research articles on stress and coping

• Research Article
• Open access
• Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

• Szabolcs Garbóczy 1 , 2 ,
• Anita Szemán-Nagy 3 ,
• Mohamed S. Ahmad 4 ,
• Szilvia Harsányi 1 ,
• Dorottya Ocsenás 5 , 6 ,
• Viktor Rekenyi 4 ,
• Ala’a B. Al-Tammemi 1 , 7 &
• László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

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Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

Department of Psychiatry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

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Department of Personality and Clinical Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Anita Szemán-Nagy

Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Dorottya Ocsenás

Doctoral School of Human Sciences, University of Debrecen, Debrecen, Hungary

Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Móricz Zs. krt. 22, Debrecen, 4032, Hungary

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All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Is intrinsic motivation related to lower stress among university students relationships between motivation for enrolling in a study program, stress, and coping strategies.

1. Introduction

1.1. motivation for enrolling in a study program, 1.2. student stress and coping, 2. materials and methods, 2.1. samples and procedure, 2.2. instruments.

• Problem-focused coping (active coping, planning, instrumental support; α = 0.72);
• Emotion-focused coping (positive reframing, acceptance, humor, religion; α = 0.64 after removing the subscale emotional support, which did not fit with the data);
• Dysfunctional coping (self-distraction, denial, behavioral disengagement, and self-blame; α = 0.67 after removing the subscales substance use and venting, for the same reason).

2.3. Statistical Analyses

3.1. interrelation between the variables.

• Intrinsic: ρ = 0.23, n.s.;
• Extrinsic—materialistic: ρ = 0.46, p < 0.01;
• Extrinsic—social: ρ = 0.34, p < 0.05;
• Socially induced: ρ = 0.02, n.s.;
• Coping-oriented: ρ = 0.35, p < 0.05;
• Insecurity: ρ = 0.38, p < 0.05;
• Motivational conflicts: ρ = 0.46, p < 0.01.

3.2. Differences in Motivation between First- and Higher-Semester Students

3.3. relationships between motivation, stress, and coping strategies, 4. discussion, 4.1. facets of motivation and their changes, 4.2. motivation, stress, and coping strategies, 4.3. limitations and future research directions, 4.4. practical implications, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Schladitz, S.; Rölle, D.; Drüge, M. Is Intrinsic Motivation Related to Lower Stress among University Students? Relationships between Motivation for Enrolling in a Study Program, Stress, and Coping Strategies. Educ. Sci. 2024 , 14 , 851. https://doi.org/10.3390/educsci14080851

Schladitz S, Rölle D, Drüge M. Is Intrinsic Motivation Related to Lower Stress among University Students? Relationships between Motivation for Enrolling in a Study Program, Stress, and Coping Strategies. Education Sciences . 2024; 14(8):851. https://doi.org/10.3390/educsci14080851

Schladitz, Sandra, Daniel Rölle, and Marie Drüge. 2024. "Is Intrinsic Motivation Related to Lower Stress among University Students? Relationships between Motivation for Enrolling in a Study Program, Stress, and Coping Strategies" Education Sciences 14, no. 8: 851. https://doi.org/10.3390/educsci14080851

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Peer-reviewed

Research Article

Stress and coping strategies among higher secondary and undergraduate students during COVID-19 pandemic in Nepal

Roles Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal

Roles Conceptualization, Formal analysis, Writing – review & editing

Affiliations Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal, Nepal Health Frontiers, Kathmandu, Nepal

Roles Supervision, Writing – review & editing

Affiliations Nepal Health Frontiers, Kathmandu, Nepal, Department of Public Health, Section for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark, COBIN Project, Nepal Development Society, Bharatpur, Chitwan, Nepal

Roles Conceptualization, Methodology, Supervision, Writing – review & editing

• Durga Rijal, 
• Kiran Paudel, 
• Tara Ballav Adhikari, 
• Ashok Bhurtyal

• Published: February 15, 2023
• https://doi.org/10.1371/journal.pgph.0001533
• Reader Comments

Coronavirus Disease (COVID-19) pandemic has profoundly affected lives around the globe and has caused a psychological impact among students by increasing stress and anxiety. This study evaluated the stress level, sources of stress of students of Nepal and their coping strategies during the pandemic. A cross-sectional web-based study was conducted during the complete lockdown in July 2020 among 615 college students. Stress owing to COVID-19 and the lockdown was assessed using the Perceived Stress Scale (PSS), and Brief Coping Orientation to Problems Experienced (Brief COPE) was used to evaluate coping strategies. To compare the stress level among participants chi-square test was used. The Student’s t-test was used to compare Brief COPE scores among participants with different characteristics. The majority of study participants were female (53%). The mean PSS score was (±SD) of 20.2±5.5, with 77.2% experiencing moderate and 10.7% experiencing a high-stress level. Moderate to high levels of stress were more common among girls (92.6%) than boys (82.7%) (P = 0.001). However, there was a significant difference in perceived stress levels disaggregated by the students’ age, fields and levels of study, living status (with or away from family), parent’s occupation, and family income. The mean score for coping strategy was the highest for self-distraction (3.3±0.9), whereas it was the lowest for substance use (1.2±0.5). Students with a low level of stress had a higher preference for positive reframing and acceptance, whereas those with moderate to high levels of stress preferred venting. Overall, students experienced high stress during the lockdown imposed as part of governmental efforts to control COVID-19. Therefore, the findings of our study suggest stress management programs and life skills training. Also, further studies are necessary to conduct a longitudinal assessment to analyse the long-term impact of this situation on students’ psychological states.

Citation: Rijal D, Paudel K, Adhikari TB, Bhurtyal A (2023) Stress and coping strategies among higher secondary and undergraduate students during COVID-19 pandemic in Nepal. PLOS Glob Public Health 3(2): e0001533. https://doi.org/10.1371/journal.pgph.0001533

Editor: Abhijit Nadkarni, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, UNITED KINGDOM

Received: October 13, 2021; Accepted: December 24, 2022; Published: February 15, 2023

Copyright: © 2023 Rijal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data are available in the Supporting information file.

Funding: The authors received no specific funding for this work.

Competing interests: The authors declare no competing interests.

Introduction

Coronavirus disease (COVID-19) pandemic profoundly affected lives worldwide, which not only threatened physical health but global public health and social systems also collapsed during the coronavirus outbreak [ 1 ]. Evidence from the previous outbreaks of the severe acute respiratory syndrome (SARS) in 2003 and H1N1 influenza in 2009 illustrates that the community suffered considerable fear and panic, resulting in a significant psychological impact. A similar scenario was seen during the COVID-19 pandemic [ 2 ]. Higher levels of anxiety, worries, and social avoidance behaviors were confirmed in the general population in many studies conducted during the earlier pandemic of Middle East Respiratory Syndrome (MERS) [ 1 , 3 ].

The effect of COVID-19 pandemic on global mental health is less studied. The increasing trend of this disease led to a global atmosphere of anxiety and depression due to disrupted travel plans, social isolation, media information overload, and panic buying of necessity goods and restrictions and economic shutdown imposed a complete change to the psychological environment of affected countries [ 4 – 6 ]. The infection has also caused a psychological impact among students by increasing stress and anxiety during the pandemic [ 7 – 9 ]. Studies showed a high prevalence of stress, anxiety, and depression among students during the COVID-19 pandemic as an effect of the disease itself and lockdowns. The reported stressors include delay in academic activities, financial difficulties, prolonged lockdown, overload of COVID-19 related information, home-schooling, fear of COVID-19 infection, and restrictive measures such as quarantine, isolation, and social distancing which caused an impact on psychological well-being [ 1 , 6 , 10 , 11 ].

In Nepal, limited studies have been conducted to assess the psychological impact of COVID-19 among students. However, studies were conducted during the non-pandemic period, which revealed stress as a problem among the students, as 27% were stressed [ 12 ]. Similar to the studies conducted among students of various countries like Spain [ 7 ], China [ 11 ], and Turkey [ 13 ], students of Nepal also showed significant psychological impact during the pandemic [ 14 ]. According to the same study, 66.7% of students had some level of anxiety, with 27.1% having severe anxiety during the pandemic in Nepal [ 14 ].

To the best of our knowledge, there are no studies to assess the psychological effect and coping strategies among students other than medical students during the pandemic in Nepal. Students can make negative assessments of the pandemic and adopt various coping strategies that may affect their health and well-being. Additionally, there is a possibility that stress is a multi-faceted psychosocial experience that can affect different people differently; therefore, in addition to the prevalence of different levels of stress, it’s important to look at how it may be disproportionately impacting different groups of students. Therefore, a timely assessment of students’ mental health status and coping strategies may help reduce future negative consequences. Therefore, this study aimed to assess perceived stress levels, the sources of stress, and the coping strategies adopted by the students during the COVID-19 pandemic.

Study design and participants

A web-based descriptive, cross-sectional study was done in July 2020 during the complete lockdown in Nepal. The study was carried out among higher secondary and university-level undergraduate students. The study population was students in grades 11 and 12 of faculties, science, and management. Likewise, university-level students, only the bachelor-level students doing a four-year course on various subjects were included in the study. In our study, the undergraduate students were primarily in the fields of pure science, management, medical, paramedical, engineering/architecture, arts/humanities, and information technology. Our study was not confined to students of a specific college as we did not select a specific college for recruiting the participants.

To calculate the sample size, the expected proportion of stress of COVID-19 among the students was taken as 28.8% from a similar study conducted in China [ 9 ]. The sample size was calculated using the formula, n = z 2 pq/d 2 , where p = 0.29, q = 0.71, z = 1.96 at 95% confidence interval, and d = 0.05, which is 315. After assuming 10% of the non-response rate, the final calculated sample size was 347. A total of 643 responses were recorded, of which 28 were redundant, and only 615 were eligible for the analysis. Therefore, the sample size was 615.

Study procedure

We followed the non-probability sampling technique, purposive and snowball sampling, and used our personal contact as well as several Facebook pages and groups of college students to invite them for the study. Google forms were disseminated among the students through email and social media platforms. Facebook groups, Facebook chat, and Viber were predominantly used to recruit participants. To limit the response from only the college students, forms were posted in the official Facebook groups of college students such as Nepal Public Health Student’s Society, institution-based Rotaract clubs, Facebook groups of students of other faculties, etc. and it was mentioned strictly that the forms should be filled only by the college students. Out of the total responses, only 16% of the responses came through email and personal invitation, and 84% of responses were from social media groups. Participation was voluntary; only those who ticked “I Agree” in the informed consent form, which was displayed on the front page of the questionnaire, could proceed further. Participants were allowed to fill out the form once, and multiple entries were not allowed.

Ethical considerations

The study protocol was approved by the Institutional Review Committee of the Institute of Medicine, Tribhuvan University, Kathmandu, Nepal [Registration number: 85/ (6–11) E 2 / 077/078]. Written digital consent was taken from study participants before completing the survey form. The informed consent form displayed on the front page of the form was for participants of age 18 and above. For the participants of age 16 and 17, it was mentioned in the consent form that the participants of this age group should fill up the form as per their parents’ consent.

The online questionnaire contained three main parts. The first part included questions about socio-demographic characteristics, COVID-19, and sources of stress. Sources of stress were assessed by a question that included variables derived from the literature review. The second part was the Perceived stress scale. Perceived stress was assessed using the Perceived stress scale (PSS-10). A PSS is a 10-item questionnaire to measure the respondents’ self-reported stress level by assessing feelings and thoughts during the last month [ 15 ]. However, to focus on the scope of the study and to reflect on perceived stress during the pandemic, “experiences because of COVID-19” was added to each question. The Cronbach’s alpha value reported for this scale was 0.79 [ 16 ]. The PSS-10 consists of six positive items (items 1, 2, 3, 6, 9, and 10) and four negative items (4, 5, 7, and 8). In PSS, each question is rated on a 5-point Likert scale ranging from “Never (score 0)”, “Almost never (score 1)”, “Sometimes (score 2)”, “Fairly often (score 3)”, “Very often (score 4)” with a range of 0 to 40 for the total score of the scale. A higher level of stress is indicated by higher scores on this scale which is the score of 0–13 indicates “Mild stress”, 14–26 indicates “Moderate stress” and 27–40 indicates “High stress”. The scores for questions 4, 5, 7, and 8 were reversed, and the scores for perceived stress were calculated by summing the scores for the relevant items.

The third part consisted of the Brief COPE scale [ 17 ]. The original brief-COPE by Carver comprised 14 subscales, including self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame.” It is an abbreviated version of the COPE Inventory consisting of 28 items, two items in every 14 subscales, and each item is rated on a 4-point Likert Scale ranging from “I have not been doing this at all (score 1)”, “A little bit (score 2)”, “A medium amount (score 3)”, “I have been doing this a lot (score 4)”. The mean score of all items in each subscale is used, and a higher number indicates a higher preference for the coping strategies reported by the participants. Only ten dimensions of coping strategies were used.

Data analysis

After completing data collection, responses stored in the web-based database (Google Drive) were downloaded, compiled, edited, and checked for errors in Microsoft Excel. Then the data was exported to Statistical Package for the Social Sciences (SPSS) version 20 for data cleaning, coding, and analysis. Continuous variables like coping strategies were expressed as mean and standard deviation (SD), whereas frequency and percentages were used to present categorical data. The chi-square test was used to assess the association of perceived stress levels among participants with different characteristics. The Student’s t-test for independent samples was used to compare the mean values of coping strategies in relation to studied variables.

Socio-demographic characteristics

Table 1 depicts the socio-demographic characteristics of the respondents. Among the 615 respondents, the majority (53.0%) were female. The age ranged from 16 to 29, with a mean age (±SD) of 20.5 (±2.5). More than two-thirds (70.2%) of the respondents were Brahmin/Chhetri. The majority of the respondents (92.7%) were living with their family, and only 9.6% of the respondents disclosed having their family/friends/relatives infected with COVID-19 or in isolation ( Table 1 ).

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https://doi.org/10.1371/journal.pgph.0001533.t001

Perceived stress

The majority of the students (77.2%) had a moderate level of perceived stress, whereas 12.0% had low perceived stress, and 10.7% had high perceived stress. The overall mean stress score (±SD) was 20.2 (±5.5). Among the socio-demographic variables, only gender was significantly associated with the level of stress. Male respondents were observed to have significantly less stress than female respondents (p-value = 0.001). Table 2 shows the association of the level of perceived stress with socio-demographic variables.

https://doi.org/10.1371/journal.pgph.0001533.t002

Sources of stress among students

The most important sources of stress reported by students were the long duration of lockdown (60.7%) and excessive hearing of news related to COVID-19 (50.1%). Out of 12 sources of stress, only one source, i.e., delay in the resumption of teaching/learning or fear of extension of the academic year, was significantly associated with the level of perceived stress.

Coping strategies used by students

Out of the ten coping strategies, only three were significantly associated with perceived stress. Students with a low stress level had a higher preference for positive reframing and acceptance, whereas those with moderate to high levels of stress preferred venting more. ( Table 3 ). Self-distraction was the highest used coping strategy, followed by acceptance, and substance use was the lowest ( Table 4 ).

https://doi.org/10.1371/journal.pgph.0001533.t003

https://doi.org/10.1371/journal.pgph.0001533.t004

Gender was observed to be one of the main factors where significant differences were observed for all the coping strategies used in the study except positive reframing (p = 0.1) and active coping (p = 0.2) ( Table 4 ).

This study examined perceived stress among college and university students during the COVID-19 pandemic and the lockdown period in Nepal. Our study found that the majority of the students (77.2%) had moderate perceived stress, which resembles the findings of other studies from Spain [ 7 ], China [ 11 ], India [ 18 ], the US, and the UK [ 19 ] which reported a high level of mental health problems during the COVID-19 outbreak. Likewise, using the same measurement scale (i.e., PSS-10), in a study among students in Saudi Arabia during the COVID-19 outbreak, more than half of the participants (55%) showed moderate levels of stress, and 30.2% showed high stress [ 20 ]. Another study from Pune, India, reported that 82.6% of the students experienced moderate perceived stress, and a high perceived stress score was seen in 13.35% of the students during the COVID-19 pandemic [ 18 ]. Likewise, university students in southeast Serbia reported a mean perceived stress score of (20.3±7.6) which is similar to our findings (20.2±5.5) [ 21 ].

However, the result of our study contrasted with the findings from Turkey, in which 71.2% reported high perceived stress [ 13 ]. In the previous studies conducted in Nepal during the non-pandemic period, stress was found among 27% of students, 20.9% faced psychological morbidity, and the majority of the students (51%, n = 350) reported moderate to extremely severe levels of stress, anxiety, and depression [ 12 , 22 , 23 ]. In another study conducted during the non-pandemic period in Nepal, 60.4% of the students experienced moderate stress levels, and only 0.6% of the students experienced high-stress levels [ 24 ]. However, in our study, the percentage of students having stress was higher than in studies conducted during a non-pandemic situation in Nepal. Adding to it, the mean perceived stress score of (20.2±5.5) suggests that our participants had relatively high stress compared with established norms for a general population sample aged 18–29 (14.2±6.2) [ 15 ]. Furthermore, the perceived stress results in our study were relatively higher (20.2±5.5) than the results obtained in an earlier pre-COVID-19 survey among the Serbian students (14.9±6.3) [ 21 ]. Likewise, the perceived stress reported by the Malaysian study during the non-pandemic period was found to be relatively lower (46.3%) [ 25 ] than the result of our study, which may indicate that the pandemic might have aggravated the stress among students across the globe.

In this study, only gender was associated with the level of perceived stress. The female students were observed to have a higher mean score of perceived stress (21.0±5.1), similar to the findings from other studies conducted during the pandemic [ 13 , 19 , 20 ] that have shown significant gender differences in the psychological response to the pandemic. Likewise, the study results are in line with the recent studies carried out among the student of Spanish University [ 7 ] and the Saudi Arabian students [ 26 ], which showed significant gender differences. Therefore, high stress levels among females might have been attributed to various factors, including hormonal changes and expression of emotions and thoughts regarding their social situation [ 20 ], and the recent pandemic might have exacerbated this situation. Sociocultural inequity and gender norms, differences in the distribution of resources and restricted control over the economy make females more vulnerable to mental health problems in most of the low-and middle-income countries [ 27 ].

In Nepal, there is a difference in the socialization pattern of men and women [ 28 ]. Women are more likely to be more open about their feelings and admit their stress, whereas men are more reluctant to report psychological duress, which may lead to gender differences in terms of the appraisal process of stressful events [ 29 ]. In addition, women in Nepal have a higher societal expectation of being in caretaking roles, which may be even more stressful during a pandemic. Sometimes, they cannot fulfill the expectation of family members, so women are often abused and victimized [ 30 ]. In addition to economic hardship during the pandemic, a mental health risk for women could have been driven by gender-based violence (GBV) embedded in social norms [ 27 ]. The United Nations identified GBV as one of the areas of the impacts of COVID-19 on women [ 31 ]. During the COVID-19 lockdown in Nepal, several cases of domestic violence against women and girls were reported, which could directly affect their mental health [ 32 ]. Therefore, these gender differences open a path for more gender-specific intervention. The high prevalence of perceived stress and significant gender difference also suggests specific psychological measures prepared to prevent perceived stress and other mental health problems, especially for women.

In one of the studies, age and educational level were significantly associated with stress, where university students had a significantly higher mean score of perceived stress than intermediate and secondary school students. However, no such association was found in our study between perceived stress and age and perceived stress and educational level [ 20 ]. Similarly, in our research, there was no significant association between educational background and the stress level, contrary to other studies. Students in management-related studies seemed to have a higher level of anxiety than medical students during the pandemic [ 33 ]. This might be because students of all the faculties in our study could have been well-informed about the pandemic and the precautionary measures.

Likewise, the parents’ occupation did not affect the level of perceived stress, unlike the findings of the previous study [ 34 ]. In one of the studies conducted among college students in China, anxiety regarding the epidemic was associated with the source of parent income, whether living with parents and whether a relative or an acquaintance was infected with COVID-19, which is not in agreement with the results of our study [ 11 ].

Given the above findings, students considered many factors as sources of stress during the pandemic. More than six out of ten study participants considered the long duration of the lockdown as the major source of stress. It corroborates with the literature suggesting that lockdown is one of the important stressors during COVID-19 and has a considerable psychological impact on the well-being of people [ 6 ]. This might be because, during the lockdown, outdoor activities were hampered. Likewise, half of the students (50.1%) indicated stress induced by news outlets, similar to those found among the US College students. This type of stress may be exacerbated by a large amount of misinformation, including false and fabricated information distributed through news and social media [ 35 ]. Also, studies suggest that people may develop “headline stress disorder” during the modern pandemic, which is characterized by stress to endless reports from the news media [ 36 ].

Similarly, in our study, students considered a delay in the resumption of teaching/learning or fear of extension of the academic year, fear of contracting the virus by family/friends/relatives, financial difficulties, worries of the future like employment, gaining weight, interpersonal conflict with roommate/family members as other important sources of stress which resembles with the recent findings [ 35 , 37 ]. However, our findings related to an overload of the assignment were different from that found in the recent study in which 66.6% considered increased class workload as the source of stress. In contrast, in our study, only 11.1% considered it the source of stress [ 35 ]. This might be because colleges and universities were closed; only limited colleges and universities ran virtual classes. In the study conducted among university students in Pakistan, major distress was related to restricted social meetings with friends (84.7%) and fear of family/friends getting infected (70.9%), but in our study, only 14.1% and 44.6% of university-level undergraduate students considered inability to meet family/friends and fear of family/friends/relatives being infected as the source of stress respectively [ 38 ]. This might be because most of the students were with their family/relatives during the period of lockdown, and the virus may not be present at the community level in their place of residence.

To cope with the stressors, students used various coping strategies in our study. The mean scores for active coping strategies (acceptance, planning, active coping, positive reframing, use of emotional support) were greater than avoidant coping strategies (venting, substance use), as well as religious coping and humor except for self-distraction. A similar result was found in the study conducted among Pakistani students, where all the active coping strategies had higher mean scores [ 38 ]. Our study found that substance use was the least common coping strategy among the students, as in the previous studies. However, the average score of substance use was found to be 1.2± 0.5 in our study, and the average score of substance use was reported as 2.5±1.0 and 2.7±1.4 from the same study conducted in Nepal and Malaysia, respectively, during the non-pandemic period which suggests that the average score of substance use was less during the pandemic period [ 22 , 25 ]. This indicates that substance use as a coping strategy for stress might have decreased during the pandemic as the shops selling these products were closed following the government rule of lockdown.

Similarly, living with parents/family members during the lockdown and getting adequate emotional support might also be a reason for decreased substance use by the students. In our study, students with moderate to high-stress levels preferred venting more than the students who perceived low stress. However, students with a low stress level had a higher preference for positive reframing and acceptance. Mixed use of both the active and the avoidant types of coping strategies might be because, in times of uncontrollable situations and diverse types of stressors, any type of coping might be helpful in reducing stress. In our study, active coping was not associated with stress level; this might be because of the uncertainty and uncontrollability of COVID–related stressors.

Likewise, religious coping was also not associated with the level of stress, which is consistent with the finding of a previous study conducted during the non-pandemic period [ 25 ]. Nevertheless, this result contradicts the recent finding that shows religious coping as the most effective coping strategy to deal with severe stress and practiced by many severely stressed students during the pandemic [ 26 ]. This might be because, in our study, the study population was a younger group of people who tend to adopt other coping measures rather than religious coping. The older students in our study used positive reframing more than the teens, which resembles the previous study’s findings [ 25 ].

Our study found the association of gender with self-distraction, planning, humor, acceptance, and religious coping. Male students used self-distraction, acceptance, and religious coping less than females, and females used humor coping less than males, according to a recent study. However, the result of our study differed in planning; males used planning more than females in our study, which contrasts with the previous study [ 38 ]. In our study, male students used active coping less and substance use more than female students, resembling the previous study’s findings [ 25 ]. In the previous study conducted during the outbreak, the mean score was higher for religious coping among university students. However, the mean score was the highest for self-distraction among undergraduate students in our study, followed by acceptance. In contrast, it was the lowest for substance use, similar to the previous findings [ 38 ]. Furthermore, there might be many reasons behind such findings. One of the reasons might be having many options like watching TV, reading books, using social media, playing online games, attending online classes, etc., as there was a lockdown and low substance use might be because students were living with their family/relatives and there was no access of substance due to lockdown. In another study conducted among undergraduate medical students, commonly used coping strategies were “regular exercise”, “watching online movies and playing online games”, “religious activities,” and “learning to live in a COVID-19 situation and accept it” which resembles active coping, self-distraction, religious coping, and acceptance and these strategies were also, commonly used by the medical students in our study [ 26 ].

Therefore, the findings of our study suggest stress management programs as well as life skills training and mindfulness therapy, which have been validated to reduce stress and anxiety [ 39 , 40 ]. Similarly, regular exercise and good sleep are recommended, which have been found to have mitigating effects on negative emotions without social, medical burden [ 9 , 41 ]. Even though female students presented higher stress levels, providing mental health support systems and promoting physical activity regularly is necessary for all students, which could decrease perceived stress levels. Online training, workshops, and contests for the students from the respective educational institutions can also be conducted to distract them from stressful situations, reduce stress, and protect them from future psychological consequences. Therefore, further studies are necessary to conduct a longitudinal assessment to analyse the long-term impact of this situation on students’ psychological states and to enable more robust evidence on causal links and pathways.

Strengths and limitations

There are certain limitations in this study. First, the study was conducted during the peak time when COVID-19 was spreading rapidly, so the study used self-reported questionnaires, which may have issues with subjectivity and reliability. However, respondents were assured of the anonymity of the data. Similarly, social desirability bias and lack of conscientious response in respondents may limit the accuracy of the present findings. Furthermore, the findings from the self-reported measures of mental health cannot be subjected to direct treatment without using diagnostic tools. However, the self-reported tools are easy and useful for assessing individual perceptions of their illness. The PSS cut-offs are the ones established in the literature and may not be the best way to capture the variation in stress expressed in this sample. Second, the study might not represent the population with no access to the internet. Third, the questionnaire was in English, which might have created a language barrier. Fourth, the study used only ten Brief COPE dimensions and missed other dimensions that the respondents could have manifested. Fifth, the limited sample size and purposive sampling approach findings may not represent the entire student population. Sixth, the study was cross-sectional under an unprecedented situation and had a limitation in determining a causal relationship between factors of interest and perceived stress and evaluating the stress level during the actual pandemic and pre-pandemic period. In addition, there may be an exacerbation of existing psychiatric illness, substance use, etc., so the findings here do not represent the only impact of the disease on mental health. Despite the limitations of this study related to web-based cross-sectional design with self-reported measures, the findings add new evidence regarding stress among students during the COVID-19 pandemic. It could also be a piece of baseline evidence for future work on stress and coping strategies among students in Nepal.

The study has shown that the COVID-19 pandemic caused a significant impact on the mental health of the students of Nepal as the majority (87.9%) of the students had moderate to a high level of perceived stress, where only gender was significantly associated with a level of stress. Delay in a resumption of teaching/learning or fear of extension of the academic year was the major source of stress associated with the level of perceived stress. Furthermore, the major coping strategies adopted by the students were self-distraction, acceptance, and active coping. Therefore, these results could be used as a baseline to find the extent of the impact of COVID-19 on the mental health of the students in Nepal. Thus, public attention should be given to the high prevalence of perceived stress and the significant gender differences, and a certain psychological intervention should focus on women to prevent perceived stress and other mental problems in women.

Supporting information

S1 table. level of perceived stress among students..

https://doi.org/10.1371/journal.pgph.0001533.s001

S2 Table. Sources of stress among students.

https://doi.org/10.1371/journal.pgph.0001533.s002

S3 Table. Association of the level of stress with sources of stress.

https://doi.org/10.1371/journal.pgph.0001533.s003

S1 Data. Data underlying the result of the study.

https://doi.org/10.1371/journal.pgph.0001533.s004

Acknowledgments

The authors would like to acknowledge all the students involved in the study and the Central Department of Public Health for supporting us during the process of this study. We thank Ulla Ashorn, Tampere University, for her comments in an earlier version of the manuscript.

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It is all about discomfort avoidance: maladaptive daydreaming, frustration intolerance, and coping strategies – a network analysis

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• Published: 08 August 2024

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• Ari Nowacki   ORCID: orcid.org/0009-0001-0072-7002 1 &
• Anna Pyszkowska   ORCID: orcid.org/0000-0002-5041-7475 1  

Maladaptive daydreaming (MD) is a need to daydream that replaces human interactions and disturbs everyday life. Research suggests that MD can be considered a stress-relief strategy, as a repeating sequence of using imagination may play a significant role in calming oneself down and seeking comfort through escapism and avoidance. The current study explored the relationships between maladaptive daydreaming, coping styles, and frustration intolerance (including discomfort and emotional intolerance) in a general population. The sample was divided into two subgroups: maladaptive daydreamers (MDers) and non-maladaptive daydreamers (non-MDers) based on the cutoff score in the Maladaptive Daydreaming Scale-16 (MDS-16). Three hundred seventeen individuals participated in the study, including 142 MDers. The results showed significantly higher levels of frustration intolerance (U = 9952.00, p  <.01) and avoidance-focused strategies (U = 10170.00, p  <.01) among the MDers. Non-MDers scored significantly higher on the Emotional support-seeking scale (U = 16117.50, p  <.001). Additionally, the network analysis proved differences in the variables’ dynamics: only in the MDers network MD exhibited significant edges with avoidant coping (0.05), discomfort intolerance (0.10), entitlement (0.07), and emotional intolerance (0.10). Entitlement was the variable of the highest expected influence in both subgroups studied. The current study proposes clinical implications: as emotional intolerance may serve as an essential factor in maintaining engagement in maladaptive daydreaming, the role of discomfort intolerance and its links to avoidance should be of significant focus in MD therapy.

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Introduction

The past two decades have introduced an increased understanding of maladaptive daydreaming (MD), described as a need to daydream that replaces human interactions and disturbs everyday life, including work and school activities or interpersonal relationships (Somer, 2002 ). Such daydreams are detailed and may have complex, movie-like plots. Real-life movements or facial expressions often accompany them. Daydreams offer a place to fulfill fantasies, find companionship, and enhance one’s mood (Somer, 2002 ). However, it can lead to fear of being discovered and seen as strange (Somer et al., 2016a ). Feelings of wasting time, embarrassment, and the intrusiveness of daydreams may result in distress (Bigelsen & Schupak, 2011 ). Given that MD can be used to modify one’s emotional state, gets in the way of other areas of a person’s life, and can often be seen as uncontrollable (Somer et al., 2016a ), some researchers suggest that MD may be conceptualized through the lens of behavioral addiction (cf. Pietkiewicz et al., 2018 ), while others propose to link it with dissociation symptoms (Ross et al., 2020 ).

Maladaptive daydreaming can lead to more stress by neglecting relationships, responsibilities, and the need for growth. Once the dreamer decides to reconnect with the real world, they will face a new dose of stress, which can be dealt with by repeatedly daydreaming (Schimmenti et al., 2019 ). Furthermore, the moment of ending one’s MD session and coming back to reality can also be unpleasant: it can activate the realization of missed opportunities that passed by while one was daydreaming and be followed by deep regret (Pietkiewicz et al., 2018 ), which can deter one from trying to stop daydreaming in the near future. That results in a vicious cycle of using MD as an escapist and avoidant strategy, especially among persons who are unable to regulate emotions and have difficulties with discomfort intolerance (Pyszkowska et al., 2023 ).

Somer et al. ( 2016a ) pointed out that maladaptive daydreaming can be an enticing form of escaping from discomfort, including unpleasant emotions and thoughts, as it provides an easy way of achieving one’s goals as long as one keeps on daydreaming. Frustration intolerance beliefs (e.g., “I cannot stand not getting what I want”) have been linked with emotion dysregulation and avoidance (Schetsche & Mustaca, 2021 ; Filippello et al., 2014 ); therefore, it may be yet another significant factor in developing MD. Frustration intolerance has been proposed by Rational Emotive Behaviour Therapy (REBT, Ellis, 2003 ; Harrington, 2005a ) as a multidimensional construct related to emotional tension resulting from a perceived threat to the comfort of life and achieving desired outcomes. Four factors of frustration intolerance have been distinguished. First, emotional intolerance manifests in the belief that emotional distress is overwhelmingly difficult to manage and must be swiftly alleviated or avoided. Second, discomfort intolerance, is characterized by thoughts related to a demand for comfort and ease, along with an expectation for life to be free of any inconvenience. Third, entitlement reflects a need for the world to be fair, an expectation for immediate gratification, and a belief that others should indulge one’s desires. Fourth, achievement, is evident in the beliefs regarding the maintenance of high standards, even when such standards impede progress, coupled with an intolerance for the frustration of these standards. Moreover, each of the factors appears to predict different mental disturbances uniquely. According to Harrington ( 2006 ) and Stanković and Vukosavljević-Gvozden ( 2011 ), emotional intolerance is linked to anxiety, discomfort intolerance to depression, entitlement to anger, achievement frustration to anxiety, and anger. Emotional intolerance and discomfort intolerance have been significantly associated with several dysfunctional coping behaviors, including behavioral and cognitive avoidance, self-harm, procrastination, and overusing medication (Harrington, 2005b ) Also an association between frustration intolerance beliefs and behavioral addictions has also been found, in particular with Internet addiction (Kewalramani & Pandey, 2020 ; Lu et al., 2019 ), and Internet gaming addiction (Lin et al., 2021 ).

Although MD has been conceptualized as a dysfunctional form of imaginative involvement (Pietkiewicz et al., 2018 ), little is still known about links between MD and coping strategies other than avoidance or escapism (Somer, Abu-Rayya, Schimmenti et al., 2020b ; Pyszkowska et al., 2023 ). One of the potential strategies associated with maladaptive daydreaming can be reflective coping, as it relies on using imagination to play out different possible ways of solving problems (Schwarzer & Taubert, 2002 ) and was conceptualized as part of the proactive approach to coping (Greenglass et al., 1999 ). Reflective coping is a part of the proactive approach to coping. Following Schwarzer and Taubert ( 2002 ), the Proactive Coping Theory (PCT) is based on the temporal distinction of coping styles. PCT consists of 4 coping types – reactive coping (coping with harm or loss experienced in the past), anticipatory coping (coping with immediate threat happening shortly), preventive coping (dealing with uncertain threats that may happen in distant future), and proactive coping (seeing upcoming stressors as potential self-promoting challenges). Furthermore, as discussed by Greenglass and colleagues ( 1999 ) in the present the person can implement such strategies as emotional support seeking (temporary regulation of distress by disclosing feelings, seeking companionship and evoking empathy) and avoidance coping (delaying actions in demanding situations).

Research shows that behavioral addictions (BA) are negatively linked with proactive and preventing coping, and positively linked with avoidant coping (Sleczka et al., 2016 ; Thomas et al., 2011 ). Similarly to other BAs, MD can act as a disturbing factor in developing proactive and preventive coping styles as the daydreaming activity takes up most of the maladaptive daydreamers’ time, preventing them from planning or preparing for problem-solving (Pietkiewicz et al., 2018 ).

The current study

This study aims to extend previous research on maladaptive daydreaming by exploring the relationship between MD, coping styles, and frustration intolerance (including discomfort and emotional intolerance) in a general population. Beliefs regarding one’s ability to withstand frustration may translate into implementation of certain coping styles and furthermore underline the reliance on maladaptive daydreaming in everyday life. The study was designed to compare two types of persons: maladaptive daydreamers and those who do not engage in this activity. The groups were divided based on the score obtained in the Maladaptive Daydreaming Scale-16 (Somer et al., 2016c ). It was hypothesized that maladaptive daydreamers, when compared to those who do not engage in MD, would (a) exhibit higher levels of frustration intolerance, avoidant coping, and reflective coping, and (b) have lower levels of proactive, preventive coping, and emotional support seeking. In order to develop a deeper understanding of the dynamics between coping, frustration intolerance, and MD, a network analysis was designed.

• Maladaptive daydreaming

The Maladaptive Daydreaming Scale-16 was used (MDS-16, Somer et al., 2016c ; Polish translation by Magdalena Jadczak, cf. Somer et al., 2015 ) to measure the intensity of MD symptoms. MDS-16 consists of 16 items (e.g., “Some people feel distressed or concerned about the amount of time they spend daydreaming. How distressed do you currently feel about the amount of time you spend daydreaming?”) and has an answer scale ranging from 0% (Never) to 100% (Very often) with 10% increments. The score is calculated as an average of the answers to each item. A score of 40 was used as a cut-off point, classifying persons who scored above 40 points into the MDer group based on Soffer-Dudek’s ( 2021 ) recommendation. Cronbach’s α for the current study is 0.92.

Proactive coping

Proactive Coping Inventory (PCI; Greenglass et al., 1999 ; Polish adaptation by Pasikowski et al., 2002 ) was used to measure the coping style preference of participants. It consists of 55 items, including seven subscales, five of which are used in this study. PCI has a 4-point Likert answer scale. Subscales related to hypotheses proposed in this study included: (a) proactive coping (α = 0.78; example item: “After attaining a goal, I look for another, more challenging one.”), (b) preventive coping (α = 0.81; example item: “I plan my strategies to change a situation before I act.”), (c) emotional support seeking (α = 0.76; example item: “Others help me feel cared for.”), (d) avoidant coping (α = 0.67; example item: “When I have a problem I like to sleep on it.”), (e) reflective coping (α = 0.79; example item: “Before tackling a difficult task I imagine success scenarios.”).

• Frustration intolerance

Frustration–Discomfort Scale (FDS; Harrington, 2005a , Polish translation by Nowacki) was used to measure the frustration intolerance as a sum score of the questionnaire’s 28 items. The scale consists of four subscales, each involving seven items: a) discomfort intolerance (α =.80), entitlement (α =.71; example item: ” I can’t stand having to persist at unpleasant tasks”), emotional intolerance (α = 0.77; ” I can’t bear disturbing feelings”), and achievement (α = 0.71; example item: ” I can’t bear the frustration of not achieving my goals”). Cronbach’s α coefficients for the whole scale was α = 0.88.

Participants

Using a snowball sampling method, participants were recruited online via adverts distributed through the social media communities. The study was advertised as exploratory research regarding various coping strategies and difficulties in frustration tolerance. The criteria for being included in the study were: (a) the ability to speak Polish fluently and (b) being over 18 years old. It was conducted via Lime Survey, and each person was informed it was a voluntary and anonymous study. All participants provided informed consent and were provided with the researcher’s e-mail address if they noticed any negative repercussions of the study participation The results were gathered as a part of a master thesis project between december 2021 and November 2022. The research was approved by the University of Silesia Ethics Committee in Katowice (KEUS251/05.2022).

Three hundred seventeen individuals participated in the study (233 women, 70 men, 14 people of other genders). After collecting the data, the participants were divided into two subgroups (maladaptive daydreamers– MDers, and control group– non-maladaptive daydreamers, non-MDers) based on the score obtained in the Maladaptive Daydreaming Scale-16 (Soffer-Dudek, 2021 ). There were 142 MDers (100 women, 31 men, and 11 people of other genders) and 175 people in the control group (133 women, 39 men, and three people of other genders). A chi-square test showed that there were significant differences in the gender distribution among the two groups (χ 2 (2, N  = 317) = 6.79, p  =.033). People not identifying with the gender binary were more likely to be MDers than non-MDers while proportions of women and men in both groups were similar. Participants marked their ages from 18 to 60, with the average for MDers being M = 24.56, SD = 6.32, and for the control group M = 24.65, SD = 7.27). Sample characteristics are presented in Table  1 .

Data analysis

The quantitative approach was applied. The Shapiro-Wilk W test was conducted to determine the normality rates of the variables studied. Correlations were conducted using the Spearman correlation analysis. The U Mann-Whitney’s test was conducted to establish differences between the MDers and the control group.

Additionally, network models were estimated using the Qgraph package of JASP software. The network consists of nodes, which represent the independent variables and edges representing the pairwise correlations between the nodes after controlling for all other nodes in the network. The graphical lasso based on the Extended Bayesian Information Criterion (EBICglasso; Friedman et al., 2007 ; Foygel & Drton, 2010 ) was used to shrink small edges to zero. Given the non-normal distribution of MDS-16 scores among the MDers and the control group, a nonparanormal transformation was used (Han et al., 2009 ). The graphical illustration of the network shows stronger connections in the form of thicker edges i.e. larger partial correlation. The layout was based on the Fruchterman-Reingold algorithm that forced strongly correlated nodes closer together (Fruchterman & Reingold, 1991 ). The expected influence (EI) was used to measure the node’s centrality, which is calculated as a sum of edge weight of a given node. Given the presented networks contained both positive and negative edges, it was more appropriate to use a centrality measure taking it into account. Central nodes are seen as crucial in understanding the changes in the network due to their interconnectedness with other nodes (Robinaugh et al., 2016 ). A nonparametric bootstrapping sampling method was used to measure centrality to test the network’s stability (Isvoranu et al., 2022 ). To test the dynamic of the relationship between different aspects of frustration intolerance, MD and coping the subscales of FDS were used in the analysis.

The analyses were conducted with JASP v 0.18.1 software (JASP Team, 2023 ). For all statistical tests, we considered an α level of 0.05 to be statistically significant.

First, a correlation analysis, including a whole sample, was conducted. The summary of the results, including the W Shapiro-Wilk normality test, is presented in Table  2 .

Maladaptive daydreaming was positively correlated with avoidant coping ( r  =.21, p  <.001), frustration intolerance– full scale ( r  =.26, p  <.001), discomfort intolerance ( r  =.29, p  <.001), emotional intolerance ( r  =.24, p  <.001), and achievement ( r  =.12, p  <.05); also, it was negatively correlated with emotional support seeking ( r = − .25, p  <.001). Frustration intolerance ( r  =.28, p  <.001), including discomfort intolerance ( r  =.39, p  <.001), emotional intolerance ( r  =.25, p  <.001), and entitlement ( r  =.19, p  <.001), exhibited weak to moderate associations with avoidant coping.

Then, two groups (MDers vs. non-MDers) were compared. The results of Mann-Whitney’s U test are shown in Table  3 .

The MDers scored significantly higher on the avoidant coping subscale (U = 10170.00), the overall score of frustration intolerance (U = 9952.00), discomfort intolerance (U = 9236.50), and emotional intolerance (U = 10051.50) subscales. The non-MDers scored significantly higher on the emotional support-seeking subscale (U = 16117.50).

In the next step, a network analysis was carried out for the (1) MDers and (2) non-MDers (control group), with three groups of variables distinguished: (1) maladaptive daydreaming (red nodes), (2) coping strategies (green nodes), (3) frustration intolerance (blue nodes). The bootstrapping method of 5,000 samples was applied. Figure  1 shows the network plots.

Network analysis for both study groups. Legend: red nodes: 1. MDS–16 score; green nodes: 2. Proactive coping, 3. Reflective Coping, 4. Preventive coping, 5. Emotional Support Seeking, 6. Avoidant coping; blue nodes: 7. Discomfort Intolerance, 8. Entitlement, 9. Emotional intolerance, 10. Achievement

In the MDers’ network, 19 of the 45 possible edges were nonzero, with 14 in the control group. In both groups, most variables were positively connected. Maladaptive daydreaming showed no significant connections in the control group. For the MDers’ group, it has significant edges with avoidant coping (0.05), discomfort intolerance (0.10), entitlement (0.07), and emotional intolerance (0.10). Although the connection between the variables was weak, the positive edges indicate that the higher intensity of MD symptoms is accompanied by higher levels of avoidant coping, discomfort intolerance, entitlement, and emotional intolerance.

The two nods with the highest EI centrality were emotional intolerance (EI = 1.27) and entitlement (EI = 1.39) in the MD group. It could be expected that changes in emotional intolerance and entitlement in this group would lead to biggest changes in other network variables. In the control group, those were entitlement (EI = 1.33) and discomfort intolerance (EI = 0.98). For the MDers, the strongest connections were exhibited between reflective–preventive coping (0.42), proactive coping–emotional support seeking (0.33), achievement–discomfort intolerance (0.29). For the control group, the most robust edges were obtained between reflective–preventive coping (0.51), achievement–entitlement (0.35), entitlement–discomfort intolerance (0.26).

The study aimed to explore differences between maladaptive daydreamers and those who do not engage in MD in the context of coping styles and frustration intolerance. The results broaden the current knowledge regarding psychological mechanisms underlying MD and highlight potential individual differences between MDers and non-MDers. Clinical implications and future research directions are also discussed.

Maladaptive daydreaming and avoidant coping

The results showed that the MDers scored significantly higher than the non-MDers in avoidant coping strategy. Additionally, maladaptive daydreaming showed significant associations with avoidant coping in the network analysis only in the MDers plot. This aligns with previous research reporting that MDers often daydream to escape their problems (Somer et al., 2016a ) and suppress unpleasant emotions (Pyszkowska et al., 2023 ). It has been reported that for some MDers, daydreaming can be an escape from complicated, often traumatic, circumstances they went through, e.g., in childhood (Somer et al., 2020a ). Furthermore, the MDers scored significantly higher than the non-MDers in the discomfort and emotional intolerance scales (and the FDS total score). It is in line with prior studies showing that emotional and discomfort intolerance scales correlate with other dysfunctional coping, including avoidance (Harrington, 2005b ).

Maladaptive daydreaming, entitlement and emotional intolerance

For both groups, entitlement (its mean score did not vary significantly) was the factor with the most expected influence. On the one hand, Somer et al. ( 2016b ) suggest that MDers often turn to daydreaming to fantasize about being appreciated and gratified quickly; therefore, the results obtained may support this hypothesis. On the other hand, as it was significant in both groups studied, entitlement cannot be considered as a specific or crucial factor for developing or maintaining MD. Perhaps entitlement, understood as a pervasive feeling of deservingness, exaggerated expectations, and vulnerability to distress (Grubbs & Exline, 2016 ), is a transdiagnostic– or simply human– self-oriented predisposition accompanying coping strategies and easing discomfort. Furthermore, it has been shown that the relationship between entitlement and addictive behaviours differs across genders (Ko et al., 2008 ) - as the current study consisted predominantly of women, it may have been impossible to identify such a relationship. Additionally, for the MDers, emotional intolerance is second when it comes to centrality. The non-acceptance of emotions as they are and using daydreaming as a strategy to manage them aligns with previous research on maladaptive daydreaming (Greene et al., 2020 ; Pyszkowska et al., 2023 ), where daydreaming was presented as linked to emotional dysregulation and a self-soothing method directed at suppressing emotional discomfort (Regis, 2013 ). The rise of emotions can become an activating even for the beliefs related to one’s inability to withstand them and furthermore regulate them, which results in implementation of MD and avoidant strategies. The network analysis showed that in both groups studied, avoidant coping exhibited relationships with discomfort intolerance, with no direct link with emotional intolerance. In previous studies, discomfort intolerance and deficits in emotional regulation abilities have been linked with avoidance (McHugh et al., 2013 ); therefore, it can be hypothesized that the beliefs regarding lack of ability to stand the hassle of taking care of one’s emotions is a more critical factor than intolerance of emotions itself.

Maladaptive daydreaming and emotional support seeking

The hypothesis concerning emotional support seeking has been supported. The MDers showed lower inclinations for seeking support from others, discussing their emotional state, or wanting to spend quality time together when difficulties arise compared to non-MDers. It can be linked with emotional dysregulation in this population as the accessibility to one’s emotional states is impaired among the MDers (Greene et al., 2020 ), as well as social isolation and childhood loneliness often seen in this population (Somer et al., 2016a ). As the current study sample consists in majority of participants identifying as women, it should be noted that support seeking has been shown as an activity dependent on gender of the seeker. The relationship between mental health and support appears to have stronger relationship with mental health for women than men (Harandi et al., 2017 ). Furthermore, as the MDer group had higher numbers of people not identifying with gender binary the results may be related to the reported difficulties people identifying as transgender may experience with finding supportive communities that would be a safe space to seek support (Moolchaem et al., 2015 ).

Maladaptive daydreaming and future oriented coping

The hypothesis regarding the differences in the future-oriented coping styles, e.g., proactive and preventive coping, was not supported. The Proactive Coping Scale considers possibilities for future growth and changing one’s perspective about setbacks (Greenglass et al., 1999 ). Although MDers report using daydreaming as a creative outlet and a source of inspiration, when the output of creative behaviors is measured, they score lower than the control group (West & Somer, 2019 )– and it can be similar in the context of proactive coping. Both preventive and reflective coping focus on actual actions to safeguard one’s future and family safety or dwelling on one’s experiences, and this concern does not seem to differentiate MDers and the control group. Given that MDers create complex worlds, often driven by impossible aspects such as suddenly becoming a secret agent fighting terrorism or what-if scenarios imagined in the past (Pietkiewicz et al., 2018 ; Somer et al., 2016b ), maladaptive daydreaming has no links with the proactive coping. Additionally, the safety concern could be universal for both MDers and non-MDers. The reflective and preventive coping scales have the most potent edge in both groups, which could be explained by the importance of imagining the possible solutions for prevalent problems in both scales.

Clinical implications

The current study allows for proposing clinical implications. As emotional intolerance may serve as an essential factor in maintaining engagement in maladaptive daydreaming, the role of discomfort intolerance and its links to avoidance cannot be omitted. Therefore, interventions aimed at lowering daydreaming for MDers might focus on emotional regulation competencies, including mindfulness and Dialectical Behaviour Therapy (DBT) interventions (cf. Lotan et al., 2013 ; Muhomba et al., 2017 ). Previous intervention among MDers using mindfulness exercises such as attention and acceptance, remaining present while unpleasant emotions arise, body scan, and self-monitoring through daydreaming diary provided positive results (Herscu et al., 2023 ). Providing MDers with skills necessary for coping with unpleasant emotions may prove especially important as MD can be seen as a stress-relief strategy (Regis, 2013 ). Additionally, focusing on cognitive schemas connected to entitlement may prove beneficial– an area in which schema therapy has shown positive results (Taylor et al., 2017 ). Therapists rely on empathic confrontation when working with entitled behaviour and supports the client whenever they admit a flaw or experience a feeling of inferiority (Young et al., 2003 ). It should be noted that previous studies have shown comorbidity between MD and depression, ADHD (Somer et al., 2017 ), borderline personality disorder (Pyszkowska et al., 2023 ), or diminished emotional regulation abilities (Greene et al., 2020 ; Pyszkowska et al., 2023 ). Therapeutic interventions may need to include treating the underlying problems while approaching MD as their visible consequence.

Limitations and future research

Despite its strengths, the current study has its limitations. First, the sample consisted mainly of university students and young adults identifying as women, although both groups were similar. It is consistent with maladaptive daydreaming being more prominent among younger generations and women (Soffer-Dudek & Theodor-Katz, 2022 ). Nevertheless, this study’s results cannot be fully generalized for older persons and people identifying as men as the relationships between the variables may differ in such samples. Second, the current study used only one general factor considering maladaptive daydreaming (the Maladaptive Daydreaming Scale-16), not taking into account more distinct features of MD (fantasies’ themes, frequency of MD sessions, situational contexts when MD occurs) and psychological aspects of MD (e.g., dissociation, PTSD, affective symptoms). Hence, future research should focus on these additional aspects. Third, the study was cross-sectional and cannot be informative about situational contexts regarding MD, and particular coping strategies applied when MD occurs. Therefore, further projects should be aimed at qualitative and experimental aspects of MD to enable a deeper and more precise understanding of the MD phenomena in terms of coping. Fourth, the study took place as the Covid pandemic was ending in Poland. Previous longitudinal study has shown that symptoms of MD were not related to the Covid exposure and the the authors proposed that while MDers adapted to the challanges of the pandemic daydreaming may be less related to proximal stressors and more of a result of distant developmental roots in childhood (Musetti et al., 2023 ). Nevertheless, in the future studies the issue of strong external stressors should be addressed.

The current study explored the differences between maladaptive daydreamers and the control group regarding coping styles and frustration intolerance. The results proved higher levels of frustration and discomfort intolerance and avoidance-focused strategies among MDers, adding to the existing body of research in this area (Musetti et al., 2021 ; Green et al., 2020 ). Furthermore, they demonstrated that the cognitive processing of one’s internal stimuli (discomfort and emotion intolerance) or external events (entitlement) may be connected to MD symptoms and coping strategies - a view in line with the cognitive-behavioural model of psychopathology (Hupp et al., 2008 ). Activation of a belief may elicit emotions and behaviour, but it is a part of an ongoing process as emotions and behaviour may become further activating events. The results allow for clinical implications and further understanding of MD phenomena.

Data availability

The datasets generated by the survey research during and/or analyzed during the current study are available in the Open Science Framework repository at https://doi.org/10.17605/OSF.IO/UBM4R .

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Nowacki, A., Pyszkowska, A. It is all about discomfort avoidance: maladaptive daydreaming, frustration intolerance, and coping strategies – a network analysis. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06382-x

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Toward better research on stress and coping

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• 1 Department of Psychology, University of California, Berkeley, USA.
• PMID: 10892209
• DOI: 10.1037//0003-066x.55.6.665

In commenting in considerable detail on the four main articles in the special section on stress and coping, the author comes to two main conclusions: First, there is an increasing amount of high quality research on stress and coping that suggests the field is finally maturing, and this research may help reduce the long-standing gap between research and clinical practice. Second, this research is increasingly using badly needed research designs that have not hitherto been sufficiently emphasized, such as longitudinal or prospective designs, focused on observations that are day-to-day, microanalytic, and in-depth, and that are compatible with a holistic outlook. The author also addresses the role of positive emotion in coping, the concept of defense as it is dealt with nowadays, and the task of evaluating coping efficacy.

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When Bullying Focuses on Weight: Trauma-focused CBT Is a Promising Treatment

Researchers at Yale School of Medicine (YSM) have tested the first psychotherapeutic treatment of any kind for bullying — specifically weight-related bullying. It is important work, because no evidence-based treatments aimed at youth who experience bullying are currently in use, according to the researchers.

Bullying can lead to a number of harmful results, such as social and academic difficulties, anxiety, depression, self-harm, and suicide. Weight-related bullying, in particular, can be a precursor for eating disorders, weight gain, and obesity. Yet until now, efforts have been directed at reducing bullying rather than treating its victims.

“Most of the research has been about preventing bullying from happening or helping schools to manage the effects of bullying, but nothing really for the individual patient, which is bizarre because we know that bullying has all of these really severe consequences,” says Janet Lydecker, PhD , assistant professor of psychiatry at YSM and first author of a new study published in the International Journal of Eating Disorders on July 15.

Lydecker and her team adapted a trauma-focused cognitive-behavioral therapy (TF-CBT) combined with CBT for eating disorders to treat youth who experienced weight-related bullying, called “TF-CBT-WB,” (which stands for trauma-focused CBT for weight bullying), and tested its feasibility in 30 adolescents. The study found that the treatment improved such symptoms as traumatic stress, eating disorder severity, and body image concerns. Lydecker hopes to expand on these promising results in future studies.

A trauma-focused approach

Historically, TF-CBT has been used to treat youth who have had such traumatic experiences as abuse or a near-death incident, but researchers are beginning to expand the definition of what counts as trauma. Bullying, in particular, has been found to cause clinical levels of traumatic stress in children . Because bullying occurs as distinct events, causing children to feel unsafe and leading to distress, it meets the criteria for treatment with TF-CBT.

“People will say [bullying] is a ‘little-T’ trauma, meaning it’s not the official trauma that the DSM [ Diagnostic and Statistical Manual of Mental Disorders ] may talk about,” says Lydecker. “But it still does function like a trauma, especially among adolescents whose whole world revolves around their peers and their peer relationships.”

Although it has not been tested clinically, a standard CBT approach to treat bullying might frame it as a stressor and help patients to learn coping strategies. By treating bullying as a trauma, Lydecker’s approach requires patients to create a narrative by recounting the bullying experiences, then go back through the narrative and identify distorted thoughts and emotions.

Lydecker says she expected TF-CBT-WB for appearance-related bullying to help prevent later development of eating disorders, rather than treat existing ones. Therefore, she was surprised to find a high initial rate of severe eating disorder psychopathology among the participants. After three months of weekly treatment sessions, she and her team compared the participants’ eating disorder symptoms before and after TF-CBT-WB treatment and saw clinically significant reductions in eating disorder severity, body image and eating concerns, and binge eating. Lydecker believes these results demonstrate that TF-CBT-WB may be promising not only for bullying treatment, but for eating disorder treatment, as well.

“In the eating disorder field, we need more treatment,” she says. “This could be a way to treat some of that underlying self-concept and distress that come from these appearance-related bullying experiences. This may be a different option for people with eating disorders, and we really need that flexibility.”

The future of TF-CBT-WB

While the results were promising, additional research will be needed to learn more about the treatment’s efficacy.

For one, it was difficult to comprehensively gauge the success of TF-CBT-WB because no other treatment was studied. For ethical reasons, the study did not have an inactive control group (such as a waitlist), and because no evidence-based treatment for bullying exists, there was no standard of care to use as comparison — something Lydecker hopes that future studies will address.

Lydecker has already begun planning for studies that will have larger cohorts and extended follow-up periods to see how long the effects of the treatment last. She’s also interested in figuring out a way to assess whether a patient would benefit more from TF-CBT or standard CBT. Additionally, she’d like to determine whether there are any differences in outcomes for youth who are “bully victims,” children who are both bullies and have been bullied. Lydecker hopes that the research will gain interest, both for scientists and patients alike.

“The goal is to get this as quickly as possible to clinicians and patients who need it,” she says. “If kids have experienced bullying, they don’t have to just work it through it on their own. Bullying might be common, but it’s not a normal part of childhood development that can be brushed over. It really does require working with a mental health provider if there’s any sort of distress.”

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From Michael Brown to Sonya Massey, a decade of police antiblack violence causes grief, worry and coping for Black parents

Assistant Professor of Psychological and Brain Sciences, Arts & Sciences at Washington University in St. Louis

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A decade ago, Michael Brown Jr. , an unarmed Black 18-year-old, was shot and killed by a white police officer in Ferguson, Missouri, a suburb of St. Louis.

The fatal incident began when the officer, Darren Wilson, saw Brown and a friend walking down the middle of a street. Wilson claimed that Brown refused to obey his order to get off the street and a fight ensued. The shooting, Wilson alleged , was in self-defense – a claim that officers have used nationwide to justify antiblack racial violence.

Brown’s death on Aug. 9, 2014, occurred just eight days after his high school graduation and triggered nearly a year of protests across the country. Three months later, a grand jury in Ferguson refused to indict the police officer, a decision that set off more protests and demands for racial justice in policing.

Nearly 10 years later and less than 90 miles away from Ferguson, Sonya Massey , an unarmed, 36-year-old Black woman and mother of two children, called local police on July 6, 2024, to investigate mysterious sounds outside of her home near Springfield, Illinois.

Instead of helping, one of the white officers , Sean Grayson, shot and killed Massey. As her son Malachi told reporters, the officer showed little regard for her humanity during the slaying that was captured on body-camera footage. At the officer’s request, Massey had taken a pot of hot water from the stove. Minutes later, she was killed when Grayson fired three bullets, including one that hit right below her eye.

Unlike Brown’s case in Ferguson, Grayson was fired from the Sangamon County Sheriff’s Office and charged with first-degree murder. Similar to Darren Wilson, he claimed he acted in self-defense.

These two instances of police violence highlight the cyclical nature of police violence against Black Americans – and the growing mistrust among Black Americans for local police.

From 2009-2019 , at least 179 people have been killed by police or while in jail within four counties of the St. Louis region near where Brown died.

These local statistics mirror nationwide patterns of police violence in the U.S. and reveal that Massey and Brown were not exceptions to the norm – but, rather, representative of the everyday racism that pervades American society.

As we have learned through our research of racist violence in Black communities, developing ways to cope is often a necessary reality of living in the United States.

What is racial grief?

With every new incident of racial violence committed by a police officer, Black people tend to experience a collective sense of racial grief.

That grief is defined by the U.S. National Institutes of Health as an “individuals’ cognitive, emotional, physical, and spiritual responses to loss due to racism and intersectional violence .”

In addition, many Black parents experience a type of anticipatory grief and stress due to the potential racial violence their children may encounter in their lifetime.

For instance, in a 2022 study , researchers found Black pregnant women experienced feelings of fear, stress and anxiety about police brutality toward their children – before their children were born. Even mothers who reported positive experiences with police officers anticipated negative treatment toward their children based on their race.

Racial grief can represent a coping response that allows Black parents to emotionally and cognitively process incidents of racial violence in community with others.

In our 2022 study , one mother told us:

“ I can’t watch the videos anymore. It is a living nightmare, and I do not need those images, because they cannot be unseen. It takes a heavy toll on me. I cope with it in therapy. I cry. I give myself space to feel my feelings. I talk with my partner about it. It gives me a sense of pain and purpose at the same time. ”

How do Black parents respond to racial violence

When parents think about how they can prepare their children for the racial discrimination they may encounter in their daily lives, many use what is known as racial socialization to improve they and their children’s adaptive coping responses in response to racial bias and discrimination.

Racial socialization refers to the process by which parents instill race-related messages and values in their children. It is considered by psychologists to be one of the most critical developmental processes for Black youth and includes both implicit and explicit practices.

For instance, some parents monitor the content of their children’s social media and limit their exposure to racial violence. Other parents balance messages on racial discrimination with affirmations that their children are loved, worthy and valued.

Common racial socialization messages include statements such as: “You should be proud to be Black.” A message on racial bias might involve: “You may be evaluated by higher standards than your white peers.”

Overall, these messages are intended to elicit racial and cultural pride, while also encouraging Black youth to be cautious and aware of the ongoing realities of racial violence.

In a forthcoming study we have on how Black parents in Missouri talk to their adolescents about race, one mother shared:

“ Like with the Sonya Massey thing, my daughter saw the video and she was like – ‘but she didn’t do anything wrong.’ That’s usually what happens. Like I told her, she called the police for help and they end up killing her. It happens sometimes because they act like they’re scared of Blacks for some reason. I feel like we are not progressing in America with this racism thing. ”

While Black parents and their children continue to resist racial discrimination through their everyday practices of care, love and joy , there remains a critical need to invest in the health and well-being of Black communities through structural policy changes in education, health care and local government.

• Michael Brown
• Police violence
• Police brutality
• Coping with grief
• Black communities
• Racial trauma

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Anxiety and Coping Stress Strategies in Researchers During COVID-19 Pandemic

Patrícia batista.

1 Universidade Católica Portuguesa, Research Centre for Human Development, Human Neurobehavioral Laboratory, Porto, Portugal

2 Universidade Católica Portuguesa, CBQF – Centro de Biotecnologia e Química Fina – Laboratório Associado, Escola Superior de Biotecnologia, Porto, Portugal

Anabela Afonso

3 Department of Mathematics, School of Science and Technology, University of Évora, Évora, Portugal

4 Center for Research in Mathematics and Applications (CIMA), Institute for Advanced Studies and Research, Évora, Portugal

Manuel Lopes

5 S. João de Deus School of Nursing, University of Évora, Évora, Portugal

6 Comprehensive Health Research Centre (CHRC), Évora, Portugal

César Fonseca

Patrícia oliveira-silva, anabela pereira.

7 Education and Psychology Department, Campus Universitário de Santiago, University of Aveiro, Aveiro, Portugal

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The current COVID-19 pandemic has affected the whole world, leading to changes in one's personal and working life. Researchers have undergone extensive changes in their roles, mainly in the area of health care, with research into the virus now the priority.

To assess the anxiety, depression, stress, fears, and coping strategies of Portuguese researchers during the COVID-19 pandemic.

Participants and Methods

A total of 243 researchers, with an average age of 37.9 ± 9.6, participated in an online questionnaire. The study was performed between 1 June 2021 and 11 August 2021. The questionnaire included depression, anxiety, and stress (DASS-21), fear of COVID-19 scale (FCV-19S), and coping inventory for stressful situations (CISS).

The findings suggest being female and younger seem to be related to more significant fears. Singles and younger researchers showed higher values of stress, depression, and anxiety. Research areas, such as medical and health sciences, presented higher levels in the DASS-21 depression and stress scale ( p < 0.05). Also, the results showed a moderate or moderate strong significant positive linear relationship between the scales ( p < 0.001): DASS-21 stress, DASS-21 anxiety, and DASS-21 depression ( r > 0.70); CISS-21 emotional-oriented with DASS-21 stress ( r = 0.683), DASS-21 depression ( r = 0.622), and DASS-21 anxiety ( r = 0.557); and emotional fear and cognitive fear ( r = 0.652).

The findings of this study support the growing concern for the psychological well-being of researchers and the need for intervention with more extensive and diverse studies.

Introduction

In December 2019, new pneumonia caused by a virus (SARS-CoV-2) of the coronavirus family emerged. It is thought to have originated in China, in Wuhan, and quickly spread worldwide ( 1 – 3 ). In March 2020, the World Health Organization (WHO) declared the existence of a pandemic situation. At that time, SARS-CoV-2 was already one of the biggest challenges to world health ( 2 ). The increasing number of infections and death related to the COVID-19 disease led to increased concern by health organizations, governments, and society.

These concerns have been substantially exacerbated by extensive media coverage and continuous social media (mis)information, factors that generate fear, anxiety, social panic, and suicide risk ( 4 – 6 ). The need to know more about the disease and the virus, the need for scientific evidence to make decisions, the constant search for strategies, and methodologies to combat the problem have caused science to evolve at an unprecedented pace, namely in the field of vaccine development ( 7 , 8 ).

At this moment, society renewed recognition of the role of science in fighting the pandemic. Across the world, most governments repeated in most press conferences: “We are following the science” ( 9 ). This is one step in the recognition that science/scientific knowledge is necessary for the prevention and search for solutions when we face contemporary challenges. However, the crucial steps are funding/economic investment into research projects and hiring human resources ( 10 – 12 ).

In the most several areas, these professionals who work for science and the increase in knowledge also had to readap not only in personal terms but also at the work level. While some research work can be done at home, such as article writing, scientific research, others require data collection, field presence, laboratory trials, and clinical trials ( 13 ). For instance, computational research and review studies about several thematic, such as rethinking psychology and the microbiota-gut-axis ( 14 ), may not have been much affected ( 15 ). However, much of research within the basic sciences involves laboratory work or clinical research, for example, studies that aimed to evaluate adverse event profiles of drugs in advanced prostate cancer and which require recruitment of participants for evaluation ( 16 ), were very much affected because they had to be suspended ( 15 ). These are two simple examples of scientific work of extreme importance but using different research methodologies.

Scientists do distinct work ranging from research, planning experiments, collecting and analyzing data, writing papers, writing fundraising proposals, teaching, clinical practice, administrative, and editorial activities. Not surprisingly, many studies have already shown that most of the pandemic-related decisions have magnified disparities among these researchers ( 13 , 17 – 19 ). For instance, the research work and the time devoted to it were massively affected during the pandemic. Many researchers had to readapt their schedules and commitments, and in some cases, change their working methods because the access to field/laboratory work was restricted by confinement measures ( 13 , 20 – 22 ). Many clinical trials were suspended due to the need for social isolation and multiple research groups felt the need to change their research projects and/or develop new ones, focusing on strategies to respond to the pandemic ( 13 , 20 ). Teleworking and supporting children and dependents were other necessary readjustments ( 15 , 23 – 25 ).

Although the pandemic affected the researchers' work in general, some researchers were more affected than others depending on their research areas, careers, and gender. There are already some publications in this sense, which report that the areas of biological sciences, biochemistry, and chemistry were more affected compared to the areas of mathematics and computer sciences ( 13 ). Similarly, studies have shown that early-career researchers ( 13 , 26 , 27 ) were also more conditioned by the pandemic, as well as the female gender ( 28 , 29 ).

These labor and personal struggles in several areas are factors that increase the level of stress and anxiety and impact mental health significantly. However, few studies have been carried out at the level of this professional class, to understand the impact of the pandemic on the researchers' mental health, with particular emphasis on the anxiety during the lockdown ( 30 ).

Several studies have been exploring the anxiety of health professionals ( 31 – 35 ), academics ( 2 , 36 , 37 ), and the general population ( 38 , 39 ). The levels of depression and anxiety were significantly higher during the outbreak and there was a need to study this topic. However, the concern with researchers is scarce ( 40 – 42 ) and it is urgent to cover this gap. Some studies, just prior to COVID-19, have been reported that researchers present high levels of stress ( 40 , 43 , 44 ). This shows that this problem existed even before COVID-19 and needs to be addressed.

On the other hand, in the attempt to resilience this problem it is necessary to implement adequate prevention or rehabilitation strategies. It is important to know positive and protective strategies to deal with this problem. Several studies have been carried out to develop and/or apply strategies to fill this gap in the population in general and in specific groups, in particular, but once again, the literature is scarce at the level of the researcher group. For example, in health professionals, several strategies were outlined, as include work-hour regulation programs, and the implementation of strategies to reduce the pressure of difficult decision-making ( 39 ). Some authors suggest interventions by the employer to improve the mental health of workers, such as providing the development of self-efficacy, resilience, promotion of social support, and guaranteeing quality and safe care ( 33 , 45 , 46 ).

Getting to know researchers better, motivating them, and promoting physical and mental well-being will bring benefits to their health, as well as to their role as researchers, contributing to the increase of scientific knowledge, fundamental for the improvement of the quality of life of our population. Thus, considering the health challenges for this understudied professional group, the aim of this study is to assess the levels of anxiety, depression, stress, fears, and coping strategies in Portuguese researchers during the COVID-19 pandemic. This knowledge is central to the development of intervention plans for these professionals, in the future.

Study Design and Participants

The target population was researchers working and living in Portugal. Inclusion criteria were to be a researcher in any scientific area and agree to participate in the online survey. This was a quantitative cross-sectional study that used a convenience sample ( n = 243) of the Portuguese population recruited via e-mail (on professional networks). All participants gave their voluntary and informed consent, which was obtained electronically before recording any data from the participants.

Data Collection

From 1 June 2021 to 11 August 2021, survey data were collected through an online questionnaire. The survey was constituted of 60 questions that took around 10 min to be completed. The questionnaire covered socio-demographic and professional information (e.g., age, sex, marital status, academic qualifications, research area, and professional activity), health-related data (general health perception and history of COVID-19 diagnosis), depression anxiety stress scale (DASS-21), fear of COVID-19 scale (FCV-19S) and coping inventory for stressful situations (CISS-21). Before the application, the questionnaire was validated by a senior researcher's panel, and then, it was transposed to Qualtrics software for final validation.

The online platform QualtricsTM software (Provo, UT, USA) was chosen because of the facilitation in the distribution and completion of surveys, according to the recommendations imposed on social distance. In addition, only the researchers directly involved in the study could access the data, thereby maintaining the confidentiality of research subjects and research data ( 47 , 48 ).

This study was approved by the ethical committee, and data confidentiality was ensured by assigning a code to each participant. No identifiable data were collected from the participant.

Depression Anxiety Stress Scale (DASS-21)

The DASS-21 was a scale developed to explore the symptoms of depression, anxiety, and stress. In this study, we used the scale validated for the Portuguese population ( 49 ). The DASS-21 instrument comprises 7-item for each subscale. The responses were collected on a 4-point scale of severity/frequency that assesses the extent to which the individual experienced each state in the previous week.

Fear of COVID-19 Scale (FCV-19S)

The FCV-19S was developed with the intent to identify and early intervene, psychologically, in people with high values of fear of COVID-19 ( 50 ). Ahorsu et al. ( 50 ) have proposed this scale, with 7-items, that assesses distinct physiological reactions of fears related to COVID-19. In this study, we used the Portuguese version of the Coronavirus Anxiety Scale (CAS) ( 51 ).

Coping Inventory for Stressful Situations (CISS-21)

The CISS-21 was developed by ( 52 ) by a psychometrically valid and reliable self-reporting instrument to identify and assess coping skills ( 51 , 53 ). There are two versions (21-items and 48-items), but the shorter version has been the most widely used ( 51 , 53 ). In this specific case, we use the Portuguese version already validated by Pereira and Queirós ( 54 ).

Statistical Analysis

Descriptive statistics were used to describe the study sample. The Pearson linear correlation was used to assess the linear correlation between age and scale, as well as between scales. The Shapiro–Wilk test was used to assess normality. The Levene test was used to assess variance homogeneity. The t -test was used to assess significant differences in scales by gender or type of contract. The Wilcoxon Mann–Whitney was used when the normality assumption was violated. To compare the scales by marital status or research area, the analysis of variance was used: the F test when both normality and homoscedasticity assumptions were verified, the Kruskal–Wallis test when only normality assumption was violated, or the Games–Howell test when the assumption of homogeneity of variances was violated.

Multivariate linear regression analyses were performed using the scores of the questionnaires as dependent variables, and gender, age, marital status, type of contract, and research area as the exploratory variables. These models allowed us to assess associations and check for confounders. It was used the forward and backward methods to select the variables. Normality and homoscedasticity assumptions were checked.

R program version 4.0.4 (R Core Team, Austria) for Windows was used to perform the statistical analyses. A significance level of 0.05.

Sociodemographic and Health Characteristics

The sample used consisted of 243 participants, 69.5% female. The participants' age ranged between 21 and 72, being an average age of 37.9 ± 9.6 years. When analyzing the professional activity, 40.8% presented a contract with the institution/center of research, 44.1% presented no contract (research fellowship), and 15.2% answered “other situation.” The study included participants from various research areas, with the majority being in the “Natural and Agricultural Sciences” (33.7%) and the “Social Sciences” (21.8%).

Most of the participants perceive their health as good (67.1%) and 7.4% have been infected with COVID-19.

Table 1 shows the sociodemographic and health characteristics of the sample.

Sociodemographic and health characteristics.

When the scales selected for this study were analyzed, the low values stand out for the cognitive fear scale [Med = 0, IQR = (0, 3)], DASS-21 depression [Med = 4, IQR = ( 2 , 9 )], and DASS-21 anxiety [Med = 3, IQR = ( 1 , 6 )] ( Figure 1 ). In the CISS-21 task-oriented (18.13 ± 5.67) and CISS-21 avoidance (10.58 ± 5.10) scales, intermediate values predominate. In the CISS-21 emotional-oriented (13.47 ± 7.39), emotional fear (5.95 ± 3.98), and DASS-21 stress (8.16 ± 5.09) scales there is great heterogeneity in the values observed. On the CISS-21 emotional-oriented scale there appears to be a similar frequency of responses across the range of possible values (uniform distribution).

Empirical distribution of scales and Pearson's linear correlation coefficient between the scales * p < 0.1, ** p < 0.05, *** p < 0.001.

The results showed a moderate or moderate strong significant positive linear relationship between the scales ( p < 0.001, Figure 1 ):

• DASS-21 stress, DASS-21 anxiety, and DASS-21 depression (all r > 0.70);
• CISS-21 emotional-oriented with DASS-21 stress ( r = 0.683), DASS-21 depression ( r = 0.622), and DASS-21 anxiety ( r = 0.557),
• Emotional fear and cognitive fear ( r = 0.652).

Analysis of Scale by Sociodemographic Characteristics

The differences between the scales and some variables, such as gender, age, professional activity, and research area, were studied.

Significant differences were only detected on the emotional fear scale between women and men ( W = 5,160, p = 0.030); women [Med = 6, IQR = ( 3 , 9 )] had higher values than men [Med = 4.5, IQR = ( 2 , 8 )]. In the remaining scales, there were no significant differences between genders ( p > 0.05).

When age and scales were compared, there was a significant but weak negative linear relationship between age and the scales CISS-21 emotional-oriented, DASS-21 depression, DASS-21 anxiety, and DASS-21 stress ( Table 2 , p < 0.001). These data were indicators of the existence of a tendency for the higher values of these scales to be associated with younger researchers and for the lower values of these scales to be associated with older researchers.

Pearson's correlation coefficient ( r ), and p -value ( p ), between age and scales.

The negative linear relationship between age and the cognitive fear and CISS-21 avoidance scales, although significant, is almost insignificant.

Marital Status

For the marital status analysis, the widowed and separated/divorced categories were joined, since there are only three widowers. We detected that cognitive fear, emotional-oriented CISS-21, and all the DASS-21 scales differ significantly between marital status (all p < 0.05, Table 3 ). Single people had higher values than married people on all these scales (all p < 0.05).

Median (1st quartile, 3rd quartile), or mean and standard deviation, for each scale by marital status of the researchers and p -value from analysis of variance [ (1) parametric ANOVA, (2) Kruskal–Wallis test, (3) Games–Howell test].

Medians or means not sharing superscript letters, in the same row, differ significantly at p < 0.05 as indicated by the post-hoc test .

Type of Contract

No significant differences were found on any scale by type of contract of the researchers (all p > 0.05).

Research Area

There were significant differences in DASS-21 depression ( p = 0.020) and DASS-21 stress ( p = 0.042) scales between research areas ( Figure 2 ). Researchers in the medical and health sciences had higher scores than those in the social sciences on the DASS-21 depression scale ( p < 0.1). The multiple comparisons test did not detect which pairs of research areas significantly differed in the DASS-21 stress scale, but by the graphical analysis, researchers in the social sciences area seem to have lower values than those in other areas.

Empirical distribution of DASS-21 depression and DASS-21 stress scales by research area of the researchers.

All the adjusted models for the several scores of the questionnaires allowed us to check the inexistence of confounders in most of the bivariate analyses presented in the previous sections on the emotional fear scale. However, the explanation power of the adjusted models was small (in all, R Adj 2 < 0.2). The adjusted models for scores in emotional fear and CISS task-oriented did not fit the data. Older researchers had significantly lower scores in cognitive fear, CISS avoidance, CISS emotional-oriented, DASS depression, DASS anxiety, and DASS stress. The multivariate models revealed that women had significantly lower scores than men only in DASS depression ( b = −0.362, p = 0.006). Also, researchers in exact sciences ( b = −0.811, p = 0.021) and in agriculture and natural sciences ( b = −0.585, p = 0.020) had significantly lower scores in cognitive fear than researchers in medical and health sciences.

This study seeks to understand the anxiety, stress, and depression researchers' perception during the pandemic period and the coping strategies that they were developed.

Sociodemographic and Professional Characteristics

Regarding sex, differences are only observed in the emotional fear scale where women have higher values than men. Another author concludes that the higher fear reported by female gender can be explained by their higher sensitivity to stress when compared to the male gender ( 55 ). However, in our study, there are no differences in anxiety, stress, and depression between the sexes. These results are not consistent with most studies that report that women have higher levels of stress, anxiety, and depression ( 33 , 55 – 57 ). These results may be due to having a sample of only researchers who may have a different response to these variables. It is important to note that regarding gender balance, women tend to be overrepresented in this profession as well as among such frontline service workers ( 58 ).

Younger researchers showed higher values of stress, depression, anxiety, and fears related to COVID-19 when compared to older researchers. Studies in the general population support these results by confirming that younger age groups are more vulnerable to symptoms of stress, depression, and anxiety ( 59 , 60 ). As well as, when analyzing the fear toward COVID-19, the older researchers showed lower levels ( 55 ). However, it may be that older people may consider that they have little to lose as they have already had relatively long lives and had a stable labor situation. For their part, the younger people are worried about the future consequences and economic challenges caused by the pandemic, as they are the most affected by their employment stability, may watch and listen to much more negative news on social media ( 2 , 61 , 62 ). Nevertheless, additional evidence is needed to examine such speculation.

Single participants had higher scores of stress, depression, and anxiety than those who are married. Other studies have obtained similar results ( 59 ). Studies suggested that being married can be a protective factor for stress and anxiety ( 63 ).

Researchers in the medical and health sciences have higher levels of depression than those in the social sciences. Although we do not have identical studies with researchers from different fields to compare these results, several studies indicate the high prevalence of stress, anxiety, and depression in health care workers ( 64 ). Medical and health sciences researchers have had to change their research projects to give priority to pandemic-related research. Also, being their field, they are more awake to the pandemic health consequences, so these factors may be contributing to higher levels of depression. Social science researchers also have lower stress scores than researchers from other areas. Perhaps researchers in the social sciences are more prepared for changes in society, since they study social and collective behaviors, and this is the reason for lower stress levels. However, more studies are needed to draw conclusions.

Anxiety, Stress, and Depression

In our study, analyzing the results of the DASS-21, we found that stress is the dominion with the highest mean (8.16 ± 5.09), followed by depression (6.01 ± 5.37), and anxiety (3.88 ± 4.09). These results are like a study in an Indian population with respect to the order of severity of the domains ( 65 ). However, the Indian study obtained higher values for the 31 researchers in the sample in all domains: stress (14.71 ± 9.89), depression (10.65 ± 8.72), and anxiety (9.81 ± 6.88).

Coping Stress Strategies

The results showed that there is a significantly positive and moderately linear relationship between the anxiety levels and emotional-oriented coping strategies, i.e., general researchers with low (/high) anxiety values also have low (/high) emotional-oriented coping strategies. However, there is no significant linear relationship between the anxiety levels, and the task-oriented and avoidance coping strategies. These results corroborate another study that showed that depressive symptoms were positively correlated with emotional coping ( 66 ). We also verified that the stress levels are significantly positively and moderately linearly related to the emotional-oriented coping strategies, but it is not linearly related to the task-oriented and avoidance coping strategies. The depression levels are significantly related in a positive and moderate linear fashion with the emotional-oriented coping strategies and in a very weak negative linear fashion with the task-oriented coping strategies, but it is not linearly related to the avoidance coping strategies.

The task-oriented coping strategies were not supported but the relationship between the use of the emotional-oriented coping strategies was found. Although some studies report that emotion-focused and problem-focused strategies play role in reducing and increasing mental health ( 67 ), the unexpected event of COVID-19 pandemic can be may have triggered a more intense emotional response, indicating the need for further studies on this pandemic. But, their use can be inappropriate ( 66 ).

In this study, we did not find the results shown in other studies that showed that people that experienced psychological distress who used more task coping strategies experienced low levels of depression, anxiety, and stress ( 68 ).

The cognitive and emotional fears of COVID-19 pandemic situations also influence coping strategies or defensive mechanisms ( 69 ). In Huang and collaborators' study, it was found that fears were significantly positively related to problem-focused coping and emotion-focused coping. Therefore, the more problem-focused coping, the more fear ( 46 ). When analyzing the FCV-19S scale the data by emotional fear scale showed significantly related in a very weak positive linear way with CISS-21 emotional-oriented, task-oriented, and avoidance domains. On the order hand, the cognitive fear scale is significantly related in a very weak positive linear fashion to the emotional-oriented and avoidance coping strategies. There is no significant linear relationship between cognitive fear and task-oriented coping strategies.

Limitations

This study presents some limitations, such as the cross-sectional nature of the study, which conditioned the monitoring of the effects and strategies adopted. Longitudinal studies are needed. Also, the methodology adopted, an online survey, may contribute to non-response bias in the study results. On the other hand, we do not know how many researchers there are in Portugal, because there are several contracting modalities, and many researchers are not in the career and presenting research grants (without contractual ties). So, it was not possible to calculate the sample size to ensure that the sample was representative.

The findings of this study support the growing concern for the psychological well-being of researchers and the need for intervention. Being a female seems to be related to greater fears. Research areas, such as medical and health sciences, presented higher depression and stress levels. Also, significant differences were found between depression and emotional-oriented coping strategies, and the type of contract. The anxiety, depression, and stress levels were significantly related positively to emotional-oriented coping strategies.

This study intended to assess the levels of anxiety, depression, stress, fears, and coping strategies in Portuguese researchers during the COVID-19 pandemic. There is a gap in the literature in terms of scientific studies on these professionals, and this knowledge is central to the development of intervention plans for these professionals, in the future. However, this study suggests more extensive and diverse studies on the improvement of mental health and the reduction of anxiety/depression and stress in researchers. It is fundamental to investigate and intervene to promote the health of these professionals and their work performance, highlighting the importance of coping strategies. It is important to prioritize essential competencies, set goals, and coping strategies that increase health and performance.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Comissão de Ética da Universidade de Évora. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

PB, LP, and AP were responsible for the concept and design of the study, interpretation of results, writing, and critical review of the manuscript. PB and LP were responsible for data collection and analysis and writing—the original draft. PB, LP, and CF were responsible for the interpretation of the results. AA was responsible for statistical analysis. AP, PO-S, and ML were responsible for writing, reviewing, and editing the manuscript. All authors contributed to the article and approved the submitted version.

The present publication was funded by Fundação Ciência e Tecnologia, IP national support through CHRC (UIDP/04923/2020). This work was partially supported by CEDH, through the Project UIDB/04872/2020 of the Fundação para a Ciência e a Tecnologia, Portugal. Also, the CIMA was supported by the Fundação para a Ciência e a Tecnologia, project UID/04674/2020.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.