**4. Discussion**

The current study aimed to investigate the state of anxiety and emotional awareness in a sample of healthy older adolescents. It was hypothesized that, because of the effects of the COVID-19 pandemic, the sample would have shown a high level of anxiety. The age group around 18 was chosen to minimize any high anxiety levels or low emotional awareness due to the emotional and affective instability in young adolescence [25–27]. The questionnaires SAS and EAQ were chosen because they did not reference the pandemic.

In the current study, over half of the SAS individual items reached a high anxiety score and, consequently, the SAS total score reached an unusually high anxiety score (SAS index 52.7).

Previous studies, during non-COVID times, found lower total SAS scores, both in large non-clinical samples of college students, in control subjects, and even in several groups of psychiatric patients [20,21,24,28]. For example, normal subjects of Zung's study (*n* = 100) had a mean SAS index significantly lower than all five groups of patients examined (33.8 ± 5.9), while the patient sample (*n* = 225) reached mean indices ranging from 45.8 to 58.7. Patients with anxiety disorders showed a mean SAS index significantly higher than those of the other four diagnostic groups (58.7 ± 13.5) [20].

Similarly, in studies comparing normal controls, psychiatric patients, and subjects with anxiety disorders found in healthy groups, SAS indices ranged between 40 and 43 [21,24,28].

Moreover, the Zung rating scale measures state anxiety as a transient expression of a temporary emotional condition, relative to the current period (within the previous week). The state anxiety construct refers to a momentary interruption of an emotional positive continuum expressed in a subjective feeling of tension, worry, restlessness, nervousness, and reactivity, also through the activation of the autonomic nervous system and several physiological activations [29,30]. Conversely, the trait anxiety construct expresses a stable modality of emotional functioning dominated by anxiety, which favors a constant perception of danger and threat, even behind neutral events, or with low anxiety values. Therefore, since the sample was a healthy, non-clinical one, and the SAS measured state and non-trait anxiety, the unusually high anxiety scores observed would not appear to be attributed to the sample's stable emotional functioning, but it is likely due to a temporary condition or feeling of tension and apprehension that favors a leavening of anxious responses.

Analyzing the single items, in the same previous studies, the item of breathing difficulties reached average scores lower than 2, both in normal subjects and in psychiatric patients [21,24,28]. Meanwhile, a study on patients with anxiety disorders [28] documented a score of 3.31 ± 0.99, very close to the score of the current studied adolescents (3.4 ± 0.81). It is interesting to point out that it is widely shared (among public opinion) that breath is a very easy vehicle for virus transmission, and coronavirus mainly affects respiratory functions, while breathing difficulties are among the first manifestations of viral activity in the human body. It is very understandable, therefore, that a high percentage of sample complaints concern not being able to "breathe in and out easily". Moreover, breathing rhythms change in accordance to emotional stress. Anxiety, stress, or panic increase the respiratory rate and the amount of air in the lungs resulting in the feeling of shortness of breath. Chronic respiratory diseases in pediatric age appeared as a significant source of stress, also, for mothers, impacting their personality traits and memory performances [31].

Likewise, items referring to sleep disorder, anxiety, panic, and a negative expectation of the future reached high average scores. Sleep is one of the great anxiety-sensitive functions. Just as the catastrophic expectations of the future, restlessness, and feeling nervous, are symptomatic expressions of anxiety through the motor and neurovegetative pathways.

Coronavirus not only brings death in the short-term, but it also destabilizes behavior patterns in the long-term. The risk and fear of contagion have modified production models, employment policies, social and interpersonal relationships, leisure habits, education, and training systems and every consolidated behavioral repertoire—this is especially so for younger people. Therefore, the overall future becomes nebulous, confused, uncertain, and distressing. An anxious phenomenology develops, affecting anxiety and the ideo-affective dimension, while the somatic symptomatology, such as fainting, tremors, dizziness, and paresthesia, appears to be less severe.

Conversely, on the EAQ, the total emotional awareness score reached quite high levels compared to the maximum score, showing valid emotional abilities in the sample. On the qualitative view, "Attending to others' emotions" and "Analyses of one's own emotions" were the two subscales with the highest scores. The participants considered it important to know, analyze, understand, and care for the emotions of others, as well as their own, both in normal and problematic conditions (i.e., "if a friend is upset"). Contrarily, they self-rated as less willing to verbally share their own emotions with others, and they showed difficulty explaining emotions, i.e., "to talk to anyone about how I feel", believing, for example, that "when I am feeling bad, it is no one else's business". On the one hand, therefore, there was openness and willingness to evaluate and understand the emotions of others and one's own, on the other, less willingness to share one's emotions with others.

In the correlational analysis, anxiety and emotional awareness overall scores appeared as two unrelated variables. Therefore, anxiety observed in the study did not seem associated with emotional awareness and management. Namely, it further confirmed the nature of state anxiety, which occurs temporarily in a particular historical condition, and the hypothesis that the epidemic promotes an increase in anxiety, even in adolescents with good awareness of their own (and others') emotions. These findings supported the hypothesis that the COVID-19 pandemic and its following restrictive measures may be a risk condition for an increased state anxiety level in older adolescents. Widespread anxiety and fear, prolonged isolation in a restricted domestic environment, forced removal from school friends and relatives, the fear of being infected, confused or contradictory information, and the uncertainties of personal and family future likely supported an increase in anxious responses.

Therefore, the group of participants examined, despite showing a good level of emotional awareness at the EAQ, achieved quite high levels of state anxiety in the SAS, which cannot be seen as a stable emotional mode of functioning, but should be associated with the particular anxiety-inducing events during the time of COVID-19. Such data are consistent with similar (recent) studies involving college students in China, indicating that the students were troubled by anxiety concerning COVID-19, for the consequences on their studies [32], future employment [33], and in their interpersonal relationships [34,35].

According to the learned helplessness stress model [36], the COVID-19 pandemic and its following restrictive measures may be viewed as uncontrollable, leading to unpredictable helplessness conditions. Moreover, in line with the cumulative stress hypothesis [37], stressors, such as the physical and psychological problems related to the pandemic and the lockdown, may activate an excessive production of glucocorticoids and a deregulation of cortisol release, increasing, over time, the individual's vulnerability to stress-related pathologies [38,39]. Given its high density of glucocorticoid receptors, the hippocampus appears as a structure particularly involved in stress responses, and in cumulative exposure to high levels of cortisol [40] that could have lasting effects on memory and cognitive processes [39,41–43].

Examining both the EAQ and SAS in relation to sex, female anxiety scale scores appeared significantly higher than those of males, whereas no significant differences were found concerning emotion awareness. It is likely that females feel the distress of the moment with greater anxiety, even though they manifest emotional awareness skills similar to that of boys. This finding was inconsistent with Cao and colleagues [1]—that male and female students in a sample of university students in China experienced similar stresses and negative emotions due to the epidemic.

Concerning psychological community implications, data suggest the need to develop intervention programs focused on the emotional and affective reactions of older adolescents [6,10]. As the pandemic is inevitable, unpredictable, and uncontrollable [44], and as the restrictive measures are the only way to contain the spread of the infection, the golden rule in addressing adolescent anxiety may be to provide 1) an effective, empathic, and reassuring communication system with the direct participation of adolescents, and 2) psychological counseling services for stress management.

In a recent editorial, in order to prevent "the disease of panic", *The Lancet* highlighted that the COVID-19 pandemic cannot be prevented; nevertheless, providing people with accurate information "is the most effective prevention against the disease of panic" [45]. Communication aimed at older adolescents should offer them the possibility of being properly and honestly informed, and of getting out of isolation by sharing with others their fears, anxieties, and irrational beliefs. Such a communication system should not be only factual, but focused on their problems, for example, the management of any physical symptoms potentially related to the infection, the real ways of transmitting the virus, the duration of the restrictive measures, the short-term effects of the pandemic on the school year, lifestyle, leisure activities, interpersonal relationships and the economic conditions of their families, the validity of fake news, and the long-term effects on their futures and their families [46].

Likewise, psychological counseling should provide online services to cope with mental health issues due to anxiety from the pandemic or from intrafamilial interpersonal relations. According to Petersen' suggestion, fear must be handled through "optimistic anxiety"—that is, being anxious enough "to take the advice of the authorities to heart" and optimistic enough to feel that one's actions make a difference [47].

Effective, empathic information, and psychological counseling monitored by experienced adults (directly involving adolescents) can mitigate the anxious reactions of adolescents, and may help them to handle uncertainty and fear contextualizing individual vulnerability.

In conclusion, it is important to underline a limitation of the presented study concerning the sample size. Unfortunately, the unusual condition of forced distancing led us to use a remote data collection method, and to dedicate a large part of the work to build the online task. This has limited us in recruiting a larger sample. The data are descriptive given the sample size, and they must be contextualized to a very specific period and to a unique condition; therefore, they cannot be generalized.

**Author Contributions:** P.S. and G.L. conceived and designed the experiment; P.S. performed the experiment; P.S. and D.S. analyzed the data; P.S. and G.L. analyzed and supervised the methodology and the form of writing; P.S. and D.S. wrote and revised the manuscript; G.L. acquired the founds; D.S. edited revised versions of the manuscript; P.S., G.L. and D.S. revised and approved the final version of the paper. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** The authors thank Cristina Leone for her valuable contribution in data collection.

**Conflicts of Interest:** The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest and in compliance with ethical standards.
