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‘PTSD can manifest itself in trance-like states’ 

25 Jan 2021

  • Report focuses on PTSD in children and adolescents in rural Sri Lanka 

  By Ruwan Laknath Jayakody   Sri Lanka’s psychiatrists should be aware that post-traumatic stress disorder (PTSD) can present itself in children and adolescents as trance-like states and states of possession, which in turn are part of the dissociative response to trauma. This was noted in a brief report titled “PTSD presenting as possession states in children and adolescents in rural Sri Lanka: A case series” authored by J. Herath and S.R. Perera (both attached to the Nuwara Eliya General Hospital) and published recently in the Sri Lanka Journal of Psychiatry. Trance-like states and states of possession are categorised as dissociative disorders, where there is a temporary loss of the sense of personal identity with full awareness of the surroundings. Dissociation is a common feature of PTSD, and involves detachment from the overwhelming emotional content of the experience during and in the immediate aftermath of the trauma. Chronic psychological, sexual, and physical trauma, as well as emotional neglect, has been linked to dissociation, while acute traumatic events can also lead to dissociation.  Evidence points towards two types of responses to trauma: one being primarily dissociative and the other, predominantly intrusive and hyper-aroused. However, an individual with PTSD can show both response patterns, either simultaneously or at different times. These subtypes can be viewed as different extremes of emotional dysregulation. The first involves under-modulation, and the second, over-modulation, to the trauma, and each appears to have distinct correlations to the central nervous system. The authors presented three case reports where children or adolescents presented themselves with dissociative symptoms in the form of states of possession, against a background of significant trauma. They had been referred by the consultant paediatrician of the relevant local hospital, and all investigations including the electroencephalogram were normal. In the first case report, a 14-year-old girl was presented with a four-month history of being possessed by her dead grandfather, with these states of possession having occurred at least twice a week. During these episodes, she had walked and gestured like a man and spoken in a deep, hoarse voice. While in the possessed state, she had been aggressive towards her father and attempted to hit him on several occasions. She had revealed that she disliked her father’s habit of consuming alcohol, as when he came home intoxicated, he would lock her in a room and physically assault her until she bled. This had been a frequent occurrence over the past two to three years. She claimed that this was her father’s way of punishing her for not achieving good enough marks (by his standards), at examinations. In the second case report, a 15-year-old schoolboy was brought in by his family due to repeated states of possession that had occurred each time he visited the local Hindu temple (kovil), behaviour which had been exhibited during the past three to four months. He had appeared to become possessed by the goddess Paththini (a female deity) during the kovil rituals. During these episodes, he had assumed a flexible posture and moved in a dance-like state with his eyes closed, assuming feminine postures and speaking in an effeminate manner with a high-pitched voice. These states had lasted for two to three minutes each time, after which he fell to the ground, and subsequently woke up refreshed and alert. He had revealed that he was never quite himself ever since inadvertently witnessing the alleged gang assault and murder of a villager by stabbing and slashing, an incident which he claimed, had occurred about eight months in prior. In the third case report, a 10-year-old girl was brought in due to repeated episodes of appearing to be possessed by a dead male, for a period of six to seven months. When possessed, she had spoken in a deep voice, and showed mannerisms similar to a male. She had revealed that her father, who was dependent on alcohol, would frequently abuse her and her older sister, both physically and sexually, for over approximately two years. She had stated that she would hide in the woodland outside her home for many hours, sometimes even spending the entire night out of doors. Her mother has been working in the Middle East for as long as she could remember. According to Herath and Perera, all three patients had presented with clear symptoms of dissociation and thereby a predominantly dissociative response, while also experiencing symptoms of PTSD, such as disturbances in sleep, irritability, and the inability to focus. They also had the unpleasant phenomena of re-experiencing the traumatic events, in the form of recurring nightmares, and the avoidance of events and places where the initial trauma occurred. They had met the prerequisites for a diagnosis of PTSD, namely, directly experiencing the traumatic event or witnessing the traumatic event in person, or experiencing first-hand, repeated or extreme, exposure to aversive details of the traumatic event. Such exposure to repeated traumatic events was likely to have increased the risk of developing the dissociative subtype of PTSD. All three patients were then managed with bi-weekly sessions of trauma-focused psychotherapy, and a particular antidepressant. Other steps in the immediate management of the conditions included necessary action being taken to ensure that they were safeguarded from further episodes of impending harm. Following such treatment, all three patients had improved significantly, with no dissociative episodes being reported as at the end of three months in the second and third patients, and after five months in the first patient. Therefore, the researchers noted that understanding the role of dissociation and the development of PTSD in children and adolescents has significant implications when planning their overall management.


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