J Relig Health DOI 10.1007/s10943-014-9927-y ORIGINAL PAPER

Negative Religious Coping Predicts Disordered Eating Pathology Among Orthodox Jewish Adolescent Girls Yael Latzer • Sarah L. Weinberger-Litman • Barbara Gerson • Anna Rosch • Rebecca Mischel • Talia Hinden • Jeffrey Kilstein Judith Silver

•

Ó Springer Science+Business Media New York 2014

Abstract Recent research suggests the importance of exploring religious and spiritual factors in relation to the continuum of disordered eating. This continuum ranges from mild disordered eating behaviors and attitudes to moderate levels of disordered eating pathology (DEP) through full-blown clinical levels of eating disorders (EDs). The current study is the first to explore the role that religious coping (both positive and negative) plays in the development DEP, which is considered a risk factor for the development of EDs. In addition, the study aims to describe levels of DEP among a non-clinical sample of 102 Orthodox Jewish adolescent females. Participants completed a questionnaire measuring religious coping strategies, DEP and self-esteem. Results indicated that greater use of negative religious coping was associated with higher levels of DEP. Mediation analyses suggested that greater negative religious coping is related to lower levels of self-esteem, which accounts for higher levels of DEP. Furthermore, findings revealed relatively lower overall levels of DEP among this sample, compared to similar populations in Israel and the USA. These results suggest that a strong religious and spiritual identity may serve as a protective factor against DEP.

Yael Latzer and Sarah L. Weinberger-Litman have contributed equally to this paper. Y. Latzer Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel Y. Latzer Psychiatric Division, Eating Disorders Clinic, Rambam Medical Center, Haifa, Israel S. L. Weinberger-Litman (&) Department of Psychology, Marymount Manhattan College, 221 E71st St., New York, NY 10021, USA e-mail: [email protected] B. Gerson
A. Rosch
R. Mischel
T. Hinden
J. Kilstein
J. Silver Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, USA

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Keywords Disordered eating pathology
Eating disorders
Adolescents
Religion
Coping
Self-esteem

Introduction The last several decades have seen a dramatic increase in the prevalence of eating disorders (EDs) and related symptoms and behaviors across Westernized nations (Smink et al. 2012; Treasure et al. 2010). These symptoms comprise a continuum ranging from mild disordered eating behaviors and attitudes to moderate levels of disordered eating pathology (DEP) through full-blown clinical levels of eating disorders. EDs are much more prevalent among women than men and usually begin during adolescence or young adulthood (Hudson et al. 2007; Keel and Klump 2003; Treasure et al. 2010). EDs are serious illnesses with a higher mortality rate than any other psychiatric illness (Fairburn and Harrison 2003; Treasure et al. 2010). Additionally, it has been estimated that over 50 % of adolescent girls exhibit some form of disordered eating and body image disturbances (Neumark-Sztainer et al. 2006) which are considered risk factors for the development of full-blown EDs (Treasure et al. 2010). Throughout this paper, the term EDs is used in reference to research relating to clinical samples and the term DEP is used in reference to research with nonclinical samples. The etiology of EDs and DEP is multifaceted and complex, with genetic, familial, personality, sociocultural and psychological variables playing a role in their development and maintenance (Treasure et al. 2010). Among the psychological characteristics associated with EDs are, affective influences, and body dissatisfaction with great emphasis on the underlying role that self-esteem plays (Polivy and Herman 2002). Significant attention is also paid to various sociocultural influences, such as media exposure, thin-ideal internalization and changing cultural norms and gender role expectations (Mensinger et al. 2007; Stice 2002, 2011). Despite limited research, empirical studies have demonstrated that religious and spiritual variables are important sociocultural contributors to the understanding of EDs and related conditions (Richards et al. 2013). Historically, EDs have been connected to religious devotion or practice, and contemporary studies indicate that EDs continue to have religious/spiritual components (Richards et al. 2007, 2013). Religious factors have been examined in both clinical samples of ED patients as well as non-clinical samples (Richards et al. 2013). Among clinical samples, it has been found that religious/spiritual factors can both exacerbate (Marsden et al. 2007) or mitigate ED symptoms (Richards et al. 2009). Among non-clinical samples of varying religious groups, some studies indicated that increased levels of religiosity may serve as a buffer toward the development of DEP (Gluck and Geliebter 2002; Latzer et al. 2007). However, certain studies have found external religious motivation (Weinberger-Litman et al. 2008b) and negative attachment to God (Boyatzis et al. 2007) are associated with increased levels of DEP. These relationships may be of particular importance to explore among Jewish women who historically have an intimate relationship with food as part of their traditional role which includes nurturing and feeding the family (Abusch-Magder 2005; Weinberger-Litman et al. 2011) Although prevalence rates of full-blown EDs appear to be similar among Jewish and non-Jewish adolescent females in Western nations (Latzer et al. 2008), dieting behaviors have been shown to be higher among Jewish Israeli women (Harel et al. 2002).

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In addition, Jewish women are more likely to overestimate body size and weight (Kim 2007). Additionally, Pinhas et al. (2008) found higher rates of DEP among Jewish female adolescents compared to their non-Jewish counterparts in a non-clinical sample. However, these results represent a secular segment of the Jewish community. Therefore, several studies have investigated among Orthodox Jewish women, whether increased levels of religiosity may serve a protective role against DEP. Latzer et al. (2007) found that among modern Orthodox Jewish high school girls in Israel, greater levels of religiosity were associated with lower levels of DEP. Similarly, (Gluck and Geliebter 2002) found that among college students, secular Jewish women had higher rates of DEP than their orthodox Jewish counterparts. A recent study of Jewish high school and college students did not find differences in rates of DEP between Orthodox and non-Orthodox students. However, it was found that individuals with an intrinsic religious orientation (i.e., greater internalization of religious ideals) had lower levels of DEP than those with an extrinsic orientation (i.e. greater social motivation related to religious practice) (Weinberger-Litman 2007; Weinberger-Litman et al. 2008b). In support of these findings, a recent study in Israel (Latzer et al. 2008) among a clinical population of ED patients found lower levels of referral rates among the Orthodox population. One aspect of religious experiences previously not explored in relation to DEP is its possible association with religious coping. It has been well documented that religious coping is a common strategy for dealing with a variety of social, psychological and physical issues (Carpenter et al. 2012; Gall and Guirguis-Younger 2013; Pargament 1997; Pargament et al. 1998, 2000). Religious coping may be particularly relevant in our sample of Orthodox Jewish women, for whom religiosity and spirituality are salient factors, and a group for whom religious struggles have been shown to have unique effects (Rosmarin et al. 2009). Positive religious coping is based on a sense of spirituality and finding meaning, and a secure relationship with God during times of stress (Pargament et al. 2000, 2013). Positive religious coping has been associated with better psychological adjustment, less psychological distress, greater quality of life for those with chronic illness and better adjustment after interpersonal trauma (Bryant-Davis and Wong 2013; Gall and GuirguisYounger 2013; Pargament 1997; Pargament et al. 2000; Pirutinsky et al. 2012). On the other hand, negative religious coping, seen as a sign of religious struggle, is characterized by conflicts relating to spirituality or conflicts with God (Pargament et al. 2000). In addition, it often refers to feeling punished or abandoned by God and has been associated with increased levels of several forms of psychopathology including anxiety, depression, obsessive-compulsiveness and somatization (McConnell et al. 2006), as well as worse overall physical health (Rosmarin et al. 2009). The aim of the current study was to describe the level of DEP among a non-clinical subgroup of Orthodox Jewish adolescent girls and to explore whether religious coping strategies predict levels of DEP among this group. To our knowledge, religious coping has not previously been explored in relation to DEP and related conditions. In addition, we aim to assess the role of self-esteem in the relationship between DEP and religious coping.

Methods Participants Participants were 102 Modern Orthodox Jewish adolescent females between the ages of 17–18, who were seniors in high school or recent high school graduates, in the New York

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metropolitan area. Forty six (45.1 %) attended or had attended a coeducational high school while 56 participants (54.9 %) attended or had attended single-gender female schools. Mean BMI [calculated as (weight in pounds)/(heights in inches)2 9 703] was 22.66 (SD = 3.29) and ranged from 17.10 to 35.14. The BMI for normal weight is between 18.5 and 24.9, indicating that the mean BMI of the sample is within the healthy range. All students indicated they would be spending the following year studying in Israel. In the Modern Orthodox community, studying abroad in Israel in the year following high school graduation is a common practice intended to strengthen one’s connection to Judaism and the Jewish community. Procedure All students were recruited from Modern Orthodox high schools or summer camps. This study was conducted as part of the first phase of a longitudinal study exploring psychological adjustment during the year of study in Israel before beginning college in the US Questionnaires were completed during class sessions and summer camp sessions with only study personnel in attendance. The study was IRB approved, and informed consent was obtained from students that were eighteen. Parental consent and student assent were obtained from students under eighteen. The questionnaire was completely voluntary and anonymous. Questionnaires took approximately 30–40 min to complete. Measures Participants completed several self-report questionnaires in addition to background demographic information, including the eating disorder inventory (EDI) (Garner et al. 1983); Eating Attitudes Test (EAT-26) (Garner and Garfinkel 1979; Garner et al. 1982), the Brief R-COPE (Pargament et al. 2000), and the Rosenberg Self-Esteem Scale (Rosenberg 1979). Eating Disorder Inventory (EDI) The EDI (Garner et al. 1983) is one of the most widely used self-report questionnaires for assessing psychological characteristics related to DEP among Western populations. It is not intended to be used as a diagnostic instrument, but rather provides a profile of certain clusters of symptoms commonly found among individuals with EDs. It consists of eight subscales, and the following were used in the current study: Drive for Thinness, Bulimia, Body Dissatisfaction, Ineffectiveness, Perfectionism, Interpersonal Distrust, Interoceptive Awareness, and Maturity Fears. The EDI contains 64 items, which are scored on a three-point scale. There are six response options, which include ‘‘always,’’ ‘‘usually,’’ ‘‘often,’’ ‘‘sometimes,’’ ‘‘rarely,’’ and never’’. Responses are scored from 0 to 3, with answers of ‘‘never,’’ ‘‘rarely,’’ and ‘‘sometimes’’ assigned a 0 and ‘‘always,’’ ‘‘usually,’’ and ‘‘often,’’ assigned scores of 3, 2, and 1, respectively. Total scores range from 0 to 192, with higher scores indicating more disordered eating pathology. Subscale scores range from 0-30 depending on the number of items in that subscale. Internal consistency as measured by Cronbach’s ranged from .91 to .65 (Garner et al. 1983). In the present study, the Cronbach’s alpha for each subscale was: .89 for Drive for Thinness; .80 for Bulimia; .92 for Body Dissatisfaction; .89 for Ineffectiveness; .56 for Perfectionism; .75 for Interpersonal Distrust; .12 for Interoceptive

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Awareness; .81 for Maturity; and .86 for the total scale. Because reliability was low for the Interoceptive Awareness scale, it was not included in subsequent analyses. Eating Attitudes Test (EAT-26) The Eating Attitude Test (EAT-26) (Garner et al. 1982) is a widely used screening instrument for measuring eating attitudes and DEP in non-clinical populations. The EAT26 consists of 26 items scored on a three-point scale. There are six response options, which include, ‘‘always,’’ ‘‘usually,’’ ‘‘often,’’ ‘‘sometimes,’’ ‘‘rarely,’’ or ‘‘never.’’ Responses are scored from 0 to 3, with answers of ‘‘sometimes,’’ ‘‘rarely,’’ and ‘‘never’’ assigned a 0, and ‘‘always,’’ ‘‘usually,’’ and ‘‘often,’’ assigned scores of 3, 2 and 1, respectively. Subscales include the Dieting, Bulimia and Oral Control subscales. The EAT-26 scores range from 0 to 78 points, with higher scores indicating more DEP. A score of 20 or above indicates a clinically significant level of DEP and is referred to as an EAT-26 ‘‘positive score’’. The EAT-26 has demonstrated high reliability and consistency, initial Cronbach’s alpha, was .90 for the total EAT-26 (Garner et al. 1982). In the current study, Cronbach’s alpha reliability was .87 for the total EAT-26, and .89, .78 and .48 for the Dieting, Bulimia and Oral Control subscales, respectively. Due to the low reliability of the Oral Control subscale, it was not used in subsequent analyses. Brief R-COPE The Brief R-COPE is a 14-item measure of positive and negative religious coping (Pargament et al. 2000), with half the items measuring negative religious coping and the other half measuring positive religious coping. The scale is scored on a 4-point scale asking about the frequency of particular coping strategies ranging from ‘‘not at all’’ (1) to ‘‘a great deal’’ (4). The authors report Cronbach’s alphas of .87 for positive coping and .78 for negative coping. In the current sample, Cronbach’s alpha was .84 and .69 for positive and negative coping, respectively. Rosenberg Self-Esteem Scale The Rosenberg Self-Esteem Scale, (Rosenberg 1979) is a widely used measure designed to assess global feelings of self-worth and self-esteem. The scale includes ten items rated on a four-point scale ranging from strongly agree (1) to strongly disagree (4). The Rosenberg Self-Esteem Scale has Cronbach’s alphas range from .73 to .85 (Corning et al. 2006; Hawkins et al. 2004). Cronbach’s alpha in the current study was .85. Statistical Analyses Independent samples t tests were used in order to compare levels of DEP as well as BMI and self-esteem between participants that attended coed versus single-gender schools. Pearson’s correlations were conducted between all variables measuring DEP, self-esteem and positive and negative religious coping. Regression analyses were conducted on significant correlations using negative religious coping as a predictor of DEP. Body mass index was included as a covariate in all analyses. A second set of analyses also included self-esteem as a mediator of the association between negative religious coping and DEP.

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Results Disordered Eating Pathology and Gender Composition Comparisons: Descriptive Statistics In order to examine differences between participants attending coed versus single-gender schools, independent samples t tests were used to compare level of DEP, BMI, self-esteem and religious coping. No significant differences were found between groups among any variable measuring DEP, BMI or self-esteem (all p values [.05). The only significant difference was seen among positive religious coping, with participants from all-girls schools, exhibiting higher levels of positive religious coping than their coed counterparts [t (97) = -3.80, p \ .001]. Table 1 presents means and standard deviations for the EDI Total and subscales and EAT-26 Total and subscales, as well as the percentage of those with an EAT-26 positive score. Correlations Pearson’s correlations were conducted between DEP variables, religious coping variables and self-esteem. Significant correlations were found between negative religious coping and the Bulimia subscale of the EAT-26 (r = .22, p \ .05), and the Drive for Thinness (r = .23, p \ .05), Ineffectiveness (p .24, \ .05), and Maturity (r = .25, p \ .05) subscales of the EDI, as well as the Total EDI (r = .28, p \ .01), indicating that higher levels of negative religious coping are associated with higher levels of DEP. Additionally, significant correlations were found between negative religious coping and self-esteem (r = -.445, p \ .001), indicating that lower levels of self-esteem are associated with higher levels of negative religious coping. On the other hand, it was found that higher levels of positive religious coping are significantly associated with higher levels of self-esteem (r = .23, p \ .05). Significant negative correlations were found between selfesteem and all DEP variables, except for the Perfectionism subscale of the EDI (EAT Total, r = -.43, p \ .001; Dieting, r = -.43, p \ .01; Bulimia, r = .43, p \ .001; EDI Total, r = -.55, p \ .001; Drive for Thinness, r = -.42, p \ .001; Body Dissatisfaction, r = -.30, p \ .01; Ineffectiveness, r = -70, p \ .001; Maturity Fears, r = -.33, p = .001). Regression Analyses Based on the above associations between variables that were found to be significant, regression analyses were conducted with negative religious coping as a predictor of DEP. In addition, in order to include self-esteem as a mediator of this association, a regression was conducted using negative religious coping as a predictor of self-esteem. BMI was included as a covariate in all analyses. As shown in Table 2, negative religious coping significantly predicted DEP for the Bulimia subscale of the EAT-26, the EDI Drive for Thinness, Ineffectiveness and Maturity Fears subscales, as well as the Total EDI. All results remained significant after controlling for BMI. However, as shown in Table 2, these findings were no longer significant after including self-esteem as a predictor, which indicates that self-esteem completely mediates the association between negative religious coping and DEP pathology.

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J Relig Health Table 1 Descriptive Statistics for Disordered Eating Pathology

n

M (SD)

EDI subscales EDI total

65

37.72 (27.42)

Drive for thinness (DT)

88

4.90 (5.62)

Bulimia (B)

91

1.88 (3.14)

Body dissatisfaction (BD)

90

10.80 (7.90)

Ineffectiveness (I)

91

2.99 (4.65)

Perfectionism (P)

94

4.29 (3.77)

Interpersonal distrust (ID)

90

2.58 (2.92)

Interoceptive awareness (IA)

87

4.01 (7.97)

Maturity fears (MF)

90

4.70 (4.40)

EAT total

65

9.93 (9.99)

Dieting

86

7.10 (7.55)

Bulimia

95

1.56 (2.74)

Oral control

94

1.50 (2.24)

EAT-26 subscales

EAT-26 Positive Score, indicates percentage with levels disordered eating pathology above 20 EDI Eating Disorders Inventory, EAT Eating Attitudes Test

EAT-26 positive score

82

14.6 %

Discussion Limited empirical evidence suggests the need for further investigation of the role that religion and spirituality play in the etiology, prevention and treatment of EDs and DEP (Richards et al. 2013; Weinberger-Litman et al. 2011). To our knowledge, the way that religious coping may relate to EDs and DEP has not previously been explored. This is despite the fact that religious coping has been explored in relation to various domains of physical and mental health outcomes (Bryant-Davis and Wong 2013; Pargament et al. 1998, 2000, 2013). Positive religious coping, which relates to finding meaning in difficult circumstances, is associated with better psychological adjustment (Pargament et al. 1998, 2000). Negative religious coping, which is related to religious struggles and ambivalence, is associated with greater levels of various forms of psychopathology among adults and adolescents (Carpenter et al. 2012; Matthews et al. 1998). In addition, avoidant coping mechanisms have found to be associated with the development and maintenance of EDs (Treasure et al. 2010), which further highlights the relevance of exploring forms of religious coping and their relationship to DEP. The primary findings of the current study suggest that negative religious coping among adolescent Orthodox Jewish women is associated with greater levels of DEP. However, positive coping was not found to be associated with lower levels of DEP. These results are consistent with previous literature, suggesting that greater levels of negative religious coping are associated with higher levels of depression, anxiety, obsessive-compulsiveness, somatization, obesity and trauma (Bryant-Davis and Wong 2013; Pirutinsky et al. 2012). These comorbid psychiatric conditions are all commonly related to the spectrum of DEP (Treasure et al. 2010). In addition, these results are in line with previous research suggesting that greater levels of religiosity are related to lower levels of DEP among Jewish (Gluck and Geliebter 2002; Latzer et al. 2007) as well as non-Jewish women (Richards et al. 2007, 2013). Further, extrinsic religious orientation, a socially motivated attitude toward religion, has been

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.20

R2

B (SE)

.18

.39 (.13)*

.62 (.17)**

-13.76 (4.34)

.26

-.40 (.13)**

.16 (.17)

.42 (.18)*

5.44 (7.46)

B (SE)

Model 2

.07

.33 (.14)*

.17 (.15)

-4.53 (3.79)

B (SE)

Model 1

EDI (I)

.53

-.64 (.08)**

-.04 (.10)

-.17 (.11)

26.52 (4.4)

B (SE)

Model 2

.06

.31 (.14)*

.08 (.14)

-.79 (3.56)

B (SE)

Model 1

EDI (MF)

* p \ .05; ** p \ .01

EAT (B) EAT Bulimia Subscale, EDI (DT) Drive for Thinness, EDI(I) Interoceptive Awareness, EDI (MF) Maturity Fears

-.21 (.06)**

Self Esteem

.07

.049 (.09)

BMI

Neg.Coping

.80 (.08)

.12 (.09)

.19 (.08)*

Constant

B (SE)

5.79 (3.54)

B (SE)

-3.38 (2.18)

Variable

Model 1

Model 1

Model 2

EDI (DT)

EAT (B)

.13

-.26 (.12)*

.20 (.15)

.02 (.16)

9.85 (6.51)

B (SE)

Model 2

.19

2.44 (.88)**

2.73 (.98)**

-52.73 (25.35)

B (SE)

Model 1

EDI Total

.37

-2.38 (.67)**

1.34 (.83)

1.40 (1.04)

60.25 (41.66)

B (SE)

Model 2

Table 2 Negative Religious Coping as a Predictor of Disordered Eating Pathology (Model 1) and Self-Esteem as a Mediator of the Association between Negative Religious Coping and Disordered Eating Pathology (Model 2)

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shown to be associated with greater levels of DEP among Jewish (Weinberger-Litman et al. 2008b) and non-Jewish women, as well as more negative prognostic outcomes among clinical samples (Richards et al. 2007, 2013). Current findings showed that greater levels of negative religious coping were significantly related to lower levels of self-esteem. Furthermore, consistent with previous research suggesting lower levels of self-esteem as a major risk factor in the etiology of EDs and DEP (Joiner et al. 1997; Polivy and Herman 2002), the current study also found a significant relationship with increased DEP and lower levels self-esteem. Consistent with these findings, lower levels of self-esteem among non-clinical Modern Orthodox adolescents in Israel, was also associated with higher levels of DEP and level of religiosity (Latzer et al. 2007). Therefore, the possible mediating role of self-esteem was assessed and was found to completely mediate the association between negative religious coping and DEP. This finding highlights the critical role of self-esteem as a risk factor in the development of DEP and can be interpreted in various ways. It is plausible that lower selfesteem may lead to more negative religious coping, which is related to greater feelings of spiritual unworthiness. Alternatively, feeling spiritually unworthy or punished may also lead to lower levels of self-esteem. Although the association between negative religious coping and DEP was no longer significant when accounting for level of self-esteem, religious coping should still be regarded as an influential psychological mechanism in the understanding of DEP and should be further explored. It is important to note that positive religious coping was not found to be associated with lower levels of DEP, nor was it related to higher self-esteem. While positive religious coping has been found to be predictive of better mental and physical health outcomes (Carpenter et al. 2012; Pargament et al. 1998, 2000; Pirutinsky et al. 2012), other studies have also found significant associations with negative but not positive religious coping (Carpenter et al. 2012). It is possible that negative religious coping may be a more salient factor than positive coping in the development of DEP. This is similar to findings indicating that extrinsic religious orientation is associated with higher levels of DEP, while an intrinsic religious orientation is not consistently associated with lower levels of DEP (Richards et al. 2013; Weinberger-Litman et al. 2008b). It is also possible, that these results relate to specific developmental factors among late adolescents, who may be struggling with the formation of identity in general (Steinberg 2013) and religious identity in particular (King et al. 2013). A secondary aim of the current study was to describe level of DEP among our nonclinical sample of Modern Orthodox adolescent females. To our surprise, levels of DEP as measured by various indices, were slightly lower than other religious samples of Modern Orthodox adolescents in Israel (Latzer et al. 2007), and much lower than samples of secular adolescent women both in Israel (Latzer and Tzischinsky 2003) and the USA (Shore and Porter 1990). In the current study, the mean EDI Total score was 37.7, the mean EAT-26 Total score was 9.9, and the percentage of an EAT-26 positive score was 14.6 %. Comparatively, in a Modern Orthodox sample of Israeli adolescent women, the mean EDI Total score was 39.4 and the mean EAT-26 Total score was 11.2 (Latzer et al. 2007), the percentage of an EAT-26 positive score was 15.6 %, (Glazer 2013). However, among a secular Israeli sample, mean EDI Total score was 60.1, mean EAT-26 Total score was 12.1, and percentage of positive EAT-26 was 16.9 % (Latzer and Tzischinsky 2003), which is similar to levels reported in other western countries including the USA (Shore and Porter 1990).These findings are consistent with those suggesting that greater levels of religiosity and spirituality are associated with lower levels of DEP among adolescents and young adults as well as better clinical outcomes (Gluck and Geliebter 2002; Latzer et al.

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2007; Richards et al. 2013). It is likely that within this specific sample, cultural norms and religious values may provide meaning and a more clear identity, both of which have been shown to improve psychological outcomes among adolescents (King et al. 2013; Steinberg 2013). While there is an expectation of high levels of academic achievement, career success and personal appearance, traditional expectations of marrying at a young age, having children and upholding family values is clearly defined and may enable identity formation (Weinberger-Litman et al. 2008a). This explanation may serve as a protective factor against the development of DEP. In addition, it may also help explain the lack of findings related to positive religious coping and DEP. This sample may represent a subgroup with highly favorable religious attitudes with a propensity toward positive religious coping. Given the relatively lower percentage of DEP overall as compared to secular samples, positive religious coping may not emerge as a relevant factor. However, individuals that are experiencing greater levels of religious struggle or ambivalence may be more prone to negative religious coping as well as to DEP. Limitations Several limitations of this study must be addressed. The small sample size, the restricted age range and specific religious subgroup from which the sample was drawn, makes it difficult to generalize results to other populations. As such, a wider age range and more religiously diverse sample is needed to further understand the extent of the association between religious coping and DEP. The sample is further limited by the use of self-report questionnaires which may be influenced by social pressure and comparisons. Additionally, further psychological variables that may mediate or moderate the observed result should be explored. For example, additional measures of psychopathology related to DEP (e.g., depression and anxiety) should be assessed as well as relevant personality characteristics (e.g., perfectionism, impulsivity, asceticism). The current study is the first to explore the relationship between religious coping and DEP. Despite its limitations, it further highlights the importance of exploring religious variables in ED research and emphasizes how various forms of one’s religious experiences may play a role in risk factors for EDs and DEP. Acknowledgments The authors would like to thank Emilie Maurer, for her help in preparation of this manuscript.

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