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158 the Behavior Therapist
THENOVEL CORONAVIRUS disease, known
as COVID-19, arose in Wuhan, China in
December of 2019. As of May 4, 2020, the
virus has infected over 3.4 million people
and led to over 239,000 deaths globally
(WorldHealth Organization, 2020a), and
the numberscontinuetoriseexponentially.
The World Health Organization declared
COVID-19apandemic on March 11, 2020.
In response to the COVID-19 pandemic,
governments have imposedunprecedented
changes, such as closures of all nonessen-
tial business and mandated self-isolation.
Health officials have also recommended
social distancing, avoidance of crowded
areas, and increased hygiene practices in
attempt to reduce the spread of COVID-19
(World Health Organization, 2020b). The
magnitudeofthe situation is further high-
lighted by the unabating news and media
revolving around COVID-19.
As aconsequence of the threat of infec-
tion, life has become characterized by
financial uncertainty, fear, stress, and other
substantial lifestyle changes (e.g., social
withdrawal, isolation) that may increase
risk for mental health problems. Indeed,
emerging empirical evidence from China
indicates that greaterthan 25% of the gen-
eral populationare currently experiencing
moderate to severe levels of anxiety in
response to COVID-19 (Qiu et al., 2020;
Wang et al., 2020). Although the full scale
of the psychological impact is not yet
known,basedonobservationsfrom prior
pandemics (Shultz et al., 2008; Taylor,
2019a), it is anticipated to be larger than the
physical impact of the COVID-19 pan-
demic. Efforts directed at minimizing the
spread of COVID-19 and managing its
psychologicalsequelae are timely and crit-
ical.
While much remains unknown about
responses to COVID-19, existing research
on past global outbreaks (e.g., SARS, Ebola,
swine flu), which is reviewed in detail by
Taylor (2019a), may be relevantand infor-
mative in this regard. Empirical evidence
from previous pandemics indicates that
psychological factors play an instrumental
role in infectious disease mitigation, social
disorder,and vulnerability to mentalhealth
problems associated with pandemics
(Taylor, 2019a). Investigating psychologi-
cal factors influencing behavioral and emo-
tional responses to COVID-19 is, there-
fore, key to reducing the impact of
COVID-19.
The current paper is structured to pro-
vide an overview of the potential influence
of mediabroadcasting, psychological
mechanisms involved in diseaseavoidance,
and psychological traitspotentially impli-
cated in responses to COVID-19. These
factors are discussed in greater detail by
Taylor (2019a).Wethen describe current
psychologicalresearchonCOVID-19 and
ourongoingresearch program aimed at
addressing gaps in understanding of psy-
chological processes and traits that influ-
ence behaviors and emotional distress
related to COVID-19. To conclude, adis-
cussion of expectations for the postpan-
demic period and implications for the
delivery of CBT is provided.
TheRole of Media
People are being inundated with infor-
mation related to COVID-19 through news
and social media outlets. Indeed, the World
Health Organization(2020c)has described
the current state of the COVID-19 pan-
demic as a“massive infodemic.” Mass
media, through the use of emotionally
charged language and images, can have a
profound influence in exaggerating the
perceived dangers associated with infec-
tious disease (Kilgo et al., 2018: Muzzati,
2005). Consequently, the media may then
exacerbate individual inclinations towards
fear or indifference. While it is important
that the publicremain informed about the
pandemic (e.g., currentgovernment regu-
lations, public health recommendations
and actions), prolonged media exposure
can also lead to “media fatigue,” in which
individuals become desensitized to the
media and potentially disregard important
information (Collinson et al., 2015). Fur-
ther compounding the issue is the abun-
dance of misinformation that may cause
increasedanxiety as people may not know
which sources of information are reliable
(Taylor, 2019a).
Government communication through
the media during apandemic is apowerful
source of influence (Devakumar et al.,
2020). On the one hand, transparent and
clear messaging can relieve anxiety and
uncertainty by providing the public with
accurate and up-to-date information on
the state of the pandemic (Eaton &Kalich-
man, 2020; Taylor 2019a). On the other
hand, the use of xenophobic language,
inconsistent information, and suggestion
of governmentconspiracies has the poten-
tial togive rise to public fear and division.It
is of the utmost importance that govern-
ments carefully construct messages in
coordination with other officials to deliver
an effective, cohesive messagetothe public
on COVID-19 (Kapiri&Ross, 2020).
Behavioral Immune System
Due to the microscopicnatureofviral
pathogens, an individual’s biological
immune systemisonly reactive to infection
and insufficient to prevent infection
(Duncan&Schaller, 2009; Taylor, 2019a).
As such, the behavioral immune system
(BIS) has evolved to mobilize in response
to the threat of infection. The BIS is acom-
plex system involved in detecting and
responding to perceived indicators of the
presence of an infectious disease (e.g.,
someone coughing or sneezing; Ackerman
et al., 2018; Schaller&Park, 2011). The BIS
further elicits emotional reactions (e.g., dis-
gust, fear, anxiety) to facilitate behavioral
avoidance of virus-relevant cues and pre-
SCIENCE FORUM
The Psychological Sequelae of the COVID-19
Pandemic: Psychological Processes, Current
Research Ventures, and Preparing for a
Postpandemic World
Michelle M. Paluszek* and Caeleigh A. Landry,* University of Regina
Steven Taylor, University of British Columbia
Gordon J. G. Asmundson, University of Regina
*contributed equally to this article
160 the Behavior Therapist
paluszek et al.
vent contact with potential pathogens
(Schaller&Park).
The cues detected by the BIS are only
sometimes indicative of infection(Schaller
&Park, 2011). To ensure protection, the
BIS tends to generate false-positiveerrors
in that it may incorrectlyperceive acue to
indicate infection when it is not present.
Further, there are individual differences in
the sensitivity of the BIS (Duncan &
Schaller, 2009; Duncan et al., 2009). Some
individuals may be especially sensitive or
attentivetothe presenceofcues that may
suggest pathogens and such cues elicit a
more intense reaction. Individuals with
higher levels of perceived vulnerability to
infectionand disgust sensitivity reflect this
phenomenon.
Disgust Sensitivity
Disgust sensitivity—the extent to which
an individual experiences emotional dis-
tressand repulsion from disgust-inducing
stimuli—is proposed to be an indicator of a
sensitive BIS (Goetz et al., 2013; Taylor,
2019a). Disgust may be elicited through
taste, sight, or smell (Terrizzi et al., 2010).
Sick or unhygienicpeople, bodily content,
and dirty environments are examples of
proposed universal disgust-inducing stim-
uli (Curtis et al., 2011). Individuals with
heightened disgust sensitivity tend to react
more intensely to disgust-inducing stimuli.
Asimilarreaction may be elicited by stim-
uli that resemble, or come into contact
with, disgust-inducing stimuli (Curtis et
al.; Oaten et al., 2009; Rozin et al., 2008).
Disgust sensitivity has been found to be
involved in the developmentand mainte-
nance of certain phobias (e.g., spider
phobia, blood-injection-injury phobia;
Olatunji, 2006; Olatunji et al., 2006) as well
as contamination-based obsessive-com-
pulsive disorder (Olatunjietal., 2005).
Empirical evidenceimplicatingdisgust
sensitivity in pandemic-related reactions
has been emerging. Disgust sensitivity has
been foundtopredict greater fear of infec-
tious disease (e.g., Ebola; Blakey et al., 2015;
Brandetal., 2013; Wheatonetal., 2012). A
recentstudy also suggests that disgust sen-
sitivity may interact with thephysicalcon-
sequences factor of anxiety sensitivity(AS;
referred to below) to predict greater con-
cern of infection from an infectious disease
(McKay et al., in press). Disgust sensitivity
may be arelevanttrait to consider for dif-
ferentiating who may be at risk for greater
COVID-19-relatedanxiety or fear.
Perceived Vulnerability to Disease
Perceived vulnerability to disease
(PVD) refers to the individual’s belief of
how likely they would be to contract an
infectious disease(Taylor,2019a). The BIS
is particularly sensitiveinindividuals with
highPVD. An individual with high PVD is
more likely to perceive adisease as athreat
and have an anxiousemotional and behav-
ioral reaction. For this reason, it is believed
that those withelevated PVD arelikely to
experiencehigh levels of emotional distress
during apandemic(Taylor). The trait may
also partly account for the drive to avoid
groups who are perceived to be likely
infected with COVID-19.
As infectious diseases are often trans-
mitted through social contact, theorists
propose that the BIS evolved to influence
attitudes and social interactions in attempt
to avoid infection (Schaller &Park, 2011).
This influence may come in the form of
xenophobia (i.e., prejudice towards for-
eigners; Schaller &Park). Whenthreatened
by an outbreak, individualswho are highly
motivated to avoid infection may exhibit
xenophobia due to the belief foreigners are
sources of infection. Studies indicate that
individuals with elevated PVD are most
likely to endorse negative attitudes towards
foreigners and avoid contactwith foreign-
ers (e.g.,Aarøeetal., 2017;Duncan et al.,
2009; Faulkneretal., 2004).
The avoidance, stigmatization, and
blame of out-groups (i.e., groupsone does
not belong to) is not an uncommon reac-
tion to the threat of an infectious disease
(Makhanova et al., 2015; Taylor, 2019a).
Evidence of xenophobia was observed
during SARS and the Bubonic Plague
(Cohn, 2010; Washer,2004). Xenophobia
directed at individuals of Chinese ancestry
is being reported during the COVID-19
pandemic (e.g., Aguilera, 2020).Discrimi-
nation may not only hinder jointefforts to
mitigate the spread of infectious disease,
but also create undue distress for out-
groups (Taylor).Marginalized groups may
already find themselves vulnerableduring
the COVID-19pandemic for anumber of
reasons. For example,members of margin-
alized groups may be less likely to seek out
or afford health care services, may lack
financial resources to effectively self-isolate
as per recommendations, or may be more
likely to have preexisting chronic health
conditions that increase risk of COVID-
19-related complications (Eaton&Kalich-
man, 2020; Hutchins et al., 2009; Smith&
Judd, 2020; Yancy, 2020). The pandemic
may further drive social, financial, and
health care disparities experienced by mar-
ginalized groups, putting them at even
greaterrisk of physical and mental health
problems (Eaton &Kalichman; Yancy).
The implementation of comprehensive
interventions directed at addressing
COVID-19-related fear, xenophobia, and
socioeconomic inequalities are needed to
bolster the protection of vulnerable groups
duringthe COVID-19 pandemic.
Psychological Traits
To slow the spread of infection, com-
munities will have to work collectively in
accordancewith publichealth recommen-
dations. Health officials are currently
encouraging social distancing and proper
hygienebehaviors(e.g., handwashing) and
will likely recommend all eligible individu-
als receive aCOVID-19vaccine when they
become available (World Health Organiza-
tion, 2020b);however, not everyone will be
willing to engage in such behaviors. Some
individualsmay magnifyinfection risk by
engaging in maladaptive behaviors (e.g.,
failingtowash hands, maintain social dis-
tancing,orreceive avaccine). Other indi-
viduals might react to COVID-19 with
moderate fear, motivating them to adhere
to recommendations, while others may
experience intense and debilitating fear.
Below we addressindividual difference fac-
tors that may influence anxietyand stress
responses and their possible downstream
effects on adaptive or maladaptive
COVID-19-related behaviors.
Unrealistic Optimism Bias
Unrealistic optimism bias is the ten-
dency to have overly positive beliefs about
one’s future (Taylor &Brown, 1988).
People who have an unrealistic optimism
bias tend to believe that positiveevents are
more likely to happen to them than to
othersand,assuch,underestimate thedan-
gers of disease and otherpotential threats
(Weinstein, 1980). During the SARS out-
break, those with unrealistic optimism bias
believed themselves to be less likely to con-
tract the infection than others (Ji et al.,
2004). Individuals with unrealistic opti-
mism bias may pose aserious societal
threat during pandemics as they are
unlikely to practice proper preventative
health behaviors, such as proper hand-
washing and vaccination (Taylor, 2019a).
Unwillingness to vaccinate, even in a
minority of individuals, can have sizeable
repercussions on the public(WorldHealth
Organization,2020d). Efforts to eradicate
thedisease through vaccine distribution
June •2020 161
psychological sequelae of covid-19 pandemic
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may be diminished. Contention arising
from opposing views on vaccine accept-
ability (e.g., potential use of “vaccination
certificates” to allow travel) could also
incite societal discord and strife. In addi-
tion to unrealistic optimism bias, other
psychological traits (discussed further
below) may influence vaccine hesitancy.
For example, individuals with high intoler-
ance of uncertainty (IU)orhealth anxiety
could be concerned about the potential
unknownside effectsofavaccine and, thus,
be unwilling to receive it (Petrie et al., 2004;
Taylor, 2019a).
Health Anxiety
The tendency to become distressed by
illness-related stimuli (e.g., fever, cough-
ing) is known as health anxiety
(Abramowitz &Braddock, 2011;Asmund-
son &Taylor, 2020a; Taylor &Asmund-
son, 2004). Both high and low levels of
health anxiety are associated with mal-
adaptive behaviors. Thosewith low health
anxiety are unlikely to engage in recom-
mended hygiene behaviors and are espe-
cially vulnerable to unrealistic optimism
bias (Gilles et al., 2011). Previous studies of
prior epidemics indicate that individuals
with low health anxiety are least likely to
adhere to social distancing and to wash
their hands as per recommendations
(Goodwin et al., 2009; Jones &Salathe,
2009; Rubin et al., 2009; Williams et al.,
2015; Wong &Sam, 2011). On the other
hand, those with elevated heath anxiety
tend to worry excessivelyabouttheir health
and can overestimate the degree of threat
posed by an illness (Hedman et al., 2016;
Taylor &Asmundson, 2004; Wheaton et
al.,2010), including COVID-19.
People with high health anxiety are
likely to overuse health care services and
experience high levels of impairment when
experiencing aperceived threat (Bobevski,
et al., 2016; Eilenberg et al., 2015; Sunder-
land et al., 2013). They are often hypervigi-
lant towards their bodily sensations and
more likely to interpret those symptoms as
dangerous (Tyrer &Tyrer, 2018). Due to
the widespread media coverage of COVID-
19, peoplemay begin paying closeratten-
tion to bodily sensations that they would
have previouslyignored.Self-isolation may
also worsen health anxiety, as environ-
ments with low external stimulimay facili-
tate awareness of internalstimuli (Taylor &
Asmundson, 2004).
Anxiety Sensitivity
Conceptually similar to healthanxiety,
AS is the fear of anxietyorarousal-related
reactions(e.g., rapidheartbeat, shortnessof
breath)based in the belief that these reac-
tions areharmful or bringaboutnegative
consequences (e.g., death; Reiss &
McNally, 1985; Taylor, 2019b). Healthanx-
iety and AS share an overarching fear of
bodily changes or sensations and misinter-
pretation of these changes or sensationsas
dangerous (Taylor, 2019a). Whenanindi-
vidual with heightened AS experiences
normal bodilysensations(e.g.,when anx-
ious), anxiety and the acquired fear
response to these sensations are magnified
(Taylor et al., 2007). AS is purported to
increase risk for arange of disorders,
including anxiety-related disorders(Bern-
stein et al., 2005; Schmidtetal., 2006; Tull
et al., 2009). Elevated AS, particularly relat-
ing to concern of physical consequences
(e.g., heart attack), may also increase risk
for pandemic-related anxiety and certain
behavioral patterns (Blakey et al., 2015;
Taylor, 2019a). The physical consequences
factor of AS has also been shown to medi-
ate the relationship between obsessive-
162 the Behavior Therapist
paluszek et al.
compulsive symptoms (e.g., checking,
washing) and fear of swine flu (Brand et al.,
2013).Further research is necessary to elu-
cidatethe potentialrole of AS in COVID-
19-related anxiety and disease-mitigating
behaviors.
Intolerance of Uncertainty
IU is another traitfactor that may have
important consequences for COVID-19-
related coping. IU refers to the individual’s
abilitytohandle missing information and
feelings of uncertainty that may accom-
pany it (Carleton, 2016). People with high
IU prefer predictability in their lives and
can feel paralyzed with indecision when
facedwith an unexpected situation (Birrell
et al., 2011). High IU has been found to
contribute to avariety of mental health
conditions and to be linked to the develop-
ment of excessive worry (Gentes &Ruscio,
2011; Rosser, 2018; Shihata et al., 2016).
Individuals with elevated IU may perceive
COVID-19 as aparticularly distressing
time given its many unpredictable situa-
tions and unknowns, including, but not
limited to, contractingthe virus, perceiving
who is infected, what could be carrying the
virus, how to protect oneself or loved ones,
as wellaspotential job loss(Taylor,2019a).
Additionally, highIUhas been associated
with health-related checking and reassur-
ance seeking(Dugas &Robichaud, 2007).
Similar to health anxiety (Asmundson &
Taylor, 2020a, 2020b), the need for confir-
mation that one is free of infection may
motivate those with higher IU to contact
medical services even with relatively
benign symptoms and consequentlyover-
burden the health care system. There is
potential that the news media may further
fuel uncertainty, especially given that there
is still much to learn aboutCOVID-19.
CurrentFindings and
OngoingResearch
At present, limited research has been
published on the psychological factors
involved in the COVID-19 pandemic.
Cross-sectional population studies from
China suggest substantial anxiety and
depression during the initial stage of the
COVID-19 pandemic (Qiu et al., 2020;
Wang et al., 2020). One study on college
students in China indicated that 25% of the
students wereexperiencing mild to severe
levels of generalanxiety and that those who
knew someone infected with COVID-19
were particularly distressed (Cao et al.,
2020). Health care workers also appear to
be especially at risk of poorer mental health
outcomes.Significantlyhigh rates of mild
to severe symptoms of depression (50%),
anxiety (45%), and insomnia (34%) were
reported in one study (Lai et al., 2020).
Another study indicated that front-line
health care workers in China are more at
risk than nonclinical staff to experience
general fear and symptoms of anxiety and
depression (Lu et al., 2020). Studies
directed at understanding psychological
factors are still ongoingasthe COVID-19
pandemic continues to unfold; for exam-
ple, the Montreal Behavioural Medicine
Centre is conducting the International
COVID-19 Awareness and Responses
Evaluation, alongitudinal online study.
While there are anumber of research
groupsworking to understand the psycho-
logical impacts of COVID-19, the evidence
to date is limited by focus on general mea-
sures of anxiety or narrow conceptualiza-
tions of COVID-19-related fears. The
breadth of COVID-19-related distress may
prove to be quite expansive.
Our own international research team is
conducting alarge-scale populationrepre-
sentative study in Canadaand the United
States using online survey methodology
across three time points (baseline, 1month,
and 3months) to examinevarious psycho-
logical traits and COVID-19-related dis-
tress. Data from the first wave, comprising
6,854 respondents, has been used in the
development and initial validation of the
COVID Stress Scales (CSS; Taylor et al.,
2020), comprising 36 items on five scales
assessing COVID danger and contamina-
tion fears, COVID fears about economic
consequences, COVID xenophobia,
COVID compulsive checking, and COVID
traumaticstress symptoms.The CSS offer
promiseastools for better understanding
the psychopathology associated with
COVID-19 and for identifying people in
need of mental health services due to the
COVID-19 pandemic in particular and
future pandemics in general. We are also
developinganonline self-assessmentplat-
form that, based on feedback from CSS
self-assessment,individuals will be offered
tailored resources to help them bettercope
with pandemic-related distress. Future
waves of our data collection will give a
clearer indication of the mental health
landscape as the pandemic evolves over
time and will helpinformefforts to combat
COVID-19aswell as anticipated fallouts in
the postpandemic era.
Preparing for the Postpandemic Era
There are numerous ways in which life
may change as aresult of the COVID-19
pandemic, and there are currently many
uncertainties. It is not clear, for example,
whether COVID-19 will disappear from
the population, as did SARS, or whether
COVID-19 will become aseasonal infec-
tion, analogoustoseasonal influenza. But
we canbefairly certain that the current
pandemic will eventually end. There are
various subtle ways in which the lives of
many people will be changed by the pan-
demic. These are discussed in detail by
Taylor and Asmundson (2020). In the
remainder of the present article, we focus
on the implications for mental health prac-
titioners.
Although the staggering infectious
impact of COVID-19 may soon subside,
clinicians will be faced with the challenge of
managing the anticipated pervasive surge
of mental health concerns. Early evidence
from China at the onset of the pandemic
suggests an increase in general mental
health problems, including anxiety and
depression (Qiu et al., 2020; Wang et al.,
2020). Stressors related to COVID-19 (e.g.,
quarantine, unemployment, financial
hardship, marital strain, isolation, social
withdrawal, death of loved ones) will likely
initiate or exacerbate mental health prob-
lems(Brooks et al., 2020; Shultzetal., 2015;
Taylor, 2019a). Some individuals infected
with COVID-19 may suffer persistent psy-
chologicaldistress, as was found with SARS
(Hong et al., 2009). Among front-line
health care workers, there may be pro-
found distress from burnout due to an
excessive workload and moral injuries
during the pandemic (Williamson et al.,
2020). Further, front-line health care work-
ers may be at an elevated risk for experi-
encing traumatic stresssymptoms related
to exposure to illness and death (Shultz et
al., 2015; Taylor, 2017), as was the case with
SARS (Naushad et al., 2019; Wu et al.,
2009). As governments ease restrictions,
stressors will involvereadjusting lifestyles,
coping with the potential threat of another
wave of COVID-19, and residualanxiety in
the absence of an illness threat. While some
may attempt to resume their previous
lifestyle, others (e.g., those who are intro-
verted,health-anxious) may remain in
seclusion to shelterfrom the world, similar
to agoraphobia or hikikomori (i.e., social
withdrawal lastinggreater than 6months;
Teo, 2010).Atpresent, the current mental
health care structure is ill-prepared to deal
with the need for psychological services
June •2020 163
psychological sequelae of covid-19 pandemic
brought upon by COVID-19. There is an
urgent need for available, quality mental
health services tailored for the distress,
lifestyle changes, and needsofthe current
and postpandemic society.
Telehealth, also referred to as telemedi-
cine, and online psychotherapy are well-
poised to respond to the growing demand
for services that are accessible from home.
Videoconferencing psychotherapy may be
an efficacious alternative to face-to-face
therapy (Berryhill et al., 2019). Likewise,
there is strong empiricalevidence to sup-
port therapist-guided and unguidedinter-
net-delivered CBT for general mental
health issues as well as arange of mental
disorders (Andersson, 2016; Andrews et
al., 2018; Hadjistavropoulos et al., 2016;
Karyotaki et al., 2017). There is anticipa-
tion that COVID-19 may serve as the cata-
lyst forthe widespread acceptance and pro-
vision of online- or telehealth-delivered
psychotherapy (Wind et al., 2020). How-
ever, it is very likely that currently online
programs will require tailoring to address
the mental health impacts specific to
COVID-19, at least in the most severely
impacted.For example, it may be necessary
to provide mental health services in a
stepped- or blended-care approach
whereby those with minorissues receive an
online or app-delivered COVID-19-spe-
cific healthinformation intervention,those
with moderate issues receive asimilarly
focused and delivered self-managed inter-
vention, and the most severely impacted
are treated with asimilarly focused inter-
vention that also includes individual
coaching via telephone or text. Suchinter-
ventions for COVID-19-specific distress
are currently in the development and test-
ing stages.
Conclusion
The COVID-19 pandemic is antici-
pated to have apervasive impact on the
actions and well-being of society as acon-
sequence of acombination of substantial,
widespread individual and societal
changes, mediaexposure, and preexisting
psychological traits and mechanisms.
Research is needed to not only assess the
extent of this concern, but also to inform
recommendations that ensure appropriate
treatment. Fortunately, this research is
under way in variouscountries.Clinicians
are urged to adapt and reform current
practice in line with evidence-based, acces-
sibleclinical practice. Government officials
and health care practitioners should make
efforts to prepare for the unknown and
potentially long-standing imprint of
COVID-19 on the mental health and well-
being of the current generation.
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...
Preparation forthispaperwas supported in
part by theCanadian Institutes of Health
ResearchCanadian2019 Novel COVID-19
RapidResearch Funding Opportunityand
the UniversityofRegina. Dr.Taylor receives
financial supportthrough payments from
various bookpublishersand as partofhis
work as Associate Editor of the Journalof
Obsessive-Compulsiveand Related Disorders.
Dr. Asmundsonisthe Editor-in-Chief of the
JournalofAnxietyDisorders and Develop-
mentEditor of Clinical Psychology Review.
He receives financial support throughpay-
ments forhis editorial work on the afore-
mentioned journalsand royaltiesfrom vari-
ous bookpublishers.
Correspondence to Gordon J. G. Asmund-
son,Ph.D., DepartmentofPsychology, Uni-
versity of Regina, Regina, Saskatchewan, S4S
0A2; gordon.asmundson@uregina.ca
