Evidence-Based Reviews

How to care for patients who have delusions with religious content

Sara M’Lis Clark, MD
Psychiatry Resident, PGY-III, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
David A. Harrison, MD, PhD
Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA

To improve outcomes, look beyond delusion content and enlist spiritual care experts


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Mr. D, a 72-year-old Christian with a long history of schizophrenia, presents to the emergency room with concerns about evil spirits in his home who have poisoned him. He has called for police assistance on numerous occasions and has tried to kill the evil spirits with his rifle, but states “they are bulletproof.” He is unable to sleep and is “fearful for my life every night because that is when the demons come out.” Mr. D also believes that God is “more powerful than the evil spirits.” Two elders at his church have prayed with him and encouraged him to go to the hospital.

Delusions with religious content (DRC) are associated with poorer clinical outcomes and dangerousness.1-6 Most mental health professionals will encounter patients with DRC because this type of delusion is relatively common in patients with symptoms of mania or psychosis. For example, in a study of 193 inpatients with schizophrenia, 24% had religious delusions.1 The prevalence of DRC varies considerably among populations and can be influenced by the local religion and culture.7-9 This article reviews clinical challenges and assessment and management strategies for patients with DRC.

A challenging course

In a UK study of 193 inpatients with schizophrenia, compared with patients with other types of delusions, those with DRC:

  • had higher Positive and Negative Syndrome Scale scores and lower Global Assessment of Functioning scores
  • waited longer before reengaging in treatment
  • were prescribed more medications.1

In addition, compared with patients with other types of delusions, patients with DRC often hold these delusions with greater conviction,1,2 making them more challenging to treat.

Dangerousness in patients with DRC can manifest as self-harm or harm to others. Extreme examples include self-inflicted enucleation of the eye and autocastration. In a review of 9 cases of severe ocular self-injury, 4 patients had DRC.3 Genital self-mutilation associated with DRC is rare, but several cases of psychotic men who performed autocastration based on a literal, erroneous interpretation of a passage in the Bible (Matthew 19:12) have been reported.4,5 Patients with DRC have committed rape and murder because they believed they were the antichrist.6

In this article we use the phrase “delusions with religious content” instead of “religious delusions” because this distinction highlights that many subtypes of delusions can have a religious theme. Categories of delusions with religious themes include:

  • persecutory (often involving Satan)
  • grandiose (messianic delusions)
  • guilt delusions.

Categorizing DRC is important because some are associated with more distress or dangerousness than others. For example, case studies of self-inflicted eye injuries found that most patients had guilt delusions with religious themes that referenced punishing transgressions, controlling unacceptable sexual impulses, and attaining prescience by destroying vision.3,10 In our example, Mr. D is experiencing a persecutory DRC. Also, using the label “religious delusion” can inadvertently pathologize religious experiences.

Tips for effective evaluation

DSM-IV-TR offers no specific guidelines for assessing DRC vs nondelusional religious beliefs.11 There is risk of pathologizing religious beliefs when listening to content alone.11-15 Instead, focus on the conviction, pervasiveness,2 uniqueness or bizarreness, and associated emotional distress of the delusion to the patient (Table 1).2,12,16-18

In the context of the patient’s spiritual history, deviations from conventional religious beliefs and practices are important factors in determining whether a religious belief is authentic or delusional. Involving family members and/or spiritual care professionals (eg, chaplains and clergy) can be especially helpful when making this differentiation.16,17 In the hospital, chaplains often are familiar with a variety of faith traditions and may provide important insight into the patient’s beliefs. In the community, clergy members from the patient’s faith also may provide valuable perspective.

Similar to how having a basic familiarity with a patient’s culture can improve care, a better understanding of a patient’s spiritual or religious beliefs and practices can build rapport and the therapeutic alliance.16,17 This is particularly important with patients with DRC because these individuals often have a poor therapeutic alliance and engagement with providers.19 Because many psychiatrists have limited time and may not be familiar with every patient’s spiritual or religious background, consultation with spiritual care professionals may be helpful.

Assess whether your patient has reservations about psychiatric treatment. Some may believe that seeking care from a doctor is evidence of weak faith, whereas others may feel that psychiatric treatment is forbidden or incompatible with their religious beliefs.19-22 Mental health clinicians need to consider their own religious biases that may cause them to minimize or pathologize a patient’s religiosity.20,23 Working collaboratively with spiritual care professionals may help reduce clinician biases or assumptions.24