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Emotion Regulation and Distress During the COVID-19 Pandemic: The Role of Childhood Abuse

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The COVID-19 pandemic may be experienced as traumatogenic and may fuel or exacerbate psychological distress and trauma-related symptoms. Based on trauma research, one might expect that survivors of childhood abuse would be susceptible to these negative outcomes during the pandemic, and that among this population a stronger relation between emotion regulation difficulties and symptomatology would be found. Aiming to explore these suppositions, an online survey was conducted among 710 Israeli adults. Of them, 370 were childhood abuse survivors. A history of childhood abuse, COVID-19-related stressors, overall psychological distress, and peritraumatic stress symptoms during the pandemic were assessed via self-report measures. Participants with a history of childhood abuse had elevated overall psychological distress as well as peritraumatic stress symptoms during the pandemic, compared to nonabused participants, above and beyond demographic characteristics and COVID-19-related stressors. Emotion regulation difficulties were related to elevated psychological distress and peritraumatic stress symptoms among both childhood abuse survivors and nonabused participants. Nonetheless, a history of childhood abuse moderated the relations between the emotion regulation difficulty of being unable to engage in goal-directed behaviors when distressed (on one hand) and mental outcomes (on the other): Although the associations between inability to engage in goal-directed behaviors, overall psychological distress, and peritraumatic stress symptoms were nonsignificant among nonabused participants, they were significant among childhood abuse survivors. The current findings suggest that a history of childhood abuse might be a risk factor for distress in the face of COVID-19, and that childhood abuse survivors would benefit from clinical interventions that promote emotion regulation skills during this ongoing global health crisis.
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https://doi.org/10.1177/08862605211021968
Journal of Interpersonal Violence
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DOI: 10.1177/08862605211021968
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Original Research
Emotion Regulation
and Distress During the
COVID-19 Pandemic:
The Role of Childhood
Abuse
Alana Siegel,1 and Yael Lahav1
Abstract
The COVID-19 pandemic may be experienced as traumatogenic and may fuel
or exacerbate psychological distress and trauma-related symptoms. Based
on trauma research, one might expect that survivors of childhood abuse
would be susceptible to these negative outcomes during the pandemic, and
that among this population a stronger relation between emotion regulation
difficulties and symptomatology would be found. Aiming to explore these
suppositions, an online survey was conducted among 710 Israeli adults.
Of them, 370 were childhood abuse survivors. A history of childhood
abuse, COVID-19-related stressors, overall psychological distress, and
peritraumatic stress symptoms during the pandemic were assessed via self-
report measures. Participants with a history of childhood abuse had elevated
overall psychological distress as well as peritraumatic stress symptoms during
the pandemic, compared to nonabused participants, above and beyond
demographic characteristics and COVID-19-related stressors. Emotion
regulation difficulties were related to elevated psychological distress and
peritraumatic stress symptoms among both childhood abuse survivors
and nonabused participants. Nonetheless, a history of childhood abuse
moderated the relations between the emotion regulation difficulty of being
unable to engage in goal-directed behaviors when distressed (on one hand)
1 Tel Aviv University, Tel Aviv, Israel
Corresponding Author:
Yael Lahav, Department of Occupational Therapy, The Stanley Steyer School of Health
Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel.
Email: yaellah1@tauex.tau.ac.il
2 Journal of Interpersonal Violence
and mental outcomes (on the other): Although the associations between
inability to engage in goal-directed behaviors, overall psychological distress,
and peritraumatic stress symptoms were nonsignificant among nonabused
participants, they were significant among childhood abuse survivors. The
current findings suggest that a history of childhood abuse might be a risk
factor for distress in the face of COVID-19, and that childhood abuse
survivors would benefit from clinical interventions that promote emotion
regulation skills during this ongoing global health crisis.
Keywords
COVID-19, childhood abuse, childhood maltreatment, emotion regulation,
peritraumatic stress symptoms
Introduction
In the 14 months (at the time of this writing) since the outbreak of a novel
corona virus in Wuhan, China, in December 2019, the world has been con-
fronted with a highly infectious respiratory virus that presents with a host of
challenging complications (Center for Disease Control, 2020). COVID-19
has taken a staggering toll on global public health, with over 111.9 million ill
and more than 2.48 million deaths worldwide as of mid-February 2021 (Johns
Hopkins University & Medicine, 2021). The global ramifications of the pan-
demic have been enormous: crippling economies, overwhelming health care
systems, and unleashing historically high levels of unemployment (World
Trade Organization, 2020). COVID-19 was first identified in Israel in
February 2020. By April 28th, there were 15,728 individuals ill and 210
deaths (Israel Ministry of Health, 2020). The government of Israel issued
shelter-in-place orders (Israel Ministry of Health, 2020), required most busi-
nesses and all educational establishments to close, and banned the gathering
of groups.
The ramifications of the pandemic are wide and multifold, and humanity
has had to contend with the new found demands of lockdown, physical dis-
tancing, and social isolation (American Psychological Association, 2020).
Myriad stressors are involved in the pandemic and may take a toll on indi-
viduals’ well-being, with the following factors reflecting only some of them.
Being diagnosed with the disease, belonging to a risk group for COVID-19
complications, evaluating one’s own physical health negatively, and having
close others who belong to a COVID-19 risk group may all act as significant
burdens, arousing or intensifying fears and worries (Fiorillo & Gorwood,
2020; Wang et al., 2020b). Experiencing negative financial changes, such as
Siegel and Lahav 3
loss of income, may result in elevated emotional distress (Bareket-Bojmel et
al., 2020). Being quarantined or living alone during the pandemic may ham-
per feelings of belonging and limit one’s ability to enjoy the beneficial effects
of social support, thus fueling psychological distress (Brooks et al., 2020).
Lastly, having close others who were diagnosed with the disease or who suf-
fer from complications, or losing close others as a result of the disease, may
take a serious toll, resulting in grief and misery (Zhai & Du, 2020).
It is not surprising that the COVID-19 pandemic has had a negative impact
on mental health (Vindegaard & Benros, 2020; Xiong et al., 2020), as indi-
cated by elevated levels of specific psychiatric symptoms such as depression
and anxiety (Gao et al., 2020; Mazza et al., 2020; Qiu et al., 2020), as well as
by high scores on indexes that reflect overall psychological distress such as
the General Severity Index (GSI; Bitton & Laufer, 2020; Tian et al., 2020),
which was assessed in this study. Moreover, given that the pandemic could be
experienced as traumatic, it could result, in some cases, in trauma-related
symptoms (Wang et al., 2020b). Peritraumatic stress symptoms—which the
present investigation also explored—are responses that occur during and
immediately following a traumatic event. Peritraumatic stress symptoms con-
sist of intrusion symptoms, which reflect re-experiencing the trauma (e.g.,
intrusive memories, flashbacks, nightmares); avoidance symptoms, which
reflect efforts to avoid stimuli associated with the event (e.g., avoidance of
trauma-related thoughts or feelings and reminders); changes in mood and cog-
nition (e.g., overly negative thoughts and negative mood states); and hyper-
arousal symptoms, which reflect increased reactivity to stimuli (e.g., irritability
and aggression, difficulty sleeping; American Psychiatric Association, 2013).
Initial research on the pandemic has documented peritraumatic stress
symptomatology. In a study conducted in China among 6,049 participants
between the ages of 17 and 63, it was found that 13.0% of the participants
exhibited moderate levels of peritraumatic stress symptoms, and 6.1% of the
participants displayed high levels of such symptoms (Jiang et al., 2020).
Another study conducted in China examined the COVID-19 outbreak over a
four-week period and found clinically significant peritraumatic stress symp-
toms in addition to moderate-to-severe stress, anxiety, and depression, all of
which remained stable throughout that period (Wang et al., 2020b). Lastly,
results from a study conducted among young adults (18-30 years) in the
United States revealed that around a third of the participants (31.8%)
reported high levels of peritraumatic stress symptoms during the pandemic
(Liu et al., 2020).
Psychological distress and trauma-related symptomatology in the face of
the pandemic, however, may vary across individuals. According to the trauma
literature, trauma survivors and especially individuals who were subjected to
4 Journal of Interpersonal Violence
protracted interpersonal maltreatment during critical developmental periods,
such as survivors of sexual, physical, and emotional childhood abuse, might
have a lower tolerance for additional stressors and thus might be more sus-
ceptible to subsequent psychopathology compared to nonabused individuals
(Hammen et al., 2000). Research has provided support for this line of thought,
indicating associations between abuse during childhood and alterations of the
hypothalamic-pituitary-adrenocortical (HPA) axis, which is the area of the
neuroendocrine system responsible for stress regulation (Neigh et al., 2009).
Additionally, evidence has revealed relations between childhood abuse and
increased vulnerability to the deleterious mental health effects of stressors
during adulthood, manifested in psychopathology such as depression, PTSD,
and anxiety disorders (Breslau et al., 1999; Hammen, 2006; Kessler et al.,
2010; McLaughlin et al., 2010).
The notion of childhood abuse survivors’ presumed vulnerability in the
face of additional stressors is likely applicable to the current pandemic. The
harsh and recurrent attacks that characterize childhood abuse have been
argued to eventuate in deep and enduring difficulties, which go beyond post-
traumatic reactions such as PTSD. As part of these multifaceted implications,
the damage to individuals’ sense of self and relational world, as well as their
heightened propensity for somatization (Cloitre et al., 2013; Van der Kolk et
al., 2005), might adversely color childhood abuse survivors’ experience of
COVID-19-related stressors and further their distress during these times.
Furthermore, difficulties in emotion regulation subsequent to childhood
abuse might also contribute to their distress during the pandemic. Emotion
regulation generally denotes intrinsic and extrinsic processes implicated in
monitoring, evaluating, and modulating emotional reactions as a way to
achieve individuals’ goals (Thompson, 1994). According to the theoretical
model of Gratz and Roemer (2004), emotion regulation involves the follow-
ing: an understanding and also an awareness of emotions; an acceptance of
one’s emotions; an ability to control behaviors that are impulsive, and to
behave in line with predetermined goals even when experiencing negative
emotions; an ability to control impulsive behaviors even when distressed;
and an ability to flexibly apply various strategies to modulate emotions that
are appropriate for the demands and goals of a situation. According to this
perspective, emotions serve as an important source of information regarding
current circumstances and promote actions that may enable adjustment to
specific situations (Izard & Ackerman, 2000). Individuals who struggle with
being aware, and with understanding and modulating their emotions, may
tend to view internal reactions as unmanageable; they may also find it hard to
choose suitable strategies with which to regulate their emotions and may
over-rely on maladaptive strategies that intensify their emotional distress
Siegel and Lahav 5
over time (Seligowski et al., 2015). These patterns, in turn, may hamper
adjustment and could lead to various negative outcomes (Gross & Jazaieri,
2014; Sheppes et al., 2015).
Difficulties in emotion regulation may impede individuals’ adjustment in
the face of the current pandemic. Individuals who suffer from difficulties in
emotion regulation are thought to experience intensified physiological
arousal and distress in response to stressors and to rely on maladaptive cop-
ing strategies, all of which increase their risk for psychopathology (Cisler et
al., 2010). Although few in number, studies that have explored the relations
between emotion regulation and psychological distress in the context of this
pandemic provide some support for this view. A study conducted in China
among 6,049 participants revealed associations between emotion regulation
strategies and peritraumatic stress symptoms during the pandemic: Although
an adaptive strategy of emotion regulation (cognitive reappraisal) was nega-
tively related to belonging to a profile that was characterized by high levels
of peritraumatic stress symptoms, a maladaptive strategy of emotion regula-
tion (expression inhibition) revealed the opposite direction of relations (Jiang
et al., 2020). Similarly, a study conducted among 127 healthy individuals
who exhibited increased trait anxiety indicated that maladaptive emotion
regulation strategies measured before the pandemic predicted state anxiety
and perceived stress during the pandemic (Brehl et al., 2021).
Childhood abuse may substantially impede emotion regulation abilities
(Powers et al., 2015), with some survivors experiencing emotion dysregula-
tion, manifested in difficulties in identifying and labeling feelings, excesses
in emotional reactivity, and difficulties in the inhibition, navigation, and
expression of negative emotions (Messman-Moore & Bhuptani, 2017).
Emotion dysregulation can contribute to the development and maintenance
of various psychiatric disorders (Berking & Wupperman, 2012). Moreover,
evidence suggests that childhood abuse survivors’ emotion dysregulation can
increase their susceptibility to psychological distress when they face new
stressors (Kim & Cicchetti, 2010).
The Present Study
Although research has provided support for the notion of increased vulnera-
bility of childhood abuse survivors when faced with additional stressors dur-
ing adulthood, to the best of our knowledge no study has explored this claim
in the context of a global crisis. Furthermore, the role of a childhood abuse
history within the relations between emotion regulation difficulties and psy-
chological distress in the face of such an ongoing stressor is not known. One
may postulate that although emotion dysregulation may be related to
6 Journal of Interpersonal Violence
individuals’ overall psychological distress and peritraumatic stress symptoms
when facing a significant stressor such as the current pandemic, these rela-
tions may be even more substantial among childhood abuse survivors. The
ability to identify and accept emotional states as well as to choose suitable
strategies to regulate them may be particularly important for childhood abuse
survivors who, due to their traumatic past, may experience frequent and
intense negative emotions during the pandemic. Hence, the lack of such abili-
ties may be more strongly associated with elevated psychological distress
and trauma-related symptoms.
The COVID-19 pandemic has, unfortunately, provided us with an oppor-
tunity to explore these questions. The current cross-sectional study explored
overall psychological distress (manifested in GSI) and peritraumatic stress
symptoms during the COVID-19 pandemic, and their associations with a his-
tory of childhood abuse and emotion regulation. Based on the aforemen-
tioned literature review, the following three main hypotheses are
formulated:
1. Childhood abuse survivors would report elevated overall psychologi-
cal distress and peritraumatic stress symptoms during the COVID-19
pandemic, compared to individuals with no history of childhood
abuse.
2. Emotion regulation difficulties would be related to overall psycho-
logical distress and peritraumatic stress symptoms during the COVID-
19 pandemic: The higher the levels of emotion regulation difficulties,
the higher the levels of overall psychological distress and peritrau-
matic stress symptoms.
3. A history of childhood abuse would moderate the associations
between emotion regulation difficulties, overall psychological dis-
tress, and peritraumatic stress symptoms in the following way: The
associations between emotion regulation difficulties, overall psycho-
logical distress, and peritraumatic stress symptoms would be signifi-
cantly stronger among childhood abuse survivors compared to
individuals with no history of childhood abuse.
Methods
Participants and procedure. An online survey was conducted among a con-
venience sample of Israeli adults. The survey was posted on Facebook and
was accessible through Qualtrics, a secure web-based survey data collection
system. Participants were invited to participate in a study on coping in the
face of the pandemic. The survey took an average of 25 minutes to complete
and was open from April 2, 2020 to April 19, 2020. It was anonymous and no
Siegel and Lahav 7
data were collected that linked participants to recruitment sources. The Tel
Aviv University institutional review board (IRB) approved all procedures
and instruments. Clicking on the link to the survey guided potential respon-
dents to a page that provided information about the purpose of the study, the
nature of the questions, and a consent form (stating that the survey was vol-
untary, respondents could quit at any time, and responses would be anony-
mous). The first page also offered researcher contact information. Each
participant was given the opportunity to take part in a lottery that rewarded
four $60 gift vouchers to the winners. A total of 1,500 people began the sur-
vey, and 976 answered some of the questionnaires. Of them, 710 participants
(47.3%) who provided data concerning the study variables were included in
this study.
Participants’ ages ranged from 18 to 81 (M = 45.27, SD = 14.41), with the
majority of the sample being below the age of 50 (58.6%). Most of the sam-
ple were women (81.2%); secular (70.5%); had a high school education or
under (51.5%); and were in a relationship (63.7%). One half of the sample
had an average or above-average income (50.0%).
Of the total sample, 370 participants (52.1%) were classified as having a
history of childhood abuse based on the Childhood Trauma Questionnaire
(CTQ; Bernstein et al., 2003). Participants were classified as having a history
of abuse if they had scores that were higher than the cutoff scores suggested
by Tietjen et al. (2010): physical abuse ≥ 8; sexual abuse ≥ 6; and emotional
abuse ≥ 9. Sensitivity and specificity for these cutoff scores have been found
to reach 89% and 97%, respectively (Tietjen et al., 2010).
Of the total 370 participants who were classified as having a history of
childhood abuse, 257 participants (69.5%) were classified as having a history
of childhood emotional abuse, 217 (58.6%) were classified as having a his-
tory of childhood sexual abuse, and 98 (26.5%) were classified as having a
history of childhood physical abuse. Thus, the majority of this group, 223
(60.3%), was classified as having a history of one type of abuse, whereas the
rest reported two (24.8%) or three (14.9%) types of abuse.
Table 1 presents background information among participants with a his-
tory of childhood abuse and participants with no such history. As can be seen
in the table, no differences were found between the two groups in terms of
education and religiosity. Yet there were significant differences between the
groups in terms of age, gender, relationship status, and income. The average
age was lower among participants with a history of childhood abuse than
among participants with no such history. Additionally, the percentage of
women, of individuals who were not in a relationship, and of individuals with
a below-average income among participants with a history of childhood
abuse was higher than among participants with no such history.
8 Journal of Interpersonal Violence
Table 1. Background Variables Among the Study Groups (n = 710).
Background Variables
Participants With
a History of
Childhood Abuse
(n = 370)
Participants
Without a History
of Childhood
Abuse (n = 340) t or χ2
Age, M (SD) 44.16 (14.31) 46.47 (14.44) 2.13*
Gender, n (%)
Female 317 (86.4) 257 (75.6) 13.45***
Male 50 (13.6) 83 (24.4)
Relationship status, n (%)
In a relationship 212 (57.5) 239 (70.5) 13.01***
Not in a relationship 157 (42.5) 100 (29.5)
Education, n (%)
High school or under 198 (53.5) 168 (49.4) 1.19
Post high school and up 172 (46.5) 172 (50.6)
Religiosity, (%)
Secular 250 (69.8) 238 (71.3) .17
Religious/traditional 108 (30.2) 96 (28.7)
Income, (%)
Below-average income 209 (56.5) 146 (42.9) 13.00***
Average income or
above
161 (43.5) 194 (57.1)
Note. *p < .05, ***p < .001.
Measures
Background variables. Participants completed a brief demographic ques-
tionnaire that assessed age, gender, education, relational status, religiosity,
and income. Of the background variables, only age, gender, relationship sta-
tus, education, and income were related to distress outcomes (ps < .05), and
thus were included in the current analyses.
COVID-19-related stressors. Specific stressors related to the COVID-19
pandemic were measured via nine items designed by the research team
(Hamam et al., 2021; Lahav, 2020). Participants were asked to indicate (1)
how they perceived their own physical health, (2) whether they were cur-
rently in quarantine, (3) whether they were living alone during the outbreak,
(4) whether they belonged to a high-risk group for COVID-19, (5) whether
they had close others who belonged to a high-risk group, (6) whether they
Siegel and Lahav 9
were diagnosed with the disease, (7) whether they had close others diagnosed
with the disease, (8) whether they had close others who were hospitalized due
to the disease, (9) whether they had experienced the loss of close others due
to the disease. In addition, in order to assess a pandemic-related economic
stressor, participants were asked whether they had become unemployed or
furloughed since the outbreak of the pandemic. All stressors, apart from the
perception of one’s health, were coded as dummy variables, with “0” reflect-
ing the stressor’s absence and “1” reflecting the stressor’s presence.
Participants’ perceptions regarding their own health ranged from 1 (bad) to 5
(excellent). Given that only six participants reported experiencing any one of
the last four stressors (being diagnosed with the disease, having close others
who were diagnosed with the disease, having close others who were hospital-
ized due to the disease, experiencing the loss of close others due to the dis-
ease), these specific stressors were not included in the present analyses.
General distress during the pandemic. General distress during the pan-
demic was assessed by the GSI of the Brief Symptom Inventory-18 (BSI-18;
Derogatis, 2001). The BSI-18 is a self-report symptom checklist measure
consisting of 18 items that describe depression (e.g., “feeling hopeless about
the future”), anxiety (e.g., “suddenly scared for no reason”), and somatization
(e.g., “feeling weak in parts of your body”) symptoms. Participants were
asked to indicate the extent to which they had been bothered by each of the
symptoms in the prior week, on a 5-point Likert scale ranging from 0 (not at
all) to 4 (extremely). Scores on all 18 items are summarized on the GSI. GSI
raw scores are converted to T scores, with an accepted cutoff point of 63
(Derogatis, 2001). The BSI-18 has been found to have adequate convergent
and discriminant validity and good reliability (Derogatis, 2001). Internal con-
sistency reliability in this study for the GSI was excellent (α = 0.93).
Peritraumatic stress symptoms during the pandemic. Peritraumatic
stress symptoms were measured via a modified version of the PTSD Checklist
for the DSM-5 (PCL-5; Weathers et al., 2013). This 20-item self-report mea-
sure asks participants to indicate the extent to which they experienced each
PTSD symptom, on a 5-point Likert scale ranging from 0 (not at all) to 4
(extremely). The original version was adapted so that the timeframe for expe-
riencing each symptom was changed from “in the past month” to “since the
outbreak of the COVID-19 pandemic,” and the index event was the COVID-
19 pandemic (example items: “feeling very upset when something reminded
you of the pandemic;” “avoiding memories, thoughts, or feelings related to
the pandemic;” “having strong negative feelings such as fear, horror, anger,
guilt, or shame;” “irritable behavior, angry outbursts, or acting aggres-
sively”). A total score of peritraumatic stress symptoms was calculated by
summing all 20 items. Although not a definitive diagnostic measure,
10 Journal of Interpersonal Violence
preliminary research suggests a cutoff score of 33 is a useful threshold to
indicate symptomatology which may be at clinical levels (Bovin et al., 2016).
The PCL-5 demonstrates high internal consistency and test-retest reliability
(Bovin et al., 2016). Internal consistency reliability in this study for the
PCL-5 total score was excellent (α = 0.94).
Childhood trauma questionnaire (CTQ; Bernstein et al., 2003). This
questionnaire includes self-reported items that indicate childhood maltreat-
ment. In this study, only 15 of the items referring to childhood abuse were
utilized, including physical abuse (e.g., “hit hard enough to see a doctor”);
sexual abuse (e.g., “was molested”); and emotional abuse (e.g., “felt that
parents wished they were never born”). The items were rated on a 5-point,
Likert-type scale with response options ranging from 1 (never true) to 5
(very often true). Participants were classified as having a history of child-
hood abuse if they had scores which were higher than one of the cutoff
scores suggested by Tietjen et al. (2010): physical abuse ≥ 8; sexual abuse ≥
6; and emotional abuse ≥ 9. Internal consistency reliability in this study was
excellent (α = 0.91).
Difficulties in emotion regulation. Difficulties in emotion regulation
were measured via the 16-item Difficulties in Emotion Regulation Scale
(DERS-16; Bjureberg et al., 2016). The DERS-16 was designed to assess
individuals’ typical levels of emotion dysregulation across five domains:
non-acceptance of negative emotions (e.g., “when I am upset, I become irri-
tated with myself for feeling that way”);being unable to engage in goal-
directed behaviors when distressed (e.g., “when I am upset, I have difficulty
getting work done”); having difficulties controlling impulsive behaviors
when distressed (e.g., when I am upset, I have difficulty controlling my
behaviors”);having limited access to effective emotion regulation strategies
(e.g., “when I am upset, I believe that there is nothing I can do to make myself
feel better”); and having a lack of emotional clarity (e.g., “I have difficulty
making sense out of my feelings”). Participants are asked to rate the extent to
which each item applies to them on a 5-point Likert-type scale from 1 (almost
never) to 5 (almost always). Higher scores on the DERS-16 are indicative of
greater emotion dysregulation. The DERS-16 has been found to have good
test-retest reliability and adequate convergent validity (Bjureberg et al.,
2016). Internal consistency reliabilities in this study for the subscales were
good (α ranged from 0.78 to 0.86).
Analytic Strategy
The current analyses were conducted using SPSS 25 and PROCESS compu-
tational macro (Hayes, 2012). To compare participants with a history of
Siegel and Lahav 11
childhood abuse to participants without such a history, in terms of overall
psychological distress and peritraumatic stress symptoms, two one-way anal-
yses of covariance (ANCOVAs) were conducted. A history of childhood
abuse was treated as the independent variable; overall psychological distress
and peritraumatic stress symptoms were treated as dependent variables; and
demographic characteristics (age, gender, relationship status, education, and
income) and COVID-19-related stressors (i.e., being in quarantine, living
alone during the outbreak, belonging to a high-risk group for COVID-19,
becoming unemployed or furloughed since the outbreak, perceiving one’s
health as poor, and having close others belonging to a high-risk group) were
treated as covariates.
To assess the associations between emotion regulation, on one hand, and
overall psychological distress and peritraumatic stress symptoms during the
pandemic, on the other, Pearson correlation analyses were conducted. To
assess the moderating role of childhood abuse within the associations between
emotion regulation difficulties, overall psychological distress, and peritrau-
matic stress symptoms, two regression analyses for overall psychological
distress and peritraumatic stress symptoms were conducted. The analyses
consisted of the following: five domains of emotion regulation, which were
treated as independent variables; childhood abuse, which was treated as a
moderator; and the interactions between emotion regulation and childhood
abuse. In addition, specific background variables and COVID-19-related
stressors that were found to be related to the dependent variables were
included in the analyses as covariates. Significant interactions were probed
using the PROCESS (Model 1) computational macro (Hayes, 2012).
Results
Stressors During the Pandemic
Several COVID-19-related stressors were reported by the respondents. These
included being in quarantine (n = 59, 8.3%), living alone during the outbreak (n
= 119, 16.8%), belonging to a high-risk group for COVID-19 (n = 243, 34.2%),
perceiving one’s health as not good or as poor (n = 48, 6.8%), having close oth-
ers who belonged to a high-risk group (n = 590, 83.1%), and becoming unem-
ployed or furloughed since the pandemic’s outbreak (n = 148, 20.8%).
Overall Psychological Distress and Peritraumatic Stress
Symptoms During the Pandemic
The average levels of overall psychological distress, manifested in GSI score,
was 0.68 (±.61), and 10.1% of the total sample (n = 72) met the GSI criteria
12 Journal of Interpersonal Violence
for clinical psychological distress. The average level of peritraumatic stress
symptoms was 15.21(±13.12). Furthermore, 76.1% (n = 540) reported expe-
riencing at least one peritraumatic stress symptom during the pandemic, and
10.8% of the total sample (n = 77) had a peritraumatic stress symptom total
score of 33 or above, indicating that these participants’ symptoms were clini-
cally significant.
Childhood Abuse, Psychological Distress, and Peritraumatic
Stress Symptoms During the Pandemic
Two ANCOVAs exploring the differences between survivors of childhood
abuse and participants without such a history, in terms of overall psychologi-
cal distress, and peritraumatic stress symptoms during the pandemic, were
conducted. Demographic characteristics and COVID-19-related stressors
were treated as covariates. Results of the analyses are presented in Table 2.
As can be seen in the table, age as well as having negative health perceptions
had significant effects in explaining overall psychological distress and peri-
traumatic stress symptoms during the pandemic. Additionally, being female
and having a lower-than-average income had significant effects in explaining
psychological distress. Also, becoming unemployed or furloughed since the
outbreak of the pandemic had significant effects in explaining peritraumatic
stress symptoms.
More importantly, there were significant differences between the study
groups in overall psychological distress and peritraumatic stress symptoms.
Childhood abuse survivors reported elevated psychological distress (M =
0.82, SD = 0.66) and peritraumatic stress symptoms (M = 17.75, SD = 13.79)
compared to participants without such a history (M = 0.51, SD = 0.52; M =
12.44, SD = 11.77, respectively). Supplementary logistic regression analyses
indicated that the risk for clinically significant psychological distress or peri-
traumatic stress symptoms during the pandemic was more than twice as high
among participants with a history of childhood abuse than among partici-
pants without such a history (odds ratio = 2.46, 95% confidence interval:
1.41-4.28; odds ratio = 2.20, 95% confidence interval: 1.33-3.65,
respectively).
Emotion Regulation, Distress, and Peritraumatic Stress
Symptoms During the Pandemic
Results of the Pearson correlations are presented in Table 3. As can be seen in
the table, there were significant correlations with a medium-to-high effect
Siegel and Lahav 13
Table 2. One-way Analyses of Covariance Models Explaining Overall Psychological
Distress and Peritraumatic Stress Symptoms During the Pandemic (n = 710).
GSI
Peritraumatic Stress
Symptoms
F(1, 697) η2pF(1, 697) η2p
Age 32.83*** .05 12.99*** .02
Gender 4.09* .01 1.31 .00
Relationship status 3.75 .01 2.06 .00
Education .16 .00 .01 .00
Income 3.93* .01 3.34 .01
In quarantine .04 .00 .37 .00
Belong to risk group .16 .00 1.10 .00
Negative perceived health 46.20*** .06 13.57*** .02
Living alone during outbreak 2.38 .00 .15 .00
Have close other in risk
group
2.84 .00 1.78 .00
Unemployed or furloughed 3.80 .00 5.48* .01
Childhood abuse 23.61*** .03 14.60*** .02
Note. *p < .05, ***p < .001.
Table 3. Intercorrelations Between Emotion Regulation Difficulties, Overall
Psychological Distress, and Peritraumatic Stress Symptoms During the Pandemic
(n = 710).
Measure 1 2 3 4 5 6 7
1. Emotion
regulation — clarity
2. Emotion
regulation — goals
.41*** –
3. Emotion
regulation — impulsiveness
.44*** .64***
4. Emotion
regulation — strategies
.50*** .75*** .71***
5. Emotion
regulation — nonacceptance
.44*** .59*** .63*** .76***
6. GSI .36*** .46*** .44*** .55*** .45***
7. Peritraumatic stress
symptoms
.32*** .38*** .38*** .45*** .41*** .85*** –
Note. ***p < .001.
14 Journal of Interpersonal Violence
size between emotion regulation difficulties, on one hand, and psychological
distress and peritraumatic stress symptoms during the pandemic, on the other:
The greater the emotion regulation difficulties (manifested in lack of emo-
tional clarity, inability to engage in goal-directed behaviors when distressed,
difficulties controlling impulsive behaviors when distressed, limited access
to effective emotion regulation strategies, and higher levels of nonacceptance
of negative emotions), the higher the levels of psychological distress and
peritraumatic stress symptoms.
Emotion Regulation and Distress During the Pandemic: The
Role of Childhood Abuse
To explore the moderating role of childhood abuse in the relations between
emotion regulation difficulties, overall psychological distress, and peritrau-
matic stress symptoms, regression analyses were conducted. Overall psycho-
logical distress and peritraumatic stress symptoms were treated as dependent
variables; emotion regulation domains were treated as independent variables;
and childhood abuse was treated as a moderator. Age, income, and negative
perceptions regarding one’s health—all three of which had a significant con-
tribution in explaining overall psychological distress and peritraumatic stress
symptoms compared to the other background variables and COVID-19-
related stressors—served as covariates. Results of the analyses are presented
in Table 4.
As can be seen in the table, the models explained 36.9% of the variance of
overall psychological distress, F(14,695) = 29.01, p < .001, and 23.9% of the
variance of peritraumatic stress symptoms, F(14,695) = 18.88, p < .001. Low
income and having negative health perceptions had significant effects in
explaining psychological distress and peritraumatic stress symptoms, and age
had significant effects in explaining psychological distress. Two out of five
domains of regulation difficulties also had significant effects. Limited access
to effective emotion regulation strategies significantly explained psychologi-
cal distress and peritraumatic stress symptoms, and difficulties controlling
impulsive behaviors when distressed significantly explained peritraumatic
stress symptoms.
More importantly, the interaction between childhood abuse and the goals
dimension of emotion regulation difficulties was significant in explaining
both overall psychological distress and peritraumatic stress symptoms.
Probing these interactions revealed the following: Although the relations
between inability to engage in goal-directed behaviors and psychological dis-
tress and peritraumatic stress symptoms were nonsignificant among
Siegel and Lahav 15
Table 4. The Role of Childhood Abuse in the Relations Between Emotion
Regulation Difficulties, Overall Psychological Distress, and Peritraumatic Stress
Symptoms During the Pandemic (n = 710).
GSI
Peritraumatic Stress
Symptoms
βR2βR2
Age –.12** 36.9 –.05 23.9
Income –.09** –.09**
Negative perceived health –.16*** –.08*
Clarity .08 .12
Goals –.08 –.10
Impulsiveness .14 .17*
Strategies .32** .24*
Nonacceptance .09 .09
Childhood abuse .06 .05
Clarity × childhood abuse .01 –.05
Goals × childhood abuse .32* .37*
Impulsiveness × childhood abuse –.21 –.21
Strategies × childhood abuse .04 –.18
Nonacceptance × childhood abuse .07 .06
Note. *p < .05, **p < .01, ***p < .001.
individuals without a history of childhood abuse (β = –.02, p = .33; β = –.44,
p = .25, respectively), they were significant among childhood abuse survi-
vors, such that greater inability to engage in goal-directed behaviors was
related to higher levels of psychological distress and peritraumatic stress
symptoms during the pandemic (β = .03, p = .02; β = 67, p = .03,
respectively).
Discussion
The COVID-19 pandemic carries with it substantial stressors and is likely to
be experienced by many as traumatic. A majority of the present sample
reported experiencing at least one peritraumatic stress symptom during the
pandemic, and around a tenth of the sample had clinically significant peri-
traumatic stress symptoms or GSI scores. These findings are consistent with
other studies that have documented elevated psychological distress and
16 Journal of Interpersonal Violence
peritraumatic stress symptoms among the general population during the
COVID-19 outbreak (Jiang et al., 2020; Mazza et al., 2020; Qiu et al., 2020).
Although research has suggested that the vast majority of individuals will
exhibit a remission of trauma-related symptoms after the threat is removed
(APA, 2013), peritraumatic reactions are known to be a risk factor for long-
lasting distress (Gelkopf et al., 2019).Thus, the present findings point to the
need to view the COVID-19 pandemic through the lens of psychological
trauma as well.
In accordance with earlier research (Bareket-Bojmel et al., 2020; Wang et
al., 2020b), having negative health perceptions was related to both psycho-
logical distress and peritraumatic stress symptoms, and experiencing nega-
tive changes such as becoming unemployed or furloughed since the outbreak
was found to be related to elevated levels of peritraumatic stress symptoms.
Nevertheless, in our final models, having negative health perceptions was the
only stressor that had a significant effect in explaining overall psychological
distress and peritraumatic stress symptoms. In times such as these, when
there is a real and present health threat, perceiving one’s own health in a
negative fashion might increase this experience of threat, potentially fueling
or exacerbating distress and trauma-related symptoms (Wang et al., 2020a).
Our results indicated that adult childhood abuse survivors had elevated
overall psychological distress and peritraumatic stress symptoms during the
pandemic, compared to participants without a history of childhood abuse,
above and beyond demographic characteristics and COVID-19-related stress-
ors. Furthermore, the risk for clinically significant distress or peritraumatic
stress symptoms during the pandemic was more than twice as high among
participants with a history of childhood abuse as among participants without
such a history. Several explanations might be offered for the present findings.
First, the cross-sectional design of this study and the lack of assessment prior
to the outbreak of the pandemic make it impossible to disentangle the poten-
tial link between former and present levels of psychological distress and
trauma-related symptoms. In other words, it might be that the higher levels of
overall psychological distress and peritraumatic stress symptoms among
childhood abuse survivors during the pandemic reflect pre-existing psycho-
pathology or its exacerbation as a result of the current pandemic.
The present findings might also be explained via the stress sensitization
model which suggests that childhood abuse sensitizes individuals to stress
and impedes their ability to cope with additional stressors (Hammen et al.,
2000). The trauma literature points to various implications of childhood
abuse that might contribute to survivors’ sensitization to stress. Abuse-related
alterations in brain functioning may increase survivors’ vulnerability to addi-
tional stressors (Sachs-Ericsson et al., 2009). For example, evidence has
Siegel and Lahav 17
indicated relations between childhood abuse and alterations of the HPA axis,
which is the area of the neuroendocrine system responsible for stress regula-
tion (Neigh et al., 2009).
Psychopathology subsequent to childhood abuse might also further inten-
sify survivors’ vulnerability during stressful times. Childhood abuse survi-
vors have been found to be at risk for psychiatric symptomatology such as
PTSD, depression, anxiety, substance use disorders, borderline personality
disorder, and suicidality (Angelakis et al., 2019; Gilbert et al., 2009; Lindert
et al., 2014; Messman-Moore & Bhuptani, 2017). These conditions substan-
tially weaken individuals’ functioning and thus might hamper survivors’ abil-
ity to cope effectively with the multifold challenges involved in the COVID-19
pandemic.
The elusiveness of the virus, and the fact that its spread is very much
dependent on the behavior of other people (World Health Organization,
2020), might be particularly challenging for childhood abuse survivors.
Given that childhood abuse often involves a betrayal of trust at the hands of
close others (Freyd, 2003), the experience in which one is dependent on oth-
ers’ adherence to formal guidelines and in which one could be easily infected
by others, could reactivate traumatic memories and lead to feelings of
defenselessness and powerlessness, as well as subsequent emotional pain.
Similarly, facing the “invisible enemy” of COVID-19 (WHO, 2020) might
intensify feelings of helplessness, and might in some cases be triggering.
Our findings further suggest that childhood abuse survivors might not
only exhibit elevated distress during the pandemic but also a particular rela-
tionship between emotion regulation difficulties on one hand and psychologi-
cal distress and peritraumatic stress symptoms on the other. Consistent with
former studies (Brehl et al., 2021; Jiang et al., 2020), we found that emotion
regulation difficulties were related to elevated overall psychological distress
and peritraumatic stress symptoms during the pandemic, and that limited
access to effective emotion regulation strategies as well as difficulty in con-
trolling impulsive behaviors made a unique contribution to explaining dis-
tress and trauma-related symptoms among both childhood abuse survivors
and nonabused participants. Nevertheless, the final model which explored
childhood abuse as a moderator indicated that such abuse might shape the
relations between emotion regulation, overall psychological distress, and
peritraumatic stress symptoms. Specifically, our findings revealed that
although the associations between inability to engage in goal-directed behav-
iors, psychological distress, and peritraumatic stress symptoms were nonsig-
nificant among individuals without a history of childhood abuse, they were
significant among childhood abuse survivors: Greater inability to engage in
goal-directed behaviors when experiencing negative emotions was
18 Journal of Interpersonal Violence
associated with elevated distress and peritraumatic stress symptoms during
the pandemic.
The inability to concentrate and focus on goal-directed behaviors when
experiencing negative emotions reflects a substantial impairment in individu-
als’ capacity to modulate emotions, which may negatively affect their adjust-
ment to current situations (Gratz & Roemer, 2004). The present finding,
which indicated that this difficulty was related to psychological distress and
peritraumatic stress symptoms during the pandemic solely among childhood
abuse survivors, implies that its negative implications might be particularly
prominent in this group of individuals.
Failure to engage in goal-directed behaviors when experiencing adverse
emotions may deepen childhood abuse survivors’ vulnerability in the face of
the varied stressors involved in the pandemic. Specifically, this incapacity
could potentially exacerbate or eventuate in functioning difficulties and fur-
ther produce additional problems in various life domains. In this way, child-
hood abuse survivors who are overwhelmed with negative emotions may not
only fail to complete important tasks in their lives but may also experience,
as a result, additional vocational, academic, or familial difficulties, which
may serve as source of stress in addition to the current pandemic-related
challenges.
On the other hand, it could be that past traumatic experiences of childhood
abuse survivors contribute to the negative impact of this specific emotion
regulation difficulty on their current distress. The inability to engage in goal-
directed behaviors when one is distressed might lead childhood abuse survi-
vors to experience themselves during these moments as helpless and out of
control. Although these experiences are likely unpleasant and frustrating for
most people, they seem to be particularly distressing for childhood abuse
survivors. Given their traumatic past, during which they underwent psycho-
logical pain while being helpless, defenseless, and powerless, these experi-
ences might be threatening and even triggering, and thus might exacerbate
their distress and trauma-related symptoms in the face of the pandemic.
The findings of the present study should be considered in light of its limi-
tations. First, our sample was gathered online, potentially leading to a self-
selection bias. Second, this study was based on self-report measures that may
have been subject to response biases and shared method variances. Third,
although gender was not related to distress outcomes, the sample was pre-
dominantly female. Previous studies have found gender differences in
response to the experience of childhood abuse (MacMillan et al., 2001).
Fourth, our analyses focused on Israeli participants. This focus limits the gen-
eralizability of the study and points to the need to explore the relations
between a history of childhood abuse and COVID-19-related distress among
Siegel and Lahav 19
a variety of populations, and specifically among clinical samples of male and
female survivors of childhood abuse with diverse cultural backgrounds. Fifth,
the present data was collected over a short period of time, on April 2020,
when the COVID-19 pandemic had just begun. Thus, the present results may
reflect initial turmoil that individuals faced, which they may have been able
to cope with later on. Finally, due to the study’s cross-sectional design, read-
ers should be cautious in assuming causal relationships between the study’s
variables. Furthermore, due to the lack of measurement prior to the pandemic,
one cannot disentangle the effect of the pandemic from other negative mental
health outcomes which resulted from participants’ past abuse.
Future longitudinal studies should continue examining this population in
light of stresses ahead. The pandemic is considered to be a Black Swan—an
unpredictable and devastating event with extreme consequences—and, as
such, experts are anticipating severe global economic and societal repercus-
sions that could last for decades (Brown, 2020). Although it is too early to
know whether predictions of unemployment, homelessness, instability, and
food shortages will be realized, the stress of the forecasts may be over-
whelming, and the actual need to navigate the aftermath of the pandemic in
the coming years (Goodman, 2020) may be an even more intense experience
for survivors of childhood abuse. Additional studies would do well to exam-
ine the coping strategies of childhood abuse survivors as they navigate the
many potential complexities, repercussions, and fallouts in the aftermath of
the pandemic.
Notwithstanding the limitations above, the present results have important
clinical implications. Our findings imply that childhood abuse survivors
might suffer from elevated distress and peritraumatic-stress symptoms during
the COVID-19 pandemic, and that their impeded ability in engaging in goal-
directed behaviors might be related to these negative outcomes. Given that
there are many survivors of childhood abuse globally, with estimates as high
as one in four adults worldwide reporting a history of childhood abuse (World
Health Organization, 2014), these findings suggest that numerous individuals
throughout the world might be at risk for distress and trauma-related symp-
tomatology during the pandemic and that their emotion regulation difficulty
of being unable to engage in goal-directed behaviors may contribute to these
adverse results. Policymakers should seek to make therapeutic support ser-
vices both financially and practically accessible to former and current patients
recognized with a history of childhood abuse. It is recommended that screen-
ing for past or present abuse should be part of medical annual physical exams
or psychological intakes with mental health services. It is also imperative to
use the social security and public social welfare systems to identify individu-
als with a history of childhood abuse who are eligible for services and develop
20 Journal of Interpersonal Violence
outreach services to deliver ad hoc interventions to this specific vulnerable
population.
Providing evidence-based therapy that promotes emotion regulation skills
during this time would seem to be critical for childhood abuse survivors.
Evidence-based interventions that are suitable for the complex presentation
and emotion dysregulation often found among childhood abuse survivors
(Wagner et al., 2007), such as the Dialectical Behavior Therapy Prolonged
Exposure protocol (Harned et al., 2014), may be particularly effective. These
treatments, which should be adapted to the current conditions, as well as be
provided online (Wind et al., 2020), may help survivors reprocess their past
abuse and obtain new coping skills to regulate their emotions while facing the
challenges of the pandemic.
It is clear that the current pandemic has led to extensive levels of stress,
illness, and hardship around the world (WHO, 2020). That said, one group in
need of extra support during this period are survivors of childhood abuse.
Given the predictions of societal and economic instability and hardships in
the months and years to come, survivors will likely need continued support as
they navigate this crisis going forward.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.
ORCID ID
Yael Lahav https://orcid.org/0000-0003-1242-9042
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Author Biographies
Alana Siegel, PsyD, is a research fellow in the Department of Occupational Therapy,
The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv
University. Her research focuses on trauma, resilience, and secondary traumatic stress.
Yael Lahav, PhD, is a senior lecturer in the Department of Occupational Therapy,
The Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel
Aviv University. Her research interests revolve primarily around the unique relations
between the psychological, interpersonal, somatic, and physiological facets of psy-
chological trauma.
... Some previous studies have reported that historical trauma (physical and emotional trauma over the life span and across generations), childhood abuse, and social support were closely related to psychological stress, sleep quality, and emotion regulation during the COVID-19 outbreak (17)(18)(19). One study found that psychological stress of COVID-19 mediated the association between childhood trauma and Pittsburgh Sleep Quality Index (PSQI) global sleep quality (18). ...
... Depression, Anxiety, and Stress Scale included 21 items and could be divided into subscales of depressive, anxiety, and stress symptoms. The DASS-21 subscales were scored as follows: normal (0-9), mild (10-13), moderate (14)(15)(16)(17)(18)(19)(20), severe (21)(22)(23)(24)(25)(26)(27), and extremely severe (28+) for depression; normal (0-7), mild (8,9), moderate (10)(11)(12)(13)(14), severe (15)(16)(17)(18)(19), and extremely severe (20+) for anxiety; normal (0-14), mild (15)(16)(17)(18), moderate (19)(20)(21)(22)(23)(24)(25), severe (26)(27)(28)(29)(30)(31)(32)(33), and extremely severe (34+) for stress (26). The Cronbach's alpha for Chinese version of DASS-21 was 0.95 for total scale, demonstrating a good internal consistency in the assessment of mental health in Chinese population (27). ...
... Depression, Anxiety, and Stress Scale included 21 items and could be divided into subscales of depressive, anxiety, and stress symptoms. The DASS-21 subscales were scored as follows: normal (0-9), mild (10-13), moderate (14)(15)(16)(17)(18)(19)(20), severe (21)(22)(23)(24)(25)(26)(27), and extremely severe (28+) for depression; normal (0-7), mild (8,9), moderate (10)(11)(12)(13)(14), severe (15)(16)(17)(18)(19), and extremely severe (20+) for anxiety; normal (0-14), mild (15)(16)(17)(18), moderate (19)(20)(21)(22)(23)(24)(25), severe (26)(27)(28)(29)(30)(31)(32)(33), and extremely severe (34+) for stress (26). The Cronbach's alpha for Chinese version of DASS-21 was 0.95 for total scale, demonstrating a good internal consistency in the assessment of mental health in Chinese population (27). ...
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Background: Coronavirus-2019 (COVID-19) has been coexisting with humans for almost 2 years, consistently impacting people's daily life, medical environment, and mental health. This study aimed to test the series mediation model triggered by childhood trauma, in which perceived psychological impact of COVID-19 pandemic and sleep quality mediated the path sequentially and led to adverse mental health outcomes. Methods: A cross-sectional design involving 817 participants were enrolled via WeChat online survey. Participants completed questionnaires, including demographic features, the Childhood Trauma Questionnaire, Impact of Event Scale-Revised (IES-R) questionnaire, Pittsburgh Sleep Quality Index (PSQI) questionnaire, and Depression, Anxiety, and Stress Scale (DASS-21). Pearson correlations and hierarchical multiple linear regression were employed to examine the association of childhood trauma and psychological stress of COVID-19, sleep quality, and mental health status. In addition, a series mediate analysis was carried out to examine sequence mediating effects of psychological impact of COVID-19 and sleep quality between childhood trauma and mental health status. Results: The results showed that childhood trauma is positively and significantly related to psychological distress of COVID-19 pandemic, sleep quality, and mental health status ( p < 0.05). Hierarchical multiple linear regression analysis shown that demographic features explained 4.4, 2.1, and 4.0% of the total variance in DASS-21, IES-R, and PSQI total scale scores, respectively. Adding childhood trauma significantly increased the model variance of DASS-21 (Δ R ² = 0.129, F = 126.092, p = 0.000), IES-R (Δ R ² = 0.062, F = 54.771, p = 0.000), and PSQI total scale scores (Δ R ² = 0.055, F = 48.733, p = 0.000), respectively. Moreover, the series mediation model showed that the perceived impact of the COVID-19 pandemic and sleep quality were sequential mediators between childhood trauma and mental health status (proportion explained: 49.17%, p < 0.05). Conclusion: Amid the ravages of COVID-19, childhood trauma predicts poor mental health status, in part because of greater psychological impact related to COVID-19 and poorer global sleep quality. In order to improve mental health, future researchers should pay more attention to individuals with childhood trauma, for its association with greater stress related to life events and poorer sleep quality.
... Emerging evidence suggests that individuals who have experienced childhood adversity may also be at greater risk of developing mental health problems during the COVID-19 pandemic. Several studies have observed that individuals with a history of child maltreatment or other adversity experiences were more likely to develop anxiety, depression, and PTSD symptoms during the pandemic relative to those without exposure to adversity; this has been observed among adolescents in rural China (Guo et al., 2020), adults in Israel and Germany (Seitz, Bertsch, & Herpertz, 2021;Siegel & Lahav, 2021), as well as children, adolescents, and adults in the U.S. (Gotlib et al., 2021;Kalia, Knauft, & Hayatbini, 2020). These associations persisted after adjustment for exposure to pandemic-related stressors (Guo et al., 2020;Siegel & Lahav, 2021) and pre-pandemic symptoms (Gotlib et al., 2021). ...
... Several studies have observed that individuals with a history of child maltreatment or other adversity experiences were more likely to develop anxiety, depression, and PTSD symptoms during the pandemic relative to those without exposure to adversity; this has been observed among adolescents in rural China (Guo et al., 2020), adults in Israel and Germany (Seitz, Bertsch, & Herpertz, 2021;Siegel & Lahav, 2021), as well as children, adolescents, and adults in the U.S. (Gotlib et al., 2021;Kalia, Knauft, & Hayatbini, 2020). These associations persisted after adjustment for exposure to pandemic-related stressors (Guo et al., 2020;Siegel & Lahav, 2021) and pre-pandemic symptoms (Gotlib et al., 2021). Few studies have examined whether the association between pandemic-related stressors and psychopathology symptoms is stronger among those with adversity experiences, however. ...
Article
The COVID-19 pandemic has introduced widespread societal changes that have required ongoing adaptation. Unsurprisingly, stress-related psychopathology has increased during the pandemic, in both children and adults. We review these patterns through the lens of several leading conceptual models of the link between stress and psychopathology. Some of these models focus on characteristics of environmental stressors—including cumulative risk, specific stressor types, and stress sensitization approaches. Understanding the specific aspects of environmental stressors that are most likely to lead to psychopathology can shed light on who may be in most need of clinical intervention. Other models center on factors that can buffer against the onset of psychopathology following stress and the mechanisms through which stressors contribute to emergent psychopathology. These models highlight specific psychosocial processes that may be most usefully targeted by interventions to reduce stress-related psychopathology. We review evidence for each of these stress models in the context of other widescale community-level disruptions, like natural disasters and terrorist attacks, alongside emerging evidence for these stress pathways from the COVID-19 pandemic. We discuss clinical implications for developing interventions to reduce stress-related psychopathology during the pandemic, with a focus on brief, digital interventions that may be more accessible than traditional clinical services.
... As our awareness and understanding of complex trauma and its negative impact has developed, a new focus on trauma-informed care and approaches has emerged, which aim to mitigate the impacts of complex trauma [8]. The COVID-19 pandemic is an example of a traumatic stressor that could increase trauma-related distress or symptoms, especially for people with a history of trauma [9][10][11][12]. ...
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Full-text available
The Coronavirus Disease 2019 (COVID-19) pandemic impacted peoples’ livelihoods and mental wellbeing. Aboriginal and Torres Strait Islander peoples in Australia continue to experience intergenerational trauma associated with colonization and may experience trauma-related distress in response to government responses to public health emergencies. We aimed to develop a culturally responsive trauma-informed public health emergency response framework for Aboriginal and Torres Strait Islander peoples. This Aboriginal and Torres Strait Islander-led study involved: (i) a review of trauma-informed public health emergency responses to develop a draft framework (ii) interviews with 110 Aboriginal and Torres Strait Islander parents about how COVID-19 impacted their lives, and (iii) a workshop with 36 stakeholders about pandemic experiences using framework analysis to refine a culturally responsive trauma-informed framework. The framework included: an overarching philosophy (cultural humility, safety and responsiveness); key enablers (local leadership and Eldership); supporting strategies (provision of basic needs and resources, well-functioning social systems, human rights, dignity, choice, justice and ethics, mutuality and collective responsibility, and strengthening of existing systems); interdependent core concepts (safety, transparency, and empowerment, holistic support, connectedness and collaboration, and compassion, protection and caring); and central goals (a sense of security, resilience, wellbeing, self- and collective-efficacy, hope, trust, resilience, and healing from grief and loss).
... By contrast, individuals who reported lower levels of reappraisal use showed a positive association between ELS severity and psychopathology during the pandemic. This finding is consistent with literature that has identified use of cognitive reappraisal as a buffer against the effects of stress on mental health outcomes (40,(81)(82)(83)(84), as well as more recent work that has identified links between stress exposure, ER, and COVID-related psychopathology (84)(85)(86)(87)(88)(89). Additionally, the current findings lend support to existing frameworks that are more consistent with a moderating role (as opposed to a mediating role) of ER in the association between stress and psychopathology (90)(91)(92). ...
Article
Full-text available
Background The ongoing COVID-19 pandemic is a major stressor that has been associated with increased risk for psychiatric illness in the general population. Recent work has highlighted that experiences of early-life stress (ELS) may impact individuals’ psychological functioning and vulnerability for developing internalizing psychopathology in response to pandemic-related stress. However, little is known about the neurobehavioral factors that may mediate the association between ELS exposure and COVID-related internalizing symptomatology. The current study sought to examine the mediating roles of pre-pandemic resting-state frontoamygdala connectivity and concurrent emotion regulation (ER) in the association between ELS and pandemic-related internalizing symptomatology. Methods Retrospective life-stress histories, concurrent self-reported ER strategies (i.e., reappraisal and suppression), concurrent self-reported internalizing symptomatology (i.e., depression- and anxiety-related symptomatology), and resting-state functional connectivity data from a sample of adults (N = 64, Mage = 22.12, female = 68.75%) were utilized. Results There were no significant direct associations between ELS and COVID-related internalizing symptomatology. Neither frontoamygdala functional connectivity nor ER strategy use mediated an association between ELS and COVID-related internalizing symptomatology (ps > 0.05). Exploratory analyses identified a significant moderating effect of reappraisal use on the association between ELS and internalizing symptomatology (β = -0.818, p = 0.047), such that increased reappraisal use buffered the impact of ELS on psychopathology. Conclusions While frontoamygdala connectivity and ER do not appear to mediate the association between ELS and COVID-related internalizing symptomatology, our findings suggest that the use of reappraisal may buffer against the effect of ELS on mental health during the pandemic.
... Furthermore, with no knowledge that a pandemic was on its way, of course, the data collection of this study took place during the first wave of the COVID-19 pandemic in Israel. Studies have indicated the pandemic to be particularly debilitating for trauma survivors (Hamam et al., 2020;Siegel & Lahav, 2021) and to have negative effects on individuals' economic, occupational, and functional domains (e.g., Bareket-Bojmel et al., 2020). Altogether, these aspects limit the study's generalizability and indicate the need for further research among clinical samples of IPV survivors from diverse cultural and social backgrounds, simultaneously taking into account the potential effects of the pandemic. ...
... Furthermore, with no knowledge that a pandemic was on its way, of course, the data collection of this study took place during the first wave of the COVID-19 pandemic in Israel. Studies have indicated the pandemic to be particularly debilitating for trauma survivors (Hamam et al., 2020;Siegel & Lahav, 2021) and to have negative effects on individuals' economic, occupational, and functional domains (e.g., Bareket-Bojmel et al., 2020). Altogether, these aspects limit the study's generalizability and indicate the need for further research among clinical samples of IPV survivors from diverse cultural and social backgrounds, simultaneously taking into account the potential effects of the pandemic. ...
Article
Study questions: Although most women who are subjected to intimate partner violence attempt to leave their abusive partners, many return, and resultantly are at risk for even greater violence. Research to date has documented relations between several factors (income and economic dependence, frequency of intimate partner violence (IPV), fear of violence escalations, history of childhood abuse, and post-traumatic stress disorder symptoms) and women's returning to their abusive partners. Nevertheless, the contribution of women's emotional bonds with their violent partners, known as identification with the aggressor (IWA), in explaining their perceived likelihood of going back to the relationship, has remained unclear. Subjects: The current study, conducted among 258 Israeli women who had left their violent partners, aimed to fill this void. Methods: An online survey was conducted. Demographic variables, history of childhood abuse, frequency of IPV, economic dependence on former partner, fear of future violence escalation, post-traumatic stress disorder symptoms, IWA, and perceived likelihood of returning to the relationship, were assessed via self-report questionnaire. Findings: Results indicated that two aspects of IWA-becoming hyper-sensitive to the perpetrator and adopting the perpetrator's experience-were related to women's perceived likelihood of returning to the relationship. Furthermore, a logistic regression analysis indicated that only two factors-income and becoming hyper-sensitive to the perpetrator-uniquely contributed to explaining the likelihood of returning to abusive partners. Major implications: The current findings suggest that women's tendency to be highly attuned to their partners' feelings and needs, as a part of IWA, may impede their ability to permanently leave abusive relationships.
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Changes in research practice during the COVID-19 pandemic necessitates renewed attention to ethical protocols and reporting for data collection on sensitive topics. We systematically searched journal publications from the start of the pandemic to November 2021, identifying 75 studies that collected primary data on violence against women and children. We assess the transparency of ethics reporting and adherence to relevant guidelines against a 14-item checklist of best practices. Studies reported adhering to best practices on 31% of scored items with highest reporting for ethical clearance (87%) and informed consent/assent (84/83%) and lowest reporting for facilitating referrals for minors and soliciting participant feedback (both 0%). Violence studies of primary data collected during COVID-19 report on few ethical standards, obscuring stakeholder ability to enforce a "do no harm" approach and to assess the reliability of findings. We offer recommendations and guidelines to improve future reporting and implementation of ethics within violence studies.
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The mental health difficulties of trauma survivors during the COVID-19 pandemic have been under-reported. This study explored the moderating role of trauma history and trauma type (interpersonal and non-interpersonal) in the association between COVID-19-related stressors and depression, anxiety, and stress. A sample of n = 321 participants ages 19 to 71 (M = 36.63, SD = 10.36) was recruited from across the United States through MTurk. Participants reported the number of COVID-19-related stressors, trauma history and psychological symptoms. Hierarchical multiple regression analyses, controlling for age, race, ethnicity, gender, education, and income levels, were used to determine (a) whether COVID-19-related stressors are associated with adverse mental health outcomes; (b) whether trauma history and (c) trauma type moderated this association. Results revealed significant interactions; for those with a trauma history, exposure to COVID-19-related stressors was associated with higher levels of depression (β = .21, p < .05) and anxiety (β = .19, p < .05). For those with a history of interpersonal trauma specifically, COVID-19-related stressors were associated with depression (β = .16, p < .05) more so than for those without a trauma history. These findings highlight the vulnerability of trauma survivors to the unprecedented COVID-19-related stress.
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The purpose of this study was to determine community activities during the implementation of the activity restriction policy (Indonesian: Pemberlakuan Pembatasan Kegiatan Masyarakat, PPKM) during the COVID-19 pandemic in Medan city. The type of research method is a quantitative descriptive study using a survey design. The instrument used in this research is a questionnaire. The sampling technique was using accidental sampling so that the number of samples obtained was 790 people. The findings of this study are that the characteristics and economic activities of the people of Medan city during the implementation of PPKM are in the essential sector of as many as 423 respondents (53.6%). Quantitatively, this figure is high because it is above 50% when compared to the non-essential sector, which is less than 367 respondents (47.4%). PPKM officers need to ensure that employees who do not work in the office are for non-essential sector companies that run work from home (WFH) to avoid the spread of COVID-19. The selection of appropriate policies and public obedience to government policies related to activity restrictions can break the chain of the spread of COVID-19 in Medan city.
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Background The Covid-19 pandemic has led to drastic public health measures with a substantial impact on the individual. Previous studies reported elevated levels of stress, anxiety, and depression in the general population as a consequence of pandemic-related public health measures. In vulnerable individuals, exposure to an uncontrolled global stressor like the Covid-19 pandemic might be felt as particularly threatening. Methods A population of 127 healthy individuals that expressed increased trait anxiety (HADS ≥ 8) already before the outbreak of the pandemic were tested on state and trait anxiety, stress and depression before and four weeks after the outbreak of the pandemic in the Netherlands. Online questionnaires were administered between April 16 and April 23, 2020. Results We observed an increase in state anxiety (STAI) during the pandemic but no change in depression. Yet, trait anxiety (STAI) before the pandemic did not predict the increase in state anxiety during the pandemic. Further, state anxiety during the pandemic was not associated with being in contact with an infected person, having symptoms of Covid-19, protective behavior, or degree of social isolation when controlling for state anxiety before the outbreak of the pandemic. However, maladaptive emotion regulation strategies measured before the pandemic predicted state anxiety and perceived stress during the pandemic, while adaptive strategies had no association with anxiety during the pandemic. Conclusion Reducing learned helplessness and self-blaming to prevent maladaptive emotion regulation strategies like giving up and self-devaluation might be more beneficial than training adaptive strategies. Limitations Time variation in baseline measurements
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The COVID-19 pandemic caught the entire world off guard. Israel, similar to all other nations, was forced to cope with the unknown. “Flattening the curve” of infections has become a common term among specialists and decision makers, while explaining restricting measurements taken toward the population. Israelis, who had previously learned to deal with life under constant security threat, are now facing a new reality. The purpose of the study was to check how Israelis are psychologically affected by and coping with the COVID-19 pandemic. The study included 925 Israelis divided into three groups: ages 18–29, 30–59, and 60–88. The data were collected between March 31 and April 8, 2020, when it was already clear that this is a global plague, the country's borders were closed, and the government's directive for citizens was to remain at home while imposing limitations on the public and private sectors. The current study examined psychological distress among the three age groups as well as the associations between levels of distress, resilience, and coping strategies. Levels of distress were measured via the BSI-18 that measures anxiety, depression, and somatization. Resilience was measured using the Connor-Davidson CD-RISC scale. Coping was measured by the short version of the COPE. Psychological distress was associated with being in a younger age group, being a woman, having economic concerns, use of emotion and problem focused coping, and lower resilience. The study also found that concern for the health of family members was the strongest concern among all age groups but was highest among the younger age group. It was also found that those in the younger age group suffered from higher levels of depression, anxiety, and somatization compared to the older age group. The middle age group suffered from elevated levels of anxiety and somatization compared to the older age group. Although the older age group was the most vulnerable to the coronavirus, in this study age was found to be a protective factor from psychological distress. The results of the study suggest the need to consider the younger age group as a risk group, which hence needs to be addressed as the focus of intervention programs. It appears that the concern for their loved ones takes a heavy toll on the younger generation, and this should be considered a major source of stress.
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Background: As a major virus outbreak in the 21st century, the Coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented hazards to mental health globally. While psychological support is being provided to patients and healthcare workers, the general public's mental health requires significant attention as well. This systematic review aims to synthesize extant literature that reports on the effects of COVID-19 on psychological outcomes of the general population and its associated risk factors. Methods: A systematic search was conducted on PubMed, Embase, Medline, Web of Science, and Scopus from inception to 17 May 2020 following the PRISMA guidelines. A manual search on Google Scholar was performed to identify additional relevant studies. Articles were selected based on the predetermined eligibility criteria. Results: Relatively high rates of symptoms of anxiety (6.33% to 50.9%), depression (14.6% to 48.3%), post-traumatic stress disorder (7% to 53.8%), psychological distress (34.43% to 38%), and stress (8.1% to 81.9%) are reported in the general population during the COVID-19 pandemic in China, Spain, Italy, Iran, the US, Turkey, Nepal, and Denmark. Risk factors associated with distress measures include female gender, younger age group (≤40 years), presence of chronic/psychiatric illnesses, unemployment, student status, and frequent exposure to social media/news concerning COVID-19. Limitations: A significant degree of heterogeneity was noted across studies. Conclusions: The COVID-19 pandemic is associated with highly significant levels of psychological distress that, in many cases, would meet the threshold for clinical relevance. Mitigating the hazardous effects of COVID-19 on mental health is an international public health priority.
Article
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The uncontrolled spread of the coronavirus disease 2019 (COVID-19) has called for unprecedented measures, to the extent that the Italian government has imposed a quarantine on the entire country. Quarantine has a huge impact and can cause considerable psychological strain. The present study aims to establish the prevalence of psychiatric symptoms and identify risk and protective factors for psychological distress in the general population. An online survey was administered from 18–22 March 2020 to 2766 participants. Multivariate ordinal logistic regression models were constructed to examine the associations between sociodemographic variables; personality traits; depression, anxiety, and stress. Female gender, negative affect, and detachment were associated with higher levels of depression, anxiety, and stress. Having an acquaintance infected was associated with increased levels of both depression and stress, whereas a history of stressful situations and medical problems was associated with higher levels of depression and anxiety. Finally, those with a family member infected and young person who had to work outside their domicile presented higher levels of anxiety and stress, respectively. This epidemiological picture is an important benchmark for identifying persons at greater risk of suffering from psychological distress and the results are useful for tailoring psychological interventions targeting the post-traumatic nature of the distress.
Article
Objective: To examine the effects of coronavirus disease-2019 (COVID-19) exposure, expressive suppression/cognitive reappraisal, and demographic variables on post-traumatic stress symptoms (PTS) among Chinese. Methods: Participants were recruited by social media through WeChat and 6 049 Chinese (aged from 17 to 63 years; median=24) from 31 provinces were included in the study. PTS symptoms, expressive suppression, and cognitive reappraisal were assessed after the outbreak of COVID-19. A regression mixture analysis was conducted in Mplus 7. Results: A regression mixture model identified three latent classes that were primarily distinguished by differential effects of COVID- 19 exposures on PTS symptoms: (1) Class 1 (mildly PTS symptoms, 80.9%), (2) Class 2 (moderate PTS symptoms, 13.0%), and (3) Class 3 (high PTS symptoms, 6.1%). The results demonstrated that the young, women and people with responsibilities and concerns for others were more vulnerable to PTS symptoms; and they had more expression inhibition and less cognitive reappraisal in three latent classes. Conclusions: The findings suggest that more attention needs to be paid to vulnerable groups such as the young, women and people with responsibilities and concerns for others. Therapies to encourage emotional expression and increase cognitive reappraisal may also be helpful for trauma survivors. © 2020 Asian Pacific Journal of Tropical Medicine Produced by Wolters Kluwer-Medknow. All rights reserved.
Article
Trauma survivors who suffer from posttraumatic stress disorder (PTSD) symptoms may be particularly vulnerable when facing the COVID-19 pandemic. Yet trauma exposure may also lead to salutogenic outcomes, known as posttraumatic growth (PTG). Nevertheless, the implications of PTG attributed to prior trauma, for trauma survivors’ adjustment when facing additional stressors, are unclear. Addressing this gap, 528 Israeli trauma survivors were assessed for PTG and PTSD symptoms attributed to prior trauma, as well as peritraumatic stress symptoms related to the pandemic, as part of an online survey. Analyses revealed that being younger, female, quarantined, negatively self-rating one’s health status, and suffering from PTSD symptoms were associated with elevated peritraumatic stress symptoms. Furthermore, PTG attributed to prior trauma made a significant contribution in explaining elevated intrusion, avoidance, and hyperarousal symptoms. The present results point to the need for clinicians to take into account reports of PTG attributed to prior trauma when treating trauma survivors during the current pandemic.
Article
Objective The novel coronavirus (COVID-19) is a substantial stressor that could eventuate in psychological distress. Evidence suggests that individuals previously exposed to traumatic events, and particularly to continuous traumatic stress (CTS), might be more vulnerable to distress when facing additional stressors. This study aimed to investigate these suppositions in the context of the ongoing shelling of Israel from the Israel-Gaza border, which continues even amidst the COVID-19 crisis. Method An online survey was conducted among Israel's general population. The sample included 976 participants. Seven-hundred-and-ninety-three participants had been exposed to traumatic events, with 255 participants reporting CTS. Trauma exposure, COVID-19-related stressors, and psychological distress related to COVID-19 (anxiety, depression, and peritraumatic stress symptoms) were assessed. Results Most participants reported experiencing at least one psychiatric symptom related to COVID-19. Being younger, female, not in a relationship, having a below-average income, being diagnosed with the disease, living alone during the outbreak, having a close other in a high-risk group, and negatively self-rating one's health status were associated with elevated distress. Individuals who had been exposed to trauma, and to CTS in particular, had elevated anxiety, depression, and peritraumatic stress symptoms compared to individuals without such a history or to survivors of non-ongoing traumatic events. CTS moderated the relations between PTSD symptoms, anxiety symptoms, and peritraumatic stress symptoms, with significantly stronger relations found among individuals exposed to CTS. Limitations This study relied on convenience sampling. Conclusions Trauma survivors, and particularly traumatized individuals exposed to CTS, seem at risk for psychological distress related to COVID-19.
Article
This study sought to identify factors associated with depression, anxiety, and PTSD symptomatology in U.S. young adults (18-30 years) during the COVID-19 pandemic. This cross-sectional online study assessed 898 participants from April 13, 2020 to May 19, 2020, approximately one month after the U.S. declared a state of emergency due to COVID-19 and prior to the initial lifting of restrictions across 50 U.S. states. Respondents reported high levels of depression (43.3%, PHQ-8 scores ≥ 10), high anxiety scores (45.4%, GAD-7 scores ≥ 10), and high levels of PTSD symptoms (31.8%, PCL-C scores ≥ 45). High levels of loneliness, high levels of COVID-19-specific worries, and low distress tolerance were significantly associated with clinical levels of depression, anxiety, and PTSD symptoms. Resilience was associated with low levels of depression and anxiety symptoms but not PTSD. Most respondents had high levels of social support; social support from family, but not from partner or peers, was associated with low levels of depression and PTSD. Compared to Whites, Asian Americans were less likely to report high levels across mental health symptoms, and Hispanic/Latinos were less likely to report high levels of anxiety. These factors provide initial guidance regarding clinical management for COVID-19-related mental health problems.
Article
Background During the COVID-19 pandemic general medical complications have received the most attention, whereas only few studies address the potential direct effect on mental health of SARS-CoV-2 and the neurotropic potential. Furthermore, the indirect effects of the pandemic on general mental health are of increasing concern, particularly since the SARS-CoV-1 epidemic (2002-2003) was associated with psychiatric complications. Methods We systematically searched the database Pubmed including studies measuring psychiatric symptoms or morbidities associated with COVID-19 among infected patients and among none infected groups the latter divided in psychiatric patients, health care workers and non-health care workers. Results A total of 43 studies were included. Out of these, only two studies evaluated patients with confirmed COVID-19 infection, whereas 41 evaluated the indirect effect of the pandemic (2 on patients with preexisting psychiatric disorders, 20 on medical health care workers, and 19 on the general public). 18 of the studies were case-control studies/compared to norm, while 25 of the studies had no control groups. The two studies investigating COVID-19 patients found a high level of post-traumatic stress symptoms (PTSS) (96.2%) and significantly higher level of depressive symptoms (p=0.016). Patients with preexisting psychiatric disorders reported worsening of psychiatric symptoms. Studies investigating health care workers found increased depression/depressive symptoms, anxiety, psychological distress and poor sleep quality. Studies of the general public revealed lower psychological well-being and higher scores of anxiety and depression compared to before COVID-19, while no difference when comparing these symptoms in the initial phase of the outbreak to four weeks later. A variety of factors were associated with higher risk of psychiatric symptoms and/or low psychological well-being including female gender, poor-self-related health and relatives with COVID-19. Conclusion Research evaluating the direct neuropsychiatric consequences and the indirect effects on mental health is highly needed to improve treatment, mental health care planning and for preventive measures during potential subsequent pandemics.
Article
As the COVID-19 outbreak peaks, millions of individuals are losing their income, and economic anxiety is felt worldwide. In three different countries (the USA, the UK, and Israel: N = 1200), the present study addresses four different sources of anxiety: health-related anxiety, economic-related anxiety, daily routine-change anxiety, and anxiety generated by social isolation. We hypothesized that, economic anxiety would have a similar or greater effect, compared to health anxiety. Results show that in all three countries, the levels of economic and health anxiety were essentially equal, and both surpassed routine-change and isolation anxiety. Although the COVID-19 crisis originated in the health field, this study emphasizes the need to move from a generalized concept of anxiety to specific types of distress, most notably economic anxiety. Economic anxiety results in serious mental and physical health problems and should be attended to by clinical professionals and by policy makers.