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vol. 9
Original paper

Uncertainty, alexithymia, suppression and vulnerability during the COVID-19 pandemic in Italy

Emanuele Maria Merlo
Federica Sicari
Fabio Frisone
Gaetano Costa
Angela Alibrandi
Giuseppe Avena
Salvatore Settineri

University of Messina, Messina, Italy
University Hospital G. Martino, Messina, Italy
Health Psychology Report, 9(2), 169–179
Online publish date: 2021/03/05
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COVID-19 represents the largest outbreak of atypical pneumonia caused by the SARS-CoV-2 virus, belonging to the coronavirus family (Orthocoronavirinae). The rapid diffusion, favored by the current globalization, was declared as an international emergency on January 30, 2020 (Mahase, 2020; Perna et al., 2020). China was the first nation to identify the virus, until the rapid increase in the number of cases led the World Health Or-ganization (WHO) to declare a pandemic (WHO, 2020).
The outcomes of the infection are being studied, data are being collected, and it has been noted that immunity is still uncertain, since the antibodies are not neutralizing the pathogens to give certain lasting im-munity. It is an RNA virus subject to mutation. The outcome of the lung infection can leave signs of respirato-ry failure which become chronic in those subjects with other pre-existing conditions (alteration of triglycer-ide metabolism, glycemia, autoimmune diseases).
Scientists and health professionals tend to focus on the biological risks associated with the virus, with the primary objective of developing measures suitable for its containment and treatment (Ornell et al., 2020). However, as demonstrated by previous studies, the total attention paid to pathogens induces these profes-sionals to neglect secondary psychological and psychiatric implications (Imperatori et al., 2020; Tsamakis et al., 2020). Furthermore, the status of health professionals and caregivers must be taken into consideration in order to avoid secondary negative outcomes both in psychiatric and psychological terms (de Pablo et al., 2020; Di Tella et al., 2020; Marchetti et al., 2020; Merlo et al., 2020a, b; Zhang et al., 2020a).
In fact, the results that emerged from empirical research conducted in comparable quarantine periods revealed the high presence of maladaptive behaviors and underlined that during epidemics the number of sub-jects reporting negative effects on their mental health was even greater than the number of individuals affected by the virus (Shigemura et al., 2020).
The perception of a growing sense of threat has had a significant impact on the population in psycho-pathological terms (Ahmed et al., 2020; Asmundson & Taylor, 2020; Brooks et al., 2020; Kolesovs et al., 2020; Rajkumar, 2020; Steardo & Verkhratsky, 2020; Wang et al., 2020).
Restrictive measures have been adopted such as the ban on social interaction (Fiorillo & Gorwood, 2020; Pfattheicher et al., 2020) and the consequent impossibility of communicating face to face, which have determined not only the development of a growing sense of anger and loneliness (Xiang et al., 2020), but also the onset of stressful conditions (Zhang et al., 2020b) and real post-traumatic disorders (Holmes et al., 2020). In this sense, a recent study carried out in China highlighted the presence of high levels of vicarious traumati-zation in the population, with higher scores for front line nurses (Li et al., 2020).
These data highlight once again the need to understand not only the extent of the phenomenon but also to identify those factors affecting the psycho-physical well-being of the general population (Bettinsoli et al., 2020; Wu et al., 2020), as in the case of the dialogue between medicine and clinical psychology (Conversano, 2019; Martino et al., 2019c; Merlo, 2019b).
Intolerance to uncertainty represents an important factor of vulnerability, involved in the develop-ment of psychopathologies. This dimension, which implies the tendency to react negatively at an emotional, cognitive and behavioral level to uncertain situations (Buhr & Dugas, 2002), could induce subjects to overes-timate the probability of unexpected events and to interpret ambiguous information as a source of threat (Car-leton et al., 2012).
In fact, false information related to the transmission of the virus and the ambiguities linked to the mortality rate, prognosis and possible therapeutic protocols, induced uncertainty and anxiety related to the still partially known and unpredictable nature of COVID-19 (González-Olmo et al., 2020).
The perception of such a vulnerability and a profound uncertainty could compromise the well-being and emotional functioning of the subjects, whose dysregulation is typical of the alexithymic condition. This dynamic tends to interfere with the processes of self-regulation and reorganization of emotions (Taylor et al., 2000). This defense mechanism allows the subjects to banish highly disturbing contents from the conscious-ness such as contamination, viruses or death (Settineri et al., 2019c; Settineri & Merlo, 2020a, 2020b). A flexi-ble use of defenses allows the individual to cope with the aforementioned conditions of fear of contagion and uncertainty in a temporarily adaptive way. The rigid and frequent use of defenses can determine maladapta-tion and predict pathological outcomes requiring clinical attention (Di Giuseppe et al., 2019a, b, 2020; Marti-no et al., 2020; Settineri et al., 2019b), in particular when the level of fear is considerable (Garaffa et al., 2020) and the need to cope with psychopathological issues becomes clear (Super et al., 2020).
In this sense, in order to plan effective interventions, which support the individual in the need to face the current health emergency (Orrù et al., 2020), some fundamental dimensions such as uncertainty, alexi-thymia, vulnerability and psychological mechanisms must be considered.


In our study, we hypothesize that: (1) there are significant correlations among the suppressive tendencies of individuals and the alexithymic condition; (2) there are significant correlations among intolerance to uncer-tainty and suppressive mechanisms (3) there are significant correlations among intolerance to uncertainty and the perception of vulnerability to pathology; (4) there are significant associations between alexithymia and the perception of vulnerability to pathology; (5) there are causal dependencies among the identified pre-dictors (Tas-20 and related factors) and the variables related to intolerance to uncertainty and perception of vulnerability to the pathology.



The observation group consisted of 355 subjects aged from 18 to 78 years old (M = 36.51, SD = 13.08) with a prevalence of female subjects (70.3%), who were involved in completing the protocol. The administration took place in the first 10 days from the Italian government decree that configured the lockdown (Decree-law of 25 March 2020, no. 19). The subjects were asked to complete the protocol in the online form, due to the impossibility of physical visits.


All the participants gave their consent to participate in this study and were evaluated by the clinical psy-chologists and physicians. This research was conducted with respect for the rights of the participants, accord-ing to the World Medical Association Declaration of Helsinki and its amendments. The data were analyzed anonymously. Each participant was properly informed about the research aim and study, and after compre-hension signed the informed written consent.


The numerical data were expressed as mean and standard deviation and the categorical variables as number and percentage. The Spearman test was applied in order to evaluate the correlations among variables of the following instruments. Multivariate linear regression was used to assess the dependence of uncertainty and infectability perception on a set of independent predictors (alexithymia). Statistical analyses were performed using the SPSS 26.0 for Windows package. A p-value smaller than .050 was considered to be statistically sig-nificant.


The module provided for the collection of personal information, such as age, gender, years of study, occupa-tion, residence and marital status.
Intolerance of Uncertainty Scale (IUS-12). The Intolerance of Uncertainty Scale (Carleton et al., 2007) is a self-report instrument based on 12 items with a 5-point Likert scale. According to Bottesi et al. (2016) reporting Carleton’s concept “intolerance to uncertainty can be considered as the individual’s dispositional incapacity to endure the aversive response triggered by the perceived absence of salient, key, or sufficient information, and sustained by the associated perception of uncertainty” (p. 31). The original version (Free-ston et al., 1994), which was reduced by Carleton et al. (2007), provided for 12 weighted items belonging to two factors: prospective anxiety and inhibitory anxiety. With reference to this bifactorial structure, strong psychometric properties of the IUS-12 and a high correlation with the original IUS (r = .96) were reported. The total and subscale scores highlighted consistent construct validity, internal reliability, and test-retest reliabil-ity (Cronbach’s α of .91, total scale, .85 for both subscale scores, r = .77) (Carleton et al., 2007; Khawaja & Yu, 2010).
Toronto Alexithymia Scale (TAS-20). The Toronto Alexithymia Scale (Bagby et al., 1994) is a well-known self-report instrument consisting of 20 items, based on a 5-points Likert scale. The original version of the TAS-20 demonstrated an internal consistency of .81 (Cronbach’s α), reporting a three-factor structure ac-counting for 31% of the total variance, respectively difficulty in identifying feelings (.78), difficulty in de-scribing feelings (.75) and externally oriented thinking (.66). In 1996 Bressi et al. published a cross validation of the TAS-20, performing the psychometric analyses with regard to both clinical and non-clinical subjects. In detail, the α coefficient scores obtained with the non-clinic sample were .75 for the total scale, .77, .67 and .52 respectively for the first, the second and the third factors; the clinical sample scores were .82 for the full scale, .79, .68 and .54 for the three factors (Bressi et al., 1996). Further studies (Caretti et al., 2011; Craparo et al., 2015) analyzed the psychometric properties of the scale, highlighting the good consistency and reliabil-ity of the three-factor structure.
Self-report scale to measure perceived vulnerability to disease (PVDQ-15). The PVDQ-15 (Duncan et al., 2009) is a self-report scale based on 15 items concerning themes related to perceived vulnerability to pathologies and pathogens easily transferable among individuals. The items consist of a 7-point ordinal Lik-ert scale from 1 (strongly disagree) to 7 (strongly agree). The original validation research provided for a two-factor structure, respectively perceived infectability and germ aversion. The internal consistency for the whole scale was .82 (Cronbach’s α), .87 and .74 for the first and second factors. Subsequent studies (Díaz et al., 2016; Klavina et al., 2011) investigated in depth the factor structure and the psychometric characteris-tics of the instrument, so that it was possible to assume that the results of its use are close to the purpose of the original study.
Suppression Mental Questionnaire (SMQ). The Suppression Mental Questionnaire (Settineri et al., 2019d) is a self-report instrument composed of 18 items. The 18 items belong to three different factors, re-spectively repressive function, regression in the service of the ego, and rationalization. The preliminary study demonstrated a good sampling adequacy (KMO = 0.65), with the following α coefficients: repressive func-tion = .74; regression in the service of the ego = .80; rationalization = .70. The significantly weighted items (18) were structured on the basis of a 5-point ordinal Likert scale. The items referred to the three above-mentioned factors for the following assignment: factor 1 – items 3, 4, 7, 8, 10, 14, 15, 16, 17, 18; factor 2 – items 5, 6, 9, 11, 12; factor 3 – items 1, 2, 7, 13. A subsequent analysis (App version) provided the following Cronbach’s α coefficients: .73 for the first factor, .77 for the second and .76 for the last one.


Descriptive statistics (mean and standard deviation) are reported in Table 1, in order to highlight the presence of considered phenomena.


The first hypothesis concerned the relationships among personal variables such as age and years of study, alexithymia variables and suppressive tendencies of the involved subjects. Regarding age, a significant and positive correlation was found with reference to the repressive function, so that it is possible to assume that these correlations highlighted the direction of the two phenomena. Increasing age corresponded to an increase of the repressive function. In specific terms, older subjects appeared to activate higher levels of repressive function, in order to cope with contents related to the work commitment and related pathological experience. In the same direction, the year of study appeared to assume the same direction of the repressive function. Higher levels of repressive function were associated with a higher number of years of study of the subjects. With reference to alexithymia correlations, the first datum referred to a significant and negative correlation between the difficulty in identifying feelings and the repressive function. This datum highlighted a common direction, so lower levels of knowledge and identifying functions related to feelings were likely to assume the opposite direction of the repressive function. The knowledge and the capacity to identify feelings and emo-tions could be considered as the main characteristic useful to operate a conscious movement in order to ban-ish the disturbing feelings from the consciousness. In an opposite sense, all scores related to the intersection between alexithymia and suppression were significantly correlated with suppression factors. The significant correlations were positive, suggesting a level of knowledge higher than the previous one, so that subjects’ perception of feelings could be considered as present, rather than completely neglected from knowledge. The variable externally oriented thinking appeared to be significantly correlated with the repressive function and with the SMQ total score, in negative terms. This datum informed us about the general inner nature of the suppressive practice and about the inverse relation emerged with the repressive function. The last significant relation that emerged was that between the total score of the alexithymia scale and the regression in the ser-vice of the ego. Specifically, the significant correlation emerged as positive, showing the direction assumed by the two phenomena. In detail, increasing levels of alexithymia corresponded to higher levels of regression in the service of the ego, and therefore greater propensity to get in touch with fantasies and unconscious regres-sions.


The second hypothesis was aimed at highlighting the directions assumed by the phenomena related to the suppressive necessity, with a particular reference to current disturbing issues, and uncertainty. As previously pointed out, a general atmosphere of uncertainty and the necessity to suppress disturbing contents represent-ed the main issues identified by this research. Relevant and significant correlations emerged, particularly in-herent to regression in the service of the ego and years of study. Years of study appears to be a protective fac-tor in several studies, with reference to a consistent amount of health professions, psychological, medical and environmental conditions. In our case, the significant correlations covered the all of the IUS-12 factors. All relations were significant and positive, suggesting the opposite direction of knowledge acquired through in-structions and educational training, with prospective, inhibitory anxiety and the general tendency to not toler-ate uncertainty related to ongoing inner and external issues. The second group of significant correlations emerged among regression in the service of the ego and all IUS-12 factors. The relations were positive, show-ing that greater levels of having recourse to fantasies and unconscious imaginings corresponded to increasing levels of prospective and inhibitory anxiety.


The third hypothesis concerned the directions of the two scales regarding intolerance to uncertainty and the specific themes of infectability, understood as anguish and aversion to pathogens. Several significant correla-tions emerged, with reference to all factors and total scores. Years of study appeared to be not significantly associated with the scales’ factors and total scores. Regarding IUS variables, prospective anxiety was signifi-cantly and positively associated with perceived infectability, germ aversion and with the PVDQ total score. Higher levels of anxiety concerning perspectives and future ideations corresponded to higher tendencies to fear the possibility to get infected by pathogens and the subsequent aversion. Inhibitory anxiety showed sig-nificant and positive directions with perceived infectability, germ aversion and the PVDQ total score, demon-strating that greater levels of inhibition provided by anxiety assumed the same direction of growing attitudes of distancing from possible infective issues. As for the just treated variables, total scores were positively as-sociated with each other. Age appeared to be significantly and positively associated with all PVDQ variables, so that it was possible to assume that age increase corresponded to greater tendencies in considering the pathogens’ role and infective outcomes.


The fourth hypothesis deepened the possible existing correlations among age, gender, PVDQ and TAS-20 vari-ables. The factors related to alexithymia played a great role; in fact, various significant relations emerged. Most of the significant correlations were positive, the only negative ones were referred to difficulty in de-scribing feelings and the total score of TAS-20. This fact highlighted the central role of educational paths, since higher number of years spent in education was inversely correlated with the two above-mentioned alex-ithymic factors. Difficulty in identifying feelings was significantly and positively associated with perceived infectability and the total score of the scale. The remaining PVDQ factors were all significantly and positively associated with all TAS-20 factors. This fact highlighted the relevant role of alexithymic structures. Alexi-thymia represents one of the main figures in the field of psychological themes. Its impact on psychological functioning has been highlighted by a large amount of scientific contributions. The decision to consider its relationships with the presented factors took into account the specific ongoing phenomena relievable from clinical contact with subjects asking for psychological support.


Regarding difficulty to identify feelings, significant associations were found with reference to all IUS-12 factors and perceived infectability (PVDQ-15). The IUS-12 total score appeared as significantly dependent from this alexithymic figure. Difficulty in identifying feelings demonstrated associations with prospective, inhibitory anxiety and with the total score. This predictor was associated with perceived infectability. Uncer-tainty appeared to assume the same causal dependence and direction, representing the final maladaptive out-come due to alexithymic issues. Difficulties in describing feelings showed no significance as a predictor, sug-gesting that the genesis of the maladaptive outcomes could be recognized specifically in a deeper process. The second group of significant relations regarded the impact of externally oriented thought with PVDQ-15 varia-bles, as perceived infectability, germ aversion and the total scale score. What appeared to be strongly signifi-cant was referred to the general role of alexithymia, since the total score of the scale contracted significant causal relations with all the considered variables (IUS-12 and PVDQ factors and total scores).


The results obtained showed statistically significant relationships, both in the correlations and in the linear regressions analyses. The hypotheses presented in the introduction and considered through the study were confirmed by the presence of the phenomena and of significant relations. The role of alexithymia as a significant predictor highlighted its strong effect on contagion anguish, even more specific due to the pres-ence of uncertainty and the need to cope with disturbing contents mediated by the mental suppression. These findings would be useful to develop interventions based on the evidence that initial psychodiagnostic paths are fundamental in order to distinguish active phenomena from a large number of manifestations. With refer-ence to this last statement, some distinctions are necessary to point out the specific nature of symptoms to be revealed and consequently treated, as in the case of underrated dynamics like solitude (Nowakowska, 2020).
The current context indicates that COVID-19 has generated radical uncertainties about the mental health of citizens. In this regard, it is pertinent to make a distinction between anxiety and anguish experiences (Merlo, 2019a; Settineri et al., 2019a). The basic distinction refers to the fact that anxiety, as well as fear, is addressed to a specific object while the experience of anguish recalls a feeling without an object, a constant state of alert that has no borders (Heidegger, 1927/1962; Imbriano, 2010; Jaspers, 1913). In our study, the reference is due to two main figures specifying the lack of knowledge typical of anguish experiences. Since alexithymia represented the main predictor, it would be proper to assume that the impossibility to get in touch with emotions and feelings can be considered as the main condition in order to experience anguish. The link is double, since a lack of knowledge both for inner and external phenomena would describe those psy-chopathological figures arising from unknown objects. The second reference is to uncertainty. It appeared as a clear outcome due to the mentioned lack of knowledge, so that its presence informed us about the persisting and ongoing unconscious dynamics taking the subjects to experience the following psychopathological expe-riences.
On the basis of the results, the challenges aroused by the pandemic seem to be more related to an-guish, since the subjects are still required to pay attention to avoid contagion without knowing where it may come from and in most of the cases conditioned by those psychological conditions decreasing the possibility to cope with medical conditions (Martino et al., 2019a, b). Citizens are called to respect physical distancing, to wash their hands repeatedly, to wear masks, to be careful in any context (work, social, family), being con-stantly updated regarding the trends of COVID-19 contagion through the media. For this reason, we assist in the increase of psychological pressure capable of generating stress and emotional malaise (Pawluk & Koerner, 2013). This state of permanent alert would leave space for anguish and a negative mood, seriously capable of compromising people’s mental health.
It is essential to continue to present contributions that can help cope with the COVID-19 pandemic al-so from a psychological point of view. This study highlighted the priority that psychological contents, wheth-er emotional or linked to defensive mechanisms, should have in dealing with emergencies. A pandemic, in fact, has its greatest impact on mental health, as well as social and financial fields (Shigemura et al., 2020). The promotion of emotional education through new technologies and the development of further research are deemed necessary to contribute to the protection of mental health during health emergencies (Di Giacomo, 2020; Glăveanu, 2020), such as the current one linked to COVID-19.


The present contribution took into account the main figures that emerged during the first ten days of re-strictions due to the pandemic. In order to distinguish previously existing structures from subsequent phe-nomena, different kinds of analyses were performed. The data highlight the main role of alexithymia along with negative outcomes related to uncertainty, contagion risk and the need to cope with linked disturbing con-tents. The psychodiagnostic paths, useful to structure interventions and treatments, would serve as a strong basis. Our contribution was aimed at highlighting the main emerging figures, in order to show how the identi-fication of specific crucial nodes would serve as a starting point for future diagnostic procedures and treat-ments.
Further research is needed, since possible changes and the tendency of the considered phenomena to get in touch with other developing figures are probable.


The study was conducted in accordance with the needs identified regarding the first psychopathological mani-festations of the patients and with the reported literature. The limitations of the study concern the limited time range, as the diagnostic measurements were performed in the first ten days of lockdown. Although this represents a limitation, the study was aimed at understanding the early manifestations. However, studies ana-lyzing pathological manifestations over longer spans are needed. Another limitation concerns the prevalence of female subjects compared to men. Subsequent studies will have to take into account the possibility of hav-ing samples paired by gender, so as to be able to perform analyses to detect significant differences.
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