Journal of Religion and Health

https://doi.org/10.1007/s10943-023-01819-2

ORIGINAL PAPER

Stress Responses Among Individuals with Spiritual

Struggles in Hungary: An Experimental Study

Szabolcs Kéri1,2,3

Accepted: 14 April 2023

© The Author(s) 2023

Abstract
Individuals with a Religious or Spiritual Problem (RSP), as defined in the DSM-5,
experience distress associated with faith-related moral dilemmas, existential mean-
ing, and transpersonal attitudes toward other people. It is unclear whether a RSP
reflects a generally heightened stress reactivity or whether the stress response is con-
fined to religious and spiritual contexts. To elucidate this issue, we measured behav-
ioral and physiological responses during social-evaluative stress (public speak-
ing—Trier Social Stress Test) and in religious/spiritual contexts (Bible reading and
listening to sacred music) in 35 individuals with RSP and 35 matched participants.
We found no stress reduction in the religious/spiritual context in RSP, as indicated
by increased heart rate, saliva cortisol, and relatively higher left than right frontal
activity. Religious stimuli evoked physiological stress responses in RSP. Contrary
to the physiological parameters, participants with RSP reported less anxiety in the
religious/spiritual context. Religious individuals with and without RSP showed
similar stress responses during public speaking. Religious individuals without RSP
displayed reduced stress responses in the religious/spiritual context. These results
indicate that specific physiological distress in religious/spiritual contexts should be
considered in the psychological care of RSP.

Keywords Religious struggle · Spirituality · Stress · Trier social stress test ·

Cortisol · Lateralized frontal activity

* Szabolcs Kéri
[email protected]; [email protected]
1
Department of Cognitive Science, Budapest University of Technology and Economics, Egry J.
Str. 1, Budapest 1111, Hungary
2
National Institute of Mental Health, Neurology and Neurosurgery - Nyírő Gyula Hospital,
Budapest, Hungary
3
Faculty of Medicine, Department of Physiology, University of Szeged, Szeged, Hungary

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 Journal of Religion and Health

Introduction

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/spirit-
ual 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 fundamen-
tal 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 Man-
ual 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 environ-
mental 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 neces-
sarily be related to an organized church or religious institution.” (American Psy-
chiatric 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 "ten-
sions, 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 dif-
ferent dimensions of religious/spiritual struggle (divine, demonic, doubt-related,
moral, ultimate meaning, and interpersonal), revealing a general religious/spir-
itual struggle factor (Stauner et al., 2016).
Most mental health professionals agree that RSP does not necessarily indi-
cate a mental disorder, but religious and spiritual struggle hinders mental health
(Pargament & Exline, 2021). However, it is unknown whether RSP, as defined in

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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 indi-
viduals with RSP demonstrate circumscribed stress reactivity in religious con-
texts or are more susceptible to stressful situations.
Stress reactivity can be investigated at multiple levels, including subjec-
tive 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 feasi-
ble in elucidating the link between religious worldviews and health. For exam-
ple, 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–pitui-
tary–adrenal stress axis (Bali & Jaggi, 2015; Dickerson & Kemeny, 2004; Nar-
vaez Linares et al., 2020). During the stress induction phase of the TSST, par-
ticipants perform a mental arithmetic task before a jury, similar to a typical
examination or public speaking. In addition to the subjective experiences of athe-
ists, 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 pres-
sure, increased heart rate, and saliva cortisol, which are putative markers of risk
for cardiovascular and metabolic diseases and mood and anxiety disorders (Sch-
nell 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 fron-
tal 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 effi-
cient 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

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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 stress-
ful situations. To evaluate the specificity of stress reactivity, we compared two con-
ditions: exposition to challenging everyday situations (public speaking) and partici-
pating 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, individu-
als 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:

Hypothesis 1 Individuals with and without RSP show similar anxiety, heart rate,
cortisol secretion, and lateralized frontal brain activity during the TSST.

Hypothesis 2 Individuals with RSP display increased anxiety, accelerated heart rate,
enhanced cortisol secretion, and higher left frontal activity than control participants
without RSP in a religious context (Bible reading and listening to sacred music).

Material and Method

Participants, Interviews, and Rating Scales

We enrolled 35 individuals with RSP and 35 matched participants who did not
experience RSP from Hungary’s Roman Catholic, Protestant, and Pentecostal com-
munities. Participants with RSP attended the pastoral psychological care service
at the Nyírő Gyula Hospital (Budapest, Hungary). All of them defined themselves
as highly religious believers. People with RSP sought help because of questioning
their faith following adverse life events. They reported moral dilemmas concerning
work and political commitment, conflicts related to differences in religious views,
and feeling guilty because of prohibited sexual behavior. RSP resulted in existential
anxiety and interpersonal conflicts.
To evaluate possible psychiatric disorders and to define RSP, we used a struc-
tured clinical interview for DSM-5 (Diagnosis and Statistical Manual of Mental
Disorders—5) (First et al., 2016). The cultural impact on clinical presentation is
especially relevant in RSP. Therefore, we administered each participant the DSM-5
Cultural Formulation Interview (CFI) (American Psychiatric Association, 2013).
We did not include individuals with psychiatric disorders in the present study. How-
ever, all participants meet the DSM-5 definition of "Problems related to other psy-
chosocial, personal, and environmental circumstances" (Religious or Spiritual Prob-
lem, [RSP, code: V62.89] (American Psychiatric Association, 2013).
We also assessed general cognitive functioning [Wechsler Adult Intelligence
Scale-IV, WAIS-IV (Wechsler, 2008)], socioeconomic status [Hollingshead Four-
Factor Index of Socioeconomic Status, SES (Hollingshead, 1975)], subjective
depressive experiences [Beck Depression Inventory-II, BDI-II (Beck et al., 1996)],

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and anxiety [Beck Anxiety Inventory, BAI (Beck et al., 1988)] (Perczel-Forintos
et al., 2018; Rózsa et al., 2010).
To delineate the religious behavior of the participants, we administered the
modified Duke University Religiosity Index (DUREL), which assesses organized
religious activity, individual religious activity, and intrinsic religiosity (Koenig &
Büssing, 2010). During the recruitment of individuals with and without RSP, we
systematically screened for potential confounding factors in stress measurements,
including nicotine, caffeine, and alcohol intake, contraception use, body mass
index, chronic diseases (e.g., cardiovascular and metabolic diseases), and working
night shifts (Narvaez Linares et al., 2020). Table 1 depicts the characteristics of the
participants.

Outline of the Procedure

Main Assessment

Participants received the interviews, rating scales, and a detailed procedure

description in the first session. Upon agreement, we arranged a second session a
few days later when we conducted the stress measurements. The sessions started
between 11 and 13 h and consisted of three phases: baseline, stress induction, and

Table 1  Characteristics of the participants

Religious or Control t p
Spiritual Problem participants
(n = 35) (n = 35)

Gender (male/female) 19/16 17/18 – –

Number of Smokers 10 9 – –
Number of chronic disease 8 7 – –
Use of contraceptives 8 9 – –
Age (years) 34.2 (12.3) 37.3 (10.0) − 1.14 0.26
Education (years) 12.9 (4.4) 13.2 (4.3) − 0.25 0.81
Wechsler Adult Intelligence Scale—IV (WAIS- 104.1 (14.9) 106.2 (11.1) − 0.67 0.50
IV)
Hollingshead Four-Factor Index (socioeco- 31.0 (14.8) 32.9 (12.3) − 0.58 0.56
nomic status)
Duke University Religiosity Index (DUREL)
Organized Religious Activity (1–5 points) 3.3 (1.5) 3.1 (1.4) 0.42 0.68
Non-organized (private) religious activity (1–5 3.5 (1.5) 3.4 (1.5) 0.16 0.88
points)
Intrinsic religiosity (1–5 points) 3.9 (1.1) 3.7 (1.4) 0.84 0.40
Beck Depression Inventory (BDI-II) 15.7 (7.2) 6.8 (4.9) 6.10 < 0.001
Beck Anxiety Inventory (BAI) 9.9 (7.9) 6.4 (4.6) 2.22 < 0.05

Data are mean (standard deviation) except for gender distribution. The two groups were compared with
two-tailed t-tests

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recovery. During the baseline phase (30 min), we presented the essential informa-
tion and provided sufficient time to acclimatize. Next, at the end of the baseline
phase, we conducted the measurements (­t[baseline]): visual analog scale (VAS) for
stress and anxiety, saliva cortisol, heart rate, and EEG. Immediately after this,
volunteers participated in the stress induction phase (20-min), which included the
TSST (simulated job interview and arithmetic calculations). At the end of the
stress induction phase, we repeated the measurements used at the end of the base-
line phase ­(t[stress]). Finally, we administered a recovery phase (40 min) when par-
ticipants relaxed and silently read verses from the Bible and listened to relaxing
religious piano music. Again, all measurements were repeated at the end of the
recovery phase (­ t[recovery]).

Replication

We asked the participants to visit the laboratory approximately two weeks after
the main assessment. In this case, we performed the baseline and the recovery
phase of the original assessment (religious context) without social-evaluative
stress. The main question of the replication experiment was whether the religious
context (Bible reading and religious music) alone could elicit a stress response in
RSP. Thirty-one individuals with RSP and 32 matched participants without RSP
were willing to complete the replication phase from the original sample included
in the main assessment.

Stress Induction and Recovery

We used a public-speaking procedure based on the TSST, which has been shown
to evoke social-evaluative stress with increased cortisol secretion and EEG signa-
tures (Dickerson & Kemeny, 2004; Düsing et al., 2016). We considered the newest
available protocol for TSST, including a standardized background questionnaire for
confounding variables and physiological recordings (Narvaez Linares et al., 2020).
Participants were informed that the test measures their public speaking and cog-
nitive abilities in front of an expert committee. They performed a simulated job
interview and then arithmetic calculations (subtracting 13 from a random num-
ber > 4800) during the procedure. In the original version, volunteers spoke in front
of an audience, but in our study, participants performed in front of a video camera
(Düsing et al., 2016). The public-speaking phase was followed by a recovery period
(40-min), during which participants listened to the Hillsong worship piano (Mus-
selman, 2019) and silently read calming verses from the Bible (Zondervan, 2019).
The subjective experience of stress and anxiety was measured using a VAS (visual
analog scale comprising a horizontal line between 0 and 10 points on the computer
screen; 0—no stress and anxiety, 10—the highest stress level and anxiety). We
administered the VAS before the stress induction phase (­ t[baseline]), immediately after
the stress induction phase (­ t[stress]), and at the end of the recovery period ­(t[recovery]).

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EEG Measurements

We recorded resting-state EEG at three time points (­ t[baseline], ­t[stress], ­t[recovery]). Each
measurement included eight 1-min resting periods (four occasions with eyes open
and four with eyes closed, counterbalanced across subjects). EEG was recorded and
processed with a NEUVO—CURRY 8X-system with a 256-channel Quik-Cap Neo
Net (high-density EEG cap, Ag/AgCl electrodes, four bipolar leads for vertical and
horizontal electrooculogram, extended international 10–20 system) (Compumedics,
NeuroScan). The electrode impedances were checked (< 5 kΩ, homologous bilat-
eral leads: < 1 kΩ). The sampling rate was 500 Hz. For data processing, we used
the EEGLAB interactive MATLAB toolbox (Schwartz Center for Computational
Neuroscience, University of California). Following built-in automatic and manual
artifact reduction, the 1-min epochs were segmented in 2-s periods with 75% overlap
between epochs (epoch amplitudes <  ± 75 μV) and were low-pass filtered at 30 Hz
(Düsing et al., 2016). We used Fourier transformation to generate the spectral power
(μV2) (resolution of 0.488 Hz) in the alpha band (8–13 Hz). Every 1 min EEG reg-
istration included at least 20 2-s epochs, and power density was averaged using all
epochs. We used logarithmic transformation (ln) for averaged power density values.
We calculated the frontal asymmetry index for the 1-min epochs by subtracting the
logarithmically transformed alpha frequency of left electrode sites from homologous
right leads (e.g., F4-F3, F8-F7). Higher alpha-asymmetry scores indicate relatively
more robust left-sided frontal activation (Duan et al., 2019; Düsing et al., 2016).

Physiological Measurements (Heart Rate and Saliva Cortisol)

Heart rate was measured with Frontier X chest-work heart monitor (Fourth Fron-
tier), which records a high-quality, continuous electrocardiogram (ECG) validated
against a GE Holter Monitor. We registered heart rates at three time points ­(t[baseline],
­t[stress], ­t[recovery]). All data were processed offline. Two measurements were con-
ducted at each time point, and the average was analyzed.
Saliva samples were also collected from each participant at the same three time
points ­(t[baseline], ­t[stress], ­t[recovery]). We used SalivaBio Passive Drool Method for
saliva sample collection and stored the samples at − 10 °C. Free salivary corti-
sol concentrations were measured by using Salimetrics immunoassays (assay range:
0.012–3.00 µg/dL; sensitivity: < 0.007 µg/dL) (Szőllősi, Pajkossy, Demeter, Kéri, &
Racsmány, 2018). We analyzed two samples at each time point with excellent con-
sistency (< 2% differences between the two samples). The average of the two sam-
ples was used for data analysis.

Data Analysis

We used STATISTICA 13.5 (Tibco) for data analysis. Before considering para-
metric tests, all data were checked for normal distribution (Kolmogorov–Smirnov
test) and homogeneity of variance (Levene’s test). Repeated-measures analyses of

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variances (ANOVAs) were conducted to determine the differences between individ-

uals with and without RSP in anxiety-VAS, heart rate, saliva cortisol, and lateralized
EEG activity at t­[baseline], ­t[stress], and ­t[recovery]. The two groups were matched for con-
founding factors (e.g., smoking, exercising before participation, hours of sleep in the
previous night, being a postmenopausal, acute or chronic illness, hormonal contra-
ception) (Narvaez Linares et al., 2020; Schnell et al., 2020). Therefore, these factors
were not included as covariates in the ANOVAs. Individuals with and without RSP
differed in BDI-II and BAI scores; these measures were covariates in the ANOVAs.
Two-tailed t-tests were performed to compare the demographic parameters and test
scores. Tukey’s HSD (honestly significant differences) tests were applied for post
hoc analysis. The level of statistical significance was set at alpha < 0.05. Effect sizes
(ƞ2) were also calculated for ANOVA main effects and interactions, and 95% confi-
dence intervals were reported.

Results

Anxiety‑VAS

Main Assessment

The ANOVA performed on the anxiety-VAS scores yielded significant main effects
of group (RSP vs. non-RSP) (F(1,68) = 8.71, p < 0.01, ƞ2 = 0.11) and test phase
­(t[baseline], ­t[stress], and ­t[recovery]) (F(2,136) = 95.22, p < 0.001; ƞ2 = 0.25). The two-way
interaction between the group and test phase was not significant (p = 0.50). However,
Tukey’s HSD tests indicated no significant differences between individuals with and
without RSP at ­t[baseline], ­t[stress], and ­t[recovery]) (ps > 0.2). Both groups scored higher
in the stress phase than in the baseline phase (­ t[stress] > ­t[baseline]), and the anxiety-VAS
scores declined in the recovery phase ­(t[recovery] < ­t[stress]) (ps < 0.05) (Fig. 1A).

Replication

There were significant main effects of group (F(1,61) = 6.30, p < 0.05, ƞ2 = 0.09)
(RSP vs. non-RSP) and test phase (baseline, religious context) (F(1,61) = 17.16,
p < 0.001; ƞ2 = 0.22). The two-way interaction between the group and test phase
was not significant (p = 0.80). Tukey’s HSD tests revealed no significant differences
between RSP and non-RSP participants. In both groups, we observed a reduction of
anxiety-VAS scores during the religious context phase (ps < 0.05) (Fig. 2A).

EEG Measures

Main Assessment

The ANOVA conducted on the frontal asymmetry index indicated signifi-

cant main effects of group (F(1,68) = 14.92, p < 0.001, ƞ2 = 0.18) and test phase

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Fig. 1  Behavioral and physiological measures in individuals with Religious or Spiritual Problem (RSP)
and matched religious individuals without RSP (non-RSP). The stress phase included a public speech
(social-evaluative stress). During the recovery phase, participants read calming Bible verses and listened
to sacred music. Data are mean, and error bars indicate 95% confidence intervals. * p < .001, RSP vs.
non-RSP, Tukey’s HSD tests

Fig. 2  Behavioral and physiological measures from the replication assessment in individuals with Reli-
gious or Spiritual Problem (RSP) and matched religious individuals without RSP (non-RSP). The reli-
gious context included reading calming Bible verses and listening to sacred music. Data are mean, and
error bars indicate 95% confidence intervals. *p < .001, RSP vs. non-RSP, Tukey’s HSD tests

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(F(2,136) = 8.24, p < 0.001, ƞ2 = 0.11). The two-way interaction was also signifi-
cant (F(2,136) = 23.91, p < 0.001, ƞ2 = 0.26). There were no significant differences
between the RSP and non-RSP groups in the baseline and stress phases ­(t[baseline]
and ­t[stress], ps > 0.05). However, individuals with RSP displayed significantly
higher frontal asymmetry in the recovery phase relative to the non-RSP participants
­(t[recovery], p < 0.001). It is noteworthy that in the RSP group, the frontal asymme-
try values significantly increased in the recovery phase relative to the stress phase
­(t[recovery] > ­t[stress]; p < 0.001). In the non-RSP group, we found the opposite effect:
the frontal asymmetry index was lower in the recovery phase than in the stress phase
­(t[recovery] < ­t[stress], p < 0.05) (Fig. 1B).

Replication

We again found significant main effects of group (F(1,61) = 26.15, p < 0.001,
ƞ2 = 0.30) and test phase (baseline vs. religious context) (F(1,61) = 10.10, p < 0.001,
ƞ2 = 0.14). The two-way interaction was also significant (F(1,61) = 29.83, p < 0.001,
ƞ2 = 0.33). At baseline, there were no significant differences between RSP and non-
RSP participants (p = 0.9), but in the religious context, individuals with RSP display
markedly higher frontal asymmetry index (p < 0.001) (Fig. 2B).

Physiological Measures: Heart Rate and Saliva Cortisol

Main Assessment

The ANOVA investigating heart rate indicated significant main effects of group
(F(1,68) = 14.12, p < 0.001, ƞ2 = 0.17) and test phase (F(2,136) = 45.21, p < 0.001,
ƞ2 = 0.40). The two-way interaction was significant (F(2,136) = 20.78, p < 0.001,
ƞ2 = 0.23). We found no significant differences between the RSP and non-RSP
groups in the baseline and stress phases ­(t[baseline] and ­t[stress], ps > 0.05). However,
individuals with RSP displayed significantly higher heart rate in the recovery phase
relative to the non-RSP participants ­(t[recovery], p < 0.001). In the RSP group, heart
rate did not change in the recovery phase compared to the stress phase ­(t[stress] =
­t[recovery], p > 0.5). In the non-RSP group, heart rate returned to the baseline level in
the recovery phase ­(t[recovery] = ­t[baseline] < ­t[stress,], p < 0.001) (Fig. 1C).
The ANOVA performed on saliva cortisol indicated significant main effects of
group (F(1,68) = 12.23, p < 0.001, ƞ2 = 0.15), test phase (F(2,136) = 6.98, p < 0.01,
ƞ2 = 0.09), and an interaction between group and test phase (F(2,136) = 9.32,
p < 0.001, ƞ2 = 0.12). Similar to the heart rate, individuals with and without RSP
differed only in the recovery phase when RSP individuals showed elevated saliva
cortisol levels (p < 0.001). Significant decreases in saliva cortisol levels were only
seen in participants without RSP (­ t[recovery] < ­t[stress], p < 0.05). In the RSP group, we
observed paradoxically higher saliva cortisol concentrations in the recovery phase
compared to the stress phase ­(t[recovery] > ­t[stress], p < 0.05) (Fig. 1D).

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Replication

In the case of heart rate, there was a significant main effect of group (RSP vs. non-
RSP) (F(1,61) = 38.50, p < 0.001, ƞ2 = 0.39), and a significant interaction between
group and task phase (baseline vs. religious context) (F(1,62) = 28.95, p < 0.001,
ƞ2 = 0.32). At baseline, we measured similar heart rate in RSP and non-RSP partici-
pants (p = 0.90). In the religious context, individuals with RSP displayed increased
heart rate. In contrast, participants without RSP showed decreased heart rate
(ps < 0.05) (Fig. 2C).
In the case of saliva cortisol, we found significant main effects of group (RSP
vs. non-RSP) (F(1,61) = 9.29, p < 0.01, ƞ2 = 0.13), task phase (baseline vs. religious
context) (F(1,61) = 5.45, p < 0.05, ƞ2 = 0.08), and a two-way interaction between
them (F(1,61) = 32.94, p < 0.001, ƞ2 = 0.35). The post hoc tests indicated that
individuals with RSP showed increased cortisol secretion in the religious context
(p < 0.001). In contrast, non-RSP participants did not display a similar change in
cortisol secretion (p = 0.08, a tendency of decreased cortisol secretion in the reli-
gious context) (Fig. 2D).

Discussion

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, physiologi-
cal 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 peo-
ple 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 differ-
ent from religiosity and stress.
Multiple factors contribute to the emergence of religious/spiritual struggle,
including the negative appraisal of stressful situations, negative affectivity, and inse-
cure 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)

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(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 lateral-
ized 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, sup-
port, 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 physi-
cal 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 reli-
gious struggle (negative affectivity) and unfavorable health outcomes because these
factors are implicated in cardiovascular and metabolic diseases, immune dysfunc-
tions, 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 exam-
ple, 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 posi-
tive association between religious participation and healthier diurnal cortisol secre-
tion. 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 experi-
ence 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 physiologi-
cal marker of coping and self-control attempts, including approach motivation,

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Journal of Religion and Health

perseverative cognition, and affect regulation. These critical cognitive factors in

RSP are related to cortisol secretion, health, and well-being (Davidson, 2004; Düs-
ing 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 indi-
cates an additional cognitive load during Bible reading. Religious individuals with-
out RSP displayed the opposite effect (reduced left frontal activity in the recovery
phase), suggesting that Bible reading and sacred music attenuated stress-related cog-
nitive efforts in their case.
These experimental findings may be relevant in understating the primary mecha-
nisms 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; Parga-
ment, 2001; Park, 2005).
Research suggests that religious coping can positively and negatively affect men-
tal health and well-being (Ano & Vasconcelles, 2005; Cheng & Ying, 2023; Par-
gament 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 reli-
gious beliefs without RSP, were characterized by positive religious coping. The
opposite neural and physiological changes in these groups may be related to nega-
tive and positive religious coping. However, we did not assess religious coping strat-
egies with separate questionnaires, and therefore, this speculation remains a hypoth-
esis for further studies.

Limitations

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

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 Journal of Religion and Health

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 meas-
ure pro-inflammatory cytokines during the stress response.

Conclusions

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.
Acknowledgements I thank Ibolya Halász, Katalin Kaza, and Péter Nagy for their assistance.

Funding Open access funding provided by Budapest University of Technology and Economics. The
authors have not disclosed any funding.

Declarations
Conflict of interest The author declares no commercial or financial conflict of interest.

Informed Consent All participants gave written informed consent and were informed that they could with-
draw from the study at any time.

Ethical Approval The study was carried out following the Declaration of Helsinki and respective ethical
standards at the National Institute of Mental Health, Neurology and Neurosurgery—Nyírő Gyula Hospital,
Budapest, Hungary. The National Medical Research Council approved the study.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
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ses/​by/4.​0/.

13
Journal of Religion and Health

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