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Phenomenology of delusions andhallucinations in schizophrenia byreligious convictionsKausar Suhail a & Shabnam Ghauri aa Department of Psychology , GC University , Kechehry Road,Lahore, PakistanPublished online: 06 Nov 2009.

To cite this article: Kausar Suhail & Shabnam Ghauri (2010) Phenomenology of delusions andhallucinations in schizophrenia by religious convictions, Mental Health, Religion & Culture, 13:3,245-259, DOI: 10.1080/13674670903313722

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Mental Health, Religion & CultureVol. 13, No. 3, April 2010, 245–259

RESEARCH ARTICLE

Phenomenology of delusions and hallucinations in schizophrenia by

religious convictions

Kausar Suhail* and Shabnam Ghauri

Department of Psychology, GC University, Kechehry Road, Lahore, Pakistan

(Received 24 February 2009; final version received 7 September 2009)

This study was conducted to assess the impact of religious affiliations on thephenomenology of delusions and hallucinations. Fifty-three Pakistani Muslimpatients with schizophrenia were interviewed using the Present State Examinationand Religiosity Index. The results indicated that the more religious patients hadgreater themes of grandiose ability and identity. These differences were moreobvious in groups divided on the basis of practice of Islam. Similar results wereobtained in the content of hallucinations. More religious patients were more likelyto hear voices of paranormal agents and had visions of the same. The results ofthis study have strong implications for mental health professionals who, withoutreinforcing threatening and pathological beliefs of patients, can utilise thisknowledge to create and maintain a therapeutic alliance with the patients as wellas to more effectively manage the disorder.

Keywords: schizophrenia; Pakistan; phenomenology; delusions; hallucinations

Religious affiliations affect symptoms of psychiatric patients in the same way as they enterinto normal individuals’ attitudes and behaviour. Studies conducted in Europe (G. Kirov,Kemp, K. Kirov, & David, 1998; Neeleman & Lewis, 1994) and North America(Brewerton, 1994; Kroll & Sheehan, 1989) have pointed out that psychiatric patients havestronger religious beliefs and attitudes than non-psychiatric patients. Indeed, in one studyconducted with 103 schizophrenic patients, the researchers found that two-thirds of themconsidered spirituality as very important in everyday life: 57% had a representation oftheir illness directly influenced by their religious beliefs (Borras et al., 2007).

A link between spirituality and psychotic experiences has been established for manydecades. In 1958, William James considered insanity as the diabolical nature of mysticism.Later studies also identified this link. A comparison between religious contemplatives,psychotic inpatients and normal adults showed that the reported mystical experiences ofcontemplatives and psychotics could be separated from normals but not from each other(Stifler, Greer, Sneck, & Dovenmuehle, 1993). Patients with schizophrenia have also beenreported to consider their psychotic experiences as religious and mystical encounters(Beers, 1981; Clay, 1987) because of which they may be more likely to stick to them.

Religious delusions are clinically important because they may be associated withseverity of psychotic symptoms as well as with self-harm and poorer outcomes from

*Corresponding author. Email: kausarsuhail@gmail.com

ISSN 1367–4676 print/ISSN 1469–9737 online

� 2010 Taylor & Francis

DOI: 10.1080/13674670903313722

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treatment (Siddle, Haddock, Tarrier, & Faragher, 2000). About one in 24 homicides in theUnited States each year is committed by a schizophrenic and a great majority of those arereported to experience religious delusions and claim religious motivations such as believingthe victim to be an enemy of God, or that God had told them to kill the victim (Torrey,1987). Studies have revealed that delusions and hallucinations with religious content maylead to violent behaviour (Kraya & Patrick, 1997) and suicidal attempts (Mohr &Huguelet, 2004). Cases of genital mutilation (Waugh, 1986) and plucking out offendingeyes (Field & Waldfogel, 1995) as a consequence of a literal interpretation of the Biblehave also been reported.

A few studies have attempted to investigate how religious beliefs and practice influencepsychotic symptoms. The content of religious delusions and hallucinations has beenstudied in this regard and they have been more frequently found in religiously committedpatients (Jackson & Fulford, 1997). The content and frequency of religious delusions havealso been reported to vary across cultures (Suhail & Cochrane, 2002; Tateyama et al.,1993) and religious groups (Getz, Fleck, & Strakowski, 2001). It seems logical to speculatethat cultures in which religion has a more powerful influence could produce higher rates ofreligious delusions.

Religion plays a dominant role in lives of people in the Islamic Republic of Pakistan,and therefore one might expect that there will be a greater prevalence of religious delusionsin Pakistani patients. Pakistan has strong traditional and cultural values that are oftenfiltered through generations. However, urban Pakistanis are also influenced by Westernculture in their adoption of dressing, eating and living habits. Despite being at thecrossroads of tradition and modernity, Pakistani society is still strongly influenced bythe Islamic religion which plays a vital role in the lives of people. This is evident in theenthusiastic celebration of all religious festivals, such as Eid and Ramadhan (the fastingmonth) as well as in the daily practice of the religion. Another significant factor is theexplicit class divide in Pakistan whereby people belonging to the higher social strata enjoya relatively more Western standard of living but the poor can often not afford the basicnecessities of life.

Mental illness is one of the major health care concerns in Pakistan, with an estimated10% to 16% of the general population suffering from mild-to-moderate mental healthillness, and 1% from severe mental illness (Mubbashar & Saeed, 2001). All the major citiesof Pakistan have psychiatric units in hospitals but many suffer from scarcity of trainedmental health professionals. Within the existing mental health services, the imbalancebetween demand and supply of mental health care is staggering. For example, the ratioof trained clinical psychologists with a postgraduate diploma to the population isapproximately 1 : 400,000 (Gadit & Khalid, 2002).

Mental health professionals in Pakistan tend to adapt modern treatment approaches tothe cultural and religious values and norms of their country. Although currently Pakistanis more aware of mental health problems than ever before, the preferred modes oftreatment for many subgroups of the population are either religious or purely physical.Treatment for mental health problems largely depends on how the causation is explained.In cases where the supernatural may be a possible interpretation for the psychologicalsymptoms, the preferred treatment is more likely to be religious or magical. Similarly, ifpsychological symptoms are associated with or interpreted as physical problems, generalphysicians will be more likely to be considered the right choice for treatment. For asizeable proportion of the population, symptoms associated with mental illness are stillconsidered as the result of magical spells or jinn possessions. In such cases, faith healersbecome the first and major source of care for people with mental health problems.

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These views are widely prevalent in villages (Kausar & Sarwar, 1997) and are largelyattributed to low literacy rate (Suhail, 2004). Saeed, Gater, Hussain, and Mubbashar(2000) observed 139 persons receiving these services in rural areas of Pakistan. The resultsshowed that the categorisations used by faith healers were based on spiritual/magicalcauses of disorders: Saya (evil spell, 27%), Jinn (spirit) possession (16%) or Churail (witch,14%). Faith healers used powerful techniques of suggestion and cultural psychother-apeutic procedures for treatment. The procedures included Taawiz (amulets), Dua(prayer), exorcism and Dumm (blowing verses from the Holy Quran on the client).

Cultural and religious factors not only influence the beliefs and behaviour of healthypeople, but also impact on those who are mentally ill (Suhail & Cochrane, 2002). Theprimary objective of this study was to ascertain how religious convictions affect thesymptoms of psychiatric illness. Another objective of the study was to assess the clinicalsignificance of religious delusions and related themes. By examining the actual content ofdelusions and hallucinations, it would be possible to find out whether symptoms of morereligious patients show greater themes of psychopathologic distortions of normativereligious beliefs like guilt, avoidance of care, self-harm, harming others, etc. On the otherhand, the same analysis might also reveal some positive elements of religious convictionswhich could be employed in the rehabilitation of the patients. The terms ‘‘less religious’’and ‘‘more religious’’ instead of ‘‘religious’’ and ‘‘non-religious’’ were intentionally usedconsidering the previous observation of positively skewed population scores on religiosityin Pakistan (Suhail & Akram, 2000). No particular hypotheses were formed for this studyexcept that more religious group, formed on the basis of strength of religious beliefs andpractice, would show greater number of delusions and hallucinations with religiouscontent.

Method

Sample

All patients who were admitted between July and December 2007 inclusive inthree psychiatric units of Lahore, the capital of province Punjab, and who agreed toparticipate were included for initial screening. There was no need to select patientsrandomly as all patients satisfying the inclusion criteria admitted during the specified timeperiod were included in the study. The following exclusion criteria were employed: patientssuffering from any drug-induced psychosis and/or patients suffering from psychoticdisorder due to general medical conditions. The following procedure was applied to selectthe patients:

(1) Two criteria were employed to diagnose the patients. In the first place, patientswith schizophrenia (with elaborate hallucinations and delusions at the time of thestudy) as diagnosed by the consultant psychiatrists were included. To confirm thediagnosis, DSM-IV-TR (American Psychiatric Association, 2000) criteria wereemployed. For inclusion, patients had to have a DSM-IV broadly definedschizophrenia (i.e. 295.7, 295.1, 295.2, 295.3, 295.4 and 295.9) of at least 4 weeks.A total of 61 patients were recruited using the first criterion. However, only 53patients (88.33 %) volunteered to participate in the study.

(2) In the second step, the Standardised Aetiology Schedule (Wing, Cooper, &Sartorious, 1974) was employed with some modifications in order to rule out theprecipitating factors in the diagnosis of the disorder, that is, to exclude all caseswith a brief psychotic episode due to medical or socio-environmental reasons.

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Three out of the original four sections were used in the study, that is, organicfactors, social factors and personality before first onset. The schedule wastranslated into Urdu by the second author (SG) and then was back translated byanother bilingual speaker into English. Both English versions were checked forcomparison by the first author (KS). Similar translations were retained and theprocess was repeated for the non-consistent statements. For all sections, thepresence of any symptom was rated as 1 and was rated 0 in case it was not present.For the ‘‘organic factor’’ section, four factors were included, that is, perceptual orcommunication difficulty (blindness, deaf and dumb, aphasia, etc.), drug abuse,alcohol abuse (specify whether episodic or habitual excessive drinking or alcoholicaddiction) and menopause. For the second section, that is, ‘‘social or psychologicalfactors,’’ only one factor was included from the Aetiology Schedule, that is, recentpsychological or social conflicts, for example, marital disharmony, separation,grief, employment problems, etc. The third section of the Aetiology Schedule(personality before onset) consisted of eight personality disorders, that is,paranoid, affective, schizoid, explosive, anankastic, hysterical, asthenic andantisocial. The rationale for using this criterion was to exclude all cases with anypersonality disorder. None of the patients were excluded on the basis of theAetiology Schedule.

The final sample consisted of 53 patients (40 men and 13 women) with an average ageof 35.16 years (SD¼ 10.29). The distribution of the sample for the three psychiatric unitswas as follows: Punjab Institute of Mental Health (n¼ 17; 32.07%), Sir Ganga RamHospital (n¼ 13; 24.52%) and Fountain House (n¼ 23; 43.39%).

Instruments

The following instruments were employed for the data collection.

(1) Demographics data sheetA demographics information sheet was used to collect information relating to the patient’sgender, age and marital status.

(2) Present State Examination (PSE)In order to get the actual content of the delusions and hallucinations, patients wereinterviewed using the PSE using the categories developed by Wing et al. (1974). The PSE isa standardised interview and symptoms rating schedule. It consists of a glossary of lengthydefinitions of symptoms seen in neurotic and psychotic disorders and an interviewschedule that allows the clinician to rate the presence, absence or intensity of expression ofeach of these symptoms from direct observation or from the patient’s response to interviewquestions. It was decided to use the PSE categories in the current study for the followingreasons: it has been used internationally to illicit symptoms of psychosis; a previous studyhad successfully employed PSE categories to extract delusional and hallucinatory themesfrom patients with psychosis in Pakistan (Suhail & Cochrane, 2002). For the current study,the required sections of the PSE were translated into Urdu using the same procedure aswas employed for the Aetiology Schedule. All the PSE sections exclusive to delusions andhallucinations along with modifications made by Suhail and Cochrane were used in thecurrent study. New themes, wherever they emerged in the patients’ interviews, were,nevertheless, noted and included. To extract themes of delusions and hallucinations, thefollowing procedure was adopted: if the response to the presence of any delusion or

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hallucination was ‘‘yes,’’ the patient was asked to describe any incident relevant to thatsymptom in order to have an access to the actual content.

(3) Religiosity scaleThe Index of Religiosity (IR; Aziz & Rehman, 1996), consisting of 27 Items, was used tomeasure the extent of religious convictions of the participants. The primary reason forusing this scale in the current study was that it was constructed in Urdu and was validatedon Pakistani Muslims. Moreover, the scale had been used effectively for assessing thestrength of Muslim religious beliefs and practice in Pakistan before (Suhail & Akram,2002). The reliability and the discriminating coefficients for IR as reported by the authorsare 0.83 and 0.94, respectively. Apart from deriving a total religiosity score, scores onreligious beliefs and practice can also be obtained by summing scores on the concerneditems. Religious belief subscale consists of items related to faith in God and the sayings ofHoly Prophet (PBUH), life after death and the Day of Judgement (items no 5, 6, 7, 8, 9, 11,12, 13, 14, 16, 20, 22, 24, 26 and 27). The Religious practice subscale is based on the rest ofthe items referring to religious practice and adherence to the tenets of Islam, that is,Prayers, Fasting, Pilgrimage (Hajj), Charity (Zekaat), conduct and theoretical knowledgeobtained through the Holy Book (Al-Quran) and Hadith (sayings of the Holy Prophet).The IR scale consists of 15 items for belief and 12 for practice subscales measured on a 4-point Likert scale, ranging from ‘‘not at all’’ to ‘‘always.’’ The final score on religiosityindex ranges from 27 to 108; scores on belief subscale ranged from 15 to 60 and from 12 to48 on practice subscale. The higher score at any subscale represents a higher incidence ofthe relevant religiosity factor.

Procedure

The consultant psychiatrists and psychologists of three psychiatric units in Lahore wererequested to refer those patients who were diagnosed with schizophrenia during thespecified time period. All patients who satisfied the inclusion criteria were informed thatthey would be interviewed in order to know more about their illness. They were assuredthat the information obtained from them would be confidential and their responses wouldonly be used for research without disclosing their identity.

A total of 53 patients were interviewed using the research instruments. Thedemographics data sheet was administered first followed by the administration of theIR and then the PSE interview. The first author trained the second author in interviewingand scoring the PSE interviews. For the training purpose, the second author rated fiveinterviews used in a previous study, and these ratings were then compared with thesupervisor’s (KS) ratings. From the descriptions and rules which indicate how theinformation elicited by the PSE interview is to be recorded, it becomes possible for anobserver present at an interview or listening to a recording of an interview by someone elseto learn to rate the items reliably without himself being able to conduct the clinicalinterview (Wing et al., 1974). A few discrepancies between the expert ratings and those ofthe second author were noted and were thoroughly discussed with the trainee. Afterobtaining satisfactory training, the second author interviewed all of the patients for thecurrent study. The questions were asked in the same order as are present in the originalPSE. Themes of delusions and hallucinations were extracted from the narratives of thepatients in response to the question asked in case of the presence of any delusion orhallucination, that is, ‘‘please narrate any incidence.’’ All interviews were tape-recordedand the second author transcribed them later for the extraction of themes. In case of the

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absence of the symptom, the interviewer proceeded to the next symptom. The presence ofany symptom was scored as 1, whereas the absence was rated as 0.

Results

The data were analysed using SPSS for Windows, Version 10.00. In the first step,frequency and percentages of different kinds of delusions, hallucinations and their themeswere calculated. The comparison between groups was computed by sets of chi-squareanalyses with cross-tabulation on the presence and absence of different types and themesof delusions and hallucinations in less and more religious patients. The statistical analysiswas not conducted in two conditions. First, if there was any empty cell and second, if theexpected frequency in any cell was less than 5. Differences were determined to besignificant at the significance level of 5% or less. Delusional explanations refer toelaborations of other delusions rated before, such as, delusions of reference, control orpersecutions. These explanations are about paranormal phenomena (category 79) andmachines (category 80). As delusions of the patients also referred to people, followingSuhail and Cochrane (2002), the code 79-II was assigned to the category of people, whileparanormal category was rated as 79-I.

An analysis of the main categories of delusions showed that the most common delusionin this sample was the delusion of grandiose ability (75.5%), followed by religious delusion(62.3%), and then delusions of persecution (58.5%) and jealousy (58.5%). Table 1 shows abreakdown of the frequency of delusions and their themes according to IR. Initially, thescale median (67) was decided as the cut-off point to divide the sample into less and morereligious patients, however, the distribution of scores appeared to be positively skewed.Suhail and Akram (2000) have also noted this trend before and have pointed out thatalthough some individual variations can be observed in the practice of Islam, a greatmajority of Pakistani Muslims have a strong belief in fundamental concepts of Islam, suchas, oneness of God, Mohammad being the last Prophet, and Al-Quran as the Holy book,due to which the majority receives elevated score on religiosity scales. Consistent with this,the scale median criterion as the cut-off score placed only seven of 53 patients in the lessreligious category. To deal with this problem, the obtained score’s median, 81, was takenas the cut-off score, and those scoring less and higher than this score were considered asthe less and more religious groups, respectively. The same procedure was adopted fordetermining low and high believers and practitioners of Islam.

Table 1 shows that more religious patients more frequently reported grandiose ability,delusions of grandiose identity and religious delusions along with the themes of ‘‘specialpower’’ and ‘‘being a prominent person.’’ On the contrary, less religious patients weresignificantly higher on delusions of reference and delusions of alien forces penetrating orcontrolling the mind or body along with themes of ‘‘external force’’ and ‘‘being talkedabout.’’ Analysis concerning delusional elaborations indicated that the more religiousgroup’s delusions referred to paranormal phenomena (like ghosts, jinn, spirits) andcelebrities. Low and high practitioners, but not believers, also appeared to be significantlydifferent on the same delusional elaborations. Themes with very low frequency are notpresented in the table.

A breakdown of the sample into low and high believers showed the same pattern withhigh believers significantly higher on religious delusions along with themes of ‘‘someonetrying to help’’ and ‘‘himself/herself a prominent person.’’ The analysis of delusions andthemes by practice of Islam indicated greater number of significant differences (a total of

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Table 1. Phenomenology of delusions by religious conviction (N¼ 53).

PSEcategory Types of delusions

Lessreligious(25) n (%)

Morereligious(28) n (%) �2

71 Delusion of control 13 (52) 11 (39.3) 0.8671a Being controlled by external force 6 (24) 5 (17.9) 0.3071b Being controlled by some person 4 (16) 7 (25) 0.6571c Thought insertion 3 (12) 6 (21.4) –72 Delusion of reference 19 (76) 9 (32.1) 10.19***72a Being talked about 14 (56) 5 (17.9) 8.35**72b Being followed/observed/spied 8 (32) 7 (25) 0.3272c Referred in media (news, TV) 8 (32) 6 (21.4) 0.7674 Delusion of persecution 17 (68) 14 (50) 1.7674a Someone is trying to kill/harm/poison 16 (64) 13 (46.4) 1.6474b Organisation/mafia are persecuting 1 (4) 2 (7.1) –75 Delusion of assistance 5 (20) 8 (28.6) 0.5275a Someone is trying to help 2 (8) 8 (28.6) 3.6575b Special force is trying to help 3 (12) 4 (14.3) –76 Delusion of grandiose ability 15 (60) 25 (89.3) 6.11*

76a Special power (psychic/spiritual/physical) 11 (44) 22 (78.6) 6.71**76b Ability to invent/have invented 5 (20) 3 (10.7) –77 Delusion of grandiose identity 9 (36) 18 (64.3) 4.22*

77a Rich person 6 (24) 8 (28.6) 0.1477b Himself/herself a prominent person (king/hero) 7 (28) 17 (60.7) 5.70*77c Identification with some famous person 2 (8) 5 (17.9) –78 Religious delusion 12 (48) 21 (75) 4.09*

78a Special relation/communication with God/Prophet 8 (32) 12 (42.9) 0.6678b Himself/herself a saint/Prophet 9 (36) 17 (60.7) 3.2281 Delusion of alien forces penetrating or

controlling mind/body

13 (52) 7 (25) 4.09*

81a External force like laser, etc./unknown 12 (48) 4 (14.3) 7.12**81b Some living thing/nonliving thing 2 (8) 3 (10.7) –84 Delusion of jealousy 17 (68) 14 (50) 1.76

86 Sexual delusion 3 (12) 9 (32) 3.06

87 Delusion of guilt 7 (28) 7 (25) 0.8190 Delusion of depersonalisation 2 (8) 6 (21.4) –

91 Hypochondriacal delusion 7 (28) 3 (10.7) 2.58

92 Delusion of catastrophe 7 (28) 8 (28.6) 0.00

Delusional elaborations79-I Delusional explanations (paranormal & occult) 15 (60) 25 (89.3) 6.11*

79-Ia Spirits/Jinee/ghosts 12 (48) 22 (78.6) 5.36*79-Ib Witchcraft/magic 13 (52) 11 (39.3) 0.8679-II Delusional explanations (people) 23 (92) 27 (96) 0.49

79-IIa Family 14 (56) 17 (60) 0.1279-IIb Unknown people/groups 20 (80) 19 (67.9) 1.0079-IIc Friends/neighbors 11 (44) 6 (21.4) 3.0879-IId Famous (king/celebrity) 9 (36) 19 (67.9) 5.37*80 Delusional explanations (machines) 19 (76) 23 (82) 0.30

Machines 8 (32) 14 (50) 1.76Laser/rays 3 (12) 4 (14.3) –Objects (books/poison/tools) 14 (56) 18 (64.3) 0.37

*p� 0.05. **p� 0.01. ***p� 0.001.

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11 differences, four on types and seven on themes of delusions) than any other pairs of

subgroups (nine differences in less and more religious groups; low and high believers weresignificantly different only on religious delusions). High practitioners reported signifi-cantly higher number of delusions of grandiose ability, grandiose identity and religiousdelusions along with the themes of ‘‘special power,’’ ‘‘rich person,’’ ‘‘himself/herself aprominent person,’’ ‘‘relation or communication with God or Prophet’’ and ‘‘himself/

herself a saint or Prophet.’’ Analysis on delusional themes by strength of beliefs andpractice is displayed in Table 2 and only the result about significant differences ispresented.

Analysis of the kinds and themes of hallucinations in the overall sample showed thatthe most common hallucination was verbal hallucination (74%), followed by visualhallucination (58.5%) and then olfactory hallucination (54.7%). The breakdown of sampleaccording to religious convictions showed that more and less religious patients did notsignificantly differ in overall frequency of verbal hallucinations (65% vs. 76%). However,

more religious group showed a preponderance of non-specific verbal, visual anddissociative hallucination along with themes of ‘‘calling by name,’’ voices congruentwith depressed mood, two-way conversation and external forces/ghosts/spirits. Also, themore religious patients reported hearing more voices of paranormal agents and had

Table 2. Significant differences in phenomenology of delusions by strength of beliefs and practice ofIslam (N¼ 53).

PSE category Types of delusions

Lowbelievers (23)

n (%)

HighBelievers (30)

n (%) �2

78 Religious delusions 10 (43.5) 23 (76.5) 6.10*

Lowpractitioners (29)

Highpractitioners (24)

72 Delusion of reference 20 (69.0) 8 (33.3) 6.69**72a Being talked about 14 (48.3) 5 (20.8) 4.30*72b Being followed/observed/spied 12 (41.4) 8 (33.3) 0.3676 Delusion of grandiose ability 18 (62.1) 22 (91.7) 6.21*

76a Special power (psychic power/spiritual power/physical power)

14 (48.3) 19 (79.2) 5.33*

76b Ability to invent/have invented 5 (17.2) 3 (12.5) –77 Delusion of grandiose identity 10 (34.5) 17 (70.8) 6.94**77a Rich person 4 (13.8) 10 (41.7) 5.24*77b Himself/herself a prominent person 9 (31.0) 15 (62.5) 5.24*77c Identification with some

famous person3 (10.3) 4 (16.7) –

78 Religious delusion 13 (44.8) 20 (83.3) 8.28**

78a Special relation/communicationwith God/Prophet

7 (24.1) 13 (54.2) 5.04*

78b Himself/herself a saint/Prophet 10 (34.5) 16 (66.7) 5.44*81 Delusion of alien forces penetrating

or controlling mind or body

14 (48.3) 6 (25.0) 3.02

81a External force like laser,etc./unknown

12 (41.4) 4 (16.7) 3.80*

81b Some living thing/nonliving thing 3 (10.3) 2 (8.3) –

*p5 0.05. **p5 0.01.

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greater visions of the same (Please see Table 3). Separate analyses by strength of beliefsand practice generated the same results, hence these results are not presented here.

Discussion

Religion is an organised system of practices and beliefs in which people engage. As adominant force religion may govern beliefs, attitudes and behaviours of a vast majority ofpeople and patients are no exception to this. This work holds merit in the sense that itappears to be the first study from Pakistan looking at the impact of religiosity on theactual content of delusions and hallucinations. Although the sample of this study was very

Table 3. Phenomenology of hallucinations by religious conviction (N¼ 53).

PSEcategory Types of hallucinations

Lessreligious (25)

n (%)

Morereligious (28)

n (%) �2

60 Non verbal auditory hallucinationsMusic/singing/noise

12 (48.0) 14 (50.0) 0.02

60a Muttering/whispering 9 (36.0) 12 (42.9) 0.2660b 4 (16.0) 4 (14.3) –61 Affective or non-specific verbal hallucinations 8 (32.0) 21 (75.0) 9.85**61a Calling by name 4 (16.0) 17 (60.7) 11.03***61b Verbal hallucinations congruent

with depressed mood6 (24.0) 19 (67.9) 10.19***

62 Voices discussing subject in third person 9 (36.0) 11 (39.3) 0.0662a Commenting on behaviour/

personality/thinking/actions3 (12.0) 2 (7.1) –

62b Talking about the patient 8 (32.0) 10 (35.7) 0.0863 Voices directly speaking to subject

Pleasant/loving/nice voices13 (52.0) 15 (53.6) 0.01

63a Hostile/threatening/upsetting/accusato 7 (28.0) 8 (28.9) 0.0063b ry/insultingCommands on day-to-day things/ 8 (32.0) 10 (35.7) 0.0863c asking to kill someone/self 12 (48.0) 17 (60.7) 0.8664 Dissociative hallucinations 8 (32.0) 19 (67.9) 6.79**

64a Two-way conversation 6 (24.0) 17 (60.7) 7.24**64b Smell something along conversation 7 (28.0) 4 (14.3) 1.5166 Visual hallucinations 11 (44.0) 20 (71.4) 4.09*

66a Formless/flashes/images/shadows 1 (4.0) 3 (10.7) –66b People 3 (12.0) 7 (25.0) –66c Spirits/ghosts/jinee/holy 3 (12.0) 14 (50.0) 8.75**66d Animals 2 (8.0) 4 (14.3) –68 Olfactory hallucinations 15 (60.0) 14 (50.0) 0.53

68a Sweet smell 13 (52.0) 11 (39.3) 0.8668b Bad smell 2 (8.0) 4 (14.3) –70 Tactile hallucinations 9 (36.0) 12 (42.9) 0.26

Voices idUnknown people/groups 9 (36) 7 (25) 0.75

Family/friends/neighbors 5 (20) 12 (42.9) 3.16Paranormal agents 12 (48) 23 (82.1) 6.86**Voices type 13 (52.0) 15 (53.6) 0.01Talking directly to the subject 7 (28.0) 8 (28.9) 0.00Talking about the subject 8 (32.0) 10 (35.7) 0.06

*p� 0.05. **p� 0.01. ***p� 0.001.

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specific (Pakistani Muslims generally believed to have strong religious tendencies), thisalso provided the advantage of having a fairly homogeneous group. The findings of thiswork support the previous observations that religious commitment is a clinically relevantphenomenon for studying schizophrenia (Larson, Pattison, Blazer, Omran, & Kaplan,1986; Koenig, 2007) by showing a greater frequency of religious and grandiose delusions inmore religious patients.

Previous works have shown a two-way association between religiosity and psychosis.People with intense spiritual or religious beliefs have been found to be significantly higherthan control groups on all dimensions of delusions (Jackson & Fulford, 1997), andreligious groups in general have shown a higher incidence of schizophrenia (Murphy &Vega, 1982; Spencer, 1975). Despite the reported crossover between psychosis andmysticism (Lukoff, 1990–1991), the exact mechanism through which religion influencessymptoms of psychiatric illnesses is not clear (Siddle et al., 2000). There is some indicationthat normal religious beliefs are held in many cases as overvalued ideas somewherebetween delusions and normal beliefs (Peters, Day, McKenna, & Orbach, 1999).Accordingly, many religiously deluded patients may have shifted along the continuumfrom the ‘‘normal’’ overvalued religious ideas and eventually to religious delusions (Siddleet al., 2000).

The major findings of this study were the predominant ideas of grandiosity in morereligious patients. These findings are consistent with various other studies where religionwas the most common content of grandiose symptoms (Ndetei & Vadhar, 1985; Suhail &Cochrane, 2002) and patients with schizophrenia believed that they have special powersgiven to them by divine sources (Mohr & Fann, 2006). Grandeur themes were apparent inpatients’ religious and jealousy delusions: ‘‘people are jealous of me because I am sobeautiful/ a special messenger of God/have a lot of money/,’’ ‘‘I am God/ Wali (a piousperson)/Prophet Mohammad/king, famous/angel/celebrity/rich/inventor/powerful/beauti-ful.’’ Apart from the grandiose identity, more religious patients also expressed ideas ofgrandiose ability: ‘‘Jinn are under my control,’’ ‘‘I can bring lightening/strong wind/rain,’’‘‘I can fly speedier than an airplane,’’ ‘‘I have written books which are kept in libraries ofScotland,’’ ‘‘I can read people’s minds,’’ ‘‘my words have strong power and whatever I sayturns out to be true.’’ Azhar, Varma, and Hakim (1995) describe similar kinds of grandiosereligious delusions in Malay patients.

A few explanations can be put forward to explain the excess of grandiose ideas in morereligious patients. First, religiosity indicates a relationship or connection with anomnipotent force (God) and/or messenger (prophet) of God, and that connection mayconfer the idea of being super human in the current patients. Second, the attributionalstyle of more religious patients may be fundamentally grandiose (taking credits for goodevents and denying responsibility for negative ones, such as, one is important enough toget connected (with God) than less religious people (Sharp, Fear, & Healy, 1997). There issome evidence that psychologically disturbed individuals refer to their psychoticexperiences as mystical encounters because of the unusualness of these experiences(Beers, 1981; Clay, 1987). Third, more religious patients may have used religion as acoping strategy, for example, one patient in this study stated, ‘‘I am a very sacred humanbeing, whoever will upset me will suffer.’’ Having a religious belief or delusional belief mayoffer a framework by which people can make sense of negative life experiences and whichmay also provide a buffer against the depressing effects of uncontrollable life stresses(Park, Cohen, & Herb, 1990).

As compared to more religious patients, less religious ones reported more delusions ofreference. They showed greater concern over people’s reactions toward them, such as

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‘‘neighbors talk about me that I do not work properly,’’ ‘‘When I go to a hotel, people

sitting at other tables look at me in a strange way,’’ ‘‘People keep looking at me because

I am no good,’’ or ‘‘The Watchman keeps an eye on me and thinks that I am doing

something wrong.’’ It appears that more religious patients responded to their inner

religious convictions and felt grandiose over their perceived strong connections with the

Almighty, whereas less religious ones were more aware of their immediate external

connections with the world.Studies have shown fatal consequences of religious delusions for patients and people

around. For example, antichrist delusions have caused violent behaviours (Silva, Leong, &

Weinstock, 1997) and suicidal attempts (Reeves & Liberto, 2006). Mohr and Huguelet

(2004) have reported suicidal attempts of two patients in the context of religious delusions.

The current patients also heard voices telling them to either harm themselves or others in

the context of religious delusions, but none of them implemented these delusional ideas.

A few examples of these ‘‘commands’’ are: ‘‘one night I heard a voice which told me to kill

my friend,’’ ‘‘voices tell me that my uncle is doing black magic on me,’’ ‘‘voices tell me to

commit suicide.’’ The positive impact of religious involvement was evident in the reports of

some patients: ‘‘I tell the voices that I don’t want to die because suicide is Heraam’’ (not

sanctioned in Islam). Studies of normal healthy individuals in Pakistan have also shown

the positive effect of religious convictions on mental health. Suhail et al. (in press) found

that none of 125 survivors of October 2005 earthquake in Pakistan contemplated suicide

despite extreme traumas of losing their loved ones and properties because taking one’s life

is prohibited in Islam. This has been clearly indicated at various places in Al-Quran. For

example, one verse of Surah Nisaa states (Chapter 4, Verse 29): ‘‘and do not kill

yourselves, surely Allah (God) is most merciful to you.’’ At another place, it has been

stated like this: ‘‘Take not life which Allah has made sacred’’ (Chapter 6, Verse 151). These

teachings not only affect normal people’s mode of action, but also determine patients’

behaviour. However, it is not only Islam which plays a protective role through

condemnation of suicide. Studies conducted with predominantly Christian patients also

showed that religious convictions were likely to decrease suicide attempts among patients

with psychosis (Mohr, Brandt, Borras, Gillieron, & Huguelet, 2006).More religious patients also reported a few other beliefs that helped them cope

better, for example, ‘‘I complain about the fact that my sister has gone away from

me to London . . .God tells me to read the Holy Quran’’ (so that peace comes to me),

‘‘I caused many problems in this world, but God is forgiving and guides at every step, so I

should not worry.’’ Similar to this, Christian patients have reported the perceived

protecting powers of the Bible, ‘‘I always have a Bible with me. When I feel I am in danger,

I read it and feel that I am protected. It helps me to control my violent actions’’ (Mohr

et al., 2006).A growing body of research has shown that religiosity and spirituality may provide

positive coping to patients with psychosis (Koenig, McCullough, & Larson, 2001; Roger &

Rogers, 2002). This positive impact has also been reported on other dimensions of illness,

for example, more patients in a study reported positive than negative influences of

religious convictions and patients with greater religious practice showed more adherence

to medication (Borras et al., 2007).In general, subgroups formed on the basis of the practice of religion (low vs. high

practitioners) showed a greater number of statistically significant differences than the

other pair of groups (low and high believers of Islam). It is possible that those practicing

religion are stronger in their convictions which also affect their delusions.

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Patient with stronger religious convictions exceeded their respective counterparts ina number of hallucinations, such as, verbal hallucinations, dissociative and visualhallucinations. Also more of them heard voices calling their names and having two-wayconversation with them. Believers and practitioners were not different along thesedimensions. Although the psychological literature views hallucinations as pathologicalafflictions, the religious literature views some hallucinatory experiences as holy andtranscending (Hood, Morris, & Watson, 1990), making religious patients more prone toexperience them.

Religious convictions also influenced how less and more religious patients explainedtheir delusions and hallucinations. For example, delusions of more religious patientsreferred to paranormal forces rather than people or physical phenomena. Similarly, morereligious patients, both believers and practitioners, had predominant visions of spirits andghosts. As far as voices identity was concerned, again more religious patients reported thatvoices were of supernatural forces.

Despite their neuro-chemical basis, delusions and hallucinations do not tend to existout of context. In a society where belief in witchcraft and supernatural influence is stillwidespread, paranormal than scientific explanation of things are expected more. Theabundance of such explanations in more religious patients may be due to the endorsementof paranormal phenomena in Islam. Various classes of beings beside humans, such as Jinn(spirits), Shaitan (satanic being) and Farishtay (angels), have been mentioned in Al-Quran(Bose, 1997), encouraging people to visualise and believe in culturally and religiouslysanctioned images and ideas (Al-Issa, 1995). In Rehman (Surah 55 of Al-Quran), Goddirectly addresses both man and Jinn, and in Al-Jinn (Surah 72) tells them that bothcreatures are endowed with special abilities but are answerable to God for their deeds. Ithas also been mentioned very clearly in Al-Quran that magical spells can be exercised onhuman beings (Surah 113 & 114) and people are encouraged to recite two Surah (113-114;jointly called Muawezataen meaning two Surah requesting shelter from God) in order tocease the effects of these spells (Suhail & Ajmal, 2009). These views are also culturallyreinforced. Suhail (2003) suggests that belief in magical forces may be an attempt to putthe responsibility of misfortune on some culturally accepted external source, such asin-laws or members of extended family circle.

The findings of this study have implications for mental health professionals andresearchers by suggesting that the religious affiliations of patients are important tounderstand as they play a dominant role in determining the content of their symptoms.Although this study did not directly assess the coping strategies employed by the patients,the examination of the actual content of delusions revealed that the religious convictionsof patients may be used as an effective coping strategy which could serve as a catalyst forrehabilitation. Cognitive behaviour therapy has been employed usefully to address andmanage delusions and omnipotence of voices (Chadwick & Birchwood, 1995; Chadwick,Birchwood, & Trower, 1996). The pathological beliefs of religious patients may bechallenged using Islamic teachings and sayings of the Prophet Mohammad, which adevoted Muslim would find difficult to challenge. Kausar and Sarwar (1997) have pointedtowards various misconceptions that the majority of their respondents living in Pakistanivillages held about the causation of mental illness, such as, visiting graveyards and gardensduring night, possession by jinn, being influenced by an evil eye and eclipses. Theresearchers indicated that these misconceptions are cultural and not religious as Islamforbids people from holding such beliefs. Mental health professionals can use religion toconfront and change these false beliefs. There is sufficient evidence that cognitivebehaviour therapy (CBT) works more effectively in Pakistan if it is incorporated with

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fundamental religious beliefs (Hamdan, 2007; Jahangir, 1995). However, reinforcingpatients’ religiously toned delusions, particularly those patients with threatening and floridgrandiose themes, should be avoided as it could be dangerous. In order to more effectivelyuse patients’ religious convictions, clinicians should try to understand the negative andpositive roles that religion may play in those with psychotic disorder (Koenig, 2007).

The current findings indicate a relationship between religiosity and the content ofdelusions, but this does not indicate the severity of the disorder in the more religiousgroup. Future studies in Pakistan should assess the impact of religious convictions ondistinguishing features of psychosis, such as, severity and course of the disorder. Since thiswas a correlational study, it does not indicate the direction of effect: does religiosity leadto greater frequency of symptoms and distinguishing themes or are such patients moreprone to religious commitment? The incidence of schizotypal tendencies in the normalpopulation and its relationships with religiosity would help clarify the observed links. Theresults of this study, therefore, need to be interpreted in the context of the patients beingtaken from three mental health units of Lahore; therefore, it may not be representing thetotal population of schizophrenic patients in Pakistan. Moreover, there is no guaranteethat the patients’ self-report of religious activity was accurate.

Conclusions

The current study looked at the impact of religion on phenomenology of delusions andhallucinations. The results of the study showed that more religious patients, particularlythose high in the practice of Islam, had a significantly greater number of delusions andhallucinations. More religious group showed an excess of religious delusions and beliefs ofgrandiose identity and ability. Also they visualised more paranormal images and heardvoices from supernatural agents. The content of the symptoms of more religious patientsalso showed that the patients were using their religious faith for coping. Withoutreinforcing the harmful delusional content, the clinicians may employ this link betweenreligiosity and symptoms of psychosis for more effective management of the disorder.

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