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

one’s body is linked with a fear of “body betrayal” via
infection, which ultimately leads to death. This fear of
the body manifests itself in different ways in the setting
of the COVID-19 pandemic. People typically become
hypervigilant about any bodily changes that might
suggest the COVID-19 infection, fearfully anticipating
their surrender to it. The other body-related fear (fear
for the body) pertains to a need to protect the body. In
this type of fear, body is not perceived as a threat, but
as a treasure that may be lost; hence, body is valued for
survival and needs to be cared for. The fear of the body
and the fear for the body can alternate very quickly,
generating inconsistent and potentially body-damaging
behaviours. For example, Italian news recently reported
that many people who survived a heart attack preferred
to stay at home than to go to the hospital for the fear of
being infected (la Repubblica, 2020). Thus, fear of the
body and a need to protect it may be so intertwined that
the underlying estimates of threat (risk of dying from a
repeated heart attack or its complications versus risk of
becoming infected with COVID-19 and dying from it)
may be biased and result in a behaviour that ultimately
does not protect the body.

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

leads to a biased reasoning, whereby “things” that are
recalled have a greater value for understanding than
those that cannot be recalled readily. Biases in reasoning
such as the availability heuristic may paradoxically
give a person some sense of understanding or control,
but they act as a defence against a profound confusion
as to what one should know or needs to know about the
pandemic as opposed to what is better left unknown.
The information is never “neutral” and a careful
balancing act between useful and survival-promoting
information and frightening and paralysing information
may be difficult to achieve. For example, we may both
want to know and avoid knowing how many people
have been infected in our local community. While this
type of information may help some people cope better,
others may find it overwhelming and would rather be
left “in the dark”. What is most confusing, as with other
types of fear described in the context of the COVID-19
pandemic, is a quick alternation of a need to know
(fear of not knowing) and a need not to know (fear
of knowing); such an alternation is likely to interfere
with decision making and related actions. For example,
frantic searching for COVID-19-related information
online may increase anxiety and distress and thus lead
to cyberchondria (Starcevic, 2017); at the same time,
important and even survival-promoting information
may be overlooked or missed due to a fear of knowing.
The result can be a paralysing inaction alternating with
risk-taking behaviour.

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.

Brief descriptions of interventions that can
be delivered to address fears in the context of the
coronavirus pandemic are provided below. Considering
that there is no substitute for a tailored clinical evaluation
and individualized therapeutic approaches (Gazzillo,
Schimmenti, Formica, Simonelli, & Salvatore, 2017),
our aim is to list and discuss procedures and techniques
that can be integrated into traditional (offline)
psychotherapeutic interventions. Importantly, these
approaches can also be used within a framework of
online or phone-mediated psychological interventions,
and some can serve as stand-alone measures for people
experiencing fear and related psychological difficulties
but are not undergoing any psychological intervention
(i.e., probably the majority of people with such
emotional problems during the COVID-19 pandemic).

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

Improving emotion regulation is central for better
coping in relation to fears of knowing and not knowing.
An adequate emotion regulation fosters the identification,
monitoring and modification of emotional reactions
and makes it possible to tolerate distress inherent in
conflictual and complex situations (Koole, 2009). There
is evidence that a limited access to adaptive emotion
regulation strategies may contribute to more severe
psychopathologies characterised by affect dysregulation
and behavioural dyscontrol (Schimmenti, Santoro,
La Marca, Costanzo, & Gervasi, 2019). Adaptive
forms of emotion regulation include a constructive reevaluation of the events and restructuring of beliefs that play a key role in the development or maintenance of
various psychopathological manifestations. In contrast,
maladaptive strategies encompass a suppression of
emotion, dramatization, blaming oneself or others,
abstract rumination, excessive reassurance seeking or
use of alcohol or psychotropic drugs (Philippot, 2013;
Watkins, 2016). Promoting and learning effective
emotion regulation strategies will help the individual
entrapped in the fear of knowing/fear of not knowing
better cope with the negative affect related to the
pandemic, also reducing the risk of activating primitive
defence mechanisms, such as denial or acting out and
exclusive use of emotion-based coping.

Adopting acceptance

One way of addressing fears of taking or not taking
action is through acceptance, which refers to the
adoption of an open, receptive, and flexible attitude
with respect to experience (Stewart, 2014). Acceptance
allows the individual to recognize and acknowledge
the reality of a current scenario, condition or situation,
even if negative, along with its related dynamics. There
is evidence that acceptance is linked with a better
quality of life (Garcia, Al Nima, Kjell, 2014). In the
context of the coronavirus pandemic, acceptance aims
to better balance one’s need to act with the realisation
that many aspects of the situation are beyond one’s
control. Meditation techniques (Stewart, 2014) and
mindfulness (Hayes, Levin, Plumb-Vilardaga, Villatte,
& Pistorello, 2013) promote acceptance and selfcompassion.

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.

References

Allen, J. G., & Fonagy, P. (Eds.). (2006). The handbook of
mentalization-based treatment. New York, NY: John Wiley
& Sons Inc.
Bouman, T. K. (2014). Cognitive and behavioral models and
cognitive-behavioral and related therapies for health
anxiety and hypochondriasis. In Starcevic, V., & Noyes,
R. (Eds.). Hypochondriasis and Health Anxiety: A Guide
for Clinicians (pp. 149-198). New York, NY: Oxford
University Press.
Bowlby, J. (1988). A secure base. Clinical applications of
attachment theory. London, UK: Routledge.
Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L.,
Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The
psychological impact of quarantine and how to reduce it:
Rapid review of the evidence. The Lancet, 395(10227),
912–920. https://doi.org/10.1016/S0140-6736(20)30460-8
Davidson, D. (1980). Essay on Actions and Events. Oxford,
UK: Oxford University Press.
Domingue, R., & Mollen, D. (2009). Attachment and conflict
communication in adult romantic relationships. Journal of
Social and Personal Relationships, 26(5), 678–696. https://
doi.org/10.1177/0265407509347932
Garcia, D., Al Nima, A., & Kjell, O. N. E. (2014). The
affective profiles, psychological well-being, and harmony:
Environmental mastery and self-acceptance predict the
sense of a harmonious life. PeerJ, 2, e259. https://doi.
org/10.7717/peerj.259
Gazzillo, F., Schimmenti, A., Formica, I., Simonelli, A., &
Salvatore, S. (2017). Effectiveness is the gold standard
of clinical research. Research in Psychotherapy:
Psychopathology, Process and Outcome. https://doi.
org/10.4081/ripppo.2017.278
Gentzler, A. L., Oberhauser, A. M., Westerman, D., &
Nadorff, D. K. (2011). College students’ use of electronic
communication with parents: Links to loneliness,
attachment, and relationship quality. Cyberpsychology,
Behavior and Social Networking, 14(1–2), 71–74. https://
doi.org/10.1089/cyber.2009.0409
Gibson, J. (2019). Mindfulness, Interoception, and the Body:
A Contemporary Perspective. Frontiers in Psychology, 10.
https://doi.org/10.3389/fpsyg.2019.02012
Gnambs, T., & Appel, M. (2018). Narcissism and Social
Networking Behavior: A Meta-Analysis. Journal of
Personality, 86(2), 200–212. https://doi.org/10.1111/
jopy.12305
Harding, K. J. K., & Fallon, B. A. (2014). Pharmacological
treatment and neurobiology of hypochondriasis, illness
anxiety, and somatic symptoms. In Starcevic, V., & Noyes,
R. (Eds). Hypochondriasis and Health Anxiety: A Guide for
Clinicians (pp. 241-258). New York, NY: Oxford University
Press.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L.,
& Pistorello, J. (2013). Acceptance and commitment therapy
and contextual behavioral science: Examining the progress
The four horsemen of fear
Clinical Neuropsychiatry (2020) 17, 2 45
of a distinctive model of behavioral and cognitive therapy.
Behavior Therapy, 44(2), 180–198. https://doi.org/10.1016/j.
beth.2009.08.002
Koole, S. L. (2009). The psychology of emotion regulation: An
integrative review. Cognition and Emotion, 23(1), 4–41.
https://doi.org/10.1080/02699930802619031
Lange, A., van de Ven, J.-P., & Schrieken, B. (2003). Interapy:
Treatment of post-traumatic stress via the internet.
Cognitive Behaviour Therapy, 32(3), 110–124. https://doi.
org/10.1080/16506070302317
la Repubblica (2020). Coronavirus, l’allarme dei cardiologi: ‘Per
il timore contagi meno ricoveri per infarto’ [Coronavirus,
the cardiologists’ alarm: “Due to fear of contagion, less
ospitalization for infartion”]. (2020, March 25). Retrieved
from https://www.repubblica.it/salute/medicina-ericerca/2020/03/23/news/coronavirus_meno_ricoveri_per_
infarto_si_teme_il_contagio-252070598/
Lemma, A., Target, M., & Fonagy, P. (2011). Brief Dynamic
Interpersonal Therapy: A Clinician’s Guide. Oxford, UK:
Oxford University Press.
Lord (2003). Aristotle’s Politics. Chicago, IL: University of
Chicago Press.
Midgley, N., Ensink, K., Lindqvist, K., Malberg, N., & Muller, N.
(2017). Mentalization-based treatment for children: A timelimited approach. Washington, DC: American Psychological
Association. https://doi.org/10.1037/0000028-000
Morganstein, J. C., Fullerton, C. S., Ursano, R. J., & Holloway, H.
C. (2017). Pandemics: Health Care Emergencies. In Ursano,
R. J., Fullerton, C. S., Weisaeth, L., & Raphael, B. (eds.).
Textbook of Disaster Psychiatry (2nd ed., pp. 270–284).
Cambridge, NY: Cambridge University Press.
Pallini, S., Chirumbolo, A., Morelli, M., Baiocco, R., Laghi,
F., & Eisenberg, N. (2018). The relation of attachment
security status to effortful self-regulation: A meta-analysis.
Psychological Bulletin, 144(5), 501–531. https://doi.
org/10.1037/bul0000134
Philippot, P. (2013). Emotion Regulation: A Heuristic Paradigm for
Psychopathology. Journal of Experimental Psychopathology,
4(5), 600–607. https://doi.org/10.5127/jep.034513
Porges, S.W., & Dana, D. (2018). Clinical Applications of the
Polyvagal Theory: The Emergence of Polyvagal-Informed
Therapies. New York, NY: WW Norton.
Roisman, G. I. (2006). The role of adult attachment security in nonromantic, non-attachment-related first interactions between
same-sex strangers. Attachment & Human Development,
8(4), 341–352. https://doi.org/10.1080/14616730601048217
Schimmenti, A., Santoro, G., La Marca, L., Costanzo, A., &
Gervasi, A. M. (2019). Emotion dysregulation: a correlation
network analysis. Psychotherapy and Psychosomatics,
88(S1), 115. https://doi.org/ 10.1159/000502467.359
Starcevic, V. (2005). Fear of Death in Hypochondriasis:
Bodily Threat and Its Treatment Implications. Journal of
Contemporary Psychotherapy, 35(3), 227–237. https://doi.
org/10.1007/s10879-005-4317-0
Starcevic, V. (2017). Cyberchondria: Challenges of Problematic
Online Searches for Health-Related Information.
Psychotherapy and Psychosomatics, 86(3), 129–133. https://
doi.org/10.1159/000465525
Stewart, J. M. (2014). Mindfulness, acceptance, and the
psychodynamic evolution. Oakland, CA: Context Press.
Stern, D. N. (1985). The Interpersonal World of the Infant: A View
from Psychoanalysis and Developmental Psychology. New
York, NY: Basic Books.
Sucala, M., Schnur, J. B., Constantino, M. J., Miller, S. J.,
Brackman, E. H., & Montgomery, G. H. (2012). The
therapeutic relationship in e-therapy for mental health: A
systematic review. Journal of Medical Internet Research,
14(4), e110. https://doi.org/10.2196/jmir.2084
Tversky, A., & Kahneman, D. (1973). Availability: A heuristic for
judging frequency and probability. Cognitive Psychology, 5(2),
207–232. https://doi.org/10.1016/0010-0285(73)90033-9
van der Kolk, B. (2015). The Body Keeps the Score: Mind, Brain
and Body in the Transformation of Trauma. New York, NY:
Penguin Random House.
Watkins, E. R. (2016). Rumination-focused cognitive-behavioral
therapy for depression. New York, NY: Guilford Press.
Weineck, F., Messner, M., Hauke, G., & Pollatos, O. (2019).
Improving interoceptive ability through the practice of
power posing: A pilot study. PLoS ONE, 14(2). https://doi.
org/10.1371/journal.pone.0211453

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.