This cross-sectional study investigated the death anxiety and fear of Covid-19 in patients with schizophrenia and BAD. The study found death anxiety and fear of Covid-19 to be higher in the BAD and in the control group than in the schizophrenia group. There was no significant difference between the BAD and control groups. Importantly, the study also found a positive correlation between death anxiety and fear of Covid-19 in both groups.
The Covid-19 pandemic is a global epidemic that affects the whole world and causes the death of millions of people 1. In order to reduce the increasing number of cases, full or partial quarantines have been implemented in many countries and many restrictions have been introduced. Social isolation has distanced people from each other and placed the thought that the virus is deadly. The absence of social relationships is a risk factor for morbidity and mortality 13. Covid-19 causes more psychological effects than death. Following the news of countless deaths every day and watching the destruction of the Covid-19 pandemic all over the world caused many negative psychological effects, especially death anxiety and fear 14. Fear is a defense mechanism for self-protection and survival. The exaggerated fear of the pandemic can weaken defense mechanisms. It has been observed that the fear of Covid-19 may initiate a psychotic attack or cause the symptoms to recur. It has been thought that fear poses a risk for psychotic attacks, especially in sensitive individuals 15.
In some studies, death anxiety was found to be higher in schizophrenia patients than in healthy subjects 16, while in some other studies, death anxiety was found to be lower in schizophrenia patients than in healthy subjects 17. In BAD patients, on the other hand, it has been observed that anxiety symptoms may accompany the clinical manifestations of the sickness 18. In the Covid-19 pandemic, higher levels of fear and anxiety about Covid-19 were observed in BAD patients compared to healthy controls 19. A study conducted in Spain observed worse psychological distress in those with anxiety or depressive disorders compared to those with schizophrenia and bipolar diagnosis during the Covid-19 pandemic 20. Another study reported more Covid-19-related stress in patients with affective disorders than in those with schizophrenia spectrum disorders 21. This study found both TDAS and FCV-19S levels to be lower in patients with schizophrenia compared to those with BAD and healthy control groups. Lower levels of anxiety and fear about Covid-19 may be related to lack of knowledge about Covid-19, low education level, and cognitive deficiencies. Preoccupation with internal problems rather than ongoing events in the world may cause schizophrenia patients to move away from anxiety 22. In addition, there is an inverse and abnormal functional connection in the amygdala networks that underlie both conscious and unconscious fear perceptions of patients with schizophrenia. Therefore, these patients have a persistent deficit in the processing of fear 23. Cognitive impairments in schizophrenia may be more severe and common than those in BAD. Cognitive functions are better preserved in BAD 24. This may be the reason why the death anxiety and fear levels of the schizophrenia group were lower in this study, and the levels of BAD patients were similar to those of the healthy group. Because anxiety states are associated with cognitions about danger 25.
A study of death anxiety found death anxiety in women to be significantly higher than in men 26. In another study, death anxiety was found to be higher in women with schizophrenia, as in other participating groups 17. In this study, both FCV-19S and TDAS levels were higher in females than males in both groups.
In the results of this study, the level of death anxiety was higher in patients with schizophrenia who had a shorter disease duration. Cognitive deficits seem to be one of the main features of schizophrenia. One of the important factors in the continuation of cognitive deterioration is the changes that occur in the brain tissue over time. And anxiety is associated with cognition 25. People having schizophrenia for a shorter period of time may have less cognitive impairment. Therefore, the level of death anxiety in such patients may be higher than in those who have had schizophrenia for a longer period of time.
This study found TDAS and FCV-19S levels to be higher in BAD patients with a history of Covid-19. Some studies have shown there may be a relationship between Covid-19 infection and inflammation of the central nervous system 27. The interactions among the immune system, neuroinflammation, and neurotransmitters support the formation mechanism of diseases such as anxiety. Apart from inflammation in Covid-19 infection, other stressors such as a long quarantine period and difficult infection processes cause increased psychological distress 28. Patients with Covid-19 may fear being infected with a new, as yet unknown virus that has a high potential risk of death. And those in the quarantine may experience anger, distress, loneliness, anxiety, and fear 29. For these reasons, death anxiety and fear of Covid-19 may be higher in BAD patients with a history of Covid-19. In the schizophrenia group, there was no significant relationship between the history of Covid-19 and TDAS and FCV-19S. The possible reason for this may be a lack of knowledge and cognitive inadequacies as explained before 22.
Dysphoric mood in schizophrenia may be associated with positive symptoms rather than negative symptoms. In one study, those with schizophrenia spectrum disorder, patients who experienced severe hallucinations had more severe anxiety 30. This study found a positive correlation between TDAS and FCV-19S and PANSS positive scores, more so with TDAS. That is, patients with more positive symptoms had higher anxiety and fear. A possible reason for this may be that patients' delusional content is affected by negative situations such as death due to Covid-19, which they are exposed to in real life or in the media. Many studies have shown the comorbidity of anxiety and bipolar disorder 31. This study saw a positive correlation between TDAS and FCV-19S and YMRS score in bipolar disorder, more so with death anxiety. Those who experienced more severe manic episodes had more anxiety and fear. A study conducted with bipolar disorder patients found general anxiety levels to be associated with manic episodes 32.
An important finding of this study was that there was a positive correlation between FCV-19S and TDAS in both patient groups, more in BAD. The possible reason for this is that there are common neural circuits related to fear and anxiety in the amygdala and there are similarities in behavioral responses related to fear and anxiety 33. In addition, this result also supports that death anxiety of both patient groups may be related to the fear of Covid-19, and that fear and death anxiety may occur due to the Covid-19 pandemic, unlike any other period.
This study has some limitations. First, it was carried out with a limited number of participants. Further studies should be conducted in large populations so that the results can be generalized. New studies can be planned by examining the history of Covid-19 in depth (type of the treatment administered at that time, the duration of the quarantine period, whether the patients were treated at home, in the hospital or in the intensive care unit, etc.). In addition, since this is a cross-sectional study, the same results may not be obtained in a different periods of the pandemic. Longitudinal studies are needed to generalize the results of the Covid-19 pandemic.
In conclusion, the important emphasis of this study is the importance of assessing the death anxiety and fear of Covid-19 experienced by patients with schizophrenia and BAD. In particular, death anxiety and fear of Covid-19 should not be neglected in patients with BAD. Although patients with schizophrenia showed lower levels of death anxiety and fear of Covid-19, anxiety and fear can be exacerbated in those with more positive symptoms. It is useful to investigate whether these patients have delusions related to the pandemic. In particular, death anxiety and fear of Covid-19 during the pandemic should be examined in schizophrenia patients with positive symptoms and those having schizophrenia of shorter durations; in BAD patients with severe manic episodes; and in female schizophrenia and BAD patients with a history of Covid-19. Decreased drug compliance and increased disease severity during the pandemic period may also pose a risk in terms of death anxiety and fear. For this reason, the general drug treatment of the patients should be reviewed and close follow-up of the patients should be ensured. Cognitive behavioral therapy has been shown to reduce death anxiety significantly 3, and it can be added to overall treatment planning, as can other approaches. Expanded treatment approaches will help prevent future disorders from occurring in vulnerable populations.
Acknowledgements: None.