Panic .

Psychiatry

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Right now is a stressful time. Schools and workplaces are shutting down. In this episode of the podcast, I wanted to cover mental health and Covid-19.

David Puder, M.D.

People with chronic diseases and the elderly are especially susceptible to this sickness, and all families are worried about their loved ones. Children are even feeling it as they stay home from school and are around their stressed-out parents.

It is a normal and healthy response to attachment to worry about our loved ones. We may have a worsening of our own health conditions because of the stress overall. People may be tempted to use more alcohol, drugs, or eat more. CDC article I talked about: here.

Stress and anxiety are going to be very common during this time. In one study of Wang et al, 2020 they found that in China, 53.8% of the respondents to a survey rated their psychological impact as moderate-to-severe and 28.8% had moderate to severe anxiety, 16.5% had moderate to severe depressive symptoms, 8.1% had moderate to severe stress levels.

“In this study, the majority of respondents spent 20–24h per day at home (84.7%), did not report any physical symptoms (60.81%), and presented with good self-rated health status (68.3%).”

“The majority of respondents (>70%) were worried about their family members contracting COVID-19, but they believed that they would survive if infected.“

Right now, there may be a higher sense of disgust around everything, so we need to be mindful in general about continuing to eat nutritious meals, if we are tempted not to eat under stress. We also need to be mindful about taking medicine that’s prescribed to us, even if we feel a sense of disgust around it. I have been giving out 90 day supplies to my patients to help them through this time.

Here are some things to consider during this time to help you:

Take a break from the news. This can be helpful for those of us who are empathic and deeply feel for the stories we are hearing.

Take a social media break. When we see other people’s worst-case scenarios, it can create the same type of stress in us. We can be aware without being overwhelmed.

Exercise. Get your blood flowing and get the positive benefits of moving around a bit. Get on youtube and find some workout videos.

Practice deep breathing. Watch some videos and tutorials about how to use the breath to bring your body and mind back into a myelinated parasympathetic state—that rest and relaxation state.

Eat healthy. Eat as healthy as you can. People are hoarding for a six month ordeal. But, if you have it, look through your cabinet and see what you can do.

Connect with others. Call people. FaceTime people. Stay in contact with people you enjoy.

Work through the 8-day Psychiatry Podcast Cognitive Distortion Journal. Our thoughts can run wild during times like this, and if we can identify the thoughts that aren’t helpful or true, we can calm down more quickly.

Some cognitive distortions are:

  • Overgeneralization: “I read a story of someone who died of Covid-19, therefore I will die of Covid-19.”
  • Jumping to conclusions—mind reading and fortune telling: “I will definitely get Covid-19. The world is heading into chaos.”
  • Magnification or minimization
  • Emotional reasoning: “I fear, therefore we must be in great danger.”

The truth is that we can’t possibly know what will happen, and just because we have these thoughts pop into our mind doesn’t mean it’s true. Put your thoughts on trial and educate yourself with the truth. Our thoughts influence our panic, anxiety and stress levels.

Consider logotherapy as a way to find meaning. Maintain your dignity, your kindness while there is widespread panic. People will remember the kindness and attitudes, so look for some of the deeper meanings. Look for ways to be meaningful to other people and find meaning in your life.

“The way in which a man accepts his fate and all the suffering it entails, the way in which he takes up his cross, gives him ample opportunity—even under the most difficult circumstances—to add a deeper meaning to his life. It may remain brave, dignified and unselfish. Or in the bitter fight for self-preservation he may forget his human dignity and become no more than an animal.” - Viktor Frankl

“We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” - Viktor Frankl

Consider in this time going to leave a note on your neighbor’s doorstep with your contact info and asking them how you might help them. What are ways you can create meaning in these times?

Why stay home?

Of course, like with any trend on the rise, there will be a peak of the virus outbreak. The goal in instituting stay at home, self quarantine, is to try and level off the statistics. If we stay at home, we can make the peak more of a hill than a sharp uprise, and we can prevent a lot of people getting sick. This gives our healthcare system a chance to be able to absorb the people who are sick and need the most acute care. Even if you’re young, if you can make the effort to stay home as much as possible, you can help prevent the spread, and keep doctors’ offices open for the elderly.

Look at the facts

Be aware of the actual facts:

  • It’s about 5% critical case scenario.
  • It’s about 2% lethality at the moment.

Now look at the lethality of previous pandemics:

  • 50% for ebola
  • MERs 30%
  • SARS 10%
  • Seasonal flu 0.1-0.2%

Also, with modernization of antibiotics, treatment for infections, the rate of death by infections has gone down. It isn’t the most dangerous illness we’ve seen, but it is dangerous, especially with the smokers, elderly, and people with diabetes.

Most people don’t die of infectious diseases. Most people die of inflammatory diseases. In 1926, heart disease replaced infectious disease as the number one cause of death in Massachusetts, and it is the same across the United States.

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Symptoms of Covid-19

The following symptoms may appear 2-14 days after exposure.*

  • Fever
  • Cough
  • Shortness of breath

If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:

  • Difficulty breathing or shortness of breath
  • Persistent pain or pressure in the chest
  • New confusion or inability to arouse
  • Bluish lips or face

For therapists continuing therapy

I think FaceTime is similar to a fax machine or telephone call in terms of HIPPA compliance, because it is encrypted on both ends and not stored anywhere. If my patients want to connect with me, I will try to do that through video, with earphones, even if I have to stay home to work.

If I have a Covid-19 patient, I will pay attention specifically to their delirium—one of the symptoms of the illness. Confusion and inability to arouse could be from lack of oxygen saturation and increase in CO2, or it could be from delirium (or all 3). In my assessments, I will test to see if they’re hypoactive or hyperactive delirium. I will do this by having the people draw a clock, draw the numbers around it, and then draw times on the clock that I specify. I will ask them to spell “world” backwards, and to count backward from 21 in intervals of 3. If they do those things, they most likely will not have delirium.

If the patient is in delirium, you treat it like you’d treat other deliriums. Treat the underlying cause, and look at their medications, take off anything that's anticholinergic (here is a list of medications that are anticholinergic and those that modify cognitive function). Also, antipsychotics can help with delirium.

Also, consider if the patient has a history of trauma, and now they are experiencing anxiety on top of that. I’d consider giving short term anti-anxiety medications, but I would not consider propranolol, because I wouldn’t want to put a beta blocker on someone with a respiratory issue. I might consider hydroxyzine, a low dose of seroquel or trazodone. If they're stable, I’d consider prazosin for nightmares. If they have anxiety or panic disorder and no delirium, I’d consider giving something like alprazolam, lorazepam, or clonazepam.

Always lead your sessions with empathy. Everyone is entitled to their feelings, including fear and anxiety about the state of the world.

In conclusion

I really want to emphasize that this is a time to come together, to express gratitude and forgive. It’s a time to be okay with experiencing emotion and spend some time journaling about it.

Check out the Covid-19 Cognitive Distortion Journal. Also check my social media for things I’ll be sharing about the pandemic.

Thank you for being part of my community here. I appreciate connecting with you all on social media and learning about your lives, and finding new ways to bring value to your lives and practice.