Influence of religious aspects and personal beliefs on psychological behavior: focus on anxiety disorders

Abstract

The current paper presents literature relevant to the relationship of religiosity, spirituality, and personal beliefs with mental health and, in particular, anxiety disorders as an empirical narrative review, providing an overview on the most important and clinically relevant research results on the topic. The relationship between religiosity/spirituality, personal beliefs (ie, magical ideation and paranormal beliefs), and mental health has lately been studied extensively, and results have indicated significant associations among these variables. However, scientific approaches to this field are complex and multidimensional, partly leading to poor operationalization, incomparable data, and contradictory results. Literature demonstrates that higher religiosity/spirituality and magical ideation scores have often been associated with increased obsessive–compulsive traits. Similar results could not be confidently replicated for other anxiety disorders. However, it is still unclear if these differences suggest a specific association with obsessive–compulsive traits and reflect deviating etiopathogenetic and cognitive aspects between obsessive–compulsive disorder and other anxiety disorders, or if these results are biased through other factors. Religiosity/spirituality and personal beliefs constitute important parameters of human experience and deserve greater consideration in the psychotherapeutic treatment of psychiatric disorders.

Introduction

The relationship between religious and personal beliefs and mental health has been studied extensively, indicating considerable correlations among these variables.¹ However, scientific approaches to this field are complex and multidimensional. With respect to anxiety disorders, the empirical evidence is scarce and warranting of further research. The current review discusses research findings on the relation of religiosity/spirituality (R/S), paranormal beliefs, and magical ideation to mental health and – in particular – anxiety disorders. Results on obsessive–compulsive disorders (OCD) and other anxiety disorders (excluding acute stress and post-traumatic stress disorder) are presented separately, in order to investigate possible etiopathogenetic and cognitive differences between both groups. The literature is presented as an empirical narrative review, providing an introduction of the topic, an overview on the most important and clinically relevant publications with respect to R/S, personal beliefs, and anxiety disorders and, finally, particular emphasis on the dimensional constructs of R/S and possible treatment options.

Religion, religiosity, and spirituality

Religion is a universal human pursuit, affecting many different cultural parameters, moral concepts, and ideals, and influencing human thinking and behavior by offering answers on the meaning of human existence.² Religion provides a comprehensive and sympathetic insight on the human orientation in the world and is an important element of human culture. The practice of dealing with the sacred sphere through ritual or nonritual cults, the interpretation of everyday and special experiences, the concordance with social norms, the contact with aesthetic and artistic expressions and symbols, as well as many other life domains, are all comparably embedded in this individual and complex system.^3–5

On the other hand, religiosity as a term reflects various aspects of religious beliefs and activities in a person's life. In the literature, intrinsic religiosity is commonly distinguished from extrinsic religiosity.^6,7 Intrinsic religiosity implies the internalization of the religions' teachings and the finding of personal master motives in religion, whereas extrinsic religiosity reflects more instrumental and utilitarian aspects of religion, providing security and solace, sociability and distraction, status, and self-justification.^6,7 During previous years, an additional emphasis has been given to spirituality, as an entity different and independent from religiosity. Spirituality is suggested to be a transcultural and transreligious parameter of human experience constituting a complex, idiographic, and multidimensional construct, not closely associated to a particular belief system, church, or cult.⁸

Personal beliefs: paranormal and magical ideation

Apart from R/S, paranormal and magical ideation are also associated with a person's individual belief system. Paranormal beliefs relate to paranormal phenomena that violate basic limiting principles in science.^9,10 The term "magical ideation" refers to beliefs about causality, in which individuals believe they have some degree of control over events that defies currently accepted physical laws.¹¹ Many studies support a significant positive but complex correlation between religious and paranormal belief variables, where higher religious scores have been associated with stronger paranormal beliefs.^12–15 Yet, R/S, religious practices, and personal beliefs are not only important for culture and social life, but they also seem to play a significant role with respect to individual physical and mental health.

Religiosity/spirituality, physical health, and well-being

Many studies indicate that R/S and religious practices may have a persistent and significant positive influence on general physical health, life satisfaction, and subjective well-being.^1,16–20 This positive impact of R/S on human well-being becomes more obvious among people under stressful circumstances and physical illness.^21,22 R/S is therefore considered a major coping factor in difficult or stressful life circumstances.^18,23 Terminal illness, cardiovascular disease, cancer, pain, and immune and endocrine diseases are only some examples in which the importance of religious coping has been put forth in the literature.¹ For some individuals, religious faith may enhance the ability to cope with negative life events, whereas for others, negative life events may result in greater religious faith.²⁴

Religiosity/spirituality and mental health

For the last three decades, the relationship between R/S and mental health has been extensively studied, indicating significant associations among these variables.^1,25 R/S has been found to be inversely correlated with the prevalence of any mental disorder^26–30 and, in particular, to have a positive impact on depression,^27,31,32 suicidal thoughts and behavior,^33,34 and alcohol dependence and drug abuse.^30,35–37 Furthermore, it is suggested that R/S is not only a protective factor for mental health, but that it also may positively influence the treatment outcomes for some mental disorders.^31,38,39 However, research has also pointed out many contradictory results.^1,40 For example, higher intrinsic orientation has been found to be associated with reduced risk for depression,^27,32 yet it also has been correlated with higher risk for most psychiatric disorders in general²³ and for depression specifically.⁴¹

The role of religious coping

Personal R/S beliefs are shown to be multidimensional, whereas several R/S aspects seem to have different and not always positive impact on mental health.^42–45 Accordingly, Kendler et al⁴³ reported that different R/S aspects show different relationships to particular externalizing mental disorders (substance dependencies and antisocial behavior) and internalizing mental disorders (major depression, generalized anxiety disorder, phobia, panic disorder, and bulimia nervosa), suggesting that different aspects of R/S can have both positive and negative influences on the individual.

Lately, research has suggested that with respect to mental health, the greatest importance seems not to lie on R/S beliefs in general, but rather on specific religious coping strategies.²³ Religious coping reflects the functional expressions of R/S in stressful situations. Positive religious coping is suggested to have a positive impact on mental health. In particular, higher worship frequency,^23,46 general religious involvement,²⁷ and prayer and scripture reading^32,47 have been shown to exert an overall positive effect and to be associated with better mental health. These effects could not be explained by possible meditative components of religious activity.⁴⁸ On the other hand, negative religious coping (ie, wondering whether God has abandoned someone or believing in a punishing, vengeful, or simply indifferent God), although less frequent than positive religious coping, has been repeatedly found in close association to negative psychological adjustment,⁴² higher psychopathology scores, and worse mental health status and treatment outcomes.^{44,45,49–54} However, although religious coping has been an increasing research focus over the last years, most studies have investigated the relationship of religious coping and depression. Only a few studies assess this parameter in association with anxiety,^51,55 and this research has mostly been conducted with hospitalized somatically ill patients.⁵⁶

Religiosity/spirituality and personal beliefs in anxiety disorders

Anxiety and anxiety disorders

Anxiety is an agonizing basic human emotion of constriction, fear, and inner restlessness that appears physiologically in unfamiliar or threatening situations and is always accompanied by a physical stress reaction.⁵⁷ The person and the specific triggering situation (stressor) are important in determining levels of provoked anxiety. Trait anxiety reflects a stable tendency to respond with state anxiety in the anticipation of threatening situations. Thus, anxiety should be viewed as a dimensional construct, where personality variables as well as congruent stressors both are influencing the increase of the level of state anxiety.⁵⁸

Anxiety disorders are characterized by a longer-lasting, pathologically intensified, and unfounded emotion of anxiety, which palsies physical and mental functions and leads to avoidance behavior. Anxiety disorders are often associated with an underlying psychobiological dysfunction^59,60 and lead to clinically significant distress, becoming a major disability for the patient. Here, the anxiety response is not an expectable or culturally sanctioned response to a stressor and does not primarily result from a social deviance or conflicts with the society.

Although R/S and other personal beliefs, such as paranormal and magical ideation, have been repeatedly suggested as important factors in the expression and course of psychiatric disorders and coping with psychiatric disorders, relevant empirical evidence is still scarce,¹ warranting further research. Research findings on the relation of R/S, paranormal beliefs, and magical ideation to anxiety and OCD are presented below.

Religiosity/spirituality and anxiety

In comparison to other psychiatric disorders, there are only a few exploratory studies investigating the specific relation between R/S and anxiety.⁶¹ Hereby, two main theories become apparent. The first one promotes the Freudian hypothesis that anxiety can arise through negative religious conflicts and that there is a positive relation between R/S and anxiety symptoms.⁶² There are only a few studies that support this hypothesis,⁶³ while most of them indicate a specific positive correlation only between anxiety and extrinsic religiosity.^64–66 Two studies support also a positive relationship only between negative religious coping and anxiety symptoms.^54,67

The second thesis suggests religiosity is negatively associated with anxiety and buffers the effects of stress, leading to lowered distress^18,19,61 and even to better outcome in the treatment of anxiety disorders.⁶⁸ Results associating positive religious coping strategies (eg, particularly regular church attendance) with lower anxiety scores have been often replicated,⁶¹ whereas other studies report results of lower anxiety levels among the more religious in samples of both healthy and medically ill subjects.^69,70

Nevertheless, many studies failed to find any significant correlation between anxiety and R/S.^54,71–75 Interestingly, Baker and Gorsuch⁶⁴ suggested a positive correlation of extrinsicness and a negative correlation of intrinsicness to trait anxiety. Accordingly, the proportion of extrinsic-oriented versus intrinsic-oriented subjects in a study could possibly affect its results.

Religiosity/spirituality and OCD

In contrast to other anxiety disorders, the specific relation of R/S and OCD has been investigated more thoroughly in the literature, as R/S has been considered to play some role in the etiopathogenesis of this disorder. The hypothesis of OCD as being to some extent an "ecclesiogenic" neurosis was postulated early in the literature.⁷⁶ Higgins et al⁷⁷ found that, indeed, the percentage of patients with reported religious conflicts was significantly higher in the OCD group than in other anxiety and nonanxiety control subjects.

Many researchers have come to the conclusion that there is a relation between R/S and some OCD traits. Especially, higher religiosity has been repeatedly found to be positively correlated with subclinical OCD symptoms and cognitions,^78–82 beliefs about overimportance of thoughts,⁸⁰ intolerance for uncertainty,⁷⁹ misinterpretation of the significance of thoughts,^83,84 control of thoughts, perfectionism, and responsibility,⁸¹ poorer insight, and more perceptual distortions.⁸⁵ Higher religiosity has also been found to correlate positively with the presence of religious themes in obsessive thoughts and compulsive rituals,⁸⁶ even across different religions.⁸⁰ In addition, patients with religious obsessions and compulsions also display significantly higher religious scores⁷⁸ than patients without these kinds of obsessions. Such results make the conclusion that OCD may be fostered by higher religiosity (ie, by the overzealous wish for spiritual purity) very tempting. Interestingly, there is an overall high percentage of OCD patients with religious obsessions.⁸⁷ Many authors found that the possibility of a diagnosis of OCD by a clinician is higher when a patient describes himself as religiously active, suggesting tautological inferences in some cases.^88,89

On the other hand, there are also many studies suggesting only a minor or a missing relationship between R/S and OCD.^{79,81,87,90–93} In marked contrast to the results mentioned above, a demographic study by Neziroglu et al⁹⁴ found more atheist/agnostic individuals amongst OCD patients compared to other disorders. Our recent study also showed no significant differences between OCD patients and healthy samples concerning most of the R/S subscales.⁵⁴ OCD patients showed higher scores of negative religious coping only.

Paranormal beliefs in anxiety and OCD

The role of paranormal beliefs in OCD and other anxiety disorders has hardly been investigated. The few available study results are similarly antithetic, with some studies suggesting an association between belief in the paranormal and lower anxiety/neuroticism,^95–97 and others reporting no significant⁹⁸ or even a negative correlation.⁹⁹

To our knowledge, the only study directly investigating and comparing differences in paranormal beliefs between healthy subjects, patients with anxiety disorders, and patients with OCD was conducted by our research group and found no differences in paranormal belief between OCD patients, anxiety patients, and healthy controls, no differences between healthy and nonhealthy subjects, and also no differences among the various anxiety subgroups.⁵⁴

Magical ideation in anxiety and OCD

Most exploratory studies investigating the specific relation of magical ideation and OCD have reported a positive correlation between magical ideation scores and OCD symptoms in clinical and nonclinical populations.^100–108 Magical ideation has generally been found to be positively related to obsessive–compulsive symptoms¹⁰³ and to many specific symptoms frequently found in OCD patients,¹⁰⁹ such as neutralizing behavior,¹¹⁰ perceptual distortions,⁸⁵ and thought–action fusion.¹¹⁰ In addition, OCD patients score higher in magical ideation scales than do healthy controls or patients with other anxiety disorders,¹⁰³ and magical ideation has been shown to predict negative outcome in OCD patients.¹¹¹ Interestingly, patients with religious obsessions and compulsions also display significantly higher magical ideation scores than do patients without these kinds of obsessions.⁸⁵

The relation between magical ideation and other anxiety disorders, on the other hand, has barely been investigated. There are only two studies found in the literature. In the first one, magical ideation scores did not differ significantly between OCD and generalized anxiety disorder, while the OCD group showed significantly higher scores than the healthy sample.¹⁰⁶ In the second study, panic-disorder patients reported significantly lower magical ideation scores compared to OCD patients.¹⁰⁴ Panic-disorder patients were found to score similarly to healthy control groups.¹⁰⁴

Our recent study showed no significant differences in magical ideation traits between OCD patients, patients with other anxiety disorders, and healthy controls.⁵⁴ We additionally suggested that the presence of four OCD-specific items in the original magical ideation scale questionnaire might result in higher magical ideation scores in OCD patients, as seen in other studies.

Discussion

Despite many encouraging clinical results and experimental data, the specific relationship between R/S and anxiety disorders has received even less attention than has the relationship of R/S with other disorders. According to available study results, specific R/S traits and magical ideation were more often correlated to subclinical OCD traits in particular, but also to clinical OCD traits, than to measures of general anxiety or other specific anxiety disorders. However, it cannot be concluded that individuals with higher OCD traits are also more religious or vice versa, and it is still unclear if these differences suggest a true association to obsessive–compulsive traits only and reflect deviating etiopathogenetic and cognitive aspects between OCD and other anxiety disorders, or if these results are biased through other factors. For example, personality traits associated with both R/S and OCD, or OCD-specific items in used questionnaires, might influence the abovementioned findings and result in a virtually closer relationship between OCD and R/S traits.

In addition, most findings suggest negative religious coping as a factor that is closely associated with various forms of psychopathology in OCD and anxiety disorders. Yet, it remains unclear whether negative religious coping represents a common expression of a mentally ill condition at a symptomatic level or a common cognitive vulnerability factor, leading to negative psychological adjustment to stress⁴² and therefore more frequently found among the symptomatic population.¹¹²

Challenges in the assessment of R/S and personal beliefs

Despite the growing focus on the impact of R/S and personal beliefs on mental health in the last decades, the failure to incorporate a broader concept of religious and spiritual constructs in relevant research represents an important limiting factor. The lack of defined and generally accepted multidimensional measures of R/S has led to poor operationalization, unmatchable and incomparable data, and to contradictory results.^61,113 For example, a recent literature review listed more than 70 different psychometric instruments designed to assess spirituality and related constructs.¹¹⁴ Most studies tend to dichotomize their results by using only a static religious variable and avoid multidimensional measures and quantified religious variables. Further limitations of the available literature include small sample sizes⁶¹ and research lacking methodological sophistication.¹¹⁵

The complexity of the field becomes clearer when considering many of the other factors that could potentially influence investigative parameters and R/S in particular. For example, age, sex, education, religious affiliation, and race show a strong relationship with R/S parameters.¹¹⁵ For example, general and social religiosity are closely associated with female sex and older age,^27,41,43 suggesting that the age and sex distribution of study samples could have a significant impact on study results.

Influence of religion and culture

Anxiety disorders belong to the most common mental disorders, with an ubiquitous presence across all continents and cultures. Thereby, cross-cultural and cross-religious norm deviations, differences in psychopathology, and prominence of various symptoms are of particular importance.^116,117 In addition, cultural and religious effects are considered not only pathoplastic, but also pathogenetic, especially in anxiety disorders.^117,118

Anxiety symptoms, but also R/S experiences and beliefs, individually manifest at a cognitive, affective, physical and behavioral level. Cultural background can strongly influence the way of manifestation in all of these areas. Thus, anxiety core symptoms may and can appear differently across religions and cultures, often leading to potential bias.¹¹⁸ The form and variety of anxiety symptoms related to religious themes is, thus, sometimes associated with certain cultures/religions.¹¹⁹ This does not, however, indicate one religion as being more pathological than others, but rather the religious symptoms as being an inseparable part of the specific culture and, thus, not pathological.^120,121 Studies in different religious contexts indicate similar results with respect to mental health.¹²¹ There are actually only sparse and controversial findings indicating a certain religious affiliation being more prevalent among, for example, OCD patients than among others,^46,78 although religions with very strict rites and regulations should be considered separately.¹²² To our knowledge, no study has investigated this topic with respect to other anxiety disorders. Nevertheless, R/S appears not to be a distinctive topic of OCD, but rather a precondition in the setting of religious patients.^82,123,124 Respectively, in a study by Siev et al,⁹⁰ thought–action fusion was shown to be a pathological marker only when such beliefs were not culturally normative.

On the other hand, specific religious affiliation might have a direct negative influence on mental health when is it the reason for discrimination, as for example among migrants.^117,125

Cognitive aspects of belief and psychotherapy

It has been recently suggested that among religious parameters, the individual cognitive aspects of religion, but not the organizational ones, show the greatest effect.^16,19 This becomes even more important when considering that religious and spiritual themes could also have an impact on the psychotherapeutic treatment and outcome of psychiatric disorders in general and of OCD and anxiety disorders in particular.^117,118 There have been studies that show the importance of personal and spiritual beliefs in the individual psychiatric and psychotherapeutic treatment.^126–128 In a study by Shafranske and Malony,¹²⁹ more than 60% of the patients expressed themselves through religious language. In accordance with this finding, religious psychotherapy for religious subjects has been proven to be significantly more effective than standard psychotherapeutic treatment.^129–133 These effects were mediated through reduction of religious and spiritual distress, which is particularly desirable in the treatment of depression and anxiety.¹³⁴ Similarly, the emotional support in a religious/spiritual group has been proven to be so effective that it is also used as a major therapeutic tool in many forms of counseling and psychotherapy.^130,131

These results suggest that religious patients may benefit more from a different form of psychotherapy that emphasizes better religious coping and that promotes positive and prevents negative religious coping and its cognitive manifestations. Over the course of the psychotherapeutic treatment, R/S-specific topics, values, and norms are often in the forefront, having a great influence on diagnosis, etiology, treatment concepts, and therapeutic goals.¹ R/S-sensitive psychotherapy might especially focus on the negative R/S cognitive assumptions (belief of being abandoned by God, etc) and give patients the opportunity to deal with their religious and spiritual struggles though an alternative kind of spiritual guidance.¹²⁸ Clinicians should, thus, strive to obtain skills in the understanding of different R/S aspects, whereby an attitude of religious openness could result in individualized therapeutic objectives and methods that are adjusted for personal beliefs.^1,121

Nevertheless, the "religiosity gap" between patients and therapists remains present, especially in some forms of psychotherapy,¹³⁵ and unheeded in scientific research,^130–132 emphasizing the need for additional religious-sensitive assessments in the research and treatment of mental disorders.¹²⁶

Conclusion

Although R/S and personal beliefs are complex and multidimensional parameters, relevant research has failed to incorporate a broader, generally accepted concept of religious and spiritual constructs, leading to poor operationalization and, thus, incomparable data and contradictory results. Nevertheless, religiosity, spirituality, and personal beliefs are important parameters of human experience and deserve greater consideration in the psychotherapeutic treatment of psychiatric disorders.

Disclosure

None of the authors received funding for this article. The authors report no conflicts of interest in this work.

References

1. Koenig HG. Religion, spirituality, and health: the research and clinical implications. ISRN Psychiatry. 2012;2012:278730.

2. Pollack D. Was ist religion? Probleme der definition [What is religion? Problems of definition]. Zeitschrift für Religionswissenschaft. 1995;3(2):163–190. German.

3. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. New York, NY: Oxford University Press; 2001.

4. Feil E. Religio (Vol 3): Die Geschichte Eines Neuzeitlichen Grundbegriffs im 17. und Frühen 18. Jahrhundert [Religio (Vol 3): The Story of a Modern Basic Concept in the 17th and Early 18th Centuries]. Göttingen, Germany: Vandenhoeck and Ruprecht; 2001. German.

5. Bochinger C. Religiosität [Religiousness]. In: Betz HD, Browning DS, Janowski B, Jüngel E, editors. Religion in Geschichte und Gegenwart. Handwörterbuch für Theologie und Religionswissenschaft [Religion Past and Present. Concise Dictionary of Theology and Religious Studies]. Tübingen, Germany: Mohr Siebeck; 2004. German.

6. Hunt RA, King M. The intrinsic-extrinsic concept: a review and evaluation. J Sci Study Relig. 1971;339–356.

7. Allport GW, Ross JM. Personal religious orientation and prejudice. J Pers Soc Psychol. 1967;5(4):432–443.

8. Pargament KI. The Psychology of Religion and Coping: Theory, Research, Practice. New York, NY: The Guilford Press; 1997.

9. Broad CD. The relevance of psychical research to philosophy. In: Ludwig JK, editor. Philosophy and Parapsychology. Buffalo, NY: Prometheus Books; 1978.

10. Tobacyk JJ. A Revised Paranormal Belief Scale. The International Journal of Transpersonal Studies. 2004;23(23):94–98.

11. Markle DT. The magic that binds us: magical thinking and inclusive fitness. J Soc Evol Cult Psychol. 2010;4(1):18–33.

12. Wain O, Spinella M. Executive functions in morality, religion, and paranormal beliefs. Int J Neurosci. 2007;117(1):135–146.

13. Orenstein A. Religion and paranormal belief. J Sci Study Relig. 2002;41(2):301–311.

14. Tobacyk J, Milford G. Belief in paranormal phenomena: assessment instrument development and implications for personality functioning. J Pers Soc Psychol. 1983;44(5):1029–1037.

15. Clarke D. Belief in the paranormal: a New Zealand survey. J Soc Psychic Res. 1991;57:412–425.

16. Maselko J, Kubzansky LD. Gender differences in religious practices, spiritual experiences and health: results from the US General Social Survey. Soc Sci Med. 2006;62(11):2848–2860.

17. Ellison CG, Gay DA, Glass TA. Does religious commitment contribute to individual life satisfaction? Soc Forces. 1989;68(1):100–123.

18. Koenig HG, Kvale JN, Ferrel C. Religion and well-being in later life. Gerontologist. 1988;28(1):18–28.

19. Ellison CG. Religious involvement and subjective well-being. J Health Soc Behav. 1991;32(1):80–99.

20. Levin JS, Markides KS, Ray LA. Religious attendance and psychological well-being in Mexican Americans: a panel analysis of three-generations data. Gerontologist. 1996;36(4):454–463.

21. Kim J. The protective effects of religiosity on maladjustment among maltreated and nonmaltreated children. Child Abuse Negl. 2008;32(7):711–720.

22. Koenig HG, Larson DB, Larson SS. Religion and coping with serious medical illness. Ann Pharmacother. 2001;35(3):352–359.

23. Baetz M, Bowen R, Jones G, Koru-Sengul T. How spiritual values and worship attendance relate to psychiatric disorders in the Canadian population. Can J Psychiatry. 2006;51(10):654–661.

24. Connor KM, Davidson JR, Lee LC. Spirituality, resilience, and anger in survivors of violent trauma: a community survey. J Trauma Stress. 2003;16(5):487–494.

25. Hackney CH, Sanders GS. Religiosity and mental health: a meta-analysis of recent studies. J Sci Study Relig. 2003;42(1):43–55.

26. Chatters LM, Bullard KM, Taylor RJ, Woodward AT, Neighbors HW, Jackson JS. Religious participation and DSM-IV disorders among older African Americans: findings from the National Survey of American Life. Am J Geriatr Psychiatry. 2008;16(12):957–965.

27. McCullough ME, Larson DB. Religion and depression: a review of the literature. Twin Res. 1999;2(2):126–136.

28. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr. 2006;28(3):242–250.

29. Wong YJ, Rew L, Slaikeu KD. A systematic review of recent research on adolescent religiosity/spirituality and mental health. Issues Ment Health Nurs. 2006;27(2):161–183.

30. King M, Marston L, McManus S, Brugha T, Meltzer H, Bebbington P. Religion, spirituality and mental health: results from a national study of English households. Br J Psychiatry. 2013;202(1):68–73.

31. Koenig HG, Cohen HJ, Blazer DG, et al. Religious coping and depression among elderly, hospitalized medically ill men. Am J Psychiatry. 1992;149(12):1693–1700.

32. Koenig HG. Religion and depression in older medical inpatients. Am J Geriatr Psychiatry. 2007;15(4):282–291.

33. Stein D, Witztum E, Brom D, DeNour AK, Elizur A. The association between adolescents’ attitudes toward suicide and their psychosocial background and suicidal tendencies. Adolescence. 1992;27(108):949–959.

34. Sisask M, Varnik A, Kolves K, et al. Is religiosity a protective factor against attempted suicide: a cross-cultural case-control study. Arch Suicide Res. 2010;14(1):44–55.

35. Miller WR. Researching the spiritual dimensions of alcohol and other drug problems. Addiction. 1998;93(7):979–990.

36. Desmond DP, Maddux JF. Religious programs and careers of chronic heroin users. Am J Drug Alcohol Abuse. 1981;8(1):71–83.

37. Edlund MJ, Harris KM, Koenig HG, et al. Religiosity and decreased risk of substance use disorders: is the effect mediated by social support or mental health status? Soc Psychiatry Psychiatr Epidemiol. 2010;45(8):827–836.

38. Braam AW, Beekman AT, Deeg DJ, Smit JH, van Tilburg W. Religiosity as a protective or prognostic factor of depression in later life; results from a community survey in The Netherlands. Acta Psychiatr Scand. 1997;96(3):199–205.

39. Sterling RC, Weinstein S, Hill P, Gottheil E, Gordon SM, Shorie K. Levels of spirituality and treatment outcome: a preliminary examination. J Stud Alcohol. 2006;67(4):600–606.

40. Mota NP, Medved M, Whitney D, Hiebert-Murphy D, Sareen J. Protective factors for mental disorders and psychological distress in female, compared with male, service members in a representative sample. Can J Psychiatry. 2013;58(10):570–578.

41. Nelson PB. Ethnic differences in intrinsic/extrinsic religious orientation and depression in the elderly. Arch Psychiatr Nurs. 1989;3(4):199–204.

42. Ano GG, Vasconcelles EB. Religious coping and psychological adjustment to stress: a meta-analysis. J Clin Psychol. 2005;61(4):461–480.

43. Kendler KS, Liu XQ, Gardner CO, McCullough ME, Larson D, Prescott CA. Dimensions of religiosity and their relationship to lifetime psychiatric and substance use disorders. Am J Psychiatry. 2003;160(3):496–503.

44. Braam AW, Schrier AC, Tuinebreijer WC, Beekman AT, Dekker JJ, de Wit MA. Religious coping and depression in multicultural Amsterdam: a comparison between native Dutch citizens and Turkish, Moroccan and Surinamese/Antillean migrants. J Affect Disord. 2010;125(1–3):269–278.

45. Hebert R, Zdaniuk B, Schulz R, Scheier M. Positive and negative religious coping and well-being in women with breast cancer. J Palliat Med. 2009;12(6):537–545.

46. Himle JA, Taylor RJ, Chatters LM. Religious involvement and obsessive compulsive disorder among African Americans and Black Caribbeans. J Anxiety Disord. 2012;26(4):502–510.

47. Boelens PA, Reeves RR, Replogle WH, Koenig HG. The effect of prayer on depression and anxiety: maintenance of positive influence one year after prayer intervention. Int J Psychiatry Med. 2012;43(1):85–98.

48. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007;52(4):260–266.

49. Bosworth HB, Park KS, McQuoid DR, Hays JC, Steffens DC. The impact of religious practice and religious coping on geriatric depression. Int J Geriatr Psychiatry. 2003;18(10):905–914.

50. Johnstone B, Yoon DP. Relationships between the Brief Multidimensional Measure of Religiousness/Spirituality and health outcomes for a heterogeneous rehabilitation population. Rehabil Psychol. 2009;54(4):422–431.

51. McConnell KM, Pargament KI, Ellison CG, Flannelly KJ. Examining the links between spiritual struggles and symptoms of psychopathology in a national sample. J Clin Psychol. 2006;62(12):1469–1484.

52. Mohr S, Perroud N, Gillieron C, et al. Spirituality and religiousness as predictive factors of outcome in schizophrenia and schizo-affective disorders. Psychiatry Res. 2011;186(2–3):177–182.

53. Dew RE, Daniel SS, Goldston DB, et al. A prospective study of religion/spirituality and depressive symptoms among adolescent psychiatric patients. J Affect Disord. 2010;120(1–3):149–157.

54. Agorastos A, Metscher T, Huber CG, et al. Religiosity, magical ideation, and paranormal beliefs in anxiety disorders and obsessive-compulsive disorder: a cross-sectional study. J Nerv Ment Dis. 2012;200(10):876–884.

55. Chapman LK, Steger MF. Race and religion: differential prediction of anxiety symptoms by religious coping in African American and European American young adults. Depress Anxiety. 2010;27(3):316–322.

56. Zwingmann C, Müller C, Körber J, Murken S. Religious commitment, religious coping and anxiety: a study in German patients with breast cancer. Eur J Cancer Care (Engl). 2008;17(4):361–370.

57. Cannon WB. Bodily Changes in Pain, Hunger, Fear and Rage: An Account of Recent Researches into the Function of Emotional Excitement. New York, NY: D Appleton and Company; 1915.

58. Endler NS, Kocovski NL. State and trait anxiety revisited. J Anxiety Disord. 2001;15(3):231–245.

59. Stein DJ. Psychobiology of anxiety disorders and obsessive-compulsive spectrum disorders. CNS Spectr. 2008;13(9 Suppl 14):23–28.

60. Martin EI, Ressler KJ, Binder E, Nemeroff CB. The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. Psychiatr Clin North Am. 2009;32(3):549–575.

61. Shreve-Neiger AK, Edelstein BA. Religion and anxiety: a critical review of the literature. Clin Psychol Rev. 2004;24(4):379–397.

62. Freud S. (1961b). The future of an illusion. In J Strachey (Ed and Trans), The standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press. 1927;21:1–56.

63. Trenholm P, Trent J, Compton WC. Negative religious conflict as a predictor of panic disorder. J Clin Psychol. 1998;54(1):59–65.

64. Baker M, Gorsuch R. Trait anxiety and intrinsic-extrinsic religiousness. J Sci Study Relig. 1982;119–122.

65. Bergin AE, Masters KS, Richards PS. Religiousness and mental health reconsidered: a study of an intrinsically religious sample. J Couns Psychol. 1987;34(2):197–204.

66. Tapanya S, Nicki R, Jarusawad O. Worry and intrinsic/extrinsic religious orientation among Buddhist (Thai) and Christian (Canadian) elderly persons. Int J Aging Hum Dev. 1997;44(1):73–83.

67. Chapman LK, Steger MF. Race and religion: differential prediction of anxiety symptoms by religious coping in African American and European American young adults. Depress Anxiety. 2010;27(3):316–322.

68. Bowen R, Baetz M, D’Arcy C. Self-rated importance of religion predicts one-year outcome of patients with panic disorder. Depress Anxiety. 2006;23(5):266–273.

69. Thorson JA, Powell FC. Meanings of death and intrinsic religiosity. J Clin Psychol. 1990;46(4):379–391.

70. Kaczorowski JM. Spiritual well-being and anxiety in adults diagnosed with cancer. Hosp J. 1989;5(3–4):105–116.

71. McCoubrie RC, Davies AN. Is there a correlation between spirituality and anxiety and depression in patients with advanced cancer? Support Care Cancer. 2006;14(4):379–385.

72. Koenig HG, Ford SM, George LK, Blazer DG, Meador KG. Religion and anxiety disorder: An examination and comparison of associations in young, middle-aged, and elderly adults. J Anxiety Disord. 1993;7(4):321–342.

73. Frenz AW, Carey MP. Relationship between religiousness and trait anxiety: factor or artifact? Psychol Rep. 1989;65(3 Pt 1):827–834.

74. Pfeifer S, Waelty U. Psychopathology and religious commitment – a controlled study. Psychopathology. 1995;28(2):70–77.

75. Shiah YJ, Chang F, Chiang SK, Lin IM, Tam WC. Religion and health: anxiety, religiosity, meaning of life and mental health. J Relig Health. Epub October 17, 2013.

76. Schätzing E. Die Ekklesiogene Neurose: Wege zum Menschen. Göttingen, Germany: Vandenhoeck and Ruprecht; 1955. German.

77. Higgins NC, Pollard CA, Merkel WT. Relationship between religion-related factors and obsessive compulsive disorder. Curr Psychol. 1992;11(1):79–85.

78. Steketee G, Quay S, White K. Religion and guilt in OCD patients. J Anxiety Disord. 1991;5(4):359–367.

79. Abramowitz JS, Deacon BJ, Woods CM, Tolin DF. Association between Protestant religiosity and obsessive-compulsive symptoms and cognitions. Depress Anxiety. 2004;20(2):70–76.

80. Yorulmaz O, Gençöz T, Woody S. OCD cognitions and symptoms in different religious contexts. J Anxiety Disord. 2009;23(3):401–406.

81. Sica C, Novara C, Sanavio E. Religiousness and obsessive-compulsive cognitions and symptoms in an Italian population. Behav Res Ther. 2002;40(7):813–823.

82. Inozu M, Karanci AN, Clark DA. Why are religious individuals more obsessional? The role of mental control beliefs and guilt in Muslims and Christians. J Behav Ther Exp Psychiatry. 2012;43(3):959–966.

83. Rachman S. The Treatment of Obsessions. New York, NY: Oxford University Press; 2003.

84. Rachman S. A cognitive theory of obsessions. Behav Res Ther. 1997;35(9):793–802.

85. Tolin DF, Abramowitz JS, Kozak MJ, Foa EB. Fixity of belief, perceptual aberration, and magical ideation in obsessive-compulsive disorder. J Anxiety Disord. 2001;15(6):501–510.

86. Rasmussen SA, Tsuang MT. Clinical characteristics and family history in DSM-III obsessive-compulsive disorder. Am J Psychiatry. 1986;143(3):317–322.

87. Tek C, Ulug B. Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Res. 2001;104(2):99–108.

88. Gartner J, Harmatz M, Hohmann A, Larson D, Gartner AF. The effect of patient and clinician ideology on clinical judgment: a study of ideological countertransference. Psychotherapy (Chic). 1990;27(1):98–106.

89. Yossifova M, Loewenthal KM. Religion and the judgement of obsessionality. Mental Health, Religion and Culture. 1999;2(2):145–152.

90. Siev J, Chambless DL, Huppert JD. Moral thought-action fusion and OCD symptoms: the moderating role of religious affiliation. J Anxiety Disord. 2010;24(3):309–312.

91. Lewis CA. Religiosity and obsessionality: the relationship between Freud’s “religious practices”. J Psychol. 1994;128(2):189–196.

92. Zohar AH, Goldman E, Calamary R, Mashiah M. Religiosity and obsessive-compulsive behavior in Israeli Jews. Behav Res Ther. 2005;43(7):857–868.

93. Hermesh H, Masser-Kavitzky R, Gross-Isseroff R. Obsessive-compulsive disorder and Jewish religiosity. J Nerv Ment Dis. 2003;191(3):201–203.

94. Neziroglu FA, Yaryura Tobías JA, Lemli JM, Yaryura RA. [Demographic study of obsessive compulsive disorder]. Acta Psiquiatr Psicol Am Lat. 1994;40(3):217–223. Spanish.

95. Kennedy JE, Kanthamani H. An exploratory study of the effects of paranormal and spiritual experiences on peoples’ lives and well-being. J Am Soc Psych Res. 1995;89(3):249–264.

96. Goulding A. Mental Health Aspects of Paranormal and Psi Related Experiences [dissertation]. Göteborg, Sweden: Göteborg University; 2004.

97. Wolfradt U. Dissociative experiences, trait anxiety and paranormal beliefs. Pers Individ Dif. 1997;23(1):15–19.

98. Tobacyk J. Paranormal belief and trait anxiety. Psychol Rep. 1982; 51(3 Pt 1):861–862.

99. Thalbourne MA, Dunbar KA, Delin PS. An investigation into correlates of belief in the paranormal. J Am Soc Psychic Res. 1995;89(3):215–231.

100. Bolton D, Dearsley P, Madronal-Luque R, Baron-Cohen S. Magical thinking in childhood and adolescence: development and relation to obsessive compulsion. Br J Dev Psychol. 2002;20(4):479–494.

101. Emmelkamp PMG, Aardema A. Metacognition, specific obsessive–compulsive beliefs and obsessive–compulsive behaviour. Clin Psychol Psychother. 1999;6(2):139–145.

102. Einstein DA, Menzies RG. Role of magical thinking in obsessive-compulsive symptoms in an undergraduate sample. Depress Anxiety. 2004;19(3):174–179.

103. Einstein DA, Menzies RG. The presence of magical thinking in obsessive compulsive disorder. Behav Res Ther. 2004;42(5):539–549.

104. Einstein DA, Menzies RG. Magical thinking in obsessive-compulsive disorder, panic disorder and the general community. Behav Cogn Psychother. 2006;34(3):351–357.

105. Fonseca-Pedrero E, Lemos-Giráldez S, Paíno-Piñeiro M, Villazón-García U, Muñiz J. Schizotypal traits, obsessive-compulsive symptoms, and social functioning in adolescents. Compr Psychiatry. 2010;51(1):71–77.

106. West B, Willner P. Magical thinking in obsessive-compulsive disorder and generalized anxiety disorder. Behav Cogn Psychother. 2011;39(4):399–411.

107. Yorulmaz O, Inozu M, Gültepe B. The role of magical thinking in obsessive-compulsive disorder symptoms and cognitions in an analogue sample. J Behav Ther Exp Psychiatry. 2011;42(2):198–203.

108. Kingdon BL, Egan SJ, Rees CS. The Illusory Beliefs Inventory: a new measure of magical thinking and its relationship with obsessive compulsive disorder. Behav Cogn Psychother. 2012;40(1):39–53.

109. Visser HA, van Megen HJ, van Oppen P, van Balkom AJ. [A new explanatory model for obsessive-compulsive disorder]. Tijdschr Psychiatr. 2009;51(4):227–237. Dutch.

110. Bocci L, Gordon PK. Does magical thinking produce neutralising behaviour? An experimental investigation. Behav Res Ther. 2007;45(8):1823–1833.

111. Moritz S, Fricke S, Jacobsen D, et al. Positive schizotypal symptoms predict treatment outcome in obsessive-compulsive disorder. Behav Res Ther. 2004;42(2):217–227.

112. Pirutinsky S, Rosmarin DH, Pargament KI, Midlarsky E. Does negative religious coping accompany, precede, or follow depression among Orthodox Jews? J Affect Disord. 2011;132(3):401–405.

113. Tanaka K. Limitations for measuring religion in a different cultural context – the case of Japan. Soc Sci J. 2010;47(4):845–852.

114. MacDonald DA, LeClair L, Holland CJ, Alter A, Friedman HL. A survey of measures of transpersonal constructs. J Transpers Psychol. 1995;27(2):171–235.

115. Larson DB, Pattison EM, Blazer DG, Omran AR, Kaplan BH. Systematic analysis of research on religious variables in four major psychiatric journals, 1978–1982. Am J Psychiatry. 1986;143(3):329–334.

116. Asnaani A, Richey JA, Dimaite R, Hinton DE, Hofmann SG. A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders. J Nerv Ment Dis. 2010;198(8):551–555.

117. Agorastos A. Religion und migration [Religion and migration]. In: Machleidt W, Heinz A, editors. Praxis der Interkulturellen Psychiatrie und Psychotherapie: Migration und Psychische Gesundheit [Practice of Intercultural Psychiatry and Psychotherapy: Migration and Mental Health]. Munich, Germany: Urban and Fischer Verlag/Eslevier GmbH; 2011:85–91. German.

118. Agorastos A, Haasen C, Huber CG. Anxiety disorders through a transcultural perspective: implications for migrants. Psychopathology. 2012;45(2):67–77.

119. de Bilbao F, Giannakopoulos P. [Effect of religious culture on obsessive compulsive disorder symptomatology. A transcultural study in monotheistic religions]. Rev Med Suisse. 2005;1(43):2818–2821. French.

120. Raphael FJ, Rani S, Bale R, Drummond LM. Religion, ethnicity and obsessive-compulsive disorder. Int J Soc Psychiatry. 1996;42(1):38–44.

121. Koenig HG, Zaben FA, Khalifa DA. Religion, spirituality and mental health in the West and the Middle East. Asian J Psychiatr. 2012;5(2):180–182.

122. Huppert JD, Siev J, Kushner ES. When religion and obsessive-compulsive disorder collide: treating scrupulosity in Ultra-Orthodox Jews. J Clin Psychol. 2007;63(10):925–941.

123. Greenberg D, Witztum E. The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society. Isr J Psychiatry Relat Sci. 1994;31(3):211–220.

124. Williams AD, Lau G, Grisham JR. Thought-action fusion as a mediator of religiosity and obsessive-compulsive symptoms. J Behav Ther Exp Psychiatry. 2013;44(2):207–212.

125. Hassan G, Rousseau C, Moreau N. Ethnic and religious discrimination: the multifaceted role of religiosity and collective self-esteem. Transcult Psychiatry. 2013;50(4):475–492.

126. Seyringer ME, Friedrich F, Stompe T, Frottier P, Schrank B, Frühwald S. [The “Gretchen question” for psychiatry – the importance of religion and spirituality in psychiatric treatment]. Neuropsychiatr. 2007;21(4):239–247. German.

127. Koenig HG, Cohen HJ, Blazer DG, Kudler HS, Krishnan KR, Sibert TE. Religious coping and cognitive symptoms of depression in elderly medical patients. Psychosomatics. 1995;36(4):369–375.

128. Koszycki D, Bilodeau C, Raab-Mayo K, Bradwejn J. A Multifaith Spiritually Based Intervention Versus Supportive Therapy for Generalized Anxiety Disorder: A Pilot Randomized Controlled Trial. J Clin Psychol. Epub 2013.

129. Shafranske EP, Malony HN. Clinical psychologists’ religious and spiritual orientations and their practice of psychotherapy. Psychotherapy (Chic). 1990;27(1):72–78.

130. Azhar MZ, Varma SL, Dharap AS. Religious psychotherapy in anxiety disorder patients. Acta Psychiatr Scand. 1994;90(1):1–3.

131. Berry D. Does religious psychotherapy improve anxiety and depression in religious adults? A review of randomized controlled studies. Int J Psychiatr Nurs Res. 2002;8(1):875–890.

132. Paukert AL, Phillips L, Cully JA, Loboprabhu SM, Lomax JW, Stanley MA. Integration of religion into cognitive-behavioral therapy for geriatric anxiety and depression. J Psychiatr Pract. 2009;15(2):103–112.

133. Rosmarin DH, Pargament KI, Pirutinsky S, Mahoney A. A randomized controlled evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community, delivered via the Internet. J Anxiety Disord. 2010;24(7):799–808.

134. Stanley MA, Bush AL, Camp ME, et al. Older adults’ preferences for religion/spirituality in treatment for anxiety and depression. Aging Ment Health. 2011;15(3):334–343.

135. Verhagen PJ. The case for more effective relationships between psychiatry, religion and spirituality. Curr Opin Psychiatry. 2010;23(6):550–555.