Possession Trance Disorder - Who Knew?

I found this fascinating article at The Neurocritic, a very cool blog "deconstructing the most sensationalistic recent findings in Human Brain Imaging, Cognitive Neuroscience, and Psychopharmacology." The blog is posted with a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 Unported License, so here is the whole very interesting article.

The post begins with a small discussion of exorcism based on an episode of American Horror Story: Asylum, a series on FX. From there, however, he goes into a discussion of the available information Possession Trance Disorder, which I am saddened to see will not be in the DSM-5 (yet another of its flaws).

I am a little saddened, seriously, as a rational person who does not believe in spirit possession, to see this piece of cultural sensitivity removed from the DSM. I have actually had a client (Latina/Mexican/Catholic) who was "exorcised" by a woman working in a thrift store (not on the sale floor). The client was borderline DID at the time, with one very destructive (self-harm, suicide attempts) and the "exorcism" silenced the voices for several weeks, although they did eventually return.

As a therapist, it seems important to honor some aspects of other cultures and other belief systems. We do not have to believe them, but we can work within their worldview employing interventions we feel address the core issue(s).

Possession Trance Disorder in DSM-5

American Horror Story: Asylum takes place in 1964 at Briarcliff Manor, a terrifying mental institution for the criminally insane. The show uses every over-the-top stereotype in the book — straightjackets, isolation cells, shock treatment, the chronic masturbator, the nymphomaniac, the sadistic nun, the evil mad doctor, unethical experimentation, wrongful commitment, alien abduction, demonic possession, you name it — yet it still manages to be scary and stylish and suspenseful.

The episode about a poor soul possessed by the devil naturally includes an exorcism by Catholic priests. The afflicted boy becomes ugly and deformed by the demon, who spews out lewd words and exerts its supernatural telekinetic powers by throwing objects (and priests) across the room.

Regarding exorcism, the Catholic Encyclopedia says:

Exorcism is (1) the act of driving out, or warding off, demons, or evil spirits, from persons, places, or things, which are believed to be possessed or infested by them, or are liable to become victims or instruments of their malice; (2) the means employed for this purpose, especially the solemn and authoritative adjuration of the demon, in the name of God, or any of the higher power in which he is subject.

Religious belief in the existence of demons is a sincere part of the Catholic faith, so demonic possession can be a particularly frightening Hollywood trope for devout Catholics (and former Catholics). Walking out of the theater into the dark parking lot and entering your empty apartment after a midnight showing of The Exorcist can be creepy for the believer and the agnostic alike. Even if Satan isn't lurking in your shower, a serial killer like "Bloody Face" could be under your bed. Indoctrination into a belief system where devils are real can haunt a young child into adulthood.

In contrast, the rationalist perspective presents historical and medically-based views of possession phenomena in terms of epilepsy, schizophrenia, and possession trance disorder (PTD), a possible variant of dissociative identity disorder. Nothing evil or supernatural takes over the identity of the person with PTD. Nonetheless, exorcisms performed on mentally ill people continue to this day.

For example, Tajima-Pozo and colleagues (2011) reported on the case of a 28 yr old woman in Spain who had been diagnosed with paranoid schizophrenia. Over the course of 5 yrs she had been treated with the antipsychotic drugs clozapine, risperidone, ziprasidone and onlanzapine, without complete remission. She was an inpatient on a psychosis ward, and yet some diabolical priests managed to get in and convince her that she was possessed by demons. Some of the priests had knowledge of the patient's psychiatric history and should have known better. But they performed multiple exorcisms anyway, which disrupted her clinical treatment (1).

In DSM-IV, spirit possession falls under the category of Dissociative Disorder Not Otherwise Specified, with more specific research criteria (but not an official diagnosis) fitting Dissociative Trance Disorder (possession trance):

This category [DDNOS] is included for disorders in which the predominant feature is a dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific dissociative disorder.
. . . 

Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control. Possession trance involves replacement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person and associated with stereotyped involuntary movements or amnesia, and is perhaps the most common dissociative disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia), latah (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice.

Note the culture-specific aspect of the disorder, which shows substantial heterogeneity in its expression. Dr. Romeo Vitelli at the blog Providentia has written about some of these phenomena. For instance, Amok is an aggressive trance-like state in Malay culture, whereas Pibloktoq is an acute dissociative reaction in the Inuit tradition, caused by evil spirits possessing the living. In two previousposts here at The Neurocritic, we also learned about cen in Uganda, ghosts that replace the identity of the afflicted individual.

Dissociative Disorders in DSM-5

Will there be changes for Dissociative Trance Disorder (DTD) in DSM-5? The new (and already reviled) psychiatric manual makes its debut in May 2013 (2). A 2011 paper by Spiegel et al. described some of the proposed changes to the dissociative disorders. The Pathological Possession Trance (PPT) component of DTD is claimed to be be similar to dissociative identity disorder (DID, or the diagnosis formerly known as "multiple personality disorder"):

It is a disorder of identity alteration that occurs during an altered state of consciousness. Of course, unlike DID, the alternate identity or identities in PPT are attributed to possession (by an external spirit, power, deity, or other person) rather than to internal personality states. Associated symptoms of PPT include stereotyped or culturally determined behaviors or movements that are experienced as being controlled by the possessing agent and/or full or partial amnesia for the event.So pathological possession trance would be included under DID, while dissociative trance without possession would remain under dissociative disorders NOS. Or...

Alternatively, DSM-5 could (a) retain all of DTD in DDNOS (and an appendix), or (b) incorporate DTD (or only PPT) as a new disorder.

“Possession” is a broader construct than PPT because it may be used as a nonspecific attribution for explaining events (e.g. illness, misfortune) that go beyond pathological identity alteration. By contrast, in PPT we focus only on the subset of possession experiences–(1) an alteration of consciousness wherein the person experiences his/her the identity as being replaced by an ancestor, spirit, or other entity (i.e. possession trance), and (2) these alterations are involuntary, distressing, uncontrollable, often chronic, and involve conflict between the individual and his/her surrounding social or work milieu (i.e. the possession trance is a pathological one).

Ultimately, the recommendation was to include PPT under the DID umbrella. The phrase “an experience of possession” would be added to Criterion A of DID.

Kibuuka Kigaanira (R) with a priestly assistant.

Photo Courtesy of Euginia Bonabana, from The Sunday Monitor [Uganda]

Alternate activism: From Kibuuka Kigaanira in the mid-19th century to Kalondoozi in the present, possession practices provide important political space for citizens to negotiate power and authority, while appointed leaders are held to account. 

-from Spirit possession and power play since pre-colonial times

Pathological Possession Trance: Perspectives from Uganda

Previously, I wrote about Spirit Possession as a Trauma-Related Disorder in Uganda and quoted from a personal narrative of spirit possession from Christine, a former child soldier. How well will the new DSM-5 criteria fit cen phenomena in Northern Uganda? The diagnosis for possession trance would now be DID. However, a recent paper by van Duijl et al. (2012) suggests this might be a nosological disaster for the classification of spirit possession in Uganda.

In their study, the authors collected narratives from 119 spirit possessed individuals. They also developed a checklist for locally relevant dissociative and possession symptoms.

The CDS-Ug is a locally designed checklist based on information obtained in focus group discussions with traditional healers, religious leaders, health professionals, and people of the community. It covers common and typical symptoms of dissociation and spirit possession, including:

• Okukangarana: described as being shocked by a situation in such a way that later on one cannot remember the situation (amnesia)

• Okurogwa: described as talking in a different voice, which others recognize as the voice of an (ancestral) spirit (possession trance)

• Eibugane: feeling influenced by unidentified forcescausing behavior different from one’s usual behavior

• Okukyekyera: traveling outside one’s home without remembering (fugues or ‘night dances’)

• Okusharara: feeling as if something from outside holds one’s body or mind so that one cannot move, think, or speak, which is attributed to an outer force (feeling paralyzed)

• Okugwa: shaking of the head or body, seen as an expression of spirits (involuntary repetitive movements)

• Okugamba endimi: speaking in tongues (glossolalia)

• Okwehindura: making sounds and movements as if one has become an animal, for example, a cock, monkey, or goat, without remembering this behavior afterward (possession by animal)Spirit possessed patients were asked whether and how these eight features applied to themselves.

The data were analyzed to examine possible clusters of symptoms, merged with a checklist developed from the personal narratives, and then compared to the old DSM-IV DTD criteria and the new DSM-5 DID criteria.

Two distinctive clusters emerged (3). One cluster included shaking, stereotyped movements, and speaking in voices of spirits ("active symptoms"). The second cluster included amnesia, fugues, and feeling paralyzed ("passive symptoms"). The passive symptoms were a better fit with DID, but the active symptoms were more like DTD. Furthermore, many symptoms fell outside either diagnosis:

...experiences such as hearing voices (e.g., of spirits or deceased), strange dreams, feeling influenced or held by powers from outside, feeling paralyzed, or moving around in fugue-like states are not explicitly covered by the experimental DSM-IV research criteria nor by proposed criteria for DID in DSM-5.

Overall, the authors felt the DSM-IV experimental criteria for dissociative trance and possession trance disorders encompassed the experience of spirit possession to a greater extent than the DSM-5 DID criteria. They do not think possession trance disorder should be subsumed under dissociative identity disorder, nor do they think dissociative trance and possession trance should be separate categories, as they occurred on a continuum in this Ugandan population. Instead, a more culturally-inclusive mindset might have prevented some of the DSM-5 changes from moving forward.

Although the presentation of DID and PTD considerably overlaps and both are covered by the criteria outlined in Table 3, we are not in full support of this approach. Ranking PTD (described in over 360 societies) under DID (described in considerably fewer societies) expresses a Western ethnocentric approach. Ranking characteristic symptoms of PTD such as stereotyped uncontrolled movements as ‘non-epileptic seizures or other sensory-motor (functional neurological) symptoms’ in DSM-5 also heavily imposes a medical descriptive framework and disregards emic attributions. In addition to this, DID is strongly associated with early childhood sexual abuse and neglect, whereas stressors associated with PTD are more broadly framed and require a culturally sensitive approach. 

In DSM-5, Possession Trance Disorder no longer exists.

Footnotes

1 Besides being backwards and barbaric, exorcisms can be deadly, as this case of Fatal Hypernatraemia from Excessive Salt Ingestion During Exorcism shows. Ingestion of salt or salt water is part of the ritual.

2 If you want to know why it's already reviled, start here and follow links. Or Google DSM-5 controversy. I don't feel a need to offer my opinion at the present time.

3 These two clusters could account for ~46 % of the variance.

References

Duijl, M., Kleijn, W., & Jong, J. (2012). Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda. Social Psychiatry and Psychiatric Epidemiology DOI:10.1007/s00127-012-0635-1

Spiegel, D., Loewenstein, R., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., Cardeña, E., & Dell, P. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28 (9), 824-852 DOI:10.1002/da.20874

Tajima-Pozo, K., Zambrano-Enriquez, D., de Anta, L., Moron, M., Carrasco, J., Lopez-Ibor, J., & Diaz-Marsa, M. (2011). Practicing exorcism in schizophrenia Case Reports, 2011 (feb15 1) DOI:10.1136/bcr.10.2009.2350