Possession: a clinical enigma

Abstract

This is a case of a 21-year-old lady who presented with history of episodes where she would display extraordinary strength while becoming aggressive towards her family members, speak in foreign language and display bizarre behaviour. The episode would last for 15–20 min and would resolve spontaneously. She would always claim amnesia for the event. This would remain irritable in the intervening period. The frequency of such episodes is at least three times a week. The family members took her to several faith healers with no improvement in her condition. On the suggestion of a family friend, the patient was brought in for consultation in the psychiatric clinic. The patient remained a diagnostic dilemma though there has been some reduction in intensity of such episodes on psychotropic medication. Unfortunately, there is no remission in episodes.

Background

Possession syndromes are being reported in literature. This can be a part of a psychotic illness and may be amenable to antipsychotic treatment. Such types of presentations are quite tricky in terms of a diagnostic category and line of management. Culture bound syndromes are popularly defined in the transcultural psychiatry literature. Some of these syndromes are unique to a country, a faith or a culture. Working in the area of transcultural psychiatry, I found this case very interesting and wished to share with medical colleagues who may have come across such situations.

Case presentation

The patient is a 21-year-old lady who is unmarried and living with her parents and two older brothers. She was alright until 1-year ago when she developed the problem of undergoing an episode of extreme aggression whereby she would hit the family members or whoever comes in front of her, break the furniture, scream loudly and utter abusive words. She would develop extraordinary strength such that even five people would not hold her back. She would also speak in foreign language which according to the family members is Arabic. It is interesting to note that the patient had never learned Arabic as a language but studied how to recite the Holy Book that is written in Arabic language. Her father had worked in an Arabic speaking country at some stage in his life. He was therefore, able to recognise that the patient was speaking in Arabic language. According to her father, what she speaks is a full conversation in Arabic, mostly cursing and blaming. Those were not the recitation of holy verses at all. She would not lose consciousness or become incontinent during the episode that would last for 15–20 min. These episodes occur at least three times during a week while she would remain irritable in the intervening period. The patient would claim amnesia for this event upon recovery. One such episode was witnessed in the clinic. There is a positive family history for depression as her mother and paternal uncle were both under treatment. She was born in middle class family. Her childhood history remained uneventful. She acquired grade 12 education, was never in any relationship, still unmarried, did not do any job. She was described as a social person who loved fun and meeting with relatives and friends. In view of her cultural background, she was not given adequate liberty to move around and mix freely with people especially the males. There was no history of psychiatric problem. She did not report any drug abuse or legal issues. Her medical history indicates that she suffers from mild asthma. She did not report any particular allergies. On mental status examination, she appeared as a well groomed lady who was cooperative. Her mood was assessed to be normothymic, affect was reactive and no psychotic features were elicited. Her cognitive functions were well intact and she had good insight apart from the amnesia for the recurring episodes.

Investigations

All routine blood work was normal. EEG and MRI did not reveal any abnormality.

Differential diagnosis

• 1.Possession syndrome (most likely diagnosis for discussion).
• 2.Schizo-Hysteria (not in the diagnostic classification system).
• 3.Schizophrenia (not meeting the criteria).
• 4.Organic brain syndrome (ruled out).

Treatment

Initial trials with Olanzepine upto 20 mg dosage for 6 weeks and Quetiapine upto 800 mg for same period did not show any improvement. Risperidone 1 mg HS was titrated up to 6 mg/day. This resulted in lowering of the intensity of the symptoms during the episodes but frequency remained the same. She developed side effects of tenderness in breast and high serum prolactin and therefore the dose was reduced to 4 mg/day. She was also referred for psychodynamic psychotherapy.

Outcome and follow-up

The patient is being followed up regularly in the outpatient psychiatric clinic. Risperidone was titrated slowly. Currently, she is on 4 mg dosage per day. There is no remission in such episodes so far.

Discussion

This case has an atypical presentation especially in terms of gaining tremendous physical strength and speaking foreign language under an episodic attack. An organic aetiology has been ruled out. An atypical seizure disorder was considered but there was no supportive evidence. Culture-bound syndromes and possession syndrome have been described in the literature and psychiatric classification systems are also recognising the importance of these presentations that pose clinical challenges. Possession by jinni has been described extensively in ethnopsychiatric literature. The reported psychiatric symptoms attributed to demonic possession include hallucinations, strange behaviour, extreme unrest, change of voice, speaking alien languages, seizures and acquiring tremendous strength. Some patients in traditional cultures that were considered to be affected by demons and treated with neuroleptics subsequently experienced remission, suggesting strong support for a biochemical theory. There may also be a explanatory role related to abnormal functioning of brain-stem structures in the region of fourth ventricle. Literature also describes the relationship between borderline personality disorder and possession syndrome. There is an emphasis on culture-based pathoplasticity of mental disorders. A correlation between dissociative identity disorder and spirit possession syndrome is worth-mentioning. It is mentioned that dissociation and dissociative identity disorder is the result of childhood trauma. Recognisable symptoms may begin to manifest in late teens and often not accurately diagnosed until mid to late thirties, though 65% of cases are found between ages of 20 and 40. In this case, the patient is 21 years old.

Learning points.

• ▶Possession syndrome is important diagnostic category that should be considered especially in cross culture contexts.
• ▶Psychotic illnesses can manifest in various forms.
• ▶Cultural consultation is important in such presentations.