CASE STUDY
HOWARD'S EXPERIENCE AS A PSYCHOTIC DISORDER
HOWARD'S EXPERIENCE AS A SPIRITUAL
EMERGENCY
CASE STUDY
To illustrate the use of the spiritual
emergency diagnostic criteria, they are applied below to a case study
of a person who was hospitalized for a psychotic episode, but whose experience
was a positively-transforming spiritual emergency. This approach is contrasted
with the medical model diagnosis of the same experience as a psychotic
disorder.
HOWARD'S EXPERIENCE
AS A PSYCHOTIC DISORDER
The presence of either delusions or hallucinations without
insight into their pathological nature is the basis for a diagnosis
of a psychotic disorder in the Diagnostic
and Statistical Manual-IV. What types of psychotic
symptoms would be considered present in Howard's Mental Odyssey?
To answer this question, the author administered a one-hour
retrospective mental status exam to Howard. This type of interview
is designed to elicit and identify specific types of hallucinations
and delusions. The following is a presentation of Howard's
Mental Odyssey as psychotic symptoms.
A delusion is defined as,
a false personal belief based on incorrect inference about
external reality and firmly sustained despite of what everyone
else believes and despite what constitutes incontrovertible
and obvious proof or evidence to the contrary (DSM-IV,
p. 765).
During his Mental Odyssey, Howard made incorrect inferences
about external reality, e.g., he thought that death rays were
being projected at him by another patient. He did not accurately
discriminate between his inner subjective experiences and objective
dimensions of the world. He sustained these beliefs despite
the insistence of everyone else that he was wrong. Howard was
preoccupied with his mythic inner reality, and in projecting
these beliefs onto outer reality, he would be considered delusional.
  
Based on the results of the mental status examination, Howard
had the following delusions: Thought Insertion, Reference,
Grandiose Abilities, Religious, Paranormal.
A hallucination is defined as,
A sensory perception that has the compelling sense of reality
of a true perception but that occurs without external stimulation
of the relevant sensory organ (DSM-IV, p. 767).
Some of Howard's experiences fit this definition. Based on
the mental status exam, had both visual and tactile hallucinations.
In addition to the above psychotic symptoms, Howard also showed
elevated mood for several weeks as well as five symptoms listed
in DSM-IV as characteristic of a manic episode: decreased
need for sleep, pressured speech, flight of ideas, inflated
self-esteem, distractibility
Because of the mixture of both psychotic and affective symptoms,
Howard's case presents a diagnostic dilemma. At the time of
his hospitalization, Howard's psychotic symptoms led to his
being assigned the DSM-I (APA, 1952) diagnosis of Acute
Schizophrenic Reaction. However, since the DSM-II (APA,
1968) was in effect at the time, his proper DSM diagnosis should
have been Acute Schizophrenic Episode, 295.4. However, he was
diagnosed, medicated, and hospitalized as a schizophrenic patient.
How would Howard be diagnosed within the DSM-IV?
Howard would meet the symptom criteria for both Schizophreniform Disorder
(schizophrenia of less than 6 months duration) and Bipolar Disorder,
Manic Type. Brief Psychotic Disorder would be ruled out since the symptoms
persisted for over 2 weeks.) In cases where criteria for both a Schizophreniform
and an Mood Disorder are met, the differential diagnosis hinges on
whether there is preoccupation with mood-incongruent hallucinations
or delusions or bizarre behavior either before or after the manic symptoms.
Persisting or predating mood-incongruent features would indicate a
Schizophreniform Disorder whereas their absence would result in a diagnosis
of Bipolar Disorder.
In Howard's case, there were transient mood-incongruent features,
i.e., psychotic symptoms not related to his elevated mood,
such as the delusion of death rays being projected at him and
seeing the face of Death. However, they did not persist outside
the period of his elevated mood. Thus, he more closely meets
the criteria for DSM-IV Bipolar Disorder, Manic with
Mood-incongruent Psychotic Features (296.04).
HOWARD'S
EXPERIENCE AS A SPIRITUAL EMERGENCY
Both the mental status exam I administered and 15 interviews
with him are used to examine Howard's experience in terms of
the diagnostic criteria for spiritual emergency.
I. Overlap with the mystical experience
A. Ecstatic mood. After first reporting that his experience was "beyond
words," Howard later went on to describe his mood with words including "ecstasy" and "rapture." Despite
finding no support or acknowledgment of his situation, this mood persisted
for several weeks of his hospitalization.
B. Sense of newly-gained knowledge. Howard believed
that he had unlocked some elemental truths of universal importance.
He felt his insights were of such importance that the scientific
community should study and document what he was discovering.
C. Perceptual alterations. While in his hospital room,
Howard had visual hallucinations of yellow birds against a
brilliant orange sky. He also saw the face of Death in a tree
stump.
D. Delusions with mythological-related themes.
- Death: Howard saw the face of Death and agreed that he
would
kill people if necessary to fulfill his mission.
- Rebirth: Howard felt he had been reborn into a new identity
as
the albatross.
- Journey: Howard thought he had the mission to show others
the way into the Mental Odyssey experience and that he was
being prepared for Enlightenment.
- Encounters with spirits: Howard communicated with his
muse
and the Devil interfered with his trip up the mountain.
- Magical powers: Howard believed he had acquired special
powers such as mastery over time and space and the ability to
summon elevators at will.
- New society: Howard thought he was the Pied Piper heralding
in a new society.
E. No conceptual disorganization. Although Howard's
metaphorical use of language was difficult for others to understand
at times, he never showed incoherence or thought-blocking.
His ideas were always expressed lucidly.
These examples show that Howard met all 5 of the criteria
which indicate overlap with the mystical experience.
II. Positive outcome likely
Good pre-episode functioning was evidenced by Howard's lack of any previous
psychotic episodes, his completion of high school and his network of
male friends. He also met the criteria for acute onset of symptoms since
they developed during a span of a few days. A positive attitude toward
the experience was maintained by Howard throughout his hospitalization.
While there was no obvious external stressor, he was at an
age (19) when many persons experience an adolescent identity
crisis. But the three criteria he clearly did meet would satisfy
the criterion of at least two good prognostic signs.
III. Low risk
When challenged by his brother's question, "Would you kill people
to achieve your mission?" Howard responded that he would. This type
of threatening statement needs to be checked out by a clinician who is
familiar both with signs of homicidal dangerousness in patients and also
with death/rebirth themes characteristic of spiritual emergencies. In
Howard's case, further probing revealed the metaphorical basis of his
preoccupation with death themes rather than a danger that he'd commit
actual homicide. He was clearly not a suicide risk, so the Low Risk criterion
would also have been met.
Thus Howard represents a clear case of spiritual
emergency, someone who could have been treated without hospitalization
or medication. His crisis would have resolved with therapy
directed toward maximizing the growth potential of his process.
(See Lesson 6.1 Spiritual Crises)
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