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Abstract

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.
CASE REPORT
published: 26 May 2022
doi: 10.3389/fpsyt.2022.891859
Frontiers in Psychiatry | www.frontiersin.org 1May 2022 | Volume 13 | Article 891859
Edited by:
Clare Margaret Eddy,
Birmingham and Solihull Mental
Health NHS Foundation Trust,
United Kingdom
Reviewed by:
Casimiro Cabrera Abreu,
Queens University, Canada
Vedat ,
Sar,
Koç University, Turkey
*Correspondence:
Igor J. Pietkiewicz
ipietkiewicz@swps.edu.pl
Specialty section:
This article was submitted to
Psychopathology,
a section of the journal
Frontiers in Psychiatry
Received: 08 March 2022
Accepted: 04 May 2022
Published: 26 May 2022
Citation:
Pietkiewicz IJ, Kłosi ´
nska U and
Tomalski R (2022) Trapped Between
Theological and Medical Notions of
Possession: A Case of Possession
Trance Disorder With a 3-Year
Follow-Up.
Front. Psychiatry 13:891859.
doi: 10.3389/fpsyt.2022.891859
Trapped Between Theological
and Medical Notions of Possession:
A Case of Possession Trance
Disorder With a 3-Year Follow-Up
Igor J. Pietkiewicz*, Urszula Kłosi ´
nska and Radosław Tomalski
Research Centre for Trauma & Dissociation, SWPS University of Social Sciences and Humanities, Katowice, Poland
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.
Keywords: Possession Trance Disorder, dissociation, assessment, religious coping, exorcism
INTRODUCTION
Possession is a broad folk category used to explain a variety of symptoms or problems (1). It
is frequently associated with possession-form presentations, marked by: talking in a different
voice, sensation of paralysis, shaking, glossolalia or making animal sounds, or “night dances”
(2). Members of different religious groups also explain possession as incomprehensible somatic
symptoms, difficulties in spiritual practice or even problems in relationships (311). Furthermore,
people in many groups perceive exposure to inappropriate music or films, using substances,
masturbation, homosexuality or extra-marital sex as spiritual threats or indicators of being
possessed per se (12,13). Even delusions of possession in patients with schizophrenia spectrum
disorders can be ascribed by some priests and community members to demonic possession (14).
Although people labeled as “possessed” represent a heterogeneous group in terms of clinical
presentations, many anthropologists view possession as an idiom of distress and a way of
communicating or expressing protest by those who are marginalized or subordinate (15,16).
The concept of possession has also been used in psychiatric language (see: Table 1). The 10th
and 11th editions of the WHO classifications list Possession and Trance Disorder (PTD) in the
dissociative disorders chapter. ICD-11 describes it as: “a marked alteration in the individual’s state
of consciousness and the individual’s customary sense of personal identity is replaced by an external
‘possessing’ identity and in which the individual’s behaviors or movements are experienced as
being controlled by the possessing agent” (17). Symptoms should be involuntary and unwanted,
and should not be a part of a collective cultural or religious practice (e.g., Cavadi, deliverance
ministries), because suggestible individuals may be prone to exhibit behaviors expected in such
situations, especially if they have been exposed to trance states or received teachings about
Pietkiewicz et al. Case Report: Notions of Possession
TABLE 1 | References to possession in ICD-10, ICD-11, and DSM-5.
ICD-10 Possession and trance disorder (F44.3)
A. The general criteria for dissociative disorder (F44) must be met:
G1. No evidence of a physical disorder that can explain the symptoms that characterize the disorder (but physical disorders may be present that give rise
to other symptoms).
G2. Convincing associations in time between the symptoms of the disorder and stressful events, problems or needs.
B. Either (1) or (2):
(1) Trance: Temporary alteration of the state of consciousness, shown by any two of:
a. Loss of the usual sense of personal identity.
b. Narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli.
c. Limitation of movements, postures, and speech to repetition of a small repertoire.
(2) Possession disorder: Conviction that the individual has been taken over by a spirit, power, deity or other person.
C. Both criterion B.1 and B.2 must be unwanted and troublesome, occurring outside or being a prolongation of similar states in religious or other culturally
accepted situations.
D. Most commonly used exclusion criteria: not occurring at the same time as schizophrenia or related disorders (F20–F29), or mood [affective] disorders with
hallucinations or delusions (F30–F39).
ICD-11 Possession trance disorder (6B63)
PTD is characterized by trance states in which there is a marked alteration in the individual’s state of consciousness and the individual’s customary sense of
personal identity is replaced by an external “possessing” identity and in which the individual’s behaviors or movements are experienced as being controlled
by the possessing agent. Possession 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 do not occur exclusively during another dissociative disorder and are not better explained by another mental, behavioral or neurodevelopmental
disorder. The symptoms are not due to the direct 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 or a sleep-wake disorder. The symptoms result in
significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning.
DSM-5 Dissociative identity disorder (300.14)
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession.
The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior,
consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by
the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another
medical condition (e.g., complex partial seizures).
DSM-5 Other specified dissociative disorder (300.15)
This category applies to presentations in which symptoms characteristic of a dissociative disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the dissociative disorders
diagnostic class. The other specified dissociative disorder category is used in situations in which the clinician chooses to communicate the specific reason
that the presentation does not meet the criteria for any specific dissociative disorder. This is done by recording “other specified dissociative disorder” followed
by the specific reason (e.g., “dissociative trance”). Examples of presentations that can be specified using the “other specified” designation include
the following:
1. Chronic and recurrent syndromes of mixed dissociative symptoms: This category includes identity disturbance associated with less-than-marked
discontinuities in sense of self and agency, or alterations of identity or episodes of possession in an individual who reports no dissociative amnesia.
2. Identity disturbance due to prolonged and intense coercive persuasion: Individuals who have been subjected to intense coercive persuasion (e.g.,
brainwashing, thought reform, indoctrination while captive, torture, long-term political imprisonment, and recruitment by sects/cults or by terror organizations)
may present with prolonged changes in, or conscious questioning of, their identity.
3. Acute dissociative reactions to stressful events: This category is for acute, transient conditions that typically last <1 month, and sometimes only a
few hours or days. These conditions are characterized by constriction of consciousness; depersonalization; derealization; perceptual disturbances (e.g., time
slowing, macropsia); micro-amnesias; transient stupor; and/or alterations in sensory-motor functioning (e.g., analgesia, paralysis).
4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as
profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger
movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative
trance is not a normal part of a broadly accepted collective cultural or religious practice.
possession. For this reason, possession-form presentations
triggered by and occurring only during exorcisms should
not qualify for this diagnosis (13). Symptoms should also
lead to significant distress or impairment in personal, family,
social, educational or occupational functioning (17). However,
adopting the role of someone “possessed” can be a source
of different gains: primary (abreaction or an opportunity
to express conflicting impulses in a culturally acceptable
manner) and secondary (attracting the attention of others
and evoking respect or awe). According to the ICD, unless
these trance episodes are recurrent, a single episode should
last at least several days to qualify for this diagnosis. Full
or partial amnesia is expected for the trance episode. ICD-
11 outlines very superficial boundaries between PTD and
Dissociative Identity Disorder (DID) or Partial DID: alternate
personality states in PTD are attributed to an external (not
internal) possessive agent. This implies there is little difference
in the overall clinical presentation of PTD and complex
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Pietkiewicz et al. Case Report: Notions of Possession
dissociative disorders, except for how patients make meaning of
their symptoms.
In the American classification, “possession” was diagnosed
as the Atypical Dissociative Disorder diagnosed in DSM-III or
DDNOS in DSM-III-R. In DSM-IV (1994), possession and trance
were diagnosed as sub-categories of the Dissociative Trance
Disorder (DTD), and in DSM-IV-TR they were merged into
one, and recognized as a cultural variant of the Dissociative
Disorder Not Otherwise Specified [DDNOS, (18)]. In DSM-5
(19), possession-form presentations are linked with criterion A
of DID: “Disruption of identity characterized by two or more
distinct personality states, which may be described in some
cultures as an experience of possession” (p. 292). In the absence
of other salient DID features (e.g., amnesia), possession episodes
can still be coded under the Other Specified Dissociative Disorder
(OSDD) category.
However, only some people with possession-form
presentations report clusters of symptoms characteristic of
complex dissociative disorders such as DID (10,2022). In
contrast to that, possession-form presentations in PTD comprise
some dissociative symptoms not matching criteria for complex
dissociative disorders. Other patients with possession-form
presentations are better described in terms of personality
disorders, marked by problems with attachment, affect
regulation, and internal conflicts associated with aggressive
or sexual impulses which they can express in a culturally-
legitimate manner (4,11,13,23,24). These people can be
encouraged by community members to attribute unacceptable
or shameful impulses to demonic influence. In this way, they
can externalize psychological conflicts, reduce feelings of guilt or
attract others’ attention. According to Pietkiewicz et al. (13) there
are qualitative differences between these disowned ego-states and
autonomous dissociative parts in complex dissociative disorders,
and treating these people as if they had such parts could be
iatrogenic. Unfortunately, in patients referred by exorcists for
diagnostic assessment of their possession-form presentations
this diagnosis is rarely taken into account.
It is intriguing how clinicians’ personal beliefs about the
phenomenal world (e.g., whether or not invisible entities exist
which can influence human behavior) affect clinical judgement
and meaning attributed to symptoms. Bayer and Shunaigat
(25) postulate, for instance, that ‘real’ possession should be
differentiated from the nosological spirit possession category.
Some authors also mention consulting priests or healers (12,26),
but their role in the diagnostic decision-making was not clear. On
the one hand, this might express clinicians’ sensitivity to patients’
religious beliefs and their expectations to involve spiritual leaders
in the treatment plan. On the other hand, it could also reveal
clinicians’ own doubts about the nature of the symptoms.
Inability to explain them in terms of psychological mechanisms
responsible for a given problem can lead some professionals
to consider non-medical explanations. For example, Khan and
Sahni (27) explicitly shared their belief that “exorcists, at times,
are able to tell whether a person has a mental illness and requires
hospitalization and drug treatment or is truly possessed” (p.
254). In another case study by Hale and Pinninti (26), prison
and hospital chaplains concurred on “genuine” possession of
a patient leading authors to the following conclusion: “If we
are to accept that there is a place for belief in real possession
in current thinking, then what we have described above might
be construed as a case of exorcism-resistant ghost possession,
successfully treated with a depot neuroleptic” (p. 388).
Assuming that guidelines for diagnosing possession episodes
and information about their prevalence or risk factors quoted
in psychiatric manuals are based on research, we decided to
review the procedures which were applied to make diagnoses
in 48 studies exploring symptoms of possession and trance
(see: Table 2). We included publications previously examined
in systematic reviews by During et al. (65) and Hecker
et al. (66). These two were the only reviews of PTD/DTD
available. We also identified nine additional studies of PTD
not included in previous reviews. The majority of research on
possession-form presentations consists of case studies describing
phenomenological aspects, but offering meager descriptions
of participants’ clinical presentations which could facilitate
differential diagnoses. In their reviews, both During et al. (65)
and Hecker et al. (66) also included anthropological publications
or ethnographic accounts, and studies in which participants
obtained other diagnoses, but they were treated as examples of
PTD. In 25 studies, diagnoses were based on general psychiatric
examination during which patients reported changes in behavior
which they attributed to demonic possession. However, authors
provided no information about the scope of these clinical
interviews and how differential diagnoses were made. Twenty
studies suggested the PTD/DTD diagnosis but there was no
diagnostic assessment performed by a mental health professional
or they contained no information about assessment whatsoever.
In four of these studies, assessment was limited to self-report
instruments which cannot be regarded as a satisfactory diagnostic
procedure per se. In four studies diagnoses were determined
retrospectively based on analyzing medical records (3234,56).
Only in four studies, in-depth clinical interviews were used in
the assessment, e.g. the Dissociative Disorder Interview Schedule,
DDIS (37,53) and the Structured Clinical Interviews for DSM–IV
(SCID) or parts of it (20,54).
Considering the above, rigorous clinical studies exploring
possession-form presentations are paramount. They should go
beyond phenomenological descriptions and analyze participants’
overall functioning in different areas, symptom dynamics,
psychological conflicts and mechanisms, attribution of meaning
and potential gains. While diagnostic manuals emphasize
patients’ meaning-making, few studies explored how patients
made sense of being diagnosed with Possession Trance Disorder,
and how this affected their help-seeking behavior. This case study
describes the clinical presentation of a Catholic woman referred
for a diagnostic assessment by priests who grew helpless about
her aggressive behavior and acts of vandalism. What meaning
she ascribed to her PTD diagnosis and how it affected her
help-seeking pathways during a 3-year period until a follow-up
interview was also analyzed
METHODS
This study was carried out in Poland between 2016 and 2021.
Qualitative data included clinical interviews and psychiatric
mental health assessment. Their transcripts were subjected
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Review of studies exploring possession trance.
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
1 Bakhshani et al.
(28)b
Iran Cross-sectional
study
21 out of
4,129
To describe Djinnati and examine
its prevalence and demographic
attributes in the rural population
of Baluchistan in southeast Iran.
Psychiatric examination
Self-report instrument:
Dissociative Experiences
Scale (DES)
DTD and
Culture-bound
syndrome (Dijnnati)
DSM-IV
2 Bayer et al. (29)bJordan Descriptive study 179 Describing the clinical features of
patients who believed they were
possessed or influenced by Jinn.
Psychiatric examination “Possessive disorder”
(Jinn)
No data provided
3 Butt et al. (30) Pakistan Cross-sectional
study
350 To determine the frequency of
anxiety and depression among
patients with dissociative trance
(possession) disorder.
Psychiatric examination
Self-report instrument:
Hospital Anxiety and Depression
(HAD) - Urdu version
PTD ICD-10
4 Castillo et al.
(31)a,b
South Asia Case study 2 Reexamining previously
published cases of spirit
possession from the dissociation
theory perspective.
No data provided “Spirit possession” No data provided
5 Chand et al. (32)a,b Oman Retrospective
chart review
19 out of 111 Retrospective analysis of clinical
manifestations and psychosocial
aspects of dissociative disorders.
Psychiatric examination:
“Information extracted from case
records included demographic
variables, illness variables, and
psychosocial variables [...]
Patients with dissociative trance
disorder presented with altered
state of consciousness,
screaming and irrelevant talk.”
DTD ICD-10
6 Chaturvedi et al.
(33)b
India Retrospective
chart review
84 out of 893 To examine patterns of
dissociative disorders among
subjects attending psychiatric
services over a period of 10
years.
Psychiatric examination PTD ICD-10
7 Das et al. (34)aIndia Retrospective
chart review
2–4 out of 42 Comparing the suitability of
DSM-III-R and ICD-10 criteria for
dissociative states
Psychiatric examination DDNOS (n=2) or PTD
(n=4)
DSM-III-R
and
ICD-10
8 Dein (35) UK Case study 1 To illustrate the relationship
between spirit possession and
psychiatric treatment in a 42
year-old Catholic women.
Psychiatric examination “Dissociative trance
and possession
disorder”
No data provided
9 Delmonte et al.
(20)
Brazil Case study 1 A comprehensive account of
possession experiences,
associated sensations and social
interactions
Clinical interview: Structured
Clinical Interview for DSM-5
(SCID)
Ruled out DID
(“non-pathological
possession”)
DSM-5
10 Etsuko (36)aJapan Case study 1 Comparing folk and psychiatric
interpretations of fox possession.
No diagnostic assessment “Fox possession” No data provided
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
11 Ferracuti and
Sacco (37)a
Italy Case series 10 Clinical assessment of people
with possession-trance states
Clinical interview:
Dissociative Disorders Interview
Schedule (DDIS), Psychological
tests: Rorschach, Standard
Progressive Matrices (SPM)
DTD DSM-IV
12 Ferracuti and
DeMarco (38)a
USA Case study 1 Describing a case of a man with
DTD who was sentenced for the
homicide of a 6-month-old baby
girl during satanic ritual.
Psychiatric examination
Neuroimaging: CT, EEG
Psychological tests: MMPI,
WAIS-R, Rorschach, TAT
DTD and
Histrionic-dependent
personality disorder
DSM-IV
13 Freed and Freed
(39)a
India Ethnographic
study
38 Describing traditional ghost
beliefs and cases of ghost
possession among villagers
No diagnostic assessment “Ghost possession” No data provided
14 Gaw et al. (40)a,b China Case series 20 Describing clinical characteristics
of patients who believed they
were possessed
No data provided “Possession states”
(kwei-fu, dzao-mo,
zhong-xea)
Chinese
diagnostic criteria
15 Guenedi et al.
(41)b
Oman Case study 1 Presenting a case of a man in an
altered state of consciousness
and comparing its
phenomenological features with
functional abnormality in specific
regions of the brain in order to
“link possession to brain
abnormality.”
Psychiatric examination
Neuroimaging: CT, EEG, SPECT
Psychological test: MMSE
An organic pathology:
functional changes in
the temporal lobe and
structural abnormality
in the left basal ganglia
No data provided
16 Hale and Pinninti
(26)a,b
UK Case study 1 Presenting pharmacological
treatment.
Psychiatric examination Dissociative state or
paranoid schizophrenia
“Exorcism-resistant
ghost possession,
successfully treated
with a
depot neuroleptic.”
No data provided
17 Hanwella et al. (6) Sri-Lanka Case study 3 Presenting three patients from
Sri Lanka whose possession
states were strongly influenced
by different religious beliefs and
backgrounds
No data provided “Possession state”
(n=1); “Trance and
Possession State”
(n=1); Acute Stress
Reaction (n=1)
No data provided
18 Igreja et al. (5)bMozambique Cross-sectional
study
175 out of
941
To evaluate the prevalence of
self-reported spirit possession in
Mozambique.
Self-report instruments:
Harvard Trauma Questionnaire
(HTQ)
Questionnaire about spirit
possession experience and
health-seeking behavior
“Spirit possession” (two
subtypes: possession
trance and ku
tekemuka)
No data provided
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
19 Khalifa and Hardie
(3)a
UK Case study 2 Describing cultural, religious and
psychiatric aspects of jinn
possession.
No diagnostic assessment “Jinn possession” No data provided
20 Khan and Sahni
(27)b
Nepal Case study 1 To present a case of possession
syndrome in a 20 year-old Hindu
girl from Nepal.
Psychiatric examination
Assessment by an exorcist
“Possession syndrome” No data provided
21 Khattri et al. (42) Nepal Cross-sectional
study
4 out of 66 To find out the prevalence of
dissociative convulsions type in
psychiatric patients suffering
from dissociative disorder.
Psychiatric examination PTD ICD-10
22 Khoe and Gudi
(43)
China Case study 1 To demonstrate an atypical
presentation of panic disorder
which imitated episodes of
possession trance.
Psychiatric examination
Neuroimaging: EEG, MRI
Panic disorder with
culture specific
symptoms
DSM-5
23 Khoury et al. (44)bHaiti Ethnographic
study
4 To investigate whether
explanatory models of mental
illness invoking supernatural
causation result in care-seeking
from folk practitioners and
resistance to biomedical
treatment.
No diagnostic assessment “Moderate to severe
mental illness”
No data provided
24 Kianpoor and
Rhoades (8)b
Iran Case series 10 Presenting psychopathology of
Djinnati and discussing it in the
light of socio-cultural,
communication, and
dissociation/psychoanalytic
theories.
Psychiatric examination Culture-bound
syndrome (Djinnati) and
PTD or DTD
ICD-10 and
DSM-IV
25 Martinez (23) Puerto Rico Case study 1 Presenting a case of a man with
possession and glossolalia
experiences, the diagnostic and
therapeutic process.
Psychiatric examination DDNOS DSM-IV
26 Mattoo et al. (45)aIndia Case study 10 Describing a case of family
hysteria and issues related to its
medical and social management.
Psychiatric examination
Neuroimaging: EEG
PTD and BPD (n=1)
“Mass hysteria manifest
with possession
attacks and
dissociative symptoms”
(n=9)
ICD-10
27 Mercer (9)aUSA Review study 1 out of 2 Describing the impact of the
Protestant belief system on the
psychopathology and clinical
interventions among children and
adolescents raised in that
religious context.
No diagnostic assessment “Trance state” No data provided
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
28 Neuner et al. (46)bUganda Cross-sectional
study
91 out of
1,113
To estimate the frequency of
harmful spirit possession
phenomena and to evaluate the
validity of harmful spirit
possession as psychological
disorder in the case of Northern
Uganda.
Self-report instruments:
Cen Spirit Possession Scale, The
Violence, War and Abduction
Exposure Scale, Posttraumatic
Stress Diagnostic Scale, Hopkins
Symptom Checklist (Depression
section), Luo Functioning Scale,
Mini International
Neuropsychiatric Interview
(module C for suicide risk),
Perceived Stigmatization
Questionnaire, Aggression
Questionnaire.
Survey about the presence of 12
common complaints or
symptoms (e.g., malaria,
diarrhea, etc.) in the 4 weeks
prior to the screening.
“Spirit possession”
(Cen)
DSM-IV
29 Ng (47)bSingapore Case series 55 Describing the characteristic
features of trance states in three
different ethnic communities
(Chinese, Malays and Indians).
Psychiatric examination DTD DSM-IV
30 Ng and Chan
(48)a,b
Singapore Case-control
study
58 out of 116 To study the psychosocial
stressors that precipitate DTD
and to identify predictors of DTD.
Psychiatric examination:
“Consecutive cases seen at the
psychiatric hospital diagnosed
with DTD were included in the
study. The psychiatric diagnosis,
assigned on the basis of
information obtained in a semi
structured psychiatric interview
and hospital chart review, were
made according to DSM-IV
criteria”
DTD DSM-IV
31 Peltzer (49)aMalawi Descriptive study 116 Describing the nosology and
etiology of Vimbuza experience.
No data provided “Spirit disorder”
(Vimbuza)
DSM-III
32 Pereira et al.
(50)a,b
India Case study 2 Describing cases of possession
by a goddess and an evil spirit.
No data provided “Spirit possession” No data provided
33 Piñeros et al. (51)aColombia Ethnographic
study
9 To describe a collective episode
of psychogenic illness in an
indigenous group (Embera).
No diagnostic assessment “Embera” (Mass
hysteria)
DSM-IV
34 Prakash et al. (52)aIndia Case study 1 Describing a woman a with
precipitation of possession
disorder by treatment with
nortriptyline.
Psychiatric examination
Neuroimaging: EEG
Dissociative epileptic
disorder
ICD-10
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
35 Ross et al. (53) USA Cross-sectional
study
1 out of 100 To determine the prevalence
of classical culture-bound
syndromes among
psychiatric inpatients with
dissociative disorders.
Clinical interviews:
Dissociative Disorders Interview
Schedule (DDIS), Dissociative
Trance Disorder Interview
Schedule (DTDIS)
Self-report instrument:
Dissociative Experiences
Scale (DES)
DTD (n=1)
Culture-bound
syndromes: latah (n=1
1), amok (n=11),
bebainan (n=2 6),
pibloktoq (n=3)
DSM-IV
36 Sar et al. (54)bTurkey Cross-sectional
study
13 out of 628 To determine the prevalence of
possession experiences and
paranormal phenomena among
and their relationships with
traumatic stress and dissociation
in Turkish women.
Self-report instruments:
Childhood Abuse and Neglect
Questionnaire
Clinical interviews: SCID (PTSD
and BPD sections), SCID-PTSD
(17-items part),
Dissociative Disorders Interview
Schedule (DDIS)
“Possession
experiences” and DID
(n=2) or DDNOS
(n=7) or
Depersonalization
disorder (n=2) or
Dissociative fugue
(n=1) or Not
diagnosed (n=1)
DSM-IV
37 Satoh et al. (55)aJapan Case study 1 To illustrate diagnostic difficulties
in patient whose possessive
state and suicidal thoughts were
precipitated by door-to-door
sales.
No data provided (DSM) Brief Reactive
Psychosis and DDNOS
and Somatization
disorder (ICD)
Somatization disorder
and Acute and
Transient Psychotic
Disorder and
Dissociative Disorder
DSM-IVand
ICD-10
38 Saxena and
Prasad (56)a
India Retrospective
chart review
6 out of 62 Presenting clinical characteristics
and subclassification of
dissociative disorders in
psychiatric outpatients in India.
Psychiatric examination Possession disorder
(subcategory of
Atypical Dissociative
Disorder)
DSM-III
39 Schaffler et al. (57) Dominican
Republic
Cross-sectional
study
47 out of 85 To evaluate demographic
variables, somatoform
dissociative symptoms, and
potentially traumatizing events in
the Dominican Republic with a
group of Vodou practitioners with
or without the experience of spirit
possession.
Self-report instruments:
Somatoform Dissociation
Questionnaire (SDQ-5),
Traumatic Experience Checklist –
Dominican Republic (TEC), Spirit
Possession Questionnaire –
Dominican Republic (SPQ);
Interview-based survey (limited
data provided).
Participants were classified as
‘possessed’ upon their positive
answer to a screening question
whether or not they had
experienced full possession by
spirits at least once in
their lifetime.
“Spirit possession” No data provided
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
40 Schieffelin (58)a,b Papua New
Guinea
Ethnographic
study
4 Analyzing the Evil Spirit Sickness
among the Bosavi people of
Papua New Guinea during a
period of intense Christian
evangelization and religious
excitement.
No diagnostic assessment “Evil Spirit Sickness” No data provided
41 Sethi and
Bhargava (59)a
India Case study 7 A description of possession
simultaneously affecting seven
family members.
No data provided “Mass possession
state”
No data provided
42 Somasundaram
et al. (60)a,b
Sri Lanka Cross-sectional
study
90 Describing phenomenology of
possession states among
psychiatric patients, somatic
patients and local mediumship
adepts of Tamil society in
Northern Sri Lanka.
Psychiatric examination (n=30)
No data provided (n=60)
“Possession states”
(n=90)
Psychiatric sample
included patients with:
Schizophrenia (n=16),
Acute psychotic
illnesses (n=6),
Bipolar disorder (n=1),
Dissociative disorder
(n=3), Somatoform
disorder (n=4)
ICD-10
43 Somer (61)aIsrael Case series 4 To describe how patients used
cultural idioms of spirit
possession to describe their
suffering.
No data provided DDNOS / DTD (n=1),
PTSD (n=1),
Schizophrenia (n=1),
Histrionic personality
disorder and
conversion disorder
with seizures (n=1).
DSM-IV
44 Szabo et al. (7)a,b South Africa Case study 1 Describing a female adolescent
with features of DTD as part of
recovery from major depression
following the death of her father
Psychiatric examination
Neuroimaging: EEG
DTD and Major
depressive disorder
No data provided
45 Trangkasombat
et al. (62)a
Thailand Descriptive study 32 To describe epidemiological and
clinical aspects of the spirit
possession epidemic in Thai
girls.
Psychiatric examination
corroborated with a family
interview.
Self-report instruments:
Children’s Depression Inventory
(CDI)
Examination of medical records.
“Mass hysteria”
(n=32)
DSM diagnoses:
Adjustment disorder
(n=9),
Dysthymia (n=1),
Major depressive
disorder (n=2),
Anxiety disorder
(n=1),
Dissociative disorder
(n=1),
Dissociative tendency
(n=1),
Histrionic personality
trait (n=6).
DSM-IIII-R
(Continued)
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 2 | Continued
No. Study Country Study type No. of
participants
Aim Diagnostic procedure Diagnosis Diagnostic
criteria
46 Van Duijl et al.
(24)b
Uganda Case-control
studies
119 out of
190
To explore the relationships
between spirit possession,
dissociative symptoms and
reported potentially traumatizing
events in Uganda.
Self-report instruments: Spirit
Possession Questionnaire
-Uganda (SPQ), Checklist
Dissociative Symptoms for
Uganda (CDS), Dissociative
Experiences Scale (DES),
Somatoform Dissociation
Questionnaire (SDQ), Harvard
Trauma Questionnaire (HTQ),
Traumatic Experiences Checklist
(TEC)
“Spirit possession” No data provided
47 Witztum et al. (63)aIsrael Case study 1 Describing the treatment of a 24
yr-old man with major depressive
disorder who complained about
being persecuted by an angel.
Psychiatric examination Major depressive
episode with psychotic
features and “Hysterical
psychosis”
DSM-III-R
48 Witztum et al. (64)aIsrael Case study 3 To illustrate the Zar phenomenon
and discuss its cultural and
anthropological aspects.
Psychiatric examination
Neuroimaging: EEG, CT
Culture-bound
syndrome (Zar)
ICD-10 and
DSM-IV
aStudies (n =28) reviewed by During et al. (65).
bStudies (n =21) reviewed by Hecker et al. (66).
to Interpretative Phenomenological Analysis (IPA), which is
grounded in phenomenology, hermeneutics, and idiography
(67). IPA explores participants’ experiences and interpretations,
followed by researchers trying to make meaning and comment
on these interpretations. Samples in IPA studies are small,
homogenous, and purposefully selected. Qualitative material is
analyzed in detail case-by-case (67,68). IPA was chosen for this
case study to explore the help-seeking pathways and meaning
attributed to the diagnosis of a Possession Trance Disorder.
Procedure
This case study is part of a larger project examining phenomena
and symptoms reported by people using exorcisms. This project
was held at the Research Center for Trauma and Dissociation,
financed by the National Science Center Poland, and approved
by the Ethical Review Board at SWPS University. Potential
candidates enrolled themselves via a dedicated website, or
were registered by healthcare providers and pastoral counselors.
They filled in demographic information and completed online
tests, including: Somatoform Dissociation Questionnaire [SDQ-
20, (69)], Dissociative Experiences Scale - Revised [DESR,
(70)]. (Elevated scores in these tests, SDQ-20 30 and DESR
72, are suggestive of dissociative disorders). They were
then subjected to semi-structured interviews exploring their
biography, family situation, religious socialization and spiritual
involvement, and motives for enrolling in the study, followed
by a diagnostic consultation using Trauma and Dissociative
Symptoms Interview [TADS-I, (71)]. The TADS-I is a semi-
structured interview intended to identify DSM-5 and ICD-
11 dissociative disorders. It includes a significant section on
somatoform dissociative symptoms and a section about other
trauma-related symptoms. The TADS-I also explores symptoms
indicating a division of the personality and alterations in
consciousness. Interview recordings were assessed by three
healthcare professionals experienced in the dissociation field,
who discussed each case and consensually came up with a
diagnosis based on ICD-11. This interview was followed by an
additional mental state assessment performed by the third author,
who is a psychiatrist. He collected medical data, double-checked
the most important symptoms, confirmed and communicated
the diagnosis and discussed available coping strategies. All
interviews and the medical consultations were divided into 60
min sessions.
Among 23 people who enrolled in the project, 12 had features
of a personality disorder, five had a schizophrenia spectrum
disorder, two met ICD-11 criteria for partial DID, two had
Complex PTSD, one had a Dissociative neurological symptom
disorder, and one had Possession Trance Disorder. The person
with PTD was selected for this analysis. An additional follow-
up interview was performed with her 3 years later to explore
the meaning she had attributed to her diagnosis and how it
influenced her help-seeking behavior. The total length of all
interviews conducted with her was 8 h 46 min.
The Participant
This is a case study of a 42-year-old woman (who will be
called Emma). She had secondary education, was divorced, and
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Pietkiewicz et al. Case Report: Notions of Possession
raised by herself her 10-year-old daughter and 9-year-old son
with autism spectrum disorder. She remained unemployed and
used care allowance. Emma came from a very religious family
and was raised by mother and grandparents. No one used
psychiatric treatment in her mother’s family and there was no
information about that from the father’s side. Her father was
born in a Nazi concentration camp and after the war he relied on
financial compensation. He was much older than Emma’s mother,
aggressive, and abused alcohol. He left the family before Emma’s
first birthday, and reappeared every 6 or 12 months thereafter.
According to Emma, her mother was controlling and turned her
against her father. Emma also perceived herself as a solution for
her mother’s pain after miscarrying a child shortly before Emma
had been conceived.
Emma had a good relationship with her maternal grandfather,
who was supportive and a model of morality and piety. He
led her to develop her interest in religion when she was in
primary school, but he died when she was 15. Around that
time her problems with aggressive or auto-aggressive behavior
started, as well as attention seeking by unlawful behavior
and breaking school regulations. She became rebellious, and
frequently quarreled with her mother who tried to control her
social life and sexuality, before running away from home for a
year to live in squats, abusing alcohol and drugs, and engaging
in risky sexual behavior for money. She was sexually abused
under the influence of substance a few times. In adulthood, she
lived abroad for almost 10 years, earning money by providing
sexual services. During that time she also experienced rape
and threats. As she never had close friends, she only used
support from priests who, based on her life history, believed
she was possessed. She was first exorcized a few times in
charismatic groups at age 16. In adulthood, she regularly used
deliverance ministries and individual exorcisms according to
Roman Catholic ritual for a few years, but her problems and
symptoms persisted.
She had elevated levels of somatoform and psychoform
dissociation (respectively, measured with SDQ-20 and DESR-
PL). More information about her symptoms reported during the
clinical interview and mental state examination is provided in
Table 3.
Data Analysis
Recordings of all the interviews were transcribed verbatim
and analyzed together with researchers’ notes using qualitative
data-analysis software (MaxQDA 2020 ver. 20.4.0). Consecutive
IPA procedures were employed in the study (68). Researchers
watched each interview and read the transcripts carefully. They
individually made notes about body language, facial expressions,
the content and language use, reported symptoms, and wrote
down their interpretative comments using the annotation feature
in MaxQDA 2020. Next, they categorized their notes into
emergent themes by allocating descriptive labels. They then
compared and discussed their diagnostic insights, coding and
interpretations. They analyzed connections between themes
and grouped them according to conceptual similarities into
main themes.
Credibility Checks
During each interview, the participant was encouraged to
illustrate reported symptoms or experiences with specific
examples. Interviewers asked clarification questions to negotiate
the meaning the participant wanted to convey. At the end of
the interview, she was also asked questions to check that her
responses were thorough. The researchers discussed her case
thoroughly, including the diagnosis and interpretative notes to
compare their understanding of the content and its meaning (the
second hermeneutics).
RESULTS
Emma shared in detail her life history, symptoms and coping
strategies. During the follow-up interview (3 years after her
assessment), she also described what it meant for her to be
diagnosed with possession-trance disorder and how the diagnosis
affected her help-seeking. Seven salient themes were identified
during the analysis: (1) Excitement and guilt for crossing
the taboo, (2) Seeking revenge on priests, (3) Possession-
form presentations attracting public attention, (4) The idiom
of possession, (5) Exacerbation of destructive behavior during
exorcisms makes priests helpless, (6) Making sense of the
psychiatric diagnosis, (7) Receiving pastoral counseling as an
alternative to professional treatment.
Each theme is discussed and illustrated with verbatim excerpts
from the interviews, in accordance with IPA principles.
Theme 1: Excitement and Guilt for
Crossing the Taboo
Emma remembered being introduced to sex when she was
six. Secret sex games with her 10-years-older cousin triggered
excitement and pleasure, and at first she didn’t think of them
as harmful. It was only while preparing for her first communion
that she learned during confession this was forbidden, shameful
and sinful.
It started when I was six. It influenced me because it woke me up
too soon and made me sexually licentious later on. I have never
talked about it. . . it was during my confession that I admitted
“playing immodestly.” The priest wasn’t satisfied and wanted to
know the details, he asked who it was with, but I couldn’t tell him.
I’ve always taken the blame.
In her secondary school, she repeatedly broke the rules and urged
boys to masturbate in class. This excited her and could also make
her feel she had control over their sexuality.
I ignored teachers and showed them I did not care. I didn’t listen
to them at all. I was also so promiscuous. I always sat on the last
bench with the boys and forced them to masturbate. I was just
very promiscuous.
In her adult life, sexuality became an important arena for
inner struggles and conflicts, evoking strong guilt and self-
loathing. Emma described sexual desire as “hell,” “the source of
corruption” and “mental weakness.” There were periods when
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Pietkiewicz et al. Case Report: Notions of Possession
TABLE 3 | The participant’s clinical presentation based on TADS-I profiles.
Treatment history She reports three hospitalizations in the past: first, at age 17, after overdosing drugs and alcohol but being wanted due to
having run away from home, she also ran away from the unit; second hospitalization at age 23 and the third one abroad at
age 25—both after suicide attempts; no medical records available. She has never used counseling or psychotherapy.
Substance use Alcohol—at age 15 she started to drink beer, wine and vodka; but is unable to define quantity and frequency. Currently
drinks recreationally and seldom. Drugs—used marihuana every day for a few years from age 17, sometimes used heroin
and LSD (especially when living in squats). During her stay abroad, used cocaine several times a month for six months.
Currently no drugs. Medication—as a teenager, she stole diazepam and other tranquilizers from her mother. At age 17,
frequently obtained them on prescription, and mixed them with drugs and alcohol.
Problems with eating Doesn’t report.
Problems with sleep Doesn’t report.
Mood and affect regulation Her mood fluctuates depending on daily problems (son’s school problems and court cases). She has felt depressed and
abandoned since ending an intimate relationship with a priest, and been left without support. She has had frequent
fantasies of committing suicide by hanging herself on a stole, or stealing the host and putting it into her vagina during
intercourse to profane sacred objects. She tends to lose control over sexual or aggressive impulses a few times a month.
She maintains this is triggered by prayer and leads to alterations in consciousness. After regaining control she feels
ashamed and guilty for what she has done (e.g., sending offensive text messages to her spiritual director).
Fear and panic She doesn’t report clinically significant symptoms. No intrusive memories, avoidance or panic attacks.
Autodestructive behavior She doesn’t report any self-mutilation. Suicide attempts, substance abuse and prostitution in the past. During the episodes
of losing control, she sometimes hits the wall.
Self image and identity She reports many conflicts associated with her sexuality, need for attention, and expressions of anger. She feels guilty for
things she has done in the past, contradicting her values and religious beliefs. She also describes herself as strong,
stubborn, and reluctant to follow rules. She thinks she is different from other people, spiritually sensitive. She also expresses
remorse that she is not as good a mother as she thinks she should be.
Problems in relationships She reports a great sense of isolation, abandonment and loneliness. She also reveals a great need for attention and being
acknowledged. She justifies her tendency for social withdrawal with shame about the work she did abroad. She maintains
superficial relationships with people and mainly relies on support offered by clergy. At the same time, she expresses distrust
and disappointment in authority figures (teachers, priests). She also feels rejected by the Church after being forbidden to
receive the sacrament of penance unless she starts psychiatric treatment. She seeks revenge by using phone or Internet to
initiate contacts with men declaring to be priests, exchanging pornographic content, and encouraging them to have sexual
conversations. All this proves to her they are dishonest and sinful. She declares having no lay friends and being fully
committed to her children.
Problems with sexuality She denies problems in intimate relationships, although she has been avoiding sexual relations for the last 10 years. During
her stay abroad, she offered sex for money, often felt numb and detached from emotions. She also reports having been
raped. She feels guilty and ashamed of her past but reports no intrusive memories associated with these incidents. She is
afraid of overindulging herself in sex or entering sexual relationships with “the wrong men,” thereby putting her children in
danger. Sex-chats with alleged priests evoke in her strong excitement and remorse.
Alterations in consciousness Depersonalization—she frequently felt emotionally detached and numb for short periods of time and without clinical
significance. Derealization—a sense of being “on a carousel” in stressful moments or during religious activities, leading to
aggression.
Somatoform symptoms She reports “seizures” at home, during which she is unable to move, and trembles, but remains aware of her daughter
calling the exorcist for help. She also has convulsions during exorcisms accompanied with rage (biting, kicking, swearing,
destroying objects), corresponding to the stereotype of the possession episode—twice a month.
Psychoform symptoms She does not report amnesia for daily events. She declares some memory gaps for trance episodes at church or events
happening when she abused alcohol and drugs.
Schneiderian symptoms—she has an impression of hearing male voices which encourage her to commit suicide, flirt with
priests, or criticize her. Rather than hearing them acoustically, they seem like voiced, intrusive thoughts, which she
experiences as ego-dystonic and attributes to “the voice of evil.” She does not report any thought broadcasting or
Messianic delusions.
Symptoms indicating a division of self There is no evidence for the existence of autonomous dissociative parts.
PTSD symptoms She does not report any.
Summary and diagnosis She maintains proper orientation, good verbal contact, affect in normal range, denies hallucinations and does not express
delusional content, nor provide evidence of it during the interview. She reports episodes of derealization and
depersonalization accompanied by partial amnesia limited to changes in behavior and speech, and convulsions. Basic
mood and drive within normal limits, proper sleep. She reports problems with self-image and interpersonal relationships
which can be interpreted as symptoms of a personality disorder. There is history of suicide attempts but currently does not
report suicidal ideations. There were also episodes of using psychoactive substances but she now abstains from them.
Changes in behavior and speech with associated alterations of consciousness occur in an isolated manner during religious
practices but also at home. This meets the premises for the diagnosis of trance and possession disorders. There are no
obvious symptoms of complex dissociative disorders. Her symptoms can be understood in relation to difficult experiences
and conflicts about experiencing needs for attention, dependence or unacceptable emotions, such as desire or anger. Her
conflicts are additionally reinforced by cultural and religious norms internalized during socialization.
F44.3 Trance and possession disorders; Features of personality disorders.
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Pietkiewicz et al. Case Report: Notions of Possession
she suppressed her needs and abstained from sex and episodes of
promiscuous behavior, prostitution, and abusing sexual partners.
It seems that eroticism, which she used to regulate her emotions,
may have taken the form of a behavioral addiction.
All this sexuality was hell and I would like to spare my children
that. Erotica may seem like some kind of beautiful sensory
stimulation, but in fact it is losing control over yourself. . . I was
trapped in the claws of erotica, I was so spoiled in that regard. I
often met guys who told me that I was hurting them. I just used
them only for sex and treated them as objects. I think it was my
way of avoiding getting hurt. I would rather take advantage of
someone and abandon him, before he could do that to me.
She did seem to have some insight into her problems with
attachment and might have used sex to gain control and hide
her vulnerability. She thinks this allowed her to avoid emotional
involvement with men.
Theme 2: Seeking Revenge on Priests
In Emma’s mind, the Church forbade expressing sexual desire,
and commanded abstinence by inducing guilt, shame, and sin.
Some priests, like her older cousin when she was a child, both
aroused her and were experienced as forbidden targets. She
recalled an early exorcism:
These men were holding me face down on the floor. The priest
sat on the back of my legs. He kind of lay down on me, holding
my hands. He started stroking my hair saying “Accept this love
of Christ” and. . . my body reacted against all reason. I also felt
discomfort, because. . . something happened to me. For the first
time I realized I had never thought about a priest before in that
way. Looking at a priest, even a handsome one, I had never seen
a man, but someone asexual. However, after this exorcism, I had
erotic thoughts about him, for 2 weeks. It may have been because
I had not been so close to a man for a long time, but common
sense won and these emotions subsided. I broke off contact with
this exorcist.
When she addressed these moral conflicts with her spiritual
father, he first used confession and prayers to help her control
sexual impulses. However, she said the relationship evolved into
a love affair which made her feel guilty for crossing the taboo.
She justified the priest’s actions saying it gave her pleasure, which
sounds like another repetition of her childhood history.
We became close and finally crossed the physical boundary
between a man and a woman. I was not harmed in a physical
sense, because it gave me pleasure. It had such an impact on me.
Suddenly the whole world, even this whole image of the church,
was blown up. I realized I had not overcome my weakness.
In order to deal with conflicting feelings she was seeking men
who introduced themselves as priests, engaging them in sex
chats and exchanging pornography, subsequently seeing them as
equally sinful.
My confessor said we must stop seeing each other, that he was
afraid of being alone with me. So I felt really alone. I got really
into this virtual reality and started looking for priests who were
addicted to erotica. I set up a profile called “Lady for a Priest”
and they started contacting me. It was some kind of revenge on
my part. Erotica with a normal guy ceased to be attractive—all I
wanted was a clergyman. Saturday nights were so exciting, I told
them all sorts of things and they masturbated and we exchanged
photos. I thought of them celebrating Holy Mass the next day in a
state of sin—I felt like a vampire feeding on their weakness, but it
also hurt me a lot.
In her mind, Emma seemed to attack and destroy any ideas
about the virtues of a person representing authority, morality,
or ethics. This could have been a payback for being shamed
for her sexuality and for being abandoned. It may also have let
her experience moral triumph. However, she also realized that it
brought about feelings of loss and pain.
Theme 3: Possession-Form Presentations
Attract Public Attention
Emma learnt from her participation in religious youth camps that
unusual behavior which group members ascribed to possession
evoked awe and interest and could also lead to receiving special
attention for which some adolescents competed.
I got involved in the Oasis movement when I was 15, and was
encouraged to participate in a so-called Community Day, a kind
of preliminary meeting and excursion. There were three other
girls who were acting weird. One started having convulsions while
singing. The priests surrounded her. . . they were st anding tightly
in a circle, so that no one could see what they were doing. I was
really curious and wanted to see what was happening. Since I
couldn’t break through, I crouched to the side and said: “Satan, if
it’s your doing, leave her and enter me. I remain at your disposal.”
At this point, I lost my temper.
This was the first time Emma’s disruptive (violent) behavior
was accompanied by derealization and convulsions. She later
compared that state to feeling dizzy, as if “riding on a merry-
go-round.” Emma remembered being given tranquilizers, which
had a delayed effect. She emphasized this was unusual, which
for herself and witnesses could have justified the supernatural
causation of her state. She saw that youth camp experience as a
turning point in her life, leading to further problems, spiritual
conflicts, and concentration on religious coping strategies.
It was like being on a merry-go-round, a carousel. My clothes were
torn—I fell on stones. The priests went on praying over that girl
and after a while she calmed down. I calmed down too and we
continued walking, but after a few meters I lost my temper again.
It was awful. They called an ambulance and gave me sedatives
but it had no effect. A priest said it was a dose for a horse, and
it didn’t work for me! It was only when the doctor took me to the
ambulance away from the priests that I fell asleep so deeply that it
was difficult to wake me later. My life has never been normal since.
Since then, in religious contexts Emma regularly experienced
bouts of anger, convulsions, and derealization, which subsided
when no priest was present. Religious people interpret that
as aversion to the sacred—clergy see that as one criteria of
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Pietkiewicz et al. Case Report: Notions of Possession
genuine possession. Her attacks attracted the attention of others
and, over time, she engaged in more provocative and socially
unacceptable actions. For example, during youth camps she killed
and sacrificed a cat. Another time, she had a possession-form
presentation after a demonology lecture held at her Catholic
high school.
I couldn’t resist the temptation to do it, consciously and
voluntarily, in front of them. . . I did a kind of ritual, I grabbed
a cat and tore it apart with my hands. Then I offered it to
Satan. . . total madness. Today I am terribly ashamed of it and
I can’t forgive myself. These girls were horrified because I tore
apart a living creature, and most of them came from traumatized
backgrounds. . . Once a priest came to our school and gave a
talk about demonology. Me and other girls were preparing the
setting and some songs for the holy mass. At one point, as I was
going upstairs, I lost it. . . I started screaming, throwing myself
around and hitting myself hard. . . A girl in my class attempted
suicide by taking pills, and then another one. The nuns said it was
my influence.
She emphasized that she knew what she was doing and apparently
had no amnesia. Despite attributing aggressive impulses to
demonic influence, she nevertheless feels guilty and ashamed
of her actions. She also realized that she could negatively affect
other people, which could also give her a sense of significance
and power.
More recently, Emma experienced a strong temptation to
steal the host with the aim of profaning it, or fantasized
about committing suicide by hanging herself on a priest’s stole.
These actions shocked and were criticized by the clergy, but
were also justified as the manifestations of evil, releasing her
from responsibility.
For me, the black mass was the most perfect form of profanation,
when the Blessed Sacrament is stolen and placed inside a vagina,
preferably just before intercourse. And when the sexual act is
done with a priest, it would be the so-called double profanation.
I brought home the host and was going to profane it. Not only
that. . . I was planning to comm it suicide in a typical s atanic ritual
of death. I wanted to hang myself on a stole which I had stolen
from the church.
Her ideas, which sound as if they were inspired by the Story
of the Eye by Georges Bataille (72) were popular among people
she met in squats, and became banned by the Church. There is
no information whether Emma was familiar with such texts, but
using the expression “so-called double profanation” suggests she
shared common knowledge about the libertine movement.
Theme 4: The Idiom of Possession
Emma has extensively studied literature about demonology and
watched local exorcists preaching on YouTube about “spiritual
threats” and “spiritual warfare”. This has made her believe that
premature or unwanted sexual activity, interest in occultism,
exposure to foreign symbols, philosophies and treatments (e.g.,
magnetic healing) can make one prone to demonic possession.
When I was a child, the first bad thing that happened to me
was the attack on my innocence, sexual I mean. That evil
was silent, unnoticeable. Later, my grandmother took me to a
magnetic healer, which only made things worse. You know, there
is bad energy which can be transferred, because God does not
bestow such healing powers. If he heals, it only happens through
sacraments and prayer. Later, as a child, I had trouble praying.
Every time I knelt down to pray, I felt that my prayer was wrong.
Something prevented me from finishing it, so I had to get up and
start over. These are things that led to this evil. And then it just
got worse and worse when I got involved in drugs.
She also believed in so-called “manifestations” associated with
the “aversion to sacrum.” These possession-form presentations
are regarded as indicators of possession in a theological sense,
and are often discussed by religious community members. Emma
observed that since her first “possession” experience at the Oasis
gathering (see: Theme 3), she grows agitated, angry, and gets
convulsions during prayers. On the other hand, all her symptoms
subside when she is not involved in religious matters. This only
reinforced her belief that she is truly possessed.
I was recently playing with my kids at home and suddenly I started
shaking. This merry-go-round appears and I bounce off the wall
like a ball. I later found out that when this happened the priest was
praying for me (my daughter knows him and called him for help).
If he prays, it only prolongs everything. If he does not pray, my
children call me back, they shout “mommy, mommy, mommy,
then I follow their voices and quickly return to my senses. The
worst thing was when my daughter turned on the speakerphone
and I could hear that priest praying. I had asked him never to do
that when I was at home with the children, so that they are not
threatened. It is not about me, but about the children. I don’t
want them to witness that. Unfortunately the priest. . . I guess,
my daughter felt safe because he was praying. Maybe she felt she
wasn’t alone, but it only prolonged everything.
This reveals interesting interactions between Emma, her children
and the exorcist. She seemed to experience conflicts about
receiving attention and help. Her daughter sought refuge in
the fatherly figure but, according to Emma, this only escalated
her symptoms. She partially identified with the feelings of
helplessness and abandonment of the 10-year-old girl, but also
saw herself as a potential source of threat for her children.
During the interview, she reported strong temptations to
do unacceptable things, which she ascribed to “inner voices”
but denied having auditory hallucinations per se. Her “voices”
were thought-like experiences and represented good and evil.
Sometimes, she engaged in inner dialogues with them.
I have three voices inside and sometimes I talk to them. There
is the good side which usually speaks softly, calms me down,
and develops some sense of peace. The second voice usually
exerts pressure. And there is my voice, that of my psyche, which
questions the previous one and tries to make sense of it all.
Rather than perceiving them as an expression of her own
mental activity, she attributed these thought-like voices to the
supernatural, saying only individuals who believe in God could
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Pietkiewicz et al. Case Report: Notions of Possession
understand the spiritual dimension of such phenomena. She
emphasized that they need to resolve conflicts between their
instincts and moral values. The struggle between good and
evil is not merely symbolic in her narrative, but attributed to
concrete entities.
In order to understand these voices, one must acknowledge the
existence of God because, if we reject the existence of God, the
existence of these voices becomes irrational. Every Christian has
this dimension of the struggle in his conscience. There is a good
side, and there is a bad side.
Emma had endorsed and identified with the concept of
possession and navigated between its clinical and theological
meanings. Despite multiple and ineffective exorcisms, she seemed
reluctant to accept priests’ suggestions that she might have a
psychological disorder. Even a clinical diagnosis, according to
her, did not rule out spiritual causation of problems.
Even if someone is mentally ill, it does not mean that no devil’s
work is involved here, because the devil can work through disease.
Satan wants to drive as many people as possible away from God.
He will take advantage of every disease, every weakness or flaw
which he can use to do evil.
She maintained that genuine spiritual possessions are uncommon
but do occur and prove to the faithful the existence of
the supernatural.
I think possession, from this theological point of view, is
something which rarely or practically never happens. And when it
does happen, it’s like a sign from God to confirm that this spiritual
world exists.
Theme 5: Exacerbation of Destructive
Behavior During Exorcisms Makes Priests
Helpless
First attempts to expel evil spirits from Emma began when she
was 15. She took part in deliverance ministries organized in a
Christian group where the pastor and his male assistants took
her aside and tried to tame her. Her agitation and resistance was
interpreted as a sign of possession. Emma managed to escape one
such event and, when news about this spread, the local parson
and her mother forbade her from joining that group again.
They picked me up a few times and took me to the church. In
this Christian community, a group of men—the pastor and his
assistants—took me to a separate room and simply tried to force
the evil spirit out of me. When I resisted, they used physical
force. . . they tied my hands, they sat on my legs, someone sat
on my arm. They hit me and used gestures to chase away the
evil. It was like in American films. I felt they were crossing
my boundaries but when I tried to protest they saw it as the
manifestation of evil. It was painful and I was bruised and torn.
I broke free once and ran away, leaving my things behind. I
went to the parish and asked for help. The parish priest and my
mother were told about everything and they insisted I never go
there again.
Because her behavior was inappropriate and scandalous in high
school, nuns who ran the school sent her to an exorcist. During
this and subsequent rituals she grew more and more violent,
offended priests, damaged chapels, and became even more
furious when they tried to restrain her.
After leaving hospital [after a suicide attempt], I sought help in the
parish. One priest arranged a meeting for me at the church with
three other priests who wanted to pray with me, but I just. . . just
demolished the church. I smashed figures, windows, and broke
benches. They were unable to do anything and even called the
police. The priest said he couldn’t help and I must be taken to
an exorcist.
Being labeled as “possessed” legitimized Emmas aggressive
behavior toward authority and allowed her to feel she had
special spiritual significance. It was also the source of secondary
gains: she received special attention and emotional support from
clergy. Perhaps this is why she was reluctant to give up on
the priests, even when there was no improvement and they felt
helpless against her behavior. Over time, she consulted different
exorcists who subjected her to exorcism, until they questioned
her possession and insisted on a psychiatric consultation.
I visited the Pauline order for the deliverance ministry and was
flailing around all day. After praying over me for a long time
they gave up and said it might be a mental illness because the
prayers weren’t working. They hoped I would change and calm
down under their influence but I was flailing as long as they
were praying. Finally, they came to the conclusion that I must be
mentally ill and the Church could not help.
Theme 6: Making Sense of the Psychiatric
Diagnosis
Emma obediently went for a diagnostic appointment as if on her
own initiative. She revealed some disappointment with exorcists
who had tried to help her. She saw them as helpless and confused,
but also ascribed a certain level of arrogance to them.
I would like someone to look at my experiences from a different,
specialized perspective, unlike the one provided by priests. There
are many exorcists in Poland but these priests are very confused,
although they think they are wise and know best.
She seemed certain in her beliefs about demonic agency and was
reluctant to consider alternative explanations for her aggressive
and sexual impulses. Despite receiving psychoeducation about
emotional regulations and the meaning of PTD, she felt
that by using the term “possession” clinicians only supported
her theories.
In the follow-up interview 3 years later, Emma could not
hide her disappointment that the priests had lost interest in her
case. It seems that receiving a medical diagnosis was an excuse
for them to stop further exorcisms and deny her sacraments
unless she started psychiatric treatment. Paradoxically, Emma
said this proved their fear and helplessness about her being
genuinely possessed, which she thinks was only confirmed by
mental health specialists.
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Pietkiewicz et al. Case Report: Notions of Possession
This diagnosis is not so clear. . . In people from outside, it
evokes. . . because if something is not clearly specified, indicated
in writing, then you may still hesitate and have different
theories. When they have confirmation that they are dealing
with something. . . For example, when I gave this [report] to
the confessor [takes a loud breath], when he read “trance and
possession,” for him there was no medical dimension, he wasn’t
thinking in medical or psychological terms, but theological. In
theological terms, there is some force, a force that is beyond your
powers. . . I came to the conclusion that before I had this [PTD]
diagnosis, they kept trying to help me and willingly controlled my
life. But when they realized I was possessed, they just stopped
because it was too overwhelming for them. . . They completely
rejected me, avoided any kind of services, confession.
Subsequently, she also broke her contacts with charismatic
groups and moved to another town. She still celebrated
holy mass every Sunday but withdrew from all groups and
focused on helping her children adapt to a new environment.
Her convulsions and derealization (feeling of merry-go-
round) disappeared.
Theme 7: Receiving Pastoral Counseling
as an Alternative to Professional Treatment
Although being denied further exorcisms caused Emma to
leave the charismatic groups, she seemed reluctant to use the
professional treatment which was recommended to her after the
diagnostic consultation. She professed faith in providence, saying
mental health professionals could potentially express God’s grace,
but never pursued any therapy.
Divine providence shows us the way forward, which can even
be in the form of therapeutic help. God does not work in a
supernatural way but through everyday life, also through lay
people rather than priests.
Perhaps this was her way for rebelling against the priests who told
her that treatment was a condition sine qua non for receiving the
sacraments. Instead, she moved to a new town and completely
changed her environment. She also found a compromise solution
in the form of pastoral counseling. Emma said she liked her
new spiritual director and accepted his strict rules regarding
appointments and timing.
I met a young priest in the confessional. I asked him for so-called
spiritual direction and he agreed. I felt obliged to show him this
[diagnostic] report and he wasn’t scared [that I was possessed].
I was surprised by his maturity and willingness to serve other
people. This priest.. . he treats me completely differently. He
sticks to our arrangements, which is very cool. For example, as
time passes and we are about to end.. . we start punctually at 4:00
p.m. and as 4:45 is approaching, he nicely sums up what we have
talked about. He teaches me about boundaries.
DISCUSSION
Emma has a history of problems relating to attachment,
emotional regulation and self-image indicating features of a
personality disorder. She also reported somatoform symptoms
accompanied by alterations in consciousness. Her ‘attacks’ were
not only limited to religious rituals or other situations associated
with the church but also occurred outside the religious context.
For this reason, PTD was an adequate diagnosis, despite her
evident personality problems.
People reporting possession are a heterogenous group from
the diagnostic perspective. Clinicians need to consider conditions
other than PTD potentially valid categories, in particular:
personality disorders (13), complex dissociative disorders or
PTSD (20,21,54,73) or psychosis (14). Analyzing stressful
experiences, existing psychological conflicts and the pathways to
the disorder can shed light on mechanisms behind alterations
of consciousness and behavior, and potential gains from illness
(4,31). This was possible to see in our case study.
Exploring the complexity of ego-dystonic behavior may
also reveal if possession-form presentations merely express
conflicting and disowned emotions and needs, or reflect a more
complex dissociative structure. In the former case, endorsement
and identification with the possession can help people justify
their shameful aggressive or sexual acts. In a similar way, people
with false-positive DID use the learnt concept of alternative
identities or parts to receive attention or express conflicting
emotions (74). In a more fragmented psyche, however, the
possessing agent can embody an autonomous dissociative part
with a first-person perspective. Their degree of mental autonomy
and complexity may differ—from simple ego-dystonic parts
embodying particular ego states (e.g., rage), to fairly complex,
characterful parts with their own sense of identity, motives,
and memories.
According to ICD-11, the boundary between PTD and DID
lies in the attribution of the possessing agent: external in PTD and
not external in DID/Partial DID. There seems to be no scientific
evidence for that distinction. Moreover, clinical observations
indicate that DID patients experience their alternate identities
as alien and ego-dystonic, therefore the external / internal
attribution is not very clear in them (75).
We also share doubts about the validity of PTD. Its diagnostic
criteria include both symptoms (changes in behavior and
sense of identity accompanied by alterations in consciousness)
and meaning which patients attribute to them. This way of
formulating diagnostic criteria would rather justify treating PTD
as a culture-bound syndrome. Whereas, culture shapes the way
in which people express and interpret their symptoms, and
possession by the goddess Kali, devil, or evil spirits in a Buddhist
context may present itself differently, Ross et al. (53) postulate
that there is an underlying dissociative pathology in people with
culture-bound syndromes which should be carefully examined.
This means that in making a diagnosis clinicians should focus on
symptoms rather than ascribed meaning.
Further research is also necessary to assess the usefulness of
a PTD diagnosis, as this category can have serious implications
for patients, their families and spiritual community, and even
healthcare providers. In those who use religious services, it
can reinforce the belief in the supernatural causation of their
symptoms, make them reluctant to use recommended treatment
and overemphasize religious coping. Externalization of conflicts
does not necessarily promote seeing and embracing unaccepted
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Pietkiewicz et al. Case Report: Notions of Possession
impulses as one’s own. While this may be functional, it may
block further development and be iatrogenic (13). Furthermore,
the double meaning of “possession” (as a cultural and medical
concept) makes it difficult for some specialists to think about
their patients in strictly clinical terms. Subsequently, they
consider “genuine possession” as a possible explanation for
reported symptoms (12,25,26). Because of the religious
connotations, we recommend to reconsider the name and
diagnostic criteria of PTD. It might be more appropriate to
use the 6B6Y category in ICD-11 (Other specified dissociative
disorders) for people with this clinical presentation, similarly
to DSM-5.
Feeling trapped between the cultural and medical notions of
possession can influence the way mental health professionals
collaborate with clergy in diagnosing and treating patients with
possession-form presentations. For some, it may be difficult to
maintain clear professional boundaries: identify and describe
symptoms of clinical significance, formulate accurate diagnosis,
and offer psychoeducation and treatment, at the same time,
staying culturally sensitive and understanding the need for
spiritual support sought by patients. The role of the clinician is
not to exclude the spiritual causation of reported symptoms but
to offer an alternative understanding of psychological conflicts
and unmet needs.
LIMITATIONS AND FURTHER DIRECTIONS
IPA studies, being focused on how people experience phenomena
and meaning-making, are naturally limited to small samples or
even case studies. Care should be taken in drawing conclusions
from such qualitative studies and further research using rigorous
methodology is required to explore problems and illness behavior
in people with possession-form presentations. More studies
are necessary comparing PTD with other dissociative disorders
(Partial DID and DID), analyzing in particular different clusters
of symptoms and emotional regulation. Longitudinal studies
exploring the development of symptoms and help-seeking
pathways, and meaning attributed to the medical and folk
diagnoses are also recommended.
CONCLUSIONS
Our review of literature shows that PTD requires further
scientific evidence to remain a valid clinical diagnosis. Thorough
diagnostic assessments should be applied to people reporting
possession-form presentations, not only exploring their
phenomenological features, but also accompanying problems
and symptoms. Use of the term “possession” by mental health
professionals is also burdened with social consequences. It can
reinforce patients’ beliefs about the supernatural causation of
problems and affect help-seeking. We thus stipulate that the
“Other” specified dissociative disorders category in ICD-11 could
be more appropriate for people with this clinical presentation.
DATA AVAILABILITY STATEMENT
The datasets presented in this article are not readily available
because Polish law regarding medical history and the guidelines
of the Ethical Board do not allow distributing the transcripts of
the interview or psychiatric assessment. This material contains
patient’s identifiable information. Furthermore, transcripts
include about 70 pages of text in Polish which cannot be
translated and edited to mask patient’s details. Requests to access
the datasets should be directed to ipietkiewicz@swps.edu.pl.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by Ethical Review Board at the SWPS University
of Social Sciences and Humanities. The patients/participants
provided their written informed consent to participate in
this study. Written informed consent was obtained from the
individual(s) for the publication of any potentially identifiable
images or data included in this article.
AUTHOR CONTRIBUTIONS
IJP developed the concept of this research, collected clinical data,
analyzed literature and transcripts, and wrote manuscript. UK
transcribed interviews and helped in literature review and data
analysis. RT performed psychiatric assessment, participated in
analyzing interviews, and reviewed the manuscript. All authors
contributed to the article and approved the submitted version.
FUNDING
This work was supported by a research grant from the National
Science Centre, Poland: 2017/25/B/HS6/01025.
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Frontiers in Psychiatry | www.frontiersin.org 19 May 2022 | Volume 13 | Article 891859
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Purpose The main objective of this study was to test the psychometric properties of the Polish version of SDQ-20 and the capacity of this instrument, alongside a set of five questions derived from it (SDQ-5), to screen for dissociative disorders. The Somatoform Dissociation Questionnaire (SDQ-20) has been used in many language versions to evaluate the severity of somatoform dissociative symptoms, but no such tool has existed in Polish. Basic procedures Both pen-and-paper (p&p) and online versions of SDQ-20 were tested. Validity and reliability were examined in a sample of 597 participants in non-clinical (N = 323) and clinical (N = 274) groups, who completed the tests p&p (N = 79) or online (N = 518). The mixed-clinical group included 20 patients diagnosed with dissociative (conversion) disorders using TADS-I, and people with other disorders. Main findings The Exploratory Factor Analysis with Principal Component Analysis method of parameter estimation without rotation confirmed unidimensionality of p&p and online versions of SDQ-20. Psychometric properties of the original SDQ-5 were unsatisfactory. Subsequently, an alternative version (PSDQ-5) with a different set of questions derived from SDQ-20 was examined. Reliability of both versions was corroborated by a Cronbach's alpha coefficient (SDQ-20 > .84, PSDQ-5 > .74). The cutoff score maximising sensitivity and specificity was 29.5 (SDQ-20) and 7.5 (PSDQ-5) for dissociative (conversion) disorders (SDQ-20: sensitivity of 95.0% and specificity of 75.6%; PSDQ-5: sensitivity of 95.0% and specificity of 65.9%). People with dissociative disorders had significantly (p< .001) higher scores in SDQ-20 and PSDQ-5 than patients with other disorders and non-clinical participants (criterion validity). Principal conclusion SDQ-20, administered p&p or online, proved to be a reliable tool for the screening of dissociative disorders in Poland. An alternative set of five questions (PSDQ-5) derived from the main instrument also presented good psychometric properties.