Clinical Research Case Report

Abstract

Background: Possession trance is characterized by a transient alteration in identity whereby one’s normal identity is temporarily replaced (possessed) by a spirit, ghost, deity, or other person. The clinical challenge lies in differentiating it from epilepsy, psychosis and culturally sanctioned “possession” states. Our case illustrates a similar situation where the clinical picture was complicated by the presence of neurological and endocrinological abnormalities.

Case outline:The patient was a 27-year-old lady who had a history of mild mental retardation with I.Q. of 66 and seizures in childhood which had been with Valproate. Four years ago the patient presented with a possession state lasting initially for 3 days and then after indigenous treatment for periods lasting for a few hours to a day. At the end of the possession spells the patient would present with breathlessness and spasmodic rapid shallow breathing followed by loss of consciousness. The patient also began to have regression in her reading, mathematic ability, social skills along with 2nd person auditory hallucinations and visual hallucinations. MRI scans of the patient showed calcifications in the basal ganglia and laboratory tests showed decreased parathormone levels. She was started on PTH replacement and antipsychotics which controlled her behavior. The patient however continued to have possession spells and episodes of breathlessness which were managed with supportive psychotherapy. She gradually recovered and is doing well in follow up.

Conclusion:Dissociative disorders and epilepsy share many clinical features including amnesia, fugue, depersonalization, de-realization, and identity change. It can therefore be misdiagnosed as epilepsy in the absence of an ictal EEG. Awareness of cultural nuances, careful history taking, strict adherence to diagnostic criteria, use of structured interviews, neurological investigations, and longitudinal follow-up facilitates accurate diagnosis and appropriate care.