In its simplest form, a delusion is a false belief that is held in the absence of evidence. Psychiatrists have generally found it necessary to include the disclaimer that religious beliefs (which, being faith based, are invariably held in the absence of evidence) should be protected from such a label, so long as they remain reasonable within the boundaries of the specific religious subculture. This disclaimer is a good thing – certainly, without it, literally billions of comparatively sane individuals would have to be regarded as delusional. The fact that religion should rely on such a proviso is in itself somewhat ominous – one would hope that a belief system would be differentiable from psychosis on intrinsic merits, rather than by forced exclusion. However, what I wish to focus on today is the more pertinent issue to psychiatry. By using religion as an exclusion criteria, we greatly increase the specificity of our diagnosis by excluding the hordes of well-adjusted faithful who would certainly have to be regarded as “false-positives” otherwise. As any statistician will tell you, increased specificity always has a payoff, and that is that you encounter decreased sensitivity. More simply put – our increased specificity means that some people who are indeed ill will go undiagnosed, by virtue of this broad exclusion.
The natural response to this is to highlight an essential component of the exclusion – religious ideas are only excluded from being called “delusions” when they are out of keeping with the normally accepted behavior of the subculture. This, however, is not a complete solution, owing to several inherent ambiguities. Firstly, it is not always clear when someone has exceeded the norms of his or her subculture, especially in less extreme cases. A patient I recently saw comes to mind – she was a 19 year old girl who, together with her mother, had been diagnosed with folie a deux – a shared delusion. They were brought to the psychiatry clinic by the girls’ grandmother, who reported what she regarded as “over-religious behaviour”. Specifically, the mother and daughter would spend several hours in prayer each day, and engage in intermittent fasts as a way of showing their devotion.
Of concern in this case was the fact that the relevant subculture in this instance – a relatively small local denomination – did not regard this behaviour as abnormal. In fact, both the girl and her mother had achieved a degree of status through their devotion, and were regarded as something to which others should aspire. By definition, then, their behaviour should not have been regarded as delusional, despite the fact that both patients were becoming increasingly socially isolated, and had ceased to function effectively in any other aspect of their lives. As it happened, the diagnosis was made despite the positive views of their religious peers, and the patients were admitted for further treatment. They later showed signs of severe psychosis, and responded well to treatment. What this case illustrates, however, is the difficulty in relying on the views of the subculture in deciding whether religious ideas are “delusional” or not. Sometimes the most deluded are in fact the ones held in the highest esteem.
The concept of a shared delusion brings us to the second point of concern – specifically, the problem of a “mass delusion”. Again, I shall make my point by referring to a case. I spoke to the daughter of a patient who was being treated as an outpatient for paranoid schizophrenia. When I asked how her mother was doing, the patient replied that although she was still very paranoid, she at least seemed happy, owing to her involvement in a new church that had started in the area. This church seemingly placed great emphasis on “spiritual experiences”, including visions and prophecies. That a schizophrenic patient should feel comfortable in such an environment seems unsurprising – but what do we say of the rest of the congregation? If one of them were to have their first contact with mental health services, would their behaviour be regarded as normal, owing to its concordance with the rest of the subculture? Again, this could be inappropriate, as it could be that the subculture itself has become floridly delusional.
Making these distinctions are difficult, and can often involve exploring very sensitive territory. Personally, I find myself again struck by the ability of religion to confound and complicate, and can offer little insight into how best to approach these issues. Perhaps one day we can drop such an exclusion without totally sacrificing specificity. Until then, let us hope that those undiagnosed are able to achieve a degree of comfort within their specific subcultures – a not unlikely prospect given the enormous degrees of faith of which the mentally ill are capable.