Dealing with COVID-19 stressful events, stress and anxiety: the mediating role of emotion regulation strategies in Italian women

Authors

  • Ilaria Di Maggio University of Padova
  • Michela Romola Academy of Cognitive Behavioral Sciences of Calabria (ASCoC)
  • Elisabetta Lacava Academy of Cognitive Behavioral Sciences of Calabria (ASCoC)
  • Raffaella Maressa Academy of Cognitive Behavioral Sciences of Calabria (ASCoC)
  • Francesco Bruno Academy of Cognitive Behavioral Sciences of Calabria (ASCoC), Regional Neurogenetic Centre (CRN)

Keywords:

perceived stress, stressful events, state anxiety, COVID-19, emotion regulation strategies

Abstract

Background
This study aims to better understand the causal relationship between COVID-19 stressful events, perceived stress, emotion regulation strategies and anxiety symptoms in Italian women. Specifically, we assumed that: (i) different COVID-19 stressful events can directly or indirectly influence the manifestation of anxiety symptoms; (ii) perceived stress and emotion regulation strategies can mediate the relationship between COVID-19 stressful events and anxiety symptoms.
Participants and procedure
An online survey was distributed during the Italian mandatory lockdown – between 18th and 28th April 2020 – across the national territory. The final sample was composed of 1132 women living in different Italian regions (North 63.30%, Centre 14.20%, South 18.50%, Islands 4.00%) with a mean age of 40.19 years, ranging from 19 to 83 years (SD = 12.87). Participants filled out the Perceived Stress Scale (PSS-10), Spielberger State-Trait Anxiety Inventory (STAI) X1/R, Emotion Regulation Questionnaire (ERQ-10), five dichotomous questions assessing the COVID-19 stressful events and a demographic form. Pearson correlation analyses were performed to examine whether associations between factors conformed to the prerequisites for path analysis. Path analysis was conducted to test the model.
Results
“Having contracted the flu during the COVID-19 pandemic” and “having a family member infected by COVID-19” have a direct effect on the level of perceived stress and an indirect effect on the manifestation of anxiety symptoms. Finally, we found that emotion regulation strategies mediate the relationship between perceived stress and state anxiety symptoms.
Conclusions
Our results allow one to select the stressful events to which, in the pandemic era, it is necessary to pay particular attention in a clinical setting and suggest the implementation of psychological interventions that make emotion regulation an essential direct target of treatment in chronic stress-related pathology such as anxiety disorders.

Downloads

Download data is not yet available.

References

AbuRuz, M. E., Al-Dweik, G., & Al-Akash, H. Y. (2019). Checking the moderating effect of perceived control on the relationship between anxiety and postoperative hospital length of stay among coronary artery bypass graft patients. International Journal of General Medicine, 12, 79–85. https://doi.org/10.2147/IJGM.S192333.

Andreotti, C., Thigpen, J. E., Dunn, M. J., Watson, K., Potts, J., Reising, M. M., Robinson, K. E., Rodriguez, E. M., Roubinov, D., Luecken, L., & Compas, B. E. (2013). Cognitive reappraisal and secondary control coping: associations with working memory, positive and negative affect, and symptoms of anxiety/depression. Anxiety, Stress & Coping, 26, 20–35. https://doi.org/10.1080/10615806.2011.631526.

Balzarotti, S., John, O. P., & Gross, J. J. (2010). An Italian adaptation of the emotion regulation questionnaire. European Journal of Psychological Assessment, 26, 61–67. https://doi.org/10.1027/1015-5759/a000009.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press. Belzung, C., & Griebel, G. (2001). Measuring normal and pathological anxiety-like behaviour in mice: a review. Behavioural Brain Research, 125, 141–149. https://doi.org/10.1016/S0166-4328(01)00291-1.

Berking, M., & Wupperman, P. (2012). Emotion regulation and mental health: Recent findings, current challenges, and future directions. Current Opinion in Psychiatry, 25, 128–134. https://doi.org/10.1097/YCO.0b013e3283503669.

Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395, 912-920. https://doi.org/10.1016/S0140-6736(20)30460-8.

Campbell-Sills, L., Barlow, D. H., Brown, T. A., & Hofmann, S. G. (2006). Acceptability and suppression of negative emotion in anxiety and mood disorders. Emotion, 6, 587–595. https://doi.org/10.1037/1528-3542.6.4.587.

Cannon, R. M., & Roe, R. T. (1982). Livestock disease surveys: a field manual for veterinarians. Australian Government Public Service. Carleton, R. N., Mulvogue, M. K., Thibodeau, M. A., McCabe, R. E., Antony, M. M., & Asmundson, G. J. (2012). Increasingly certain about uncertainty: Intolerance of uncertainty across anxiety and depression. Journal of Anxiety Disorders, 26, 468–479. https://doi.org/10.1016/j.janxdis.2012.01.011.

Cattell, R. B. (1966). Anxiety and motivation: Theory and crucial experiments. In C. D. Spielberger (Ed.), Anxiety and behavior (pp. 23–62). Academic Press.

Chambers, R., Gullone, E., & Allen, N. B. (2009). Mindful emotion regulation: an integrative review. Clinical Psychology Review, 29, 560–572. https://doi. org/10.1016/j.cpr.2009.06.005/.

Chrousos, G. P. (2009). Stress and disorders of the stress system. Nature Reviews Endocrinology, 5, 374–381. https://doi.org/10.1038/nrendo.2009.106.

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396. https://doi.org/10.2307/2136404.

Cohen, S., & Williamson, G. (1988). Perceived stress in a probability sample of the United States. In S. Spacapan & S. Oskamp (Eds.), The social psychology of health (pp. 31–68). Sage.

Daviu, N., Bruchas, M. R., Moghaddam, B., Sandi, C., & Beyeler, A. (2019). Neurobiological links between stress and anxiety. Neurobiology of Stress, 11, 100191. https://doi.org/10.1016/j.ynstr.2019.100191.

di Fronso, S., Costa, S., Montesano, C., Di Gruttola, F., Ciofi, E. G., Morgilli, L., Robazza, C., & Bertollo, M. (2022). The effects of COVID-19 pandemic on perceived stress and psychobiosocial states in Italian athletes. International Journal of Sport and Exercise Psychology, 20, 79–91. https://doi.org/10.1080/1612197X.2020.1802612.

Dryman, M. T., & Heimberg, R. G. (2018). Emotion regulation in social anxiety and depression: a systematic review of expressive suppression and cognitive reappraisal. Clinical Psychology Review, 65, 17–42. https://doi.org/10.1016/j.cpr.2018.07.004.

Eckenrode, J. (1984). Impact of chronic and acute stressors on daily reports of mood. Journal of Personality and Social Psychology, 46, 907–918. https://doi.org/10.1037/0022-3514.46.4.907.

Esler, M. (2017). Mental stress and human cardiovascular disease. Neuroscience & Biobehavioral Reviews, 74, 269–276. https://doi.org/10.1016/j.neubiorev.2016.10.011.

Fassbinder, E., Schweiger, U., Martius, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion regulation in schema therapy and dialectical behavior therapy. Frontiers in Psychology, 7, 1373. https://doi.org/10.3389/fpsyg.2016.01373.

Flesia, L., Monaro, M., Mazza, C., Fietta, V., Colicino, E., Segatto, B., & Roma, P. (2020). Predicting perceived stress related to the COVID-19 outbreak through stable psychological traits and machine learning models. Journal of Clinical Medicine, 9, 3350. https://doi.org/10.3390/jcm9103350.

Fofana, N. K., Latif, F., Sarfraz, S., Bashir, M. F., & Komal, B. (2020). Fear and agony of the pandemic leading to stress and mental illness: an emerging crisis in the novel coronavirus (COVID-19) outbreak. Psychiatry Research, 291, 113230. https://doi.org/10.1016/j.psychres.2020.113230.

Gan, Y., Ma, J., Wu, J., Chen, Y., Zhu, H., & Hall, B. (2022). Immediate and delayed psychological effects of province-wide lockdown and personal quarantine during the COVID-19 outbreak in China. Psychological Medicine, 52, 1321–1332. https://doi.org/10.1017/S0033291720003116.

Grecucci, A., Pappaianni, E., Siugzdaite, R., Theuninck, A., & Job, R. (2015). Mindful emotion regulation: Exploring the neurocognitive mechanisms behind mindfulness. BioMed Research International, 2015, 670724. https://doi.org/10.1155/2015/670724.

Gross, J. J. (1998a). Antecedent- and response-focused emotion regulation: Divergent consequences for experience, expression, and physiology. Journal of Personality and Social Psychology, 74, 224–237. https://doi.org/10.1037/0022-3514.74.1.224.

Gross, J. J. (1998b). The emerging field of emotion regulation: an integrative review. Review of General Psychology, 2, 271–299. https://doi.org/10.1037/1089-2680.2.3.271.

Gross, J. J. (2002). Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology, 39, 281–291. https://doi.org/10.1017/S0048577201393198.

Gross, J. J. (2014). Emotion regulation: Conceptual and empirical foundations. In J. J. Gross (Ed.). Handbook of emotion regulation (2nd ed., pp. 3–22). Guilford Press.

Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: Implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85, 348–362. https://doi.org/10.1037/0022-3514.85.2.348.

Gross, J. J., & Thompson, R. A. (2007). Emotion regulation: Conceptual foundations. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 3–24). Guilford Press.

Gumus, M., Akalin, T. C., Tutkun, E., & Acar, H. (2016). Assessment of state and trait anxiety levels of national team athletes during camping period. International Journal of Academic Research, 8, 36–39. https://doi.org/10.7813/2075-4124.2016/8-4/B.5.

Hallion, L. S., Steinman, S. A., Tolin, D. F., & Diefenbach, G. J. (2018). Psychometric properties of the Difficulties in Emotion Regulation Scale (DERS) and its short forms in adults with emotional disorders. Frontiers in Psychology, 9, 539. https://doi.org/10.3389/fpsyg.2018.00539.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: an experiential approach to behavior change. Guilford Press.

Hu, T., Zhang, D., Wang, J., Mistry, R., Ran, G., & Wang, X. (2014). Relation between emotion regulation and mental health: a meta-analysis review. Psychological Reports, 114, 341–362. https://doi.org/10.2466/03.20.PR0.114k22w4.

Jeong, S. J., Chung, W. S., Sohn, Y., Hyun, J. H., Baek, Y. J., Cho, Y., Kim, J. H., Ahn, J. Y., Choi, J. Y., & Yeom, J. S. (2020). Clinical characteristics and online mental health care of asymptomatic or mildly symptomatic patients with coronavirus disease 2019. PloS One, 15, e0242130. https://doi.org/10.1371/journal.pone.0242130.

Jones-Bitton, A., Best, C., MacTavish, J., Fleming, S., & Hoy, S. (2020). Stress, anxiety, depression, and resilience in Canadian farmers. Social Psychiatry and Psychiatric Epidemiology, 55, 229–236. https://doi.org/10.1007/s00127-019-01738-2.

Kalokerinos, E. K., Greenaway, K. H., & Denson, T. F. (2015). Reappraisal but not suppression downregulates the experience of positive and negative emotion. Emotion, 15, 271–275. https://doi.org/10.1037/emo0000025.

Klumpp, H., Roberts, J., Kennedy, A. E., Shankman, S. A., Langenecker, S. A., Gross, J. J., & Phan, K. L. (2017). Emotion regulation related neural predictors of cognitive behavioral therapy response in social anxiety disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 75, 106–112. https://doi.org/10.1016/j.pnpbp.2017.01.010.

Krishnan, V., & Nestler, E. J. (2008). The molecular neurobiology of depression. Nature, 455, 894–902. https://doi.org/10.1038/nature07455.

Leal, P. C., Goes, T. C., da Silva, L. C. F., & Teixeira-Silva, F. (2017). Trait vs. state anxiety in different threatening situations. Trends in Psychiatry and Psychotherapy, 39, 147–157. https://doi.org/10.1590/2237-6089-2016-0044.

Linehan, M. M. (1993). Dialectical behavior therapy for treatment of borderline personality disorder: Implications for the treatment of substance abuse. NIDA Research Monograph, 137, 201–216.

Maaravi, Y., & Heller, B. (2020). Not all worries were created equal: The case of COVID-19 anxiety. Public Health, 185, 243–245. https://doi.org/10.1016/j.puhe.2020.06.032.

MacKinnon, D. P., Fairchild, A. J., & Fritz, M. S. (2007). Mediation analysis. Annual Review of Psychology, 58, 593–614. https://doi.org/10.1146/annurev.psych.58.110405.085542.

Martin, R. C., & Dahlen, E. R. (2005). Cognitive emotion regulation in the prediction of depression, anxiety, stress, and anger. Personality and Individual Differences, 39, 1249–1260. https://doi.org/10.1016/j.paid.2005.06.004.

McLean, C. P., & Anderson, E. R. (2009). Brave men and timid women? A review of the gender differences in fear and anxiety. Clinical Psychology Review, 29, 496–505. https://doi.org/10.1016/j.cpr.2009.05.003.

Mennin, D., & Farach, F. (2007). Emotion and evolving treatments for adult psychopathology. Clinical Psychology: Science and Practice, 14, 329–352. https://doi.org/10.1111/j.1468-2850.2007.00094.x.

Mondo, M., Sechi, C., & Cabras, C. (2021). Psychometric evaluation of three versions of the Italian Perceived Stress Scale. Current Psychology, 40, 1884– 1892. https://doi.org/10.1007/s12144-0190132-8.

Morey, J. N., Boggero, I. A., Scott, A. B., & Segerstrom, S. C. (2015). Current directions in stress and human immune function. Current Opinion in Psychology, 5, 13–17. https://doi.org/10.1016/j.copsyc.2015.03.007.

Mousavi, S. A. M., Hooshyari, Z., & Ahmadi, A. (2020). The most stressful events during the COVID-19 epidemic. Iranian Journal of Psychiatry, 15, 220– 227. https://doi.org/10.18502/ijps.v15i3.3814.

Musazzi, L., Tornese, P., Sala, N., & Popoli, M. (2017). Acute stress is not acute: Sustained enhancement of glutamate release after acute stress involves readily releasable pool size and synapsin I activation. Molecular Psychiatry, 22, 1226–1227. https://doi.org/10.1038/mp.2016.175.

Nowlan, J. S., Wuthrich, V. M., & Rapee, R. M. (2016). The impact of positive reappraisal on positive (and negative) emotion among older adults. International Psychogeriatrics, 28, 681–693. https://doi.org/10.1017/S104161021500205.7

O’Leary, K., Bylsma, L. M., & Rottenberg, J. (2017). Why might poor sleep quality lead to depression? A role for emotion regulation. Cognition and Emotion, 31, 1698–1706. https://doi.org/10.1080/02699931.2016.1247035.

Osborne, M. T., Shin, L. M., Mehta, N. N., Pitman, R. K., Fayad, Z. A., & Tawakol, A. (2020). Disentangling the links between psychosocial stress and cardiovascular disease. Circulation: Cardiovascular Imaging, 13, e010931. https://doi.org/10.1161/CIRCIMAGING.120.010931.

Pandey, D., Bansal, S., Goyal, S., Garg, A., Sethi, N., Pothiyill, D. I., Sreelakshmi, E. S., Sayyad, M. G., & Sethi, R. (2020). Psychological impact of mass quarantine on population during pandemics – the COVID-19 lock-down (COLD) study. PLoS One, 15, e0240501. https://doi.org/10.1371/journal.pone.0240501.

Renna, M. E., Fresco, D. M., & Mennin, D. S. (2020). Emotion regulation therapy and its potential role in the treatment of chronic stress-related pathology across disorders. Chronic Stress, 4, 1–10. https://doi.org/10.1177/2470547020905787.

Rice, S. M., Treeby, M. S., Gersh, E., Ogrodniczuk, J. S., & Kealy, D. (2018). The emotion regulation questionnaire: ERQ-9 factor structure and measurement invariance in Australian and Canadian community samples. TPM – Testing, Psychometrics, Methodology in Applied Psychology, 25, 369–377. https://doi.org/10.4473/TPM25.3.3.

Rincón-Cortés, M., Herman, J. P., Lupien, S., Maguire, J., & Shansky, R. M. (2019). Stress: Influence of sex, reproductive status and gender. Neurobiology of Stress, 10, 100155. https://doi.org/10.1016/j.ynstr.2019.100155.

Rossi, R., Socci, V., Talevi, D., Mensi, S., Niolu, C., Pacitti, F., Di Marco, A., Rossi, A., Siracusano, A., & Di Lorenzo, G. (2020). COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy. Frontiers in Psychiatry, 11, 790. https://doi.org/10.3389/fpsyt.2020.00790.

Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the unified protocol as a transdiagnostic emotion regulation-based intervention. Clinical Psychology Review, 72, 101751. https://doi.org/10.1016/j.cpr.2019.101751.

Salari, N., Hosseinian-Far, A., Jalali, R., Vaisi-Raygani, A., Rasoulpoor, S., Mohammadi, M., Rasoulpoor, S., & Khaledi-Paveh, B. (2020). Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Globalization and Health, 16, 57. https://doi.org/10.1186/s12992-020-00589-w.

Sanavio, E., Bertolotti, G., Michielin, P., Vidotto, G., & Zotti, A. M. (1997). CBA-2.0 scale primarie [CBA2.0 primary scales]. Giunti Organizzazioni Speciali.

Schmidt, S. (2020). Cannabidiol in the management of stress and anxiety. South African Pharmaceutical Journal, 87, 13–15.

Sorbello, M., El-Boghdadly, K., Di Giacinto, I., Cataldo, R., Esposito, C., Falcetta, S., Merli, G., Cortese, G., Corso, R. M., Bressan, F., Pintaudi, S., Greif, R., Donati, A., Petrini, F., & Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI) Airway Research Group, and The European Airway Management Society (2020). The Italian coronavirus disease 2019 outbreak: Recommendations from clinical practice. Anaesthesia, 75, 724–732. https://doi.org/10.1111/anae.15049.

Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (Form Y). Consulting Psychologists Press. Spielberger, C. H., & Rickman, R. L. (1990). Assessment of state and trait anxiety. In N. Sartorius, V. M. Andreoli, G. Cassano, L. Eisenberg, & P. Kielholz (Eds.), Anxiety: Psychobiological and clinical perspectives (pp. 69–84). Hemisphere.

Spoorthy, M. S., Pratapa, S. K., & Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic: a review. Asian Journal of Psychiatry, 51, 102119. https://doi.org/10.1016/j.ajp.2020.102119.

Stage, F. K., Carter, H. C., & Nora, A. (2004). Path analysis: an introduction and analysis of a decade of research. The journal of Educational Research, 98, 5–13. https://doi.org/10.3200/JOER.98.1.5-13.

Sylvers, P., Lilienfeld, S. O., & LaPrairie, J. L. (2011). Differences between trait fear and trait anxiety: Implications for psychopathology. Clinical Psychology Review, 31, 122–137. https://doi.org/10.1016/j.cpr.2010.08.004.

Szabo, A., Ábel, K., & Boros, S. (2020). Attitudes toward COVID-19 and stress levels in Hungary: Effects of age, perceived health status, and gender. Psychological Trauma: Theory, Research, Practice, and Policy, 12, 572–575. https://doi.org/10.1037/tra0000665.

Talevi, D., Socci, V., Carai, M., Carnaghi, G., Faleri, S., Trebbi, E., di Bernardo, A., Capelli, F., & Pacitti, F. (2020). Mental health outcomes of the COVID-19 pandemic. Rivista di Psichiatria, 55, 137–144. https://doi.org/10.1708/3382.33569.

Valdivia-Salas, S., Sheppard, S. C., & Forsyth, J. P. (2010). Acceptance and commitment therapy in an emotion regulation context. In A. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: a transdiagnostic approach to etiology and treatment (pp. 310–338). Guilford.

Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, 17, 1729. https://doi.org/10.3390/ijerph17051729.

Westerlund, M., Santtila, P., & Antfolk, J. (2020). Regulating emotions under exposure to negative outgroup-related news material results in increased acceptance of out-groups. The Journal of Social Psychology, 160, 357–372. https://doi.org/10.1080/00224545.2019.1675575.

Wong, L. P., Hung, C. C., Alias, H., & Lee, T. S. H. (2020). Anxiety symptoms and preventive measures during the COVID-19 outbreak in Taiwan. BMC Psychiatry, 20, 376. https://doi.org/10.1186/s12888-020-02786-8.

Xu, C., Xu, Y., Xu, S., Zhang, Q., Liu, X., Shao, Y., Xu, X., Peng, L., & Li, M. (2020). Cognitive reappraisal and the association between perceived stress and anxiety symptoms in COVID-19 isolated people. Frontiers in Psychiatry, 11, 858. https://doi.org/10.3389/fpsyt.2020.00858.

Zahniser, E., & Conley, C. S. (2018). Interactions of emotion regulation and perceived stress in predicting emerging adults’ subsequent internalizing symptoms. Motivation and Emotion, 42, 763–773. https://doi.org/10.1007/s11031-018-9696-0.

Downloads

Published

2023-03-28

How to Cite

Di Maggio, I., Romola, M., Lacava, E., Maressa, R., & Bruno, F. (2023). Dealing with COVID-19 stressful events, stress and anxiety: the mediating role of emotion regulation strategies in Italian women. Health Psychology Report, 11(1), 70–80. Retrieved from https://czasopisma.bg.ug.edu.pl/index.php/HPR/article/view/8203

Issue

Section

Artykuły