Health, Spirituality and Medical Ethics

 

Introduction

T

he diagnostic and statistical manual of mental disorders (fifth edition) defines social anxiety disorder as marked or severe anxiety or fear of social situations in which individuals are being watched or monitored by others. When faced with social situations, these individuals are terrified to be negatively evaluated by others as well as be judged as anxious, weak, ignorant, tedious, and non-friendly people (1).




Social anxiety disorder is one of the most common psychological diseases and the third most common psychiatric disorder in the general population (2). Social anxiety has severe negative effects on mental, physical and social health, as well as the quality of life and performance of the patients. This disorder leads to considerable disabilities, thereby reducing levels of meaningfulness and purposefulness in daily life (3).
Generally, people who panic recall irritating thoughts in their minds. These thoughts form personal beliefs and people believes in and live with them (4). Mind and personal belief management is a kind of caring for and awareness of our personal activities towards growth and excellence. In other words, one can use mind power to do the right things and improve the situations in critical circumstances.
People usually tend to think about the past and future and let these thoughts ruin their mind power and abilities. These thoughts are the origin of many anxieties and concerns in any human being (5). In this regard, Shipherd and Salter indicated a significant relationship between ineffective personal beliefs and post-traumatic anxiety (6). In general, ineffective personal beliefs are the main causes of many social conflicts, anxieties, depressions, and unpleasant as well as negative emotional experiences (7).
Spirituality is one of the variables that has been recognized as an effective factor in anxiety and depression (8). Spiritual intelligence is considered as a four-dimensional component. For instance, some believe that spiritual intelligence includes critical thinking, personal meaning and purpose, transcendental consciousness, and expansion of consciousness (9).
King defines spiritual intelligence as a set of psychological compatibility capabilities based on the intangible and transcendental aspects of the reality, especially those which are related to the nature of individual's being, personal meaning, transcendence, and higher levels of consciousness.
These capabilities facilitate the process of problem-solving, abstract thinking, and coping with challenges in routine activates (10,11). In a study conducted by Ebadi and Mousavi, a significant relationship was revealed between spiritual intelligence and anxiety among youth in Izeh, Iran (12).
Moreover, Bakhshande and Jadidi showed that spiritual intelligence can predict anxiety. In other words, people with high spiritual intelligence experience lower levels of anxiety (13). In the same line, research findings proved that spiritual intelligence component training significantly reduced the anxiety among Quran teachers and tutors (14).
Furthermore, Anxiety has detrimental effects on students' educational achievement at university as well as their mental health and their future job performance. Currently, there are 15 million adolescent and young people living in this country who are recognized as the dynamic force in society. Accordingly, it is advisable to pay special attention to the problems of these individuals since they are precious human capital in each country. Therefore, the negligence of youth priorities and demands causes irreparable damages (15).
Given the importance of social anxiety, the leading role of personal beliefs and spiritual intelligence, as well as a dearth of research in this regard, there is a need to conduct research in this domain. Therefore, the present study aimed to evaluate the role of spiritual intelligence and personal beliefs in social anxiety among university students at Azad University, Ferdows Branch, South Khorasan, Iran.
Methods
The population of this analytical cross-sectional study included all students at Faculty of Psychology and Educational Sciences affiliated to Azad University, Ferdows Branch, South Khorasan, Iran, from 2017 to 2018. In correlational studies, the sample size is considered at least 100 people (16). Therefore, in this study, 300 subjects were enrolled through stratified random sampling based on Morgan's table. A total of 300 participants were selected among the students who were admitted to the university in the academic years 2015 (n=100), 2016 (n=100), and 2017 (n=100). Data were analyzed using descriptive statistics, such as mean±SD, and inferential statistics, including Pearson correlation and multiple regression.
The data were collected utilizing the following tools:
King's Spiritual Intelligence Scale: This questionnaire was developed by King and includes 24 questions that measure spiritual intelligence using a 5-point Likert scale (0=Neutral, 1=Not true, 2=Fairly true, 3=Very true, 4=Perfectly true). Moreover, it has four subscales, including existential critical thinking (questions 1,3,5,9,13,17,21), personal meaning and purpose (questions 7,11,15,19,23), transcendental consciousness (questions 2,6,10,14,20,22), and expansion of consciousness (questions 4,8,12,16,24) (10). According to Cronbach's alpha and split-half formula (Spearman-Brown), the reliability of this scale was obtained at 0.92 and 0.91, respectively.
The validity of existential critical thinking, personal meaning and purpose, transcendental consciousness, and the expansion of consciousness according to Cronbach's alpha was obtained at 0.78, 0.78, 0.87, and 0.91, respectively (17). Moreover, in a study conducted by Raghib et al., the reliability of this scale was estimated to be 0.88 using Cronbach's alpha coefficient (18).
The face and content validity of this scale were confirmed by experts in psychology. To estimate the convergent validity, Ghobaribonab's spiritual experience questionnaire was used simultaneously. In addition, the correlation coefficients of these two questionnaires were obtained at 0.66. The exploratory factor analysis and first-order confirmation factor analysis were used to calculate the construct validity of the scale. The validity of King's spiritual intelligence scale was also confirmed in the present study and was obtained at 0.89 through Cronbach's alpha internal consistency.
 Personal Beliefs Scale: Personal beliefs assessment questionnaire has been developed and compiled by Ellis (19). This questionnaire consists of 50 questions and aims to assess individual personal beliefs. The scoring is based on a 6-point Likert scale from 1=strongly agree to 6=strongly disagree (19). In a study carried out by Hashemi Barzabadi (20), the content validity of this questionnaire was confirmed by professors at Ferdowsi University. Moreover, its reliability is estimated to be 0.90% according to Cronbach's alpha coefficient. It should be noted that the validity of personal beliefs scale was 0.89 in this study through Cronbach's alpha internal consistency.
Social Anxiety Scale: This scale has been developed by Connor et al. to evaluate social anxiety. This tool is a self-assessment questionnaire including 17 items with three subscales of fear (questions 1-3-5-10-14-15), avoidance (questions 4-6-8-9-11-12-16) and physiological disturbances (questions 2-7-13-17). Each item is scored based on a 5-point Likert scale from 0=Never to 4=Extremely (21). The test-retest reliability of this scale has been reported from 0.78 to 0.89 in people suffering from a social anxiety disorder. Connor et al. estimated the internal consistency of this scale at 0.94 in normal groups for the whole scale (21).
In a study conducted by Hassanvand Amouzadeh et al. in Iran, the internal consistency values of this scale with a non-clinical study at the first and second halves of the test were reported at 0.82, and 0.86, respectively. Moreover, the correlation coefficient of the first and second halves of the test and the Spearman-Brown correlation coefficient were 0.76 and 0.91, respectively. Moreover, the internal consistency regarding the subscales of fear, avoidance, and physiological discomfort was determined at 0.74, 0.75, and 0.75, respectively (22). The validity of the social anxiety scale was also confirmed in the present study and obtained at 0.78 through Cronbach's alpha internal consistency.
The participants in this study were all informed of the research procedure, voluntary participation in completing the questionnaires, the anonymity of the questionnaires, the confidentiality of data, and the right to withdraw from participation. Moreover, written informed consent was obtained from all participants.
Result
According to the results of the present study, out of 300 subjects, 45% (135 students) of the participants were male and 60.66% (182 students) of the cases were married. Moreover, 62, 70, and 112 participants were within the age range of 18-20, 21-25, and 26-

Table 1: Matrix of correlation coefficients between spiritual intelligence and personal beliefs with social anxiety
	Mean ±SD	1	2	3	4	5	6	7
1. Existential Critical Thinking	19.21±3.15	1	*0.456	*0.557	*0.178	*0.771	*-0.249	*-0.501
2. personal meaning and purpose	15.79±2.86		1	*0.474	*0.212	*0.756	*-0.331	*-0.489
3. Transcendental consciousness	17.36±2.94			1	*0.207	*0.748	*-0.149	*-0.535
4. Expansion of consciousness	18.09±3.10				1	*0.547	*-0.356	*-0.317
5. Spiritual Intelligence (total score)	70.45±8.22					1	*-0.388	*-0.651
6. Irrational personal beliefs	84.93±11.37						1	*0.335
7. Social anxiety	38.54±6.71							1

30 years old, respectively. Furthermore, 30 participants were over 30 years old. Regarding the educational status, 72% (216 students) of the cases were postgraduate students, whereas 28% (84 students) of them were undergraduate students. Table 1 summarizes the descriptive findings and correlation coefficient of the research variables.
The results of the correlation coefficient matrix between spiritual intelligence and personal beliefs with social anxiety showed a negative correlation between spiritual intelligence and its components with social anxiety. Consequently, it indicates an indirect correlation among these variables. Accordingly, it can be concluded that individuals with higher spiritual intelligence had lower social anxiety. Furthermore, there was a positive association between irrational personal beliefs and social anxiety indicating a direct correlation between these two variables. Therefore, individuals who obtained higher scores of irrational personal beliefs had higher levels of social anxiety. Additionally, multiple regression tests were used to predict social anxiety through spiritual intelligence components and personal beliefs.

Table 2: Multiple regression analysis of spiritual intelligence components to predict social anxiety
Model	B	Standard error	Standardized beta	T	p-value	R squared	F value	P value
Fixed	32.134	3.180		10.105	0.001	0.429	55.478	0.01
Existential Critical Thinking	-0.606	0.166	-0.201	-3.646	0.001
Personal meaning and purpose	-0.637	0.158	-0.211	-4.031	0.001
Transcendental consciousness	-0.925	0.171	-0.301	-5.421	0.001
Expansion of consciousness	-0.581	0.129	-0.204	-4.508	0.001

The results of multiple regression analysis showed multiple correlation coefficient between independent and dependent variables at 0.655. Moreover, the coefficient of determination (R squared) was determined at 0.429 which indicates that components of spiritual intelligence determine 42.9% of social anxiety variance (Existential critical thinking: P<0.01, β=-0.201, Personal meaning and purpose: P <0.01, β=-0.211, Transcendental consciousness: P<0.01, β=-0.301), Expansion of consciousness: P<0.01, β=-0.204).
Therefore, some of the components of spiritual intelligence, such as existential critical thinking, personal meaning and purpose, and transcendental consciousness inversely predict social anxiety. In other words, the higher the levels of these components, the lower the levels of social anxiety.
Discussion
Social anxiety is an emotional state characterized by specific and constant concern and fear of being negatively judged in social situations. Therefore, the present study aimed to evaluate the role of spiritual intelligence and personal beliefs in social anxiety among university students at Azad University, Ferdows Branch, South Khorasan, Iran.
The results primarily showed an inverse and significant relationship between spiritual intelligence and its components with social anxiety among university students. Moreover, spiritual intelligence negatively predicted social anxiety in students. Accordingly, an increase in spiritual intelligence leads to decreasing levels of social anxiety among university students.
The results of this study are consistent with the findings of studies conducted by Khorrami et al., Bayrami et al., Asgari et al., and Mahbobi et al. (23-26). Khorrami et al. conducted a study on nursing and midwifery students at Qom University of Medical Sciences, Qom, Iran. Their results showed an inverse and significant relationship between test anxiety and the total spiritual intelligence score.
Moreover, among the components of spiritual intelligence, the level of self-awareness, interest in and act based on moral issues had the most significant effect on test anxiety (24).In another study conducted by Bayrami et al., it was revealed that spiritual intelligence had a significant negative correlation with perceived stress, anxiety, and depression (25).
In a study carried out by Asgari et al, a significant relationship was observed between spiritual intelligence and existential anxiety among students at Azad University, Ahwaz Branch, Ahwaz, Iran. Accordingly, spiritual beliefs helped individuals to find coping strategies to deal with adversities, psychological pressure, and inevitable losses in life. Therefore, the students will be hopeful and optimistic towards the existence of life after death which is full of peace. Furthermore, participating in religious activities provides people with social support, and individuals who have a spiritual life often lead a healthier lifestyle (25).
A study by Mahbobi et al. proved that the strengthening of the spiritual health can control social anxiety in chemical warfare veterans since it acts as a strong power on physical, psychological and social health (26). Social anxiety disorder is a disabling disorder that affects a high percentage of the population. Accordingly, a socially anxious person focus on his.her feelings and how to deal with others instead of focusing on the social situation. These people have negative perceptions about themselves which makes the social world more threatening (27). Furthermore, research shows that spiritual intelligence has a negative and positive relationship with neurosis and extroversion, respectively (28). In this regard, spirituality makes spiritual beliefs active and inner leading to the higher levels of self-esteem and health in individuals (29).
Spiritual intelligence also forms meaning in life. Individuals who have meaning and purpose in life will cope with critical situations better which enable them to experience less mental disturbances (30). Individuals with spiritual beliefs can change their thoughts and behaviors into positive ones and effectively deal with problems in undesirable circumstances. Moreover, when a person needs a counselor's help to deal with stress, spiritual intelligence can help him.her find meaning in stressful situations. This can be described as an attempt to find meaning in stressful situations (31).
The results indicated a direct and significant relationship between irrational personal beliefs and social anxiety among students. Accordingly, those with higher scores in irrational personal beliefs had higher levels of social anxiety. Additionally, personal beliefs can explain the changes related to social anxiety. It can be argued that an increase in irrational personal beliefs leads to increasing levels of social anxiety.
The results of the present study are in line with the findings of studies performed by Shipherd and Salters, George et al., Ellis, and Hamidi as well as Hosseini (6,7,32,33). The results of a study conducted by George et al. proved that changes in maladaptive beliefs predicted the changes in the severity of the social anxiety symptoms (32). Another study by Hamidi and Hosseini indicated an inverse correlation between personal beliefs and compatibility components, such as general, social, emotional, and educational ones (33).
Considering the ability of personal beliefs to predict social anxiety using cognitive and metacognitive theories regarding the pathology of social anxiety, it is important to note the significance of bias and its role in the negative assessment of the events as the main reason leading to social anxiety.
It can be said that the bias in interpreting social situations leads to the creation of wrong assumptions about people and the social environment. This results in the activation of inefficient self-regulation strategies and the negative assessment of the social situations (22).
In other words, socially anxious people with negative irrational beliefs interpret new situations as threatening ones; therefore, they prefer isolation rather than participating in social situations. For instance, this negative belief "I have no control over my thoughts" is consistent with the ability of an individual to ignore adaptive thinking style. In addition, negative beliefs, such as " these thoughts make me lose control of my mind" exacerbates the fixed attention in current situations (34). In this regard, the cognitive approach to social anxiety considers irrational and maladaptive beliefs as a factor towards anxiety in new situations. This anxiety provokes avoidable behaviors in a defective cycle that results in the persistence of ineffective beliefs (35).
Conclusion
The results of this study showed that spiritual intelligence and personal beliefs had a significant effect on managing social anxiety. One of the limitations of this study was the cross-sectional nature of the research and the utilization of a self-reporting instrument. Based on the findings of this study and the relationship between spiritual intelligence and social anxiety, it is recommended that university officials and other educational institutions plan and provide appropriate educational services to promote the spiritual intelligence among students. It is also suggested that educational workshops be held to promote health and reduce anxiety among students. These workshops can employ interventions based on the improvement of the spiritual intelligence and changing the ineffective personal beliefs with cognitive-behavioral approaches. Finally, in order to improve the generalizability of the results, it is suggested to examine the effects of other psychological variables, such as maladaptive schemas and emotion adjustment strategies that may affect the results. Moreover, gender differences should be considered in future studies.
Conflict of interest
The authors state that there is no conflict of interest regarding the publication of this study.
Acknowledgements
The authors would like to thank all the students at Azad University, Ferdows Branch, South Khorasan, Iran, for their cooperation in this study. In addition, there is no conflict of interest among the authors. This study is extracted from an independent research project with no finical support. The study protocol was approved by the Ethics Committee on Biomedical Research of Shahid Beheshti University of Medical Sciences, Tehran, Iran on 29.7. 2018.
 References

1. American Psychiatric Association. Diagnostic and Statistical Manual of DSM-5 Psychiatric Disorders. Rezaei F, Fakhraei A, Fermand A, Niloufari A, Hashemi Azar J, Shamlou F, translator. Tehran: Arjmand; 2015. [Persian] [Link]
2. Moitra E, Herbert JD, Forman EM. Behavioral avoidance mediates the relationship between anxiety and depressive symptoms among social anxiety disorder patients. J Anxiety Disord. 2008;22(7):1205-13. [Link]
3. Beidel DC, Alfano CA. Child anxiety disorders: A guide to research and treatment. Taylor & Francis; 2011. [Link]
4. Parsa M. New general psychology. Tehran: Besat; 2009. [Link]
5. Eskandari H. The Survey of Veterans’ Depression and Anxiety and its Relationship with Veterans’ Social-Economic Activities. J Milit Med. 2015;16(4):197-203. [Persian] [Link]
6. Shipherd JC, Salters-Pedneault K. Do acceptance and mindfulness moderate the relationship between maladaptive beliefs and posttraumatic distress? Psychol Trauma. 2018;10(1):95-102. [Link]
7. Ellis A. New directions for rational emotive behavior therapy: Overcoming destructive beliefs, feelings, and behaviors. New York, NY: Prometheus; 2001. [Link]
8. Michael SY, Luckhaupt SE, Mrus JM, Mueller CV, Peterman AH, Puchalski CM, et al. Religion, spirituality, and depressive symptoms in primary care house officers. Ambul Pediatr. 2006;6(2):84-90. [Link]
9. Abedini Y, Brat Dastjerdi N. [The relation between religiosity and spiritual intelligence and their effect on students' academic achievement (Persian). New Educ Approaches. 2014;9(1):37-52. [Persian] [Link]
10.  King DB. Rethinking claims of spiritual intelligence: A definition, model, & measure (MA thesis). Peterborough, Ontario: Trent University; 2008. [Link]
11.  Alavi S. [The relationship between spiritual intelligence and attitude to love and orientation to the relationship before marriage in Isfahan Industrial University (Persian). [MA thesis]. Isfahan: Islamic Azad University; 2011. [Persian] [Link]
12.  Ebadi Z, Mousavi S. The Relationship between Spiritual Intelligence and Youth Anxiety. The 8th International Conference on Psychology and Social Sciences: 2017; Tehran. [Persian] [Link]
13.  Bakhshande M, Jalali M. The Relationship between Spiritual Intelligence and Anxiety. The 5th International Conference on Psychology and Social Sciences: 2016; Tehran. [Persian] [Link]
14.  Isfahani AN, Nobakht M. Impact of spiritual intelligence on the staff happiness (case study: Golpayegan Petrochemical Company). Int J Acad Res Bus Soc Sci. 2013;3(7):253. [Link]
15.  Akbari J, Agha-mohamadian H, Ghanbari-Hashemabadi B. Effect of cognitive behavioral therapy and pharmacotherapy on anxiety and impulsivity symptoms in men with borderline personality disorder. Fund Ment Health. 2009;10(40):317-23. [Persian] [Link]
16.  Delaware A. Research Methods in Psychology and Educational Sciences. Tehran: Virayesh; 2014. [Persian] [Link]
17.  Shafiee Taba M. The Relationship between Mindfulness Knowledge with Depression, Anxiety and Stress in Students. The First International Conference on Psychology and Educational Sciences: Shiraz; 2015. [Persian] [Link]
18.  Raghib M, Siadat S, Hakiminya B, Ahmadi S. Validation of King's Spiritual Intelligence (SISRI-24) Scale in University Students of Isfahan University. J psychol Achiv. 2010;17(1):141-64. [Persian] [Link]
19.  Ellis A. Humanistic psychotherapy: The rational-emotive approach. Three Rivers Press; 1973. [Link]
20.  Hashemi Brazabadi H. The Relationship between Emotional Intelligence and Irrational Thinking in Ferdowsi University Students in Mashhad [Master's thesis]. Mashhad: Ferdowsi University of Mashhad; 2008. [Persian] [Link]
21.  Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, Foa E. Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale. Br J Psychiatry. 2000;176(4):379-86. [Link]
22.  Hassanvand Amouzadeh M, Hassanvand Amouzadeh A, Ghadampour M. The Prediction of Social Anxiety Symptoms (Fear, Avoidance, Physiological Arousal) on the Basis of Early Maladaptive Dchemas. Mod Psycholl Res. 2013;8(32):89-110. [Persian] [Link]
23.  Khoramirad A, Arsangjang S, Ahmaritehran H, Dehghani H. The Relation between Spiritual Intelligence and Test Anxiety among Nursing and Midwifery Students: Application of Path Analysis. Iran J Med Educ. 2013;13(4):319-30. [Persian] [Link]
24.  Bayrami M, Movahedi Y, Movahedi M. The Role of Spiritual Intelligence in Perceived Stress, Anxiety and Depression of Lorestan Medical University Students (Iran). J Babol Univ Med Sci. 2014;16(1):56-62. [Persian] [Link]
25.  Asgari M, Heidari A, Asgari P. The relationship between spiritual intelligence and religious orientation with psychological well-being and existential anxiety in students. Res Educ System. 2016;9(31):163-90. [Persian] [Link]
26.  Mahbobi M, Etemadi M, Khorasani E, Ghiasi M. The Relationship between Spiritual Health and Social Anxiety in Chemical Veterans. J Mil Med. 2012;14(3):186-91. [Persian] [Link]
27.  Mohammadi A, Zargar F, Omidi A, Bagherian Sararoudi R. Etiological models of social anxiety disorder. J Res Behav Sci. 2013;11(1):68-80. [Persian] [Link]
28.  Naderi F, Roshani Kh. The Relationship between Spiritual Intelligence and Social Intelligence and the Death Anxiety of Older Women. Women Cult. 2011;2(6):55-67. [Persian] [Link]
29.  Esmaeili M, Basiri N. Efficacy Spirituality Therapy and Meta-Cognitive Therapy on the Psychological Well-being of Veterans and Martyrs’ Daughter. J Psychol. 2017;21(3):269-83. [Persian] [Link]
30.  Agishtein P. I Shall Not Fear": Secure Attachment to G-d as a Buffer against Anxiety. City University of New York; 2015. [Link]
31.  Mabe PA, Josephson AM. Child and adolescent psychopathology: spiritual and religious perspectives. Child Adolesc Psychiatr Clin N Am. 2004;13(1):111-25, vii-viii. [Link]
32.  Gregory B, Wong QJ, Marker CD, Peters L. Maladaptive Self-Beliefs during Cognitive Behavioral Therapy for Social Anxiety Disorder: A Test of Temporal Precedence. Cog Ther Res. 2018;42(3):1-12. [Link]
33.  Hamidi F, Hosseini ZM. The relationship between irrational beliefs and social, emotional and educational adjustment among junior students. Procedia Soc Behav Sci. 2010;5:1631-6. [Link]
34.  Wells A. Emotional disorders and metacognition: Innovative cognitive therapy. John Wiley & Sons; 2002. [Link]
35.  Wells A, Cartwright-Hatton S. A short form of the metacognitions questionnaire: properties of the MCQ-30. Behav Res Ther. 2004;42(4):385-96. [Link]