Are religious delusions related to religiosity in schizophrenia?

Summary. This article attempts to explore the phenomenology of religious delusions in patients suffering from schizophrenia and to determine parallels between personal religiosity and content of religious delusions. We have studied the content of delusions in patients with schizophrenia looking for religious themes using Fragebogen fur psychotische Symptome (FPS) – a semi-structured questionnaire developed by the Cultural Psychiatry International research group in Vienna. A total of 295 patients suffering from schizophrenia participated in this study at Vilnius Mental Health Center in Lithuania, among whom 63.3% reported religious delusions. The most frequent content of religious delusion in women was their belief that they were saints and in men – that they imagined themselves as God. Univariate multiple logistic regression analyses revealed that four factors such as marital status, birthplace, education, and subjective importance of religion were significantly related to the presence of religious delusions. However, multivariate analyses revealed that marital status (divorced/separated vs. married OR (odds ratio)=2.0; 95% CI, 1.1 to 3.5) and education (postsecondary education vs. no postsecondary education OR=2.3; 95% CI, 1.4 to 3.9), but not personal religiosity, were independent predictors of the religious delusions. We conclude that the religious content of delusions is not influenced by personal religiosity; it is rather related to marital status and education of schizophrenic patients.


Introduction
Religion is one of the ways we understand the world and give meaning to our lives (1). There are numerous religions in different societies and even within the same society that directly or indirectly shape our lives and influence our thoughts and behavior. In psychiatric patients, religiosity may impact psychopathology and treatment of the patient (1,2).
Despite the intensive efforts in research that began with Emil Kraepelin (3) and Eugen Bleuler (4,5), the etiology and pathogenesis of the schizophrenic psychoses have hitherto been only partially clarified (6); thus, many fundamental questions about the phenomenology of delusions remain unanswered (7). Crosscultural psychiatry studies also tried, by means of its methodological inventory, to analyze the influence of cultural and environmental factors on the pathogenesis and phenomenology of schizophrenia (6). Some events in society may create delusional environment, described by E. Bleuler (4,5), which could find a reflection in the psychopathology (8).
Data on phenomenology of delusions, hallucina-tions, or Schneider's first rank symptoms in schizophrenia demonstrate a remarkable influence of culture on content of psychotic symptoms (9). The discussion whether and to which extent the prevalence and content of psychotic symptoms depends on cultural environment has a long-standing tradition. In German psychiatry, Zutt (10) established the term pathoplasticity to describe the culture-sensitive part of the symptomatology of mental disorders. However, until today this term has more or less a metaphoric character. Although most psychiatrists would agree that a cultural pattern might influence psychotic features, it is an unsolved question to what extent the variability of psychotic symptoms is caused by cultural factors such as socialization, religion, and believes. A number of case reports published during the last 20 years describe a quick inclusion of new technologies and cultural innovations into schizophrenic delusions (9,11). The way a patient expresses his/her illness is influenced by his/her cultural environment (13,14). The importance of understanding of religious beliefs of psychiatric patient was reported by several studies (15)(16)(17)(18)(19)(20)(21). One of the most interesting delusional themes, which were found in almost every culture, was religious content of delusions (9). Schizophrenic religious delusions were described in different cultures (6,22) and in different times (23). The existence of different phenomenological forms of religious delusions is clinically evident. The term "religious delusions" comprehends such different phenomena like acute apocalyptic ideas as well as chronic ideas of being damned by God or being God (9,24,25).
Aim of this study was to evaluate religious delusions determining relationship between personal religiosity and religious content of delusions.

Material and methods
Data for this study were obtained from the research project, entitled "Research in cultural psychiatry. Research of the content of delusions and hallucinations." Protocol of the study was approved by the Lithuanian Bioethics Committee. All patients of the study signed informed consent form. Patients were included into the study if they met following criteria: established clinical diagnosis of schizophrenia, according to the International Statistical Classification of Diseases (ICD-10), age between 18 and 80 years, male and female, who were capable for participating in a productive interview according to their mental state (26). Content of delusions, hallucinations and first rank symptoms were evaluated by means of the "Fragebogen fur psychotische Symptome" (FPS) -a semi-structured questionnaire developed by Cultural Psychiatry International research group in Vienna (27). The FPS was translated into Lithuanian using method of double translation. The FPS consists of Introduction that contains questions on demographic and clinical data; and of three modules describing different symptoms of psychoses as mentioned above. For this study, we used data from the Introduction of the FPS and from the module describing content of delusions. From this module, we took question describing religious content of delusions, "Did you think you were an important personality, a saint, God, the devil, or a demon?" with two possible answers "Yes" or "No." In a case of the positive answer, patient was asked to describe specific content of delusion.
In addition to the FPS interview, all patients were asked about their personal religiosity, asking "Are you religious person?" and "Is your faith personally important for you?" We examined 295 patients (mean age, 42.4 (SD 9.7) years; women -51.5%) at the Mental Health Center in Vilnius, Lithuania.

Statistical analysis of the data
The statistical analysis applied a χ 2 test for 2×2 and 2×k tables, Fisher's exact test, Spearman's rank correlation, and logistic regression. Continuous or ordinal data were analyzed using t test. The quantitative evaluation of the impact of the studied determinants (age, sex, duration of illness, age at illness onset, education, birthplaces, marital status, and the personal importance of the faith) on the development of religious delusions was performed using logistic regression.
The relationships of the analyzed determinants with the evaluation of religious delusions were calculated in two stages: using the univariate and multivariate (applying Forward LR selection algorithm) logistic regression analysis. The data on male and female subjects were analyzed separately, followed by the analysis of the total contingent of subjects. During the first stage of the analysis, we investigated all separate determinants, taking into consideration the impact of the age, and included separate determinants and age into the logistic regression model. The quantitative evaluation of the impact of the studied determinants on the development of religious delusions was performed using the odds ratio (95% confidence interval (CI)) that shows the increase in the risk of a subject to enter the group of those experiencing religious delusions with respect to the subject's attribution to some of the classification categories of the studied factors with respect to the reference category. After that, the step-wise (Forward LR algorithm) procedure was used to include statistically significant variables into the model (P>0.10 -excluded). Level of statistical significance was set at 5%. Statistical analysis of the data was performed using the statistical software package SPSS 11.5.

Results
Sociodemographic characteristics of 295 surveyed patients with schizophrenia are presented in Table 1. Male and female patients were similar with respect to age, birthplace, duration of illness, age at illness onset, and education. There was a significant difference in the patients' distribution in marital status groups according to sex. Male patients were more likely to be divorced/separated than female patients.

Prevalence
Of 295 respondents, there were 248 (84.1%) patients for whom their faith was of personal importance (Table 1). Men and women differently evaluated the importance of their faith; 89.5% of men and 78.9% of women reported their faith as important for them (χ 2 =6.1, df=1, P<0.05).
The religious delusions were confirmed in 190 (64.4%) patients. There were no significant differences in the frequency of the development of the religious delusions between men and women, 89 (62.2%) and 101 (66.4%), respectively (χ 2 =0.57, df=1, P>0.05). However, there was a significant difference in the content of religious delusions between men and women (χ 2 =70.03, df=7, P<0.001). The distribution of themes of the religious delusions in patients with schizophrenia according to sex is presented in Fig. 1. Most frequent content of religious delusion in women was belief that they were saint women, and most rare content was that they were God. In contrast to women, in men being God was the most popular theme of delusions, and being saint man was a second popular theme.

Determinants of the development of the religious delusions
A significant but weak correlation has been found between the development of the religious delusions and the personal importance of the faith (Spearmen correlation r=0.12, P<0.05). The religious delusions were reported by 66.9% of those schizophrenia patients for whom their faith was of personal importance and by 51.1% of those schizophrenia patients for whom their faith was not important (sex-and ageadjusted OR=1.9; 95% CI, 1.1 to 3.6). However, there were no significant differences in the occurrence of religious delusions separately in the male patients' group and in the female patients' groups regarding to the importance of their faith (Fig. 2).
Results of univariate multiple logistic regressions. After controlling for age and sex, four independent factors remained significant for the development of  Table 2).
The divorced patients independently of the age and sex more frequently experienced the religious delusions compared to married patients (sex-and age-adjusted OR=2.2; 95% CI, 1.3 to 3.9).
Education was also associated with a higher frequency of the development of the religious delusions (some postsecondary education vs. no postsecondary education (OR=2.6; 95% CI, 1.5 to 4.3). Patients with rural birthplace had a lower risk of development of religious delusions (rural vs. urban OR=0.4; 95% CI, 0.3 to 0.8).
For evaluation of the impact of socio-demographic factors on development of religious delusions, multivariate logistic regression analysis was employed (Table 3). Marital status (divorced/separated vs. married OR=2.0; 95% CI, 1.1 to 3.5) and education (some postsecondary education vs. no postsecondary education OR=2.3; 95% CI, 1.4 to 3.9) significantly predicted religious content of delusions. In this model, the personal importance of the faith was a statistically insignificant predictor of the religious delusions.

Discussion
Results of our study have demonstrated that religiosity in general as well as personal importance of the faith are not directly related to the religious content of delusions in patients with schizophrenia and are associated with education and family status of the patient. Content of religious delusions is gender specific. Among women prevailed a theme of being saint, and among men prevailed a theme of being God.
The affinity of schizophrenia to religion was recognized and was a topic for intense research already in the 19th century (6). German psychiatrist Spitzer claims that clinically religious delusions can only be diagnosed indirectly. Indirect signs of delusions are the incidence of other symptoms of mental disease, inconsistencies between utterances and behavior, constriction or torpor of thinking, feeling and acting (6,     (29). The prevalence of delusions and hallucinations with religious content varies between cultures and over time (30). Religious practices have been associated with a higher rate of religious delusions (31), but personal religiosity is not necessary for the development of religious delusions. Stompe and colleagues (1999) found that neither in Pakistan nor in Austria any connection was established between contents of delusions and social status as well as level of education of patients with schizophrenia (6). A study of mental health status of immig-rant farm workers in the United States has discovered higher acculturative stress and higher anxiety levels in immigrants who reported lower religiosity and higher education (50). During occupation and isolation, religious roots of the nation were damaged with no other spiritual source offered (51). This long-standing spiritual deprivation might, at least in part, be responsible for the poor mental health situation in Lithuania, including high suicide rate, high alcohol consumption, and high prevalence of psychoses (52).
Cross-sectional design of the study does not allow us to speak about causal relationships between independent factors, such as marital status or education and religious delusions. Another limitation of the study is that we did not verify psychiatric diagnoses with standard diagnostic interviews and relayed on clinical diagnoses; however, these clinical diagnoses were established using standard ICD-10 diagnostic criteria for schizophrenia. Moreover, assessing psychopathology, we used validated structured psychiatric instrument, FPS.

Conclusions
1. Delusions of religious content were reported by males and by females. Male patients most often considered themselves as God, while female patients most often considered themselves as Saints.
2. Religiosity and personal importance of the faith were not confirmed as independent predictors of religious content of delusions in schizophrenic patients.
3. Marital status and educational level independently predicted religious content of delusions in patients with schizophrenia.