What images can make someone spiritually
Esoteric and psychosis
Assuming a psychosis continuum within the general population as well as among people with an interest in esotericism, the diagnosis of patients with subculturally deviating interests or experiences is not always clear from the start. Thus, under the guise of esotericism, not only psychosis-like, but also manifest psychotic illnesses that require treatment can be concealed. For the compliance of those affected, the consideration of the individual disease concept plays a relevant role in the course of treatment.
Presuming a continuum of psychotic symptoms within the general population as well as in individuals interested in esotericism, a diagnosis is not always unambiguous. Psychotic disorders with treatment indication might be hidden under the guise of esotericism. Taking the patients ’individual concept of the development of psychiatric disorders into account is an important factor regarding treatment engagement and course.
The first occurrence of psychotic symptoms can be viewed along a continuum between psychosis-like experiences within the healthy population, psychotic symptoms and psychotic episodes in individuals with affective disorders and illnesses from the schizophrenic group. Taking this psychosis continuum into account, the demarcation of psychotic symptoms from subculturally accepted and non-impairing phenomena cannot always be unambiguous. When assessing psychosis-like experiences, a distinction is made between those with clinical significance due to the suffering and seeking help behavior of those affected, but without meeting the diagnostic criteria of a psychotic illness, and those that do not have any psychological stress or behavior seeking help and thus have no clinical effect. The former can be referred to as subclinical psychotic symptoms and in studies show a prevalence of up to 4%. In fact, studies in people with a particular interest in paranormal phenomena and esotericism as well as out-of-body experiences or practices such as meditation and Qi Gong, which are ascribed a mind-expanding effect, have shown evidence of an increased level of psychotic and psychosis-like experiences.
The 29-year-old patient, Ms. S., went to the acute psychiatric outpatient department because of ideas of guilt and a subjectively depressed mood. In the first contact, the patient appeared stressed, emotionally unstable, with psychomotor restlessness, fidgeting movements and slightly increased drive with a given orientation towards all qualities.
Ms. S. described that she was no longer able to perceive the presence of a certain person, who is very dear to her and with whom she has been in constant communication both telepathically and via the Internet in the past few weeks. Because of this, she now feels depressed and joyless. In the time before, she was often in an uplifted to euphoric mood, v. a. this was the case when she came into contact with said person. Aura fusions had occurred and she felt she was actually inhabited by the person. Ms. S. also described tactile, coenesthetic and visual changes in perception. In the last few nights she had the feeling of being scanned or as if lasers were cutting into her body and, in view of minimal skin changes, asked herself whether these had been caused by aliens. You saw geometric shapes in space at night. Ms. S. feared that someone was harming her or trying to trick her and often had the feeling that something was wrong in her environment.
At our ward, Ms. S. initially showed herself to be largely incoherent in the ductus, clearly distracted, rambling and often talking past me. During the admission interview, on the one hand, the rapidly changing mood with alternating depressive to euphoric and elevated mood became clear. In addition to the described changes in perception and the paranoid willingness to react, a feeling of what has been done, a delusional mood with delusional perception, external control experiences as well as delusional and imposing relationship and impairment ideas perceived as threatening determined the clinical picture of the patient.
"Working on a common understanding of the complaints plays an important role"
Appersonation and transitivistic experience were still in the foreground. Ms. S. stated that she experienced feelings such as grief or pain from people close to her as if they were her own. Often she can hardly distinguish between what belongs to herself and what belongs to other people. Although she also referred to this ability as a “gift”, it could become a “curse” if it was too intense. Furthermore, Ms. S. suspected that it was actually her brother and not herself who was suffering from a psychotic illness.
Ms. S. described several stressful life events. The patient had already experienced depressive phases in her youth, and manic episodes had not occurred so far. The only previous psychiatric treatment concerned a questionable adjustment disorder a few years ago without regular medication. With regard to the collection of an external medical history, the patient was initially ambivalent and ultimately rejected it. Family history revealed the father's alcohol dependence and the mother's attempt to commit suicide. The brother may have a reactive anxiety disorder.
Ms. S. stated that she graduated from school with a Matura. Afterwards, she was not able to pursue a regular job over a longer period of time. She has been unemployed for several years now. Ms. S. live alone. So far there has been no long-term partnership and she also has no children.
An electroencephalogram and magnetic resonance imaging of the skull were performed to exclude organic causes of this initially acutely polymorphic psychotically impressive condition, which remained without any pathological findings. No relevant deviations were found in the laboratory tests either. Nor was there any evidence of substance use in drug urine. The psychological test of the cognitive performance showed an above-average crystallized intellectual performance. A standardized personality diagnosis using a SKID-II interview showed an accentuation of schizotypic characteristics without fulfilling all the necessary criteria for the diagnosis or other indications of an Axis II disorder.
Drug treatment was carried out with aripiprazole, which was slowly and gradually increased to 25 mg / day. There was a rapid and clear decrease in the acute psychotic symptoms. Significant overstimulation experiences and the difficult delimitation from fellow patients in the context of the ego-boundaries disorder continued to be very stressful for Ms. S. even after partial response to the antipsychotic medication.
A transfer to a single room seemed to have a positive effect both subjectively and objectively on the course of treatment. Symptoms that became increasingly depressive after partial remission of the psychotic complaints were treated with sertraline. The attempt to add-on therapy with Quetiapine XR to further stabilize mood and in the case of recurring moments of restlessness could not be carried out with a dose of more than 50 mg / d due to morning tiredness without habituation effect.
Appersonation experiences and transitive phenomena remained unchanged. For the patient, this fluid boundary between the ego and the environment was directly related to the inclination to esoteric topics, which she described as spiritual openness, media skills and high sensitivity. Ms. S. wanted to keep this ability, which was perceived as a gift, in the future and was afraid of losing it as a result of the antipsychotic medication. The patient attributed the other psychotic symptoms, which were in the foreground at the time of admission, as well as the clear affective component, on the one hand to a long-term burden within the family, and on the other hand to the problem with the man in contact with her described immediately before admission.
The diagnosis of a schizoaffective disorder was made by looking at the anamnesis and the clinical picture with the ego disorders, the feeling of what was made, the delusional influencing ideas, the initial incoherence and the mixed-image affective component, which seemed to shape the clinical picture equally.
As part of the collaboration with the patient, after the acute symptoms had subsided, the focus was on the issue of the disease value of her complaints, which, from our point of view, she seemed to be cognitively trivializing, despite the continuing considerable suffering, assuming her own disease concept.
Regular conversations were held with Ms. S., which often discussed the comparison of the psychiatric concept of psychosis and the concept of a spiritual high sensitivity developed by the patient. The aim was to find a way to integrate these two concepts together with the patient. Self-stigmatization and the fear of being stigmatized by others became clear. In particular, the aspect of suffering and difficulties in various psychosocial areas, as well as the concept of psychotic symptoms on a continuum, could be well accepted by Ms. S.
At the time of discharge, the ego boundaries continued to be somewhat fluid, but to an extent that the patient perceived as corresponding to her habitual state and which did not seem to interfere with her performance. No other psychotic symptoms were detectable any more, and the mood was balanced. The patient had specific goals for optimizing her living situation and was aiming for psychiatric rehabilitation afterwards.
As part of the diagnosis and treatment of Ms. S., the concept of a psychosis continuum, which assumes that psychotic symptoms are found both in the healthy general population and in individuals with affective disorders and diseases of the schizophrenic type, was repeatedly taken into account.
Indeed, the literature shows evidence of increased levels of psychosis-like and psychotic symptoms in people interested in esoteric practices. It therefore seemed important to avoid a possible pathologization of unusual experiences that deviated from the subcultural norm, but were not pathological. This prudence could, however, also help to play down the already existing tendency towards fluid ego-environment boundaries under the guise of esotericism as psychosis-like experiences, whereby an already manifest psychotic state could remain undetected.
The patient's reduced level of function, which has made it impossible for her to pursue a regular job for years, does not ultimately answer the question of a psychotic illness that may have existed for a long time, but does not seem to be insignificant in this context.
"Individual disease concept increases compliance"
The initial diagnosis of an acutely polymorphic psychotic disorder with symptoms of schizophrenia was rejected in the course of the inpatient stay, in view of the duration of the symptoms and anamnestic evidence of psychotic symptoms with an affective component in the past. Likewise, the fact that the patient had not been able to take up regular employment for a long time, despite the given intellectual capacity, suggested that the level of psychosocial function had not been restricted recently.
In terms of differential diagnosis, the diagnosis of bipolar affective disorder with a current mixed episode was discussed after v. a. At the beginning of the stay the patient's mood was subject to a rapidly changing, fluctuating course and several depressive episodes were recorded in the past. Nevertheless, the clinical picture with the delusional influencing ideas, the ego boundary disorders as well as the delusional perception, the feeling of what was made and the incoherence of thinking, using the criteria of the ICD-10 classification, seemed to be more compatible with a diagnosis from the schizophrenic group of forms . The existing first-rate symptoms according to Schneider, such as the bodily influencing experiences, thought input, thought spreading, the feeling of what has been made and the delusions, support the diagnosis in this regard.
Finally, considering the additional affective component, a diagnosis of schizoaffective disorder was made. From the point of view of the Leonhard classification of endogenous psychoses, the clinical picture of the patient corresponded to an anxiety-happiness psychosis. The patient was fearful and suspicious of existing impairment and relationship ideas as well as vague reinterpretations of her environment. The condition changed quickly between this anxiety and a euphoric-ecstatic mood with feelings of happiness and ideas of size, whereby v. a. the fluctuating character of the affect is characteristic of the fear-happiness psychosis.
Our differential diagnostic considerations are also reflected in the literature, in which the schizoaffective disorder is described on the one hand as a condition that is clinically, prognostically and epidemiologically between a schizophrenic disease and an affective disease. On the other hand, it is discussed whether the schizoaffective illnesses can be assigned to the affective disorders and are only characterized by a higher degree of severity and the presence of psychotic symptoms. Further ideas include the fact that psychotic symptoms can be classified on a continuum on which the various diseases, such as affective disorders and diseases of the schizophrenia spectrum, are classified not according to entities, but according to the severity of the psychotic symptoms.
In summary, it appeared relevant for the patient's positive course of treatment to take into account her subcultural background and her personal disease concept. Some of the patient's perceptions and experiences, which from a medical point of view could be described as symptoms or deviations from the normal psychopathological state, were described by the patient as positively experienced abilities and gifts and remained unchanged even after successful antipsychotic treatment.
The patient considered the existing symptoms only partially, or depending on the degree of intensity, as being relevant to the disease. In this context, the effects of the duration of the symptoms and the positive reinforcement in the subcultural context of esotericism as well as psychodynamic influences could play a role in maintaining delusingly impressive content. Over the course of the stay, together with Ms. S., it was possible to work out overlaps between the different concepts of the disease or to allow the concepts to stand side by side, whereby it was agreed to treat those symptoms which caused the patient to suffer.
Assuming a continuum of psychosis and the indications of an increased occurrence of psychotic and psychosis-like symptoms in people with an interest in esoteric and paranormal practices, a similar continuum of psychotic experience can be assumed for people with an esoteric interest. It should be taken into account that under the guise of esotericism, under certain circumstances, a manifest psychotic clinical picture with need for treatment can be concealed.
conclusion for practice
A differentiated approach to diagnosis and treatment could be particularly relevant for people with an interest in esoteric practices, assuming a continuum between esoteric and psychotic experiences.
It should be borne in mind that under the guise of esoteric experiences, not only psychotic, but also already manifest psychotic illnesses can be hidden.
The integration of the patient's individual disease concept can promote the therapeutic relationship and thus positive treatment processes.
In the context of medical-psychiatric and psychotherapeutic treatment, working on a common understanding of the complaints plays an important role. It may be necessary to initially let the different disease concepts stand side by side and gradually bring them closer together in terms of content and concept.
Clinical Department for Social Psychiatry, University Clinic for Psychiatry and Psychotherapy, Medical University of Vienna, Währinger Gürtel 18–20, 1090, Vienna, Austria
Dr. Barbara Hinterbuchinger, Dr. Zsuzsa Litvan & Dr. Nilufar Mossaheb
Correspondence to Dr. Barbara Hinterbuchinger.
Conflict of interest
B. Hinterbuchinger, Z. Litvan and N. Mossaheb state that they have no conflict of interest.
The information relating to the patient has been anonymized and changed accordingly so that it is not possible for the reader to identify it.
Literature from the author
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Hinterbuchinger, B., Litvan, Z. & Mossaheb, N. Esotericism and Psychosis. psychopraxis. neuropraxis19, 38-42 (2016). https://doi.org/10.1007/s00739-016-0307-0
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