Anxiety and Depression in COVID-19 Times

*Hamilton Lima Wagner*

#### **Abstract**

The millennial generation has been known as the most anxious and depressed one, due to lack of more physical attachment. During these COVID-19 times, these problem had been widened for everyone - many had been panic about the illness, the media had played an awful hole on it, creating a scenario of huge risk for lives and jobs. We are facing a perfect storm, where we are not allowed to do most of the recreation and healthie programs - like visit the ones beloved, go to gym, go to a party. The use of internet have a lot of misinformation about the pandemic and even physicians, scientists and health politicians overload us with useless information. It was really hard to identify what was important. In this situation, dealing with uncertainty, anxiety and depression had created a huge problem for physicians and psychologists. How to help and support that. There are many strategies that we have used. First to diminish the search of information over COVID-19, selecting one trustable source. Second, contact your beloved ones, if possible with video call on an everyday basis. Third, develop a routine of physical activities in order to keep your body health. Fourth try to develop a health pattern of food. Together they can diminish the chance of having anxiety and depression. But if you need support for a professional, it's important to have teams of professional available to give attention to that issues. The very first is a phone support or internet support, by teams that could discuss the problems and develop a personal strategy to deal with this situation. But when that is not enough, we must have a consultation with a physician or a psychologist. The approach must discuss fillings, worries and how to plan this isolation times. Most of us have a hidden agenda and fear that must be addressed and at this time it is important to allow the patients to talk about freely, and to develop empathy with their worries. After that we can promote some activities to diminish the fillings of anxiety and depression.

**Keywords:** anxiety, depression, COVID-19, therapy

#### **1. Introduction**

Much is said about the epidemic of mental problems due to the pandemic caused by COVID19, particularly anxiety and depression. People have difficulties in dealing with confinement and more than that, facing excessive information - usually causing fear and panic. The scenario completes the fact that a very large number of families lost family members and acquaintances as a result of the complications of COVID19 [1–6].

But beyond all that, the world population, in particular the western one, has experienced a radical change in living conditions, life expectancy, mobility and

access to information without precedent. For those who did not make this reflection, in the year 1900 - that is 121 years ago - there were no radio broadcasts, the telephone was a novelty and rare people had access. The automobile was being invented and there was no aviation. More than 90% of the western population knew nothing more than 10 km from their place of birth. And the vast majority were illiterate, unable to read simple texts or understand the context in which they were inserted.

Over these 121 years, the exchange of information has become increasingly accelerated and people have come to consider formal education an essential need and today it is mandatory in most of the western world. But this is not linear and even in developed countries there are many people who have difficulty interpreting texts and information, dealing with divergent information and knowing how to separate it by assessing what is relevant is even more complex. All of this is already a powerful stressor, generating feelings of inadequacy and difficulties in adapting.

With the emergence of the pandemic, the first movement was one of denial both by governments and the population. But the bill came heavy, Italy, Spain, France, Belgium and England had an explosion of cases in the beginning of 2020, with many deaths and an inability of the health sector to offer an adequate response - not to mention the mortality of health professionals, generating more care deficit.

This, plus the action of the media, which dedicated a huge portion of its programming to address the issue, generating stories that scare and misinform more than anything else. First, doctors and scientists had no appropriate answers to offer, and speculation only served to increase anxiety. Secondly, the lack of consensus on the best attitudes to be taken and what response should be given has generated a complex and certainly inconclusive debate, as there was no experience and scientific knowledge to support the decisions [7].

#### **2. Anxiety**

By definition, anxiety is the suffering caused by the anticipation that something will happen and people suffer from it, losing sleep, being afraid to perform tasks or being exposed to situations that would be part of their lives.

DSM-5 [8] defines it according to the following criteria:

	- 1.Excessive and recurring discomfort when a separation from home or the closest figures is anticipated or experienced.
	- 2.Excessive and persistent preoccupation with the possible loss of the most attached figures or who may suffer possible damage, such as illness, injury, calamity or death.
	- 3.Persistent and excessive concern about the possibility that an adverse event (for example, getting lost, being abducted, having an accident, getting sick) will cause the separation of a highly attached figure.
	- 4.Persistent resistance or refusal to leave the house, go to school, work or elsewhere for fear of separation.

At a time when there was persistent talk about the death of many people, the possibility of contagion and the need for social isolation, it is easy to imagine that anxiety symptoms become common, and people who are prone to develop pathological symptoms related to this feeling.

## **3. Depression**

It is a defense mechanism of the brain that, losing the perspectives of an organized and structured life, descends to the depths of its interior, leading individuals to close themselves in their inner worlds, not always with pleasant memories and experiences. This can lead to isolation and feelings of worthlessness, with ideation of death. But the process is usually self-limiting, tending to spontaneous recovery in a period of 6 to 12 months.

DSM-5 [8] defines it according to the following criteria:

A. "Five (or more) of the following symptoms were present during the same twoweek period and represent a change from previous functioning; at least one of the symptoms is (1) depressed mood or (2) loss of interest or pleasure.

Note: Do not include symptoms that can be clearly attributed to another medical condition.

1.Depressed mood most of the day, almost every day, depending on whether you get subjective information (eg, you feel sad, empty, hopeless) or other people's observation (eg., it is observed weeping). (Note: in children and adolescents, the mood can be irritable.)


Note: criteria A - C constitute an episode of major depression.

Note: Responses to significant loss (eg, grief, financial ruin, losses due to a natural disaster, serious illness or disability) can include feelings of intense sadness, rumination about loss, insomnia, loss of appetite and weight loss listed in Criterion A, and can simulate a depressive episode. Although these symptoms may be understandable or considered appropriate for the loss, the presence of a major depressive episode, in addition to the normal response to significant loss, should also be considered carefully. This decision inevitably requires clinical judgment based on the individual's history and cultural norms for the expression of distress in the context of loss.


Note: This exclusion does not apply if all episodes of the manic or hypomanic type are substance-induced or can be attributed to the physiological effects of another medical condition."

The feelings triggered by the orientation to isolate oneself, to move away from loved ones and especially the loss of love and acquaintances to COVID19 can lead to feelings very close to the situation described as depression. Not to mention the modern language, which calls all sadness a depressive episode or depressed mood.

#### **4. Reflecting on the functioning of our brain**

The human brain is apparently redundant, as it has one side focused on logic and the control of volitional functions, but the other side of the brain works by understanding contexts and is based on feelings and emotions - which the logical side usually cannot explain. This concept, developed by Watzlawick [9], helps to understand people's difficulties in controlling their feelings and why complex contexts, such as the one experienced during the COVID pandemic19, generate responses of suffering and anguish, sometimes leading to the emergence of pathologies.

The rapid changes in the way of living, which have occurred over these years, alone have already caused adaptive disturbances. This led to changes in family structures, with greater absences from adults - necessitating the development of work activities to support families. This led the elderly or institutions to take care of the education and training of children and adolescents - without them having a parental presence. Add to that the revolution caused by the mass media and more recently by access to the internet.

Social models were diluted and behaviors became more related to external models, living and acting in different contexts. This creates a complex stress context that is difficult to interpret by people and families, and the systemic context approach [10] is central to understanding adaptation difficulties.

Considering the model proposed by Grassano [11] it is from adults that one learns to be a person, to survive in the world, it is from this primary coexistence that the individual develops and he learns to relate to his surroundings and to have stable social relationships and balanced. The loss of this benchmark generates insecurities that are profound and are often not easily understood by people.

The lack of understanding of feelings and emotions - explored by Watzlawick [9] - makes personal, family and peer conflicts difficult and is often not even properly perceived. And this without the presence of the pandemic.

With the advent of it, the situation of anguish with the illness and death of acquaintances, friends and relatives, people seek internal support to deal with the pressures. But what if these are not solid? How to face loneliness and isolation, especially if you do not know how to deal with your own emotions? What strategy to develop to deal with the fear of falling ill, of losing loved ones, the fear of losing your job or business?

Abruptly, the pandemic created the need to look within oneself, to reflect on the choices and possibilities. For many, this rethinking in life is healthy and opens up horizons to seek more suitable paths to dreams and perspectives, but for people who cannot be just with themselves, this is frightening.

For them, living depends on third parties, and the absence - either by distance or by illness or death - is traumatic. It causes suffering and insecurity that can lead to the development of mental illness.

In a very digital world, like the current one, relationships and experiences are often fictitious - people play games to get in touch, post their presence in places they do not know and talk to strangers about their own or third party fantasies. This world turns out to be a house of cards, and the pandemic makes isolation and fear bring the castle down.

#### **5. Dealing with information overload**

The first step, which is fundamental to controlling feelings of insecurity, anxiety and depression, is to reduce the consumption of information. As much as possible using the most reliable and the minimum necessary to orient yourself.

The massacre of the media when talking all the time about the spread of the pandemic, about the numbers of serious cases and deaths, only increases the panic. It does not guide or allow the stabilization of people in the search for suitable alternatives to move on with their lives.

The pandemic is complex due to its high transmissibility, although the rates of serious cases and deaths are not very high - as it has a very high volume of people, it ends up generating frightening numbers. This causes overload of health services and restriction of care. To increase the complexity, many health professionals fell ill and several died from the disease.

Today, more than a year after the onset of the condition in Wuhan - China (12/2019), there is still no adequate response and studies on different therapeutic approaches still do not indicate an appropriate treatment.

Even mass vaccination, a response proposed by the World Health Organization [12], generates insecurities - typical of the rush to develop immunizers quickly and without the necessary studies. This also generates the refusal of many to become immunized.

It is this conflict of information that the media exploits - often even with political overtones, supporting or discrediting government officials. The more people read this type of information, the more insecure they become and this makes the environment prone to suffering and anxiety. For this to evolve into mental suffering is a step.

The selection of less sensational sources is a necessary path, and the need to seek confirmation of data, avoiding the magnification that ends up occurring within social networks. And the people who take refuge in these networks, for not being able to deal with their moments of isolation, are victims of this unbridled exchange of dubious and alarming information.

Social networks deserve a separate paragraph. The quick access to the networks made the relations progressively more virtual, reaching absurdities of people in the same room exchanging messages over the networks instead of talking. This cooling of interpersonal relationships, generates the need to be accepted and supported by virtual friends - often unknown and in no way significant in real life. But these virtual contacts end up being artificial life and the cause of many to despair.

It is essential to search for real contacts, even if virtual - with real people who have meaning in people's lives. And this first strategy is necessary to maintain balance and mental health in a time of collective stress. Listening to people and dealing with real consolation when people close to them eventually fall ill or perish is essential for the emotional maintenance of the population.

People's credibility must be valued, and if there are people who are very anxious or who propagate dubious information, it is essential that this is worked on to keep the group of relatives and acquaintances stable and healthy. Seeking balanced and well-informed references helps to keep this under control.

Studies about how does emotions had been built show the complexity of paths, and that an answer flashes when it had been provoked, but when it starts, it is out of control [13].

#### **6. Anxiety and depression in times of pandemic**

The human being is gregarious, by definition, has difficulties in dealing with loneliness and needs to work on his self-knowledge to become more independent.

#### *Anxiety and Depression in COVID-19 Times DOI: http://dx.doi.org/10.5772/intechopen.98215*

But the accelerating changes of the past 120 years have slowed down many processes. It is more and more frequent to see adolescences extending to 30, and sometimes more. People are unable to become autonomous, living with their parents and not assuming their role as adults. They find it easier to live with their mothers who pamper them with favorite foods and taking care of their rooms and clothes as if they were still children.

This makes establishing mature relationships with peers and loves become difficult and at any difficulty people escape to their comfort areas, without learning to deal with the difficulties that life presents, or even accepting that relationships with other people go through sharing feelings and difficulties and giving in is essential for harmony to be developed.

In the present situation, in which the pandemic generates many uncertainties, this adolescent attitude - in which the consequences of the actions taken are not foreseen, in which the comfort of protectors who welcome fears and insecurities is sought, it is very easy to develop symptoms.

Developing autonomy is fundamental and the approach to people who show symptoms must start by understanding the stage of personal development that the person presents, their surroundings - including family and personal contacts. According to Sluzki [14] realize how is the people's social network, its functionality and balance helps to perceive the resistance to the aggressions that the environment offers. The work of strengthening connections and expanding networks helps to maintain health, and is essential to reinforce the emotional balance of people who have symptoms.

Encouraging conversation about signifiers - identifying weaknesses, such as virtual contacts with people who are physically unknown or very distant, favors the person to identify their needs and seek a more balanced network. Within the conditions caused by the pandemic, it is essential to recognize that very fragile networks will have difficulties to be expanded, but even so, the recognition of the weaknesses and the work for this to become a goal, makes life more concrete and reduces the risk of becoming ill.

Personal development failures, resulting from the absence of more significant people during childhood and the weaknesses in structuring concrete and healthy connections are one of the essential difficulties to be faced. But as the problem recognition block exists, being inherent to the emotional side, a conversation is essential in which these factors are explored.

Watzlawick [9] presents us with the difficulties to access deep areas of the emotional side and how people react, denying problems and difficulties. How to explore this is the key to care without the use of drug therapy, which can hinder a more adequate solution - making people dependent on drugs or feeling unable to face the problems that life presents.

Using a protocol developed by Schutz [15] and adapted by Doherty and Colangelo [16] for health interventions, it is possible to explore the forms of communication between people, how they perceive themselves within their different groups and how this defines the way of interacting.

Exploring how the person perceives his communication, how much he perceives himself heard and understood opens the door to the emotional side. By adding questions about how central (or not) the person perceives herself in her own life, it allows deep feelings to spring up. Within this context, the social network is being explored, and the reinforcement for understanding their own uncertainties and difficulties for true relationships. The flaws in the construction of personality, consequence of the lack of models, become apparent, making a more curative and constructive approach possible.

It is from these keys that it is possible to reduce the feelings of fear, anxiety and worthlessness, which are often characterized by the pathologies described as anxiety and depression.

Once the difficulties are identified, it is necessary to reframe the difficulties so that the potential and competences are perceived. Strengthening resilience and helping to improve symptoms.

#### **7. Conclusion**

Working in a time of extreme pressure, either due to the volume of cases and mortality associated with them, or due to pressure from the media and the population itself, frightened by the proportions of the situation, is not an easy task.

The search for viable alternatives to support the stress situations generated requires creativity and the ability to find collective and applicable solutions - as much as possible - via mass communication or in group activities. Seeking to guide the population on the different ways to better deal with social isolation, with care to avoid contamination of their own - and of third parties, in addition to stimulating the search for alternatives to obtain the most efficient and soonest possible immunization.

But when the need for individualized care arises - it is central to seek a holistic approach, using a systemic approach and deepening the study of the emotional side of patients - in order to give transparency to the deep reasons for fears.

The reframing of skills and ways of dealing with past problems will offer the possibility to find appropriate responses to the present situation. That will allow an ethical answer, respecting the history of the individual and strengthen their on capacity to face challenges.

#### **Author details**

Hamilton Lima Wagner

Residency in Family and Community Program of Curituba, Health System Preceptor, Curitiba, Brazil

\*Address all correspondence to: hamilton.wagner@me.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Anxiety and Depression in COVID-19 Times DOI: http://dx.doi.org/10.5772/intechopen.98215*

#### **References**

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[2] CULLEN, W.; GULATI, G.; KELLY, B. D. Menthal health in the COVID-19 pandemic. Internal Journal of medicine. 2020. 311-312.

[3] LAI, J. ET ALL. Factors associated with menthal health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open. March, 23, 2020.

[4] ORNELL, F. ET ALL. "Pandemic fear" and COVID-19: menthal health burden and strategies. Brazilian Journal of Psychiatry. 2020. May-Jun 42(3) 232-235.

[5] MORENA-PERAL, P. ET ALL. Use of a personalised depression intervention in primary care to prevent anxiety: a secondary study of a cluster randomised trial. British Journal of General Practice. February. 2021.

[6] PFEFFERBAUM, B.; NORTH, C. S. Menthal health and the COVID-19 pandemic. The New England Journal of Medicine. August, 6, 2020

[7] GIROLAMO, G. ET ALL. Menthal health in the coronavirus disease 2019 emergency - the Italian response. JAMA Psychiatry. September 2020. V 77, N9.

[8] AMERICAN PSYCHIATRIC ASSOCIATION. DSM-5. Washington. 2014.

[9] WATZLAWICK, PAUL. El lenguaje del cambio. Barcelona. Herder. 2012.

[10] WAGNER, H.L., WAGNER, A.B.P. e PINTO, M.L.O. Abordagem Familiar

Sistêmica. Curso do PSF. Fazenda Rio Grande. 1997.

[11] GRASSANO, S. ET ALL. Abordagem sistêmico integrativa. CD Rom – Chaim. Curitiba. 1996.

#### [12] WORLD HEALTH

ORGANIZATION. COVID-19 vaccine introduction and deployment costing tool (CVIC tool). https://www.who.int/ publications/i/item/who-2019-ncovvaccine\_deployment\_tool-2021.1

[13] PANKSEPP, J. (2008). The affective brain and core consciousness: How does neural activity generate emotional feelings? In M. Lewis, J. M. Haviland-Jones, & L. F. Barrett (Eds.), Handbook of emotions (p. 47-67). The Guilford Press.

[14] Sluzki, C. A rede social na prática sistêmica. São Paulo. Casa do Psicólogo. 1997.

[15] SCHUTZ, W. C. FIRO: A three dimensional theory of interpersonal behaviour. New York: Holt, Rinehart & Winston, 1958. Also reprinted as The interpersonal underworld. Palo Alto, CA: Science and Behaviour Books, 1966.

[16] Doherty, W. J. & Colangelo, N. The family FIRO model: Implications for conceptualizing family issues, assigning treatment priorities, and selecting suitable therapies. Paper presented at the Theory and Methods Workshop, American Association for Marriage and Family Therapy Annual Conference, Dallas, TX, October 1982.

#### **Chapter 15**

Adversity, Uncertainty and Elevated Symptoms of Obsessive Compulsive Disorder: A New Understanding through Resiliency and Positive Psychotherapy

*Sevgi Güney*

## **Abstract**

The content of thought, which emerges from the processing of information from the social context lived, is a critical factor that guides whether the behavior is psychopathological or not. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological processes. Adversity and uncertainty are the main factors that lead to the experience of worry, anxiety and fear which is the last point of these. Uncertainty of information from the social context lived, when matched with adversity, may lead to chaotic situations at the cognitive level, e.g., thought contents such as distortions in thought, severe anxiety and fear. Obsessive compulsive disorder derives from severe worry and anxiety. Although the disorder is classified under anxiety disorders, it is actually a thought distortion disorder. The individual finds himself repeating the strange behavior patterns accompanied by strange thought contents in order to get rid of the severe anxiety and accelerated thought cycle he is exposed to. Ambiguity and uncertainty also may lead to the accelerated thought cycle, ruminations, severe thought distortions, over-generalizations. Ruminations, especially, impair the individual's ability to think and process emotions gradually. Obsessive Compulsive Disorder will be discussed in terms of ambiguity and uncertainty with the combination of adversity. Positive Psychotherapy, which is one of the latest effective technique in recovery processes of the diseases, will be mentioned.

**Keywords:** Adversity, Uncertainty, Obsessive Compulsive Disorder, Positive Psychotherapy, Resiliency

## **1. Introduction**

The concept of mental health corresponds to the individual's ability to function satisfactorily in his intellectual, emotional and behavioral adjustment. Events experienced in the ongoing flow of daily life, when combined with certain conditions, negatively affect mental health and even physical health. As long as the conditions that cause these negative effects persist, the groundwork is prepared for the occurrence of mental health disorders. That's why there is a motto among

mental health professionals: "No mental health illness can occur overnight." This is a process. The content of thought, which emerges from the processing of information from the social context lived, is a critical factor that guides whether the behavior is psychopathological or not. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological processes. Adversity and uncertainty are the main factors that lead to the experience of worry, anxiety and fear which is the last point of these. Uncertainty of information from the social context lived, when matched with adversity, may lead to chaotic situations at the cognitive level, e.g., thought contents such as distortions in thought, severe anxiety and fear. When this process is not managed properly, the disorders may occur.

The World Health Organization (WHO) defines being healthy as follows: "… It is not only the absence of disability or illness, but also the state of all mental and social well-being" [1]. Dealing with mental health, the organization describes that mental health includes, as well as other things, subjective well-being, perceived self-efficacy, self-confidence, autonomy, competitiveness, intergenerational dependence, and the ability to realize own intellectual and emotional potential. The World Health Organization (WHO) also adds the following to the definition of mental health; "It also includes the individuals' well-being to realize their abilities, cope with daily stress, be productive and beneficial to the society". As can be understood from the definitions, mental health is a complex phenomena. Therefore mental health disorders are not occurred due to one factor. Multiple factors come together and reveal about the relevant mental health disorder. These factors are called as "risk factors". The risk factors can be discussed under three subheadings. These are biological, psychological and social factors. These factors shortly explained as follows;

*Biological factors* contain problems during birth or pregnancy period, someone in the family has a mental illness, suffering from traumatic brain injury, having chronic medical physical disease such as cancer, diabetes, Alzheimer's etc., eating problems, alcohol abuse and/or drug use.

*Psychological factors* covers negative self-perceptions and experiences in the past and present. For example low self-esteem, perceived incompetence, negative perspective of World, traumatic life experiences such as serving in the armed forces, suffering from long term financial problems, physical/sexual abuses etc.

*Social factors* include poor communication and social skills, suffering from discrimination, experienced adverse events, suffering from long term adversity, having an abusive relationship, suffering from bullying, being abused or neglected as a child, prolonged mourning, lack of social support resources etc.

Having all these or some of the risk factors do not necessarily mean being exposed to a mental disorder indeed. However the combination of these risk factors and difficult life events/conditions may somehow create a predisposing ground for mental disorder in some individuals.

#### **2. Adversity**

Adversity may lead to lots of short and long-term psychological problems. It may compromise functioning of the nervous system and even immune system. The more adverse experiences in everyday life routine, the greater the likelihood of mental health problems.

Adversity has a critical influence on especially anxiety related disorders such as obsessive compulsive disorder (OCD), adjustment disorder, post traumatic stress disorder (PTSD), phobic disorders, panic disorder, and somatoform disorders.

*Adversity, Uncertainty and Elevated Symptoms of Obsessive Compulsive Disorder… DOI: http://dx.doi.org/10.5772/intechopen.98304*

The somatoform disorders correspond to the symptoms being ambiguous, in other words it means that no physical cause that could explain the current discomfort was found as a result of the medical examination. From the definition, it is also directly related to uncertainty too. Moreover there is an interactive relation between adversity and worry especially during uncertain times and under pressure. Weinberg [2] pointed out two components of anxiety; 1. Cognitive anxiety, 2. Somatic anxiety. He defined cognitive anxiety as "a mental component of anxiety during worry, and apprehension." As known cognitive component of anxiety deals with the thought content in feeling pressure and threatening during adverse and uncertain situations. Naman [3] stated that worry and rumination are transdiagnostic and both worry and rumination are include in DSM 5 under the three disorder categories. These are OCD, PTSD and GAD. While stating that OCD is a though disturbance, she also mentioned that "OCD is a disorder including recurrent and persistent thoughts, urges or images being experienced at some time during disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety". She added that "in order to relieve distress from intrusive and repetitive worries, individuals engage in compulsions. Rumination is a common type of compulsion." It is well known that thought disturbance is triggered by adverse and uncertain conditions.

Psychosocial adversity is taken into account as life-influencing happening that may be concluded obsessive thoughts and compulsions.

#### **2.1 Resiliency after experiencing adversity**

There are many theories that go beyond the classical theories of mental health. One and most effective of them is Positive Psychology. Number of studies throughout human mental health have demonstrated that there is an interconnected and mutually reinforcing gain/achievement to be found in suffering during last two decades. It is also known by mental health professionals positive gains can come about as a result of suffering [4–8].

Resiliency is defined as the individual's ability to cope with adversity and uncertainty. In other words, resiliency deals with a successful adaptation to highly adverse conditions, and situations. Resilient individual is able to bounce back from adverse conditions with competent functioning. To be resilient is not an unusual capacity or ability. Every individual, by the way, have this ability as there is a tendency to handle with the adverse conditions. It is a kind of process rather than a characteristic to be had. A resilient individual develop healthy coping strategies allowing him to effectively deal with the adverse conditions. There is a critical key in the thinking atmosphere of a resilient individual, this is creating a balance between adversity and positivity of the conditions. As everyone has already this ability, it is functional to let the individual to realize their resilient abilities. For this, positive psychologists have been identified the components that make the individual resilient [7]. Some of them are as follows;


According to positive psychologists, everyone has these characteristics. During therapy, it is aimed to raise awareness that they have them and to teach to use when they need all of these.

#### **3. Uncertainty**

Uncertainty is associated with the future and what happens. It is often experienced in the routine of everyday life. It causes fundamental restrictions on the behavior of the individual, whatever the decision is, regardless of his observation, in daily life. Lack of sufficient clues about any observed situation may cause worry, anxiety and even fear about the situation or related situations. Uncertainty has three main components. These are respectively 1. A feeling in the individual that the situation cannot be controlled, 2. Feeling and worrying that there will be some negative consequences in the future, 3. Perceiving an imaginary experience or situation as a threat as if it were experienced.

Uncertainty, although, is not expressed as a cause for anxiety according to Quantum physics, it also has a tendency to create a serious problem in the process of human behavior. How can uncertainty, which is in the usual routine of life, act as a factor that negatively affects human life? Human being strives to minimize uncertainty in the face of life events. For this, assumptions are put forward, and tested. Individuals' perceptions of what happened may differ according to their preferences, lifestyle, and even educational status. On the other hand, the perceptions about what should be, in other words, the perceptions about the value system can appear as a life order with more certain and defined it's border, far from uncertainty. The differentiation between values, that is, what should be and the life routine, that is, what happens, directly corresponds to the need for change. If the individual tries to survive through a resistant personality structure to change, uncertainty may lead to severe psychopathological situations. Under the resistant structure, an interactive process takes place in every social situation where there are many layers and many actors in these layers. Which decision is taken for whom for what and why is passed through the reasoning filter of the mind and the situation is tried to be made certain. In order to avoid uncertainty, participatory, fair and open ways of coping where the opinions of others are included and are applied. Under the imperceptible circumstances, uncertainty clues are percept and this may elevate the tendency of control the process. Today it has been demonstrated when the dynamics in the social situation are imperceptible, and therefore not mobilized, the tendency to control processes is increased [9–12].

There is a term for explaining why some people much more effected in uncertain situation; "Uncertainty Paralysis". It is defined as "Uncertainty Paralysis represents a sense of being stuck and unable to respond effectively when faced with uncertainty, resulting in a paralysis of cognition and action" [13]. However intolerance of uncertainty plays a major role in the formation of psychopathology especially anxiety and mood disorders. Many studies have demonstrated intolerance of uncertainty, worry and emotional regulation process [14–17]. It is described "tendency of a person to consider the possibility of a negative event occurring as unacceptable and threatening irrespective of the probability of its occurrence" [18]. Intolerance of Uncertainty (IU) have been taken into account a vulnerability factor for OCD.

#### **4. Obsessive compulsive disorder as a way of coping with adversity and uncertainty**

As in all mental disorders, the roots of obsessive – compulsive disorder come from the risk factors such as biological, psychological and social factors for mental health. The interaction of these factors may lead to suffering from the disorder. Although the disorder is classified under the anxiety disorders, the main component is on the thinking and perception style. The content of thought, which emerges from the processing of information from the social context lived, is a critical factor. In cases where worry, anxiety and fear are dominant in the content of thought, the individual may find himself in some psychopathological thinking style processes. Obsessive–compulsive disorder (OCD) derives from severe worry and anxiety. Within the atmosphere of the severe anxiety, the individual finds himself repeating the strange behavior patterns accompanied by strange thought contents in order to get rid of the severe anxiety and accelerated thought cycle he is exposed to. In this point it is a thought disturbance disorder. In the disorder, compulsions, that's why, is so resistant to stop as they are automatic response in the habitual way that are easy to perform them without thinking. For every rehearsal, the individual can avoid the anxious thoughts content. In all cases, the triggering stimuli is uncertainty, adversity and the resistance to change. Today it is well known that OCD symptoms may worsen in the times of severe adversity conditions and uncertainty.

Ruminations are another thought distortion problem. The individual thinks about the same thoughts which tend to be in two-ended, good or bad, sad and dark. This thinking circle goes on and on avoiding the tension from anxious thought content. In the content of OCD thinking style, ruminations become a kind of habitations. The individual cannot stop himself, this process, unfortunately impair the healthy thinking ability and emotions. They leads to isolation as the individual push his social environment away. The isolation also may cause gradually intensive depression. Which factors cause ruminating? Personality traits, perfectionism, low self-esteem, difficulty in expressing emotions and self, excessive focus on one's relationships with others, encountering ongoing stressors either from uncertainty and the conditions cannot be controlled, over generalized thinking style, ineffective and/or maladaptive coping style, poor social skills and so on.

Why the individual has difficulty in stopping obsessions and compulsions? The answer is on the road of adversity and uncertainty dichotomy. The main characteristic of Obsessive Compulsive Disorder is trying to make situations certain. This effort is the result of the controlling thought content. As the individual cannot bear uncertainty, he produces symptoms to reduce the anxiety caused by uncertainty. As will be remembered, one of the common thought contents in Obsessive Compulsive disorder is resistance to uncertainty, innovation and change. This resistance develops with the belief that the individual is attributing these situations potentially dangerous. Uncertainty sometimes feeds ambiguity. In situations perceived both uncertain and ambiguous, the individual experiences discomfort, tension, worry and reacts in the form of rigidity, anxiety and avoidance behaviors as he cannot stop the obsessive thoughts from running through his mind. There are number of research studies related to causal role of uncertainty [14, 15, 18]. They have studied the causal role of intolerance to uncertainty. For example Gentes and Ruscio [15] found that higher anxiety level may come from the intolerance of uncertainty. Dugas et al. [14] describes the term of intolerance to uncertainty as the "individual's dispositional incapacity to endure the aversive response triggered by the perceived absence of salient, key, or sufficient information and sustained by the associated perception of uncertainty". They found intolerance of uncertainty was related to obsessions/compulsions in nonclinical sample. Further the

relationship between intolerance and worry statistically significant with combined adversity. Fergus and Wu [18] have examined the intolerance of uncertainty and the symptoms of Obsessive Compulsive Disorder (OCD) and the related cognitive process such as threat estimation, perfectionism, desire to certainty, and the control thoughts. They found that the only intolerance of uncertainty was the cognitive component predicting the unique variance in OCD symptoms. Fourtounas and Thomas [13] examined two hypothesis; 1. The prospective intolerance of uncertainty (IU) was associated with checking behaviors 2. The inhibitory IU was associated with procrastination.

Childhood Trauma and the severity of the symptoms of OCD had been studied by Carpenter & Chung in 2011 [19]. They pointed out that a significant correlation between severity of OCD and intolerance of uncertainty. Boger et al. [20] reached the same results. However as in the all this kind of studies, their sample size is so small and the intermediate variables could not be controlled so the results of the studies are far from being scientific evidence. Longitudinal studies should be done.

#### **4.1 What can be done?**

There are number of ways to bear with uncertain situations and adversity. In uncertain situations, to stop ruminations,


*Adversity, Uncertainty and Elevated Symptoms of Obsessive Compulsive Disorder… DOI: http://dx.doi.org/10.5772/intechopen.98304*


#### **5. Positive psychotherapy for elevated symptoms of obsessive compulsive disorder**

Group/individual therapies are systematic evidence-based improvement methods used in the rehabilitation process of social skill deficiencies or insufficiencies, impairments in thought content, and thus behavioral problems.

Positive group and/or individual therapies aim at uncovering five main components of self-actualization. These are in a nutshell trust, responsibility, selfawareness, adaptability, and sense of purpose. It is rooted on the strength-based approach explored by Chris Peterson [26], and primarily is based on Martin E.P. Seligman's [27] work on happiness and psychological well-being. He has formulated to be happy via PERMA which has scientifically measurable and teachable five components. The formulation of PERMA corresponds to (P) Positive emotion, (E) Engagement, (R) Relationships, (M) Meaning and (A) Accomplishment. Rashid [28, 29] explains that positive therapy consists of 14 sessions, the topic of each session and the strengths the session corresponds to. These 14 sessions are general components of Positive Psychotherapy (**Table 1**).


#### **Table 1.**

*The general components of positive psychotherapy (PPT).*

Throughout the sessions the individual realized his not only personal resources but also social ones. By discussing the each subject of the sessions, it is gained awareness on confidence, responsibility, emotional mastery, open to challenging beliefs and assumptions, able to manage adversity, and sense of purpose in their life. As working through on positive exercises during sessions, the individual cultivates positive emotions such as gratitude, and savoring. In contrast the negative thinking content and emotions which is the basement of ruminations were constricted.

#### **6. Conclusion**

Obsessive Compulsive Disorder (OCD) derives from severe worry and anxiety. Within the atmosphere of the severe anxiety, the individual finds himself repeating the strange behavior patterns accompanied by strange thought contents. At this point OCD is a thought disturbance disorder.

Stopping obsessions and compulsions is a serious problem in obsessive compulsive disorder. Worry and ruminations together may lead to obsessions as well known ruminations are a common type of compulsions. On the other hand worry is a cognitive process which is directly related to feeling anxiety coming from a threats and/or danger. In all cases, the triggering stimuli is uncertainty, adversity and the resistance to change. Today it is well known that OCD symptoms may worsen in the times of severe adversity conditions and uncertainty [31–33].

Positive psychotherapy directly helps to increase self-esteem, self-confidence, to build optimistic thinking style, courage, perseverance, and flexibility.

#### **Author details**

Sevgi Güney Ankara University, Ankara, Turkey

\*Address all correspondence to: sevgiguney@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Adversity, Uncertainty and Elevated Symptoms of Obsessive Compulsive Disorder… DOI: http://dx.doi.org/10.5772/intechopen.98304*

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#### **Chapter 16**
