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Article

Resisting Fear: The Role of Problem-Solving Appraisals in Post-Traumatic Stress Disorder and Depression

by
Tyrone B. Pretorius
* and
Anita Padmanabhanunni
Department of Psychology, University of the Western Cape, Bellville 7530, South Africa
*
Author to whom correspondence should be addressed.
Soc. Sci. 2023, 12(5), 269; https://doi.org/10.3390/socsci12050269
Submission received: 15 March 2023 / Revised: 13 April 2023 / Accepted: 24 April 2023 / Published: 2 May 2023
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Abstract

:
The COVID-19 pandemic represented a global public health emergency and was associated with adverse mental health outcomes. Individual differences in response to traumatic stressors can be attributed to subjective cognitive appraisals. The current study investigated the role of problem-solving appraisals in the association between COVID-19-related fear and mental health outcomes. Participants were university students (N = 322). They completed a web-based survey comprising the Center for Epidemiological Studies depression scale, the fear of COVID-19 scale, the problem-solving inventory, the post-traumatic stress disorder (PTSD) checklist, and the satisfaction with life scale. Correlational analysis revealed that a heightened fear of COVID-19 was related to greater PTSD and depressive symptoms and a lower life satisfaction. Self-appraised ineffective problem-solving was associated with higher levels of PTSD and depression and a lower life satisfaction. Problem-solving appraisal moderated the relationship between fear of COVID-19, life satisfaction, PTSD, and depression, respectively. The findings suggest that problem-solving appraisals are a protective resource and have the potential to promote positive psychological functioning among young adults.

1. Introduction

The COVID-19 pandemic posed a significant threat to public health and well-being on a global scale. A significant body of research has confirmed that the pandemic and the measures taken to contain it have contributed to unprecedented levels of distress. The regulation of emotional states is important for mental health and well-being and is characterized by efforts to determine the type and timing of emotions, as well as the personal experience and outward expression of these internal states. Deficits in emotional regulation have consistently been identified as factors that contribute to mental health disorders. Prominent theories of stress and coping (Lazarus and Folkman 1984) propose that cognitive appraisals determine emotional responses, as well as adaptation to adverse events. When confronted with stressors, individuals appraise whether a stressor or event is benign, threatening, or relevant to their well-being (primary appraisal) and whether they have the resources necessary to cope with it (secondary appraisal). Primary appraisals determine the nature of the emotional response (i.e., positive or negative), while secondary appraisals influence the intensity of the emotion and the individual’s coping responses. If individuals appraise a situation as harmful, they are likely to experience feelings of fear and anxiety. However, if they also appraise themselves as having the ability to cope effectively with the stressor (secondary appraisal), they may experience increased self-confidence and a reduction in fear and anxiety.
Individuals have varied significantly in their appraisals of and responses to the COVID-19 pandemic. To date, there is limited research investigating the role of cognitive appraisals of the pandemic in mental health outcomes. Brose and colleagues (Brose et al. 2021) reported that primary appraisals of the pandemic as a major threat and negative secondary appraisals regarding individuals’ ability to cope were related to psychopathology (i.e., anxiety and depression). In contrast, more positive appraisals pertaining to self-concept and sense of control were associated with reduced negative emotions. Similarly, Starick and colleagues (Starick et al. 2021) reported that cognitive appraisals of COVID-19 stressors as opportunities or challenges that could be overcome were associated with more positive mental health outcomes.
This study focused on the role of appraisals of problem-solving ability in the association between fear of COVID-19 and mental health outcomes among university students. Problem-solving appraisal refers to individuals’ appraisals of their problem-solving ability and reflects a secondary appraisal process (Heppner et al. 2002). It differs from the concept of problem-solving, which denotes the cognitive and behavioral processes that individuals undertake to manage and resolve everyday life problems (D’Zurilla and Nezu 2010).
Although young adults are not at the highest risk of infection and mortality, studies have reported that they experience more COVID-19-related negative mental health outcomes due to disruptions to their daily lives and academic routines, greater access to information about the pandemic through social media, and stressors associated with friends and family contracting the virus (Mauer et al. 2022; C. Wang et al. 2021). The closure of universities and on-campus housing to curb the spread of the disease and the implementation of remote digital teaching and learning aggravated anxiety among students. Many students experienced technology-related stress due to online classes, limited access to digital resources, and the need to adapt quickly to an online learning and teaching environment. Furthermore, difficulties with food security and access to personal protective equipment were found to aggravate anxiety and distress among students (Mauer et al. 2022). Lack of peer companionship and significantly reduced social activities due to quarantine and restrictions on social gatherings have been associated with depression among young adults (C. Wang et al. 2021). In a study of Chinese college students, Wang and colleagues (Z.-H. Wang et al. 2020) reported increased levels of depressive symptoms among students with family members who were suspected or confirmed to have contracted COVID-19. A Bangladeshi study (Faisal et al. 2022) found that COVID-19-related worries and reduced social contact predicted anxiety and depression among college students in their sample. A U.S. study of college student mental health before and during the pandemic reported heightened levels of depression and alcohol-use disorder (Kim et al. 2022). A meta-analytic study (C. Wang et al. 2021) focusing on the mental health status of college students reported elevated levels of anxiety, depression, and stress. Students experiencing more depressive and anxiety symptoms were also found to be more prone to using alcohol and other substances as a means of coping (Singleton et al. 2022).
Most studies on the psychological sequelae of COVID-19 have identified fear as a dominant emotional response to the pandemic. Although fear reflects an adaptive reaction to a perceived threat, elevated levels of fear can precipitate mental health problems, including depression, anxiety, hopelessness, post-traumatic stress disorder (PTSD), and reduced life satisfaction (Rodríguez-Hidalgo et al. 2020). Fear in the context of the pandemic has been attributed to the high transmissibility of the virus, concerns about contagion, and worries about losing loved ones in the event of infection. For students, the disruption of daily academic routines, limited access to peers and academic staff, technology-related challenges, and concerns about their future and the well-being of their family contributed to increased levels of fear (Mauer et al. 2022). However, not all people who experienced fear developed adverse mental health outcomes, and this differential vulnerability highlights the role of protective factors in facilitating coping. The majority of existing studies investigating protective resources have focused on psychosocial factors (e.g., social support), intrinsic characteristics (e.g., trait resilience, self-esteem, and optimism), and behavioral strategies (e.g., problem-focused coping; (Pedersen et al. 2023). Few studies have focused on the role of adaptive cognitive appraisals in facilitating coping. We thus hypothesized that problem-solving appraisal would moderate the relationship between COVID-19 related fear and life satisfaction, PTSD, and depression, respectively.

2. Materials and Methods

2.1. Participants and Procedure

The sample (n = 322) consisted of a cohort of university students enrolled at a major South African university located in the Western Cape Province. They were randomly sampled from a sampling frame of 1700 students. A web-based survey was used. An email containing an invitation to participate and information on how to access the survey was distributed to 1700 respondents. Mostly female students responded to the survey (77%) and most participants resided in an urban area (87.3%). In total, 86% reported being vaccinated, and 40.7% indicated that they had lost a family member due to COVID-19. The average age of the students in the sample was 26.01 years (range 17–63 years, SD = 10.19).

2.2. Instruments

The instruments used for this study were the fear-of-COVID-19 scale (FCV-19S; (Ahorsu 2020)), the problem-solving inventory (PSI; (Heppner and Petersen 1982)), the post-traumatic stress disorder (PTSD) checklist for DSM-5 (PCL-5; (Blevins et al. 2015)), the satisfaction-with-life scale (SWLS; (Diener et al. 1985)), and the shortened version of the Center for Epidemiological Studies depression scale (CESD-10; (Zhang et al. 2012)).
The FCV-19S assesses fear responses in relation to COVID-19 and is a 7-item instrument that is scored on a 5-point Likert scale. Examples of items in the FCV-19S include “I am afraid of losing my life because of coronavirus-19” and “My heart races or palpitates when I think about getting coronavirus-19”. Respondents indicate their level of agreement with statements on the scale with responses ranging from strongly agree to strongly disagree. The authors of the scale reported satisfactory reliability indices (alpha = 0.82, test-retest = 0.72). In addition, the correlation with depression, anxiety, perceived infectability to disease, and germ aversion served as evidence of validity. Pretorius and colleagues have confirmed the reliability (α = 0.91), as well as the construct, convergent, and concurrent validity, of the scale in the South African context.
The PSI consists of 32 items and measures perceptions of effective problem-solving, rather than actual problem-solving skills. Participants respond by indicating their level of agreement with statements using a 6-point Likert scale ranging from strongly agree to strongly disagree. Examples of items in the PSI include “When faced with a novel situation, I have confidence that I can handle problems that may arise” and “When making a decision, I weigh the consequences of each alternative and compare them against each other”. Elevated scores in the PSI reflect increased perceptions of being an ineffective problem-solver. Heppner and Petersen (1982) reported an internal consistency reliability of 0.90 and, in terms of validity, demonstrated that the PSI measures a construct that can be changed through training in problem-solving skills. The PSI has previously been used in South Africa with reported reliability estimates of 0.89 (Heppner et al. 2002) and 0.84 (Pretorius 1996).
The PCL-5 consists of 20 items that measure the presence and severity of PTSD symptoms. The PCL-5 uses a 5-point Likert scale that ranges from not at all to extremely. Examples of items included “How much were you bothered by repeated, disturbing dreams of the stressful experience?” and “How much were you bothered by trouble remembering important parts of the stressful experience?”. Blevins and colleagues reported alpha coefficients of 0.94 and 0.95 in two separate studies and confirmed the discriminant and convergent validity of the PCL-5 (Blevins et al. 2015). Padmanabhanunni and Wiid reported an alpha coefficient of 0.93 for a sample of South African students (Padmanabhanunni and Wiid 2022).
The SWLS is a measure of global life satisfaction and comprises 5-items. Respondents indicate their level of agreement with each item on a 7-point Likert scale ranging from strongly disagree to strongly agree. Examples of items in the SWLS include “The conditions of my life are excellent” and “I am satisfied with my life”. The SWLS has been correlated with other measures of subjective well-being (Diener et al. 1985) and the developers reported a satisfactory internal consistency reliability of 0.87. In South Africa, Pretorius and colleagues demonstrated the scale’s validity and unidimensionality (Pretorius and Padmanabhanunni 2022).
The CESD-10 is a short form of the original 20-item version (Radloff 1977). The 10 items were selected based on the correlations between the individual items and the total score. Responses are indicated using a 4-point Likert scale ranging from rarely or none of the time to most or all of the time. Examples of items in the CESD-10 include “I felt hopeful about the future” and “I felt fearful”. Zhang and colleagues found a satisfactory internal consistency reliability of 0.88 for the instrument and reported that the CESD-10 was effective in terms of being able to classify participants that had depressive symptoms compared to the original 20-item version (Zhang et al. 2012).

2.3. Ethics

The principles of the Declaration of Helsinki were adhered to for this study. The project was approved by the institutional review board of the University of the Western Cape (ethics reference number: HS22/2/9, February 2022). Participation was voluntary, and participants provided informed consent.

2.4. Data Analysis

IBM SPSS for Windows version 28 was used for all analyses, including descriptive statistics for all the variables of interest (means and standard deviations) and intercorrelations of variables of interest (Pearson r), as well as the reliabilities of the measuring instruments (Cronbach’s alpha). The moderation analysis was conducted with the PROCESS macro developed by Hayes for SPSS (Hayes 2017). The interaction term (predictor X moderator) was created using mean-centered variables. To illustrate the nature of the interaction, graphs of the relationship between the predictor and the dependent variable were plotted for three different groups: effective problem-solvers (−1 SD), moderate problem-solvers (mean), and ineffective problem-solvers (+1 SD). The plots were obtained using the visualization code provided by the PROCESS macro.

3. Results

The means and standard deviations, estimates of reliability (alpha) coefficients, and the correlations between the variables of interest are presented in Table 1.
Table 1 reveals that all the scales demonstrated a satisfactory reliability (α = 0.84–0.94). There was a negative association between fear of COVID-19 and life satisfaction (r = −0.13, p = 0.022, small effect) and a positive association between fear of COVID-19 on the one hand and PTSD (r = 0.30, p < 0.001, medium effect), as well as depression (r = 0.29, p < 0.001, medium effect), on the other hand. Therefore, a heightened fear of COVID-19 was related to a lower life satisfaction and greater PTSD and depression symptomology. There was a negative association between problem-solving appraisal and life satisfaction (r = −0.38, p < 0.001, medium effect). In addition, there was a positive association between problem-solving appraisal and PTSD (r = 0.48, p < 0.001, medium effect), as well as depression (r = 0.47, p < 0.001, medium effect). High scores on the PSI are reflective of perceived ineffective problem-solving; thus, the observed relationships indicate that participants who appraised themselves as ineffective problem-solvers reported a lower life satisfaction and higher levels of PTSD and depression.
The analysis of the moderating role of problem-solving is presented in Table 2 and Figure 1.
Table 2 indicates that the direct effects of problem-solving appraisal on life satisfaction (B = −0.23, [−0.33, −0.13]), PTSD (B = 0.41, [0.33, 0.50]), and depression (B = 0.15, [0.12, 0.18]) were significant. In addition, problem-solving appraisal moderated the fear of COVID-19 and life satisfaction relationship (B = 0.01, [0.00, 0.01]) and the fear of COVID-19 and PTSD relationship (B = −0.01, [−0.03, −0.00]), as well as the fear of COVID-19 and depression relationship (B = −0.01, [−0.01, −0.00]). Figure 1 visually illustrates the moderating role of problem-solving appraisal.
Figure 1 demonstrates that participants who perceived themselves as effective problem-solvers reported higher levels of life satisfaction than those who perceived themselves as ineffective problem-solvers in the presence of heightened levels of fear of COVID-19. Similarly, self-appraised effective problem-solving was associated with lower PTSD and depression symptomology in the presence of heightened levels of COVID-19-related fear.

4. Discussion

Individual responses to stress and adversity are heterogenous. When confronted with a stressor, subjective cognitive appraisals of the event as either threatening or as a challenge that can be overcome can influence emotional responses and adaptation. Existing research has confirmed that initial negative cognitive appraisals of stressful events are related to depression, anxiety, hopelessness, and PTSD. The current study investigated the role of appraisals of problem-solving ability in the relationship between COVID-19 related fear and PTSD, depression, and life satisfaction. The salient findings of the study are detailed below.
First, the study established that an elevated fear of COVID-19 was associated with greater PTSD and depressive symptoms and lower levels of life satisfaction. Similar results have been reported in the existing literature. For example, Lathabhavan and colleagues (Lathabhavan and Sudevan 2022) reported higher levels of fear of COVID-19 among Indian college students, and this was associated with greater psychological distress and reduced life satisfaction. The higher levels of fear were ascribed to the high mortality rate, as well as limited availability of medical care for those infected with the virus. Liu and colleagues (Liu et al. 2020) also reported high levels of PTSD, anxiety, and depression among college students in the US. Social isolation and disconnection from sources of support, as well as residing in areas identified as COVID-19 infection “hotspots”, were among the factors reported to underlie these adverse mental health outcomes. It is probable that similar factors contributed to an escalation of fear among students in the current study. Concerns of contracting the virus, infecting significant others, losing loved ones due to infection, and worries about not being able to receive treatment in the event of infection can aggravate fear (Olapegba et al. 2022; Yasin 2020). Young adults in South Africa are also at increased risk of exposure to traumatic events due to the high prevalence of crime in the country. Prior exposure to trauma is a risk factor for developing PTSD in response to future traumatic events (Padmanabhanunni and Wiid 2022).
Second, self-appraised ineffective problem-solving was associated with heightened PTSD symptomology and depression and a lower life satisfaction. This finding can be compared to the literature on self-efficacy, which is defined as beliefs about one’s ability to impact their well-being through their own actions. Prior studies (Blackburn and Owens 2015; Brown et al. 2016) have demonstrated that a greater self-efficacy is associated with lower PTSD symptoms. Samuelson and colleagues (Samuelson et al. 2017), for example, reported that coping self-efficacy mediated the relationship between responses to traumatic life events and negative psychological outcomes including PTSD among trauma-exposed adults. Lower appraisals of self-efficacy have been found to give rise to feelings of defeat, leading to maladaptive coping responses and psychological distress (Siddaway et al. 2015). Furthermore, cognitive theories of autobiographical memory propose that self-efficacy is sustained by selectively retrieving prior experiences in memory and generating future experiences that are supportive of the view of self as competent and capable (Brown et al. 2016). When applied to problem-solving appraisals, the selective recall of experiences where an individual demonstrates poor problem-solving may impact appraisals of problem-solving ability and thereby maintain the individual’s level of distress.
Third, problem-solving appraisal had a direct effect on life satisfaction, PTSD, and depression. Problem-solving appraisal also moderated the relationship between COVID-19-related fear and PTSD, depression, and life satisfaction, respectively. This finding corresponds to the literature on the association between self-efficacy and both depression and PTSD symptomology. It has been proposed that increased appraisals of the ability to accomplish positive outcomes may contribute to a heightened sense of personal control, thereby potentially reducing distress (Blackburn and Owens 2015). Positive appraisals of one’s problem-solving ability can also lead to the use of active coping strategies. The successful negotiation of a stressor through the use of these strategies may bolster confidence in one’s ability to effectively solve problems and can thus enhance life satisfaction.
The findings of the study have important implications. Given the salience of problem-solving appraisals in COVID-19-related fear and mental health, interventions need to focus on identifying and targeting negative appraisals of problem-solving ability. Cognitive-behavioral therapies have been found to be particularly beneficial in addressing the maladaptive appraisals underlying psychological distress through the use of cognitive restructuring interventions. Individuals with PTSD tend to doubt their ability to effectively cope with stressful life events and anticipate adverse outcomes when confronted with feared situations. In such cases, problem-solving appraisals can be enhanced by training individuals to selectively recall autobiographical memories in which they demonstrated effective problem-solving. Focusing their attention on experiences characterized by mastery can increase tolerance of distress and contribute to improved function.
The study had several limitations. First, self-report measures were used and might have been subject to recall, response, and social-desirability biases. Second, a cross-sectional research design was used which limits conclusions about temporal associations and causal inferences. It is probable, for example, that there was a bi-directional relationship between anxiety and fear and problem-solving ability. Longitudinal research is needed to corroborate the findings and provide causal and directional interpretations. Furthermore, self-report of symptomology can be prone to bias and future research assessing the study variables using a structured interview may assist in addressing this limitation. Third, the sample was mostly comprised of women, thereby limiting the generalizability of the findings to men. Finally, the research was undertaken in South Africa and the generalizability of the findings to other contexts needs to be ascertained.
This study lends further support to the role of adaptive cognitive appraisals in mental health outcomes. The results suggest that problem-solving appraisals are protective resources in promoting positive psychological functioning among young adults. Interventions aimed at enhancing problem-solving appraisals may be beneficial in promoting adaptation and coping during disease outbreaks.

Author Contributions

Conceptualization, T.B.P. and A.P.; methodology, T.B.P.; formal analysis, T.B.P.; investigation, T.B.P. and A.P.; writing—original draft preparation, T.B.P. and A.P.; writing—review and editing, T.B.P. and A.P.; visualization, T.B.P.; supervision, A.P.; project administration, A.P.; funding acquisition, A.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the South African Medical Research Council (SIR grant).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Humanities and Social Sciences Ethics Committee of the University of the Western Cape (ethics reference number: HS22/2/9, February 2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in this study.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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Socsci 12 00269 g001a 550Socsci 12 00269 g001b 550
Figure 1. Illustration of the moderating effect. (a) Problem-solving appraisal and the association between fear of COVID-19 and life satisfaction; (b) problem-solving appraisal and the association between fear of COVID-19 and PTSD; (c) problem-solving appraisal and the association between fear of COVID-19 and depression.
Figure 1. Illustration of the moderating effect. (a) Problem-solving appraisal and the association between fear of COVID-19 and life satisfaction; (b) problem-solving appraisal and the association between fear of COVID-19 and PTSD; (c) problem-solving appraisal and the association between fear of COVID-19 and depression.
Socsci 12 00269 g001aSocsci 12 00269 g001b
Table
Table 1. Means, standard deviations, alpha coefficients, and correlation coefficients.
Table 1. Means, standard deviations, alpha coefficients, and correlation coefficients.
12345
1. Fear of COVID-19—
2. Problem-solving appraisal0.12 *—
3. Life satisfaction−0.13 *−0.38 **—
4. PTSD0.30 **0.48 **−0.48 **—
5. Depression0.29 **0.47 **−0.53 **0.68 **—
Mean17.497.919.438.514.2
SD6.520.37.119.06.8
Alpha0.870.890.860.840.94
PTSD = post-traumatic stress disorder, SD = standard deviation, ** p < 0.001, * p < 0.05.
Table
Table 2. Analysis of the moderating role of problem-solving appraisal.
Table 2. Analysis of the moderating role of problem-solving appraisal.
VariableBetaSE95% Confidence Intervalp-Value
Life satisfaction as dependent variable
Fear of COVID-19−0.6440.056[−1.18, −0.11]0.019
Problem-solving appraisal−0.2270.050[−0.33, −0.13]<0.001
Fear of COVID-19 X problem-solving appraisal0.0050.003[0.00, 0.01]0.039
PTSD as dependent variable
Fear of COVID-190.7160.138[0.44, 0.99]<0.001
Problem-solving appraisal0.4140.044[0.33, 0.50]<0.001
Fear of COVID-19 X problem-solving appraisal−0.0160.007[−0.03, −0.00]0.017
Depression as dependent variable
Fear of COVID-190.2460.049[0.15, 0.34]<0.001
Problem-solving appraisal0.1480.016[0.12, 0.18]<0.001
Fear of COVID-19 X problem-solving appraisal−0.0060.002[−0.01, −0.00]<0.017
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Pretorius, T.B.; Padmanabhanunni, A. Resisting Fear: The Role of Problem-Solving Appraisals in Post-Traumatic Stress Disorder and Depression. Soc. Sci. 2023, 12, 269. https://doi.org/10.3390/socsci12050269

AMA Style

Pretorius TB, Padmanabhanunni A. Resisting Fear: The Role of Problem-Solving Appraisals in Post-Traumatic Stress Disorder and Depression. Social Sciences. 2023; 12(5):269. https://doi.org/10.3390/socsci12050269

Chicago/Turabian Style

Pretorius, Tyrone B., and Anita Padmanabhanunni. 2023. "Resisting Fear: The Role of Problem-Solving Appraisals in Post-Traumatic Stress Disorder and Depression" Social Sciences 12, no. 5: 269. https://doi.org/10.3390/socsci12050269

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