The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique

Trapped Between Theological and Medical Notions of Possession: A Case of Possession Trance Disorder With a 3-Year Follow-Up

Few studies on Possession Trance Disorder (PTD) describe diagnostic and research procedures in detail. This case study presents the clinical picture of a Caucasian Roman-Catholic woman who had been subjected to exorcisms because of her problems with affect regulation, lack of control over unaccepted sexual impulses, and somatoform symptoms accompanied by alterations in consciousness. It uses interpretative phenomenological analysis to explore meaning attributed by her to "possession" as a folk category and a medical diagnosis; how this affected her help-seeking was also explored. This study shows that receiving a PTD diagnosis can reinforce patients' beliefs about supernatural causation of symptoms and discourage professional treatment. Dilemmas and uncertainties about the diagnostic criteria and validity of this disorder are discussed.

Djinnati syndrome as the first manifestation of temporal lobe epilepsy: A case report

Culture-bound syndromes are a group of abnormal behavior patterns occurring only in definite cultural groups. As a form of culture-bound syndromes, possession trance is known as the “replacement of personal identity customary sense by a new identity.” Djinnati syndrome is a possession state restricted to specific areas of Iranian and Pakistani Baluchestan. Preceding studies suggested that complex behavioral manifestations of temporal lobe epilepsy (TLE) were likely to contain dissociative states symptoms. Nonetheless, people in numerous developing countries hold a belief that Jinn possession causes epilepsy even in quite well-educated people. The aims of the present report are to describe a patient who presented Djinnati syndrome as the very first manifestation of TLE and address the feasible detrimental impacts of cultural misconceptions on diagnosing and treating epileptic seizures.

Legacies of civil wars: A 14-year study of social conflicts and well-being outcomes in farming economies

Community processes to address fractured social relationships and well-being remain the least examined dimensions in studies of legacies of civil wars. This article addresses these limitations by analyzing how the wartime and postwar generations have negotiated the legacies of the civil war (1976-1992) in a farming economy region in Mozambique. Based on a 14-year (2002-2015) study of community courts in Mozambique, we analyzed the types of social conflicts and the associations with gender, age, risk factors, self-described health impairments, and the timing of farming activities. We identified n = 3,456 participants and found that perennial sources of disputes were related to family formation and maintenance, defamation, accusations of perpetration of serious civil wartime violations, mistrust, debts, and domestic violence. Furthermore, conflict relations were associated with gender, age, risk factors, and health problems. This study concludes that civil wars have lasting multifaceted legacies, but generational tensions, availability of community institutions, and economic resources shape social relationships and well-being outcomes while averting revenge cycles among civilian war survivors.

Characteristics of Adolescents Affected by Mass Psychogenic Illness Outbreaks in Schools in Nepal: A Case-Control Study

This paper presents the first systematic case-control study of correlates of mass psychogenic illness (MPI) in an adolescent school population. MPI is generally construed as a dissociative phenomenon spread by social contagion to individuals who are prone to dissociation. We sought to test if the correlates of dissociative experiences most commonly proposed in the literature could predict caseness among students affected by episodes of mass psychogenic illness occurring in schools in Nepal. We assessed 194 cases and 190 controls (N = 384) of ages 11-18 years from 12 public schools. Cases and controls were comparable on all demographic variables, except for family configuration, with nuclear families more common among those affected. In bivariate comparisons, caseness was associated with childhood physical neglect and abuse, as well as living in nuclear families, peritraumatic dissociation, dissociative tendencies, and depressive and post-traumatic stress symptoms. Hypnotizability emerged as the strongest correlate of psychogenic illness among the cognitive and personality trait variables. However, in multivariable logistic regression, the correlates of dissociation did not predict caseness, suggesting that they do not adequately account for the phenomenon of mass psychogenic illness. An ad-hoc Classification and Regression Trees analysis showed that if an adolescent was highly hypnotizable and reported high rates of peritraumatic dissociative experiences, then there was a 73% probability of being a case in a mass psychogenic illness episode. Future studies involving other psychological, social and cultural factors, as well as school- and family-related factors are needed to understand the correlates of mass psychogenic illness and guide prevention and intervention.

Predictors of Dissociative Experiences Among Adolescents in Nepal: A Path Analysis

In recent years, many adolescents in Nepal have been affected by episodes of mass psychogenic illness, which seem to involve dissociative symptoms. To identify the potential contributors to dissociation, the present study examined correlates of dissociative experiences among adolescents in Nepal. In a cross-sectional survey, 314 adolescents were assessed with the Adolescent Dissociative Experiences Scale and measures of childhood trauma exposure, as well as cognitive and personality traits found to be associated with dissociation in studies on other populations. Path analysis confirmed that childhood trauma, cognitive and personality traits, and current distress each predicted dissociative experiences and behaviors. However, an integrated path model found that the effect of childhood trauma on dissociation was mediated either by posttraumatic stress symptoms or by cognitive failures. Future studies should develop and test multifactorial models of dissociation and multiple pathways.

A Transcultural Model of the Centrality of "Thinking a Lot" in Psychopathologies Across the Globe and the Process of Localization: A Cambodian Refugee Example

We present a general model of why "thinking a lot" is a key presentation of distress in many cultures and examine how "thinking a lot" plays out in the Cambodian cultural context. We argue that the complaint of "thinking a lot" indicates the presence of a certain causal network of psychopathology that is found across cultures, but that this causal network is localized in profound ways. We show, using a Cambodian example, that examining "thinking a lot" in a cultural context is a key way of investigating the local bio-cultural ontology of psychopathology. Among Cambodian refugees, a typical episode of "thinking a lot" begins with ruminative-type negative cognitions, in particular worry and depressive thoughts. Next these negative cognitions may induce mental symptoms (e.g., poor concentration, forgetfulness, and "zoning out") and somatic symptoms (e.g., migraine headache, migraine-like blurry vision such as scintillating scotomas, dizziness, palpitations). Subsequently the very fact of "thinking a lot" and the induced symptoms may give rise to multiple catastrophic cognitions. Soon, as distress escalates, in a kind of looping, other negative cognitions such as trauma memories may be triggered. All these processes are highly shaped by the Cambodian socio-cultural context. The article shows that Cambodian trauma survivors have a locally specific illness reality that centers on dynamic episodes of "thinking a lot," or on what might be called the "thinking a lot" causal network.

Dissociative trance and spirit possession: Challenges for cultures in transition

The cross-cultural validity of dissociative possession and trance disorders is a matter of some debate, limiting research and meaningful interpretation of prevalence data. Intimate to these concerns is the status of spirit possession categories studied in the social sciences, particularly anthropology. These two categories are phenomenologically related and display similar epidemiological associations. In India, dissociative and conversion disorders are fairly common in clinical settings. There is no doubt that there are true cultural variations in possession and trance disorders. A new framework may enable clinicians to better understand possession states and spirit possession.

Traumatic Experience and Somatoform Dissociation Among Spirit Possession Practitioners in the Dominican Republic

Recent studies in African contexts have revealed a strong association between spirit possession and severe trauma, with inclusion into a possession cult serving at times a therapeutic function. Research on spirit possession in the Dominican Republic has so far not included quantitative studies of trauma and dissociation. This study evaluated demographic variables, somatoform dissociative symptoms, and potentially traumatizing events in the Dominican Republic with a group of Vodou practitioners that either do or do not experience spirit possession. Inter-group comparisons revealed that in contrast to non-possessed participants (n = 38), those experiencing spirit possession (n = 47) reported greater somatoform dissociation, more problems with sleep, and previous exposure to mortal danger such as assaults, accidents, or diseases. The two groups did not differ significantly in other types of trauma. The best predictor variable for group classification was somatoform dissociation, although those items could also reflect the experience of followers during a possession episode. A factor analysis across variables resulted in three factors: having to take responsibility early on in life and taking on a professional spiritual role; traumatic events and pain; and distress/dissociation. In comparison with the non-possessed individuals, the possessed ones did not seem to overall have a remarkably more severe story of trauma and seemed to derive economic gains from possession practice.

Hypnosis as a model of functional neurologic disorders

In the 19th century it was recognized that neurologic symptoms could be caused by "morbid ideation" as well as organic lesions. The subsequent observation that hysteric (now called "functional") symptoms could be produced and removed by hypnotic suggestion led Charcot to hypothesize that suggestion mediated the effects of ideas on hysteric symptoms through as yet unknown effects on brain activity. The advent of neuroimaging 100 years later revealed strikingly similar neural correlates in experiments matching functional symptoms with clinical analogs created by suggestion. Integrative models of suggested and functional symptoms regard these alterations in brain function as the endpoint of a broader set of changes in information processing due to suggestion. These accounts consider that suggestions alter experience by mobilizing representations from memory systems, and altering causal attributions, during preconscious processing which alters the content of what is provided to our highly edited subjective version of the world. Hypnosis as a model for functional symptoms draws attention to how radical alterations in experience and behavior can conform to the content of mental representations through effects on cognition and brain function. Experimental study of functional symptoms and their suggested counterparts in hypnosis reveals the distinct and shared processes through which this can occur.

Global mental health and trauma exposure: the current evidence for the relationship between traumatic experiences and spirit possession

BACKGROUND

We present a literature review on trauma exposure and spirit possession in low- and middle-income countries (LMICs). Despite the World Health Organization's objective of culturally appropriate mental health care in the Mental Health Action Plan 2013-2020, and the recommendations of the Inter-Agency Standing Committee to consider local idioms of distress and to collaborate with local resources, this topic still receives very little attention. Pathological spirit possession is commonly defined as involuntary, uncontrollable, and occurring outside of ritual settings. It is often associated with stigmatization, suffering, and dysfunctional behavior. While spirit possession has been discussed as an idiom of distress in anthropological literature, recent quantitative studies have presented support for a strong relationship between traumatic experiences and pathological possession states.

OBJECTIVE

The aim of this review was to investigate this relationship systematically in LMICs, in view of the debate on how to address the mental health gap in LMICs.

METHODS

Twenty-one articles, published in peer-reviewed English-language journals between 1994 and 2013, were identified and analyzed with regard to prevalence of possessive trance disorders, patients' sociodemographic characteristics, and its relation to traumatic experiences.

RESULTS

The review and analysis of 917 patients with symptoms of possessive trance disorders from 14 LMICs indicated that it is a phenomenon occurring worldwide and with global relevance. This literature review suggests a strong relationship between trauma exposure and spirit possession with high prevalence rates found especially in postwar areas in African countries.

CONCLUSIONS

More attention for possessive trance disorders in mental health and psychosocial intervention programs in humanitarian emergency settings as well as in societies in transition in LMICs is needed and justified by the results of this systematic literature review.

A village possessed by "witches": a mixed-methods case-control study of possession and common mental disorders in rural Nepal

In Nepal, spirit possession is a common phenomenon occurring both in individuals and in groups. To identify the cultural contexts and psychosocial correlates of spirit possession, we conducted a mixed-method study in a village in central Nepal experiencing a cluster of spirit possession events. The study was carried out in three stages: (1) a pilot study consisting of informal interviews with possessed individuals, observations of the possession spells, and video recording of possession events; (2) a case-control study comparing the prevalence of symptoms of common mental disorders in women who had and had not experienced possession; and (3) a follow-up study with focus group discussions and in-depth interviews with possessed and non-possessed men and women, and key informants. Quantitative results indicated that possessed women reported higher rates of traumatic events and higher levels of symptoms of mental disorder compared to non-possessed women (Anxiety 68 vs. 18 %, Depression 41 vs. 19 %, and PTSD 27 vs. 0 %). However, qualitative interviews with possessed individuals, family members, and traditional healers indicated that they did not associate possession states with mental illness. Spirit possession was viewed as an affliction that provided a unique mode of communication between humans and spirits. As such, it functioned as an idiom of distress that allowed individuals to express suffering related to mental illness, socio-political violence, traumatic events, and the oppression of women. The study results clearly indicate that spirit possession is a multi-dimensional phenomenon that cannot be mapped onto any single psychiatric or psychological diagnostic category or construct. Clinical and public health efforts to address spirit possession must take the socio-cultural context and systemic dynamics into account to avoid creating iatrogenic illness, undermining coping strategies, and exacerbating underlying social problems.

Unravelling the spirits' message: a study of help-seeking steps and explanatory models among patients suffering from spirit possession in Uganda

As in many cultures, also in Uganda spirit possession is a common idiom of distress associated with traumatic experiences. In the DSM-IV and -5, possession trance disorders can be classified as dissociative disorders. Dissociation in Western countries is associated with complicated, time-consuming and costly therapies. Patients with spirit possession in SW Uganda, however, often report partial or full recovery after treatment by traditional healers.

The aim of this study is to explore how the development of symptoms concomitant help-seeking steps, and explanatory models (EM) eventually contributed to healing of patients with spirit possession in SW Uganda. Illness narratives of 119 patients with spirit possession referred by traditional healers were analysed using a mixed-method approach.

Treatments of two-thirds of the patients were unsuccessful when first seeking help in the medical sector. Their initially physical symptoms subsequently developed into dissociative possession symptoms. After an average of two help-seeking steps, patients reached a healing place where 99% of them found satisfactory EM and effective healing. During healing sessions, possessing agents were summoned to identify themselves and underlying problems were addressed. Often-mentioned explanations were the following: neglect of rituals and of responsibilities towards relatives and inheritance, the call to become a healer, witchcraft, grief, and land conflicts.

The results demonstrate that traditional healing processes of spirit possession can play a role in restoring connections with the supra-, inter-, intra-, and extra-human worlds. It does not always seem necessary to address individual traumatic experiences per se, which is in line with other research in this field. The study leads to additional perspectives on treatment of trauma-related dissociation in Western countries and on developing effective mental health services in low -and middle-income countries.

Posttraumatic stress in emergency settings outside North America and Europe: a review of the emic literature

Mental health professionals from North America and Europe have become common participants in postconflict and disaster relief efforts outside of North America and Europe. Consistent with their training, these practitioners focus primarily on posttraumatic stress disorder (PTSD) as their primary diagnostic concern. Most research that has accompanied humanitarian aid efforts has likewise originated in North America and Europe, has focused on PTSD, and in turn has reinforced practitioners' assumptions about the universality of the diagnosis. In contrast, studies that have attempted to identify how local populations conceptualize posttrauma reactions portray a wide range of psychological states. We review this emic literature in order to examine differences and commonalities across local posttraumatic cultural concepts of distress (CCDs). We focus on symptoms to describe these constructs - i.e., using the dominant neo-Kraepelinian approach used in North American and European psychiatry - as opposed to focusing on explanatory models in order to examine whether positive comparisons of PTSD to CCDs meet criteria for face validity. Hierarchical clustering (Ward's method) of symptoms within CCDs provides a portrait of the emic literature characterized by traumatic multifinality with several common themes. Global variety within the literature suggests that few disaster-affected populations have mental health nosologies that include PTSD-like syndromes. One reason for this seems to be the almost complete absence of avoidance as pathology. Many nosologies contain depression-like disorders. Relief efforts would benefit from mental health practitioners getting specific training in culture-bound posttrauma constructs when entering settings beyond the boundaries of the culture of their training and practice.

Validation of the Kirundi versions of brief self-rating scales for common mental disorders among children in Burundi

BACKGROUND

In Sub Saharan Africa, there has been limited research on instruments to identify specific mental disorders in children in conflict-affected settings. This study evaluates the psychometric properties of three self-report scales for child mental disorder in order to inform an emerging child mental health programme in post-conflict Burundi.

METHODS

Trained lay interviewers administered local language versions of three self-report scales, the Depression Self-Rating Scale (DSRS), the Child PSTD Symptom Scale (CPSS) and the Screen for Child Anxiety Related Emotional Disorders (SCARED-41), to a sample of 65 primary school children in Burundi. The test scores were compared with an external 'gold standard' criterion: the outcomes of a comprehensive semistructured clinical psychiatric interview for children according the DSM-IV criteria (the Schedule for Affective Disorders and Schizophrenia for School-Age Children - K-SADS-PL).

RESULTS

The DSRS has an area under the curve (AUC) of 0.85 with a confidence interval (c.i.) of 0.73-0.97. With a cut-off point of 19, the sensitivity was 0.64, and the specificity was 0.88. For the CPSS, with a cut-off point of 26, the AUC was 0.78 (c.i.: 0.62-0.95) with a sensitivity of 0.71 and a specificity of 0.83. The AUC for the SCARED-41, with a cut-off point of 44, was 0.69 (c.i.: 0.54-0.84) with a sensitivity of 0.55 and a specificity of 0.90.

CONCLUSIONS

The DSRS and CPSS showed good utility in detecting depressive disorder and posttraumatic stress disorder in Burundian children, but cut-off points had to be put considerably higher than in western norm populations. The psychometric properties of the SCARED-41 to identify anxiety disorders were less strong. The DSRS and CPSS have acceptable properties, and they could be used in clinical practice as part of a two-stage screening procedure in public mental health programmes in Burundi and in similar cultural and linguistic settings in the African Great Lakes region.

Djinnati syndrome: symptoms and prevalence in rural population of Baluchistan (southeast of Iran)

OBJECTIVE

The present study describes "Djinnati," a culture-bound syndrome and examines its prevalence and demographic attributes such as age, gender and education level in the rural population of Baluchistan in southeast Iran.

METHOD

In this cross-sectional study, the participants (n=4129) were recruited from people living in rural areas of Baluchistan (southeast Iran) by multistage sampling. The data were collected through interviews with local healers, health care personnel, family health records, interview patients suspected with the disorder and their relatives. We administered the dissociative experiences scale.

RESULTS

Prevalence of Djinnati syndrome was about 0.5% in the studied population and 1.03% in women. All patients who experienced episodic symptoms of Djinnati were female. The most common reported symptoms were altered consciousness and memory, muteness, laughing, crying, incomprehensible speech and hallucination that have been attributed to a foreign entity called "Djinn." In addition loss of speech or change in speech rhythm and tone of voice was observed in a subgroup. In one case, speaking in a different language during the attack was reported. There was partial and rarely complete amnesia during the attack. Attacks usually lasted from 30 min to 2h.

DISCUSSION

It is suggested that future studies explore prevalence of Djinnati syndrome in women and explore predisposing, precipitating, and maintaining factors. It is further suggested that a comprehensive pathology model should integrate the data related to socio-cultural context in order to prevent and treat this syndrome.

Collective trauma processing: dissociation as a way of processing postwar traumatic stress in Guinea Bissau

Guidelines on psychosocial interventions in postconflict areas commonly mention that interventions should be based on local needs and be built on culture-specific expertise. This paper is based on a dissociative cult, the Kiyang-yang (KYY), in Guinea Bissau. In a previous article, we used a refined definition of the concept of idiom of distress to analyze the dissociative behavior displayed in KYY as a symbolic language addressing politically dangerous truths. This paper uses the concept of "collective trauma processing" to analyze how the idiom offered the local population a pathway to mitigate the consequences of protracted and widespread political violence. The paper first argues that the field of psychotraumatology lacks a comprehensive ecological theory on trauma. Moreover, within clinical psychology and psychiatry, little attention is paid to local cultural healing mechanisms addressing traumatic stress. This paper is an effort to study such mechanisms in their own right. To compare trauma processing mechanisms across the globe, we propose to analyze trauma processing mechanisms with the help of a comprehensive model discerning five ontological dimensions that are considered to be involved in suffering and are addressed in healing approaches. Our paper describes similarities and differences between psychological healing traditions and collective trauma processing within the West African context of Guinea Bissau. We will illustrate how the KYY movement uses the idiom of dissociation as both a collective expression of distress and as a vehicle to process social suffering and traumatic stress as a circular phenomenon.

Children enacting idioms of witchcraft and spirit possession as a response to trauma: therapeutically beneficial, and for whom?

This article examines children's enactment of spirit possession idioms and witchcraft in Africa including the meanings such idioms provide and the local healing resources they mobilize. Idioms of haunting spirits in Northern Uganda and witch-children elsewhere in Africa can be interpreted as manifestations of social crises and mass traumatic stress. On the other hand, such idioms also allow children to articulate, reflect upon, and communicate the complex feelings resulting from their precarious positions within families and communities under duress. With the help of Dow's transactional model of symbolic healing, this article explores obstacles to the effectivity of the rich variety of symbolic healing available for haunting spirits in Uganda and points to the generational gap between children and their families and communities. Elsewhere, witchcraft idioms may act as a healing resource at the group level, but at the expense of the accused child. The idioms of evil spirits and witchcraft speak of these children's navigation of the moral universe of their postconflict communities. Given that children's appraisal of their experiences through these notions may also exacerbate their anxiety, interdisciplinary research examining the microprocesses that lead to children being haunted or accused, including emotional and physiological levels effects, is urgently needed.

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

INTRODUCTION AND AIMS

As in many cultures, spirit possession is a common idiom of distress in Uganda. The DSM-IV contains experimental research criteria for dissociative and possession trance disorder (DTD and PTD), which are under review for the DSM-5. In the current proposed categories of the DSM-5, PTD is subsumed under dissociative identity disorder (DID) and DTD under dissociative disorders not elsewhere classified. Evaluation of these criteria is currently urgently required. This study explores the match between local symptoms of spirit possession in Uganda and experimental research criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5.

METHODS

A mixed-method approach was used combining qualitative and quantitative research methods. Local symptoms were explored of 119 spirit possessed patients, using illness narratives and a cultural dissociative symptoms' checklist. Possible meaningful clusters of symptoms were inventoried through multiple correspondence analysis. Finally, local symptoms were compared with experimental criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5.

RESULTS AND CONCLUSION

Illness narratives revealed different phases of spirit possession, with passive-influence experiences preceding the actual possession states. Multiple correspondence analysis of symptoms revealed two dimensions: 'passive' and 'active' symptoms. Local symptoms, such as changes in consciousness, shaking movements, and talking in a voice attributed to spirits, match with DSM-IV-PTD and DSM-5-DID criteria. Passive-influence experiences, such as feeling influenced or held by powers from outside, strange dreams, and hearing voices, deserve to be more explicitly described in the proposed criteria for DID in the DSM-5. The suggested incorporation of PTD in DID in the DSM-5 and the envisioned separation of DTD and PTD in two distinctive categories have disputable aspects.

Haunted by ghosts: prevalence, predictors and outcomes of spirit possession experiences among former child soldiers and war-affected civilians in Northern Uganda

Phenomena of spirit possession have been documented in many cultures. Some authors have argued that spirit possession is a type of psychopathology, and should be included as a category in diagnostic manuals of mental disorders. However, there are hardly any quantitative studies that report the prevalence of spirit possession on a population level and that provide evidence for its validity as a psychopathological entity. In an epidemiological study that was carried out in 2007 and 2008 with N = 1113 youths and young adults aged between 12 and 25 years in war-affected regions of Northern Uganda we examined the prevalence, predictors and outcomes of cen, a local variant of spirit possession. Randomly selected participants were interviewed using a scale of cen, measures of psychopathology (PTSD and depression) as well as indicators of functional outcome on different levels, including suicide risk, daily activities, perceived discrimination, physical complaints and aggression. We found that cen was more common among former child soldiers then among subjects without a history of abduction. Cen was related to extreme levels of traumatic events and uniquely predicted functional outcome even when the effects of PTSD and depression were controlled for. Our findings show that a long-lasting war that is accompanied by the proliferation of spiritual and magical beliefs and propaganda can lead to high levels of harmful spirit possession. In addition, we provide evidence for the incremental validity of spirit possession as a trauma-related psychological disorder in this context.