Fear is a basic emotion that is activated in response to perceived threat

COVID-19 Milestone Series

This post republishes: “The four horsemen of fear: An integrated model of understanding fear
experiences during the COVID-19 pandemic” by Adriano Schimmenti, Joël Billieux and Vladan Starcevic

Citation: Schimmenti, A., Billieux,J., Starcevic, V. (2020). The four horsemen of fear: An integrated model of understanding fear experiences during the COVID-19 pandemic. Clinical Neuropsychiatry, 17 (2), 41-45. https://doi.org/10.36131/ CN20200202 Copyright: © Clinical Neuropsychiatry

Authors: Adriano Schimmenti, Joël Billieux and Vladan Starcevic

In this article, we argue that fear experiences during the COVID-19 pandemic are organized on the psychological level around four interrelated dialectical domains, namely (1) fear of the body/fear for the body, (2) fear of significant others/fear for significant others, (3) fear of not knowing/fear of knowing, and (4) fear of taking action/fear of inaction. These domains represent the bodily, interpersonal, cognitive, and behavioural features of fear, respectively. We propose ways of addressing these fears and minimising their impact by improving appraisal of the body, fostering attachment security, improving emotion regulation, adopting acceptance and promoting responsibility.

The coronavirus pandemic poses a huge challenge to the society because it tests its ability to cope with a multifarious threat under the constraints of the situation.
Political actions are taken in the realm of health
management, public security, financial economics,
protection of assets and production of goods. Although
important, psychological health is probably the most
neglected aspect of the COVID-19 pandemic. It is
not an immediately visible part of the global picture
of this disaster, but the negative psychological impact
of the pandemic and measures taken in response to
the pandemic is well known (Brooks et al., 2020;
Morganstein, Fullerton, Ursano, & Holloway, 2017).
Crucially, the resilience of a society facing such a
catastrophic event also depends on how its individual
members cope with their anxiety and fears. Widespread
fears of aloneness, contagion and death affect our
sense of agency, relatedness and the way we behave,
in addition to restrictions imposed by governments.
Coping with these fears is thus critical on the individual
level, and effective coping can also help the society to
better manage the pandemic.

Fear is a basic emotion that is activated in response to perceived threat.
In the current article, we propose that fear during the COVID-19 pandemic
is organized on the psychological level around four
interrelated dialectical domains. These domains of fear
are (1) fear of the body/fear for the body, (2) fear of
significant others/fear for significant others, (3) fear
of not knowing/fear of knowing and (4) fear of taking
action/fear of inaction, and they represent the bodily,
interpersonal, cognitive, and behavioural features of
fear, respectively. We contend that the four domains of
fear observed during the COVID-19 pandemic reflect
the main psychological means of grasping the reality.
Moreover, we propose a dialectical structure of the
identified fears, whereby each aspect of a fear domain
may coexist with its counterpart (the apparent opposite)
and may relate to the aspects of other fear domains.
Thus, fear domains and their aspects are not organised
in a hierarchical manner and represent “ingredients” of
the complex experience of fear during the pandemic.
Figure 1 provides a graphical representation of
the domains of fears and their reciprocal interactions.
These “four horsemen of fear” are discussed in more
detail in the next section.


The four horsemen of fear during the COVID
pandemic


The first domain of fear (fear of the body/fear for the
body) concerns the body and its signals. The body is the
first organizer of our human experience (Stern, 1985)
and it “keeps the score” (van der Kolk, 2015) of events
that threaten our physical and psychological integrity. In
the current experience of the COVID-19 pandemic, fear
of the body relates to a sense of physical vulnerability
due to which the body is a potential source of danger and
cannot be trusted (Starcevic, 2005). Such perception of

The second domain of fear (fear of significant
others/fear for significant others) relates to important
interpersonal relationships. As Aristotle said in his
Politics (Lord, 2003), human beings are by nature
“social animals”. Interpersonal relationships are at
the core of human identity, especially those involving
attachment figures such as parents, offspring and people
with whom we have romantic relationships. These
individuals provide us with a safe haven and a secure
base (Bowlby, 1988) from which we feel comfortable
to explore our internal experience and the external
world. The COVID-19 pandemic has affected our
perception of close interpersonal relationships with the
recommendations surrounding “social distancing”. We
are told by the authorities that maintaining a physical
distance even from people to whom we are attached
will slow down the spread of the coronavirus and keep
everyone safe. The consequence of this is a perception
that even the loved ones might harm us or kill us,
although unwittingly. Therefore, instead of providing
protection or a sense of safety, a parent, a child or an
intimate partner becomes a potential threat, with our
survival possibly depending on protecting ourselves
against people with whom we have the strongest
affective bonds. Conversely, we experience ourselves
as being potentially dangerous to our loved ones and
responsible if they become infected. We are thereby
deprived of our normal role to care for them or protect
them. These changes have profound consequences not
only in terms of how we relate to the significant others,
but also in terms of further undermining our sense of
safety and our need to “be there” for our loved ones.

The third domain of fear (fear of not knowing/fear
of knowing) concerns the cognitive aspect of mastering
the situations. In the context of the current COVID-19
pandemic, knowledge about the pandemic is bounded
and partial, which is deeply unsettling. One way of
coping with this situation is using the availability
heuristic (Tversky & Kahneman, 1973), that is, relying
on information that can be recalled, usually information
to which the person was exposed very recently. This

Figure 1. The “four horsemen” of fear (the four domains of fear) during the COVID-19 pandemic. Each fear

The fourth domain of fear (fear of taking action/fear
of inaction) concerns behavioural consequences of fear
during the COVID-19 pandemic. Our lives also consist
of actions, that is, intentional and purposeful activities
that are not reflexive, but are subjectively meaningful
(Davidson, 1980). As already noted, fears in the bodily,
interpersonal and cognitive domains often have a direct
impact on the behaviour. This is especially the case
when the “mutually opposing” fears alternate quickly,
producing indecisiveness and paralysing action. For
example, it may be very difficult to decide whether to
visit one’s elderly parents because of the possibility
of infecting them; such a person is torn between a
duty to care for parents and responsibility for keeping
them safe by avoiding such visits. In some vulnerable
individuals, a fear of taking action may manifest itself
in obsessive doubts about doing simple things, such
as buying groceries or opening a package sent from a
parent living in a heavily contaminated area. The other
“side of the coin” in this fear domain relates to people
who have a strong need to take some action and who
may be afraid of being passive or of being perceived
as such. This may explain the behaviour of individuals
who became hyperactive on social networking sites
only during the COVID-19 pandemic. Such individuals
spend most of the time online, going live on webcams,
publishing their own pictures or videos or posting news
related to the pandemic. In addition to alleviating these
individuals’ fear of inaction and of being invisible in
the world of the social media, such behaviour may
satisfy their narcissistic needs (Gnambs & Appel,
2018) and/or a need for belonging to a group that might
provide a sense of security. However, this behavioural
pattern may also reflect the problematic use of social
networking sites or apps which may have addictive
aspects that are difficult to attenuate and could require
clinical intervention.


Managing fear domains


Conquering pathological fear in the context of
the COVID-19 pandemic requires measures that
are relatively simple, as well as those that are more
complex and are best implemented in collaboration
with a mental health professional. Considering a
need to maintain social distance, psychoeducation
and psychological treatment delivered remotely via
communication technologies can provide individuals
with appropriate support (Sucala, Schnur, Constantino,
Miller, Brackman, & Montgomery, 2012) and improve
their quality of life (Lange, van de Ven, & Schrieken,
2003).

In fact, improving psychological health of
individuals is vital for strengthening the resilience
of the society as a whole. We argue here that this
objective could be achieved by applying the following
measures: (a) improving appraisal of the body, (b)
fostering attachment security, (c) improving emotion
regulation, (d) adopting acceptance and (e) promoting
responsibility.


Improving appraisal of the body


It is crucial for people in the midst of a pandemic
to be able to accurately appraise the physiological
signals of their bodies and to neither underestimate
nor overestimate their susceptibility to infections and
the associated physical threat. Most people find useful
physical and mental exercises that increase the feelings
of safety and control over the body, such as improving
posture (Weineck, Messner, Hauke, & Pollatos, 2019),
tracking the body autonomic response (Porges & Dana,
2018) and practicing mindfulness (Gibson, 2019).
People who are severely anxious about their health or
develop a full-blown hypochondriasis may need further
psychological treatment that specifically addresses
their bodily concerns (Bouman, 2014); sometimes,
this approach can be accompanied by antidepressants
(Harding & Fallon, 2014).


Fostering attachment security


Developing secure attachments is likely to improve
coping with the fear of the significant others and fear for
the significant others. Secure attachment has been linked
with the positive quality of interpersonal interactions
(including interactions with strangers; Roisman, 2006)
and with a capacity for effective self-regulation and topdown control (Pallini, Chirumbolo, Morelli, Baiocco, Laghi, & Eisenberg, 2018). Attachment security can
be fostered in the family and in other relationships via
mutually constructive communication (Domingue &
Mollen, 2009) that involves synchronous interactions
(e.g., by phone, if the communication partner is not
present; Gentzler, Oberhauser, Westerman, & Nadorff,

2011). When problematic relationships in the context of
the fears of COVID-19 call for a clinical intervention
improving the capacity to represent and mentalize the
internal states and the interpersonal motivations of
the significant others may be critical for both adults
(Allen & Fonagy, 2006) and children (Midgley, Ensink,
Linqvist, Malberg, & Muller, 2017). Also, it is important
to assess the quality of the attachment relationships,
identify the problems in these relationships and address
any internal conflicts that may surround the problems
(Lemma, Target, Fonagy, 2011). This should make a
tailored intervention to interpersonal fears possible.


Improving emotion regulation


Adopting acceptance

Clinical interventions based on acceptance
and compassion target the maladaptive emotional
avoidance and the unwillingness to experience
negatively evaluated feelings, sensations and thoughts
that generate inappropriate or detrimental behaviours.
These interventions increase flexibility and allow
adaptive behavioural change.


Promoting responsibility


Finally, situations like the COVID-19 pandemic
may bring out both the best and the worst in people.
It is a test of human ability to empathise, exhibit
solidarity and put the good of the society above one’s
own interests. Thus, individual responsibility is crucial
in the time of the COVID-19 pandemic. Individuals
are moral agents and their actions may positively or
negatively affect the lives of other people. Therefore,
promoting awareness of the pandemic and responsible
behaviour towards oneself and others may help people
feel morally sustained when confronting their fears.
Ultimately, it is responsible action that may prove
critical for our survival.


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Commentary by DFM:

  1. There are multiple connections between this paper and the The General Theory of Behaviour.
  2. Emotion regulation by the ‘four horsemen’ follows principles of homeostasis laid out in the theory.
  3. The regulation of fear makes the difference between chaos and control.

Published by David F Marks

Author, editor, psychologist.

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