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

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.  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.  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.  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.  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.

Related papers:

title: Dissociative Symptoms and Reported Trauma Among Patients with Spirit Possession and Matched Healthy Controls in Uganda
abstract: Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

title: SPIRIT POSSESSION REVISITED: Beyond Instrumentality
abstract: Spirit possession commonly refers to the hold exerted over a human being by external forces or entities more powerful than she. These forces may be ances­ tors or divinities, ghosts of foreign origin, or entities both ontologically and ethnically alien. Some societies evince multiple spirit forms. Depending on cultural and etiological context such spirits may be exorcised, or lodged in relatively permanent relationship with their host (or medium), occasionally usurping primacy of place in her body (even donning their own clothes and speaking their own languages) during bouts of possession trance. Possession, then, is a broad term referring to an integration of spirit and matter, force or power and corporeal reality, in a cosmos where the boundaries between an individual and her environment are acknowledged to be permeable, flexibly drawn, or at least negotiable. Recent studies (e.g. 39, 114, 173, 210) suggest that spirit possession rests on epistemic premises quite different from the infinitely differentiating, rationalizing, and reifying thrust of global material­ ism and its attendant scholarly traditions. Because it appears dramatically and intransigently exotic, unrecognizable to those so schooled (but see 1, 34, 79, 103, 104; also 147: 132), possession continues to hold the anthropological gaze despite heroic attempts to tame it, render it harmless or understood. In contrast to anthropological accounts of the body (145) or of time (162), spirit posses-

title: Evaluation of the evidence for the trauma and fantasy models of dissociation.
abstract: The relationship between a reported history of trauma and dissociative symptoms has been explained in 2 conflicting ways. Pathological dissociation has been conceptualized as a response to antecedent traumatic stress and/or severe psychological adversity. Others have proposed that dissociation makes individuals prone to fantasy, thereby engendering confabulated memories of trauma. We examine data related to a series of 8 contrasting predictions based on the trauma model and the fantasy model of dissociation. In keeping with the trauma model, the relationship between trauma and dissociation was consistent and moderate in strength, and remained significant when objective measures of trauma were used. Dissociation was temporally related to trauma and trauma treatment, and was predictive of trauma history when fantasy proneness was controlled. Dissociation was not reliably associated with suggestibility, nor was there evidence for the fantasy model prediction of greater inaccuracy of recovered memory. Instead, dissociation was positively related to a history of trauma memory recovery and negatively related to the more general measures of narrative cohesion. Research also supports the trauma theory of dissociation as a regulatory response to fear or other extreme emotion with measurable biological correlates. We conclude, on the basis of evidence related to these 8 predictions, that there is strong empirical support for the hypothesis that trauma causes dissociation, and that dissociation remains related to trauma history when fantasy proneness is controlled. We find little support for the hypothesis that the dissociation-trauma relationship is due to fantasy proneness or confabulated memories of trauma.

title: 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
abstract: Introduction and aimsAs 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.MethodsA 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 conclusionIllness 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.

title: Experiences of Possession and Paranormal Phenomena Among Women in the General Population: Are They Related to Traumatic Stress and Dissociation?
abstract: This study sought to determine the prevalence of experiences of possession and paranormal phenomena (PNP) in the general population and their possible relations to each other and to traumatic stress and dissociation. The study was conducted on a representative female sample recruited from a town in central eastern Turkey. The Dissociative Disorders Interview Schedule, the posttraumatic stress disorder (PTSD) and borderline personality disorder sections of the Structured Clinical Interviews for DSM–IV Axis-I and Personality Disorders, and the Childhood Abuse and Neglect Questionnaire were administered to 628 women. Of these, 127 (20.2%) women reported at least 1 type of PNP and 13 (2.1%) women reported possession. Women with a dissociative disorder reported all types of possession and PNP (except telepathy) more frequently than those without. Whereas women with a trauma history in childhood and adulthood or PTSD reported possession more frequently than those without, PNP were associated with childhood trauma only. Factor analysis yielded 4 dimensions: possession by and/or contact with nonhuman entities, extrasensory communications, possession by a human entity, and precognition. These factors correlated with number of secondary features of dissociative identity disorder and Schneiderian symptoms. Latent class analysis identified 3 groups. The most traumatized group, with predominantly dissociative and trauma-related disorders, had the highest scores on all factors. Notwithstanding their presence in healthy individuals, possession and PNP were associated with trauma and dissociation in a subgroup of affected participants. Both types of experience seem to be normal human capacities of experiencing that may be involved in response to traumatic stress. Given the small numbers, this study should be considered preliminary.

title: A Critical Review of Dissociative Trance and Possession Disorders: Etiological, Diagnostic, Therapeutic, and Nosological Issues
abstract: Although the Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, acknowledges the existence of dissociative trance and possession disorders, simply named dissociative trance disorder (DTD), it asks for further studies to assess its clinical utility in the DSM-5. To answer this question, we conducted the first review of the medical literature.  The MEDLINE, CINAHL, and PsycINFO databases were searched from 1988 to 2010, seeking case reports of DTD according to the DSM or the International Classification of Diseases definitions. For each article, we collected epidemiologic and clinical data, explanatory models used by authors, treatments, and information on the outcome.  We found 28 articles reporting 402 cases of patients with DTD worldwide. The data show an equal proportion of female and male patients, and a predominance of possession (69%), compared with trance (31%). Amnesia is reported by 20% of patients. Conversely, hallucinatory symptoms during possession episodes were found in 56% of patients and thus should feature as an important criterion. Somatic complaints are found in 34% of patients. Multiple explanatory models are simultaneously held and appear to be complementary.  Data strongly suggest the inclusion of DTD in the DSM-5, provided certain adjustments are implemented. DTD is a widespread disorder that can be understood as a global idiom of distress, probably underdiagnosed in Western countries owing to cultural biases, whose incidence could increase given the rising flow of migration. Accurate diagnosis and appropriate management should result from a comprehensive evaluation both of sociocultural and of idiosyncratic issues, among which acculturation difficulties should systematically be considered, especially in cross-cultural settings.

title: An Examination of Dissociative Symptoms As They Relate To Indigenous Filipino Concepts
abstract: In one phase of a larger study entitled Dissociation in a student sample in the Philippines (Gingrich, 2004), interviewees were asked to give their opinions about various scenarios involving dissociative symptoms, including whether they would regard specific dissociative experiences as normal or pathological. These college students were also requested to suggest indigenous terms for dissociative symptoms in Filipino languages. In order to provide a context for a discussion of these qualitative research findings, dissociation is defined, and placed in its historical and cross-cultural context. A summary of how dissociative symptoms have generally been viewed within the Philippines is also included. The methodology used in the larger study is briefly outlined, while the procedures used to collect the data most relevant to the purposes of this article are more thoroughly described. Relevance of the findings for the social sciences is discussed, and recommendations for further research made.

title: Dissociative Experience and Cultural Neuroscience: Narrative, Metaphor and Mechanism
abstract: Approaches to trance and possession in anthropology have tended to use outmoded models drawn from psychodynamic theory or treated such dissociative phenomena as purely discursive processes of attributing action and experience to agencies other than the self. Within psychology and psychiatry, understanding of dissociative disorders has been hindered by polemical “either/or” arguments: either dissociative disorders are real, spontaneous alterations in brain states that reflect basic neurobiological phenomena, or they are imaginary, socially constructed role performances dictated by interpersonal expectations, power dynamics and cultural scripts. In this paper, we outline an approach to dissociative phenomena, including trance, possession and spiritual and healing practices, that integrates the neuropsychological notions of underlying mechanism with sociocultural processes of the narrative construction and social presentation of the self. This integrative model, grounded in a cultural neuroscience, can advance ethnographic studies of dissociation and inform clinical approaches to dissociation through careful consideration of the impact of social context.

title: A Qualitative Study of Mental Health Problems among Children Displaced by War in Northern Uganda
abstract: While multiple studies have found that children affected by war are at increased risk for a range of mental health problems, little research has investigated how mental health problems are perceived locally. In this study we used a previously developed rapid ethnographic assessment method to explore local perceptions of mental health problems among children and adults from the Acholi ethnic group displaced by the war in northern Uganda. We conducted 45 free list interviews and 57 key informant interviews. The rapid assessment approach appears to have worked well for interviewing caretakers and children aged 10—17 years. We describe several locally defined syndromes: two tam/par/kumu (depression and dysthymia-like syndromes), ma lwor (a mixed anxiety and depression-like syndrome), and a category of conduct problems referred to as kwo maraco/gin lugero. The descriptions of these local syndromes were similar to western mood, anxiety and conduct disorders, but included culturespecific elements.

title: Common mental disorders in postconflict settings
abstract: Research into postconflict psychiatric sequelae in low-income countries has been focused largely on symptoms rather than on full psychiatric diagnostic assessment. We assessed 3048 respondents from postconflict communities in Algeria, Cambodia, Ethiopia, and Palestine with the aim of establishing the prevalence of mood disorder, somatoform disorder, post-traumatic stress disorder (PTSD), and other anxiety disorders. PTSD and other anxiety disorders were the most frequent problems. In three countries, PTSD was the most likely disorder in individuals exposed to violence associated with armed conflict, but such violence was a common risk factor for various disorders and comorbidity combinations in different settings. In three countries, anxiety disorder was reported most in people who had not been exposed to such violence. Experience of violence associated with armed conflict was associated with higher rates of disorder that ranged from a risk ratio of 2.10 (95% CI 1.38-2.85) for anxiety in Algeria to 10.03 (5.26-16.65) for PTSD in Palestine. Postconflict mental health programmes should address a range of common disorders beyond PTSD.

title: Lifetime events and posttraumatic stress disorder in 4 postconflict settings.
abstract: Little is known about the impact of trauma in postconflict, low-income countries where people have survived multiple traumatic experiences.



To establish the prevalence rates of and risk factors for posttraumatic stress disorder (PTSD) in 4 postconflict, low-income countries.



Epidemiological survey conducted between 1997 and 1999 among survivors of war or mass violence (aged >/=16 years) who were randomly selected from community populations in Algeria (n = 653), Cambodia (n = 610), Ethiopia (n = 1200), and Gaza (n = 585).



Prevalence rates of PTSD, assessed using the PTSD module of the Composite International Diagnostic Interview version 2.1 and evaluated in relation to traumatic events, assessed using an adapted version of the Life Events and Social History Questionnaire.



The prevalence rate of assessed PTSD was 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Conflict-related trauma after age 12 years was the only risk factor for PTSD that was present in all 4 samples. Torture was a risk factor in all samples except Cambodia. Psychiatric history and current illness were risk factors in Cambodia (adjusted odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3-5.4 and adjusted OR,1.6; 95% CI, 1.0-2.7, respectively) and Ethiopia (adjusted OR, 3.9; 95% CI, 2.0-7.4 and adjusted OR, 1.8; 95% CI, 1.1-2.7, respectively). Poor quality of camp was associated with PTSD in Algeria (adjusted OR, 1.8; 95% CI, 1.3-2.5) and in Gaza (adjusted OR, 1.7; 95% CI, 1.1-2.8). Daily hassles were associated with PTSD in Algeria (adjusted OR, 1.6; 95% CI, 1.1-2.4). Youth domestic stress, death or separation in the family, and alcohol abuse in parents were associated with PTSD in Cambodia (adjusted OR, 1.7; 95% CI, 1.1-2.6; adjusted OR, 1.7; 95% CI, 1.0-2.8; and adjusted OR, 2.2; 95% CI, 1.1-4.4, respectively).



Using the same assessment methods, a wide range of rates of symptoms of PTSD were found among 4 low-income populations who have experienced war, conflict, or mass violence. We identified specific patterns of risk factors per country. Our findings indicate the importance of contextual differences in the study of traumatic stress and human rights violations.

title: Use of khat and posttraumatic stress disorder as risk factors for psychotic symptoms: a study of Somali combatants.
abstract: The chewing of the khat leaves, which contain the amphetamine-like cathinone, is a traditional habit in Somalia. Our objective was to explore the effects of khat use and Posttraumatic Stress Disorder (PTSD) on paranoid symptoms and to test a potential causal chain. We report on a cross-sectional study in Somalia that was conducted in 2003. Trained local staff interviewed 8723 personnel of armed groups in seven regional convenience samples. Of them, 8124 were included in the analysis. We assessed current khat use, PTSD symptoms, functional drug use and paranoid ideation using items from the Composite International Diagnostic Interview (CIDI) and the Somali version of the Posttraumatic Stress Diagnostic Scale (PDS). Applying the causal steps approach, in a series of logistic regression models, we used PTSD as independent and paranoia as outcome variable; the quantity of khat use was defined as mediator variable and functional drug use as moderator. The results showed that respondents with PTSD used khat more frequently. Khat chewers with PTSD reported a higher intake compared to khat chewers without PTSD. Among excessive khat chewers with PTSD, paranoia was most frequent. The greatest amount of khat use was among respondents with PTSD who indicated that they found drugs help them to forget war experiences. The proposed mediated moderation model was supported by the data, i.e. besides the direct effects of PTSD and functional drug use on paranoia, the amount of khat use appeared to be a mechanism, by which paranoia is caused. We conclude that in our data we have uncovered a relationship between khat, PTSD and paranoia. Khat is functionally used by respondents with PTSD. Findings support a dose effect: the more khat consumption and when a respondent has PTSD, the higher the odds for paranoid ideation. However, the proposed causal chain needs to be confirmed in longitudinal studies. Demobilization and reintegration programs in Somalia need to be prepared to deal with complex psychological problems.

title: The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique.
abstract: In this article we assess the prevalence rates of harmful spirit possession, different features of the spirits and of their hosts, the correlates of the spirit possession experience, health patterns and the sources of health care consulted by possessed individuals in a population sample of 941 adults (255 men, 686 women) in post-civil war Mozambique in 2003-2004. A combined quantitative-qualitative research design was used for data collection. A major study outcome is that the prevalence rates vary according to the severity of the possession as measured by the number of harmful spirits involved in the affliction. The prevalence rate of participants suffering from at least one spirit was 18.6 percent; among those individuals, 5.6 percent were suffering from possession by two or more spirits. A comparison between possessed and non-possessed individuals shows that certain types of spirit possession are a major cause of health impairment. We propose that knowledge of both local understandings of harmful spirit possession and the community prevalence of this kind of possession is a precondition for designing public health interventions that sensitively respond to the health needs of people afflicted by spirits.

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

title: Possession States in Northern Sri Lanka
abstract: Possession states are still commonly seen in developing societies as acceptable cultural phenomena in normal persons as well as in those with psychiatric illness. ‘Possession’ is defined here as the experience of being taken over, controlled or occupied by another spirit or force.  This is a descriptive cross-sectional study of possession states among psychiatric patients, general population and popular adepts in Northern Sri Lanka, using semi-structured questionnaires and clinical observations.  Thirty psychiatric patients were identified as having possession states. They were compared with 30 controls each from the general population admitted to a general hospital outpatient department and selected popular adepts in the community. The latter are individuals who are well known as having possession states. An analysis of social factors and other variables showed that education, marital status, age, employment, strength of belief, alterations in personality, past or family psychiatric history, previous exposure to similar phenomena, help-seeking behavior and treatment outcome differed between the three groups. Religion of the subjects or recent changes in values showed no correlation with possession while monetary gain from possession states showed only a partial correlation. Western medical treatment was of value only when possession states were seen as part of psychotic illness.  Possession is a spectrum of experiential and behavioral phenomena seen in culturally acceptable form in normal people, popular adepts, as well as manifestations of psychotic illness. Possession states which fit normal cultural stereotypes could, if necessary, be better managed by traditional methods. However, clinicians need to be familiar with culturally abnormal forms of possession which are manifestations of psychotic illness that benefit from western psychiatric treatment.

title: Making sense of 'possession states': psychopathology and differential diagnosis.
abstract: Possession is a common manifestation of distress in a multicultural setting. It is increasingly likely to be encountered by mental health professionals who may be unaware of the phenomenon. A review of the literature is presented with clinical guidelines for a culturally sensitive assessment and management.

title: Possession syndrome at high altitude ( 4575 m/15000 ft ).
abstract: In a first of its kind, a 20 year old Hindu, highlander, working girl presented with abnormal behavior, unrelenting symptoms, had limited benefit by usual treatment and was diagnosed as possession syndrome. Exorcism offered symptomatic relief. The girl resumed normal activities with no recurrence in a 12 month follow up. Possession syndrome is explained in both medical and theological perspectives. Modern medicine associates it with a mental illness though True Possession syndrome without associated mental illness has been reported. Theological perspective can be amalgamated with current scientific theory and practice, thereby complimenting existing concepts.

title: Dissociative Disorders in a Psychiatric Institute in India - A Selected Review and Patterns Over a Decade
abstract: The prevalence — and type — of dissociative disorders is considered to vary across cultures and over time.  The aim of the study was to examine patterns of dissociative disorders among subjects attending psychiatric services over a period of 10 years.  The sample consisted of both inpatients and outpatients attending a psychiatric hospital between 1999 and 2008. Information of those subjects diagnosed to have dissociative disorders was reviewed. A semi-structured proforma was used to collect information about demographic details and diagnosis.  A total of 893 patients had been diagnosed with dissociative disorder over the past decade: 591 (66%) were outpatients and 302 (34%) were inpatients. The proportion of patients diagnosed with dissociative disorders ranged between 1.5 and 15.0 per 1,000 for outpatients and between 1.5 and 11.6 per 1,000 for inpatients. The majority of patients were diagnosed with dissociative motor disorder (43.3% outpatients, 37.7% inpatients), followed by dissociative convulsions (23% outpatients, 27.8% inpatients). Female preponderance was seen across all sub-types of dissociative disorder except dissociative fugue.  Dissociative disorders are still commonly diagnosed in both inpatient and outpatient settings. Dissociative motor disorders and dissociative convulsions are the most common disorders. Unlike in the West, dissociative identity disorders were rarely diagnosed; instead, possession states were commonly seen in the Indian population, indicating cross-cultural disparity.

title: Evil spirit sickness, the christian disease: The innovation of a new syndrome of mental derangement and redemption in Papua New Guinea
abstract: This essay analyses the cultural and historical processes involved in the emergence of Evil Spirit Sickness, a form of mental or behavioral derangement that appeared among the Bosavi people of Papua New Guinea during a period of intense Christian evangelization and religious excitement. It explores the the emergence of the disorder both as a form of psychological breakdown under the burden of intolerable life stress and a socially innovated, ritually structured, and performatively achieved mode of seeking redemption in a Papuan Christian context.

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



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.



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.



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.

title: Sociodemographic and clinical characteristics of possessive disorder in Jordan.
abstract: To study the sociodemographic and clinical characteristics of possessive disorder in Jordan.



This study was carried out prospectively at Prince Rashid Ben Al-Hassan Hospital, Irbid, Jordan between January 1997 and December 2000. It included all psychiatric patients who presented to the psychiatric outpatient clinic with a mono-symptom of being possessed or influenced by the Jinn, a total of 179 patients were studied.



Possessive disorder is more common among males (111) than females (68) with a male:female ratio of 1.6:1. With a mean age of 23.15 years and standard deviation of 6.93, the majority (82.1%) of patients were young of low educational attainment from rural areas (67.6%). The mean duration of illness was 24.61 months (standard deviation of 10.64) and the most common site of possession was head and neck (19.6%) followed by chest (11.7%) and upper limbs (11.7%). The most common mode of perception was somatic both visual and auditory (25.7%) and the most common behavioral changes induced by the possessing agent were loss of control (17.3%) followed by abnormal movement (16.6%), pseudo seizure (15.6%), loss of consciousness (14%) and change in tone of voice (14%). Sixty-eight (38%) of the patients had history of sexual intercourse with the possessing agent, more males (53) than females (15) had such experience. Two thirds of the patients had single possessing agent and almost all patients had been treated by native healers and about 2 thirds of the patients had reported psychosocial stresses prior to the onset of their illness.



Possessive disorder is a common condition in clinical practice that poses a diagnostic problem, it affects young males of low educational attainment from rural areas. Education and awareness is needed to prevent improper traditional therapy that may negatively affect the prognosis of this disorder.

title: Phenomenology of Trance States Seen at a Psychiatric Hospital in Singapore: A Cross-Cultural Perspective
abstract: This study investigates the characteristic features of trance states in three different ethnic communities (Chinese, Malays and Indians) in Singapore by administering a semi-structured interview to 55 patients with the condition and analysing witnesses’ accounts. Trance disorder among the three groups displays remarkable similarities in phenomenology but differences also exist. Most of the trances were reportedly precipitated by fear, anger and/or frustration. Seventy per cent of patients reported prodromal symptoms. Common manifestations include unusual vocalizations and movements, shaking, apparent immunity from pain, and unfocused or fixed gaze. The patients tend to assume the identities of gods from their own cultures. For individuals reported to be possessed by deities, the embodied identities are gods lower down in the hierarchy of Chinese gods or a minor supernatural figure on the Hindu pantheon. The recognizable prodromal symptoms and hierarchy among the gods may have therapeutic implications.

title: Psychosocial stressors that precipitate dissociative trance disorder in Singapore.
abstract: To study the psychosocial stressors that precipitate dissociative trance disorder (DTD) and to identify predictors of DTD.



We conducted semistructured interviews in which detailed information was obtained for 58 cases diagnosed with DTD at a psychiatric hospital in Singapore. A comparison group of 58 patients who received treatment at the same hospital for major depression (MD) were also interviewed, using the same instrument.



While 100% of the DTD group described at least one psychosocial stressor, only 80% of the MD group did so. Common stressors for the DTD group include problems with military life (38%), conflicts over religious and cultural issues (38%), and domestic disharmony and marital woes (24%). Conflicts over religious and cultural issues seemed to be important in the precipitation of DTD but not in the precipitation of MD (p < 0.001). Logistic regression reveals that the following are positive predictors for DTD: conflicts over religious and cultural issues; prior exposure to trance states; and being a spiritual healer or his/her assistant.



An understanding of the precipitating psychosocial stressors that overwhelmed the patient's coping abilities would have implications for treatment and enable the clinician to devise strategies for intervention and prevention.

title: Jinni possession: A clinical enigma in mental health.
abstract: The concept of demonic and especially jinnic possession in causation of mental illness is prevalent in this modern era, both in the developing and the developed world which is evidenced in the literature. Jinni has been described as an entity that is living, but invisible to human beings, can assume various shapes, maintain culture and family and have capability to over power the human brain. This in turn, leads to different manifestations related to mental illness, but having the distinction of not being amenable to medical  This concept is described in religious books dating back to the 16th century where two types of mental diseases were differentiated: those caused by natural reasons and those by jinni possession which manifested as hallucinatory diseases or disorders with a queer, unusual and antisocial behaviour, conditions of extreme unrest, vomiting of queer things, prediction of future, and talking foreign

title: The clinical characteristics of possession disorder among 20 Chinese patients in the Hebei province of China.
abstract: This paper describes the clinical characteristics of 20 hospitalized psychiatric patients in the Hebei province of China who believed they were possessed.



A structured interview focused on clinical characteristics associated with possession phenomena was developed and administered to 20 patients at eight hospitals in the province. All patients had been given the Chinese diagnosis of yi-ping (hysteria) by Chinese physicians before being recruited for the study.



The subjects' mean age was 37 years. Most were women from rural areas with little education. Major events reported to precede possession included interpersonal conflicts, subjectively meaningful circumstances, illness, and death of an individual or dreaming of a deceased individual. Possessing agents were thought to be spirits of deceased individuals, deities, animals, and devils. Twenty percent of subjects reported multiple possessions. The initial experience of possession typically came on acutely and often became a chronic relapsing illness. Almost all subjects manifested the two symptoms of loss of control over their actions and acting differently. They frequently showed loss of awareness of surroundings, loss of personal identity, inability to distinguish reality from fantasy, change in tone of voice, and loss of perceived sensitivity to pain.



Preliminary findings indicate that the disorder is a syndrome with distinct clinical characteristics that adheres most closely to the DSM-IV diagnosis of dissociative trance disorder under the category of dissociative disorder not otherwise specified.

title: Past horrors, present struggles: the role of stigma in the association between war experiences and psychosocial adjustment among former child soldiers in Sierra Leone.
abstract: Upon returning to their communities, children formerly associated with armed forces and armed groups--commonly referred to as child soldiers--often confront significant community stigma. Much research on the reintegration and rehabilitation of child soldiers has focused on exposure to past war-related violence and mental health outcomes, yet no empirical work has yet examined the role that post-conflict stigma plays in shaping long-term psychosocial adjustment. Two waves of data are used in this paper from the first prospective study of male and female former child soldiers in Sierra Leone. We examined the role of stigma (manifest in discrimination as well as lower levels of community and family acceptance) in the relationship between war-related experiences and psychosocial adjustment (depression, anxiety, hostility and adaptive behaviors). Former child soldiers differ from one another with regard to their post-war experiences, and these differences profoundly shape their psychosocial adjustment over time. Consistent with social stress theory, we observed that post-conflict factors such as stigma can play an important role in shaping psychosocial adjustment in former child soldiers. We found that discrimination was inversely associated with family and community acceptance. Additionally, higher levels of family acceptance were associated with decreased hostility, while improvements in community acceptance were associated with adaptive attitudes and behaviors. We found that post-conflict experiences of discrimination largely explained the relationship between past involvement in wounding/killing others and subsequent increases in hostility. Stigma similarly mediated the relationship between surviving rape and depression. However, surviving rape continued to demonstrate independent effects on increases in anxiety, hostility and adaptive/prosocial behaviors after adjusting for other variables. These findings point to the complexity of psychosocial adjustment and community reintegration in these youth and have a number of programmatic and policy implications.

title: Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress, Ethnopsychology and Ethnophysiology in Alleviating Suffering and Preventing Stigma
abstract: In the aftermath of a decade-long Maoist civil war in Nepal and the recent relocation of thousands of Bhutanese refugees from Nepal to Western countries, there has been rapid growth of mental health and psychosocial support programs, including posttraumatic stress disorder treatment, for Nepalis and ethnic Nepali Bhutanese. This medical anthropology study describes the process of identifying Nepali idioms of distress and local ethnopsychology and ethnophysiology models that promote effective communication about psychological trauma in a manner that minimizes stigma for service users. Psychological trauma is shown to be a multifaceted concept that has no single linguistic corollary in the Nepali study population. Respondents articulated different categories of psychological trauma idioms in relation to impact on the heart-mind, brain-mind, body, spirit, and social status, with differences in perceived types of traumatic events, symptom sets, emotion clusters and vulnerability. Trauma survivors felt blamed for experiencing negative events, which were seen as karma transmitting past life sins or family member sins into personal loss. Some families were reluctant to seek care for psychological trauma because of the stigma of revealing this bad karma. In addition, idioms related to brain-mind dysfunction contributed to stigma, while heart-mind distress was a socially acceptable reason for seeking treatment. Different categories of trauma idioms support the need for multidisciplinary treatment with multiple points of service entry.

title: Agricultural cycle and the prevalence of posttraumatic stress disorder: a longitudinal community study in postwar Mozambique.
abstract: The influence of physical activity on the prevalence and remission of war-related mental disturbances has never been systematically evaluated. This study examined the influence of participation in the agricultural cycle on the posttraumatic stress disorder (PTSD) prevalence and correlated symptoms longitudinally in post civil war Mozambique. Prevalence rates were examined in the end and the outset of the agricultural cycle in a community population (N = 240). The agricultural cycle, which is characterized by fluctuations in physical activities, social connectedness, and the sense of purpose in life influences the PTSD prevalence and correlated symptoms. By studying the influence of the agricultural cycle on PTSD prevalence, severe PTSD cases that fail to respond to the agricultural cycle can be identified, and subsequently evaluated regarding the need for specialized care.

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

title: Spirits, devils and trauma: Dissociation in south-west Uganda
abstract: This thesis originates from an interest to understand more about pathological dissociative presentations in Uganda, as a way of addressing traumatic stress and other adverse events within a cultural and social-political context.

title: The Haunting of Alice: Local Approaches to Justice and Reconciliation in Northern Uganda
abstract: Through the story of a former rebel fighter, this article examines some of the justice and reconciliation challenges in northern Uganda today. While talks between the Lord's Resistance Army (LRA) and Government of Uganda have generated the best chance for peace in the 20-year conflict, the International Criminal Court's indictment of rebel leaders threatens this process. The rebels refuse to disarm if indicted; the Chief Prosecutor refuses to withdraw indictments as he believes withdrawal will foster impunity. To resolve this dilemma, local cultural and religious leaders advocate adapting local justice and reconciliation mechanisms to the situation, arguing that these will both hold rebels accountable and achieve peace. However, little is known about local justice processes or their potential to foster reconciliation in war-torn northern Uganda. On the basis of participatory research (2004–2006) with war-affected persons, the article seeks to address this gap, illustrating the potential and limitations of such locally relevant mechanisms.

title: Dissociation and Symptoms of Culture-Bound Syndromes in North America: A Preliminary Study
abstract: The aim of this study was to determine whether classical culture-bound syndromes occur among psychiatric inpatients with dissociative disorders in North America. The Dissociative Trance Disorder Interview Schedule, the Dissociative Experiences Scale, and the Dissociative Disorders Interview Schedule were administered to 100 predominantly Caucasian, American, English-speaking trauma program inpatients at a hospital in the United States. The participants reported high rates of childhood physical and/or sexual abuse (87%), dissociative disorders (73%), and membership in the dissociative taxon (78%). They also reported a wide range of possession experiences and exorcism rituals, as well as the classical culture-bound syndromes of latah, bebainan, amok, and pibloktoq. Our data are consistent with the view that possession and classical culture-bound syndromes are predominantly dissociative in nature and not really culture-bound from the perspective of Caucasian, English-speaking America.