At the end of January 2020, with the massive outbreak of COVID-19 in China, the government called the populace at home and not necessarily go outside. Getting in and out of the streets, public transport, and other places, the public needed to wear masks, detect body temperature, and maintain social distance, which became the moment's social behavior norms to counter the threat from virus transmission.
Obsessive-Compulsive (OC) symptoms are composed of intrusive thoughts and repetitive behaviors, essentially trying to suppress or prevent excessive emotional expression (Foa et al., 1998; American Psychiatry Association, 2013). OC symptoms incorporating COVID-19-related social norms manifested as over-checking, over-washing, obsessing, and metal neutralizing. Several kinds of dysfunctional beliefs might induce negative emotions and evaluations, such as, exaggerating external threats, paying too much attention to the correctness of their thoughts and trying to control them, not tolerating uncertainty and perfectionism. Combined with the context of the epidemic, when intrusive thoughts (e.g., exaggerating the possibility of infection with a virus) came, compulsive behaviors would be used to alleviate the pain of negative emotions temporarily. However, the repeated execution of the compulsions can also accumulate painful emotions in the long run, especially when people lack understanding of emotions and confidence in regulating painful emotions (Luterek, Mennin, & Fresco, 2005; Calkins et al., 2013). Therefore, due to these negative beliefs, people would continue to use compulsive behaviors, resulting in a vicious circle. Repeated OC symptoms will solidify into OC disorders (Stern et al., 2014).
Difficulties in Emotion Regulation (DER) measures whether an individual responds to negative emotions in an unbalanced way (Gratz & Roemer, 2004). Gratz and Roemer (2004) identified four aspects involved in emotion dysregulation: (1) poor awareness and understanding of emotions, (2) poor acceptance of emotions, (3) lack of the ability to engage in goal-directed behavior, and refrain from impulsive behavior, when experiencing negative emotions, and (4) access to maladaptive emotion regulation strategies. As indicating by previous studies, avoiding internal experience is the basis of many psychological symptoms, and DER is directly related to various psychopathological symptoms (Hu et al., 2014). In the face of crises and a forced social quarantine, the public needs to adjust their negative emotions promptly. It is speculated that individuals with DER are more difficult in adapting to the epidemic environment and quickly suffer from psychological problems (e.g., Groarke et al., 2021).
Dominated by cross-sectional studies, most existing findings have confirmed the intimate relationship between OC and DER. Gross (1998) proposed that the process of emotion regulation is shown as “situation selection→ allocation of attention→ appraisal→ response.” Calkins et al. (2013) expanded this process model and considers that OC symptoms, especially compulsions, are a maladaptive emotion regulation strategy. It takes suppression during the response process, in which people try to reduce emotional expression. Furthermore, Moritz et al. (2018) pointed out that the recurrence of OC symptoms may be due to a lack of adaptive coping rather than an excess of maladaptive coping. Stern et al. (2014) conducted a study on undergraduates (n = 170) and results showed that OC symptoms were significantly correlated with poor understanding and fear for both negative and positive emotions.
In addition, DER would promote and maintain OC symptoms. For instance, in clinical samples(n = 59) and non-clinical samples(n = 331), even if anxiety, depression, and demographic variables were controlled, the positive correlation between OC and DER was still established (Yap et al., 2018). In another non-clinical sample, Fergus and Bardeen (2014) showed that difficulties in impulse control and lack of emotional clarity were uniquely associated with each dimension of OC symptoms. Yap et al. (2018) suggested that non-acceptance of emotions and non-participation in goal-oriented behaviors were markedly associated with OC across samples.
So far, however, no longitudinal finding has pointed out the bidirectional relationship between OC symptoms and DER. Although some cross-sectional studies obtained a significant mediation path that DER affected OC, this inference was not causally persuasive. For instance, Eichholz et al. (2020) confirmed that DER played a mediating role in self-compassion affecting OC symptom severity in patients (n = 90). Combining the previous research and the epidemic's situation, it can be inferred that they are more likely to present a mutual influence. When individuals lack effective and adaptive emotion regulation strategies during the epidemic, they would rely on current social norms to alleviate negative emotions. Influenced by dysfunctional beliefs, intrusive thoughts would make individuals be more inclined to adopt maladaptive compulsions to avoid, un-clarify, uncomprehend and un-accept their negative and distressed emotions, which further promote the formation of DER. Besides, when this vicious circle begins, it makes them be less confident in regulating emotions and difficult to control their impulsive behaviors as well. To conclude, discussing the relationship between OC and DER under the epidemic environment would help guide the public in informing appropriate response strategies when facing an emergency public crisis.
Following the predecessors' suggestion, when discussing the relationship between OC and DER, the effects of anxiety and depression should be considered covariates. And anxiety and depression were reported to be closely related to both (e.g., Yap et al., 2018). When confronted with the health threats posed by COVID-19, individuals are prone to worry about the health of themselves and their close persons, which quickly leads to health anxiety (Asmundson & Taylor, 2020). Health anxiety (HA) refers to the state that people overly worry about getting sick, exaggerate their physical feelings, and negatively explain physical symptoms (Salkovskis & Warwick, 1986). According to the cognitive model of HA (Salkovskis & Warwick, 1986), it will further produce distorted beliefs, destructive emotions, and maladaptive behaviors, resulting in more OC symptoms and DER (e.g., Sunderland et al., 2013; Görgen et al., 2014). During the COVID-19 lockdown, individuals barely went to the hospital for a diagnosis in time or relied on work to be distracted. In that case, they were supposed to be more likely to use compulsions to get rid of emotional distress. Therefore, HA may also play an essential role in the relationship between the association of OC symptoms and DER.
Sleep problems are also an important topic that cannot be ignored during social interaction (Altena et al., 2020). As an extension, we explored the predictive effect of the relationship between the OC symptoms and DER on daily sleep. Sleep problems (SP), including difficulty in falling asleep, waking up early, and not getting enough sleep were the COVID-19-related features, which are also shown to be part of the characteristics of sleep disorders in DSM-5 (American Psychiatric Association, 2013). Past research has found intrusive thoughts, uncontrollable worries, and other cognitive arousals that may hinder sleep onset and then cause insomnia (Harvey, 2000). Riemann et al. (2010) proposed a hyperarousal model of insomnia. It was pointing out that psychological stress before going to bed (e.g., intrusive thoughts) and the dysregulation of emotion regulation are accompanied by excessive reflection, which leads to a variety of SP. In a cross-sectional study with non-clinical samples, similar results were confirmed, especially, that obsessions aggravated insomnia (Timpano et al., 2014). And compulsions are also a good predictor of sleep time reduction and sleep loss (Alfano & Kim, 2011). Moreover, SP was considered to be related to the accumulation of negative emotions, decreased positive emotions, and insufficient emotional regulation (Tsypes, Aldao, & Mennin, 2014). A longitudinal study of three years (n = 942) has examined that DER positively predicted SP, and DER played an intermediary role in social relationships and SP (Tavernier & Willoughby, 2015). Moreover, a review of 44 cross-sectional epidemic articles worldwide summarized multiple factors that could lead to SP (Jahrami et al., 2021), such as negative emotions, stress, and the deficiency of social support. Nevertheless, no research has discussed OC symptoms in cross-sectional studies and used longitudinal analysis during the COVID-19 pandemic. It can be inferred that both OC and DER could affect SP, and even OC would further impact SP through DER.
Until now, only a minimal number of studies have combined longitudinal research design to measure the same batch of subjects to psychology changes of OC symptoms or DER. For example, a study in the UK (n = 1958) used four-time points to indicate the association between loneliness and depressive symptoms, finding that DER was not the moderator of temporal interaction (Groarke et al., 2021). However, these conventional longitudinal studies collected developmental process data to concern between-person change and covariates affecting change. Ambulatory assessment (AA) highlights its advantage in timely and acutely recording the subtle changes of the public's psychological states (Trull & Ebner-Priemer, 2013). The stable process data measured by AA would fluctuate around the mean, focusing on within-person variability and covariates predicting when values will deviate from the mean (McNeish & Hamaker, 2020). It provides daily measurement to assist to draw a more stable causal inference for OC and DER.
To conclude, the present study used an ambulatory assessment design with a sample of 122 Chinese adults to conduct questionnaires twice in the morning and evening for 14 consecutive days, with 28 measurement intervals. The Dynamic Structural Equation Modeling (DSEM; Asparouhov, Hamaker, & Muthén, 2018) framework was utilized to create a multilevel cross-lagged model that examined the bidirectional relationships between OC symptoms and DER. Next, to ensure the reliability of causal inferences, we also added factors related to the two variables and the epidemic — the level of health anxiety, anxiety, and depression — as covariates. As a corresponding extension, we tested the predictive effect of the two-way relationship on SP.