Daily stress and worry are additional triggers of symptom fluctuations in individuals living with Long COVID: Results from an intensive longitudinal cohort study

Background: Recent research has shown that exertion in physical, cognitive, social and self-care activities trigger symptom severity in individuals with Long COVID.

Purpose: The current study aimed to investigate whether daily emotional exertions (stress, worry, rumination) were associated with symptom exacerbation, over and above influences of effortful daily activities, in individuals with Long COVID.

Methods: 376 participants were recruited from UK Long COVID clinics and community settings and completed daily assessments of activity and severity of 8 core symptoms every 3 hours for up to 24 days. 155 participants completed daily assessments of stress, worry and rumination for at least seven consecutive days.

Results: Days with higher stress scores were associated with increased severity of all symptoms on the same day, after adjusting for activities, demographic and medical factors (p-values ≤ 0.007). Days with higher stress scores also predicted more severe anxiety and depression symptoms 1-day later (p<0.001) and more severe anxiety (p<0.001) and dizziness symptoms (p=0.003) 2-days later. Days with higher worry scores were associated with increased fatigue (p<0.001), anxiety (p<0.001), depression (p<0.001) and cognitive dysfunction (p=0.002) on the same day, but decreased anxiety (p=0.003) and depression (p=0.002) symptoms 1-day later and less severe pain (p=0.002) symptoms 2-days later. Daily rumination was only associated with two symptoms.

Conclusions: Daily stress and worry are distinct factors linked to fluctuations in same-day and next day Long COVID symptoms, with daily stress showing the strongest association—consistent with patterns of post-exertional symptom exacerbation. These findings highlight the importance of considering stress and worry as potential therapeutic targets and integrating their management into self-care programmes.