Introduction

In recent years, the COVID-19 outbreak has left an indelible mark on societies across the world. Beyond its immediate health implications, this crisis has brought forth an array of psychological and emotional challenges (Negri et al., 2023). The psychological impact of the pandemic has been particularly profound among young adults, who have faced disruptions in their daily lives, educational pursuits, employment prospects, and social interactions (Graupensperger et al., 2022; Qiu et al., 2020).

Recent psychological research has indicated that the COVID-19 outbreak and subsequent quarantine measures have been linked to a range of psychopathological symptoms including anxiety, depression, post-traumatic stress disorder, and sleep disturbances (e.g.; Cao et al., 2020; Cavalera et al., 2023; Le et al., 2020; Liang et al., 2020). Liu and colleagues (2020), for example, found a high prevalence of anxious and depressive symptoms in a sample of American adults. Comparable results were observed in studies conducted in England (Zaninotto et al., 2022), Vietnam (Tran et al., 2020), China and Poland (Wang et al., 2020), Portugal (Paulino et al., 2021), Spain, and Greece (Papandreou et al., 2020). Similarly, a multinational study across 26 European countries found a self-reported worsening in mental health during the pandemic, compared to pre-pandemic (Mendez-Lopez et al., 2022). Available data among the Italian population highlight a considerable psychological impact of the pandemic outbreaks and quarantine restrictions, with a high percentage of individuals experiencing depressive symptoms, anxious feelings, obsessive thoughts, and insomnia (Di Renzo et al., 2020).

Furthermore, it has been suggested that the pandemic had a significant impact on eating disorder (ED) risk and symptoms in a variety of population groups, also leading to an escalation in dysfunctional eating behaviours (Bonfanti et al., 2023; Cipriano et al., 2022; Linardon et al., 2022). The enforced isolation, threats of food shortages, disruption to daily activities, and increased screen time may have a detrimental impact on eating behaviours through multiple pathways (Flaudias et al., 2020) and, also, exacerbate the severity and occurrence of EDs’ symptoms, further deteriorating the mental well-being of individuals who were already vulnerable (Weissman & Hay, 2022). An international survey has found a worsening in individual eating behaviours (e.g., food types, uncontrolled eating, meal patterns), which have become more disordered after the pandemic outbreak (Ammar et al., 2020). Moreover, the changes in everyday activities and in lifestyle during the coronavirus pandemic have exacerbated preoccupation with weight and body shape which may trigger body dissatisfaction and other EDs symptoms (Miniati et al., 2021). In brief, research has demonstrated that the disruptions in routine, coupled with the increased emphasis on body image concerns and food-related anxieties in the media, limited access to support systems and therapeutic interventions during lockdowns have contributed to an exacerbation of ED’ symptoms (Haghshomar et al., 2022).

Beyond its psychopathological implications, the COVID-19 pandemic has been observed to have a substantial impact on various individual-level factors, suggesting that the crisis has broadly influenced numerous facets of human functioning.

Recent studies evidenced the critical role of self-esteem in maintaining mental health balance through the pandemic adversities (Kondratowicz et al., 2022; Vall-Roqué et al., 2021). Self-esteem is defined as the correspondence between the ideal and actual self-concept of an individual and it is related to various psychological outcomes, including psychological adjustment and prosocial behaviour (Leary & MacDonald, 2003). Low self-esteem is characterized by a lack of self-confidence and can be associated with mental health problems (Lin & Chen, 2021) and self-harming behaviours, such as non-suicidal self-injury (Cipriano et al., 2020) and disordered eating (Cella et al., 2021, 2022). Recent studies evidenced that self-esteem moderated the relationship between COVID-19 perceived threat and fear of arousal (Lin & Chen, 2021) and that it had a strong role in maintaining life satisfaction throughout the pandemic (Kondratowicz et al., 2022). However, the role of this variable in determining psychological distress in young adults in the post-pandemic era has yet to be clarified.

Psychological implications of COVID-19 were also related to the presence of recursive shame and guilt emotional experiences (Cavalera, 2020). These two self-conscious emotions share a connection to the self, but they have important distinct characteristics. While shame represents a global devaluation of the self ("I am a bad person"), guilt evaluates a faulty action («I did a bad thing»; Lewis, 1971), and they display different neurobiological correlates (Michl et al., 2014). Recursive experiences of shame or guilt can lead to the development of a personal predisposition defined shame- or guilt-proneness, respectively (Tangney et al., 2007). Shame-proneness has been associated with various mental health problems such as depression, anxiety, and EDs (Cavalera et al., 2016; Kim et al., 2011) while guilt-proneness showed either small or no association with psychopathology, especially when accounted for shame (Cândea & Szentagotai-Tătar, 2018). A recent study on the role of shame and guilt in mental well-being after COVID-19 pandemic evidenced mixed results (Cavalera et al., 2023): although shame- and guilt-proneness were significantly higher in people showing at-risk traumatic symptoms, they weren't significant predictors of traumatic symptoms severity. Therefore, the impact of shame- and guilt-proneness on the psychological functioning of young adults in the aftermath of the pandemic remains to be elucidated.

Given the profound sense of personal and social uncertainty experienced in the aftermath of the pandemic, researchers have embarked on exploring the role of defence mechanisms in how individuals facing with such stressors. Within the psychodynamic framework, defence mechanisms are psychological strategies that play a central role in mitigating the distressing effects of emotions and mental representations generally associated with psychological conflicts (Vaillant, 2020; Walker & McCabe, 2021). The range of individual defensive mechanisms is conceptualized as a spectrum that stretches from primitive and pathological to mature and adaptive. The healthier side of the spectrum includes mechanisms such as humour, altruism, sublimation, and suppression that typically ease the individual emotional experience, allowing one to effectively aware, regulate and integrate personal needs and desires (Boldrini et al., 2020). The less adaptive side of the spectrum includes mechanisms related to the disruptions in the individual perceptual system (self, others, reality), such as denial, acting out, projective identification, and splitting, serving to suppress emotional awareness and mitigate its threatening and distressing effect (Boldrini et al., 2020). Research has demonstrated that the maturity of defensive functioning serves as a protective factor against psychological disorders (Conversano & Di Giuseppe, 2021). However, in response to trauma, individuals may experience a reduction in overall defensive functioning and rely on less adaptive defenses (Hayden et al., 2021). While living through the COVID-19 outbreak, individuals have employed a variety of explicit and implicit emotional coping strategies to confront the impact of pandemic-related psychological distress. In this regard, evidence has highlighted that immature and neurotic defences are markedly associated with psychopathologic symptoms and perceived stress, while mature defences exert a protective role from subjective distress during the COVID-19 pandemic (Di Giuseppe et al., 2020; Gori et al., 2020, 2022). Given the salience of defensive styles in psychological functioning throughout such traumatic experiences, further exploration is required.

Alongside defense mechanisms, another key variable involved in the management of psychological implications of stressful and traumatic events are the mental functioning capacities. Bateman and Fonagy (2004) define mentalization as the mental process by which an individual considers their own and others' actions as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs, and reasons. The automatic dimension refers to the implicit processes of recognizing inner mental states in oneself and others, while controlled mentalization refers to a deliberate action (e.g., talking about our feelings or motivations). It may be that the stress conditions presented by the COVID-19 pandemic affected mental health balance by undermining mentalizing abilities and reducing the range of strategies through which people usually regulate their emotions (Lassri & Desatnik, 2020). In response to the pandemic, individuals have shown a strong pattern of association between poor mentalization and maladaptive coping patterns (Tanzilli et al., 2022), suggesting a subsequent collapse of the mentalization abilities and, then, an increased vulnerability. However, the role of mentalization in shaping individuals’ adaptation to threatening events, like the pandemic, needs further investigation.

As the world grapples with the multifaceted consequences of the pandemic, it is imperative to gain a deeper understanding of the psychological factors at play in the young-adult age group, contributing to the deterioration of overall well-being. The literature indicates that both psychopathological aspects and individual-level factors have been significantly influenced by the COVID-19 pandemic. However, a notable gap in the current research is the lack of comprehensive exploration of these factors in an integrated manner, examining their mutual interactions. Italy was one of the early and severely affected countries during the initial stages of the COVID-19 pandemic (https://ourworldindata.org/grapher/coronavirus-cfr), leading to stringent measures to control the spread of the virus, which have been demanding for the Italian population. Short-term studies have demonstrated that COVID-19 has affected the population's psychological, social, relational, and economic health (Busetta et al., 2023; Favieri et al., 2021). While existing research has aptly highlighted the pandemic's immediate challenges, there remains a notable gap in understanding the enduring psychological implications.

Thus, to address these gaps, we employed a network analysis (NA) approach (more details in Statistical analysis) to explore the complex pattern of relationships and the statistical structure of our set of variables (EDs and psychopathological symptoms, self-esteem, defensive styles, shame- and guilt-proneness, and mentalization abilities), elucidating how they mutually influence and interact two years after the COVID-19 outbreak. By delving into the intricate dynamics between these factors through a data-driven methodology, such an exploration holds the potential to inform interventions aimed at pinpointing the reinforcing links between symptoms and, in turn, provides a valuable roadmap for prioritizing primary targets for effective intervention strategies. However, due to the exploratory character of the NA technique and, in turn, of our study, no hypotheses on influential symptoms have been proposed.

Method

Participants and procedure

Participants were 651 Italian young adults (females = 593, 91.1%) aged between 18 and 38 (Mage = 23.84, SD = 3.74) years. The study is part of a wider project aimed at thoroughly investigating the psychological implications of the COVID-19 pandemic on young adults in Italy. Inclusion criteria comprised individuals meeting the following requirements: a) aged between 18 and 38 years old, b) Italian native speakers, and c) residing in Italy during the COVID-19 outbreak. Data were gathered from the general population through a self-selection sampling procedure. Upon receipt of ethical approval, the recruitment of participants occurred by advertising online an anonymous link through community groups. After reading a detailed sheet informing them about the nature and aims of the study, data confidentiality, and their right to withdraw at any time, participants were asked to fill out anonline questionnaire and provide informed consent electronically before starting. No reward was envisaged for participation. Data collection took place during the period from March 4th to August 19th, 2022. The survey was hosted on a digital platform (SurveyMonkey), and participants completed the questionnaire at their convenience (about 35 min). To protect identity and privacy, each research respondent was given a personal encrypted code. The study was designed and carried out according to the ethical standards of the Declaration of Helsinki and its later amendments (World Medical Association, 2013), and the Internal Review Board of the last author’s institution provided the ethical approval (n. 30/2023).

Measures

Sociodemographic sheet

An ad hoc sociodemographic sheet was administered to collect data about gender, age, and education.

Eating disorders symptomatology

The first three scales (i.e., Drive for Thinness, Bulimia, and Body Dissatisfaction) of the Eating Disorder Inventory-3 (EDI-3, Garner, 2004) were used to evaluate the symptomatology associated with eating disorders. The EDI-3 consists of 91 items organized into 12 primary scales: the first three scales have 25 items, responded on a 6-point Likert scale from 0 (“Never”) to 4 (“Always”). Drive for thinness evaluates an extreme desire to be thinner (7 items, “Think about dieting”). Bulimia assesses the tendency to think about and to engage in bouts of uncontrollable overeating (8 items, “Think about binging”) and Body dissatisfaction assesses discontentment with the overall shape and size of the body parts (10 items, “Think my stomach is too big”). Summing the item in each dimension yields a total score. In the present study, the Cronbach alphas were 0.92 for Drive for Thinness, 0.91 for Bulimia, and 0.87 for Body Dissatisfaction.

Guilt- and shame-proneness

The Italian adaptation of the Personal Feelings Questionnaire-2 (PFQ-2; Di Sarno et al., 2022) is 22-item self-report measure assessing shame-proneness (e.g., "embarrassment", "feeling ridiculous") and guilt-proneness (e.g., "regret", "intense guilt"). Participants are asked to rate how often they experience the feeling described in each item using a 5-point Likert scale from 0 ("Never") to 4 ("Continuously or almost continuously"). In the Italian version, the measure presents a two-factor structure in which 6 items load on the guilt-proneness factor and 10 on the shame-proneness factor. The remaining 6 items are filler items that are not considered in the scoring procedure. Averaging items for each factor yields a total score for the shame- and guilty-proneness scales, respectively. Higher scores indicate a higher level of corresponding experience. The measure has shown acceptable internal consistency, adequate test-retest reliability, and significant convergent validity (Di Sarno et al., 2022). In the present study, Cronbach’s alfas were: 0.89 for shame-proneness and 0.79 for guilty-proneness.

Psychopathological symptoms

The Brief Inventory (BSI, Derogatis, 1975) is a 53-item self-report measure designed as a short alternative to the complete Symptom Checklist 90 (SCL-90, Derogatis & Unger, 2010). The BSI evaluates clinically relevant psychopathological and psychological symptoms in adolescents and adults during the last 7 days. The measures cover nine dimensions (i.e., Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, and Psychoticism) that can be summed up to reflect a measure of severity, namely Global Severity Index (GSI). Respondents are asked to rank each feeling item (e.g., “Feeling weak in parts of your body”), thinking about the past 7 days on a 5-point scale ranging from 0 (“Not at all”) to 4 (“Extremely”). Each dimension is derived by averaging items included in that dimension. The GSI corresponds to the mean of all 53 items. The measure has demonstrated good psychometric properties (Derogatis & Melisaratos, 1983). The reliability coefficients for the present study were: Somatization = 0.86, Obsession-Compulsion = 0.86, Interpersonal Sensitivity = 0.83, Depression = 0.87, Anxiety = 0.85, Hostility = 0.78, Phobic anxiety = 0.80, Paranoid ideation = 0.80, and Psychoticism = 0.76.

Self-esteem

The Rosenberg Self-Esteem Scale is a 10-item self-report questionnaire assessing the overall self-worth (“On the whole, I am satisfied with myself”). Participants indicate their degree of agreement on a 4-point Likert scale from 0 (“Strongly agree”) to 3 (“Strongly disagree”). Lower scores indicate lower self-esteem. The measure is valid and reliable (Rosenberg, 1965). In the present study, the internal consistency coefficient was 0.89.

Defence style

The Italian adaptation of the Defence Style Questionnaire-40 (Farma & Cortinovis, 2000) is a 40-item self-report measure assessing twenty defence mechanisms, categorized into three defence styles: mature (8 items, “I’m able to keep a problem out of my mind until I have time to deal with it”), neurotic (8 items, “If I have an aggressive thought, I feel the need to do something to compensate for it”) and immature (24 items, “If my boss bugged me, I might make a mistake in my work or work more slowly so as to get back at him”). Participants respond to each item rated on a 9-point Likert scale from 1 ("Strongly disagree”) to 9 (“Strongly agree"). The defence style score is calculated by averaging items on each style, with higher scores indicating higher utilization of the target style. In the present study, the Cronbach’s alpha values were comparable to those reported in the original version (Andrews et al., 1993) and the Italian version (Farma & Cortinovis, 2000) of the DSQ-40. Specifically, the values were as follows: mature = 0.56, neurotic = 0.51, immature = 0.79.

Mentalization

The Brief Mentalized Affectivity Scale (B-MAS, Liotti et al., 2021) is a 12-item self-report measure assessing mentalized affectivity (i.e., the capacity to reflect on emotions). The Italian validation of the B-MAS has revealed a three-factor structure: 1) identifying emotions refers to the ability to be aware, correctly identify and label emotions as well as reflect on influencing elements (3 items, “I try to put effort into identifying my emotions”), 2) processing emotions indicates the ability to modulate and regulate emotions (4 items, “I am good at controlling my emotions”), and 3) expressing emotions refers to the ability to communicate them and convey their meaning, both inwardly and outwardly (5 items, “people tell me I am good at expressing my emotions”). Each factor is interconnected with others. Participants are asked to indicate their degree of agreement with each statement using a 7-point Likert scale from 1 (“Completely agree”) to 7 (“Completely disagree”). The Italian adaptation demonstrated that the B-MAS has good psychometric properties regarding both reliability and convergent validity (Liotti et al., 2021). In the present study, reliability coefficients were: identifying emotions = 0.81, processing emotions = 0.76, and expressing emotions = 0.69.

Statistical analysis

We computed mean values, standard deviations, and frequencies employing the Statistical Package for the Social Sciences (V.26, IBM Corp, 2019). Before running NA, we conducted an examination of the correlation matrix and collinearity diagnostics. All variables exhibited moderate correlations in the anticipated direction, with none exceeding 0.90 (Tabachnick & Fidell, 2001). Tolerance values ranged from 0.211 to 0.814 (Allison, 1999), and VIF scores (< 5) suggested no multicollinearity problems (Tabachnick & Fidell, 2013).

Data were analysed with the R packages qgraph (Epskamp et al., 2012) and glasso (Friedman et al., 2018). We modelled a weighted, undirected graphical LASSO (Least Absolute Shrinkage and Selection Operator) network. Each variable was depicted as nodes, while their interconnections were represented as edges. We applied the LASSO regularization that shrinks small partial correlations, setting them to zero and set the Extended Bayesian Information Criterion (EBIC) at 0.50 to derive a parsimonious network optimizing the ratio between the number of correctly identified edges and the total number of edges for sparse graphs (Epskamp & Fried, 2018). To address the skewed distributions of the variables, we employed the nonparanormal transformation (Isvoranu & Epskamp, 2021) through the use of the huge.npn function (Zhao et al., 2012). The node’s importance in the network was estimated through the centrality indices of strength, betweenness, closeness, and expected influence. Strength refers to the sum of all absolute edge weights incident to the node, quantifying how well a node is directly connected to other nodes. Betweenness defines how much a given node is in-between others, quantifying how important a node is in the average path between two other nodes. Closeness refers to the total amount of direct and indirect connections a node has, quantifying how well a node is indirectly connected to other nodes. Expected influence quantifies the cumulative influence a node has on a network, taking into account both positive and negative relationships. Thus, assessing its potential role in influencing the network's activation, persistence, and remission dynamics (Robinaugh et al., 2016). Nevertheless, given that the assumptions of flow presence and shortest paths may not align with the context of a psychological network (Bringmann et al., 2019), betweenness and closeness were not deemed especially pertinent for this study. These metrics are only provided for transparency purposes. Following the recommendations by Epskamp and colleagues (2018), the network stability and accuracy were tested using the bootnet package by estimating the 95% confidence intervals around the edge weights through the bootstrap procedure with 1000 samples (Costantini et al., 2019). This procedure allows calculating the correlation stability (CS) coefficient, representing the estimated maximum proportion of the population that could be dropped from the sample so that the original network statistics and bootstrap subsets’ statistics have a 95% probability of correlating 0.7 or higher. The CS coefficients should not be below the value of 0.25 and preferably above 0.5 to indicate sufficient stability and allow interpretation of indices (Epskamp & Fried, 2018).

Results

Graphical network analysis

Figure 1 visualizes the EBIC gLASSO network composed of the 3 eating disorder symptoms, guilt and shame proneness sub-scales, 9 psychopathological domains, self-esteem, 3 defensive styles, and 3 mentalization dimensions. Out of 210 possible edge weights, 112 (53.33%), were non-zero edges.

Fig. 1
figure 1

gLASSO network. Black edges indicate positive regularized correlations between nodes, and red edges indicate negative ones. The thickness of the edge indicates the magnitude of the association, so thicker edges represent stronger correlations

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Edge weights

The strongest estimated positive edges were observed between drive for thinness and body dissatisfaction (0.54); drive for thinness and bulimia (0.31); shame proneness and guilty proneness (0.38); psychoticism and depression (0.29); paranoid ideation and interpersonal sensitivity (0.28); immature and neurotic defences (0.27); and anxiety and somatization (0.27), depression and anger (0.33), psychosis and suicidal ideation (0.30).

Centrality indices

In the Fig. 2 are reported the standardized estimates of the centrality indices. The most interconnected nodes (highest strength centrality) for the network were: psychoticism (S = 1.48), interpersonal sensitivity (S = 1.40), OCD symptoms (S = 1.18), and depression (S = 1.13). Psychoticism (EI = 1.21), interpersonal sensitivity (EI = 1.08), anxiety (EI = 0.97), OCD symptoms (EI = 0.81), paranoid ideation (EI = 0.79), and immature defences (EI = 0.62) showed the highest expected influence values (highest sum of edge weights, accounting for both positive and negative relationships). Self-esteem (B = 2.69; C = 2.36), depression (B = 2.24; C = 1.80), and immature defences (B = 1.35; C = 0.71) had the shortest distance relative to other nodes (betweenness) and showed the highest closeness.

Fig. 2
figure 2

Strength, closeness, betweenness, and expected influence centrality measures of the estimated network. Centrality measures are visualized using standardized values to facilitate comparisons. The x-axis represents standardized centrality values, and the y-axis represents each node

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Stability of network

The case-dropping bootstrap resample (1000 cases) procedure resulted in CS-coefficients (Fig. 3) staying above the desired 0.50 threshold (Epskamp et al., 2018), indicating appropriate stability for the centrality measures of the network.

Fig. 3
figure 3

Bootstrapped expected influence stability, indicating the accuracy of the estimated network

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Discussion

To the best of our knowledge, this study stands as the first of its kind, undertaking an exploration of the intricate connections among eating disorder symptomatology, guilt- and shameproneness, psychopathological symptoms, self-esteem, defence mechanisms, and mentalization in a cohort of young adults in the aftermath of the COVID-19 pandemic. The network structure proved to be sufficiently stable for interpretation. Our results showed that the most critical nodes in the network were psychoticism, interpersonal sensitivity, anxiety, OCD symptoms, paranoid ideation, and immature defences. Although eating disorders' symptoms were highly interconnected, they were not central in the network activation, suggesting a deterioration of the general psychological well-being not explicitly related to eating habits.

Our results further substantiate existing studies indicating the huge emotional impact of the COVID-19 pandemic on the psychological well-being of the Italian population (Burrai et al., 2020; Quaglieri et al., 2021). Undoubtedly, the pandemic and its consequences represent a prominent and impactful stressor, exposing countries to unique challenges. In Italy, as the first European country affected, COVID-19 and the uncertainties related to its characteristics and absence of treatments created a huge source of stress, leading to prevalence rates of anxiety, depression, and stress of 18.7, 32.7 and 27.2%, respectively (Mazza et al., 2020). In our network, anxiety and depression emerged as prominent nodes, suggesting a worsening of young adults’ mental health in the later stages of the pandemic. As previously suggested, anxious and depressive symptoms may be related to the economic crises due to the pandemic, including job loss and financial insecurity (e.g., Matsubayashi et al., 2022). Also, such symptoms seem to be a significant outcome of a chain mediational pathway from physical symptoms resembling COVID-19 infection, suggesting that the uncertainty of potential infection may trigger adverse mental health outcomes through the need for health information (cyberchondria) and the escalation of concerns about pandemic’s impact (Wang et al., 2021). Alongside the mental health worsening, research has demonstrated that the prolonged anti-pandemic measures and the uncertainties pandemic-related lead to exhaustion, psychological burnout (Lau et al., 2022), fatigue, and cognitive impairment (Ceban et al., 2022).

Psychoticism, intended as the presence of the core psychotic symptoms (i.e., hallucination and thought broadcasting) and a withdrawn, isolated, or schizoid lifestyle, showed both the highest strength centrality and expected influence, emerging as the most crucial node in the network. Since the Spanish Flu pandemic in the eighteenth century, there has been evidence linking influenza infection to psychosis, documenting acute aftereffects of "psychoses of influenza" in several pandemics (Kępińska et al., 2020). Recently, case series studies have demonstrated an emergence of incident cases of psychosis COVID-19-related (e.g., Rentero et al., 2020; Valdés-Florido et al., 2020). Psychotic symptoms have been diagnosed in individuals infected by COVID-19, even in the absence of a prior history of psychiatric disorders (Parra et al., 2020). Additionally, these symptoms have also been reported in those who did not contract the virus. D’Agostino and colleagues (2021), for example, found that patients– negative for COVID-19– admitted with a first-episode psychosis during the lockdown satisfied the criteria for brief psychotic disorder/acute and transient psychotic disorder diagnoses during the follow-up visits. These cases, occurring in non-infected individuals, suggest a potential link between the intense psychosocial stress experienced during the pandemic and the onset of psychotic symptoms (Valdés-Florido et al., 2022). Our results suggest the persistence of psychosis-related symptomatology two years after the pandemic's outbreak, underscoring the enduring impact of the pandemic on mental health.

Paranoid ideation showed a strong involvement in the network. Previous studies have demonstrated that the pandemic’s experience was associated with paranoia (Lopes et al., 2020). Also, paranoid ideas have been related to conspiratorial thinking during the pandemic (Larsen et al., 2021). Indeed, conspiracy theories related to COVID-19 emerged in the initial weeks of the outbreak, gained rapid traction shortly after that (Grey, 2020), and have since consistently maintained prevalence (Romer & Jamieson, 2020). Additionally, vaccination campaigns have exerted a strong influence on the development or exacerbation of paranoid thoughts (Gaudiano et al., 2023). However, it is noteworthy that a longitudinal observation among Italian adults has demonstrated a significant decrease in paranoid ideation during the lockdown period (Castellini et al., 2021). Speculatively, it could be assumed that lockdown and confinement measures (no social interactions) have created a kind of refuge (Steiner, 1993), an alternative and secure world. With the gradual easing of restrictions, the real world was perceived as persecutory and hyper-stimulating, also leading to controlling and compulsive behaviors. In this regard, paranoid ideation could be related to a sense of profound uncertainty about the world, safety, and livelihood caused by the pandemic, contagion's fear, and constantly changing availability of information.

Our pattern of results is also consistent with the research highlighting a worsening of OCD symptoms due to the pandemic. While OCD patients have been shown to be particularly vulnerable to an exacerbation of symptoms during the pandemic (Zaccari et al., 2021), legitimate health messages (e.g., washing hands, being careful with hygiene, and minimizing interpersonal contacts) have also affected the OCD symptomatology within the non-clinical populations (e.g., Albertella et al., 2021; Fontenelle et al., 2021). It could be hypothesized that our findings align with previous research demonstrating that OCD symptoms in the general population are associated with pandemic-related stress (Grant et al., 2022).

The identification of interpersonal sensitivity as a crucial node within our network may be due to the significant changes that the global health crisis has imputed to the dynamics of social interactions. These findings could be explained by the assumption that the social isolation measures have exacerbated interpersonal distress (Goodwin et al., 2020). According to a recent study, people's interpersonal sensitivity increased dramatically during COVID-19 (Sfendla & Hadrya, 2020). Furthermore, interpersonal sensitivity has been identified as a factor capable of triggering or intensifying internalizing symptoms, including conditions such as anxiety and depression (Vidyanidhi & Sudhir, 2009). Indeed, our network highlights a strong edge weight connecting such node with depression and psychoticism. Similarly, interpersonal sensitivity is strongly related to shame-proneness, suggesting that shame functions to regulate relationships and acceptance. Conversely, guilt-proneness showed a strong link with neurotic defense mechanisms, reinforcing the idea that guilt feelings are accompanied by the use of unconscious psychological processes in the attempt to contain the anguish (Lewis, 1971).

It is also noteworthy that immature defense mechanisms showed a central role in the network, in line with the psychodynamic assumption that an immature defensive style helps in facing the anxious situation through a distortion of the external reality (Marčinko et al., 2020).

From our perspective, the COVID-19 pandemic has acted as a catalyst for the emergence of significant psychological distress among young adults. Our results seem to suggest the widespread presence of regressive mechanisms, as though the pandemic has disrupted the (fragile) intrapsychic organization.

Specifically, we could hypothesize that the pandemic's restrictions and home confinement have led to a flattering relationship with others and oneself, coercively excluding the bodily dimensions. In this sense, the endurance and centrality of primitive organizations (e.g., psychoticism, paranoid ideation, immature defenses) may be related to a severe disruption in the mind–body relationship (Ferrari, 1992; Lombardi, 2019). The forced deprivation of contacts and sensorial experiences may regressively lead to primary and primitive areas of psychic life and self-integration, which may have been traumatic due to an inadequacy of containment. Consequently, the loneliness experienced during the lockdown can be conceptualized as the recurrence of an absence of necessary containment and physicality, which can be highly destabilizing.

Limitations and future directions

The results of our study should be interpreted in consideration of specific limitations. First, the cross-sectional design limits the exploration of causal relationships, symptoms' dynamic nature, and their interconnections over time. Longitudinal approaches would better capture the evolving nature of symptoms, especially in a post-COVID scenario where psychological states may vary across different phases of recovery or adaptation. Also, research may investigate other post-COVID-19 symptoms, such as fatigue, burnout, and cognitive impairment. Secondly, the sample predominantly consisted of females, reducing the generalizability of the results. A more extensive analysis involving a diversified population, including individuals with various demographic characteristics, might offer additional insights, presenting a more comprehensive understanding of the psychological landscape within the broader Italian population. Third, the exclusive reliance on self-report questionnaires introduces the potential for recall bias or exaggeration in responses, as participants may recall events or experiences selectively or be influenced by social desirability. Future studies should use structured interviews for evaluating psychological functioning. Fourth, cross-cultural differences may limit the generalizability of the network model to individuals from culturally diverse backgrounds. Varied cultural norms, values, and perceptions can influence the manifestation and interconnectedness of psychological variables, potentially altering the structure of the network model. Fifth, our study was carried out over approximately five months, covering two seasons. A notable limitation is that our network structure may be influenced by seasonal variations, which have been shown to impact mental health (Zhang & Volkow, 2023). Future research should consider controlling for seasonal effects and extending data collection over a full year to encompass all four seasons. Sixth, data was collected using an online survey. Although it offers numerous advantages, such as accessibility and cost-effectiveness, it also presents inherent limitations, such as the lack of direct supervision and control over responses and participants’ identity, levels of participant engagement or attention, and technical issues or errors. Future research should explore alternative methods or hybrid approaches to data collection. Lastly, the absence of centrality associated with guilt and shame proneness may be attributed to the fact that the measures adopted in this study focused on trait predispositions. It is plausible that shame and guilt could assume a more prominent role when evaluated in their state presence, as transient emotional experiences linked to stressful events related to COVID-19. Future studies could expand this investigation to include samples of young adults and diverse populations.

Clinical implications

Our study provides a snapshot of the psychological functioning of Italian young adults in a later stage of the COVID-19 pandemic. Understanding the intricate connections between eating disorder symptomatology, guilt and shame proneness, psychopathological symptoms, self-esteem, defence mechanisms, and mentalization in young adults post-COVID-19 has important implications for intervention and clinical practice. From a therapeutic perspective, the prominence of psychoticism and paranoid ideation suggests that they could be a key focus in the treatment process, yielding significant clinical benefits. This strategic focus can contribute to more comprehensive and impactful outcomes in the therapeutic journey for individuals dealing with these complex mental health challenges. Moreover, our results can help clinicians recognize late-stage signs of pandemic-related distress and adequately assess vulnerable groups. This, in turn, can inform targeted interventions/treatments aimed at improving mental health trajectories, ultimately contributing to more resilient and positive post-pandemic outcomes.

Likewise, by tailoring interventions to the specific dimensions of interpersonal sensitivity, depression, anxiety, and OCD symptoms, mental health professionals may enhance the effectiveness of their efforts, creating cascading effects on other interconnected dimensions within the network.

In conclusion, our study provides a nuanced understanding of the psychological dynamics post-COVID-19 among young adults. Clinicians can leverage these insights to develop targeted interventions that address the core nodes identified, thereby fostering a more holistic and effective approach to mental health care in the aftermath of the pandemic.

Conclusions

Through our analysis, we contribute to the existing body of knowledge by providing a snapshot of the psychological functioning of the young Italian population two years after the COVID-19 outbreak. Given the unprecedented nature of the COVID-19 crisis, coupled with its multifaceted implications on various aspects of daily life, the examination of our network allows the identification of several crucial symptoms and edges, which offers potential targets and pathways for mental health interventions and guides policy decisions.

From our perspective, the core symptoms of the network suggest that the global crisis, necessitating drastic changes to living conditions, social life, personal freedom and economic activity, still significantly impacts various aspects of the mental health of the Italian population.