Trance disorder

Trance Disorder is characterized by recurrent or single and prolonged involuntary marked alteration in an individual’s state of consciousness involving a trance state (without possession). Trance Disorder typically involves the repetition of a small repertoire of behaviours.

Most trance states are brief and transitory and are related to cultural and religious experiences. These experiences are not considered pathological and a diagnosis should not be assigned based on their occurrence. Trance states should only be considered to be features of a mental disorder when they are involuntary and unwanted, not accepted as a part of a collective cultural or religious practice, and result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

Essential Features:

• Occurrence of a trance state in which there is a marked alteration in the individual’s state of consciousness or a loss of the individual’s normal sense of personal identity, characterized by both of the following:
• Narrowing of awareness of immediate surroundings or unusually narrow and selective focusing on specific environmental stimuli; and
• Restriction of movements, postures, and speech to repetition of a small repertoire that is experienced as being outside of one’s control.
• The trance state is not characterized by the experience of being replaced by an alternate identity.
• Trance episodes are recurrent or, if the diagnosis is based on a single episode, the episode has lasted for at least several days.
• The trance state is involuntary and unwanted and is not accepted as a part of a collective cultural or religious practice.
• The symptoms are not due to the effects of a substance or medication on the central nervous system (including withdrawal effects), exhaustion, or to hypnagogic or hypnopompic states, and are not due to a Disease of the Nervous System (e.g., complex partial seizures), head trauma, or a Sleep-Wake Disorder.
• The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Trance Disorder tends to involve recurrent episodes, rather than a persistent trance state. To qualify for a diagnosis, a single, persistent trance state must last for at least several days.
• Full or partial amnesia may occur in Trance Disorder.
• The actions performed during a trance state (e.g., staring, falling), are generally not complex.

Boundary with Normality (Threshold):

• A diagnosis of Trance Disorder should not be applied to experiences that are accepted in the individual’s context as collective cultural phenomena or as a part of religious practices. Moreover, the diagnoses should not be applied to trance episodes when these do not result in significant distress or impairment in functioning.
• Single and transitory (minutes to hours) trance experiences that are mildly distressing or impairing may occur under stressful circumstances, especially in the context of preexisting Mood Disorders or Anxiety or Fear-Related Disorders. These single, transitory states are not a sufficient basis for a diagnosis of Trance Disorder.

Course Features:

• Prevalence of Trance Disorder is highest among young adults, with a mean age at onset of between 20 and 25 years.
• The long-term course of Trance Disorder is variable, ranging from a single prolonged episode to multiple recurrences over years.
• Duration and intensity of trance episodes vary considerably. Most recurrent episodes are brief, and individuals may fall in and out of trance states multiple times within a given episode.
• Acute recurrent episodes of trance usually last minutes to hours and are followed by a period of exhaustion.
• Trance states can be evoked by significant emotional stress, anger or enhanced frustration. Domestic disharmony, war-related trauma and interpersonal conflicts related to religious or cultural issues have also been shown to play a significant role in the precipitation of trance states.
• Trance states can occur in clusters (i.e., multiple cases taking place in close temporal and/or spatial proximity) and may be associated with mass suggestibility.
• Individuals with prior exposure to trance states or who are spiritual healers are at higher risk of developing involuntary trance states themselves, outside of culturally sanctioned rituals.
• Patients with Trance Disorder often report prodromal symptoms. Somatic complaints as well as a sense of presence (i.e., feeling that one is not alone) are common. However, presence or absence of prodromal symptoms does not predict the number of trance episodes.

Developmental Presentations:

• Trance-like states may manifest in children in various ways, including vacant staring or loudly talking to themselves in different voices.
• Adolescents characterized by nervousness, excitability and emotional instability are more likely to develop trance states.

Cultural Presentations:

• Episodes of Trance Disorder have been documented in a wide range of cultures. Prevalence may increase as part of a collective (mass) response to traumatic events affecting an entire community, such as a measles epidemic. Increases in prevalence have also been attributed to rapid social or cultural change in the affected communities, possibly as an expression of distress and opposition to changing values and circumstances.
• Specific local instances of Trance Disorder show considerable variation cross-culturally regarding the behaviours during the altered state, the presence of dissociative sensory and motor alterations, and the identity assumed during these states. The identities of the possessing agents typically correspond to figures from the religious traditions in the society.
• Some individuals with Trance Disorder may gradually develop control and acceptance of the trance experience based on participation in religious or cultural groups where these possession trance experiences are normative. Over time, these individuals do not have a higher prevalence of mental disorders than in the general population.

Sex- and/or Gender-Related Features:

• The prevalence of Trance Disorder appears to be comparable among males and females.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Possession Trance Disorder: Both Trance Disorder and Possession Trance Disorder involve marked alterations in the individual’s state of consciousness and loss of the individual’s normal sense of personal identity. In Possession Trance Disorder, the individual’s normal sense of personal identity is experienced as being replaced by an external ‘possessing’ spirit, power, deity or other spiritual entity, which is not the case in Trance Disorder. Possession trance states often include more complex activities (e.g., coherent conversations, characteristic gestures, facial expressions, specific verbalizations) than are typical of trance states, which tend to involve less complex activities (e.g., staring, falling).
• Boundary with other Dissociative Disorders: A variety of dissociative symptoms may occur as a part of Trance Disorder, including dissociative amnesia, sensory or motor symptoms, depersonalization, and derealization. However, these should not be considered as a basis for a separate diagnosis of an additional Dissociative Disorder when they occur solely during the trance or possession trance state. Symptoms that persist after the trance or possession trance state has ended may be considered as a basis for a co-occurring diagnosis of the corresponding Dissociative Disorder.
• Boundary with Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder: Post-Traumatic Stress Disorder and Complex Post-Traumatic Stress Disorder may include flashbacks or other dissociative trance-like states characterized by narrowing of awareness of immediate surroundings and re-experiencing of the traumatic experience as though it were happening again in the here and now. These episodes are generally not experienced as under the person’s voluntary control. If trance-like states are limited to episodes of re-experiencing in the context of Post-Traumatic Stress Disorder or Complex Post-Traumatic Stress Disorder, an additional diagnosis of Trance Disorder should not be assigned.
• Boundary with Delirium: Delirium and Trance Disorder may both present with transient and marked alteration in the individual’s state of consciousness, but Delirium typically presents as significant confusion or global cognitive impairment. In contrast, Trance Disorder is characterized by a loss of a normal sense of personal identity, narrowing of awareness, and restriction of behaviour. Unlike Trance Disorder, Delirium is typically attributable to the direct physiological effects of a medical condition and/or a substance or medication, including withdrawal.
• Boundary with Epilepsy: Individuals with Trance Disorder may exhibit features resembling focal unaware (partial complex) seizures, but have normal EEGs even during trance episodes.