Religion and Spirituality in Psychiatry

102 Arjan W. Braamable to express high levels of religiousness andthose unable to do so. It is not completely certainwhether a history of previous depressive episodesor other markers of vulnerability could be sufficientlyaccounted for in these studies.3.4. Type of Symptoms (and Syndromes)Moral issues play an important role in the Judeo-Christian belief tradition, with its adherence tomoral codes, emphasis on conscience, and keenawareness of guilt. People involved in religionmay therefore more often report feelings of guilt,even though this may reflect more about theirperceived moral standards and religious upbringingthan about pathological guilt. Indeed, in acommunity-based study among older adults witha major depression in the Netherlands, depressedRoman Catholics and depressed Protestants moreoften reported feelings of guilt than depressednonchurch members.(19) Stompe and colleagues(20) focused on the symptom of guilt in a crossnationalcomparison between depressive patientsfrom Austria (Vienna) and Pakistan (Lahore).The authors stated that feelings of guilt may beprominent in non-Christian societies as well,for example, in Islamic cultures. In their empiricalapproach, they draw a distinction betweenethical guilt representing more or less normalexpressions of guilt and delusionlike ideas representingmore exaggerated conceptions of guiltor false judgments about guilt. Ethical feelingswere observed in both countries to the sameextent, with Pakistanis generally only expressingmild self-reproach and Austrians tending toexpress feelings of guilt. Delusionlike ideas aboutguilt were less prevalent and only reported byAustrians.The issue of symptom formation can also beaddressed at a higher level, no longer regardingspecific symptoms within the depressive syndromebut ascending to groups of symptoms.A relevant distinction here is drawn betweeninternalizing and externalizing mental disorders.Internalizing disorders mainly correspondto depression and anxiety, whereas externalizingdisorders manifest themselves in altered behaviorsuch as substance abuse or antisocial conduct.This type of categorization has been applied byKendler and colleagues, (21) who assessed a widerange of aspects of religiousness in a populationbasedsample of twins in Virginia. They analyzedthe associations between these aspects and thelifetime history of nine psychiatric and substanceuse disorders, internalizing as well as externalizing.In their study, the social dimensions ofreligiousness, such as church attendance, wereassociated with lower rates of all types of disordersunder study. A positive God image ( InvolvedGod ) was only associated with a lower prevalenceof externalizing disorders. It might be useful tofollow the approach taken by Kendler and colleagues,using different samples with respect toage, region, culture, or religious affiliation. Withrespect to religious affiliation, the last aspect,Levav and colleagues (22) showed that the rateof major depression was significantly higheramong male Jews than among Roman Catholicsand Protestants, but the rate of alcoholism amongJews was lower.3.5. Pietistic Orthodox CalvinismA particular aspect of the relationship betweenreligiousness and depression can be found in onetradition, of a modest size, in the Netherlands.Strict adherence to Reformed, Calvinist doctrinesis thought to give rise to a mind-set characterizedby depressed mood, a tendency to refrain frompleasure, a sense of insufficiency, and guilt feelings.These aspects are in keeping with a more orthodoxapplication of the doctrines of John Calvin and theHeidelberg Catechism. This catechism formulatesthree articles, one on misery, one on salvation( How I may be delivered from all my sins and miseries),and one on gratitude as requirements forknowing whether one will be saved. The emphasison misery and powerlessness in Calvinist doctrinemight have certain implications for mentalwell-being. In their small and relatively closedcommunities, pietistic orthodox Calvinists characterizetheir attitude as heavy , with positive socialsanctions for behavior in line with the Catechism.There is ongoing interest in the Netherlands in this