Tinnitus not heretofore been described as the only manifestation of delusional possession in Kandinsky-Clerambault syndrome. Such a case is presented.

Case Report: A 70-year-old left handed (pathological) man, eight years prior to presentation, noted gradual onset of decreased hearing and high- pitched constant tinnitus AU made worse with stress. Initially only present in quiet, it intensified, ultimately present in all situations, even with ambient background noise. He believed that the Devil was inside of his head, had been there for many years, and was making his life unbearable by subjecting him to the tinnitus. Other than the tinnitus, the devil did not cause any other symptoms, nor did it communicate with him in any fashion. In an effort to eliminate the Devil-induced tinnitus, he twice attempted suicide through self-strangulation. The tinnitus persisted despite treatment with mirtazapine and lumateperone.

Abnormalities in physical examination: General: Decreased blink frequency. Continuous fidgeting and generalized tremulousness. Neurological examination: Mental status examination: Hypoverbal. Able to remember 5 digits forwards and 3 digits backwards. Unable to remember any of four objects in 3 minutes with and without reinforcement. Presidents as follows: Biden, Obama, ?. Animal Fluency Test: 7 (Abnormal). Cranial Nerve (CN) Examination: CN I Alcohol Sniff Test: 0 (Anosmia). CN VIII Calibrated Finger Rub Auditory Screening Test: Strong 2 AU. Motor Examination: 1+ cogwheel rigidity in the right upper extremity. Gait Examination: Unstable tandem gait. Reflexes: 1+ throughout. Other: Tinnitus Severity Questionnaire : 38/40 (Severe tinnitus). Tinnitus Handicap Inventory: 94/100 (Grade 5- Catastrophic handicap).

While Kandinsky Clerambault Syndrome, Delusion of Possession Syndrome is uncommon in the United States (Dimkov, 2020; Enoch, 2020), 46% of Italians believe in the Devil (Marra, 1990) and 0.6% of Canadians believe that they have been possessed by a demon (Ross & Joshi, 1992). Although the most common neurological presentation of Kandinsky Clerambault syndrome is glossolalia, sensory phenomenon of anosmia (Chand et al, 2000; Medeiros De Bustos et al, 2014), ageusia (Chand et al, 2000), kinaesthesia (Gedevani et al, 2022), allochiria (Medeiros De Bustos et al, 2014), synesthetic neuralgia (Medeiros De Bustos et al, 2014), cenesthesia (Medeiros De Bustos et al, 2014), pain (Medeiros De Bustos et al, 2014) and anaesthesia (Yap, 1960) have also been described. While tinnitus has not been reported with Kandinsky Clerambault, it has been noted to occur with depression, anxiety (Zöger et al, 2006; Salviati et al, 2013), and psychosis (Frankenburg & Hegarty, 1994; Jain et al, 2017). Given the widespread belief in the general population of the Devil and possession by external entities, assessment of presence of Kandinsky Clerambault Syndrome in those with intractable tinnitus may be worthwhile.

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