title: Global mental health and trauma exposure: the current evidence for the relationship between traumatic experiences and spirit possession.
abstract: BACKGROUND
  We present a literature review on trauma exposure and spirit possession in low- and middle-income countries (LMICs). Despite the World Health Organization's objective of culturally appropriate mental health care in the Mental Health Action Plan 2013-2020, and the recommendations of the Inter-Agency Standing Committee to consider local idioms of distress and to collaborate with local resources, this topic still receives very little attention. Pathological spirit possession is commonly defined as involuntary, uncontrollable, and occurring outside of ritual settings. It is often associated with stigmatization, suffering, and dysfunctional behavior. While spirit possession has been discussed as an idiom of distress in anthropological literature, recent quantitative studies have presented support for a strong relationship between traumatic experiences and pathological possession states.
  
  
  OBJECTIVE
  The aim of this review was to investigate this relationship systematically in LMICs, in view of the debate on how to address the mental health gap in LMICs.
  
  
  METHODS
  Twenty-one articles, published in peer-reviewed English-language journals between 1994 and 2013, were identified and analyzed with regard to prevalence of possessive trance disorders, patients' sociodemographic characteristics, and its relation to traumatic experiences.
  
  
  RESULTS
  The review and analysis of 917 patients with symptoms of possessive trance disorders from 14 LMICs indicated that it is a phenomenon occurring worldwide and with global relevance. This literature review suggests a strong relationship between trauma exposure and spirit possession with high prevalence rates found especially in postwar areas in African countries.
  
  
  CONCLUSIONS
  More attention for possessive trance disorders in mental health and psychosocial intervention programs in humanitarian emergency settings as well as in societies in transition in LMICs is needed and justified by the results of this systematic literature review.
authors.affiliation: Department of Psychology, University of Zurich, Zurich, Switzerland.|Department of Psychology, University of Konstanz, Konstanz, Germany.|vivo international, Konstanz, Germany; t.hecker@psychologie.uzh.ch.
authors.forename: Tobias
authors.initials: T
authors.lastname: Hecker
authors.affiliation: Department of Psychology, University of Konstanz, Konstanz, Germany.
authors.forename: Lars
authors.initials: L
authors.lastname: Braitmayer
authors.affiliation: Amulet Consultancy for Cultural Psychiatry and Global Mental Health, Leiden, The Netherlands.
authors.forename: Marjolein
authors.initials: M
authors.lastname: van Duijl
keywords: PTSD; dissociative disorders; mental health gap; possessive trance disorder; spirit possession; trauma exposure; trauma-related disorders