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Religious Factors in Bipolar Disorder

Both delusions and support can spring from religious beliefs

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Updated March 16, 2013

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Included on the list of mania and hypomania symptoms is "increased focus on religion or religious activities." This isn't unique to bipolar by any means, as this symptom is also common in schizophrenia, schizophreniform disorder, schizoaffective disorder and other psychotic disorders.

This increased religiosity may take many forms. Some examples (using hypothetical patients):

  • Janie was raised in a Protestant home but stopped going to church in her teens. After the onset of bipolar symptoms, though, she began going to more than one service a week, volunteering, joining study groups, and seeking personal religious counseling from the minister.

  • Ed had never been to any religious service or events in his life, but as he developed symptoms of a mental illness, later diagnosed as schizophrenia, he began talking to friends about God more and more, reading the Bible, eventually falling to his knees and praying aloud regardless of where he was.

  • When Terri, a devout Jew all her life, developed schizoaffective disorder, she became convinced that God felt she was unworthy and attempted suicide.

  • Jerry, who has bipolar disorder, began to focus more on his religious beliefs when his symptoms began, finding they help sustain him in difficult times.
Terri's doctor may well immediately diagnose her with having religious delusions. But in the cases of Janie and Ed, a psychiatrist might feel such a diagnosis would be premature. And in Jerry's case, at this point his beliefs appear to be supportive rather than problematic.

As Professor H.G. Koenig, in his review of literature on the subject, wrote in his findings, "While about one-third of psychoses have religious delusions, not all religious experiences are psychotic." Indeed, he went on to say, they may be of benefit to the patient -- as in Jerry's case. When religious delusions aren't immediately obvious, the treating clinician needs to examine the patient's religious beliefs and behaviors carefully, said Koenig.

What Are Religious Delusions?

Delusions are defined as "false beliefs firmly held," and types include paranoid or persecutory delusions, delusions of reference, delusions of grandeur, delusional jealousy and others. Two of these in particular may express themselves in a religious context. Here are examples:

Religious paranoid delusions: "Demons are watching me, following me, waiting to punish me if I do anything they don't like," or "If I put on my shoes, God will set them on fire to punish me, so I have to go barefoot all the time." Auditory hallucinations, such as, "The voices keep telling me there are devils in my room," are often combined with religious paranoia.

Religious delusions of grandeur: "God has exalted me above you normal people. He tells me I don't need help, don't need medicine. I'm going to heaven and all of you are going to go to hell," or "I am Christ reborn."

Cultural Effects on Religious Delusions

Interestingly, one meta-analysis reported on studies that appear to show a higher incidence of religious delusions among schizophrenia patients in predominantly Christian countries than in other populations. For example:
  • The rate of religious delusions in Germany was 21.3% vs. 6.8% in Japan.
  • The rate in Austria was 21% vs. 6% in Pakistan.
That culture has a strong impact on this was supported by the finding that "[i]n Egypt, the fluctuations in the frequency of religious delusions over a period of 20 years have been linked to changing patterns of religious emphasis." The same analysis reported, "A rate of 36% of religious delusions was observed among inpatients with schizophrenia in the USA." In addition, research found that "in the case of paranoid delusion, the persecutors were more often supernatural beings among Christians than among Muslims and Buddhists."

Koenig reported that "Persons with severe and persistent mental illness often present for treatment with religious delusions. In the United States, approximately 25-39% of patients with schizophrenia and 15-22% of those with mania/bipolar disorder have religious delusions."

Impact of Religion and Religious Delusions in Psychotic Disorders

This is an area, researchers say, that needs further study. It appears that a high proportion of patients with psychotic disorders consider spiritual faith to be an important coping mechanism. For those who are not delusional, religious beliefs and activities as coping mechanisms have been found in some studies to be associated with better outcomes for the illness as a whole.

Conversely, having religious delusions has been found to be associated with a more serious course of illness and poorer outcomes. One study found that patients with religious delusions had more severe psychotic symptoms, a longer history of illness, and poorer functioning prior to the onset of a psychotic episode.

You can see why, then, it's essential for clinicians to be aware of these differences. Researchers urge doctors to include a patient's beliefs in evaluating the patient as a whole, and use care in distinguishing between strong beliefs and delusions.

Religion, Delusion and Psychosis

The fact that the culture of a country has a profound effect on the incidence of religious delusions suggests many areas of interest -- especially when you add in study results that found Protestants had twice the rate of religious delusions than Catholics or non-religious patients.

Writers and researchers agree on one thing -- that those who treat people with psychoses need to be sensitive to a patient's non-delusional religious beliefs, both in distinguishing them from delusions and in evaluating how helpful they are to the patient.

Sources:

Koenig, HG Religion, spirituality and psychotic disorders. Revista de Psiquiatria Clínica 34, supl 1; 40-48, 2007.

Mohr, S, Huguelet, P. The relationship between schizophrenia and religion and its implications for care. Swiss Medical Weekly. 2004 Jun 26;134(25-26):369-76.

Raja M, Azzoni A, Lubich L. Religious delusion (PDF). Schweizer Archiv für Neurologie und Psychiatrie. 2000;151:22–9.

Tateyama M, Asai M, Kamisada M, Hashimoto M, Bartels M, Heimann H. Comparison of schizophrenic delusions between Japan and Germany. Psychopathology. 1993;26(3-4):151-8.

Stompe T, Friedman A, Ortwein G, Strobl R, Chaudhry HR, Najam N, et al. Comparison of delusions among schizophrenics in Austria and in Pakistan. Psychopathology. 1999;32: 225–34.

Atallah SF, El-Dosoky AR, Coker EM, Nabil KM, El-Islam MF. A 22-year retrospective analysis of the changing frequency and patterns of religious symptoms among inpatients with psychotic illness in Egypt. Social Psychiatry and Psychiatric Epidemiology. 2001 Aug;36(8):407-15.

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