Psychological Characteristics of Religious Delusions

Soc Psychiatry Psychiatr Epidemiol (2014) 49:1051–1061 DOI 10.1007/s00127-013-0811-y ORIGINAL PAPER Psychological characteristics of religious delusions Robel Iyassu • Suzanne Jolley • Paul Bebbington • Graham Dunn • Richard Emsley • Daniel Freeman • David Fowler • Amy Hardy • Helen Waller • Elizabeth Kuipers • Philippa Garety Received: 30 May 2013 / Accepted: 16 December 2013 / Published online: 31 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013 Abstract (OR 7.5; 95 % CI 3.9–14.1), passivity experiences, having Purpose Religious delusions are common and are con- internal evidence for their delusion (anomalous experi- sidered to be particularly difficult to treat. In this study we ences or mood states), and being willing to consider investigated what psychological processes may underlie alternatives to their delusion (95 % CI for ORs 1.1–8.6). the reported treatment resistance. In particular, we focused Levels of negative symptoms were lower. No differences on the perceptual, cognitive, affective and behavioural were found in delusional conviction, insight or attitudes mechanisms held to maintain delusions in cognitive models towards treatment. of psychosis, as these form the key treatment targets in Conclusions Levels of positive symptoms, particularly cognitive behavioural therapy. We compared religious anomalous experiences and grandiosity, were high, and delusions to delusions with other content. may contribute to symptom persistence. However, contrary Methods Comprehensive measures of symptoms and to previous reports, we found no evidence that people with psychological processes were completed by 383 adult religious delusions would be less likely to engage in any participants with delusions and a schizophrenia spectrum form of help. Higher levels of flexibility may make them diagnosis, drawn from two large studies of cognitive particularly amenable to cognitive behavioural approaches, behavioural therapy for psychosis. but particular care should be taken to preserve self-esteem Results Binary logistic regression showed that religious and valued aspects of beliefs and experiences. delusions were associated with higher levels of grandiosity Keywords Psychosis Á Schizophrenia Á CBT Á Cognitive model R. Iyassu Á S. Jolley (&) Á A. Hardy Á H. Waller Á E. Kuipers Á P. Garety PO77 Department of Psychology, King’s College London, Institute of Psychiatry, University of London, Denmark Hill, Introduction London SE5 8AF, UK e-mail: [email protected] Delusions are a cardinal feature of psychotic illness, present in around three quarters of people with a schizo- P. Bebbington Department of Mental Health Sciences, UCL, London, UK phrenia spectrum diagnosis [1, 2]. Religious themes are common across delusion categories and types, with G. Dunn Á R. Emsley between a fifth and two-thirds of all delusions reflecting Health Sciences Research Group, School of Community Based religious content [3–6]. To be classified as a religious Medicine, University of Manchester, Manchester, UK delusion, the belief must be idiosyncratic, rather than D. Freeman accepted within a particular culture or subculture [7]. Department of Psychiatry, University of Oxford, Oxford, UK Strongly held beliefs that are shared within an existing religious or spiritual context would not, therefore, be D. Fowler School of Medicine, Health Policy and Practice, considered to be religious delusions, irrespective of co- University of East Anglia, Norwich, UK occurring psychosis. For example, believing oneself to be 123 1052 Soc Psychiatry Psychiatr Epidemiol (2014) 49:1051–1061 able to hear the voice of Jesus is not uncommon in a religious beliefs to be held with high conviction, certainty Christian society and thus would not in itself be classified of rectitude (rather than possibility of being mistaken), and as a religious delusion. In contrast, believing oneself to be without alternatives. Should these features of religious inhabited by the warring spirits of multiple interspatial beliefs equally characterise delusions with religious con- deities, would be considered to be a religious delusion. tent, reasoning biases may be particularly prominent, and Culturally acceptable religious beliefs are cited as an thus contribute to severity, persistence, and higher levels of important coping strategy for many people with schizo- conviction. phrenia, and may contribute to lower symptom severity in Affective disturbance Affective processes are implicated both severe and enduring mental illnesses [8, 9] and in the onset and maintenance of delusions by their impact common mental disorders [10, 11]. Religious delusions, in on attentional, perceptual, interpretative and memory pro- contrast, have routinely been linked to poorer prognosis for cesses, and through maladaptive coping and affect regu- people with psychotic disorders [12]. lation strategies [25]. Religious delusions, by definition, Levels of disability, distress and conviction have all concern themes of universal existential import, and are been reported to be higher in people with religious delu- therefore likely to be particularly associated with strong sions compared to other types of delusions [1, 3, 4, 13–15]. affect, with consequent cognitive-perceptual and behav- Religious delusions are also associated with poor engage- ioural changes which may act to further increase delusion ment, low satisfaction with services and with treatment, severity [26]. and longer duration of untreated psychosis [12, 16–19]. Beliefs about illness, treatment and recovery How a People with religious delusions appear, therefore, to be a person makes sense of the changes associated with psy- particularly problematic group to treat effectively, and chosis is important to their adjustment and to their ought to be targeted for psychological therapies [20, 21]. engagement with treatment [27, 28]. Religious delusions However, as the mechanisms underlying the treatment may be particularly likely to involve a rationale at odds resistance are poorly understood, further study is required with the tradition of Western psychiatric empiricism that to establish what the particular foci of psychological characterises mental health services in the UK. This mis- intervention for people with religious delusions should be, match of explanatory models may underpin the association and what issues are likely to arise in implementation. of religious delusions with poor engagement with treatment Cognitive models of psychosis [22, 23] identify specific and with services [28, 29]. psychological maintaining factors for delusions. Prominent amongst these are persisting anomalous experiences, rea- Aims of the current study soning biases, affective processes, and poor adjustment to psychosis resulting from personal beliefs about illness, We set out to compare a large sample of people with treatment and recovery. Religious delusions can be plau- religious delusions to people with other kinds of delusions sibly linked to increased difficulty in all these areas. to identify the psychological factors which may contribute Anomalous experiences These may be perceived as to the increased persistence, disability and distress reported having religious significance (e.g., communications from to be associated with religious delusions. All participants higher powers) and thus be specifically attended to, had current delusional symptomatology, and a schizo- engaged with and even deliberately induced. Frequent phrenia spectrum diagnosis verified by trained assessors. anomalous experiences provide repeated evidence to sus- The aim was to develop a better psychological under- tain the delusion. standing of religious delusions to inform model develop- Reasoning biases Delusions are considered to arise ment and, thereby, intervention. from, and be maintained by, biases and errors in evidence- We tested the following specific hypotheses: based reasoning. These include ‘jumping to conclusions’ (JTC) by making decisions based on limited data, and 1. In line with previous studies, people with religious belief inflexibility, comprising difficulty adjusting beliefs delusions will have higher levels of symptomatology in response to contradictory evidence; difficulty consider- and delusional conviction, and poorer engagement in ing the possibility of being mistaken; and difficulty iden- treatment than people with other kinds of delusions. tifying plausible alternative explanations [24]. Faith, by its 2. People with religious delusions will have more anomalous nature, relies on foundations other than a systematic and experiences, more negative affect and more reasoning evolving evidence base, and religious or spiritual insights biases than people with other kinds of delusions. tend to be based on revelation, dramatic events or inner 3. People with religious delusions will have less insight conviction, rather than a process of hypothesis testing. It is and more unhelpful attitudes towards their treatment also common, and, in some religions, even desirable, for than people with other kinds of delusions. 123 Soc Psychiatry Psychiatr Epidemiol (2014) 49:1051–1061 1053 Methods includes a global rating of severity, rated by an interviewer on a Likert scale in the following way: 0 = none, Participants 1 = questionable, 2 = mild, 3 = moderate, 4 = marked and 5 = severe. For this study, the global ratings of each Participants in the present study were the combined sam- domain were summed to give an indication of symptom ples from two studies by the psychosis research partner- severity. Both of the measures

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