Dr. David H. Barlow and Aversion Therapy for Gays

Should a professional society honor a highly accomplished investigator who conducted studies in the past that would now be considered unethical?

Distinguished professor and clinical psychologist Dr. David H. Barlow was recognized for his achievements by the Association for Psychological Science (APS) last year as the recipient of the 2012 James McKeen Cattell Fellow Award:

David H. Barlow has made enormous theoretical and empirical contributions in many areas of clinical psychology. He is best known for his efforts to develop psychological treatments for anxiety disorders. His early work on the treatment of agoraphobia laid the groundwork for exposure-based treatments that are today regarded as the gold standard. As we learned more about the relationship of agoraphobic avoidance to the occurrence of panic attacks, Barlow led the way in the development of treatments for the remediation of panic symptoms.

Much of Barlow’s research is based on the notion that anxiety is a disorder of emotion. He holds this to be the case regardless of the specific emotional disorder, and this has led him in the later years of his career toward the development and testing of a unified protocol for the transdiagnostic treatment of such disorders....

What you might not have known is that such disorders have included homosexuality and transsexualism. Barlow advocated and practiced aversion and conversion therapies to "cure" gay and transgendered people of their "deviant" sexuality.

While I do not wish to detract from Dr. Barlow's many positive accomplishments, I feel it is important to expose the questionable practices of the past and to hold people accountable for their actions. I looked far and wide to find a mea culpa from Dr. Barlow, much like Dr. Robert Spitzer's public apology for his published work on reparative therapy as a "cure" for homosexuality (Spitzer, 2003).¹ But I did not find such a statement anywhere.

Should we question the judgment of APS in honoring Dr. Barlow with the Cattell Award? ² Are they tacitly condoning exorcism in transsexuals (Barlow et al., 1977) and aversion therapy in gay men (Barlow et al., 1969; Hayes et al., 1983)? At the very least, APS did not publicly acknowledge or condemn these former practices, which remain secretly buried in the past.

I contacted two divergent experts to ask their opinions. Psychologist Dr. John Grohol, who founded the mental health networking and education site Psych Central, turned the question around:

"Should we honor professionals who may have made questionable judgments in their early career? I would ask a question in return -- Should we forever withhold such honors for the poor judgments one makes in one's early career?"

On the other hand, Professor Lynn Conway, the pioneering computer scientist, electrical engineer, and transgender activist, was surprised about the award. She felt an appropriate course of action is...

"... to expose these old miscreants and get their misdeeds on the record. That way they'll all have to run for cover in the years ahead..."

Let's examine some of these practices below so you can decide for yourself.


Exorcism for Transsexualism?

As some of you might have gathered, I came across this paper during my exorcism research.  Barlow and colleagues (1977) didn't actually perform the exorcism themselves, but observed the resulting change in behavior "fortuitously" and used it as an example of how atypical gender identity could be modified, if not prevented all together:

Although the prevention of transsexualism is the ideal, work in this area has been fraught with ethical problems...

The authors reported the detailed case history of "John", a 21 year old patient who had a clear identity as female and wished to transition. Before doing so, John was persuaded to visit a Fundamentalist Christian doctor, who performed an exorcism:

The physician administered a total physical exam and said that he could live quite well as a woman, but the real problem was possession by evil spirits. After some discussion of this, John reported a session which lasted 2-3 hr and involved exhortations and prayers over John by the physician and laying on a hands on John's head and shoulders. During this period, John reported fainting several times and arising to the continuing of the prayers and exhortations, resulting in the exorcism of 22 evil spirits which the physician called by name as they left his body.  ... The physician noted ... that he showed John that his life was a fake and that Jesus could redeem him and that a standard prescription of Scripture readings caused the spirit of the woman in John to disappear.

Immediately after the session John announced he was a man, discarded his female clothes (hiding his breasts as best he could), and went to the barber shop to have his long hair cut into his current short, masculine style...

Rather than condemn the outlandish and unethical behavior of this physician, and counsel John (who had identified as Judy) on her previously excellent adjustment as female and readiness for surgery, they considered this a successful change in gender identity. An even more questionable event was a visit to a faith healer. After the laying on of hands, John reported that his breasts (size 36B) had disappeared immediately. Personally, I think a psychiatric assessment would have been in order.

Very worth reading in regard to this paper is the text on Rogue Theories of Transsexualism written by Professor Conway. She says that "By seeing a collection of such theories side-by-side, we grasp the strangeness of them all."


Aversion Therapy to Cure Sexual Deviance

Even more outrageous were the papers on aversion therapy. As a prelude to the actual practices described by Barlow et al. (1969), I will use American Horror Story: Asylum as a near-exemplar.

The year is 1964. Lana Winters is a reporter investigating the unethical practices at Briarcliff Manor, a mental institution for the criminally insane. She's caught snooping around and is committed against her will to keep her quiet, with the ostensible reason being that she is gay. She is forced to have shock treatment. Sympathetic psychiatrist Dr. Oliver Thredson tries to persuade her to undergo aversion therapy, which is presented as more "humane." She eventually agrees because she thinks it'll get released her from Briarcliff once Thredson pronounces her "cured."

Under the direction of Dr. Thredson, Winters views a slide show of erotic pictures of women. She has an iv drip going into her left arm. She starts to get physically ill while viewing the slides and then throws up into a metal bucket.

Winters: "What is this stuff?"

Thredson: "Apomorphine. Standard drug for this kind of cutting edge aversion therapy. They use it at Harvard, Brigham Young, Cornell. The theory is that we're training your body to be physically repelled by certain.....triggers."

Next slide: a picture of her girlfriend smoking a cigarette in bed. He cranks up the apomorphine until she vomits again.


Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization

Come on, you're saying, it couldn't have been that bad in real life. Plus the paper was published in 1969, that's ancient history by now. But if you were one of the men interviewed for this story on When gays were 'cured', you might think otherwise.

Barlow et al. (1969) didn't actually administer apomorphine, but they did try to make same sex attraction as physically repulsive as possible. The study was a case report of two patients treated with aversion therapy. One especially offensive aspect of the paper is that a pedophile and a gay man were treated as equivalently deviant. The description of the gay subject was particularly condescending:

The S2 was a 32-yr.-old married male who reported a 14-yr. history of homosexual experiences averaging about three contacts per week, usually in public toilets. He recently had fallen in love with a "boyfriend," which was threatening his marriage and which motivated him to seek treatment. Sexual relations with his wife, although prevalent early in the marriage, had been virtually nonexistent for the previous 3 yr.

The protocol paired descriptions of sexually arousing scenes with nauseating scenes.  I'll quote the noxious script in its entirety to allow the full impact to wash over you:

In each session Ss were given relaxation instructions and presented with eight scenes. In four scenes S was described approaching the small girl (male), feeling nauseous and vomiting. For example, in one of the homosexual scenes, S2 was described approaching his boyfriend's apartment.

"As you get closer to the door you notice a queasy feeling in the pit of the stomach. You open the door and see Bill lying on the bed naked and you can sense that puke is filling up your stomach and forcing its way up to your throat. You walk over to Bill and you can see him clearly, as you reach out for him you can taste the puke, bitter and sticky and acidy on your tongue, you start gagging and retching and chunks of vomit are coming out of your mouth and nose, dropping onto your shirt and all over Bill's skin."

The description of the nauseous scene was usually expanded and lasted from 30 to 60 sec. In the remaining four scenes S would be described approaching the small girl (male) and beginning to feel nauseous. At that point he would turn, start walking away from the scene, and immediately feel relieved and relaxed.

They concluded that an intensely disgusting and obnoxious scenario could serve as a substitute for apomorphine and shocks in aversion therapy designed to straighten out gay men.

A follow-up experiment with four gay male subjects manipulated the instructions given during phases of covert sensitization (pairing of sexually arousing scenes with vomiting scripts) and extinction (no pairing). To assess the effects of treatment on arousal patterns, penile circumference was measured while the subjects viewed slides of nude men (Barlow et al., 1972).


1973 and Beyond

The American Psychiatric Association removed homosexuality from its list of mental illnesses in 1973. (see DSM-II Homosexuality Revision). Should we forgive Barlow for work conducted before then? He was still a strong advocate of aversion therapy around this time (Barlow, 1973):

"[other authors] speak of the necessity of increasing more appropriate and assertive heterosocial behaviors in the treatment of sexual deviation. Despite these views, aversion therapy aimed at eliminating sexual deviation is increasingly advocated as the treatment of choice (Barlow, 1972), due in part to the growing application of the experimental behavioral sciences to the clinic and in part to the relative success of this technique..."

Dr. Grohol made the following observation:

"At the time, [homosexuality] was a recognized mental disorder, so it may have been a reasonable area in which to conduct research. While it's both difficult and repugnant to utter those words today, it highlights one of the drawbacks of the DSM classification system -- it's a malleable, social-constructed manual as much as it is based in hard, scientific data."

Barlow continued to publish accounts of homosexual conversion treatments after 1973 — involving exposure to male and female nudes (and porn) while penile circumference was measured (Herman et al., 1974; Barlow et al., 1975).  The latest one I could find was from 1983, which treated one exhibitionist, two pedophiles, and one gay man with covert sensitization (Hayes et al., 1983). The technique paired arousing scenes with aversive scenes designed to disgust or humiliate the participant. The authors issued a caveat, yet accepted the gay man into this treatment program and continued to use the term "deviant" (just to be consistent with the criminals):

Subject 2, an unemployed 39-yr-old single white male, sought treatment to decrease homosexual behavior and to increase heterosexual arousal (thus, he is not sexually deviant by current classification).* 
. . .

Despite the strong recommendations by some (e.g. Begelman, 1975) not to treat homosexuals for their homosexuality, this individual had clearly stated his preferences and was accepted into treatment.

*The use of terms like ‘deviant arousal’ is problematic with this subject, but they are used for the sake of consistency. ‘Undesired arousal’ is more accurate and better reflects our attitudes towards this case.

Did any of these behavior therapy techniques work? There's no evidence that they did. Studies were poorly controlled and overly reliant on self-report, follow-ups were brief, and participants were inadequately characterized (Serovich et al., 2008). Moreover, there is ample evidence that the treatments were harmful (King & Bartlett, 1999). Some patients became severely depressed and suicidal.

Not all behavior therapists were in favor of pathologizing homosexuality in the early-mid 1970s. Dr. Gerald C. Davison, President of the Association for Advancement of Behavior Therapy (AABT) from 1973-1974, gave an impassioned speech at the annual meeting where he argued against the use of conversion therapies for gays and lesbians (Sept. 2003 AABT Newsletter, PDF).³


In their review on British psychiatry and homosexuality, King and Bartlett (1999) suggested that mental health professionals should be aware of past mistakes, including ones they themselves may have committed:

Although many professionals may have been well intentioned in helping a disadvantaged group of patients towards what they regarded as a better adjustment to life, very few seem to have later questioned the wisdom of their work. In the past 20 years, one psychiatrist has written of the excesses of the profession (Bancroft, 1975, 1995). Bancroft claimed that he would not now provide aversion therapy because of its limited effectiveness and because of different social attitudes towards homosexuality (Bancroft, 1991, 1995). Others who published in the British psychiatric press, such as Nathaniel McConaghy in Australia, continued to defend their methods into the 1980s.  ...  Professionals who published extensively on this topic, such as Bancroft, McCulloch, McConaghy, McDougall, Storr and Glasser, remain in prominent positions as commentators or as principals or chairs in institutions around the world.

It is my view that many more of these distinguished professionals should publicly reconsider their earlier work, as did Spitzer and Bancroft. To be forgiven, they must acknowledge their wrongdoing.

I e-mailed to Dr. Barlow to ask if he had any comments about his early work in light of contemporary views of homosexuality, or whether he had issued such a statement in the past. I haven't heard back, but I will post such remarks (with permission) if I receive them.

Ironically, Barlow ended his 2012 acceptance speech with the following important yet vague words:

"Time marches on. Ideas change — hopefully for the better."

Footnotes

¹ From Spitzer reassesses his 2003 study of reparative therapy of homosexuality in the Archives of Sexual Behavior (the same journal that published his original study):

I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some “highly motivated” individuals.

² However, APS is certainly not unique in honoring Dr. Barlow, who is the author of over 500 articles.

³ Meanwhile, Barlow (who was AABT President from 1978-1979) published the "Heterosocial Skills Behavior Checklist for Males" in 1977 (Barlow et al., 1977). It was used to evaluate the behavior of sexual deviants (in this case, "five homosexuals, two transsexuals, one pedophiliac, one sadist, and one rapist"). One nugget of wisdom: when interacting with a member of the opposite sex, it is inappropriate to "giggle or laugh in a high-pitched manner, staccato and uncontrolled."


References

Barlow DH (1973). Increasing heterosexual responsiveness in the treatment of sexual deviation: A review of the clinical and experimental evidence. Behavior Therapy 4:655-671.

Barlow DH, Abel GG, & Blanchard EB (1977). Gender identity change in a transsexual: an exorcism. Archives of sexual behavior, 6 (5), 387-95. PMID: 921523

Barlow DH, Agras WS, & Leitenberg H (1972). The contribution of therapeutic instruction of covert sensitization. Behaviour research and therapy, 10 (4), 411-5. PMID: 4637499

Barlow DH, Agras WS, Abel GG, Blanchard EB, Young LD. (1975). Biofeedback and reinforcement to increase heterosexual arousal in homosexuals. Behav Res Ther. 13:45-50.

Barlow DH, Leitenberg H, & Agras WS (1969). Experimental control of sexual deviation through manipulation of the noxious scene in covert sensitization. Journal of abnormal psychology, 74 (5), 597-601. PMID: 5349402

Hayes SC, Brownell KD, & Barlow DH (1983). Heterosocial-skills training and covert sensitization. Effects on social skills and sexual arousal in sexual deviants. Behaviour research and therapy, 21 (4), 383-92, PMID: 6138027

Herman SH, Barlow DH, Agras WS. (1974). An experimental analysis of exposure to "explicit" heterosexual stimuli as an effective variable in changing arousal patterns of homosexuals. Behav Res Ther. 12:335-45.

King M, Bartlett A. (1999). British psychiatry and homosexuality. Br J Psychiatry 175:106-13.

Serovich JM, Craft SM, Toviessi P, Gangamma R, McDowell T, Grafsky EL. (2008). A systematic review of the research base on sexual reorientation therapies. J Marital Fam Ther. 34:227-38.

Spitzer RL. (2003). Can some gay men and lesbians change their sexual orientation? 200 participants reporting a change from homosexual to heterosexual orientation. Arch Sex Behav. 32:403-17.

Spitzer RL. (2012). Spitzer reassesses his 2003 study of reparative therapy of homosexuality. Arch Sex Behav. 41:757.

 

Dr. David H. Barlow - APS 24th Annual Convention (2012)

"Time marches on. Ideas change — hopefully for the better."
-David H. Barlow

Intergalactic Cognitive Science

Be a pioneer! Get in on the ground floor! Launch your career into orbit! Submit a paper to the Intergalactic Journal of Science special issue on “New Perspectives in Intergalactic Cognitive Science.”

Here's the Call for Papers:

Cognitive Science is expanding at an exponential rate. However, the field is in need of unification. A unification of the how and why of the great diversity of cognitive architectures. A unification of the experiental contents now believed to be so diverse. A unification of scientific method, now varying per stellar community.

If you’ve been itching to write about “Phenomenology of guilt in a recently discovered synthetic-based species of robots” or “An experimental study on the effect of space-travel on short-term memory within carbon-based species,” then this is the journal for you.

The Neurocritic has been a forward-looking blog since its inception seven years ago today, so it’s only appropriate to celebrate by embracing the cutting edge of cognitive science.

See you in the future!

The Ethics of Public Diagnosis Using an Unvalidated Method

The last post covered a new study claiming to identify markers of chronic traumatic encephalopathy (CTE) in living patients using a method called FDDNP PET (Small et al., 2013). Previously, the disease could only be diagnosed at autopsy due to the requirement to process post mortem tissue for the presence of tau protein. The paper made a big splash in the media because the patients in the study were five former NFL football players.

Combining the journal article with two different news reports, I was able to identify the following information about the players and their brains (which are shown in the figure above):

• NFL1: Fred McNeill, 59-year-old former Vikings linebacker - mild cognitive impairment, experienced momentary loss of consciousness after each of two concussions
• NFL2: Wayne Clark, 64-year-old former backup quarterback - no symptoms except age-consistent memory impairment, experienced momentary loss of consciousness and 24-hour amnesia following one concussion
• NFL3: 73-year-old former guard - dementia and depression, suffered brief loss of consciousness after 20 concussions and a 12-hour coma after one concussion
• NFL4: 50-year-old former defensive lineman - mild cognitive impairment and depression, suffered two concussions w/ loss consciousness for 10 min after one of them
• NFL5: 45-year-old former center - mild cognitive impairment, sustained 10 concussions and complained of light sensitivity, irritability, and decreased concentration after the last two

ESPN identified two players by name and the others by position and age. The San Francisco Chronicle identified the players by position and symptoms. The actual journal article reported the symptoms along with histories of concussion.

Mr. Clark, who has been doing quite well in his post-football life, was quoted in ESPN:

Clark, now 65, said in an interview that he was exposed to limited contact and sustained only one major concussion during his career. During a 1972 game at Miami, he was holding on a field goal attempt that was blocked and was injured while trying to make the tackle.

Film of the play failed to show how the injury occurred, and Clark didn't remember. "It was a total blackout," he said.

Clark, who ran a Southern California video services business and officiated high school football games after his playing career ended, said he reacted with "interest, not alarm," after being told that he had signs of CTE.

"I don't feel like I'm suffering from any real symptoms at this point, and didn't have any sense of anything going on except normal age-related issues," he said. He decided to participate in the hope that "it could help other people and maybe help me."

What are the ethics of telling Mr. Clark that he has "signs of CTE" after a undergoing a scan that has not been validated to accurately diagnose CTE? It seems unethical to me. I imagine it would be quite surprising to be told you have this terrible disease that has devastated so many other former players, especially if your mood and cognitive function are essentially normal.

One objection I raised previously was that FDDNP is not specfiic for tau; it also labels beta amyloid and prion proteins. If you take a look at the NFL3 brain above, it shows extensive signs of atrophy.¹ He is the oldest participant, and his lifetime injuries were the most severe. But it's not clear whether this former player has Alzheimer's disease, CTE, or another neurodegenerative disorder.

ESPN says the evidence in favor of CTE is definitive, however:

CTE found in living ex-NFL players

By Steve Fainaru and Mark Fainaru-Wada 

Brain scans performed on five former NFL players revealed images of the protein that causes football-related brain damage -- the first time researchers have identified signs of the crippling disease in living players.

Researchers who conducted the pilot study at UCLA described the findings as a significant step toward being able to diagnose the disease known as chronic traumatic encephalopathy, or CTE, in living patients.

The SF Chronicle was a little more circumspect:

A clue to brain disorder - before death

By Drew Joseph 

For the first time, scientists think they have detected in living patients a protein that accumulates in the brains of people suffering from chronic traumatic encephalopathy, a neurodegenerative disorder tied to repeated brain injuries that afflicts football players and military veterans.

. . .

The study was limited by the small number of participants, and the scientists could not definitively determine the protein was tau.

That article also quoted an outside expert, UCSF neurosurgery professor Dr. Geoffrey Manley:

More to be done
Researchers cannot be sure if the protein was tau because the chemical marker binds to other proteins as well. Dr. Geoffrey Manley, a neurosurgery professor at UCSF and chief of neurosurgery at San Francisco General, said the study raises interesting ideas but cautioned that the findings need to be verified.

"We need to make sure that all the basic science behind this is solid and we know beyond a shadow of a doubt that we're looking at tau," he said.

Nonetheless, the bulk of the coverage has already diagnosed these men with CTE. It seems that Dr. Gary Small, study coauthor and FDDNP patent holder, has also diagnosed these patients, according to CNN:

"We found (the tau) in their brains, it lit up," said Dr. Gary Small, professor of psychiatry at the Semel Institute for Neuroscience and Human Behavior at UCLA and lead author of the study, published Tuesday in the American Journal of Geriatric Psychiatry.

What was startling, said Small, was the specific pattern of the tau they found: "It was identical to what's seen in a condition called chronic traumatic encephalopathy, CTE, that has only been diagnosed at autopsy." [NOTE: no, it's not.²]

As I said before, I could be wrong about all of this and maybe FDDNP PET does provide a definitive diagnosis of CTE (the definition of which may need amending). But don't you want to be sure before breaking the news to one of your patients?


Footnotes

¹ It's very easy to see enlargement of the ventricles and widening of the cortical sulci on this scan.

² In post mortem brain tissue, McKee et al. (2012) found neurofibrillary tangles (NFTs) in "focal epicentres in cerebral cortex, usually frontal lobe" in CTE stages I–II. It was not until CTE stages III-IV that they found "High densities of NFTs in thalamus, hypothalamus, mammillary bodies, brainstem." Presumably NFL1, NFL2, NFL4, and NFL5 are not showing advanced signs of pathology, given their mild (or non-existent) symptoms.


References

McKee, A., Stein, T., Nowinski, C., Stern, R., Daneshvar, D., Alvarez, V., Lee, H., Hall, G., Wojtowicz, S., Baugh, C., Riley, D., Kubilus, C., Cormier, K., Jacobs, M., Martin, B., Abraham, C., Ikezu, T., Reichard, R., Wolozin, B., Budson, A., Goldstein, L., Kowall, N., & Cantu, R. (2012). The spectrum of disease in chronic traumatic encephalopathy. Brain.

Gary W. Small, Vladimir Kepe, Prabha Siddarth, Linda M. Ercoli, David A. Merrill, Natacha Donoghue, Susan Y. Bookheimer, Jacqueline Martinez, Bennet Omalu, Julian Bailes, Jorge R. Barrio (2013). PET Scanning of Brain Tau in Retired National Football League Players: Preliminary Findings. Am J Geriatr Psychiatry, 21.

Is CTE Detectable in Living NFL Players?

Chronic traumatic encephalopathy (CTE) is a progressive neurodegenerative disease seen most often in athletes with repeated concussions.¹ The condition has drawn extensive media attention due to the number of cases reported among retired NFL players. The disease can only be diagnosed at autopsy, because the brain tissue has to be stained for characteristic protein abnormalities which cannot be visualized in a living human.

Until now, that is, according to a new study by Gary Small and colleagues at UCLA (Small et al., 2013). Positron emission tomography (PET) and the molecular imaging probe FDDNP ² were use to visualize levels of the protein tau, which forms neurofibrillary tangles in Alzheimer's disease and other tauopathies. Or what is presumed to be tau.

Elevated levels of FDDNP were observed in in the brains of 5 former NFL players relative to those of 5 control participants. The players were referred for testing because of symptoms of mild cognitive impairment. These five participants in the study (out of 19 potential volunteers) had a mean age of 59 yrs; MMSE scores of 28 vs. 30 in controls; and higher depression scores than controls, but no clinically significant depression in most.

The authors admit this is a very preliminary study that needs to be replicated and validated in larger samples. Yet they are optimistic they have a discovered a means of imaging CTE pathology in the brains of living patients.

But I would like to cast some doubt on this notion for two reasons:

(1) FDDNP is supposedly a tracer for both tau and amyloid beta (which forms plaques in Alzheimer's and other dementia), but some experts think it's neither. Studies have shown that it binds to a variety of misfolded proteins. For example, it selectively labels prion plaques in Creutzfeldt–Jakob disease (Bresjanac et al., 2003).

At any rate, FDDNP does not appear to be specific for CTE pathology.


(2) The distribution of FDDNP binding in the brains of the retired players does not appear to be the same as CTE tau pathology that has been observed at autopsy (McKee et al., 2012). Last month the Boston University group found evidence of CTE in the brains of in 68 male subjects, most of whom played contact sports. McKee et al. identified a series of four stages of CTE, with progressive worsening of clinical symptoms and neuropathology.

My guess is that the participants in the Small et al. study, if they do indeed have CTE, might be at stage I or perhaps stage II, but this is hard to tell given the very limited clinical and cognitive data on these patients (they had "a history of cognitive or mood symptoms").

The FDDNP results showed elevated signals in the players in a number of subcortical regions (including caudate, putamen, thalamus, subthalamus, midbrain, and amygdala), but nowhere in the cerebral cortex. On the other hand, stage I CTE tau pathology in post mortem brains is found in limited discrete locations: mild pathology in the cerebral cortex and minimal pathology in the amygdala and hippocampus (McKee et al., 2012). In stage II, pathology within the cortex spreads, and pathology in the medial temporal lobe (amygdala and hippocampus) is still mild.

Maybe there's a bias for subcortical labelling with FDDNP PET, versus cortical pTDP-43 immunoreactivity in post-mortem tissue. ³  That's possible, but Small and colleagues have previously reported extensive neocortical FDDND signal in mild cognitive impairment (Small et al., 2012).


I'm not an expert, and I could certainly be wrong about all of this. Development of in vivo imaging probes for neurodegenerative diseases is a very active area of research. The new hyperphosphorylated-tau radioligand [F-18]-T807 could be more specific for imaging tauopathies (Chien et al., 2012). Scientific developments like these will be especially crucial once any type of treatment for CTE comes along.

- Original link to study via Deadspin and Nature editor Noah Gray.

Footnotes

¹ More background information, taken from my earlier post on Blast Wave Injury and Chronic Traumatic Encephalopathy: What's the Connection?

 A defining pathological feature is tauopathy - abnormal accumulations of the tau protein seen in other dementias (e.g., Alzheimer's disease). Aggregations of hyperphosphorylated tau into neurofibrillary tangles (NFTs) are a defining feature, as in frontotemporal lobar degeneration and amyotrophic lateral sclerosis -- yet CTE is distinct from both of these (McKee et al., 2009). CTE results in cognitive and behavioral changes including memory impairments, poor impulse control, alterations in mood, suicidal behavior, disorientation, and ultimately dementia.

² Co-authors Small and Barrio are among the inventors of the FDDNP approach. They have received royalties and may receive royalties on future sales.

³ Noah Gray raised this point.


References

Bresjanac M, Smid LM, Vovko TD, Petric A, Barrio JR, Popovic M. (2003). Molecular-imaging probe 2-(1-[6-[(2-fluoroethyl)(methyl)amino]-2-naphthyl]ethylidene) malononitrile labels prion plaques in vitro. J Neurosci. 23(22):8029-33.

Chien DT, Bahri S, Szardenings AK, Walsh JC, Mu F, Su MY, Shankle WR, Elizarov A, Kolb HC. Early Clinical PET Imaging Results with the Novel PHF-Tau Radioligand[F-18]-T807. J Alzheimers Dis. 2012 Dec 12. [Epub ahead of print]

McKee, A., Stein, T., Nowinski, C., Stern, R., Daneshvar, D., Alvarez, V., Lee, H., Hall, G., Wojtowicz, S., Baugh, C., Riley, D., Kubilus, C., Cormier, K., Jacobs, M., Martin, B., Abraham, C., Ikezu, T., Reichard, R., Wolozin, B., Budson, A., Goldstein, L., Kowall, N., & Cantu, R. (2012). The spectrum of disease in chronic traumatic encephalopathy Brain DOI: 10.1093/brain/aws307

Gary W. Small, Vladimir Kepe, Prabha Siddarth, Linda M. Ercoli, David A. Merrill, Natacha Donoghue, Susan Y. Bookheimer, Jacqueline Martinez, Bennet Omalu, Julian Bailes, Jorge R. Barrio (2013). PET Scanning of Brain Tau in Retired National Football League Players: Preliminary Findings. Am J Geriatr Psychiatry, 21

Possession Trance Disorder in DSM-5

American Horror Story: Asylum takes place in 1964 at Briarcliff Manor, a terrifying mental institution for the criminally insane. The show uses every over-the-top stereotype in the book — straightjackets, isolation cells, shock treatment, the chronic masturbator, the nymphomaniac, the sadistic nun, the evil mad doctor, unethical experimentation, wrongful commitment, alien abduction, demonic possession, you name it — yet it still manages to be scary and stylish and suspenseful.

The episode about a poor soul possessed by the devil naturally includes an exorcism by Catholic priests. The afflicted boy becomes ugly and deformed by the demon, who spews out lewd words and exerts its supernatural telekinetic powers by throwing objects (and priests) across the room.

Regarding exorcism, the Catholic Encyclopedia says:

Exorcism is (1) the act of driving out, or warding off, demons, or evil spirits, from persons, places, or things, which are believed to be possessed or infested by them, or are liable to become victims or instruments of their malice; (2) the means employed for this purpose, especially the solemn and authoritative adjuration of the demon, in the name of God, or any of the higher power in which he is subject.

Religious belief in the existence of demons is a sincere part of the Catholic faith, so demonic possession can be a particularly frightening Hollywood trope for devout Catholics (and former Catholics). Walking out of the theater into the dark parking lot and entering your empty apartment after a midnight showing of The Exorcist can be creepy for the believer and the agnostic alike. Even if Satan isn't lurking in your shower, a serial killer like "Bloody Face" could be under your bed. Indoctrination into a belief system where devils are real can haunt a young child into adulthood.

In contrast, the rationalist perspective presents historical and medically-based views of possession phenomena in terms of epilepsy, schizophrenia, and possession trance disorder (PTD), a possible variant of dissociative identity disorder. Nothing evil or supernatural takes over the identity of the person with PTD. Nonetheless, exorcisms performed on mentally ill people continue to this day.

For example, Tajima-Pozo and colleagues (2011) reported on the case of a 28 yr old woman in Spain who had been diagnosed with paranoid schizophrenia. Over the course of 5 yrs she had been treated with the antipsychotic drugs clozapine, risperidone, ziprasidone and onlanzapine, without complete remission. She was an inpatient on a psychosis ward, and yet some diabolical priests managed to get in and convince her that she was possessed by demons. Some of the priests had knowledge of the patient's psychiatric history and should have known better. But they performed multiple exorcisms anyway, which disrupted her clinical treatment.¹

In DSM-IV, spirit possession falls under the category of Dissociative Disorder Not Otherwise Specified, with more specific research criteria (but not an official diagnosis) fitting Dissociative Trance Disorder (possession trance):

This category [DDNOS] is included for disorders in which the predominant feature is a dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific dissociative disorder.
. . .

Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control. Possession trance involves replacement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person and associated with stereotyped involuntary movements or amnesia, and is perhaps the most common dissociative disorder in Asia. Examples include amok (Indonesia), bebainan (Indonesia), latah (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice. 

Note the culture-specific aspect of the disorder, which shows substantial heterogeneity in its expression. Dr. Romeo Vitelli at the blog Providentia has written about some of these phenomena. For instance, Amok is an aggressive trance-like state in Malay culture, whereas Pibloktoq is an acute dissociative reaction in the Inuit tradition, caused by evil spirits possessing the living. In two previous posts here at The Neurocritic, we also learned about cen in Uganda, ghosts that replace the identity of the afflicted individual. 


Dissociative Disorders in DSM-5

Will there be changes for Dissociative Trance Disorder (DTD) in DSM-5? The new (and already reviled) psychiatric manual makes its debut in May 2013.²  A 2011 paper by Spiegel et al. described some of the proposed changes to the dissociative disorders. The Pathological Possession Trance (PPT) component of DTD is claimed to be be similar to dissociative identity disorder (DID, or the diagnosis formerly known as "multiple personality disorder"):

It is a disorder of identity alteration that occurs during an altered state of consciousness. Of course, unlike DID, the alternate identity or identities in PPT are attributed to possession (by an external spirit, power, deity, or other person) rather than to internal personality states. Associated symptoms of PPT include stereotyped or culturally determined behaviors or movements that are experienced as being controlled by the possessing agent and/or full or partial amnesia for the event.

So pathological possession trance would be included under DID, while dissociative trance without possession would remain under dissociative disorders NOS. Or...

Alternatively, DSM-5 could (a) retain all of DTD in DDNOS (and an appendix), or (b) incorporate DTD (or only PPT) as a new disorder.

“Possession” is a broader construct than PPT because it may be used as a nonspecific attribution for explaining events (e.g. illness, misfortune) that go beyond pathological identity alteration. By contrast, in PPT we focus only on the subset of possession experiences–(1) an alteration of consciousness wherein the person experiences his/her the identity as being replaced by an ancestor, spirit, or other entity (i.e. possession trance), and (2) these alterations are involuntary, distressing, uncontrollable, often chronic, and involve conflict between the individual and his/her surrounding social or work milieu (i.e. the possession trance is a pathological one).

Ultimately, the recommendation was to include PPT under the DID umbrella. The phrase “an experience of possession” would be added to Criterion A of DID.

Kibuuka Kigaanira (R) with a priestly assistant.

Photo Courtesy of Euginia Bonabana, from The Sunday Monitor [Uganda]
 

Alternate activism: From Kibuuka Kigaanira in the mid-19th century to Kalondoozi in the present, possession practices provide important political space for citizens to negotiate power and authority, while appointed leaders are held to account.

-from Spirit possession and power play since pre-colonial times

Pathological Possession Trance: Perspectives from Uganda

Previously, I wrote about Spirit Possession as a Trauma-Related Disorder in Uganda and quoted from a personal narrative of spirit possession from Christine, a former child soldier. How well will the new DSM-5 criteria fit cen phenomena in Northern Uganda? The diagnosis for possession trance would now be DID. However, a recent paper by van Duijl et al. (2012) suggests this might be a nosological disaster for the classification of spirit possession in Uganda.

In their study, the authors collected narratives from 119 spirit possessed individuals. They also developed a checklist for locally relevant dissociative and possession symptoms.

The CDS-Ug is a locally designed checklist based on information obtained in focus group discussions with traditional healers, religious leaders, health professionals, and people of the community. It covers common and typical symptoms of dissociation and spirit possession, including:

1. Okukangarana: described as being shocked by a situation in such a way that later on one cannot remember the situation (amnesia)
2. Okurogwa: described as talking in a different voice, which others recognize as the voice of an (ancestral) spirit (possession trance)
3. Eibugane: feeling influenced by unidentified forces causing behavior different from one’s usual behavior
4. Okukyekyera: traveling outside one’s home without remembering (fugues or ‘night dances’)
5. Okusharara: feeling as if something from outside holds one’s body or mind so that one cannot move, think, or speak, which is attributed to an outer force (feeling paralyzed)
6. Okugwa: shaking of the head or body, seen as an expression of spirits (involuntary repetitive movements)
7. Okugamba endimi: speaking in tongues (glossolalia)
8. Okwehindura: making sounds and movements as if one has become an animal, for example, a cock, monkey, or goat, without remembering this behavior afterward (possession by animal)

Spirit possessed patients were asked whether and how these eight features applied to themselves.

The data were analyzed to examine possible clusters of symptoms, merged with a checklist developed from the personal narratives, and then compared to the old DSM-IV DTD criteria and the new DSM-5 DID criteria.

Two distinctive clusters emerged.³ One cluster included shaking, stereotyped movements, and speaking in voices of spirits ("active symptoms"). The second cluster included amnesia, fugues, and feeling paralyzed ("passive symptoms"). The passive symptoms were a better fit with DID, but the active symptoms were more like DTD. Furthermore, many symptoms fell outside either diagnosis:

...experiences such as hearing voices (e.g., of spirits or deceased), strange dreams, feeling influenced or held by powers from outside, feeling paralyzed, or moving around in fugue-like states are not explicitly covered by the experimental DSM-IV research criteria nor by proposed criteria for DID in DSM-5.

Overall, the authors felt the DSM-IV experimental criteria for dissociative trance and possession trance disorders encompassed the experience of spirit possession to a greater extent than the DSM-5 DID criteria. They do not think possession trance disorder should be subsumed under dissociative identity disorder, nor do they think dissociative trance and possession trance should be separate categories, as they occurred on a continuum in this Ugandan population. Instead, a more culturally-inclusive mindset might have prevented some of the DSM-5 changes from moving forward.

Although the presentation of DID and PTD considerably overlaps and both are covered by the criteria outlined in Table 3, we are not in full support of this approach. Ranking PTD (described in over 360 societies) under DID (described in considerably fewer societies) expresses a Western ethnocentric approach. Ranking characteristic symptoms of PTD such as stereotyped uncontrolled movements as ‘non-epileptic seizures or other sensory-motor (functional neurological) symptoms’ in DSM-5 also heavily imposes a medical descriptive framework and disregards emic attributions. In addition to this, DID is strongly associated with early childhood sexual abuse and neglect, whereas stressors associated with PTD are more broadly framed and require a culturally sensitive approach.

In DSM-5, Possession Trance Disorder no longer exists.


ADDENDUM (Jan 20, 2013): I should have posed this question directly: Does it make any sense to use DSM-5 (or DSM-IV) criteria to diagnose spirit possession across cultures?


Footnotes

¹ Besides being backwards and barbaric, exorcisms can be deadly, as this case of Fatal Hypernatraemia from Excessive Salt Ingestion During Exorcism shows. Ingestion of salt or salt water is part of the ritual.

² If you want to know why it's already reviled, start here and follow links. Or Google DSM-5 controversy. I don't feel a need to offer my opinion at the present time.

³ These two clusters could account for ~46 % of the variance.


References

Duijl, M., Kleijn, W., & Jong, J. (2012). Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda. Social Psychiatry and Psychiatric Epidemiology DOI: 10.1007/s00127-012-0635-1

Spiegel, D., Loewenstein, R., Lewis-Fernández, R., Sar, V., Simeon, D., Vermetten, E., Cardeña, E., & Dell, P. (2011). Dissociative disorders in DSM-5. Depression and Anxiety, 28 (9), 824-852 DOI: 10.1002/da.20874

Tajima-Pozo, K., Zambrano-Enriquez, D., de Anta, L., Moron, M., Carrasco, J., Lopez-Ibor, J., & Diaz-Marsa, M. (2011). Practicing exorcism in schizophrenia Case Reports, 2011 (feb15 1) DOI: 10.1136/bcr.10.2009.2350

Fisher-Price Synesthesia

Synesthesia is a rare perceptual phenomenon in which the stimulation of one sensory modality, or exposure to one type of stimulus, leads to a sensory (or cognitive) experience in a different, non-stimulated modality. For instance, some synesthetes have colored hearing while others might taste shapes.

GRAPHEME-COLOR SYNESTHESIA is the condition in which individual printed letters are perceived in a specific, constant color. This occurs involuntarily and in the absence of colored font. It is the most common and widely-studied of all types of synesthesia (Mattingley, 2009). Many studies have suggested that the phenomenon is not due to associative learning, i.e. exposure to colored letters or blocks as a child (Rich et al., 2005). One neurological explanation is that it's due to greater white matter connectivity between the inferior temporal lobe regions that process letters and colors (Rouw & Scholte, 2007). ¹


Learned Synesthesia

However, a new study has identified 11 synesthetes whose grapheme-color mappings appear to be based on the Fisher Price plastic letter set made between 1972-1990 (Witthoft & Winawer, 2013). ² Letter-color mapping data were obtained from the participants using either The Synesthesia Battery Web site (synesthete.org) or in-house software. This required that the subjects use a color picker to identify the hue of 26 upper case letters and 10 numerals three times each (presented in random order). They did this in two separate sessions, and then the consistency within and across sessions was evaluated. The participants also completed a speeded Stroop-like task, where they had to identify whether the color font was congruent (A) or incongruent (A) relative to their synesthetic mapping.

Lo and behold, the resultant mappings were "startlingly similar" to the colors used in the Fisher Price toys from their childhoods! And 10 of the 11 participants reported owning the colorful plastic magnetic letters. In the figure below, the subjects are arranged left to right according to the number of matches with the Fisher Price set. S11 showed the fewest matches (n=14), yet the probability of obtaining 14 or more matches in 26 chances was estimated to be less than 1 in 1 billion...

Fig. 2 (modified from Witthoft & Winawer, 2013). Letter-color matching data from the 11 subjects. The diagram shows the color selected for each letter, averaged across three trials for each subject. The left-most column indicates the colors of the Fisher-Price refrigerator magnets used by all but 1 of the subjects as children.


Thus, the results provided clear evidence of a learned contribution to color-grapheme synesthesia, at least in this group of participants. But they don't negate a more purely perceptual version of the phenomenon in other synesthetes. The two synesthesiae can peacefully coexist:

Whereas some researchers have focused on genetic and perceptual aspects of synesthesia, our results indicate that a complete explanation of synesthesia must also incorporate a central role for learning and memory. We argue that these two positions can be reconciled by thinking of synesthesia as the automatic retrieval of highly specific mnemonic associations, in which perceptual contents are brought to mind in a manner akin to mental imagery or the perceptual-reinstatement effects found in memory studies.

Nonetheless, for some color-grapheme synesthetes, it's always a Red Letter A...


Footnotes

¹ However, a newer study says it's more complicated than that (Hupé et al., 2012). These authors found that synesthetic letter experience did not activate color area V4, and that grapheme-color synesthetes did not show greater connectivity in the inferior temporal cortex:

At the end, careful reading of the relevant literature casts some doubt on the textbook story that synesthetes activate “color area V4” when viewing achromatic graphemes (but experiencing color) and on structural brain differences reported between synesthetes versus nonsynesthetes.

²  Interestingly, Witthoft and Winawer cited a 19th century study that proposed the same thing (Calkins, 1893).


References

Mattingley JB. (2009). Attention, automaticity, and awareness in synesthesia. Ann NY Acad Sci. 1156:141-67.

Rich AN, Bradshaw JL, Mattingley JB. (2005). A systematic, large-scale study of synaesthesia: Implications for the role of early experience in lexical-colour associations. Cognition 98:53-84.

Rouw R, Scholte HS (2007). Increased structural connectivity in grapheme-color synesthesia. Nature Neuroscience 10:792-797.

Witthoft, N., & Winawer, J. (2013). Learning, Memory, and Synesthesia Psychological Science DOI: 10.1177/0956797612452573

It's a Red Letter A...

Letters A-Z, plus extra letters E, I, L, N, O, P, R, S, and T:

• FPT971 - Red letter "A".
• FPT972 - Orange letter "B".
• FPT973 - Yellow letter "C".
• FPT974 - Green letter "D".
• FPT975 - 2 each - Blue letter "E".
• FPT976 - Purple letter "F".
• etc. ... 

"The spirit came for me when I went to fetch firewood" - Personal Narrative of Spirit Possession in Uganda

"I was lost in the wilderness, and I could smell something strange. I was near a main road and someone asked me what I was waiting for. I said I was lost. I saw smoke around me, and I was told my eyes were swollen. All of a sudden, something started moving all over my body."

-Christine, a former child soldier in Uganda





DWOG PACO

This video was made as part of an extraordinary multimedia project that chronicles the lives of 40 women in northern Uganda. It recounts the harrowing experiences of these former child soldiers and portrays the current difficulties of reintegrating into society. The piece focuses on five women who had been abducted by the Lord’s Resistance Army (LRA) as children. Each of these five were given a digital camera, so each woman became a more active participant in the telling of her story - a participatory anthropographia of sorts.

My previous post discussed Spirit Possession as a Trauma-Related Disorder in Uganda. In the process of doing a follow-up on how cen phenomena might be classified in the forthcoming DSM-5, I came upon the video above and the larger DWOG PACO project of Marc Ellison, a photojournalist from Vancouver, Canada. This work deserved to be highlighted separately, so the evolution of Dissociative Disorder Not Otherwise Specified and Dissociative Trance Disorder (possession trance) will be discussed in the next post.

The Acholi phrase dwog paco (“come back home”) is used as a derogatory and stigmatizing label, which hinders recovery and reintegration into the community. Post-traumatic stress disorder, spirit possession, and other mental health issues faced by the Ugandan women are discussed at length as part of the multimedia project:

The Acholi tribe, which inhabits much of the worst affected regions of northern Uganda, believe in the existence of jogi – spirits or forces that can be either good or evil (Mpyangu, 2010). Usually in conflict and post-conflict zones inhabitants complain of hunger, mortality, disease, poverty, homelessness. However, the Acholi are more concerned about the vengeful spirits of those killed during the conflict. They are believed to have a pernicious influence if not appeased. The cen, or polluting spiritual force, possesses those who have killed, done wrong, witnessed a killing, or touched the body of a corpse, by entering that person’s mind or body resulting in dissociative states, nightmares, flashbacks or psychosis that remain until the wrongdoing is put right (Mpyangu, 2010). The Acholi also believe that cen is contagious and can infect an entire family or community (SWAY, 2008). Consequently anyone thought to be haunted by cen is shunned and avoided by the community.

The project is moving and unforgettable. Learn more about Alice, Christine, Janet, Jennifer and Mary. You can also view the galleries of Janet's, Christine's, Jennifer's and Alice's photography.

Spirit Possession as a Trauma-Related Disorder in Uganda

The Lord's Resistance Army (LRA) has waged a long and brutal campaign to overthrow the government of Uganda. Rape and torture are commonly used tactics. Children are kidnapped and forced to serve as soldiers — children and youth comprise almost 90% of the LRA, according to the UN. These child soldiers experience incredibly high rates of trauma exposure, post-traumatic stress, and depression.

A recent study examined the culturally-specific psychological syndrome of spirit possession in this population (Neuner et al., 2012). Although spirit possession is common in many cultures, the phenomenon investigated here is a local variant called cen, where "the ghost of a deceased person visits the affected and replaces his or her identity." It is particularly prevalent in former child soldiers who have killed others. Although some forms of spirit possession are considered relatively benign in Northern Uganda, cen is seen as harmful.

It is important here to consider the complex role of religion and magical belief in motivating and sustaining the LRA (Jackson, 2010), along with socioeconomic and political grievances. The Acholi ethnic group has been depicted as marginalized victims of the Ugandan government by the LRA leader, Joseph Kony. Religion is used as a further means of control (Jackson, 2010):

The quasi-religious aspects of Kony’s internal cosmology take this sense of victimhood and expand it, through a magpie-like propensity to adopt elements from other belief systems into which he has come into contact. The result is a hotch-potch of beliefs that are used to reinforce the idea that the Acholi are victims and Kony the mystic who can stop protect them. Violence, in this world-view, is conveniently seen as a means of ‘cleansing’ – an evil that is necessary to purify the Acholi so that they can be saved...

Furthermore, the Neuner et al., (2012) paper notes that Kony...

...justified his claim to power by spirit possession and said to have supernatural abilities.¹ It is reasonable to assume that this propaganda, which drew on widespread local beliefs, has been a fertile ground for the development of harmful forms of spirit possession in the local population, in particular former child soldiers.

With this background in mind, the authors conducted a survey of 1,113 individuals between the ages of 12 and 25 yrs to determine the rates of spirit possession, trauma exposure, and psychological distress. The actual interviewers were members of vivo, an organization that provides psychosocial support to children in Northern Uganda. During a pilot study, the five-item Cen Spirit Possession Scale was developed (shown below).

-- click on image for a larger view --

Notably, a high level of spirit possession (four or more characteristics) was observed in 14.3% of those who were abducted, but only 3.7% of the participants who were not abducted. Girls were more likely to experience cen than boys. In addition, spirit possession was associated with extreme poverty, greater trauma exposure, sexual trauma, and being forced to kill. Most of the youths were treated via traditional means:

Among those who had ever sought help for spirit possession, 15.2% had carried out the nyono tonggweno ritual (stepping on the egg in a cleansing ceremony), 7.9% mato oput (reconciliation ritual after killing), 7.9% lwoko pik wang (washing away the tears), 31.5% other traditional interventions, mainly taking traditional herbs, and 70.2% sought help at a church or from a priest.

Cen led to worse outcomes compared to those without spirit possession, including higher suicide risk, lower functioning, greater perceived discrimination, and higher incidence of PTSD (44.5% vs. 9.8%).² The authors conclude:

Although cen was not limited to former child soldiers, they reported higher rates of spirit possession, which may be related to the fact that they were more intensely exposed to the LRA belief system.

At the same time it has to be emphasized that spirit possession is usually not perceived as psychopathology within the local culture. Although our data is consistent with the association of cen with impaired mental health, a reduction of this phenomenon to mere psychopathology is inappropriate. The clinical perspective taken in this survey must be complemented by sociological, historical and anthropological studies investigating the cultural and social interpretation of this phenomenon.

Given the cultural specificity of cen, it might be interesting to consider how Western psychiatry views cases of spirit possession.³ In DSM-IV, this syndrome would be classified as Dissociative Disorder Not Otherwise Specified, with more specific research criteria (but not official diagnosis) fitting Dissociative Trance Disorder (possession trance). Has this changed in DSM-5? We'll take a look in the next post.


Footnotes

¹ The New York Times has a fascinating document that details Kony's religious beliefs. He was "possessed" by quite a large number of spirits...

² See also Remembering and Forgetting in Traumatized Ugandan Refugees.

³ The film industry presents its own flamboyantly supernatural depiction of demon possession for entertainment, as we all know.


References

Jackson P (2010). Politics, Religion and the Lord’s Resistance Army in Northern Uganda. Religions and Development, Working Paper 43. University of Birmingham.

Neuner, F., Pfeiffer, A., Schauer-Kaiser, E., Odenwald, M., Elbert, T., & Ertl, V. (2012). Haunted by ghosts: Prevalence, predictors and outcomes of spirit possession experiences among former child soldiers and war-affected civilians in Northern Uganda. Social Science & Medicine, 75 (3), 548-554 DOI: 10.1016/j.socscimed.2012.03.028


Grace, Milly, Lucy… Child Soldiers (trailer)