Openings in the DSM-5TR

Review of problematic DSM-5-TR diagnostic categories that overlap with EPEEs

Owing to the work of Drs David Lukoff, Francis G. Lu, and Robert Turner, in 1993 the Diagnostic and Statistical Manual added criteria to exempt those from a diagnosis of mental illness who were experiencing hallucinations, delusions, or other unusual experiences that were expected in their spiritual tradition who also maintained sufficient function and didn’t meet other criteria for mental illness. Previously, were one inclined to do so, one could have used the criteria in the DSM-III and previous editions to diagnose nearly anyone with religious beliefs or spiritual experiences as having some sort of mental illness.

Examining the text of DSM-5-TR itself, we find there is simultaneously a profound upgrade from what came in the DSM-III and before, but also significantly lacking the degree of depth and detail that the added material presupposes should be available to clinicians either in their clinical education, life experience, or in further supplementary references.

Specifically, and quoting the DSM-5-TR, Page lxix, from the index: “Additional Conditions or Problems That May Be a Focus of Clinical Attention (834) Z65.8 Religious or Spiritual Problem (834)”

General Exceptions to Mental Disorders

From page 14, we notice that spiritual concerns and exemptions are baked into their core definition of mental illness:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”

The concept of spiritual and cultural exemption is further explained here on page 366:

“Culture-Related Diagnostic issues

Many differences between cultural contexts may influence psychological factors and their effects on medical conditions, such as those in language and communication style, idioms of distress, explanatory models of illness, patterns of seeking health care, service availability and organization, doctor-patient relationships and other healing practices, family and gender roles, and attitudes toward pain and death. Psychological factors affecting other medical conditions must be differentiated from culturally specific coping behaviors such as accessing faith, spiritual, or traditional healers or other variations in illness management that are acceptable within cultural contexts and represent an attempt to help heal the medical condition. These local practices may complement rather than obstruct evidence-based interventions. Use of alternative healing practices may delay use of medical services and affect outcomes, but when the intent of the healing practice is to address the problem in a culturally sanctioned way, these practices should not be pathologized as psychological factors affecting other medical conditions.”

General Exceptions to Specific Symptoms

On page 102, the DSM-5-TR gets more specific about how this might apply to a general symptom:

“Hallucinations

Hallucinations are perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. They may occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders. Auditory hallucinations are usually experienced as voices, whether familiar or unfamiliar, that are perceived as distinct from the individual's own thoughts. The hallucinations must occur in the context of a clear sensorium; those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the range of normal experience. Hallucinations may be a normal part of religious experience in certain cultural contexts.”

General Exemptions to Specific Disorders

The DSM-5-TR begins its description of Delusional Disorder (F22) on page 104. On page 107, the DSM-5-TR adds this as a modifying consideration:

“Culture-Related Diagnostic Issues

An individual’s cultural and religious background must be taken into account in evaluating the possible presence of delusional disorder; in fact, some traditional beliefs unfamiliar to Western cultures may be wrongly labeled as delusional, so their context must be carefully assessed. The nature and content of delusions also vary among different cultural groups.”

Similarly, on page 108, the DSM-5-TR begins it section on Brief Psychotic Disorder (F23), but then adds this modifier on page 110:

“Culture-Related Diagnostic issues

It is important to distinguish symptoms of brief psychotic disorder from culturally sanctioned response patterns. For example, in some religious ceremonies, an individual may report hearing voices, but these do not generally persist and are not perceived as abnormal by most members of the individual’s community. In a wide range of cultural contexts, it would be common or expected for bereaved relatives to hear, see, or interact with the spirit of a recently deceased loved one without notable pathological sequelae. In addition, cultural and religious background must be taken into account when considering whether beliefs are delusional.”

The description of Schizophrenia (F20.9) begins on page 113, with the following modifier added on page 118:

“Culture-Related Diagnostic Issues

The form and content of schizophrenia symptoms can vary cross-culturally, including the following ways: the relative proportion of visual and auditory hallucinations (e.g., while auditory hallucinations tend to be more common than visual hallucinations around the world, the relative proportion of visual hallucinations may be particularly higher in some regions compared with others); the specific content of the delusions (e.g., persecutory, grandiose, somatic) and hallucinations (e.g., command, abusive, religious); and the level of fear associated with them. Cultural and socioeconomic factors must be considered, particularly when the individual and the clinician do not share the same cultural and socioeconomic background. Ideas that appear to be delusional in one cultural context (e.g., evil eye, causing illness through curses, influences of spirits) may be commonly held in others.”

On page 330, in the section on Dissociative Identity Disorder (F44.81), a disorder that can involve multiple distinct patterns of identity and behavior, which includes the following diagnostic features description on page 332:

“Possession-form identities in dissociative identity disorder typically manifest behaviorally as if a “spirit,” supernatural being, or outside person has taken control, with the individual speaking or acting in a distinctly different manner. For example, an individual’s behavior may give the appearance that her identity has been replaced by the “ghost” of a girl who died by suicide in the same community years before, speaking and acting as though she were still alive. The identities that arise during possession-form dissociative identity disorder present recurrently, are unwanted and involuntary, and cause clinically significant distress or impairment (Criterion C). However, the majority of possession states that occur around the world are usually part of a broadly accepted cultural or religious practice and therefore do not meet criteria for dissociative identity disorder (Criterion D).”

Further, on page 334, also for Dissociative Identity Disorder:

“Culture-Related Diagnostic issues

Many features of dissociative identity disorder can be influenced by the individual’s sociocultural background. In settings where possession symptoms are common (e.g., rural areas in low- and middle-income countries, among certain religious groups in the United States and Europe), all or some of the fragmented identities may take the form of possessing spirits, deities, demons, animals, or mythical figures. Acculturation or prolonged intercultural contact may shape the presentation of the other identities (e.g., identities in India may speak English exclusively and wear Western clothes). Possession-form dissociative identity disorder can be distinguished from culturally accepted possession states in that the former is involuntary, distressing, and uncontrollable; involves conflict between the individual and his or her surrounding family, social, or work milieu; and is manifested at times and in places that violate cultural or religious norms. Combined dissociative-psychosis episodes may be more common in cultural contexts with marked communal violence or oppression and limited opportunity for redress.”

Furthermore, on page 347 for Other Specified Dissociative Disorder (F44.89), and example on page 348 is given of:

“4. Dissociative trance: This condition is characterized by an acute narrowing or complete loss of awareness of immediate surroundings that manifests as profound unresponsiveness or insensitivity to environmental stimuli. The unresponsiveness may be accompanied by minor stereotyped behaviors (e.g., finger movements) of which the individual is unaware and/or that he or she cannot control, as well as transient paralysis or loss of consciousness. The dissociative trance is not a normal part of a broadly accepted collective cultural or religious practice.”

The description of Depersonalization/Derealization Disorder (F48.1) begins on page 343, and demonstrates on page 345 at least a passing knowledge of meditation and the possible difficulties that can result from it:

”Culture-Related Diagnostic issues

Volitionally induced experiences of depersonalization/derealization can be a part of meditative practices that are prevalent in many religious, spiritual, and cultural contexts and should not be diagnosed as a disorder. However, there are individuals who initially induce these states intentionally but over time lose control over them and may develop a fear and aversion for related practices. Cultural frameworks may affect the level of distress or perceived severity associated with uncontrolled depersonalization/ derealization experiences by providing explanations for them (e.g., spiritual/supernatural causes), which may alleviate individuals’ fears that they are “losing their mind.”

The description of Bipolar I Disorder begins on page 139, and includes the following in its description of a Manic episode on page 145, which will also likely be familiar to anyone who has helped someone with a strong presentation of what has been described by the likes of Dr. Abraham Maslow as a "peak experience":

“The increase in goal-directed activity (Criterion B6) often consists of excessive planning and participation in multiple activities, including sexual, occupational, political, or religious activities. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often also display psychomotor agitation or restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously. Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media.”

Further cultural, religious, and spiritual modifiers along these lines occur in a number of other disorders, such as on page 301 for PTSD (F43.10), page 319 for Adjustment Disorders, various sexual disorders, and other conditions, essentially reiterating the same themes.

The specific diagnostic/billing code is defined on page 834:

“Z65.8 Religious or Spiritual Problem

This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution.”

Culture-Related Diagnoses and Exemptions

Page 873 has a section titled Examples of Cultural Concepts of Distress, where a total of ten culturally specific conditions[6]  are listed.

Page 587 begins the DSM-5-TR’s section on Hallucinogen-Related Disorders and, on page 593 states:

“Culture-Related Diagnostic issues

Historically, hallucinogens have been used as part of established religious or spiritual practices, such as the use of peyote in the Native American Church and in Mexico. Ritual use by Indigenous populations of psilocybin obtained from certain types of mushrooms has occurred in South America, Mexico, and some areas in the United States, or of ayahuasca in the Santo Daime and União de Vegetal religious groups.”

Page 733 begins the DSM-5-TR’s section on Personality Disorders, and on page 736 adds:

“Culture-Related Diagnostic Issues

Core aspects of personality like emotion regulation and interpersonal functioning are influenced by culture, which also provides means of protection and assimilation and norms for acceptance and denunciation of specific behaviors and personality traits. Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background. Personality disorders should not be confused with problems associated with acculturation following migration or with the expression of habits, customs, or religious and political values based on the individual’s cultural background or context. Behavioral patterns that appear to be rigid and dysfunctional aspects of personality disorder may reflect instead adaptive responses to cultural constraints. For example, reliance on an abusive relationship in a small community where divorce is proscribed may not reflect pathological dependence; conscientious political protest that puts friends and family members at risk with authorities or in conflict with legal norms does not necessarily reflect pathological callousness. There are marked variations in the recognition and diagnosis of personality disorders across cultural, ethnic, and racialized groups. Accuracy of diagnosis can be enhanced by attention to culturally patterned conceptions of self and attachment, assessment biases resulting from clinicians’ own cultural backgrounds or use of diagnostic instruments that are not normed to the population being assessed, and the impact of social determinants such as poverty, acculturative stress, racism, and discrimination on feelings, cognitions, and behaviors. It is useful for the clinician, especially when evaluating someone from a different background, to obtain additional information from informants who are familiar with the person’s cultural background.”

Of particular interest in this section on pages 744-745 is the Schizotypal Personality Disorder (F21), whose diagnostic criteria are:

"A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of reference).

2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).

3. Unusual perceptual experiences, including bodily illusions.

4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).

5. Suspiciousness or paranoid ideation.

6. Inappropriate or constricted affect.

7. Behavior or appearance that is odd, eccentric, or peculiar.

8. Lack of close friends or confidants other than first-degree relatives.

9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.”

Clearly, these diagnostic criteria could be loosely applied to many with religious beliefs and spiritual experiences, and many of these ideas for abnormality are culturally specific. On page 746, the DSM-5-TR adds:

“Cultural-Related Diagnostic issues

Cognitive and perceptual distortions must be evaluated in the context of the individual’s cultural milieu. Pervasive culturally determined characteristics, particularly those regarding supernatural and religious beliefs and practices (life beyond death, speaking in tongues, voodoo, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to health and illness), can appear to be schizotypal to the uninformed clinician[7] . Thus, observed cross-national and cross-ethnic variations in the prevalence and expression of schizotypal traits may be a true epidemiological finding or one due to differences in the cultural acceptance of these experiences.” [italics added for emphasis]

The question of the “uninformed clinician” is a key one, as it is often the case that both the patient and the mental health practitioner might be considered “uninformed”. Specifically, to properly apply these criteria, the presumption is that either the patient, the mental health practitioner, or some external source they have easy access to are well-versed in the range of beliefs and experiences that the tradition they are participating in considers normal vs pathological. It also makes no provisions for such things arising out of a specific religious or spiritual practice setting, nor does it allow for an experience found in one religious or spiritual setting to arise in another. An essential goal of EmergeWiki is to fill those critical knowledge gaps.

Of perhaps greatest concern is that material discussed in the section on Suicidal Behavior Disorder, whose section begins on page 920. Curiously, the proposed criteria are:

“A. Within the last 24 months, the individual has made a suicide attempt.

Note: A suicide attempt is a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death. (The “time of initiation” is the time when a behavior took place that involved applying the method.)

B. The act does not meet criteria for nonsuicidal self-injury—that is, it does not involve self-injury directed to the surface of the body undertaken to induce relief from a negative feeling/cognitive state or to achieve a positive mood state.

C. The diagnosis is not applied to suicidal ideation or to preparatory acts.

D. The act was not initiated during a state of delirium or confusion.

E. The act was not undertaken solely for a political or religious objective.

Specify if:

Current: Not more than 12 months since the last attempt. In early remission: 12-24 months since the last attempt.” [italics added for emphasis]

It is not made clear what the accepted "religious objective[s]" might be here, so these will need to be clarified in sources such as EmergeWiki.

Its section on culturally-related diagnostic issues does not mention religion or spirituality. However, in the section on Comorbidity on page 923 it states:

“Suicidal behavior disorder is seen in the context of a variety of mental disorders, most commonly bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders (in particular, panic disorders associated with catastrophic content and PTSD flashbacks), substance use disorders (especially alcohol use disorders), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders.”

On page 864, the DSM-5-TR has a section on the Core Cultural Formulation Interview (CFI), which is a structured approach to ascertaining information that might be helpful in multiple ways, such as eliciting information about their beliefs, resources, what they have already tried, how they conceptualize the problem they are presenting with, as well as information useful to attempt to apply the Culturally-Related Diagnostic considerations mentioned above.

However, for it to be most helpful, it presumes that the patient or another person interviewed in connection with the patient was familiar with the vast range of possibly expected presentations of spiritual experiences that might occur in their tradition and what would be considered normal vs pathological. As commonly noticed today, plenty of people who encounter spiritual experiences are in contexts where that detailed knowledge is neither fully disclosed nor even fully known to those in a position to disclose. They may also not be in a spiritual context at all when spiritual experiences occur.

Again, these are gaps in knowledge that EmergeWiki is designed to fill.