THEDIFFEREl\TIALDIACl\OSIS OF

POSSESSIO:'.; STATES

Philip.\1. Coons, .\1.0.

Philip M. Coons, M.D., is Professor of Psychiatry at IndianaUnivcrsi ty Seh001 ofMedici ne and Staff PsychiatristatLarueD. Carter Memorial Hospital in Indianapolis, Indiana.

For reprints write Philip M. Coons, M.D., Larue D. CarterMemorial Hospital, 1315 West 10th Street, Indianapolis,Indiana 46202.

This paper is a revision of a paper initially presented at theMidwest Regional Meeting of the American Academy ofReligion, Indiana University, Bloomington, Indiana, April8,1989.

ABSTRACf

Although the literature contains numerous historical and contem­porary case reports ofpossession disorder, the possession syndromehas never been an officially aP/JToved !Js)'chiatnc diagnosis. Thispaper reviews these case repom and suggests a l)'P0wg)'for varioustypes ofpossession disorder. Possession disorder is contrasted withthe religious beliefofpossession and various t)1Jes of ritual trancepossession which are seen worldwide. Theps),cllOpll)'siology oftranceand dissociation will be discussed. Finally, the lCD-10 nosology andproposed DSM-IV classification for possession disorder will bereviewed.

INTRODucnON

Newcontemporaryn.'Viewson possession exist (Goodman,1988; Pattison & Win throb, 1981; Prins, 1992). Althoughthere are several small series ofcases (Ludwig, 1965; Peltzer,1989; Schcndel & Kourany, 1980; Suwanlert, 1976; Teja,Khanna, & Subrahmanyam, 1970), the largest series ofpos­session cases was described byYap (1960) and his paper remainsa classic. During a two-year period 50 women and 16 menexhibited signsofthe possession syndrome (i.e., either believ­ing that they were possessed or actually exhibiting anotherego state characteristic ofpossession) were admitted to HongKong Mental Hospital; this represented 2.4% ofall firstadmis­sions. Although their ages were not significantly differentfrom the general population, there was an overrepresenta­tion of widowed and divorced persons. Diagnoses includedhystcria (48%), schizophrenia (24%), depression (12%),and mania (6%). Thirty'"Cightexhibitedatleastsomedegreeofclouding ofconsciousness, skin anaesthesia, identity alter­ation, and amncsia. A follow-up of 41 cases revealed thatthose with hysteria and depression were well, but two-tllirds

of the schizophrenics remained symptomatic.Dissociative disorders, particularly th ose involvi ng ide n­

tily alteration such as multiple personality disorder (MPO)and one form of dissociative disorder not othenvise speci­fjed (DONOS), share several commonalities with possessionstates, particularly ritual trance possession. Both dissocia­tive disorders and ritual trance possession involved trance(Bliss, 1986) and altered identity formation (Bourguignon,1989). This altered identity formation is influenced by theindividual's use offantasy (Young, 1988) and societal expec­tations (Spanos, Weekes, & Bertrand, 1985).

The precise amount ofobserTer, treater, or participantexpectation, and even whether MI'O trulyexisls, are still hotlydebated subjecLS in leading psychiatricjournals on both sidesoftheAtlantic (Fraser, 1992; Martinez-Taboas, 1992; Mersky,, 992; Novello & Primavera, 1992). Likewise, the precise bound­ary between possession and dissociation is hotly debated aswell (Kirmeyer, 1992).

AJthough dissociative disorders and ritual trdnce pos­session stales share many superficial similarities, there aresome fundamental differences. For example, ritual trancepossession states, unlike the dissociative disorders, arc notviewed as illnesses, nor are curatives sought. In addition, notall ritual possession states involve the use oftrance, and notall mentaJ disorders involving the belief of possession arcdissociative in nature. These differences are further eluci­dated in subsequcnt sections of this paper.

TranceA discussion of possession would be incomplete with­

OUla rudiment.'lI)'discussion ofo-dnce, a phenomenon under'­lying both ritual trance possession and the dissociative dis­orders characterized by lhe prcsence ofalterego states. Tranceisan altered state ofconsciousness (Lud\vig, 1966; Tart, 1990).Trance-like states occur during meditation, religious ritual,automatic writing, brain-washing/interrobration, sensorydeprivation, day-dreaming, and mediumship, a nineteenthccntury phenomena, and channeling, its twentieth centurycounterpart.

Interestingly, the French and English have different con­ventions when speaking about trance. The English define"trance" as a sleep-like state with limited sensory and motorfunclion, while the French resen'e the term "extase~" forthis state. In English, ecstasy may refer 10 a state of religiousfelTor involving trembling, swooning, falling, jumping, run­ning, convulsing. There may even be an insensitivity to sur­roundings and Lhe occurrence of glossolalia or visual hal-

213DlS~{){ 1.\110:\. \ 0). I"I.~, Dmmbrr 1993

.....DIFFERENTIAL DIAGNOSIS OF POSSESSION STATES

lucimnions. It is this lauer state that the French refer to as"lransc" (Rougcl.. 1985).

Trance is commonly confused Wilh hypnosis, which isa t)-PC of trance induced in a subject as the result ofan inter­action with ahypnotisl. \\Then the hypnotislisamental healthprofessional. the hypnosis is lhcrapeulic in nature. The lennhypnosis is actuallya misnomer, since the subject is not asleep:the subject's electroencephalograph shows a relaxed wake­fulness.ln addition, the hypnosis isa state of both increasedconCCnlrdtion and suggestibility. During hypnosis alter­ations may occur in memory. mood. perception, idclllity,and motor function. Material generated through hypnosismay be contaminated by fantasy, confabulation, or lying.Persons cannot be hypnotized against their will, and it isdoubtful that they can be induced to do something againsttheir moral code. Susceptibility to hypnosis occurs along abell-shaped cUlVe among the general population.(Ludwig,1966; Spiegel & Spiegel, 1978; Tart, 1990).

BeliefAdiscussion ofpossession would also be incomplete with­

out mentioning the role of belief. Depending upon one'sbelief system, possession may have either a supematuralis­tic or naturalistic explanation. Although much of the sci­entific world does not accept the concept of possession b}'spirits, beliefin spirit possession still flourishes in nearlyeverysociety .....orld.....ide (Bourguignon, 1976). In America, thereis a polarization in beliefalxmt the existence of posse.ssionby spirits. For example. a pentecostal Christian might con­sider an ache or pain to be a manifestation of possession.....hich .....ould require delh'erance or exorcism. He or shcmight visit a minister first, .....hile an atheist might initiall}'consult with a ph~ician.

This polarization in beliefabout possession is mirroredby the polarization in beliefabout .....hether MPD really exists.Even within the therapeutic community treating dissocia­tivc disorders, there is a polarization in beliefabout the exactctiolob'r of dissociative disorders. For example, some clini­cians believe that ritual abuse is a causativc factor of severedissociation, while other clinicians think that ritual abuscdocs not literally exist and that patient reports ofsuch abusecan be explained by a number of psychodynamic explana­tions including auention-seeking behavior. defensive elab­oration, psychosis, screen memory, urban legend. errors ininterview style, mmorand mass h}'steria (Rogers. 1992). Thetherapeutic community is further divided by disagreementover proper therapeutic techniquc (Kluft. I988a) , the pre­cise incidence ofMPD (Kiuft, 1988b).the existence and/orimportallce of inner self helpers (Comstock, 1991). andwhether patients with MPD can be possessed b}' spirits(Bowman, this issue).

POSSESSION AND DISSOCIATION:NORMAL AND ABNORMAL

It is be}'ond tJle scope ofthis papcr to provide an exhaus­tivc rcvicw of possession and its differential diagnosis, par­ticularly with the othcr altercd states of consciousness and

214

dissociative disorders; for this, the reader is referred else­.....here (Ludwig, 1966; Pauison &Winthrob, 1981). The rcad­er should be aware, however. that there are different typesof possessioll and dissociation, that both phenomena occurworldwide in both spiritual and psychopathological contexts,and that these phcnomena can be either nonnal or abnor­mal. My purposc is to offer guidelines and prmide a fewexamples to help professionals understand the similaritiesand differences between possession and dissociation and beable to discern normal from abnormal.

DissociationDissociation occurs along a wide spectrum ranging from

normal to abnormal. Dissociation is a defense mechanism,which is usually rcsclVcd to help individuals cope with over­whelming trauma. Other more common forms of cverydaydissociation include absorption phenomena such as read­ingan engrossing ix>ok, \'Vatching an cnthralling movie, becom­ing immersed in work. engaging in meditation, or becolll­ing entranced in a fantasy. Abnormal forms of dissociationare called dissociative disorders and include depersonaliza­tion disorder, psychogenic amnesia. psychogenic fugue.DDNOS, and multiple personality disorder. As one movesalong this continuum. increasing changes in identity andamnesia occur. (Spiegel, 1991).

PossessionThe concept of possession is ancient. There are numer­

ous biblical refcrences to possession (Prins. 1992). CentralAsian shamans participate in ritual trance possession (Lewis,1971). Oesterreich's (1974) monumental work and Naegeli.Osjord's (1988) morccontcmporary\'olume provide numer­ous other examplcs. ''''hat is often misunderstood, howev­er, is that possession phenomena may be normal, and occuras an evel)day part of cultural or religious experience.

Anthropologist Erika Bourguignon has most eloqucnt­Iy described the phcllomenon of possession (1976). Thereare three types: nontranec possession belief, trance pos­session,and ritual possessioll.ln non trance possession belief,eithcr the individual or close obsen'ers believe that one ispossessed, usually by the dcvil or demons. In trance posses­sion an ahered state of consciousness. usually of a god orspirit, alternates with the indhidual's normal identity. In rit­ual possession, trance possession occurs within a rilual, usu­ally religious in nature.

Trance possession and ritual trance possession OCCllron a world\\ide basis and have been observed in 90% of437cultures in North and South America, Europe, Africa, Asia.and the Caribbean and Pacific Islands (Bourguignon. 1974).Furthermore, trance and possession states occur as part offormal religious practice in all oftJle world's major religions.

Ritual trance rna}' be associated with numerous metJl­ods of induction. including music and/or dmm bcating(Ravenscroft, 1965), dancing (Belo. 1960), spinning(Goodman, Hcnney & Pressel, 1982). chanting (Goodman,el ai, 1982). hypen'cntilation or hypo\'cntilation (Bcsmcr,1983),and drug lise (Furst &Coe, 1977). Duringsuch trancestates it is not uncommon to have helpers or guides who pro-

U1SS0Cl\TIO\. \01 \ I. I. O~(~llIber 1993

teet the tranccr-s from hurting themselves. Methods of ter­minating lfance possession include inhaling smoke, beingshakcl10rslapped (Goodman,claL, 1982),orbcingexposed10 noise. Usually, however, mcdiumssimplycomeolltoftrancethrough the use of suggestion.

Rituals have many functions (Wallace, 1966).Technological rituals control nature, as in rain-making rites.Therapy riles conITol health. Ideological rituals, such as ritesof passage, control individuals for the sake of the commu­nity. Salvation rituals, such as ritual possession or exorcism,repair damaged self esteem. Finally, revitalization rituals,such as religious revivals. ser.:c (0 create a bener cuhure.The belief in possession and exorcism scn'es more special­iled functions, including identifying and dramatizing unac­ceptable behavior, enabling social change to occur by i~lating disruptive influences, reunifYing devialll individualswith society when unacceptable behavior has ceased, recon­firming ofa group's beliefs, resolvingconOict, protecting ofthe community against disintegration, reenacting of deathor resurrection, and demonstrating that living beings havecontrol over the spiritual world (Pattison & Win throb, 1981;Prins, 1992; Ward, 1980; \Vard & Breabrun, 1980).

Nonpsychapalhological FOn/1$ ofPossession and Trona: PossessionPentecostalism. Pentecostalism is a branch ohhe protes­

lant holiness movement which emphasizes biblical literal­ism, emotional fervor, purilanical mores, and receiving theHolySpirit in an experience separate from conversion. Thecharismatic gifts of the Holy Spirit are strongly emphasized(Anderson. 1979). Trance states in pentecoslalism mayoccur with any of the following: medilation or prayer, glos­solalia or speaking in tongues, faith healing,coll\'ersion, snakeand fire handling, and exorcism rituals (Kane, 1974). E<:Slaticforms of trance characterized by clapping. stomping, leap­ing, running, climbing, falling, rolling, jerking, and danc­ing may occur.

Haitian Voodoo. There are literally thousands of rcfer­ences to possession and trance possession in Africa and Afro­America (Zaretsky & Shambaugh, 1978). A number of nice­Iy edited volumes describe such phenomena (Beattie &Middleton, 1969; Crapanzano & Garrison, 1977; Goodman,Helmy, & Pressel, 1982; Prince, 19(6). A rather well-knownexample of trance possession in Afro-America is Voodoo\'Ihich occurs on the Caribbean island ofHaiti (Ravenscroft,1965).

Voodoo is a combination of African polytheism,Catholicism, and European folklore which i~mlves the wor­ship of Loa, or gods and spirits, and the practice of blackmagic and sorcery. The religious hierarchy includes aHungan or priest, Lapas (male priest assistants), a HUIBenikon(fcmale chorus leader), and Hunsi (female chorus mem­ber). The remainder of the ceremonial participants includednLrnmers, dancers, and spectators, somc ofwhom engagein trance possession. During Voodoo ceremonies individu­als engage in rimal possession. This practice is a group phe­nomena and persons are socialized in its aspects beginningin early childhood.

COONS

Voodoo possession occurs in a religious context withthe group expectation that participants will enter trance.Trance is induced through repetith'e and monotonoussinging, dancing, and drumming. Trance quickly follows aninitial dizziness, disorientation, and los.sofbalance. The pos­sessing agent is usually a god or dead relative. Women arcpossessed more frequently than men. The duration oftrancemay last from a few minutes to a few hours. One-way amne­sia exists betwecn the individual and possessing spirit.

Brazilian Spiritism. Trance possession occurs amongdivcrse types of Brazilian spiritism. including Umbanda,Candomble, Kardecismo, Caboclo, Macumba, Xango,Batuque. and Casa das Minas. As in Haitian Voodoo, trancepossession occurs within a religious context with a groupexpectation that possession will occur. Trance is induced b}'drumm ing, dancing, and handclapping. The possessing agen tmay be a god, spirit, or a dead human being. Personalityalteration occurs and amnesia is usually experienced by thehosl. As in Voodoo. women are possessed more frequentlythan men. However, in contrast to Voodoo, individuals whobecome possessed are mediums who then engage in heal­ing rites with other ceremonial participants.

In the Brazilian form of spiritism known as Umbanda,adherents meet in an Umbanda center. In Sao Paulo alone,there areestimatcd to be 4,OOOsuch storefront centers (Pressel,1973). Individuals who come for spiritual help sit in the backOfSllCh cenlers,the men on one side and the women on theatller. Ritual activities lake place in the fronL There are usu­ally about 40 mediums, most of them women. The spiritswhich possess these mediums are of different types: caboc­los (stern spirits of dead Brazilian Indians), Preto vclhos(Gentle old spirits of dead Afro-Brazilian sla\'cs), criancas(playful spiritsofdead children) •exus and pomba-gir3s (wickedmale and female spirits), and orixias (godlike spirits). Theinteraction between the possesscd medium and her clientwho comes for social or psychological advice is the final resultof Umbanda ceremonies in which there is a marriagebetween religion and indigenous psychiatry.

Med.iumship and Channeling. Thespiritualist mo\'ementarose in nineteenth century America. This movementinmlvcd mediums who claimed the ability to communicatewi.th tlIe spirits of the dead (Wilson, 1987). Although a num­ber of these mediums undoubtedly hoaxed the public outof their hard-earned money by feigning trance and com­munication with the departed spirits oflo\'ed ones (Randi,1982), some of the mediums were thought to ha\'e enteredhypnotic-like trances and thei r com m1I nications with depart­ed spirits were undoubtedly dissociative in nature. TheSpiritualist Church, a remnant of the spiritualist movement,remains on thc fringes of today's society and nominal feesare charged for the services of one of their mediums(Goodman, 1988). Channeling. a revival of mediumship,has recently become popular, primarily in California (Klimo,1987) and channeling has become big business, with manywell-two followers. Atleasl some ofthe challnelersare repon­ed to be frauds. These channelersenter into lrance-l.ike pos-

215D1'iSOCL\T10\ \ol \ J. t Immbl'r 1993

•

DIFFERENTIAL DIAGNOSIS OF POSSESSION STATES

session states during which they give pseudomaturc adviceto their adhcrcn1.5. Nowadays occult sections in large bookstores are lined with volumes of such advice.

The trance states of mediums and channelers arc usu­ally induced by meditation and/or self-hypnosis. Possessingagents may include dead, reincarnated, orotherworldlyspir­iL~ who arc markedly different from the host personality.Amnesia mayor may not occur. The duration ofsuch a trancemay last from minutes to several hours.

Shamanism and Indigenous Medicine. Shamanism isdefined as the practice of healing in primitive societies viathe use of magico-religious powers (Kiev, 1964). In manyinstances the shaman will enter a sL.1.te of trance possessionfrom which he works his healing powers. Although the Shamanoriginated in Asia, today shamans or indigenous healers prac­tice worldwide. Indigenous healers go by many names(Torrey, 1986). Among NorthAmerican Indians he is knownas the "medicine man ~ and among various African tribes heis known as the "witch doctor." In Siberia he is the "shaman."In Latin America and the Caribbean she is the "curandero"or medium. In the Middle East he is the "marabouL" Thefunctions of indigenous healers are to treat physical andmental illness, give religious or political advice, exorcise evilspirits, cast hexes, control nature, and preside over publicceremonies. According toJerome Frank (1961) these formsof nonmedical healing occur between a suffering individu­al and healer. Through their interaction, hope is evoked insufferers and self esteem is bolstered.

Psych(}jJathological Forms ofPossessioo and DissociatiooMultiple Personality Disorder. For the sake of brevity,

only one ofthe DSM-JlJ-R (American Psychiatric Association,1987) dissociative disorders, multiple personality disorder(M!'D), will be described here. ExcellentdescriptionsofMPDand the other dissociative disorders are found elsewhere.(Kluft, 1988b; Putnam, 1989; Spiegel, 1991).

r-.fPD is a mental disorder characterized by the presenceoft".-o or more personalities or personality sL.1. tes which recur­rently take control of the individual's behavior. This disor­der serves as an adaptive coping mechanism to severe child­hood trauma, usually prolonged and severe child abuse.Amnesia is present between some of the personality states.Onset is thought to occur in childhood, although MPD doesnot usually manifest itself in its most blatant form until thelate teens or early 20's. Emotional stress causes the host per­sonality state to svvitch into one of its alters; there usually islittle voluntary control of switching early in the course ofthe illness. These alter personality states may be quite dis­crepant in age, gender, mood, demeanor, and behavior.Although the mean number of personality states is 13(Putnam, Guroff, Silberman, Barban, & Post, 1986), it mayrange from 2 to more than 50. In psychiatric settings MPDis more common among women. MP[) is a polysymptomat­ic disorder because oftlle large number ofdepressive, somat­ic, posttraumatic, and dissociative symptoms that are pre­scnt (Loewenstein, 1991). At times other personality statesarc experienced through the perception of inner voices.

216

Amnesia, or lost periods of time, may last anywhere from afew minutes to several hours, or sometimes even longer.

Demon Possession. Demon possession (Montgomery,1976),which occursamong conservative and/or charismaticgroups of both protestants and Catholics, is a direct coun­terpart to other forms oftrance possession including Voodooand various types of Brazilian spiritism described previous­Iy. However, unlike these other forms of trance possession,this form of possession is not desired by the possessed indi­vidual, minister, and other adherents to the faith. I suspectthat the unwanted nature ofpossession may be partlya resultof the marked polarity in Christianity between manifesta­tions of good and evil.

Like its counterparL~ in the Caribbean and SouthAmerica, demon possession includes one or more possess­ing spirits. Those who are possessed may be amnesic for thetime when the possessing spirit is in executive control. As inMPD, possessions usually occur during times of emotionaldistress and may last anywhere from a few minutes to a fewhours. The possessing agent is usually quite different fromthe individual's usual self. These visitations are involuntaryand do not occur in the context of a ritual. Complex ritu­alistic exorcism rites may be used by ministers or priests toride the individual of demons. (Montgomery, 1976).

Richards (1974) developed diagnostic criteriafor demonpossession. The first criterion consistsofpersonalitychangesinvolving appearance, character, demeanor, and intelligence.The second is comprised of physical changes includingincreasedstrengtll, convulsions, catatonia, catalepsy, and atlaes­thesia. The third encompasses diverse behavior such as glos­solalia, clairvoyance, and telepathy. The fourth includes spir­itual changes of a violent reaction and/or fear of Christ orprayer on the part of the possessing demon.

Trance Possession Disorder. Trance possession disor­der, listed in the lCD-Wand being considered for inclusionin the DSM-N, occurs worldwide. Most such cases would cur­rently fall under the rubric of DDNOS. The literature con­tains numerous examples of this disorder (Cramer, 1980;Freed & Freed, 1964; Galvin & Ludwig, 1961; Peltzer, 1989;Suwanlert, 1976). Both the lCD-Wand proposed DSM-IVdiag­nostic criteria for this disorder are described later in thispaper. Cases of mass trance possession of the dissociativetype have also been described (Suryani &Jensen, 1992).

DelusionsofPossession. Although not an ofliciallyaccept­ed diagnosis, the symptom of delusional possession is notuncommon. VVhcn the movie, The Exorcist, was released, anumber of patients developed the delusion that they werepossessed. Currelllly, those having such delusions would beclassified under a variety ofdiagnoses depending upon spe­cific symptomatology; these diagnoses include schizophre­nia,'briefpsycbosis, delusional disorder, and major depres­sion with psychosis. Arnold Ludwig (1965) has described anumber of such cases in adults and Schendel and Kourany(1980) described five cases in children in which they con­sidered the child and parent to have a variant offolie adeux.

mssoclmo~.\01 \"1.4. Occemllrr 1993

Culture-Bound Psychiatric Disturbances. BOlh Lebra(1976) and Simonsand Hughes (1985) have publishedexcel­lenl edited volumes on culture-bound syndromes. so thesepsychiatric disorders will not be described in detail. A cul­ture-bound syndrome is a psychiatric disorder which occursin some, but not all, cultures. and iLS differential distribu­tion depends on ps)'chosocial factors specific 10 a particularculture. It is not due to an accident of geography, nor is ita disorder occurring in different regions of t.he world andmerely ha\1ng different labclsAn exampleofa culture-boundsyndrome i.s amok. which occurs almost exclusively amongmen in Malaysia. During an attack. the individual enters anunprovoked r.rngc, runs madly about, indiscriminately killingothers. The individual is amnesic for the attack and oftencommits suicide. Anotherexample is piblokto which occursamong Alaskan wOillen and is characterized by attacks ofrunning wildly about and tearing off one's clothing. Theindividual may feel possessed, imitatc animal noiscs, and isusually amnesic for thc auack. A final cxamplc is whitigo,which is confined to the Cree and Ojibwa Indians of NorthAmerica. This illness is charactcrizcd by a delusion of beinglrdnsformed into a monster. It has been proposed that thedissociative types of culture-bound syndromes be classifiedunder DDNOS in thc DSM-IV.

PSYCHOPHYSIOLOGICAL ASPECTS OFPOSSESSION AND DISSOCIATION

Lex (1975-76) and Ervin, ralmour, Murphy, Prince. andSimons (1988) havc studied tJ1e psychophysiology of pos­session trance. Lex speculates that the right cerebral hemi­sphere operates LO control the autonomic nCPo'OlIS systemthrough a ~tuning~ process which ultimatcly rcsults in achron­ically activated altered state of consciousness. En>in and hiscolleagues actually studied experienced lrancers during thefestival ofThai pusam in Malaysia. These trancers are adeptaf. impaling themselves with sharp objects during trance pos­session. The investigators found Ihat f.rance onset was char­acterized by increased muscle lOne, tremor, and pupillarydilmion consistent with sympmhetic aCli\~<l.tion.\Vhen tranceswere tcrminated, there was an abrupt hypotonia, uncon­sciousness, areOexia, and slowed pulse. Further recovery \,,'asfollowed by headache and confusion as ifin a postictal state.Measurement of urinary metabolites showed decreasedendorphin-like immunoreactivity over the se\'eral days ofthe festival. They concluded that the limbic system, morcparticularly the centnl.l opiate mechanism, was involved inthis particular form oft.rnnce possession aAd speculate thata special state of neurocndocrine function may underlie awide variety of trance states.

NOSOLOGICAL ISSUES

The five majordissociati\'e disorders -MPD, psychogenicamncsia and fugue, depersonalization disorder, and DDNOS- have bcen official ps}'chiatric diagnoses since 1980.Refinementsin description ha\"e been suggested forthe DSM­11'(American Psychiatric Association, 1991). Several new dis-

COONS

sociative disorder diagnoses have been suggested includingtrance possession disorder. whose diagnostic criteria arc asfollows:

MA. Either (1) or (2):

(1) trance, i.e., temporary alteration in the state ofconsciousness, as e\'idencedby two of the fol­lowing:(a) loss of customary sense of personal

identity(b) narrowing of awareness of personal

surroundings. or unusuall)' narrow andselectivc focusing on el1\>ironmentalstimuli

(c) stereotyped behaviors or movemellls thatarc experienced as being beyond one'scontrol

(2) possession, i.e., conviction that the individualhas been taken over by a spirit. power, deity, orother person

B. The trance or possession state is not authorized asa normal part of a collecti\'e culrural or religiouspracticc.

C. The trance or possession slate causes significantimpairmcllt in social or occupationalfunctioning, or causes marked distress.

D. NOI occllrringexciusivclyduring the course ofa psychotic disorder (including Mood Disorder WithPsychotic Features and Brief ReaClive Psychosis) orMultiple Personalily Disorder, and is not due to aSubstance-Induced Disorder (e.g., SubstanceIn LOxicalion) ora Secondary Dissociative Disorder. ~

Whelher or not trance and possession disorder will beaccepted by lhe AI'A as an official psychiatric diagnosis is amaller of intense debate. Official acceptance would provideconformity with the position taken in the InternationalClassification of Diseases (IQ)-/O) described below as well asstimulate further research.

A similar group ofdisorders, trance and possession dis­orders, have been added 10 the ICD-JO (World HealthOrganization. 1992). In tJlis group of disorders tJlere is atemporary loss of idelllity and a\\~drenessand the indi\'idu­al may appear to be takcll over by another personality or aspirit or deity. These disorders are limited to those that areinvoluntary and unwanted and occur outside of acceptedreligious or cuhur-II experiences. Excluded are psychoses.MPD, substance-induced disorders and temporallobeepilep­sy. This new classification lakes into consideration the size­able number ofdissociative disorder diagnoses which occurin nonindustrialized nations and have been previousl}'diag­nosed as atypical dissociative disorder or DDNOS (C<xlns.Bowman, Kluft, & Milstein, 1991).

217DlSSOCl\TIO\. \01 \1. to Dmnbrr 1"1

DIFFERENTIAL DIAGNOSIS OF POSSESSION STATES

TABLE ICross-Cultural Comp'1irson of TrdllCC Slates

PentecostalTr.mce States

VoodooPossession

MultiplePersonalityDisonler

Age or Onset Teens Tecns-20s Childhood

IndUClion Meditation or Singing Drumming & Dancing Emodona! Stress

Voluntary Yes Yes NoDuration Minutes Minutes-Hours Minutes-Hours

Possesing Agent Holy Spirit Gods/Dead Alter Personalities

Number of Aller Egos NA 3 (2-60+) 13 (1-50+)

Sex differclllial No Yes Ve,Nature Spiritual Spiritual Menlal Disorder

Ritual Ve, Ve, No

Leader Minister Hungan (Therapist)

Demon Braxilian MediumshipPossession Spiritism Channeling

Age of Onset Teens-20s 20s-30s 20s-30s

Induction Emotional Stress Drumming & Dancing Self-Induced

Voluntary No Yes Yes

DuraLion Minutes-Hours Minutes-Hours Minutes-Hours

Possessing Agent Demons God/Spirits/Dead Spirits/Dead

Number of Alter Egos 2 (2-20+) 2 (3-5+) 2 (2-10+)

Sex differential No Ve, NoNature Spiritual Disordcr Spiritual Magic/Occult

Ritual 0 Ve, '0

Leader (Pricst) Mcdium Ghanneler

DISCUSSION AND CONCLUSIONS

l'ossession states. dissociative disorders. hypnosis, andothcr forms of trance havc much in common. Changes inspecch, posture, facies attitude, mood, bchavior, identity,and mcmory may be observed in all of thesc statcs and arccommon manifestations of trance. The physiological man-

218

ifestations of these various forms of trance ha\'c nOI becnextcnsi\'cly studicd. but many similarities are expected.There may be psychoneuroendocrinological differences. how­ever, between the two major forms of trance. hypnotic andecstatic.

Table I comparcs the major forms of ITance revicwedin this paper. Thc differences between these types oftrancc

mSSOC1\T10\. \01 \ 1. t l>tctmbn 1993

staleS occur mainly between culturallyacccptcd trance statesand psrchop,nhological types. Ward (1980) has bcsldescribcdthe differences which occur benvccn culturally accepted rit­ual possession and the dissociative disorders. Ritual posses­sion is induced volullt.arily in a ceremonial setling, is sup­ported b)'cultural belief, and serves LO maintain lhe culture.This l}pe of trance is brief and no curatives are sought by(he participant. Dissociation, bowe\'cr, occurs involuntarily.is induced by psychogenic stress, functions as a pathologi­cal defense, and is \>lcwcd as disturbed behavior. This typeoflrance maybe prolonged and curatives arc usual1ysought.

Prins (1992) points Ollt that possession is an emotiveword. The word ~posscssion~ prO\'okes strong cmolion pos­sibly because it is intimately tied to our belief systems. Theconcept of possession can also be used as a scapegoat for allt)'pesofull\\'anted lhoughts, behaviors, and feelings by bothobservers and subjects (Prins, 1992).

It is in this context ofslrong emotion that we study pos­session and dissociation. Questions arise about who is qual.Hied to discern possession, what professional works with whatType ofsubject, what is an effective working relationship, andwhich techniqu<:sare trulyeffectiw:. Theseareallgood researchquestions which can only besol\'ed in an atmosphere ofopen­ness and collegiality between di\'erse groups of profession­als who do not customarily work together. Hopefully,increased exposure to one another's work will enrich ourexperiences and help those whom we wish to serve.•

REFERENCFS

Am~rican Ps)'chiatric Association (1987). DiagrlOsti( and Statutiro/ManualofMtntalDisordm (Srd ed. re\'., pp. 269-277). Washington,1)(:; American Ps)'chiatric Pr~ss.

Arnerican Psychiatric As.sociation (1991). DSM·n'options book: I¥orkill frmgrt:.f.!, 9/1/91 (pp. KI-K6). \Vashington, DC: AmericanPsychiatric Press.

Anderson, R. M. (1979). Vision oftM disinhoiUd: TM nw./ringo!Ammcon pmtn»slalism. New York: Oxrord Unhw'Sity Press.

8eallie,j., & Middletoll,J. (Eds.). (1969). Spiril m«1ium.sJripandsoci·tIJ 111 Africa. New York: Mricana Publishing Corporation.

Iklo,J. (1960) Tranu in Bali. New York: Columbia University Press.

Uesmer, F.E. (1983). Hors,.s, musiciallJ, aml gods: ,TlJr J-Jausa cult ojpoue!;sion-tranu, Massachusetts: Bergin & Garvey Publisher'S.

Bliss, E.L (1986). MuUipk pawnality, aDitd diwrdm, and Jrypnom.New York: Oxford UniversilY Press.

Bourguignon, E. (1974). Cultuu and the varidits oj lOnJaoUSlltn.R.eading, Massachusetts: Addison-Wesley I'ublishing Company.

Bourguignon, E. (1976), PUsstssion. San Francisco: Chandler andSharp.

COONS

Bourguignon, E. (989). Multiple personality. possession trance,and the psychic unity ormankind. Ethos, 17,371-384.

Bowman, E.S. (this issue). Clinical and spiritual effects orexorcismin firtec:n patientsv.ith multiple personality. DlSSOClAnON, this issue.

Comstock. G.M. (1991). Thcinnersclf-helpcrandconCePl~ofinncrguidance: l-lislOricai alllccedcllls, its role v.ithin dissociation. andclinical Ulilization. DlSSOCLo\TlON, 4, (4) 165-177.

Coons, I'.r-.L Bowman, E.S.. KIllrt, RP., & Milstein, V. (I99I).1l1ecross<ullural occurrence or MPD: Additional cases rrom a recentsurvey. DlSSOClA TlON, 4(4), 124-128,

Cramer. M. (1980). Psychopathologyand Shanlanism in ru.-JJ Mexico:A case study orspirit possession. Britishjournal ojAltdicol P5)'lhology,53,67-73.

CrdpaJllano. V., & Garrison, V. (ub.). (1977). Cast studies in spir­it jJrostSsiOli. New York: John Wiley.

Eli1in. F.R., Palmour, R.M., Murphy, B.E.P., Prince, R, & Simons,R.c. (1988). The psychobiology of trance: II: Physiological andendocrillecorrclatcs. TmnsculturalPJJchialril1~n:h. 25,267·284.

Frank.J.D. (1961). Pmuosion and healing: A comporativtsllldJoJPSY­dwihnah. Baltimore:Johns Hopltins Unh'Crsi[}' Press.

Fraser, C.A. (1992). Multiple personality disorder [letter to theeditor.l British journal ojPsy{hialry. 161, 41 &417.

Freed, S.A.. & Freed, R.S. (1964). Spirit possession as illness in anonh Indian Village. Etlwlog')', 3, 152-171.

Furst, P.T.. & Coe. M.D. (1977). Ritual enemas. Natural HislDr)"86(3).88-91.

GaI\'in.J.AV.. & Ludwig, A.M. (1961). A casc ofwitchcrnft.journal0JNtI1JOus and Mmlall>ismM, 133, 161-168.

Goodm'ln. F.D. (1988). How about demo1lJ: POSStU;Olj and t.wrcism inthe modem world. Bloomington, Indiana: Indiana Uni\'ersity Press.

Goodman. F.D., Henny,J.H.. & PresseL E. (1982). Tron«, healing,and hal/urination. Malabar, Florida: Robert E. Krieger Compan)'.

Kane, S.M. (1974). Ritual posst:ssion in a southern Appalachianreligious sect. journal ojAmmcan Folklorr. 87, 293-302.

Kie\', A. (Ed.). (1964). Magic, Jait}" and healing: Studies ill primitivepsylhiatry today. New York: Macmillan.

Kirmcrer, LJ. (Ed.), (1992). [Special issue on possession and dis­sociation 1. TronJm/tural Psychialril /Warth lv"i~. 29(4).283--358.

Klimo, J. (1987). Channeling: 1nvesligationJ on rtaiving in!OT'1Mlionfrom pamnonnal.wurm Los Angeles: Jeremy P. Tarchcr.

Klurt. R.I'. (1988a). Editorial: Today's therapeutic pluralism. DIS­SOCIATION, 1(4). 1-2.

Kluft, R.P, (1988b). The dissociative disorders. InJ.A. Talbott, RE.Hales, & Yudorsky, S,C. The Ammam PS)'chialril Press Uxlbook ojp~chiaJr)' (pp. 557-585). WashinglOn. DC: American Ps)'chialric Press.

219DrSSOCl\TIOII. \ 01 \1. Uk'(M11hN 1993

DIFFERENTIAL DIAGNOSIS OF POSSESSIO;,\/ STATES

Lcbra. W.P. (Ed.). (1976). CulJurt bound SJ1Idromn, tlhnopSJehlfltry,and alUnlattvt tJvmpia. Honolulu: Unh'cnil}' of Hawaii Press.

Lewis, I.M. (1971). Ecsto.tic rtligifm: An A'lthropologicalstudy ofspirit/JOSSMSion and sJwmanisllL Middlesex, England: Penguin.

Lex, B.W. (1975-76). Ph}'siological aspects of rituallrance. journalofAllrud Stales of ConsdQUS1lt5$. 2, 109-122.

Loewenstein. R.J. (1991). An office mental status examination forcomplex chronic dissociati\c s)'fllptoms and multiple personalitydisorder. Ps'Jehiatric Qinia oj.!l,'orth Ammca, 14,567-604.

Ludwig, A.M. (1965). Witchcraft today. ~(}flhLNmNJILSSystffll,26. 288-291.

Ludwig, A.M. (1966). Altered States of consciousness. ArchivtJ ojGenn-al Psychiatry', J5, 225-234.

~brtinel.-Taboas. A. (1992). Multiple peuonality disorder [Letterto the editor). BritishJoumal ofPsychiatry, 161, 417-418.

Ml!rsky, H. (1992). Multiple penonalit}'disorder (Letter to the edi­tor]. Brili.shJQll.nwl ofPsychiatry. 161, 418420.

Montgomery',j.W. (Ed). (1976). Dmwn possasitm: A. mnJical. h;51(11"­lcal. anthropological, and Iht!olDgimlsymposium. Minneapolis. Minnesota:Bethany House: Publishers.

Nageli-o~ord,1-1. (Ed.). (1988)./~onamiExon:i5m: UrukrstmuiingIhehu71UlnprytMin lunntJl"L Oregon. Wisconsin: New FrontiersCenter.

No\·ello. P.. & Prima\·era. A. (1992). :\Iultiple personality disorder(Letter to the editor). Brituh jQII.rnal ofPsychlQtry. 161. 415c.

Oesl.errC'ich, T.K. (1974). Pont:SSionandtxareism. :-.IewYork:CaWC'\\"3.}'Boo"'-

Pattison. E.M .. & W·mthrob. R.M. (1981). Possession and exorcismin contemporary America. joumal ofOfxrntiorlal Prychiatl)'. 12. 13­20.

Peltzer, K. (1989). Nosology and etiology of a spiril disorder(Vimbuza) ill Malawi. Psychopatho/.ogJ\ 22, 145-151.

l'ressel. E. (1973). Umbanda in Sao Paulo: Religious innO\"3.tion inadC'o"elopingsociety.ln E. Bourguignon (Ed.) ,lUligion. alUrtd5ta~0/ ronsciousnm and social dumgr (pp. 264-318). Columbm. Ohio:Ohio State Uni\'enit}' Press.

Prince. R. (Ed.). (1966). Trana and~ion slam: PYoatdings ofthe Sromd Annual Con/urna. Montreal: R.M. Bucke MemorialSociety.

Prins, H. (1992). Besieged by dl'vils - tllOughts on posses..~ion andpossession states. MMical &ima and lhe Law, 32. 237-246.PUlnam,. f.W. (1989). Diagrullu and trtatm.mt o/mullipk pownalitydiwrdn-.. New 'lork.: Guilford Press.

PULnam. f.W.. Guroff.JJ., Silbennan. EX, Barban. L. & Post, R.M.(1986). The clinical phenomenology of multiple personalin dis­order. A TC"iew of I00 rean l C35(';S. jou malofGinitalPsychiatry. 47.285-293.

220

Randi.j. (1982). Fbm:flom.. Buffalo, Ne'o'I' York: PTometheus Book..

Ravenscroft. K. (1965). Voodoo possession: A natural experimentin hypnosis. InlnTlationaljOlJ, maloJQlnico.landExptrimmtalHJpnosis,13.157-182.

Richards,j. (1974). But dtlivrry wfrom evil: An inlrodurtion to 1!Itdcnonic duntrmon in pastaml co.l"t'. London: Danon, Longman. &Todd.

Rogers. M.L (Guest Editor, 1992). Satanic rilual abuse: The cur­reot state of knowledge. jQII.rnal 0/ Psychology and 1'ht:oIog]. 20(3),173-339.

Rougel, G. (1985). Music and trana: A IhtOt)' aJtht I"t'wtlons bttwmlmusic and possession. Chicago: University of Chicago Press.

Sargant, W. (1971). Tht mind posusud. New York: Lippincott.

Schendel, E..• & Kourany, RC. (1980). Cacodemonomaniaandexor­cism in children. journal a/Ginical PS)'chlatry, 41. 119-123.

Simons, R.C., & Hugh". e.G. (EcIs.). (1985). Thtcv.ltllrt-bound.ryn­drortV3: "Dill ilJn.es.sa ofpSJchiatric and anlhropoltJgiw.1 inttmL Boston:D. Reidel Publishing Compan}.

Spanos. N.r., \\'eekes.j.R., & Bertrand. LD. (1985). Multiple per­sonalitydisorder:Asocial psychological perspecti\'C.joumalofA.lJrnJnnolPS)'choiog)'. 94.362-376.

Spiegd, D.. (Ed.). (1991). Dissociati"e disorders. In A. Tasman &S.M. Goldfinger (Eds.) .. Ammw.n Psychiatric Prti-l rtrJiLw 0/pSJchia­try (\"()I. 10, pp. 141-276). Washington. DC: American PsychiatricPress.

Spiegel, H. & Spiegel. D. (1978). Tmnu and hmttttmt: Gin/cal usa0/hypnosi.s. New York: Basic Books.

SUT)'ani, LK.. &Jenson. G.D. (1992). Psrchiatrisl. traditional heal­er and culture integrated in clinical practice in Bali. MMilalAnlhropolog)'. 13.301-314.

Suwan lert. S. (1976). Phii Bob: Spiritl>ossession in nlT-a1 Thailand.In W.P. Lebra. Culturt-bOlmd sJfldromc, tthnopS)'cniatry, and al1tn1a­livt Ihnaplc (pp. 68-85). Honolulu: University of Ha\\-aii Press.

Tan. G.T. (Ed.). (1990, 3rd edition). Alltr'rd 51aUS of ronsdousnt:».San francisco: Harper.

Teja.j.S.. Khanna. 8.S.• & Snbrahman}-am. T.B. (1970). ·Possessionstates· in Indian patienlS. Indian jQII.mal 0/PSJchiall)" 12, 71-87.

Torrt:y. E.,F. (1986). IWtrMQ(tors and pS)'chialrisLs: The common rooLsof/JsychothrraJry and iLs futtll"t'. New York: Ilarper and Row.

Wallace. A.f.C. (1966). IYligion: An anthropologilal vi~. New York:Random House.

Ward, C. (1980). Spiril possession and mental healing: A ps)'­

choanthropological perspecti\·e. HllJftan lWaIioru. 33. 149-163.

Ward.G., & Beaubrun, M.H. (1980). The psychod}llamicsofdemonpossession.journalJor 1M SnmtiJir Study o/Ivligiqn. 19.201-207.

DlSSOCL\TlO\. \oL \1. t [\(o{"",bfr 1'"

,

-

-I COONS

Wilson, C. (1987). Aftt:rlife: An ill1~tig(lliolloJlhe roidmctfor life aftt:rrho/h. Gardell City, New York: Doubleday.

World licalth Organi7.alion (1992). The IU).10 cla5Sification ofmm­tal and bthaviural disordt1l: Gin/tal damP/ions and diagnostic guid~linl!3 (pp. 156-157). Geneo.-a: World Ileahh Organization.

Yap. P.M. (1960). The possession syndrome: Acomparison ofHongKong and French findings. }ollmal ofMrota/ &inlet', 106, 114-137.

Young. W.C. (1988). Obscn,'atiollS on fantaS}' in the fonnauon ofmultiple personality disorder. VlSSOCll\TJON. 1(3), 13-20.

Zaretsky. 1.1.. & Shambaugh, C. (1978). Spirit~ion and spiritMtdi~m.sh;pmAfrica and Ajro-Amm'co: An annotatnJ bibliography. NewYork: Garland Publishing.

221

Dl~~mO\.\oI \l.t~l9t3

.