“The Demons Made Me Do It”

Background: Throughout history, mental illness has often been attributed to witchcraft or possession by malicious entities (Ventriglio et al., 2018). Current opinions vary but suggest that supernatural beliefs exist on a continuum from overvalued ideas to delusions, and the line between culturally sanctioned possession and mental illness is blurry (Ventriglio et al., 2018). Many cultures today may consider spiritual possession normal until it renders the victim severely distressed or dysfunctional (Gaw et al., 1998). In delusions of possession, a person believes that they have been seized by a supernatural entity (Pietkiewicz et al., 2021). Those diagnosed with a schizophrenia spectrum illness are at greatest risk of having these delusions. In this population, 33%–74% also experience command auditory hallucinations (CAHs), further animating the beliefs and even encouraging thoughts of suicide or homicide (Braham et al., 2004). Suicide remains a major public health concern. The age-standardized suicide rate in the Americas increased by 17% between 2000 and 2019 (World Health Organization, 2021). In the United States, suicide accounted for 47,458 deaths in 2021 alone (Ahmad et al., 2022). However, despite increasing suicide rates and attention in the scientific literature, standardized risk assessment tools have not been found to reliably predict suicide. An individualized patient-centered approach—particularly one that takes into account the phenomenology of psychosis—may be prudent (Bürgy, 2008; Saab et al., 2022). The risk of suicide in schizophrenia is upward of 22 times greater than in the general population (Hjorthøj et al., 2017). It is a significant contributor to decreased life expectancy, as 5% of people with schizophrenia complete suicide (Freeman et al., 2019; Sher and Kahn, 2019), whereas over five times as many make an attempt during their lifetime (Lu et al., 2020). Furthermore, schizophrenia is the diagnosis most frequently associated with suicide that occurs during an inpatient hospitalization. Contributing factors include comorbid substance use, severe anxiety or agitation (Chammas et al., 2022), depressive symptoms (Sher and Kahn, 2019), and positive psychotic symptoms like persecutory delusions and CAH (Freeman et al., 2019; Pompili et al., 2005). Despite 20%–60% of psychotic patients reporting religious delusions and 20%–40% reporting delusions of possession during the course of their illness, literature focused on such delusional content and its connection to suicidality is lacking (Pietkiewicz et al., 2021). We describe an illustrative case of a patient presenting after a suicide attempt precipitated by delusions of demonic possession and CAH. CASE PRESENTATION A middle-aged woman with a history of schizoaffective disorder, multiple psychiatric hospitalizations, and no prior suicide attempts was medically admitted after a suicide attempt at an outside hospital. She initially presented with weeks of auditory hallucinations, paranoid delusions, intermittent agitation, and bizarre arm motions, and was started on oral risperidone. Four days later, the patient was found down in her room after an attempted hanging with clothing from her room door. The patient required cardiopulmonary resuscitation, intubation, sedation, and intensive care unit admission. Upon extubation, the patient described male- and female-voiced demons that had been following her and commanding her to harm herself, harm others, and engage in degrading behaviors for years. She had become increasingly distressed by the demons as they repeatedly “took over” and “gained control” of her body to “send [her] to hell.” The day prior, the demons threatened to possess her and insisted that her life was over. Fully believing that this would occur, she “gave up” and tried to hang herself in a final attempt to prevent the demons from successfully entering her body. After the attempt, the patient verbalized strong feelings of helplessness and hopelessness that the demons would never stop tormenting her, and that she was, in essence, already dead.

Discussion: Delusions of demonic possession represent a unique psychiatric phenomenon in which an individual fears or perceives losing control of themselves to the malevolent will of another. When coupled with a sense of futility about their situation, they may react in unexpected and severely maladaptive ways to mitigate the perceived threat. Left without alternatives or hope that their symptoms will improve, they may resort to self-harm or suicide. The elevated suicide risk in schizophrenia is frequently correlated with the presence of positive psychotic symptoms (Freeman et al., 2019). Hallucinations predict suicidal ideation, planning, and attempts (Kjelby et al., 2015). CAH, in particular, are significantly associated with suicidal behavior and attempts when compared with noncommand hallucinations, even after controlling for depressive episodes and substance use (Wong et al., 2013). Additional studies have examined the risk of complying with command hallucinations. Impulsivity and perception of the voice as omnipotent independently predict compliance with harmful CAH (Bucci et al., 2013). Our patient's appraisal of auditory hallucinations as voices of demons with incredible power likely impelled her to attempt suicide. The bodily movements and psychomotor agitation that were reportedly under demonic control may have further contributed to the sense of helplessness that led to her acquiescence. Such motor restlessness may instigate the switch from suicidal ideation to suicide attempt, and increase the risk of repeat attempts (Park et al., 2020). Feelings of defeat and entrapment, rumination, and persecutory delusions are also associated with suicidality in people with schizophrenia (Freeman et al., 2019). Even in the context of otherwise well-controlled depressive symptoms, hopelessness may independently predict suicide attempts (Chammas et al., 2022). The subjective terror and high level of psychological distress experienced by patients with active persecutory delusions during this acute moment of helplessness and hopelessness may be referred to as “persecutory panic” (Freeman et al., 2019). Although expressions of religious delusions may be adaptive or protective in some situations, they often lead to considerable distress, even in comparison to other delusional content (Noort et al., 2018). In this state, death by suicide may be perceived as the preferable outcome to demonic possession and body inhabitation (Goldblatt et al., 2016). A limitation of this report is that it pertains to a single case, and there were few details of the patient's prior symptomatology and psychotic episodes. Moreover, the constellation of psychotic symptoms was primarily positive rather than negative or cognitive, limiting the generalizability of this case to those with similar symptom clusters. Discourse surrounding delusions of possession and the unique risks they confer on suicidality is lacking. Heightened emphasis should be placed on personalized risk assessment for individuals that report persecutory delusions or delusions of possession, particularly in an acute inpatient setting. Further study in this area is warranted.