Stress Responses Among Individuals with Spiritual Struggles in Hungary: An Experimental Study

A wealth of evidence indicates that religion and spirituality positively affect physical and mental health (Koenig et al., 2012). However, religious and spiritual struggle negatively impacts everyday life. Effective coping with religious/spiritual crises carries a potential for transformation and growth (Exline & Rose, 2005; Grof & Grof, 1990; Pargament et al., 2004). Religious and spiritual struggle results in anxiety, uncertainty, anguish, despair, and social isolation, substantially influencing beliefs, attitudes, values, and identity (Greenfield & Marks, 2007; Hall, 1997). Adverse life events and transformation experiences raise fundamental issues regarding one's relationship with the divine in the form of questioning faith, moral dilemmas, existential significance, ultimate meaning, and attitudes toward other humans (Pomerleau et al., 2020).

The publication of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) constituted a landmark in the clinical interpretation of Religious or Spiritual Problem (RSP), clearly distinguishing it from psychopathological phenomena (Lukoff, 1998; Prusak, 2016). A section in the DSM-5 focusing on problems related to psychosocial, personal, and environmental circumstances defines RSP: “This category is relevant when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution.” (American Psychiatric Association, 2013). The category of RSP is also included in the revised version of DSM-5 (DSM-5-TR) (American Psychiatric Association, 2022).

The concept of RSP is similar to religious/spiritual struggle, defined as "tensions, strains, and conflicts about what people hold sacred" (Exline & Rose, 2005; Exline et al., 2014; Pargament & Exline, 2022). Comparing DSM-5 RSP and religious/spiritual struggle is of particular importance. For example, the “loss or questioning of faith” and “conversion to new faith” in DSM-5 RSP correspond to divine struggles (“Anger or disappointment with God, and feeling punished, abandoned, or unloved by God.”) and doubt-related struggles (“Feeling confused about religious/spiritual beliefs, and feeling troubled by doubts or questions about religious/spiritual.”) (Exline et al., 2014). Moreover, the “questioning of spiritual values” in the DSM-5 is similar to moral struggles (“Tensions and guilt about not living up to one’s higher standards and wrestling with attempts to follow moral principles.”) and struggles of ultimate meaning (“Concerns that life may not really matter, and questions about whether one’s own life has deeper meaning.”) (Exline et al., 2014). However, evidence suggests a high correlation among different dimensions of religious/spiritual struggle (divine, demonic, doubt-related, moral, ultimate meaning, and interpersonal), revealing a general religious/spiritual struggle factor (Stauner et al., 2016).

Most mental health professionals agree that RSP does not necessarily indicate a mental disorder, but religious and spiritual struggle hinders mental health (Pargament & Exline, 2021). However, it is unknown whether RSP, as defined in the DSM-5, is specific to faith-related problems or part of a generally heightened stress responsiveness. In other words, the question may arise as to whether individuals with RSP demonstrate circumscribed stress reactivity in religious contexts or are more susceptible to stressful situations.

Stress reactivity can be investigated at multiple levels, including subjective experiences, autonomic nervous system (e.g., heart rate acceleration due to increased sympathetic nervous system activity), endocrine changes (heightened cortisol secretion in the adrenal cortex), and frontal brain activation. Critically, stress-related activation of the hypothalamic–pituitary–adrenal axis results in increased cortisol secretion, which affects metabolism, inflammation, immune responses, cardiovascular functions, and homeostatic balance (Sapolsky, 2021).

Recently, it has been proven that a multidisciplinary approach is highly feasible in elucidating the link between religious worldviews and health. For example, Schnell et al. (2020) used the Trier Social Stress Test (TSST) to explore the relationship between worldview security and social stress responsiveness. The TSST is a widespread experimental paradigm in psychological sciences to assess the reactivity of the sympathetic nervous system and the hypothalamic–pituitary–adrenal stress axis (Bali & Jaggi, 2015; Dickerson & Kemeny, 2004; Narvaez Linares et al., 2020). During the stress induction phase of the TSST, participants perform a mental arithmetic task before a jury, similar to a typical examination or public speaking. In addition to the subjective experiences of atheists, religious individuals, and spiritual seekers during the TSST, Schnell et al. (2020) also measured cardiovascular reactivity (blood pressure and heart rate) and endocrine responses (saliva cortisol). The key finding was that existential search and worldview instability positively correlated with systolic blood pressure, increased heart rate, and saliva cortisol, which are putative markers of risk for cardiovascular and metabolic diseases and mood and anxiety disorders (Schnell et al., 2020).

However, studies focusing on RSP have not investigated physiological changes and stress-related brain activity. The alpha-rhythm asymmetry in left vs. right frontal areas in the electroencephalogram (EEG) is a well-known measure of cortical activity related to emotional and cognitive processing during stress. Several studies revealed that individuals with greater right than left frontal resting-state neuronal activity experience higher negative feelings and emotions (Allen & Cohen, 2010; Coan & Allen, 2004; Reznik & Allen, 2018; Tops et al., 2017). Moreover, higher right frontal activity predicts the intensity of the physiological stress response (increased heart rate and cortisol secretion) (Ma et al., 2021; Zhang et al., 2018). Therefore, higher baseline left than right frontal activity is a marker of more efficient coping with adverse events, resulting in better psychological well-being (Urry et al., 2004). However, pronounced left frontal brain activity may also indicate an overload of cognitive coping mechanisms (Davidson, 2004). When individuals faced a social-evaluative threat and uncontrollability in a public speaking test, higher left frontal activity marked the intensity of endocrine stress responses (increased cortisol secretion) (Düsing et al., 2016). At the level of subjective experiences and cognitive processes, enhanced left frontal activity indicates action orientation (to approach goals in appetitive or aversive situations), heightened hesitation and decisional uncertainty, repetitive thought patterns, and rumination to cope with the stressful situation effortfully (Düsing et al., 2016; Haehl et al., 2021; Roth & Cohen, 1986).

An essential and unexplored question is how individuals with RSP react in stressful situations. To evaluate the specificity of stress reactivity, we compared two conditions: exposition to challenging everyday situations (public speaking) and participating in religious/spiritual activities. For example, individuals with RSP may feel overwhelmed when reading Bible verses relative to people with stable religiosity who experience calming and supporting Bible reading. On the other hand, individuals with RSP may feel the same stress level as religious people without RSP during mundane situations (e.g., social evaluation in public speaking).

Therefore, the hypotheses of the present study were the following:

The core finding of the present study was that individuals with RSP exhibited increased stress responses only in a religious context relative to matched religious people without RSP. We also found that during social-evaluative stress, the RSP and non-RSP groups showed similar responses on subjective anxiety ratings, physiological measures (cardiovascular activity and cortisol secretion), and lateralized frontal EEG activity. Moreover, when the social-evaluative stress situation was followed by a recovery phase in a religious context (Bible reading and sacred music), only people without RSP displayed alleviated stress responses. It is essential to underline that the results were replicated when the task was solely Bible reading and listening to sacred music without preceding social-evaluative stress, confirming that religious materials alone can be stressful at the physiological level in people with RSP.

The results from the present study are in accordance with the findings of Stauner et al. (2016). In this study, the authors identified a general factor in addition to the five components of religious/spiritual struggle (divine, demonic, interpersonal, moral, and doubt-related). The general factor showed a definitive correlation with religiousness but did not alter the correlation of the five factors with neuroticism, depression, anxiety, and stress (Stauner et al., 2016). The findings of Stauner et al. (2016) confirmed that religious/spiritual struggle is a psychological construct different from religiosity and stress.

Multiple factors contribute to the emergence of religious/spiritual struggle, including the negative appraisal of stressful situations, negative affectivity, and insecure and ambivalent attachment to God (Ano & Pargament, 2013). When adverse life events are appraised as a sacred loss, individuals experience intrusive thoughts, depression, and pronounced posttraumatic growth (appreciation of life, deepened relationships with others, spiritual change, new possibilities, and empowerment) (Pargament et al., 2005). Accordingly, RSP can be interpreted as a consequence of negative religious coping with stress and not general dispositional factors. It is important that RSP was linked to stress responses exclusively in a religious context. Individuals with RSP did not show unusually high responses in a mundane context (social stress).

Notably, there was an intriguing dissociation between subjective anxiety and physiological parameters in the RSP group. Although people with RSP reported a resolution of anxiety during Bible reading, their physiological responses and lateralized frontal EEG activity still indicated heightened stress levels. Decreased reported anxiety might be a form of social desirability because religiously committed people are explicitly or implicitly expected to experience positive emotions in a religious context. Indeed, it has been shown that social desirability biases personal reports on religious orientation, coping, and spiritual experiences (Jones & Elliott, 2017).

Positive religious coping helps deal with adverse life events, trauma, and loss by focusing on a sacred higher power, positive reframing, transcendent meaning, support, empowerment, and spiritual growth. In contrast, negative religious coping and struggle, closely related to DSM-5 RSP, are associated with adverse feelings, inner tension, anxiety, and strain (e.g., scrupulousness, punishment from the sacred higher power, awe, desolation, and spiritual discontent) (Exline & Rose, 2005; Pargament, 2001; Pargament et al., 1998, 2011).

Not surprisingly, positive religious coping predicts beneficial mental and physical health outcomes, whereas prolonged religious struggle is related to poor health and worse well-being (Magyar-Russell et al., 2014; Pargament et al., 2001; Ramirez et al., 2012). Abnormal cortisol secretion, circulating pro-inflammatory cytokines, and low-grade peripheral inflammation are critical biological factors linking religious struggle (negative affectivity) and unfavorable health outcomes because these factors are implicated in cardiovascular and metabolic diseases, immune dysfunctions, and mental disorders (Ai et al., 2010a, 2010b; Ai et al., 2010a, 2010b; Exline & Rose, 2005; Ironson et al., 2002; Sapolsky, 2021; Sephton et al., 2001). For example, Tobin and Slatcher (2016) obtained data on religious participation, religious coping, and diurnal cortisol levels from 1470 subjects from the Midlife in the United States (MIDUS) study. Findings indicated that religious struggle mediated the positive association between religious participation and healthier diurnal cortisol secretion. In other words, intensive religious attendance predicted low religious struggle a decade later, associated with a regular pattern of daily cortisol secretion (Tobin & Slatcher, 2016). Our present interventional study adds novel data to these large-scale observational studies, indicating that RSP is not a condition with a generally elevated stress response. Individuals with RSP exhibit the same stress response as non-RSP people in a social-evaluative situation, but religious practice and experience have no stress-reducing effect. Instead, we observed enhanced physiological stress responses in a religious context in RSP.

As discussed above, religious struggle in RSP and elevated cortisol levels may impact mental health and physical well-being. At the level of cognitive processing, perseverative thinking and rumination on negative feelings are typical features of religious struggle (Pargament, 2001). Lateralized frontal activity is a physiological marker of coping and self-control attempts, including approach motivation, perseverative cognition, and affect regulation. These critical cognitive factors in RSP are related to cortisol secretion, health, and well-being (Davidson, 2004; Düsing et al., 2016; Pitchford & Arnell, 2019; Urry et al., 2004).

In accordance with previous findings, we found increased left relative to right frontal activity during stress, which may reflect the apprehension of negative feelings and preoccupation with future outcomes (Carter et al., 1986; Düsing et al., 2016; Engels et al., 2007). A critical finding was that in individuals with RSP, increased left frontal activity did not return to the baseline level in the religious recovery phase. Paradoxically, we observed that left frontal activity further increased in the religious recovery phase compared to social-evaluative stress in RSP, which indicates an additional cognitive load during Bible reading. Religious individuals without RSP displayed the opposite effect (reduced left frontal activity in the recovery phase), suggesting that Bible reading and sacred music attenuated stress-related cognitive efforts in their case.

These experimental findings may be relevant in understating the primary mechanisms of religious coping, which refers to how individuals use their religious beliefs, practices, and resources to manage the challenges and stresses of life (Pargament, 2001). It involves turning to religious or spiritual beliefs, rituals, and practices as a source of comfort, hope, and meaning during difficult times. Religious coping can take many forms, including prayer, meditation, attending religious services, reading sacred texts, seeking guidance from religious leaders and fellows, and engaging in religious or spiritual practices such as fasting or pilgrimage (Koenig, 2010; Pargament, 2001; Park, 2005).

Research suggests that religious coping can positively and negatively affect mental health and well-being (Ano & Vasconcelles, 2005; Cheng & Ying, 2023; Pargament et al., 1998; Schwalm et al., 2022). On the one hand, religious coping can provide individuals with a sense of meaning, purpose, and social support, which can promote resilience and help them to cope with stressors. However, on the other hand, some forms of religious coping are associated with negative outcomes, such as increased anxiety, awe, guilt, or feelings of inadequacy.

Our results raise the possibility that individuals with RSP used negative religious coping strategies, whereas the control group, including participants with solid religious beliefs without RSP, were characterized by positive religious coping. The opposite neural and physiological changes in these groups may be related to negative and positive religious coping. However, we did not assess religious coping strategies with separate questionnaires, and therefore, this speculation remains a hypothesis for further studies.

There are several limitations to consider during the interpretation of our results. First, as mentioned above, religious coping strategies were not assessed. Second, the sample was confined to a relatively small number of help-seeking individuals. To improve statistical power and to perform correlational and mediation analyses among behavioral parameters, physiological measures, and brain activity, we need larger representative samples in which scales for religious coping and struggle are administered. Third, we need long-term data on the mental and physical health of the participants, which warrants future studies to focus on the direct relationship between RSP, physiological changes, health status, and well-being. Fourth, to avoid type 2 errors, we strictly reduced the variables according to the main hypotheses. For example, only heart rate indexed cardiovascular reactivity, and we did not measure pro-inflammatory cytokines during the stress response.

Religious individuals display a marked reduction of stress responses elicited by a social-evaluative situation when reading the Bible and listening to sacred music, as indicated by subjective anxiety reports, physiological changes, and brain activation. However, when RSP is present, religious context does not reduce stress. Instead, it may paradoxically affect physiological responses (heart rate and saliva cortisol) and brain activity (lateralized frontal activation). Therefore, increased physiological stress reactivity in a religious context should be considered during the pastoral care of individuals with RSP.