"Jinn Possession" and Delirious Mania in a Pakistani Woman.

Abstract

Our diagnosis in this case is deliriousmania presenting as the phenomenon of “jinn possession,” which brings to attention an important association of the manifestation of psychiatric symptoms in terms of cultural and religious beliefs (1, 2). A 25-year-oldmarriedmother of three living inKarachi, a homemaker with a high school education and of lowermiddle socioeconomic status, was brought to clinic because of bizarre behavior. The illness started 25 days earlier with increasing anger, agitation, and anxiety and decreased sleep. She was seen by a local physician and received a prescription for fluoxetine at 20mg/day. After a few days, she started talking and pacing excessively, making calls to family members and asking for forgiveness, spending more time praying, and having frequent panic attacks. She also started hearing voices of “jinn” and could feel their presence in the room. She then developed discrete episodes of confusion lasting 5–15 minutes several times a day, during which she lost awareness of her surroundings, had clouded consciousness, talked gibberish, sometimes in a loudmasculine voice, heard voices of jinn, and saw jinn. She also had a few episodes of incontinence and at times needed help with toileting, bathing, and feeding. Episodesofmuteness and staringwere also reported. She was not able to take care of her children or perform household chores. The patient’s family reported that she had a similar episode after the birth of her third child 1 year earlier and was thought to be “possessed.” At that time, she was treated for jinn possession by an aamil (spiritual healer), whogaveher a “special armband” towear and some “holy water” to drink. She had no history of illicit drug use. No other medical condition was identified or had been treated in the past, and the results of a medical workup, which included a complete blood count, renal and liver function tests, electrolyte levels, fasting blood glucose level, thyroid-stimulating hormone level, urine toxicology screen, and erythrocyte sedimentation rate, were unremarkable. The patient’s family history was significant for bipolar disorder in a sibling. On examination, the patient was a young woman of average build and height; she wore a burka (veil) but uncovered her face while talking to the female examiner. She appeared inattentive and perplexed and avoided eye contact. Her clothes were unironed and shabby, her hair was uncombed, and shewore no makeup. No abnormal movements were observed, but the patient was restless and fidgety and got up from the chair purposelessly a few times during the interview. She took long pauses to respond to questions and spoke at a low volume. She reported her mood to be “theek” (“OK”). Her affect was anxious, and her thought process was tangential. The theme of jinn possession was notable in her thought content. She denied hearing voices or seeing things during the interview. Insight into the illness was absent: “I am possessed by jinn, I don’t need any medication.” She was oriented to place and person but not to time. The patient and family declined admission to a psychiatric unit and any other workup because of their firm belief that the patient was possessed and needed to be treated by the aamil, and admission might cause a disruption in her spiritual treatment. We recommended stopping the fluoxetine and prescribed quetiapine and clonazepam. The patient did not follow up in the clinic.