Spiritual Well-being in Patients With Generalized Anxiety Disorder and General Medical Conditions: Demographics in Context

Received 14 Sep, 2015

Accepted 21 Feb, 2021

Published 31 Mar, 2021

The purpose of current study was to examine the predictive role of various socio demographic variables for spiritual well-being among participants with Generalized Anxiety Disorder (GAD) and those with minor General Medical Conditions (GMC). Using purposive sampling technique, 90 participants including 40 (22 men, 18 women) with GAD and 50 (23 men, 27 women) with GMC with the age range of 18-58 years completed a socio-demographic questionnaire along with Spiritual Wellness Inventory (Ingersoll, 1998). The findings of the regression analysis revealed that for GAD group, age appeared to be the only significant predictor for spiritual well-being. Analyses on the subscales revealed that Concept of Hereafter was positively predicted by religious inclination, Conscientiousness was positively predicted by age, Mystery was predicted by age and gender for group with GAD; while, for GMC group, gender predicted Practicing Rituals. Furthermore, the findings of t-test revealed that women with GMC utilized more religious rituals than men; however, no such difference was found in the GAD group. The results have important implications to address the spiritual issues concerning anxiety problems during the course of therapy.

Spiritual well-being is regarded as a driving source of faith in self, meaning, fulfillment in life as well as personal stability (Rovers & Kocum,2010); it also enhances psychological well-being, which in turn, facilitates coping abilities and enhances life satisfaction (Hafeez & Rafique, 2013). The spirituality is defined as “a subjective belief system that incorporates self-awareness and reference to a transcendence dimension, provides meaning and purpose in life, and feelings of connectedness with God or the larger reality” (Bensley, 1991, p. 288). Ingersoll (1998) was of the view that spirituality can only be described in the context of spiritual well-being, which is required to explore spirituality quantitatively. Ellison (1983) conceptualized spiritual well-being as a reflection of one’s spiritual growth. It is further maintained that a spiritual person lives by submitting oneself to the will of God and experiences harmony in one’s life. Moreover, in monotheistic perspective, the spiritual well-being reflects love and trust on God as well as living life by submitting self to His will, which in turn, leads to calmness of mind, internal feeling of security, and life satisfaction (Mousavimughadam & Delpisheh, 2012).

According to Ingersoll (1998), spiritual well-being comprises of 13 synergistic dimensions including conception of divinity, connectedness, mystery, meaning, spiritual freedom, forgiveness, rituals, knowledge, conscientiousness, altruism, hope, present centeredness, and concept of hereafter. The dimension of conception of divinity reflects person’s image or experience of the absolute, while the dimension of connectedness refers to the relationship an individual has with the higher power that is, God, other people, the environment, and community in general. The dimension of mystery measures the person’s comfort level and ways of dealing with the uncertainties and ambiguities in life, whereas meaning reflects a sense of life being worthwhile and purposeful as well as a sense of being at peace with oneself. Spiritual freedom is associated with a sense of freedom from internal and external compulsions and a willingness to make commitment. Forgiveness is indicative of a person’s inclination to give and receive forgiveness; rituals dimension measures healthy spiritual rituals and practices, while the dimension of knowledge shows the increased interest in learning about self and other things in the environment. Conscientiousness is a willingness to carry out the duties thoroughly and altruism reflects selfless concern for others. The dimension of hope reflects a person’s belief that his sufferings are not in vain or permanent and a sense of being safe in life. Present centeredness depicts one’s ability to be aware of the present moment, as spiritual well-being enhances with truth and truth is what is revealed in the present moment and the concept of hereafter reflects a belief in the day of judgment (Hanif & Gohar, 2010; Shahbaz & Shahbaz, 2015). Flannelly (2017) was of the view that healthy relationship with God affects mental health positively. A secure attachment and feeling of connectedness with God lead to improved mental health and life satisfaction (Szcześniak & Tomczak, 2020). In addition, Maslow (as cited in Gold, 2013) regarded spirituality as a strategy to attain self-actualization and inability to do so tends to lead to psychopathology. Most patients with religious background seek religious and spiritual guidance for the resolution of their problems, and hence, it becomes rather challenging to ignore religious and spiritual issues in therapeutic settings, especially in a country like Pakistan (Gladding & Crockett, 2018; Pargament, 1997), which came into being in the name of religion. Spiritual issues need to be addressed in therapy as they tend to empower a person by providing stability, inner strength, direction, meaning in life, hope, and sense of connectedness with High power in the face of life crises (Matise, Ratcliff, & Mosci, 2017).

The positive relationship between mental health and spirituality supports the view that human beings are bio, psycho, socio, and spiritual beings. Furthermore, the human’s quest for achieving wholeness in personality is only fulfilled by addressing spirituality in psychotherapy (Hughes, 2011). Thus, spirituality integrated therapy is a holistic one as it addresses physical, psychological, and spiritual need of the patient and contributes towards significant improvement in mental health (Mahida, 2015). Many researches have proved that spirituality lowers the sense of loneliness, depression (Peselow, Lopez, Besada, & Ishak 2014; Pleeging, Burger & van Exel, 2019; You et al., 2009), anxiety (Lin, Mack, Enright, Krahn, & Baskin, 2004; Rosmarin & Leidl, 2020), shame and interpersonal difficulties (Waldron, Scarpa, & Kim-Spoon, 2018), and reduced stress and intensity of PTSD (Perera, Pandey, & Srivastava, 2018). Research based on patients with Schizophrenia also proved the beneficial effect of spirituality-based therapy as it provides a feeling of belongingness with family, meaning in life, and a secure environment to explore future goals (Weisman, Tuchman, & Duarte, 2010) as well as an enhanced quality of life in these patients (Shah et al., 2011).

There are many researches that focused on influence of religiosity and spirituality on mental and physical health; however, few have explored the demographic characteristics of the sample that can significantly predict the different dimensions of spiritual well-being. Ziapour (2017) showed that men were more altruistic than women; while, Vosloo, Wissing, and Temane (2009) found that gender moderated the relationship between spirituality and psychological well-being. In addition, Zhang (2010) in study with old people found that women involved themselves in religious activities more than men. Furthermore, Gök, Arslan, and Duyan (2017) depicted that unmarried participants experienced more worry than married as well as women worried significantly more than men. Bożek, Nowak, and Blukacz (2020) showed that the mental health of married individuals is better than unmarried persons regardless of their physical health status; while, Dunning (2012) found that aged people tend to have more need of spiritual growth. In the light of this literature, it seemed pertinent to explore the relationship of these sociodemographic variables with spiritual wellbeing in patients with generalized anxiety disorder as they often present worry around spiritual concerns (Rosmarin & Leidl, 2020), which are highlighted in therapy (Gladding & Crockett, 2018). As negative thinking and worry tend to be an integral part of most psychiatric population, it was decided to include a comparison group with minor general medical conditions, so as to draw a more comprehensive conclusion vis-à-vis demographics and spirituality (Ahmad & Bokharey, 2013).

Pakistan is considered as the host to one of the largest population of Muslims in the world, and the lives of its population generally fulcrum around religious practices and spirituality. Consequently, clinical psychologists have to address various spiritual themes in therapy frequently (Charania & Hagerty, 2016), thus, there is a dire need to explore various facets of spiritual well-being to equip the mental health professionals to deal with such issues more adequately, as spiritual wellness acts as a major contributor to happiness in many cultures (Feizi, Nasiri, Bahadori, HosseiniAmiri, & Mirhosseini, 2020). In view of the mentioned literature, this study was conducted to explore how the socio-demographic variables and the spiritual well-being differentially predict patients with generalized anxiety disorder (GAD) and general medical conditions (GMC). This study, thus, aimed to draw a comparison between participants with GAD and a clinically controlled group (with no psychopathology) that is, participants with minor GMC in terms of their socio-demographics that predicted spiritual well-being. This would provide direction and empower clinicians with insights around how to acknowledge and address these issues in the course of psychotherapy.

Hypotheses

The following hypotheses were formulated:

1.	There will be a positive relationship of age, education, monthly income, being women, subjective rating of religiosity with spiritual well-being.
2.	Female participants will score higher on spiritual well-being than male participants with GAD.

METHOD

Sample
The sample comprised of 90 participants, including patients with GAD (n = 40), and those with GMC (n = 50). Their age ranged between 18 to 58 years (M = 30.55, SD = 11.22) and minimum education was five years. Purposive sampling was used for the selection of participants and the data were collected from the outpatient departments of psychiatry and medicine of four public sector tertiary care hospitals of Lahore; namely, Mayo Hospital, Services Hospital, Sir Ganga Ram Hospital, and Jinnah Hospital. In the GAD sample, the participants fulfilling the diagnostic criteria of DSM-IV TR for generalized anxiety disorder were included. For participants with GMC, the patients with extreme general medical conditions such as cardiac problem, diabetes, and any other disease as well as with any psychological disorder were excluded.

Measures
Demographic information sheet. The demographic information sheet was devised for the present study in order to seek the sociodemographic information of the participants. It was comprised of variables such as gender, age, education, occupation, marital status, number of children, religion, birth order, number of siblings, monthly income, family system, presenting complaints, and duration of illness. It also included the subjective rating of religious inclination taken on a visual analogue scale of 0-10, where 0 indicated no religious inclination, 5 indicated average religious inclination, while 10 reflected strong religious inclination.

Spiritual Wellness Inventory. This inventory was originally developed by Ingersoll (1998) and translated into Urdu language by Gohar (2005). The inventory consisted of 65 items and 13 subscales including Conception of Divinity, Concept of Hereafter, Connectedness, Spiritual Freedom, Meaning, Altruism, Present-centeredness, Forgiveness, Knowledge/learning, Conscientiousness, Mystery, Rituals, and Hope. The items were scored on a 4-point Likert Scale ranging from 0 = strongly disagree to 3 = strongly agree. Gohar (2005) reported adequate discriminant validity (r = -.63) and convergent validity (r = .97) of the inventory. In the present study, the Cronbach’s alpha reliability of .70 was found for the total scale.

PROCEDURE

The data were collected from psychiatry and medical outpatient departments of four tertiary care hospitals in Lahore. The patients with GAD were referred by the senior clinical psychologist, while the GMC patients were referred by the physician in the outpatient departments of psychiatry and medicine respectively. Initially, the demographic questionnaire was administered, and mental state examination conducted. Then for the confirmation of diagnosis, interview according to the diagnostic criteria of DSM IV TR was conducted and the subjective ratings from participants with GAD were obtained on each criterion. The subjective ratings on each criterion gave intensity of symptoms. In this research the Cronbach’s alpha reliability of ratings was .76. In addition, Mental State Examination (Gelder, Gath, Mayou, & Cowen, 1987) of each participant of both independent populations was done to rule out any co-morbid psychiatric disorder. It is perhaps worthwhile to mention here that using a demographic questionnaire, assessing the intensity of religiosity and other symptoms on a visual analogue scale, as well as conducting mental state examination of patients presenting in psychiatry outdoors constitute a part of routine informal assessment in most psychiatric care facilities (Klimek et al., 2017). In the end, Spiritual Wellness Inventory was administered. The total duration comprising the informal and formal assessment was about 50-60 minutes per participant. Regarding ethical considerations, written informed consent was taken from the participants and confidentiality was assured. Moreover, they were informed that they would not be given any monitory compensation, however, they would be offered free counseling services at Services Hospital, Lahore, Pakistan in case they became distressed in the course of their interviews.

RESULTS

Pearson Product Moment was performed to examine the relationships among study variables. Linear regression analysis was used to determine the predictive role of sociodemographic variables with spiritual well-being among participants.

Table 1:	Mean, Standard Deviations and Inter Scale Correlations of Spiritual Well-being Inventory for Participants with GAD and GMC (N = 90)
Note. Correlations for participants with GAD (n = 40) shown above the diagonal, and for participants with GMC (n = 50) are shown below the diagonal. *p < .05. **p < .01

Table 1 shows in GAD (n = 40) group, mystery is positively related with age and negatively related with gender. Ritual is positively related to age and negatively associated with education; while, hope is negatively associated with gender and conscientiousness is positively associated with age. Religious inclination is negatively related with spiritual freedom while positively with hereafter. The total score of spiritual well-being is positively related with age. Most of the subscales of spiritual wellbeing are positively related to each other. On the other hand, in GMC (n = 50) group, education is positively associated with connectedness and gender is positively associated with ritual and knowledge. In addition, monthly income is positively associated with education and negatively associated with gender. Religious inclination is positively related with the hereafter. Similarly, as observed in the GAD group, most of the subscales of spiritual wellbeing scale are related to each other. However, only in case of spiritual freedom and altruism, a negative association emerged with knowledge and mystery respectively.

Linear Regression analysis enter method is tabulated for socio-demographic variables which shows significant correlation with subscales of spiritual well-being. Only those analyses are reported where a significant model emerged for either of the groups.

Table 2:	Age as Predictor of Total Spiritual Well-being Score in GAD Group (N = 40)

Table 2 shows that the model is significant indicating that age is positively predicting total score of spiritual well-being in participants with GAD. The Model was able to account for 14% of the variance in total score of spiritual well-being.

Findings in Table 3 show that for concept of hereafter, religious inclination is the positive predictor for participants with GAD and the model accounts for 11% of the variance in belief in hereafter. For mystery, being man is positively predicting mystery in participants with GAD. The Model is able to account for 19% of the variance in mystery. The above results indicate that the model is significant (p < .05). It is found that age is positively predicting conscientiousness in participants with GAD. The model is able to account for 10% of the variance in conscientiousness.

Table 3:	Demographic Predictors for the Subscales of Spiritual Well-being in GAD Group (N = 40)
*p < .05. **p < .01. ***p < .00

Results presented in Table 4 indicate that the model is significant (p < .01). It is found that being women is positively predicting rituals in participants with GMC. The Model is able to account for 9% of the variance in belief in participation in rituals.

Table 4:	Gender as Predictor of Ritual in GMC Group (N = 50)

The results reveal that there are nonsignificant gender differences on dimensions of spiritual wellbeing among people experiencing GAD. In the GMC group, women scored significantly higher on ritual subscale of spiritual wellbeing scale than men. Nonsignificant differences are found on all other subscales of spiritual wellbeing.

DISCUSSION

The purpose of current study was to examine the predictive role of various sociodemographic variables for spiritual well-being among participants with GAD and those with minor GMC. Empirical evidence suggests that various dimensions of spirituality have implications in lowering the symptoms of psychological problems (Kirkpatrick & Shaver, 1992; Koenig & Larson, 2001; Rosmarin, Pargament, Pirutinsky, & Mahoney, 2010; Shaw, Joseprh, & Linley, 2005) and lead to positive mental health outcomes (Mousavimughadam & Delpisheh, 2012; Shah et al., 2011; Weisman et al., 2010). However, there is limited literature available about how various sociodemographic variables relate with dimensions of spiritual wellbeing among people experiencing a psychological disorder and those without it.

The first hypothesis of the study explored the positive correlation between the different dimensions of spiritual well-being and socio-demographic variables in GAD and GMC groups. The hypothesis was partially supported. The results revealed that most of the subscales of spiritual wellbeing shared positive relationship amongst them, which is supported by literature as well and endorses the construct validity of the questionnaire for Pakistani population. However, in GMC group, it was found that altruism and forgiveness is negatively related to mystery and spiritual freedom to knowledge. This raises some concerns about the cultural relevance of these subscales and how they are defined and relate with the construct of spiritual well-being. However, since the data of the current study is relatively small, therefore such an assertion can be tested in future research.

In the GMC group, amongst the socio-demographic variables, education was positively related with connectedness as well as with monthly income while religious inclination with the concept of hereafter. There is evidence which supports that greater levels of education is associated with better financial standing, Moreover, people who acquire higher education, have greater chances of getting high paid jobs (Baker, 2014). Furthermore, there is mixed evidence in literature about how education relates with faith. Islam places great emphasis on education and suggests that it can help individuals to seek better understanding about their relationship with God and hence, might relate to higher connectedness. The concept of hereafter is central to the faith of most religions (Stark & Bainbridge, 1996) and a Muslim with a higher belief in the concept of hereafter is likely to report higher levels of subjective inclination towards religion as it corresponds to their basic belief system. This is also consistent with literature, which suggests that self-rated inclination is related with higher levels of spirituality (Taylor, Chatters, & Jackson, 2009).

In GAD group ritual was positively related with age while negatively with education. The unconventional concept of spirituality, which is seen in some conceptualizations, can be a reason why rituals and education share negative correlation. People who are more educated might be favoring more western based formulation of spirituality (Koenig et al., 2001), and therefore, more oriented towards not observing the ritualized religious practices. However, with increasing age people become more sensitized towards religious practices and tend to follow them more routinely (Bengtson, Silverstein, Putney, & Harris, 2015). Further, being women was seen to be negatively related with monthly income while positively related with rituals and education. This is also backed by the literature as women even with greater education are either nonworking or generally underpaid in comparison to men as explained by the gender wage gap (Virginija, 2006). In addition, the practicing of religious rituals is also more commonly observed by women than men. This finding is also reflected in the results of t-test. This is consistent with literature, Zhang (2010) in his study also found that women are involved in religious activities more than men. The independent sample t-test for participants with GAD did not reveal any significant gender difference with respect to spiritual well-being and its dimensions. This suggests that women and men don’t vary in their ritualistic tendencies when undergoing a psychological problem. Furthermore, it was found that religious inclination was positively related with spiritual freedom. This can be explained in the light of the assertion made in the preceding paragraph about subjective rating being linked with higher levels of spirituality (Taylor et al., 2009).

The results of regression analysis for the GAD group revealed that the religious inclination is a positive predictor of belief in hereafter. As stated earlier the concept of hereafter is central to the values of Islam and it is only natural then that the people with greater religious inclination are likely to endorse stronger belief in the hereafter as well. In Islamic perspective anxiety is a sign that an individual has trespassed any moral limits and has a blockade at the level of soul which can thus provide a chance for repentance and correction (Rothman & Coyle, 2020). Therefore, the anxiety vulnerability of people with GAD might be making them more religiously inclined and endorsing their faith in the basic premises of Islam per se. The notion that people seeking help for psychological issues hold religion as important (Gladding & Crockett, 2018; Pargament, 1997), has further received impetus from this finding. These findings are consistent with Muslim’s belief that their virtues and good deeds will be rewarded in this world as well as in life of hereafter. Furthermore, regression analysis revealed that being man predicted mystery for GAD group. Although, mystery is seen as the ability to handle the uncertainties of life and GAD is considered a disorder where people are unable to deal or tolerate the uncertainties, however, even in this group it seems that men are better able to handle uncertain situations than women. Hunt et al. (2003) also found this trend of women reporting greater worrying symptoms than men. This can have implications for the prognostic factors when dealing with GAD patients, however future research would help to better elucidate these findings, since the current sample size was small.

Increasing age is a positive predictor of both conscientiousness and total score of spiritual well-being in GAD group. As age progresses people get better insights into the vicissitudes and the inherent coping mechanisms, spatiality being one of them (Beyon, Gerard, & Nancy, 2014). The findings of this study are also consistent with Ai’s (2000) proposition that the aged people tend to have more need of spiritual growth on account of their experienced difficulties, poor health and limited available resources as well as anticipating death threat. Hence, in old age the spiritual well-being enables the old people to reconstruct a new meaning of their life. The findings direct that spiritual interventions can be more effective for people with advancing age. Furthermore, the result of t-test showed that women in GMC group utilize religious rituals more than men. Being woman also emerged as significant predictor for performing rituals. These finding are consistent with the previous literature as Zhang (2010) in his study also found that women involved in religious activities more than men.

LIMITATIONS AND SUGGESTIONS

The research used a relatively small sample due to time constraints so the future research should include larger sample in order to make results more generalizable. Although, the current research provides rudimentary evidence about the pattern of spiritual wellbeing in GMC and GAD conditions, there is still room to evaluate these constructs in greater depth and detail. The dimensions of spiritual wellbeing can be studied in greater details as they are conceived as multidimensional constructs and may not be fully understood as to how and through what psychological mechanism they are differentially predicting GAD from GMC.

IMPLICATIONS

In the light of these findings, therapeutic intervention can be designed to help the patients suffering from GAD to deal effectively with their problems. The study will also help to deepen the understanding of the mental health experts about the relationship of spirituality and anxiety, enabling them to target specific aspects of spirituality in intervention program. As spirituality is essential for the holistic conceptualization of patients with psychopathologies therefore, Shah et al. (2011) proposed that clinicians should consider the spiritual status of patients as well as its meaning in their lives as it helps them to deal with the life sufferings more effectively. Cognitive restructuring based on the Islamic precepts can help provide indigenous intervention to the local Muslim population. These findings can also help to design preventive programs such as awareness campaigns for sensitizing the general population about the effect of certain domains of spirituality on anxiety.

CONCLUSION

The present research has highlighted that the pattern of spirituality differs in anxious and non-anxious group and thus points towards the need to address spiritual issues in counseling and psychotherapy. The research has outlined important demographic predictors which can be taken in consideration while planning or dispensing psychotherapy.

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