Post-Dissociative Trance Disorder: Traditional Culture of Nini Pagar from Tigabinanga

Abstract

BACKGROUND:

Dissociative Trance Disorder is uncommon, particularly in the eastern part of the world. Complexity and uniqueness of the symptoms, triggers, as well as the management strategy of this disease, make it an exceptional burden for the family.

CASE REPORT:

We reported a 17-year-old woman of a Karo descent who was admitted to Tiga Binanga Primary Health Center by her family due to frequent depressive mood, secluding herself, loss of interest, and frequent fatigue. The complaints persisted for about three weeks. The patient had a confirmed history of dissociative trance disorder known as trance or kesurupan in the local language. This condition is often linked to the local cultural tradition of Nini Pagar performed by the patient. There was neither a history of delusional thoughts, illusions, nor hallucinations. However, the eidetic image was evident.

CONCLUSION:

Nini Pagar, in this case, induces trans dissociative disorder and feature of this post dissociative trance disorder is moderate depression. We found that the eidetic image with sensorium is clear (compos mentis). Psychotherapy and pharmacotherapy were helping.

Introduction

Dissociative disorder is a group of behavioural disorders that manifest as altered mental status in terms of memory and identity. According to DSM-5 criteria, Dissociative Disorders include [5]:

• 1. Dissociative Identity Disorder (DID);

• 2. Dissociative Amnesia (DA);

• 3. Depersonalization/Derealization Disorder (DPDRD);

• 4. Other Specified Dissociative Disorders (OSDD);

• 5. Unspecified Dissociative Disorder (UDD).

In contrast to the assumption existing in the general society that Trance phenomenon (Dissociative Trance Disorder / DTD) is believed as something mystical, in medicine, especially in the field of psychiatric medicine, it is considered as a psychological alteration characterised by the presence of distorted perception and identity disorder. From the five different types of dissociative disorders mentioned earlier, the trance phenomenon suits the criteria of an identity disorder, albeit in several notable cases, the patient could also demonstrate amnesia, depersonalization or derealization [5], [7].

Nini Pagar is a cultural tradition of the local people to wish for rain. During this cultural event, the spirits are lauded and asked to rain down, by the permittance of the Almighty God, indeed. This tradition is done through a dance performance. It starts with a specific mantra or prayer read by the customary leader and ends with the rain not long after the ceremony is completed. It is finished by placing some offerings in a particular place. Uniquely, according to the local people, if the stone in that place is taken home, it shall return to the place on itself by the following day. The possession or Dissociative Trance disorder often occurs during the ritual or sometime after the ritual is completed [4].

Overall if we look closely to the entire phenomenon, there is no single cause of this dissociative trance disorder; at least there are several factors attributed to the development of this illness, namely [2], [3]:

• 1. Psychosocial stressors, including the death of a relative, conflicts over religious or cultural issues, internal tension due to social and economic difficulties, etc.

• 2. Past traumatic events, particularly in childhood which include sexual abuse or violence during childhood, getting involved in a war, witnessing a suicidal action and other traumatic events.

• 3. Some people may have an inherited tendency to develop certain mental illnesses such as psychotic and neurotic disorders. These sorts of individuals are more vulnerable to getting this dissociative disorder.

• 4. The cultural factors cannot be overlooked as it profoundly affects the formation of perception that further forms one’s character and personality. Dissociative trance phenomenon found in Asia would be so different from the one found in the European or African countries.

• 5. Trance phenomenon could also be regarded as a form of subconscious communication to express something that cannot be disclosed in a conscious state.

• 6. Several conditions also demonstrate that some people intended to receive secondary gain from the trance event, such as getting more attention from their partner/spouse and many others.

In the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), the diagnosis of dissociative trance disorder can be made only if the patient shows the following criteria: disruption of identity and altered consciousness to the surroundings that may be perceived as an experience of being controlled by an external supernatural power. Trance disorder only applies to those who experience an unusual involuntary event, and neither a regular activity nor a part of a broadly accepted religious practice and any organic causes such as traumatic brain injury, epilepsy and the effects of any psychoactive substances has to be ruled out [1].

Psychotic disorders, such as Schizophrenia, is the main differential diagnosis of dissociative trance disorder. The symptoms can be misleading that is attributed to the overdiagnosis of psychotic disorders owing to the presence of delusional thoughts and hallucinations. The delusion in schizophrenia is apparent and primarily consists of the delusion of control, the delusion of passivity, etc.; there is also a clear symptom of auditory hallucination along with loose association (derailment). In dissociative trance disorder, if we track down to the past, it is correlated with a significant traumatic event either admitted consciously or suppressed subconsciously [7].

Case Report

A young woman was brought to Tiga Binanga Primary Health Center with the chief complaint of frequent depressive mood, lack of energy, and avoiding interaction with other people. This sort of complaints emerged after she engaged in an event called possession by the locals. Possession or trance, in medical term, is a dissociative trance disorder that commonly found among people living in the eastern part of the world.

From the psychiatric assessment, the patient was found to show selective inattention at the beginning of the first session that improved during the end of the first, the second, and the subsequent sessions. Also, it was noted that the patient showed a slightly depressive mood, appropriate affect, and apprehensive response, particularly during the first contact with the examiner. Neither illusion nor hallucination was found during the session. We are still unable to come up with a solid conclusion regarding the presence of delusion. There was a dysfunction of short-term memory, but immediate and long-term memory were considered normal. There was mild dyscalculia, coherent thinking, and neither tangential, circumstantial, a flight of ideas, nor derailment was noted. During the beginning of the first session, the patient only answered to what was asked by the examiner, but after some time, she got more relaxed and started to tell the story about what had happened to her. During the assessment, the patient did not perceive any depersonalization or derealization feeling. She showed good reading, writing, and visuospatial skills. The overall assessment concluded an insight of level V with critical judgment.

Her family reported that precisely three days before their visit, the patient suddenly fell and fainted, did not respond when she was called, and her breath was getting faster. Then, she suddenly screamed and ask for help to everyone around the house. The situation was so dreadful, they said. Sometimes, the patient became stiff and twitched. Her eyes were closed yet occasionally blinked. Not long after that, the patient involuntary performed a rhythmic movement that resembled a dance, while focusing on a sort of melodies to synchronise her dance moves even though there was no such music heard by the rest of the family members. Her hand, leg, and neck movements attracted anyone who saw it. Her eyes were closed, and she walked like a drunk person. She sometimes laughed out loud and screamed, and she kept quiet and stood like a statue at another time. “Udan ko wari…Udan ko wari…” was spoken out of her mouth several times. The family said that exactly one day before their visit, the patient involved in a local ritual called nini pagar. This tradition is highly believed by the locals in Tiga Binanga as a practical tradition to wish for rain. During the ritual, the spirits are lauded and asked to rain down. The patient was presumed to be possessed by the lauded spirits during the nini pagar ritual.

The patient’s family told us that she was a cheerful person and had many friends though no one was close-knit. She actively joined several extracurricular activities, such as flag raiser team, scout and many others. She had a pretty good academic achievement as she was always one of the top 10 in her class. There was no history of psychoactive substance and alcohol abuse as denied by the family by saying that they are a good person. There was no history of comorbidities like asthma and many other medical illnesses. There was no history of regular medical treatment. The patient did not take any cough- and flu-relieving medication by the time of the assessment. She was not in her period. Any history of trauma involving any part of her head was denied.

On the physical examination, the level of consciousness was compos mentis, and the vital signs were considered normal. The patient weighed 45 kg and stood 150 cm tall with a normal BMI. There were no signs of the thyroid gland and cervical lymph node enlargements. Oral cavity, teeth, tongue, and tonsil showed no abnormalities nor signs of inflammation. There were no signs of irritation or inflammation around her eyes, nose and ears; her facial structure was normal; her hair was long and straight and was covered by a veil. Lung examination showed vesicular breathing sound on both lungs; no additional sound was found. The hearing sound was normal, regular, neither murmur, gallop, nor other additional sound was heard, and the heart rate was 88 beats/minute. Bowel peristalsis was normal. There was no abnormality found around the abdomen and pelvis externally, and there was no organomegaly on palpation. The jugular vein pressure was R-2. There were no signs of paresis and paresthesia in all extremities. No pretibial oedema was found. She has brown skin with good turgor and elasticity. There were no signs of jaundice and anaemia.

Diagnosis of post-Dissociative Trance Disorder was made, which was predominated by depressive symptoms with the Global Assesment of Functioning Scale (GAF Scale) of 60-51. The assessment of depression in this patient was using DSM-5 criteria. This patient was treated by pharmacotherapy and psychotherapy. Cognitive Behavioral Therapy. The CBT was conducted in several sessions. We told the patient that all the things that had happened had already passed. We should accept the fact while keep on moving forward and to live the way we usually do. Social and Family Management are also given. Her family was involved in the effort of improving her psychological well-being. The family was educated to put more attention to the patient and asked them to not talk about anything related to this event. The patient was also given 1 mg Risperidone taken twice daily for one week, and 50 mg Sertraline is taken once daily for one month and was followed-up for any improvements.

In conclusion, there are a number of factors that predispose someone to suffer from a dissociative trance disorder, including inherited genetic factor, socio-cultural factor, economic factor and many others, however, according to the existing body of evidence in the literature, past history of trauma, especially during childhood, is strongly correlated with the incidence of dissociative trance disorder. The first-line treatment of this disorder includes psychotherapy, but medical therapy could also be employed in some instances.