Religious Delusions of Possession in Schizophrenia: A Case Report

Dear Editor, Religious themes are frequently observed in the symptomatology of psychotic disorders, particularly in the content of delusions and hallucinations. The prevalence of religious delusions in individuals with psychosis is estimated to range between 20% and 60%.1 Such delusions often originate from the individual’s cultural and religious interpretations of abnormal experiences and gradually evolve into fixed beliefs with high personal significance.2 Despite their frequent occurrence, religious delusions lack a consistent phenomenological profile due to wide variations in spiritual beliefs, religious practices, and sociocultural contexts across the globe.3 One specific manifestation within religious delusions is the belief of being possessed, commonly termed a “delusion of possession.” This involves a firm conviction that one is under the control of a supernatural force – be it a deity, spirit, or demonic entity – resulting in a loss of autonomy and sometimes dramatic behavioral changes. This phenomenon has diagnostic complexity due to its symptomatic overlap with dissociative disorders, particularly dissociative identity disorder (DID). Possession states often involve a shift in self-perception and agency, where individuals report feeling overtaken by another entity. This overlap can blur the clinical distinction between psychotic and dissociative disorders, complicating accurate diagnosis and management.3 In DID, patients typically experience episodic possession characterized by behavioral shifts, speaking in unfamiliar voices or languages, and amnesia for these episodes. In contrast, patients with schizophrenia and possession delusions generally exhibit a more chronic illness course with prominent features such as auditory hallucinations, delusions of control, and lack of amnesia for possession episodes.4 Accurate diagnosis is critical because it influences the therapeutic approach and long-term outcomes. Misattributing culturally sanctioned possession experiences to pathology or vice versa can delay medical intervention and lead to poor prognosis. This case report describes a woman with schizophrenia presenting with elaborate religious delusions of possession, highlighting the cultural context, phenomenological overlap with dissociative disorders, and treatment challenges. CASE REPORT Our patient is a 48-year-old unmarried female residing with her two younger brothers and an elder sister. Premorbidly, she was well adjusted, although she held religious beliefs and engaged in regular prayer; her devotion was consistent with other family members and aligned with cultural norms. She has a family history of dementia in her father. Her psychiatric symptoms began 12 years ago, at age 36 years, following a stressful interpersonal conflict with a relative, when the patient had experienced repeated criticism and moral policing from a relative following a reported remark that caused marked distress and preceded the onset of psychotic symptoms. The first episode was characterized by suspiciousness toward family members, fearfulness, and social withdrawal. Symptoms were of moderate severity and resolved over 2–3 years with treatment. She was initially treated with aripiprazole (up to 15 mg), trifluoperazine (5 mg), and quetiapine (50 mg) for 6 months, which led to good recovery, but treatment was stopped prematurely. Over the next 2 years, in view of subthreshold re-emergence of symptoms, she was treated intermittently with aripiprazole (up to 30 mg) and quetiapine (up to 100 mg), though adherence was poor. She then remained asymptomatic for nearly a decade without medications. The second episode began at age 48 and had been ongoing for 10 months at the time of her most recent evaluation. Her current symptoms included a firm belief that the Hindu goddess Eshwaridevi had entered her body. She would frequently speak in a dialogical format – alternating between herself and the deity – without any change in tone, voice, or rhythm. She described the goddess as guiding her daily actions, such as eating, bathing, and sleeping. Additionally, she reported auditory hallucinations in the voice of the goddess, who she claimed was constantly communicating with her. Another prominent feature of her presentation was misidentification delusions. She believed her siblings had been replaced by demonic impostors, consistent with Capgras syndrome. She became highly suspicious of them, convinced that they were poisoning her food. As a result, she significantly reduced her food intake and lost weight. Her functional status declined, and she became increasingly socially withdrawn. During her mental state examination, she appeared cheerful but spontaneously expressed prominent delusions. She exhibited two-way conversations, speaking alternately as herself and the deity. Occasionally, she would chant mantras spontaneously, interspersed with statements like, “Say aloud, chant aloud. I will protect you, my child,” to which she would respond, “Yes, Mother, I will chant.” These dialogues were internally consistent but clearly delusional. Hospital course and treatment She was first admitted during her current episode and was diagnosed with paranoid schizophrenia. Although she occasionally appeared cheerful during interviews, this was interpreted in the context of her delusional beliefs, and in the absence of manic features such as increased psychomotor activity, pressured speech, flight of ideas, distractibility, or expansive mood (as per Diagnostic and Statistical Manual of Mental Disorders-5), a diagnosis of bipolar affective disorder was not considered. Neurological evaluation included a computed tomography brain (plain), which was reported as normal. She was prescribed risperidone 6 mg/day, along with trihexyphenidyl (2 mg/day) and clonazepam (0.5 mg/day). She showed a dramatic 95% improvement in delusions and hallucinations within 2 weeks, with emerging insight. However, within 6 weeks of discharge, she relapsed despite adherence to medication. Risperidone was discontinued due to treatment failure, and she was switched to amisulpride. Risperidone was gradually tapered from 4 mg/day to 2 mg/day over 3 days, and discontinued after a further 3 days, while amisulpride was introduced concurrently. It was initiated at 200 mg twice daily for 3 days, and subsequently increased to 400 mg twice daily. Electroconvulsive therapy (ECT) was initiated after 10 days of admission due to poor food intake and the severity of symptoms. After just two sessions of modified bilateral ECT, she showed rapid clinical improvement – reporting 80% subjective relief and a 50% reduction in her Brief Psychiatric Rating Scale score. Later, due to elevated prolactin levels (76.8 ng/mL) and menstrual irregularities, aripiprazole 2 mg was added. Unfortunately, she developed extrapyramidal symptoms (rigidity, tremors, dysphagia), which resolved after discontinuation of the drug. She was ultimately discharged on amisulpride 1000 mg/day, trihexyphenidyl 2 mg/day, propranolol 40 mg/day, and clonazepam 0.5 mg/day. Since discharge, she has remained clinically asymptomatic and adherent to the prescribed medications, though her follow-up visits are irregular. DISCUSSION This case exemplifies the complex interplay between cultural beliefs, religious themes, and psychotic psychopathology. As described by,2 religious delusions often have a background history of rooted cultural influences, traumatic experiences, and early religious exposures. In this case, her longstanding devotion to Eshwaridevi shaped the form and content of her delusion. Phenomenologically, this case resembled DID in some aspects. However, the absence of amnesia, lack of identity switching, and presence of auditory hallucinations favored a diagnosis of schizophrenia. As noted by,5 DID involves distinct personality states and memory gaps, whereas schizophrenia involves persistent delusions and hallucinations without memory fragmentation. The manifestation of Capgras syndrome and persecutory delusions further complicated her presentation. Functional impairment was severe – she restricted her food intake and required inpatient care. Importantly, although the concept of being “possessed by a deity” is culturally accepted in many South Asian communities, the degree of conviction, associated paranoia, and functional decline clearly demarcated her experiences as pathological. Cultural variations significantly influence the expression of possession states. Among Muslims, jinn possession is common, while in Japan, possession delusions may involve sea or wind deities.6 In the West, demonic possession predominates.7 These differences emphasize the need for culturally informed clinical assessments. At the onset, her experiences were interpreted within a religious framework, prompting rituals rather than medical consultation. This delayed engagement with psychiatric care contributed to the chronicity of her illness. The delay in treatment is not uncommon, as religious delusions are often culturally sanctioned, blurring the line between pathology and belief.8 Patients with religious delusions tend to have poorer outcomes due to strong belief conviction, family endorsement of spiritual explanations, and treatment non-adherence.9,10 However, she showed a surprisingly rapid and robust response to antipsychotic medication and ECT, highlighting the potential for recovery with timely, appropriate intervention. CONCLUSION This case highlights the intricate relationship between culture, religion, and psychopathology in schizophrenia. Delusions of possession can closely mimic dissociative disorders, making diagnosis challenging. Culturally sensitive assessments are essential for distinguishing pathological beliefs from normative religious experiences. Early recognition and intervention, combined with appropriate pharmacological and somatic treatments, can lead to significant improvement – even in complex presentations. Author contributions SBB – Writing original draft and revisions. PJ – Conceptualization and editing of the draft. CA – Editing the draft. MS – Editing the draft. VK – Conceptualization and revision. Disclosure of use of AI assistive or generative devices The authors declare that authors have used AI only for improving readability and grammar in the manuscript. Declaration of use of copyright tools Not Applicable. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.