Exploring psychotherapeutic issues and agents in clinical practice
The COVID-19 pandemic has aroused a level of anxiety and uncertainty that spans demographics and diagnoses. Within a few short months, the ordinary person has had to cope with confusing and contradictory public messages foretelling doom and disaster, and to complicate matters, must cope in personal isolation. Furthermore, health care professionals and first responders are asked to set aside their concerns for the health and safety of themselves and their families to serve the vulnerable public.
Calling this a unique situation is somewhat false, however. Certainly, the HIV/AIDS pandemic of the 1980s, the H1N1 pandemic in 2009, the Ebola outbreak in 2014, and the Zika epidemic in 2018 bear similarities to our current situation, which can provide important lessons, albeit they were limited to specific populations. In addition to the health crisis and consequences of these infectious diseases, there are pronounced sociopsychological ramifications, including stigma, xenophobia, homophobia, germaphobia, and general hysteria, that affects all of us in some way.
Because the coronavirus is a novel variant, the expert scientific community presents to the public as uncertain and inconsistent in information and ways to deal with potential infection, which creates disbelief and uncertainty. The most consistent recommendation is physical distancing and self-imposed isolation to reduce the spread of the virus. However, such isolation adds to individual and community distress. In compensation, many have turned to social media as a safe way to remain in contact with others. Do the advantages of social media outweigh the disadvantages of technological stress, confusing and contradictory information, and shared anxiety and distress?
This column focuses on the neurobiological explanations for anxiety, complications to pre-existing psychiatric disorders, ordinary states of stress and anxiety, and pharmacological and nonpharmacological ways of addressing this anxiety.
Normative and Dysfunctional Anxiety
Anxiety is a normal state of living and varies in intensity across a continuum. Peplau (1952) described the anxiety continuum based on the work of Sullivan as extending from anticipation to panic. Severe anxiety and panic are extreme states that are maladaptive, whereas mild anxiety is the mirepoix that provides the flavor of ordinary living. That is, mild anxiety is what allows us to awaken to the alarm clock and set an agenda for the day. Mild and moderate anxiety are motivating states that make us feel the need to function (Peplau, 1952). As anxiety increases in intensity, the perceptual field narrows to focus on the problem and the person feels more alert. When anxiety reaches maladaptive ranges, perception explodes, and there is a sense of intense discomfort, disorganization, defensiveness, cognitive and perceptual distortion, and physical symptoms (LeDoux, 2015).
Anxiety is an internal alerting state in response to anticipated impending danger, whereas fear is a response to a known, nonconflictual, external, definite threat (Sadock et al., 2015). Both are warning signals and activate the autonomic nervous system to adapt to the situation, thereby permitting the person to act in a protective manner. When a person has a functioning ego, the response is to seek balance and problem solving, but with a more tenuous ego, a person may experience chronic anxiety (Sadock et al., 2015) or other anxiety disorders, and their daily life is disrupted.
In a crisis such as this pandemic, stress compounds the ordinary stresses and strain and makes the perfect storm. There is a heightened sense of uncertainty that challenges coping mechanisms and relationships (Taha et al., 2014). For instance, the person who is mildly phobic of germs and contagion hears of a virus that is airborne and could reside on surfaces for differing times; a homeless person with schizophrenia now sees people wearing masks and due to COVID-19 restrictions is denied entry into public bathrooms; or an older adult who has chronic obstructive pulmonary disease and must self-isolate without access to adult children, friends, and grandchildren. Primary care and health facilities must limit visitation to telehealth, and refill prescriptions are delayed or left unfilled, which are further complications. Not only are individuals affected, but the entire community—for that matter, worldwide population—experiences increased anxiety and heightened stress of uncertainty and imposed isolation, resulting in a shared traumatic response of ambiguous duration (Chakraborty, 2020; Garfin et al., 2020). Families who are isolating together experience the stress and strain of loss of natural boundaries, such as school and work, and shared space becomes competitive for alone time. Childcare has the additional burden of home schooling and supplanting peer companionship, with parents feeling the strain on their relationships with their children as they fulfill the roles of parent and teacher (Canady, 2020).
Health care workers are not immune to the stress of this pandemic and are expected to make remarkable adjustments to the manner and location of their services as well as cope with family and personal life. Studies have found increased anxiety and depression among physicians, nurses, psychologists and counselors, and paramedics as they push themselves to exceed capacity and protect their patients, sometimes to their own peril (Chatterjee et al., 2020; Frias et al., 2020). They assume greater responsibility for patients' emotional support because family visitations are curtailed and are fully present in deaths and critical transitions. Health professionals return to their families who worry about them and seek their comfort and support.
Complicating Pre-Existing Psychiatric Disorders
Individuals with pre-existing psychiatric disorders carry an added burden during this pandemic. They continue to struggle with anxiety, depression, schizophrenia, and other disorders as well as experience fears of how COVID-19 has or might affect them physically, combined with the imposed isolation and reduction of basic services (Matias et al., 2020). These individuals may resort to excessive social media use that exacerbates their fears or self-medication with unhealthy food, alcohol, and/or drugs. Social distancing and reduced activity may challenge their self-care and complicate their medication regimen, as they may have limited resources and lower socioeconomic status to endure this crisis (Mesa Vieira et al., 2020). Others wearing masks and the general distancing strategies may exacerbate paranoid delusions to the extent that the person becomes easily agitated in public and around others (Maguire et al., 2019).
Children and teens with pre-existing anxiety or depressive disorders may feel overwhelmed by the current crisis, especially if their parents are struggling to cope. During Hurricane Katrina, children with these disorders experienced service disruption, lapse in prescriptions, and increase in symptoms, and many failed to return to treatment (Storch et al., 2018). Children and teens with traumatic histories may experience social isolation as further trauma, especially if they are living in disturbed homes or foster care (Connor et al., 2015).
Older adults are more vulnerable to COVID-19 as well as mental health problems as a consequence of isolation, worry for their friends and family, and possible losses of those in their cohort. If alone in isolation, older adults may experience cognitive impairment, confusion, loneliness, and depression, especially if they have difficulty using technology to compensate for isolation. Older adults in nursing facilities or senior communities may be protected from despairing by caregivers being attentive to their needs as a compensation for reduced contact with family and friends who cannot visit (Baker & Clark, 2020).
How can we help counteract the stress of this pandemic? Certainly, trying to socially extend to vulnerable people within the necessary constraints of physical distancing is essential. Many church and social organizations have made it a mission to reach out to their consumers by telephone, social media, and online meeting tools. Primary care and mental health clinics have converted face-to-face appointments to telehealth visits and videoconferencing (Conrad et al., 2020). Telehealth is an innovation that improves health outcomes; allows monitoring of chronic health conditions; and provides counseling, communication, and psychotherapy safely (Totten et al., 2016; Tuckson et al., 2017).
For individuals already receiving services before the stay-at-home requirements, continuing their medication regimens by refilling prescriptions through mail services or arranging delivery from pharmacies is essential. Anxiety may be treated with herbal and over-the-counter products, such as kava or tryptophan (e.g., 5HT) (Hood et al., 2016, Sarris et al., 2011). Although these products have been shown to be efficacious in reducing anxiety symptoms, kava must be considered with caution in individuals who use alcohol or have liver impairment (Savage et al., 2015).
Serotonin reuptake inhibitors are a reasonable consideration for individuals with significant symptomatology and history of use or anxiety or depressive diagnoses. These medications would need to be maintained for up to 6 months or 1 year to assure complete remission of symptoms (Hathaway et al., 2018; Hofmann et al., 2014). Benzodiazepines would be a last resort and for short-term use of up to 3 weeks only due to their tolerance and dependence potential (Limandri, 2018). Serotonin agonists, such as buspirone, enhance serotonergic activity in the amygdala and prefrontal cortex and would be effective in managing anxiety and fear arousal and need to be prescribed on a daily basis as opposed to an as-needed basis (Stahl, 2013).
Summary and Clinical Pearls
Anxiety and depressive symptoms are likely occurrences during these stressful times of the COVID-19 pandemic. Struggling with stay-at-home orders, illness, fear of illness of COVID-19, experiencing losses of loved ones from the virus, and even phased release from quarantine arouse fear and uncertainty that challenges quality of life. Individuals providing care during the pandemic are equally at risk for mental health consequences of the illness and require attention and care to their health. We can help our clients, colleagues, and ourselves by using self-care measures, such as relaxation exercises, socialization within physical distancing constraints, physical activities and exercise, comforting and healthy nutrition, and supportive communication. Pharmacological interventions may be necessary if symptoms become excessive or intense, especially if suicidal ideation or behaviors present. Non-prescriptive measures may be equally comforting, including herbal teas, over-the-counter herbal remedies, aromatherapy, yoga, meditation, and bibliotherapy. Psychotherapy and counseling through telehealth, if feasible for the client, are also recommended.
Some clinical practices that would be effective include:
- Promoting social supportive services in the community, including support groups and online videoconferencing.
- Encouraging family members to contact each other, especially older family members, on a regular basis.
- Assessing clients, on an individual and private basis, for possible family violence or abuse while in isolation.
- Screening for suicidal thinking and behaviors, and assessing in greater depth if there is a positive screen.
- Checking in with long-term clients and those with chronic and severe mental disorders to assure contact, symptom stability, and maintenance of medications.
- Providing telehealth appointments as much as possible.
- Reaching out to clients without telehealth means to receive face-to-face appointments or contacts within protective measures.
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