Moral Injury, Trance and Possession State or a Schizophrenic Illness. a Case report

Moral injury—a strong cognitive and emotional response to acts that violate one's ethical code—may precipitate a first episode of schizophrenia, according to a case report of a 22-year-old Nigerian man. His symptoms, including delusions of guilt, disorganized behavior, and beliefs of being possessed by four different people, emerged after he had intercourse for the first time, which conflicted with a conservative religious prophecy. Treatment with olanzapine led to significant improvement within two weeks. The authors suggest that cultural and religious factors can shape how moral injury manifests in psychosis, and call for further research into this association.

Study at a glance

Abstract

Aims Moral Injury is a strong cognitive and emotional response occurring upon witnessing, participating in, or failing to prevent an act that goes against one's ethical code. This has been linked with Post Traumatic Stress Disorder, Depression, Suicidality, and Anxiety, amongst others. Data on its association with Schizophrenia are however lacking. Trance and Possession Disorders defined by the ICD-10 refers to a group of disorders involving temporary loss of both the sense of personal identity and full awareness of the surrounding with individuals acting in some cases as if taken over by another personality, spirit, deity, or force with reports of such states occurring in primary psychotic disorder. This case presentation describes a 22-year-old male whose first episode of schizophrenia was preceded by moral injury Methods A 22-year-old male Nigerian with a strong conservative Christian religious upbringing and a history of receiving a prophecy against having intercourse with women. He started showing symptoms of a mental illness a month after attaining coitarche with a lady. This presentation was characterized by irrelevant speech, intrusive flashbacks and unusual beliefs (excessive guilt, ill health). 7 months after, he was presented to the hospital with above symptoms and disorganized behavior characterized by beliefs of being possessed by four different people, shouting in different voice textures, throwing himself on the floor. We kept in view a diagnosis of schizophrenia and placed him on oral Olanzapine 5mg nocte following which he made significant improvement within 2 weeks with no memory of the event. Results Different factors can be considered in the aetiopathogenesis and presentation of symptoms in this patient. According to Williamson V. et. al; An Individual's experience of moral injury may lead to feelings of shame or guilt which was present in this patient (delusion of guilt). The pathogenic effect of culture and religion(e.g through prophecy against intercourse with women) may account for this illness. Moreso, pathoplastic and pathoreactive effects of culture could be said to have contributed significantly to the presentation of a psychotic disorder with trance and possession state as a reaction to moral injury. Conclusion Moral Injury, not previously considered to be associated with primary psychotic disorder may not only possibly precipitate a primary psychotic disorder but also show cultural/religious differences in phenomenology. Further studies are therefore required to explore these associations.