Delusion of possession vs. dissociative state?

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Sara91Helal

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Hello, fellow doctors!

I'm a bit confused regarding the difference between delusions of possession (e.g. a female patient insults people in a male-like voice which she attributes to being possessed by a demon) and dissociative states. Could both co-occur?

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Consider roleplaying, where the person knows on some level that they are directing the aberrant behavior, for secondary gain. I hesitate to call this malingering, because that has the connotation of deliberate falsehood. But I've known people who partook in similar behaviors and in some cases, it was a matter of an almost childlike "Let's Pretend" exercise, that allowed the person to say things and experience emotional states that they did not permit to themselves during their "normal" life. During the episode, they would have asserted fiercely that they weren't making it up, that it really was an external influence, but later the person was able to admit that they were steering the experience based upon their emotional needs. Is that delusion, or dissociation, or is it the equivalent of having an imaginary friend who sticks up for you when you aren't feeling brave enough or empowered enough to insult people in your own voice? It clearly sounds maladaptive, but it may be accomplishing something for the person that makes the downsides of "being posessed by a demon" worth enduring.
 
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Note that there are religious traditions built around this sort of thing (Vodou, Santeria, Candomble, really anything that originally derived from Yoruba belief-systems). This somewhat complicates labeling it as pathological without running very quickly into the morass of figuring out what religious experiences get a pass and which are considered evidence of psychopathology. I realize that some standard of what the person in question's community generally believes is possible is probably what that judgment comes down to, but suppose they are members of a smaller subculture that is on board with this while the local dominant culture is not...
 
I'm a bit confused regarding the difference between delusions of possession (e.g. a female patient insults people in a male-like voice which she attributes to being possessed by a demon) and dissociative states. Could both co-occur?

You mentioned multiple different processes:

1) "Delusion of possession" (what does this mean to you?): Patient has a fixed, false belief (delusion) that they have been "possessed by a demon?" (What does this "possession" mean to them?)
2) Objectively observed behavior: a patient's voice occasionally takes on different qualities and she aggressively insults others, which she later "attributes to demon possession" (whatever this means to her)
3) "Dissociative state" (whatever this means to you)

It may be more helpful to talk about the process using words that are more digestible and convey a clearer meaning to you and your audience... this takes work because you've brought up a lot of underlying assumptions in your question which need to be clarified/challenged. A more detailed pretend case or more data about a pretend situation may help us better describe what we think is going on in this pretend person's mind.

That being said, I think the responses have practically captured the biggies: cultural religious responses/delusions, psychoses, traumatic processes, malingering (imaginary friend / absolution of responsibility), being possessed by a demon (seriously, I can't rule that out %100).
 
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This happens outside of movies?

Consider roleplaying, where the person knows on some level that they are directing the aberrant behavior, for secondary gain. I hesitate to call this malingering, because that has the connotation of deliberate falsehood. But I've known people who partook in similar behaviors and in some cases, it was a matter of an almost childlike "Let's Pretend" exercise, that allowed the person to say things and experience emotional states that they did not permit to themselves during their "normal" life. During the episode, they would have asserted fiercely that they weren't making it up, that it really was an external influence, but later the person was able to admit that they were steering the experience based upon their emotional needs. Is that delusion, or dissociation, or is it the equivalent of having an imaginary friend who sticks up for you when you aren't feeling brave enough or empowered enough to insult people in your own voice? It clearly sounds maladaptive, but it may be accomplishing something for the person that makes the downsides of "being posessed by a demon" worth enduring.

If this patient is not psychotic, then I would look for the other criteria for BPD and treat that.

Note that there are religious traditions built around this sort of thing (Vodou, Santeria, Candomble, really anything that originally derived from Yoruba belief-systems). This somewhat complicates labeling it as pathological without running very quickly into the morass of figuring out what religious experiences get a pass and which are considered evidence of psychopathology. I realize that some standard of what the person in question's community generally believes is possible is probably what that judgment comes down to, but suppose they are members of a smaller subculture that is on board with this while the local dominant culture is not...

You mentioned multiple different processes:

1) "Delusion of possession" (what does this mean to you?): Patient has a fixed, false belief (delusion) that they have been "possessed by a demon?" (What does this "possession" mean to them?)
2) Objectively observed behavior: a patient's voice occasionally takes on different qualities and she aggressively insults others, which she later "attributes to demon possession" (whatever this means to her)
3) "Dissociative state" (whatever this means to you)

It may be more helpful to talk about the process using words that are more digestible and convey a clearer meaning to you and your audience... this takes work because you've brought up a lot of underlying assumptions in your question which need to be clarified/challenged. A more detailed pretend case or more data about a pretend situation may help us better describe what we think is going on in this pretend person's mind.

That being said, I think the responses have practically captured the biggies: cultural religious responses/delusions, psychoses, traumatic processes, malingering (imaginary friend / absolution of responsibility), being possessed by a demon (seriously, I can't rule that out %100).


Thanks for all your responses, I appreciate that you guys took the time to think and comment.

Some facts about the patient:


  • Culturally, she's a Muslim Egyptian 29-year-old, from a poor social class where beliefs of demons and possessions are common.
  • She's divorced, has 3 kids.
  • She believes her ex-husband made some "dark magic" and that's why a demon possessed her. (Persecutory delusion?)
  • She's been "sick" for 10 years (according to her mother). Sought medical help, with poor outcome.
  • She was hospitalized because of agitation, verbal and physical aggression.
  • On examination, the patient is dysphoric, looked distressed and anxious and wanted to leave. "I'm not crazy, I'm possessed." she says. She talks in average volume with sudden intervals of loud, male-like insulting voice (which actually startled me a couple of times), other patients in the ward (even nurses) avoid dealing with her. The patient says she is aware of the "male voice"; she hears herself speak, but she cannot control or anticipate what "it" is going to say.
  • She claims seeing shadows of demons who sometimes hit her. (Visual hallucinations?)
  • No obvious formal thought disorders.
  • Patient has no distinct borderline or hysterical traits.
The picture goes with schizophrenia (delusions of control/passivity), but her visual hallucinations confuse me, she denies hearing voices.
 
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Looks like Clausewitz's intuition was working best on this case. It sounds like a cultural expression of psychological distress both the religious component and the somatic component. Tough case. I would think treating the depression and avoiding medications with too many somatic side effects and if possible refer to psychotherapist familiar with Arab or Muslim culture which will be quite the challenge. her statement of not being crazy and being possessed could be translated to "my negative emotions as a result of the divorce and/or abusive ex have taken over my ability to think rationally. "
 
Looks like Clausewitz's intuition was working best on this case. It sounds like a cultural expression of psychological distress both the religious component and the somatic component. Tough case. I would think treating the depression and avoiding medications with too many somatic side effects and if possible refer to psychotherapist familiar with Arab or Muslim culture which will be quite the challenge. her statement of not being crazy and being possessed could be translated to "my negative emotions as a result of the divorce and/or abusive ex have taken over my ability to think rationally. "


I'm a junior resident in a mental institute in Egypt, psychotherapists are familiar with that culture. Do you think her symptoms are somatic manifestations of depression, or depression with psychotic features? I interviewed the patient once (she's just been admitted), but I don't think mood symptoms prevail.
 
I'm a junior resident in a mental institute in Egypt, psychotherapists are familiar with that culture. Do you think her symptoms are somatic manifestations of depression, or depression with psychotic features? I interviewed the patient once (she's just been admitted), but I don't think mood symptoms prevail.
Ahh, I see where it says location: Cairo. :) As I look at what you are describing more carefully, it does appear that there is a psychotic process going on.
 
Focus on the phenomenology (her experience), not even her interpretation of it. What precedes speaking in a male voice? Is it voluntary? Triggered during duress? Is it ego-dystonic? Is she able to report back what she did after? Does she have a history of abuse from her ex-husband, and if so could some of this be flashbacks? Does she see the shadows with her eyes? Nightmares? Stigmata of being "hit?" Is her "sickness" related to these symptoms? Does she appear otherwise to be RIS?

Dissociation is a state, where part of consciousness splits off and seemingly works autonomously. Conversion disorder is IMPO a dissociative disorder. Many people who are dissociative are also very suggestible (probably accounting for prior reports of possession, witchcraft, etc). So if she believes it'll happen, it can then exist involuntarily. I would keep this high on the differential.

If you have anyone on staff trained in hypnosis, I'd do a standardized hypnotic scale (SHSS or HIP are good). Those with true schizophrenia are generally not hypnotizable (their split attention d/t paranoia or hallucinations impairs their ability to concentrate enough to get into a state), whereas dissociative people are very hypnotizable.

I've caught a handful of cases that were misdiagnosed as CPS that were really severe dissociative disorders that way. Much improved with proper therapy and not chasing it with meds.
 
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Focus on the phenomenology (her experience), not even her interpretation of it. What precedes speaking in a male voice? Is it voluntary? Triggered during duress? Is it ego-dystonic? Is she able to report back what she did after? Does she have a history of abuse from her ex-husband, and if so could some of this be flashbacks? Does she see the shadows with her eyes? Nightmares? Stigmata of being "hit?" Is her "sickness" related to these symptoms? Does she appear otherwise to be RIS?

Dissociation is a state, where part of consciousness splits off and seemingly works autonomously. Conversion disorder is IMPO a dissociative disorder. Many people who are dissociative are also very suggestible (probably accounting for prior reports of possession, witchcraft, etc). So if she believes it'll happen, it can then exist involuntarily. I would keep this high on the differential.

If you have anyone on staff trained in hypnosis, I'd do a standardized hypnotic scale (SHSS or HIP are good). Those with true schizophrenia are generally not hypnotizable (their split attention d/t paranoia or hallucinations impairs their ability to concentrate enough to get into a state), whereas dissociative people are very hypnotizable.

I've caught a handful of cases that were misdiagnosed as CPS that were really severe dissociative disorders that way. Much improved with proper therapy and not chasing it with meds.

Thanks for responding. Some of my colleagues suggested hypnosis, I'll check with my senior staff and see how it goes. Will update everyone. :)
 
Conversion disorder is IMPO a dissociative disorder.
the WHO would agree with you, in ICD-10 there is no diagnosis of conversion disorder, it is called "dissociative disorder". in my experience pts with conversion disorder are highly highly hypnotisable in keeping with this idea, and dissociation is a marker of high hypnotisability. There is good neuroimaging data to suggest that conversion disorder is a dissociative disorder involving dissociation between the emotional and motor/sensory regions. In this model, PTSD is also best conceptualized as an hysterical conversion neurosis, with the dissociation being between the amygdala and the DLPFC. Interesting high hypnotisability is also a risk factor for the development of PTSD.
 
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I think there's 2 subtypes of PTSD emerging in the literature, simplified into the hypervigilant and the dissociative. I have a suspicion only the hypervigilant responds to exposure therapy, but I'm not aware of any studies to look at this.
 
Interesting. I can see why you might think that as a strong tendency to dissociate could interfere with any exposure work. I haven't done PE yet as I'm doing my CPT training and they discouraging learning the two at the same time. The only study that has looked at dissociation properly in terms of treatment outcomes found that patients with strong dissociative features in PTSD responded better to CPT than CPT-C. The difference is in CPT you have to write a trauma narrative, whereas in CPT-C is cognitive only, no trauma narrative. This has overlap with exposure therapy (although unlike PE you don;t have to read it again and again necessarily, mainly interested in the "stuck points" generated from the narrative), but suggests that actually writing a trauma narrative may actually be more beneficial with people with prominent dissociation.

The Ref:
Resick, P.A., Suvak, M.K., Johnides, B.D., Mitchell, K.S., and Iverson,K.M. (2012).The impact of dissociation on PTSD treatment with cognitive processing therapy. Depression and Anxiety, 29, 718-730

Great study. Interestingly from that data all three treatment groups improved, but for those with highest dissociation (and depersonalization) they improved the most with CPT. What's further interesting is that the trauma narrative alone for the high dissociation group only did as well as CPT-C in the end, indicating there's some synergistic benefit of the cog tx and narrative component for this group. Which makes sense.

What I guess I have taken some umbrage against is some "dogmatic" therapists who push the exposure as the only beneficial treatment component for PTSD, and everything else as fluff. Which I think is crap. We need to make sense out of these experiences. Revisiting them is fine, as long as we can process them too.
 
Um, I'm still holding onto schizophrenia, but considering your POVs, I'll need to examine the patient more and get more details from her mother.
 
to answer the original question it is technically possible for one to be both psychotic and to be experiencing a possessive state. possessive states are distinct from passivity phenomena however, and there is no evidence from your description this patient has any passivity phenomena in the Schneiderian sense. that is to say the patient speaking in a demonic voice is not a disorder of willed action. that does not mean the patient is not experiencing a believe held with delusional intensity. but again, it is not the belief which makes something delusional, it is the way the belief is held that makes it delusional. it is perfectly acceptable for one to believe in demonic possession, in fact, you assert the family subscribes to this. What is different in delusions is the inflexibility of the belief, the reasoning of the belief, and the conviction of the belief. These lead to psychotic acting out - people behave in ways they wouldn't otherwise because of the incontrovertible nature of their beliefs.

what i want to know is whether she hears the demon speak without her speaking or others hearing the voices. asking about voice hearing per se is useless that is what you want to be ascertaining.

also have we excluded that she isn't actually possessed by a demon?
 
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to answer the original question it is technically possible for one to be both psychotic and to be experiencing a possessive state. possessive states are distinct from passivity phenomena however, and there is no evidence from your description this patient has any passivity phenomena in the Schneiderian sense. that is to say the patient speaking in a demonic voice is not a disorder of willed action. that does not mean the patient is not experiencing a believe held with delusional intensity. but again, it is not the belief which makes something delusional, it is the way the belief is held that makes it delusional. it is perfectly acceptable for one to believe in demonic possession, in fact, you assert the family subscribes to this. What is different in delusions is the inflexibility of the belief, the reasoning of the belief, and the conviction of the belief. These lead to psychotic acting out - people behave in ways they wouldn't otherwise because of the incontrovertible nature of their beliefs.

what i want to know is whether she hears the demon speak without her speaking or others hearing the voices. asking about voice hearing per se is useless that is what you want to be ascertaining.

also have we excluded that she isn't actually possessed by a demon?

I'll know more details tomorrow. As for your question, I'm not sure if you're serious, but anyway, it's not my job to decide or agree that she's possessed. And for the record, she sought the help of traditional healers who tried variable ways of exorcism with no success.
 
Interesting update:

  • Patient has obvious delusions of passivity (the demon controls not only her speech, but also her body movements), and thought insertion (the demon inserts ideas in her head).
  • She has multiple somatic complaints which she attributes to being possessed.
  • She claims seeing its shadow before her eyes, but when asked how it looked like, she said "it makes me sick when it talk about him."
  • She denies hearing its voice (she just hears her own male-like voice), but her mother told me she talked about "hearing a voice inside her head," will verify this today.
  • She talked about not being able to recognize herself in the mirror, and feeling as if she doesn't exist (depersonalization?)
  • She's been on Clozapine with poor improvement.
 
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