By Dr. Gamini Jayasinghe,MBBS, MSc, PhD Reading
Introduction and classification-
Dissociation has been described in psychiatric literature as early as 1815. Before the publication of the fourth edition (DSM-IV) of diagnostic and statistical manual of mental disorders in 1994, the condition was known as multiple personality disorder. The name was changed to address both misconceptions regarding the nature of the disorder and the clinical transition from a rare to a more commonplace diagnosis. Pathological possession trance (PPT) was formally known as dissociative trance disorder in the DSM psychiatric manual and currently PPT is included within the dissociative identity disorder (DID) criteria in the DSM-IV. Psychiatric diagnosis of DID has been under serious scrutiny for more than 10 years. Dissociative identity disorder( DID) is the most complex of dissociative identity disorder (American psychiatric association,1994 ).
Possession and trance disorder or pathological possession trance is characterized by a transient alteration in identity and one’s normal identity is temporarily replaced or possessed by a spirit, ghost, deity, or other person. This condition is associated with stereotype involuntary movements or amnesia. Why I interest for this disorder is one of the most common dissociative disorders in Asia. The important fact is PPT covers only the involuntary possession experience.
These patients experienced wide range of dissociative symptoms including made or intrusive feeling, loss of control of action, loss of awareness of surrounding, insensitivity to pain, inability to speak or move, and loss of personal identity. At the same time it must include “experience of possession”, amnesia and clinically significant distress and / or functional impairment. When we considering the latest update of ICD (ICD-11 Beta) trance and possession disorder and dissociative identity disorder (formerly multiple personality disorder) are classified in different sub category of dissociative disorder. Here trance and possession disorder is characterized by a temporary loss of both the sense of personal identity and full awareness of the surrounding. These individuals also act as they are taken over by a spirit, deity, other person or force. Attention and awareness may be limited to or concentration upon only one or two aspects of the immediate environment. Same as DSM religious or other culturally accepted situation should be excluded before the diagnosis of trance and possession disorder.
The theory of structural dissociation of the personality (TSDP) proposes that dissociative identity disorder (DID) patients are fixed in traumatic memories as “emotional parts” (EP), but mentally avoid these as “apparently normal parts” (APN) of the personality. In TSPD, personality is understood as a biopsychosocial system, and dissociative parts as subsystems of this whole system. Van der Hart et al. (2006) proposes a distinction between “Emotional Parts” and “Apparently Normal Parts” (ANP) of the personality. DID involves more than one part of EP and more than one part of ANP as well as switching between these dissociative parts is a major characteristic of DID.
Considering the theory of theory of structural dissociation of the personality (TSDP) (Nijenhuis et al., 2002; Van der Hart et al., 2006), DID is severe form of posttraumatic stress disorder (PTSD) encompassing different types of dissociative parts of the personality. EP is fixed in traumatic memories and also ANP may associated with degree of amnesia of these patents with DID. STSPD distinguishes different prototypical subtypes of EP (Nijenhuis and Den Boer, 2009). Severe and chronic dissociative symptoms tend to develop in the context of severe and chronic childhood traumatization, which include profound attachment disruptions (Dalenberg et al., 2012 ; Nijenhuis and Den Boer, 2009; Nijenhuis et al.,2002). EP demonstrated strong psychophysiological reactions to the trauma script, and also was psychobiologically aroused.
ANP showed a brain activation pattern similar to patients with depersonalization disorder ( Simeon et al., 2000 ) and also PTSD patients with negative dissociative symptoms to trauma- related stimuli (Lanius et al., 2002).
DID is caused by high fantasy proneness, role-playing, suggestibility, and iatrogenic suggestions (Giesbrecht et al.,2008 ; Merckelbach and Muris,2001 ) . There are few suggestions would suffice to generate dissociative parts in suggestible, fantasy prone individuals (Spanos, 1996) but recent functional brain imagine study is not accepting the fantasy proneness. DID patients are fixed in traumatic memories and demonstrate unusually strong cortical, sub cortical and vegetative reactions (eg. Hyper arousal) to reminders of traumatic experiences.
Memory is assessed unconsciously is also called implicit memory. It represents increase amount of memories and humans use it when they decide how to act. Neuroscientists believe that the 5% of the actions are controlled over consciously. This ability to function “unconsciously “or automatically has a great deal to do with what happen to people in trance state or state of “altered” consciousness such as possession.
The main features of the dissociative disorders are a disruption in the usually intergraded function of consciousness, memory, identity, or perception of the environment. Their clinical disturbances may be sudden, gradual, transient or chronic. DID is characterized by the two or more distinct identities, or personality states. These identities take control over and individuals’ behavior and also difficulty to recall personal information. This condition is not due to ordinary forgetfulness. At the same time these disturbances cannot be due to direct physiological effect of a substance or general medical condition and amnesia or memory gaps are frequent in the personal history. The condition may associated with self mutilation, aggressiveness, and suicidal and conversion symptoms (eg.pseudoseizures ).
Men with DID may show frequent antisocial traits or infrequent in seeking treatment. The other interesting fact that whether, DID patients is freely identified in prison population than clinical population. Their common neurological symptomatic presentation is headache and most of the time not responds to treatment. Unexplained physical symptoms (nausea, abdominal pain, pelvic pain) are found in about a third of patients (Putnam et al., 1986)
Despite the effective diagnosis and treatment of psychiatric illnesses, recent studies have identified the increase number of natural deaths in psychiatric patients. At the same time excessively high numbers of unnatural deaths are occurred due to suicides, homicides and accidents. Studies have suggested that, the rate of suicide in patients with psychiatric illness had fifteen times and five times of homicide compare to normal population. Suicides contribute to excess mortality in patients with psychiatric illness and complete suicides occur in young ages.
The study identified the ratio of suicidality between psychiatric patients and general population was 5:1. Although, suicide can range from ten 10 to 15% in different psychiatric illnesses, but it is not easy to predict exactly which patients will attempt or suicide. This may be due to serious undetected physical illnesses comorbid with these patients (Rose et al., 1991). Thus due to comorbid conditions, statistical measures are underwriting the group of patients with DID they would be categorize as very high mortality risk ( Von Braunsberg , 1994 ).
Dissociative identity disorder (DID) has been diagnosed more frequently in recent years but because of comorbidity , the underwriting risk must be evaluated so that to decide morbidity and mortality. DID is often coexist with other diagnosis such as bipolar affective disorder, psychotic disorder, major depression, past traumatic stress disorder, anxiety disorder somatization and personality disorders. At the same time high incidence of substance abuse and eating disorders are coexists with DID.
Treatment for stable patients, range from two to three years psychotherapy and up to six years for complex patients. Axis II disorder and comorbidity increase the period of treatment. At times hospital admission and inward patient care may need for comorbidity with DID (eg. Depression, Anxiety disorders). Being a prolong period of treatment, lack of satisfactory treatment can lead to consequences in their occupation. They spent average 98 months before the diagnosis and also average 32 months care after the diagnosis.
psychological, social, financial, cultural and religious factors influencing lack of western psychiatric treatment seeking behavior for Trance and possession disorder
Considering the evidence, majority of the people have accepted this experience as cultural phenomenon in people than considering as psychiatric with illness. Spiegel et al.(2011) states that already noted identities are shaped by posttraumatic, developmental, intrafamilial, psychosocial, interpersonal and cultural substrates. Dissociative trance disorder is a widespread disorder that can be understood as a result of distress. . Though possession is common experience in many cultures, it not much common in western industrialized cultures. This disorder probably undiagnosed in western countries due to cultural biases.
Accurate diagnosis and appropriate management should result from a comprehensive evaluation of sociocultural and idiosyncratic issues. There are different types of alternate identities can be identified in PPT specially represent supernatural agents, typically the spirit of dead person, or a culturally accepted spirit, demon, god, animal, or mythical figure. At times same spirit may possess different family members in many generations and also different areas in same generation. The interesting fact that in the more sociocentric Eastern cultures, dissociative identities take the form of a member of community but in the more individually focused western cultures , the dissociation involves a variety of internal individual identities (Spiegel et al.(2011). According to the cultural belief system there are different meaning for being possessed by person, god, demon, animal or inanimate objects.
Many trance or possession trance states have occurred within the context of religious experience (eg. ritual ceremonies ) but the disorder is not a normal part of a broadly accepted cultural or religious practice. Though many geographical regions the condition named in differently (eg. Bebainand at Indonesia and pibloktoq at arctic ). Especially possession is used in India and Sri Lanka.
The concept of spirit possession exists in many religions including Christianity, Buddhism, Haitian Vodou, Wicca, Hinduism, Islam, southeast Asian and African traditions. Even though behavioral manifestations differ widely in various trance states, commonly accepted idea is their body has been entered and control over by a demon. Possession trance involves acceptance of distinct alternative identity including deity, an ancestor, or a spirit but dissociative trance phenomena is characterized by a sudden alteration in consciousness but difficulty to recognize distinct alternative identities. This disorder is managed mainly by traditional healers due to lack of awareness and understanding about the problem.
Global research evidence of trance and possession disorder
The possession disorder is probably more common than is usually thought. I think one of the main problems is lack of precise clinical data and research evidence. Evidence suggest that these patients may have been treated up to 7 years before an appropriate diagnosis.
The single most common presenting symptom in DID is depression (Anderson et al., 1993). Research found that depression in 88% of the cases, and about 75% reported mood swings in DID patients. (Putman, 1989). Study subjects presenting for obsessive compulsive disorder, 20% presented with dissociative symptoms (Goff et al., 1992). DID has been associated with phobic anxiety ( Ellason et al., 1997 ).
Most of the DID patients reported severe physical and sexual abuse in their childhood. The survey reported that 97% of DID patients claimed their childhood trauma as well as 68% reporting incest (Putnam et al., 1986). Ross et al., 1991 found that a 95% incidence of physical and/ or sexual abuse and also two third of surveys reported that combination of physical and sexual abuse contribute to DID. The survey of 51 sexual abusers reported that 94% had depression, 65% had substance abuse history, and 55% had DID (Anderson et al., 1993). Ross et al., 1995 suggested that trauma is a major etiological factor in all psychiatric disorders and DID is a part of a normal human response to severe chronic childhood trauma. Von Braunsberg, 1994 concluded that the experience of dissociation at the time of trauma is the most significant long-term predictor of for development of PTSD. Almost all people with dissociative experience associated with history of trauma.
Substance abuse is another frequent problem in DID patients. Rose and Norton,1995 found that 43% of a group of 100 subjects with substance abuse met criteria for a dissociative disorder, and of those, 14 met the criteria for DID.
Rose, 1995 found that 60% of substance abusers met criteria for dissociative disorders, including 18% with DID. Coons et al., 1988 found a 10% incidence of previously diagnosed eating disorders in a 50 patients with DID. Most of the people with DID come out with some sort of disrupted eating patterns (Levin et al., 1993). Considering psychotic disorders, higher percentage of DID patients reported auditory
and /or visual hallucinations. Ellason and Rose, 1997 noted that 24-50% of patients with dissociative disorder have been previously diagnosed and treated for schizophrenia.
Ross et al., 1991 found that patients with DID report a greater number of Schneideran first-rank symptoms than do schizophrenics. This suggests that Schneideran symptoms are more indicative of DID than schizophrenia. Fink and Golinkoff, 1990 found that persons with DID had a greater number of somatic symptoms , dissociative symptoms , prevalent major depression and frequent childhood trauma than patients diagnosed with schizophrenia.
Suicide is one of the most common presenting feature of DID. It consists of suicidal ideation as well as suicidal attempts. Ross and Norton, 1989 identified that 72% of subjects out of their 100 people who was diagnosed as DID had attempted suicide. Putnam et al., 1986 noted suicidality as a presenting symptom in nearly 70% out of 100 patients of DID. Studies have indicated that more than 50% of patients with DID have clinical features that meet the criteria for borderline personality disorder. Around 8.7% of the DID patients meet the criteria for borderline personality disorder (Ellason etal., 1996). Dell identified that identical personality pathology in DID and chronic PTSD patients. Ross and Norton study group, DID patients have engage in antisocial activities.
Ross et al., 1991 pointed out that both DID and borderline personality disorder and exist as comorbid condition. Common comorbid disorders of DID are substance misuse, eating disorders, sexual disorders, mood disorders, and anxiety (Ross et al., 1991). Complex and partial seizures (temporal lobe epilepsy)are listed in the DSM-IV as an exclusion criteria for DID. But, persons could have both disorders, and then it is controversial to differentiate without electroencephalogram. Kolk et al pointed out that close association between somatization and dissociation and PTSD.
Considering the prevalence of the disorder, Clinical studies have identified that 12-30% of psychiatric inpatients have a dissociative disorder and approximately 3-5% would be diagnosed with DID (Von Braunsberg, 1994). Using the semi structured interviews of randomly selected psychiatric inpatients, Rifkin et al., found an incidence rate of 1% for DID. Non clinical subjects, prevalence rates of 3.5-11% were found for dissociative and 0.5-1.3% were diagnosed with DID (Coons et al., 1988) .
Ross et al., 1991 found that prior to the MPD (or DID) diagnosis, patients average 2.74 other diagnosis, including 64% affective disorder, 57% personality disorder, 44% anxiety disorder , 40% schizophrenia and 31% substance abuse. Saxe et al., 1993 found that all the psychiatric in patients with DID have comorbid psychiatric illness. Almost all studies of DID have identified that the comorbidity with other mental and physical activities.
Evidence suggested that average number of lifetime comorbid Axis I disorder was 7.3 (SD-2.5) while the average number of Axis-II diagnosis was 3.6 (SD-2.5).these data did not include DID, post traumatic stress disorder, sleep disorder and psyhosexual disorders. Final conclusion regarding the average DID patients was that they meet the criteria for about 15 different DSM-IV disorders (Ross et al., 1995)
Herman and van Kolk et al., 1996 suggest that DID has to diagnosed as complicated post traumatic stress disorder, because it has clear association with early traumatic experiences. The Sidran foundation estimated that 80-100% of people out of 14 advocacy group with DID have secondary PTSD. Majority of DID patients meet the criteria PTSD and major depression. Approximately two third of this patients met the criteria for substance misuse behavior and borderline personality disorder.