Management of Dissociative Disorder: Trance and Possession
Trauma-focused psychotherapy should be initiated immediately as the primary treatment for dissociative trance and possession disorders, without delaying for a stabilization phase, as this approach is both effective and safe. 1
Primary Treatment Approach
Implement trauma-focused psychotherapy as first-line treatment using one of the following evidence-based modalities 1:
- Prolonged Exposure (PE) - directly addresses traumatic memories through systematic exposure 1
- Eye Movement Desensitization and Reprocessing (EMDR) - processes trauma through bilateral stimulation 1
- Cognitive Processing Therapy (CPT) - restructures trauma-related cognitions 1
These interventions are effective even in patients with childhood trauma histories and comorbidities, and do not pose significant risks for complex presentations 1.
Critical Clinical Pitfall to Avoid
Do not delay trauma-focused treatment with a prolonged stabilization phase. This practice lacks evidence support and may have iatrogenic effects by inadvertently communicating to patients that they are incapable of dealing with their traumatic memories 1. Similarly, avoid labeling patients as "complicated" or "complex," as this gives the impression that traditional treatments will be ineffective 1.
Specific Interventions for Trance and Possession States
For functional symptoms related to dissociation, therapy should focus on regaining voluntary control through automatic movement patterns and extending these into graded, functionally relevant activities 1. Help the person understand their diagnosis and sensitively communicate when they are likely using integrated functioning 1.
Adjunctive Behavioral Interventions
Implement Dialectical Behavior Therapy (DBT) skills concurrently to address emotion regulation difficulties that commonly accompany dissociative disorders 1. Incorporate cognitive-behavioral therapy (CBT) principles to help patients notice and challenge unhelpful thoughts related to their dissociative symptoms 1.
Pharmacotherapy Considerations
Medications play only a supportive role, not a primary treatment role:
- Use anxiolytics and hypnotics cautiously as part of a comprehensive treatment plan, not as standalone interventions 1
- Avoid benzodiazepines as first-line treatment - they may worsen symptoms long-term and should not be overused 1
- Do not initiate antidepressants for depressive symptoms in the absence of a diagnosed depressive episode 1
- Consider "start low, go slow" dosing if pharmacotherapy is needed for comorbid conditions 1
A 2024 case report demonstrated improvement with combined cognitive behavioral therapy, antidepressants, antipsychotics, and benzodiazepines in severe dissociative trance 2, though a 2019 systematic review found only modest evidence for paroxetine and naloxone in controlling dissociative symptoms 3.
Treatment Monitoring
Evaluate treatment response after 8 weeks - if symptom reduction is poor despite good compliance, alter the treatment approach 1. Maintain vigilant monitoring of suicidal ideation throughout treatment, as patients with dissociative symptoms have increased suicide risk 1.
Managing Comorbidities
- For comorbid anxiety: incorporate specific anxiety management techniques within the trauma-focused framework 1
- For comorbid psychotic disorders: trauma-focused treatment can still be safely and effectively used without evidence of iatrogenic effects 1
Patient and Family Education
Educate patients and families about the origin of dissociative symptoms as a method of coping with trauma, and provide supportive reinforcement of cognitive and relaxation skills during follow-up visits 4. This educational component strengthens the therapeutic alliance while reducing distress and acting-out behaviors 4.