Religion and Spirituality in Psychiatry

Religion, Spirituality, and Anxiety Disorders 129anxiety. Conventional wisdom would argue thatreligious teachings about hellfire, punishment,and damnation could worsen psychiatric symptomsin the individual predisposed to anxiety.Freud described religion as the “obsessional neurosisof humanity” and believed that most peoplewould be better off without it.(4)These negative aspects of religion, however,may have been overemphasized by mental healthprofessionals in the past, and the benefits of religionunderemphasized. There is little doubt thatthroughout history, many of the anxieties andworries that humans faced as they encounteredthe immense and threatening universe aroundthem were dealt with through religious belief,which provided peace, security, and a sense ofcontrol.(5)The chapter will also focus on the role that religiousbeliefs and practices play in the assessmentand management of anxiety disorders. Anxietydisorders addressed in this chapter include generalizedanxiety disorder, panic disorder, posttraumaticstress disorder, obsessive-compulsivedisorder, and phobia. I examine the relationship ofthese disorders to religion, rather than spirituality,because religion can be more easily measured, andthere is more agreement on what religion actuallyis (versus spirituality).(6) Before proceeding inthat regard, however, I first examine how religionand anxiety may affect one another.1. RELIGION AS A CAUSESome studies show a positive cross-sectionalrelationship between religious involvement andanxiety.(7) In other words, the greater the religiousinvolvement, the greater the anxiety. Thisis particularly true when religion is measured aseither extrinsic religiousness, (8–10) (where religiousinvolvement is motivated by external concernsother than religion, such as economic orsocial goals) or negative religious coping (whereGod is seen as punishing, distant, abandoning, orpowerless).(11) In contrast to extrinsic religiosityis intrinsic religiosity, which describes religiousinvolvement motivated by religion itself, wherereligious concerns are the ultimate goal andend of the religious activity. Intrinsic religiosityis often inversely related to anxiety (that is, theintrinsically religious person is less anxious thanothers).(8 , 12–14)Furthermore, there is uncertainty about whatthe positive associations reported between religionand anxiety in cross-sectional studies reallymean. Do they exist because religion causes peopleto become more anxious or because anxietymotivates people to become more religious (likethe soldier who prays for safety or turns to Godwhile being shot at by the enemy)?As noted earlier, certain religious teachingsabout the afterlife and possible retributions therefor less-than-devout behavior could indeed fosteranxiety in vulnerable persons. Anxiety may appearin religious persons who are not living up to the highexpectations of their faith with regard to spiritualprogress. These individuals may worry about notbeing “good enough” to please God (for Christians,Jews, or Muslims) or to improve their karma forthe next rebirth (for Hindus or Buddhists). Suchconcerns could create psychological strains thatincrease anxiety. Although systematic longitudinalresearch documenting such phenomena is lacking,simple logic make such clinical scenarios quiteplausible (even if they are not widespread, as suggestedby the research below).2. RELIGION AS A COMFORTAlthough religion can potentially arouse anxiety,much data from cross-sectional and longitudinalstudies also suggest a protective effect for religion.Indeed, these epidemiological associations are buttressedby a handful of randomized clinical trialsshowing that religious interventions decrease anxietyand other symptoms of distress. For example,Hughes and colleagues (15) examined the crosssectionalrelationships between social support, religiosity,and anxiety in 282 hospitalized patients withheart disease. This patient population is of particularimportance given the negative effect that anxietyhas on cardiac outcomes. In the Hughes study,greater religiosity was related to lower state anxietyand also lower trait anxiety. Although those whowere more religious also had greater social support,