CHAPTER 1

INTRODUCTION

COVID-19 disease is caused by a virus which belongs to the family of corona viruses.  It is
named as corona virus because the outer surface of the virus has crown-like spikes called corona.
These viruses are so small in size with a diameter of approximately 65-125 nm. As nucleic
material, they contain 26-32 kb long single-stranded RNA (Hayat et Al. 2020). 

Alpha (α), beta (β), gamma (γ), and delta (δ) are the subgroups of this family. Some of these
viruses can infect human beings as well such as the ongoing COVID-19. It causes multiple
respiratory diseases which have higher fatality rates such as SARS-CoV, mild respiratory
disease, and MERS-CoV (Shereen et Al. 2020).

COVID-19 is the recent corona virus disease which emerged in 2019 by one virus of this family
called SARS-CoV-2. The incubation period of the disease is up to 14 days, with median time of 5
days. Within 12 days after contaminating people develop most of the symptoms of the disease
(Weissleder & Lee, 2020). 

The symptoms of the disease ranged from mild to severe. The symptoms usually common among
COVID19 patients are vomiting, shortness of breath, nausea, flu, headache, bad throat, fever,
cough etc. Some patients may die from the disease if they develop ARDS or pulmonary edema,
or their organs may severely damage (Rahman et Al. 2020).

The infection of COVID-19 can be diffused through two main ways. It can spread directly or
indirectly. It can be transmitted directly through aerosols from surgical tools, through secretions
such as saliva, semen, and urine. It can also be directly transmitted from mother to child. An
infected person can spread the virus to others by coughing, sneezing, being closely distanced to
other people (Karia, Gupta & Yadav, 2020). 

It can also spread indirectly such as through the tools used on the patient such as thermometer or
if any other person in the environment of infected person touches any surface such as furniture or
walls (Cai et Al., 2020).

In December 2019, in Wuhan, a city in China, the outburst of this new contagious Corona virus
disease was reported which the world now recognizes as the COVID-19. The previous viruses of
the corona family, such as MERS and SARS had higher mortality rates i.e, 34.4% and 9.6%
respectively whereas the mortality rate of COVID-19 is not more than 6%. The risk of deaths
from the COVID-19 is higher among those people who are enduring from diseases such as
diabetes, heart problems, and respiratory diseases, or even hypertension. This is because these
people have lesser immunity as compared to health individuals, so they are more prone to death
from this infection. The death rates are also reported to have variations of age and gender
(Nadeem et Al. 2020). 

1.1 Anxiety

Anxiety is a psychological emotional state or reaction to a situation which appears to be

threatening. According to DSM 5, “anxiety disorder includes conditions that share common
features of excessive fear, anxiety and related behavioral difficulties” (APA,2013).

“It is an emotion characterized by feelings of tension, worried thoughts and physical changes like
increased blood pressure.” (APA,2013).

Anxiety is just an overreaction to a threatening situation which might sometimes be beneficial as

it helps us to be prepared for alarming situations so that we can pay attention to the situation
(APA, 2013). 

1.1.1 Anxiety Disorders:

“A person with anxiety disorder has recurring intrusive thoughts or concerns.” (APA, 2013).
Anxiety interferes with activities of daily life once it becomes a disorder. 

1.1.2Types Of Anxiety Disorders:

1-Generalized Anxiety Disorder:

Generalized anxiety disorder is basically excessive anxiety and distress about different events
like job performance, that persists for many days, but note more than 6 months (APA 2013).

It is one of the common mental disorders. It provokes fear, stress, constant worry, and a
persistent feeling of being repressed. In this disorder, people unrealistically and excessively feel
worried about everything. This worry could have multiple sources such as family problems,
financial problems etc. It is hard to control the excessive worry of generalized anxiety disorder, it
has variety of psychological and physical symptoms. Although it has many characteristics, but
excessive worry is the central characteristic of this disorder (Munir & Takov, 2021).

According to DSM-5, the characteristics of Generalized Anxiety Disorder include the following:

1. Impatience 

2. Muscle tension 

3. Unable to control worry.

4. Getting tired easily.

5. Excessive anxiety for at least 6 months.

6. Sleeping difficulty. 

7. Restlessness 

8. In, social or occupational settings, the distress leads to anxiety. 

9. Cannot be associated with physical reasons.

2-Social Anxiety

Social anxiety is also known as social phobia. It results when any social situation threatens and
limits the normal functioning of a person (Jefferies & Ungar, 2020).

Some of the common problems which occur in social anxiety are fear of shaking, incompetence,
sweating and appearing anxious. Individuals who experience social anxiety do a lot of struggles
in in social situations. Some signs of people having social anxiety they avert their gaze; fewer
facial expressions are shown face a lot of difficulty in initiating and maintaining conversations
whereas on other hand people without social anxiety do not face all these difficulties. And if
people come to know about these signs, they become shyer, communicate less with others.
(Jefferies & Ungur 2020).
3-Panic disorder

When recurrent and unexpected panic attacks occur, they characterize panic disorder. According
to the DSM-5 panic attacks is defined as "an abrupt surge of discomfort or intense fear." which
goes to the peak within minutes. Panic attack is accompanied by four or more physical
symptoms. (Cackovic Nazir and Marwaha 2020).

According to DSM - 5 criteria of panic disorder the person experiences recurrent occurrence of
panic attacks followed by again and again for at least one month or there is maladaptive behavior
because of fear of these attacks. (APA 2013).

Panic attacks occur when there is abrupt fear or intense discomfort and any 4 or more of
following 13 systematic symptoms occur (Cackovic Nazir and Marwaha 2020)

· Sweating

· Discomfort/restlessness

· Cause chest pain

· Always in fear of going crazy.

· Losing self-control

· Trembling, shaking.

· Chocking feeling

· Nausea

· Getting numb

· Getting chills

· Shortness of breath

· Accelerated heartbeat /rate.

· Fear of death
Separation anxiety:

Separation anxiety disorder (SAD) is the one in which there is unrealistic fright or excessive
anxiety on detachment from major attachment figures. (Joshua Sussman 2021)

It is a disorder in which the person exaggerates, or normal anxiety is proved by excessive worries
and concerns and anticipation separation from there attachment figures. (Feriante and Bernstain
2021).

If a person has following symptoms, then according to DSM 5 he is diagnosed with this disorder
(APA 2013)

· A lot of unusual worry about losing their pet or person.

· Excessive concern that if they leave the person alone then that person will be harmed.

· Fear of being left alone.

· Need to know where their partner or spouse is all time.

· When they come to know that they will be separated from person physical symptoms also
occur.

All these symptoms may last for six or more months, and they cause a lot of distress and
discomfort and effects personal, social, occupational functioning of person.

Agoraphobia

Agoraphobia is a nervousness of being in situations were getting away is tough. You feel
helplessness worry about being embers or may be in developing a panic attack from symptoms
and triggers to safety behaviors. Agoraphobia in a number of situations in crowds, on sub ways,
airplanes open spaces etc. (Balaram and Marwaha 2012).

The patient with agoraphobia must be afraid into at least two of the five following situations:

· Using open spaces

· Using subways cars airplane public transports

 · Standing in line or crowds like movie theaters, hospitals

· Being outside of at home alone

1.2 Relationship between anxiety and COVID 19 Pandemic

A global epidemic reported as taking place all around the world and overpassing all the
intercontinental borderlines and influencing haphazardly a plenty of individuals. In the period of
pandemic difficulties may begin such as sheltering, sustaining food and essential requirements
influenced by the epidemic also physiological and psychological wellbeing of individuals can be
influenced (Fiorillo and Gorwood.2020).

Fear of becoming unwell, people experience different problems such as social concerns or
financial issues and experiencing lockdown can develop anxiety signs in individual. (Book et al,
2020; Firoillo and Gorwood, 2020; Shah et al, 2020; Shigemura et al, 2020 ;).

The first announcement of COVID 19 was made by WHO on December 31.2019 as a novel viral
infection, and after which turn out to be pandemic. On 11 March 2020, the WHO carried out a
virtual briefing and verified the fairs of the viral disease. A global epidemic with such a wide
reach the requirement of lockdown was introduced, and travelling was prohibited. This pandemic
changed a lot thing; the mental health and life was destroyed. Within the five months of the
outburst of the disease, around 0.4 million people were infected and 0.2 million died globally
(WHO, 2020).

Health anxiety is a critical problem, and each will increase and reduces can result in troubles
(GJG, 2004). The individual’s anxiety can be categorized as high anxiety, low anxiety and health
anxiety considering as a broad gamut. (Taylor 2019).

During the epidemic, some people with significant health anxiety may generate overcrowding in
the wellness by visiting doctors and health care systems regularly. People with significant
anxiety may be hesitant to get physiological from fear that hospitals would spread the disease.
People with minimal anxiety, on the other hand, could be hesitant to heed warnings about
containing the epidemic and may act in a laid-back manner (Asmundson & Taylor, 2020).
Females are more prone to suffer from anxiety and depressive symptoms than males (Alexander
et al., 2007), Hence females are expected to get more influenced during epidemic (Kim et al.,
2014).

Social isolation is a consequence of restrictions and lockdown measures relate to emotions such
as uncertainty about the future, dread of novel viral pathogens, and excessively high anxiety
(Khan et al.2020).

Anxiety may be associated with sensational reduction and extensive isolation; in this context,
restlessness was replaced by sadness and PTSD. Moreover, anxiety is related with tiredness,
poor performance among medicare workers, but weariness, loneliness are related with rage,
irritation, and tolerating isolation limitations (Torales, Higgins, Mauricio, Maia & Ventriglio,
2020)

 Additionally, in an epidemic time, additional catastrophic impacts connected with chronic

anxiety consists of perceived diminished social support, detachment from significant others,
absence of independence, uncertainties, and restlessness (Lee and You in the Year 2020).

Droplet-transmitted 2019-nCoV is more likely to spread in crowded locations. People who live
in urban communities are likely to be more affected as a result. Individuals having a record of
present or recent psychological disorder are most influenced, as earlier outbreaks have shown
(Page et al., 2011).

 COVID19 is reported to have a more acute course in people over 60 and those who have chronic
disease. As a result, this population, as well as those who live with someone over 60, may be
more seriously affected (Zhou et al., 2020).

During the Corona virus crisis, medical specialists in Wuhan are trying to control threat of
disease and reduced security against the virus, exhaustion, disheartenment, assurance,
disconnection, anxious patients, distancing from family and tiredness. (Kang et al, 2020).

The recent affairs causing emotional and psychological like depression, strain related problems,
oppressive side effects, sleeping difficulties, anxiety, fury, and terror. These psychological
problems are not only affecting cognitive abilities, thorough vital skills of medical staff, which
makes the battle against Corona virus difficult for them, however they could likewise have an
enduring impact on their well-being. (Kang et al, 2020).

Corona virus pandemic and overall lockdown are probably going to cause anxiety and to cause
worsening of indications in analyzed cases. Any indicating flu-like cause side effects increase in
nervousness and under current conditions, Corona virus is relied upon to have a more extreme
effect. OCD patients particularly who have checking storing, and washing impulse, are at higher
danger. (Qiu et al, 2020) 

The information on an expanding number of infections by COVID just as perished in various

nations and countries have caused stress among the mass individuals. The circumstance has been
raised further with the overemphasize 'viral' news via web-based media, for example, Facebook,
Instagram, twitter, etc. just as deception by electronic sources, like news reports and online web
journals. (Ahorsu et Al., 2020,)

The wild deception and bogus reports, along with adverse disposition of individuals being
infected with viruses have filled a wide scope of psychopathological prominence, including
stress, depression, and anxiety. (Pakpour and Griffiths 2020)
It is prominent that females are more inclined to anxiety and depression (ALEXANDER,
DENNERSTEIN, KOTZ & RCHARDSON 2014). What is more accounted for to encounter
more elevated levels of anxiety during past pandemics (Kim et Al 2014).

Females likewise showed more risk of anxiety that was 3.01 occasions higher than males in
examinations performed to survey the overall population's mental wellbeing during the current
Corona virus pandemic in china (Wang, Di, Ye & Wei.).

Rationale Of the Study:

Corona Virus is the viral infection which is recently came across. CoV2 is the new form of
virus is spreading fastly in all the part of the words. More than 164,000,000 people in the
word have been infected. Over 3,400,000 people have died. This viral infection effects the word
badly and it becomes the challenge for overall system of the word. 
The lockdown effects the people h mentally and physically. Depression and anxiety are common
and most prevailing mental disorders among general population. Crisis of the lockdown due to
this viral infection may increase the spreading of these mental illnesses, specifically with
widespread social isolation resulting from necessary safety measures.

Corona Virus is the whole world problem and has spread with alarming speed, so collective
efforts are required to handle the lockdown. In Pakistan with increasing in the number of Corona
virun, students have to take online classes which affect them mentally and increase their stress.
There are over the great population in Pakistan who is suffering from the mental health due to
this viral infection.

People related to different fields trying their level best to study how this lockdown effect the
people mentally and physically. In Pakistan in the recent survey researchers use Urdu language
to check the anxiety level of the individuals due to the lockdown. They use CAS, which is used
to measure the anxiety level in the individuals which occurs due to this viral infection. 
The CAS scale is first used in the United States to measure the anxiety level of the adults, who
complain anxiety due to the lockdown of Corona Virus.
 CHAPTER 2

LITERATURE REVIEW

    A two-section survey study was held in Kuwait to investigate the existence of anxiety and
depression symptoms among the Kuwaiti nationals and foreigners. This report identifies
the relation between sociodemographic traits and physical exercise commitment, with mental
issues like distress, depression during the current pandemic. The result of this study found
that 55% of the respondents face psychological problems (Alsharji 2020).

Anxiety and depression were significant (P<0.01) the regression analysis. Factors affecting
anxiety were age, gender, and education whereas the factors associated with depression were
marital status, age, and gender. Being female, married, young, and bachelor was significantly
associated with psychological issues and COVID-19. The symptoms of anxiety during COVID-
19 are immediately and persistently reduced by a regular PA (Alsharji 2020).

In 2020 an interview study was conducted with 195 students bin US to predict the influence of
COVID -19 on college student’s psychological health. Data was collected through qualitative
and quantitative methods. 71% students reported to have symptoms of anxiety due to the global
epidemic. To contend with anxiety and tension, participants seek support from others to adopt
either positive or negative coping mechanism. According to the results of the study there is a
need to develop the interposition and restrictive strategies to reduce the mental issues of students
(Son, Hedge & Smith, 2020).

An online survey study was conducted on 1687 subjects in 2020 to study the mental influence of
COVID-19 pandemic on the people for the purpose to fine the ratio of depression, anxiety, stress,
and other psychological issues. 40% of the subjects had anxiety.

74% of the participants reported stress whereas 74% of them reported psychological distress. The
study concluded that lockdown had made every 2/5 people to face psychological issues (Grover,
2020).
Due to lockdown, common mental health disorders are being experienced by people during
COVID’19 (Grover et Al. 2020)

To explore implications related to COVID’19, a research of 347 undergraduate students were

conducted during the outbreak in 2020 to date. As sample it showed some doubts. Doubts that
are related to COVID and doubts were common like unhappy, sensitivity, sensitivity due to
anxiety, body concerns, unhygienic thoughts, and distress. Results for this suggested that people
are underestimating the fact that these signs are the significant predictors of COVID’19 i.e.,
contaminated thoughts, unhappy mood, bodily changes and consequent safety behaviors (Waqas,
Hania and Hongbo 2020).

For determining facts and people’s point of views, treatment and factors associated with
COVID’19, a study of 389 frontline physicians of Pakistan was conducted. Physicians were from
four provinces and 65 cities of Pakistan. Anxiety/depression was popularly seen in 43% of
frontline doctors. To ensure the mental health of doctors while fighting against this was
suggested in study. Controlled environments with interventions were suggested to promote
mental health of medical staff. (Amin, Noureen; Durrani & Jilani 2020).

In Republic of Georgia, to explore the symptoms of mental disorders that are associated with
COVID’19, a survey of 2088 respondents (adults) using selective sampling was used for the
study. For mental disorders, some extreme levels of symptoms of anxiety were recorded during
the study. (in women; 23.9%, and for men it was 21.0%) for the symptoms of depression it was
(30.3% women and 25.27% men), for PTSD it was (11.8% in women and 12.5% in men) lastly
for AD it was (40.7% women and 31.0% men) (Makhashvili et Al, 2020).

To conclude the impact of COVID’19 on mental well-being of general population in Pakistan, a

study of 1756 respondents was conducted. It also showed the factors associated with the COVID.
Data was collected through survey which was held online. Poor well-being was commonly found
in 41.2%. Being female, difference of gender, not going to work due to pandemic, living days
like unemployed, living in Sindh and ICT, terror of COVID and having severity in illness were
significantly associated with poor well-being (Khan et Al.2020)
Another study conducted in China to find the probability of psychological outcomes and the
factors related to it in the doctors examining corona patients found that 44% of them had anxiety,
and 71% had stress (Lai et Al.2020).
A cross-sectional research was conducted in 2020, 1257 health workers participated in this study
investigated in china. It was conducted to evaluate the immensity of mental health results and
factors related to the patients with COVID-19 and their health care staff in china. A reasonable
number of participants of study had symptoms of stress anxiety, and depression (Lai, et Al.
2020).

In north California, a survey study was regulated including 24-items.it was to assess the
abundant associations between loneliness, social isolation, and anxiety in north California 514
samples of older adults, keeping in views the SOPs of COVID-19. The results concluded that
56.4% participants have perceived isolation and 36.0% participants have loneliness. Outcome
showed the loneliness relation with both COVID-19 and social isolation, but corona-virus
associate anxiety and social isolation were not related (Gaeta & Brydges, 2020).

In 2020, 584 participants were chosen to conduct a cross-sectional study in China to find the
results of COVID-19 on the psychological health among youth groups and to probe the factors
that affect the mental health of young people. The tendency to have a psychological problem
among the young group was almost 40.4%. hence it proved that mental health of youth may be
influenced by infectious diseases like Corona virus (Liang, 2020).

In 2020 in china a cross-sectional study was conducted with 8079 respondents in order to
estimate that how COVID-19 had effect anxiety and depressive symptoms socio-demographic
and prevalence rate in Chinese adolescents. the results showed frequency of anxiety symptoms
37.4%, depressive symptoms 43.7% and the blend of anxiety and depressive symptoms was
31.3% during corona virus outbreak among high scholars of china (Zhou et Al. 2020).

In 2020, an online research was made to study the effect of quarantine during COVID-19
outbreak 2019 on the psychological of children in Hubei province. According to this study about
22.6% students are facing depressive symptoms. Outdoor activities and interaction with the
social circle have been reduced during the COVID-19 breakdown that increases in children’s
depressive symptoms. About 19% of respondents have reported anxiety symptoms which is

greater in prevalence than other studies (Xie et Al 2020).

A study was conducted in 2020with 673 respondents of Chinese force with initial mental-health
condition and psycho neuro-immunity prevention measures. In the report of respondents, there
was a low prevalence of anxiety depression stress. Due to reliance infused by psycho neuro-

immunity measures the prevalence of psychotic symptoms are low (Tan et Al. 2020).

The cross-sectional study was conducted in Amman to study the anxiety level of the pandemic
on health care staff. Participant have showed extremely severe depression, distress, and anxiety.
Being male, married, middle aged and with clinical history are associated factors. (Alnazly,
Khraisat, Bashaireh, and Bryant 2020).

A survey study was conducted in 2020 to find “fear of COVID-19” influence on future armed

forces’ indirect effect of the fear on career anxiety and future workplaces for career anxiety. Due
to fear of COVID the future workforces are getting anxious about their career according to
empirical studies. Depression from the COVID-19 caused by fear to get the virus as a mediator,
has a significant indirect effect on the relationship between COVID fear and career anxiety about
future, results in a full mediation. (Mahmud, Talukder, and Rahman 2020).

To access the mental health of German public over duration of 50 days after the COVID-19

outbreak a web-based survey was conducted in Germany with sample of respondent 16245.
About 35% respondents report less sleep quality, and 7.2% a moderate generalized anxiety: with
high peak. Finally, many respondents show psychological burden more than twice. (Hetkamp et
AL.2020).

In the current scenario, researcher looks at symptoms of anxiety in pregnant females and looked
identified variables that were linked to psychological distress. The results showed disturbingly
significant levels of stress among pregnant females during the outbreak of the deadly virus, that
could have persistent influence on their offspring’s. Increased social support and exercise were
possible protective factors because they were related to the less problems and so may help
mitigate long-term negative outcomes (Lebel, MacKinnon, Bagshawe, Madsen, and Giesbrecht
2020).
A survey was conducted with 5545 individuals from Spanish general population to give
preliminary evidence of actions linked to a reduction in symptoms in the currentCOVID-19
epidemic and shutdown Sixty-five percent of the participants said they had anxiety or depression.
The best predictors of reduced levels of anxiety symptoms were eating a healthy/balanced diet
and during the COVID-19 pandemic and lockdown, this study reveals that coping techniques
may protect against anxiety and depression symptoms’ reading news/updates regarding COVID-
19 very often. (Fullana, Mazzei, Vieta and Radua, 2020).

During the COVID-19 pandemic in 2020, a cross-sectional study with 56 teens was conducted
to investigate the presence of anxiety disorder (AD) symptoms in adolescents with hearing
problems (HL). Deaf adolescents showed higher scores of Panic Disorder, Social Anxiety
Disorder, and Anxiety than adolescents (Ariaporan and Khezeli 2020).

A total of six thousand adults from Germany participated in a longitudinal study of 4 months
with four evaluation waves. During the pandemic, the researchers looked at how anxiety and
depression symptoms changed over time. People with psychological problems, such as anxiety
appear to be prone to psychological distress in the pandemic, according to our findings (Bendau
et Al.2020).

During the COVID-19 epidemic in New York City, an online survey of 1821 adult students was
undertaken to investigate the incidence of depression and anxiety symptoms among under-
resourced public university students. More exposure to COVID-19–related stressors was linked
to greater depressive symptoms (27.0 percent, 41.4 percent, and 63.1 percent for low-, medium-,
and high-risk groups, respectively) between April 8, 2020, and May 2, 2020, according to a study
to low, medium, and high-level stresses) and anxiety symptoms, respectively. this data reveals a
terrible picture of psychological anguish among students from lower socioeconomic levels in the
COVID-19 epidemic epicenter in the United States (McNeal et Al.2020).

To better understand and define the psychosocial consequences of the COVID-19 pandemic in
the general community, as well as to identify risk and protective factors that predict alterations,
an online survey study was done. n the European island country of Cyprus, a total of 1642 adult
participants (71.6 percent women, 28.4% men) completed the poll. A high number of people
(48%) expressed serious financial problems, and 66.7 percent indicated major changes in their
quality of life. About 41% reported mild anxiety symptoms, while 23.1 percent experienced
moderate-to-severe anxiety symptoms (Solomou & Constantinidou, 2020).

An online pilot research with 1311 people in Bangladesh was performed to determine panic and
anxiety among people. Panic and generalized anxiety were found in 79.6% and 37.3 percent of
people, respectively. Being older having a better education, being married, and joint family were
all significant predictors of fear. In another research, being female, older, educated being
married, and working for a private organization were all statistically significant predictors of
generalized anxiety (Islam, Ferdous and Potenza 2020).

A research was done in March 2020 to measure anxiety and depression in Ireland the pandemic.
More than one thousand people participated in the study. Results showed that old age was linked
to corona anxiety than young age. It also indicated that depression and anxiety were in people
during the outbreak of the pandemic (Hyland et Al.2020).

During the COVID-19, a cross-sectional research in the United States found COVID-19-related
fears, mourning, as well as present psychological symptoms) in women. 36.4 percent said they
had clinically significant depression, 22.7 percent said they had generalized anxiety, and 10.3
percent said they had PTSD. Women are much of the population. for the treatment of PTSD.
Women who had previously self-reported mental health disorders were 3 times more prone to
sadness, basic anxiety, and PTS. (Liu, Erdei & Mittal 2020). In U.S, a cross-sectional research
investigated the concerns related to corona and psychological distress symptoms in women
during the ongoing pandemic. 35% people reported depression, 23% reported anxiety. Females
who already had mental issues were 3 times more prone to anxiety (Liu, Erdei & Mittal 2020).

A study was conducted in 2022 on a population to evaluate some psychological problems.

Depression and anxiety of Hong Kong People was evaluated. Randomly sampling was used to
select respondents who were informed to fill questionnaires. Questionnaire included Patient
health questtionare-9 (PHQ-9), Generalized Anxiety disorder-7 (GAD-7), global rating of change
of scale and of course items related to COVID-19, 19% of the 600 participants had depressive
symptoms and 14% of them were anxious. Moreover, 25.4% people had reported that their
psychological wellbeing was disturbed and declined since the COVID-19 (Choi, Hui & Wan
2020).
244 individuals were part of a cross sectional study. This research conducted to find anxiety and
ways of copying in Israelian students. In result of study conducted prevalence of moderate and
severe anxiety was 43% and 14% respectively. Things which were related and associated with
higher anxiety score were Gender, fear of infection and lack of PPE. Higher anxiety is linked
with mental quilt whereas resilience is linked with low anxiety (Savitsky, Findling, Ereli and
Hendel 2020).

An extensice study was conducted to measure the mental issues of corona on society and to
know anxiety levels of the individuals and some parameters ere also studied such as anxiety
related sleep habit. Questionnaire was used to collect the data. Questionnaire was generated by
Researcher and GAD-7 (Generalized Anxiety Disoder-7). It came to know big part of individuals
of this study had high anxiety levels. It was also discovered individuals had trouble during sleep
in COVID-19 pandemic and individuals sleeping habit changed. The study conducted found that
those individuals who have trouble sleeping had a higher inclination to have generalized anxiety
(Citak and Pekxtimir, 2020).

In the month of April another study was conducted among the 3122 Bangladeshi students. The
research conducted to assess ratio of the psychological distress with the DASS-21 and related
factors in Bangladeshi graduates in COVID-19 outbreak. In the study results the prevalence of
depression, anxiety, and stress was 77%, 61% and 72.1% respectively mild symptoms, 63%,
64% and 57.4% for at moderate symptoms, 36.3%, 41.2% and 38% for severe symptoms and
20%, 28.2%% and 17.3% for severe symptoms. These results were more relevant in other
COVID-19 studies of Bangladesh. (Islam et Al,2020).

In Pakistan, a study of among 10178 individuals, was conducted to find mental influence of
COVID-19 on trainers in Pakistan by separating the symptoms of depression, anxiety and stress
and also analyzing the predictive factors related with these symptoms. Results revealed that
prevalence of depressive symptoms, anxiety and stress were 27%%, 23%% and 5%, respectively.
Women postgraduates, trainers and front-line health workers experiencces more symptoms of
anxiety, depression, and stress (Imran, Masood, Ayub and Gondal 2020).
 CHAPTER-3

MATERIAL AND METHODS

The purpose of the study was to translate and validate the COVID-19 anxiety scale. This chapter
defined the participants, sampling techniques and instruments that used to measure the COVID-
19 anxiety among general population.

3.1 Population

The targeted population of this study was general population of district Gujrat .

3.2 Sampling technique:

Selecting sampling technique is an important part of the research for getting a representative
sample. In this research, for selecting sample the convenient sampling was used.

3.3 Sample Size:

The sample size was comprised of 1016 participants. Sample was collected from general
population of District Gujrat

3.4 Inclusion Criteria:

The sample participants contain general population of district Gujrat

3.5 Exclusion criteria:

The population outside of District Gujrat was excluded.

3.6 Instruments

The following instruments were used in the study.

3.6.1 Demographic sheet

In view of the literature, a demographic sheet was created, and those demographic characteristics
were included that were found to be correlated with COVID-19 anxiety. Age, gender, father's
education, mother's education, family system, monthly income, socioeconomic level, and so on
are all factors to consider.

A brief description of the COVID-19 Anxiety scale  is required before writing the specifics about
the translation and adaptation processes.

3.6.2 COVID-19 Anxiety Scale

The Corona Virus Anxiety Scale (CAS) is a simple mental health screening tool that can help us
to identify cases of dysfunctional anxiety linked to the COVID-19 outbreak. This scale was
developed by Sherman A. Lee (2020). It consists of 5 items. The CAS is effective in
distinguishing between people who have and don't have anxiety disorders.

The measure is scored using a 5-point time anchored scale (0=not at all to 4= nearly every day
over the last 2 weeks). The range of CAS score is from 0 to 20, higher scores indicate higher
levels of COVID-19 anxiety

3.7 Procedure Of Adaptation, Translation And Validation Of COVID-19 Anxiety Scale

The rational of study was to translate and validate and indigenous scale in Urdu for general
population so that COVID anxiety among general population can be identified.

Firstly, permission was taken from the author ( Sherman A. Lee; 2020) to adapt and translate
COVID-19 anxiety scale into (Urdu Language).The First objective of the study was to translate
and adapt the Covid-19 anxiety scale according to Pakistani culture so that the utility of the scale
for non English speaking participants will be increase.

The study was conducted in two phases. In the first study the translation and adaptation of the
scale was done and in the second study Psychometric properties of the scale was establish.

Phase 1: Procedure Of Translation And Adaptation Of COVID-19 Anxiety Scale ( CAS)

The aim of the first phase was to translate Urdu version of the English scale of CAS that was
theoretically relevant to the target language and the culture. The key purpose of this process was
to enable the scale acceptable in both English and Urdu language. The focus was on cross culture
linguistic equality to achieve the goal. A well established method was used for the forward and
backward translation (Nisar et al. 2020)

The translation and the cross language validation of the scale accomplish in the steps

Step 1: Forward translation

The Covid-19 anxiety scale ( Sherman A.lee, 2020) was translated with the help of expert panel.
Five experts two PHD Doctors (both are lecturers ) and three PHD scholars (1 lecturer) in
psychology. All of the experts were also requested to direct those items that think were not
related to Pakistani culture. They were asked to suggest better alternative if they found any
problem or mistake in the translation

Step 2: Expert panel

In a meeting with 3 experts an assistant professor, one lecturer and a research scholar , each item
was analyzed and the most appropriate translation that reflect the meaning of item was selected
by mutual consensus. During the process of translation and adaptation some minor changes were
made in Original scale of COVID-19 anxiety

Step 3: Backward translation

The Urdu translation version of CAS was given to five experts. The procedure was same as
followed in forward translation. The two PHD doctors both were lecturers and three PHD
scholars (1 lecturer) were involved in this process.

Step 4: Expert panel

The backward Urdu translation and original English version of CAS items scrutinized by the
same panel who helped in forward translation. Lastly, selected translated items were organized in
same order like they were in original scale. 5-items were translated and finalized after the expert
panel discussion.

Phase 2: Psychometric Properties of the COVID19 Anxiety Scale CAS

Data Analysis:

The study's respondents' characteristics were assessed using descriptive statistics (frequency,
percentages, mean, and standard deviation). Internal consistency reliabilities (Cronbach's alpha)
and corrected item-total correlations between items were also evaluated.

Confirmatory factor analysis (CFA):

The factor structure of the CAS Urdu version was assessed using confirmatory factor analysis
(CFA). The author's proposed uni-dimensional factor structure was tested using CFA. Model fits
were evaluated through the χ2/df value, comparative fit index (CFI), Tucker–Lewis index (TLI),
root mean square error of approximation (RMSEA), and standardized root mean square residual
(SRMR). The χ2/df ratio value ≤ 2 indicates a good fit (Schermelleh-Engel and Moosbrugger
2003). According to Marsh and Hocevar (1988) this value should be less than 5. The CFI and
TLI values of 0.95 indicate that the model is well-fit (Hu and Bentler 1999) A RMSEA value of
0.06 to 0.08 and an SRMR value of ≤0.08 (Schreiber et al. 2006) also indicate a better-fitted
model.

3.8 Ethical consideration

The study was conducted while maintaining the rights, dignity, and welfare of the participants
as well as the competence of the study researcher. The right to withdraw and the
confidentiality of the personal information were completely ensured to the individuals who
participated in the study. They were also briefed about the purpose and the procedure of the
study.

3.9 Statistical analysis

 After data collection, data was analyzed by using SPSS 22. Descriptive analysis was run to find
the frequencies and percentages of variables and PEARSON correlation analysis was run to see
the relationship between all items of scale. The factor structure of the CAS Urdu version was
assessed using confirmatory factor analysis (CFA).
 CHAPTER 4

RESULTS

Reliability analysis, percentages and Pearson Correlation were run on SPSS 22 version to test the
results of study. A total of 1016 participants successfully completed the online questionnaires.
355 males and 661 females had participated in this study. Table 4.1 depicts the further details of
demographic’s variables

Table 4.1: Table shows the frequency (f) and percentage (%) values of demographical variables
of Gender, Education, Residential area and Marital status (N=1016)

Variables Category F %

Gender Male 355 34.9

Female 661 65.1

Education Middle 20 2.0

Matric 75 7.4

FA 93 9.2

BA 94 9.3
 MA 33 3.2

BS 691 68.0

M.Phil 10 1.0

Residential Area Urban 612 60.2

Rural 404 39.8

Marital status Married 202 19.9

Unmarried 806 79.3

Divorced 4 4

Widow 4 .4
Table 4.1 shows percentage of Gender, Education, Residential Area and Marital status. 355
representing 34.9% of the respondents were Male and 661 representing 65.1 % were Female.
The majority number of participants i.e 691 representing 68% of respondents who had Bachelors
degree and only 10 participants representing 1% of respondents who had M.Phil degree. The
majority of the participants were belong to Urban area representing 60.2% and 39.8%
respondents belongs to Rural area. 79.3% of respondents were unmarried, 19.9% respondents
were married and 0.4% were divorced & widow

Table-4.2: Table shows the frequency (f) and percentage (%) values of demographical
variables of

Variables category F %

Family system joint 557 54.8

Nuclear 459 45.2

Family income less than 15,000 66 6.5

15,000 to 30,000 173 17.0

30,000 to 50,000 273 26.0

More than 50,000 504 49.6

Father’s education Middle 294 28.9

 Matric 296 29.1

F.A 140 13.8

B.A 133 13.1

MA 57 5.6

BS 82 8.1

M.Phil 14 1.4

Mother’s Education middle 403 39.7

Matric 302 29.7

FA 125 12.3

BA 78 7.7
 M.A 38 3.7

BS 66 6.5

M.Phil 3 3
Table 4.2: shows the percentage of Family status, Family income, Fathers Education and
Mothers education: The majority of the participants belong to joint family system as compared to
nuclear family system. It depicts that majority of the participants belonged to high monthly
income more than 50 thousand representing 49.6% of respondents and few participants were
belonged to family income of ranged less than 15 thousand representing 6.5% of
respondents.26% is the average percentage of respondents who belonged to family income
ranged 30 thousand to 50 thousand. 296 representing 29.1 % of respondents whose father
education was middle,13.1% is the average percentage of respondents whose fathers education
was B.A and 1.4% represents the respondents whose Fathers education was M. Phil.

4.1 Pearson correlation coefficients

The calculated Pearson Correlation Coefficient are depicted in Table 4.2.All correlation values
are significant at .001 level. The values between 0.1-0.3 range shows low correlation. Values
between 0.3 to 0.5 shows medium correlation and values between 0.5 to 0.9 shows strong
correlation .Further details are shown in table given below:

Table-4.3: Pearson Correlation Coefficient

1 2 3 4 5

1 DZ .50** .42** .43** .49**

2 SP .47** .52** .52**

3 FZ .46** .46**
 4ET .57**

5 ST

NOTE: DZ= Dizzy, SP= Sleep, FZ = Froze, ET= Eat, ST= Stomach and ** = P < .001

Table 4.3 shows the correlation of all items with each other.DZ has strong correlation with SP
(0.50) and medium correlation with FZ, ET, and ST (0.42, 0.43, and 0.49 respectively). SP has
strong correlation with ET and ST (.52) and medium correlation with FZ(.47). It also shows that
FZ has medium Correlation with ET and ST (.46). ET has strongest correlation with ST (.57).

4.2 Confirmatory factor analysis CFA

Confirmatory factor analysis was performed with the help of AMOS (V21) to evaluate the
model. Figure 1 depicts the detailed analysis

According to Hu and Bentler (1999), for acceptable model fit root mean square error
approximation (RMSEA) values are close to .06 or below, comparative fit index (CFI) and
Tucker-Lewis index (TLI) values are close to .95 or greater (Hoyle, 2012).

The values obtained were: χ2 = 19.12, df = 5, p = .002; CFI = .992; TLI = .983; RMSEA = .053
(90% CI = 0.029-0.79); SRMR = .0174, showing that the given model appropriately fit the data
 Fig 1: Confirmatory Factor analysis Model

Table-4.4: Kaiser-Meyer-Olkin Measure of sampling Adequacy

KMO 0.848

χ2 1677.220

df 10

α .001

Note: KMO= Kaiser-Meyer-Olkin, χ2= Bartlett test, df= degree of freedom, α = Cronbach
alpha
Table 4.4 shows the Value of KMO (0.848) indicates that the sampling is adequate.

4.3 Discussion
People are affected by COVID19 outbreak both physically and emotionally (Wang et al. 2020).
Scientists, psychologists, and researchers are trying to design alternative techniques to assess
people's physical and mental health in order to better understand the consequences of the
epidemic.

The Corona Virus Anxiety Scale CAS is the First one that was validated on a large sample of
particularly US adults who experienced high anxiety during the initial phases of the corona virus
pandemic, including a considerable number of people who had been infected with the virus (Lee
2020). Data was gathered using an online questionnaire, and item and scale psychometric
qualities were evaluated as part of the CAS adaption process.

The focus of this research was to develop, translate, and validate the COVID19 anxiety scale
(Lee 2020) in Urdu so that it could be used to evaluate dysfunctional COVID19 anxiety in
Pakistan's general public. Data was obtained through an internet survey during the CAS's
adaptation phase.

The objective of this research was to look at the psychometric properties of the Urdu version of
CAS in the setting of Pakistani socioculture. The psychometric features of the scale were also
preserved from the original form. The goal of adopting this type of translation and adaptation
was to keep the translation process at a high level of quality.

Item analysis contained no negative values and inter item correlation was significant. The item
analysis indicated that the test items are simple, compatible and valid with the test objectives.
The translated scale was well matched with Sherman Lee original scale consisting of 5 items.
Confirmatory factor analysis results strongly supported the construct validity of the Urdu version
of this scale.

The CAS Urdu version's internal consistency reliability was good, according to the results. Lee
(2020) discovered that the CAS has high internal consistency reliability (as ranging between 0.92
and 0.93). The Urdu version of the instrument also showed good internal consistency by
displaying a Cronbach Alpha value of full scale =.826.

Although the Corona Virus Anxiety Scale items are primarily concerned with anxiety and stress
related emotions, the fact that they're still only concerned with uncomfortable bodily symptoms
makes them particularly relevant to somatic symptom and related disorders (such as sickness
anxiety disorder) (APA, 2013). This is a critical feature of the CAS because many people who
are not affected but believe they are infected with virus believe they are infected.

Using mental health screeners like the CAS to assess and manage these persons with adequate
mental health treatment before the COVID-19 pandemic overwhelms emergency response and
medical facilities is a vital step in controlling the COVID-19 outbreak.

CHAPTER 5

Limitations

There are some following limitations of this study:

· First, data was gathered using a self-reported online questionnaire, which could have
been influenced by the social biasness.

· Second, we selected our respondents from a convenience sample of individuals (mostly

adults)

· Thirdly, as there were various internet surveys running concurrently with the data
collection for this investigation, divergent validity was not examined. People were
hesitant to participate in a longer survey,  To preserve participants' reports valid and
 comprehensive, the instrument for testing divergent validity was removed from the
survey.

· Fourth, data were collected using a non-clinical sample. Thus, a clinical sample should be
used in further studies to validate the scale for clinical use.
These limitations within this research should be taken in consideration
Recommendation:
· Despite these drawbacks, the CAS Urdu version of the COVID-19 anxiety scale has
strong psychometric qualities for assessing dysfunctional COVID-19 anxiety in
Pakistanis. This scale can be used to quickly assess anxiety over the COVID-19
epidemic.
· Using this screening instrument, health professionals could address the general public's
mental health difficulties induced by COVID-19
· Despite the fact that this method is common in psychological research, researchers should
replicate this study using a probability sampling method so that the findings can be
applied to the entire Pakistani population and self-selection bias can be avoided.
· Thee CAS could be utilized for diagnosis in clinical practice as well as the development
of prevention programes. Because it only contains five items, the CAS can be
administered rapidly, potentially benefiting doctors in congested clinical settings.

Conclusion
The COVID19 Anxiety scale CAS produced by Lee (2020), was the very first
psychopathology related assessment tool for COVID-19 anxiety and  also this is among the
first few published scales to evaluate its construct. This study intended to establish an Urdu
version of the CAS to broaden the reach of examining persons that are exposed by this global
pandemic.
Our findings confirmed the CAS as a valid tool for detecting dysfunctional corona virus
anxiety in the Pakistani general public after completing an online study and other analyses.
With the validation of the CAS Urdu version, persons influenced psychologically by the
virus in Pakistan can be successfully screened in a reasonable time by both psychological and
healthcare specialists.
Furthermore, more study should be conducted to investigate our suggestions, such as testing
the CAS Urdu version on a clinical sample and using it to treat COVID-19 anxiety through
online psychotherapy.