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Wednesday, May 27, 2020

A Psychiatrist’s Guide to Coping with COVID-19

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It’s hard to be a human right now. We are living in unprecedented times. We are trying to navigate a reality we don’t recognize. We have never been here before and naturally, it feels terrifying.

We are receiving invaluable guidance and wisdom from the infectious disease experts, epidemiologists and physicians on the front lines here and abroad on how to minimize our risk of catching and spreading this virus. And for that, we are so grateful. But let’s also talk about our mental health.

We are all swimming in a sea of extreme uncertainty and emotional discomfort. The tides continue to change and it’s hard not to fear the tsunami that is coming. But that doesn’t mean we are all going to drown. As a psychiatrist who has been working with anxious patients for over 17 years, I’d like to share with you some strategies to cope.

Understand what anxiety is and learn how to differentiate between productive and unproductive anxiety.

Anxiety is about difficulty tolerating uncertainty and unknowns. In my initial meetings with patients, I try to help them understand the bio-evolutionary origins of anxiety and why we as humans adapted it as a means of survival. During cave times, if there was a saber tooth tiger on the horizon and we couldn’t identify what it was, our sympathetic nervous systems (aka fight, flight or freeze response) would go into overdrive. The uncertainty that tiger posed was a legitimate and immediate threat to our safety. Being anxious and reactive was the only way to stay alive.

In modern times, at least among the patients I see, most of the circumstances that trigger anxiety are not usually life-threatening. Will I get that job? What if I get stuck on the freeway? Will I get trapped in that elevator? What if I screw up this presentation? Will I have a panic attack in public and faint? I remind patients on a daily basis that just because something is unknown, it doesn’t mean it’s unsafe. It’s simply uncomfortable. Uncertainty isn’t usually dangerous, but it is unsettling. A lot of our work together is about learning how to get comfortable with the discomfort of not knowing- recognizing that we often don’t get to have control over the knowing.

But what happens when the unknown actually is unsafe? What happens when there is a genuine threat to our survival as there is right now? When is it time/ appropriate/okay to be anxious? Before I answer that question, let’s talk about the difference between productive and unproductive anxiety.

Anxiety is fueled by adrenaline. Adrenaline keeps us awake, alert and reactive enough to make vital decisions to ward off predators and avoid danger. In the context of this pandemic, the answer to the above question is yes, we do need to be anxious, enough so that we can practice hypervigilance around handwashing and be responsible about social distancing. Enough so that we can recognize our need to stock up on provisions and medications and figure out how to make changes like working from home and managing childcare. Anxiety is such an uncomfortable feeling. We try to avoid feeling it at all costs. We sometimes go so far as to resort to denial- a more primitive defense mechanism- to try to convince ourselves that maybe it’s not that bad. Typically, engaging in denial is only risky to the individual doing the denying. But in the face of this pandemic, it is dangerous. In fact, it can be deadly. We all need to rapidly evolve into our most mature adult selves. Everyone’s lives depend on it.

Unproductive anxiety is when that same adrenaline results in not just thinking and processing, but rather in obsessing and ruminating or “spinning.” When anxiety is unproductive, our minds engage in “cognitive distortions,” unhelpful ways of thinking such as catastrophizing and fortune-telling. Rather than having an accurate assessment of what is going on, eg “This is an incredibly scary time and I have to do everything I can to stay safe,” the unproductively anxious mind panics and says, “Oh my god, we are all going to die.”

Once you have allowed yourself to feel the discomfort of what’s going on and invested it in preparing and protecting yourself from things you can control, it’s time to then work on the discomfort of letting some of it go. Unless the continued anxiety is going to alter an outcome or fuel a different decision, it’s no longer productive to hold onto it with the same level of intensity. In other words, once your anxiety has motivated you to take precautionary measures, you can thank it for looking out for you and then kindly show it to the door.

Workers inside a building at Tel HaShomer Hospital near Tel Aviv which was converted to receive the Israelis who were under quarantine on the cruise ship Diamond Princess in Japan due to the spread of the coronavirus, Feb. 20, 2020. (Avshalom Sassoni/Flash90)

Possible versus Probable

Feelings aren’t facts. That may seem obvious but remember, in times of extreme anxiety, our perceptions of reality get distorted and our minds tell us stories that aren’t true. (Naturally, it’s hard to think clearly if we feel like we are about to die.)

You may be worried that this virus will kill you or your loved ones. The uncomfortable and terrifying truth is that it’s possible. And neither I nor anyone can reassure you otherwise. But it’s important to remember that anxiety’s job is to prepare us for every possible outcome. Anxiety permanently resides in the land of possibilities. Our best defense against it is to live in the world of probabilities. To do so simply requires us to rely on the facts.

The data and evidence thus far support that the majority of COVID-19 infections are mild. 

A study of 44,672 confirmed cases in Mainland China showed that 80.9% of patients stay home with flu-like symptoms, 13.8% have severe symptoms requiring hospitalization and 4.7% end up in the ICU needing critical care. The rate of mortality is a bit trickier to figure out, but it’s estimated to be anywhere from 0.5% to 4%. So you are allowed to remind yourself that the majority of people don’t die. But that’s not our only concern.

The real threat here is people remaining in some level of denial of the seriousness of this. The feared outcome based on the data is that our healthcare system will be overwhelmed and ultimately, not have the resources to support those in need. If that provokes anxiety in you, let it. Let that discomfort in your heart and shallowness in your breath serve as a warning- think twice before you leave the house for a non-essential errand. Peoples’ lives depend on it.

Remember, we adapted a sympathetic nervous system to protect us. Let’s use it productively. It’s what inspires us to take precautions. It’s incumbent upon all of us to make room for it.

There is a space between denial and panic. Now is the time to find it. 

Try to frame it as a short-term versus long-term discomfort- it is incredibly uncomfortable to feel this anxiety right now, and yet, it will be far more devastatingly uncomfortable later on if we don’t.

Growth and comfort are on opposite ends of the spectrum. Whether we like it or not, this is happening, right here and now. We as humans have an opportunity to evolve in this moment- to learn how to hold fear and pain right alongside rational and logical thought. To learn how to practice kindness even when we’re terrified. To remember to take deep breaths even when it feels like there isn’t enough room to breathe.

It’s not comfortable. And, we can do it.

Dr. Jennifer Yashari is a psychiatrist in private practice in Los Angeles

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