Religion and Spirituality in Psychiatry

Religion/Spirituality and Dissociative Disorders 147doctors of practicing illegal medicine as anact of unlawful competition unless the priestcould prove that the origins of the fever wereexclusively spiritual.The distinction between illness and the phenomenonof possession appeared in the Roman ritualthat Pope Paul V promulgated in 1614. Througha differential approach, this ritual ascribed threesigns to the demon possessed: (1) pronouncing orunderstanding words in a language unknown bythe possessed person, (2) revealing hidden knowledge,and (3) the exhibition of a force that transcendsthe natural human condition.In practice, priests who performed exorcismswere more likely to express aversion toward religiousthings as the determining criterion. Forthis reason, Gassner (1727–1779), a priest whopracticed exorcism in the regions of Constanceand Ratisbonne, took the precaution of startingwith what he called a trial exorcism (p. 85). (6)To ensure that he did not cross over into thesphere of the medical doctor, he began the ritualby presenting a crucifix and asking the individualto kiss it. He also sprinkled holy water,and so on. If the individual remained quiet andpeacefully submitted to the veneration of holyobjects, then their suffering was caused by a naturalillness and they had to be seen by a medicaldoctor. But if the person began to blasphemeand/or have convulsions, then their sufferingwas caused by a supernatural illness requiringtreatment by an exorcist.This specific division of tasks is not exclusivelyreserved to Catholicism. The way of expressingour symptoms has been strongly influenced bythis division of tasks, which partly explains whypatients who consult a doctor whose practicecorresponds to the Western medical paradigmprefer not to formulate their suffering in religiouslanguage in front of the doctor. Instead, it is totheir religious authorities that they address theirmetaphysical fears or, if they feel the need, theirrequests for prayers or rituals. For this reason,individuals who believe that they are possessedand that they need the help of an exorcist rarelydiscuss this within the context of a psychiatricconsultation.3. DISSOCIATIVE DISORDERS ANDPOSSESSION IN DSM-IV AND ICD-10In the American Psychiatric Association’sDSM-IV, Text Revision ( DSM-IV-TR ), the multiplepersonality diagnosis has been renamedthe “dissociative identity disorder (DID).” It nowconstitutes only one of the five subcategories ofdissociative disorder, along with dissociativeamnesia (DA), dissociative fugue, depersonalizationdisorder, and dissociative disorder nototherwise specified (DDNOS). Complaints ofpossession are considered a kind of dissociativedisorder because the individual presents a state ofmind that appears to be under the control of twoor more entities that organize the individual’s psychiclife. But possession is no longer considereda form of multiple personality disorder as it wasin the DSM-III . The DSM-IV places pathologicalpossession in the category of possession trancesunder the diagnosis of dissociative disorder nototherwise specified (Code F 44.9). This showsthat a clear distinction has been made betweenthe phenomenon of possession and DID.The criteria for the differential diagnosis clarifythis distinction. While the DID is describedas a “mental state where separate and distinct differentpersonalities can cohabit (criterion A), andwhere one after another can take control of theperson’s behaviour (criterion B),” in mental statesof trance or possession (DDNOS), “subjects typicallysay that spirits or entities coming from theoutside have entered their body and have takencontrol of it.” The cultural dimension is importanthere. The DSM-III continued to associatepossession with a multiple personality disorder,whereas the DSM-IV specifies that dissociativestates of trance are disturbances “related to certainplaces or cultures” and are not necessarily ofa pathological nature. The ICD-10 also has a categoryfor trance and possession disorder.The ICD-10 provides a special category fordissociative disorder called trance disorder andpossession states. In this group of disorders,there is a temporary loss of identity and awareness,and the individual may appear to be takenover by another personality, a spirit, or a deity.