religious delusions

Discussion in 'Psychiatry' started by icebreakers, Apr 6, 2007.

  1. icebreakers

    icebreakers Member
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    i had a patient recently who was blatantly psychotic. she was preaching to an imaginary croud, loud as hell, and bizarely delusional. she kept on inviting us to her wedding for that evening...telling us that we were blessed, we were going to be involved in the wedding etc etc....and of course, she was getting married to jesus.

    i dont recall her endorsing any hallucinations, but she was extremely tangential, and speaking in gibberish language intermittently. Neologisms, right?

    anyways...someone brought to my attention that in the pentacostal church, her speech is known as 'speaking in tongues' and that only people who have a direct connection with 'god' , are capable of this language. of course, the only way to confirm this is if you infact are connected with god, b/c it cant be proved/disproved by others.

    so my question is...can i describer her speech as widespread use of neologisms? is the use of a language in which no one else can prove/disprove, delusional? i guess it wouldn't be a bizzare delusion because its not that hard to believe...., versus someone saying that they are speaking in an undecipherable langugae that was taught to them by a tree...for example

    any thoughts...on delusions, hyper-religiosity, and their boundaries ...
    also is there any literature on the prevelance of psychotic illness/behavior in those who are fanatical about religion?
     
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  3. Anasazi23

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    Speaking in tongues and what you're describing are two different things. The former, in the correct setting, being a phenomena that is known and accepted within that branch of religion.

    It's unlikely that she was speaking in true neologisms, as this implies a novel word that has a meaning, or usually represents something to the patient. Rapid nonsensical rambling is not really classified as a neologism. An example of the latter would be a patient consistently calling a pencil, a "paracot," or, inserting an unknown word in a sentence that appears to have meaning only to them.

    When describing speech in terms of mental status report, the modulation (loudness and softness), in this case sounds abnormal, as does the inherent quality of the speech. Differentials of various aphasias notwithstanding, it sounds like classic manic rambling with an incorporated religious overtone. In this case, speaking in tongues.

    The descriptive word itself is not as important as a good quality description in terms of psychopathology. In other words, you could describe the speach in rounds as "meaningless, short one syllable utterances produced in rapid succession at a high volume and pitch." This gives an entirely different meaning than simply saying "neologism," which implies head injury, possibly an aphasia or a psychotic process.

    One must be careful not to, for fear of not being "PC," attribute any and all hyper-religiousness to cultural or spiritual influences, and miss the underlying pathology.

    I remember a case of a Hispanic female who was brought in by her daughter for manic-type behavior, manifested mostly though incessant house cleaning and extreme hyper-religiosity. She was a long-standing bipolar, and while on the unit, would continually bless everyone, pray loudly, and would hold up pictures of the Virgin Mary during community meeting and move it around like a boxing ring rounds bikini girl. She had created a shrine to Jesus in her room, which consisted of her placing her rolling nightstand in front of the mirror, which was covered in religious pictures, and was completely covered in ornate fabrics, plastic religious non-artifacts, and reading material, all of which she pieced together from her own belongings and from various sources around the unit.

    Erroneosly, someone might claim that this is her right to be religious, and that "who are we to say that she has too much faith, or loves God," or what have you. Of course, this is a large departure from her normal level of functioning. Her day was absolutely consumed with these activities, and her ability to adequately function was severely hampered. Just because pathological manifestation falls under a topic which many police as being "cultural" or "religious" does not mean that it is therefore not a departure from their normal functioning, and is actually harmful to them.

    I think every psychiatrist has felt bad at some point giving an infectious, euphoric manic more lithium, which caused them to more or less crash and return back to normal, but this is the nature of the business. And indeed, psychiatrists have been sued for failing to treat such conditions, as these patients often wind up in legal trouble, bankruptcy, or worse.
     
  4. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Really good answer--I'd just add two thoughts:
    1) Try to involve co-religious supports with these patients. They will often be able to tell you whether or not the patient's behavior is out of line with their shared religious beliefs.
    2) Stabilizing mental illness never destroys real faith. It allows the patient to interact with their God and community with a sound mind. I've treated many a manic believer who continued in their faith with appropriate affective range, once their lithium level was therapeutic.

    Happy Passover and/or Happy Easter to those of you who are so inclined, BTW.
     
  5. NoleRad

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    that is a very important point. It is my understanding from discussing this matter in my Christian church that when someone is speaking in tongues there WILL always be an interpreter. basically 1 person will be overcome with an angelic message and another who hears this WILL be bless with the ability to understand and interpret the message for the people gathered (to put it bluntly, God isn't going to send down pearls of wisdom yet not allow people to understand them). My church would definitley say that a person speaking in tongues alone is more of a sign of a medical condition than a religious experience.
     
  6. OldPsychDoc

    OldPsychDoc Senior Curmudgeon
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    Just to clarify a little, and it does depend somewhat on the tradition, but most churches which endorse glossalia would also endorse the practice of private individual speaking in tongues alone as a devotional "prayer language". You are correct as far as the public utterances go. Our manic patient ejaculating gibberish wildly for everyone to hear would fit neither practice.
     
  7. toby jones

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    the boundary between delusional and non delusional is indeed a tricky one and the DSM criteria has been challenged on every substantial point that it makes. Some delusions are true (e.g., delusions of jealousy may be true), oftentimes their content is such that they are hard to falsify if not unfalsifyable, it is very controversial whether they are the result of inference (e.g., see Maher) even less 'faulty' inference, they are often about internal processes rather than external reality, and most people grant that a whole cultural group can be delusional as in some cults.

    Religious experiences have been found to be correlated with temporal lobe epilepsy.

    Hard to see how 'I am drinking the blood of Jesus and eating his body' is different in kind from more paradigmatically delusional beliefs.

    But that being said... Is the idea supposed to be that instead of treating certain beliefs that are culturally accepted with anti-p's oftentimes they can adequately be treated from within the belief system. The example that springs to mind here is a lady in NZ who was hospitalised and treated because she was distressed about hearing the voice of her dead husband. She said that the house needed to be blessed by an elder and eventually they sent an elder out to bless the house at which point her delusion ceased. The anti-p's didn't have any effect on the other hand.
     
  8. Anasazi23

    Anasazi23 Your Digital Ruler
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    I wasn't on the unit at the time, so I'm not privy to all the details, but we had a similar thing happen in our inpatient unit when I was an intern.

    There was a woman from Africa who had some sort of delusional process, and was not being helped by antipsychotics. Eventually the decision was made with the family to bring in a recommended "witch doctor," who did some kind of treatment with the patient, who soon after became better.

    Now, I believe that there are at least a couple 'kinds' of delusions, and I'm not referring to "religious vs. somatic, etc." There are classic delusions - the type with which we are familiar in psychiatry; i.e. "The neighbors are putting poison material in my mailbox, hoping to kill me," which are long standing, and somehow engrained biologically, for lack of a better word.

    I also think that there are other, I'll call them "pseudo-delusional" beliefs, which carry a different inherent quality. This may not be dissimilar to the concept of "pseudo-hallucination" whereby certain 'types' of hallucinations are thought to represent either internal monologue, or something similar, but are believed to be a pathological process. Incidentally, there are described in the literature as having "a better prognosis," largely because they are not inherent, engrained, biological pathological entities. The classic example is, "Yes doc, I hear someone calling my name."

    I could call an example of a so-called pseudo-delusion O.J., who at this stage, actually BELIEVES he did not kill Nicole or Ron. There is an internal process that to him is so powerful...even the belief that he must sustain to continue to have his lawyers support him, that he adapts this erroneous thinking as an adaptive mechanism to help ensure his well-being. Psychodynamic psychiatrists might call this an example of a primitive defense mechanism - and they'd probably be right.

    You can see the inherent quality difference, however, between these two types of delusions:

    1: Neighbors are poisoning me
    2: I didn't kill Nicole and Ron / I'm overtaken with an evil spirit because of a shameful act I did.

    Knowing that delusional disorders are notoriously difficult to treat, if we were to give O.J. an antipsychotic, would we expect him to step off the golf course and admit to perpetrating the double murder? The answer of course is no, and (in his eyes) for good reason. Likewise, we can expect that a "soft" religious delusion might also not respond to pharmacological treatment. Though, benzodiazepines may help in this situation, much like it would help in a selective mute.

    I think the inherent difference is that one is acting as a clear secondary effect or defense to what is perceived as an intolerable insult to the psyche, and this defense is garnered as a (mal)adaptive mechanism. In the example of the former, one could argue that the difficulty in treating this is that for them, it also has reached a part of the psyche whereby the act is adaptive in helping to shield from an otherwise intolerable state. This is in opposition to flagrantly positive psychotic symptoms, which in some ways are much easier to treat.

    Just some thoughts.
     
  9. toby jones

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    I thought (though I could be wrong on this) that the hallucination pseudo-hallucination distinction was around whether the person lacks insight into the non-veridicality of some of their experiences (hallucination) or whether the person has insight that some of their experiences are non-veridical but insists that they are having those experiences (pseudohallucination). The DSM seems to build lack of insight into the definition of hallucinations and I have wondered at times whether a consequence of this is that hallucinations turn out to be a proper subset of delusion such that when someone meets criteria for hallucination they also meet criteria for delusion. For example, if someone hears a voice that they attribute to an external agency then they are having a hallucinatory experience and they are also having delusion with respect to its origin. But... I could well be missing something. (If hallucination is a proper subset of delusion then it would be an uninteresting empirical finding that hallucinations tended to be correlated with delusions, however. Much more interesting would be finding cases where someone was regarded as having hallucination in the absence of delusion. It would be interesting to know whether these cases were really cases of pseudohallucination rather than delusion or whether they had been incorrectly regarded as non-delusional).

    There has been a lot of debate around how delusions are distinct (if they are in fact) from religious beliefs and from over-valued ideas and so forth. I'm not sure that it is helpful to say that those beliefs that respond to anti-psychotics must have been biologically based whereas those beliefs that do not respond to anti-psychotics are not biologically based. Surely our beliefs are in fact represented in our neurology and hence all beliefs are biologically based. I guess that ethical issues come up around whether it is or is not okay to attempt to treat someone for their belief especially if they are not wanting treatment for this. E.g., political dissentors in Russia were diagnosed as having 'sluggish schizophrenia' and treated on the basis of their political beliefs. The psychiatrists who treated them genuinely believed that those beliefs were signs of pathology (to be charitable to those psychiatrists).

    Jaspers attempted to distinguish between primary delusions (delusions 'proper') and secondary delusions ('delusion like ideas') as follows: Secondary delusions arise understandably from prior experiences whereas primary delusions are the result of disease process and they are ununderstandable. The trouble with this distinction is that it makes whether a person is delusional or not a matter of understandability or, in other words, a matter of how much the clinician is able to empathise with the client (hence it may well say more about the limitations of the psychiatrist than the limitations of the patient). One example of supposed ununderstandability was a case where a woman said 'there are bees buzzing around inside my skull' and pressure on her temporal lobe was found upon autopsy. It was possible that this pressure resulted in a buzzing sound. Another example was 'Dr B has turned me into a portfolio' where investigation revealed that the patient had some rare condition that Dr B was interested in and Dr B had indeed written her up as a case study.

    Another distinction in the vicinity is the distinction between 'bizzarre' and 'non-bizzare' delusions where it is possible for non-bizzare delusions to be true (e.g., the FBI are following me) whereas it is impossible for bizzare delusions to be true (e.g., my body is a nuclear power plant). I won't even get started on problems in specifying the relevant notion of possibility, however (e.g., logical, metaphysical, physical, nomic).

    I'm fairly confident that for every proposed distinction there would be counter-examples or cases that fell between the categories. This would be expected if it were the case that there was a continuum between ordinary beliefs and delusional beliefs with over valued ideas being somewhere between those. I've been reading Bentall at the moment where he argues against the notion that there is a hard and fast line between mentally disordered and not mentally disordered and also between kinds of mental disorder (e.g., schizophrenia and bi-polar).

    I would suppose that in this particular case (the onepresented in the start of the thread) it isn't going to make a great deal of difference to the treatment whether the persons speech is regarded as culturally appropriate or not. The context seems to place it as culturally inappropriate but more than that the greater context of the patient would seem to indicate intervention at any rate...
     
  10. Anasazi23

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    Not necessarily. Simply having or lacking insight cannot, by itself, mean the difference between the existence of a phenomena which may or may not be indicitive of a particular disorder - in this case, psychosis. In that scenario, the same could be argued for any hallucination.

    This happens all the time, and depends on no small part, on the 'sophistication' of the patient, and that patient's use and adaptation of defenses.
    This isn't really what I intended to imply. Rather, using my example above, it would be unlikely that a pseudo-hallucination would respond to a medication (dopamine antagonist) which by definition, is not produced by a pathway malfunction in the sense that a "regular" hallucination is.
    An extreme example to be sure...and there are quite a few others. Siding with this view is basically what the scientologists and other anti-psychiatry zealots preach: that psychiatrists are tools of the government that are employed to quell social uprising against a totalitarian regime.

    The DSM casebook still makes similar distinctions, but instead of using the terms "understandable," uses the term "bizarre vs. non-bizarre." Unfortunately, they then go on to cite the example of a person who believes that poison gas is coming into her apartment via heating ducts through by her neighbors. Is this bizarre or not? In some ways yes, and in others, no. A horrible example that they used to try and illustrate a concept.

    I'll leave it up to the readers to look up or remember how the DSM casebook classifies the above delusion.

    See above! Somehow I skipped over this paragraph the first read-through.
    :)
    I would find it much easier to argue Bentall's point, than the counterpoint...wouldn't most?
    And that's where the rubber hits the road. These discussions are great for helping us to understand the phenomenology behind these abnormal? processes, yet at this stage, treatment remains largely the same. On a more basic level, the decision to treat at all, is ironically the harder question in some ways. That, of course, depends on a thorough history of the patient, previous level of functioning, medical conditions, and many more factors.
     
  11. toby jones

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    > Simply having or lacking insight cannot, by itself, mean the difference between the existence of a phenomena which may or may not be indicitive of a particular disorder - in this case, psychosis.

    Hmm. I know that it is controversial whether there is a worthwhile distinction between psychosis and neurosis but I'm fairly sure that one of the distinguishing features was thought to be whether there was insight into the supposedly pathological nature of ones condition or not. consider the muller-lyer illusion. the illusion that the lines are of different length persists in the face of insight into the fact that the lines are actually of the same length. in this instance the visual system is fooled into having a hallucinatory experience. the majority have insight into the pathological origins of their experience, however (which is just to say that they know they are undergoing an illusion / hallucination). it would be pathological indeed to insist that the lines were actually the way they appeared to be despite rational evidence to the contrary (such as after measuring the lines and coming to know a little something about how the visual system is fooled), however. In this case we typically don't regard the experience of the illusion as pathological. Maybe the illusory experience of visual illusions is on a continuum with the illusory experiences of hallucinations with insight, however? Which in turn is on a continuum with the illusory experiences of hallucinations without insight?

    I really am fairly sure that the hallucination / pseudohallucination distinction was supposed to be a distinction as to whether reality testing / insight is present or absent. I could be wrong... But I would like to see a reference ;-)


    > it would be unlikely that a pseudo-hallucination would respond to a medication (dopamine antagonist) which by definition, is not produced by a pathway malfunction in the sense that a "regular" hallucination is.

    I think here we are talking past each other because we have different conceptions of what hallucinations and pseudohallucinations are. In my sense there could be the same pathway malfunction for hallucination and pseudohallucination. It would just be a matter of whether the person accepted their illusory experience as veridical or not (which could well be the product of other brain regions). I thought that was why LSD illusory experiences (for example) were commonly regarded as pseudohallucinatory - because people most often tend to retain insight into the drug induced nature of their experiences.

    > Siding with this view is basically what the scientologists and other anti-psychiatry zealots preach: that psychiatrists are tools of the government that are employed to quell social uprising against a totalitarian regime.

    Whoa... I know you aren't meaning to do this but I really don't want to be written off as an anti-psychiatrist (or IMHO even worse - a scientologist). Truth be told... I think there is a great deal of important insights and horrific errors to be found both within the psychiatry and anti-psychiatry movement. Figuring out the important insights of each (and dismissing the nonsense) is an important step forward to a more adequate conception of reality, however...

    > I would find it much easier to argue Bentall's point, than the counterpoint...wouldn't most?

    The implications of Bentalls point include the notion that the DSM should be revised from its current categorical foundations (where disorders are discrete disease like processes that are categorically different from each other and categorically different from normality) into a dimensionally based system.

    > And that's where the rubber hits the road.

    Indeed.

    > On a more basic level, the decision to treat at all, is ironically the harder question in some ways.

    Yeah, thats kind of the crux of the issue. In the absense of distress... How do we decide???
     
  12. worriedwell

    worriedwell Senior Member
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    "I think here we are talking past each other because we have different conceptions of what hallucinations and pseudohallucinations are. In my sense there could be the same pathway malfunction for hallucination and pseudohallucination. It would just be a matter of whether the person accepted their illusory experience as veridical or not (which could well be the product of other brain regions)."

    The point, though, is that as a physician, one does not just "treat the hallucination". One worries about the tenacity of the beliefs and puts it into context with the insight and other cognitive sequelae of the syndromal illness. This is why, as research is very clearly showing, Schizophrenia has important cognitive symptoms that we don't routinely test but we should soon start incorporating into the diagnosis, along with imaging etc. Its just a matter of progress.

    Unfortunately, the current medicine that we have treats predominantly hallucinations via a dopminergic pathway and patients tend to have less of this particular distressing symptom of halluninations once treated but what we are really after is treating this person suffering from this disease and trying to get to the bottom of where the pathways are screwed up and how to treat these brain abnormalities. We are notoriously terrible at treating the negative symptoms of schizophrenia but we sure as hell want to...and we don't want to just so that we can control people, but so that we can help them lead a happier and more productive life.

    The problem lies in the current state of the specificity of the tools we have to diagnose illness. Even when we can define the illness based on some other measure, whether to treat symptomatically becomes a clinical determination based on the physician and the patient's decision makers. Unfortunately many times the primary decision maker (the patient) has flawed thinking based on their brain disorder. Thus, if possible as many surrogate decision makers need to be involved and the physician may end up taking on more of a "parental" role for the best interests of the patient. This has its slippery slope arguments and its flaws, but using the extreme examples of social control to dictate how medicine is practiced is not productive and probably ends up being more inflammatory than anything else.
     
  13. Anasazi23

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    Toby, there are a couple things I want to mention...

    1) I don't think you're a scientologist. ;)

    2) The concept of hallucination vs. pseudohallucination may indeed be different depending on the theoritician that is discussing the issue. To provide a reference to that definition is fruitless, since it is simply a theoretical construct. No one is particulary right or wrong in this case. Discussions, panel symposia, and new literature alludes to the case of pseudohallucinations as something more than simply "insight orientated hallucinations."

    3) We have an issue again here when we talk of clinical utility. There are many apathetic psychotic syndromes (call it negativism - not to be confused with negative symptoms) which do not bother or disturb the patient, and cause them no distress. The hebephrenic comes to mind. Another good example is the euphoric manic, who not only is not disturbed, but is adamently fighting against treatment. This doesn't mean that they should therefore not be treated. There is clearly a pathological process that necessitates medical intervention.

    4) You bought up the topic of psychosis vs. neurosis. Personally, I think it is a worthwhile distinction, and unlike some conditions in psychiatry, has far-reaching treatment implications.
     
  14. halflife

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    I am finding this thread fascinating.

    To my mind there is perhaps a split between cultural and religious issues. Or, perhaps there is not?

    toby jones' post about the example of the NZ woman:

    "She said that the house needed to be blessed by an elder and eventually they sent an elder out to bless the house at which point her delusion ceased. The anti-p's didn't have any effect on the other hand."

    (I'm sorry, I suck at quoting correctly on message boards)

    I am from NZ / Aotearoa and for me, hearing this is not something unusual in many ways. From the oriori (rituals) at birth to something like this example of Maori elders being asked to cleanse, it is a cultural mechanism that is just 'there'. As palangi (white) I sometimes struggle with choosing the correct approach, even though I have grown up with both cultures. However, this is why there is strong advocacy of tino rangatiritanga (respect of sovereigncy), and working within a kaupapa framework.

    Hey we come from a land that was fished up from the sea by a god called Maui :p Maybe we're all just crazy ;)

    How closely have you worked with patients who engage with their culture to the point of seeming 'abnormal' or at least unusual to someone outside of their identity? I would be really interested to hear some more stories - apologies if this feels somewhat off track from the religious slant of the initial postings. And probably a little more about where one draws the line.
     
  15. Dramkinola

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    In Louisiana, the physicians' commitment is called a Physicians emergency certificate, or PEC, which gives us 72 hours of involuntary commitment authority until a psychiatrist from the coroner's office comes evaluates the patient and either negates it (essentially discharging the patient) or confirms the commitment, turning it into a coroner's emergency certificate (CEC) validating it for 15 days.

    So in cases involving the hyper-religious delusions, I often ask, "Would we PEC Jesus?"
     

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