Anxious Symptom Change Patterns, Underlying Mechanisms, and Long-Term Clinical Outcomes: A Three-Year Longitudinal Study During the COVID-19 Pandemic

Existing evidence has primarily examined population-level changes in anxiety during the COVID-19 pandemic, overlooking substantial heterogeneity in individual symptom courses. Moreover, longitudinal evidence covering the full pandemic period remains limited, and links between distinct anxious symptom change patterns, their underlying risk and protective factors, and long-term clinical outcomes are poorly understood. This pre-registered longitudinal study conducted 43,610 observations of 4,361 adults in the general population, assessed 10 times over three years. A Latent Change Score Mixture Model identified five distinct anxious symptom change patterns. Two reflected resilience: Stable Resilience (48.16%) and Initial Shock-to-Resilience (10.57%). Three indicated risk: Persistently High Anxiety (6.79%), Mild Maladaptation (27.02%), and Strong Maladaptation (7.46%). Risk patterns were predicted by greater intolerance of uncertainty, emotion regulation difficulties, lower trust in governmental pandemic response, and reduced vaccination uptake. Notably, risk patterns, particularly Strong Maladaptation, predicted high probability of treatment-seeking and receiving a future psychiatric diagnosis. Screening for risk factors may guide targeted support during infectious disease outbreaks, while strengthening coping, transparent governance, and adherence to health measures can protect against development of adverse anxious states.