks. Research found that specific areas of the brain become hyperactive during a panic attack. These areas of the brain that indicate an irregular activity during a panic attack are the amygdala, a part of the brain very important for the processing of emotions, and also another region called the Periaqueductal gray, which is an area that provokes the body’s defensive responses, such as freezing.

Triggers of Khyal Attack
According to the traumatised Cambodian refugees, typical triggers of a khyal attack are worrying too much about a possible issue (which then produces dizziness, tiredness and pain in the body), standing up, turning their head from one side to the other, or climbing stairs (which produces dizziness), a change in the weather, being exposed to crowded places, a specific odour (usually unpleasant) , any kind of fright, such as trauma recall or being awakened from a nightmare (which induces rapid heartbeat and dizziness) and having fever. Nevertheless, sometimes symptoms of khyal attack occur suddenly, without any trigger causing them.

Levels of severity
Khyal attacks can be classified to a level of severity depending on the severity of the symptoms displayed. If symptoms are mild such as slight dizziness or tiredness, this khyal attack is labelled as mild. If the symptoms are more severe, then a moderate khyal attack is thought to occur. In case where the symptoms are not treated at the time being exhibited, then khyal attack will progress to more serious stages, such as severe khyal or khyal overload and symptoms will get even worse. It is believed that severe khyal is more dangerous and is not easily treated. Khyal overload is considered as the worst stage of khyal attack, and describes a condition at which the patient while being conscious is unable to speak and move. Depending on the level of severity of symptoms, which determines the stage of khyal attack, different treatment methods are used.

Traditional Cambodian treatment methods
According to the Cambodian perception, khyal attacks can be treated by many different methods. The first treatment method used is called 'Coining' and it involves dragging a coin along the skin. It is believed that coining warms up the body, which helps the restoration of khyal flow, and brings the toxins in the surface of the body which are exposed by bruises. This is why ‘coining’ is also used as diagnosis technique, since the colour of the bruises reveal the level of severity of khyal attack, meaning that the darker the colour of the bruise, the more severe the illness. The second treatment method used is called 'Cupping' and it includes applying warm glasses to the body, which results in the skin being pulled into the glass. Cupping is used to remove khyal symptoms, because it is believed that in this way khyal is pulled through the skin pores and it is then trapped in the glass. Another method used to treat khyal attack is ‘Pinching’, which involves pinching the skin in order to cure the symptoms by helping the khyal flow regularly again. Furthermore, ‘Doing the vessels’ is another traditional method used to treat khyal attack, which entails moving your head from one side to another and putting pressure to some parts of the body that khyal is thought to be trapped. Finally, applying khyal oil or ointment is a method used to treat khyal attack, which is typically used after the methods mentioned before. Khyal oil or ointment contains camphor and menthol and is thought that it helps to open the skin pores and allow khyal to exit more easily.

Cognitive Behavioural Therapy (CBT)
It was discovered that khyal attacks result in worsening of Post-traumatic stress disorder (PTSD). Cognitive behavioural therapy (CBT) which is a talking therapy that helps the patient to manage their problems by changing and improving the way of thinking, feeling and behaving, was found to be a very effective method for treating khyal attack among traumatised Cambodian refugees. Specifically, a study revealed that Cognitive behavioral therapy (CBT) helped in decreasing Post-traumatic stress disorder (PTSD) by reducing the frequency of khyal attacks and by increasing the emotion regulation capacity, which has been found to be strongly related to Post-traumatic stress disorder (PTSD). Furthermore this study revealed that reducing Post-traumatic stress disorder (PTSD) resulted in increasing of vagal tone (a component of Parasympathetic nervous system), which improved orthostatic blood pressure response, a key aspect of khyal attacks since patients characterise standing up as a very common trigger of khyal attacks.