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July 2010 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Menezes, A, Jr. and Moreira-Almeida, A. "Religion, spirituality, and psychosis." Current Psychiatry Reports 12, no. 3 (June 2010): 174-179.


SUMMARY and COMMENT: This month's article is a research-minded review arguing for more research into the relationship between spirituality and mental illness and greater attention to the clinical differentiation between spiritual experiences and psychoses --a subject of practical importance for many chaplains. The piece is also noteworthy in bringing a perspective from South America, specifically Brazil. Menezes is a psychologist with the Research Center in Spirituality and Health at the Federal University of Juiz de Fora School of Medicine, and Moreira-Almeida is the Director of that Center and Professor of Psychiatry. They draw largely upon their work in an article published in 2009 in the Brazilian journal, Revista de Psiquiatria Clínica: "Differential diagnosis between spiritual experiences and mental disorders of religious content" [--see Related Items of Interest, §1, below.]

The piece is set out in four main parts: 1) consideration of the concept of a Religious or Spiritual Problem (i.e., the DSM-IV diagnostic category) and Spiritual Emergence/Emergency, 2) notes about the incidence of psychotic symptoms in nonclinical populations, 3) a brief review of how religion often plays into psychotic experience, and 4) the proposal of a set of criteria for differential diagnosis. For chaplains, the first and fourth parts will likely be the most interesting, though the middle two parts fill out the picture of "the relationships between religion, spirituality, and psychosis" [p. 174] and touch upon a number of intriguing research findings.

In the section on Spiritual or Religious Problems, the authors explain the use of the DSM-IV category for religious/spiritual experiences that "may in certain situations be distressing and lead to the search for assessment and medical or psychological treatment" [p. 175]. Such problems "are not necessarily mental disorders and instead may be just an a new phase or life experience with potentially positive future effects" [p. 175]. Menezes and Moreira-Almeida focus specifically on the need to distinguish Spiritual Emergence/Emergency from psychosis.

Spiritual emergence is defined as critical stages of a deep psychological change that result in uncommon states of consciousness, intense emotions, visions, unusual thoughts, and several physical manifestations. A near-death experience, the birth or loss of a child, a divorce, financial ruin, as well as spiritual practices such as chanting religious hymns or doing meditation or yoga exercises may be triggering agents of spiritual emergences. …When this process occurs in an ordained and gradual way, the experience does not generate crisis, but when it occurs in a fast and chaotic way, it does cause a crisis. In this sense, there is a difference between spiritual emergence and spiritual emergency. The former refers to the spiritual unfolding of a spiritual potentiality without the disturbance of psychological functions, whereas the latter is the uncontrolled occurrence of a spiritual experience along with disturbances in psychological, social, and occupational functioning. …The symptoms of spiritual emergency may be similar to those of the psychotic prodome, the period that precedes the onset of full-blown psychosis. …[But, they] should not be diagnosed as mental disorders because they can evolve into spiritual awakening in the end. From this awakening, the person may reach a more mature form; a sensation of deep connection with other people, nature, and the cosmos; as well as overall well-being and functioning." [p. 175]
Ultimately, the authors address particular criteria for a differential diagnosis between spiritual experiences and psychotic disorders. They review several models by Koenig, Lukoff, Hufford, and Jackson & Fulford [--see Items of Related Interest, §3, below], before presenting their own (summarizing the nine criteria from their 2009 article):
  • Absence of psychological suffering: the individual does not feel disturbed due to the experience he or she is having.
  • Absence of social and occupational impediments: the experience does not compromise the individual’s relationships and activities.
  • The experience has a short duration and happens occasionally: it does not have an invasive character in consciousness and in the individual’s daily activities.
  • There is a critical attitude about the experience: the capacity to perceive the unusual nature of the experi- ence is preserved.
  • Compatibility of the experience with some religious tradition: the individual’s experience may be understood within the concepts and practices of some established religious tradition.
  • Absence of psychiatric comorbidities: there are no other mental disorders or other symptoms suggestive of mental disorders besides those related to spiritual experiences.
  • Control over the experience: the individual is capable of directing his or her experience in the right time and place for its occurrence.
  • Life becomes more meaningful: the individual reaches a more comprehensive understanding of his or her own life.
  • The individual is concerned with helping others: the expanded consciousness develops a deep link with other human beings.

The content of the article seems quite generally applicable beyond its Brazilian context, but it contains some indications that it comes from outside of the mainstream of the North American literature on spirituality and health. For one, it notes research on "spiritist mediums" in Brazil [p. 176]. Spiritism, a branch of the spiritualist movement that emerged in France in the latter 19th century, is rarely mentioned in the health care literature in the United States in spite of the presence of the tradition [--the 3rd US Spiritist Medical Congress was held on the campus of George Washington University in Washington, DC, in June 2010] and its widespread popularity in Puerto Rico. Moreira-Almeida has done considerable research on this subject in Brazil. Another shift apparent from the North American literature lies in a more global perspective on the research literature, for example: one paragraph (--beginning at the bottom of p. 176) cites studies from Nigeria, Brazil, Germany, Japan, and the US.

One final note: The authors specially mark those items in their bibliography that are deemed "of importance" and "of major importance." This practice adds stand-alone value to the list of references.


Suggestions for the Use of the Article for Discussion in CPE: 

While this article would be of obvious interest to psychiatric chaplains, it should be engaging to CPE students in general. Students might want to consider at the outset what informal criteria they've used to distinguish between a patient's spiritual concerns that could potentially be addressed by a chaplain and possible psychotic symptoms for which psychiatric expertise would be necessary for full assessment. In their own work with patients, how have they differentiated between extraordinary spiritual experience and pathological issues, especially in a non-psychiatric patient population? When have they thought (to put it bluntly), "This person needs psych meds," and why? The complexity of the relationship between spirituality and mental health is illustrated throughout this brief article. What do students make of the authors' nine-point criteria [pp. 177-178]? Can a valid spiritual experience involve experiences contrary to the notion of mental health (for example, prolonged psychological suffering)? Such a question may have a theological answer in tension with a medical one, and if so, how do students work with that professional and/or personal tension? Also, students should pay attention to the authors' perspective from their Brazilian context --the subtle shift in language, allusions, and research references from the North American authors who dominate English literature on spirituality and health.


Related Items of Interest:

I. For more on the authors' criteria for differentiating spiritual experiences from mental disorders, see:

Menezes, A. de, Jr. and Moreira-Almeida, A. "Differential diagnosis between spiritual experiences and mental disorders of religious content." Revista de Psiquiatria Clínica 36, no. 2 (2009): 75-82. [This article goes into more detail about the criteria that the authors' propose (--see especially, pp. 80-81) and gives numerous references for each criterion. It is available online at]

Moreira-Almeida A. "Differentiating spiritual from psychotic experiences." British Journal of Psychiatry 195, no. 4 (October 2009): 370-371. [This is a letter in response to short column in the journal: Stein, G., "Did Ezekiel have first-rank symptoms?" (vol. 194, no. 6, p. 551).]


II. Health care research on spirituality is just now emerging in Brazil. The recently established website of the Research Center in Spirituality and Health (Nucleo de Pesquisa em Espiritualidade e Saude) at the Federal University of Juiz de Fora School of Medicine offers a good bit of information pertinent to the work of Alexander Moreira-Almeida. Also, for a brief background to spirituality as a topic in current Brazilian medicine, see:

Lucchetti, G. and Granero, A. "Integration of spirituality courses in Brazilian medical schools." Medical Education 44, no. 5 (May 2010): 527. [The authors note the important role of the journal, Revista de Psiquiatria Clínica, specifically a groundbreaking special issue in 2007. That issue is available in English at]


III. Menezes and Moreira-Almeida mention several models for differentiating spiritual experience from psychosis (--see p. 177). Below are the references for those models. [Note that the date of the Jackson & Fulford reference is corrected from that which appears in Menezes and Moreira-Almeida's bibliography.]

Hufford, D. J. "Visionary spiritual experiences and cognitive aspects of spiritual transformation." The Global Spiral 9, no. 5 (September 2008): online journal, available at [The author presents the historical understanding of visionary spiritual experiences in health science and makes a case for these phenomena to be accepted as relatively common and usually healthy occurrences. Bereavement visits, near death experiences, and sleep paralysis with a spiritual presence are specifically considered, with the former two especially linked to helpful spiritual transformation in people's lives. The article is available online at 10610/Default.aspx.]

Jackson, M. and Fulford, K. W. M. "Spiritual experience and psychopathology." Philosophy, Psychiatry, and Psychology 4, no. 1 (March 1997): 41-65. [(Abstract:) A recent study of the relationship between spiritual experience and psychopathology (M. C. Jackson, 1991) suggested that psychotic phenomena could occur in the context of spiritual experiences rather than mental illness. In the present paper, this finding is illustrated with 3 detailed case histories. Its implications are then explored for psychopathology, for psychiatric classification, and for the understanding of the concept of mental illness. It is argued that pathological and spiritual psychotic phenomena cannot be distinguished by form and content alone (as in traditional psychopathology), by their relationship either with other symptoms or with pathological causes (as in psychiatric classification), or by reference to the descriptive criteria of mental illness implied by the "medical" model. The distinction is shown to depend, rather, on the way in which psychotic phenomena themselves are embedded in the values and beliefs of the person concerned. This in turn is shown to have implications for diagnosis, for treatment, and for research in psychopathology.]

Koenig, H. G. "Religion, spirituality and psychotic disorders." Revista de Psiquiatria Clínica 34, suppl. 1 (2007): 40-48. [This article is available online at (Abstract:) Background: Religion is often included in the beliefs and experiences of psychotic patients, and therefore becomes the target of psychiatric interventions. Objectives: This article examines religious beliefs and activities among non- psychotic persons in the United States, Brazil and other areas of the world; discusses historical factors contributing to the wall of separation between religion and psychiatry today; reviews studies on the prevalence of religious delusions in patients with schizophrenia, bipolar disorder, and other severe mental disorders; discusses how clinicians can dis- tinguish pathological from non-pathological religious involvement; explores how persons with severe mental illness use non-pathological religious beliefs to cope with their disorder; examines the effects of religious involvement on disease course, psychotic exacerbations, and hospitalization; and describes religious or spiritual interventions that may assist in treatment. Methods: Literature review. Findings: While about one-third of psychoses have religious delusions, not all religious experiences are psychotic. In fact, they may even have positive effects on the course of severe mental illness, forcing clinicians to make a decision on whether to treat religious beliefs and discourage reli- gious experiences, or to support them. Conclusions: Clinicians should understand the negative and positive roles that religion plays in those with psychotic disorders.]

Lukoff, D. "Visionary spiritual experiences." Southern Medical Journal 100, no. 6 (June 2007): 635–641. [This exposition on Visionary Spiritual Experiences is available online at]


IV. For more on spirituality and mental health, see our June 2009 Article-of-the-Month page, and see also the following:

Moreira-Almeida, A., Neto, F. L. and Koenig, H. G. "Religiousness and mental health: a review." Revista Brasileira de Psiquiatria 28, no. 3 (September 2006): 242-250. [This review, with 100 references, is available online at Note that the lead author is Alexander Moreira-Almeida, and Harold G. Koenig is a co-author.]



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