ICD-10s limitations to distinguish between psychosis and spiritual emergencies: The need for a new diagnosis in ICD-11 for

spiritual or religious problems

Dinu- Stefan Teodorescu, Ph.D. candidate, Institute of Psychiatry, University of Oslo, Ssterhjemmet Ullevl Universitetssykehus, Kirkeveien 166, N- 0450 Oslo, Norway and Sykehuset Innlandet HF, DPS Gjvik, poliklinikk Toten, N-2850 Lena, Norway E-mail address: d.s.teodorescu@medisin.uio.no ABSTRACT- Background and Objectives: ICD-10 diagnosis manual falls short to address religious or spiritual problems and this may have a negative influence on patients that may experience a spiritual emergency. The limitations of the ICD-10 increase the risk that a person experiencing a spiritual emergency may be misdiagnosed with psychosis or even with schizophrenia. Transpersonal oriented psychiatrists and psychologists have accumulated research and experience which can differentiate between psychosis and spiritual emergencies. The Psycho-Kundalini Syndrome Index is an instrument that identifies a spiritual emergency, kundalini awakening type, and can be used to make a differential diagnosis. To exemplify the limitations of the ICD-10, a case history of a patient experiencing a spiritual emergency which was misdiagnosed with psychosis is presented. Given the present limitations of the ICD-10 to diagnose religious and spiritual problems, a proposal for the introduction of a new diagnosis for religious or spiritual problems, including also spiritual emergencies in ICD-11, may be appropriate. Methods: Review of the literature describing spiritual emergencies, in particular kundalini awakenings, and differentiation guidelines between psychosis and a spiritual emergency, kundalini awakening type. A case example of a misdiagnosed spiritual emergency, kundalini awakening type as psychosis is presented. Results: I present a case of a misdiagnosed spiritual emergency, kundalini awakening type, and I point to the limitation of the ICD-10 diagnosis manual in distinguishing between psychosis and spiritual emergency. I show some of the existing research in distinguishing a spiritual emergency- kundalini awakening type, from psychosis. Conclusion: I have shown the need for the introduction of a new diagnosis for religious or spiritual problems, including spiritual emergencies, in the ICD manual under a Z code, in the chapter 21 Factors influencing health status and contact with health services.

Keywords: ICD-10, ICD-11, spiritual emergencies, kundalini awakening, psychosis.

Introduction

In many European countries health professionals use ICD- 10 as a diagnosis manual for mental health problems1. ICD-10 does not have yet a diagnosis concerning religious or spiritual problems. Spiritual adherents in Europe and elsewhere where this diagnosis system is used, run the risk to be misdiagnosed with psychosis or schizophrenia when in fact, it may be a case of a spiritual emergency.
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The closest diagnosis for spiritual emergencies that can be found in the ICD-10 is the diagnosis F 48.8 Other specified neurotic disorders found under the larger category of F 48 Other neurotic disorders. The ICD-10 completes the F 48.8 diagnosis with Annex 2: Culture specific disorders, but spiritual emergencies or kundalini awakening is not mentioned. With the exception of this culture-specific disorders diagnoses, there is no other help to understand such conditions that in essence are not pathological, but on the contrary, they represent, in spiritual traditions, a sign of a higher development of the human consciousness 2,3,4,5,6,7,8,9 . Unfortunately, there are many western mental health practitioners that do not share this view of the spiritual traditions 10, and due to the limitations of the ICD10, they tend to categorize such exceptional experiences under aberrant experiences that are so common in psychopathologies of psychoses and schizophrenia11,12,13,14,15,16. In the U.S.A. the mental health practitioners use another diagnostic manual, the DSM-IV17 which has a special diagnosis concerning religious and spiritual problems, namely V 62.89 Religious or spiritual problems which enlists the following limited list of problems: 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 ( p.741) 17. One of the intentions of the proposal of the diagnosis V62.89 Religious or Spiritual Problem, was to help health professionals to distinguish between psychosis and spiritual emergencies. Unfortunately, the DSM revision committee changed the name of the diagnosis as well as excluded spiritual emergencies as proposed by Lukoff, Lu and Turner, turning it into a more general and less specific diagnosis18,19,20 . The field of mental health still requires more competency in understanding and addressing the religious and spiritual needs of their patients,21,22,23,24,25,26,27 even if the number of mental health professionals who are becoming aware of the importance of these needs is increasing 28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47.

Spiritual emergency and its varieties Spiritual emergency was first coined in 1989 by Stanislav and Christina Grof in theirs book Spiritual emergency- when personal transformation becomes a crisis. They define spiritual
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emergencies thus: dramatic experiences and unusual states of mind that traditional psychiatry diagnoses and treats as mental disease and which are actually crises of personal transformation. Episodes of this kind have been described in sacred literature of all ages as a result of meditative practices and as signposts of the mystical path. (p. x)48. Spiritual emergencies49,50,51,52,53,54,55 have been acknowledged by both the west and the east spiritual traditions through the centuries and written down in important spiritual books, for example in the book of St. John of the Cross The dark night of the soul56. As a type of spiritual emergency, the Indian tradition has identified a phenomenon named kundalini which may give rise to powerful experiences that in extreme cases may resemble those seen in psychotic conditions57,58,59,60,61,62.

Christina Grof in the eighties has founded the Spiritual Emergence Network (SEN), a worldwide organisation dedicated to support the individuals undergoing spiritual crisis, though providing information concerning the process of spiritual emergencies as well as providing information on the available alternatives to traditional treatment48,9.

There are several forms of spiritual emergencies: shamanic crisis, awakening of Kundalini, episodes of unitive consciousness (peak experiences), psychological renewal through a return to the centre, crisis of psychic opening, past-life experiences, communications with spirit guides and Channelling, near-death experiences, experiences of close encounters with UFOs, possession states, opening to life myth, and emergence of a karmic pattern48,63,64,65,66,67

Spiritual emergency, kundalini awakening type

One of the most common types of spiritual emergencies is kundalini awakening, which is wide known in the Indian spiritual tradition68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89 . Some western researchers have studied some of the physiological correlates of the Kundalini and found evidence for this phenomenon90,91,92,93,94 . The scientific interests for research on the Kundalini is a part of a general interest of the western scientists in research on spirituality, religious experiences, meditation and mystical states 95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115. Lee Sanella was one of the first to propose a classification of the kundalini symptoms and he categorized kundalini phenomena under four main categories of symptoms: motor- any
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manifestation that can be independently observed and measured, sensory- inner sensations such as lights, sounds and experiences normally classified as sensations, interpretative- any mental process that interprets experience, and non-physiological- phenomena that, taken at face value as genuine occurrences, must involve factors for which physiological explanations are not sufficient. Thus, the motor phenomena includes: automatic body movements and postures, unusual breathing patterns and paralysis; The sensory phenomena is made up of: tickling sensations, heat and cold sensations, and inner sounds; The interpretative phenomena comprises: unusual or extreme emotion, distortion of thought processes, detachment, dissociation, single seeing, and great body experience; The non-physiological phenomena are: out-of-body experience, and psychic perceptions 7 .

Kundalini Research Network (KRN), a collaborative between western scientists and spiritual practitioners has been trying to map the kundalini process and phenomena since the eighties, and managed to develop the Kundalini Research Network Questionnaire version 2,0 for its research purpose into Kundalini and Spiritual Emergency phenomena 116 . The KRNs questionnaire distinguishes several Kundalini- type experiences including the following: sensations of energy rising up the spine or through the bodyrushes of light, energy or heat, perception of unusual lights or sparks; pervasive luminosity; the enhancement of the visual perception; perception of inner sounds- such as the buzzing of bees, humming, the dull roar of distant waterfalls, music of the spheres etc ( not related to inner ear problems), expansive episodes- feelings of expansion of your consciousness, head and/or body; bliss episodes- a sensation of profound bliss, all-encompassing love, overwhelming joy, nerves tingling, excitement; recipient of shaktipat (so called transmission of power from one individual to another for the purpose of awakening kundalini) (p. 12-13) 116.

The Indian tradition gives the most thoroughly description of the kundalini awakening process and Guru Sri Yoganandji Maharaja gives a thoroughly description to this process in his book Mahayoga Vijnana .58 From a western mental health perspective, the above descriptions of symptoms overlap much with psychotic symptoms, thus giving rise to confusion and questioning of the validity of the Indian traditional kundalini awakening model. A problem can arise when a spiritual adherent undergoing a kundalini awakening may seek help from a western educated mental health practitioner who may mistake the condition for psychosis or even for schizophrenia and treat the condition as such.
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Differentiating Kundalini awakening from psychosis Countless of people have experienced kundalini awakenings and survived this trial and many have written autobiographical books about this process 117, ,62,80. Sanella suggests in his book The Kundalini experience 7 from 1992, that there is enough clinical evidence in order to make a distinction between the physio-kundalini complex and psychosis. Even if a schizophrenia-like condition can appear due to a kundalini awakening, the two conditions must not to be confused. He comments: Sensations of heat are common in kundalini states but are rare in psychoses. Also very typical are feelings of vibration or fluttering, tingling and itching that moves in definitive patterns over the body, usually in the sequence described earlier. In addition to this, bright lights may be seen internally. There may be pain, especially in the head, which arises suddenly and ceases equally suddenly during critical phases in the process. Unusual breathing patterns are common, as well as other spontaneous movements of the body. Noises such as chirping and whistling are heard, but seldom do voices intrude in a negative way, as is the case in psychotic states. When voices are heard, they are perceived to come from within and are not mistaken for outer realities( p. 110) 7. Furthermore, Sanella says: Symptoms caused by kundalini will disappear spontaneously over time. Because we are dealing essentially with a purifying or balancing process, and since each person represents a finite system, the process is self-limiting. Disturbances must not be viewed as pathological. Instead, they are therapeutic inasmuch as they lead to a removal of potentially pathological elements. (p.111) 7.

In 1993, psychiatrist Bruce Greyson created a 19-items questionnaire, the Physio-Kundalini Syndrome Index to compare the physio-kundalini syndrome with mental illness 118 . His intention with the study was to differentiate kundalini awakening from mental illness. The Physio-Kundalini Syndrome Index has 4 scales: motor physio-kundalini symptoms, somatosensory physio-kundalini symptoms, audiovisual physio-kundalini symptoms, and mental physio-kundalini symptoms. The motor physio-kundalini symptoms includes the following four symptoms: ones body assuming and maintaining strange positions, becoming frozen or locked, immovable; breathing spontaneously stopping or becoming rapid, shallow or deep; and spontaneous involuntary body movements. The

somato sensory physio-kundalini symptoms include the following six indicators: physical sensations starting in the feet, legs; extreme sensations of heat or cold moving through the body; moving pockets of extremely high heat or cold; pain in body parts, pain which stops abruptly; tingling, vibration, itching, tickling on the skin; and spontaneous orgasmic sensations. The audiovisual physio-kundalini symptoms includes the following four indicators: internal noises, whistling, chirping; internal voices; internal lights; and colours illuminating parts of the body, or external light bright enough to illuminate a dark room. The mental physio-kundalini symptoms includes the following five indicators: observing ones self, as if one were a bystander; sudden intense ecstasy, bliss, peace, love, joy, cosmic unity; sudden and intense fear, anxiety, depression, hatred; thoughts spontaneously speeding up, slowing down or stopping; and experiencing one self larger than the body.

Dr. Greyson applied the 19 items Physio-Kundalini Syndrome Index to 138 patients admitted to an impatient psychiatric unit for a period of 6 months. The conclusion of this study was that individuals who were experiencing a kundalini awakening were having more symptoms of the physio-kundalini syndrome than psychotic patients did. Dr. Greyson found seven items that are more common in people experiencing a kundalini awakening, unlike the psychotic patients. These seven symptoms are: spontaneous orgasmic sensations, ascending anatomic progression of sensations, internal noises, internal voices, internal lights or colours, watching oneself as if from a distance, and sudden positive emotions for no apparent reason. These seven items may be used as indicators for differentiating kundalini awakening symptoms from psychosis. Psychologist David Lukoff suggested that psychotic symptoms in the context of kundalini experiences should not be diagnosed as schizophrenia, but as mystical experience with psychotic features119.

A case of misdiagnosed Spiritual Emergency, kundalini type symptoms

A 63 years old retired higher-ranking psychiatric nurse has been practicing yoga alone for many years in a remote place in Norway. She had been active all her life and worked as a chief psychiatric nurse in a mental hospital for more than 25 years. She never suffered from psychosis. After retiring from an active life in the mental health services, she began to practice yoga at home, following a correspondence course from France. After a period of intense yoga practice she began to feel energies running throughout her body. She began to feel vibrations in many places of her body, and a flow of energy in the body as well as in the
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feet and arms. She felt electricity like sensations passing through her body and sometimes she was shaking and jumping involuntarily. The hands and feet were stretching out forcefully against her will. Other times she became so active that she was unable to sit still. During the most intense body movement or during the feelings of energy running through her, she heard an internal vibration, something like a distant sound of a waterfall. Other symptoms included: involuntary deep inhaling and exhaling, as well as faster or slower breathing patterns, powerful trembling of the body, involuntary laughing and weeping and loss of the feeling that she had a body. Everything looked vacant to her. She involuntary closed and opened her eyelids. She uttered strange sounds. Taken by surprise, she sought help at the local doctor. The doctor thought of her as psychotic and referred her to the regional psychiatric hospital where she was confined to an acute psychiatric ward and treated for psychosis with forced medication and massive doses of narcoleptics. Nobody listened to her complaints that she doesnt need medication and that the narcoleptics were having no effect. Additionally, the patient felt sad and depressed because the staff were not taking her seriously in acknowledging her experiences and giving her support and understanding to cope with this condition that was frightening to her. The patient was forcibly treated for several months with huge doses of narcoleptics which had no effect on her, except that of she got depressed because the psychiatrist and the staff were not taking her seriously and her symptoms were dismissed as psychotic. The end of this story is not known. I was fired from the department because of my expressed opposition to the psychiatrists treatment and my support to the patient. The conflict between the psychiatrist and me was about the right diagnosis for the patient and the right treatment for it. Unfortunately for the patient, ICD-10 had no diagnosis that could have allowed for a differential treatment, and thus the psychosis diagnosis was given and treated with forced medication.

From the perspective of the Indian tradition, the symptoms described above are clear signs of an awakened kundalini and as such, are not to be considered psychosis, but a spiritual opening to a higher consciousness for the person 62,58,59,7,48, 52 ,65.

Conclusion The ICD-10 diagnosis system is limited today in its ability to diagnose religious or spiritual problems, especially spiritual emergencies, particularly kundalini awakening. This paper has
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presented a case of a misdiagnosed spiritual emergency. The limitations of the ICD-10 had traumatic consequences for the patient. The pioneer work of Lukoff, Lu and Turner in 1993 to convince the DSM revision committee to include a new diagnosis in DSM-IV concerning religious or spiritual problems, has been a partial victory for the religious and spiritual community 120,121, as well as for the transpersonal oriented therapists, but still falls short of acknowledging explicit spiritual emergencies.

Every new diagnosis helps better map the huge diversity of human experience. The religious or spiritual experiences are some of the most diverse experiences, but also some of the most precious of the human consciousness. The population that is active and engaged in spiritual practices is growing and may feel safer in seeking help from the established mental health professionals122 as well, instead of seeking help mostly from the alternative medicine practitioners or the clergy, in the case of a spiritual emergency. In the past, the mental health community had made grievous mistakes in diagnosing people undergoing spiritual emergencies with psychosis or schizophrenia, and now it may be the time to rectify all that. I believe that the ICD diagnosis manual can be enriched with a new diagnosis in the chapter 21 Factors influencing health status and contact with health services, as a Z-code, that may address all these problems, thus doing justice to the religious and spiritual communities. In 2007 I have proposed for the ICD Update and revision platform committee a new diagnose and today my proposal is under consideration in the TAGMH group. Today, spiritual practitioners experiencing spiritual emergencies may run the risk to be, using the ICD-10, misdiagnosed with psychotic disorders or schizophrenia.

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