Beyond Possession: A Case Report of Dissociative Trance Disorder in the Context of Trauma and Cultural

Abstract:

·       Background: dissociative trance disorder (DTD) is a rare dissociative condition characterised by altered Consciousness and identity disturbance which cannot be explained by neurological disorders, psychosis or culturally accepted religious practices

·       Case Presentation: we report the case of a 22 years old female homemaker from Maharashtra with history of childhood neglect, sexual abuse, domestic violence. With the sudden death of her new born and all these stressors she developed the recurrent episodes of altered Consciousness and uncontrolled movement with results in the death of the two own children. Neurological, laboratory investigation is normal whereas her psychological assessment supported a severe emotional distress and dissociative symptoms

·        Treatment: patient treated with both pharmacotherapy and psychotherapies like CBT which improved her during follow-ups

·       Conclusion:  This case highlights the importance of trauma-based assessment and culturally based evaluation while differentiating dissociative trance disorder from culturally accepted trance experiences. Early diagnosis and interventions helps to reduce the risk of consequences

Keywords:

• ·       Dissociative Trance Disorder
• ·       Other Specified Dissociative Disorder
• ·       Trauma
• ·       Cultural Psychiatry
• ·       Possession Trance
• ·       Dissociation
• ·       Case Report

Introduction:

Dissociative Trance Disorder is the rare dissociative disorder characterised by a altered Consciousness, identity disturbance  and memory gaps that cannot be explained by neurological diseases, psychotic disorders, substance use or culturally accepted religious practices. In the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, Text Revision (DSM-5-TR), DTD is classified under other specified dissociative disorder (OSDD) whereas in International Classification of Disease, 11^th Revision (ICD-11) recognise Possession Disorder within the Dissociative Spectrum. Although DTD is rare and uncommon in western countries this more prevalence in regions where trance is considered as the culturally accepted traditions. Differentiating the culturally meaningful trance and clinically significant dissociative disorder is major challenge for the mental health professional. This case illustrate the complex relationship between different stressors and cultural beliefs states the importance of comprehensive medical evaluation, assessment and informed clinical judgement

Patient Information:

·       Age: 22 years Old

·       Gender: Female

·       Marital Status: Married

·       Occupation: Homemaker

·       Residence: Maharashtra, India

·       Children: Three (5 years, 3 years and newly born 25 days old)

·       Past Psychiatric History: No previous history of depression, psychotic disorders, or post-traumatic disorder or other diagnosed psychiatric illness.

History and Psychosocial Background:

During early childhood, she faced significant emotional neglect and trauma. During interview she described her father been very supportive and affectionate but he cannot able to spend much time with here since he works in another city. When she growing up, she was suffered from emotional and sexual abuse from her relatives but when she reported incident to her mother, she returned the arrow towards her and blamed her for what happened. These experiences had a severe impact on her interpersonal trust and emotional well-being  

At the age of 16 she was married to guy who is 16 years older than her. She accepted this marriage mainly to escape from the suffering in the parental family. What happened was completely different her suffering was continued in her husband’s home. She gone through sexual and physical abuse many times.

Two years later she was diagnosed with a benign breast tumour during the treatment process both of her family didn’t support her and her husband’s neglect together formed an emotional distress.

The patient recently initiated the romantic relationship with another man, but when she founded the man has in relationship with her sister, she got emotionally drowned.  her 25-day old newborn died suddenly, the cause of death remained unclear even though third pregnancy was accident and she don’t want to keep it due to family pressure she decided to keep and during pregnancy her husband came to know the affair this led to family estrangement. these cumulative stressors were followed by profound psychological distress before the onset of the symptoms. Collectively, these cumulative traumatic experience and psychosocial stressors preceded the onset of the patient’s dissociative symptoms.  

Presenting Complaints and Illness:

Patient experienced a significant accumulation of psychosocial stressors over the short period of time before the onset of symptoms. One week after the death of new born, the patient reported the decrease of Conscious, change in identity and she reported experiencing a perceived external force that instructed her to perform specific actions. She reported had period of thinking about killing her own daughter. She reported involuntary hand movements try to choke her daughter she was not Consciousness and try to move her hand and crying but she cannot able to do that. After her daughter dead she feared and covered corpse. Following the death of her daughter, the patient attempted to leave home because she feared experiencing another episode and harming her remaining child but both her home or husband’s home helped her so she stayed. A few days later, she experienced another episode characterised by altered Consciousness, involuntary hand movements and perception that controlled by the external forces, during which she choked her five-year-old daughter. These recurrent episodes initiated the psychiatric evaluation and medical investigations to determine the underlying cause of her symptoms

Clinical Assessment:  

During clinical interviews, she was calm and composed when she talks about her childhood, marital life and family. When she asked about the death of three children, she replied that regret won’t make any difference that she can start a new life with the right person who treats her well, she will try to forget all bad experience she faced. She denied experiencing any visual hallucinations, auditory hallucinations, delusions, Mania, disorganised speech or thoughts, lack of sleep or appetite changes, apathy or social withdrawal. The patient stated that the deaths of her daughters were “God’s Will” and believed they would have a better life than she experienced.

The Minnesota Multiphasic Personality Inventory (MMPI) test was performed on three scales (paranoia, schizophrenia, and depression), and in all these scales moderate elevations were observed. Which may due to recent happening of stressful events, fear of judiciary and future life. Beck’s depression inventory indicated severally depressive symptoms due to past stressors. In Thematic Apperception Test (TAT) and Sentence Completion Test (SCT) she was very collaborative and interested and told her life experiences, hurdles she faced and provided valuable insights into her psychological state.

Medical evaluation:

She was undergone a comprehensive medical evaluation to exclude neurological and other medical causes of her symptoms. Both neurological exams and electroencephalography (EEG) revealed no abnormalities. Laboratory investigation, including complete blood count, metabolic panels, liver function tests and thyroid function tests were within normal limits.

Patient medical, psychological and surgical histories revealed no significant findings. She reported no history of chronic medical conditions like hypertension or diabetes mellitus. Additionally, there is no history of any psychiatric illness, suicidal thoughts or head trauma.  

Treatment:

The patient received a multidisciplinary treatment consisting pharmacotherapy and psychotherapy. Pharmacological interventions include second generation antidepressants, antipsychotics. She also undergone cognitive behavioural therapy (CBT) to address her dissociative symptoms, trauma related distress, and maladaptive coping strategies. During follow-up, the patient showed a gradual clinical improvement, with reduction in dissociative symptoms and improved overall functioning

Discussion:

According to the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition, Text Revision (DSM-5-TR), Dissociative Trance Disorder is classified under Other Specified Dissociative Disorder (OSDD). It is characterised by an alteration in Consciousness, identity disturbance , loss of self-awareness that cannot be explained by neurological disorders, substance use or culturally accepted religious practices. DTD is considered a rare disorder in Western countries. Worldwide, there is limited cases of DTD where it approximately equals distribution. These disorders are more prevalent in the area where trance was socially and culturally accepted as the part of tradition. In several regions of India, including the part of Tamil Nadu, trance and possession experiences may be interpreted within cultural or religious traditions as spirit possession, divine communication, ancestral influences or other spiritual beliefs. Such experiences are not considered mental disorders when they occur within accepted cultural context and do not cause significant distress or impairment. Many of these experiences are accepted cultural or religious practices and are not as mental disorders. Then how can we differentiate DTD and these practices? A mental health professional considers a diagnosis when,

·       The trance or possession experience occurs outside accepted cultural or religious practices

·       It causes clinically significant distress or impairment in social, occupational or daily functioning

·       Neurological disorders, psychotic disorders, substance use and other medical conditions have been reasonable excluded.

These principles highlight the importance of culturally informed assessment to avoid misdiagnosing culturally normative experiences as psychiatric disorders.

Pathophysiology and Clinical Mechanisms DTD:

Dissociative Trance (DTD) is characterized by a disruption in Conscious, self-awareness, memory and identity resulting in involuntary trance states that may be perceived as spirit possession or control by an external force. It also involves the identity disturbance  resulting in involuntary trances that perceived as spirit possession.

Dissociative symptoms are generally considered psychological responses to overwhelming trauma or severe stress, allowing individuals to temporarily detach from distressing experiences. This might result in many altered states of Consciousness that disrupt the sensory perception and executive functions that comes with concurrent gaps of memory, Clinicians says that DTD shares several clinical features with Dissociative Identity Disorder (DID), including alterations in Consciousness and identity. However, DID is characterized by two or more distinct identity states, whereas DTD typically involves a transient trance or possession state without persistent identity fragmentations.

 Although the exact neurobiological mechanism of DTD remains unclear, studies of dissociation suggest altered functioning involved in memory, emotional regulation, self-awareness, including the hippocampus, amygdala and prefrontal cortex. Further research is needed to clarify the neurobiology of DTD. According to DSM-5-TR, DTD is classified under Other Specified Dissociative Disorder (OSDD) and is diagnosed when the trance state causes clinically significant distress or impairment and cannot be explained by culturally accepted practice or another medical conditions.

The duration of trance episode may vary greatly and can occurs spontaneously or to specific stimulus such as religious rituals emotional sufferings or cultural events for an example in some culturally accepted religious rituals in Tamil Nadu, trance experience may be triggered by rhythmic drumming or ceremonial practices. Such experiences alone do not indicate the mental disorders. These episodes can last few minutes to hours and may occurs repeatedly. 

Clinical features of DTD

1.       Altered Consciousness and Identity Disturbance:
During the episode the patient feels detached from the self-awareness. The patient identity was replaced by the distinct state which is attributed to the external force or spiritual possession

2.       Involuntary Episodes:
Unlike culturally accepted trance states, episodes of DTD occur involuntarily and outside the individual’s voluntary control. These episodes are unplanned, the individual feel of loss of themselves like patient reported the involuntary uncontrollable hand movements where she choked their own daughter

3.       Impairment in response to the external stimuli
During the episode the individual cannot able to respond to the external stimuli as if they are zoned out or completely unaware of the surroundings. In our case even when child tries to push mother’s hand the patient unaware of it. This may also include like individual stare blank for lot of time, repetitive movements or unusual postures. In regions like Tamil Nadu, People who possessed suddenly speaks in unfamiliar language, muscle rigidity or change in tone these are some symptoms.

4.       Dissociative Amnesia:
It is common among the people who has DTD,  people who affected by DTD would not able to partial or completely not  remember the event happened during the episodes. These memory gap could cause significant distress when they return to Consciousness state

5.       Emotional and Behavioural symptoms:
Patients with DTD after the episode often feels depressed, anxiety or fatigue. In cultural context it can be seen in two ways. For an example regions like Tamil Nadu trance which related to God may seen as divine but they may feel physical fatigue in other side if it related to evil the person may very depressed and suffers social withdrawal

6.       Absence of psychotic Features:
Unlike another psychotic disorders, person with DTD typically do not exhibit delusions or hallucinations outside of trance episode. Their trance state may include the expression or behaviour that resemble the possession by the spirit or external forces but they don’t have reality distortions seen in schizophrenia or other psychotic disorder

Conclusion:

This case highlights the complex relationship between psychological trauma, cultural beliefs and dissociative symptoms. The case also emphasizes the importance of understanding the cultural context in the clinical practice. Experiences interpreted as spirit possession or divine influence may be culturally accepted and indeed not be a mental illness. When these trance behaviours cause significant impairment or distress then it should be consulted with trained mental health professional. Early recognition, trauma informed assessment and appropriate physical and psychological interventions might reduce the risk of future harm. This case serves as a remainder that effective mental health requires both scientific understanding and cultural sensitivity allowing clinicians differentiate between culturally meaningful experience and clinically significant disorders and provide the required evidence-based care.

Take Home Points:

·       Childhood trauma and repeated psychosocial stressors are important risk factors for dissociative disorders

·       Cultural belief should be taken as matter of fact before diagnosing DTD

·       Before finalizing with DTD, other neurological and psychiatric disorders must be excluded

·       Assessment and Therapies should be both trauma informed and culturally sensitive

·       Early interventions may reduce the risk of serious consequences

References:

·       Salama AZ, Dabash MR, Elayan A, Saadeh S, Ikhmayyes I. Dissociative Trance Led to a Catastrophe: A Case Report. Cureus. 2024 Dec 27;16(12):e76458. doi: 10.7759/cureus.76458. PMID: 39867031; PMCID: PMC11765154.

·       DSM-5-TR (2022)

·       ICD-11