International Review of Psychiatry

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Methodological guidelines to investigate

altered states of consciousness and anomalous
experiences

Alexander Moreira-Almeida & Francisco Lotufo-Neto

To cite this article: Alexander Moreira-Almeida & Francisco Lotufo-Neto (2017): Methodological
guidelines to investigate altered states of consciousness and anomalous experiences, International
Review of Psychiatry, DOI: 10.1080/09540261.2017.1285555

To link to this article: http://dx.doi.org/10.1080/09540261.2017.1285555

Published online: 17 Feb 2017.

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INTERNATIONAL REVIEW OF PSYCHIATRY, 2017
http://dx.doi.org/10.1080/09540261.2017.1285555

ARTICLE

Methodological guidelines to investigate altered states of consciousness and

anomalous experiences
Alexander Moreira-Almeidaa and Francisco Lotufo-Netob
a
Research Center in Spirituality and Health (NUPES), School of Medicine, Federal University of Juiz de Fora (UFJF), Juiz de Fora, Brazil;
b
Department of Psychiatry, School of Medicine, University of S~ao Paulo (USP), S~ao Paulo, Brazil

ABSTRACT KEYWORDS
Anomalous experiences (AE) (uncommon experiences or one that is believed to deviate from the Methodology; altered states
usually accepted explanations of reality: hallucinations, synesthesia, experiences interpreted as of consciousness;
telepathic … ) and altered states of consciousness (ASC) have been described in all societies of spirituality; anomalous
experience; science;
all ages. Even so, scientists have long neglected the studies on this theme. To study AE and ASC research
is not necessary to share the beliefs we explore, they can be investigated as subjective experien-
ces and correlated with other data, like any other human experience. This article presents some
methodological guidelines to investigate these experiences, among them: to avoid dogmatic
prejudice and to ‘pathologize’ the unusual; the value of a theory and a comprehensive literature
review; to utilize a variety of criteria for pathology and normality; the investigation of clinical
and non-clinical populations; development of new appropriate research instruments; to be care-
ful to choose the wording to describe the AE; to distinguished the lived experience from its
interpretations; to take into account the role of culture; to evaluate the validity and reliability of
reports and, last but not least, creativity and diversity in choosing methods.

Introduction AE and ASC have been reported in all civilizations

The term ‘anomalous experience’ (AE) is employed to
designate an uncommon experience (e.g. synesthesia),
or those, even being reported by many people (e.g.
experiences interpreted as telepathic), they are
believed to be different from the usual as well as from
the usually accepted explanations of reality. AE do
not necessarily relate to pathology or abnormality
(Carde~na, Lyinn, & Krippner, 2000).
Closely related to the AE are the ‘altered states of
consciousness’ (ASC), which Charles Tart (1972, p.
1203) defined as ‘a qualitative alteration in the overall
pattern of mental functioning, such that the experien-
cer feels his consciousness radically different from the
way if functions ordinarily’. The same author makes
an analogy between the changing from an usual state
of consciousness to an ASC, describing [comparing]
that the same computer can function with two differ-
ent programs. In this situation, the same set of data
or information may be processed through much dif-
ferent ways and generate greatly diverse out puts.
Although there is overlapping between AE and
ASC, the previous may happen during usual states of
consciousness (e.g. hallucinations).
throughout ages, many times playing an important
role in the history of societies and, especially, of their
religions (e.g. Delphi oracle, Socrates hearing his dai-
mon's advices, Moses, Saint Paul, Mohamed etc). It
has a profound impact, either in the lives of those
who experience it directly and in the lives of those
who are indirectly affected. The religious and the spir-
itual dimensions of the culture are between the most
important factors shaping the faith, the values, the
behavior and the pattern of human illness, in sum-
mary, the human experience (Lukoff, Lu, & Turner,
1992). Dissociative experiences very frequently happen
in religious/spiritual contexts, many times as ASC.
Despite being specific concepts, AE, ASC, religious
and dissociative phenomena are so closely intercon-
nected that we are going to refer to them in a manner
more or less interchangeable in this paper.
Frequently, scientific papers have considered such
experiences as rare phenomena, vestiges of ‘primitive
Cultures’ or indicators of psychopathology (Freud,
1969; Horton, 1974; Mulhern, 1991; Munro &
Persinger, 1992; Persinger, 1992; Greenberg et al.,
1992). However, population surveys have

CONTACT Alexander Moreira-Almeida alex.ma@ufjf.edu.br School of Medicine, Federal University of Juiz de Fora, Av. Eug^enio do Nascimento s/n
- Dom Bosco, 36038-330 Juiz de Fora, MG, Brazil
ß 2017 Institute of Psychiatry and John Hopkins University
2 A. MOREIRA-ALMEIDA AND F. LOTUFO-NETO
demonstrated that dissociative (Ross, Joshi, & Currie,
1990), spiritual and the so-called paranormal experi-
ences (Carde~ na et al., 2000; Ross & Joshi, 1992) are
very frequent. In this last study, some ‘paranormal’
experiences (including telepathy, precognitive dreams,
deja vu, knowledge of past lives etc) were reported by
65% of the population of a region in Canada. In a
survey conducted in 2009 in the USA, 29% of the
public overall said that they have been in touch with
someone who has already died and 18% reported
have seen or been in the presence of a ghost. These
figures have increased, they have almost doubled from
1996, when they were 18% and 9% respectively (Pew
Research Center, 2009).
AE are so frequent in the general population that
no psychological theory about the normal or patho-
logical can be comprehensive if it does not take them
into consideration (James, 1902/2002; Ross & Joshi,
1992). The view that these experiences are rare and
pathological has been a subtle manner of social con-
trol, which has become a sort of self-fulfilling proph-
ecy. Since it is usually assumed that AE are obvious
traces of psychopathology, it prevents ‘all but the flor-
idly psychotic from speaking openly about this aspect
of their lives’ (Hufford, 1992, p. 362). Those healthy
individuals with preserved insight keep their AE to
themselves.
Notwithstanding their enormous importance, the
anomalous, mystic, religious and ‘paranormal’ experi-
ences have been widely neglected by the research and
psychiatric practice. Towards the end of the nine-
teenth century and the beginning of the twentieth, the
subject was seriously investigated by many leading
scholars (Alvarado, 2012; James, 1902/2002; Sech, de
Freitas, & Moreira-Almeida, 2013; Sommer, 2016), but
during most of the twentieth century these widespread
human experiences tended to be either neglected or
excluded from the agenda of the scientific establish-
ment (Ross & Joshi, 1992). In the last decades the
research in this area has flourished again, with papers
being published in academic journals with an average
impact factor similar to those related to papers on
more mainstream areas (Daher, Damiano, Lucchetti,
Moreira-Almeida, & Lucchetti, 2017; Lucchetti &
Lucchetti, 2014; Moreira-Almeida & Santos, 2012;
Sleutjes, Moreira-Almeida, & Greyson, 2014).
It is important to emphasize that it is possible to
study AE without sharing the involved beliefs, but it
is necessary to take into seriously consideration their
implications and do not underestimate the reason
why so many people share these beliefs (Hufford,
1992; King & Dein, 1998). Such phenomena can be
studied as subjective experiences, and such as this,
correlated with any other data (King & Dein, 1998).
In addition to the cognitive value and the increase
of human knowledge that a better understanding of
AE can provide, there are also important ethical
implications. Mental health professionals often do not
receive adequate training to deal with such questions,
but, as AE are often reported by patients, clinicians
will have to manage situations they were not properly
trained to. Depending on the approach performed,
the same experience (e.g. near-death experience) could
be utilized as a stimulus for personal growth or
repressed as a bizarre event, indicator of mental
instability (Moreira-Almeida & Carde~ na, 2011). We
share with Carde~ na et al. (2000, p. 17) the hope that
in the future, the clinician will be able to consult diag-
nostic manuals ‘to help clarify the extent to which an
experience does or does not imply pathology’.
Taking into consideration the importance, as well
as the lack of studies in this matter, this article aims
to discuss methodological guidelines for the rigorous
study of AE and ASC, including religion and spiritual-
ity. These guidelines will be presented in separated
but interconnected topics.
Methodological guidelines
To avoid "dogmatic prejudice"
Regardless the recognition that there is not an entirely
neutral observation, one totally deprived of theoretical
assumptions (Kuhn, 1970; Popper, 1982), it is of vital
importance to be open to reconsider positions and
hypothesis. Especially in a field so little studied in a
legitimate and rigorously ‘scientific’ way such as this,
the existent hypothesis are generally accepted more
based on the authority of those who pronounce them,
than in the scientific evidences available. In the field
of psychiatry and religion, for example, it is remark-
able to see how certain ideas persist, nonetheless
abounding contrary evidence (Lotufo Neto, 1997).
Studying AE, it is advisable to tread the narrow path
between two abysms: the dogmatic denial and the
naïve credulity, always keeping an open mind to
explore the several possible hypothesis (Chibeni &
Moreira-Almeida, 2007; Stevenson & Greyson, 1979;
Stevenson, 1977).
To search for a theory
In any investigation, it is very important the existence
of a theory or at least a general paradigm. It guides
the outline of the study, the collect of data and their

interpretation (Hertz-Picciotto, 1999; Victora, Huttly,
Fuchs, & Olinto, 1997). In its absence, one is unable
to know which pieces of information are important
and ought to be collected, generally selecting the most
easily accessible, which frequently are not the most
relevant to the understanding of the problem in ques-
tion (Berenbaum, Kerns, & Raghavan, 2000; Kuhn,
1970). In the area of AE, we find ourselves clearly in
a pre-paradigmatic period in a Kuhnian, for there is
no any set of pattern of methods or of phenomena
that all the scholars of the area feel compelled to util-
ize and explain, existing almost so many theories such
as the number of the researchers in activity in the
field (Chibeni & Moreira-Almeida, 2007; Kuhn, 1970).
A few good criteria in the selection of a theory or a
paradigm are: empirical adequacy, falsifiability (the
capacity of making risky predictions, which are passive
of being tested), predictive accuracy, broadness of
scope (capacity to solve the greatest possible number
of problems), simplicity, theoretical integration, theor-
etical ordering, and heuristic power (capacity to pre-
dict new kinds of phenomena, ability to lead to new
discoveries) (Chibeni & Moreira-Almeida, 2007; Kuhn,
1970; Popper, 1982; Lakatos & Musgrave, 1970).
Special precaution ought to be considered in order
not to force all the data available to be fitted into a
partial and/or prematurely conceived theory. This is a
common problem, since there is a tendency to see
only the evidences that support our theory, and
underestimate or distort contrary evidences (Popper,
1982; Tart, 1972; Kuhn, 1970). The explanation for a
specific case might not be adequate for the majority
of others and similar AE might possess diverse etiolo-
gies and mechanisms. The same is valid for fraud: the
fact that frauds have being demonstrated on certain
accounts of AE does not imply that all the others be
equally hoaxes (Pekala & Carde~ na, 2000).
Exhaustive literature review
This is one of the ‘obvious’ recommendations, anyhow
it needs to be reinforced due to the fact that it is too
often neglected. In most cases, the authors seem to be
always ‘starting from scratch’, ignoring existing works,
or, at least, mentioning only references that support
their approach (Rao & Stevenson, 1979).
It is fundamental to make a comprehensive and
systematic review of the literature regarding the theme
under study (Clarke & Oxman, 2001), trying to cover
not only the psychiatric one, but also the historical,
sociological, psychological and religious (Lotufo Neto,
1997). William James (1902/2002, p. 8–9) clarifies
that, in the investigation of the religious experiences,
INTERNATIONAL REVIEW OF PSYCHIATRY 3
‘The documents humains which we shall find most
instructive need not then be sought for in the haunts
of special erudition’, but, ‘the documents that will
most concern us will be those of the men who were
most accomplished in the religious life and best able
to give an intelligible account of their ideas and
motives’. This is a very opportune reminder, for usu-
ally the literature produced by the very community or
the individuals who experience the phenomena under
study, are ignored or underestimated.
To avoid "pathologize" the different and the
"anomalous"
It is essential to keep an intellectually humble
approach, since the intolerance to the unknowing and
the mental pain resulting from the ignorance is propi-
tious to foster the hasty development and acceptance
of answers and conclusions (Amaro, 1996). The
psychiatrist Osorio Cesar (1941) made a very pertin-
ent point: ‘The psychiatrists are distrustful people who
has the bad habit of cataloguing, most of time with a
bit of craziness, the ideas and the facts which surpass
the frontiers of the common sense of the epoch’. This
has been a customary attitude in the history of the
psychiatry, that is, to consider psychopathologic any
manifestation out of habitual patterns. It is well
known how much this attitude has retarded a better
comprehension of the human mind and gave rise to
discriminatory attitudes (Moreira-Almeida, Silva de
Almeida, & Neto, 2005; Moore, 2000).
At the present time there is already a recognition,
even by the DSM-5, that the majority of the dissocia-
tive experiences, even the hallucinatory ones which
happen inside culturally accepted contexts, are not
evidences of psychopathology (Carde~ na, Lewis-
Fernandez, Bear, Pakianathan, & Spiegel, 1994;
Moreira-Almeida & Carde~ na, 2011).
Charles Tart (1983/2000, pp. 33–50) emphasizes
that the prejudice that our ordinary state of con-
sciousness is something natural and that it is the only
way to correctly deal with the reality is a great obs-
tacle to the comprehension of the nature of mind and
of the states of consciousness. The perceptions we
have about the world and ourselves, as well as the
reactions to them, are semi-arbitrary constructions.
Although they have a base on the physical reality,
they rely on the resources of our biologic apparatus
and are molded by the cultural environment where
we grow up. Due to the fact that we are humans, a
huge (but finite) range of potentials are available to
us. Given the fact that we were born in a particular
culture, only a small portion of these potentials will
4 A. MOREIRA-ALMEIDA AND F. LOTUFO-NETO
be realized. Each culture values and develops a certain
repertoire of abilities, and condemns or suppress
others. Each one of us is the beneficiary of this cul-
tural inheritance and victim or slave of this narrow-
ness of our own culture. Such as almost all people
from all cultures, in all epochs, we think that our cul-
ture is the best and that the others are savage and
primitive. Usually we do not perceive that our ordin-
ary state of consciousness, with its advantages and
limitations, is only one amongst many possible to
interpret and interact with the environment. Each state
of consciousness is able to bring additional informa-
tion, helping us to have a more global comprehension
of ourselves and of the world where we live in. Then,
the author challenges us by asking: ‘Will scientific
method be extended to the development of state-spe-
cific sciences so as to improve our human situation?
Or will the immense power of ASC's be left in the
hands of man, cults and sects? (Tart, 1972, p. 1210).
As Glen Gabbard, Twemlow, and Jones, (1982)
have well asserted more than thirty years ago: ‘as psy-
chiatrists, it is incumbent upon us to be thoroughly
familiar with the range and breath of human experi-
ence, whether pathological or healthy. We must
respect and differentiate the unusual but integrating
experiences from those which are distressing and dis-
organizing’ (p. 368).
To utilize a variety of criteria for normality and
pathology
There is not an universally accepted criteria to iden-
tify a mental disorder and psychiatric classifications
have their limitations. Many diagnostic criteria do not
take into consideration the fact that AE are not neces-
sarily associated with mental disorders. In the DSM-
II-R, all the 12 citations about religion in the Glossary
of Technical Terms were used to illustrate psycho-
pathology (Post, 1990). Several scales are theoretically
biased, valuing negatively religious and spiritual expe-
riences. For example, in the Minnesota Multiphasic
Personality Inventory (MMPI), affirmative answers to
queries about religious faith, prayer and experiences
of the presence of God were considered evidence of
psychopathology (Batson & Ventis, 1982).
As each criteria or psychiatric scale has its theoret-
ical guidelines, AE may be associated in different
ways with the various existing evaluating tools. It is
recommended to use different concepts on mental
disorder while investigating AE (Berenbaum et al.,
2000). In addition to the diagnostic criteria of the
manuals, it is also very useful evaluating social adjust-
ment, quality of life, impairment and suffering of the
person(s) under investigation. Special attention must
be given to the consequences of a specific experience,
for it may be initially a source of suffering and
impairment, but, at the end, it may bring benefits
such as a greater sense of physical and mental well
being. This is the case of the so called ‘spiritual
emergences’ which may be manifested as crisis (Grof
& Grof, 2001; Moreira-Almeida & Carde~ na, 2011).
To evaluate the ASC under appropriate criteria
Each ASC has a pattern of functioning which privi-
leges certain aspects of the reality. In any state of con-
sciousness there is a limited selection of the wide
range of human potentialities. There is a common
mistake of considering a certain ASC as ‘good’ or
‘bad’, valuing it simply according to the most devel-
oped criteria in our usual state of consciousness
(logical thinking, mathematical skills … ). It is neces-
sary to evaluate the functioning during a certain ASC
under the conditions to which it is normally utilized.
Generally, it is inadequate to valuate a state of con-
sciousness as better or worse than another in general.
The question should be: is it better or worse in relation
to which ability? (Tart, 1983/2000). The state of sleepi-
ness is not appropriate to drive an automobile, but it
is the ideal state to have a good night of sleep …
To investigate the clinical and the non-clinical
populations
Until recently, the majority of the studies about spir-
ituality and AE were carried out on clinical popula-
tions. Notwithstanding its value, such studies usually
do not allow inferences to the general population.
Clinical populations have a series of selection bias
that makes them not representative of the general
population (Sims, 1988). The motivations behind
similar behavior may differ between individuals clinic-
ally affected or not (Carde~
na et al., 2000).
A good example are the hallucinations, which have
been usually considered one of the most classic and
obvious symptom of psychopathology. However, for
more than a century, epidemiologic surveys have
demonstrated that more than 10% of the general
population report of hallucinatory phenomena, but
only 1/10 of these 10% actually has a psychotic dis-
order (Nuevo et al., 2012; Sidgwick, 1894). These and
others data point out to the existence of a substantial
minority of the population that experience hallucina-
tions. There is a great lack of information regarding
hallucinations in the non-clinical population, being
very important to know how the latter differs from

those who suffer from mental disorders (Bentall, 2000;
Moreira-Almeida & Carde~ na, 2011).
Dissociative experiences and those seen as paranor-
mal are also frequent in the general population and
they are not usually associated with higher levels of
mental disorders (Hales, 1994; Lewis-Fernandez, 1998;
Moreira-Almeida & Carde~ na, 2011; Ross et al., 1990;
Ross & Joshi, 1992).
To develop appropriate tools to evaluate beliefs
and experiences
Quite often experiences are inadequately evaluated.
For example, it is well known that evaluating religios-
ity based only on the religious affiliation of an indi-
vidual is incomplete and poorly informative.
However, this used to be the most employed method
(Weaver, Samford, & Larson, 1998). The evaluation of
religiosity must be always multidimensional (Hill &
Pargament, 2003) and the same is applied for the
majority of AE. We need to develop and refine scales
to evaluate such experiences in a more comprehensive
and reliable way.
Careful choosing of terminology to describe the
experiences
The repertoire already available on the Western
vocabulary to describe the spiritual experiences is
insufficient (Hufford, 1992). The language that we use
to communicate amongst ourselves in regard to our
daily matters is not adequate to the description of the
experiences in an ASC, which many times is perceived
as ineffable. The words and the structure of our lan-
guage are very inappropriate tools to describe ASC's
nature and dimensions, especially to those who have
not experienced them (Grof, 2000).
It is very important to be cautious in choosing the
terminology. Some expressions may inhibit the report
of the experiences. Stevenson (1983a) argues that, due
to the fact that the word ‘hallucination’ is so con-
nected with the idea of mental imbalance, ‘normal’
people avoid reporting their hallucinatory experiences.
The author even questions the use of this term for all
non-shared sensory experiences lived by healthy or
mentally disordered persons, and proposes the use of
another term, ‘ideophany’.
Another illustrative example comes from a US
national survey (Pew Research Center, 2009).
Seventeen per cent of the US population reported
that they already have seen or been in the presence
of ghosts, but almost twice as much (29%) reported
being already in touch with someone who has
INTERNATIONAL REVIEW OF PSYCHIATRY 5
already died. The surveyors may allege that to them
ghost is a sort of a scary flying white blanket and
not a dearly beloved one who had already died
(Hufford, 1992).
In a general sense, it is always better to avoid terms
with casual or theoretical implications, but rather pre-
fer the phenomenological descriptions (Hufford,
1992). When we make the translation of a term from
one language to another, this translation must be
based on the involved concepts and not only on the
words (Alarcon, 1995).
To distinguish the lived experience from its
interpretations
Regardless the importance of both, the phenomeno-
logical description of a lived experience and its later
interpretation by the individual, they may relate in
different ways with other variables (Berenbaum et al.,
2000). When required to describe, not the cause
(why), but the content (what) of their subjective expe-
riences, people tend to be much more precise (Pekala,
1991).
Many of the patients who report and believe that
they have had a near death experience, actually were
not, under a medical perspective, close to death.
Although their experiences share a lot of similarities
with the individuals who really were closed to death,
there seems to be a few differences which have been
studied (Owens, Cook, & Stevenson, 1990).
To take in consideration the role of culture
If a particular dissociative experience is regarded as
pathologic is largely influenced by the cultural envir-
onment (Lewis-Fernandez, 1998). Culture may be
defined as a set of meanings, behavioral norms and
values which shape the particular understandings that
human groups have about the world and themselves
(Favazza & Oman, 1978). Culture may influence clin-
ical practice in many ways: as an explanatory tool, a
pathogenic or pathoplastic agent, a diagnostic factor,
and as a therapeutic and protector element (Alarc on,
Westermeyer, Foulks, & Ruiz, 1999).
Transcultural studies may help to determine which
characteristics of a given experience are invariant and
which are molded by the environment and individual
beliefs. Studies in this sense have been carried out on
near death experiences (Athappilly, Greyson, &
Stevenson, 2006; Greyson, 2007; Parischa &
Stevenson, 1986; Stevenson & Greyson, 1979) and on
the alleged past lives memories (Schouten &
Stevenson, 1998; Stevenson, 1977, 1983b).
6 A. MOREIRA-ALMEIDA AND F. LOTUFO-NETO
Researcher's attitude: neutral, but empathetic
The attitude of the researcher may have serious impli-
cations over the collected data and over the individual
who reports his/her experiences. One risk is the
experiencer embellishing or minimizing the experien-
ce's report depending if the researcher assumes an
enthusiastic or hostile attitude (Stevenson & Greyson,
1979; Owens, Cook, & Stevenson, 1991). As people
often assume that ‘scientists’ tend to disqualify AE or
consider it as a sign of mental imbalance, large part
of these experiences are disguised (Hufford, 1992).
As much as due to their training (which often
tends to neglect or emphasize a negative view about
the religious and mystic dimensions of life), as well as
due to the fact that the mental health professionals
are often less religious than the general population,
they may have a great difficulty in empathizing with
such experiences (Menegatti-Chequini, Gonçalves,
Le~ao, Peres, & Vallada, 2016; Lukoff et al., 1992). A
hostile and/or pathologizing attitude towards many
potentially healthy experiences and beliefs may bring
negative iatrogenic consequences for those who
experience them (American Psychiatric Association,
1990; Lu, Lukoff, & Turner, 1994).
Be careful in establishing the causal nexus
A casual association is that one in which the changing
in the frequency or in the quality of an exposition
results in a correspondent changing in the frequency
of the illness or in the outcome of interest. The dis-
covery of casual relations between risk factors and
outcomes constitutes a primary objective of the epi-
demiology, for it furnishes valuable information to
direct the actions on public health in order to
improve population's health.
Judgment over causality comprises two principal
steps:
 If the association between the exposition and the
outcome found in a given study is valid, i.e. if it
cannot be explained by chance, bias or confound-
ing variables;
 To evaluate if the body of the available evidences
points to a causal relation.
It is always useful to remember that there is no
statistical test to prove a casual relationship, the sig-
nificance tests only show what is the probability of
the association found in a certain study be found by
chance. The determination of causality is always a
judgment performed by the researcher based on the
available evidence. To help in this evaluation, Hill
(1965) proposed a few criteria which became classic:
 Strength of the association: how much the expos-
ition increases the risk of the outcome;
 Consistency: the same association is found by dif-
ferent researchers in different settings using differ-
ent methods;
 Specificity of the relation between the exposition
and the outcome;
 Temporal relationship: the exposition precedes the
outcome;
 Biological gradient: dose-response curve;
 Biological plausibility;
 Coherence with known facts about the disease;
 Experimental evidence;
 Analogy: if there is already any similar described
casual relationship.
Hill emphasized that these new items were just
guidelines, none of them may be considered unques-
tionable evidence, neither may be taken as a sine qua
non condition. One of the major criticisms related to
studies on AE is the lack of biological plausibility or
of coherence with the existing knowledge about the
world. However, Hill himself cautioned that biological
plausibility is helpful, but ‘we cannot demand it’, since
it ‘depends upon the biological knowledge of the day.
[ … ] In short, the association we observe may be one
new to science or medicine and we must not dismiss
it too light-heartedly as too odd. As Sherlock Holmes
advised Dr. Watson, ‘when you have eliminated the
impossible, whatever remains, however improbable,
must be the truth’’ (Hill, 1965, p. 10).
Case reports or case series
The detailed study of the characteristics of a given
number of similar and illustrative cases may be very
useful for an initial exploration and to engender
hypothesis that will be tested in future more elabo-
rated studies (Grisso, 1993). William James (1902/
2002) strongly emphasized the importance of studying
the extreme cases, the ones more ‘paradigmatic’, for
they show in a fuller way the main characteristics of
the investigated phenomenon. ‘When one seeks earn-
estly for its full significance, one must always look to
its more completely evolved and perfect forms ( … )
such individuals are “geniuses” in the religious line’
(p. 9–11). The experience of the beginners with an
ASC may be much different from the one felt by a
trained individual. The beginner is learning how to
cope with the ASC at each new occurrence, which

involves doubts, fear and lack of knowledge (Menezes,
Alminhana, & Moreira-Almeida, 2012; Tart, 1983/
2000).
The selected cases should present the phenomena
of interest in a fully developed form and they need to
be evaluated through different methods in order to
extract from them the most information possible.
Regardless the importance of case reports in the
development of science, it is imperative to be aware
of unwarranted inferences. A common practice is the
extrapolation of the findings of a given clinic case or
the ‘clinical experience’ in order for them to assume
the status of ‘scientific facts’. It is vital to recognize
the many biases to which are subject the findings of
our clinical experience. Amongst them there are the
placebo effect, selection bias, regression to the mean,
natural history of disease and the biases of the
patient and the examiner in the outcomes evaluation
(Guyatt et al., 1986; Lilienfeld, Lorie, Steven, Robin,
& Robert, 2014; Sackett et al., 1985). Besides these,
there is the fact that many patients who do not feel
better with the received approach, simply seek help
with other clinician. This results in a return bias of
those who had better outcomes. In summary, case
reports and our clinical experience are very useful to
raise hypothesis to be further tested. One needs to be
very careful in making inferences based on such
studies, especially when assessing treatment efficacy
and prognosis.
Longitudinal studies
Longitudinal studies often provide good evidence to
support causal inferences, for they allow to establish
the temporal sequence between the variables under
investigation. For example, one may find a higher
prevalence of mental disorders in a given religious
group. In such case, it would be very useful to know
what came first: the affiliation to the religious group
or the mental disorder? This knowledge would help
us to formulate or discharge hypothesis such as: the
hypothetic religious group is increasing the risk of
mental disorders or the person who suffers from men-
tal disorders seeks this group as a coping strategy?
To take in consideration the complexity of
relationship between AE and psychopathology
Berenbaum et al. (2000) divide into four the possible
relationships between AE and psychopathology:
 Overlap between AE and psychopathology: the AE
is considered the disease itself or its sign/symptom;
INTERNATIONAL REVIEW OF PSYCHIATRY 7
 AE contributes to psychopathology: by the reaction
of the individual himself (e.g. anxiety or the devel-
opment of delusions to deal with the unusual per-
ceptual experiences) or the environment to the AE,
which may reject the experience and the individual
as bizarre, demoniac or insane;
 Psychopathology contributes to AE: this contribu-
tion may be in a direct way (use of substances
and/or mood disorders generating hallucinations)
or indirectly (psychopathology causing stress which
may trigger AE);
 Individual differences contributing to both AE and
psychopathology: traumatic events, personality
traits (openness for experiences), temporal lobe
disorders etc.
We could add a fifth form of association:he inde-
pendent and casual coexistence between the AE and
psychopathology.
As these relations are complex, we may explore
mediators, moderators, confounding variables.
Associations may be categorical and not continuous
(Putnam, Carlson, & Ross, 1996); or there may be a
threshold from which starts a connection with
pathology.
To evaluate reports' reliability and validity
One way to evaluate reports' internal consistency is by
trying to obtain the same information through similar
questions throughout the evaluation (Pekala, 1991).
Measurement's validity may be assessed by the con-
gruence with other findings on the same AE (conver-
gent validity, e.g. physiological alterations recorded
during the period reported as having the AE), by the
capacity to differentiate from reports of other types of
AE (discriminant validity) and by the consistency
with other reports of the same type of AE (Pekala &
Carde~na, 2000).
Creativity and diversity in choosing the
appropriate research methods
In order to obtain a most accurate and comprehensive
assessment of the AE under study, it is extremely use-
ful to combine different research strategies, such as
quantitative and qualitative methods; self-reports and
interviews; psychological, neuropsychiatric and socio-
logic approaches, amongst others.
Many times AE will challenge our scientific know-
ledge and ingenuity. Frequently, they may not be
adequately investigated by the traditional standard
research designs (Berenbaum et al. 2000). While
8 A. MOREIRA-ALMEIDA AND F. LOTUFO-NETO
keeping the scientific rigor and the critical mind, it
will often be necessary to develop new approaches.
The task of creating new and bold methodological
paradigms is the endeavor of those who venture
themselves through a barely travelled path (Chibeni &
Moreira-Almeida, 2007).
Acknowledgments
This is an updated English version of the paper: Almeida,
Alexander Moreira de, & Lotufo Neto, Francisco. (2003).
Diretrizes metodol ogicas para investigar estados alterados
de consci^encia e experi^encias an^
omalas. Archives of Clinical
Psychiatry, 30(1), 21–28. We would like to thank Antonio
Cunha Lacerda Leite for generously translating the manu-
script from Portuguese to English.
Disclosure statement
The authors report no conflicts of interest. The authors
alone are responsible for the content and writing of this
article.
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