Abstract

Outbreak of COVID-19 has adversely affected the world with harmful effects on the mental health of people of all ages. In the present cross-sectional research, we were interested to explore anxiety, rejection sensitivity, fear of death and resilient coping as a result of COVID-19 among participants of generation X (1965-1980) and Y (1981-2000). A sample of 235 covid-negative (GX=104, GY=131; M=97, W=138) was taken using convenient sampling. Anxiety self-rating scale, rejection sensitivity questionnaire revised death anxiety scale and brief resilience coping scale were used to collect data. Pearson Product Moment Correlation revealed positive relationship between anxiety, rejection sensitivity and fear of death. Anxiety and rejection sensitivity indicated negative relationship with resilient coping. Mediate analysis showed that anxiety significantly predicted rejection sensitivity and fear of death, rejection sensitivity significantly predicted fear of death and rejection sensitivity significantly mediated between anxiety and rejection sensitivity. Moderated-mediation analysis showed anxiety as negative predictor of death anxiety while resilient coping and rejection sensitivity are positive predictors of fear of death. Resilient coping didn’t moderate between anxiety and fear of death but the indirect effects of resilient coping on low and moderate level was significant. Independent Sample T-Test revealed significant generational differences in anxiety, significant gender differences in fear of death and significant family differences in rejection sensitivity. Significant family system differences were found only on rejection sensitivity with nuclear scored high. Study implications are discussed in health, clinical and counselling psychology.

Keywords

Generation X, Generation Y, Anxiety, Rejection Sensitivity, Fear of death, Coping Strategies, COVID-19

Introduction

Coronavirus first emerged in the end of 2019 as an epidemic but now it has become global pandemic disease affecting more than 200 countries of the world with exceeding death rate. People all around the world are taking precautionary and preventive measures to protect them. Almost all countries affected with COVID-19 have taken measures of social distancing, lockdown and self-isolation to avoid the spread of the disease [1]. Though the measures are protective in nature but confinement to home and threat of covid-19 has imposed several psychosocial challenges and caused serious threats to psychological and mental health of the public [2]. The fear of disease, death anxiety and an imaginative sense of separation from loved one have imposed negative impact on people of all ages and broadly to all existing generations. Currently this pandemic disease is being experienced by four main generations: baby boomer (born during 1946-1964), generation X (born during 1965-1980), generation Y (born during 1981-2000) and generation Z (born during 2000-2020). Considering the suspected vulnerability and maximum ratio of these generations, this study aimed to observe the psychological effects of covid-19 on the people from two main generations (X and Y). Researchers were interested to observe the differences in level of anxiety, fear of death, rejection sensitivity and resilient coping among both generations.

Health emergency situation as a result of COVID-19 has significantly increased distress in the entire population which can trigger anxiety disorders [3,4]. As observed in previous SARS outbreak, almost 70% of the people reported extreme level of anxiety [5]. Anxiety is a feeling of apprehension and fear including physical manifestations of fear such as palpitations, trembling and sweating during the anxious state. Environmental changes such as social isolation and limited face-to-face contact as a result of pandemic has heightened the risk of anxiety in people with mild to moderate depressive symptoms.

The uncertainty of disease has brought changes in the emotions of people and they are more likely to develop negative emotions (i.e. anxiety). It has also resulted in avoidant behaviors especially among those who have pneumonia like symptoms such a fever, flu and sore throat [6]. They try to avoid contact with people and try to follow SOPs more in order to overcome their anxiety. Although alertness, disease anxiety and avoidant behaviors can help people to protect them from contagious disease however, long-term exposure to these negative emotions can cause devastating effects to both physiological and psychological health.

Persistent exposure to long term anxiety provoking situation can further lead to fear of death in people of all ages with or without disease. Fear and hypervigilence has been observed a common response to infectious diseases [7]. Although death anxiety exists in all human being but mortality salient situation like COVID-19 has increased uncertainty and fear of death in public. Though virus proven more dangerous for elderly people between 60-69 years old than younger generation still all are vulnerable also found positive relationship between depression and death anxiety among elderly patients [8,9]. Though less vulnerable, some studies have found young people to have high fear of death than elderly people [10,11].

In addition to anxiety and fear of death, people may also experience rejection sensitivity which refers to extreme sensitivity involving perceived rejection or criticism by others in difficult situations. Rejection sensitivity has almost been ignored by researchers in pandemic literature but the present study initiated to assess it during pandemic situation. Since outbreak of COVID-19, the quarantine centers were established almost in all countries to isolate the affected people form healthy one.

The sense of stigmatization associated with coronavirus, complete isolation and quarantine has potentially increased the rejection sensitivity in the people with the perception that they will be separated from their loved one, the people around them may not accept them, will not come close to them or may not visit them to hospital if they ever infected with the disease. Therefore, rejection sensitivity may be associated with anxiety and fear of death. Although mediating role of rejection sensitivity has been explored in literature with anxiety and body dysmorphic concerns but it is not explored in the context of fear of death and pandemic so this study will explore it mediating role.

Moreover, the SOPs regarding the care of patients and burial of dead body has increased the death anxiety in people. Vulnerable population such as older adults or people with certain medical issue may assume the discrimination and rejection by the loved ones or caregivers as reported that specific vulnerable groups such as patients with psychiatric conditions, older adults and residents of high incidence areas reported frequent discrimination, social rejection and Xenophobia [12].

Besides, coronavirus also resulted in economic devastation, so people may also experience the rejection in getting financial assistance from others in the time of need. Due to extreme anxiety, the ability to maintain a resilient posture has become difficult but resilient and coping can lead to optimism and help people to combat with the stressful situation. Psychological resilience can serve as a protective factor and linked to better mental health outcomes during pandemic. Resilience act as moderating variable and high resilient people are less affected by the stress than low resilient people during covid-19 [13].

Low level of anxiety and high resilience also contribute to better response to treatment. Hence, considering the severity of the situation, present study aimed to explore the relationship and prediction between study variables as well as to explore the differences between generation X and Y. Moreover, mediating role of rejection sensitivity and moderating role of resilient coping is also focus of present study.

Hypotheses

1.Anxiety, rejection sensitivity and fear of death are likely to be positively related with each other.

HII. Anxiety, rejection sensitivity and fear of death are likely to be negatively related with resilient coping.

HIII. Rejection sensitivity is likely to mediate between anxiety and fear of death (Figure 1).

Figure 1. Hypothesized model of rejection sensitivity as mediator of anxiety and fear of death

HIV. Resilient coping is likely to moderate the direct effect of anxiety on fear of death and indirect effect of anxiety on fear of death through rejection sensitivity (Figure 2).

Figure 2. Hypothesized moderated mediation model

1.Generation X is likely to differ from generation Y in their level of anxiety, rejection sensitivity, fear of death, and resilient coping.

HVI. Men and women are likely to differ in their level of anxiety, rejection sensitivity, fear of death, and resilient coping.

HVII. People from nuclear family system are likely to differ from joint family system in their level of anxiety, rejection sensitivity, fear of death, and resilient coping.

Method

Sample

The study was quantitative in nature and cross-sectional research design was used. Non-probability convenience sampling was used and data was collected online due to lockdown situation in the country. The sample comprised of 235 participants (M=34.98, SD=9.97) from two generations X (1965-1980) and Y (1981-2000). Among 235 participants 104 (44.3%) were from generation X while 131 (55.7%) were from Y generation.

Only those participants were selected who were experiencing symptoms of COVID-19 and went for PCR test but no virus was detected. Symptoms were divided in 3 categories i.e., mild (fever, cough, tiredness, flu), moderate (sore throat, body aches, diarrhoea, headache, loss of smell and taste) and serious (serious difficulty in breathing, chest pain, loss of speech or movement).

None of the participants reported serious symptoms, 67.7% reported mild symptoms and 76 reported moderate symptoms with minimum 2-3 prominent symptoms. About 138 (58.7%) were women and 97 (41.3%) were men. The minimum qualification of the participants was graduation (21.3%), 40% were masters and 38.7% were M.Phil.PhDs.

Participants belonged to both joint (43.4%) and nuclear family system (56.6%). As for marital status, about 156 (66.4%) were married and 79 (33.6%) were unmarried. Both employed (64.3%) and unemployed (35.7%) participants participated in the study.

Measures

Anxiety

Anxiety Self-Rating Scale developed by Komor was used to assess the level of anxiety among participants. Participants were instructed to report their level of anxiety considering the current situation of COVID-19 [14]. The scale consisted of 10 items with a 5-point Likert scale ranging from 0 (never applies to you) to 4 (always applies to you). Scores of the participants on the scale can be ranged from minimal (0-8) to extreme anxiety (33-40). Alpha reliability of the scale was good α=0.89 in this research.

Rejection sensitivity

Adult version of Rejection Sensitivity Questionnaire (ARSQ) developed by Berenson was used and adapted to assess the rejection sensitivity among individuals due to COVID-19 [15]. The scale is based on two components; rejection concern and expectancy. SPSS scoring procedure suggested by the author was used to compute scores the total score of rejection sensitivity. Adapted version in the present research showed good alpha reliability of .70.

Fear of death

Revised Death Anxiety Scale by Thorson and Powell was used to assess the fear of death among participants [16]. Scale is comprised of 25-items with scoring on a 5 point Likert scale from strongly agree (5) to strongly disagree (1). Participant reported their fear of death by keeping in Negative items in the scale were reverse scored with strongly agree=5 and strongly disagree=1. Scale showed good alpha reliability of .79 in our sample.

Resilient Coping

A 4-item, Brief Resilient Coping Scale was used to assess the behaviours that people adopt to cope with their anxiety and fear as a result of COVID-19 [17]. Participants responded on 5-point Likert scale from 1 (does not describe me at all) to 5 (describes me very well). Cronbach Alpha reliability of the scale in this research was 0.72. 

Procedure

Formal permission was taken from the authors to use and adapt the scales. After finalizing the measures, an online Google form was generated and link was send to participants to get their responses. Due to lock down, data was collected online using convenience sampling as it was difficult to visit participants and have face-to-face assessment.

Participants were informed about the purpose of the study and their ethical rights. Their anonymity was ensured. Participants’ responses were recorded in Excel file and results were compiled and calculated in SPSS (v21).

Results

Bivariate correlation was run to explore the relationship between study variables (Table 1).

Results of correlation analysis supported hypothesis I and revealed positive relationship between anxiety with rejection sensitivity and fear of death. Hypothesis II was also supported for anxiety and rejection sensitivity indicating significant negative relationship with resilient coping. But no significant association was found between fear of death and resilient coping however direction of the relationship is negative. For demographics, generations showed significant relationship with anxiety and gender showed significant negative relationship with fear of death. Furthermore, mediating role of rejection sensitivity between anxiety and fear of death was observed. A simple mediation analysis was run using model 4 of process to explore mediation (Table 2).

In Table 2 of the mediation model, the path (direct effect) from anxiety to fear of death was positive and statistically significant. Anxiety positively predicted rejection sensitivity. The direct effect of rejection sensitivity on fear of death was positive and statistically significant indicating that persons scoring high on rejection sensitivity are more likely to have excessive fear of death. The indirect effect was tested using 5000 bootstrapped with 95% confidence interval. Indirect effect of anxiety in predicting the fear of death was significant in presence of rejection sensitivity (mediator) which supported our hypothesis. A moderated mediation analysis was run to investigate resilient coping as moderator of direct and indirect effect between anxiety, fear of death and rejection sensitivity (Table 3).

The results of moderated mediation analysis showed that their anxiety is negative predictor of death anxiety while resilient coping and rejection sensitivity are positive predictors of fear of death. Anxiety and resilient coping are not significant predictors of rejection sensitivity. The relationship between anxiety and fear of death is not moderated by resilient coping (F (1,231)=.02, >0.05) but the indirect effects of resilient coping on low and moderate level was significant. An Independent sample t-test was run to explore the generational differences in anxiety, rejection sensitivity, fear of death and resilient coping. (Table 4).

Result of t-test revealed significant generational differences in anxiety with GY indicating more anxiety. While no significant differences were found for rejection sensitivity, fear of death and resilient coping however mean differences provide slight indication with generation Y scoring more on rejection sensitivity and fear of death. Mean of resilient coping was equal for both generations. An Independent sample t-test was run to explore the generational differences in anxiety, rejection sensitivity, fear of death and resilient coping (Table 5). Result of t-test revealed significant gender differences in fear of death with women indicating more fear. While no significant differences were found for anxiety, rejection sensitivity and resilient coping (Table 6).

Discussion

The contagious coronavirus imposed certain threats to mental health of public. It brought sudden change all around the world and still impacts a lot of people mentally and economically. It caused serious psychological disturbance to people of all ages. High prevalence of depression and anxiety has been reported among public due to pandemic. Considering the unignored impacts of covid-19, the present study aimed to explore anxiety, rejection sensitivity, fear of death among people of generation X and generation Y. Moreover, the role of resilient coping was assessed. Initially the relationship between study variables was assessed and result supported hypothesis 1 and 2 showing positive relationship between anxiety, rejection sensitivity and fear of death. Anxiety and rejection sensitivity (but not fear of death) indicated negative relationship with resilient coping. Anxiety, rejection sensitivity and fear of death also positively predicted each other. The findings of the study are consistent with previous studies that explored anxiety, depression and fear of death in patient and high-risk population. Pandemic and epidemic diseases increased death-related thoughts [18,19]. Fear and anxiety of pandemic trigger death related fear and thought Menzies et al. [20] also explore relationship between death anxiety and stress. Rejection sensitivity has also been found to confer the risk of depression, there is absence of supportive literature on rejection sensitivity in the context of pandemic so the results of this study are unique in exploring rejection sensitivity as a significant predictor of fear of death.

Importantly, results of mediation analysis were unique in exploring mediating role of rejection sensitivity between anxiety and fear of death supporting hypothesis 3. Research by Fang et al. supports mediation role of rejection sensitivity between social anxiety and body dysmorphic concerns. Covid related anxiety can trigger rejection sensitivity which can increase fear of death. The pandemic can heighten anxiety, isolation and rejection sensitivity dysphoria. Individual with high rejection sensitivity often respond dramatically to the situation and show more concern of being isolated when they are in difficult situation like pandemic. Poggi et al. [21] also supported that under conditions of stress, people experience more fear and rejection sensitivity. Where pandemic increases anxiety, rejection sensitivity and fear of death, resilience and self-efficacy can serve as protective factor to cope with this situation. Exposure to covid-19 and depression can be moderated through resilience and self-efficacy; therefore, we were also interested to explore the moderating role of resilient coping.

Although the moderating role of resilience is supported by previous research in effectively managing stressful situation but results of moderated mediation did not supported hypothesis 4 and moderating role of resilient coping was not observed however, indirect effects of resilient coping on low and moderate level was significant. Results are in line with the study of which did not support the moderating effect of self-efficacy on exposure to covid and depression. However, there is a need to conduct more studies to explore moderation effect of resilience.

Besides exploring relationship and prediction between study variables, the prime focus of this study was to investigate generational differences. Prevalence of covid revealed more harmful effects on elderly people than younger in different countries however still literature is scarce. Contrary to expectations and previous researches the present research showed more anxiety in generation Y than generation X. The study of supported our findings indicating that younger adults were more vulnerable to depression, stress and anxiety [22]. Findings are also similar to Rossell et al. [23] where respondent below 45 years were more vulnerable to stress. When compared participants on the basis of their gender, the results showed more fear of death in women than men but no significant differences were found on other variables [24,25].

Supporting our findings showed that women experience more death anxiety than me Saeed and Bokharey also highlighted women to be more death anxious than men [26,27]. Lastly, we explored differences in participants on the basis of the family system they were living in and results revealed that participants from nuclear family system showed more rejection sensitivity than joint family system but no significance differences were found on the rest of study’ variables. Results are supported by indigenous research by Arshad, Khadim and Masood revealing that participant living in nuclear family system experienced more rejection sensitivity. In joint family people experience less loneliness and other members around can help them better in coping with stressful situation and support each other emotionally, financially and psychologically while people living alone in the absence of senior family members may feel a sense of being rejected or ignored in difficult situation and find less support of others [28-30]. 

Conclusion

The study explored positive relationship between anxiety, rejection sensitivity, fear of death and a negative relationship between anxiety, rejection sensitivity and resilient coping. Anxiety significantly predicted rejection sensitivity and fear of death. Rejection sensitivity also predicted fear of death. Rejection sensitivity also mediated between anxiety and fear of death. While resilient coping did not moderate the relationship of variables however indirect effects of resilient coping on low and moderate level was significant. Generation Y showed more anxiety than generation X, women showed more fear of death and participants from nuclear family system revealed more rejection sensitivity. These results are unique in opening the door for future researches. The study is exclusive in exploring all variables together and rejection sensitivity within the context of COVID-19. Interventions and psycho-education should be provided to educate people and to decrease stigmatization.

Strengths, Limitations and Future Suggestions

Study was novel contribution to existing literature in exploring psychological effects of COVID-19 among people of different generations who were experiencing the pandemic situation at the same time. Addition of rejection sensitivity along with anxiety and fear of death was unique and its mediating role also led to more researches in future.

Besides its strengths, study also had some limitations. One of them was small sample of both generations due to which significant differences may not explored. Future research should take larger sample size. Furthermore, participants from only two generations were taken while pandemic have equal effect on children, future researches should also take Gen Z and Gen Alpha into account. Data of the study was collected online their study faced limitation in response rate and respondent biases were not controlled. All questionnaires were not directly related to COVID-19, participants were asked to assume the current situation and respond to given statements. Only rejection sensitivity scale was adapted. Future researches should use COVID-19 specific measure. Brief coping strategies questionnaire measuring a single construct used to avoid strain of responding on excessive number of items so future researchers should use scale assessing different strategies. Participants from generation Z were not included because questionnaires were in foreign language that needs to translate in national language. Future researches may include participants from generation Z and more focus should be given on the coping strategies they are using. significant. Generation Y showed more anxiety than generation X, women showed more fear of death and participants from nuclear family system revealed more rejection sensitivity.

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