Using Anxiety Amid COVID-19 as a Tool for Personal Growth
Like me, you are probably noticing more and more in recent weeks that emotions, like viruses, seem to be spreading from person to person. Fear and anxiety have risen in the general population in the face of the evolving COVID-19 pandemic, and, perhaps more notably, in the patients I have been seeing in my office.
I often tell my patients that tragedy has a way of pulling off the blinders we wear to protect ourselves from seeing the true dangers in the world around us. Without these blinders, many of us might never leave our homes for fear of any number of mortal dangers. Yet, in order to live in a world full of potential dangers, we use heuristics based on cognitive biases that allow us to feel safer than we are. When the blinders come off, we realize that the world is dangerous, we have little control over our destinies, and, perhaps more importantly, the world and the future are uncertain.
Events such as the COVID-19 pandemic highlight for many of us this grave uncertainty of what the future will look like. Most of us are uncomfortable with uncertainty, and people with anxiety disorders perhaps more so. Anxiety is a necessary emotion system set in place to warn us of true dangers. (I tell my patients that getting rid of anxiety altogether would be dangerous: like sending someone with no pain or heat receptors in their hands in the kitchen to cook.) Anxiety disorders often set our danger sensitivity detectors too high and thus interfere with day-to-day living.
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Anxiety disorders highlight a cognitive distortion: that thoughts (eg, worries) or behaviors (eg, control) might lend more certainty to an uncertain situation or world. I have seen in my office this week alone several individuals who do not meet criteria for an anxiety disorder, but who spend their session discussing their fears and worries about COVID-19 as well as how they are changing their lives, with frequent hand washing and social distancing, to try to protect themselves.
This is not necessarily a bad thing, as these precautions have been put in place by the
US Centers for Disease Control and Prevention (CDC) to help people “flatten the curve” of infection. In other words, by reducing rapid transmission of the novel coronavirus we can reduce the peak number of people infected and requiring critical care at any given point in time so that hospitals have can care for everyone. It is important to recognize here that the hope is not the complete arrest of the virus (most experts speculate that the majority of the population will become infected with the virus), but rather the protection of an underprepared healthcare system that does not have enough beds or ventilators for everyone in the country, should we all simultaneously get sick and require critical care.
Educating Our Patients
What I have noticed, however, is that my patients have turned to me for knowledge and assistance with how to approach the COVID-19 pandemic. I am not an epidemiologist, but I find that my patients are not looking for statistics; they are looking for guidance on how to regulate their fears. Without this guidance, even my patients without anxiety disorders have begun to act as if they have obsessive-compulsive disorder (OCD), with frequent obsessive thoughts and compulsions regarding contamination, and my patients with already diagnosed OCD appear to be almost paralyzed by recent fears over COVID-19.
My patients with OCD, especially those who have contamination fears, have in recent days canceled (necessary) appointments, hyperventilated in the (empty) waiting room while wearing gloves and a mask, or even attempted to open doors with their feet so as to avoid a doorknob. Turning to telemedicine (as Medicare and Medicaid relax policies to allow us to reach our patients while still helping to “flatten the curve”) has helped me reach out to my patients most paralyzed by fear, but once I have the telemedicine appointment with them, I find that I need to be strategic about how to approach their fears.
How can we as providers reach those most fearful of contamination in these times when everyone is fearful of contamination? We certainly want everyone to follow CDC and state guidelines regarding social distancing, shelter in place, and quarantines. However, we also want our patients to recognize that the situation is perhaps not as personally dire as they believe it is. We are not trying to prevent infection but rather timing of infection. We are trying to come together as a community of humans to prevent simultaneous mass infection. As it is likely many of us will be infected with this virus, the questions remaining are: When will I get sick? How sick will I become? When I do become sick, if I require critical care, will there be a bed at the hospital for me?
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For a person with OCD, the thought of becoming infected with the novel coronavirus is likely terrifying, even if the odds of requiring hospitalization and dying from the illness are low. They are not as low as the flu, but they are not as high as Ebola. Thus, we can use facts to help balance out the fear.
We are armed with the knowledge that only 10%-20% of those infected with coronavirus require hospitalization, and that of those hospitalized, the death rate for people up to the age of 64 is likely lower than the original 2%-3% originally set forth by early data from Wuhan, China. On a personal level, this means that we can validate our patients’ fears, but also reassure them that even if infected by the virus, they are more likely to not require hospitalization.
Social media and 24-hour news cycles often highlight the less probable but more highly emotional stories of the most severe outcomes of COVID-19, and these stories tend to be the most salient to us all as we ask ourselves “What will this pandemic look like for me, and for the world?” Asking our patients to limit exposure to these outlets to once a day or less, and for a prescribed period of time, is a good starting point to anxiety reduction.
Anxiety Reduction Strategies
In addition, facts aside, it is important for patients with OCD and anxiety disorders to reflect on the idea that feelings and anxieties do not reflect truths or facts. Learning to separate feelings from facts allows us all to approach situations from a more rational standpoint. I have had success in teaching mindfulness-based cognitive behavioral therapy (CBT) techniques that allow people to visualize their thoughts and worries as clouds floating by in the sky, or twigs moving in a stream. This allows people to gain more distance and relief from their anxiety, and gives them a tool to use outside the office in times of stress.
Diaphragmatic breathing as well as relaxation techniques such as visualization or guided imagery are also stress reduction skills that can be taught, and then utilized outside of the office. Guidance on yoga, mindfulness, and meditation are all widely available to people, even during these times of social distancing via social media, apps, video sessions, and YouTube tutorials.
We are social animals but physical separation (via social distancing) in a digital age no longer means we need to isolate socially. I encourage my patients to stay connected with others in this time of increasing physical separation from others. Reaching out to others via telephone or video-call can be a highly rewarding event, especially for those who feel socially isolated because of quarantine or shelter-in-place directives.
Connecting with nature remains a valuable tool that is available to us all, even as we physically isolate from others. I remind my patients that it is actually therapeutic to go outside and enjoy nature. For my most resistant patients, the ones who look at me skeptically as I list off the benefits of mindfulness, meditation, or yoga, I try to incentivize wellness by educating them that stress hormones can actually weaken the immune system.
A Greater Meaning
Finally, I encourage my patients to create meaning in their lives, and to live their lives to the fullest, even in a pandemic. All of my patients are benefiting from acceptance and commitment therapy (ACT) techniques that demonstrate it is OK to be anxious and worried, but we have a choice about how to move forward and live our lives to the fullest. I remind them that Holocaust survivor Viktor Frankl, a neurologist and psychiatrist, found meaning in his life even when imprisoned in a concentration camp. He survived and shared his wisdom with us. Now we have logotherapy to help others in these uncertain times.
In a time when fear and panic are rising, it is worthwhile to remind people that we humans as a population have survived and surmounted epidemics of viral disease for thousands of years. In many ways, it is our duty as mental health providers to arm our patients with the best tools possible to help them survive this pandemic. Handwashing and social distancing are helpful on a population level, but on a personal level, we can help guide the emotional response of our most panicked patients and we can also be valuable guides to fearful coworkers, colleagues, staff, friends, and family.
Although none of us signed up for this impromptu therapy session, COVID-19 may end up being the ultimate counselor in Exposure and Response Prevention. We, most of us, will likely be exposed to this virus, and the majority of us will get sick, but hopefully when we are recovered over the next months or year, we and our patients can reflect on the idea that true wellness stems from the ability to live in an uncertain world partnered with our emotions, not ruled by them. I invite you all, as I do with my patients, to begin to make friends with your anxiety, and use it is a tool for self-exploration and growth, rather than as a barrier to living a meaningful life. Viktor Frankl would be proud of all of us.
Holly Hendin, PhD, MD, is a faculty physician in the psychiatry department at Dignity Health St. Joseph Medical Group, Phoenix, Arizona, and assistant professor, Health Sciences Associated Faculty in the department of psychiatry at Creighton Medical School, Omaha, Nebraska. She received her PhD from the University of California, Davis and her MD from the University of Arizona, Tucson. Her PhD is in personality psychology, and her graduate research was on narcissism, shyness, and self-esteem. She believes that all forms of therapeutic interventions from yoga and mindfulness-based CBT to eye movement desensitization and reprocessing (EMDR) and psychedelic-assisted therapy can be useful in building a touchstone community of wellness both within the self and outside of the self.
