“Jinn Possession” and Delirious Mania in a Pakistani Woman
A 25-year-old married mother of three living in Karachi, a homemaker with a high school education and of lower-middle 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 20 mg/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 loud masculine 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. Episodes of muteness and staring were 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), who gave her a “special arm band” to wear 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 she wore 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.
Discussion
Our diagnosis in this case is delirious mania 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). Delirious mania is a neuropsychiatric syndrome seen in severe forms of mania in bipolar disorder that has features of delirium such as confusion and dreamlike clouding of consciousness, with psychosis and often catatonic features (3).
According to Islamic belief, a jinn is a supernatural being created by God from the “fire of scorching wind” or “smokeless fire” (4), as mentioned in Quran in several places. In Pakistan, where 97% of the population is Muslim, cultural beliefs and practices are heavily influenced by religion, and the phenomenon of “jinn possession” is prevalent and accepted (5). According to the cultural belief, jinn possession is believed to occur when a jinn, in most cases a bad or evil jinn, enters the human body or takes charge of it without that person’s will; the possessed individual’s actions and emotions are then believed to be under the jinn’s control (6). People identify discrete periods of time when a jinn takes over mostly as periods of altered consciousness during which the possessed person may be unable to think or speak from his or her own will; become aggressive, restless or agitated; act like a jinn, such as speaking in an incomprehensible language or a woman speaking in a male voice; see or hear strange things, or talk to other jinns; eat large amounts of food or be unable to eat; show disorganized or bizarre behavior; feel weak or dizzy; and lose consciousness or lose touch with reality (7). According to common cultural belief, these episodes last a few minutes or longer and are repeated frequently until a spiritual or religious intervention is performed by a religious figure to make the jinn leave the body of the afflicted person (8).
Jinn possession may be used in society as an explanation for serious psychiatric illnesses such as delirious mania. Lack of knowledge about this association among physicians, limited awareness among the public about psychiatric illnesses in general, poor access to health care, low socioeconomic status and education levels, stigma attached to mental health conditions, a wide availability of and belief in spiritual healers (9), and lack of insight by the afflicted person as a result of the disease process are some of the factors that contribute to this practice and compromise psychiatric treatment by causing nonadherence.
It is essential to increase awareness among physicians about the possible association of delirious mania with jinn possession by conducting training, continuing medical education, workshops, and the like. Other useful measures may include increasing awareness and making access to mental health care easier for the general public and training community health workers to educate and encourage people to seek medical treatment for the jinn possession phenomenon. Confronting or challenging the family’s religious and spiritual beliefs will likely hamper treatment and damage the rapport between family and health care provider. Efforts should be made to establish collaborations with spiritual healers and to incorporate them into the treatment plan (10) by inviting them for talks and educational sessions in mosques, community centers, schools, and madrassas (religious schools). Efforts might also be made to raise awareness among the masses by distributing health care information in the form of leaflets and brochures and through drama performances and videos in local languages, especially in underprivileged and rural areas; providing information about local physicians who can treat psychiatric illnesses; and offering incentives in the form of edibles or free bus rides, passes, and so on. The efficacy of these measures has not been established, however, and is an area for further exploration and research.
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