COVID-19: Is Catastrophizing Clouding Decision-Making?

More countries are increasingly implementing emergency lockdown protocols and restricting people's movements at a level that would ordinarily only be seen during times of war. Such unprecedented action is being taken to reduce the loss-of-life related to COVID-19, including minimizing the burden on public healthcare infrastructure.

The situation relating to COVID-19 is rapidly evolving and understandably requires governments to reevaluate their response on a frequent basis. Unsurprisingly, the increasing and tightening of government restrictions appear to be prompted by growing fears and reports of the infection spreading at a faster rate, along with associated increases in loss of life.

Whether at a governmental or individual level, there are many factors to consider to strike the right balance between under- and overreacting to COVID-19. In order to evaluate these factors effectively, calm and clear decision-making informed by accurate information is essential. This is because, amidst current heightened global levels of psychological and economic tension related to COVID-19, there is likely to be an increased risk of choices and actions being influenced by catastrophizing.

Catastrophizing corresponds to a cognitive process involving an exaggerated level of negativity that assumes the worst outcomes and interprets workable problems as major calamities. Repeated exposure to information that is negatively-valenced (i.e., weighted toward negative emotional content), such as via TV reports, has been shown to increase the tendency to catastrophize, as well as increase anxiety more generally.

Typical characteristics of catastrophizing include pessimism related to a specific problem, despair, repeatedly wanting to analyze the problem, and feelings of inadequacy. Another key feature is attention bias in favor of threat, which can distort how information is interpreted and reduce an individual’s ability to see a situation clearly.

This is particularly important in the context of COVID-19 because amidst such a high frequency and volume of negatively valenced information relating to the disease, care is clearly required to ensure that information is interpreted accurately and without assuming the worst. Indeed, ambiguity and inconsistency in relation to information concerning the harmfulness of COVID-19, including among the scientific and medical community, makes it even more necessary to avoid any form of cognitive bias.

For example, it is widely acknowledged that reports of confirmed cases of COVID-19 are likely to significantly underestimate the true number of people infected. There are various reasons for this, ranging from differences between countries in monitoring and detection practices to the fact that people exhibiting only mild symptoms are less likely to appear on the detection radar. This means that reports of the COVID-19 case fatality rate (i.e., the proportion of confirmed COVID-19 cases that result in death) are likely to over-estimate the fatality of the disease.

However, perhaps of greater concern is inconsistency and misunderstanding in terms of how a COVID-19 fatality is defined. For example, in a paper recently published in the Journal of the American Medical Association, Dr. Graziano Onder and colleagues of the Istituto Superiore di Sanità in Rome, Italy, acknowledged that “COVID-19-related deaths are not clearly defined in the international reports available so far, and differences in definitions of what is or is not a COVID-19-related death might explain variation in case-fatality rates among different countries.” In other words, there is a difference between a person who dies and has COVID-19, and a person who dies because of COVID-19.

Within the UK, COVID-19 is now classed as a “notifiable disease," which means that if a person who dies is suspected to have the disease, there is an obligation for the death notification to specify COVID-19. The situation appears to be similar in Italy, where according to Dr. Onder, case-fatality statistics for COVID-19 reflect deaths from patients who test positive for COVID-19 “independently from preexisting diseases that may have caused death”.

Clarity in terms of how COVID-19 case fatality rates are calculated is particularly important in light of a recent model by Dr. José Lourenço and colleagues from the University of Oxford in the UK, which reported that between 36-68% of the UK population may already have been infected with COVID-19 as of the 19th March 2020.

If this is correct, it’s unsurprising that a large number of people who have recently died have tested positive for COVID-19. In other words, bearing in mind that under “normal” circumstances, in the region of 1,700 people typically die each day in countries such as the UK and Italy, it’s inevitable that a proportion of people testing positive for COVID-19 would have died in any event.

Another issue that seems to have been under-estimated in some government responses to COVID-19 is the extent to which psychological factors, such as catastrophizing, panic and stress could begin to exert lateral pressure on healthcare infrastructure (as well as lead to civil unrest more generally).

For example, research shows that prolonged stress, anxiety, and social isolation are associated with a variety of health problems, including a weakening of the immune system and reduced life expectancy. Consequently, psychological distress due to blanket social distancing measures and home confinement for long periods of time, coupled with growing financial worries, could aggravate pre-existing medical conditions as well as trigger an increase in new physiological and psychological health problems.

It appears that COVID-19 will inevitably and unfortunately result in some “premature death," particularly amongst the oldest of age groups and individuals with certain serious underlying health problems. It is therefore essential that targeted measures are taken to protect people deemed to be most vulnerable to the disease.

However, it's also important to understand how anxiety-related psychological processes such as catastrophizing can distort how information is interpreted as well as reduce a country’s ability to respond to COVID-19 in an optimum and proportionate manner. Similarly, the short- and long-term impact on the health of the wider population needs to be carefully considered as part of “locking-down” a country.