On the border of deep spirituality and psychosis… A case study

Abstract This article is a case study of a 28-year-old patient diagnosed with F23. The report is preceded by an extensive literature review describing the situation of the mentally ill, in which psychiatry intermingles with spirituality and the sacrum. The aim of the study was to investigate the relationship between religion/spirituality and schizophrenia as well as to draw attention to the complex problem of differential diagnosis of religious and spiritual problems. When is psychiatric treatment enough and when is intervention of a priest really essential? The authors discuss the problem of mental disorders in connection with religion and spirituality in the clinical context. The article shows that it is very important that the processes of diagnosis and treatment take into account the patients’ individual traits, beliefs, values and spirituality.


Introduction
Typical schizophrenia treatment is based on the biopsychosocial model, which means it involves prescription of antipsychotic drugs and psychological interventions for patients and their families. This model the disease, however, fails to take into account the patient's religious beliefs. Yet, both religion and spirituality exert strong influence on the lives of people suffering from schizophrenia.
It is worth distinguishing a psychotic state from the so-called "spiritual emergency". The latter is a traumatic experience in which individuals feel their sense of identity is fragmenting; they have the impression that the values they have cherished so far are no longer valid, that the solid ground beneath their personal reality is radically changing. Often, new realms of mystical and spiritual experience enter their lives abruptly and dramatically, generating fear and confusion. This is accompanied by anxiety, problems coping with everyday life, work and relationships, and preoccupation with one's own mental health [1]. In this context, psychiatry hugely intermingles with religion and spirituality.

The metaphysics of the schizophrenic world according to Kępiński
According to Antoni Kępiński, the world of internal experiences in case of patients suffering from schizophrenia is characterized by a specific type of metaphysics, in which ultimate things come to the fore; these things dominate the content of schizophrenic delusions making them different from non-schizophrenic delusions. The metaphysical world of a schizophrenic patient revolves around three main trends: ontological, eschatological and charismatic. The ontological trend is a turn towards the fantasy and magic of a world imbued with mysterious energies, the forces of good and evil, as well as waves penetrating human thoughts and behavior. The perception of a patient with schizophrenia is characterized by the fact that they see anything as filled with divine or satanic substance. This means, from their perspective anything can have an impact in the battle between good and evil or between beauty and ugliness. There are certain recurring motifs in schizophrenia, like the pretended character of the customary picture of the world, a conflict of opposing forces and the possibility of action per distance. In this context, there are no independent events. One event depends on another, with some mutual influence, with the patient being in the center of this dense structure of the world. The eschatological trend, in turn, is mainly related to issues like the end of the world, the ultimate purpose of man, etc. The image of the end of the world might be more or less apocalyptic -either it is limited to the patient's immediate family or encompasses the entire globe. In schizophrenia, the catastrophic mood reaches a climax, which is preceded by a state of apprehension -the world becomes very mysterious; the anxiety increases. The Charismatic trend, as understood by Kępiński, is associated with the fact that the patient, who is in the central position of the world, feels immortal, immaterial, almighty, as either God or Satan; the fate of the entire world depends on them. They are endowed with holiness, divinity, Satanism; they live their entire life under the sign of a gift (charisma) [2].

Religious practices of schizophrenic patients
Researchers have looked at religious practices among patients with schizophrenia. A study from Switzerland showed that about one third of schizophrenic patients were highly involved in a religious community. Another 10% of the patients surveyed in the same study were engaged in minority religious movements. According to another study conducted in the same country, nearly one-third of the patients were members of religious communities and another third believed that spirituality played a significant role in human life. Studies from other parts of the world devoted to religious practices of mentally ill patients suggest that such practices are common in Europe and North America. More than 91% of the patients admitted to taking part in private religious or spiritual practices and 68% participated in religious activities. Some studies which have compared religious practices in both patients with schizophrenia and the general population suggest that religious involvement is higher among the patients, while other findings indicate that religious attendance is lower in schizophrenic patients [3].

Psychopathology and religion in schizophrenia
Among the various aspects of religion and spirituality, the influence of religion and spirituality on psychopathology seems to be one of the best explored areas of research. Janus, in his book Psychopatologia a religia [Psychopathology and Religion, in Polish] describes structural parallels between mental health and religion against the background of the difficult field of research on the border of psychology, psychiatry and religion. Religious elements in mental disorders can be identified in three forms: as belonging to the picture of the disease (explicitly expressed religious content or overtly religious behavior) or as utterances and pathological behavior influenced by religious culture, or as systems of behavior, thought and ideas manifested in mental disorders which have no direct source in religious culture, but can be considered as modalities of functioning consistent with religious standards. Janus says that, along with Jung's proposition the soul is inherently religious. Jung talked about the religious function of the soul, which he understood as the wholeness of the conscious and unconscious components of the psyche. The structure of the soul, manifesting itself in dreams, visions, and other elements of mental functioning, is consistent with universal religious images. Thus, broadly understood religiosity is a function of mental life as such. In one of the chapters of his monograph, Janus pays attention to the dimensions of schizophrenia such as messianism, splitting and coincidentia oppositorum. The image of an individual fantasizing that they are a prophet, a messiah or God Himself has grown into a symbol of madness. Delusions of grandeur and of being a messenger are very common among schizophrenic patients and fulfil the important functions of isolation and social attunement as part of the dynamics of the disturbed mind. Entering into normal interpersonal relationships is always associated with a collapse of the sense of grandeur. In turn, splitting is connected with dualism -the tendency to divide people into the good and the bad, wise and foolish or pretty and ugly, which is especially prominent in episodes of disorganized thinking. The emergence of polarity can also be observed in the way schizophrenic patients transform certain religious ideas. Polar splitting involves idealization, that is assigning a maximum positive or a maximum negative value to an object manifested as deification or demonization of that object. Patients use splitting constantly in both their individual and social lives [4].
Generally speaking, delusions and hallucinations of religious nature are further categorized into those associated with religious and supernatural motifs. Religious delusions and hallucinations are closely linked to certain religious motifs, such as prayer, sin, possession, or religious figures, such as God, Jesus, Satan, prophet. Supernatural delusions and hallucinations have more general mystic references to black magic, spirits, demons, being bewitched, mythical heroes, sorcery, or voodoo. Research conducted among in-patients with schizophrenia suggest that the prevalence of religious delusions and hallucinations differs from country to country, ranging from 6-63.3%. For instance, studies which have compared religious delusions in different countries have shown that they are more common in Germany than in Japan [16].
Other research studies suggest that patients who experience religious delusions value religion as much as those without such delusions. Yet, patients who suffer from religious-themed delusions report receiving less support from religious communities. Studies which have looked at religion in the context of psychopathology suggest that Christians are more likely to have religious delusions, especially those related to guilt or sin, than patients who are followers of other religions such as Islam. Other studies have shown that Buddhists experience delusions with religious content less frequently than Christians and Protestants are more likely to have religious delusions compared to Catholics or people without any religious affiliation. Another study shows that Roman Catholics suffering from schizophrenia are more likely to have religious delusions of guilt, as compared to Protestants and Muslims. A cross-cultural study which has compared people of different ethnic backgrounds indicates that in the case of paranoid delusions, Christian patients more often report being persecuted by a supernatural being than do Muslim and Buddhist patients. Other study suggests that religious and supernatural themes are more common in delusions of patients from Korea than those of their Korean-Chinese and Chinese counterparts [3]. Greenberg and Brom investigated patients who were followers of Judaism and reported that in those subjects hallucinations occurred more frequently during the night, which was connected with the patients' beliefs that they were more susceptible to demonic powers and demons at night [5]. Peters et al., who compared patients who were followers of Hinduism (Hare-Krishnas), Christianity and New Religious Movements with non-religious groups, demonstrated that patients from New Religious Movements experienced religious delusions more often than the other two groups [6]. Another study suggested that, compared to patients from Saudi Arabia, patients from the UK were more likely to experience religion-related auditory hallucinations. There are some contradictory findings regarding the relationship between religiosity and the presence of religious delusions. Some studies suggest a higher prevalence of religious delusions and hallucinations in patients with higher religiosity and other studies suggesting a lack of correlation between these two factors. Regarding socio-demographic variables, reports suggest that the religious content of delusions is associated with the marital status and education of patients with schizophrenia. Only a few studies suggest a relationship between religious delusions and cognitive deficits. Religious delusions have an impact on help seeking, treatment and outcome. It has been demonstrated that individuals who have religious delusions need more time to establish service contact, take more medications, have overall higher symptom scores and poorer social functioning. Those with religious delusions and hallucinations look for magico-religious healing, are not satisfied with psychiatric treatment and are more likely not to comply with it. There is ample evidence that patients experiencing delusions involving religious themes have poor treatment outcomes. They are also more likely to indulge in violence and self-harm. Some authors suggest that religious delusions may affect patients' health belief models, and consequently lead to poor treatment adherence [3].

The influence of religious personality
Erikson claims that due to its orientation toward worldly and ultimate matters, religion, though susceptible to pathological distortions, is essential to the development of an integrated mature personality [7].
Many studies have evaluated the effects of religion on the severity of psychopathology and have come up with contradictory conclusions. While some authors suggest that religious activity and beliefs are more intense in people who present more severe symptoms of the disease, especially psychotic and general symptoms, other authors have reported that increased religious activity is associated with reduced severity of symptoms. Furthermore, data suggest that higher religiosity or piety is associated with the absence of first-rank symptoms [3]. At this point, it is worth considering what religious personality is. Pastoral psychology defines religious personality as a complex whole of thoughts, emotions and behaviors which gives direction and coherence to human life. Just like the human body, personality is made up of a number of structures and reflects the influences of nature (genes) and the religious environment. The concept of religious personality also encompasses the temporal aspect of human existence; understood in this way, it contains memories of the religious past, mental representations of the present and ideas and expectations regarding the future. Religious personality is characterized by a distinctive set of attitudes, i.e., direct attitude toward God/the sacred; attitude toward forms of communication about God/the sacred offered to an individual in the course of education and socialization; and attitude toward organized, individual and communal forms of worship of God/ the sacred. Religiosity is one of the properties which constitute the human person through his/her relation to transcendent values [8]. Allport, in his book The Individual and His Religion states that the development of religion within each individual is conditioned by their bodily needs, temperament, and mental capacity, their psychogenic interest in values, his/her pursuit of rational explanation, and his/her response to his/her culture. Allport elaborates on the notions of adolescent and mature religious sentiment, conscience and mental health. He explains what is at the heart of doubt and faith, assuming that mature religious sentiment is diversified, has a dynamic character, that despite its derivative nature, it engenders consistent morality, that it is versatile, holistic and heuristic [9].
Researchers show that religiosity in patients with schizophrenia is predictive of increased social integration, reduced risk of suicide attempt, reduced consumption of psychoactive agents, reduced smoking rates, better quality of life and a better prognosis. The conclusions regarding the relationship between religion and psychosocial adaptation are contradictory with a slight advantage of the notion that religiousness improves psychosocial adaptation. Religious support and spirituality foster social recovery and reduce relapse in some patients. In others, however, higher religiosity religiosity means an increased risk of a suicide attempt [18,23].
A study which has examined the relationship between the level of religious activity and mental health in sub-groups of Catholics, Protestants and Jews has found that patients who do not get involved in religious practice have higher levels of mental disorders. A 1983 metaanalysis of 24 studies confirmed that religiosity was moderately but positively correlated with psychological outcome. The healing effect of religious involvement was related to factors such as suicide rate, addiction to drugs and alcohol, crime, marital satisfaction, and depression [7]. Religiosity affects people's susceptibility to illness, including mental illness because religiously mature people are characterized by good control of healthenhancing behaviors. In addition, such individuals enjoy social support and live in traditional religious relationships. As a result, they more often experience positive emotions and are generally healthier [10]. A 2009 issue of the Canadian Journal of Psychiatry contains a review of research on religion, spirituality and mental health written by Koening. This systematic study of mental health research conducted in medical, psychiatric, and other settings and encompassing many ethnic backgrounds (Caucasians, African Americans, Hispanic and Native Americans), different age groups (young, middle-aged and elderly) and different locations (the United States, Canada, Europe, and countries in the East), shows that religious involvement is associated with better coping with stress and lower suicidal tendencies, lower depression, anxiety, and substance buse [11].

Religious coping
Religious coping is the use of religious beliefs or behaviors to facilitate problem-solving with a view to prevent or alleviate the negative emotional consequences of distressing life circumstances. It is a multidimensional concept which refers to functionally-oriented expressions of religion in times of distress. The concept of religious coping has been refined and categorized as helpful and positive or harmful and negative or as having mixed implications. Strategies of positive religious coping include: purification, forgiveness, spiritual direction religious assistance, seeking support from the clergy, setting of certain moral boundaries. Negative religious coping strategies include spiritual discontent, demonic reappraisal, passive religious deferral, falling out of a social role, the reappraisal of supernatural forces and pleading for direct intercession. Religious coping strategies with mixed implications include religious rituals in response to crises, self-directing and deferral [3,21].
Several studies have included cases describing schizophrenic patients and the role of religion in their dealing with stressful situations. These studies suggest that more than 80% of patients use religion to cope with their illness. Others report that in 45% of cases spirituality and religiousness helped the patients deal with their disease. Studies which have compared different disorders demonstrate that patients with a diagnosis of schizophrenia, bipolar disorder and schizoaffective disorder use "religious coping" on a long-term basis and see it as being more helpful in fighting the disease compared to patients with depressive disorder [17,18].
Studies also indicate that religious coping affects other parameters. It turns out that religious coping in patients with schizophrenia is positively correlated with psychological and existential well-being. In the light of these reports, proper religious development corresponds with better well-being, better adjustment and lesser sense of loss associated with mental illness, whereas punishing God reappraisal and reappraisal of God's powers are associated, with a greater correlation, with poorer wellbeing and adjustment and greater personal loss caused by mental illness [3].
Positive religious coping is also predictive of a higher quality of life with regard to psychological health. By contrast, negative religious coping is associated with a lower quality of life and an increased level of distress measured on the Depression, Anxiety and Stress Scale. Longitudinal studies have shown that a stronger impact of religion on the patient's life and use of positive religious coping are predictive of a higher quality of life and better scores on the Clinical Global Impression scale [17,22].

The priest or the psychiatrist?
Studies from around the world which have evaluated the explanatory models of disease held by patients with schizophrenia suggest that many patients have nonmedical explanations for their illness. Most of the nonmedical explanations across various analyses revolve around the influence of supernatural forces. Various explanations include being under the spell of a witch or a genie; esoteric, spiritual or mystical factors; family problems; inner problems of the self, economic difficulties, supernatural powers, ghosts, devils, being possessed by a demon, divine wrath, planetary/astrological influences, unsatisfied souls, evil deeds from the past. A study conducted in India reports that approximately 66-70% of patients have a non-biomedical explanatory model of their disease, while studies from other parts of the world indicate the presence of such explanatory models of schizophrenia in approximately 10% of patients. A cross-cultural study of Muslims from Arabia, patients from Jordan and Germany suggests that Jordanians are more likely to believe in esoteric factors affecting their illness and thus perceive it as being more dangerous. Other studies suggest that Caucasians mention biological causes more frequently than African-Caribbeans and Bangladeshis, who often point to social conditions as the cause of their disease. Data also suggest that non-medical explanatory models of schizophrenia affect insight and help-seeking and are associated with a worse clinical outcome [19].
A study from India shows that many patients seek treatment from healers who can get rid of the symptoms, which shows that native methods of healing are considered as being complementary to medical management of mental disorders. A survey conducted among in-patients of a mental hospital in Tamil Nadu, in Southern India showed that 58% of the psychotic patients had visited a religious healer before referring to a psychiatrist. In fact, studies suggest that seeking religious support is often the first step in the management of mental disorders, which is the consequence of patients holding culturally-rooted explanatory models of the disease. Research from other parts of the world suggests that patients with schizophrenia who are admitted for a long duration experience spiritual suffering. Studies devoted specifically to religiosity suggest that higher religiosity is associated with a lower preference for psychiatric treatment [20].
The role of priests in psychiatric treatment, whether or not they react maturely to the challenge and to what extent they are able to tell religious content in a mental illness from religious experience (natural or pathological) may crucially determine the patient's fate. Recent medical education curricula in psychiatry postulate that psychiatrists should have some knowledge about religion and recommend that that they should be sensitive to matters of religion and be able to talk with patients about their spiritual life and religious needs [7]. The domains of religion and health, especially mental health, should be linked in a way that would allow the psychotherapist and the priest, also an exorcist priest, to cooperate for the good of the patient. The more so that mental health in modern societies seriously falters: hard indicators such as the number of suicides, addictions, crime, post-stress disorders, and prevalence of depression are growing at a rapid pace. Some thirty percent of patients, especially psychiatric patients, experience spiritual problems. An analysis of studies on psychotic phenomena, especially those regarding subjective religious experiences, demonstrates that cooperation between a priest and a physician for the good of the patient is viewed as obvious and necessary [10].

A clinical perspective
Prusak, in his work "Diagnoza różnicująca problemy religijne bądź duchowe -możliwości ograniczenia kodu V 62.89 w DSM-5" [Differential diagnosis of religious and spiritual problems -the possibilities of restricting code V 62.89 in the DSM-5, in Polish] examines religion and spirituality in the clinical context -it turns out that psychological help is the most effective when it is adjusted to the traits of a specific person, their beliefs, values, spirituality and religiousness [12].
Category V 62.89 (Z 65.8) can be used when a clinician deals with a religious or spiritual problem. Examples include distressing experiences that involve the loss or questioning of faith, problems associated with conversion to a new faith or questioning of spiritual values, not necessarily related to an organized church or religious institution [13]. Until the publication of the DSM-IV, in its earlier versions, and in the ICD, religious and spiritual experiences had been perceived as the cause of psychopathology or as symptomatological expressions of psychopathology, while religion and spirituality were over-represented in the examples used to illustrate psychopathology. Psychiatrists and psychologists who developed the outline of code V 62.89 consider these anomalous experiences to be cases of "spiritual crises" or "spiritual emergencies", as discussed in the introduction to the present article [12,14].
As this very review shows, elements of religion are ubiquitous in psychopathology. Religious content is often found in schizophrenia and the metaphysical themes of delusions described by Kępiński manifest themselves in three ways: ontological, eschatological and charismatic. In endogenous depression, a psychiatrist must deal with delusions of condemnation, guilt and punishment and an obsessive-compulsive disorder he/she has to alleviate the patient's obsessive religious thoughts. Psychiatrists have to switch their focus when they have to handle the patient's existential dilemmas or ideological crisis. In such cases, the psychiatrist is should be acting with great caution and stay sensitive to the patient's value hierarchy. The commonly postulated neutrality of the therapist not only requires them to be mindful and respectful of the patient's spiritual dimension, but also to suggest contacting a spiritual leader, like a theologian or a priest [7].

Case report
The patient was a 28 year-old male, single, childless, living with his aunt and uncle. The patient's parents had died from cancer when he was 8 and 10 years old. Both parents had probably suffered from paranoid schizophrenia. The parents parted soon after the patient's birth and he met his father only a few times in his life. The man had no siblings and was raised by his maternal grandparents. His grandmother died three years before this study was commenced and his grandfather died when the patient was 9 years old; the patient still considers his grandfather as his greatest authority. The patient did not know his grandparents from the side of the father.
He regularly attended school, had reasonably good marks, did not play truant, and never showed any discipline problems. He attained secondary education with the certificate of technician economist but never worked in the profession. He enrolled at a university, probably to avoid military service, but did not complete his studies. Since the age of 19, he had been earning his living working at construction sites in Poland and Norway. He quit his job in November 2012, at the age of 26, when he felt a calling and decided to join a religious order. Even as a child he had been very religious, with religiosity hugely instilled in him by his grandmother. He very often prayed and went to church: "Mary was the most important figure in my life; I always asked her to intercede with God for help." In recent years, he went to church more often ("I had this need"); he traveled to holy places to pray; he went on a pilgrimage to Fatima. "I sensed God's help, I felt protected." In addition, the patient had dreams in which he saw various churches and the Mother of God calling people to prayer. In reaction to these dreams, the patient traveled around Poland looking for the churches from his dreams and then he prayed in them for the souls in the Purgatory. He described these dreams as "prophetic." The amount of time he devoted to religion clearly increased when his five-year relationship broke up. The patient had been planning a wedding, but the girl's parents had decided he was not the right candidate. "It's a good job I didn't get married; marriage would forestall my spiritual development." He spent a year in a monastery, serving his novitiate until January 2014, when the prior ordered him to leave the monastery and consult a psychologist. Upon taking history, he was reluctant to describe his condition in that period but admitted to having had "unwanted, strange and blasphemous" thoughts. At that time, he claimed "he had been unable to tell good from evil." He had had a lot of thoughts in his head alternating with a fear of something bad, of Satan. "I had the impression that Satan was in me, I wondered whether I was possessed." "I did not hear any voices, I did not see any signs." "Satan wanted to destroy my soul; that was probably because I had prayed the Rosary many times, and Satan did not like it." The patient consulted a psychiatrist, but seeing no improvement, discontinued the prescribed medications after one and a half week. In February 2014, his aunt, worried about his condition, took him to Mental Health Hospital in Radecznica. . The patient agreed to hospitalization and spent two months in the ward. At that time, as he claimed, he was receiving medication on a regular basis. After discharge, he withdrew from taking medication (olanzapine) as it, as patient put it, "fuddled his brain" The patient did not feel he was mentally ill; explaining all the difficulties as punishment for his sins instead; he said he had no one to pray to because Jesus had left him. "I have forsaken God, and now I feel nothing when praying; I would do everything to make Him come back to me." "In church, I felt that God was speaking directly to me through the person of the priest, but those on a lower level of spirituality do not understand this." As the patient's condition failed to improve, his aunt persuaded him to report to the Department of Psychiatry in Lublin. In the admission room, he refused to answer questions concerning his symptoms, denied having any somatic illnesses, addictions, allergies or head injuries. He had good orientation as to place, time and person, was calm and his behavior was appropriate to the circumstances. It was observed he had thought disturbances; he expressed delusional ideas but showed no signs of a personality disintegration. The patient refused to receive medical treatment. He claimed that his problems were only "a spiritual matter." There were no reasons to start the treatment, especially that the patient has not agreed for it. Due to that, he was discharged with a diagnosis of brief reactive psychosis (F23) and a recommendation of follow-up observation for suspected schizophrenic process. During hospitalization, the patient underwent an electroencephalographic examination (normal result), neuropsychological testing (result within the normal range), and psychological evaluation using MMPI-I (the result pointed to an attitude of dissimulation).
According to the information obtained from the doctor who treated the patient in the out-patient mental health clinic, the man felt good after discharge from the Department of Psychiatry. He did not exhibit any psychotic symptoms and asked the doctor for a health certificate, as he wanted to join the monastery again. Later on, he received the certificate.

Discussion
Even despite the relationship between religion and schizophrenia is so close, the spiritual aspect is often overlooked in mental health assessment, diagnosis, and treatment. The limited pool of available studies show that religion exerts influence over the expression of psychopathology, behaviors related to treatment seeking, and treatment outcome. Taking into account the importance of both religion and spirituality to many patients, the biopsychosocial model of schizophrenia should incorporate these factors in order to achieve a whole-person approach to treatment. Findings suggest that clinicians are rarely aware of the importance of religion to patients, even in cases when spirituality should be incorporated into treatment and patient care [15]. Hence, there is a strong need to make clinicians aware of the needs of patients suffering from schizophrenia and encourage them to evaluate the religious and spiritual aspects of their patients [3]. Religion sometimes intermingles with pathology. In fact, religious delusions are common among psychotic individuals. Yet, normal, healthy beliefs and religious practices play a stabilizing role and may reduce the overwhelming isolation, fear and loss of control experienced by psychotic patients. Clinicians should be aware of the beliefs, as well as both religious and spiritual involvement of their patients, appreciate their value, treat them as a resource which benefits healthy psychological and social functioning. They should also be able to recognize the situations where these functions are impaired. There is a need for some further investigation in this area, especially from a crosscultural perspective. More in-depth knowledge of the relationships between religion and various aspects of schizophrenia will lead to better treatment outcomes, as doctors will understand their patients better.
This case report illustrates the particular difficulty that psychiatrists might be facing while assessing psychopathology at the border of the cultural and religious areas. For a physician looking throught the lens of their own culture, the fact that the patient was raised in a deeply religious family might be tantamount to the diagnosis of a mental disorder. Various authors pay attention to the importance of taking an in-depth medical history of the patient and getting acquainted with the cultural and religious determinants of his/her behavior and words, i.e. so-called cultural aspects of diagnosis. Much research indicates that psychiatric and psychological assistance is most effective when it takes into account the specific beliefs, values, spirituality and religiosity of the patient [24,25]. Moreover, studies show that patients are less inclined to trust professionals and reveal their religious experiences [24] if they either feel or even suspect their negative attitude toward the spiritual life [26,27]. A good example is our own patient, who did not perceive his problem to be of a medical nature but rather a spiritual one. Therefore, he assumed that he would be misunderstood by the people around him. This is why he had refused to cooperate from the very beginning of hospitalization claiming that he could not be understood. Accordingly, he dissimulated and gave only brief descriptions of his religious experiences. This made the diagnostic process much more difficult.
In this particular case, apart from suffering from psychosis, the patient also showed an immature religious sentiment. He experienced religion in a child-like fashion, which was indicated by the fact that he had been counting his prayers (he prayed the Rosary five thousand times during a year).
According to statistical data [28], one third of university students have religious or spiritual problems that hugely affect their lives. In light of the above, obliviousness to the patient's religious and spiritual history is a serious negligence [29]. Research on the attitudes of clinicians toward patients' spirituality [30,31] suggests that they usually judge patients' experiences by their own cultural standards, which means they may diagnose a non-psychotic patient as psychotic or "potentially psychotic", or the other way round. A short example for illustration only. A patient reports a peak experience, i.e a sense of delight, elation, illumination, or even ecstasy felt in a moment of self-actualization. Such peak experiences can occur in healthy people and have been described by Maslow as those that remain within the limits of a psychological norm [32] . However, when a physician only takes a cursory history and does a brief physical examination, he/she may overlook the fact that he/she is dealing with a different way of experiencing things and categorize the experience as psychopathological.
In the life of a patient, religious experiences may cooccur with psychopathology without affecting it, or affecting it through one of the three functions that religion can fulfil. These include: 1. The positive (salutogenic) function -religion helps patients to build relationships, encourages them to take an active attitude, and is a source of support, 2. The pathoplastic function -spirituality becomes an expression of different forms of thinking and behavior; it provides refuge, 3. The pathogenic function -spirituality can act as a stressor by deepening the patient's weakness or leading to serious maladjustment. [33].
In the case reported in this paper, religion played a pathoplastic function; it served as a shelter, a way of coping with the disease, an explanation for it and a means through which to deny it. The patient regarded his problem not as a medical one but rather as a spiritual one. This led to mistrust of the medical staff (dissimulation, a sense of being misunderstood, failure to cooperate) and frustrated the diagnostic process. There was also another difficulty in the diagnostic process -the lack of standardized instruments allowing a physician to draw the line between deep spirituality and psychopathology.