Long COVID, Trauma and ‘Possession’ Reports: Emerging Clinical Patterns & Protocols

Introduction: Why clinicians and pastoral teams are seeing more 'possession' reports

Since the first waves of SARS‑CoV‑2 infection, large numbers of people have developed persistent, multi‑system symptoms now commonly grouped under “long COVID” or post‑COVID‑19 condition. The World Health Organization’s working definition emphasizes new or continuing symptoms 3 months after acute infection that last at least 2 months and cannot be otherwise explained; common features include fatigue, cognitive dysfunction and sleep disturbance.

Recent clinical reviews and cohort data document substantial neuropsychiatric and sleep‑related sequelae after COVID‑19—including cognitive slowing, anxiety/depression, sleep disruption and new onset dissociative or perceptual phenomena—that can be distressing and culturally interpreted as spirit possession in some communities.

Concurrently, faith leaders and some diocesan reports have described an increase in requests for deliverance and exorcism since lockdowns and the pandemic’s social disruption—an observation that appears to reflect increased distress, greater visibility of unusual episodes (viral videos), and renewed help‑seeking from religious sources rather than proof of changing metaphysical incidence. Clinicians should therefore be prepared to assess presentations framed as “possession” with both cultural sensitivity and rigorous medical/psychiatric differential diagnosis.

Emerging clinical patterns: neuropsychiatric, sleep and dissociative presentations

Key presentations clinicians are encountering include:

• Cognitive and affective symptoms: persistent brain fog, memory problems, mood lability and anxiety/depression after SARS‑CoV‑2 infection. These symptoms are commonly reported in long COVID cohorts.
• Disruptive sleep phenomena: insomnia, fragmented sleep, and sleep‑paralysis‑type episodes with vivid hypnagogic/hypnopompic hallucinations (the so‑called “incubus” or entity experiences) are well documented and can be terrifying to patients. Systematic reviews place sleep‑paralysis phenomena and associated hallucinations as fairly prevalent in vulnerable groups.
• Dissociation and possession‑framed experiences: in many cultural contexts, dissociative episodes, alterations in identity/agency, and involuntary trance states are labeled as spirit possession. Research from diverse settings links traumatic exposure, PTSD, and other stressors with higher rates of pathological possession states or possession idioms of distress. Clinically these may co‑occur with PTSD, complex PTSD, or dissociative disorders.
• Overlap with psychiatric disorders: some cases meet criteria for psychotic disorders, functional neurological (motor) disorders, or substance‑related presentations; others reflect primarily sleep or trauma physiology. A careful history is required to avoid misdiagnosis.

Practical note: the form the experience takes (voices, entity encounters, loss of control, ritualized behaviors) is strongly influenced by cultural context and explanatory models. That context matters for both risk assessment and engagement.

An evidence‑based assessment protocol: stepwise differential diagnosis and documentation

The following structured approach is recommended when a patient presents with complaints described by them or their family as “possession.” This protocol is intended for mental‑health clinicians, primary care physicians, sleep specialists, and pastoral care teams working collaboratively.

1. Immediate safety and medical exclusion
   • Assess risk of harm to self/others, altered consciousness, inability to maintain nutrition or hydration, or signs of medical emergency—act immediately if present.
   • Basic medical workup (CBC, electrolytes, glucose, toxicology as indicated, and targeted tests based on exam) to exclude delirium, metabolic causes or substance intoxication/withdrawal.
2. Screen for long COVID and common contributors
   • Confirm history of prior SARS‑CoV‑2 infection and timing of symptom onset relative to infection (use WHO definition of post COVID‑19 condition as a guide).
   • Screen for fatigue, orthostatic symptoms, autonomic dysfunction, and cognitive impairment (brief cognitive screens or refer for neuropsychology if needed).
3. Psychiatric and sleep evaluation
   • Use validated brief measures: PHQ‑9 for depression, GAD‑7 for anxiety, PCL‑5 for PTSD symptoms, and a dissociation screen such as DES‑II or the Trauma‑Related Dissociation Screen when relevant. Consider the Pittsburgh Sleep Quality Index (PSQI) and targeted questions about sleep paralysis, vivid dreams, and REM intrusion phenomena.
   • Obtain a focused substance use history and consider urine/serum toxicology when indicated.
4. Neurology and sleep medicine referral
   • For recurrent entity‑type episodes, confirm whether events occur at sleep–wake transitions (suggesting sleep‑paralysis/REM intrusion) and consider polysomnography or actigraphy if nocturnal events are frequent or injurious.
   • Neurology consult for new focal deficits, seizures or atypical movement phenomena; EEG if paroxysmal or unresponsiveness is observed.
5. Cultural formulation and engagement with faith leaders
   • Perform a Cultural Formulation Interview (CFI) or equivalent to understand the patient’s explanatory model, social supports, and expectations for care. Document the patient’s own language about “possession.”
   • With patient consent, coordinate with trusted clergy or spiritual advisors—set boundaries (no invasive rituals while medical evaluation is pending), agree on safeguarding, and arrange joint care plans when appropriate.
6. When to consider psychiatric diagnoses or specialist interventions
   • Evidence of persistent hallucinations outside sleep transitions, clear thought disorder, sustained functional deterioration, or high suicide risk warrants urgent psychiatric evaluation for possible psychosis or severe mood disorder.
   • Trauma‑focused psychotherapy (TF‑CBT, EMDR) is indicated when PTSD or complex trauma patterns are identified; dissociative disorders require specialist trauma‑informed care.

Clinical documentation should include a clear timeline (onset relative to infection), eyewitness descriptions, sleep timing, triggers, cultural/faith framing, and capacity/consent for any collaborative ritual interventions.

Conclusions, risk management and research priorities

Practical takeaways:

• Do not assume supernatural causation; pursue rapid medical and psychiatric triage to exclude treatable causes (delirium, intoxication, seizure, severe mood or psychotic illness) before any solitary ritual intervention.
• Screen routinely for long COVID features, sleep‑related REM intrusion phenomena, and trauma histories because these are plausible, evidence‑based explanations that respond to targeted interventions (sleep hygiene and treatment, trauma therapy, neurorehabilitation).
• Collaborative care models—primary care, neurology/sleep medicine, psychiatry, and pastoral teams—reduce risk, speed diagnosis, and preserve cultural dignity while ensuring safety and access to evidence‑based treatments.

At a systems level, guidelines for evaluating long COVID already emphasize multi‑disciplinary assessment and rehabilitation services; clinicians assessing possession‑framed distress should link to local long COVID or post‑infectious clinics where available. Continued research is needed to quantify how frequently long COVID and pandemic‑related trauma are being interpreted as possession across different communities, and to test interventions that integrate culturally competent pastoral care with trauma‑informed medical treatment. Recent large reviews and guideline initiatives underscore both the scale of long COVID’s neuropsychiatric burden and the current gaps in objective biomarkers—so careful history, standardized screening and multidisciplinary pathways are the best available approach today.

For clinicians and pastoral teams: adopt a shared triage checklist, document informed consent for any joint interventions, and prioritize patient safety and access to empirically supported treatments while respecting cultural meaning‑making.