Development of Schizoaffective Psychosis in the Course of a Long-Term Occupation as Spiritual Healer: Coincidence or Causality?

Case Presentation

“Ms. A,” a 46-year-old woman working as a spiritual healer, presented to our psychiatric department for the first time. Coming from a small town in southern Germany, she was concerned about her privacy and, on the advice of a friend, had decided to seek help away from her place of residence.

Even at first glance, the patient appeared to be markedly impaired by the symptoms she described. She initially stated that she was “not able to feel anything anymore.” She felt unable to cope with her daily routines and to make decisions. Furthermore, she suffered from intense feelings of guilt. By performing her spiritual work, Ms. A felt that she would “take something away” from her clients without giving much in return. She had tried to discipline herself and regain self-control and control over her spiritual activities by intense fasting, which resulted in substantial weight loss and a current BMI of 16.2. Additional symptoms were poor concentration, thought blocking, disturbed sleep, severe loss of energy, noticeable psychomotor retardation, and poverty of speech. The patient denied any suicidal thoughts. Besides these obvious psychopathological symptoms, the patient reported a ceaseless intrusion of external mental energies and information, which she explained as the perception of the auras of other persons or even objects.

After completing secondary school (the German Abitur) and a 3-year vocational training program, Ms. A worked in a skilled job in health care for several years. During this time, she became increasingly interested in alternative healing methods. After an additional apprenticeship in spiritual healing, she started to work as a self-employed healer, using especially the principles of Pranic Healing (1). This method, which requires intense meditative and trancelike states, was described by the patient as follows:

The healer can perceive (and even influence) physical, mental, emotional, and spiritual conditions or processes in people. Our patient perceived these energies or spiritual information constantly and involuntarily, which was causing her a great deal of suffering.

Physical examination showed no pathology other than the weight loss. Results of blood tests were normal. Because of the patient’s fear of magnetic fields, we could not use MRI. A cranial CT was performed, without any pathologic results. Neuropsychological testing revealed marked deficits in multiple cognitive domains.

We initially diagnosed a major depression. Meditative and trancelike states, as well as the perception of external mental energies, were not considered pathological, as they were inherent to the patient’s occupation as a spiritual healer. Antidepressant treatment was initiated with agomelatine, and later switched to venlafaxine, without improvement in symptoms.

The persistence of symptoms, and especially the constant suffering from intruding external mental energies, made us doubt the diagnosis of only an affective disorder. We therefore performed a new and more detailed anamnesis with both the patient and a friend of hers who was also familiar with spiritual healing, now focusing on the possible impact of her occupation. By inquiring thoroughly about the specific procedures of Ms. A’s work and the changes she had experienced, we were finally able to distinguish the functional aspects of her spiritual practices from the now pathologic quality.

In contrast to the regular meditation she had performed for many years, Ms. A felt no longer able to shut her “third eye” at the end of a session. The ability to receive mental energies was now experienced as uncontrollable, unbounded, and independent of her own will. She felt the constant intrusion of other people’s auras, and this external information would enter her mind unfiltered, resulting in a permanent sensory (or spiritual) overload. Furthermore, this uncontrolled flow of mental information was associated with a general disturbance of the patient’s self-experience, which she described as an inability to feel the boundaries of her body and to distinguish between her self and the environment.

According to this information, we reappraised the above described phenomena as psychotic symptoms. The diagnosis was changed to schizoaffective disorder, and antipsychotic therapy was initiated with olanzapine and later combined with risperidone. The psychotic symptoms subsided, and Ms. A reported a better “protection” against the external mental information. She described the effect of antipsychotic medication as a cover or cap that helped her to demarcate herself against the environment.

Discussion

This unique case of a patient diagnosed with schizoaffective disorder in the course of a long-term occupation as a spiritual healer shows some exceptional features and brings with it diagnostic challenges that deserve thorough consideration. We discuss three major aspects: first, the cultural aspects of the case (namely, the obscure boundary between esoteric practices and psychotic experiences), which complicated the differential diagnosis; second, the exceptional features of the case, which largely differed from those of previously published cases of psychotic reactions in the context of meditation and spiritual techniques; and third, the unclear link between the patient’s occupation and the subsequent development of psychotic symptoms.

Culture-Sensitive Differential Diagnosis

In psychiatry, the patient’s individual cultural background must be thoroughly considered for the correct assessment of psychopathology. In this particular case, it was crucial to distinguish the features that were normal in the cultural context of professional spiritual healing from features judged pathologic even against the background of this occupation. Our patient reported a ceaseless, stressful intrusion of external mental information (the perception of the auras of other persons and objects). We first interpreted this to be inherent in her occupation as a spiritual healer, since these symptoms very much resembled the patient’s former practices. Only after a more detailed and painstaking anamnesis with the patient and a colleague of hers were we able to recognize the profound shift in her psychological experience and disentangle the normal phenomena in this cultural setting from the pathologic (or psychotic) features that had emerged after years of healthy and functional occupation in this milieu (Figure 1).

The main difference was the experience of a total loss of control over the spiritual information she constantly received. Whereas previously she had prepared herself by intense meditation to be able to receive mental energies volitionally and purposefully, she now involuntarily experienced herself (her “third eye”) as constantly “open,” exposed, and susceptible to external influences. Moreira-Almeida and Cardeña (2) have, in the context of spiritual experiences in Latin American populations, described criteria to distinguish culture-bound spiritual phenomena from pathologic psychotic symptoms. These criteria clearly support the pathologic quality of our patient’s experiences (Table 1).

We are aware that the diagnosis of schizoaffective disorder in general may be questionable (3). Moreover, the psychotic nature of our patient’s experiences per se might be doubted because of the uncommon symptom configuration. However, her experience of an unwanted and passively received stream of external mental information can well be interpreted as “thought insertion,” and it is also very similar to other schizophrenia first-rank symptoms—passivity experiences, ego disturbances, and “made” experiences (4). Further supporting the psychotic character of the patient’s symptoms are the response to antipsychotics (without relevant improvement of depressive symptoms) and the cognitive and functional impairments to a degree typically seen in psychotic disorders. Furthermore, despite the lack of hallucinations and delusions, DSM-IV and ICD-10 diagnostic criteria are fulfilled, as our patient also exhibited formal thought disorder and negative symptoms (alogia, poverty of speech, social withdrawal).

Exceptional Features

Our case shows some unique features when compared with previous reports of psychotic conditions in the context of meditation and spiritual practices. According to the literature (5–8), these psychotic reactions are usually characterized by acute, transient (days to few weeks), often self-limiting polymorphic symptoms with full remission. The premorbid level of functioning is typically regained. Even two related cases of “mediumistic psychoses” (9) published as early as 1919 share these features, and thus a uniform pattern of “meditation-induced psychoses” may be assumed. According to the current diagnostic systems, most such cases would be diagnosed as “brief psychotic disorder” (DSM-IV) or “acute transient psychotic disorders” (ICD-10).

In contrast to these typical features of meditation-induced psychoses, our case exhibits several distinct characteristics. First, the onset of symptoms was not acute. The symptoms did not occur in the context of a single meditation session but increasingly developed in the course of a sustained occupation as a spiritual healer with the frequent use of intense meditation. Moreover, our patient suffered from a persistent and stable set of symptoms. Even under adequate treatment, full remission was not obtained. The patient continued to suffer (albeit much less so) from the above-described symptoms, along with marked functional impairment.

A Causal Link Between Spiritual Healing and Psychosis?

Another interesting aspect of this case concerns the link between the development of schizoaffective disorder and a long-standing practice as a spiritual healer. Although it would be impossible to prove a causal link (much less its direction) between these two factors, some potential relationships should be discussed. First, it could of course be a mere coincidence of an exceptional occupation and the late manifestation of a schizoaffective disorder at an age that constitutes the second peak of schizophrenia onset in women (10).

Second, it may be speculated that some kind of prodromal state or schizotypal personality (11) preceded the now overt symptoms and possibly even led to the special interest in spiritual healing. However, we have no evidence that any abnormalities or changes in the patient’s mental state preceded the onset of symptoms. According to Scharfetter (12), psychiatrists should not carelessly pathologize peculiar interests and beliefs as long as they do not lead to “infirmity” and functional impairment. Since our patient did not show any signs of such impairment before the development of full-blown schizoaffective syndrome (in contrast, she had worked successfully in her occupation and was even certified as a trainer), we do not have any evidence for a preexisting prodrome or latent psychotic disorder.

Third, there could be some kind of causation between the patient’s spiritual techniques and the subsequent development of psychotic symptoms. One argument in support of such causation is the specific configuration of the patient’s psychotic symptoms that can be convincingly traced back to the former functional use of spiritual healing, with the only difference being the now completely uncontrolled character of the same phenomena (see Figure 1). Moreover, no other, more typical, symptoms, such as auditory hallucinations or paranoia, were present at any time. Thus, the specific psychopathology with preeminently disturbed self-experience and its strong coherence with the patient’s spiritual practices suggest at least a contributory role in this case.

Conclusions

We present a unique case of a patient who developed a schizoaffective disorder in the course of her long-term occupation as a spiritual healer. Of course a single case report is not suited to prove general mechanisms of psychotogenesis. However, we deem phenomenology (13), that is, the clinical observation and thorough description of individual psychopathology, a valuable source for generating hypotheses—in this case, a potential link between repeated intense meditation and spiritual practices and the development of specific psychotic symptoms. To substantiate such a hypothetical relationship, however, large cohort or cross-sectional studies would be needed. Furthermore, our case again stresses the importance of a thorough anamnesis and integration of the patient’s specific (sub)cultural context for the appraisal of psychopathology.