Possession trance disorder

Possession Trance Disorder is characterized by recurrent or single and prolonged involuntary marked alteration in an individual’s state of consciousness involving a possession trance state. The distinctive feature of Possession Trance Disorder is that the individual’s normal sense of personal identity is replaced by an external ‘possessing’ identity attributed to the influence of a spirit, power, deity or other spiritual entity, which does not occur in Trance Disorder. In addition, in Possession Trance Disorder a greater range of more complex behaviours may be exhibited, which are experienced as being controlled by the possessing agent.

Most possession 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. Possession 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 and the individual’s normal sense of personal identity is replaced by an external ‘possessing’ identity. The trance state is characterized by behaviours or movements that are experienced as being controlled by the possessing agent.
• Trance episodes are attributed to the influence of an external ‘possessing’ spirit, power, deity or other spiritual entity.
• Trance episodes are recurrent or, if the diagnosis is based on a single episode, the episode has lasted for at least several days.
• The possession 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) or a Sleep-Wake Disorder.
• The symptoms result in significant distress or 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:

• Possession Trance Disorder tends to involve recurrent episodes, rather than a persistent possession trance state. To qualify for a diagnosis, a single, persistent possession trance state must last for at least several days.
• Possession Trance Disorder is usually characterized by full or partial amnesia for the trance episode.
• During possession trance states, the activities performed are often relatively complex (e.g., coherent conversations, characteristic gestures, facial expressions, specific verbalizations that are frequently culturally accepted as belonging to a particular possessing agent). These behaviours or movements are often stereotyped and may reflect cultural influences.
• Presumed possessing agents in Possession Trance Disorder are usually spiritual in nature (e.g., spirits of the dead, gods, demons, or other spiritual entities) and are often experienced as making demands or expressing animosity.

Boundary with Normality (Threshold):

• A diagnosis of Possession 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) possession 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 Possession Trance Disorder.

Course Features:

• Prevalence of Possession Trance Disorder is highest among young adults, with a mean age at onset of between 20 and 25 years.
• The long-term course of Possession Trance Disorders 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. Episodes of possession trance usually take longer to resolve, with many shifts over days or even weeks in and out of trance states.
• 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 or possession 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 Possession 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.
• Possession trance states are often characterized by involuntary motor movements, glossolalia, auditory hallucinations or amnesia. Possession trance states in which the individual’s sense of identity is replaced are often preceded by a phase of other, more passive dissociative experiences (e.g., feeling influenced by forces or spirits from the outside, hearing voices, being unable to speak).

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 Possession 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 Possession 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 Possession 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 Possession Trance Disorder appears to be comparable among males and females.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with 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 Dissociative Identity Disorder and Partial Dissociative Identity Disorder: Possession Trance Disorder involves a marked alteration in the individual’s normal sense of personal identity that is attributed to an external possessing agent. This is distinguished from Dissociative Identity Disorder and Partial Dissociative Identity Disorder, which are characterized by the experience of two or more distinct, alternate personality states that are not attributed to an external possessing agent. Individuals describing both internally and externally attributed alternate identities should receive a diagnosis of Dissociative Identity Disorder or Partial Dissociative Identity Disorder. In this situation, an additional diagnosis of Possession Trance Disorder should not be assigned.
• Boundary with other Dissociative Disorders: A variety of dissociative symptoms may occur as a part of Possession 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 possession trance state. Symptoms that persist after the possession trance state has ended may be considered as a basis for a co-occurring diagnosis of the corresponding Dissociative Disorder.
• Boundary with Schizophrenia or Other Primary Psychotic Disorders: Intrusive symptoms of Possession Trance Disorder such as hearing voices, insertion of feelings and thoughts, or exhibiting behaviours attributed to the possessing agent are distinguished from symptoms of Schizophrenia or Other Primary Psychotic Disorders because they occur primarily during the possession trance state and are usually of brief duration. Possession Trance Disorder is also distinguished from Schizophrenia and Schizoaffective Disorder by the absence of other types of positive psychotic symptoms or of negative symptoms.