​Drawing on two examples to illustrate the results of confusing the diagnostic criteria of one for the other, I shall attempt to explain some repercussions following any misdiagnoses. Alters mentioned in the narratives are memory fragments that seemed to have a life of their own yet are part of the memory system. Alters may be co-conscious (i.e., aware) of each other but in these two cases the majority of alters were not co-conscious with the patient.  If you wish to understand more about dissociation, please refer to the topic “Dissociative Disorders” under “Categories.”
 
Anne had been put on a stage by her senior pastor to showcase before the congregation the extent of her ‘demonisation’ with subsequent exorcisms performed. Months later, Anne and her husband turned up at my counselling office, ostensibly for partner relational issues. At their second interview, while talking about the couple’s acrimonious relationship, she suddenly went into a self-induced trance and slipped gently from her chair onto the floor. Anne’s husband excitedly commented that that was her modus operandi a couple of nights each week, claiming that she was ‘possessed’ and would then attempt to attack him. She spoke with a different voice from her normal self, and claimed she was a Buddhist. This was in contradiction to her Christian baptism years ago. When confronted with that fact, she said that she was a different person and can accept the faith of that ‘other person.’ At the third session, I sought to clarify her alter’s reason for claiming she was ‘possessed.’ Anne’s alter said that that terrified her husband, and she enjoyed frightening him due to his earlier infidelities. My tentative conclusion then was that this alter was not ‘a demon.’ I informed her accordingly that I did not consider her a demon, and therefore, she need not collapse onto the floor whenever she surfaced. Her alters never repeated that again. At no time throughout the seven years of counselling were any of Anne’s alters blasphemous nor was there any opposition to the differential faith schemas of over twenty alters, many of whom spoke with different vocal pitches. Towards the end of therapy, when I thought that all of Anne’s alters were fully integrated in her memory system, three separate new alters came forward. On further enquiry why they chose to self-disclose at this late session, they all claimed that when they did surface years ago, a pastor accused them of being demons and attempted to exorcise them. That was when they went into hiding, and waited until they could trust me before resurfacing. They further claimed that they had been listening to me treat the other alters with respect and kindness and chose to reveal themselves presently. Despite a couple of alters being co-conscious with each other, all the alters were not co-conscious with Anne.
 
The second case concerned a young lady, Susan, who would occasionally go into a trance at a Sunday church service. She would scream at the top of her voice for minutes on end, disrupting the pastor’s sermon. Susan was often escorted out of the service by the staff, who would invariably attempt to exorcise her ‘demons.’ When queried about her emotional outbursts, she had no memory of them. Susan was not co-conscious with her alter. Eventually, she was sent to me as her histrionics apparently remained ‘incurable.’ One day, after inducing Susan into a trance state, I identified and called out the alter who was responsible for these flare-ups. When asked for the reason behind these frenzies, the alter confessed. While in a trance during an exorcism attempt several months prior, she had overheard a pastor make a humorous joke about her situation, causing much laughter in the room. This alter felt ashamed being laughed at! It took revenge on that pastor whenever he was preaching, and repeatedly disrupted his sermon to embarrass him.  
 
A misdiagnosis would result in alters or memory fragments remaining silent, and hiding deep in the subconscious of the patient, until they feel comfortable to resurface, which may be months or years later. What this implies is that the patient remains untreated for a longer term. Further, to stigmatise someone as being ‘demonically possessed’ can be damaging to how the patients view themselves or how others see them. Hence, to discern judiciously would likely lead to a correct diagnosis for an appropriate treatment regime.
​

It would not be unusual for anyone to mistake dissociation for possession or vice versa. In fact, most dissociated cases that surface in a religious or church context would be invariably treated as possessions, and the treatment regime through exorcism would inevitably be counterproductive. The logic being a dissociated mental memory cannot be exorcised! It is inherently part of the individual’s personality. Only a spiritual entity distinct from the individual can be exorcised. Hence, diagnostic wisdom is necessary to tease out the differences for an effective treatment strategy. I shall initially delineate the clinical views of these conditions and add a Christian perspective to them.
 
Dissociation is a mental process where a person experiences a disconnection or lack of continuity between thoughts, memories, surroundings, actions, and identity. This can manifest as feeling detached from oneself or the environment, memory gaps, altered sense of time, and even feeling as if the world or oneself is not real. Dissociation is often a response to overwhelming stress or trauma, serving as a coping mechanism to distance oneself from distressing experiences. Its common symptoms include:
Memory loss (amnesia) for certain periods, events, or personal information;
Feeling emotionally numb or detached from one’s body (depersonalization);
Feeling the world is unreal (derealization);
Identity confusion or fragmentation; and
Difficulty coping with daily life.
 
Possession, however, refers to an altered state of consciousness in which an individual believes their body or mind is controlled by an external entity, such as a spirit, deity, or supernatural force. In many cultures, possession is interpreted through religious or spiritual frameworks and may be seen as either channeling spirits or a straight-forward demonic possession. The clinical features of possession experiences can include:
Temporary loss of personal identity;
Uncharacteristic behaviors or speech;
Amnesia for the period of possession; and
Perception of being controlled by an external force.
 
Clinical and Diagnostic Overlap
Modern psychiatry recognizes a significant overlap between dissociation and possession. The DSM-5 and ICD-10 include “trance and possession disorders” as types of dissociative disorders, characterized by a temporary loss of identity and awareness of surroundings. In some cultures, what is interpreted as spirit possession may clinically resemble dissociative identity disorder (DID) or other dissociative states. Possession-form DID is distinguished from culturally accepted possession states by being involuntary, distressing, and disruptive to daily functioning. In contrast, culturally sanctioned possession (such as in religious rituals) is not considered pathological unless it causes significant distress or impairment. 
 
Trauma in Childhood May Link Dissociation and Possession
Research indicates that both dissociation and possession experiences are often linked to trauma, especially in childhood. Individuals reporting possession experiences frequently exhibit higher levels of dissociative symptoms and are more likely to have histories of traumatic events compared to control groups. However, in many cultures, individuals do not subjectively associate their possession experiences with trauma, instead interpreting them through spiritual or cultural lenses. In some societies, possession is integrated into religious or healing practices and may be associated with positive outcomes, such as social support or personal meaning. In others, possession may be stigmatized and linked to distress or mental health issues, especially if the experiences are involuntary or disruptive. 
 
Example Scenarios
Dissociative Symptom Example: A person under stress feels as if they are watching themselves from outside their body (depersonalization) or cannot recall important personal information (amnesia) but does not attribute these experiences to an external force.

Possession Experience Example: A person suddenly speaks in a different voice, claims to be a spirit or deity, and later has no memory of the episode. The experience is interpreted as possession by the person or their community.

​Both can involve amnesia, changes in behavior, and a sense of loss of control. The main distinction is that dissociative symptoms are self-referential disruptions in consciousness, while possession experiences involve the belief or perception of being overtaken by an external entity.
 
What I have found with distinctly malevolent possession cases is that the patients regularly blaspheme or even act violently towards the interlocutor’s or psychologist’s Christian faith, often without any religious provocations. It is as though the spirit entity is aware of the faith schema of those present and chose to confront them. Dissociated individuals can sometimes claim possession through their alters but these assertions need verification and not to be taken at face value, even when they speak in a different voice. The individual being non-co-conscious with an alter does not always imply a possession too.
 
In summary, dissociative symptoms are disruptions in self-experience and memory, typically understood as psychological phenomena, while possession experiences involve the sense of being controlled by an external force and are often interpreted through cultural or spiritual frameworks. 
 
References:
(2023, August 31). Dissociative Disorders. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/dissociative-disorders/symptoms-causes/syc-20355215
 
(2023, January). Mind. Dissociation and Dissociative Disorders. https://www.mind.org.uk/information-support/types-of-mental-health-problems/dissociation-and-dissociative-disorders/about-dissociation/
 
Delmonte, R., Farias, M., Bastos Juniour, M.A.V., Madeira, L. & Sonego, B. (2022, July 15). The Mind Possessed: Well-Being, Personality, and Cognitive Characteristics of Individuals Regualrly Experiencing Religious Possession. Brazil Journal of Psychiatry, Vol. 44 (5), Pages 486-494.
 
Wiginton, K., Mitchell, K., & Amandolare, S. (2024, July 14). What is Dissociation? WebMD. https://www.webmd.com/mental-health/dissociation-overview