Psychological characteristics of religious delusions

Robel Iyassu 0 1 2 3 4 Suzanne Jolley 0 1 2 3 4 Paul Bebbington 0 1 2 3 4 Graham Dunn 0 1 2 3 4 Richard Emsley 0 1 2 3 4 Daniel Freeman 0 1 2 3 4 David Fowler 0 1 2 3 4 Amy Hardy 0 1 2 3 4 Helen Waller 0 1 2 3 4 Elizabeth Kuipers 0 1 2 3 4 Philippa Garety 0 1 2 3 4 0 G. Dunn R. Emsley Health Sciences Research Group, School of Community Based Medicine, University of Manchester , Manchester, UK 1 P. Bebbington Department of Mental Health Sciences , UCL, London, UK 2 R. Iyassu S. Jolley (&) A. Hardy P. Garety PO77 Department of Psychology, King's College London, Institute of Psychiatry, University of London , Denmark Hill, London SE5 8AF, UK 3 D. Fowler School of Medicine, Health Policy and Practice, University of East Anglia , Norwich, UK 4 D. Freeman Department of Psychiatry, University of Oxford , Oxford, UK Purpose Religious delusions are common and are considered to be particularly difficult to treat. In this study we investigated what psychological processes may underlie the reported treatment resistance. In particular, we focused on the perceptual, cognitive, affective and behavioural mechanisms held to maintain delusions in cognitive models of psychosis, as these form the key treatment targets in cognitive behavioural therapy. We compared religious delusions to delusions with other content. Methods Comprehensive measures of symptoms and psychological processes were completed by 383 adult participants with delusions and a schizophrenia spectrum diagnosis, drawn from two large studies of cognitive behavioural therapy for psychosis. Results Binary logistic regression showed that religious delusions were associated with higher levels of grandiosity H. Waller E. Kuipers (OR 7.5; 95 % CI 3.9-14.1), passivity experiences, having internal evidence for their delusion (anomalous experiences or mood states), and being willing to consider alternatives to their delusion (95 % CI for ORs 1.1-8.6). Levels of negative symptoms were lower. No differences were found in delusional conviction, insight or attitudes towards treatment. Conclusions Levels of positive symptoms, particularly anomalous experiences and grandiosity, were high, and may contribute to symptom persistence. However, contrary to previous reports, we found no evidence that people with religious delusions would be less likely to engage in any form of help. Higher levels of flexibility may make them particularly amenable to cognitive behavioural approaches, but particular care should be taken to preserve self-esteem and valued aspects of beliefs and experiences. - Delusions are a cardinal feature of psychotic illness, present in around three quarters of people with a schizophrenia spectrum diagnosis [1, 2]. Religious themes are common across delusion categories and types, with between a fifth and two-thirds of all delusions reflecting religious content [36]. To be classified as a religious delusion, the belief must be idiosyncratic, rather than accepted within a particular culture or subculture [7]. Strongly held beliefs that are shared within an existing religious or spiritual context would not, therefore, be considered to be religious delusions, irrespective of cooccurring psychosis. For example, believing oneself to be able to hear the voice of Jesus is not uncommon in a Christian society and thus would not in itself be classified as a religious delusion. In contrast, believing oneself to be inhabited by the warring spirits of multiple interspatial deities, would be considered to be a religious delusion. Culturally acceptable religious beliefs are cited as an important coping strategy for many people with schizophrenia, and may contribute to lower symptom severity in both severe and enduring mental illnesses [8, 9] and common mental disorders [10, 11]. Religious delusions, in contrast, have routinely been linked to poorer prognosis for people with psychotic disorders [12]. Levels of disability, distress and conviction have all been reported to be higher in people with religious delusions compared to other types of delusions [1, 3, 4, 1315]. Religious delusions are also associated with poor engagement, low satisfaction with services and with treatment, and longer duration of untreated psychosis [12, 1619]. People with religious delusions appear, therefore, to be a particularly problematic group to treat effectively, and ought to be targeted for psychological therapies [20, 21]. However, as the mechanisms underlying the treatment resistance are poorly understood, further study is required to establish what the particular foci of psychological intervention for people with religious delusions should be, and what issues are likely to arise in implementation. Cognitive models of psychosis [22, 23] identify specific psychological maintaining factors for delusions. Prominent amongst these are persisting anomalous experiences, reasoning biases, affective processes, and poor adjustment to psychosis resulting from personal beliefs about illness, treatment and recovery. Religious delusions can be plausibly linked to increased difficulty in all these areas. Anomalous experiences These may be perceived as having religious significance (e.g., communications from higher powers) and thus be specifically attended to, engaged with and even deliberately induced. Frequent anomalous experiences provide repeated evidence to sustain the delusion. Reasoning biases Delusions are considered to arise from, and be maintained by, biases and errors in evidencebased reasoning. These include jumping to conclusions (JTC) by making decisions based on limited data, and belief inflexibility, comprising difficulty adjusting beliefs in response to contradictory evidence; difficulty considering the possibility of being mistaken; and difficulty identifying plausible alternative explanations [24]. Faith, by its nature, relies on foundations other than a systematic and evolving evidence base, and religious or spiritual insights tend to be based on revelation, dramatic events or inner conviction, rather than a process of hypothesis testing. It is also common, and, in some religions, even desirable, for religious beliefs to be held with high conviction, certainty of rectitude (rather than possibility of being mistaken), and without alternatives. Should these features of religious beliefs equally characterise delusions with religious content, reasoning biases may be particularly prominent, and thus contribute to severity, persistence, and higher levels of conviction. Affective disturbance Affective processes are implicated in the onset and maintenance of delusions by their impact on attentional, perceptual, interpretative and memory processes, and through maladaptive coping and affect regulation strategies [25]. Religious delusions, by definition, concern themes of universal existential import, and are therefore likely to be particularly associated with strong affect, with consequent cognitive-perceptual and behavioural changes which may act to furth (...truncated)