10.22491/1678-4669.20210010

SOCIAL AND COMMUNITY PSYCHOLOGY AND MENTAL HEALTH

 

Anxiety in the COVID-19 pandemic context: merging demands and reflections for the practice

 

Ansiedade no contexto da pandemia da COVID-19: demandas emergentes e reflexões para a prática

 

Ansiedad en el contexto de la Pandemia de COVID-19: Demandas emergentes y reflexiones para la práctica

 

 

Lauro Miranda Demenech^I; Beatriz Schmidt^I; Maria Aparecida Crepaldi^II; Lucas Neiva-Silva^I

^IUniversidade Federal do Rio Grande
^IIUniversidade Federal de Santa Catarina

Endereço para correspondência

 

 

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ABSTRACT

During the COVID-19 pandemic, it is natural for people to feel anxious, due to the real risks imposed by the situation. However, the complex interrelationship between individual and collective characteristics can turn this health crisis into an especially favorable period for the development of anxiety disorders. Through a critical review of the technical-scientific literature on the subject matter, we sought to investigate the prevalence of anxiety, the individual risk and the protective factors associated with this outcome, and the underlying mechanisms that may be involved in the production of anxiety in the current scenario. Based on the outcomes found, the role of information in the production of this phenomenon was discussed, considering the features of the Brazilian context. Finally, reflections on interventions and therapeutic paths for managing anxiety during the pandemic were presented.

Keywords: anxiety; pandemic; psychology; covid-19; mental health.

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RESUMO

Durante a pandemia da COVID-19, é natural que as pessoas se sintam ansiosas, em função dos perigos reais que a situação impõe. Contudo, a complexa inter-relação entre características individuais e coletivas pode fazer desta crise sanitária um momento especialmente propício para o desenvolvimento de transtornos de ansiedade. Por meio de revisão crítica da literatura técnico-científica sobre o assunto, buscou-se investigar a prevalência de ansiedade, quais os fatores de risco e proteção individuais para esse acometimento, e quais os mecanismos subjacentes que podem estar envolvidos na produção de ansiedade no atual cenário. A partir dos resultados encontrados, discutiu-se o papel da informação na produção desse fenômeno, considerando as caraterísticas do contexto brasileiro. Por fim, foram apresentadas reflexões sobre intervenções e caminhos terapêuticos para o manejo da ansiedade na vigência da pandemia.

Palavras-chave: ansiedade; pandemia; psicologia; covid-19; saúde mental.

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RESUMEN

Durante la pandemia de COVID-19, es natural que las personas se sientan ansiosas, debido a los peligros reales que impone la situación. Sin embargo, la compleja interrelación entre las características individuales y colectivas puede hacer que esta crisis de salud sea un momento especialmente favorable para el desarrollo de trastornos de ansiedad. A través de una revisión crítica de la literatura técnico-científica sobre el tema, buscamos investigar la prevalencia de la ansiedad, cuáles son los factores de riesgo y protección individuales para esta afección y cuáles son los mecanismos subyacentes que pueden estar involucrados en la producción de ansiedad en el presente contexto. A partir de los resultados encontrados, se debatió el papel de la información en la producción de este fenómeno, considerando las características del contexto brasileño. Finalmente, se presentaron reflexiones sobre intervenciones y caminos terapéuticos para manejar la ansiedad durante la pandemia.

Palabras clave: ansiedad; pandemia; psicología; covid-19; salud mental.

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In December 2019, a new coronavirus strain (Severe Acute Respiratory Syndrome 2 – Sars-Cov-2) was identified among human beings living in the province of Wuhan, China (Lai et al., 2020). The Coronavirus Disease 2019(COVID-19) spread rapidly throughout the world, being recognized as a pandemic by the World Health Organization (WHO). In general, during a health crisis like this, fighting against the pathogen and people's physical health are the main attention focuses of health managers and professionals (Ornell, Schuch, Sordi, & Kessler, 2020). However, the psychological distress associated with the COVID-19 health crisis and the contingency measures (e.g., social isolation) can be severe and long-lasting and should not be disregarded at this moment (Brooks et al., 2020).

Among the possible psychological reactions, the current scenario seems to be particularly favorable for the development of anxiety disorders, especially in Brazil, which is considered the most anxious country in the world, with 9.3% of its population presenting some type of anxiety disorder (WHO, 2017). Anxiety can be understood as a "threat state" characterized by a set of physiological, behavioral and physiological reactions associated with a situation of fear and anticipation of potentially dangerous future events (Barlow & Durand, 2015). It is a natural and adaptive mechanism of human beings, but it can turn into pathological if the anxiety responses become disproportionate or displaced from the real stimulus (Clark & Beck, 2012). Consequently, anxiety plays a dominant emotional role in the face of an infectious outbreak such as that of COVID-19 (Rajkumar, 2020). However, the worldwide state of alert towards a real risk (which has been called "the greatest health crisis of the century"), associated with the information (true or not) overload, the economic recession and the unpredictability regarding the future (Q. Chew, Wei, Vasoo, Chua, & Sim, 2020; Hiremath, Suhas Kowshik, Manjunath, & Shettar, 2020; Jakovljevic, Bjedov, Jaksic, & Jakovljevic, 2020), can provoke excessive and poorly adapted fear and anxiety in the population. There is a fine line between ideal concern, which makes people adopt the necessary protection measures to contain the spread of the new coronavirus, and pathological concern, which can make individuals experience excessive psychological distress.

Understanding this phenomenon and tracing strategies of psychosocial support at an individual and collective level is important for at least three reasons. In the first place, anxiety disorders can be long-lasting and severely disabling, producing a high burden of distress, as has already happened in previous health crisis (Q. Chew et al., 2020; Troyer, Kohn, & Hong, 2020). In the second place, psychological mechanisms can generate a distorted interpretation of physical symptoms, resembling the COVID-19 symptomatology (Asmundson & Taylor, 2020b), with the consequence that, in addition to the individual distress arising from the concern of being infected with COVID-19, the health services receive even more people, who can end up being really infected in these places. In the third place, although humanity has already overcome similar situations in the past (Q. Chew et al., 2020), there is no certainty as to how the near future will be. In this sense, preparing people to adapt to a "new normality" will be an important task of the Psychology professionals.

Considering this problem, the aim of this article was to conduct a critical narrative review (Ferrari, 2015; Pautasso, 2020) of the technical-scientific literature available on anxiety in the context of the COVID-19 pandemic. The intention was to investigate the prevalence of anxiety, what the individual risk and protection factors for this disorder are, and which underlying mechanisms may be involved in the production of anxiety in the current scenario, in order to consider this problem in the Brazilian context and propose a reflection on the Psychology professionals' practice.

To understand the impact of the COVID-19 pandemic on the production of anxiety and related disorders, the authors conducted searches in the PubMed, PsycINFO and LILACS databases on different days of May 2020, using the following descriptors: "coronavirus", "COVID-19", "anxiety" and "anxiety disorders"'. The references of the materials found were also analyzed to comprise the evidence corpus exposed in this study. A total of 116 publications were identified: 108 in PubMed, 6 in PsycINFO and 2 in LILACS. After reading the titles and abstracts, 50 records were excluded due to duplicity or for being studies not related to the topic in question. Of the 66 remaining records, three were excluded for not finding the full texts. 63 publications were fully read, of which 12 were excluded for dealing with studies on the development of scales/instruments or for not addressing anxiety. Finally, three manuscripts were added from the list of references of the publications included. Consequently, this review was based on 54 publications.

The summarization and critical analysis of the information obtained from the materials reviewed will be presented through four thematic axes, as follows:Past epidemics and pandemics and production of anxiety (3 studies); Preliminary results about the impact of COVID-19 on the production of anxiety (32 studies); The role of information in the production of anxiety in the COVID-19 context (19 studies); and Reflections on anxiety during the pandemic in Brazil and implications for the practice (13 studies). This last axis presents not only the synthesis of the evidence from the literature, but also extrapolations made by the authors in relation to the material as a whole. Additional references (seminal texts, books and institutional reports) were included in order to scientifically ground the guidelines and interventions proposed. It is highlighted that the articles could be present in more than one axis, as they addressed the respective themes.

 

Past epidemics and pandemics and production of anxiety

In a literature review on the psychological responses in past health crises such as Severe Acute Respiratory Syndrome (SARS), Influenza A (H1N1) and Ebola, it was observed that anxiety was the most frequently reported outcome (Q. Chew et al., 2020). Among the studies included, the prevalence of clinically relevant anxiety varied from 3.2% to 12.6%, with anxiety among survivors generally being higher to that found in general population samples (Q. Chew et al., 2020). Health professionals who worked in the Ebola outbreaks in Sierra Leone and in the Democratic Republic of Congo reported high levels of anxiety and stigma due to contact with people infected by this disease (Torales, O'Higgins, Castaldelli-Maia, & Ventriglio, 2020). Among the SARS survivors, 32.5% were diagnosed with panic disorder and 15.6% with obsessive-compulsive disorder, in the period from 31 to 50 months after infection (Troyer et al., 2020).

The following were reported among the reasons identified for the high anxiety levels found in these situations: fear of another infectious outbreak, beliefs of vulnerability to the infection, uncertainties about the available procedures and their possible side effects, concern about the well-being of family members and having to be distanced from them, interruption of work life, and the respective economic impact (Q. Chew et al., 2020; Torales et al., 2020; Troyer et al., 2020). Those who were infected, survivors of these diseases, health professionals, people with chronic diseases, and those who lost family members and perceived themselves as with high risk for infection and death had greater chances of suffering psychological distress. On the other hand, individuals with higher schooling levels, with a positive perception about their health status and high levels of life satisfaction presented lower chances of psychological distress (Q. Chew et al., 2020; Torales et al., 2020). During health crises, people generally seek information about what is happening. When there is lack of information or when this is inconsistent, people may end up exposing themselves to or grounding their decisions on less reliable information available on the social media (Torales et al., 2020).

Previous experiences and reports present, in a consistent way, that psychological distress is high in situations similar to that imposed by COVID-19, but which tend to decrease in the course of time, especially if there is psychosocial monitoring (Q. Chew et al., 2020). Fear of the unknown can result in the development of clinically relevant symptoms of anxiety both in people who are supposedly healthy and in those with pre-existing mental health disorders. In contexts such as pandemics, people's emotional responses may include extreme fear and uncertainty; in addition, negative social behaviors are frequently driven by distorted perceptions of the risks (Torales et al., 2020). Given the above, it is possible that there is a growth in the number of relevant psychological distress cases, especially of anxiety disorders, during the COVID-19 pandemic.

 

Preliminary results about the impact of COVID-19 on the production of anxiety

Research studies conducted with general population samples showed prevalence values of clinically significant anxiety during the pandemic, varying from 3.8% to 50.9% (M. Z. Ahmed et al., 2020; Gao et al., 2020; Huang & Zhao, 2020a, 2020b; Lei et al., 2020; Moghanibashi-Mansourieh, 2020; Qiu, Shen, & Zhao, 2020; Tan et al., 2020; C. Wang, Pan, Wan, Tan, Xu et al., 2020; C. Wang, Pan, Wan, Tan, Xu, McIntyre et al., 2020; Y. Wang, Di, Ye, & Wei, 2020; W. R. Zhang et al., 2020). However, in assessments in which screening instruments were not used, the researchers found that 52.1% of the participants were afraid and apprehensive regarding the disease (Y. Zhang & Ma, 2020), that 70.0% presented high psychological distress, which included compulsive obsessions and phobic anxiety (Tian et al., 2020), and that 80.0% were worried thinking about the virus (Roy et al., 2020).

Women seem to present higher prevalence values of anxiety (Moghanibashi-Mansourieh, 2020; Qiu et al., 2020; C. Wang, Pan, Wan, Tan, Xu et al., 2020; Y. Wang et al., 2020). The evidence indicates that both the youngest individuals (M. Z. Ahmed et al., 2020; Gao et al., 2020; Huang & Zhao, 2020a, 2020b; Moghanibashi-Mansourieh, 2020; Qiu et al., 2020; Y. Wang et al., 2020) and oldest people (Qiu et al., 2020; Tian et al., 2020) were the most anxious when compared to middle-aged adults. In general, people with lower schooling presented higher anxiety levels (Gao et al., 2020; Lei et al., 2020; Tian et al., 2020), although one study found the opposite (Qiu et al., 2020). Presenting physical symptoms similar to those of COVID-19 (Tan et al., 2020; C. Wang, Pan, Wan, Tan, Xu et al., 2020), some previous medical condition (Tan et al., 2020; C. Wang, Pan, Wan, Tan, Xu et al., 2020; Y. Zhang & Ma, 2020) and worse self-perception of health (Gao et al., 2020; Lei et al., 2020) were also associated with high anxiety levels. Lower family income, greater concern about being infected, not having access to psychological support, having a family member and/or friend who contracted the disease, and being an immigrant were also risk factors for anxiety (Lei et al., 2020; Moghanibashi-Mansourieh, 2020; Qiu et al., 2020). On the other hand, receiving updated information about adequate prevention measures, such as hand hygiene and mask wearing, trusting in the physicians and perceiving themselves as with low risk for infection and death due to COVID-19 were protective factors against the development of anxiety (Tan et al., 2020; C. Wang, Pan, Wan, Tan, Xu et al., 2020; C. Wang, Pan, Wan, Tan, Xu, McIntyre et al., 2020).

The studies identified that assessed the mental health of health professionals presented prevalence values of clinically relevant anxiety during the pandemic, which varied from 15.7% to 46.7% (Chen, Zhou, Zhou, & Zhou, 2020; N. Chew et al., 2020; Lai et al., 2020; Xu, Xu, Wang, & Wang, 2020). In addition to that, it was observed that, among nurses, 50.0% felt anxious (Sun et al., 2020) and that 87.0% of the dentists were afraid of being infected (M. A. Ahmed et al., 2020); and, in a sample comprised by psychiatrists and neurologists, 30.0% reported being deeply concerned about the COVID-19 pandemic (Bohlken et al., 2020). It is highlighted that, in a study carried out with a group of surgeons in China, a team of professionals had a reduction in the prevalence of anxiety, dropping from 46.7% during the COVID-19 outbreak period to 10% in the post-outbreak period, which can be attributed to the reduction in the uncertainty and concern about being infected (Xu et al., 2020).

Anxiety and stress seem to be strongly associated with each other (Mo et al., 2020; Xiao, Zhang, Kong, Li, & Yang, 2020a). Frontline professionals who presented physical symptoms similar to those of COVID-19 were more likely to experience high anxiety levels (Chen et al., 2020; N. Chew et al., 2020; Lai et al., 2020), with a two-fold higher risk of being anxious (Lu, Wang, Lin, & Li, 2020). Finally, having good social support was associated with lower anxiety and stress levels and with better sleep quality (Xiao et al., 2020a).

A number of qualitative studies identify that health professionals have at least eight sources of anxiety, as follows: 1) lack of access to appropriate protection equipment; 2) possibility of transmitting the virus to their family environment; 3) not having quick access to testing in case of symptoms onset; 4) uncertainty about the assistance offered by the work institution if they develop the disease; 5) care to their children due to the increase in the working hours and closure of schools; 6) support for personal needs due to the increase in workload; 7) ability to offer quality care when transferred to a new expertise area (e.g., starting to work in an ICU; and 8) lack of access to updated information (Shanafelt, Ripp, & Trockel, 2020; Sun et al., 2020). On the other hand, it is highlighted that there is also personal growth when working under pressure, which includes more affection and gratitude, development of professional responsibility and self-reflection, and that positive and negative emotions occur concomitantly (Sun et al., 2020).

Research studies with other specific subgroups were also identified. For example, a survey with university students identified that 24.9% presented clinically relevant anxiety, being more prevalent among those who had family members and/or loved ones infected by COVID-19, and who felt economic impacts and delays in their academic routine due to the pandemic (Cao et al., 2020). In a study with pregnant women, more than half reported feeling anxious, and their main sources of concern were their oldest family members, followed by their children and babies during pregnancy (Corbett, Milne, Hehir, Lindow, & O'Connell M, 2020).

In a research study with multiple sclerosis patients, almost half of the sample presented high anxiety levels, which can worsen even more the clinical status of the disease (Moghadasi, 2020). Among patients with some type of immunological deficiency, 42.3% presented clinically relevant anxiety, and they also had worse quality of life scores (Pulvirenti et al., 2020). According to the authors of this study, the anxiety arising from running out of the necessary medications, in view of the interventions to stop the spread of the virus, was an important issue among these individuals (Pulvirenti et al., 2020).

Among people who were home-isolated for 14 days due to COVID-19 infection or suspicion, lower levels of social capital (i.e., trust, belonging and social participation) were associated with increased anxiety and stress levels, as well as with worse sleep quality (Xiao, Zhang, Kong, Li, & Yang, 2020b). Finally, a study identified that parents of children who were hospitalized during the COVID-19 pandemic period had significantly higher scores of anxiety when compared to parents of children who were hospitalized outside the pandemic period (Yuan et al., 2020), emphasizing the increase in people's concern about the new coronavirus pandemic.

 

The role of information in the production of anxiety in the COVID-19 context

In previous health crises, information played an important role in the onset and permanence of anxiety and stress symptoms (Q. Chew et al., 2020; Torales et al., 2020). However, the way in which contemporary society is facing the pandemic is unprecedented, characterized by the availability and dissemination of information about an infectious disease of this magnitude (Q. Chew et al., 2020).

The analysis of the materials produced in relation to the COVID-19 pandemic revealed the existence of a continuum about the information levels. On the one hand, total lack of information and, on the other, its excess. Both extremes can contribute to psychologically delicate situations both at the individual and at the collective level, which can result in important harms in both cases.

During a health crisis, the population expects the press and media to convey accurate and updated information for adequate decision-making about prevention behaviors (Garfin, Silver, & Holman, 2020). When information is lacking, either because it does not exist or because it has been inefficiently communicated, feelings of ambiguity can emerge. This situation, combined with an invisible threat (such as the new coronavirus), can increase fear, concern and anxiety, which also contributes to the dissemination of misinformation (Garfin et al., 2020). In addition to that, lack of information opens space for sensationalism, which can intensify health-related fears and phobias, including coronaphobia, which represents a disproportionate fear of infection by the new coronavirus (Asmundson & Taylor, 2020a). Diverse evidence indicates that receiving conflicting information can also impose important harms on psychological health (Torales et al., 2020). Currently, misinformation, which has already been a prevalent problem in the past, seems to be being somehow compensated by excess of information. Higher exposure to the media is associated with higher anxiety levels within the COVID-19 pandemic context (Fatke, Holzle, Frank, & Forstl, 2020; Gao et al., 2020; Huang & Zhao, 2020a, 2020b; Li et al., 2020; Moghanibashi-Mansourieh, 2020; Roy et al., 2020).

Excess of information can produce distress in various ways. In the first place, information overload alone seems to cause harms to mental health. Dong and Zheng (2020) present the term Headline Stress Disorder, which corresponds to an emotional response of anxiety and stress to endless pieces of news reported by the media. Despite not being a clinical diagnosis, permanent anxiety and stress reactions can cause various functional physical disorders (Dong & Zheng, 2020).

Likewise, it is possible to highlight health anxiety, which concerns the catastrophic interpretation of bodily sensations, dysfunctional beliefs about health and disease, and maladaptive coping strategies (Asmundson & Taylor, 2020b). People with high levels of health anxiety tend to have excessive and maladaptive behaviors, such as excess of hand hygiene, social exclusion, and panic purchases (i.e., stocking supplies such as water, food, alcohol gel, etc.). In addition to that, people with high anxiety levels (and also with the specific type of health anxiety) tend to consume more information, either through official means, social media, or through appointments with professionals, which can further increase psychological distress (Asmundson & Taylor, 2020b; Garfin et al., 2020). Health professionals also seem to feel anxious and stressed because of the information, since they are having more extensive and intense workdays and the knowledge about this new disease progresses exponentially (Shanafelt et al., 2020), being difficult to stay updated.

Concern about the extent, severity and economic and social impacts of the COVID-19 pandemic can produce the phenomena of infomania and infodemic. Infomaniais the disabling state of information overload due to the obsessive need to constantly check social media, websites, online news, and other information channels in a frenetic manner to acquire as much information as possible and understand what is happening (Jakovljevic et al., 2020). Infodemic, on its turn, regards the fast dissemination of all kinds of information, including adequate and accurate content, and also rumors, gossip, misinformation and conspiracy theories (Jakovljevic et al., 2020; Shuja, Aqeel, Jaffar, & Ahmed, 2020). Due to this movement, everybody can have – and spread – a private opinion and an alternative truth. For example, in general, content creators receive more attention with bizarre and controversial stories. In this era of "post-truth", in which objective facts exert less influence on the public opinion that emotional appeals and personal beliefs (Seixas, 2019), "alternative truths" and the explosion of fake news, the truth in which people believe depends on their own point of view (Jakovljevic et al., 2020).

The information overload and misinformation caused by these processes can produce consequences at the individual and collective levels. At the individual level, this scenario can lead to confusion, irrationality, fear and extreme behaviors, as well as to avoidance coping strategies, such as denying the severity and significance of the pandemic (Q. Chew et al., 2020; Jakovljevic et al., 2020; Rajkumar, 2020), paranoia about infection by COVID-19 (Roy et al., 2020) and high stress and anxiety levels (Torales et al., 2020). At the collective level, it can lead to distrust in relation to the public authorities and to discrimination against population subgroups (e.g., Asians in the case of COVID-19) (Rajkumar, 2020). This can produce varied negative effects in cascade, such as non-adherence to non-pharmacological virus containment strategies, and psychological distress due to xenophobia and stigma (Jakovljevic et al., 2020; Rajkumar, 2020; Shuja et al., 2020).

Information content also seems to be relevant. Despite being well-intentioned and effective for most of the population, the messages that are being conveyed can be especially problematic for people with some psychological disorder (or with vulnerability to develop them). Case reports in the literature help to illustrate this specific argument, such as people who present obsessive-compulsive symptoms due to excess of exposure to information about personal hygiene (Mehra et al., 2020), and older adults who present worsening of their clinical conditions of anxiety and depression due to news conveyed about older adults being the main risk group (Mehra et al., 2020). However, it is known that the information often conveyed in the media and in popular speech stating that severe cases with high risk of death due to COVID-19 occur exclusively among older adults is mistaken. This thought can comfort part of the population, but it may affect older adults' psychological health.

 

Reflections on anxiety during the pandemic in Brazil and implications for the practice

Three different situations enable some projections to be made about the impact of COVID-19 on the psychological distress of Brazilians. In the first place, and as already highlighted, Brazil is considered the most anxious country in the world, with approximately 18.6 million people with some anxiety disorder (WHO, 2017). Therefore, there is "fertile" land for the worsening of pre-existing conditions or for the re-emergence of symptoms among individuals who had had an improvement or total remission of the disorder. In the second place, the country goes through a period of economic instability, with high levels of unemployment and informal work, which tends to be worsened by the consequences of COVID-19 and measures to prevent the spread of the disease. As highlighted, work and economic uncertainties can produce feelings of concern and anxiety (Cao et al., 2020; Q. Chew et al., 2020; Jakovljevic et al., 2020). In the third place, the country faces a chronic crisis of misinformation and fake news. Approximately 85% of the Brazilian population does not know if they can discern what is real and what is false regarding the content conveyed on the Internet, turning Brazil into the leader in relation to concern about fake news (far ahead countries like Germany and Holland, with 38% and 31% of people who reported such concern, respectively) (Newman, Fletcher, Kalogeropoulos, & Nielsen, 2019). As discussed in the previous section, this phenomenon opens space for sensationalism, conspiracy theories and denialism (Asmundson & Taylor, 2020a; Q. Chew et al., 2020; Jakovljevic et al., 2020). This instability can generate confusion, fear and concern in the population, as well as it can extend the need to adopt restrictive measures.

In view of these adversities, the probability of increasing the number of cases of anxiety disorders and other related disorders stands out (such as the obsessive-compulsive disorder). Psychology professionals and those from other mental health areas need to be aware of this problem and have knowledge and tools to provide guidance and therapeutic support both in the private context and in the public health network.

The first action front targeted at the general population to cope with anxiety symptoms can be the psychoeducation. The use of explanatory booklets and the dissemination of educational materials in different media (e.g., television, radio and social networks) has been encouraged by researchers and health institutions (Enumo, Weide, Vincentini, Araujo, & Machado, 2020; Garfin et al., 2020; Schmidt, Crepaldi, Bolze, Neiva-Silva, & Demenech, 2020). Therefore, it is suggested for the professionals to participate in the elaboration of this type of material, either through institutional links to universities or health services or in an individual and spontaneous manner, through any and all channels available. It is important that Psychology professionals and those from other mental health areas occupy the spaces offered to them, either in television or radio programs, lectures and live transmissions via social media, among others.

However, taking into account the literature analyzed in this article, it is fundamental that these communications are adapted to the characteristics of the target audience. For example, it was observed that both the youngest and oldest individuals, as well as people with lower income and schooling, are more likely to present high anxiety levels in the pandemic context. Therefore, sensitive communication with an adequate language for the group to which the material (or the speech/presentation) is directed is indispensable for the effectiveness of the intervention (Schmidt et al., 2020).

Another possible format is psychological support in the remote modality, which has been widely spread due to the COVID-19 pandemic. Individual and group consultations via the Internet, as well as appointments via telephone and structured letters, have proved to be viable alternatives to the traditional in-person consultations (Schmidt et al., 2020). However, severe cases (e.g., people with psychotic symptoms), multiproblematic cases and/or cases with active suicidal ideation are contraindicated for remote individual consultation (Stoll, Müller, & Trachsel, 2020), and in-person appointments must be prioritized. In these situations, it is possible to activate the Psychosocial Care Network of the territory, whose devices remain open.

Regarding the content to be worked on, the first recommendation is to bear in mind the risk factors for high anxiety levels presented in this article since, by assisting people with such characteristics, the professional will have more chances of finding anxiety symptoms. In addition to that, information seems to play a fundamental role in the production of anxiety in a pandemic context. Being able to provide adequate information about COVID-19 can, on its own, be a powerful tool to manage anxiety.

On the other hand, anxiety symptoms (and also of related disorders, such as the obsessive-compulsive disorder) seem to be associated with the incorrect interpretation of external and internal stimuli. In a certain way, despite being mostly correct, legitimate, well-intentioned and good for a large part of the population, the information conveyed about the risks of the disease and the prevention and hygiene strategies can intensify and "confirm" exaggerated and distorted concerns of anxious individuals (Schmidt et al., 2020). For those with biological and psychological vulnerabilities (Barlow & Durand, 2015), the situation of pandemic and excess of information can act as a trigger for the development of anxiety disorders (Neto et al., 2020). Among individuals who already have such disorders, dysfunctional beliefs (e.g., the world being a dangerous place) and cognitive distortions (e.g., catastrophizing) can be deeply stimulated, which may intensify psychological and physical anxiety symptoms (Clark & Beck, 2012; Taylor, 2019).

Consequently, some of the possible outcomes resulting from the excess of exposure to COVID-19-related news among individuals with some predisposition to anxiety disorders (and those who already have them) can be as follows: a) development of the belief that coronavirus is a synonym of death, which can trigger anxiety disorders, including panic attacks, deeply characterized by the sensation of danger or imminent death; b) agoraphobia can also be developed, characterized by the person feeling anxiety or difficulty to remain in open spaces (such as squares and big supermarkets) or in closed spaces (such as stores), use of public transportation (such as buses and subways), remaining in queues or going out alone (American Psychiatric Association, 2014; Taylor, 2019); and c) onset (or re-emergence) of extreme hygiene habits, such as washing hands so frequently to the extent of causing injuries. Therefore, an adequate assessment is suggested in order to identify the possible existence of these thought and behavior patterns (Clark & Beck, 2012).

In these situations, it may be important that the mental health professional focuses on the deconstruction of the "coronavirus" "death" binomial, stimulating the individual to identify which risks are real and which can be considered "imaginary" or excessive. Therefore, cognitive and behavioral strategies and techniques to re-establish a person's ability to identify the difference between the real danger imposed by the COVID-19 pandemic and the distorted and exaggerated interpretation are recommended. For example, systematic desensitization processes can be performed (Abreu & Guilhardi, 2004), stimulating the subject to gradually get back into contact with the outer world, resuming important habits of daily life. It is worth mentioning that this recommendation is only one of the possible ways of intervention, which is related to the theoretical framework adopted by the authors. Other Psychology practices can be used, always observing their respective technical and theoretical precepts.

Guidance and stimulation to carry out healthy and self-care practices are also encouraged. A number of studies indicate that restorative sleep, exposure to sunlight, organization of a daily routine, performance of physical activities in a safe environment, balanced diet and development of pleasant activities can contribute to reducing concern and anxiety (Altena & Baglioni, 2020; Hiremath et al., 2020; Kim & Su, 2020; Liu, 2020). In addition to that, both lack and excess of information can impair people's mental health, who should be instructed to conscientiously choose on which sources and moments of the day they will seek information about the pandemic situation. Finally, it is to be emphasized that the distancing that is being stimulated is physical, not social. Therefore, it is important to encourage the patient's contact with a network of family members and friends, even if it is not face-to-face, a factor that has been consistently pointed out as mitigating psychological distress (Brooks et al., 2020; Cao et al., 2020; Hiremath et al., 2020; Kim & Su, 2020; Ornell et al., 2020; Schmidt et al., 2020; Xiao et al., 2020a).

 

Final considerations

In this study, the intention was to investigate the occurrence of anxiety in the context of COVID-19 pandemic and which underlying mechanisms may be involved in the production of this phenomenon. In summary, it was identified that, in general, the prevalence values presented in the epidemiological studies are high. Women, youngest and oldest individuals, with lower schooling and income, who presented physical symptoms similar to those of COVID-19, who have chronic diseases, and with reduced social support were the most prone to present high anxiety levels. Health professionals, in particular those in the frontline, are also especially susceptible to feeling anxious in this context. Information seems to play an important role both in the prevention and in the production of anxiety, so that both lack and excess of exposure to the news about the pandemic must be avoided.

One of the main limitations of this study was the predominant inclusion of international literature, especially of research studies conducted in Asian and European countries. Consequently, it is important to make some considerations about the Brazilian context. The country has faced the social and economic impacts of the pandemic with some difficulty, even implementing policies of direct income transfer to try to stop the unemployment and poverty cycle that affects the most vulnerable individuals. The instability resulting from this process can either increase the concern and anxiety of the population in the face of the various uncertainties and sensations of insecurity, or reduce the system's capacity to effectively respond to the psychological impacts. The use of strategies to offer remote psychosocial support seems to be a viable alternative; however, it should not be forgotten that, in view of the different social realities in the country, this type of assistance may not be accessible to many Brazilians. Future research studies must be conducted to assess the impact of the pandemic on the production of anxiety in Brazil, both in the general population and in specific subgroups. In addition to that, given the exponential growth in the number of publications about psychological distress in pandemic times, new narrative reviews exploring similarities and differences in the anxiety reactions across populations or specific subgroups may contribute to the general understanding of this problem. Despite the challenges imposed by the pandemic, it is understood that there are various possibilities for the performance of Psychology professionals, contributing to the maintenance of the population's mental health and assisting in the process to overcome this health crisis.

 

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Endereço para correspondência:
Universidade Federal do Rio Grande, Campus Carreiros
Prédio da Psicologia, Centro de Estudos sobre Risco e Saúde
Av. Itália, Km. 8
Rio Grande, RS
CEP 96203-900
Telefone: (53) 3293-5236
Email: lauro_demenech@hotmail.com

Received in 31.may.20
Revised in 25.fev.21
Accepted in 18.mar.21

 

 

Lauro Miranda Demenech, Mestre em Saúde Pública pela Universidade Federal do Rio Grande (FURG), é Psicólogo (Técnico Administrativo em Educação) da Universidade Federal do Rio Grande (FURG).
Beatriz Schmidt, Doutora em Psicologia pela Universidade Federal do Rio Grande do Sul (UFRGS), Pós-Doutora pela Universidade Federal do Rio Grande do Sul (UFRGS), é Professora Adjunta da Universidade Federal do Rio Grande (FURG). Email: psi.beatriz@gmail.com
Maria Aparecida Crepaldi, Doutora em Saúde Mental pela Universidade Estadual de Campinas (UNICAMP), Pós-Doutora pela Université du Quebec à Montreal (UQÀM), Pós-Doutora pelo Hospital de Clínicas de Ribeirão Preto – USP, é Professora Titular da Universidade Federal de Santa Catarina (UFSC). Email: maria.crepaldi@gmail.com
Lucas Neiva-Silva, Doutor em Psicologia pela Universidade Federal do Rio Grande do Sul (UFRGS), Pós-Doutor pela Universidad Autónoma de Madrid (UAM), é Professor Adjunto da Universidade Federal do Rio Grande (FURG). Email: lucasneivasilva@gmail.com