Interplay between traditional healing and modern psychiatry resulting in timely diagnosis of autoimmune encephalitis: A case report from a low- and middle-income country setting

Bushra S Imtiyaz; Chahat Jamwal; Mushtaq Ahmad Margoob; Hadiqa Maryam; Sandeep Grover

doi:10.4103/jmhhb.jmhhb_79_22

CASE REPORT

Year : 2022 | Volume : 27 | Issue : 1 | Page : 65-67

Interplay between traditional healing and modern psychiatry resulting in timely diagnosis of autoimmune encephalitis: A case report from a low- and middle-income country setting

Bushra S Imtiyaz¹, Chahat Jamwal¹, Mushtaq Ahmad Margoob², Hadiqa Maryam¹, Sandeep Grover³
¹ Department of Psychiatry, Institute of Mental Health and Neurosciences, Government Medical College, Srinagar, Jammu and Kashmir, India
² Advanced Institute of Management of Stress and Life Style Related Problems, Srinagar, Jammu and Kashmir; Supporting Always Wholeheartedly All Broken-Hearted, Kashmir, India
³ Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission	03-Apr-2022
Date of Decision	21-Apr-2022
Date of Acceptance	07-May-2022
Date of Web Publication	13-Aug-2022

Correspondence Address:
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmhhb.jmhhb_79_22

Abstract

There is poor coordination between mental health professionals and traditional healers. This often leads to mismanagement of patients with various mental disorders, which can sometimes result in a fatal outcome. It is often suggested that there is a need to improve the coordination between mental health professionals and traditional healers. In this report, we present the case of a young girl whose family initially consulted a traditional healer for her condition and was then referred to appropriate mental health facilities. This coordination resulted in the timely diagnosis of autoimmune encephalitis.

Keywords: Autoimmune encephalitis, coordination, traditional healers

How to cite this article:
Imtiyaz BS, Jamwal C, Margoob MA, Maryam H, Grover S. Interplay between traditional healing and modern psychiatry resulting in timely diagnosis of autoimmune encephalitis: A case report from a low- and middle-income country setting. J Mental Health Hum Behav 2022;27:65-7

How to cite this URL:
Imtiyaz BS, Jamwal C, Margoob MA, Maryam H, Grover S. Interplay between traditional healing and modern psychiatry resulting in timely diagnosis of autoimmune encephalitis: A case report from a low- and middle-income country setting. J Mental Health Hum Behav [serial online] 2022 [cited 2023 Mar 26];27:65-7. Available from: https://www.jmhhb.org/text.asp?2022/27/1/65/353755

Introduction

Autoimmune encephalitis (AE) is a rare but potentially treatable autoimmune condition with notable overlap between neurologic and psychiatric manifestations.^[1],[2] It is associated with a high mortality rate. Hence, timely diagnosis can have serious prognostic implications.^[3]

In an underdeveloped world, particularly in South Asian and African countries where traditional forms of treatment often supplant modern medicine, understanding treatment-seeking behavior can also greatly facilitate early diagnosis and appropriate management of these patients.^[4]

This case report describes the finely balanced coordination between faith healing, psychiatry, and the internal medicine departments in diagnosing the unusual presentation of AE that resulted in prompt intervention and gratifying results.

Case Report

A 17-year-old female from a low-income family with no past or family history of psychiatric illness was brought to a community-based outpatient psychiatry clinic with chief complaints of acute-onset jerky movements of the body, followed by unresponsiveness, anxiety, anorexia, and insomnia for 3 days following a minor psychosocial stressor. In addition, the clinical presentation was marked by persistent screams that involved using the word “wai” (a word commonly used to express distress in the Kashmiri language) and were associated with abnormal body movements and urinary incontinence rigidity and fever.

Thinking she was “accursed,” family members took her to a local faith healer who insisted that the patient should be taken to a mental health professional. Through a community mental health services delivery model, the faith healer had developed a working professional relationship and facilitated the appointment for the patient with the mental health professionals.^[5]

At the first presentation, on clinical examination, she was febrile, stuporous, had significant tongue and lip injury, and had tachycardia. Neurological examination revealed upper limb dystonia and rigidity. Suspecting an organic etiology, an urgent referral to the medical emergency department was made. Upon referral to the nearest public tertiary care hospital, the patient was immediately admitted and evaluated. The real-time reverse transcription-polymerase chain reaction assay for severe acute respiratory syndrome-coronavirus-2 was negative.

Her blood investigations revealed leukocytosis, and the analysis of cerebrospinal fluid (CSF) showed pleocytosis. Other baseline investigations, i.e., urine toxicology and neuroimaging, did not reveal any abnormality, as shown in [Table 1].

Table 1: Investigation findings of the patient leading to the diagnosis of autoimmune encephalitis

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As her clinical condition deteriorated, she was shifted to the intensive care unit (ICU) to manage antiepileptic medication-resistant seizures. Her clinical presentation qualified for a probable diagnosis of AE in view of acute-onset psychiatric symptoms, focal neurological findings, new-onset seizures, and CSF pleocytosis. This was later confirmed when her CSF autoimmune profile returned with a positive result for anti-N-methyl-d-aspartate receptor antibodies. Failing a course of pulse steroid therapy and a subsequent intravenous immunoglobulin therapy course, she responded well to rituximab. Her condition stabilized after nearly 3 months of ICU stay, after which she was shifted to the ward and then discharged once she was clinically stable.

During the follow-up at 1-month post discharge, she reported persistent irritability and sleep disturbances for which low-dose quetiapine was prescribed. During the subsequent follow-up, these symptoms disappeared. Her detailed neuropsychological assessment at a 3-month follow-up revealed mild deficits in abstract thinking, moderate deficits in working memory, and mild-to-moderate deficits in overall memory functions.

Discussion

Potentially treatable psychiatric illnesses, especially those associated with high mortality and morbidity, demand prompt referral to medical care for time management. In low- and middle-income countries (LMICs), where no proper pathway for referring patients is in place, cultural, and spiritual beliefs of the local population serve as essential determinants of treatment-seeking behavior and frame of reference in clinical decision-making.^[4],[6] Traditional and faith healers (TAFH) form a significant part of the global mental health workforce. The World Health Organization estimates that around 80% of the population in developing countries depends on TAFH for their health-care needs.^[7] There is an evident scarcity of formal health-care facilities and personnel, especially in LMIC settings,^[8] thus, making faith healers serve as an affordable and accessible first point of contact for the majority of the population.^[9] In spiritually invested populations such as Kashmir, patients under the treatment of mental health professionals wishing to use the local resources are hardly objected to except for instructions not to approach an imposter using unethical measures such as branding. The indigenous healers, in turn, continue to refer complicated cases to mental health professionals,^[10] for example, in the index case, the family found the clinical presentation puzzling and hence preferred seeking aid from a faith healer to start with, who then referred the patient to a mental health professional resulting in expeditious management. Therefore, even in an established organic phenomenon such as AE, clinicians need to have a wider lens and look at it through the sociocultural context of the pertaining demography. This has become all the more crucial in the light of the new-onset COVID-related psychosis associated with the high level of psychosocial stress and biologically mediated effects on the brain is now reported.^[11],[12] Hence, mental health professionals need to develop close liaison with the TAFH and educate them adequately about various mental health conditions. This will facilitate timely referral of patients with severe mental disorders and reduce the duration of untreated illness. This may also lead to a reduction in stigma associated with mental illnesses, considering people's faith in TAFH. Accordingly, aligning mental health services and traditional healing practices may thus help in addressing unmet mental health needs in the community and overcoming the barriers to treatment acceptance and delivery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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