Evidence-Based Reviews

How to care for patients who have delusions with religious content

Current Psychiatry. 2012 January;11(1):47-51

References

1. Siddle R, Haddock G, Tarrier N, et al. Religious delusions in patients admitted to hospital with schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2002;37(3):130-138.

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5. Waugh AC. Autocastration and biblical delusions in schizophrenia. Br J Psychiatry. 1986;149:656-658.

6. Silva JA, Leong GB, Weinstock R. Violent behaviors associated with the antichrist delusion. J Forensic Sci. 1997;42(6):1058-1061.

7. Atallah SF, El-Dosoky AR, Coker EM, et al. A 22-year retrospective analysis of the changing frequency and patterns of religious symptoms among inpatients with psychotic illness in Egypt. Soc Psychiatry Psychiatr Epidemiol. 2001;36(8):407-415.

8. Bhavsar V, Bhugra D. Religious delusions: finding meanings in psychosis. Psychopathology. 2008;41(3):165-172.

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11. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington DC: American Psychiatric Association; 2000.

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Table 1

Assessing patients with DRC

Use caution when making a diagnosis to decrease risk of pathologizing religious beliefs
Do not focus solely on the content of the delusion; instead look at conviction, pervasiveness, bizarreness, and associated distress
Look at the spiritual/religious context and deviations from conventional religious beliefs of the patient’s culture
Establish an open dialogue with the patient, the family, and individuals from the patient’s faith community to understand the psychosocial issues and any reservations about psychiatric care
Be aware of the categories of delusions, especially those associated with harm (eg, grandiose antichrist delusions, guilt delusions, and some persecutory delusions)
Perform a thorough safety assessment that includes previous self-harm, drug use, and severity of mental illness
Be vigilant for patients who are actively seeking evidence to support their misguided/dangerous beliefs
DRC: delusions with religious content Source: References 2,12,16-18

Evaluating safety

When constructing a differential diagnosis and evaluating patients for safety, remember that DRC are a feature of many psychiatric disorders (eg, persecutory DRC in schizophrenia, grandiose DRC in mania). Consider the course and severity of the patient’s illness, and determine if he or she has a history or evidence of self-injury or substance abuse. Be cognizant of the categories of delusions in the context of the diagnosis. For example, grandiose delusions that involve the antichrist can be associated with harm toward others.⁶ Patients who express extreme feelings of guilt or shame (as seen in psychotic depression) and the need to be physically punished may be at risk for self-harm. Finally, patients seeking evidence to support misguided and dangerous beliefs—for example, obsessing over a religious text regarding self-injury while in a delusional state—may be at high risk for self-harm.¹⁸

Clinical Point

Patients who are seeking evidence to support misguided and dangerous beliefs may be at high risk for self-harm

Researchers have suggested clinicians question patients to determine if they trust their delusions.²⁵ Patients who trust their delusions may appear calm if they already have decided to act on their thoughts.²⁵ Preventive measures for patients at risk of self-harm include close observation, hospitalization, and pharmacotherapy.

Pharmacotherapy for DRC

There are no clear recommendations on specific psychotropics or dosages for treating patients with DRC. When a patient with DRC is at high risk of self-harm or harming others, using antipsychotics, anxiolytics, hypnotics, or a combination of these agents sometimes is needed to quell agitation, along with close observation and restraints when necessary (Table 2).^5,18,25,26 Mr. D benefited from risperidone, 3 mg at bedtime, and zolpidem, 10 mg as needed for insomnia.

Table 2

Treating patients with DRC

If a patient is at risk for self-harm or harming others, take preventive measures such as hospitalization or close observation
Rapid tranquilization may be necessary to reduce risk of harm
Encourage positive religious coping and spiritual practices, when appropriate
DRC: delusions with religious content Source: References 5,18,25,26

Using spirituality to cope

Many persistently mentally ill patients identify themselves as religious and use religious activities or beliefs to cope with their illness.^27,28 In a study of 1,824 seriously mentally ill patients, self-reports of religiousness were positively associated with psychological well-being and diminished psychiatric symptoms.²⁹ Longitudinal research has shown that some aspects of spirituality and religion are associated with positive mental and physical health effects, whereas other aspects can worsen symptoms.³⁰ Specifically, positive religious coping such as benevolent religious reappraisals (eg, “Jesus is my shield and savior”), collaborative religious coping, and spiritual support are associated with positive mental health.³¹ However, negative religious coping, such as punishing God reappraisals and reappraisals of God’s power (eg, “my illness is punishment for my sins”), are associated with distress and personal loss.³²

For patients with psychotic disorders—and with schizophrenia in particular—religious beliefs can be a source of meaning, hope, strength, and recovery. In a study of 115 outpatients with psychosis, 71% used positive religious coping, compared with 14% who used negative religious coping.³³ Among 38 patients with DRC, 45% used spirituality and religion to help cope with their illness, even though they received less support from religious communities than patients with other types of delusions.¹⁹ In this study, the authors suggest that positive religious coping among patients with DRC may alleviate delusion severity by decreasing levels of conviction and fear and preventing maladjusted behaviors.¹⁹ Religious beliefs and activities are associated with fewer hospitalizations among patients with persistent mental illness²⁸ and are a significant protective factor against suicide in patients with psychotic disorders.^34,35 However, some studies have found that intense, obsessive participation in spiritual activities can worsen psychiatric symptoms and undermine recovery.^1,36,37

Clinical Point

For some patients with psychosis, religious beliefs can be a source of meaning, hope, strength, and recovery