SPECIAL ARTICLES

THE FIRST PSYCHOTIC EPISODE WITH A MYSTICAL THEME

Aurel Niretean1, Emese Lukacs2, Dana Cmpan3
Abstract: The matter of the first psychotic episode is always a challenging subject. Its etiological and pathogenetical complexity is also confirmed through psychopathological manifestations corresponding to the spiritual dimension of psychism and of human personality. Among them, those involving religious theme occupy a particular position which confirms the interrelations between psychiatry and religion in an area delimited by beliefs, symbols, visions, sufferings, healing and moral values. In this context, increasingly frequent during later years, the psychiatric practice develops psychotic debuts with mystical subject as well as evolutive types, most of the time strictly individualized. Key words: first episode psychosis, personality, religion. Rezumat: Problematica primului episod psihotic este ntotdeauna un subiect provocator. Complexitatea sa etiologic i patogenetic este confirmat i prin manifestrile psihopatologice corespunztoare dimensiunii spirituale a psihismului i a personalitii umane. Printre acestea, tulburrile care implic teme mistice ocup o poziie aparte care confirma interferenele dintre psihiatrie i religie pe un teritoriu delimitat de credine, simboluri, viziuni, suferine, vindecare i valori morale. n acest context ale crui dominante sunt tot mai frecvent decelabile n ultimii ani, practica psihiatric evideniaz modaliti de debut i evoluie cu tematic mistic ale psihozelor, de cele mai multe ori strict individualizabile. Cuvinte cheie: primul episod psihotic, personalitate, religie. and doctrines that appear overnight, and often an anarchic mass-media. Having the freedom to seek self- realization according to false models, and always in search of fleeting values, contemporary humans detach themselves from traditions and confound freedom with the illusion of freedom (2). By the same token, the emphasis on individual differences, and the concentration on the self and self-interest, are considered normal in Western cultures, while in Oriental cultures the same values are labeled as signs of psychological immaturity. Within this framework, human beings often live anxious lives which lack certainty and the depth of traditional values. Consequently, in the last decades, one notices a need for, an emphasis on, and an opening towards the supernatural, and the sacred. This seems to be tied to a fundamental tendency of the human mind to attribute inexplicable or intolerable phenomena to supernatural forces (4). Contemporary society has seen a growth in the number of people that adhere to various religions or religious cults. In the US, where 95% of the population affirm their belief in God, religion has become an institution at the forefront of the social, economic, and political dynamics (5). When they are deliberately and elaborately assumed, when their message is not diluted by dogma, formalism or consumerism, religious practices can cultivate in a person admirable psychological and moral qualities such as optimism, vitality, perseverance, rectitude, solidarity, charm, altruism, and selftranscendence. They can teach people to enjoy the moment, and feel gratitude for and contentment with what

The subject of the first psychotic episode remains to this day a challenge for clinicians and psychopathologists. This fact is due not only to a clinical and phenomenological, but also to an etiologic polymorphism. The reciprocal interferences and interconditionings among the various psychoses-both at the level of the components of the pre-morbid stage, and of the risk factors involved-allow the framing of the concept of unique psychosis or psychotic continuum. In turn, this concept motivates studies dedicated to the initial psychotic episode. Functional psychoses are known to be determined by the contribution of genetic, familial and pre-natal factors, by the individual personality, and the oscillations of individual biological and psychological rhythms, as well as by the vulnerabilities of marriage. The latter include the diverse psychological and socio-cultural dynamics between individuals and their environment. Today's world is dominated by pragmatism, by contradictory phenomena, and fleeting values. The unbridled advances and applications of technology opened the way to hyper-consumerism, and the unconditional ascent of biological and material values. Humans produce more than they consume, and consequently have a distorted sense of freedom. This in turn compels them to work even harder, as well as to look for ever new ways of rest, relaxation and health care. Since a person's selfworth is mostly connected with money and success, the feelings of false happiness are more and more dominant (2, 3). There are laws that regulate social life, but there are also an infinite number of motivations, values, idols,

Senior Psychiatrist, MD, PhD, University Professor, UMF Trgu Mure, Department of Psychiatry, Trgu Mure, Romania. MD, Psychiarist, Psychiatric Clinic No. 2, UMF Trgu Mure, Department of Psychiatry, Trgu Mure, Romania. 3 MD, Psychiarist, Psychiatric Clinic No. 2, UMF Trgu Mure, Department of Psychiatry, Trgu Mure, Romania. Received November 21, 2011, Revised January 18, 2012, Accepted February 03, 2012..
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Aurel Niretean, Emese Lukacs, Dana Cmpan : The First Psychotic Episode With A Mystical Theme

they already have (6, 7). At the same time, Freudian psychoanalysis views religion as a regression to a primary narcissistic stage, and religious manifestations as group neurotics (8). Selfknowledge and personal responsibility are seen as being diminished, since they depend exclusively on the relationship between the individual and the divine. At the same time, religious belief could be used to manipulate and subdue the young generation or various groups of individuals or social classes. It can decisively influence individual destiny, dividing people, by disallowing interfaith marriages, condemning pregnancy or abortion, and curtailing access to a professional or social status, for example. Nevertheless, human beings can find new essential meanings through mystical experiences. They do it in search of happiness; though it seems that the majority of them are either atheists or believers according to whether they feel happy or unhappy. The distinctions between psychopathological manifestations- especially the psychotic ones- and spiritual experiences, including religious experiences, were always difficult to make. Dreams and imaginary scenarios with mystical themes can be easily taken for illusions, hallucinations, and delirious ideas on the same theme (9, 10, 11). Still, psychiatrists have always tried to find natural explanations for the phenomena they noticed. When these phenomena have a mystical content, the question that arises is whether it is morally correct to treat a person for their religious beliefs, while also taking into account the necessity to safeguard the confidentiality of the intervention. Throughout history, a significant number of very cultured people- contrary to some, probably atheistic, ideas- have described the experience of hearing voices not coming from an verifiable source, had visions or revelations, and felt they were under the influence of unknown outside forces. Socrates for example described a voice which warned him in advance that he could be mistaken. Saint Peter felt he was transported to Paradise where he was questioned by voices not of this world. Saint Theresa of Avila had several mystical visions which marked her life, and so did George Fox, the founder of the Quakers (9, 10, 11). When these productive manifestations of the psyche have a beneficent, relaxing, tonic, supportive and morally refreshing effect, they are considered mystical experiences. When their effect on the psyche and on one's personal life are contrary to those mentioned before, we can consider them psychotic episodes. The manifestations of the first psychotic episode are extremely unstable and non-specific, and thus become a first argument for the concept of unique psychosis. They can take hold suddenly or insidiously, and are more likely to manifest on a pre-morbid background that includes disharmonic schizoid, affective, anxious and borderline features (1, 12). In the last two decades we have observed a significant rise in the number of mystical experiences during the first psychotic episodes, independent of demographics (7). The personal clinical experiences show a significant increase in religious psychotic episodes in young people as well as in adults who have difficulties in adapting and functioning in their professional and social 8

roles. We comparatively evaluated 18 patients who had a first psychotic episode with a mystical theme, either unique or recurrent. They were inpatients at the Psychiatric Clinic II in Tirgu-Mures in the past 3 years. We used the PANSS and SCID II scales in order to obtain accurate diagnoses for the Axis I and II disorders.We first observed the diverse social and professional status of the patients. The great majority of the patients were admitted late, 6 months to 1 year after the first clinical manifestations of their symptoms. The main reasons for admission into the clinic were the intensity of the delirious hallucinations which significantly perturbed the patients' relation to society or drew them to attempt suicide. The most important precipitating factors were the unforeseen changes in their social and professional roles, and drug abuse. The nature of these factors was biological, socio-cultural and dependent on personality. We can thus mention the asthenic biotype, the low affectivity caused by a lack of parental models, tension in the parental home or the birth succession even among twin siblings. The strong or pathological personality disorders such as schizoid, borderline, histrionic, dependent and obsessive-compulsive, intervened in and enabled the psychotic episode or its recurrence in almost 2/3 of the patients under study. The same enabling role was played by the conversion to another religion and life changes that occurred as a result of psychic trauma. The themes of the psychoses contained megalomaniac ideas of grandeur and mysticism, as well as ideas of reference, prejudice, and self-guilt. They integrate archetypal models such as ascetic knights, great mystics, or satanic types. The congruent hallucinations with a delirious content were sometimes difficult to differentiate from the imaginative representations. The depersonalizing and self-effacing phenomena are constantly seen in all the patients and they lead to identity crises, especially during the pre-morbid stage, and to swings in motivation. Half of the patients experienced passing states of ecstasy and beatitude, which alternated with dysphoric manifestations. The impulsivity and the intolerance exhibited in interpersonal relationships were constantly aggravated by drug and alcohol abuse. Here are several peculiar situations: Q A unique mystic psychotic episode with paranoiac and pseudo-stupor catatonic syndrome was identified in a 28 year old man with dependent personality features. The episode was precipitated by a breakup with a dominant twin brother, as well as the stress of the last year of university studies. His psychic vulnerability was due to the lack of a male parental role model and the corresponding hyper-protectiveness of the mother. Added to this, the uncontested authority of the twin brother- a knight who inspires a hermit- is a source of mystical meanings for the various events of his personal life. He responded well and persistently to treatment. Q Recurrent mystical psychotic episode with grandeur and xenopathic influence delusions, dysphoric crises and addictive consumption of alcohol and minor drugs in a 42year old woman with borderline type personality, aggravated by membership in a neo-protestant group. Her vulnerabilities are both biographical, and personological the patient was single, had been sexually abused in her youth, was dependent on biblical precepts, and had an

Romanian Journal of Psychiatry, vol. XIV, No.1, 2012 uncertain employment status. She is only partially compliant and responsive to treatment. Q Recurrent psychotic episode with mystical delirium of self-guilt and suicide attempt in a 40-year old adult without a pre-morbid personality. Was triggered by the death of his brother caused by chronic renal disease. Biographic vulnerability brought about by unconditional adherence to a neo-protestant group after the loss of his brother whom he feels responsible for as a man of the Bible- He had a partial response and compliance to treatment. Q Recurrent mystical episode with paranoid relational and erotomanic delusions in a 52-year old patient with no premorbid personality background, triggered by several therapeutic meetings with a charismatic but controversial orthodox priest. Her familial vulnerability was due to the absence of communication and empathetic manifestations. Biographical vulnerability due to religious practices which caused her erotomanic slide toward a person with a peculiar social status. She responded and complied to treatment only partially. In general, the psychotic episodes were followed by defective states dominated by depressive symptoms, and dependent and obsessive-compulsive type character changes. One quarter of the patients had comorbid conditions such as endocrine, neurological and cardiac diseases that were mostly ignored. We noticed a positive correlation between the number not the gravity- of hospital admissions, the first psychotic episode being always the most severe, and the presence of pre-morbid personality disorders. Cluster A type personalities displayed inhibition and social isolation, and cluster B personalities exhibited expansive but unstable manifestations, as well as ideas of grandeur that pointed to their connection to God, or for women, to a marriage partner. The disharmonic anxious features triggered micromaniac and relational delusions just like in the case of the patients without personality disorders. The suicide attempts or severe deficiency states which lead to the urgent hospitalization of the patients later took on mystical meanings and were attributed to delirious interpretations. During hospitalization we observed several cases of mystical contagion among the patients - as was the case with a male patient who had a well structured Ego, and who participated pre-morbidly in stable religious roles and activities.The initial therapies with neuroleptics, mood stabilizers and anti-depressives were more readily accepted by the patients when we could appeal to their intellectual stance and spiritual open-mindedness. Understanding the power and transcendence of the mystical experience, we often wondered if, under similar circumstances, we could have had the same reactions and manifestations as some of the patients we described. This is because psychiatry and religion had and continue to have common motivations and means of dealing with the body-soul relationship, with the major human values, and the human condition in general. They both need to focus on the effort to mobilize the human capacity for self knowledge and self improvement, so human beings can reach the level of understanding of objective and transcendental reality that can offer them a moment of daily happiness. REFERENCES
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