1. Review Paper
A Critical Review of Dissociative Trance and
Possession Disorders: Etiological, Diagnostic,
Therapeutic, and Nosological Issues
Emmanuel H During, MD1; Fanny M Elahi, MD, PhD2; Olivier Taieb, MD, PhD3;
Marie-Rose Moro, MD, PhD4; Thierry Baubet, MD, PhD5
Objective: 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.
Method: 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.
Results: 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.
Conclusion: 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.
Can J Psychiatry. 2011;56(4):235–242.
Clinical Implications
•
The DSM and the International Classification of Diseases present dissociative trance and
possession disorder as a transient involuntary state of dissociation causing distress or
impairment.
•
Although reported worldwide, and possibly owing to various psychosocial stressors, in
industrialized societies the disorder may more specifically concern people from ethnic
minorities for whom acculturation difficulties may play a key role.
•
A cross-cultural approach seems necessary for a better understanding of the disorder as well
as to increase the validity of diagnosis and efficacy of management.
Limitations
•
This review was limited to articles written in English and indexed on major medical
databases, thus reducing the number of studies and reported patients.
•
Owing to cultural biases and misconceptions about altered states of consciousness in
Western societies, the disorder may still be underdiagnosed.
•
Papers showed important discrepancies in both the amount and the precision of data.
Key Words: dissociation, trance, possession, Diagnostic and Statistical Manual of Mental
Disorders, International Classification of Diseases, culture, acculturation, ethnic minorities,
migration, traumatism
The Canadian Journal of Psychiatry, Vol 56, No 4, April 2011 
235

2. Review Paper
ince 1989, the ICD1 has listed the existence of a trance
and possession disorder before officially featuring it
in the 10th edition2, p 156 under the category of dissociative
(conversion) disorders. Five years later, the DSM-IV3 listed
a similar dissociative disorder with the same 2 subtypes—
trance and possession—more succinctly named DTD
(Table 1). The divergence between the ICD and the DSM is
that in the latter classification the DTD is solely mentioned
as an example of “Dissociative Disorder Not Otherwise
Specified”4, p 532 and its full definition is merely found
in Appendix B.p 783 According to the DSM, the disorder
requires further studies to determine its “utility” (“criteria
sets and axes provided for further study”4, p 759). Despite this
discrepancy, both classifications use similar criteria and view
DTD as a transient ASC, the features of which are shaped
by a person’s culture. Anthropologists and ethnologists
have provided countless descriptions and possibly useful
explanatory frameworks for these culturally sanctioned
phenomena.5,6 Notwithstanding the obvious existence of
a common pattern of behaviour both for pathological and
for nonpathological states, the 2 classifications cite that
the episodes of ASC in DTD are not accepted as a normal
part of a collective cultural or religious practice. The
diagnosis should also be considered when individuals enter
these states involuntarily and suffer significant distress
and impairment, which demarcates them from voluntary
and purposeful ASC. According to these criteria, certain
culture-bound syndromes7,8 could henceforth be understood
within the framework of DTD. The DSM4, p 533 enumerates
6 of these culture-bound syndromes as potentially fulfilling
the criteria for DTD: amok and bebainan (Indonesia), latah
(Malaysia), pibloktoq (Arctic), ataque de nervios (Latin
America), and possession (India). Finally, the manual
notes that the prevalence of DTD “appears to decrease with
industrialization but remains elevated among traditional
ethnic minorities in industrialized societies.”4, p 784
S
More than 15 years have passed since the initial request of
the DSM-IV for further studies, and 20 years since the ICD
officially acknowledged the existence of the disorder. We
must review the accumulated evidence and ask whether it
sufficiently supports the inclusion of DTD into the DSM-5.
We performed a review of the current literature to answer
this question, while providing clinical data that might
contribute to the enhancement of the validity of the current
criteria.
Method
Articles written in English reporting cases of patients with
trance or possession disorders from 1988 to April 2010 in
accord with either ICD or DSM definitions were included
in this review. MEDLINE, CINAHL, and PsycINFO
databases were searched using the following search string:
trance or possession, and dissociation or case report or
disorder. The titles and abstracts of all identified articles
were reviewed to assess their relevance, and all potentially
relevant articles were retrieved to identify patients
meeting our inclusion criteria. For each article selected,
the reference list was scrutinized to find new, potentially
relevant, papers. We continued until the point at which new
papers did not yield new patients. Only patients who either
explicitly refer to either of these classifications or provide
sufficient clinical features to corroborate the diagnosis were
selected. Conversely, cases of patients labelled as trance
or possession within articles that neither proved clinical
features nor referred to the ICD and the DSM were excluded.
We were able to find 29 articles (see online eTable 2),9–37 of
which 2 are based on the same sample of 32 patients.32,33
For each patient, we extracted information regarding the
criteria used by the authors, the number of patients reported,
demographic data such as sex, age, ethnic origin, location,
and cultural background of the patients, clinical features,
nature and identity of the possessing agent, existence of
potential triggering factors, explanatory models used by
the authors, traditional methods of healing, psychiatric
treatments offered with their respective efficacies, and
information on the outcome.
Results
Number of Patients
We found 402 cases of patients with DTD during the period
from 1988 to 2009. Among the 402 patients, 58 feature a
comprehensive clinical history. The remaining 344 patients,
although not as thoroughly detailed as the former, provide
demographic and clinical data.
Cultural Overview
Cases of patients with DTD are mostly reported in Asian
countries (19 articles). Other cases are reported in Europe
(5 articles), America (2 articles), and Africa (2 articles).
Sex and Age
Abbreviations
ASC
altered state of consciousness
DID
dissociative identity disorder
DSM
Diagnostic and Statistical Manual of Mental Disorders
DTD
dissociative trance disorder
ECT
electroconvulsive therapy
ICD
International Classification of Diseases
236
Sex is specified in 253 patients, showing a female to
male ratio of 1.16:1. The age of onset, acknowledged
in 188 patients, reveals a mean age of 25.2 years for the
occurrence of the first episode of DTD.
Diagnostic Procedure and Clinical Data
Twenty-one articles explicitly refer to at least 1 psychiatric
classification, whereas 7 articles do not refer to
any.9,16,18,20,28,34,37 Among the 402 selected cases of patients
with DTD, 325 supply workable clinical features for a
reliable categorization, of whom 69% (n = 226) belong
La Revue canadienne de psychiatrie, vol 56, no 4, avril 2011

3. A Critical Review of Dissociative Trance and Possession Disorders: Etiological, Diagnostic, Therapeutic, and Nosological Issues
Table 1 ICD-10 criteria for dissociative (conversion) disorders and DSM-IV-TR criteria for DTD
ICD-10 criteria:
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).
DSM-IV-TR criteria:
A. Either (1) or (2):
(1) trance, i.e., temporary marked alteration in the state of consciousness or loss of customary sense of personal identity without
replacement by an alternate identity, associated with at least one of the following:
(a) narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli
(b) stereotyped behaviors or movements that are experienced as being beyond one’s control
(2) possession trance, a single or episodic alteration in the state of consciousness characterized by the replacement of customary
sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person, as
evidenced by one (or more) of the following:
(a) stereotyped and culturally determined behaviors or movements that are experienced as being controlled by the
possession agent
(b) full or partial amnesia for the event
B. The trance or possession trance state is not accepted as a normal part of a cultural or religious practice.
C. The trance or possession trance state causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
D. The trance or possession trance state does not occur exclusively during the course of a Psychotic Disorder (including Mood Disorder
With Psychotic Features and Brief Psychotic Disorder) or Dissociative Identity Disorder and is not due to the direct effects of a
substance or a general medical affection.
to the possession subtype and 31% (n = 99) to the trance
subtype. The 77 remaining cases do not provide sufficient
data for a distinction between the 2 subtypes.10,22
In most cases of possession, the possessing agent is unique and
well known, whether it corresponds to a local entity belonging
to the culture of the patient or to the universal figure of God
or the devil. We recognized 6 categories of agents, listed in
order of decreasing frequency: goddesses, deities, God, the
Holy spirit, or an angel34 (43%); deceased relatives and human
ancestral spirits (29%); malevolent spirits and demons (for
example, jinn or zâr) (18%); animals such as snakes, foxes,
and turtles (5%); the devil (for example, Lucifer, Asmodeus,
or Satan) (4%); and a local saint in one patient.12
In addition to the symptoms described by current
classifications (Table 1), we found auditory and (or) visual
The Canadian Journal of Psychiatry, Vol 56, No 4, April 2011 
hallucinations in 44% to 56% of patients with possession,
and somatic complaints in 20% to 34% of all patients. In
a few patients, we found features of depression,17,29,34,36
suicidal thoughts,26 social withdrawal,17,22 isolation, fear,
or suspicion of others.20 One patient manifested with selfmutilation (carving on her arms), which led to a suicide
attempt.20 Regarding the risk of aggression, even though
patients are prone to threaten their entourage, possibly
using weapons when available,36 only 3 cases of physical
violence are reported,12,28,35 among which 1 concluded with
a ritual homicide.12
Total or partial amnesia of the experience is reported in
20% of patients (n = 79),12,25,33,36 whereas in 80% of them
(n = 323) amnesia of the episodes is either not commented
on or documented as absent.16,17,29
237

4. Review Paper
Table 3 Proposal of criteria for trance and possession dissociative disorders in the DSM-5
A. Either (1) or (2):
(1) Trance type: temporary marked alteration in the state of consciousness or loss of customary sense of personal identity without
replacement by an alternate identity, associated with at least one of the following:
(a) narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli
(b) stereotyped behaviors or movements, which may be repetitive or limited, and experienced or perceived as being beyond
one’s control
(2) Possession type: a single or episodic alteration in the state of consciousness characterized by the replacement of customary
sense of personal identity by a new identity, identified by the patient or his entourage as the spirit of an animal, a deceased
individual, a deity or a power, evidenced by at lea st one of the following:
(a) determined behaviors, movements, speech or attitude that are experienced or recognized as being controlled by the
possession agent
(b) visual or auditory hallucinations relating to the possessing agent
B. The trance or possession trance state is not accepted as normal by the patient or his community and is usually not part of a cultural
or religious practice.
C. The trance or possession trance state occurs involuntarily and causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
D. The trance or possession trance state does not occur exclusively during the course of a Psychotic Disorder (including Mood Disorder
With Psychotic Features and Brief Psychotic Disorder), cases in which all symptoms cannot be accounted for by the presence of the
external agent. The disorder is not due to the direct effects of a substance or a general medical affection.
Etiology
We identified 9 major etiological frameworks that are used
by the authors to account for trance or possession episodes:
1. Psychosocial stressors, including the death of a
relative, pathological mourning, conflicts over
religious or cultural issues, tension owing to economic
or social difficulties, altered group dynamics, a
future engagement or marriage, sexuality or other
societal taboos, feelings of guilt, hard-sell approach,
coercive persuasion, or any unspecified inner
conflict.10,12–14,17,18,21–24,26,28,29,31,33–37
2. Traumatic theory, including sexual abuse or violence
during childhood, war, or unexpected suicide of a
relative.9,12,13,29,33
3. Underlying psychiatric condition, such as a psychotic
disorder or a personality disorder (other than
histrionic or hysteria), a neurosis, or any idiosyncratic
psychopathology.12,13,29,30,33,36
4. Cultural factors, when authors consider the disorder to
be based on a culturally ascribed stereotype or learned
behaviour.10,12,14,15,17–22,24–26,29,33–37
5. Communication theory, considering trance and
possession as the expression of nonspecific difficulties
by oppressed people and manifesting needs that have
been left unfulfilled.10,12,15,17,36,37
6. Gain seeking, where trance is seen as capable of
bringing about an economic, social, or psychological
gain, mediumistic abilities or extrasensory competences,
and when the disorder is exhibited for a regenerative
purpose in addition to benefiting from positive
labelling.13,17–20,24,35
7. Dissociation theory, which considers dissociation as the
central phenomenon, relying on the evidence that some
people have a propensity to dissociate.9,13,15,17,33
238
8. Theory of hysteria, viewing such a disorder as a
manifestation of histrionic personality,12,32,37 involving
an unresolved oedipal conflict,30 with the possibility of a
mass hysteria.19,24,32,37
9. Acculturation issues,22,24,28,35 considering acculturation
difficulties as the major problem. In the latter case, such
difficulties can follow migration from one country to
another,35 from a rural environment to urban centres,22,24
or ensue from a religious conversion from a local belief
system to Christianity.28
Three authors do not refer to any theoretical framework,11,16,27
whereas the other 25 articles refer to 1 to 6 explanatory
models (mean = 3), which are, in descending order:
psychosocial stressors (68%), cultural factors (64%), gain
seeking (29%), hysteria theory (25%), communication
theory (25%), traumatic theory (18%), underlying
psychiatric condition (18%), dissociation theory (18%), and
acculturation issues (14%). Other comments regarding the
etiology of DTD are summarized in online eTable 2.
Therapeutic Strategy
We found data relating to treatments for 114 patients in
19 articles, which can be organized in 6 major approaches:
1. Traditional medicine involving folk healers, faith
healers, shamans, but not labelled as exorcism
2. Exorcism
3. Psychotherapy
4. Medications
5. ECT
6. Hospitalization in a psychiatric ward
Psychotherapy was the most commonly used treatment
(59%) and seems to provide relief in all patients21,26,29–31,34,35,37
La Revue canadienne de psychiatrie, vol 56, no 4, avril 2011

5. A Critical Review of Dissociative Trance and Possession Disorders: Etiological, Diagnostic, Therapeutic, and Nosological Issues
except for one who chose to end the follow-up.30 Traditional
medicine was used by 30% of patients of the sample and
was reported as efficient for all14,15,17,19,24,26,29,35 but 2.18,35 One
patient benefited from an initiation to becoming a shaman.18
Exorcism was performed in 7% of the patients, with variable
reported efficiency.13–16,28,30,34 Medications were prescribed
in 30% of patients.13–16,19,23,25,26,29–31,34,35,37 Nine patients
were prescribed antipsychotic medication,13,16,23,25,26,30,34,35
with 5 showing clinical improvement,16,25,30,34,35 of whom 2
were receiving low doses.30,34 Of note, 4 patients showed
no improvement.13,23,26 Two patients were prescribed
antidepressants, showing clinical improvement.34,35 In
contrast, one patient suffering from “dissociative epileptic
disorder,”25, p 432 according to the author, was treated with the
antidepressant nortryptiline, which interrupted the disorder
and resulted in the new onset of a DTD (possession type).
Anxiolytics were prescribed to 3 patients and brought about
some relief.29 In the 19 remaining patients, the authors
do not specify the drug that was prescribed. ECT was
used in one patient without success.17 Six patients were
hospitalized.23,29,37
Outcome
Data referring to the outcome were found for only
85 patients, showing a positive outcome for 95% of
them.15–18,21,23–25,29–31,35, 37
Comorbidity
Only 3 patients with DTD showed evidence of psychiatric
comorbidity: depressive disorder in 3 patients,26,31,34 1 of
whom was also diagnosed with generalized anxiety disorder.31
Discussion
To date, current and lifetime prevalence rates of DTD have
not yet been studied in either Western or non-Western
countries, and systematic studies in general and psychiatric
populations have not been conducted either. Thus the exact
magnitude of the disorder remains unknown. Our review
reports 402 patients with DTD since 1988. However, we
consider this figure to be an underestimation for several
reasons. First, our review only selected papers written in
English and indexed on major medical databases. Second,
certain articles report patients but lack sufficient criteria for
their inclusion in our review, explaining the exclusion of
81 patients.14,22,35 Four additional patients were excluded
because they did not meet the criteria for DTD, although
presented as such by the authors.17,23,30,38 Third, we assume
that most patients suffering from DTD are managed by
traditional healers. Fourth, owing to a lack of awareness and
understanding of the disorder among health care workers,
DTD may be mistaken for other disorders—other specified
dissociative disorders, conversion and somatoform
disorders, psychotic disorders, or malingering. Given these
selection biases and the resulting limited sample size, our
conclusions should be considered tentative.
Patients with DTD are found in every continent and culture,
including indigenous populations living in industrialized
The Canadian Journal of Psychiatry, Vol 56, No 4, April 2011 
societies, as illustrated in Pentecostal and Catholic
communities in North America and Italy, respectively.12,13,20
At least 18% (n = 73) of patients are migrants or belong
to an ethnic or religious minority. The implications of this
finding will be discussed below.
Our review reports a larger proportion of possession
patients, compared with trance patients (a ratio of 2.28:1),
which advocates the need to rename the disorder as
dissociative trance and possession disorders, were the
DSM-5 to maintain the 2 subtypes in a unique category.
Besides the dissociative symptoms described by the DSM
and ICD classifications, we identified other symptoms
that are not part of the standard criteria for the diagnosis.
Significantly, reports of hallucinations could reach 56% of
patients with possession. These phenomena were closely
related to the perceived presence of an invisible entity and
the ability of the person to communicate with it. Therefore,
we interpret them as being part of the whole experience
of the subject rather than additional symptoms. Although
not cited as frequently associated with the disorder,
according to the DSM, “in some cultures, visual or auditory
hallucinations with a religious content may be a normal part
of religious experience.”6, p 306 This consideration should
prevent us from the cultural bias that possibly leads to the
overdiagnosis of psychotic disorders in people belonging to
cultures that have a strong belief in the supernatural. The
opposite bias would consist in interpreting hallucinations
involving symbols and spirits that comprise part of a
culture as systematically being normal experiences. In
this respect, Ng36 notes that although human beings are
commonly possessed by lower level spirits in Chinese
society, possession by a spirit of higher rank is readily
recognized as a manifestation of severe mental disorder.
Mercer20 highlights 2 risks of producing what Kleinman39
defines as a “category fallacy”p 4 by pathologizing a normal
religious experience, and mistaking a possibly dangerous
clinical condition as ordinary albeit unfamiliar religiosity.
We also note a high occurrence of somatic complaints
that can manifest as prodromes of a trance or possession
episode in certain patients.36 This could also be mentioned
as a possible associated symptom in future classifications.
In contrast, amnesia is reported in only 20% of patients.
Thus amnesia does not appear as an essential feature for the
diagnosis of possession, but should rather be mentioned as a
possible additional symptom of dissociation that can occur
both in trance and in possession episodes. It should be noted
that ICD-10 classification does not consider amnesia as a
criterion for either trance or possession.
Authors advocate a wide variety of etiologies, referring
to a mean of 3 explanatory models for each patient with
DTD. Except for the general and unspecific models of
psychosocial stressors and cultural factors, none of the
6 other explanatory models is significantly represented
over the others. Notably, only 18% of articles refer to
the traumatic theory and, among their authors, none but
239

6. Review Paper
Castillo9 defends the theory of sexual child abuse. Even
though studies of the patients’ explanatory models are still
needed, these findings plead for the absence of a specific
cause for DTD. We rather consider pathological trance
and possession as a final common behavioural pathway
for various sociocultural, interpersonal, and idiosyncratic
psychological issues. Based on Linton’s40 seminal concept
of “patterns for misconduct,”p 433 later developed by
Devereux,41 we consider DTD a worldwide help-seeking
behaviour, a nonlocal but global idiom of distress, existing
in most societies and branched into several culture-bound
syndromes.
In light of our findings and analysis, although acculturation
issues are raised by only 4 authors,22,24,25,35 they may provide
the most specific framework for understanding DTD. In
the particular context of acculturation, DTD may indeed
appear as a reliable means of obtaining help, assuming it
is considered as a universal means of expressing distress.
Moreover, our own studies42,43 corroborated the relation
between acculturation difficulties and DTD from evidence
of trance and possession disorder suffered by immigrants
in France. One additional difficulty related to immigrants
arises when their familial and social entourage is missing,
depriving psychiatrists from an essential source of
expertise. For this reason, in cross-cultural settings patients
suffering from DTD may be subject to misdiagnosis and
aberrant management, which in turn could aggravate the
symptoms.42 To minimize cultural biases and provide more
than a “minimal recognition of sociocultural factors,”44, p 560
a thorough study of cultural implications is pivotal; it is
insufficient, however, and should not be done at the expense
of a standard psychiatric evaluation. Mercer20 reports the
paradoxical situation where the mother of the patient sees
her daughter’s experiences as normal, owing to the family
involvement in Pentecostal religion, whereas the therapist
recognizes some highly pathological symptoms. Besides,
patients manifesting with possession are in many cases
obtaining an immediate gain in social status and authority
within their community, which precludes the diagnosis of
DTD according to DSM’s Criterion C.
rather than a theory, drawing on a multitude of theoretical
perspectives regarding the same phenomenon. Thus
ethnopsychiatry is based on the validity both of social
and of psychiatric explanatory models. Nevertheless,
Devereux45 commits himself to a notion of normality that
is not contained simply by the particular context in which
it appears but is also defined by structural (that is, contextindependent) criteria. These seminal concepts are developed
by other authors46–48 who employ them to raise the validity
of their diagnostic and efficacy of their management in
cross-cultural settings.
Differences based on treatments should not be given
significant weight considering the small sample size for
which data are available (n = 114) and the absence of
control groups. Psychotherapy seems to be the prevailing
approach to DTD; however, there is a scarcity of data
regarding specific techniques used. A pair of authors21
argue that psychotherapy should focus on specific stressors
rather than trance episodes. Therapies combining modern
psychiatry with a culture-specific approach are advocated
by one group of authors,34 while another author30 conducted
an exorcismlike session with the help of the patient’s
brother. Authors do not define the criteria used for labelling
an outcome as positive, thus we assume they implicitly
refer to the level of distress and the frequency and intensity
of episodes. In all eventualities, most patients do not need to
be hospitalized, and, in addition to psychotherapy combined
with a traditional method of healing, could benefit from
sedative medications that might be neuroleptics at low
doses.
Conclusions
1. Psychiatric assessment for evaluating the balance that
exists between impairment and secondary benefits,
owing to the social impact of the condition, as well as
possible comorbidity with depression or other mental
disorders.
2. A comprehensive sociocultural study exploring the
patient and their entourage’s experience and explanatory
models.
Our review and analysis of 402 patients with DTD reported
since 1988 suggests there is accumulating evidence for
the inclusion of DTD as a discrete disorder in the DSM-5,
provided the following adjustments are considered (Table 3).
First, there is a need for a more practical definition both of
the trance and of the possession subtypes to help distinguish
one from the other, especially in cultural settings that admit
the existence of possessing agents. DSM Criterion A for the
possession subtype should not feature amnesia, while both
the DSM and the ICD should acknowledge the possibility of
hallucinations relating to the possessing agent. Moreover, it
should be mentioned that for possession, the new identity
may be identified by the patient or their entourage (Table
3). Second, without a reliable approach, Criterion B and C
are subject to biased interpretations that can possibly lead
to misdiagnosis. Therefore, we emphasize the importance
of interviewing not only patients but also their family
and community about their culture and religion and their
ordinary implications in daily life. In any event, a clinical
approach to DTD should ideally combine psychiatric and
sociocultural perspectives.
At this point, the contribution of complementarism defined
by Devereux41,45 seems particularly useful. Devereux defines
complementarism as a methodological generalization
The American Psychiatric Association49 recently
acknowledged, online, its proposal that the possession
type in the DSM-5 be subsumed under the existing DID.
All these issues point to the need for a specific approach to
DTD. More rigorous diagnostic processes and more efficient
treatment plans result from a multiple-frame approach:
240
La Revue canadienne de psychiatrie, vol 56, no 4, avril 2011

7. A Critical Review of Dissociative Trance and Possession Disorders: Etiological, Diagnostic, Therapeutic, and Nosological Issues
As for the trance subtype, it would remain in dissociative
disorder not otherwise specified. This option, by implying
only minor changes in the current DSM, would increase
the cross-cultural validity of the next edition. However,
based on our findings and analysis, we deem it necessary to
create a discrete category both for trance and for possession
dissociative disorders. Indeed, from a phenomenological
standpoint, possession and DID are 2 different conditions
that may require different treatments. In addition, by
allocating a discrete place for DTD in the next edition of
the DSM, we could more easily subsume several culturebound syndromes under a unique practical framework. In
this respect, we understand DTD as a universal behavioural
archetype or, in other words, a pattern for patterns of
misconduct.
Finally, migration and especially acculturation issues may
be a risk factor for DTD. Given the trends of migration
flows around the world and in North America for the
past 2 decades, levels and rates of international migration
may well remain elevated.50 In these circumstances,
the acculturation situation can be seen as a novel and
central paradigm51 that may contain key concepts for the
understanding of what could be called not a culture-bound
syndrome but rather an acculturation-bound syndrome.
Acknowledgements
No funding was provided for this research. We thank
Richard Rastegar for his help during the redaction of the
article.
References
1. World Health Organization. Chapter V, categories F00–F99, mental
and behavioral disorders. Clinical descriptions and diagnostic
guidelines. In: International classification of diseases (draft of 10th
edition) (ICD-10). Geneva (CH): WHO; 1989.
2. World Health Organization. The ICD-10 classification of mental and
behavioral disorders: clinical descriptions and diagnostic guidelines.
Geneva (CH): WHO; 1992.
3. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th ed. Washington (DC): American Psychiatric
Press; 1994.
4. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 4th ed. Text revision. Washington (DC):
American Psychiatric Press; 2000.
5. Bourguignon E. Possession. San Francisco (CA): Chandler & Sharp
Publishers; 1976.
6. Bastide R. Le rêve, la transe, la folie. Paris (FR): Flammarion; 1972.
7. Yap PM. Classification of the culture-bound reactive syndromes.
Aust N Z J Psychiatry. 1967;1(4):172–179.
8. Guarnaccia PJ, Rogler LH. Research on culture-bound syndromes:
new directions. Am J Psychiatry. 1999;156:1322–1327.
9. Castillo RJ. Spirit possession in South Asia, dissociation or hysteria?
Part 2: case histories. Cult Med Psychiatry. 1994;18(2):141–162.
10. Chand SP, Al-Hussaini AA, Martin R, et al. Dissociative disorders in
the Sultanate of Oman. Acta Psychiatr Scand. 2000;102(3):185–187.
11. Das PS, Saxena S. Classification of dissociative states in DSM-III-R
and ICD-10 (1989 draft). A study of Indian out-patients.
Br J Psychiatry. 1991;159:425–427.
The Canadian Journal of Psychiatry, Vol 56, No 4, April 2011 
12. Ferracuti S, DeMarco MC. Ritual homicide during dissociative
trance disorder. Int J Offender Ther Comp Criminol.
2004;48(1):59–64.
13. Ferracuti S, Sacco R, Lazzari R. Dissociative trance disorder:
clinical and Rorschach findings in ten persons reporting
demon possession and treated by exorcism. J Pers Assess.
1996;66(3):525–539.
14. Freed RS, Freed SA. Ghost illness in a North Indian village.
Soc Sci Med. 1990;30(5):617–623.
15. Gaw AC, Ding Q, Levine RE, et al. The clinical characteristics
of possession disorder among 20 Chinese patients in the Hebei
province of China. Psychiatr Serv. 1998;49(3):360–365.
16. Hale AS, Pinninti NR. Exorcism-resistant ghost possession treated
with clopenthixol. Br J Psychiatry. 1994;165(3):386–388.
17. Khalifa N, Hardie T. Possession and jinn. J R Soc Med.
2005;98:351–353.
18. Matsuoka E. The interpretations of fox possession: illness as
metaphor. Cult Med Psychiatry. 1991;15:453–477.
19. Mattoo SK, Gupta N, Lobana A, et al. Mass family hysteria:
a report from India. Psychiatry Clin Neurosci. 2002;56(6):643–646.
20. Mercer JA. The Protestant child, adolescent and family.
ChildAdolesc Psychiatr Clin North Am. 2004;13:161–181.
21. Ng BY, Chan YH. Psychosocial stressors that precipitate
dissociative trance disorder in Singapore. Aust N Z J Psychiatry.
2004;38(6):426–432.
22. Peltzer K. Nosology and etiology of a spirit disorder (Vimbuza)
in Malawi. Psychopathology. 1989;22:145–151.
23. Pereira S, Bhui K, Dein S. Making sense of ‘possession states’:
psychopathology and differential diagnosis. Br J Hosp Med.
1995;53(11):582–586.
24. Pineros M, Rosselli D, Calderon C. An epidemic of collective
conversion and dissociation disorder in an indigenous group
of Colombia: its relation to cultural change. Soc Sci Med.
1998;46(11):1425–1428.
25. Prakash R, Singh LK, Bhatt N et al. Possession states precipitated
by nortriptyline. Aust N Z J Psychiatry. 2008;42(5):432–433.
26. Satoh S, Obata S, Seno E, et al. A case of possessive state with
onset influenced by ‘door-to-door’ sales. Psychiatry Clin Neurosci.
1996;50(6):313–316.
27. Saxena S, Prasad KV. DSM-III subclassification of dissociative
disorders applied to psychiatric outpatients in India. Am J
Psychiatry. 1989;146(2):261–262.
28. Schieffelin EL. Evil spirit sickness, the Christian disease:
the innovation of a new syndrome of mental derangement
and redemption in Papua New Guinea. Cult Med Psychiatry.
1996;20(1):1–39.
29. Somasundaram D, Thivakaran T, Bhugra D. Possession states in
Northern Sri Lanka. Psychopathology. 2008;41:245–253.
30. Somer E. Paranormal and dissociative experiences in MiddleEastern Jews in Israel: diagnostic and treatment dilemmas.
Dissociation. 1997;10(3):174–181.
31. Szabo CP, Jonsson G, Vorster V. Dissociative trance disorder
associated with major depression and bereavement in a South
African female adolescent. Aust N Z J Psychiatry. 2005;39(5):423.
32. Trangkasombat U, Su-Umpan U, Churujiporn V, et al. Epidemic
dissociation among school children in Southern Thailand.
Dissociation. 1995;8(3):130–141.
33. Trangkasombat U, Su-Umpan U, Churujiporn V, et al. Risk factors
for spirit possession among school girls in southern Thailand.
J Med Assoc Thai. 1998;81(7):541–546.
34. Witztum E, Buchbinder JT, van der Hart O. Summoning a punishing
angel: treatment of a depressed patient with dissociative features.
Bull Menninger Clin. 1990;54(4):524–537.
35. Witztum E, Budowski D. The ‘Zar’ possession syndrome among
Ethiopian immigrants to Israel: cultural and clinical aspects.
Br J Med Psychol. 1996;69:207–225.
36. Ng BY. Phenomenology of trance states seen at a psychiatric
hospital in Singapore: a cross-cultural perspective. Transcult
Psychiatry. 2000;37(4):560–579.
241

8. Review Paper
37. Sethi S, Bhargava SC. Mass possession in a family setting.
Transcult Psychiatry. 2009;46(2):372–374.
38. Gangdev PS, Matjane M. Dissociative disorders in Black South
Africans: a report on five cases. Dissociation Prog Dissociative
Disord. 1996;9(3):176–181.
39. Kleinman AM. Depression, somatization and the “new cross-cultural
psychiatry.” Soc Sci Med. 1977;11:3–10.
40. Linton R. The study of man: an introduction. New York (NY):
Appleton-Century; 1936.
41. Devereux G. Ethnopsychoanalysis: psychoanalysis and
anthropology as complementary frames of reference. Berkely and
Los Angeles (CA): University of California Press; 1972.
42. During E. 2008. Analyse du « trouble dissociatif de type transe et
possession » proposé a l’étude par le DSM-IV. Etude des aspects
nosologiques, épidemiologiques, cliniques, psychopathologiques et
thérapeutiques liés à cette éventualité diagnostique [doctoral thesis].
[Paris (France)]: Paris 7 University. French.
43. Baubet T. 2008. Effroi et métamorphose : psychothérapie
transculturelle des névroses traumatiques en situation d’impasse
thérapeutique [doctoral thesis]. [Paris (France)]: Paris 13 University.
French.
44. Alarcón DR, Becker AE, Lewis-Fernández R, et al. Issues for
DSM-V. The role of culture in psychiatric diagnosis. J Nerv Ment
Dis. 2009;197(8):559–660.
45. Devereux G. Basic problems of ethnopsychiatry. Chicago (IL):
The University of Chicago Press; 1980.
46. Nathan T. La folie des autres. Traité d’ethnopsychiatrie clinique.
Paris (FR): Dunod; 1986.
47. Moro MR. Parents en exil. Psychopathologie et migrations.
Paris (FR): PUF; 1994.
48. Moro MR. Parents and infants in changing cultural context:
immigration, trauma and risk. Infant Ment Health J.
2003;24(3):240–264.
49. American Psychiatric Association. DSM-5 development:
dissociative trance disorder [Internet]. [place of publication
unknown]: APA; 2010 [cited 2011 Jan 20]. Available from:
http://www.dsm5.org/ProposedRevisions/Pages/
proposedrevision.aspx?rid=436#50. United Nations Population
Division. Department of Economic and Social Affairs. International
migration stocks: the 2008 revision [Internet]. [place of publication
unknown]: UN; 2008 [cited 2011 Jan 20].
Available from: http://esa.un.org/migration.
51. Bhugra D. Migration and mental health. Acta Psychiatr Scand.
2004;109(4):243–258.
This paper was presented at the 7e Congrès de l’Encéphale, Paris, France,
2009 Jan 22–24.
Manuscript received June 2010, revised, and accepted December 2010
1
Docteur en médecine, Psychiatre, Chercheur, Service de psychopathologie de l’enfant et de l’adolescent, psychiatrie générale et addictologie,
Hôpital Avicenne (AP-HP), Université Paris 13, France; Chercheur,
Center for Brain Health, NYU School of Medicine, Department of
Psychiatry, New York, New York.
2
Docteure en médecine, Mount Sinai School of Medicine, New York,
New York; Chercheure, Wellcome Trust Centre for Human Genetics,
University of Oxford, Roosevelt Drive, Headington, Oxford, England.
3
Docteur en médecine, Psychiatre, Praticien Hospitalier, Service de
psychopathologie de l’enfant et de l’adolescent, psychiatrie générale et
addictologie, Hôpital Avicenne (AP-HP), Université Paris 13, France.
4
Professeure de Psychiatrie, Chef de Service, Maison des adolescents,
Cochin Hospital (AP-HP), Université Paris Descartes, France, INSERM
U669.
5
Professeur de Psychiatrie, Chef de Service, Service de psychopathologie de l’enfant et de l’adolescent, psychiatrie générale et addictologie,
Hôpital Avicenne (AP-HP), Université Paris 13, France.
Address for correspondence: Dr E H During, Center for Brain Health,
NYU School of Medicine, Department of Psychiatry, 145 East 32nd
Street, New York, NY 10016; emmanuel.during@nyumc.org
Résumé : Une revue critique de la littérature médicale sur les troubles de transe et de possession
dissociatifs : enjeux étiologiques, diagnostiques, thérapeutiques et nosologiques
Objectif : Bien que le Manuel diagnostique et statistique des troubles mentaux (DSM), 4e édition,
reconnaisse l’existence des troubles de transe et de possession dissociatifs, simplement nommés troubles de
transe dissociatifs (TTD), il faut plus d’études pour en évaluer l’utilité clinique dans le DSM-5. Pour répondre à
cette question, nous avons mené la première revue de la littérature médicale.
Méthode : Nous avons recherché dans les bases de données MEDLINE, CINAHL, et PsycINFO, de 1988
à 2010, des rapports de cas de TTD selon les définitions du DSM ou de la Classification internationale des
maladies. Pour chaque article, nous avons recueilli les données épidémiologiques et cliniques, les modèles
explicatifs utilisés par les auteurs, les traitements, et l’information sur le résultat.
Résultats : Nous avons trouvé 28 articles rapportant 402 cas de patients souffrant de TTD dans le monde
entier. Les données montrent une proportion égale de patients masculins et féminins, et une prédominance
de possession (69 %), comparé à la transe (31 %). L’amnésie est déclarée par 20 % des patients.
Réciproquement, les symptômes hallucinatoires durant les épisodes de possession ont été constatés chez
56 % des patients et devraient donc constituer un critère important. Les plaintes somatiques s’observent
chez 34 % des patients. Des modèles explicatifs multiples sont utilisés simultanément et semblent être
complémentaires.
Conclusion : Les données suggèrent fortement l’inclusion des TTD dans le DSM-5, à condition que
certains ajustements soient effectués. Le TTD est un trouble répandu qui peut être compris comme étant
une expression universelle de détresse, probablement sous-diagnostiqué dans les pays occidentaux en
raison des biais culturels, et dont l’incidence pourrait s’accroître étant donné le mouvement migratoire à la
hausse. Le diagnostic exact et la prise en charge appropriée doivent résulter d’une évaluation complète
des enjeux socioculturels et idiosyncratiques, parmi lesquels les difficultés de l’acculturation devraient être
systématiquement examinées, surtout dans les milieux interculturels.
242
La Revue canadienne de psychiatrie, vol 56, no 4, avril 2011