Case Report

A 14-year old Thai girl was brought to the local hospital by her hostel warden with unusual behaviour. The patient had moved to Singapore for her studies a month previously and resided in a boarding hostel. She had been sent together with her 15-year old step-sister who also lived in the hostel. The history had to be obtained from the step-sister as the patient was uncommunicative. The patient had been out shopping with her step-sister and 2 friends during the day. She had been her usual self with no complaints of illness. The girls returned to the hostel in the evening and had dinner as usual. Later that evening, the patient went to have her usual nightly shower pre-bedtime and was heard screaming in the shower. She was found by her friends awake, shivering and crying. She refused to communicate with her friends and had to be brought to the Accident & Emergency department of the local hospital.

On examination, she was apyrexial with normal vital signs and blood pressure. She was awake and aware, but looked scared and refused to communicate verbally or by gestures. She could obey commands and had no unusual movements or mannerisms. Examination of all systems including neurological system was normal. Her step-sister denied that the patient had been drinking or taking drugs recently. She was not aware of any recent illness, psychiatric issues or previous similar episodes. The patient was not on any long term medications and had not been hospitalized previously. Her parents were divorced; mother had remarried and worked in Kenya and father lived in the USA with his new partner.

A diagnosis of altered mental status was made possibly secondary to ingestion of drugs or alcohol. Investigations included ECG, urine pregnancy test, blood urea & electrolytes, blood glucose, calcium, magnesium and a toxicology screen. All results were subsequently normal. The patient was admitted and monitored on the ward.

She continued to be uncommunicative for 2 days although she was cooperative with examination on the ward and would eat her meals when it was mealtime. Her vital signs remained normal and she did not go on to develop any new signs or symptoms.

A psychiatric opinion was sought but the patient refused to communicate and a Thai intepreter could not be found at the time of the consult. The stepsister was interviewed and she confided that they had been discussing the upcoming Chinese festival of the hungry ghost. The patient was not speaking much to her stepsister in hospital and the mother was making her way to Singapore. The adolescent nurse attempted to engage with the patient and only managed to get her to say that she was scared and had seen a hand in the shower preceding admission.

When the patients’ mother arrived, the patient perked up and started talking to mother normally. A doctor of Thai origin was eventually found and confirmed with the mother that the patient was otherwise well and not known to have any psychiatric diagnosis. The mother was calm about her daughter’s problem and simply concluded that she had been ‘visited by a ghost’ and a visit to the Thai temple was necessary to banish the spirit. She claimed this happened often in Thailand and was not an unusual event. The patient returned to her normal activity and speech when mother arrived, though she refused further conversation with the psychiatrist about events leading to admission. The family chose to discharge early in order to attend the local Thai temple. A follow-up appointment was made for the family but they did not attend and did not present again to the hospital.

Discussion

The concept of spirit possession has been recorded in almost every country in the world. Traditional societies often intepret altered states of consciousness as evidence of possession by another being (1). In Thailand, the term “Phii” refers to spirits and ghosts that have power over human beings. Victims appear to be mostly females (2). One case-control study analysed risk factors for spirit possession among Thai schoolgirls (3). Among 32 girls aged between 9-14 years, traits associated with possession were first-born child, small family units, previous trance-like states, anxious and histrionic behaviours. Exposure to spirit possession ceremonies were more frequent in spirit-possessed children than in the control group but this difference was not significant.

In our patient, her mother on hearing about her daughters’ illness immediately concluded that it was a case of possession. However, the patient in this case had just migrated to Singapore and had been discussing the ‘Hungry Ghost’ festival with friends leading up to the admission. In Singapore the ‘Hungry Ghost’ festival is celebrated in the seventh month of the Chinese lunar calendar. The Chinese believe that during this time, the gates of hell open for spirits to visit their living relatives. Hence, the seventh month is a time to reminisce and pay respects to deceased friends and relatives. It is possible that the patient was influenced by these stories and this lead to her visual hallucinations on the day of admission.

We were not able to establish a history of previous psychiatric type symptoms in our patient. Unusual behaviours can be a presenting feature of psychiatric or psychological illness and should be screened for. Our case highlights some important points. With the advent of large-scale migration around the world, there may be a clash of cultures involved with traditional and western medicines, as well as traditional behaviours or cultural expectations. The modern physician should be wary of these cultural differences and be sensitive to patient needs. Medical interpreters have also become an integral part of healthcare, as taking an adequate history can be difficult with language barriers.