Religion, Spirituality, and Schizophrenia: A Review

Religion and spirituality exert a significant role in the lives of many individuals, including people with schizophrenia. However, the contribution of religion and spirituality to various domains (psychopathology, explanatory models, treatment seeking, treatment adherence, outcome, etc.) has not received much attention. In this article, we review the exiting data with regards to the relationship of religion, spirituality, and various domains in patients with schizophrenia. Available evidence suggests that for some patients, religion instills hope, purpose, and meaning in their lives, whereas for others, it induces spiritual despair. Patients with schizophrenia also exhibit religious delusions and hallucinations. Further, there is some evidence to suggest that religion influences the level of psychopathology. Religion and religious practices also influence social integration, risk of suicide attempts, and substance use. Religion and spirituality also serves as an effective method of coping with the illness. Religion also influences the treatment compliance and outcome in patients with schizophrenia. religiosity, different combinations the identified. which assessed various aspects of in relation to were included. the that and caregivers of patients with


Religiousness/religious practices among patients with schizophrenia
Studies have evaluated religious practices among patients with schizophrenia. A study from Switzerland suggested that about one-third of the patients with schizophrenia are very highly involved in religious community. Another 10% of the patients in same study were involved in minority religious movements. [2] Another study from the same country reported that one-third of the patients were highly involved in a religious community, and another one third considered that spirituality had significant role in their life and they carried out spiritual practices every day, without getting involved in a religious community. [3] Studies from other parts of the world which have assessed the religious practices of psychiatrically ill patients suggest that these are common in Europe [4,5] and North America. [6,7] A study found that as high as 91% of patients reported indulging in private religious or spiritual activities and 68% reported participation in public religious services or activities. [8] Some studies which have compared religious practices in patients with schizophrenia and in the general population suggest that religious involvement is higher among patients, [9] whereas others suggest that religious attendance is less in patients of schizophrenia. [10] Religion and psychopathology Among the various aspects of religion and spirituality, the influence of religion and spirituality on psychopathology has been one of the most explored areas of research. Broadly speaking, delusions and hallucinations of religious nature are further categorized as those with religious and supernatural themes. [11] The religious delusions and hallucinations have a direct reference to organized religious themes (e.g., prayer, sin, possession) or religious figures (e.g., God, Jesus, devil, Prophet). The supernatural delusions and hallucinations have more general mystic references (e.g., black magic, spirits, demons, being bewitched, mythical forces, ghosts, sorcery, and voodoo). [11] However, in the literature, delusions and hallucinations of either type are usually referred to as religious delusions.
Studies conducted among inpatients of schizophrenia suggest that the prevalence of religious delusions and hallucinations varies from country to country and the prevalence rates of the same vary from 6 to 63.3%. [12][13][14][15][16] Studies which have compared religious delusions across different countries suggest that religious delusions are more common in Germany compared to Japan. [13] Studies which have evaluated the delusional themes of various religious/spiritual delusions report that the common themes are that of persecution (by malevolent spiritual entities), influence (being controlled by spiritual entities), and self-significance (delusions of sin/ guilt or grandiose delusions). [17,18] Studies also suggest that when the non-content dimensions (conviction, pervasiveness, preoccupation, action, inaction, and negative affect) of different types of delusions (persecutory, body/mind control, grandiose, thought broadcasting, religious, guilt, somatic, influence on others, jealousy, and other) are compared, findings suggest that religious delusions are held with more conviction and pervasiveness than other delusions. [12] Data also suggest that patients with religious/spiritual delusions value religion as much as those without these types of delusions, but patients presenting delusions with religious content report receiving less support from religious communities. [18] Studies which have evaluated the religion in the context of psychopathology suggest that Christian patients have more religious delusions, especially delusions of guilt and sin, than their counterparts belonging to other religions (Islam). [11] Other studies have shown that compared to Christians, Buddhists have a lower frequency of religious themed delusions [19] and that protestants experience more religious delusions than Catholics and those without religious affiliations. [20] Another study reported higher prevalence of religious delusions of guilt in schizophrenia patients of Roman Catholic affiliations, when compared to Protestants and Muslims. [21] Cross -cultural studies which have compared people from different ethnic backgrounds suggest that in case of paranoid delusions, Christian patients more often report persecutors to be supernatural beings, compared to Muslims and Buddhists patients. [21] Other studies suggest that religious and supernatural themes in delusions are more common in Korean patients than Korean-Chinese patients or Chinese patients. [22] Greenberg and Brom [23] investigated hallucinations of patients belonging to Judaism and reported that hallucinations occurred more frequently during the night and this was linked to beliefs of the patients that they were more susceptible to evil spirits and demons at the night time. Peters et al. [24] compared patients belonging to Hinduism (Hare Krishna followers), Christianity, and New Religious Movements with those of non-religious groups and found that patients from New Religious Movements scored higher on delusional measures than the other two groups. Other studies suggest that compared to the patients from Saudi Arabia, patients from the United Kingdom more clearly hear the religious-based auditory hallucinations. [25] With regards to the relationship between religiosity and presence of religious delusions and hallucinations, findings are contradictory with some studies suggesting higher prevalence of religious delusions and hallucinations in those with higher religiosity [26] and others suggesting lack of relationship between the two. [16] With regard to socio-demographic variables, reports suggest that the religious content of delusions is related to the marital status and education of schizophrenic patients. [16] Occasional studies suggest a relationship between religious delusions and cognitive deficits. [27] Religious delusions influence help seeking, treatment, and outcome. Evidence suggests that those with religious delusions take longer to establish service contact, [28,29] receive more medications, have overall higher symptom scores, and have poorer functioning. [28] Those with religious delusion/hallucination are more likely to receive magico-religious healing, are not satisfied with psychiatric treatment , [26] and are more likely not to adhere to psychiatric treatment. [27] Evidence also suggests that those with religious delusions have poor outcome [30,31] and more frequently indulge in violence [32,33] and self-harm. [34][35][36] Some authors suggest that religious delusions can influence the health beliefs models and consequently lead to poor treatment compliance. [37] In a review of 70 studies, the authors evaluated the relationship between religion, supernatural beliefs, and psychopathology. [11] The authors reported that 30 out of the 70 studies (43%) have found a relationship between delusions and hallucinations, and religion and the supernatural beliefs. Majority of the studies (27 of 30 studies) directly described religious delusions, of which 20 studies described delusions to be of a religion-based nature and 14 considered delusions to be of supernatural nature. Thirteen studies reported on religious hallucinations, with 11 having religious content and 9 finding more supernatural content. [11] Many studies have evaluated the influence of religion on severity of psychopathology and the findings are contradictory. Some suggest that religious activities and beliefs are more in persons who experience more severe symptoms, especially psychotic and general symptoms, [38] whereas others suggest that increased religious activity is associated with reduced level of symptoms. [39] Data also suggest that higher religiosity is associated with absence of first-rank symptoms. [40]

Relationship of religion and other clinical aspects in patients of schizophrenia
Researchers have shown that religion/religiousness in patients with schizophrenia is associated with increased social integration, reduced risk of suicide attempts, [38,41] reduce risk of substance use, [38,42] decreased rate of smoking, [43] better quality of life, [10,44,45] lower level of functioning, [26] and better prognoses. [46] With regard to the relationship of religion and psychosocial adaptation, the findings are contradictory, with some reporting better psychosocial adaptation [47] and others reporting poor social and psychological status in a majority of patients. [9] Religious support and spirituality has also been found to be associated with better recovery [42,48,49] and reduced relapse rate. [47,50] However, in some patients, higher religiosity has been linked to higher risk of suicide attempt. [38] Religion and treatment adherence in schizophrenia Some studies suggest that religion/religiousness in patients with schizophrenia is associated with better treatment adherence with psychiatric treatment, [4,38,47] whereas others suggest association of religion with poor treatment adherence. [38,51] Some studies suggest that higher religiosity is associated with lower preference for psychiatric treatment.

Religious coping in schizophrenia
Religious coping is multidimensional and refers to functionally oriented expressions of religion in times of stress. Religious coping is operationally defined as "the use of religious beliefs or behaviors to facilitate problem-solving to prevent or alleviate the negative emotional consequences of stressful life circumstances." [52] The concept of religious coping has been refined and categorized as helpful or positive, harmful or negative, and with mixed implications. The positive religious coping strategies include religious purification/forgiveness, religious direction/conversion, religious helping, seeking support from clergy/members, collaborative religious coping, religious focus, active religious surrender, benevolent religious reappraisal, spiritual connection, and marking religious boundaries. The negative religious coping strategies include spiritual discontent, demonic reappraisal, passive religious deferral, interpersonal religious discontent, reappraisal of God's powers, punishing God reappraisal, and pleading for direct intercession. [53] The religious coping strategies with mixed implications include religious rituals in response to crisis, self-directing, deferring, and pleading religious coping.
Few studies have evaluated the types of religious coping employed by patients with schizophrenia and their role in dealing with the stressful situation. [18,54,55] Studies suggest that up to 80% of patients use religious coping as a means of dealing with their illness. [39] Others have reported that in 45% of patients, spirituality and religiousness was helpful in coping with the illness. [18] Studies which have compared different disorders suggest that patients with schizophrenia, bipolar disorder, and schizoaffective disorder use religious coping for a significantly greater number of years and perceive the same to be more helpful than those diagnosed with depressive disorders. [56] Studies also suggest that religious coping influences other parameters. Studies suggest that religious coping in patients of schizophrenia is associated positively with psychological and existential well-being, with positive religious coping being the primary predictor of psychological well-being. [57] A study revealed that benevolent religious reappraisal was associated with better well-being, better adjustment, and lesser personal loss from mental illness, whereas punishing God reappraisal and reappraisal of God's powers were associated, with a greater correlation, with lesser well-being and adjustment and greater personal loss from mental illness. [58] Positive religious coping has also been associated with higher quality of life in the domain of psychological health. [8] Negative religious coping has been associated with lower quality of life [8] and higher distress (assessed by Depression, Anxiety and Stress scale). [59] Longitudinal studies have shown that higher salience of religion and use of positive religious coping at the baseline are predictive of lesser negative symptoms, better quality of life, and better clinical global impression. [49] Participation in spiritual activities has been shown to be associated with better social functioning and dealing with negative symptoms. [60] Religion and explanatory models held by patients with schizophrenia Studies from different parts of the world have evaluated the explanatory models of illness held by the patients with schizophrenia and suggest that many patients have non-medical explanations for their illness. [61][62][63][64][65] Most of the non-medical explanations across different studies pertain to the supernatural causes. The different explanations include obsession by witches or jinns, [61] esoteric, [66] spiritual, and mystical factors, [63] family trouble, inner problems of self, economic difficulties, supernatural forces, [64] sorcery, ghosts/evil spirit, spirit intrusion, divine wrath, planetary/astrological influences, dissatisfied or evil spirits, and bad deeds of the past. [65] A study from India reported that about 66-70% of the patients have at least one non-biomedical