Hearing spirits? Religiosity in individuals at risk for psychosis—Results from the Brazilian SSAPP cohort Alexandre Andrade Loch a,b, ⁎, Elder Lanzani Freitas a , Lucas Hortêncio a , Camille Chianca a , Tania Maria Alves a , Maurício Henriques Serpa a,b , Julio Cesar Andrade a , Martinus Theodorus van de Bilt a,b , Wagner Farid Gattaz a,b , Wulf Rössler a,b,c,d a Laboratory of Neuroscience (LIM 27), Institute of Psychiatry, University of São Paulo, Brazil b Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBION), Conselho Nacional de Desenvolvimento Cientifico e Tecnológico, Brazil c Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland d Department of Psychiatry and Psychotherapy, Charité University of Medicine, Berlin, Germany abstract article info Article history: Received 2 May 2018 Received in revised form 6 August 2018 Accepted 17 September 2018 Available online 25 September 2018 In the last decades, biological and environmental factors related to psychosis were investigated in individuals at ultra-risk for psychosis (UHR) to predict conversion. Although religion relates to psychosis in a variety of ways, it is understudied in subclinical samples. Therefore, we assessed the interplay between religion and prodromal symptoms in 79 UHR and 110 control individuals. They were interviewed with the Duke University Religion Index and the Structured Interview for Prodromal Syndromes (SIPS). Organizational religious activity, a measure of how often someone attends churches/temples, was positively related to perceptual abnormalities/hallucina- tions (Spearman's rho = 0.262, p = 0.02). This relationship was replicated in a path analysis model (β = 0.342, SE = 0.108, p = 0.002), as well as a link between organizational religious activity and lower ideational richness (β = 0.401, SE = 0.105, p = 0.000) with no influence of sex, age, religious denomination, or socioeco- nomic class. Intrinsic religious activity was negatively correlated with suspiciousness (SIPS P2) (β = -0.028, SE = 0.009, p = 0.002), and non-organizational religious activity was correlated with higher ideational richness (N5) (β = -0.220, SE = 0.097, p = 0.023). We hypothesize that subjects with subclinical psychosis may possibly use churches and other religious organizations to cope with hallucinations. Indeed, Brazil is characterized by a religious syncretism and a strong influence of Spiritism in the popular culture. The mediumistic idea that some might be able to hear and/or see spirits is probably employed to explain subclinical hallucinations in the lay knowledge. Our results emphasize the importance of assessing religion and other region-specific aspects of var- ious cultures when studying UHR individuals. This sort of assessment would enhance understanding of differ- ences in conversion rates, and would help to transpose prevention programs from high-income countries to other settings. © 2018 Elsevier B.V. All rights reserved. Keywords: Schizophrenia Prodromal psychosis Subclinical psychosis Psychosis continuum Exceptional experiences 1. Introduction In the last decades, the concept of psychosis as a dimensional mani- festation instead of an all-or-nothing event was consolidated (Verdoux and van Os, 2002). Today's view is that psychotic phenomena happen in a continuum, ranging from normality to severe symptomatic states. Also, prodromal stages of the disorder were better identified (Yung and McGorry, 1996), and ultra-high risk for psychosis (UHR) criteria were established to prevent people with subclinical conditions from progressing along the continuum to a psychotic disorder (Yung et al., 2008). Therefore, it is generally accepted that biological traits such as genes interact with environmental factors during one's life until a cer- tain threshold is achieved, leading to the first episode of psychosis after a years-long prodromal phase (van Os et al., 2009). To further in- vestigate the risk of conversion, several environmental factors related to psychotic disorders have been studied in UHR populations, such as migration (O'Donoghue et al., 2015), urbanicity (Dragt et al., 2011), and socioeconomic class (Loch et al., 2017), for instance. On the other hand, religion, a factor also related to psychosis in a variety of ways, ap- pears underobserved in UHR studies. The interplay between religiousness and psychosis has long been studied. In early psychiatry, Phillipe Pinel stated that religious fanati- cism might be a causative factor of madness (Huneman, 2017; Pinel, 1806). Emil Kraepelin described a high frequency of mystical and reli- gious content in his psychotic patients, and Kurt Schneider reported a heightened religiousness in schizophrenia patients (Menezes and Schizophrenia Research 204 (2019) 353–359 ⁎ Corresponding author at: Laboratório de Neurociências – LIM 27, Rua Dr. Ovídio Pires de Campos 785, 3 andar, CEAPESQ sala 1, CEP 05403-010 São Paulo, SP, Brazil. E-mail address: alexandre.loch@usp.br (A.A. Loch). https://doi.org/10.1016/j.schres.2018.09.020 0920-9964/© 2018 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect Schizophrenia Research journal homepage: www.elsevier.com/locate/schres