He raised poignant questions that are rarely discussed in academic medicine.
Every day, physicians, nurses, psychologists, and social workers alike encounter and care for people who experience psychotic symptoms. On what basis do we distinguish between the experiences of psychiatric patients and those of religious figures in history? A review of the medical literature revealed little discussion of these specific issues utilizing modern neuropsychiatric and behavioral neurologic principles.
An examination of the revelation experiences of prominent religious figures was needed to determine whether new insights could be achieved about their nature through the application of neuropsychiatric and behavioral neurologic principles.
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We undertook this examination with the intent of promoting scholarly dialogue about the rational limits of human experience and to educate persons living with mental illness, healthcare providers, and the general public that persons with psychotic symptoms may have had a considerable influence on the development of Western civilization. It is hoped that this investigation will help translate the veneration, love, and devotion felt by many for these religious figures into increased compassion and understanding for persons with mental illness.
The Bible is the earliest source of information about the life of Abraham, the patriarch of Judaism, Christianity, and Islam.
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The historical existence of Abraham is the subject of some academic controversy. Our discussion will proceed on the premise that he was a historical figure. The events occurring during his lifetime are generally thought to have taken place sometime between BCE and BCE, but this is a subject of some debate. He is described as having had interactive mystical experiences of an auditory and visual nature see Figure 1 , that influenced his behaviors throughout most of his life see Table 1. These psychiatric features occur together as a constellation in psychotic disorders of both primary psychiatric origin and secondary to medical and neurological conditions.
Criterion A might theoretically be fulfilled by the presence of his auditory and visual perceptual experiences. Abraham is not recounted as having had symptoms that can now be appreciated as disorganization, catatonia, negative psychiatric symptoms affective flattening, alogia, or avolition , or cognitive difficulties such as impaired concentration, attention, or memory. The lack of detailed information about his life prevents us from understanding whether he experienced a decline in social or occupational functioning, as compared with the period before the onset of his perceptual experiences, as required by Criterion B.
His generally good state of health is indicated by a purported lifespan of years without mentioned infirmity. Abraham appeared not to suffer from debilitating depressive- or manic-like symptoms, thereby diminishing the likelihood of mood disorder associated psychoses, such as depression with psychotic features, bipolar disorder, or schizoaffective disorder.
Delusions with other themes, such as jealousy, religiosity, or somatization may also occur. They are usually organized around a theme. Other potential causes of such experiences need to be explored. The ingestion of hallucinogenic substances is known to produce mystical experiences. There has been speculation that plants with psychoactive properties were valued by the ancient Israelites, but no direct evidence has been uncovered for their actual use for inducing mystical experiences in this population.
Grandiose and messianic-type delusions are recognized as occurring in association with complex partial seizure disorders. The greater similarities may lay in positive symptomatology; that is, that of thought disorder, delusions, and hallucinations. Abraham is not recounted as having had any infirmities that might resemble the phenomena we now commonly understand to accompany seizures. Specifically, there are no signs of repetitive behaviors, such as uncontrolled generalized or partial shaking, orofacial automatisms, stereotyped behavioral changes, recurrent and consistent auras of fear although fear did accompany some episodes , staring spells, loss of consciousness, falling spells, tongue-biting, or incontinence.
His ability to engage in varied dialogue with his hallucinations would not be very typical of an ictal perceptual change, since seizures tend toward being stereotyped in nature and not to be so changeable and interactive. A postictal or interictal psychotic state cannot be excluded, but is not particularly suggested on the basis of the available information.
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The absence of apparent affective, medical, or neurological conditions increases the possibility that a psychotic disorder could have been present. Schizophrenia is often accompanied by both disorganized behavior and thought processes that interfere with life functioning. Paranoid schizophrenia PS , however, is a subtype of schizophrenia that tends to manifest little or no disorganization, has preserved functional affect, and is associated with better occupational and social functioning.
PD NOS includes those persons with psychotic symptomatology for which there is inadequate or contradictory information or symptoms that do not meet criteria for any specific psychotic disorder. Abraham stands as the earliest case of a possible psychotic disorder in literature. Moses had perceptual experiences and behaviors that find closest parallel today with the DSM-IV-TR—defined phenomena of command AHs, VHs, hyperreligiosity, grandiosity, delusions, paranoia, referential thinking, and phobia about people viewing his face.
See Table 3 for examples. Many of these features may occur together in schizophrenia, affective disorders, and schizoaffective disorder. Criterion A for schizophrenia could theoretically be fulfilled by his experiences that resemble delusions and hallucinations. His flight from Egypt occurred before the onset of AH and VH, thereby suggesting a prodromal decline in functioning before the onset of psychosis.
A prodrome refers to the early symptoms and signs of an illness that precede the characteristic manifestations of the acute, fully developed illness. His social functioning and leadership skills were sufficiently intact to have made it less likely that he had periods of debilitating major depression or florid mania that might have undermined his effectiveness as a leader.
This could fulfill Criterion D by reducing the likelihood of mood disorder-associated psychosis. Such hypergraphia is a nonspecific finding more commonly associated with mania, hypomania, or mixed states; however, it is also a feature of schizophrenia and temporal lobe epilepsy. They are often loosely mystical, and both perseverative and vague in content. There is no indication in the Bible that Moses experienced metabolic dysregulations or that he used hallucinogenic intoxicants as an explanation for his behavioral or perceptual changes.
There are also no key features, as previously mentioned, to implicate epilepsy as a cause of mystical experiences. He lived a long life, in excess of years, arguing against the presence of progressive medical or neurological illnesses. The criteria for diagnosis of PS would be fulfilled by the predominance of delusions and hallucinations in the absence of disorganization, negative psychiatric symptoms, or cognitive impairment.
An increased propensity for violence has been observed in some individuals with PS. Reasonable diagnostic alternatives might include PD NOS, bipolar disorder, and schizoaffective disorder. He also did not appear to have signs or symptoms of disorganization, negative psychiatric symptoms, cognitive impairment, or debilitating mood disorder symptoms.
NT accounts about Jesus mention no infirmity. In terms of potential causes of perceptual and behavioral changes, it might be asked whether starvation and metabolic derangements were present. The hallucinatory-like experiences that Jesus had in the desert while he fasted for 40 days Luke —13 may have been induced by starvation and metabolic derangements.
Arguing against these as explanations for all of his experiences would be that he had mystical or revelation experiences preceding his fasting in the desert and then during the period afterward. During these periods, there is no suggestion of starvation or metabolic derangement.
If anything, the stories about Jesus and his followers suggest that they ate relatively well, as compared with the followers of his contemporary, John the Baptist Luke — Epilepsy-associated psychotic symptoms are possible, but Jesus is not recounted as having any of the previously-mentioned common hallmarks of epilepsy. A decline in his occupational and social functioning cannot be established because of a lack of sufficient information.
His experiences appear to have occurred over the course of at least the year before his death. The absence of physical maladies or apparent epilepsy leaves primary psychiatric etiologies as more plausible. Other reasonable possibilities might include bipolar and schizoaffective disorders. In advance, he explained to his followers the necessity of his death as prelude for his return Matthew —28; Mark ; John — If this occurred in the manner described, then Jesus appears to have deliberately placed himself in circumstances wherein he anticipated his execution.
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Although schizophrenia is associated with an increased risk of suicide, this would not be a typical case. The more common mood-disorder accompaniments of suicide, such as depression, hopelessness, and social isolation, were not present, 40 but other risk factors, such as age and male gender, were present. Paul lived during the first century CE.
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It has been speculated that his religious experiences resulted from temporal lobe epilepsy. He manifested increased religiosity and fears of evil spirits, which resembles paranoia. These features may occur together, in association with primary and mood disorder-associated psychotic conditions. We propose that he perceived an apparition or voice that he understood to be a harassing, demonic messenger from Satan.
This perception might have afflicted him with some amount of negative commentary of the type characteristic for psychotic conditions, resulting in psychological distress. Paul does, however, manifest a number of personality characteristics similar to the interictal personality traits described by Geshwind, 48 — 50 such as deepened emotions; possibly circumstantial thought; increased concern with philosophical, moral and religious issues; increased writing, often on religious or philosophical themes; and, possibly, hyposexuality 1 Corinthians —9.
These characteristics are controversial as to their specificity for epilepsy, 51 , 52 with a preponderance of larger studies not confirming a specific personality type associated with seizure disorders. This is persuasive toward Paul having a mood disorder, rather than schizophrenia or epilepsy. This blindness has been hypothesized to have been postictal in nature 43 or psychogenic.