A 22-year-old right-handed Omani man first presented to us in 2002. His family brought him into our clinic reporting a history of a recent change in personality and impairment of sensory perception. The patient complained of abnormal auditory experiences when alone. He also complained that the appearance of his father had changed to that of a 'devil'. He claimed that his meals were shared by Jinn (evil spirits) which 'made the food taste nasty'. According to the patient's family, the patient had become isolated, disinterested and withdrawn. He had poor sleep with unremitting restlessness.
The patient reported altered attention and concentration coincident with the emergence of his personality change. His personality change had been attributed to various causal agents including supernatural forces such as Jinn, contemptuous envy (Hassad), the envy-related 'evil eye' ('Ain) and sorcery (Sihr). He had previously sought traditional treatment for his condition. However, consultation in a traditional healing practice failed to return him to his premorbid self. The family also took him for an Umra (optional Muslim pilgrimage to Mecca). Possibly as a result of the stress of traveling, on returning from the Umra he became increasingly agitated, which often led to violence towards his family members.
The patient had a positive family history of psychiatric illness: one of his uncles has suffered from symptoms akin to a psychotic illness. In 2001 the patient had been involved in a traffic accident and incurred head trauma, but with no evidence of loss of consciousness or seizures. Immediately after the accident, most of the typical post-concussion syndromes dissipated and he regained physical functionality. About 6 months after the accident, his conduct was noted by the family member to be very different from his premorbid state. He deteriorated in academic competence, which resulted in repeated academic failures and having to leave school. He was noted to be less stressed than normal and his social interaction and self-care regressed drastically to the point at which he was dependent on others for his welfare. This marked deterioration in performing daily living activities coincided with the emergence of auditory hallucinations that came to the attention of the caregivers about 9 months after the accident.
Before seeking consultation with us, he had been seen in two different psychiatric hospitals; he had received electroconvulsive therapy in one of them, but his condition remained impervious to the treatment. During this time, all tests conducted complete blood count, blood biochemistry, immunological workup and electrocardiogram) produced normal results. He sought consultation with an ophthalmologist for double vision, and was diagnosed with retinitis pigmentosa. He was seen by a neurologist for vertigo, double vision, headache and abnormal movements, and was diagnosed with migraine. A computed tomography scan performed at that time showed an encephalomelacia in the left basal ganglia. Electroencephalography suggested possible temporal lobe epilepsy (bilateral with no generalization), but no seizure activity was observed. There were no other abnormal findings. No treatment course had been approved by his family. Because of his obvious personality changes, they continued to attribute his distress to supernatural forces; traditional healing approaches were therefore sought, but they did not improve his condition.
Our preliminary consultation indicated an abnormal temperament, and his social behavior deviated from his culture's social modesty and etiquette. Concurrently, his cognitive functioning was severely compromised. Cognitively, he was inattentive and distractible and showed a strong presence of auditory hallucinations. His psychosocial history did not indicate the presence of alcohol or drug misuse, and physical examination indices were unremarkable. Although there was no indication of receptive and expressive language impairment, he had a disturbance in word generation, suggestive of aphonia and indicative of dysarthria. He was uninterested in maintaining a prosocial behavior and never initiated conversation with others. He remained motionless unless prompted. In formal cognitive testing using the Folstein Mini-Mental State Exam, his scores were in the clinically abnormal range, with a total score of less than 19. Blood tests revealed normal complete blood count, blood biochemistry, thyroid functions and lipid levels. Brain perfusion single-photon-emission computed tomography (SPECT) was performed 45 min after injection of a dose of 740 MBq 99mTc-ethyl cysteinate dimer (Bristol-Myers Squibb Medical Imaging) through an existing intravenous line. The image acquisition parameters were 360° of rotation, 64 images, 20s per image with a 128 × 128 pixel matrix [6]. Brain perfusion SPECT was analyzed by an iterative reconstruction method [6]. The indices of tomographic imaging during acute exacerbation of the symptoms are shown in Figure 1; they clearly indicate low perfusion in the left temporal lobe.
The patient was initially prescribed risperidone (2 mg at bedtime about 3 months later it was combined with lamotrigine (50 mg twice daily). The patient showed a marked improvement in his mood, cognitive functioning, and social behavior after having been on the medications for 3 weeks. His perceptual disorders gradually receded. He relapsed when he was allowed to spend a weekend at home, during which he was not adherent to the medications. After his relapse he was given long-acting intramuscular risperidone in the clinic every 2 weeks. For a period of 4 months. On subsequent follow-ups, he seemed to have returned to his premorbid self. He was well oriented to time and place, was cooperative, and all indicative psychotic features had fully receded. His quality of life had improved, and he had resumed his studies and had progressed in his quest for a certificate-granting secondary school. In addition to these behavioral changes, repeated brain perfusion studies (Figure 2) showed an improvement of perfusion in the left temporal lobe.
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