Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-V
This volume is one in a series of 13 books published by American Psychiatric Publishing focusing on "refining the research agenda for DSM-V." Some of these address diagnostic issues while others focus on dimensions important for consideration as DSM-5 is developed, including age and gender considerations, relational processes, and, of course, religious and spiritual issues.
Beyond advancing a research agenda to improve the next iteration of the diagnostic and statistical manual, this volume provides a comprehensive review of the literature in all the major diagnostic areas (depression, schizophrenia and other psychotic disorders, substance use disorders, anxiety and adjustment disorders, posttraumatic stress disorder, personality disorders, and the "V code" of religious and spiritual problems). Each chapter also provides recommendations for changes in the wording of the next version of the DSM to incorporate religious and spiritual factors. In addition, there are chapters addressing child and adolescent psychopathology, religious and spiritual issues in the outline for cultural formulation, and a unique section, more philosophical in nature, on "mapping the logical geography of delusion and spiritual experience" using linguistic analysis. Each section includes 2 brief commentaries allowing for critique or additional ideas to be considered.
The book unfolds with the first 2 chapters focusing on areas in which there is a more robust literature that pertains to religion and/or spirituality—depression, and schizophrenia and other psychotic disorders. The authors of these chapters provide a rich and somewhat dense discussion, including historical background and phenomenology, of the ways in which religious or spiritual themes are present in these 2 large classes of illnesses. Most studies demonstrate that religion and/or spirituality appears to be protective or helpful in preventing mental illness or lessening its severity, but the point is also made that religious influences can be the source of guilt, shame, and scrupulosity.
The chapter by Galanter and Glickman on substance use disorders was a bit surprising. The authors focus their discussion on the use of illicit substances in religious rituals or other accepted social contexts (such as peyote rituals in the Native American Church or community). This provides an interesting and eye-opening revelation of the ways in which illicit substances are utilized and therefore should not be regarded as a substance use disorder, as well as ways in which the stated reason for use (being religious or spiritual) might be abused. Interestingly, however, their chapter did not include any discussion of the application of spirituality so prevalent in 12-step programs for substance use disorder treatment.
Another somewhat surprising chapter was Cloninger’s discussion of "Religious and Spiritual Issues in Personality Disorders." He essentially argues that personality disorders are spiritual (virtue) deficits and that self-awareness and spiritual development are the interventions necessary to address these diagnostic categories. He cites his own work primarily, although he does acknowledge the work of Linehan (who employs mindfulness in dialectical behavioral therapy) and others (D’ Souza, Hayes) who utilize spirituality in cognitive-behavioral therapy. While his argument has some validity, there is a sense of stepping back in time reading this essay, when such things as addiction and mental illness were thought to be due to weakness in moral character. However, both commentators (Stephen Strack, PhD, and George Vaillant, MD) applaud Dr Cloninger for his boldness and integrative thinking, although Dr Vaillant does suggest that some important contributors to this discussion were omitted from Cloninger’s bibliography.
A theme that is ever-present throughout the volume is the relatively recent acceptance by psychiatry in particular and medicine in general of being willing to incorporate issues related to religion or spirituality into its understanding of patients or even include these topics in history-taking and diagnostic formulation. Drs Lukoff, Lu, and Yang, in their chapter "DSM-IV Religious and Spiritual Problems," point out that the inclusion of a V code, Religious or Spiritual Problem, appeared for the first time in DSM-IV (1994), opening the door as an important area for study. The description in DSM-IV-TR is quite limited: "Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution."1(p1393) The authors include many other examples and divide their discussion into typology of religious experiences and spiritual experiences separately. The discussion of typology of spiritual problems is enlightening and interesting. They include mystical, near-death, psychic, alien abduction, meditation and spiritual practice-related, and possession experiences. Although alien abduction seems like an outlier here, the authors support its inclusion because of individuals’ frequent reports of "their lives having been radically altered on a deep spiritual level by the encounters with aliens" (p 186) as well as the need to integrate this anomalous experience (when it is not the product of psychosis).
Gellerman and Lu, who address integrating religion and spirituality into the outline for cultural formulation, provide a very practical set of questions that allow the clinician to easily incorporate religious and spiritually centered information into an interview, while also sensitizing the clinician to the potential for countertransference and bias due to either lack of knowledge or the clinician’s own religious or cultural background.
The final chapter, "Mapping the Logical Geography of Delusional and Spiritual Experience: A Linguistic-Analytic Research Agenda Covering Problems, Methods and Outputs," by Fulford and Sadler, provides us with a philosophical approach and invites psychiatrists to carefully think about what they mean when they apply higher-level concepts such as psychosis and mental illness. The authors introduce (but cannot fully explain in this brief chapter) the analytic philosophy called linguistic analysis. They do present a most interesting case, however, that challenges the reader to be very cautious in determining whether the manifestations of an experience are spiritually derived or the result of a mental illness.
This is a masterful volume, edited by leaders in the field, and provides the reader with excellent literature reviews, practical suggestions, and thought-provoking discussions of an area of psychiatry we must all integrate into our practices to truly understand and provide the best treatment for our patients.
Author affiliations: Departments of Psychiatry and Bioethics, Case Western Reserve University School of Medicine, Cleveland, Ohio. Potential conflicts of interest: None reported.
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