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DSM-IV Religious and Spiritual Problems

LESSON 5.1 Differential Diagnosis

Differential Diagnosis of Intense Spiritual Crisis & Psychotic DisordersDiagnostic Criteria for Spiritual Emergency Differential Diagnosis of Intense Religious Experiences & Psychotic Disorders Case Example

Differential Diagnosis of Spiritual Crisis & Psychotic Disorders
The DSM-IV highlights the need for cultural sensitivity when clinicians assess for schizophrenia in socioeconomic or cultural situations different from their own:

Ideas that may appear to be delusional in one culture (e.g., sorcery and witchcraft) may be commonly held in another. In some cultures, visual or auditory hallucinations with a religious content may be a normal part of religious experience (e.g., seeing the Virgin Mary or hearing God's voice). (p. 281)

Criteria for making the differential diagnosis between psychopathology and authentic spiritual experiences have been proposed by Agosin [1], Grof and Grof [2] and Lukoff [3]. There is considerable overlap among the proposed criteria. Ken Wilber argues that confusion in distinguishing intense spiritual experiences from psychosis has been created by failing to make the critical distinction between pre-rational states and authentic transpersonal states. This "pre/trans fallacy" has been perpetuated:

    Since both prepersonal and transpersonal are, in their own ways, nonpersonal, then prepersonal and transpersonal tend to appear similar, even identical, to the untutored eye. (Wilber, p. 125 [4])

The diagnostic criteria listed below were originally published in the Journal of Transpersonal Psychology in 1985, in an article entitled Diagnosis of Mystical Experience with Psychotic Features. The use of operational criteria is intended to identify cases of spiritual emergency with a high degree of accuracy (validity) and consistency across different diagnosticians (reliability). The specific criteria proposed below represent hypotheses that must be subjected to studies to determine whether they achieve acceptable levels of interrater agreement and whether they accurately identify positively transforming experiences.

Diagnostic Criteria for Spiritual Emergency

  1. Phenomenological overlap with one of the types of spiritual emergency
  2. Prognostic signs are indicative of a positive outcome
  3. The person is not a significant risk for homicidal or suicidal behavior

1. Phenomenological overlap with one of the types of spiritual emergency
Criterion 1 is based on the clinician's ability to recognize phenomenological characteristics of the types of spiritual emergency. I have proposed five criteria by which phenomenological overlap with a mystical experience can be identified. Assessment of overlap for other types can be based on the phenomenology as described in Lesson 3 Types of Spiritual Problems on. The critiera below are presented as an example for Mystical Experience problems.

a) ecstatic mood
The most consistent feature of the mystical experience is elevation of mood. Laski (1968) describes it as a state with "feelings of a new life, another world, joy, salvation, perfection, satisfaction, glory" (cited in Perry [5] p. 84). Bucke [6] examined the experiences of well-known mystics, leaders, and artists, as well as his own mystical experience, and noted they all shared "a sense of exultation, of immense joyousness (p. 9). James [7] also points to the "mystical feeling of enlargement, union and emancipation" (p. 334), and claims that "mystical states are more like states of feeling than like states of intellect" (p. 300).

b) sense of newly-gained knowledge
Feelings of enhanced intellectual understanding and the belief that the mysteries of life have been revealed are commonly reported in mystical experiences (Leuba [8]). James [7] describes this phenomenon of newly-gained knowledge ("gnoesis") as states of insight into the depths of truth unplumbed by the discursive intellect. They are illuminations, revelations, full of significance and importance (p. 33). Jacob Boehme, a seventeenth-century shoemaker whose mystical experience ushered in a new vocation as a nature philosopher, reported: "In one-quarter of an hour, l saw and knew more than if I had been many years together at a university. For I saw and knew the being of all things" (cited in Perry [5] p. 92).

c) perceptual alterations
Mystical experiences often involve perceptual alterations ranging from heightened sensations to auditory and visual hallucinations. Boehme felt himself surrounded by light during his mystical experience. Visual and auditory hallucinations with religious content are also common, e.g., Saint Therese saw angels and Saint Paul heard the voice of Jesus Christ saying "Paul, Paul, why persecutest thou me?' (Acts: 3-4).

d) delusions with specific themes related to mythology
James [7] and Neuman [9] have both commented on the diversity of content in mystical experiences across time and cultures. The mystical experience does not have

specific intellectual content of its own. It is capable of forming matrimonial alliances with material furnished by the most diverse philosophies and theologies. (James [7] p. 333)

Electronic media have greatly increased the repertoire of cultural material available for incorporation into both mystical and psychotic experiences. Individuals who in the past might have claimed to be St. Luke, may now claim to be Luke Skywalker.

However, John Perry, MD, points out that below the surface level of specific identities and beliefs are thematic similarities in the accounts of patients whose psychotic episodes have good outcomes:

There appears to be one kind of episode which can be characterized by its content, by its imagery, enough to merit its recognition as a syndrome. In it there is a clustering of symbolic contents into a number of major themes strangely alike from one case to another (p.9).

Based on Perry's research and other accounts of patients with positive outcomes, the following eight themes were identified as occurring commonly in spiritual emergencies

1. Death: being dead, meeting the dead or meeting Death
2. Rebirth: new identity, new name, resurrection, apotheosis to god, king or messiah
3. Journey: Sense of being on a journey or mission
4. Encounters with Spirits: demonic forces and/or helping spirits
5. Cosmic conflict: good/evil, communists/Americans, light/dark, male/female
6. Magical powers: telepathy, clairvoyance, ability to read minds, move objects
7. New society: radical change in society, religion, New Age, utopia, world peace
8. Divine union: God as father, mother, child; Marriage to God, Christ, Virgin Mary, Radha or Krishna

In contrast, not all delusions have content related to the eight mythic themes described above. The following statements from schizophrenic patients with whom I have worked illustrate different themes.

My brain has been removed.
A transmitter has been implanted into my brain and broadcasts all my thoughts to others.
My parents drain my blood every night.
The Mafia is poisoning my food and trying to kill me.
My thoughts are being stolen and it interferes with my ability to think clearly.
The person claiming to be my wife is only impersonating her; she's not my wife.

Familiarity with the range and variation of content in myth, religion and psychosis is essential for determining which delusions have mythic themes.

e) absence of conceptual disorganization
Some psychotic patients have cognitive deficits which cause them difficulty with their basic thought processes. For example, a person with schizophrenia complained, "I get lost in the spaces between words in sentences. I can't concentrate, or I get off onto thinking about something else" (in Estroff [10] p. 223). Systematic comparisons of first person accounts of mystical experiences and schizophrenia have found that "Thought blocking and other disturbances in language and speech do not appear to accompany the mystical experience" (Buckley p. 521). Therefore, the presence of conceptual disorganization, as evidenced by disruption in thought, incoherence and blocking, would indicate the person is experiencing something other than a spiritual emergency.

2. Prognostic signs are indicative of a positive outcome
Criterion 2 is based on research-validated good prognostic indicators that help predict positive long term outcome. The features listed below are based on a survey of the outcome literature (Lukoff, 1986). Good prognostic indicators include:

1) good pre-episode functioning
2) acute onset of symptoms during a period of 3 months or less
3) stressful precipitant to the psychotic episode
4) a positive exploratory attitude toward the experience.

3. The person is not a significant risk for homicidal or suicidal behavior
Criterion 3 concerns issues which might require treatment in a restricted environment. Psychotic disorders can be the basis for homicidal and suicidal behaviors. Both John Lennon and President Reagan were shot by persons with previously diagnosed psychotic disorders. Arieti & Schreiber [11] have described the case of a multiple murderer whose auditory hallucinations from God and delusions of being on a religious mission fueled his bizarre and bloody killings.

Assessment of dangerousness and suicidality are legal responsibilities of licensed mental health professionals. This exclusionary criterion should be implemented only if the danger seems imminent. Behavior which appears bizarre, but presents no risk to self or others, does not warrant use of this criterion.

Even with the use of these criteria, it is often difficult to distinguish spiritual emergencies from episodes of mental disorder. Agosin (1991) has pointed out that, "Both are an attempt at renewal, transformation, and healing" (p. 52).

Zen Master Jakusho Kwong Roshi observed that powerful spiritual awakenings can have varied outcomes,
Anybody with a body and mind can experience realization. Often they don't tell anybody because they think it is strange. They either keep it quiet, go crazy, or their search leads them to a teacher who can explain their situation.

Differential Diagnosis of Intense Religious Experiences and Psychotic Symptoms
Based on their experience working with an ultra-orthodox Jewish sect in Israel, Greenberg and Witzum [12] have proposed the following criteria to distinguish between normative strictly religious beliefs and experiences from psychotic symptoms:

1. Psychotic experiences are very personal, e.g., may involve special messages from religious figures.
2. The details of psychotic experiences exceed accepted beliefs, e.g., they are more intense than normative religious experiences in their religious community.
3. The person in a psychotic episode may be terrified by the experience rather than excited by it.
4. The person in a psychotic episode is preoccupied by the experience and can think of little else.
5. The onset of the experience is associated with deterioration of social skills and personal hygiene.

These criteria should be viewed as guidelines and applied in a culturally and contextually sensitive manner. Some genuine intense religious experiences can be awesome and frightening, can preoccupy the individual for a period of time, and can lead to the performance of private rituals. In addition, Greenberg and Witzum (1991) point out that, "Differentiating religious beliefs and rituals from delusions and compulsions is difficult for therapists ignorant of the basic tenants of that religion (p. 563).

Case Example
The application of these diagnostic criteria is illustrated in the

Diagnostic Example

Hearing Voices

Hearing voices when no one is present is

a) a sign of a spiritual emergency b) a symptom of a mental disorder c) potentially a or b

Record your answer for later insertion into the Quiz.


Agosin, T. (1992). Psychosis, dreams and mysticism in the clinical domain. In F. Halligan & J. Shea (Eds.), The fires of desire. New York: Crossroad.

2 Grof, S., & Grof, C. (Eds.). (1989). Spiritual emergency: When personal transformation becomes a crisis. Los Angeles: Tarcher.

3 Lukoff, D. (1985). The diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology, 17(2), 155-181.

4 Wilber, K. (1980).The pre/trans fallacy. Re-Vision, 3, 51-72.

5 Perry, J. (1974). The far side of madness. Englewood Cliffs, NJ:Prentice Hall.

6 Bucke, R. (1969). Cosmic Consciousness. New York: Dutton.

7 James W (1961). The varieties of religious experience. New York: MacMillan.

8 Leuba J H (1929). Psychology of religious mysticism. New York: Harcourt and Brace.

9 Neumann E (1964) Mystical man. In J Campbell (Ed), The mystic vision. Princeton, NJ: Princeton University Press.

10 Estroff, S. (1981). Making it crazy. Berkeley: Univ. California Press.

11 Arieti, S. and Schreiber, F. (1981). Multiple murders of a schizophrenic patient. J American Academy of Psychoanalysis, 9(2), 501-529.

12 Greenberg, D. and E. Witztum (1991). "Problems in the treatment of religious patients." American Journal of Psychotherapy 45(4): 554-565.



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