key: cord-312362-i18rlo2r
authors: Yan, Linlin; Gan, Yiqun; Ding, Xu; Wu, Jianhui; Duan, Hongxia
title: The relationship between perceived stress and emotional distress during the COVID-19 outbreak: Effects of boredom proneness and coping style
date: 2020-10-29
journal: J Anxiety Disord
DOI: 10.1016/j.janxdis.2020.102328
sha: 
doc_id: 312362
cord_uid: i18rlo2r

The outbreak of a novel coronavirus (COVID-19) pandemic was a great threat to the physical and mental health of the general population. Our research aimed to investigate the relationship between perceived stress and emotional distress during the initial outbreak. Furthermore, potential risk and protective factors, i.e., coping and boredom proneness, of stress-related emotional distress were also explored. Data from 3233 participants in China were collected through an online survey platform during the initial outbreak of the COVID-19 from January 31 to February 9 in 2020. The results showed that higher perceived stress was associated with more emotional distress including depression, fear, compulsion-anxiety, neurasthenia, and hypochondria. Boredom proneness significantly and positively mediated the relationship between perceived stress and emotional distress. Moreover, coping style moderated the stress-emotional distress relationship, i.e., individuals who mainly adopted positive coping strategies suffered fewer symptoms of depression, compulsion-anxiety, and neurasthenia under stress, while negative coping strategies aggravated emotional distress. The results from the present study provide practical value for mental health intervention during the emergent public health events.

Since pandemic (Duan & Zhu, 2020) . A recent online survey found that moderate-to-severe stress, anxiety, and depression were noted in 8.1%, 28.8%, and 16.5%, respectively, However, few studies explored the relationship between perceived stress related to the current pandemic and emotional distress.

Boredom was considered as one of the most relevant stressors in those who had experienced isolation during the pandemic (Presti et al., 2020). The tendency to experience boredom or boredom proneness might be one of the potential variables that explain emotional distress during lockdown time. Boredom was defined as a state that relates too low arousal with dissatisfaction due to perceived monotony and repetition (Mikulas & Vodanovich, 1993) . It was proposed that disengagement from the environment is a key contributor to the boredom feeling (Eastwood et al., 2012) .

Boredom proneness refers to the propensity toward experiencing boredom, and it will vary across individuals (Farmer & Sundberg, 1986) . Individuals with high scores on the boredom proneness scale (trait) were likely to report more frequent boredom experience (state) (Mercer-Lynn, Bar, & Eastwood, 2014) .

Previous studies indicated that boredom proneness was related to higher stress levels (Wang, 2015; Elhai et al., 2018; Lee & Zelman, 2019) . Boredom proneness had also been demonstrated to be associated to emotional distress including depression, anxiety, and fear (Farmer & Sundberg, 1986 ; LePera, 2011; Leong & Schneller, 1993) . Similarly, Sommers and Vodanovich (2000) found that individuals with a higher level of boredom proneness reported higher scores on the Hopkins Symptom Checklist (Derogatis et al., 1974) including obsessive-compulsive, somatization, J o u r n a l P r e -p r o o f anxiety, interpersonal sensitivity, and depression. People who scored higher on boredom proneness felt less control of themselves and thus persist disengagement from their environment (Eastwood et al., 2012; Isacescu, Struk, & Danckert, 2017) . In turn, uncontrollability and disengagement might lead to an emotional response to a demanding situation. Therefore, boredom proneness might play a mediating role in an individual's perceived stress to the COVID-19 pandemic and their emotional response to it.

One of the factors which had been demonstrated in the effectiveness of mitigating the relationship between stress and mental health was coping style (Coiro, Bettis, & Compas, 2017; Wood & Bhatnagar, 2015) . Derived from the transactional model of stress, coping referred to "behavioral and cognitive efforts to reduce or tolerate the internal and external demands that were appraised as exceeding the person's resources" (Lazarus & Folkman, 1984) . In terms of its influence on physical and mental health, the coping style was divided into positive and negative (Berman et al., 1996; Xie, 1998) . Positive coping is associated with better mental health outcomes while negative coping is related to worse mental problems (Mark & Smith, 2012a , 2012b . Positive coping styles, such as problem-solving efforts, seeking information and social support, focus on active attempts to deal with stress and change the problematic situation. The characteristic items of negative coping styles include avoidance, wishful thinking, and substance use. Negative coping focuses on stressorelicited emotion rather than the stressor itself (Nowack, 1989) . Adaptive emotion regulation, such as positive refocusing and appraisal, acted as a possible buffer between the subjective perception about the pandemic and the current virus anxiety (Jungmann & Witthöft, 2020) . Differences in how individuals coped with events made some more susceptible to the negative consequences of stress (Vollrath & Torgersen, 2000) . For example, the influence of negative life events on depression was greater among those who took more negative coping strategies, such as worrying about problems instead of solving them (Sawyer, Pfeiffer, & Spence, 2009 ). Similarly, among females who adopted more negative coping strategies like passive acceptance and wishful thinking, high negative life events scores implicated significant increases in depressive and anxiety symptoms (Blalock & Joiner, 2000) .

Yu and colleagues (2016) also found that soldiers who tended to use more negative strategies and less positive strategies had higher levels of anxiety and depression during their recruit training. Recently, a web-based survey of mental health during the COVID-19 pandemic demonstrated that coping style was one of the influencing factors of psychological distress, i.e., participants with negative coping styles had higher levels of psychological distress, such as being nervous, hopeless and restless (Wang et al., 2020c) . Therefore, coping style might moderate the relationship between perceived stress and emotional distress during the outbreak of the COVID-19 pandemic.

J o u r n a l P r e -p r o o f

This study aimed to explore (a) whether the level of perceived stress to the COVID-19 pandemic would link with emotional distress (i.e., depression, fear, compulsion-anxiety, neurasthenia, and hypochondria), (b) whether boredom proneness would mediate the relationship between perceived stress and emotional distress, (c) and whether the direct path between perceived stress and emotional distress would be moderated by individuals' coping style.

As an integrated model, the present study was guided by the following 

3233 Chinese respondents participated in this study and filled in the whole questionnaires. The sample had a moderately wide range in age, education, and monthly income (see Table 1 ). information and responses would be anonymous and confidential.

The PSS10 is a 10-item scale to assess the respondents' perceived stress related to the COVID-19 pandemic. This scale was originally compiled by Cohen (1983) and the revised Chinese version had been demonstrated to have good reliability and validity (Yang et al., 2003) . Items are rated from 1 (not at all) to 5 (very much).

Participants were asked to respond according to their feelings or thoughts of the COVID-19 for the past month. The higher the score, the more stressful the respondents. The PSS10 demonstrated good internal consistency (α = .801) in the current sample.

J o u r n a l P r e -p r o o f

The emotional distress to the COVID-19 pandemic was measured by the PQEEPH. The 

The SBPS ( 

The SCSQ includes two dimensions, i.e., negative and positive coping styles (Xie, 1998 ). The individual coping tendency is calculated by the standard score of positive coping minus the standard score of negative coping. If the value is greater than 0,

indicates that the individuals' coping tendency is mostly positive (for example, "ask friends and family for advice"); if the value is less than 0, indicates that the individual mainly uses negative coping strategy (for example, "try to forget the whole thing"). In our study, the internal consistency coefficients of the positive and negative coping style subscale were .797 and .637, respectively.

All the analyses were implemented by IBM SPSS Statistics, version 24.0 (IBM Corp., Armonk, NY). The analyses of the hypothetical mediating role of boredom proneness and the moderating role of coping tendencies were conducted by Hayes's (2017) PROCESS macro (Model 4 and Model 5). All continuous variables were standardized and the interaction effects were computed from these standardized scores. The bootstrapping method produces 99% bias-corrected confidence intervals of these effects from 5,000 resamples of the data. Confidence intervals that do not include zero indicate significant effects (Hayes, 2013) . Before testing the models in J o u r n a l P r e -p r o o f PROCESS macro, the Scatter Plot of the standardized residuals showed that our data violated the homoscedasticity assumption as "the residuals roughly rectangularly distributed, with most of the scores concentrated in the center (along with the 0 points)" (Pallant, 2011) . Therefore, the HC3 heteroscedasticity-consistent standard error estimator proposed by Davidson and MacKinnon (1993) was applied for regressions in the current study, since HC3 was recommended (Hayes & Cai, 2007) and confirmed as the most reliable estimator (Cribari-Neto, Ferrari, & Oliveira, 2005).

This estimator was also proposed to keep the test size at the nominal level regardless of the presence or absence of heteroscedasticity (Long & Ervin, 2000) .

Means and standard deviations (SD) for scores of all the questionnaires are presented in Table 2 . Pearson correlations between variables are shown in Table 3 .

The results demonstrated that individuals who experienced greater perceived stress about the COVID-19 pandemic reported more emotional distress measured by PQEEPH including depression, fear, compulsion-anxiety, neurasthenia, and hypochondria. Likewise, individuals with higher boredom proneness had stronger emotional distress. Additionally, individuals who mainly adopted negative coping would experience more emotional distress as well. Note. * p < .05. ** p < .01. *** p < .001.

Correlation analysis showed significant and positive correlations among perceived stress, boredom proneness, and emotional distress, which provided a precondition for testing the mediating effect of boredom proneness. Firstly, to examine Hypothesis 1, a general linear model was built in which PSS10 was treated as a predictor, emotional distress as outcome variables, boredom proneness as a mediator, and demographic variables (gender, age, education, and monthly income) as covariates. The indirect and direct path between perceived stress and emotional distress are presented in Table   4 . As displayed in Table 4 as the direct path of boredom proneness and distress was still significant. Therefore, Hypothesis 2 was supported that boredom proneness mediates the relationship between perceived stress and emotional distress.

The PROCESS macro (Model 5) by Hayes (2013) was used to test the moderated mediation model. As demonstrated in Table 6 , the interaction effect of PSS10 and coping tendency negatively and significantly explained depression (β=-.047, p < .01), compulsion-anxiety (β=-.083, p < .001) and neurasthenia (β=-.100, p < .001).

However, the interaction did not significantly associate with fear (β= .003, p > .05) and hypochondria (β= .013, p > .05). Hypothesis 3 was largely supported that coping tendency moderates the relationship between perceived stress and emotional distress including depression, compulsion-anxiety, and neurasthenia.

J o u r n a l P r e -p r o o f Note. Bootstrap sample size = 5000; PSS10 = Perceived stress; BP = Boredom proneness. * p < .05, ** p < .01., *** p < .001. Note. Bootstrap sample size = 5000; PSS10 = Perceived stress; BP=Boredom proneness; CT=Coping tendency. * p < .05, ** p < .01., *** p < .001.

To further explain the interaction effect, we plotted PSS10 against emotional distress (i.e., depression, compulsion-anxiety, and neurasthenia), separated for low (M -SD) and high (M + SD) levels of coping tendency.

The results showed that as the coping tendency moved from positive to negative, the interpretative effect of perceived stress on the depression was gradually strengthened, and β increased from .220 (p < .001) to .314 (p < .001) (see Figure 2 .

A); β increased from .333 (p < .001) to .498 (p < .001) for compulsion-anxiety (see Figure 2 . B); β increased from .250 (p < .001) to .449 (p < .001) for neurasthenia (see Figure 2 . C). These results indicated that, compared with the positive coping tendency, when participants tended to adopt more negative coping, perceived stress might lead to higher levels of depression, compulsion-anxiety, and neurasthenia.

In summary, boredom proneness mediated the relationship between perceived stress and emotional distress (i.e., depression, compulsion-anxiety, and neurasthenia), and participants' coping tendency moderated the stress-emotional distress relationship. 

The current cross-sectional study explored the relationship between stress Under the situation of lockdown during corona time, boredom proneness was discovered to play a partially mediating role in the relationship between perceived J o u r n a l P r e -p r o o f stress and emotional distress, i.e., individuals with a propensity to experience boredom were more likely to report greater emotional distress. It was proposed that individuals with higher boredom proneness might focus on themselves or their internal states, and further tend to have more awareness of existing psychological symptoms (Sommers & Vodanovich, 2000) . Meanwhile, they were less able to regulate their emotion when experiencing a high level of stress (Culp, 2006) . adopting positive coping strategies were more likely to experience less emotional distress, suggesting that positive coping might be a "resilient" factor. That is, positive and adaptive coping, such as training on stress management and encouragement of self-care, would contribute more to the improvement of emotional resilience (Taylor, 2019) . In contrast, those who prefer to use more negative coping strategies are more likely to experience more emotional distress, therefore, are a "high-risk" population for mental illness under stress.

There are several implications in the present study. Firstly, psychological stress is related to emotional distress in the early stage of the pandemic during which the whole society is under panic. Hotopf and Wessely (1994) found that people with high levels of stress were more tend to fall ill with a viral infection and suffer more There are also some limitations to this study. First of all, it should be noted that this was a cross-sectional study without the temporal factor. It would be informative to follow up on the dynamic change of mental health along with the development of the COVID-19 pandemic. For example, compared with the initial peak of the COVID-19 pandemic, levels of stress and fear were decreased while depression levels were significantly increased during the remission phase when the number of cases declined . Considering that the second wave of the COVID-19 might be approaching, it remains to be investigated whether the rising number of cases and persistent social distancing are associated with a further deterioration of mental J o u r n a l P r e -p r o o f health. However, it is worthwhile to mention that data in our research was collected at the initial as well as the most serious stage of the outbreak, which may to a large extent reflect the most significant impact of pandemic-related stress on mental health. Secondly, all questionnaires were self-reported, which might not be consistent with the objective assessment by mental health professionals. Nevertheless, subjective measurements were widely used during the emergent public health events (Lau et al., 2008; Leder, Pastukhov, & Schütz, 2020) , and all questionnaires used here had been demonstrated high internal consistency. Thirdly, though we aimed at the general population, our sample mainly consists of well-educated young people, who may have higher immunity to viruses as well as a better capability to manage stress. Clinical characteristics of COVID-19 showed that the mortality rate of the elderly patients was higher than that of young and middle-aged patients (Liu et al., 2020), which implicated possibly higher psychological stress and more emotional distress in elderly individuals. Last but not least, it should be noted that COVID-19 has a greater negative impact on individuals with anxiety or mood disorders when compared with mentally healthy people . Considering that the current study only recruited healthy people, future studies should focus more on this vulnerable group.

A higher level of perceived stress due to the COVID-19 pandemic was related to more emotional distress. Stress-related increase in emotional distress is mediated by boredom proneness. Furthermore, positive coping strategies act as a buffer in 

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