Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: https://www.tandfonline.com/loi/udst20

Coronavirus Anxiety Scale: A brief mental health

screener for COVID-19 related anxiety

Sherman A. Lee

To cite this article: Sherman A. Lee (2020): Coronavirus Anxiety Scale: A brief mental health
screener for COVID-19 related anxiety, Death Studies, DOI: 10.1080/07481187.2020.1748481

To link to this article: https://doi.org/10.1080/07481187.2020.1748481

Published online: 16 Apr 2020.

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DEATH STUDIES
https://doi.org/10.1080/07481187.2020.1748481

Coronavirus Anxiety Scale: A brief mental health screener for COVID-19

related anxiety
Sherman A. Lee
Department of Psychology, Christopher Newport University, Newport News, Virginia, USA

ABSTRACT
Mental health concerns of people impacted by the coronavirus pandemic have not been
adequately addressed. The objective of this study was to develop and evaluate the proper-
ties of the Coronavirus Anxiety Scale (CAS), which is a brief mental health screener to iden-
tify probable cases of dysfunctional anxiety associated with the COVID-19 crisis. This 5-item
scale, which was based on 775 adults with anxiety over the coronavirus, demonstrated solid
reliability and validity. Elevated CAS scores were found to be associated with coronavirus
diagnosis, impairment, alcohol/drug coping, negative religious coping, extreme hopeless-
ness, suicidal ideation, as well as attitudes toward President Trump and Chinese products.
The CAS discriminates well between persons with and without dysfunctional anxiety using
an optimized cut score of
9 (90% sensitivity and 85% specificity). These results support
the CAS as an efficient and valid tool for clinical research and practice.

On 31 December 2019, a novel viral pneumonia origi-
nating from Wuhan, China was announced to the
World Health Organization (WHO, 2020a). As of 23
March 2020, this novel coronavirus (COVID-19)
quickly spread across the globe, infecting more than
294,110 people in 187 countries and killing 12,944
individuals (WHO, 2020b). Changes to daily life have
been swift and unprecedented, as cases of the virus
surge, the death toll escalates, and draconian measures
to contain the spread of the disease increase across
regions of the globe. Although there has been substan-
tial attention to measures to identify people with the
coronavirus infection, identifying the mental health
care needs of people impacted by this pandemic have
been relatively neglected (Xiang et al., 2020).
This is surprising given that mass tragedies, par-
ticularly ones that involve infectious diseases, often
trigger waves of heightened fear and anxiety that are
known to cause massive disruptions to the behavior
and psychological well-being of many in the popula-
tion (Balaratnasingam & Janca, 2006). For instance, in
a recent, large survey of people highly susceptible to
the coronavirus infection (i.e., Chinese medical work-
ers), the prevalence rate of traumatic stress was at an
alarming 73.4%, depression was at 50.7%, generalized
anxiety was at 44.7%, and insomnia was at 36.1%
(Liu et al., 2020). Although these findings are disturb-
ing, they are not isolated, as research on the psycho-
logical impact of previous global disease outbreaks has
demonstrated clear links between pandemic-related
anxiety and elevated symptoms of stress, anxiety, con-
tamination concerns, health anxiety, post-traumatic
stress, and suicidality (Chong et al., 2004; Wheaton
et al., 2012; Wu et al., 2009; Yip et al., 2010).
Therefore, the purpose of this study was to fill a void
in the mental health response to this growing public
health crisis by developing and evaluating a brief
mental health screener that can be used to reliably
identify probable cases of dysfunctional anxiety and
symptom severity associated with the coronavirus.
Method
Participants and procedure
Online survey data from 775 adults were collected
from 11–13 March 2020. The participants were
recruited through Amazon MTurk in exchange for
payment ($0.50) and were eligible if they provided
consent, complete information, and followed the
directions to a validity item. Because the study
focused on anxiety about the coronavirus, participants

CONTACT Sherman A. Lee sherman.lee@cnu.edu Department of Psychology, Christopher Newport University, 1 Avenue of the Arts, Newport
News, VA 23606, USA.
Due to the urgent and developing nature of the topic this paper was accepted after an expedited peer review process different to that outlined in the
journal’s instructions for authors. The paper has been reviewed by the journal’s Editor-in-Chief and by an additional, independent single-blind reviewer.
ß 2020 Taylor & Francis Group, LLC
2 S. A. LEE
also had to have spent at least one hour during the
past two weeks thinking about and/or watching media
about the coronavirus, as well as have experienced sig-
nificant anxiety, fear, or worry about the dis-
ease outbreak.
The study’s sample consisted of 446 men and 329
women with a combined mean age of 32.72
(SD ¼ 9.35) years. Most of the participants were White
(n ¼ 360; 46.5%), followed by Asian (n ¼ 320; 41.3%),
Hispanic (n ¼ 44; 5.7%), Black (n ¼ 43; 5.5%), and
other (n ¼ 8; 1.0%). Most of the participants were
from the south (n ¼ 270; 34.8%), followed by the west
(n ¼ 145; 18.7%), “other” (n ¼ 126; 16.3%), the north-
east (n ¼ 117; 15.1%), and the Midwest (n ¼ 117;
15.1%) regions of the U.S. The majority of the partici-
pants had a Bachelor’s degree or higher (n ¼ 644;
83.1%), had not been diagnosed with coronavirus
(n ¼ 661; 85.3%), and reported that they had never
suffered from or sought treatment for anxiety
(n ¼ 527; 68.0%).
Over the past two weeks, most of the participants
spent 1–3 hours (n ¼ 287; 37.0%), followed by
5–7 hours (n ¼ 181; 23.4%), 3–5 hours (n ¼ 154;
19.9%), and 7 hours or more (n ¼ 153; 19.7%) thinking
about and/or watching media about the coronavirus.
In terms of significant anxiety, fear, or worry about
the coronavirus during the past two weeks, most of
the participants spent several days feeling elevated
anxiety (n ¼ 283; 36.5%), followed by more than seven
days feeling elevated anxiety (n ¼ 209; 27.0%), less
than a day or two feeling elevated anxiety (n ¼ 177;
22.8%), and nearly every day feeling elevated anxiety
(n ¼ 106; 13.7%).
Measures
Background information
Participants were asked to report their age, gender,
ethnicity, education, current residency, coronavirus
diagnosis, and history of anxiety.
Validity item
Participants were asked to choose, using a 5-point
time anchored scale (0 ¼ not at all to 4 ¼ nearly every
day over the last 2 weeks), the rating of “2” as the item
response. This item was imbedded into the question-
naire for the purpose of eliminating participants who
may threaten the integrity of the study’s results by not
appropriately attending to the questionnaire’s content
(Barger et al., 2011). Consequently, 35 participants
were eliminated from the study sample.
Social attitudes
Participants were asked to rate, using a 5-point scale
(1 ¼ very dissatisfied to 5 ¼ very satisfied), their satis-
faction with President Trump (M ¼ 3.20; SD ¼ 1.40)
by the item, “Overall, how satisfied are you with
President Donald Trump’s responses to coronavirus?”
Participants were asked to rate, using a 5-point scale
(1 ¼ very unlikely to 5 ¼ very likely), their likelihood of
avoiding Chinese food/products (M ¼ 3.29; SD ¼ 1.50)
by the item, “How likely will you avoid eating
Chinese food or avoid purchasing Chinese products
because of the coronavirus?” Participants were asked
to rate, using a 5-point scale (1 ¼ very unlikely to
5 ¼ very likely), their likelihood of changing future
plans (M ¼ 3.80; SD ¼ 1.22) by the item, “How likely
will you change your future travel, vacation, or shop-
ping plans because of the coronavirus?”
Psychological effects
Participants were asked to rate, using a 5-point time
anchored scale (0 ¼ not at all to 4 ¼ nearly every day
over the last 2 weeks), how often they experienced the
psychological effects of the coronavirus outbreak.
Extreme hopelessness (M ¼ 1.83; SD ¼ 1.31) was meas-
ured by the item, “After thinking about the corona-
virus, I felt extremely hopeless about the future.”
Passive suicidal ideation (M ¼ 1.58; SD ¼ 1.46) was
measured by the item, “I wished I was already dead
so I did not have to deal with the coronavirus.”
Maladaptive coping
Participants were asked to rate, using a 5-point time
anchored scale (0 ¼ not at all to 4 ¼ nearly every day
over the last 2 weeks), how often they engaged in mal-
adaptive coping with the coronavirus. Negative reli-
gious coping (M ¼ 1.71; SD ¼ 1.41) was measured by
the item, “After thinking about the coronavirus, I
wondered if God was angry with or had abandoned
some people.” Alcohol/drug coping (M ¼ 1.61;
SD ¼ 1.41) was measured by the item, “I used alcohol
or other drugs to help me get through the fear and/or
anxiety caused by the coronavirus.”
Functional impairment
Participants were asked to rate five items, using a 9-
point severity scale (0 ¼ not at all to 8 ¼ very severely),
how much impairment they experienced because of
their fear or anxiety over the coronavirus. This
adapted version of Mundt et al. (2002) Work and
Social Adjustment Scale (WSAS) demonstrated solid
reliability (a ¼ 0.93). A total WSAS score above 20
suggests moderately severe or worse levels of

functional impairment. Based on this cut-score, 53.4%
of the sample were classified as functionally impaired.
Coronavirus Anxiety Scale
A pool of 20 candidate items was created based on
the psychology of fear and anxiety literature
(American Psychiatric Association, 2013; Barlow,
1991; Cosmides & Tooby, 2000; Ekman, 2003;
Ohman, 2000). Each item was written to capture a
unique manifestation of this particular form of anx-
iety. Specifically, these included the cognitive (i.e.,
repetitive thinking; worry; processing biases; dream-
ing; planning), behavioral (i.e., dysfunctional activities;
avoidance; compulsive behaviors), emotional (i.e., fear;
anxiety; anger), and physiological (i.e., sleep distur-
bances; somatic distress; tonic immobility;) dimen-
sions of coronavirus anxiety. Each item was rated on
a 5-point scale to reflect the frequency of the symp-
tom, ranging from 0 (not at all) to 4 (nearly every
day) over the preceding two weeks. This scaling for-
mat is based on the DSM-5’s cross-cutting symptom
measure, adult self-rated version (APA, 2013, pp.
734), to be consistent with the American Psychiatric
Association’s system of measuring psychiatric symp-
toms over time and response to treatment.
Analytic approach
A succession of factor analytic methods was applied
to the anxiety symptoms in order to identify a small
and reliable subset of symptoms that best represent
the latent construct of coronavirus anxiety
(Thompson, 2004). To address the influences of sam-
pling error, an internal replicability approach was
employed by subjecting one half of the study’s data to
a principal component analysis (PCA) and the other
half to a series of confirmatory factor analyses (CFAs)
using bias-corrected bootstrap Maximum Likelihood
estimations (2,000 samples). The PCA was used to
identify the five most robust and representative symp-
toms of coronavirus anxiety, while a CFA was used to
test the replicability of the PCA results.
A series of multiple group CFAs were also run on
the second half of the study’s data in order to deter-
mine if the construct of coronavirus anxiety is meas-
ured equivalently across demographic groups. The
entire data set was then used to examine the construct
validity and diagnostic viability of the coronavirus
anxiety symptoms using a series of correlations and
receiver operating characteristic (ROC) analyses,
respectively. Statistical analyses were calculated using
SPSS version 26.0, except for the confirmatory factor
DEATH STUDIES 3
analyses (CFA), which were run using AMOS ver-
sion 25.0.
Criteria for determining the five symptoms for the
CAS were based on the properties of a psychometric-
ally sound item (Ford et al., 1986). Specifically, the
symptoms had to be extracted from the first compo-
nent of the PCA because they account for the highest
possible squared correlations among the item pool.
The five symptoms with the strongest loadings on the
first component had to also yield high pattern/struc-
ture coefficients (>0.40), high communality coeffi-
cients (>0.40), and minimal cross-loadings (<0.40)
with the second component, in order to be considered
for the CAS.
Criteria for determining CFA model fit and meas-
urement invariance were based on conventional stand-
ards (Brown, 2006; Byrne, 2001). Specifically, adequate
model fit for a CFA model was defined by a chi-
square/df value <2, a standardized root-mean-square
residual (SRMR) value 0.05, root-mean-square-error
of approximation (RMSEA) value 0.10, and com-
parative fit index (CFI) and Tucker Lewis index (TLI)
values
0.90. Measurement invariance was defined by
both adequate model fit statistics and a non-signifi-
cant value (p
0.05) on a chi-square difference test.
Criteria for determining the diagnostic viability of
the CAS as a mental health screener and an optimal
cutoff value for scoring the CAS were based on psy-
chiatric screening test research (Spitzer et al., 2006;
van Dam et al., 2013; Weinstein et al., 1989).
Specifically, an adequate screening test must yield an
area under the curve (AUC) value
0.70 and be visu-
ally represented by a ROC curve that has a convex
shape toward the upper left corner of the graph. The
optimal cut-score must have a sensitivity value
80%
and a specificity value
70% to be considered feasible
for mental health screening.
Results
Data screening
A preliminary screening of the data suggested that the
20 CAS items were suitable for factor analysis
(Tabachnick & Fidell, 2001). Specifically, the data did
not have issues pertaining to sample size, missing
data, nonnormality, multicollinearity, or singularity.
Moreover, the correlation matrices were deemed fac-
torable (Bartlett’s test of sphericity ¼ p < .001; Kaiser-
Meyer–Olkin test ¼ 0.98). Chi-square tests and t-tests
revealed that the PCA sample (n ¼ 390) was not socio-
demographically different from the CFA sam-
ple (n ¼ 385).
4 S. A. LEE
Table 1. Properties of the CAS items from the principal com-
ponents analysis.
# Anxiety Symptom LD h2
1 Dizziness 0.84 0.79
2 Sleep Disturbances 0.83 0.74
3 Tonic Immobility 0.82 0.74
4 Appetite Loss 0.82 0.75
5 Abdominal Distress 0.81 0.75
Note. #: Number; LD: Pattern/Structure coefficients of the first component;
h2: Extracted Communality Coefficients; M:
Standard Deviation.
Principal component analysis
Twenty coronavirus anxiety symptoms were subjected
to a PCA with Varimax rotation. The results identi-
fied a two-component structure, with the first compo-
nent accounting for 59.85% of total variance
explained. The five strongest loadings on the first
component were chosen for the CAS because they
well exceeded the criteria for psychometrically sound
items (see Table 1). Specifically, pattern/structure
coefficients ranged from 0.81 to 0.84, communality
coefficients ranged from 0.74 to 0.79, and cross-load-
ings ranged from 0.23 to 0.29. These symptoms assess
distinct, physiological reactions of fear and anxiety
related to the coronavirus and were highly reliable as
a cluster (a ¼ 0.93).
Confirmatory factor analyses
A CFA was run to test whether or not the five symp-
toms identified in the previous PCA cohered together
into a single, coronavirus anxiety construct. The
results supported the PCA findings (see Figure 1) by
demonstrating that the single-factor model [v2
(5) ¼ 2.68, p ¼ 0.75] yielded excellent fit for all of indi-
ces [v2/df ratio ¼ 0.54; CFI ¼ 1.00; TLI ¼ 1.00;
SRMR ¼ 0.01; RMSEA ¼ 0.00 (0.00, 0.05; 90% CI)]
and was also highly reliable (a ¼ 0.93). Multigroup
CFAs were run to examine if the coronavirus anxiety
construct was being measured the same way across
the demographic variables of age (18–29 vs 30 and
older), gender (women vs men), and race (Whites vs
non-Whites). The results demonstrated no gender dif-
ferences, which were evidenced by excellent model fit
[v2(10) ¼ 11.80, p ¼ 0.30] for all of the indices [v2/df
ratio ¼ 1.18; CFI ¼ 1.00; TLI ¼ 1.00; SRMR ¼ 0.02;
RMSEA ¼ 0.02 (.00,.06; 90% CI)] and a non-signifi-
cant increase in v2 value [Dv2 (5) ¼ 4.93, p ¼ 0.42, ns]
between the models.
The results of the multiple group CFA also demon-
strated no age differences, which were evidenced by
excellent model fit [v2(10) ¼ 10.77, p ¼ 0.38] for all of
the indices [v2/df ratio ¼ 1.08; CFI ¼ 1.00; TLI ¼ 1.00;
M SD
1.72 1.36
1.81 1.20
1.62 1.28
1.69 1.32
1.78 1.38
Mean; SD:
Figure 1. Single-factor CFA model. Note. Model based on
Bootstrap Maximum Likelihood (ML) estimations (2000 sam-
ples). All of the standardized coefficients are significant at the
0.05 level. Dizzy: dizziness; Sleep: sleep disturbance; Froze:
tonic immobility; Eat: appetite loss; Stomach: nausea or
abdominal distress.
SRMR ¼ 0.02; RMSEA ¼ 0.01 (.00, .06; 90% CI)] and a
non-significant increase in v2 value [Dv2 (5) ¼ 8.56,
p ¼ 0.13, ns] between the models. The results for race
differences, however, demonstrated some nuanced
findings. Although model fit [v2(10) ¼ 5.96, p ¼ 0.82]
were excellent across all of the global fit indices [v2/df
ratio ¼ 0.57; CFI ¼ 1.00; TLI ¼ 1.00; SRMR ¼ 0.00;
RMSEA ¼ 0.00 (.00,.03; 90% CI)], there was a signifi-
cant increase in v2 value [Dv2 (5) ¼ 12.8, p ¼ 0.03]
between the models, indicating a difference between
race groups. Analysis of the parameter estimates
revealed that sleep disturbances (0.84 vs 0.77) and
appetite changes (0.87 vs. 0.77) were much stronger
indicators of the coronavirus anxiety construct for
Whites than for the non-Whites. Although the
strength of these two indicators were different
between the races, the measurement of coronavirus
anxiety was still valid for both groups.
Analysis of variance and correlation analyses
CAS total scores were correlated with measures of dis-
ability, distress, and coping, to examine the validity of
the construct and explore its relationship with relevant
attitudes and demographic factors (see Table 2). CAS
scores were strongly, positively correlated with
 DEATH STUDIES 5

Table 2. Zero-order correlations.

Variables CAS
Age 0.32
Gender 0.06
Race (Whites) 0.21
Race (Blacks) 0.08
Race (Hispanics) 0.03
Race (Asians) 0.25
Race (Other) 0.07
Education 0.30
Coronavirus 0.30
Anxiety 0.03
Impairment 0.86
Alcohol 0.80
Religious 0.78
Hopelessness 0.75
Suicidal 0.79
Trump 0.47
Chinese 0.26
Plans 0.07
Note. N: 775; CAS: Coronavirus Anxiety Scale total
score; Gender: (0 ¼ male; 1 ¼ female); Race:
(0 ¼ non-race group; 1 ¼ race group); Education
(0 ¼ Less than a Bachelor’s degree; 1: Bachelor’s
degree and higher); Coronavirus: (0 ¼ not diag-
nosed with coronavirus; 1: diagnosed with cor-
onavirus); Anxiety (0 ¼ no history of anxiety; Figure 2. Area under the ROC curve. Note. AUC: 0.94, p < .001
1: history of anxiety); Impairment: WSAS score;
Alcohol: alcohol or drug coping; Religious: nega-
tive religious coping; Hopelessness: extreme
hopelessness; Suicidal: passive suicidal ideation; Receiver operating characteristic analyses
Trump: satisfaction with President Trump’s
responses; Chinese: likelihood of avoiding Receiver operating characteristic (ROC) analyses
Chinese food/products; Plans: likelihood of chang- were used to evaluate the diagnostic viability of the
ing future plans (e.g., vacation). p < .05.
p < .01. p < .001. CAS as a mental health screening tool, as well as
determine a cut score that best distinguishes indi-
viduals who experience clinically significant impair-
ment because of coronavirus anxiety (individuals
functional impairment, alcohol or drug coping, nega- who scored >20 on the WSAS) from those who
tive religious coping, extreme hopelessness, and pas- were also anxious but not disabled by the pandemic.
sive suicidal ideation, in support of this instrument’s The ROC graph displayed the convex pattern that is
construct validity as a measure of dysfunctional anx- indicative of good discrimination ability (see Figure
iety. Crucially, and as expected, higher scores were 2), while the area under the curve (AUC) demon-
strated solid diagnostic accuracy for the CAS
associated with diagnosis of COVID-19.
(AUC ¼ 0.94, p < .001). A CAS score
9 optimally
An analysis of variance (ANOVA) showed that
classified adults as having (90% sensitivity) or not
there were some race differences in CAS scores,
having (85% specificity) dysfunctional levels of anx-
F(4,770) ¼ 14.88, p < .001. Post hoc analyses using the
iety (Youden’s index of 75) with a false positive
Scheffe criterion for significance indicated that Asians
rate of 15%. Thus, these results support the CAS as
(M ¼ 10.39; SD ¼ 5.39) had significantly higher CAS
a diagnostically accurate mental health screening
score than Whites (M ¼ 7.38; SD ¼ 5.76) and Blacks
tool with strong classification features.
(M ¼ 6.79; SD ¼ 4.37). No other race differences were
found in CAS scores. Correlation analysis showed that
younger adults and people with higher education Discussion
reported higher CAS scores than their counterparts. The purpose of this study was to develop and evaluate
In terms of social attitudes, CAS scores were also the properties of a brief mental health screener that
positively correlated with approval of President health professionals and researchers can readily use to
Trump’s responses to the coronavirus outbreak and identify probable cases of dysfunctional anxiety associ-
likelihood of avoiding Chinese food and products in ated with the coronavirus (see Table 3). The CAS is
the future. There were no relationships found between the first published measure of COVID-19 related psy-
CAS scores and gender, history of anxiety, and likeli- chopathology validated on a large sample of adults
hood of changing future plans. who reported significant anxiety in the beginning
 6 S. A. LEE

stages of the coronavirus pandemic including a signifi-

Note. CAS: Coronavirus Anxiety Scale. The CAS is placed in the public domain to encourage its use in clinical assessment and research. No formal permission is therefore required for its reproduction and use by
cant sample of people infected with the disease.
over the last 2 weeks
Nearly every day
Principal component and factor analyses were used to

______ þ
identify psychometrically sound items for the CAS,
4

4
which was shown to be a highly reliable (a ¼ 0.93),
thematically consistent (i.e., distressing physical symp-

Total Score ________

toms associated with coronavirus fear and anxiety),
and stable (i.e., CFA confirmed PCA results) instru-
ment. Moreover, the CAS was shown to measure anx-
More than 7 days

______ þ
iety symptoms in similar ways across demographic
groups, with the minor exception that two items were
3

slightly more indicative of dysfunctional anxiety for

Whites than non-Whites.
The results of this study also support the CAS as a
Several days

______ þ

useful mental health screener, as its diagnostic qual-

2

ities (90% sensitivity and 85% specificity) are compar-

able to other psychiatric screening tests. For instance,
the sensitivity (89%) and specificity (82%) values for
Rare, less than a day or two

the Generalized Anxiety Disorder 7 (GAD-7), a popu-

lar measure of anxiety disorder symptoms, are slightly
______ þ

below those of the CAS (Spitzer et al., 2006).

1

Relatedly, the sensitivity (73%) and specificity (74%)

values for the State Trait Inventory for Cognitive and
Somatic Anxiety (STICSA), another measure of anx-
iety, also fall below those of the CAS (van Dam et al.,
______ þ
Not at all

2013). In terms of a general psychiatric screener, the

0

sensitivity (77%) and specificity (71%) values for the

General Health Questionnaire (GHQ), a measure
extensively used in primary care research to assess
thought about or was exposed to information about
I felt paralyzed or frozen when I thought about or was

I lost interest in eating when I thought about or was

depression, anxiety, somatic concomitants, and social

I had trouble falling or staying asleep because I was

exposed to information about the coronavirus.

exposed to information about the coronavirus.

I felt nauseous or had stomach problems when I

impairment, also fall below those of the CAS

I felt dizzy, lightheaded, or faint, when I read or

(Weinstein et al., 1989).

listened to news about the coronavirus.

The content validity of the CAS was also demon-

How often have you experienced the following activities over the last 2 weeks?

strated by the items, which each represent physio-

thinking about the coronavirus.

logical arousal symptoms associated with clinically

CAS

elevated fear and anxiety (APA, 2013; Barlow, 1991;

Cosmides & Tooby, 2000; Ekman, 2003; Ohman,
2000). For instance, dizziness, which is the first item
the coronavirus.

others, beyond appropriate citation of the present article.

of the CAS, is a major symptom of panic attacks and

Column Totals

an associated feature of generalized anxiety disorder

(APA, 2013). Sleep disturbance, which is the second
Table 3. Brief mental health screener.

item of the CAS, is a common symptom of both gen-

eralized anxiety disorder and post-traumatic stress dis-
order (APA, 2013). Tonic immobility, which is the
third item of the CAS, is not a major symptom of any
psychiatric condition. However, motor inhibition is an
involuntary response to extreme fear and perception
of inescapability (Marx et al., 2008) and is typically
experienced by victims of highly traumatic situations,
such as sexual assault (Moller et al., 2017).
Appetite loss, which is the fourth item of the CAS,
is a common symptom of major depressive disorder, a
1.

2.

3.

4.

5.

condition that often co-occurs with panic disorder
(APA, 2013). Appetite loss is also a noticeable sign of
fear because it reflects the biological process of blood
leaving the digestive tract into areas of the body that
mobilize the person to deal with imminent threat
(Cosmides & Tooby, 2000). Nausea or abdominal dis-
tress, which is the last item of the CAS, also captures
the digestive changes associated with a fear response
(Cosmides & Tooby, 2000). Similar to dizziness, nau-
sea and abdominal distress are also major symptoms
of panic attacks and are associated features of general-
ized anxiety disorder (APA, 2013).
Although the CAS items center on anxiety and
trauma related reactions, the fact that they are also
exclusively focused on distressing bodily symptoms,
make them highly relevant to somatic symptom and
related disorders (e.g., illness anxiety disorder), as well
(APA, 2013). This is an important quality of the CAS,
because many people who are not infected, but believe
that they are infected with coronavirus due to the
effects of mass hysteria, will seek unnecessary medical
evaluations and care (Balaratnasingam & Janca, 2006).
Using mental health screeners, like the CAS, to iden-
tify and treat these people with appropriate mental
health services before they overwhelm emergency
response and medical facilities, is an important step
toward combating the COVID-19 pandemic.
The correlations between the CAS scores and rele-
vant measures of disability, distress, and coping, sup-
port the construct validity of the instrument.
Specifically, CAS scores were strongly, positively asso-
ciated with functional impairment, alcohol or drug
coping, negative religious coping, extreme hopeless-
ness, and passive suicidal ideation. Because these
results demonstrate clinically significant disturbances
across psychological, interpersonal, and behavioral
processes that are attributed to coronavirus related
fear and anxiety, the CAS appears suitable for mental
health evaluation. In fact, the finding that those with
a positive COVID-19 diagnosis reported significantly
elevated levels of coronavirus anxiety compared to
their non-infected, but anxious peers, further highlight
the clinical utility of the CAS and the importance of
assessing and treating the psychological needs of those
infected with the virus (Xiang et al., 2020). If some
expert opinions are correct, then that would mean
that up to 70% of the world’s population could poten-
tially need both medical and psychological care with
their COVID-19 infections (Axelrod, 2020).
The results of this study also revealed significant
sociodemographic differences in CAS scores. For
instance, Asians were the only group that
DEATH STUDIES 7
demonstrated elevated CAS scores relative to Whites
and Blacks. Although speculative, this elevated anxiety
may be due to many of the Asians in the study having
close communications with people (e.g., family mem-
bers) in China and the surrounding countries where
the virus has had a devastating effect. The correlations
also showed that younger age and higher education
levels were associated with higher coronavirus anxiety.
Although the reasons for these particular differences
are not known, and systematic research on this topic
is sparse, additional investigations into this area are
clearly warranted.
Coronavirus anxiety was also found to significantly
influence social attitudes. For instance, the positive
correlation between coronavirus anxiety and approval
of President Trump’s responses to the coronavirus
outbreak, was consistent with the results of a related
study that showed that anxiety related to a mass
shootings event was associated with increased
approval of President Trump (Joslyn & Haider-
Markel, 2018). These findings confirm what the social
and political psychologists call the “conservative
shifts” phenomenon, where existential fear tends to
move people toward supporting political conservatism
and conservative leadership (Jost et al., 2017). The
positive correlation between coronavirus anxiety and
avoidance of Chinese food and products also followed
longstanding xenophobic attitudes that associate the
Chinese with infectious diseases. For instance, during
the 2003 SARS outbreak, many people avoided close
contact with people of Chinese descent for fear that
could catch the “Chinese disease” (Keil & Ali, 2006).
This research has a couple of limitations worth not-
ing. First, the use of single-item scales could have
reduced the complexity and validity of the psycho-
logical, attitudinal, and coping constructs measured in
this study. Although single-item scales are efficient
and can yield comparable psychometric qualities as
multi-item instruments (Bergkvist & Rossiter, 2007),
future research should nonetheless reproduce this
study using multi-item measures. Second, the results
of this study may be an underestimate of the psycho-
logical impact of the COVID-19 pandemic because
the data were collected in the U.S. during the begin-
ning stages of the crisis, before Americans experienced
massive school and work closures. Future research
should implement longitudinal and multisite designs
to track the psychological effects of the pandemic cri-
sis through its course and impact in different regions
of the world. Notwithstanding these limitations, this
study reports essential data regarding the psycho-
logical effects of COVID-19 and provides health
8 S. A. LEE
professionals and researchers a brief mental health
screener to aid their efforts to fight this global
health crisis.
Disclosure statement
No potential conflict of interest was reported by
the author(s).
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