* COVID-19 brought profound changes to the way we live. There has been a significant increase in the proportion of adults reporting anxiety or depressive disorder, when compared to 2019.
* As early as spring 2020, psychologists and behavioural experts observed changes in human behaviour, and they have studied and attempted to model them.
* This week’s note looks at the work of Professors Marcantonio Spada and Ana Nikčević. They, and later joined by colleagues, developed and validated a tool, which they named the COVID-19 Anxiety Syndrome Scale (C-19ASS).
* The scale asks nine questions – three of which are about avoidance behaviours (e.g., I have avoided using public transport) and six of which are about ‘getting stuck’ behaviours (e.g., I regularly check the news or check myself for symptoms).
* The scale has been validated against an established personality profiling tool – the Big Five Inventory – and against peer anxiety models developed in 2020.
* It has turned out to be a valid tool for measuring the level of anxiety related to COVID-19. It was also found to be uniquely helpful for identifying attentional bias (where one’s attention is most focused).
* Understanding human reaction to unprecedented situations is interesting per se. It is also important to be able to identify people more likely to experience greater anxiety, and how that manifests itself in behaviour, to be able to direct professional care resources. The C-19ASS helps us to understand COVID-19 anxiety as a specific syndrome and this may help us to alleviate it and restore individuals and society to more tolerable anxiety levels.
In September, I had the pleasure of doing a podcast with Professor Marcantonio Spada. He and a fellow researcher, Ana Nikčević, have been researching people’s reaction to COVID-19 since we first became aware of it. They have developed and evaluated a measure that is being used to identify the presence of anxiety syndrome associated with COVID-19. The podcast was fascinating – it can be heard at the bottom of this note – and I hope that a review of some of Marcantonio’s key publications on this topic will also be of interest.
Marcantonio’s bio and Ana’s bio can be seen here (Ref 2). In brief, Marcantonio is Professor of Addictive Behaviours and Mental Health in the School of Applied Sciences at London South Bank University. He has significant expertise in psychological therapies and Cognitive Behaviour Therapy (CBT) and has made a significant contribution to our understanding of addiction. In the podcast, we discuss substance addition (alcohol, smoking, drugs), as well as behavioural addition (gambling, gaming, smart phones) and the connections between these.
There can be no doubt that that COVID-19 brought profound changes to the way we live. Non-pharmaceutical interventions (lockdown measures) achieved the greatest impact on the daily lives of hundreds of millions of people worldwide seen outside times of war. War also tends to generate a sense of togetherness against a common enemy. Lockdowns have proved divisive on an unprecedented scale – those able to work from home vs. those who can’t. Those whose finances benefited vs. those for whom the opposite was the case. Those supportive of measures vs. those not and so on. Marcantonio and Ana noticed in the spring of 2020 that societal changes had led to a surge of pandemic-related psychological distress including fear, anxiety, perceived threat, and stress. They decided to investigate further…
COVID-19 Anxiety Syndrome
I wrote about anxiety at the end of March 2020 (Ref 3). The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used by health care professionals in the US, and much of the world, to define and diagnose mental disorders. The DSM was first published in 1952 and has been revised a number of times since, as our understanding and treatment of mental health has evolved (Ref 4). The current version of the manual is DSM-5, which was extensively updated and republished in 2013. I used the DSM definition of anxiety (Ref 5). Marcantonio and Ana noticed early on in the response to COVID-19 that they were not seeing generalised anxiety. They observed that a new syndrome was emerging.
Their first paper noted that “Given the role that pandemic psychological distress appears to be laying in shaping behavior, it is of critical importance to understand the nature and degree of this distress” (July 2020) (Ref 6). The central aim of the study was to widen the mental health response to the COVID-19 pandemic by developing and evaluating a measure that could be used to identify the presence of anxiety syndrome features associated with COVID-19.
The authors summarised other measures that had already emerged, which tried to explore COVID-19 related fear, anxiety, threat and stress. This was important for two reasons – 1) for background and context and 2) because the other scales were used to validate Marcantonio and Ana’s tool, which was named the COVID-19 Anxiety Syndrome Scale (C-19ASS).
Marcantonio and Ana’s first paper reported that the Fear of COVID-19 scale (Ahorsu et al., 2020) was one the first measures to explore fear specific to COVID-19. This scale had a narrow focus on fear, however. Lee and colleagues (Lee, 2020a; Lee 2020b; Lee et al., 2020a; Lee et al., 2020b) developed the Coronavirus Anxiety Scale (CAS), which Marcantonio and Ana found to be highly reliable and valid. A Perceived Coronavirus Threat Questionnaire (PCTQ; Conway et al., 2020) was developed in spring 2020, as were the COVID Stress Scales (CSS; Taylor et al., 2020). The COVID Stress Scales were developed to better understand and assess COVID-19-related distress. All of these were reported as of June 2020, so academics working in psychology were clearly very interested in quantifying human responses to the new coronavirus from the outset (The references in brackets are set out in full in the paper, if you are interested in exploring this field further).
The C-19ASS was also validated against one of the most commonly used personality profiling tools – the Big Five Inventory (BFI) (Ref 7). This is a tool, which was originally developed in 1949 by D.W. Fiske (Ref 8). It has subsequently been built upon by other authors – notably Goldberg, which is the citation I have used. (Goldberg’s paper has been cited in academic literature over 7,200 times). The Big Five personality traits are extraversion, agreeableness, conscientiousness, neuroticism (vs emotional stability), and imagination/intellect/openness to experience. (Please note neuroticism can feel like a judgmental word nowadays, but psychology does not intend this and certainly didn’t back in the middle of the last century. In Ana and Marcantonio’s second paper, neuroticism is described as “a vulnerability factor”) (Ref 9).
(“Extraversion” captures characteristics such as sociable, forceful, energetic, enthusiastic, and outgoing. “Agreeableness” captures characteristics such as forgiving, straightforward, altruistic, modest and sympathetic. “Conscientiousness” captures characteristics such as organised, reliable, efficient, careful, thorough, and diligent. “Neuroticism” captures characteristics such as tense, irritable, moody, and lacking self-confidence. “Imagination/intellect/openness” captures characteristics such as curious, imaginative artistic, excitable, and unconventional. I don’t know why one of the big five – neuroticism – is positioned on the negative side of a scale and the other four on the positive side) (Ref 10).
If you are interested in self-evaluation, you can do a test here (Ref 11). It will report your results as a raw score and as a percentile e.g., if you score 85% for agreeableness as a percentile, you scored higher on agreeableness than 85% of other people.
Marcantonio and Ana developed and tested a COVID-19 Anxiety Syndrome Scale (C-19ASS). The C-19ASS was constructed by examining the relevant literature and by noting aspects of the anxiety syndrome identified in other measures and by consulting experts in the field. The scale was tested on community participants.The scale was found to be a reliable and valid measure of the syndrome that they had identified.
The scale developed originally by Ana and Marcantonio comprised 11 items. When participants were invited to test the items, they were told: “A series of statements regarding people’s ways of dealing with the threat of coronavirus (COVID-19) are listed below. Please rate the extent to which each statement applies to you over the last two weeks.” Participants were asked to respond to each statement on a five-point Likert-type scale to indicate their level of agreement (“1. Not at all”, “2. Rarely, less than a day or two”, “3. Several days”, “4. More than seven days”, and “5. Nearly every day”).
The 11 statements which were developed to design and test the scale were:
1. I have avoided using public transport because of the fear of contracting coronavirus (COVID-19).
2. I have checked myself for symptoms of coronavirus (COVID-19).
3. I have avoided going out to public places (shops, parks) because of the fear of contracting coronavirus (COVID-19).
4. I have been concerned about not having adhered strictly to social distancing guidelines for coronavirus (COVID-19).
5. I have avoided touching things in public spaces because of the fear of contracting coronavirus (COVID-19).
6. I have read about news relating to coronavirus (COVID-19) at the cost of engaging in work (such as writing emails, working on word documents or spreadsheets).
7. I have researched symptoms of coronavirus (COVID-19) at the cost of off-line social activities such as spending time with friends/family.
8. I have avoided talking about coronavirus (COVID-19).
9. I have checked my family members and loved one for the signs of coronavirus (COVID-19).
10. I have been paying close attention to others displaying possible symptoms of coronavirus (COVID-19).
11. I have imagined what could happen to my family members if they contracted coronavirus (COVID-19).
Questions 7 and 8 were dropped during the validation process (as they were found not to be significant) to leave a nine-question scale. The scale was further categorised into avoidance behaviours – 1, 3 and 5 – and what were called perseveration behaviours (perseveration being defined as when someone gets ‘stuck’ on an idea or thought). The perseveration behaviours were the remaining questions – 2, 4, 6, 9, 10, and 11. C-19ASS-A was the abbreviation used to capture the avoidance behaviours and C-19ASS-P captured the perseveration behaviours.
The first assessment of the scale involved 292 participants in the US (99 females, average age 37 years). The participants completed the C-19ASS and the results were used to evaluate the construction of the scale. The second study involved 426 participants in the US (166 females, average age 39 years). This was used to validate the scale that had been constructed. Complex statistical methods were used and described in the paper.
These revealed that:
(1) the C-19ASS-P was positively correlated with the Perceived Coronavirus Threat Questionnaire (PCTQ) and the Coronavirus Anxiety Scale (CAS). i.e., people experiencing the perseveration (getting stuck) behaviours identified by Ana and Marcantonio also scored higher on scales assessing perceived threat from, and anxiety about, COVID-19.
(2) the C-19ASS-A was positively correlated with the PCTQ but not with the CAS. i.e., people adopting the avoidance behaviours identified by Ana and Marcantonio scored higher on perceived threat, but not on the Coronavirus Anxiety Scale.
(3) the C-19ASS-P was negatively correlated with the Big Five Inventory (BFI) extraversion and BFI conscientiousness, and positively correlated with the BFI neuroticism. i.e., the perseveration (getting stuck) behaviours identified by Ana and Marcantonio were less likely to be experienced by people higher on the extraversion scale and higher on the conscientiousness scale and more likely to be experienced by people higher on the neuroticism scale.
(4) the C-19ASS-A was negatively correlated with the BFI conscientiousness, and positively correlated with the BFI agreeableness and BFI openness. i.e., avoidance behaviours identified by Ana and Marcantonio were less likely to be experienced by people higher on the conscientiousness scale and more likely to be experienced by people higher on the agreeableness and openness scales.
Paper 2, published in October 2020 (Ref 12), built on the work of the July 2020 paper. It involved 502 participants in the US (234 females, average age 39 years). The participants were asked to complete a number of tests including a short version of the Big Five Inventory, the Coronavirus Anxiety Scales (Lee 2020) and the C-19ASS, as previously. The Whiteley Index 7 (Fink et al 1999) was added into the tests this time. This self-reported measure includes seven items assessing health anxiety (e.g., “Do you think there is something seriously wrong with your body?”) The Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS; Kroenke et al., 2016) was also added to the tests. This self-reported measure assesses the severity of generalised anxiety and depression symptoms.
The aims of the second study were to extend the understanding of vulnerability and protective factors to COVID-19 related and general psychological distress. Results showed that people scoring higher on extraversion, agreeableness, and conscientiousness, were less likely to exhibit generalised anxiety. Conversely, neuroticism and openness were positively associated with COVID-19 anxiety generally and the COVID-19 anxiety syndrome, respectively. These relationships were independent of age, gender, employment status and risk status. That last part was interesting and I explored this in the podcast with Marcantonio – are different types of people more likely to experience COVID-19 anxiety?
Paper 3 (Ref 13) explored further who might be more likely to experience COVID-19 anxiety. This time UK participants were used. A sample of 298 UK-based adults aged 18+ were recruited, with a mix of age, sex and ethnicity profiles. Participants were asked whether they considered themselves to be at ‘high-risk’ health wise should they contract COVID-19 (yes or no) and to provide a reason from the following categories: current health problem, older age, pregnancy, disability or other. Participants were also asked whether they had had a COVID-19 test, a positive COVID-19 test, a COVID-19 vaccine (the study was conducted in February 2021 when approximately 20% of participants had had a vaccine) and whether someone close had died as a result of COVID-19 (yes, no).
The third paper focused on something called “attentional bias”, which is defined as “the tendency to prioritize the processing of certain types of stimuli over others.” The research observed that there was an attentional bias towards COVID-19 related stimuli, which was not surprising given that the study took place in lockdown in the UK in February 2021 and COVID-19 was still the main news story 24-7. What was surprising was that it might have been expected that certain factors would have resulted in threat related stimuli being processed differently (e.g., people being more alert to threats based on one’s own risks). However, this was not the case for factors such as one’s age and whether or not one had received a vaccination, a positive COVID-19 test, or knew of someone close who had died as a result of COVID-19.
What must have been a great result for Ana and Marcantonio (and colleagues for papers 2 and 3) was that this attentional bias towards COVID-19-related stimuli was only positively and significantly correlated with their scale – the C-19ASS. This suggests that increasing attentional bias is a cognitive marker for increasing COVID-19 anxiety syndrome as measured by the C-19ASS and is not associated with either COVID-19 anxiety (as measured by the CAS) or health anxiety (as measured by the Whiteley Index 7).
This week’s research (and the podcast with Marcantonio) has been a merger of my previous life as a Human Resources Director and my current life in diet and health. Mental health is a key component of overall health and there is substantial and growing evidence that the COVID-19 period has been, and continues to be, very damaging to human mental health. A February 2021 study reported that “During the pandemic, about 4 in 10 adults in the U.S. have reported symptoms of anxiety or depressive disorder… up from one in ten adults who reported these symptoms from January to June 2019” (Ref 14).
I was impressed by how quickly academic behavioural analysts started to study the human response to COVID-19 and to develop models that could help our understanding of this. They have used long-standing personality models (Big Five Inventory) and referenced each other’s work, as models have been developed, to accelerate learning. The COVID-19 Anxiety Syndrome Scale (C-19ASS) brought a new dimension to the research with its subsets of avoidance behaviours and ‘getting stuck’ behaviours. It also turned out to be uniquely helpful for identifying attentional bias (where one’s attention is most focused).
The validation of the C-19ASS scale, which has been done to date, has shown personality characteristics (agreeableness etc.) that might predict people more or less likely to experience higher COVID-19 anxiety. The ability to be able to identify component parts of COVID-19 anxiety (avoidance, worry, checking and threat monitoring etc.) is valuable. There will also be a significant value to this work to help us (hopefully) move beyond the current crisis. For example, interventions aimed at interrupting ‘getting stuck’ thinking, reducing checking, safety behaviours and avoidance, as well as re-focusing attention, may serve to weaken the COVID-19 anxiety syndrome. This is something that we are going to need to achieve if we are going to return to normal. The longer something continues, the more it becomes the norm. It would be very unhealthy, for individuals and society as a whole, for anxious behaviour to continue indefinitely. Therefore, understanding more about this behaviour, who might experience it and how we might re-direct it is vital work.
Ref 1: https://www.zoeharcombe.com/2021/11/covid-19-anxiety-syndrome-scale
Ref 2: https://www.lsbu.ac.uk/about-us/people/people-finder/prof-marcantonio-spada
Ana’s bio is here https://www.kingston.ac.uk/staff/profile/professor-ana-nikcevic-559/
Ref 3: https://www.zoeharcombe.com/2020/03/anxiety-and-the-power-of-now/
Ref 4: https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions
Ref 5: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
Ref 6: Paper 1: Nikčević et al. The COVID-19 anxiety syndrome scale: Development and psychometric properties. Psychiatry Research. 22 July 2020.
Ref 7: Goldberg, Lewis R. “The development of markers for the Big-Five factor structure.” Psychological assessment 4.1 (1992): 26. https://projects.ori.org/lrg/PDFs_papers/Goldberg.Big-Five-Markers-Psych.Assess.1992.pdf
Ref 8: https://www.thomas.co/resources/type/hr-guides/what-are-big-5-personality-traits
Ref 9: Paper 2: Nikčević et al. Modelling the contribution of the Big Five personality traits, health anxiety, and COVID-19 psychological distress to generalised anxiety and depressive symptoms during the COVID-19 pandemic. Journal of Affective Disorders. 29 October 2020.
Ref 10: https://fetzer.org/sites/default/files/images/stories/pdf/selfmeasures/Personality-BigFiveInventory.pdf
Ref 11: https://openpsychometrics.org/tests/IPIP-BFFM/
Ref 12: Paper 2: Nikčević et al. Modelling the contribution of the Big Five personality traits, health anxiety, and COVID-19 psychological distress to generalised anxiety and depressive symptoms during the COVID-19 pandemic. Journal of Affective Disorders. 29 October 2020. https://www.sciencedirect.com/science/article/pii/S0165032720328974
Ref 13: Paper 3: Albery et al. The COVID-19 anxiety syndrome and selective attentional bias towards COVID-19-related stimuli in UK residents during the 2020–2021 pandemic. Clinical Psychology Psychotherapy. 25 June 2021.
Ref 14: Panchal et al. The Implications of COVID-19 for Mental Health and Substance Use. February 2021. https://www.kff.org/coronavirus