Investigation of the Cerebral Blood Flow of an Omani Man with Supposed 'Spirit Possession' Associated with an Altered Mental State : A Case Report

Amr A Guenedi; Ala'Alddin Al Hussaini; Yousif A Obeid; Samir Hussain; Faisal Al-Azri; Samir Al-Adawi

Disclosures

J Med Case Reports. 2009;3:9325 

In This Article

Discussion

The reported case is of a patient who sought psychiatric consultation from tertiary care. After protracted neurological, psychiatric and medical observation, the patient's distress was critically associated with specific functional changes in the temporal lobe and structural abnormality as well as encephalomelacia in the left basal ganglia. After pharmacological intervention, the patient's emotional and cognitive distress eventually receded. The psychological and behavioral improvements coincided with measurable changes in blood perfusion in temporal regions of the brain. Despite the severity of the patient's condition before treatment, his recovery was dramatic but seemingly consistent with available literature. Although the exact mechanisms by which atypical antipsychotic medications (such as risperidone) produce their ameliorative effects remain unclear. Such compounds frequently alleviates symptoms such as those in the presented case (that is, delusions, auditory hallucinations and catatonic behavior).[6–8]

To our knowledge, this is the first case report associating neurobehavioral impairment, neuro-imaging data and a common local idiom of distress in Oman, namely spirit possession. Within traditional Omani society, abrupt personality changes or altered states of consciousness are commonly attributed to spirit possession.[4] The belief in possession is embedded in social- cultural teaching, in which invisible spirits are deemed to inhabit the earth and influence humans by appearing in the form of an anthropomorphic being. In anthropological literature,[9,10] possession is classified into three types. The first is the symbiotic type, in which the spirit and the human being have a 'platonic' form of relationship. The second type of possession is a partial possession that is reminiscent of dissociative identity disorders in psychiatric parlance.[4,10] The final type (discussed in this case report) represents total possession, in which a person's behavior is totally controlled by a spirit. Psychiatric interest in possession owes its origin to the writing of Jean-Étienne Esquirol, who described the phenomenology of spirit possessions as 'disease'.[11] Despite similarities between neurologically induced disorders and the 'abnormal behavior' deemed to be triggered by possession, there has yet to be a report linking possession to brain abnormality. This problem is compounded by critiques urging that, even if biomarkers are found for psychological disorders, it will prove to be even more difficult to establish whether such defects are truly representative of the pathology or are simply by-products of a compensatory adaptation to the distressed state.[12]

From a biomedical perspective, the condition of the current patient would suggest symptoms of chronic schizophrenia, a diagnosis that is supported by a family history of psychosis. In the parlance of modern psychiatry, the patient met criteria for schizophrenia and responded to risperidone, a known treatment for psychosis. A closer observation of his sustained traumatic brain injury revealed the presence of intransigent and persistent cognitive and behavioral dysfunctions, and poor response to electroconvulsive therapy, which could point to an organic pathology. With the background of observed abnormal electroencephalographic activity in the present case, the possibility remains that lamotrigine may have ameliorated the patient's psychotic symptoms by controlling 'non-convulsive seizures'. It is interesting to note that many patients diagnosed with schizophrenia have a history of traumatic brain injury.[13] From the perspective of the present case, functional (SPECT) and structural neuro-imaging data indicated abnormalities in the left temporal lobe and left basal ganglia, regions that have been shown to accentuate the spectrum of cognitive, emotional and motor disorders, as observed in the present case.[14]

By correlating functional brain activation with spirit possession, this case study bridges the gap between cultural phenomena and modern psychiatry. To come to grips with this complex issue, as well as to explain variants of mental illness, Kiev[15] suggested that the 'hardware' or pathology of mental illness can be traced back to brain abnormalities, whereas the phenotypical presentation of the observed 'abnormal behavior' constitutes 'software'. The present study suggests that possessive states - in this context, culture-bound syndromes - may be accompanied by specific neural structural and functional activities that warrant further investigation. SPECT revealed that the patient had a biological illness with two possible diagnoses, schizophrenia or sequelae of traumatic brain injury. There is therefore heuristic value in undertaking more biological research on culture-bound syndromes.

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