Have you ever made a wish that came true? Or considered Fate or Providence to be at play when someone or something entered your life at an opportune time? What about dreaming about an event that intriguingly played out in real life? Have you ever mourned the passing of a loved one, only to inexplicably feel their presence?
Most people probably identify with such experiences, and many would assign value or meaning to them—perhaps identifying them as divine intervention, believing in the gift of clairvoyance or feeling a special connection with the spiritual realm. Such experiences can impact an individual’s life by providing reassurance, guidance or a stronger sense of spirituality.
Is it possible that people’s stories about miracles or spiritual encounters are merely symptomatic expressions of something more ominous—a psychiatric illness perhaps? From a diagnostic viewpoint, such experiences may be labeled “magical thinking,” “delusional” or “psychotic.” Could they be chalked up to a diagnostic label? And how do clinicians have the authority to make this determination—especially as they interpret such experiences through their own spiritual (or agnostic) lens?
A matter of perspective
The issue of spirituality versus psychopathology seems to be a matter of perspective. Overvalued ideas about one’s spiritual belief system can be interpreted by others as symptoms of a personality disorder or psychosis. How do we differentiate between healthy spirituality and psychopathology? The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers some guidance, defining delusional beliefs as beliefs “not ordinarily accepted by other members of the person’s culture or subculture.” However, with ever-increasing spiritual sects, it can be difficult for the clinician to know what beliefs might be shared. Additionally, the DSM references the level of impairment, context of behavior or belief and symptoms that may be substance-induced. Thus, isolated experiences that are not part of a broad pattern of disturbance should not be diagnosed.
At times a patient’s spiritual beliefs can interfere (from the clinician’s perspective) with their ability to function in a social, occupational or academic setting. These cases can be challenging to filter through the diagnostic decision tree, especially when it seems as though no one can know for sure the extent of truth to any unusual experience.
For example, I met with a patient who had a strong sense that he was “different” from others; he believed he had lived many past lives and had a special connection with the world that most people he encountered could never understand. He described countless “messages from the universe” directing him in his everyday activities.
From a diagnostic perspective his descriptions bordered on quirky if not impairing. He became quite concerned with physical symptoms, such as feeling like his body was being taken over by an unexplained force, which doctors could not explain. He continually found hidden meanings in TV commercials or friends’ comments that most would consider ordinary experiences. Although he was able to function for the most part independently, he maintained an outlook on the world that made it difficult for him to relate to others and ultimately caused rifts in his relationships.
The topic of unusual events, or what some define as paranormal or supernatural phenomena, is not typically at the forefront of most clinical discussions between patients and clinicians, in part because they are not of primary concern for patients seeking treatment. However, in my role conducting the Structured Clinical Interview for the DSM Disorders (SCID), I have a platform for discussing them.
In the psychotic symptoms module is a question about unusual religious experiences. Inevitably, patients pause before asking, “What do you mean by unusual?” At this point a dialogue ensues regarding a patient’s personal experience with the supernatural (however they choose to define it) and their interpretation of this experience. The question “Have you ever had visions or seen things others couldn’t see?” sometimes elicits responses about encounters with apparitions of deceased loved ones or patients hearing their name being called or seeing menacing, dark entities.
In the schizotypal personality disorder module are questions about experiences with the supernatural, unseen forces and unusual perceptional experiences. Interestingly, many patients will disclose personal experiences, such as encountering an animal they believe is the spirit of a deceased relative or describing an ability to predict events that others cannot. Some patients report being guided by entities not of this world—or being protected from near fatal situations by inexplicable forces. Such experiences, while unexplainable, may have a profound impact on their outlook for the future or their belief in forces that transcend our worldly knowledge.
I am always struck by patients’ initial hesitancy in sharing these extraordinary events; however, I understand discussing them during a diagnostic interview can seem more stigmatizing than normalizing. I find interesting patients’ insistence on presenting their story with the disclaimer,
“This probably means I’m crazy, but….”
It seems as though there is a tendency in the mental health field to dismiss such occurrences as not only strange but indicative of psychiatric illness, implied, in part, by the fact that such questions even exist in the SCID. At times patients decline further elaboration because their experience is deeply personal and meaningful and fear a diagnostic label or quizzical reaction would be demeaning.
James vs. Freud
The topic of supernatural experiences is nothing new in psychology. In fact, psychologist and philosopher William James wrote about an enormous range of spiritual experiences in The Varieties of Religious Experience: A Study in Human Nature. James believed in an unseen reality and that mystical experiences contributed to a more fulfilling life. Rather than categorizing them as pathological, James sought to include spirituality as a healthy component of psychological functioning. James recounts examples of patients’ mystical encounters in which they felt connected to a higher power through events that ranged from auditory experiences of God talking to them to inexplicable physical energies.
In contrast to James, Sigmund Freud tended to pathologize religion and religious experiences. In The Future of an Illusion, he depicted religion as a manmade illusion created in an attempt to control human instincts (cannibalism, incest and desire to hurt or kill one another). Freud, an outspoken atheist, likened religious practices to neurosis, claiming that humankind had an obsessive need for protection which could only be achieved through a relationship with a father figure (God). Unlike James, Freud viewed spiritual beliefs and experiences as illusions, in part because they lacked scientific explanation. The opposing viewpoints of James and Freud reflect the significant divergence in clinical perception regarding spiritual experiences that persists to this day.
So is it psychotic or on the fringe of psychosis to believe in a spiritual connection with a deceased loved one? Should you be diagnosed with schizotypal personality disorder if you believe that ordinary things in your life are meant to give you a special message? The answer is a resounding…it depends. Schizotypal personality disorder is diagnosed not on the basis of isolated experiences or quirky beliefs, but rather on a cluster of problematic traits. Psychotic disorders are diagnosed on the basis of a major break with reality and significant impairment in functioning. It is unlikely that science will ever be able to make an absolute distinction between what is symptomatic of psychopathology and what is merely an aspect of diverse human experience. This illustrates the significant influence of cultural considerations on diagnoses and demonstrates that diagnoses cannot be reduced to a science. Ultimately, we must rely on human judgment, which makes my work all the more intriguing.