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      Iranian Emotional Experience and Expression During the COVID-19 Crisis

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      , PhD 1 , , PhD 2
      Asia-Pacific Journal of Public Health
      SAGE Publications

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          Abstract

          The outbreak of coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China, in December 2019. 1 This disease has spread rapidly in many countries, including Iran, where a cumulative number of cases has been reported since the end of February 2020. 2 From the beginning of this pandemic, all public places, even mosques and holy shrines, were closed in Iran, and social distancing and home quarantine were encouraged. A remarkable point about the spread of this disease in Iran was the coincidence of the COVID-19 pandemic with the Iranian New Year (“Nowruz”). Consequently, the New Year ceremonies, including family visits, long-distance travel, celebrations, and gatherings, were suspended. In the COVID-19 pandemic, people’s mental health has been negatively affected due to the increase in morbidity and mortality, besides changes in living conditions and self-quarantine. Almost everyone is experiencing a type of mental health problem, such as anxiety, depression, 3 fear of death, anger, posttraumatic stress disorder, 4 and suicide. 5 However, the associated awareness of potential health-related threat can be protective and prompt health-promoting behavior, when if excessive can be detrimental. 6 From an Emotion-Focused Therapy perspective, the COVID-19 pandemic can trigger maladaptive emotional schemas, as people tend to suppress their emotions and rely on avoidance mechanisms. 7 In other words, many people may ignore this real-life problem and dismiss the COVID-19 outbreak. In Iran, it took about 1 month for people to accept the life-threatening nature of COVID-19; even some politicians failed to acknowledge the importance of this disease. Denial is the first stage of emotional expression in critical situations. Therefore, people may misinterpret and catastrophize their thoughts, behaviors, and bodily sensations regarding the COVID-19 pandemic. Reactions to this critical condition depend on the emotional processing style. In this article, we tried to observe and report the Iranians’ emotional processing pattern since the beginning of the COVID-19 pandemic. Fear has been the most important and common emotion during the COVID-19 pandemic. This primary adaptive emotion has encouraged people to maintain sanitation during quarantine. Iranian people, similar to other populations, may experience fear as an adaptive emotion. 8 However, if fear is experienced maladaptively, secondary emotions, such as anxiety, worry, panic, and phobia, may appear. People during quarantine may become very anxious and phobic due to social isolation, especially when they are unable to understand their anxiety. The COVID-19 pandemic has created catastrophic expectations about the future and has caused major anxiety in people. There are numerous discussions and misconceptions about this disease in the cyberspace and social media, triggering maladaptive emotions, such as fear, among people. Shame caused getting virus, as an adaptive emotion, can protect one’s privacy. During the COVID-19 crisis, this shame has encouraged people to social distancing. Due to the common purpose and unity of Iranian people in eradicating COVID-19, they have experienced shame adaptively; only some groups, who have lost their jobs due to the pandemic, feel worthless. Also, in the COVID-19 pandemic, anger has been triggered in the following 3 situations: Value conflicts: Due to the Corona crisis, mosques and shrines have been closed; therefore, people who used to pray in these sites cannot visit them anymore. The coincidence of the peak of the COVID-19 pandemic with the New Year holidays (Nowruz) in Iran: Nowruz provides this opportunity for people to go sightseeing, socialize with others, and travel; however, the pandemic prevented these holiday activities. Threatening of the family status: Since family members are required to stay at home and avoid visiting their relatives and friends, family conflict may arise. Also, couples who did not have any major conflicts before the outbreak may be involved in new conflicts. 9 Moreover, some people feel grief and sadness due to the loss of their loved ones to COVID-19 or other causes. In the Iranian culture, burial and mourning ceremonies are religious rituals, which can soothe people and accelerate the grieving process. Due to social restrictions and quarantine during this pandemic, people cannot attend the mourning ceremonies, which are special events in the Islamic and Iranian culture. Consequently, they may feel unresolved grief and cannot fully express their sadness. Overall, delayed grief, grief disorder, and subsequent depression symptoms are predictable. The COVID-19 pandemic has imposed emotional burdens on the public. It seems that after the end of this pandemic, another pandemic of mental and social disorders will arise. Generally, the majority of community interventions are based on cognitive-behavioral models. 10 We suggest that emotional problems and related treatments be also included in these interventions. In addition to Emotion-Focused Therapy, patience is also of paramount importance in stressful situations. In religious terms, patience results from the individual’s trust in a higher power and stems from his/her understanding of mental and spiritual principles; therefore, people with patience have a more secure state of mind. In other words, patience entails acceptance, positivity, responsibility, commitment, faith, hope, and trust.

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          The Impact of COVID-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users

          COVID-19 (Corona Virus Disease 2019) has significantly resulted in a large number of psychological consequences. The aim of this study is to explore the impacts of COVID-19 on people’s mental health, to assist policy makers to develop actionable policies, and help clinical practitioners (e.g., social workers, psychiatrists, and psychologists) provide timely services to affected populations. We sample and analyze the Weibo posts from 17,865 active Weibo users using the approach of Online Ecological Recognition (OER) based on several machine-learning predictive models. We calculated word frequency, scores of emotional indicators (e.g., anxiety, depression, indignation, and Oxford happiness) and cognitive indicators (e.g., social risk judgment and life satisfaction) from the collected data. The sentiment analysis and the paired sample t-test were performed to examine the differences in the same group before and after the declaration of COVID-19 on 20 January, 2020. The results showed that negative emotions (e.g., anxiety, depression and indignation) and sensitivity to social risks increased, while the scores of positive emotions (e.g., Oxford happiness) and life satisfaction decreased. People were concerned more about their health and family, while less about leisure and friends. The results contribute to the knowledge gaps of short-term individual changes in psychological conditions after the outbreak. It may provide references for policy makers to plan and fight against COVID-19 effectively by improving stability of popular feelings and urgently prepare clinical practitioners to deliver corresponding therapy foundations for the risk groups and affected people.
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            Mental Health Strategies to Combat the Psychological Impact of COVID-19 Beyond Paranoia and Panic.

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              How health anxiety influences responses to viral outbreaks like COVID-19: What all decision-makers, health authorities, and health care professionals need to know

              Heath anxiety occurs when perceived bodily sensations or changes, including but not limited to those related to infectious diseases (e.g., fever, coughing, aching muscles), are interpreted as symptoms of being ill (Asmundson, Abramowitz, Richter, & Whedon, 2010; Taylor & Asmundson, 2004). Almost everyone experiences health anxiety to some degree, and the associated vigilance to potential health-related threat can be protective, helping identify early signs of health issues that prompt health-promoting behavior. But, when excessive, health anxiety can be detrimental. As illustrated by Kosic, Lindholm, Jarvholm, Hedman-Lagerlof, and Axelsson (2020) in this volume, high levels of health anxiety are becoming increasingly common and, given that high health anxiety is known to manifest following exposure to disease-related popular media (Asmundson et al., 2010), of which there is no current shortage with COVID-19, levels around the world and particularly in areas reporting confirmed cases are likely to be on the rise. Psychological factors are known to play a vital role in the success of public health strategies used to manage epidemics and pandemics; that is, risk communication, vaccination and antiviral therapy, hygiene practices, and social distancing. Health anxiety is important in influencing the success or failure of each of these strategies (Taylor, 2019). Accordingly, it is critical that public health decision-makers, health authorities, and health care providers across disciplines understand how health anxiety will influence responses to viral outbreaks, including current responses to COVID-19. Contemporary cognitive-behavioral models (e.g., Asmundson et al., 2010; Taylor & Asmundson, 2004) posit that health anxiety occurs along a continuum; that is, it varies in degree, from very low levels to very high levels, as opposed to varying in quality. These models also suggest that high levels of health anxiety are characterized primarily by catastrophic misinterpretations of bodily sensations and changes, dysfunctional beliefs about health and illness, and maladaptive coping behaviours. People with high health anxiety tend to misinterpret benign bodily sensations and changes as dangerous. In the case of viral outbreaks, depending on prior experiences with influenza and available information about the current outbreak, a person with high health anxiety may misinterpret benign muscle aches or coughing as a tell-tale signs that they are infected (Taylor & Asmundson, 2004; Wheaton, Abramowitz, Berman, Fabricant, & Olatunji, 2012). This, in turn, increases their anxiety. Misinterpretations of bodily sensations and changes are influenced by one’s beliefs about health and disease, which in those with high health anxiety often include beliefs that all bodily sensations and changes are signs of illness and that one is especially weak or vulnerable to becoming ill. In short, in the context of a viral outbreak or pandemic, individuals with high health anxiety are prone to misinterpreting harmless bodily sensations and changes as evidence that they are infected. This will, in turn, increase their anxiety, influence their ability to make rational decisions, and impact their behaviour. There are several ways in which high health anxiety may influence behavioural responses to the belief of being infected. On the one hand, some people with high health anxiety may regard hospitals and doctor’s offices as a source of contagion and, therefore, avoid seeking medical assistance. On the other hand, other people with high health anxiety tend to seek out health-related information and reassurance, often from doctors. As such, they may visit multiple doctors or even attend hospital emergency rooms in their pursuit of reassurance that their bodily sensations and changes are not due to infection. This behaviour, if it occurs, would add undue burden to health care resources. This was evident during the 2009 H1N1 influenza pandemic, where the surge of patients on hospitals occurred even when the outbreak was only a rumor. At the time in the state of Utah, for example, there was heightened public concern about influenza but little actual disease prevalence; however, emergency room departments experienced substantial surges in patient volumes, with the volumes comparable to the increases experienced when the disease actually reached the state (McDonnell, Nelson, & Schunk, 2012). Most of the surge was due to pediatric visits. Young children frequently contract diseases with flu-like features (e.g., fever, cough, congestion), which were likely misinterpreted by their parents as possible signs of pandemic influenza. A recent article in the Journal of the American Medical Association highlights the need for hospital and medical clinic preparedness so that that concerns regarding COVID-19 do negatively impact normal medical care or compound its direct morbidity and mortality (Adalja, Toner, & Inglesby, 2020). People with high health anxiety also tend to engage in a variety of other maladaptive safety behaviours. In the context of viral outbreaks, this may include excessive hand washing, social withdrawal, and panic purchasing. It is noteworthy that all of these behaviours are consistent with public health recommendations for managing epidemics and pandemics; however, in the case of those with high health anxiety, they are taken to an extreme that can have negative consequences to the individual and their community. For example, the false sense of urgency for various products needed for self-quarantine may lead the health anxious person to over-spend on stockpiling unneeded resources (e.g., hand sanitizer, medications, protective masks). This can have a rippling detrimental impact on a community in need of these resources for other purposes, including normal medical care. Low levels of health anxiety can also have negative impacts on health behaviour (Asmundson, Taylor, Carleton, Weeks, & Hadjistavropoulos, 2012), including public health strategies for managing epidemics and pandemics. To illustrate, during the 2009 H1N1 influenza pandemic, people who viewed themselves as having a low risk of infection were less likely to wash their hands (Gilles et al., 2011) and less likely to seek vaccination (Taha, Matheson, & Anisman, 2013). People who view themselves as being at low risk of infection will also be unlikely to change their social behaviour and disregard recommendations for social distancing. Failure to adhere to even the simplest recommendations, such as washing one’s hands and social distancing, can have significant negative impacts on any efforts to mitigate viral spread. Given that some people are now changing travel plans, organizers are cancelling conferences and other large public events, and hand sanitizer and other health “safety” and “survival” products are flying off the shelves, it is apparent that concern for personal safety is mounting as the number of COVID-19 cases continues to rise around the world. Health anxiety is one of the several psychological factors that will influence the way any given person responds to a viral outbreak (Taylor, 2019), including COVID-19. As per our recent recommendations (Asmundson & Taylor, 2020), more research is needed to understand how individual difference factors, including health anxiety, specifically impact behaviour in response to COVID-19. This will take some time. In the meantime, basic knowledge of how high and low levels of health anxiety will impact behaviour as it relates to strategies for containing and mitigating viral spread is important for all decision-makers, health authorities, and health care professional and needs to be communicated to the public in an effort to curb maladaptive or irresponsible decisions that may negatively impact these efforts.
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                Author and article information

                Journal
                Asia Pac J Public Health
                Asia Pac J Public Health
                APH
                spaph
                Asia-Pacific Journal of Public Health
                SAGE Publications (Sage CA: Los Angeles, CA )
                1010-5395
                1941-2479
                7 July 2020
                : 1010539520937097
                Affiliations
                [1 ]Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
                [2 ]Iranian Institute of Emotion-Focused Therapy, Tehran, Iran
                Author notes
                [*]Khodabakhsh Ahmadi, Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Mallasadra Avenue, Sheykhbahaie Street, Tehran 17166, Iran. Email: kh_ahmady@ 123456yahoo.com
                Author information
                https://orcid.org/0000-0001-8969-8449
                Article
                10.1177_1010539520937097
                10.1177/1010539520937097
                7342931
                32633555
                a1a0c44a-4524-4969-9eb8-64819d6886bc
                © 2020 APJPH

                This article is distributed under the terms of the Creative Commons Attribution 4.0 License ( https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

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