Case Example: Diagnostic Criteria for Spiritual Emergency
From Spiritual Competency Resource Center
© Dr. David Lukoff 1994, 2014


To illustrate the use of the spiritual emergency diagnostic criteria, they are applied below to a case study of a person who was hospitalized for a psychotic episode, but whose experience was a positively-transforming spiritual emergency. This approach is contrasted with the medical model diagnosis of the same experience as a psychotic disorder.<

  • Brief account of the case of Howard
  • Full case study of Howard

The presence of either delusions or hallucinations without insight into their pathological nature is the basis for a diagnosis of a psychotic disorder in the Diagnostic and Statistical Manual-IV. What types of psychotic symptoms would be considered present in Howard's Mental Odyssey? To answer this question, the author administered a one-hour retrospective mental status exam to Howard. This type of interview is designed to elicit and identify specific types of hallucinations and delusions. The following is a presentation of Howard's Mental Odyssey as psychotic symptoms.

A delusion is defined as,
    a false personal belief based on incorrect inference about external reality and firmly sustained despite of what everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary (DSM-IV, p. 765).

During his Mental Odyssey, Howard made incorrect inferences about external reality, e.g., he thought that death rays were being projected at him by another patient. He did not accurately discriminate between his inner subjective experiences and objective dimensions of the world. He sustained these beliefs despite the insistence of everyone else that he was wrong. Howard was preoccupied with his mythic inner reality, and in projecting these beliefs onto outer reality, he would be considered delusional.

Based on the results of the mental status examination, Howard had the following delusions: Thought Insertion, Reference, Grandiose Abilities, Religious, Paranormal.

A hallucination is defined as,
    A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ (DSM-IV, p. 767).

Some of Howard's experiences fit this definition. Based on the mental status exam, had both visual and tactile hallucinations.

In addition to the above psychotic symptoms, Howard also showed elevated mood for several weeks as well as five symptoms listed in DSM-IV as characteristic of a manic episode: decreased need for sleep, pressured speech, flight of ideas, inflated self-esteem, distractibility

Because of the mixture of both psychotic and affective symptoms, Howard's case presents a diagnostic dilemma. At the time of his hospitalization, Howard's psychotic symptoms led to his being assigned the DSM-I (APA, 1952) diagnosis of Acute Schizophrenic Reaction. However, since the DSM-II (APA, 1968) was in effect at the time, his proper DSM diagnosis should have been Acute Schizophrenic Episode, 295.4. However, he was diagnosed, medicated, and hospitalized as a schizophrenic patient.

How would Howard be diagnosed within the DSM-IV?
Howard would meet the symptom criteria for both Schizophreniform Disorder (schizophrenia of less than 6 months duration) and Bipolar Disorder, Manic Type. Brief Psychotic Disorder would be ruled out since the symptoms persisted for over 2 weeks.) In cases where criteria for both a Schizophreniform and an Mood Disorder are met, the differential diagnosis hinges on whether there is preoccupation with mood-incongruent hallucinations or delusions or bizarre behavior either before or after the manic symptoms. Persisting or predating mood-incongruent features would indicate a Schizophreniform Disorder whereas their absence would result in a diagnosis of Bipolar Disorder.

In Howard's case, there were transient mood-incongruent features, i.e., psychotic symptoms not related to his elevated mood, such as the delusion of death rays being projected at him and seeing the face of Death. However, they did not persist outside the period of his elevated mood. Thus, he more closely meets the criteria for DSM-IV Bipolar Disorder, Manic with Mood-incongruent Psychotic Features (296.04).

Both the mental status exam I administered and 15 interviews with him are used to examine Howard's experience in terms of the diagnostic criteria for spiritual emergency.

I. Overlap with the mystical experience
A. Ecstatic mood. After first reporting that his experience was "beyond words," Howard later went on to describe his mood with words including "ecstasy" and "rapture." Despite finding no support or acknowledgment of his situation, this mood persisted for several weeks of his hospitalization.

B. Sense of newly-gained knowledge. Howard believed that he had unlocked some elemental truths of universal importance. He felt his insights were of such importance that the scientific community should study and document what he was discovering.

C. Perceptual alterations. While in his hospital room, Howard had visual hallucinations of yellow birds against a brilliant orange sky. He also saw the face of Death in a tree stump.

D. Delusions with mythological-related themes.
  • Death: Howard saw the face of Death and agreed that he would kill people if necessary to fulfill his mission.
  • Rebirth: Howard felt he had been reborn into a new identity as the albatross.
  • Journey: Howard thought he had the mission to show others the way into the Mental Odyssey experience and that he was being prepared for Enlightenment.
  • Encounters with spirits: Howard communicated with his muse and the Devil interfered with his trip up the mountain.
  • Magical powers: Howard believed he had acquired special powers such as mastery over time and space and the ability to summon elevators at will.
  • New society: Howard thought he was the Pied Piper heralding in a new society.

E. No conceptual disorganization. Although Howard's metaphorical use of language was difficult for others to understand at times, he never showed incoherence or thought-blocking. His ideas were always expressed lucidly.

These examples show that Howard met all 5 of the criteria which indicate overlap with the mystical experience.

II. Positive outcome likely
Good pre-episode functioning was evidenced by Howard's lack of any previous psychotic episodes, his completion of high school and his network of male friends. He also met the criteria for acute onset of symptoms since they developed during a span of a few days. A positive attitude toward the experience was maintained by Howard throughout his hospitalization.

While there was no obvious external stressor, he was at an age (19) when many persons experience an adolescent identity crisis. But the three criteria he clearly did meet would satisfy the criterion of at least two good prognostic signs.

III. Low risk
When challenged by his brother's question, "Would you kill people to achieve your mission?" Howard responded that he would. This type of threatening statement needs to be checked out by a clinician who is familiar both with signs of homicidal dangerousness in patients and also with death/rebirth themes characteristic of spiritual emergencies. In Howard's case, further probing revealed the metaphorical basis of his preoccupation with death themes rather than a danger that he'd commit actual homicide. He was clearly not a suicide risk, so the Low Risk criterion would also have been met.

Thus Howard represents a clear case of spiritual emergency, someone who could have been treated without hospitalization or medication. His crisis would have resolved with therapy directed toward maximizing the growth potential of his process. (See Lesson 6.1 Spiritual Crises)

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