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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


Introduction and aims

As 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.


A 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 conclusion

Illness 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.

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  1. 1.

    Van Duijl M, Nijenhuis E, Komproe IH, Gernaat HB, de Jong JT (2010) Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda. Cult Med Psychiatry 34:380–400

    PubMed  Article  Google Scholar 

  2. 2.

    Odenwald M, Van Duijl M, Schmitt T (2007) Psychology and culture: disorders of possession and dissociation in intercultural practice. In: Bhui Kamaldeep, Bhugra Dinesh (eds) Culture and mental health, a comprehensive textbook. Hodder Arnold, London, pp 87–97

    Google Scholar 

  3. 3.

    Neuner F, Pfeiffer A, Schauer-Kaiser E, Odenwald M, Elbert T, Ertl V (2012) Haunted by ghosts: prevalence, predictors and outcomes of spirit possession experiences among former child soldiers and war-affected civilians in Northern Uganda. Soc Sci Med 75:548–554

    PubMed  Article  Google Scholar 

  4. 4.

    During EH, Elahi FM, Taieb O, Moro MR, Baubet T (2011) A critical review of dissociative trance and possession disorders: etiological, diagnostic, therapeutic, and nosological issues. Can J Psychiatry 56:235–242

    PubMed  Google Scholar 

  5. 5.

    Sar V (2006) The scope of dissociative disorders: an international perspective. Psychiatr Clin N Am 29:227–244 (xi)

    Article  Google Scholar 

  6. 6.

    Cardeña E, Van Duijl M, Weiner L, Terhune DB (2009) Possession/trance phenomena. In: Dell PF, O’Neil JA (eds) Dissociation and dissociative disorders: DSM V and beyond, 1st edn. Routledge, New York

    Google Scholar 

  7. 7.

    Bourguignon E, Evascu TL (1977) Altered states of consciousness within a general evolutionary perspective: a Holocultural analysis. Cross Cult Res 12:197–216

    Article  Google Scholar 

  8. 8.

    De Jong JT, Reis R (2010) Kiyang-yang, a West-African postwar idiom of distress. Cult Med Psychiatry 34:301–321

    PubMed  Article  Google Scholar 

  9. 9.

    Igreja V (2003) ‘Why are there so many drums playing until dawn?’ Exploring the role of Gamba spirits and healers in the post-war recovery period in Gorongosa, Central Mozambique. Transcult Psychiatry 40:459–487

    PubMed  Article  Google Scholar 

  10. 10.

    Behrend H (1999) Power to heal, power to kill: spirit possession and war in northern Uganda (1986–1994). In: Behrend H, Luig U (eds) Spirit possession: modernity and power in Africa. James Currey, Oxford, pp 20–33

    Google Scholar 

  11. 11.

    Halliburton M (2005) “Just some spirits”: the erosion of spirit possession and the rise of “tension” in South India. Med Anthropol 24:111–144

    PubMed  Article  Google Scholar 

  12. 12.

    Igreja V, Dias-Lambranca B, Hershey DA, Racin L, Richters A, Reis R (2010) The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique. Soc Sci Med 71:592–599

    PubMed  Article  Google Scholar 

  13. 13.

    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, DSM-IV-TR. American Psychiatric Association, Washington

    Google Scholar 

  14. 14.

    World Health Organization (2010) International statistical classification of diseases and related health problems 10th revision.

  15. 15.

    Spiegel D, Loewenstein RJ, Lewis-Fernandez R, Sar V, Simeon D, Vermetten E, Cardena E, Dell PF (2011) Dissociative disorders in DSM-5. Depress Anxiety 28:E17–E45

    PubMed  Article  Google Scholar 

  16. 16.

    Ross CA (2011) Possession experiences in dissociative identity disorder: a preliminary study. J Trauma Dissociation 12:393–400

    PubMed  Article  Google Scholar 

  17. 17.

    American Psychiatric Association (2012) Task force DSM-5 development. Consulted September 2012: proposed text for DSM-5, available untill 30 Nov 2012

  18. 18.

    Alarcon RD, Becker AE, Lewis-Fernandez R, Like RC, Desai P, Foulks E, Gonzales J, Hansen H, Kopelowicz A, Lu FG, Oquendo MA, Primm A (2009) Issues for DSM-V: the role of culture in psychiatric diagnosis. J Nerv Ment Dis 197:559–660

    PubMed  Article  Google Scholar 

  19. 19.

    Kleinman A (1980) Patients and healers in the context of culture. University of California Press, Berkeley

  20. 20.

    Corbin J, Strauss A (2008) Basics of qualitative research, 3rd edn. Sage, Los Angeles

    Google Scholar 

  21. 21.

    De Jong JT, Reis R, Poortinga Y (2010) Onderzoeks methodologie (research methodology). In: de Jong JT, Colijn (eds) Handboek Culturele Psychiatrie en psychotherapie. De Tijdstroom, Utrecht

  22. 22.

    De Jong JT, van Ommeren M (2002) Toward a culture-informed epidemiology: combining qualitative and quantitative research in transcultural contexts. Transcult Psychiatry 39:422–433

    Article  Google Scholar 

  23. 23.

    Van Duijl M, Cardena E, de Jong JT (2005) The validity of DSM-IV dissociative disorders categories in south-west Uganda. Transcult Psychiatry 42:219–241

    PubMed  Article  Google Scholar 

  24. 24.

    World Health Organization (2005) Mental health atlas (Online 2012)

  25. 25.

    Tankink M (2007) ‘The moment I became born-again the pain disappeared’: the healing of devastating war memories in born-again churches in Mbarara District, Southwest Uganda. Transcult Psychiatry 44:203–231

    PubMed  Article  Google Scholar 

  26. 26.

    Van Duijl M (2003) Culturally sensitive counselling in Uganda. Memisa Medisch 69:18–27

    Google Scholar 

  27. 27.

    World Medical Association declaration of Helsinki (1997) Recommendations guiding physicians in biomedical research involving human subjects. JAMA 277:925–926

    Article  Google Scholar 

  28. 28.

    Dell PF (2009) The phenomena of pathological dissociation. Dissociation and dissociative disorders: DSM V and beyond. Routledge, New York

    Google Scholar 

  29. 29.

    Steele K, van der Hart O, Nijenhuis E (2009) The theory of trauma-related structural dissociation of the personality. In: Dell PF, O’Neil JA (eds) Dissociation and the dissociative disorders: DSM-V and beyond. Routledge, New York, pp 239–258

    Google Scholar 

  30. 30.

    Van der Hart O, Nijenhuis E, Steele K, Brown D (2004) Trauma-related dissociation: conceptual clarity lost and found. Aust N Z J Psychiatry 38:906–914

    PubMed  Article  Google Scholar 

  31. 31.

    De Jong JT, Reis R (2010) Kiyang-yang, a West-African postwar idiom of distress. Cult Med Psychiatry 34:301–321

    PubMed  Article  Google Scholar 

  32. 32.

    Seligman R (2005) Distress, dissociation, and embodied experience: reconsidering the pathways to mediumship and mental health. Ethos 33:71–99

    Article  Google Scholar 

  33. 33.

    Seligman R, Kirmayer LJ (2008) Dissociative experience and cultural neuroscience: narrative, metaphor and mechanism. Cult Med Psychiatry 32:31–64

    PubMed  Article  Google Scholar 

  34. 34.

    Castillo RJ (1994) Spirit possession in South Asia, dissociation or hysteria? Part 1: theoretical background. Cult Med Psychiatry 18:1–21

    PubMed  Article  CAS  Google Scholar 

  35. 35.

    Castillo RJ (1994) Spirit possession in South Asia, dissociation or hysteria? Part 2: case histories. Cult Med Psychiatry 18:141–162

    PubMed  Article  CAS  Google Scholar 

  36. 36.

    Gaw AC, Ding Q, Levine RE, Gaw H (1998) The clinical characteristics of possession disorder among 20 Chinese patients in the Hebei province of China. Psychiatr Serv 49:360–365

    PubMed  CAS  Google Scholar 

  37. 37.

    Ng BY (2000) Phenomenology of trance states seen at a psychiatric hospital in Singapore: a cross-cultural perspective. Transcult Psychiatry 37:560–579

    Article  Google Scholar 

  38. 38.

    Saxena S, Prasad KV (1989) DSM-III subclassification of dissociative disorders applied to psychiatric outpatients in India. Am J Psychiatry 146:261–262

    PubMed  CAS  Google Scholar 

  39. 39.

    Moskowitz A, Corstens D (2008) Auditory hallucinations: psychotic symptom or dissociative experience? J Psychol Trauma 6:35–63

    Article  Google Scholar 

  40. 40.

    Bentall RP, Fernyhough C (2008) Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull 34:1012–1020

    PubMed  Article  Google Scholar 

  41. 41.

    Honig A, Romme MAJ, Ensink BJ, Escher SDMA, Pennings MHA, Devries MW (1998) Auditory hallucinations: a comparison between patients and non patients. J Nerv Ment Dis 186:646–651

    PubMed  Article  CAS  Google Scholar 

  42. 42.

    Varese F, Barkus E, Bentall RP (2012) Dissociation mediates the relationship between childhood trauma and hallucination-proneness. Psychol Med 42:1025–1036

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Brand B, Classen C, Anins R (2009) A naturalistic study of dissociative identity disorder and dissociative disorder not otherwise specified patients treated by community clinicians. Psychol Trauma Theory Res Pract Policy 1:153–171

    Article  Google Scholar 

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We like to thank all the healers who gave us their trust and collaborated in this research by referring their patients. We especially want to thank all the participants in this study. We are also very grateful to our research assistants Andrew Ainomugisha and Blanka Conze for their valuable assistance in the fieldwork and to Ellert Nijenhuis and Jeroen Knipscheer for their very valuable comments in earlier stages of this study.

Conflict of interest

The authors declare that they have no conflict of interest.

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Correspondence to Marjolein van Duijl.

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van Duijl, M., Kleijn, W. & de Jong, J. 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. Soc Psychiatry Psychiatr Epidemiol 48, 1417–1430 (2013).

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  • Spirit possession
  • Dissociative trance disorders
  • Dissociative disorders
  • Dissociative identity disorder
  • DSM-IV
  • DSM-5