In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
COVID-19 Pandemic as a T auma ic E en and I s Associa ions
wi h Fea and Men al Heal h: A Cogni i e-Ac i a ion App oach
Ma in Sanchez-Gomez 1,* , Gab iele Gio gi 2, Geo gia Libe a Fins ad 3, Fla io U bini 2, Giulia Fo i 3,
Nicola Mucci 4, Sal a o e Za ina 5and JoséM. León-Pe ez 6,*


Ci a ion: Sanchez-Gomez, M.;
Gio gi, G.; Fins ad, G.L.; U bini, F.;
Fo i, G.; Mucci, N.; Za ina, S.;
León-Pe ez, J.M. COVID-19
Pandemic as a T auma ic E en and
I s Associa ions wi h Fea and Men al
Heal h: A Cogni i e-Ac i a ion
App oach. In . J. En i on. Res. Public
Heal h 2021,18, 7422. h ps://
doi.o g/10.3390/ije ph18147422
Academic Edi o s: Paul
B. Tchounwou and Michael Holli ield
Recei ed: 14 June 2021
Accep ed: 10 July 2021
Published: 12 July 2021
Publishe ’s No e: MDPI s ays neu al
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Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
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A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Depa men o E olu iona y, Educa ional, Social Psychology and Me hodology, Uni e si a Jaume I,
12071 Cas ellón de la Plana, Spain
2Depa men o Human Science, Eu opean Uni e si y o Rome, 00163 Rome, I aly;
gab iele.gio gi@unie .i (G.G.); la io.u bini@unie .i (F.U.)
3Business@Heal h Labo a o y, Eu opean Uni e si y o Rome, 00163 Rome, I aly;
[email p o ec ed] (G.L.F.); [email p o ec ed] (G.F.)
4Depa men o Expe imen al and Clinical Medicine, Uni e si y o Flo ence, La go Pie o Palagi 1,
50139 Flo ence, I aly; [email p o ec ed]
5Occupa ional Heal h Uni , Medical Di ec ion, Bambino GesùChild en’s Hospi al IRCCS, 00165 Rome, I aly;
sal a o e.za [email p o ec ed]
6Depa men o Social Psychology, Uni e sidad de Se illa, 41004 Se illa, Spain
*Co espondence: [email p o ec ed] (M.S.-G.); [email p o ec ed] (J.M.L.-P.)
Abs ac :
The COVID-19 global pandemic s ill ep esen s a majo h ea wi h de imen al heal h
consequences. Analyzing he psychological ou comes, COVID-19 could be in e p e ed as a collec-
i e auma ic e en ha can gene a e symp oms ela ed o pos - auma ic s ess diso de (PTSD).
Conside ing his, he pu pose o his pape is wo old: i s , o in es iga e he ela ionship be ween
in usi e hough s and ea ela ed o he COVID-19 pandemic and be ween in usi e hough s
and men al heal h; second, o es he media ing ole o hype a ousal and a oidance in hese wo
ela ionships. In o de o each hese aims, he p esen s udy in es iga ed hese ela ionships and
es ed a media ion model in wo c oss-sec ional s udies in I aly. Al oge he , 627 indi iduals and
495 wo ke s comple ed an online su ey o s udy 1 and s udy 2, espec i ely. Media ion analyses
we e pe o med ia he SPSS mac o PROCESS; he signi icance o o al, di ec , and indi ec e ec
was es ed ia boo s apping. The esul s showed ha wi hin he PTSD amewo k, hype a ousal
compa ed wi h a oidance media ed he ela ionship be ween in usion and he analyzed ou comes.
In conclusion, he p esen s udy p o ided empi ical e idence o he in luence o hype a ousal on
indi idual consequences such as ea o COVID-19 and men al heal h. Resea ch, as well as heo e ical
and p ac ical implica ions, a e discussed.
Keywo ds: COVID-19; men al heal h; PTSD; pa e n; in usion; hype a ousal; a oidance
1. In oduc ion
Since he Wo ld Heal h O ganiza ion (WHO) decla ed a s a e o in e na ional heal h
eme gency due o he Co ona i us ou b eak, COVID-19 has led o an unexpec ed e olu ion
o con agion and a scena io o dea h and isola ion. Many coun ies ha e adop ed lockdown
measu es and ha e adically changed hei li es yles by swi ching o p o ec i e de ices and
social dis ancing. Se e al s udies ca ied ou du ing he pandemic es i y o he signi ican
impac COVID-19 pandemic has had on he men al heal h o indi iduals, causing s ess,
anxie y, dep essi e symp oms, insomnia, denial, ange , and ea [
1
]. The qua an ine
s a us led o nega i e psychological consequences like heal h anxie y, inancial wo y,
and loneliness [
2
]. In addi ion, “headline s ess diso de ” can be obse ed du ing his
pandemic. This diso de is cha ac e ized by high emo ional esponse (such as s ess
and anxie y) o he endless media epo s ha may cause physical symp oms including
palpi a ion and insomnia [
3
]. The e o e, COVID-19 pandemic can be in e p e ed, o all
In . J. En i on. Res. Public Heal h 2021,18, 7422. h ps://doi.o g/10.3390/ije ph18147422 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 7422 2 o 14
in en s and pu poses, as a collec i e auma ic e en ha can gene a e pos auma ic
symp oms [
4
]. F om his pe spec i e, esea ch and clinical p ac ice showed ha auma pe
se is a powe ul isk ac o o men al diso de s being pos auma ic s ess diso de (PTSD)
cha ac e is ic o he mos common ones [
5
,
6
]. PTSD can be de ined as a diso de ha may
occu in people who ha e expe ienced o wi nessed a auma ic e en such as, o example,
a na u al disas e [
5
]. In his ega d, ecen scien i ic e idence has highligh ed he exis ence
o a ela ionship be ween he COVID-19 pandemic and inc eased le els o PTSD [
7
,
8
].
Acco ding o he In e na ional Classi ica ion o Diseases (ICD-11) [
9
], PTSD is composed o
h ee co e symp oms: ‘In usions’ o in usi e hough s such as epea ed and in olun a y
memo ies o conce ns abou he auma ic e en ha in e up a low o hough (also
dis essing d eams o lashbacks o he auma ic e en , which can be so i id ha people
eel hey a e e-li ing he auma ic expe ience); ‘A oidance’ o pu pose ully a oiding
people, places, ac i i ies, objec s, and si ua ions ha may igge dis essing memo ies
ela ed o he auma ic e en ; and ‘Hype a ousal’ o excessi e igilance ha occu s wi h
exagge a ed s a le esponse, di icul y in concen a ing o emembe ing. These symp oms
we e epo ed in he i s s udies conduc ed on he COVID-19 eme gency in China and
I aly [7,10,11].
Wi hin he li e a u e, in usion seems o be he mos equen symp om ollowed by
hype a ousal and a oidance [
12
]. Mo e speci ically, in usi e hough s compa ed o o he
elemen s a e ecognized as a hallma k and oublesome ea u es o PTSD [
13
]. Howe e , as
B idgland and colleagues no iced, mos heo e ical models do no accoun o po en ial
h ea s looming in he u u e as he causes o PTSD [
8
]. In esponse, we in eg a e a h ee-
dimensional app oach o s udy PTSD (e.g., in usion, hype a ousal, and a oidance) wi h
he Cogni i e-Ac i a ion Theo y o S ess (CATS) o add ess he ela ionship be ween
he dimensions o PTSD (i.e., in usion, hype a ousal, and a oidance) and he COVID-19
pandemic- ela ed ea and men al heal h in di e en I alian samples [14–18].
The emphasis on iden i ying he op imal s uc u al model o PTSD has a leas wo
main p ac ical implica ions: a di ec implica ion in diagnos ic p ocedu e and he assessmen
o como bidi y wi h o he psychopa hologies [19,20].
1.1. COVID-19 Pandemic T auma and Fea Feelings
COVID-19 has led o a d as ic scena io o in ec ions and se ious consequences o he
heal h o indi iduals. Fu he mo e, he pandemic sp eads a gene al ea ha d ama ically
a ec s people’s li es. Speci ically, anxie y is due o wo easons; ea o in ec ion and he
symp oma ic consequences ha may esul om i [21,22].
Recen esea ch conduc ed in Pakis an in es iga ed he p esence, in ensi y, and dy-
namics o ea o he co ona i us among gene al popula ion [
23
]. Pa icipan s we e gi en
an online ques ionnai e, which included in o ma ion on socio-pe sonal da a and closed-
and-open-ended ques ions ega ding co ona i us ea . Responden s who had a high le el
o ea we e asked o desc ibe i s na u e. The esul s showed ha he le el o ea was
highe o women. Fu he mo e, nine main hemes we e ex apola ed om hei esponses:
‘Co ona ea ’ ( ea o he disease i sel , ea o no ecei ing ea men , ea o alling ill, ea
o sp eading he disease o amily membe s, con agiousness, imelessness o he disease,
apid sp ead, and he bu den o ca ing o he amily i in ec ed), loss (loss o lo ed ones
and loss o job), ea o isola ion ( ea o li ing away om one’s amily and s aying a
home o a long ime), ea associa ed wi h eligion, ea o dea h ( ea o dying, ea o he
dea h o o he s, ea o dying be o e eaching one’s goals and ha ing a ho ible dea h), he
consequences o COVID-19 in e ms o blocking he u u e, he unde de elopmen o he
coun y, ea o psychological consequences (sense o powe lessness, sense o unce ain y,
ea o being w ong and s ess/dep ession, anxie y abou inc eased mo ali y, dependence
and inac i i y) and inally, empa hy ( o he poo es people and conce n o he global
sp ead o he disease).
Fu he mo e, ea o COVID-19 has consequences o bo h physical and psychological
heal h and a g ea e impac on he mos ulne able popula ion. This is also con i med by
In . J. En i on. Res. Public Heal h 2021,18, 7422 3 o 14
he esul s o a s udy conduc ed in he Uni ed S a es ha in es iga ed he p e alence o
ea and i s consequences, desc ibing he a ia ion among he mos socially ulne able sub-
popula ions [
24
]. The s udy e ealed a popula ion ha is wo ied, a aid, and unce ain
abou he pandemic si ua ion and i s consequences o he indi idual, he amily, and he
communi y as a whole. Fea o con agion pe ades mul iple aspec s o li e o he poin o
being a pe asi e hough ha has also led he mos ulne able people o commi suicide.
In pa icula , a s udy ca ied ou in India examined 69 cases o suicide and analyzed ela ed
media in o ma ion [
25
]. I has been hypo hesized ha mos o he suicides we e caused by
he ea o con ac ing he in ec ion, al hough a e he au opsy mos o he subjec s es ed
nega i e o COVID-19. Fu he mo e, he p e alence o men in suicide cases was highe
ega dless o age g oup (19–95 yea s).
In his sense, we ollow a cogni i e app aisal model o PTSD. These models sugges
ha cogni i e ac o s, pa icula ly app aisals o ongoing h ea , a e c ucial o unde s and
auma esponse. Fo example, Ho owi z’s (1982) model o PTSD, conside s in usion as
he p ima y ac o in he onse o pos - auma ic symp oms ha may p ecede hype a ousal
and a oidance esponses. In u n, his ac i a ion (i.e., hype a ousal) and a oidance may
inc ease nega i e eelings such as ea o he COVID-19 pandemic. In his aspec , acco ding
o CATS heo y, he COVID-19 pandemic can be in e p e ed as a auma ic expe ience
i sel associa ed wi h PTSD symp oms [
7
,
8
]. Fu he mo e, his auma elici s in usi e
hough s, which can be conside ed as a h ea ening s esso (i.e., cogni i e ac i a ion) ha
sus ains a physiological ac i a ion (i.e., hype a ousal) ha leads he indi idual o cope
wi h he s esso (in his case, o a oid he s esso o auma ic e en ) [
26
]. Then, as
he exposu e o he COVID-19 pandemic con inues, he cogni i e-ac i a ion pe sis s (and
p obably epea edly ac i a es he HPA axis) wi h i s po en ially nega i e consequences in
e ms o bo h inc eased nega i e eelings such as ange , i i abili y, o ea , and diminished
men al heal h.
The e o e, aking as a baseline hese p e ious indings, he i s aim (S udy 1) was o
in es iga e he ela ionship be ween he dimensions o PTSD (i.e., in usion, hype a ousal,
and a oidance) and he COVID-19 pandemic- ela ed ea among gene al popula ion. In
pa icula , we in es iga ed whe he he ela ionship be ween in usion and ea o COVID-
19 is media ed by hype a ousal and a oidance. In o he wo ds, we hypo hesize ha
he causal ela ionship be ween in usion and ea o COVID-19 will be media ed by
hype a ousal and a oidance. The p oposed mul iple sequen ial media ion model can be
seen in Figu e 1.
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 3 o 14
Fu he mo e, ea o COVID-19 has consequences o bo h physical and psychologi-
cal heal h and a g ea e impac on he mos ulne able popula ion. This is also con i med
by he esul s o a s udy conduc ed in he Uni ed S a es ha in es iga ed he p e alence
o ea and i s consequences, desc ibing he a ia ion among he mos socially ulne able
sub-popula ions [24]. The s udy e ealed a popula ion ha is wo ied, a aid, and unce -
ain abou he pandemic si ua ion and i s consequences o he indi idual, he amily, and
he communi y as a whole. Fea o con agion pe ades mul iple aspec s o li e o he poin
o being a pe asi e hough ha has also led he mos ulne able people o commi sui-
cide. In pa icula , a s udy ca ied ou in India examined 69 cases o suicide and analyzed
ela ed media in o ma ion [25]. I has been hypo hesized ha mos o he suicides we e
caused by he ea o con ac ing he in ec ion, al hough a e he au opsy mos o he sub-
jec s es ed nega i e o COVID-19. Fu he mo e, he p e alence o men in suicide cases
was highe ega dless o age g oup (19–95 yea s).
In his sense, we ollow a cogni i e app aisal model o PTSD. These models sugges
ha cogni i e ac o s, pa icula ly app aisals o ongoing h ea , a e c ucial o unde s and
auma esponse. Fo example, Ho owi z's (1982) model o PTSD, conside s in usion as
he p ima y ac o in he onse o pos - auma ic symp oms ha may p ecede hype -
a ousal and a oidance esponses. In u n, his ac i a ion (i.e., hype a ousal) and a oid-
ance may inc ease nega i e eelings such as ea o he COVID-19 pandemic. In his aspec ,
acco ding o CATS heo y, he COVID-19 pandemic can be in e p e ed as a auma ic ex-
pe ience i sel associa ed wi h PTSD symp oms [7,8]. Fu he mo e, his auma elici s in-
usi e hough s, which can be conside ed as a h ea ening s esso (i.e., cogni i e ac i a-
ion) ha sus ains a physiological ac i a ion (i.e., hype a ousal) ha leads he indi idual
o cope wi h he s esso (in his case, o a oid he s esso o auma ic e en ) [26]. Then,
as he exposu e o he COVID-19 pandemic con inues, he cogni i e-ac i a ion pe sis s
(and p obably epea edly ac i a es he HPA axis) wi h i s po en ially nega i e conse-
quences in e ms o bo h inc eased nega i e eelings such as ange , i i abili y, o ea , and
diminished men al heal h.
The e o e, aking as a baseline hese p e ious indings, he i s aim (S udy 1) was o
in es iga e he ela ionship be ween he dimensions o PTSD (i.e., in usion, hype a ousal,
and a oidance) and he COVID-19 pandemic- ela ed ea among gene al popula ion. In
pa icula , we in es iga ed whe he he ela ionship be ween in usion and ea o
COVID-19 is media ed by hype a ousal and a oidance. In o he wo ds, we hypo hesize
ha he causal ela ionship be ween in usion and ea o COVID-19 will be media ed by
hype a ousal and a oidance. The p oposed mul iple sequen ial media ion model can be
seen in Figu e 1.
Figu e 1. Sequen ial media ion model p oposed o es he associa ions be ween in u-
si e hough s, hype a ousal, a oidance, and ea o COVID-19 (S udy 1). +: posi i e ela-
ionship
Figu e 1.
Sequen ial media ion model p oposed o es he associa ions be ween in usi e hough s,
hype a ousal, a oidance, and ea o COVID-19 (S udy 1). +: posi i e ela ionship.
1.2. COVID-19 Pandemic T auma and Men al Heal h
The esul s o he e e ed li e a u e highligh he ex en o which he COVID-19
pandemic may ha e a signi ican impac on he psychological heal h o indi iduals. A
ecen esea ch conduc ed in Hubei p o ince a emp ed o ex apola e he main symp-
oms o PTSD as a esul o he pandemic. In he ne wo k o COVID-19 pandemic- ela ed
In . J. En i on. Res. Public Heal h 2021,18, 7422 4 o 14
PTSD symp oms, esul s showed s ong connec ions be ween a oidance o hough s and
a oidance o eminde s, be ween hype igilance and exagge a ed ala m esponse, be-
ween in usi e hough s and nigh ma es, be ween lashbacks and hype esponsi eness
o emo ional signals, and be ween de achmen and limi ed a ec ion. Fu he mo e, he
s udy sugges ed ha he main symp om was sel -des uc i e/ eckless beha io , which
was posi i ely co ela ed wi h he p esence o dep ession and loss o in e es [27].
Fu he mo e, p e ious s udies ha e shown an associa ion be ween PTSD symp oms
ela ed o he COVID-19 pandemic and se e al measu es o men al heal h, including
anxie y, dep ession, and psychological unc ioning [
8
]. Fo example, a me a-analysis
examined he e ec o 62 s udies add essing he impac o PTSD symp oms on gene al
heal h and concluded ha people wi h high le els o PTSD symp oms also epo ed
poo e heal h ou comes [
28
]. Simila ly, a s udy o 168 e u ning e e ans ound ha PTSD
symp oms ha e a unique con ibu ion o men al heal h (6%) when con olling o he e ec
o se e al p edic o s such as se e i y o auma exposu e, physical inju y, o subs ance
abuse [29].
The e o e, ollowing he same a ionale as in he p e ious sec ion, we assume ha
he COVID-19 pandemic is a auma ic e en ha leads o expe iencing PTSD symp oms,
which, in u n, a e associa ed o poo e men al heal h. As men ioned abo e, based on
CATS heo y and cogni i e app aisal models o PTSD, cogni i e mechanisms (i.e., in u-
sion) p oduce a physiological ac i a ion (hype a ousal) ha p omp s he coping esponse
(a oidance in his case, as he e en canno be con olled o sol ed); howe e , as his
cogni ion-ac i a ion pe sis s and he coping s a egies a e maladap i e o unsuccess ul,
indi iduals’ men al heal h is nega i ely a ec ed. Thus, he second aim (S udy 2) was o
in es iga e he ela ionship be ween he PTSD dimensions (i.e., in usion, hype a ousal,
and a oidance) and men al heal h in a sample o I alian wo ke s. In his case, we hy-
po hesized ha he ela ionship be ween in usion and men al heal h will be media ed by
hype a ousal and a oidance. This media ion model is illus a ed in Figu e 2.
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 4 o 14
1.2. COVID-19 Pandemic T auma and Men al Heal h
The esul s o he e e ed li e a u e highligh he ex en o which he COVID-19 pan-
demic may ha e a signi ican impac on he psychological heal h o indi iduals. A ecen
esea ch conduc ed in Hubei p o ince a emp ed o ex apola e he main symp oms o
PTSD as a esul o he pandemic. In he ne wo k o COVID-19 pandemic- ela ed PTSD
symp oms, esul s showed s ong connec ions be ween a oidance o hough s and a oid-
ance o eminde s, be ween hype igilance and exagge a ed ala m esponse, be ween in-
usi e hough s and nigh ma es, be ween lashbacks and hype esponsi eness o emo-
ional signals, and be ween de achmen and limi ed a ec ion. Fu he mo e, he s udy sug-
ges ed ha he main symp om was sel -des uc i e/ eckless beha io , which was posi-
i ely co ela ed wi h he p esence o dep ession and loss o in e es [27].
Fu he mo e, p e ious s udies ha e shown an associa ion be ween PTSD symp oms
ela ed o he COVID-19 pandemic and se e al measu es o men al heal h, including anx-
ie y, dep ession, and psychological unc ioning [8]. Fo example, a me a-analysis exam-
ined he e ec o 62 s udies add essing he impac o PTSD symp oms on gene al heal h
and concluded ha people wi h high le els o PTSD symp oms also epo ed poo e
heal h ou comes [28]. Simila ly, a s udy o 168 e u ning e e ans ound ha PTSD symp-
oms ha e a unique con ibu ion o men al heal h (6%) when con olling o he e ec o
se e al p edic o s such as se e i y o auma exposu e, physical inju y, o subs ance abuse
[29].
The e o e, ollowing he same a ionale as in he p e ious sec ion, we assume ha
he COVID-19 pandemic is a auma ic e en ha leads o expe iencing PTSD symp oms,
which, in u n, a e associa ed o poo e men al heal h. As men ioned abo e, based on
CATS heo y and cogni i e app aisal models o PTSD, cogni i e mechanisms (i.e., in u-
sion) p oduce a physiological ac i a ion (hype a ousal) ha p omp s he coping esponse
(a oidance in his case, as he e en canno be con olled o sol ed); howe e , as his cog-
ni ion-ac i a ion pe sis s and he coping s a egies a e maladap i e o unsuccess ul, indi-
iduals’ men al heal h is nega i ely a ec ed. Thus, he second aim (S udy 2) was o in es-
iga e he ela ionship be ween he PTSD dimensions (i.e., in usion, hype a ousal, and
a oidance) and men al heal h in a sample o I alian wo ke s. In his case, we hypo hesized
ha he ela ionship be ween in usion and men al heal h will be media ed by hype -
a ousal and a oidance. This media ion model is illus a ed in Figu e 2.
Figu e 2. Sequen ial media ion model p oposed o es he associa ions be ween in usi e
hough s, hype a ousal, a oidance, and men al heal h (S udy 2). +: posi i e ela ionship; −: nega-
i e ela ionship
2. Ma e ials and Me hods
2.1. Sample and Design
In S udy 1, we ollowed a c oss-sec ional design. The s udy was de eloped du ing
he second hal o 2020 and ea ly 2021, in pa allel wi h he COVID-19 pandemic. S udy 1
Figu e 2.
Sequen ial media ion model p oposed o es he associa ions be ween in usi e hough s,
hype a ousal, a oidance, and men al heal h (S udy 2). +: posi i e ela ionship;
−
: nega i e ela ionship.
2. Ma e ials and Me hods
2.1. Sample and Design
In S udy 1, we ollowed a c oss-sec ional design. The s udy was de eloped du ing
he second hal o 2020 and ea ly 2021, in pa allel wi h he COVID-19 pandemic. S udy 1
sample consis ed o 627 subjec s. Table 1shows he socio-demog aphic cha ac e is ics o
he pa icipan s.
In . J. En i on. Res. Public Heal h 2021,18, 7422 5 o 14
Table 1. Socio-demog aphic cha ac e is ics o he sample (S udy 1, N= 627).
Cha ac e is ics
Age (Mean, SD) 31.4, 13.9
Gende (%)
Male 35.2
Female 64.8
Ma i al s a us (%)
Single 71.5
Ma ied 28.5
Educa ional le el (%)
P ima y 1.9
Seconda y 48.6
Uni e si y 39.4
Mas e 8.3
PhD 1.8
Job s a us (%)
S uden 22.3
Unemployed 17.6
Employed 60.1
Simila ly, S udy 2 ollowed a c oss-sec ional design and was de eloped du ing he
second hal o 2020 and he beginning o 2021. The sample o he second s udy consis ed o
495 wo ke s selec ed om se e al I alian companies. Table 2shows he socio-demog aphic
cha ac e is ics o hese pa icipan s.
Table 2. Socio-demog aphic cha ac e is ics o he sample (S udy 2, N= 495).
Cha ac e is ics
Gende (%)
Men 67.7
Women 32.3
O ganiza ional senio i y (%)
4 yea s o less 19.1
5–9 yea s 43
10–20 yea s 21.8
Mo e han 20 yea s 16.1
Job ca ego y (%)
Chie 3.1
Middle managemen 20.1
Employee 76.8
2.1.1. PTSD Gene a ed by COVID-19
The Impac o E en Scale in i s six-i em e sion was used o assess he s ess gene a ed
by he COVID-19 pandemic (IES-6) [
30
]. Fo his pu pose, he i ems we e ansla ed
in o I alian. The esponden s we e ins uc ed o answe he ques ionnai e conside ing
he Co ona i us pandemic as he po en ially s ess ul e en . This ques ionnai e is an
abb e ia ed e sion o he o iginal IES-R, a 22-i em sc eening es o assess pos auma ic
s ess diso de (PTSD) [
31
]. The i ems a e ela ed o eelings o dis ess expe ienced o e
he las 7 days, exp essly ollowing a speci ic auma ic si ua ion, which, in ou case, is he
COVID-19 pandemic. Following a i e-poin Like scale, he IES-6 includes wo i ems o
each o he dimensions o pos auma ic s ess: in usion (e.g., “Since he beginning o he
COVID-19 eme gency, I hough abou i when I didn’ mean o”), a oidance (e.g., “Since
he beginning o he COVID-19 eme gency, I was awa e ha I s ill had a lo o eelings abou
i , bu I didn’ deal wi h hem”) and hype a ousal (e.g., “Since he beginning o he COVID-

In . J. En i on. Res. Public Heal h 2021,18, 7422 6 o 14
19 eme gency, I had ouble concen a ing”). The in e nal eliabili y o he a iables was
adequa e (S udy 1: In usion = 0.85, Hype a ousal = 0.82 and
A oidance = 0.66
; S udy 2:
In usion = 0.86, Hype a ousal = 0.73 and A oidance = 0.66). This scale was used in bo h
S udy 1 and S udy 2.
2.1.2. Fea o COVID-19
We measu ed he ex en o which he pandemic cons i u ed a h ea o people wi h
an eigh -i em scale de eloped o his pu pose (e.g., I am a aid o con ac ing he i us).
The scale uses a i e-poin Like scale anging om 1 (s ongly disag ee) o 5 (s ongly
ag ee). A o al sco e is calcula ed by ob aining he sum o all eigh i ems. The highe
he sco e, he g ea e he ea o COVID-19. This ques ionnai e demons a ed a s able
unidimensional s uc u e and showed adequa e psychome ic p ope ies (see Table 3).
Mo eo e , i s in e nal consis ency was high (
α
= 0.90). This scale was used only in S udy 1.
Table 3. I ems and psychome ic p ope ies o he ea o COVID-19 ques ionnai e.
I em Fac o loading * I em-To al
Co ela ion
Mean
(SD) Skewness Ku osis
1. I am a aid o con ac ing he i us 0.477 0.69 3.61 (1.09) −0.419 −0.475
2. I am a aid o he possibili y o buying
po en ially con amina ed goods 0.488 0.70 2.71 (1.28) 0.234 −0.995
3. I am a aid o buying goods in shops 0.567 0.75 2.44 (1.15) 0.405 −0.683
4. I am a aid o using u ban anspo 0.691 0.83 4 (1.15) −1.087 0.425
5. I am a aid o using ains 0.763 0.87 3.72 (1.23) −0.728 −0.410
6. I am a aid o using planes 0.651 0.81 3.61 (1.24) −0.558 −0.711
7. I am a aid o going o acili ies o use heal h
se ices (gene al p ac i ione , hospi als, e c.) 0.502 0.71 3.58 (1.15) −0.595 −0.034
8. I am a aid o going o acili ies o basic
necessi ies (bank, pos o ice, supe ma ke , e c.). 0.642 0.80 2.96 (1.06) −0.082 −0.555
No e: * Ex ac ion me hod: Fac o loadings using he ex ac ion me hod: unweigh ed leas squa es. SD = s anda d de ia ion.
2.1.3. Men al Heal h
The I alian e sion o he Gene al Heal h Ques ionnai e (GHQ-12) was used in o de
o assess he symp oms o men al dis ess [
32
]. This is a sel -adminis e ed ques ionnai e
adap ed om he o iginal de eloped by Goldbe g and Williams o assess non-speci ic
psychia ic diso de s [
33
]. Following a ou -poin Like -scale, pa icipan s answe ed
12 i ems
based on hei cu en expe ience o men al dis ess (e.g., I was unable o enjoy
daily ac i i ies). I is impo an o no e ha in his s udy, unlike he o iginal ques ionnai e,
he sco ing was pe o med in he opposi e di ec ion. Thus, he highe he sco e, he g ea e
he men al heal h. C onbach’s alpha alues indica e a good le el o eliabili y (
α
= 0.86).
This scale was used only in S udy 2.
2.2. P ocedu e
Following simila p e ious s udies, pa icipan s in S udy 1 we e ec ui ed h ough
psychology g adua es and PhD s uden s who had expe ience in psychological assessmen .
The p ocedu e was pe o med based on he ecommenda ions o e ed by Wheele e al.
o apply his ype o sampling echnique [
34
]. The es ba e y was de eloped using he
Google Fo ms pla o m and was emailed using a esea ch lab da abase o 2702 people.
627 subjec s comple ed he ull o m ( esponse a e = 23.2%). The o ma included a i s
page in which i was manda o y o demons a e a minimum age o 18 and in which he
olun a y and con iden ial na u e o he collabo a ion was cla i ied. All he pa icipan s
accep ed he condi ions o his esea ch. The whole p ocess was conduc ed in acco dance
wi h he Decla a ion o Helsinki. Gi en he obse a ional na u e o he s udy along wi h
he absence o any in ol emen o he apeu ic medica ion, no o mal app o al o he
Ins i u ional Re iew Boa d o he local E hics Commi ee was equi ed. Fu he mo e, he
In . J. En i on. Res. Public Heal h 2021,18, 7422 7 o 14
Ame ican Psychological Associa ion’s (APA) E hical P inciples o Psychologis s and Code
o Conduc we e ollowed.
In S udy 2, pa icipan s we e ec ui ed om se e al I alian companies ollowing a
con enience sampling p ocedu e. Fi s ly, he esea che s o his s udy con ac ed se e al
companies om a ious sec o s and in o med Human Resou ces (HR) manage s o he
oppo uni y o pa icipa e. Once accep ed, an email in i a ion was sen o 786 people, 495 o
whom esponded ( esponse a e = 62.9%). All pa icipan s ag eed o pa icipa e olun a ily
in he esea ch and s a ed ha hey we e a leas 18 yea s old. The ques ionnai es we e
adminis e ed h ough he Google Fo ms pla o m. The whole p ocess was pe o med
ollowing he APA E hical P inciples and Code o Conduc and in acco dance wi h he
Decla a ion o Helsinki. Gi en he obse a ional na u e o he s udy, and in he absence o
any in ol emen o he apeu ic medica ion, no o mal app o al o he Ins i u ional Re iew
Boa d o he local E hics Commi ee was equi ed.
2.3. Da a Analysis
The s a is ics so wa e IBM SPSS
®
( . 26, package o Windows, SPSS Inc., Chicago, IL,
USA) was used o analyze he da a. Ini ially, he dis ibu ion o he a iables was analyzed
using he Kolmogo o –Smi no es o check o no mali y. A e es ablishing he no mali y
o he dis ibu ion, he desc ip i e s a is ics, including he mean and he s anda d de ia ion
and Pea son co ela ions be ween In usion (independen a iable), hype a ousal ( i s
media o ), a oidance (second media o ), and ea o COVID-19 (dependen a iable o
S udy 1)/men al heal h (dependen a iable o S udy 2) we e ob ained. Secondly, eliabili y
analyses we e pe o med o he s udy a iables. Fu he mo e, he SPSS mac o PROCESS
3.3 (And ew F. Hayes, AB, Canada) was used o es he p oposed associa ions ega ding
he media ion models (Figu es 1and 2) [
35
]. Then, a s anda d p ocedu e was ollowed
using a 10,000 boo s ap sample, which p oduced 95% bias-co ec ed con idence in e als.
A pa h is s a is ically signi ican i he associa ed 95% con idence in e al (CI; bias co ec ed)
does no include ze o. The le el o signi icance was se a p≤0.05.
3. Resul s
3.1. Desc ip i e Analyses
Desc ip i e s a is ics (i.e., means, s anda d de ia ions) and bi a ia e co ela ions
be ween he s udy a iables ega ding S udy 1 and S udy a e desc ibed in Tables 4and 5,
espec i ely. As expec ed, in usion co ela ed posi i ely wi h hype a ousal ( = 0.65 in
S udy 1; = 0.63 in S udy 2), a oidance ( = 0.53 in S udy 1; = 0.52 in S udy 2), and ea o
COVID-19
( = 0.42
in S udy 1). Also, In usion co ela ed nega i ely wi h men al heal h
( = −0.25
in S udy 2). Fu he mo e, hype a ousal ( = 0.41) and a oidance ( = 0.36) we e
posi i ely co ela ed o ea o COVID-19 (S udy 1); whe eas hype a ousal ( =
−
0.49) and
a oidance ( = −0.43) we e nega i ely co ela ed o men al heal h (S udy 2).
Table 4. Mean, s anda d de ia ion, and co ela ions among he s udy a iables in S udy 1.
M SD 1 2 3
1. In usion 3.40 1.07
2. Hype a ousal 2.75 1.08 0.65 **
3. A oidance 2.84 1.19 0.53 ** 0.75 **
4. Fea o COVID-19 26.63 7.21 0.42 ** 0.41 ** 0.36 **
No e: N= 627. M = mean. SD = s anda d de ia ion. ** p< 0.01.
In . J. En i on. Res. Public Heal h 2021,18, 7422 8 o 14
Table 5. Mean, s anda d de ia ion, and co ela ions among he s udy a iables in S udy 2.
M SD 1 2 3
1. In usion 2.92 1.08
2. Hype a ousal 2.09 0.96 0.63 **
3. A oidance 2.12 1.11 0.52 ** 0.70 *
4. Men al heal h 1.98 0.45 −
0.25 **
−
0.49 **
−
0.43 **
No e: N= 495. M = mean. SD = s anda d de ia ion. * p< 0.05; ** p< 0.01.
3.2. Mul iple Media ion Analyses
The i s mul iple media ion analysis was pe o med o es he associa ions be ween
in usi e hough s, hype a ousal, a oidance, and ea o COVID-19. As can be seen in
Figu e 3, in usion was posi i ely and signi ican ly ela ed o hype a ousal (a
1
= 0.65;
p< 0.01)
, and a oidance (a
2
= 0.07; p< 0.01). The ela ionship be ween in usion and ea
o COVID-19 (c = 0.42; p< 0.01) was pa ially media ed by hype a ousal. Meanwhile, he
di ec e ec kep i s signi icance (c’ = 0.88; p< 0.01). Once he mul iple media ion pa hways
we e es ed, only pa h 1 (a
1
b
1
= in usion–hype a ousal– ea o COVID-19) was signi ican
(B = 0.41; SE = 0.13; 95% CI = 0.14; 0.67). Thus, highe in usion ac i i y esul ed in highe
hype a ousal, which inc eased he ea o COVID-19.
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 8 o 14
Table 4. Mean, s anda d de ia ion, and co ela ions among he s udy a iables in S udy 1.
M SD 1 2 3
1. In usion 3.40 1.07
2. Hype a ousal 2.75 1.08 0.65 **
3. A oidance 2.84 1.19 0.53 ** 0.75 **
4. Fea o COVID-19 26.63 7.21 0.42 ** 0.41 ** 0.36 **
No e: N = 627. M = mean. SD = s anda d de ia ion. * p < 0.05; ** p < 0.01.
Table 5. Mean, s anda d de ia ion, and co ela ions among he s udy a iables in S udy 2.
M SD 1 2 3
1. In usion 2.92 1.08
2. Hype a ousal 2.09 0.96 0.63 **
3. A oidance 2.12 1.11 0.52 ** 0.70 *
4. Men al heal h 1.98 0.45 −0.25 ** −0.49 ** −0.43 **
No e: N = 495. M = mean. SD = s anda d de ia ion. * p < 0.05; ** p < 0.01.
3.2. Mul iple Media ion Analyses
The i s mul iple media ion analysis was pe o med o es he associa ions be ween
in usi e hough s, hype a ousal, a oidance, and ea o COVID-19. As can be seen in
Figu e 3, in usion was posi i ely and signi ican ly ela ed o hype a ousal (a1 = 0.65; p <
0.01), and a oidance (a2 = 0.07; p < 0.01). The ela ionship be ween in usion and ea o
COVID-19 (c = 0.42; p < 0.01) was pa ially media ed by hype a ousal. Meanwhile, he
di ec e ec kep i s signi icance (c’ = 0.88; p < 0.01). Once he mul iple media ion pa hways
we e es ed, only pa h 1 (a1b1 = in usion–hype a ousal– ea o COVID-19) was signi ican
(B = 0.41; SE = 0.13; 95% CI = 0.14; 0.67). Thus, highe in usion ac i i y esul ed in highe
hype a ousal, which inc eased he ea o COVID-19.
Figu e 3. Sequen ial media ion model p oposed o es he associa ions be ween in usi e
hough s, hype a ousal, a oidance, and ea o COVID-19. * p < 0.05. ** p < 0.01.
The second mul iple media ion analysis was pe o med o es he associa ions be-
ween in usi e hough s, hype a ousal, a oidance, and men al heal h. As can be seen in
Figu e 4, in usion was posi i ely and signi ican ly ela ed o hype a ousal (a1 = 0.55; p <
0.01), and a oidance (a2 = 0.13; p < 0.01). The ela ionship be ween in usion and men al
heal h (c = −0.10; p = 0.02) was pa ially media ed by hype a ousal and he di ec e ec
con inued o be signi ican (c’ = −0.05; p < 0.01). Once he mul iple media ion pa hways
we e es ed, h ee signi ican pa hs we e ound: pa h 1 (a1b1 = in usion-hype a ousal-
men al heal h; B = −0.11; SE = 0.02; 95% CI = 0.07; 0.15), pa h 2 (a1d21b2 = = in usion-hype -
a ousal-a oidance-men al heal h; B = −0.07; SE = 0.02; 95% CI = 0.02; 0.12), and pa h 3 (a2b2
Figu e 3.
Sequen ial media ion model p oposed o es he associa ions be ween in usi e hough s,
hype a ousal, a oidance, and ea o COVID-19. ** p< 0.01.
The second mul iple media ion analysis was pe o med o es he associa ions be-
ween in usi e hough s, hype a ousal, a oidance, and men al heal h. As can be seen
in Figu e 4, in usion was posi i ely and signi ican ly ela ed o hype a ousal (a
1
= 0.55;
p< 0.01)
, and a oidance (a
2
= 0.13; p< 0.01). The ela ionship be ween in usion and men al
heal h (c =
−
0.10; p= 0.02) was pa ially media ed by hype a ousal and he di ec e ec
con inued o be signi ican (c’ =
−
0.05; p< 0.01). Once he mul iple media ion pa hways
we e es ed, h ee signi ican pa hs we e ound: pa h 1 (a
1
b
1
= in usion-hype a ousal-
men al heal h; B =
−
0.11; SE = 0.02; 95% CI = 0.07; 0.15), pa h 2 (a
1
d
21
b
2
= in usion-
hype a ousal-a oidance-men al heal h; B =
−
0.07; SE = 0.02; 95% CI = 0.02; 0.12), and pa h
3
(a2b2= in usion
-a oidance-men al heal h; B =
−
0.02; SE = 0.01; 95% CI = 0.01; 0.04).
A e examining he pai wise con as s o indi ec e ec s, he i s pa h was ound o be he
mos impo an . Thus, g ea e in usion ac i i y esul ed in highe hype a ousal, which
educed pe cei ed men al heal h.
In . J. En i on. Res. Public Heal h 2021,18, 7422 9 o 14
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 9 o 14
= in usion-a oidance-men al heal h; B = −0.02; SE = 0.01; 95% CI = 0.01; 0.04). A e exam-
ining he pai wise con as s o indi ec e ec s, he i s pa h was ound o be he mos
impo an . Thus, g ea e in usion ac i i y esul ed in highe hype a ousal, which e-
duced pe cei ed men al heal h.
Figu e 4. Sequen ial media ion model p oposed o es he associa ions be ween in usi e
hough s, hype a ousal, a oidance, and men al heal h. * p < 0.05. ** p < 0.01.
4. Discussion
This s udy aimed o u he -de elop he unde s anding o he consequences o
COVID-19 pandemic wi hin he PTSD amewo k. Speci ically, hype a ousal and a oid-
ance ha e been sugges ed as possible unde lying mechanisms be ween in usion, consid-
e ed as he p ima y ac o in he onse o pos - auma ic symp oms o PTSD, and wo
di e en ou comes, ha is, ea o COVID-19 and men al heal h. Nowadays, PTSD is
widely ecognized as one o he mos p obable psychosocial consequences o he COVID-
19 pandemic (e.g., [11]). Al hough in e es on he psychological impac o COVID-19 pan-
demic is inc easing (e.g., [36]) exis ing esea ch has no ully conside ed ye he ole o
PTSD and i s consequences on men al heal h and COVID-19 ela ed issues. In he p esen
esea ch, wo s udies we e designed o add ess his gap by de eloping and es ing wo
independen models in which wo dimensions o PTSD, hype a ousal and a oidance, me-
dia ed he e ec s o in usion on wo indi idual ou comes. S udy 1 examined he associ-
a ion o in usion wi h a ype o indi idual eac ion closely ela ed o COVID-19: ea o
COVID-19. S udy 2 in es iga ed he ela ionship be ween in usion and men al heal h.
Bo h models a e d awn on he heo e ical model o Ho owi z, which conside s in usi e
hough s as a ac o ha may p ecede a oidance and hype a ousal [37].
The cu en indings p o ided u he e idence o his app oach. Fi s , he esul s
suppo ed he ela ionship be ween he a iables. In his ega d, in S udy 1 in usion co -
ela ed posi i ely wi h hype a ousal, a oidance, and ea o COVID-19. Fu he mo e, hy-
pe a ousal and a oidance we e nega i ely ela ed o ea o COVID-19. In S udy 2, in u-
sion co ela ed posi i ely wi h hype a ousal and a oidance and nega i ely wi h men al
heal h. Simila ly o S udy 1, hype a ousal and a oidance we e nega i ely co ela ed wi h
men al heal h. Wi h espec o pa h model in s udy 1, in usion had a posi i e and signi -
ican di ec e ec on ea o COVID-19; u he mo e, he indi ec e ec o in usion on ea
o COVID-19 ia wo media o s (hype a ousal and a oidance) was posi i e and signi i-
can only o hype a ousal. Rega ding he pa h model in S udy 2, in usion had a posi i e
and signi ican di ec e ec on men al heal h. Fu he mo e, he indi ec e ec o in usion
on ea o COVID-19 ia wo media o s (hype a ousal and a oidance) was nega i e and
signi ican only in he case o hype a ousal. The e o e, hype a ousal media ed he ela-
ionship be ween in usion and wo indi idual ou comes, emphasizing he key ole ha
hype a ousal plays in he domain o PTSD. Despi e he ac ha in usi e symp oms can
Figu e 4.
Sequen ial media ion model p oposed o es he associa ions be ween in usi e hough s,
hype a ousal, a oidance, and men al heal h. * p< 0.05. ** p< 0.01.
4. Discussion
This s udy aimed o u he -de elop he unde s anding o he consequences o COVID-
19 pandemic wi hin he PTSD amewo k. Speci ically, hype a ousal and a oidance ha e
been sugges ed as possible unde lying mechanisms be ween in usion, conside ed as
he p ima y ac o in he onse o pos - auma ic symp oms o PTSD, and wo di e en
ou comes, ha is, ea o COVID-19 and men al heal h. Nowadays, PTSD is widely
ecognized as one o he mos p obable psychosocial consequences o he COVID-19
pandemic (e.g., [
11
]). Al hough in e es on he psychological impac o COVID-19 pandemic
is inc easing (e.g., [
36
]) exis ing esea ch has no ully conside ed ye he ole o PTSD and
i s consequences on men al heal h and COVID-19 ela ed issues. In he p esen esea ch,
wo s udies we e designed o add ess his gap by de eloping and es ing wo independen
models in which wo dimensions o PTSD, hype a ousal and a oidance, media ed he
e ec s o in usion on wo indi idual ou comes. S udy 1 examined he associa ion o
in usion wi h a ype o indi idual eac ion closely ela ed o COVID-19: ea o COVID-19.
S udy 2 in es iga ed he ela ionship be ween in usion and men al heal h. Bo h models
a e d awn on he heo e ical model o Ho owi z, which conside s in usi e hough s as a
ac o ha may p ecede a oidance and hype a ousal [37].
The cu en indings p o ided u he e idence o his app oach. Fi s , he esul s
suppo ed he ela ionship be ween he a iables. In his ega d, in S udy 1 in usion
co ela ed posi i ely wi h hype a ousal, a oidance, and ea o COVID-19. Fu he mo e,
hype a ousal and a oidance we e nega i ely ela ed o ea o COVID-19. In S udy 2,
in usion co ela ed posi i ely wi h hype a ousal and a oidance and nega i ely wi h men-
al heal h. Simila ly o S udy 1, hype a ousal and a oidance we e nega i ely co ela ed
wi h men al heal h. Wi h espec o pa h model in s udy 1, in usion had a posi i e and
signi ican di ec e ec on ea o COVID-19; u he mo e, he indi ec e ec o in usion
on ea o COVID-19 ia wo media o s (hype a ousal and a oidance) was posi i e and
signi ican only o hype a ousal. Rega ding he pa h model in S udy 2, in usion had
a posi i e and signi ican di ec e ec on men al heal h. Fu he mo e, he indi ec e ec
o in usion on ea o COVID-19 ia wo media o s (hype a ousal and a oidance) was
nega i e and signi ican only in he case o hype a ousal. The e o e, hype a ousal medi-
a ed he ela ionship be ween in usion and wo indi idual ou comes, emphasizing he
key ole ha hype a ousal plays in he domain o PTSD. Despi e he ac ha in usi e
symp oms can gene a e highe le els o a oidance, his s udy highligh ed he p e alence
o hype a ousal o e i [38].
This esul suppo s he idea ha COVID-19 pandemic is a pe asi e and speci ic
mass auma ic e en ha people undamen ally pe cei e by shi ing o a posi ion o
hype igilance a he han a oidance. Such indings a e cohe en wi h he CATS heo y,