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Evidence of phenotypes and dissociative diagnostic markers for demonic

possession syndrome

Article in European Journal of Trauma & Dissociation · December 2024

DOI: 10.1016/j.ejtd.2024.100436

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 European Journal of Trauma & Dissociation xxx (xxxx) 100436

Contents lists available at ScienceDirect

European Journal of Trauma & Dissociation

journal homepage: www.elsevier.com

Research Paper

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Evidence of phenotypes and dissociative diagnostic markers for demonic
possession syndrome

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Álex Escolà-Gascón a, ⁎, Neil Dagnall b, Kenneth Drinkwater b
a Department of Quantitative Methods and Statistics, Comillas Pontifical University, established by the Holy See, Vatican City State
b Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, United Kingdom

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ARTICLE INFO ABSTRACT

Keywords: Objective: According to clinical models of personality, patients with dissociative identity disorder (DID) who have
Possession syndrome experienced demonic possession (psychiatric possession syndrome or PPS) may present two profiles: the schizo-
Personality phenotype paranoid profile (characteristic of psychotic spectrum disorder or PSD) and the hysteroid-histrionic profile (charac-
Psychotic spectrum disorder
teristic of affective disorders). The present study aimed to examine the clinical and statistical evidence of these
Dissociation identity disorder
phenotypic personality structures in patients with PPS and DID (with and without PSD).
Demonic possession
Possession experience Methods: The design of this investigation was based on structural equation modeling. A total of 303 patients were
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diagnosed with DID without psychosis and 306 were diagnosed with DID with PSD; the diagnosis was made by
clinical professionals who collaborated on this research and conducted the assessment tests. All patients com-
pleted clinical questionnaires on their personality structures, and dissociation level was also measured. The
physician-psychiatrist assessed each patient using the Psychiatric Possession Syndrome Checklist (PPS-C), a new
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hetero-applied questionnaire on the symptomatic intensity of PPS.

Results: The results led to the conclusion that both personality structures were 65 %–66 % predictive of posses-
sion syndrome. Dissociative symptoms attributable to DID modulated the PPS variance by 21 % to 26 %. Validity
evidence has been obtained for the combined phenotypic personality model that integrates DID and PSD struc-
tures.
Conclusions: We discuss the psychopathological and therapeutic implications of the analysis on the dissocia-
tive mechanisms involved in each personality phenotype. We also provide a graphical summary of the PPS
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symptoms, organized into a normalized distribution, which may prove useful for professional practice. Addi-
tionally, we present potential clinical scores from the PPS-C.

Introduction cal risks for the sufferer (Pietkiewicz & Lecoq-Bamboche, 2017). Con-
ceptually, consistent within the field of anthropology, theorists classify
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In conventional psychiatry and clinical practice, demonic possession these as core or central possessions (Lewis, 1979). Due to the anthropo-
is a psychopathological state, whereby a person believes a supernatural logical and ethnographic focus, psychiatry has paid little attention to
entity (e.g., a demon or spirit) takes them over (Perrotta, 2019). Theo- central possessions (Innamorati et al., 2019).
rists conceive this psychopathological state at two levels (Mercer, Regarding spirit possessions that are not necessarily psychopatho-
2013). Either possession may obey a ritual process that characterizes logical, we can add that: (a) the phenomenon in question has been vari-
the dogmas and beliefs of a community, sect, or religion (Saki & ously referred to as "demonic or diabolical possession" which may or
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Ahmadi, 2022), or else possession is a cultural construct that allows the may not be a variant of more general "spirit possession" cases reported
victim to explain his/her situation in a way that aligns with his/her be- across cultures and throughout history; (b) such experiences can some-
liefs and offers him/her a solution (Lloyd and Waller, 2020; Oparin, times be deliberately cultivated via trance or psychedelics but also seem
2020). When this happens, the possession itself is not considered clini- to occur spontaneously; (c) these accounts have been traditionally dis-
cally significant, and usually, no medical treatment is required. How- cussed in terms of dissociative phenomena (Maraldi, 2024) whose con-
ever, it does not mean that it is not dangerous or poses significant clini- tents or interpretations can be culture-bound (Krüger, 2020) [e.g.,

⁎ Corresponding author at: Prof. Dr. Álex Escolà-Gascón, Department of Quantitative Methods and Statistics, Comillas Pontifical University (established by the

HolySee, Vatican City State), ICADE Campus, Madrid, Spain

E-mail address: [email protected] (Á. Escolà-Gascón).

https://doi.org/10.1016/j.ejtd.2024.100436
Received 9 May 2024; Received in revised form 20 June 2024; Accepted 23 June 2024
2468-7499/© 20XX

Note: Low-resolution images were used to create this PDF. The original images will be used in the final composition.
Á. Escolà-Gascón et al. European Journal of Trauma & Dissociation xxx (xxxx) 100436

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Fig. 1. Analysis of the validity of the unidimensional PPS-C model. Regression coefficients for all patients (n = 609). All coefficients were significant.

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Table 1 cated when any of the following symptoms occur (see Enoch &
PPS-C Items According to Scientific Literature. Trethowan, 1979 for a complete review). (1) Motor disturbances with
Instructions: Before applying this test, make sure that the patient has a dissociative greater intense physical force than normal, including motor stiffness
identity disorder or a diagnosis of PSD. For each item, you must indicate the intensity states, jerky movements, vomiting, and stereotypies (Kemp & Williams,
with which the patient presented the symptom during an illness episode. Graduated
1987; Pietkiewicz & Lecoq-Bamboche, 2017). (2) The ability to speak in
scale from 0 to 3: 0 = none/absence of symptom, 1 = low intensity, 2 = moderate
intensity, and 3 = high intensity. languages that appear unfamiliar (glossolalia), including changes in
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… tone/type of voice (Lindsey, 1972; Obeyesekere, 1970; Pietkiewicz et
1 … in which he/she performs repetitive motor Motor al., 2021). (3) The patient is convinced they are under the control of, or
movements. disturbances dominated (i.e., psychically, emotionally, cognitively, and behav-
2 … in which he/she exhibits more intense physical Motor
iorally) by a supernatural entity. This belief may be related to culture
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strength than usual. disturbances

3 … in which he/she exhibits jerky movements, Motor and/or religion, but it has a dysfunctional impact on both the patient
actions, or gestures. disturbances and his/her environment (Joelsson, 2020; Leon, 1975). (4) The pres-
4 … in which he/she physically contorts. Motor ence of perceptual disturbances that include visual hallucinations (e.g.,
disturbances the patient sees the possessing entity), auditory hallucinations (e.g., the
5 … in which he/she physically staggers as if dizzy. Motor
disturbances
patient hears voices, noises, or music that he/she attributes to the pos-
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6 … in which he/she bodily holds rigid positions. Motor sessing entity), olfactory hallucinations (e.g., the patient perceives
disturbances smells similar to “rotting flesh” or pestilential), and tactile hallucina-
7 … with abnormal changes in the pitch of his/her Paralinguistic tions (e.g., the patient feels the possessing entity hitting him/her)
voice. disturbances
(Escolà-Gascón, 2020a, 2020b, 2021). In certain circumstances, hallu-
8 … in which he/she articulates words from other Glossolalia
languages. cinations and delusions may be shared by persons assisting the pos-
9 … with abnormal changes in the volume of his/her Paralinguistic sessed patient (e.g., the exorcist priest, relatives). However, very few
voice. disturbances studies refer to this in relation to possessions (see Suhail & Cochrane,
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10 … with abnormal changes in the rhythm/speed of Paralinguistic 2002 for more information).
his/her voice. disturbances
All these symptoms, taken together, form a syndrome not classified
11 … with hallucinations and/or perceptual Perceptual disturbances
disturbances. in diagnostic manuals of psychopathology but are present in scientific
12 … in which h/she manifests verbal content without Verbal speech literature (e.g., Irmak, 2012), which we refer to as psychiatric possession
logical meaning. disturbance syndrome (PPS). Oesterreich (1966) originally described PPS (see also
13 … in which he/she claims to be - explicitly or Delusion
Kopeyko et al., 2019) and refers to the peripheral possession only, and
implicitly - another entity/person/object.
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14 … in which he/she expresses socially extravagant Theatricalization

not central possession, which refer to possessions that serve a social
and grandiloquent verbal contents. function (Lewis, 1979). In contrast, theorists refer to non-socially ap-
proved symptoms and those that have no cultural purpose as peripheral
Sersch (2019) discussed several studies that showed exorcisms working possession (Al-Adawi et al., 2019).
as well or better than clinical therapy in cultures that accepted 'spirit The use of the term PPS as a specific designation for these symptoms
possession' as a reality] or progress in a tiered fashion (Lange et al., is functional because it phenomenologically groups together behaviors,
2022); and that (d) Escolà-Gascón et al. (2023) literature review found perceptions, and anomalous experiences that align with belief systems
that some cases of demonic possession necessitate more advanced or considering demonic possession a real phenomenon. This does not in-
nuanced models of dissociation, personality, or psychopathology to validate or preclude the use of other diagnostic labels and offers a
properly account for their phenomenology. unique category for investigating these experiences. The idea of con-
ceptualizing possession as a syndrome in this research was inspired by
Psychiatric possession syndrome O'Keeffe et al. (2019), who defined Haunted People Syndrome to describe
the anomalous perceptions associated with places believed to have
Possessions may have clinically significant psychopathological rele- paranormal activity due to religious beliefs, cultural legends, etc. (e.g.,
vance. Medical treatment and psychiatric intervention may be indi- Houran & Laythe, 2022). This approach has proven very useful for re-

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Table 2
Descriptive Statistics and the Contrast of Means Between Patient Groups.
Group Direct Standard t-test U test Size effect
Means deviation (Hedges’ g)

Absorption Dissociative 97.53 14.030 0.988 48,362.5 N.S.

Psychosis 96.41 13.943
Amnesia Dissociative 51.21 9.116 0.079 46,352 N.S.
Psychosis 51.16 8.733
Derealization and depersonalization Dissociative 50.61 9.311 0.571 47,288 N.S.
Psychosis 50.20 8.684

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Total score dissociation (DES) Dissociative 7.12 1.006 0.703 47,369 N.S.
Psychosis 7.06 0.994
Histrionism (Hi) Dissociative 52.12 8.588 37.6262* 91,392* 3.016

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Psychosis 26.14 8.617
Schizotypy (Ez) Dissociative 23.72 6.359 −28.251* 4850.5* −2.287
Psychosis 36.36 4.523
Paranoia (Pa) Dissociative 23.96 6.422 −27.057* 5894* −2.190
Psychosis 36.34 4.730
Psychiatric Possession Syndrome Checklist (PPS-C) Dissociative 17.46 12.414 −10.849* 25,386.5* −0.878
Psychosis 27.80 11.046

Note: *p < 0.001; N.S. = Not significant.

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search and has shown clinically valuable implications in the field of dis- Personality structures and possessions
sociation (see Laythe et al., 2021).
Other research studies have explored what clinical personality traits
Psychiatric possession syndrome in current psychopathological characterize possessed patients (Ferracuti & Sacco, 1996; Rashed,
classifications 2018). Font (2016) developed extensive scientific research linking typi-
cal personality disorders in DSMs to dissociation in patients claiming
PPS is not a currently recognized syndrome. However, PPS repre- possession. Font (2016) found that schizotypal, paranoid, and histrionic
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sents a very useful construct for understanding the psychopathological personality disorders predicted symptoms characterizing PPS. Other
aspects and the contemporary significance of the classifications. The Di- authors demonstrated relationships that were consistent with Font's
agnostic and Statistical Manual of Mental Disorders classified possession (2016) findings (Westerink, 2014; Borisova et al., 2021; Escolà-Gascón,
(as peripheral possession) under “unspecified dissociative disorders,” 2020a, 2020b). In his research, Font (2016) concluded that two dimen-
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within the category of dissociative trance disorder (300.15) (see Diag- sions characterize peripheral possession: (1) the schizo-paranoid dimen-
nostic and Statistical Manual of Mental Disorders-IV-Text Revision or DSM- sion, and (2) the hysteroid-histrionic dimension (also called histrionic-
IV-TR, American Psychiatric Association, 2002). Episodes in which the narcissistic, see Escolà-Gascón et al., 2023). These dimensions are im-
patient presented involuntary stereotypic movements, amnesia, and the portant because they indicate that PPS is not limited to a question of dy-
belief that a supernatural entity dominated the patient's body and psy- namic symptoms over time. Instead, different clinical phenotypes may
che characterize dissociative trance disorder (Littlewood, 2004). be associated with patients affected by PPS (Rössler et al., 2015;
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The DSM-IV-TR reported that these episodes were related to the cul- Sengutta et al., 2021).
tural systems of each country (religious or non-religious). For this socio- Font's (2016) work is particularly relevant to this research, as it
cultural reason, the American Psychiatric Association (2002) classified presents a phenomenological model developed several years ago
such possession as “non-specific.” In the most recent versions of the when Father Font was appointed as a psychiatrist to conduct medical
DSM (the 5th edition and edition 5 with revised text), classification of evaluations of alleged demonic possession cases for the Archdiocese
demonic possession is under “dissociative identity disorder” (300.14) of Barcelona. His theoretical proposal posited that schizo-paranoid
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(American Psychiatric Association, 2013, 2022). In the DSM-5 classifi- and hysteroid-histrionic structures are part of a continuum, located at
cation, possession is understood as a disturbance of identity and person- opposite ends. Although each of these dimensions exhibits its own
ality, which is characterized by the experience and belief of being pos- quantitative gradient, their phenomenological interpretation allows
sessed by a supernatural entity (Delmonte et al., 2015). In contrast to us to distinguish them qualitatively as two distinct symptomatic ar-
the DSM-IV-TR, the current classification includes culture-related hallu- eas. Font's (2016) theory suggested that, depending on the level of
cinatory and delusional symptoms (Paniagua, 2018). Classification no peripheral possession within these two dimensions, certain psychi-
longer regards PPS as an “unspecified dissociative disorder” (Spiegel et atric treatments might be more appropriate. This was reviewed by
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al., 2011). Additionally, the DSM-5-TR also clarified that the symptoms Escolà-Gascón et al. (2023), who concluded that liberation rituals for
should not be confused with the state of imagination or fantasy (e.g., possession states would only be effective for profiles located in the
when a child claims to have imaginary friends) (American Psychiatric hysteroid-histrionic area. This is one of the points we aim to address
Association, 2022; Drinkwater et al., 2022). Concerning this final point, in this study, providing empirical evidence to support the effective-
children who claim to have imaginary companions (ICs) is not necessar- ness of Font's (2016) approach.
ily dissociative or pathological, but "deep ICs" showing ostensibly au- Within the framework of psychotic spectrum disorders, clinicians
tonomous wills, personalities, or behaviors are something different and widely accept the presence of a psychopathological phenotype (Escolà-
might well indicate dissociation and at a clinically-relevant level (Lange Gascón, 2022a; Stefanis et al., 2002). The phenotype concept suggests
et al., 2023). that individuals with attenuated psychotic symptoms (i.e., those pos-
This distinction clarifies that, while imaginary friends in children sessing a subtle schizotypal personality profile) are more likely to de-
are not typically pathological, certain levels of fantasy could present a velop more intense and pathological psychotic episodes in the future
clinical risk for developing dissociative disorders in the future. (Murphy et al., 2018; Wright et al., 2020). The current model of psy-
chosis, the continuum model, is compatible with Font's (2016) proposal
(see van Os et al., 2008 for more information).

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Fig. 2. The complete theoretical model of possession syndrome from schizo-paranoid and histrionic personality structures (includes mediation effects). Standardized
regression coefficients for the two groups (n = 609).
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The present study and 10 % male) and 303 had a diagnosis of psychotic spectrum disorder
(PSD) with dissociation symptoms (40 % female and 60 % male). All pa-
Considering the theoretical bases provided, we believe that it is pos- tients were middle-aged (DID group: mean age = 31.16 years, standard
sible to reorganize the information and propose a current theory inclu- deviation DID = 4.118 years PST group: mean age = 35.31 years,
sive of the DSM classifications and the continuum model of psychosis. standard deviation PST group = 4.239 years).
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Based on the two dimensions proposed by Font (2016), we hypothesize Diagnosis of patients occurred after the first episode of DID or PSD
that dissociation acts are a mediating variable between the phenotype (see the inclusion criteria in the Procedures subsection). A physician
based on schizo-paranoid and histrionic personalities, and PPS or pos- and psychiatrist made the diagnosis. All participants volunteered to
session syndrome. This hypothesis implies that dissociative disorders participate in this study and received no financial compensation. All
characterize PPS (as stated in the DSMs), but that specific personality data were de-identified.
structures form the basis. Identifying and validating these structures All patients were receiving treatment (pharmacological and psycho-
can be useful because it would enable treatment to be amplified and logical) and came from seven different Spanish clinical hospitals. These
psychological intervention to be supported as an important adjunct to clinics collaborated anonymously.
pharmacological therapy.
Materials
Methods
Multivariable multiaxial suggestibility inventory-2 (MMSI-2)
Sampling MMSI-2 is a psychological test that measures 16 dimensions related
to personality and certain psychopathological traits. Of the 16 scales, 3
The study involved 609 patients. Of these, 306 had a formal diagno- that met the objectives of this research were selected for convenience:
sis of dissociative identity disorder without psychosis (DID) (90 % female schizotypy (Ez, 10 items), histrionics (Hi, 13 items), and paranoia (Pa, 10

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Fig. 3. The theoretical model for the patients with DID (without psychosis). Prediction of histrionics with possession syndrome. Standardized regression coefficients
for the DID group (n = 306).
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items). The participants indicated the degree of agreement with each Psychiatric possession syndrome checklist (PPS-C)
item, using a scale from 1 (strongly disagree) to 5 (strongly agree). The authors developed the Psychiatric Possession Syndrome Checklist
MMSI-2 has been validated with thousands of participants (Escolà- (PPS-C) for this study. This was necessary because examination of ex-
Gascón, 2020a, 2020b) and was also adapted to English (Escolà-Gascón tant literature did not identify any measurement instruments that quan-
et al., 2021). Its validity and reliability for all test scales are excellent. tified psychiatric symptoms associated with possession syndrome. To
In this study, the Ez, Hi, and Pa scales obtained acceptable reliability ensure accuracy, the PPS-C is heteroapplied. This means that the test
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coefficients in the two patient groups (alpha >0.8 and omega >0.8). was not the patient who answered the questions, but rather it was the
psychiatric physician who had to specify whether the symptoms associ-
Dissociative experiences scale –II (DES) ated with PPS were present in the patient. The wording of items was
The DES is a psychometric scale designed to assess dissociative based on the clinical and behavioral characteristics described in posses-
symptoms in clinical and non-clinical populations. It consists of 28 sion syndrome (the introduction outlines characteristic specification).
items measuring three dimensions: absorption, amnesia, and deperson- Following the recommendations of Escolà-Gascón (2022b), the authors
alization-derealization. Participants record their responses on a per- drafted 14 statements intended for physician-psychiatrists and re-
centage-based scale, with 10 alternatives (from 0 % to 100 %). The par- viewed by three clinical psychologists. The qualitative review allowed
ticipants indicated the degree to which each of the dissociative experi- the content to accurately match the PPS construct. For each item, the
ences occurred to them. Following item summation, division of totals psychiatrist marked the response that best matched his/her clinical ob-
by 28 produced mean values. Researchers have previously established servation of the patient (0 = absence of symptoms, 1 = low symptom
the validity and reliability of the DES on numerous occasions (Bernstein intensity, 2 = moderate symptom intensity, and 3 = high symptom in-
et al., 2001; Jeong et al., 2021; Pietkiewicz et al., 2019). In this study, tensity). Our study assessed the validity and reliability of the PPS-C.
the reliability indices were very good in both patient groups (alpha and Structural equation modeling assessed validity, and classic Cronbach's
omega coefficients > 0.85). alpha and omega coefficients reliability. Owing to the categorical na-

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Fig. 4. The theoretical model for patients with DID (without psychosis). Prediction of the variable histrionics with possession syndrome and including media-
tion effects. Standardized regression coefficients for the DID group (n = 306). AB = Absorption; AM = Amnesia; and HA = depersonalization/derealization.

ture of the PPS-C variable items, the weighted least square mean and the Catholic Church through their dioceses. As stipulated by the Vatican
variance adjusted (WLSMV) criterion served as an estimator. Fig. 1 City State, the exorcist priests of each diocese (and their respective bish-
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shows the factor loadings and unidimensional model of the PPS-C. ops) referred the individuals to hospital centers for psychiatric diagno-
The fit indices that guaranteed the unidimensional validity of the sis and treatment. Each hospital center designated a psychiatrist coordi-
PPS-C were as follows: χ2 = 263.580 (p < 0.001), Normed nator in charge of collecting data from each patient. Similarly, the med-
χ2 = 3.423, RMSEA (root mean square error of approximation)= 0.06 ical evaluations and psychiatric diagnoses were conducted by the pro-
(0.055–0.072), (threshold= <0.10); CFI (comparative fit index)= fessionals at each hospital. The investigators had no direct contact with
0.999, (threshold= >0.9), and TLI (Tucker-Lewis index)= 0.999, the patients and the application of the questionnaires depended on the
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(threshold= >0.9). Except for the chi-square statistic, the other indices coordinators of each center. Participants completed applications digi-
indicated excellent fit for the unidimensional validity of the PPS-C. Uni- tally and storage of responses was in an automated EXCEL file.
dimensional reliability was also excellent (alpha = 0.996, The study only included patients who met the following inclusion/
omega = 0.996), thus ensuring minimal inference errors. These analy- exclusion criteria: (1) the patient had his/her first psychiatric evalua-
ses confirmed that this novel checklist possessed adequate validity and tion for a psychotic or dissociative episode, (2) the patient had no or-
reliability and was suitable for use with DID and TSP patients. Descrip- ganic medical illnesses that could account for the psychopathological
tive measures of the total scores are provided in the Results section. picture he/she presented with (for example, epilepsy), (3) the patient
Table 1 lists the test items. had not consumed any psychotropic substance that could explain the
presenting symptoms; (4) the patient did not have any disability, inca-
Procedures pacity, or preservation of his/her cognitive abilities, (5) the patient (or
his/her legal guardians, when necessary) agreed to participate in this
The design of this study was predictive-correlational and based on study anonymously and voluntarily, having been informed of what the
the use of structural equation modeling. Sample collection took five research details, and (6) after the evaluation and diagnostic process, the
years and involved seven hospital centers and nine Catholic dioceses. A patient was diagnosed with DID (without psychosis) or PSD (with disso-
total of 286 patients initially resorted to exorcism services provided by ciation). All included participants completed the questionnaires. Com-

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Fig. 5. The theoretical model for patients with PSD. The prediction of the schizo-paranoid variable with possession syndrome. Standardized regression coefficients for
the PSD group (n = 303).
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pliance with these criteria depended on the coordinator assigned to Results

each hospital center.
The initial analyses provided descriptive statistics and a comparison
Statistical analysis between the two groups of patients. These results appear in Table 2, to-
gether with the effect size indicators.
Statistical software MPlus (for the validation of the PPS-C), AMOS- The mean differences between the DID and PSD groups were only
SPSS (for the mediation structural equation models), and JASP (for the
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significant for the personality-related variables: histrionism, schizo-

calculation of reliability indicators, mean contrasts, and obtaining de- typy, paranoia, and PPS. These differences had very high effect sizes.
scriptive statistics) processed data. The creators of the free Jamovi pro- Paying attention to the trend of the means, we concluded that patients
gram developed JASP, which uses the R programming language (see R with a DID diagnosis without psychosis scored significantly lower on
Core Team, 2022; The Jamovi Project, 2022). Structural equation mod- the schizotypy and paranoia scales. The same group of patients ob-
eling analyzed the histrionic and schizo-paranoid personality structures tained higher histrionics scores than patients with PSD. In contrast, the
that form the basis of possession syndrome. Additional examination PSD group scored higher on the schizotypy and paranoia scales than the
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considered the effects of DID medications. To obtain a larger number DID group (as expected, given the theory). These results support our hy-
and types of fit indices, the method of parameter estimation was set at pothesis that patients with psychosis have a schizo-paranoid personal-
the maximum likelihood. It should be noted that other robust mathe- ity structure and that patients without psychosis have a histrionic struc-
matical estimation methods, such as the one used in the validation of ture.
the PPS-C, allow the calculation of fewer fit indices, and consequently, To examine the association of these personality traits with posses-
provide less information on the evidence of the validity of the model. sion syndrome and the mediation effects of dissociative symptoms, the
The fit indices used, and their thresholds were as follows (see Kline, researchers assessed theoretical model depicted in Fig. 2. To ensure the
2013): chi-square, normalized chi-square, RMSEA (root mean square er- validity of the full theoretical model (which includes mediation), we
ror of approximation) (threshold <0.10), CFI (comparative fit index) specify the specific theoretical configuration for each group (without
(threshold >0.9), TLI (Tucker-Lewis index), (threshold >0. 9), NFI mediation effects and with mediation effects). Fig. 3 shows the histri-
(normed fit index), (threshold >0.9); IFI (incremental fit index), (thresh- onic model for the group of patients with DID, without mediation. Fig.
old >0.9); RFI (relative fit index), (threshold >0.9); AIC (Akaike infor- 4 shows the schizo-paranoid model for the group with PSD without me-
mation criterion), (no threshold set); BIC (Bayes information criterion), diation. Similarly, Figs. 5 and 6 show the theoretical models for each
(no threshold set). For all analyses, there was an adjustment of confi- group including the effects of dissociative symptom mediation. Table 3
dence level to 99 %.

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Fig. 6. The theoretical model for the patients with PSD. The prediction of the schizo-paranoid variable with possession syndrome and includes mediation Effects.
Standardized regression coefficients for the PSD group (n = 303). AB = Absorption; AM = Amnesia; and HA = Depersonalization/derealization.
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contains all information regarding the fit indices for each theoretical prevalent personality structures in patients presenting with PPS: the
model. schizo-paranoid personality, and the histrionic personality. Therefore,
For the DID group without mediation, PPS was 65.1 % predicted. PPS does not have an exclusive psychopathological relationship with
For the PSD group without mediation, PPS was 66 %. Inclusion of medi- schizophrenia (as theorists widely recognized). Fig. 7 presents a sum-
ation effects increased prediction of possession syndrome to 81.1 % and mary of the evidence derived from the symptomatology. The normal-
84.8 %, respectively. This implied that dissociative symptoms ex- ized distribution indicates a polarized continuum between the two pro-
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plained 21.1 % to 26.4 % of PPS. These weights supported Font's (2016) file types. We note that the term histrionic-narcissistic in Fig. 7 is equiv-
theoretical model and reinforced the application of the continuum alent to hysteroid-histrionic, which is more commonly used in psycho-
model in PPS with two possible distinct phenotypic sources: schizo- analytic settings.
paranoid and histrionic. The information in Fig. 7 specifically relates to Font's (2016) theo-
Analysis of the fit indices revealed the validity of most of the models retical model and has been configured based on our results. From our
analyzed in Figs. 2–6, indicating that the proposed theory fitted data ac- results, as well as evidence from current psychopathology, it appears
ceptably. This can be questioned for the models in the PSD group, that PPS could also have a hysteroid-histrionic origin. This has two cru-
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which showed a higher number of fit indices below the minimum cial clinical implications for psychiatry and medical psychology: (1)
threshold than other models. Consideration of implications occurs with based on the personality structures studied, what type of dissociation
the Discussion. mechanisms engage in PPS, and (2) what are implications and risks re-
Thus, dissociative symptoms were present in PPS with either a psy- lated to the practice of ritual-exorcism for patients suffering from PPS,
chotic (or phenotypically, schizo-paranoid) or a histrionic or non- considering both the personality structures.
psychotic basis. Overall, finding supported the main hypothesis of this
research. The effects of dissociative symptoms play a mediating role in Clinical implications of the dissociative mechanisms in PPS
both personality structures.
Our findings confirmed that dissociation of both personality struc-
Discussion tures is present and acts as a mediating variable that modulates the
symptomatic picture of PPS. Since dissociation is a variable with signifi-
The study aimed to review and analyze the effects of the clinical cant effects on both structures, patients may have distinct types of dis-
structures of schizo-paranoid and histrionic personality in PPS inte- sociation.
grated with the formal diagnoses of dissociative disorders with and On the one hand, when a patient presents with a schizo-paranoid
without psychosis. The results allowed us to conclude that there are two structure, clinicians consider the dissociation involved in PPS psychotic

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Á. Escolà-Gascón et al. European Journal of Trauma & Dissociation xxx (xxxx) 100436

Table 3
Fit Indices of the Analyzed Models.
Indices Complete Without mediation With mediation
model
(n = 609) DID PSD PSD DID PSD PSD
(Fig. 2) model model model model model model
(Fig. 3) (with three correlations* between the (Fig. 5) (Fig. 4) (with three correlations* between the (Fig. 6)
residuals) residuals)

2
χ 2086.479 1298.703 1.147.723 1942.173 1372.418 1206.702 1999.882
(p < 0.001) (p < 0.001) (p < 0.001) (p < 0.001) (p < 0.001)
2
4.556 4.021 11.477 18.856 3.414 8.265 13.422

F
χ
normalized
RMSEA 0.076 0.100 0.186 0.243 0.089 0.155 0.203
(0.73–0.080) (0.094– (0.177–0.196) (0.234– (0.084- (0.147–0.163) (0.195–

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0.105) 0.253) 0.094) 0.211)
CFI 0.957 0.933 0.911 0.845 0.936 0.915 0.852
TLI 0.953 0.927 0.894 0.819 0.930 0.901 0.830
IFI 0.957 0.933 0.912 0.845 0.936 0.915 0.852
RFI 0.941 0.905 0.885 0.811 0.904 0.889 0.819
NFI 0.945 0.913 0.904 0.837 0.912 0.905 0.842
⁎⁎
AIC 2226.479 1408.703 1219.723 2008.73 1498.418 1294.702 2081.882
(38,149.386) (14,955.195) (11,983.582) (11,983.582) (15,582.884) (12,729.305) (12,729.305)
⁎⁎
BIC 2535.306 1613.500 1353.417 2130.726 1733.004 1458.106 2234.145

PR
(38,290.564) (15,055.731) (12,043.001) (12,043.001) (15,694.592) (12,799.866) (12,799.866)

Note: RMSEA = root mean square error of approximation (threshold <0.10); CFI = comparative fit index (threshold >0.9); TLI = Tucker-Lewis index (threshold >0.
9); NFI = normed fit index (threshold >0.9); IFI = incremental fit index (threshold >0.9); RFI = relative fit index (threshold >0.9); AIC = Akaike information criterion
(no threshold set); and BIC = Bayes information criterion (no threshold set).
⁎ Residual correlations were observed among the following PPS items: 2–12, 3–14, 4–7.
⁎⁎ In the case of the AIC and BIC indicators, the values in parentheses represent the values for these criteria when the model is null, indicating the level of misfit (i.e.,

how much the null model deviates from the observed data when none of the predictor variables are used).
D
(i.e., vertical dissociation). Following classical trauma theories (see Van Personality structures implications in belief systems
Der Hart et al., 2004 for a revision), this means that there would be an
alteration in the patient's levels of consciousness and, consequently, Another important point to consider is whether these two structures
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there would also be a loss of contact with reality (the central element of or dimensions would persist at a lower level or with attenuated symp-
psychosis). This implies that the patient would face and act in reality toms of PPS and both types of personality in central possession cases.
according to multiple independent psychic systems. Possessing such in- This would be an interesting point for future studies, including anthro-
dependent systems would entail the development of multiple senses pological analyses of the meanings of the supernatural beliefs involved
and sources of identity, which would lead to the formation of dissocia- in the possession experience.
tive identity disorders and would fit into the spectrum of dissociative Indeed, we should mention that recent scientific literature suggests
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disorders typified in the DSM-5-TR (American Psychiatric Association, that in possession episodes, the belief systems of both the affected indi-
2022). viduals and their communities provide meaning and value to the expe-
On the other hand, when the patient does not have a schizo- rience, which should be considered in both medical and religious inter-
paranoid structure and has a histrionic basis, the type of dissociation is vention processes (e.g., Maraldi, 2024). In this context, dissociative
not psychotic. Instead, a neurotic dissociation (i.e., horizontal dissocia- symptoms would vary according to beliefs that offer a sense of transcen-
tion) is involved. This means that there is no alteration in the levels of dence and spirituality. For example, the path analysis by Lange et al.
consciousness and no loss of direct contact with reality. In these pro- (2022) found that when derealization and depersonalization occur se-
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files, the patient's psychic system is also fragmented but within the quentially, it triggers dissociation affecting the person's identity. Ac-
same level of consciousness and, consequently, using the same source cording to Font's (2016) model, this would only apply to the schizo-
or sense of identity. Following this logic, in these patients, no consis- paranoid structures, where psychotic dissociation alters the sense of in-
tent, defined, or independent multiple personalities are identified dividual identity. The extent to which spirituality and transcendence
within the functioning of the patient's psyche. This does not prevent the (characteristics of central possessions) could prevent these hallucina-
patient from believing that he/she is possessed by a supernatural entity, tory states typical of psychoses would be the specific line of future re-
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nor does it prevent critical episodes in which the patient presents crises search we propose to pursue.
of exaltation and motor excitation (Font, 2016). In other words, the The distinction between central and peripheral possessions is a de-
symptomatic manifestation of PPS may be the same in both schizo- bated issue in anthropological terms but not in clinical terms. Thus, if
paranoid and histrionic structures, but the dissociative mechanisms are both personality structures manifested in an attenuated manner in cen-
different. Identifying these differences to determine the possible type of tral possessions, it would not make much sense to distinguish between
dissociation may facilitate the application of a more precise psychiatric the two forms of possession. However, if only one of the structures
treatment and possible psychological intervention, and thus, improve (likely the hysteroid-histrionic) characterized central possessions, then
the patient's well-being. For a schizo-paranoid structure, clinicians we would have rational grounds to argue that the spiritual beliefs asso-
should adopt intervention models focused on psychosis. In contrast, for ciated with central possessions somehow prevent the hallucinatory cy-
a histrionic structure, results advocate a clinical approach based on the cle proposed by Lange et al. (2022), thereby preventing the individual
neurotic axis. from developing a pathological peripheral (or psychotic) possession. As
we have discussed, this is a speculative point aimed at promoting fur-
ther and more rigorous research in this field, but new sources of evi-
dence are necessary to support this hypothesis.

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Á. Escolà-Gascón et al. European Journal of Trauma & Dissociation xxx (xxxx) 100436

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PR
D
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Fig. 7. Proposed continuous model for schizo-paranoid and histrionic profiles, inspired by the framework suggested by priest-psychiatrist Font in 2016. Our findings
support the validity of this continuum, indicating that PPS fluctuates between these two symptomatic poles. © 2024 Graphically designed by Prof. Dr. Alex Escolà-
Gascón.
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Psychiatric implications on the practice of exorcisms On the other hand, if the dissociation is horizontal (i.e., of a histri-
onic type), ritual-exorcism could have a certain placebo effect because
When the patient and his closest affective environment believe that the patient would be connected with reality and the ritual-exorcism
the PPS is a genuine diabolic possession, it is common for them to con- would be a stimulus that would reinforce the belief system in the real
sult or seek advice from a religious authority (e.g., an exorcist priest) or existence of the possessions. The patient's belief system may allow the
to seek the intervention ritual of a spiritist, medium, or witchdoctor re- patient to attribute beneficial meanings to ritual exorcism to explain
lated to esotericism. Logically and commonly, physician-psychiatrists their perceived well-being and health (Escolà-Gascón et al., 2021).
tend to reject these non-medical practices. Although this may be the Based on our findings with cautious consideration of our proposed in-
practitioner's belief, knowing the type and the dissociative mechanisms terpretation, perhaps exorcism could benefit some patients. This con-
that are associated with the patient with PPS, may enable the patient's nection between central possession (Lewis, 1979) and the clinical prac-
practice of ritual exorcism is used to provide a placebo effect. If the in- tice of psychiatry may enable the integration of treatment into the cul-
terfering dissociation is vertical (schizo-paranoid), the practice of exor- tural/religious organization to which the patient belongs.
cism as a liberation ritual should not have any restorative effect on the
patient because there would be an alteration of consciousness and the
loss of contact with reality.

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Á. Escolà-Gascón et al. European Journal of Trauma & Dissociation xxx (xxxx) 100436

Limitations of the research (4) The schizo-paranoid personality structure explains 66 % of the
PPS variance, and the histrionic structure explains 65.1 %.
The limitations highlighted below do not invalidate the results of Dissociative episodes modulated PPS symptoms in 21 % and 26.4
this study. Instead, these limitations should be considered as disadvan- % of patients, respectively. Therefore, it is necessary to analyze
tages to be avoided in future research that attempts to replicate this the personality structures underlying dissociative identity
study. disorders (schizo-paranoid and histrionic) to refine and optimize
The first limitation is related to the methodological-statistical condi- the therapeutic approach for a particular patient.
tions of the structural equation models. Specifically, the errors associ-
ated with the observable variables (rectangles) are assumed to be ran- Funding details
dom, and consequently, should be independent of each other. The sig-

F
nificant covariances between the errors in Figs. 5 and 6 represent statis- The authors confirm that this research received no financial fund-
tical artifacts with no rational interpretation applicable to the results. ing.
Following Brown (2015), these types of statistical artifacts are usually

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not problematic in model theorizing, unless the amount of covariance Ethical statement
between errors is predominant or abusive (not in our case). Further-
more, the theoretical setup of the other models did not have this anom- The Committee of Ethical Guarantees of the UASR (as an official
aly, which could be due to an issue attributable to the sample of PSD pa- Spanish institution with public I.D. 58,210-J/1) reviewed, favourably
tients and not related to theorization. In future research, we recom- evaluated and approved this research with I.D. UASR202001253. All
mend paying attention to these covariations between errors to see if participants collaborated voluntarily and signed an informed consent
they recur. form that guaranteed the anonymity and confidentiality of their re-

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The second limitation is the fit indices obtained. It is true that in all sponses. Likewise, the procedures of this study adhere to the Spanish
analyses, there are fit indices with positive values that allow us to ac- Government Data Protection Act 3/2018 and the Declaration of Helsinki of
cept the validity of the theorization. However, considering the results of 1975, revised in 2013.
the RMSEA index, we must be cautious about the validity of the models
represented in Figs. 5 and 6. The fact that the errors are related to each CRediT authorship contribution statement
other generates noise in the data matrix, which future studies should
neutralize (see Escolà-Gascón, 2022b). The diversity present in patients Álex Escolà-Gascón: Writing – review & editing, Writing – original
with PSD is likely to increase anomalous responses. Therefore, it is ad- draft, Visualization, Software, Resources, Methodology, Investigation,
D
visable to enlarge the sample size and to define more precisely the pro- Formal analysis, Data curation, Conceptualization. Neil Dagnall: Writ-
file of psychotic patients who will participate in new studies. ing – review & editing, Resources, Project administration, Methodol-
Finally, based on the cultural and religious characteristics of our ogy, Investigation. Kenneth Drinkwater: Writing – review & editing,
study population, our results may not be generalizable. Various Spanish Validation, Supervision, Software, Resources.
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bishops referred 286 patients, who were regular practitioners of the

Catholic religion. Not including other forms of religion or faith limited Declaration of competing interest
the generalizability of results to patients with Christian beliefs diag-
nosed with DID and/or PSD. For future studies, we recommend broad- The authors confirm that there are no known conflicts of interest as-
ening the cultural focus to other religions (beyond Christianity) and sociated with this publication.
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conducting cross-cultural analyses to better understand the formation

of personality structures and the dissociative mechanisms implicating Acknowledgments
PPS.
The authors would like to express their sincere appreciation for the
Conclusions anonymous collaboration provided by the clinical professionals who as-
sisted in the data collection process and administered the assessment
Our findings and inferred proposal confirmed the following: tools utilized in this study. Furthermore, we extend our profound grati-
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tude to the patients who generously volunteered to participate in this

(1) Psychotic personality structures (i.e., schizo-paranoid) and non- research, irrespective of whether they were referred by exorcists,
psychotic structures related to the histrionic profile interfere with priests from Catholic dioceses, or other clinical practitioners. Without
psychiatric PPS. According to these personality structures, the extensive support received, conducting this research would not
schizophrenia is not the only diagnosis associated with PPS, and have been feasible.
dissociative identity disorder could occur with or without
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