SPIRITUAL EMERGENCIES AS DSM-IV SPIRITUAL PROBLEMS
DIAGNOSIS OF SPIRITUAL EMERGENCY
DIAGNOSTIC CRITERIA FOR SPIRITUAL EMERGENCY
CASE EXAMPLE

SPIRITUAL EMERGENCIES AS DSM-IV SPIRITUAL PROBLEMS
Spiritual emergencies warrant the DSM-IV diagnosis of Religious or Spiritual Problem (V62.89), even though at times there may be symptoms of a mental disorder present. In this way, Religious or Spiritual Problem is comparable to the category Bereavement for which the DSM-IV notes that even when a person's reaction to a death meets the diagnostic criteria for Major Depressive Episode, the diagnosis of a mental disorder is not given because the symptoms result from a normal reaction to the death of a loved one. Rather, the diagnosis of Bereavement, which is in the same section as Religious or Spiritual Problem (Other Conditions that may be the Focus of Clinical Attention) is assigned.

Similarly, in the case of spiritual emergencies, sequellae involving hallucinations, delusions, anger, and interpersonal difficulties occur so frequently that they should be considered normal and expectable reactions to the stressful spiritual awakening. Therefore they should not be diagnosed or treated as mental disorders, but rather as Religious or Spiritual Problems that can lead to long-term improvement in overall well-being and functioning.

DIAGNOSIS OF SPIRITUAL EMERGENCY
Criteria for making the differential diagnosis between psychopathology and authentic spiritual experiences have been proposed by Agosin [1], Grof and Grof [2] and Lukoff [3]. There is considerable overlap among the proposed criteria. Wilber [4] argues that confusion in distinguishing intense spiritual experiences from psychosis has been created by failing to make the critical distinction between pre-rational states and authentic transpersonal states. This "pre/trans fallacy" has been perpetuated:

    "since both prepersonal and transpersonal are, in their own ways, nonpersonal, then prepersonal and transpersonal tend to appear similar, even identical, to the untutored eye" (p. 125).

The diagnostic criteria listed below were originally published in the Journal of Transpersonal Psychology, in 1985 in an article entitled Diagnosis of Mystical Experience with Psychotic Features. The use of operational criteria is intended to identify cases of spiritual emergency with a high degree of accuracy (validity) and consistency across different diagnosticians (reliability). The specific criteria proposed below represent hypotheses that must be subjected to studies to determine whether they achieve acceptable levels of interrater agreement and whether they accurately identify positively transforming experiences.

DIAGNOSTIC CRITERIA FOR SPIRITUAL EMERGENCY

  1. Phenomenological overlap with one of the types of spiritual emergency
  2. Prognostic signs are indicative of a positive outcome
  3. The person is not a significant risk for homicidal or suicidal behavior

1. Phenomenological overlap with one of the types of spiritual emergency
Criterion 1 is based on the clinician's ability to recognize phenomenological characteristics of the types of spiritual emergency. I have proposed five criteria by which phenomenological overlap with a mystical experience can be identified. Assessment of overlap for other types can be based on the phenomenology as described in Lesson 4 on Types of Spiritual Emergencies.

1) ecstatic mood
The most consistent feature of the mystical experience is elevation of mood. Laski (1968) describes it as a state with "feelings of a new life, another world, joy, salvation, perfection, satisfaction, glory" (cited in Perry [5] p. 84). Bucke [6] examined the experiences of well-known mystics, leaders, and artists, as well as his own mystical experience, and noted they all shared "a sense of exultation, of immense joyousness (p. 9). James [7] also points to the "mystical feeling of enlargement, union and emancipation" (p. 334), and claims that "mystical states are more like states of feeling than like states of intellect" (p. 300).

2) sense of newly-gained knowledge
Feelings of enhanced intellectual understanding and the belief that the mysteries of life have been revealed are commonly reported in mystical experiences (Leuba [8]). James [7] describes this phenomenon of newly-gained knowledge ("gnoesis"): They are states of insight into the depths of truth unplumbed by the discursive intellect. They are illuminations, revelations, full of significance and importance (p. 33). Jacob Boehme, a seventeenth-century shoemaker whose mystical experience ushered in a new vocation as a nature philosopher, reported: In one-quarter of an hour, l saw and knew more than if I had been many years together at a university. For I saw and knew the being of all things (cited in Perry [5] p. 92).

3) perceptual alterations
Mystical experiences often involve perceptual alterations ranging from heightened sensations to auditory and visual hallucinations. Boehme felt himself surrounded by light during his mystical experience. Visual and auditory hallucinations with religious content are also common, e.g., Saint Therese saw angels and Saint Paul heard the voice of Jesus Christ saying "Paul, Paul, why persecutes thou me?' (Acts: 3-4).

4) delusions with specific themes related to mythology
James [7] and Neuman [9] have both commented on the diversity of content in mystical experiences across time and cultures. The mystical experience does not have

specific intellectual content whatever of its own. It is capable of forming matrimonial alliances with material furnished by the most diverse philosophies and theologies. (James [7] p. 333)

Electronic media have greatly increased the repertoire of cultural material available for incorporation into both mystical and psychotic experiences. Individuals who in the past might have claimed to be St. Luke, may now claim to be Luke Skywalker.

However, Perry points out that below the surface level of specific identities and beliefs are thematic similarities in the accounts of patients whose psychotic episodes have good outcomes:

There appears to be one kind of episode which can be characterized by its content, by its imagery, enough to merit its recognition as a syndrome. In it there is a clustering of symbolic contents into a number of major themes strangely alike from one case to another (p.9).

Based on Perry's research and other accounts of patients with positive outcomes, the following eight themes were identified as occurring commonly in spiritual emergencies

1. Death: being dead, meeting the dead or meeting Death.
2. Rebirth: new identity, new name, resurrection, apotheosis to god, king or messiah
3. Journey: Sense of being on a journey or mission.
4. Encounters with Spirits: demonic forces and/or helping spirits.
5. Cosmic conflict: good/evil, communists/Americans, light/dark, male/female.
6. Magical powers: telepathy, clairvoyance, ability to read minds, move objects.
7. New society: radical change in society, religion, New Age, utopia, world peace.
8. Divine union: God as father, mother, child; Marriage to God, Christ, Virgin Mary, Radha or Krishna.

In contrast, the following statements from schizophrenic patients I have worked with illustrate that not all delusions have content related to the eight mythic themes described above.

My brain has been removed.
A transmitter has been implanted into my brain and broadcasts all my thoughts to others.
My parents drain my blood every night.
The Mafia is poisoning my food and trying to kill me.
My thoughts are being stolen and it interferes with my ability to think clearly.
The person claiming to be my wife is only impersonating her. She's not my wife.

Familiarity with the range and variation of content in myth, religion and psychosis is essential for determining which delusions have mythic themes.

5) absence of conceptual disorganization.
Some psychotic patients have cognitive deficits which cause them difficulty with their basic thought processes. For example, a person with schizophrenia complained, "I get lost in the spaces between words in sentences. I can't concentrate, or I get off onto thinking about something else" (in Estroff [10] p. 223). Systematic comparisons of first person accounts of mystical experiences and schizophrenia have found that "Thought blocking and other disturbances in language and speech do not appear to accompany the mystical experience" (Buckley p. 521). Therefore, the presence of conceptual disorganization, as evidenced by disruption in thought, incoherence and blocking, would indicate the person is experiencing something other than a spiritual emergency.

2. Prognostic signs are indicative of a positive outcome
Criterion 2 is based on research-validated good prognostic indicators that help predict positive long term outcome. The features listed below are based on a survey of the outcome literature (Lukoff, 1986
). Good prognostic indicators include:

1) good pre-episode functioning
2) acute onset of symptoms during a period of three months or less
3) stressful precipitant to the psychotic episode
4) a positive exploratory attitude toward the experience.

3. The person is not a significant risk for homicidal or suicidal behavior
Criterion 3 concerns issues which might require treatment in a restricted environment. Psychotic disorders can be the basis for homicidal and suicidal behaviors. Both John Lennon and President Reagan were shot by persons with previously diagnosed psychotic disorders. Arieti & Schreiber [11] have described the case of a multiple murderer whose auditory hallucinations from God and delusions of being on a religious mission fueled his bizarre and bloody killings.

Assessment of dangerous and suicidality are legal responsibilities of licensed mental health professionals. This exclusionary criterion should be implemented only if the danger seems imminent. Behavior which appears bizarre, but presents no risk to self or others, does not warrant use of this criterion.

Even with the use of these criteria, it is often difficult to distinguish spiritual emergencies from episodes of mental disorder. Agosin (1991) has pointed out that,

Both are an attempt at renewal, transformation, and healing (p. 52).

CASE EXAMPLE
The application of these diagnostic criteria is illustrated in the Case Library of Spiritual Emergencies.

Diagnostic Example.

REFERENCES
Agosin, T. (1992). Psychosis, dreams and mysticism in the clinical domain. In F. Halligan & J. Shea (Eds.), The fires of desire. New York: Crossroad.

Grof, S., & Grof, C. (Eds.). (1989). Spiritual emergency: When personal transformation becomes a crisis. Los Angeles: Tarcher.

Lukoff, D. (1985). The diagnosis of mystical experiences with psychotic features. Journal of Transpersonal Psychology, 17(2), 155-181.

Wilber, K. (1980).The pre/trans fallacy. Re-Vision, 3, 51-72.

Perry, J. (1974). The far side of madness. Englewood Cliffs, NJ: Prentice Hall.

Bucke, R. (1969). Cosmic Consciousness. New York: Dutton.

James W (1961). The varieties of religious experience. New York: MacMillan.

Leuba J H (1929). Psychology of religious mysticism. New York: Harcourt and Brace.

Neumann E (1964) Mystical man. In J Campbell (Ed), The mystic vision. Princeton, NJ: Princeton University Press.

Estroff, S. (1981). Making it crazy. Berkeley: Univ. California Press.

Arieti, S. and Schreiber, F. (1981). Multiple murders of a schizophrenic patient. J American Academy of Psychoanalysis, 9(2), 501-529.

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