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Chapter: Essentials of Psychiatry: Dissociative Disorders

Dissociative Trance Disorder

Dissociative trance disorder has been divided into two broad categories, dissociative trance and possession trance.

Dissociative Trance Disorder


Dissociative Trance


Dissociative trance disorder has been divided into two broad categories, dissociative trance and possession trance (American Psychiatric Association, 2000). Dissociative trance phenomena are characterized by a sudden alteration in consciousness, not ac-companied by distinct alternative identities. In this form the dis-sociative symptom involves an alteration in consciousness rather than identity. Also, in dissociative trance, the activities performed are rather simple, usually involving sudden collapse, immobili-zation, dizziness, shrieking, screaming, or crying. Memory is rarely affected, and if there is amnesia, it is fragmented.


Dissociative trance phenomena frequently involve sudden, extreme changes in sensory and motor control. A classic example is the ataque de nervios, prevalent in Latin American countries. For example, this phenomenon is estimated to have a 12% life-time prevalence rate in Puerto Rico (Lewis-Fernandez, 1994). A typical episode involves a sudden feeling of anxiety, followed by total body shakes, which may mimic convulsions. This is then followed by hyperventilation, unintelligible screaming, agitation and often violent bodily movements. Often, this is followed by collapse and probably transient loss of consciousness. After the episode is over, subjects complain of fatigue and having been confused, although this behavior is dramatically different from classic postictal states. Some subjects may experience amnesia at least to some aspects of the event (Lewis-Fernandez, 1994).


Other examples include lata and “falling out”. Lata repre-sents the Malay version of trance disorder. In these episodes, af-flicted individuals usually experience a sudden vision, mostly of a threatening spirit. The observable behavior includes screaming or crying and physical manifestation of overtly violent behav-ior which often requires the sufferer to be physically restrained. Patients often report episodes of amnesia, but there is no clear possession by the offending spirit. On the other hand, “falling out” more commonly occurs among African-Americans in the southern USA. Similarly to other trance episodes, the affected in-dividual may enter a trance state, followed by bodily collapse, the inability to see or speak, despite the fact that they are fully con-scious. Temporary confusion may be observed, although subjects are not usually amnesic to what occurred during the episode.


Possession Trance


In contrast to dissociative trance episodes, possession trance in-volves the assumption of a distinct alternative identity. The new identity is presumed to be that of a deity, ancestor, or spirit who has transiently taken possession of the subject’s mind and body. Different from dissociative trance episodes, which are charac-terized by rather crude, simplistic, regressive-like behaviors, possession trance victims often exhibit rather complex behav-ior. During these episodes, subjects may, for example, express otherwise forbidden thoughts or needs, engage in unusually and uncharacteristic aggressive behavior (e.g., verbal or physical ex-pressions of aggression), or may attempt to negotiate for change in family or social status. Also, in contrast to dissociative trance episodes, possession trance episodes often are followed by dense amnesia for a large portion of the episode during which the spirit identity was in control of the subject’s behavior.


Cultural Context


Dissociative-like phenomena have been described in virtually every culture. Yet they appear to be more prevalent in the less heavily industrialized Second and Third World countries. Stud-ies on the prevalence of dissociative disorders in India have sug-gested that the 1-year prevalence of dissociative trance disorder is approximately 3.5%; of all psychiatric hospitalizations, mak-ing it a highly frequent mental disorder. Trance and possession syndromes are by far the most common type of dissociative dis-orders seen around the world. On the other hand, DID, which is relatively more common in the USA, is virtually never diagnosed in underdeveloped countries. This difference in prevalence and distribution of dissociative disorder across different populations may be mediated by cultural as well as biological factors. For ex-ample, Eastern culture is far more sociocentric than Western cul-ture. Thus, being “possessed” by an outside entity would be more culturally comprehensible and acceptable in the East. On the other hand, an apparent proliferation of individual identities would fit better with the Western preoccupation with individualism. None-theless, the underlying dissociative mechanism inhibiting integra-tion of perception, memory and identity may suggest a common underlying mechanism amongst these dissociative syndromes.


Trance and possession episodes are usually understood as an idiom of distress and yet they are not viewed as normal. That is, they are not a generally accepted part of cultural and religious practice, which often does involve normal trance phenomena, such as trance dancing in the Balinese Hindu culture. Trance dancers enjoy the remarkable privilege of being the only portion of this socially rigid society able to elevate their social status. The way they are able to do that is by developing the ability to enter trance states. During these altered states of consciousness, which usually occur within the context of a socially acceptable ceremony setting, they dance over hot coals, hold a sword at their throat, or in other ways exhibit supernormal powers of concentration and physical prowess. The mechanism mediating these phenomena is not fully understood, but there is evidence of elevations in plasma noradrenaline, dopamine and beta-endorphin among Balinese trance dancers during trance states. This form of trance is con-sidered socially normal and even exalted.


By contrast, disordered trance and possession trance are viewed by the local community as an aberrant form of behavior that requires intervention. Such symptoms often arise in the con-text of family or social distress, for example, discomfort in a new family environment. Thus, cultural informants make it clear that people with dissociative trance disorder are abnormal.




Dissociation and Trauma


One of the important developments in the modern understand-ing of dissociative disorders is the establishment of a clearer link between trauma and dissociation. Trauma can be understood as the experience of being made into an object, a thing, the victim of someone else’s rage or of nature’s indifference. Trauma represents the ultimate experience of helplessness: loss of control over one’s own body. There is growing clinical evidence that dissociation occurs as a defense during traumatic experiences, constituting an attempt to maintain mental control at the moment when physi-cal control has been lost. Assault victims report floating above their body, feeling sorry for the person being assaulted beneath them. Patients, victims of childhood abuse, have reported “taking themselves elsewhere” where they could “safely play” by them-selves or with imaginary friends, while their bodies were brutally abused by a perpetrator. In fact, there is evidence (Terr, 1991) that children exposed to multiple traumas as opposed to single-blow traumas are more likely to use dissociative defense mechanisms, which include spontaneous trance episodes and amnesia.


As noted in the section on DID, there is an accumulating literature suggesting a connection between a history of child-hood physical and sexual abuse and the development of disso-ciative symptoms. Similarly, dissociative symptoms have been found to be more prevalent in patients with Axis II disorders, such as borderline personality disorder, when there has been a history of childhood abuse. Another means of examining the pu-tative connection between dissociation and trauma is to look at the prevalence of dissociative symptoms after recent trauma. If it is indeed the case that trauma seems to elicit dissociative symp-toms, they should be observable in the immediate aftermath of trauma. In the early literature examining responses to trauma, Lindemann (1944), studying the aftermath of the Coconut Grove fire, observed that the individuals who acted as though little or nothing had happened had an extremely poor long-term prog-nosis. These were individuals who had been injured or had lost loved ones. Indeed, it was the absence of post traumatic symp-toms in this group, compared with the agitation, dysphoria, and restlessness that typified the majority of survivors, that led him to formulate the normal process of acute grief. Several subsequent researchers have observed that psychic numbing is a predictor of later PTSD symptoms.


Research on survivors of other life-threatening events, including hostage taking, indicated that more than half have ex-perienced a sense of detachment, feelings of unreality (i.e., de-personalization), lack of emotions, hyperalertness, and automatic movements. Although these dissociative responses to traumatic stressors have been conceptualized as adaptive defenses to over-whelming situations, the thrust of the literature indicates that the presence of dissociative symptoms in the immediate aftermath of trauma is a strong predictor of the development of later PTSD. Physical trauma seems to elicit dissociation, perhaps in individu-als who are prome to the use of this defense by virtue of either previous traumatic experience or a constitutional tendency to dissociate. This dissociative reaction may, in some cases, resolve quickly. However, in others it may become the matrix for later post traumatic symptoms, such as dissociative amnesia for the traumatic episode. Indeed, more extreme dissociative disorders, such as DID, have been conceptualized as chronic PTSDs (Kluft, 1984, 1991; Speigel, 1985, 1986b). Recollection of trauma tends to have an off–on quality involving either intrusion or avoidance (Horowitz, 1976), in which victims either intensively relive the trauma as though it were recurring or have difficulty remem-bering it. Thus, physical trauma seems to elicit dissociative re-sponses, which, in turn, predispose to the development of later PTSD, perhaps by reducing the likelihood of working through the traumatic experiences afterward.


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