How to care for patients who have delusions with religious content To improve outcomes, look beyond delusion content and enlist spiritual care experts r. D, a 72-year-old Christian with a long history of schizophrenia, presents to the emergency room with Mconcerns about evil spirits in his home who have poi- soned him. He has called for police assistance on numerous occasions and has tried to kill the evil spirits with his rifle, but states “they are bulletproof.” He is unable to sleep and is “fearful for my life every night because that is when the demons come out.” Mr. D also believes that God is “more powerful than the evil spirits.” Two elders at his church have prayed with him and encouraged him to go to the hospital. Delusions with religious content (DRC) are associated with poorer clinical outcomes and dangerousness.1-6 Most mental health professionals will encounter patients with DRC because this type of delusion is relatively com- © IMAGES.COM/CORBIS mon in patients with symptoms of mania or psychosis. For example, in a study of 193 inpatients with schizo- Sara M’Lis Clark, MD phrenia, 24% had religious delusions.1 The prevalence of Psychiatry Resident, PGY-III DRC varies considerably among populations and can be David A. Harrison, MD, PhD influenced by the local religion and culture.7-9 This article Assistant Professor reviews clinical challenges and assessment and manage- • • • • ment strategies for patients with DRC. Department of Psychiatry and Behavioral Sciences University of Washington Seattle, WA A challenging course In a UK study of 193 inpatients with schizophrenia, compared with patients with other types of delusions, those with DRC: • had higher Positive and Negative Syndrome Scale scores and lower Global Assessment of Functioning Current Psychiatry scores Vol. 11, No. 1 47 continued Table 1 tinction highlights that many subtypes of delusions can have a religious theme. Assessing patients with DRC Categories of delusions with religious Use caution when making a diagnosis to themes include: decrease risk of pathologizing religious beliefs • persecutory (often involving Satan) Do not focus solely on the content of • grandiose (messianic delusions) the delusion; instead look at conviction, • guilt delusions. Delusions with pervasiveness, bizarreness, and associated Categorizing DRC is important because distress religious content some are associated with more distress or Look at the spiritual/religious context and deviations from conventional religious beliefs of dangerousness than others. For example, the patient’s culture case studies of self-inflicted eye injuries Establish an open dialogue with the patient, the found that most patients had guilt delu- family, and individuals from the patient’s faith sions with religious themes that referenced community to understand the psychosocial punishing transgressions, controlling un- issues and any reservations about psychiatric care acceptable sexual impulses, and attaining 3,10 Be aware of the categories of delusions, prescience by destroying vision. In our Clinical Point especially those associated with harm (eg, example, Mr. D is experiencing a persecu- grandiose antichrist delusions, guilt delusions, tory DRC. Also, using the label “religious Working with and some persecutory delusions) spiritual care delusion” can inadvertently pathologize Perform a thorough safety assessment that religious experiences. professionals may includes previous self-harm, drug use, and severity of mental illness help reduce clinician Be vigilant for patients who are actively seeking biases that could evidence to support their misguided/dangerous Tips for effective evaluation beliefs pathologize a DSM-IV-TR offers no specific guidelines for DRC: delusions with religious content assessing DRC vs nondelusional religious patient’s religiosity Source: References 2,12,16-18 beliefs.11 There is risk of pathologizing re- ligious beliefs when listening to content alone.11-15 Instead, focus on the conviction, • waited longer before reengaging in pervasiveness,2 uniqueness or bizarreness, treatment and associated emotional distress of the de- • were prescribed more medications.1 lusion to the patient (Table 1).2,12,16-18 In addition, compared with patients In the context of the patient’s spiritual with other types of delusions, patients history, deviations from conventional re- with DRC often hold these delusions with ligious beliefs and practices are important greater conviction,1,2 making them more factors in determining whether a religious challenging to treat. belief is authentic or delusional. Involving Dangerousness in patients with DRC family members and/or spiritual care pro- can manifest as self-harm or harm to fessionals (eg, chaplains and clergy) can others. Extreme examples include self- be especially helpful when making this inflicted enucleation of the eye and auto- differentiation.16,17 In the hospital, chap- castration. In a review of 9 cases of severe lains often are familiar with a variety of ocular self-injury, 4 patients had DRC.3 faith traditions and may provide impor- Genital self-mutilation associated with tant insight into the patient’s beliefs. In ONLINE ONLY DRC is rare, but several cases of psychotic the community, clergy members from the men who performed autocastration based patient’s faith also may provide valuable Discuss this article at on a literal, erroneous interpretation of a perspective. www.facebook.com/ passage in the Bible (Matthew 19:12) have Similar to how having a basic familiar- CurrentPsychiatry been reported.4,5 Patients with DRC have ity with a patient’s culture can improve committed rape and murder because they care, a better understanding of a patient’s believed they were the antichrist.6 spiritual or religious beliefs and practices In this article we use the phrase “delu- can build rapport and the therapeutic al- sions with religious content” instead of liance.16,17 This is particularly important Current Psychiatry 48 January 2012 “religious delusions” because this dis- with patients with DRC because these in- dividuals often have a poor therapeutic Table 2 alliance and engagement with providers.19 Because many psychiatrists have limited Treating patients with DRC time and may not be familiar with every If a patient is at risk for self-harm or harming patient’s spiritual or religious background, others, take preventive measures such as consultation with spiritual care profession- hospitalization or close observation als may be helpful. Rapid tranquilization may be necessary to reduce risk of harm Assess whether your patient has reser- Encourage positive religious coping and vations about psychiatric treatment. Some spiritual practices, when appropriate may believe that seeking care from a doc- DRC: delusions with religious content tor is evidence of weak faith, whereas oth- Source: References 5,18,25,26 ers may feel that psychiatric treatment is forbidden or incompatible with their religious beliefs.19-22 Mental health clini- cians need to consider their own religious Pharmacotherapy for DRC biases that may cause them to minimize There are no clear recommendations on or pathologize a patient’s religiosity.20,23 specific psychotropics or dosages for treat- Clinical Point Working collaboratively with spiritual care ing patients with DRC. When a patient with Patients who are professionals may help reduce clinician bi- DRC is at high risk of self-harm or harm- seeking evidence ases or assumptions.24 ing others, using antipsychotics, anxiolyt- ics, hypnotics, or a combination of these to support agents sometimes is needed to quell agita- misguided and Evaluating safety tion, along with close observation and re- dangerous beliefs 5,18,25,26 When constructing a differential diagnosis straints when necessary (Table 2). Mr. may be at high risk and evaluating patients for safety, remem- D benefited from risperidone, 3 mg at bed- ber that DRC are a feature of many psy- time, and zolpidem, 10 mg as needed for for self-harm chiatric disorders (eg, persecutory DRC in insomnia. schizophrenia, grandiose DRC in mania). Consider the course and severity of the pa- tient’s illness, and determine if he or she Using spirituality to cope has a history or evidence of self-injury or Many persistently mentally ill patients substance abuse. Be cognizant of the cate- identify themselves as religious and use gories of delusions in the context of the di- religious activities or beliefs to cope with agnosis. For example, grandiose delusions their illness.27,28 In a study of 1,824 serious- that involve the antichrist can be associat- ly mentally ill patients, self-reports of reli- ed with harm toward others.6 Patients who giousness were positively associated with express extreme feelings of guilt or shame psychological well-being and diminished (as seen in psychotic depression) and the psychiatric symptoms.29 Longitudinal re- need to be physically punished may be at search has shown that some aspects of risk for self-harm. Finally, patients seek- spirituality and religion are associated ing evidence to support misguided and with positive mental and physical health dangerous beliefs—for example, obsessing effects, whereas other aspects can worsen over a religious text regarding self-injury symptoms.30 Specifically, positive religious while in a delusional state—may be at high coping such as benevolent religious reap- risk for self-harm.18 praisals (eg, “Jesus is my shield and sav- Researchers have suggested clinicians ior”), collaborative religious coping, and question