|

Received: 15 June 2020    Accepted: 2 July 2020

DOI: 10.1111/jocd.13601

REVIEW ARTICLE

Psychological aspects of COVID-19

Caroline Stamu-O’Brien MD1  | Simona Carniciu MD, PhD2 | Elizabeth Halvorsen MD3 |

Mohammad Jafferany MD4

1
Department of Psychiatry, NYU School of
Medicine, Woodhull Medical and Mental Abstract
Health Center, Brooklyn, New York, USA Background: COVID-19 pandemic has affected the world from every aspect.
2
Center for Research, Diagnosis and
Individuals are drained from social, financial, and emotional percussion of this pan-
Treatment in Diabetes and Metabolic
Diseases Corposana, Bucharest, Romania demic. Psychosocial consequences are far greater than are being perceived. It is
3
Halvorsen Psychiatric LLC, Guilford, anticipated that once the pandemic is over the psycho-emotional turbulence would
Connecticut, USA
4
shake the whole populations of affected countries.
Central Michigan University, Saginaw,
Michigan, USA Aims and Objectives: To review the psychological consequences of COVID-19
pandemic.
Correspondence
Mohammad Jafferany, Central Michigan Methods: A literature search was conducted on major databases from January 2020
University, Saginaw, MI 48603. to April 2020 with the search terms of Covid-19, Corona virus, psychological, depres-
Email: mjafferany@yahoo.com
sion, anxiety, phobias, obsessive behaviors, paranoia, parental relationship, marital
life and maternal and fetal bond.
Conclusion: Patients with COVID-19 infection are more likely to suffer from a myriad
of psychological consequences, and this infection may have profound effect on par-
enting, relationships, marital life, elderly, and maternal-fetal bond.

KEYWORDS

COVID-19, psychodermatology, psychological aspects

1 |  I NTRO D U C TI O N stress, anxiety/fears, post-traumatic stress, stigmatization, insomnia,

Since December 2019, starting in Wuhan, China, continuing in 2020 in
around 212 countries all over the Globe, a cluster of acute respiratory
illness, named coronavirus disease (COVID-19) has affected in early
May 2020 around 3 500 000 persons, and around 245 000 related
deaths.1 On January 30, 2020, the World Health Organization (WHO,
2020) designated the COVID-19 outbreak a “public health emergency
of international concern.” This dominated the headlines around the
2
World and on 11th of March World Health Organization declared this
3
as a pandemic. Although several researchers and authors predicted a
possible pandemic,4 the World lacked education regarding this matter
and the general population was not ready, as the authorities as well.
The current pandemic infection COVID-19 with its medical and
psychosocial implications leads to mental health problems around
the Globe such as excessive fear, discrimination, 2 anger, guilt, denial,
and depressive symptoms5 that increases the risk for acute compli-
cations or aggravation of pre-existing chronic diseases,6 but also to
positive changes and cognitive restructuring.7 One review identified
that there were emerging coping strategies like problem-focused
coping (seeking alternatives, self-, and other-preservation), seeking
social support, avoidance, and positive appraisal of the situation.7
The risk factors for mental health problems are female sex, lower
socioeconomic status, interpersonal conflicts, and lower resilience
and social support,8 frequent social media use,9 lack of information,
and misinformation, often aided by sensational popular media head-
lines and foci.10 Post-traumatic syndrome usually has a prevalence
between 4% and 41%, but since the outbreak it has increased with at
least 7% in some studies.8
Psychological factors are well-known factors that can influence
public health strategies used to manage epidemics and pandemics11

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2170       STAMU-O’BRIEN et al.
that can influence virus spread, severity of the disease, economy,
social behavior as discrimination, criminality, and so on.
After the outbreak across China, on January 29th, 2020 (UTC + 8)
a study based on an online survey was conducted by Zhan S et al on
different Chinese persons and 84.9% felt “extremely” or “very” ner-
12
vous about the novel coronavirus pandemic. Other studies found
that younger people and healthcare workers were at an especially
high risk of displaying psychological issues when they spent too
much time thinking about the outbreak13
2 |  P S YC H I ATR I C D I AG N OS E S R E L ATE D
TO COV I D -19
The exposure to an actual or threatening death or serious injury
is very traumatic whether personal or as a witness. In COVID-19,
through its manifestation as either intrusive symptoms, negative
mood, dissociation, avoidance, or arousal symptoms, it clinically
describes acute stress disorder. The symptoms usually occur within
four weeks of the traumatic event and last between two days and
four weeks. In the case of post-traumatic stress disorder (PTSD),14
the exposure to actual or threatened death, injury lasts longer than
one month. Sometimes, the symptoms can onset with a delay of six
months after the stressor.
2.1 | Anxiety in COVID-19 pandemics
Health anxiety is vital to the success or failure of public health
4
strategies in pandemics. Health anxiety can be experienced by
almost everyone in lifetime. This can be defined as perceived
changes bodily sensations with the interpretation that illness is
established. The types of sensations that can trigger health anxi-
ety are various, among these are the ones related to infectious
11,15
diseases. In the pandemic context, the importance of health
anxiety is vital for limiting spreading the infectious disease. The
adherence to the prevention recommendations like washing
hands, social distancing, even for the low-risk self-included per-
sons is a matter of great importance in the efforts to limit viral
spreading.11 Vigilance to potential health-related threat can be
protective when a low induced anxiety, but excess can be detri-
mental, including health issues like lowering immunity, increasing
blood glucose in diabetic patients,16,17 impaired sleep quality,18
mental health disorders, 6 and other psychological and neurologi-
cal disturbances.11
In contemporary cognitive-behavioral models, health anxiety
occurs along a continuum. It varies in degree, from very low levels
to very high levels, not in quality. High levels of health anxiety are
characterized primarily by catastrophic misinterpretations of bodily
sensations and changes, dysfunctional beliefs about health and ill-
ness, and maladaptive coping behaviors. 2,11,14
In the pandemic context, the degree of anxiety can increase with
factors such as: prior experiences to viral infectious diseases like
influenzas, current information about the outbreak and its symp-
toms,9 existing comorbidities, and so on. The misinterpretations of
symptoms vary among individuals and their beliefs about diseases,
and lead to increased anxiety, affected decision-making ability, and
behavioral changes.11
Different behaviors can occur in the high-anxiety persons. In the
previous epidemics, like 2009 H1N1 influenza pandemic, this per-
sons with auto-suspicion of viral infection had the tendency to seek
medical information and check for multiple doctor's checkups11 that
can negatively impact the healthcare economics. As in COVID-19
pandemic the social distancing in one of the main induced preven-
tion factors, persons have more of the tendency to avoid hospitals
and doctors’ offices, as these can be a source of contagion, delaying
the admission in case of real symptoms of viral infection and aggra-
vation of existing chronic diseases. This can lead to poor response to
treatment and increased morbidity.
Other maladaptive safety behaviors include excessive hand
washing, social withdrawal, and panic purchasing. Panic purchas-
ing leads to over-spending on stockpiling unneeded resources that
can have a detrimental impact on a community in need of these re-
sources. In the case of over-purchasing in products like sanitizers,
medications, protective masks, and surgical gloves, normal medical
care can be seriously affected.11
Excessive hand washing can lead to two major affections: irritant
contact dermatitis with symptoms that can vary from quite mild to
debilitating, including dryness, irritation, itching, and even cracking
and bleeding; allergic contact dermatitis, that is, rare and includes lo-
calized symptoms or generalized like respiratory distress and other
symptoms of anaphylaxis.19 In the case of increased health anxiety
persons, the excessive use of hand sanitizers can lead to even chronic
dermatitis.19 Irritant contact dermatitis is extremely common among
healthcare workers, for example, in a study on nurses, prevalence
was varying from 25% to 55% and as many as 85% relate a history of
having skin problems. 20 Hand hygiene products damage the skin by
causing denaturation of stratum corneum proteins, changes in inter-
cellular lipids, depletion of the lipid barrier, and damages to the skin
flora, resulting in more frequent colonization by staphylococci and
Gram-negative bacilli.19,21
The exposure to an actual or threatening death or serious injury
is very traumatic whether personal or as a witness. In COVID-19,
through its manifestation as either intrusive symptoms, negative
mood, dissociation, avoidance, or arousal symptoms, it clinically
describes acute stress disorder. The symptoms usually occur within
four weeks of the traumatic event and last between 2 days and
4 weeks. In the case of post-traumatic stress disorder (PTSD),14
the exposure to actual or threatened death, injury lasts longer than
one month. Sometimes, the symptoms can onset with a delay of six
months after the stressor.
In a psychiatrist's daily clinical work, COVID-19 is a source of con-
stant stressor as described by patients, leading to the development of
adjustment disorder which consists of the development of emotional
and behavioral symptoms in response to a stressor occurring within
3 months of the onset of stressor. It is usually clinically significant,
STAMU-O’BRIEN et al.
and induces marked distress and significant impairment in various
areas. The symptoms no longer persist once the stress is over.
Depressive disorder due to COVID-1914 is a persistent period of
depressed mood or marked diminished interest or pleasure in activi-
ties. There is evidence from history and laboratory that it is related to
COVID-19, it does not occur during delirium or other mental disorders,
and it causes significant distress in various areas. It is associated with
insomnia, loneliness, despair, and social withdrawal. In certain situa-
tions, patients resort to substance use to alleviate their symptoms.
While obsessive compulsive disorder (OCD) due to COVID-19 has
not particularly been identified as a novel anxiety entity, it consists
of obsessions, compulsions, body-focused repetitive behaviors evi-
denced by physical history, laboratory, not explained by other men-
tal disorder. It does not occur in the course of delirium and induces
marked distress (it can be with OCD-like symptoms, with appearance
preoccupation, with hoarding symptoms, with hair-pulling symp-
toms, and with skin-picking symptoms). The constant hand washing
as a precaution measure to prevent infection with the coronavirus
can either exacerbate previous OCD symptoms or induce it de novo.
Excoriation disorder (skin-picking disorder) is a recurrent skin
picking resulting in skin lesions, repeated attempts to decrease or
stop skin picking which causes significant distress, is not attributable
to substance use or medical condition, and is not related to other
mental disorder. It can be triggered by excessive hand washing which
induces dry skin and scaling. 22
Neurocognitive disorder due to COVID-19 may be associated
with reported cases of acute hemorrhagic necrotizing encepha-
litis manifested clinically by headaches, confusion, lethargy, and
disorientation. The brain MRI scan usually identifies abnormal le-
sions in both the temporal lobes and thalami. 22 Olfactory pathway
symptoms related to COVID-19 can also persist. Cognitive decline
in one or more cognitive domains (attention, executive function,
learning, memory, language, perceptual motor, and social) can
ensue and interfere with the independence of daily activities. It
does not occur in the context of delirium, substance use, or other
mental disorder.
2.2 | Psychological effects in caregivers of elderly
due to COVID-19
The people who are in quarantine may experience loneliness,
confinement, boredom, anger, and frustration. Caregivers can be
more anxious due to fear of contracting COVID-19. Fever, cough,
and respiratory symptoms can worsen the cognitive function in
the elderly and can enhance depression, anxiety, insomnia, de-
lirium, psychotic symptoms, and suicide. 23 Fear of being in public
and the social stigma can make affected individuals hide their ill-
ness. Only in Italy alone 9% of the healthcare workers have been
24
infected with COVID-19. At least 9,000 healthcare workers have
been ill from COVID-19 in the United States. It will be incumbent
upon geriatric psychiatry to study the postpandemic effects in the
elderly population. 25
|
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2.3 | Psychological effects of family members who
lost beloved ones to COVID-19
Family members who lost family or friends to COVID-19 can
display acute post-traumatic stress disorder in which emotional
numbness and insomnia are prevalent. Bereavement is also a nat-
ural occurring phenomenon. In cases in which the deceased had
contracted the illness from another family member, guilt can take
over. Psychological first aid is imperative to provide a supportive
and compassionate care. It is paramount to encourage survivors to
share their experience, hopes, and sadness either in individual or
group therapy.
2.4 | Psychological effects of COVID-19 on
healthcare workers
At the forefront of global mental health concerns are healthcare
workers (HCW) who witness the suffering of those afflicted by the
ravages of COVID-19. The psychological state of the professionals
who knowingly risk their own lives while meeting the demands of
their profession under substandard conditions like limited supplies,
unestablished medical treatments, and risking the health of their
own families and themselves.
2.5 | Psychological effects of COVID-19
on parenting
There has been a profound impact of parents trying to explain to
their children the drastic change in family routines. School clo-
sures with a total disruption of a child's sense of predictability and
“world order” have abruptly pivoted. Many parents' work sched-
ules may have changed. Children who routinely spent time with
extended family or friends have stopped or drastically reduced.
Parents struggle to teach abstract concepts such as illnesses
due to respiratory viruses, hand washing, and wearing masks.
Regardless of age, all children are reassured by knowing that their
parents will be there to care for and that they will be safe. Many
parents themselves are struggling to deal with their own emo-
tions dealing with a plethora of uncertainty in addition to being
calm enough to support their child's feelings. This is a daunting
task to ask parents who are merely trying to keep a roof over their
heads and food on the table let alone now to become a school-
teacher/information technologist to ensure virtual classrooms.
Two major concerns upon parents that indirectly have a conse-
quential outcome on a given individual's ability to parent and the
well-being of their children is social isolation and economic loss.
This might be a glimpse of the family disruption for American fam-
ilies. In summary, the outcome results demonstrated two sides of
a coin, a dialectical opposite but true simultaneously. Parents were
now spending more time doing activities with their children feeling
a closer bond of warmth while during the same period more likely
 |
2172       STAMU-O’BRIEN et al.
to punish, yell, and spank their children. 26 Experts and child advo-
cates are actively monitoring whether this change in ability to parent
children interactions trend toward healthy relationships or tendency
toward child abuse.
2.6 | Psychological effects of COVID-19 on
maternal-fetal mental health
The World Health Organization has policies that focus on the
physical well-being and support of mother/infant units but less
27
on the mental health aspects for childbirth during a disaster.
Conflicting information about vertical transmission and policy
practice of separation of mother from newborn started in China
may be based on anecdotal evidence which was followed in the
United States and elsewhere. The reports of vertical transmission
COVID-19–positive maternal, perinatal, and neonatal outcomes
28,29.
have been inconsistent There is a growing volume of infor-
mation on the physical health of child birthing since the pandemic
but by sharp contrast, there is a sprinkling of maternal-fetal men-
tal health with a few case reports and observational studies are
30-32
the most common published article in medical literature.
Again, here is an area of questions to prioritize for potential
areas for research in the area of maternal-fetal medicine. What
level of maternal stress (cortisol level) of a mother diagnosed with
COVID-19 on the fetus while making the decision to separate the
neonate upon delivery to whether to co-habitat postdelivery?
What would the mother's/partner's oxytocin level be when they
reunite with the newborn? What duration of time of separation of
14 days disrupts maternal-fetal bond? If there is a partner to ad-
minister pumped breast milk to the infant if the mother is seques-
tered due to being positive to COVID-19, what is the experience/
symptoms of the mother? What would be the fears of contamina-
tion of the child by the mother impacting their interactions in the
future? How does a neonate eye tracking facial recognition change
if its mother/caretaker is wearing a mask? Would a mother who
has already been diagnosed with postpartum mood disorder (PMD)
have higher symptoms? Would a woman who may not have PMD
but rather postpartum blues convert to postpartum mood disor-
der? We have yet to see. In terms of emotional intelligence, there
is clear evidence that emotions impact cognition especially in deci-
sion-making and if the mental health researchers are able to quan-
tify these experiences, we as a community will be better equipped
to support them.
3 |  U S E O F TE LE P S YC H I ATRY FO R
TR E ATM E NT A N D S U PP O RT
The extended periods of quarantine increase the risk of mental
health problems in those diagnosed with COVID-19, those exposed
to it, and healthcare professionals. Psychiatric inpatients and outpa-
tients are more susceptible to COVID-19 and viral infections due to
less self-care, limited insight and understanding of prevention rules,
and limited implementation of protective measures. The existence of
chronic mental illness also lowers the immune response, thus making
patients more vulnerable to COVID-19 pneumonia and acute res-
piratory distress syndrome (ARDS).33
Due to this unprecedented situation, telepsychiatry/telemedicine
became the new normal. In most cases, the simplest modality of com-
munication is the telephone. The preoccupation with privacy became
less important in the face of the possibility of death from COVID-19.
Zoom and other platforms for video calls have been used. For the se-
verely ill patients, the visits in-person are still used.16 In addition, most
staff meetings are conducted virtually to minimize personnel exposure.1
4 | CO N C LU S I O N
In conclusion, the humanitarian global health crisis has impacted the
psychological states of all humankind. The second wave of this pan-
demic will be in mental health such that there is a monumental void
of scientific data which needs to be prioritized. History repeats itself.
As in 1918-1919, the field science of psychology/psychiatry/neurol-
ogy/maternal-fetal mental health was in its infancy so research in
this area will be the first of its kind and may help people now as well
as in 100 years from now.
ORCID
Caroline Stamu-O’Brien  https://orcid.
org/0000-0002-5832-3510
Mohammad Jafferany  https://orcid.org/0000-0001-6358-9068
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How to cite this article: Stamu-O’Brien C, Carniciu S,
Halvorsen E, Jafferany M. Psychological aspects of COVID-19.
J Cosmet Dermatol. 2020;19:2169–2173. https://doi.
org/10.1111/jocd.13601