Asian Journal of Psychiatry 82 (2023) 103500

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Asian Journal of Psychiatry

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Short communication

Ashamed or afraid? Traumatic symptom severity and emotional activations

of Covid-19-related events
Cesare Cavalera a, *, Angélica Quiroga b, Osmano Oasi a
a
Department of Psychology, Università Cattolica del Sacro Cuore, Milano
b
Department of Psychology, Universidad de Monterrey, Monterrey

A R T I C L E I N F O A B S T R A C T

Keywords: This study investigates the role of shame, guilt, and fear activations related to Covid-19 stressful experiences in
Traumatic symptoms predicting traumatic symptoms. We focused on 72 Italian adults recruited in Italy. The primary outcome was to
COVID-19 explore the traumatic symptoms severity and negative emotions associated with COVID-19-related experiences.
Stress
The presence of traumatic symptoms was met by a total of 36%. Shame and fear activations predicted traumatic
Shame
scales. Qualitative content analysis identified Self-centered, and Externally-centered counterfactual thoughts and
Guilt
Fear five relevant subcategories were also identified. The present findings suggest the importance of shame in the
maintenance of traumatic symptoms related to COVID-19 experiences.

1. Introduction characterized by specific counterfactual thoughts that focus on negative

The Coronavirus Disease (COVID-19) vaccines have decreased the
chance of severe illness leading to hospitalization or death, even as the
virus is still among us and its tendency to mutate precludes its complete
mutations (Tandon, 2022). As the pandemic subsides, we are facing its
consequences in terms of ongoing uncertainties and traumatic symptoms
that persists over the long period. The COVID-19 spread allows the study
of the different emotional components of trauma proposed by the new
DSM-V categorization (APA, 2013). Besides the ongoing threat it poses
to personal safety (Brahmi et al., 2020; Liu et al., 2022), COVID-19 can
be traumatic in terms of the intrusive experience of guilt and of shame,
which may undermine mental well-being (Cavalera, 2020; Volpato
et al., 2022).
Guilt can become maladaptive for mental health when people
develop an exaggerated sense of responsibility for events that occur out
of their control, or when reparation is not possible (Cherry et al., 2017).
Therefore, guilt can be easily elicited by experiences related to
COVID-19 transmission. Even where all the necessary safety attentions
are followed carefully, recurrent thoughts may be related to the possi­
bility of being a COVID-19 carrier and a risk to family members (Sahoo
et al., 2020).
Social responses to COVID-19 have the potential to exacerbate
dangerous stigma and shameful experiences (Logie and Turan, 2020).
Shame activations are related to low mental well-being and are
global characteristics of the self (Cavalera et al., 2018; Niedenthal et al.,
1994). After being infected, people may perceive themselves as defec­
tive, triggering self-criticism toward the entire self. COVID-19 patients’
experiences showed shameful intrusive thoughts and the fear of being
stigmatized by friends, colleagues, and neighbors (Sahoo et al., 2020).
As recent evidence showed that high scores in disturbances in self-
organizations (Cloitre et al., 2018) and shame-proneness
(López-Castro et al., 2019; Cavalera et al., 2016) were related to a
greater likelihood of developing psychological symptoms, the relation­
ship between these trait variables and traumatic symptoms
Covid-19-related should be addressed.
Through a qualitative-quantitative approach, this study aims to
investigate the potential role of fear, guilt, and shame activations on
traumatic symptoms severity of stressful experiences related to COVID-
19 pandemic. Our primary aim is to quantitatively detect traumatic
symptoms prevalence and significant differences in fear, guilt, and
shame in predicting traumatic severity. The role of socio-demographical
and trait variables (disturbance in self-organizations, shame- and guilt-
traits) is also considered to understand eventual differences in partici­
pants with and without traumatic symptoms. Furtherly, the study aims
to qualitatively explore the contents and the emotional experiences of
counterfactual thoughts related to the most unpleasant COVID-19 per­
sonal experiences.

* Correspondence to: Department of Psychology, Università Cattolica di Milano, Via Nirone 15, 20123 Milano, Italy.
E-mail address: cesarem.cavalera@unicatt.it (C. Cavalera).

https://doi.org/10.1016/j.ajp.2023.103500
Received 17 January 2023; Received in revised form 27 January 2023; Accepted 31 January 2023
Available online 4 February 2023
1876-2018/© 2023 Elsevier B.V. All rights reserved.
C. Cavalera et al. Asian Journal of Psychiatry 82 (2023) 103500

2. Methods 2.0.0.0). Demographic and clinical data were compared using analyses
of variance for continuous variables and chi-square for categorical var­
2.1. Study design and procedure iables. Correlations between variables were tested by calculating
Spearman coefficients. Subsequently, only considering the variables that
After reading and accepting the informed consent, the participants showed a significant correlation, to determine the relative contributions
completed a large cross-sectional web-based study to assess socio­ of emotions to traumatic symptoms, a one-block hierarchical regression
demographic characteristics. Subsequently, they were given the with enter method was applied (Pedhazur, 1997). Four regression
following instructions: “Take a few minutes and think back to the most models were set with respectively TSS, and the 3 IES-R subscales as
unpleasant event you’ve experienced related to the COVID-19 target variables and state-emotions as independent determinants.
pandemic. Identify the worst scene and report it on a separate sheet of Qualitative thematic analysis of counterfactual thoughts was con­
paper. Write freely without worrying about mistakes. When finished, ducted using Ligre software. The analyses involved a first extrapolation
you can do whatever you want with this sheet. What you write will not of the emerging sub-categories that described the different aspects of the
be read by anyone.” counterfactual thoughts. Subsequently, sub-categories were grouped
After the recall procedure, a manipulation check was performed to into superordinate conceptual categories, and frequencies analysis was
assess the intensity of fear, guilt, and shame emotional activations by conducted.
administering the state-emotions scales (cfr. Measures). Subsequently,
trait measures were administered to explore the personal predispositions 3. Results
of the participants. Finally, the Impact of Event Scale-Revised was
administered and participants were asked to complete the sentence “If Table 1 shows the mean and standard deviation scores for each
only ….” to explore counterfactual thoughts. variable of interest.
Table 2 shows participants’ characteristics divided into those with
2.2. Participants at-risk Traumatic Symptomatology (TS) and those without (No-TS; IES-R
cut-off = 24).
The sample consisted of 72 adults recruited in Lombardy region Spearman analysis was launched to identify the variables signifi­
(Italy) from June 2021 to February 2022. Mean age was 27.31 = (SD = cantly correlated to TSS (see Supplementary Materials for details).
8.14, range 20–49). Respondents were recruited through the main stu­ Considering the significant results of the correlation, a first regression
dents’ social networks related to the Catholic University of Milan. All the was performed entering TSS as the dependent variable. S-Shame, S-
participants provided informed consent after receiving a complete Guilt, S-Fear, T-Shame, and Negative self-concept were added as inde­
description of the study and had the opportunity to ask questions before pendent variables in step 1. The model was statistically significant (R2 =
completing the self-report questionnaires via the Qualtrics online plat­ 0.32, F(5,57) = 5.47, p ≤ .001), more specifically shame and fear were
form. The present study was approved by the Ethics Board of the statistically significant determinants of IES-R Tot (Table 3).
Catholic University of Milan. Three more regressions were performed (cfr. Statistiscal Analysis).
The models were statistically significant (Avoidance, R2 = 0.34, F(5,57) =
2.3. Measures 5.97, p ≤ .001; Intrusivity, R2 = 0.27, F(5,57) = 4.18, p ≤ .01; Hyper­
arousal R2 = 0.24, F(5,57) = 3.53, p ≤ .01).
State Shame and Guilt Scale-8 is a self-reported questionnaire con­ The first extrapolation of counterfactual thoughts identified five sub-
sisting of 8 questions based on a 5-point scale (Cavalera et al., 2017). categories of contents. Subsequently, sub-categories were grouped into
Examples of shame and guilt items are “I feel small”, or “I feel tension two superordinate conceptual categories (Self-centered and Externally-
about something I have done”. centered). The Leaf Cloud of the sub-categories is reported in Fig. 1.
Beck’s fear/life threat questions. The questions developed by Beck Table 4 shows the frequency of the extracted categories from
et al. (2011) were asked to rate the emotional reactions during the recall
of the stressful experience and were included in the current study as
indicators of the traumatic perceptions of fear/life threat latent variable. Table 1
Examples of questions were: “I’m feeling in danger”, “I fear that a loved Participants’ characteristics.
one is in danger. Sociodemographic characteristics (Range) n % M SD
Impact of Event Scale-Revised is a 22-item self-report measure that
Age 27.31 8.14
assesses subjective distress caused by traumatic events (Craparo et al., Educational Level
2013). The IES-R yields a total score of Traumatic Symptoms Severity Middle school 2 3
(TSS, ranging from 0 to 88) and subscale scores can also be calculated for High school 38 53
the Intrusion, Avoidance, and Hyperarousal subscales. Scores greater University 13 18
Postgraduate 19 26
than or equal to 24 indicate the presence of traumatic symptoms (Asukai
TSS (0-88) 19.14 17.02
et al., 2002). Avoidance (0-32) 7.53 6.22
Personal Feelings Questionnaire-2 was used to measure personality Intrusivity (0-32) 6.78 7.19
proneness to chronic feelings of guilt and shame (Di Sarno et al., 2019). Hyperarousal (0-24) 4.82 5.08
Examples of guilt items are “mild guilt”, “remorse” while examples of N of elapsed months 11.18 6.05
State-emotions
shame items are “feeling ridiculous”, and “feeling humiliated”. S-Shame (4-20) 6.85 2.83
International Traumatic Questionnaire consists of items referring to S-Guilt (4-20) 7.54 4.17
PTSD and three symptom clusters referring to Disturbances in Self- S-Fear (0-600) 123.30 120.71
Organization (DSO; affective dysregulation, disturbances in relation­ Trait-emotions
T-Shame (0-44) 15.97 7.75
ships, and negative self-concept), (Rossi et al., 2022). To assess the role
T-Guilt (0-44) 11.98 5.03
of disordered self-organizations, only the three DSO subscales were Disturbances of self-organizations
considered. Affect dysregulation (0-8) 3.34 1.87
Negative self-concept (0-8) 2.62 2.44
2.4. Statistical analyses Disturbances in relationship (0-8) 2.71 2.14

Notes: N=72; TSS=Traumatic Stress Severity; S-Shame=state shame; S-Guilt=­

Quantitative statistical analysis was conducted using Jamovi (version state guilt; T-Shame=trait shame; T-Guilt=trait guilt.

2
C. Cavalera et al. Asian Journal of Psychiatry 82 (2023) 103500

Table 2 Table 4
Characteristics of subjects with (TS) and without at-risk Traumatic Symptom­ Frequency of extracted categories from counterfactual thoughts.
atology (No-TS). Over-ordinal categories %
Characteristics No-TS (n = 46, TS (n = 26, 36%) Sub-categories %
64%)
Self-centered 57%
n(%) M(SD) n M(SD) χ2 (dF, p Self-criticism 31%
(%) N) Personal misfortune 27%
Externally centered 43%
Age 27.26 27.38 0.19 ns Others’ mistake 11%
(8.41) (7.82) (3,72) Others’ misfortune 12%
Educational 1.88 ns Environmental factors & restrictions 20%
(3,72)
Level
Middle school 2 0(0)
counterfactual thoughts.
(100)
High school 24 14
(63) (37) 4. Discussion
University 7(54) 6
(46)
The high presence of a risk situation in terms of traumatic symp­
MS 13 6
(68) (32) tomatology (36%) evidenced the dramatic impact that the pandemic
N of elapsed 11.70 10.27 1.33 ns had on mental health. These results are consistent with previous work on
months (12.00) (9.50) (1,72) similar populations (Bassi et al., 2021) and add evidence that the trau­
State-emotions matic impact seems to persist beyond the number of months elapsed
S-Shame 5.76 8.77 17.89
since the event.
<.001
(2.21) (2.82) (1,72)
S-Guilt 6.80 8.85 4.37 <.05 Comparing the No-TS with the TS participants, disordered self-
(3.92) (4.34) (1,72) organization variables and shame- and guilt-proneness showed signifi­
S-Fear 105.85 155.40 3.39 ns cantly different mean scores. Although these results are consistent with
(112.02) (131.57) (1,72)
previous studies (Cândea and Szentagotai-Tătar, 2018; Cloitre et al.,
Trait-emotions
T-Shame 13.82 19.32 7.26 <.01 2018), the importance of these trait variables scores seemed to be
(6.54) (8.40) (1,72) limited in predicting TSS.
T-Guilt 10.72 13.96 5.66 <.05 Considering the regression model, only S-Shame and S-Fear were
(4.12) (5.75) (1,72) significant determinants. Conversely, guilt didn’t show any significant
Disturbances of
self-
correlations with traumatic symptoms. It is possible that the selected
organizations events were characterized by a non-maladaptive type of guilt that may
Affect 3.24 3.58 0.41 ns have been subject to functional repair and that was unrelated to current
dysregulation (1.90) (1.79) (1,72) traumatic activations (Chrdileli and Kasser, 2018).
Negative self- 1.96 3.62 6.54 <.01
The relationship between shame and traumatic symptoms is consis­
concept (2.05) (2.76) (1,72)
Disturbances in 2.35 3.38 3.88 <.05 tent with previous results indicating the negative effect of this negative
relationships (2.01) (2.17) (1.72) self-conscious emotion (Cândea and Szentagotai-Tătar, 2018; Leskela
et al., 2002). The present data confirm the cumulative nature of
N=72; TSS=Traumatic Symptoms Severity; S-Shame=state shame; S-Guilt=­
state guilt; T-Shame=trait shame; T-Guilt=trait-guilt.
COVID-19-related stressors and that shame related to COVID-19 can
engender traumatic aspects based on perceptions of having no value to
others, or worse, of being dangerous to them (Cavalera, 2020). Consis­
Table 3 tently with previous results (Zoellner et a, 2014), also state-fear acti­
Regression to identify significant predictors of traumatic symptoms severity. vated by COVID-19-related experiences is evidenced as being a
95% CI for Exp
significant predictor of traumatic symptoms severity. The traumatic
condition of prolonged Covid-19 alert related to the constant risk of
Outcome Predictors SE t p Lower Upper
exposure to threatened death and physical injury may explain the pre­
β

TSS S-Shame 2.48 0.72 3.43 .001 1.04 3.93 sent results. More specifically, observing Beta coefficients S-Fear seems
S-Guilt -0.48 0.47 -1.01 .319 -1.42 0.47
to be less intense than that of shame in global score, avoidance and
S-Fear 0.04 0.02 2.52 .015 0.01 0.07
T-Shame 0.51 0.29 1.74 .087 -0.08 1.09 intrusivity. Consistently with previous results (Tran and Beck, 2019),
Negative Self- -0.80 0.95 -0.85 .401 -2.69 1.09 peritraumatic perceptions of fear/life threat and posttraumatic negative
concept self-conscious appraisals/emotions are independently associated with
Notes: N=72; TSS=Traumatic Symptoms Severity; S-Shame=state shame; S- PTSD symptoms, although effect sizes for the latter tended to be more
Guilt=state guilt; T-Shame=trait shame; T-Guilt=trait guilt. robust.
The thematic content analysis explored the different counterfactual
thoughts related to stressful COVID-19-related events. The categoriza­
tion into “Self-centered” and “Externally-centered” reflect the need to
control and identify clear factors related to COVID-19 unpleasant events
(Gherman et al., 2022). Sub-categories frequencies analysis confirmed
the crucial presence of negative self-related counterfactual thoughts
about stressful events. This is consistent with the fact that negative
self-critical narratives play a central role in analyzing covid-related
Fig. 1. Leaf cloud of counterfactual thoughts sub-categories. stressful experiences (Quiroga-Garza et al., 2021; Tran and Beck, 2019).

4.1. Conclusion

The present study confirmed that the current pandemic situation

3
C. Cavalera et al.
may have dramatic consequences for mental health not only in terms of
the constant alert of being infected (Liu et al., 2o22) but also of shame
activations. In line with these recent revisions, results from the present
study further support expanding the conceptualization of PTSD beyond
fear/anxiety to also involve posttraumatic negative self-conscious ap­
praisals and negative self-conscious emotions. Further analysis should
explore the role of previous cumulative adverse events in determining
COVID-19 PTSD severity related to fear or shame activations. At the
same time, an analysis of neural and epigenetic correlates may explore
dissociable biomarkers and specific patterns of activations involved in
the two different circuits (shame vs fear) (Montirosso et al., 2020).
Eventual epigenetic correlations may reflect differences in the way
COVID-19-related PTSD is displayed by women and men, as already
shown in recent studies (Liu et al., 2022). Besides theoretical relevance,
our findings offer empirical support for the importance of focusing on
negative self-conscious emotions and counterfactual thoughts with
people seeking help for posttraumatic symptomatology.
Ethical statement
Hereby, I Cesare Cavalera consciously assure that for the manuscript
Ashamed or afraid? Traumatic.
symptom severity and emotional activations of COVID-19-related events
the following is fulfilled:
1) This material is the authors’ own original work, which has not been
previously published elsewhere.
2) The paper is not currently being considered for publication
elsewhere.
3) The paper reflects the authors’ own research and analysis in a
truthful and complete manner.
4) The paper properly credits the meaningful contributions of co-
authors and co-researchers.
5) The results are appropriately placed in the context of prior and
existing research.
6) All sources used are properly disclosed (correct citation). Literally
copying of text must be indicated as such by using quotation marks
and giving proper reference.
7) All authors have been personally and actively involved in substantial
work leading to the paper, and will take public responsibility for its
content
Funding
This research was conduct without financial support (i.e. no grant or
institutional funding).
Conflict of Interest
Hereby, I Cesare Cavalera consciously assure that for the manuscript
Ashamed or afraid? Traumatic symptom severity and emotional acti­
vations of COVID-19-related events the authors declare that there is no
conflict of interests regarding the publication of this paper.
Acknowledgement
The authors want to thank Professor Thanos Karatzias for inspiring
encouraging them to write this paper.
Clinical trial registration
The study procedure of the present research was registered in
PsyArXiv.
4
Asian Journal of Psychiatry 82 (2023) 103500
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.ajp.2023.103500.
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