Brazilian Psychiatric Association guidelines on the integration of spirituality into mental health clinical practice: Part 1. Spiritual history and differential diagnosis

Mosqueiro, Bruno Paz; Costa, Marianna de Abreu; Caribé, André C.; Oliveira e Oliveira, Fabrício H.A.; Pizutti, Leandro; Zimpel, Rogério R.; Baldaçara, Leonardo; da Silva, Antônio Geraldo; Moreira-Almeida, Alexander

doi:10.47626/1516-4446-2023-3056

Bruno Paz Mosqueiro

Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

https://orcid.org/0000-0002-4405-0718

Marianna de Abreu Costa

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

Núcleo de Pesquisas em Espiritualidade e Saúde (NUPES), Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil

https://orcid.org/0000-0003-0303-943X

André C. Caribé

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil

Hospital Universitário Professor Edgar Santos, Universidade Federal da Bahia, Salvador, BA, Brazil

Fabrício H.A. Oliveira e Oliveira

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

Núcleo de Pesquisas em Espiritualidade e Saúde (NUPES), Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil

Leandro Pizutti

Departamento de Psiquiatria e Espiritualidade, Associação de Psiquiatria do Rio Grande do Sul (APRS), Porto Alegre, RS, Brazil

https://orcid.org/0000-0002-4390-9201

Rogério R. Zimpel

Departamento de Psiquiatria e Espiritualidade, Associação de Psiquiatria do Rio Grande do Sul (APRS), Porto Alegre, RS, Brazil

Leonardo Baldaçara

Universidade Federal do Tocantins, Palmas, TO, Brazil

ABP, Rio de Janeiro, RJ, Brazil

https://orcid.org/0000-0002-5201-8515

Antônio Geraldo da Silva

ABP, Rio de Janeiro, RJ, Brazil

Asociación Psiquiátrica de América Latina, Santo Domingo, Dominican Republic

https://orcid.org/0000-0003-3423-7076

Alexander Moreira-Almeida

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

Núcleo de Pesquisas em Espiritualidade e Saúde (NUPES), Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil

https://orcid.org/0000-0002-9135-2532

Correspondence: Bruno Paz Mosqueiro, Av. Coronel Lucas de Oliveira, 505, sala 808, CEP 90450-045, Porto Alegre RS, Brazil. E-mail: brunopazmosqueiro@gmail.com

How to cite this article: Mosqueiro BP, Costa MA, Caribé AC, Oliveira e Oliveira FHA, Pizutti L, Zimpel RR, et al. Brazilian Psychiatric Association guidelines on the integration of spirituality into mental health clinical practice: Part 1. Spiritual history and differential diagnosis. Braz J Psychiatry. 2023;45:506-517. http://doi.org/10.47626/1516-4446-2023-3056

Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil

Comissão de Estudos e Pesquisas em Espiritualidade e Saúde Mental, Associação Brasileira de Psiquiatria (ABP), Rio de Janeiro, RJ, Brazil

Núcleo de Pesquisas em Espiritualidade e Saúde (NUPES), Faculdade de Medicina, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brazil

Escola Bahiana de Medicina e Saúde Pública, Salvador, BA, Brazil

Hospital Universitário Professor Edgar Santos, Universidade Federal da Bahia, Salvador, BA, Brazil

Departamento de Psiquiatria e Espiritualidade, Associação de Psiquiatria do Rio Grande do Sul (APRS), Porto Alegre, RS, Brazil

Universidade Federal do Tocantins, Palmas, TO, Brazil

ABP, Rio de Janeiro, RJ, Brazil

Asociación Psiquiátrica de América Latina, Santo Domingo, Dominican Republic

Barriers	Recommendations
Ethical concerns	Most patients would like to talk about R/S with mental health professionals. A respectful, open, culturally sensitive, non-proselytizing, and patient-centered approach is recommended and supported by research and international guidelines.
Lack of time	Brief SH assessments (5-minute interviews) have shown benefits in clinical practice in time-limited contexts and can provide a reliable initial perspective of the patient’s R/S concerns and interests.
Lack of training	Evidence confirms the efficacy and viability of SH training to provide the knowledge and skills needed to take a SH. Structured questionnaires and interviews are helpful resources for mental health interviews.
Concerns about causing distress or exacerbating the psychopathology	Most patients are comfortable with and wish to talk to mental health professionals about R/S issues. Taking a SH has been associated with greater treatment satisfaction with better doctor-patient relationships.
Extensive knowledge needed about religion and diverse cultural backgrounds	No prior extensive knowledge is required for primary assessment of R/S in mental health care. Creating an open environment and encouraging patients to share R/S concerns in a respectful, open, and considerate interview are achievable goals.
Concerns about negative mental health outcomes resulting from R/S beliefs or practices	The literature confirms that R/S measures in mental health have a predominantly positive outcome. For patients with R/S struggles or who are suffering, SH-taking enables clinicians to understand and helps patients find resources to deal with perceived negative effects.

Routine questions for a brief SH
1) Are you a spiritual or religious person? or, Do you have a religious or spiritual beliefs? Tell me more about that.
2) To what extent is religion or spirituality important in your life?
3) Are you part of a religious or spiritual community?
4) Are religion or spirituality important sources of strength for you when dealing with stress or life’s difficulties? or, What are your sources of strength when dealing with life’s difficulties or stress? Do you have any beliefs or practices that help you cope?^† † Question based on Royal College of Psychiatrists Assessment. ^‡ ‡ Question based on Spiritual Assessment Interview.
Questions for exploring specific R/S topics when necessary
Beliefs concerning meaning and life
What gives you meaning or purpose?^† † Question based on Royal College of Psychiatrists Assessment.
What are your beliefs concerning death?^† † Question based on Royal College of Psychiatrists Assessment.
Private practice
Do you have any personal or private religious practices, such as meditating, praying, playing or singing sacred music, or reading the scriptures? Are they helpful?^† † Question based on Royal College of Psychiatrists Assessment. ^‡ ‡ Question based on Spiritual Assessment Interview.
Organized practice
Do you have any community religious practices, such as belonging to a faith tradition, participating in services, rituals, worship, pilgrimages, retreats, helping other people, engaging in a study group? Are they helpful?^† † Question based on Royal College of Psychiatrists Assessment. ^‡ ‡ Question based on Spiritual Assessment Interview. If you do not, would you be interested in engaging in a religious or spiritual community?^‡ ‡ Question based on Spiritual Assessment Interview.
Community relationship
Do you receive support from or have difficulties with your faith community?^† † Question based on Royal College of Psychiatrists Assessment.
Spiritual experiences
Have you ever had any spiritual experiences? What meaning did you attribute to these experiences?^† † Question based on Royal College of Psychiatrists Assessment.
Relationship with God/the transcendent, R/S struggles, and coping
Do you believe in God or some transcendent or higher power?^† † Question based on Royal College of Psychiatrists Assessment.
If so, what is God like?^† † Question based on Royal College of Psychiatrists Assessment.
Do your R/S beliefs and practices support your well-being and mental health, or do they make it more difficult to deal with some part of your treatment?^† † Question based on Royal College of Psychiatrists Assessment. ^‡ ‡ Question based on Spiritual Assessment Interview.
Do you find yourself struggling with concerns about God or your spiritual beliefs?^† † Question based on Royal College of Psychiatrists Assessment.
Do you feel loved, accepted, a sense of belonging, forgiven, closer to God, or rejected, guilty, ashamed, afraid, and more distant from God?^† † Question based on Royal College of Psychiatrists Assessment. ^‡ ‡ Question based on Spiritual Assessment Interview.
Do you have any R/S needs in your life that are not being met?^‡ ‡ Question based on Spiritual Assessment Interview.
Integrating R/S into treatment
Do you believe that your R/S practices and beliefs can support your recovery? If so, how?^† † Question based on Royal College of Psychiatrists Assessment.
Do you have R/S questions that you want to explore? Is there someone who cares for you with whom you can talk about your spiritual life?^† † Question based on Royal College of Psychiatrists Assessment.
If there is something that might help you but you cannot access it, how can I help you get access? It is important for you to know that:
You can talk to your faith leaders and involve them in your treatment.^† † Question based on Royal College of Psychiatrists Assessment.
Several current treatments consider R/S issues, such as 12-step programs for alcohol and substance misuse, mindfulness-based interventions for dealing with stress, anxiety and depression, and spiritually and religiously integrated psychotherapy.^† † Question based on Royal College of Psychiatrists Assessment.

	Level of evidence	Observations
Improves treatment satisfaction	2	RCT of oncology patients²⁷27. Kristeller JL, Rhodes M, Cripe LD, Sheets V. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med. 2005;35:329-47 and hospitalized patients²⁸28. Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients’ religious and spiritual concerns: predictors and association with patient satisfaction. J Gen Intern Med. 2011;26:1265-71.
Improves treatment attendance or adherence	2	RCT of patients with schizophrenia²⁹29. Huguelet P, Mohr S, Betrisey C, Borras L, Gillieron C, Marie AM, et al. A randomized trial of spiritual assessment of outpatients with schizophrenia: patients’ and clinicians’ experience. Psychiatr Serv. 2011;62:79-86.
Improves psychological well-being and quality of life	2	RCT including oncology patients²⁷27. Kristeller JL, Rhodes M, Cripe LD, Sheets V. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med. 2005;35:329-47
Reduces negative psychological symptoms	2	RCT of oncology patients²⁷27. Kristeller JL, Rhodes M, Cripe LD, Sheets V. Oncologist Assisted Spiritual Intervention Study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med. 2005;35:329-47
SH training improves spiritual assessment in health care	2	Medical students and other health-related undergraduates³⁷37. Osório IHS, Gonçalves LM, Pozzobon PM, Gaspar Jr JJ, Miranda FM, Lucchetti ALG, et al. Effect of an educational intervention in “spirituality and health” on knowledge, attitudes, and skills of students in health-related areas: A controlled randomized trial. Med Teach. 2017;39:1057-64.,³⁸38. King DE, Blue A, Mallin R, Thiedke C. Implementation and assessment of a spiritual history taking curriculum in the first year of medical school. Teach Learn Med. 2004;16:64-8.

Criteria	Studies	Specifiers	Recommendation	Level of evidence	Comments
1	Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^‡ ‡ Case series.	Characteristics of the experience	Assess the duration of loss of contact with reality.	5	The clinical group tends to lose contact with reality for longer periods of time than the non-clinical group.
2	Peters et al.⁴⁰40. Peters ER, Joseph SA, Garety PA. Measurement of delusional ideation in the normal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophr Bull. 1999;25:553-76Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.Bronn & McIlwain⁴²42. Bronn G, McIlwain D. Assessing spiritual crises: peeling off another layer of a seemingly endless onion. J Humanist Psychol. 2015;55:345-82. ^† † Studies that included only non-clinical samples. Escolà-Gascón⁴³43. Escolà-Gascón Á. Researching unexplained phenomena II: new evidences for anomalous experiences supported by the Multivariable Multiaxial Suggestibility Inventory-2 (MMSI-2). Curr Res Behav Sciences. 2020;1:100005. ^† † Studies that included only non-clinical samples. Humpston et al.⁴⁴44. Humpston CS, Walsh E, Oakley DA, Mehta MA, Bell V, Deeley Q. The relationship between different types of dissociation and psychosis-like experiences in a non-clinical sample. Conscious Cogn. 2016;41:83-92. ^† † Studies that included only non-clinical samples. Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^† ‡ Case series. Moreira-Almeida et al.⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.Unterrassner et al.⁴⁶46. Unterrassner L, Wyss TA, Wotruba D, Haker H, Rössler W. The intricate relationship between psychotic-like experiences and associated subclinical symptoms in healthy individuals. Front Psychol. 2017;8:1537. ^† † Studies that included only non-clinical samples. Vencio et al.⁴⁷47. Vencio S, Caiado-Vencio R, Caixeta L. Differential diagnosis between anomalous experiences and dissociation disorder using the Dissociative Disorders Interview Schedule (DDIS). J Trauma Dissociation. 2019;20:165-78.Brett et al.⁴⁸48. Brett CM, Peters EP, Johns LC, Tabraham P, Valmaggia LR, McGuire P. Appraisals of Anomalous Experiences Interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. Br J Psychiatry Suppl. 2007;51:s23-30.Brett et al.⁴⁹49. Brett C, Heriot-Maitland C, McGuire P, Peters E. Predictors of distress associated with psychotic-like anomalous experiences in clinical and non-clinical populations. Br J Clin Psychol. 2014;53:213-27.	Characteristics of the experience	Most content and form of anomalous experiences and paranormal beliefs do not differ between clinical and non-clinical groups.	2	Extrasensory perception, dissociative experiences, hallucinations, paranormal beliefs, unusual perceptions, thought insertion, mind reading, and feelings of being controlled do not differ between clinical and non-clinical groups.
3	Peters et al.⁴⁰40. Peters ER, Joseph SA, Garety PA. Measurement of delusional ideation in the normal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophr Bull. 1999;25:553-76	Characteristics of the experience	The intensity of the phenomenon did not differ between clinical and non-clinical groups.	3	The intensity of the phenomenon/number of anomalous experiences did not differ between clinical and non-clinical groups.
4	Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Characteristics of the experience	Assess lifetime history of anomalous experiences.	3	Age of onset is earlier and time lived with anomalous experiences is longer in the non-clinical group than the clinical group.
5	Cicero et al.⁵⁰50. Cicero DC, Gawęda Ł, Nelson B. The placement of anomalous self-experiences within schizotypal personality in a nonclinical sample. Schizophr Res. 2020;218:219-25. ^† † Studies that included only non-clinical samples. Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.Unterrassner et al.⁴⁶46. Unterrassner L, Wyss TA, Wotruba D, Haker H, Rössler W. The intricate relationship between psychotic-like experiences and associated subclinical symptoms in healthy individuals. Front Psychol. 2017;8:1537. ^† † Studies that included only non-clinical samples.	Characteristics of the experience	Assess paranoid symptoms	2	Ideas of reference and suspiciousness are more frequent in clinical groups than non-clinical groups.
6	Brett et al.⁴⁸48. Brett CM, Peters EP, Johns LC, Tabraham P, Valmaggia LR, McGuire P. Appraisals of Anomalous Experiences Interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. Br J Psychiatry Suppl. 2007;51:s23-30.Brett et al.⁴⁹49. Brett C, Heriot-Maitland C, McGuire P, Peters E. Predictors of distress associated with psychotic-like anomalous experiences in clinical and non-clinical populations. Br J Clin Psychol. 2014;53:213-27.Bronn & McIlwain⁴²42. Bronn G, McIlwain D. Assessing spiritual crises: peeling off another layer of a seemingly endless onion. J Humanist Psychol. 2015;55:345-82. ^† † Studies that included only non-clinical samples. Humpston et al.⁴⁴44. Humpston CS, Walsh E, Oakley DA, Mehta MA, Bell V, Deeley Q. The relationship between different types of dissociation and psychosis-like experiences in a non-clinical sample. Conscious Cogn. 2016;41:83-92. ^† † Studies that included only non-clinical samples. Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^† ‡ Case series. Peters et al.⁴⁰40. Peters ER, Joseph SA, Garety PA. Measurement of delusional ideation in the normal population: introducing the PDI (Peters et al. Delusions Inventory). Schizophr Bull. 1999;25:553-76Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.Preti et al.⁵¹51. Preti A, Bonventre E, Ledda V, Petretto DR, Masala C. Hallucinatory experiences, delusional thought proneness, and psychological distress in a nonclinical population. J Nerv Ment Dis. 2007;195:484-91. ^† † Studies that included only non-clinical samples. Preti et al.⁵²52. Preti A, Cella M, Raballo A, Vellante M. Psychotic-like or unusual subjective experiences? The role of certainty in the appraisal of the subclinical psychotic phenotype. Psychiatry Res. 2012;200:669-73. ^† † Studies that included only non-clinical samples.	Consequences of the experience	Assess the patient’s reaction to anomalous content	2	The clinical group acts out delusions with bizarre behavior, experiences greater distress, and loses contact with reality.
7	Brett et al.⁴⁸48. Brett CM, Peters EP, Johns LC, Tabraham P, Valmaggia LR, McGuire P. Appraisals of Anomalous Experiences Interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. Br J Psychiatry Suppl. 2007;51:s23-30.Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^† ‡ Case series. Marzanski & Bratton⁵³53. Marzanski M, Bratton M. Psychopathological symptoms and religious experience: a critique of Jackson and Fulford. Philos Psychiatr Psychol. 2002;9:359-371. ^† ‡ Case series. Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Consequences of the experience	Assess how the anomalous experience is embedded in the individual’s values, context and beliefs	2	The non-clinical group tends to integrate the experience positively in their life, perceiving it in line with some religious-narrative context or values and are more able to adopt a mindful and accepting attitude, feeling psychological well-being as a result of their experience.
8	Marzanski & Bratton⁵³53. Marzanski M, Bratton M. Psychopathological symptoms and religious experience: a critique of Jackson and Fulford. Philos Psychiatr Psychol. 2002;9:359-371. ^‡ ‡ Case series.	Context and perception of the experience	Assess insight	5	The non-clinical group has greater insight into the unusual quality of their experience than the clinical group.
9	Brett et al.⁴⁸48. Brett CM, Peters EP, Johns LC, Tabraham P, Valmaggia LR, McGuire P. Appraisals of Anomalous Experiences Interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. Br J Psychiatry Suppl. 2007;51:s23-30.Brett et al.⁴⁹49. Brett C, Heriot-Maitland C, McGuire P, Peters E. Predictors of distress associated with psychotic-like anomalous experiences in clinical and non-clinical populations. Br J Clin Psychol. 2014;53:213-27.Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.Moreira-Almeida⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.Damiano et al.⁵⁴54. Damiano RF, Machado L, Loch AA, Moreira-Almeida A, Machado L. Ninety years of multiple psychotic-like and spiritual experiences in a Doctor Honoris Causa: a case report and literature review. J Nerv Ment Dis. 2021;209:449-53.	Context and perception of the experience	Assess the feeling of control during the experience	2	The non-clinical group has more control over the experience than the clinical group and does not usually present with greater distress when appraising the experience. A feeling of control may be developed after training in some spiritual tradition.
10	Unterrassner et al.⁴⁶46. Unterrassner L, Wyss TA, Wotruba D, Haker H, Rössler W. The intricate relationship between psychotic-like experiences and associated subclinical symptoms in healthy individuals. Front Psychol. 2017;8:1537. ^† † Studies that included only non-clinical samples. Cicero et al.⁵⁰50. Cicero DC, Gawęda Ł, Nelson B. The placement of anomalous self-experiences within schizotypal personality in a nonclinical sample. Schizophr Res. 2020;218:219-25. ^† † Studies that included only non-clinical samples. Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Negative symptoms	Assess negative symptoms	2	The non-clinical group reported fewer negative symptoms and anhedonia than the clinical group.
11	Cicero et al.⁵⁰50. Cicero DC, Gawęda Ł, Nelson B. The placement of anomalous self-experiences within schizotypal personality in a nonclinical sample. Schizophr Res. 2020;218:219-25. ^† † Studies that included only non-clinical samples. Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Cognitive factors	Assess cognitive performance	2	The clinical group has more cognitive difficulties, a lower IQ, and more disorganization than the non-clinical group.
12	Brett et al.⁴⁸48. Brett CM, Peters EP, Johns LC, Tabraham P, Valmaggia LR, McGuire P. Appraisals of Anomalous Experiences Interview (AANEX): a multidimensional measure of psychological responses to anomalies associated with psychosis. Br J Psychiatry Suppl. 2007;51:s23-30.Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Cognitive factors	Assess cognitive style	2	The clinical group has a more negative view of self and others than the non-clinical group.
13	Gabbard et al.⁵⁵55. Gabbard GO, Twemlow SW, Jones FC. Differential diagnosis of altered mind/body perception. Psychiatry. 1982;45:361-9.Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^† ‡ Case series. Moreira-Almeida et al.⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.Vencio et al.⁴⁷47. Vencio S, Caiado-Vencio R, Caixeta L. Differential diagnosis between anomalous experiences and dissociation disorder using the Dissociative Disorders Interview Schedule (DDIS). J Trauma Dissociation. 2019;20:165-78.	Comorbidities	Assess other mental symptoms and disorders	2	The clinical group experiences other mental symptoms and requires antipsychotic medication more frequently than the non-clinical group. The non-clinical group is less likely to be diagnosed with borderline personality disorder and has fewer other mental disorders and less somnambulism than the clinical group with DID. There were no differences in somatic complaints or personality traits between the non-clinical group and the group without anomalous experiences.
14	Unterrassner et al.⁴⁶46. Unterrassner L, Wyss TA, Wotruba D, Haker H, Rössler W. The intricate relationship between psychotic-like experiences and associated subclinical symptoms in healthy individuals. Front Psychol. 2017;8:1537. ^† † Studies that included only non-clinical samples. Cicero et al.⁵⁰50. Cicero DC, Gawęda Ł, Nelson B. The placement of anomalous self-experiences within schizotypal personality in a nonclinical sample. Schizophr Res. 2020;218:219-25. ^† † Studies that included only non-clinical samples. Escolà-Gascón⁴³43. Escolà-Gascón Á. Researching unexplained phenomena II: new evidences for anomalous experiences supported by the Multivariable Multiaxial Suggestibility Inventory-2 (MMSI-2). Curr Res Behav Sciences. 2020;1:100005. ^† † Studies that included only non-clinical samples. Jackson & Fulford³⁹39. Fulford KWM, Jackson M. Spiritual experience and psychopathology. Philos Psychiatr Psychol. 1997;4:41-65. ^‡ ‡ Case series.	Personality	Assess personality traits	3	Harm avoidance, introverted anhedonia, and novelty-seeking predict psychopathology or lower quality of life while self-transcendence, self-directedness, and ego-strength are predictors of better mental health.
15	Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Family history	Assess family history of psychosis	3	Family history of psychosis is more frequent in the clinical group than the non-clinical group.
16	Cicero et al.⁵⁰50. Cicero DC, Gawęda Ł, Nelson B. The placement of anomalous self-experiences within schizotypal personality in a nonclinical sample. Schizophr Res. 2020;218:219-25. ^† † Studies that included only non-clinical samples. Moreira-Almeida et al.⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.Vencio et al.⁴⁷47. Vencio S, Caiado-Vencio R, Caixeta L. Differential diagnosis between anomalous experiences and dissociation disorder using the Dissociative Disorders Interview Schedule (DDIS). J Trauma Dissociation. 2019;20:165-78.	Premorbid history	Assess history of childhood trauma	2	No difference in childhood trauma or psychiatric history between the non-clinical group and the group without anomalous experiences.
17	Moreira-Almeida et al.⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Sociodemographic factors	Assess functionality	2	The non-clinical group tends to obtain higher educational levels, have better jobs, and use mental health services less than the clinical group.
18	Brett et al.⁴⁹49. Brett C, Heriot-Maitland C, McGuire P, Peters E. Predictors of distress associated with psychotic-like anomalous experiences in clinical and non-clinical populations. Br J Clin Psychol. 2014;53:213-27.Peters et al.⁴¹41. Peters E, Ward T, Jackson M, Morgan C, Charalambides M, McGuire P, et al. Clinical, socio-demographic and psychological characteristics in individuals with persistent psychotic experiences with and without a “need for care”. World Psychiatry. 2016;15:41-52.	Sociodemographic factors	Assess relationship history	2	The non-clinical group enjoys longer relationships and experiences less lifetime discrimination than the clinical group.
19	Gabbard et al.⁵⁵55. Gabbard GO, Twemlow SW, Jones FC. Differential diagnosis of altered mind/body perception. Psychiatry. 1982;45:361-9.	Sociodemographic factors	Religious affiliation does not differentiate individuals	3	Current religious affiliation did not differentiate the non-clinical group from the group without anomalous experiences.
20	Moreira-Almeida et al.⁴⁵45. Moreira-Almeida A, Neto FL, Cardeña E. Comparison of brazilian spiritist mediumship and dissociative identity disorder. J Nerv Ment Dis. 2008;196:420-4.	Sociodemographic factors	Sex does not differentiate individuals	3	No sex differences regarding DID in non-clinical groups.

[1] Correspondence: Bruno Paz Mosqueiro, Av. Coronel Lucas de Oliveira, 505, sala 808, CEP 90450-045, Porto Alegre RS, Brazil. E-mail: brunopazmosqueiro@gmail.com

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Brazilian Psychiatric Association guidelines on the integration of spirituality into mental health clinical practice: Part 1. Spiritual history and differential diagnosis

Objectives:

Methods:

Results:

Conclusion: