The Demon Within
Exorcisms and Immunotherapy
VIDEO: VITALIYMATEHA/ADOBE STOCK
A 2022 article in the Journal of Family Medicine and Disease Prevention reports that an 8-year-old girl experiencing involuntary jerking of her extremities, slurred speech, anxiety, changes in affect, lowered levels of activity and communication was brought into a hospital ER. The child had also been seeing “dark shadow people.” She was diagnosed and treated for a “complex partial seizure disorder,” prescribed Keppra (an anticonvulsant) for seizure control, and was released from the hospital. After this initial visit, she returned, still suffering from hallucinations and purportedly yelling “in a different language” as well as chanting in “an unrecognizable language.”1 In that visit, the child had a violent outburst and multiple seizures. The parents believed that the girl had become possessed following physical contact with a Bible in their home and stated that they were contemplating having the child undergo an exorcism. Laboratory and imaging results that came back during the hospital stay were all normal. Against medical advice, the mother had the child discharged so that the girl could be taken to an exorcist to cast out the demon the mother thought to be the cause of the child’s bizarre behaviours. The idea that a spirit, whether malevolent or benign, may take control of a living person is common to many belief systems.2 Exorcisms, the use of rituals or prayers meant to force an evil spirit out of a person or place, are often associated with Roman Catholicism, but are also practiced by some Protestant denominations (where it is often called deliverance),3 and by members of non-Christian religions. The 2008 death of an 18-year-old woman in the U.S., for example, was thought to have been related to an exorcism performed under an ancient shamanistic Korean ritual.4 In fact, 18 per cent of people in Britain and 51 per cent of people in the U.S. believe that demons can take possession of a person.5,6 Instances of demonic control and its resolution through exorcism have been portrayed in popular films, most notably in The Exorcist,7 purportedly based on the exorcism of a teenage boy in 1949.8 Similarly, another film, The Exorcism of Emily Rose,9 was based on the legal case surrounding the death of a young woman in 1976, after she underwent 67 exorcisms over the course of 10 months.10 Given that it has become a well-known horror subgenre, even nonreligious people are familiar with the concept of demonic possession. In the medical journal article referenced above, the young girl’s sudden behavioural changes conformed to phenomena that may be interpreted as signs of demonic possession. This includes speech in a language that the person did not previously know.2 In the case of the young girl, the speech is not identified, perhaps an indication that it was not actually a language. Other signs of alleged demonic possession may be an aversion to religious symbols (such as the girl’s reaction after contact with the Bible) and displays of superhuman strength (perhaps her violent outburst was interpreted as such), but can also include facial contortions, the uttering of threats, irreverence towards God or other sacred entities, spitting, cursing and excessive sexual activity.2,11 Within some religious groups, a disproportionate number of women are thought to be demon-possessed and subsequently undergo exorcisms. The pastor of a Lutheran church in Fort Wayne, Indiana, reported that around 80 per cent of the exorcisms he performed were on females, including a 3-year-old girl.3 A 2021 study of demonic possession among people of Italian nationality found that the majority of individuals who were thought to be victims of demonic possession were female (20 per cent more females than males) and young (62.9 per cent were between the ages of 18 and 37).12
“The belief in demonic control can produce fear, misery and physical harm, not unlike the stigma surrounding some psychiatric disorders.”
PHOTOGRAPHY: TOF - PHOTOGRAPHIE
Perhaps not coincidentally, being female and young also happen to be factors for a potentially fatal medical condition that may, in some circumstances, be misinterpreted as demonic possession. In anti-NMDA-receptor encephalitis, antibodies attack N-methyl-D-aspartate receptors in the brain, interfering with the activity of the neurotransmitter glutamate.1 The female-to-male ratio for this autoimmune condition is 4:1, and the most commonly affected group are young women between 25 and 35 years old.13 However, it can occur in children, and adults older than 85. It can be triggered by tumours, and in females it is often associated with ovarian teratomas (a tumour composed of hair, tooth, bone or other tissues).13,14 In the absence of neoplasms, the disorder may be triggered by bacteria or viruses, such as Herpes simplex virus. In addition to anti-NMDA-receptor antibodies, autoimmune encephalitis may be caused by several different types of autoimmune antibodies, including anti-LGI1, anti-CASPR2, anti-GABAA, anti-GABAB, anti-DPPX, anti-GAD65 and anti-AMPAR antibodies.16 Anti-NMDA-receptor encephalitis is the most common form of AIE,17 although the actual frequency of the disorder is likely underestimated, owing to a lack of awareness or standardized diagnostic protocols.15 A UK study of pediatric anti-NMDA-receptor encephalitis, conducted between November 2010 and December 2011, found the incidence among children in that country to be 0.85 per million per year.18 In Denmark, an all-ages study (median age 27 years old) covering the decade 2009 to 2019 found an incidence of 0.17 per 100,000 persons per year or 1.7 per million persons per year. The disorder is rare, but it will likely become increasingly recognized as awareness of the disorder increases.20 Anti-NMDA-receptor encephalitis affects mood, memory, behaviour and cognition.21,22 It often begins with flu-like symptoms, but progresses to a psychotic phase.13 A patient may present with seizures or movement disorders affecting the face or limbs, suffer from memory loss, cognitive impairment, have speech difficulties, a decreased level of consciousness, show signs of agitation and display psychotic features, including paranoia, hallucinations and delusions, which may be mistaken for substance abuse or a major psychiatric disorder.13,14,16,22,23 In one Canadian case, a woman was initially misdiagnosed with bipolar disorder, but four years later was discovered to be suffering from anti-NMDA-receptor encephalitis.24 Given its strong association with neuropsychiatric symptoms, psychiatrists are often the first medical personnel to encounter the patient suffering from this disorder.22 The timely diagnosis and treatment of anti-NMDA-receptor encephalitis are essential as the disorder can lead to devastating neuropsychological damage and death.1 In the case of the 8-year-old girl removed from hospital care so that she could undergo an exorcism, it was only after she had been discharged that the results of her anti-NMDA-receptor titres were completed and indicated that she was ill with anti-NMDA-receptor encephalitis.1 Behavioural manifestations of autoantibody-mediated encephalitis may be mistaken for demonic possession,14 and the parents had been seeking an exorcism for a condition that ultimately required medical treatment.1 Thankfully, after the correct diagnosis was established and the appropriate treatment provided, the 8-year-old patient made a complete recovery. Journalist Susannah Cahalan, who has recovered from anti-NMDA-receptor encephalitis and authored a book about the illness, Brain on Fire: My Month of Madness, asks, “How many children throughout history have been ‘exorcised’ and then left to die when they did not improve?”25 Tragically, alleged instances of injury and death from attempted exorcisms have been documented among members of Roman Catholic, Protestant and non-Christian faiths.4,26,27,28 Unfortunately, it is impossible to know how many people have been subjected to an array of horrifying experiences, institutionalized in psychiatric facilities and died due to anti-NMDA-receptor encephalitis, a disease that was only identified in 2007.15,21
PHOTOGRAPHY: MY OCEAN STUDIO/ADOBE STOCK
In order to address the challenges of arriving at a timely diagnosis and initiation of treatment of autoimmune encephalitis, the international medical community has produced a set of recommendations.29 In Canada, researchers have produced the Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults.30 Autoimmune encephalitis disorders, such as anti-NMDA-receptor encephalitis, should be ruled out in any patients who present with new-onset psychotic symptoms accompanied by mental status changes, memory loss, seizures, movement disorders or other unexplained symptoms.14,15,17 Typically, diagnostic recommendations will include imaging, such as MRI, EEG and Fluorodeoxyglucose-Positron Emission Tomography (FDG-PET),30,31 but medical laboratory personnel also have a critical role in helping to determine a diagnosis of autoimmune encephalitis. In order to rule out systemic inflammatory conditions and metabolic issues, routine bloodwork should be performed, but samples should be collected prior to the administration of immunoglobulin or plasmapheresis therapies.29,30 In suspected AIE, routine CSF examination should be completed, and infection ruled out.30 Generally, in autoimmune encephalitis, there will be increased lymphocytes, protein, and IgG index.15,30 CSF-specific testing for oligoclonal bands should be performed on both CSF and serum. Nevertheless, CSF findings may be normal. Critical to a diagnosis of autoimmune encephalitis, a comprehensive neural antibody testing panel is recommended on CSF as well as serum.13,20,30 Canadian guidelines warn that improper methodologies used in neural antibody detection may lead to false positive results.30 The use of tissue indirect immunofluorescence/immuno-histochemistry (TIIF/IHC) is recommended in order to increase sensitivity and specificity in cases of suspected AIE.30,33 Treatment of anti-NMDA-receptor encephalitis emphasizes early diagnosis, the administration of high dose steroids and aggressive immunotherapies, which may include IVIG (intravenous immunoglobulin — an infusion of antibodies collected from thousands of donors), therapeutic plasma exchange (in which blood is drawn from the body, harmful plasma constituents are removed and cellular components are re-suspended in an appropriate fluid before going back into the patient’s body) and Rituximab (a monoclonal antibody preparation that attacks B cells).1,13,14,15,20,30 Diagnostic imaging should be done to rule out teratomas and other neoplasms and, if applicable, surgery should be performed. In the treatment of seizures and behavioural symptoms, antiepileptic agents may be ineffective and some antipsychotics may cause neuroleptic malignant syndrome.13 While awaiting results, if there are concerns that the illness may be of an infectious nature, empiric treatment with antibiotics or acyclovir (if Herpes simplex virus is suspected) is recommended. 13,30 Autoimmune encephalitis can sometimes help explain psychotic symptoms that, even today, may be misinterpreted as demonic possession. The belief in demonic control can produce fear, misery and physical harm, not unlike the stigma surrounding some psychiatric disorders. Indeed, the identification of autoimmune encephalitis has sparked interest in determining whether autoimmune diseases might also have a role in mental illness.15,34 It has been suggested that auto-antibody screening may eventually become a routine diagnostic tool for patients who present with psychiatric symptoms.34 Perhaps further investigation into autoimmune disorders will shed light on the diagnosis and treatment of major mental illnesses, such as schizophrenia and bipolar disorder, in the same manner that it has in other cases which, in an earlier time, would have been misunderstood as demonic possession.
John Buhler
MLT, BGS
Alberta Precision Laboratories
John Buhler
MLT, BGS Alberta Precision Laboratories