key: cord-323690-dp51djtz
authors: Arora, Alisha; Jha, Amrit Kumar; Alat, Priya; Das, Sitanshu Sekhar
title: Understanding Coronaphobia
date: 2020-09-06
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102384
sha: 
doc_id: 323690
cord_uid: dp51djtz

COVID-19 pandemic, in addition to being a global health emergency, has multiple socioeconomic and psychological ramifications. COVID-19 research and media reports have revealed a rise in fears related to contracting the virus. Though fear is a common psychological outcome during pandemics, the COVID-19 pandemic is a continuously evolving disease outbreak and has unique risk factors. Therefore, fear related to COVID-19 might manifest in not only fear and anxiety related to disease contraction and dying but also associated socio-occupational stress. We attempt to understand the psychosocial process of the development of coronaphobia and postulate what constitutes coronaphobia, a new emerging phobia specific to COVID-19. We present a conceptual model delineating the risk factors causing coronaphobia and the underlying mechanisms, for a better understanding of its developmental process. From review of relevant research, the factors identified are, an unforeseen reality, unending uncertainties, need of acquiring new practices and avoidance behavior, loss of faith in health infrastructure, contraction of COVID-19 by head of states, cautionary statements from international bodies, and infodemia. These factors are assumed to cause interference with routine life, catastrophizing interpretation of benign symptoms, and social amplification of risk which lead to coronaphobia. The conceptualization of coronaphobia and the model will aid future research in developing psychometric measure of coronaphobia for use in clinical and research settings and design of policies and interventions for mitigating risk factors.

review of relevant research, the factors identified are, an unforeseen reality, unending uncertainties, need of acquiring new practices and avoidance behavior, loss of faith in health infrastructure, contraction of COVID-19 by head of states, cautionary statements from international bodies, and infodemia. These factors are assumed to cause interference with routine life, catastrophizing interpretation of benign symptoms, and social amplification of risk which lead to coronaphobia. The conceptualization of coronaphobia and the model will aid future research in developing psychometric measure of coronaphobia for use in clinical and research settings and design of policies and interventions for mitigating risk factors.

Keywords: COVID-19; Coronaphobia; fear; anxiety; pandemic

In the COVID-19 pandemic, as in other pandemics, fear, anxiety, and worries have been the major psychological consequences (Roy et al., 2020; Tandon, 2020a; Xiang et al., 2020) .

COVID-19 related fear, mortality rates, unemployment, protective strategies have become the most searched topics in Google search history (Charlton, 2020; Sullivan, 2020) . Researchers have used the expressions "fear of COVID-19" (Ahorsu et al., 2020; Mertens et al., 2020) and 'coronaphobia' (Asmundson & Taylor, 2020) to indicate the fear of contracting COVID-19. Now that there is unanimity that COVID-19 is an endemic (BBC, 2020b; Kissler et al., 2020) and living with the coronavirus with constant precautions becomes the new normal, fear may become more pronounced (Tanner, 2020) . COVID-19 affects all spheres of life and the risk factors are more unique, numerous, and diverse than in other pandemics. Therefore, fear may extend beyond falling ill or dying due to contracting the virus and evoke other fears such as that J o u r n a l P r e -p r o o f of economic adversity (Yoon, 2020) and infecting others. This paper attempts to postulate the contents and antecedents of coronaphobia, identify the associated risk factors and the underlying mechanisms of its development which might inform policy decisions and healthcare activities.

A phobia is an anxiety disorder characterized by persistent, excessive, unrealistic fear of an object, person, animal, activity or situation. Phobia makes people avoid the triggers of fear; when such avoidance is not possible, it causes anxiety and distress (American Psychiatric Association, 2013) .

A search in the Scopus database using the keywords "COVID-19" and "Coronavirus" with "fear", "anxiety/anxious", "uncertainty", "worry/worries/worried", "phobia", "public place" and "public transport" resulted in 499 studies after excluding studies with no abstract or in a language other than English. Various components and outcomes of COVID-19 fear have been reported such as functional impairment leading to hopelessness, suicidal ideation, and coping deficits (Lee, 2020) , fatal cognitions leading to association of COVID-19 with terminal end (Dubey et al., 2020; Goyal et al., 2020; Huang & Zhao, 2020) , and anxiety and depression while coping with the 'new normal' (Cao et al., 2020; Chakrabarty & Chatterjee, 2020; Haleem et al., 2020) .

Based on a review of these studies, we define coronaphobia as an excessive triggered response of fear of contracting the virus causing COVID-19, leading to accompanied excessive concern over physiological symptoms, significant stress about personal and occupational loss, increased reassurance and safety seeking behaviors, and avoidance of public places and situations, causing marked impairment in daily life functioning. The triggers involve situations or J o u r n a l P r e -p r o o f people involving probability of virus contraction, such as, meeting people, leaving house, travelling, reading the updates or news, falling ill or going for work outside.

The definition implies three essential components, which reinforces the process of fear:

i. Physiological: The fight or flight response of fear is triggered, on being exposed to antecedent event. Constant worry can cause symptoms such as palpitations, tremors, difficulty in breathing, dizziness, change in appetite, and sleep (Wang et al., 2020) .

Cognitive , leading to phobia ( (Table 1) . We observe fear of specific stimuli in all kinds of phobia, accompanying triggered physiological responses, cognitions of lack of control, helplessness, and/or death. Phobias share pattern of behavioral avoidance and reassurance which is beyond realistic proportions. While coronaphobia share similarities with the other phobias, the fear in it is not only limited to only public places/situations/objects, but, primarily coming in contact with human, physically. Given the novelty and transmission rate of the COVID-19, the coronaphobia is intense, widespread, and involves socio-occupational and personal domains, with J o u r n a l P r e -p r o o f apprehensions ranging beyond the self and the present time. It might be perceived as equivalent entity in syndromes of phobia, given the presence of unique triggers and fear of the unknown.

Traumatic events can lead to specific phobias (Garcia, 2017) . (Goodenough, 2020) . The genetic mutation of the virus is quite mysterious with asymptotic cases, fast mutation, incubation period of 2-14 days with some cases even reaching 19-27 days, adaptability to changing environments, and variable strains (Kaplan et al., 2020; Kumar, 2020; Worldometres, 2020b) .

Unforeseen reality -Change in any form is threatening initially, as it disturbs the equilibrium and the stability, seeding insecurity. The enforced instability due to COVID-19 is threatening, compulsive, and unpleasing. The termslockdown, quarantine, and self-isolation, which now are frequently in use among the masses, normally carries negative connotations and were assigned to prisoners, making them experience chronophobia (Naguy et al., 2020) . Similarly, J o u r n a l P r e -p r o o f people locked during the early and peak days of this pandemic, dwelt over thoughts related to the unlocking of the lockdown and the hardships.

Acquiring new practices and avoidance behavior -Acquiring new behavioral change requires considerable thoughts, mindfulness, and change in habits. The recent forced behavioral changes-social distancing, wearing mask, consistent hygiene practices of hand washing, and avoidance behavior including avoiding touching face and large gatherings-will initiate a vicious loop of discomfort, fear, and anxiety. A human normally touches their face on an average 23 times an hour (Kwok et al., 2015) . Now that touching face is a risk factor, people have to be mindful of not engaging in a practice which was practiced mindlessly since birth (Markman, 2020) . Inculcating a habit of not performing a practice is primarily discomforting, ineffective, and requires a habit reprograming, which further requires 68 to 254 days to acquire and done involuntarily (Lally et al., 2009 ). Unable to acquire such changes in a short span will further create fear and anxiety. People then tend to panic more and lose control, making them more susceptible to the coronaphobia. Even our unconscious mind operates to reduce the contagion and produce unconscious psychological responses, termed behavioral immune system (Murray & Schaller, 2016) , acting as a first line of defense, warning us from the possible infection.

However, being instinctive in nature, the system attacks rationality and leads to alternations and errors in decision-making.

Statements from the International Organizations -People deeply rely on international organizations and their predictions for hope and optimism. UN and IMF terming the COVID-19

as the worst global crisis ever since the Great Depression of 1930s respectively (BBC, 2020a;

UN, 2020), has further set the tone for a scary future and uncertainty. World Economic Forum (Scott, 2020) , had even referred this pandemic as several crises packed in one, namely, J o u r n a l P r e -p r o o f healthcare crisis, economic crisis, energy crisis, and humanitarian crisis, worsening the geopolitical risks, globally. WHO and studies have further cautioned that COVID-19 hasn't run its full course with the worst yet to unravel (Tandon, 2020b) . 

The relentless infodemia taking the shape of an infodemic -The pandemic is witnessing global infodemia facilitated by social media and other online resources. WHO had warned of the infodemic accompanying COVID-19, an over-abundance of informationsome accurate and some notthat makes it hard for people to find trustworthy sources and reliable guidance (WHO, 2020b, February 2). The COVID-19 infodemic, considered as the first true social-media infodemic (Hao & Basu, 2020) . It has established how social media can be global public health threat (Larson, 2018) due to conflicting and manipulative misinformation in the form of fake news about possible cures, symptoms, and mortalities. These platforms have become breeding grounds for distorted thinking, leading to panic, confusion, racism, and threat perception of an unrealistic intensity (Kulkarni et al., 2020) .

Why do people become fearful or fall into a panic state? Epidemic psychology has seen its roots in the order and routine of human species (Schutz, 1970) . The human brain is pre-wired to thrive on certainty and has disdain for uncertainty, which represents danger (Robinson, 2020) . For the brain, anticipating a pain is acceptable, but not an uncertainty. Stability is indispensable to humans' schema and meaning-making. Normally, people have a blueprint of each day, with a taken-for-granted array of solutions for the life tasks which is a part of their personal consciousness (Strong, 1990) . A daily life is more assumed rather than planned. We do innumerous tasks daily, pay attention to few, while others are conducted on 'auto-pilot' mode. A crisis like current pandemic disturbs the set system and questions the certainty with which we were habituated, forcing us to reset. The mystery over the origin of the virus and the associated J o u r n a l P r e -p r o o f and prolonged uncertainties give rise to fear of the unknown, considered a fundamental fear of human (Carleton, 2016) . Less portion of our life remains steady, demanding us to change our ways and coping mechanisms. Such an attack of uncertainty on our fragile life and temporal stability lead to outburst of irrational and negative emotions, like panic and phobia. Furthermore, humans are cognitive miser (Fiske & Taylor, 1986) , making them more vulnerable during crisis to fall for decision-making biases, fueling anxiety and fear.

Based on the cognitive-behavioral model, it can be said that pandemic reactions such as misinterpretations of health-related stimuli, cognitive distortions, irrational beliefs, maladaptive behaviors, and attention processes have a central role in coronaphobia (Leventhal et al., 2016; Taylor & Asmundson, 2017) . For instance, in Agoraphobia, the person fears getting a panic attack in a 'specific' situation (Mineka & Zinbarg, 2006) or appraises the bodily sensations in catastrophizing manner (Barlow, 2004) . Hence, it is the appraisal of the threat in the situation which causes phobia.

Appraisal of bodily sensations, such as fever, cough, tiredness, and breathing difficulty, reported as the most felt symptom of COVID-19 (WHO, 2020c), together with the selfevaluation of inability to cope with such threatening cues can lead to health anxiety.

Subsequently, individuals may then seek consultation, not only because of the physical discomfort, but also due to presence of varied anxiety-provoking cognitive events. For instance, the knowledge that COVID-19 spreads through human contact, may get connected to an outside symptoms are related to COVID-19 (Sinha & Dev, 2020) . Such catastrophic interpretations may not be satisfied by the clinical measurements and hence, they are preoccupied with symptoms and seek repeatedly reassurance, leading us to the behavioral part of coronaphobia.

Reassurance can be sought in a variety of subtle ways, including repeated checking on bodily sensations, measuring fever, self-medicating, reading news, and discussing with family, as in agoraphobia, where patients seek presence of a 'safe' reassuring person (Carter et al., 1995) to cope up. Long term engagements in such safety seeking behaviors may lead to overdoing of activities which will provide them gratification and sense of protection, or prevent the threat fueling physical changes and elevation of the stress, consequently leading to state of coronaphobia.

The social and cultural model of pandemic encapsulates fear and phobia as born out of risk perception and response based on psychological, sociological and cultural factors, commonly referred as 'social amplification of risk' (Kasperson, 2017) . Factual risk of events combines with socio-cultural perspectives and amplifies public responses. This occur through two processes -(a) transfer of information about risk, and (b) mechanism of social response. In the former, individuals learn about risk from various sources, called 'amplification stations'.

Such information colors risk perceptions and levels of concern and act as a key factor in deciding the volume of risk, disputation of information, and its symbolic connotations. This is followed by J o u r n a l P r e -p r o o f the interpretation of the risk in the context of social, institutional, and cultural factors, such as social groups, stigma attached, and polarized social views. Hence, an amplified risk perception builds up, leading to heightened behavioral response, like phobia.

The 'amplification stations' enormously influence the social construction of the risk presentation and transmission. These include loved ones, scientists, researchers, risk managing organizations, leaders, and news agencies (Kasperson, 2017) with social media and networking sites being the latest entry. During the SARS outbreak in 2002-03, news agencies were held responsible for the exaggerated display of news, leading to mass anxiety, and xenophobia (Muzzatti, 2005) . Hence, the perception of the health threat comes from the perceptual and symbolic representation, created by the media and digital platforms. At present, two of the widely used social media platforms -Facebook and WhatsAppare flooded with unverified information related to COVID-19 and contain inaccurate information (Tewari, 2020) . The rapid spread of unverified news can create a ripple effect of misinformation. Elevated worries and avoidance behavior has been reported in agoraphobics, wherever they were exposed to catastrophic visuals of infections, deaths, and separation from family (Day et al., 2004) . Such unreliable information creates panic and phobia for even neutral things, places, and situations 

The paper attempts to extend the existing limited research on fear of COVID-19 through a detailed conceptualization of coronaphobia including definition, risk factors, and underlying psycho-social processes. This conceptualization can aid future research on development of psychometric measures of coronaphobia and help all stakeholders in understanding the cause, framing the diagnosis, devising policies and interventions for the masses to mitigate coronaphobia.

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