Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC

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We want this to be over—definitively over.  We (human beings) do not like uncertainty.  Our brains are hardwired for conclusions.  We prefer stories and problems that end and conclude, so that we can comfortably move on and expend energy on the thousand other items on the to do list.  Within weeks covid was teach us all how fragile our plans are.  To do lists were scrapped, routines suspended, plans canceled.  If we are honest, we all had moments where we quietly said, if not aloud to ourselves—“how long are we expected to live this way?”  And the only answer any of us received was—“who knows?”

Ponder for a moment what that must do to the human brain.  Multiply that by three hundred million (roughly the U.S population) and divide by 5 (anxiety disorders occur in about 20% of the population).  That is a lot of anxiety to begin with, and we’re not even sure that we’re through this.  We are a population that is anxious, frustrated, and tired, and that means millions of brains interacting with millions of other brains under conditions of chronic stress.  Some have even speculated that there may be a post-covid form of PTSD.  

At the time of this writing the delta variant appears to pose a certain degree of threat, especially for populations where vaccination rates are low.  This places a burden on an already strained healthcare system. Frontline healthcare workers are certainly at increased risk for PTSD due to the duration and continued exposure to stress.  The effects of chronic stress do not always present immediately.  The body produces certain hormones in response to stress, which can lead to a sort of paradox in which we seek stress—think “adrenaline junkie” or the combat veteran who signs up for additional tours. It is easy to lose one’s perception of risk when the body craves a certain level of activity.

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This week the Nexus blog on mental health will be addressing the ongoing impact of covid on mental health, where we are now, and where we may be headed.  A recent posting at the AMA was entitled What Doctors Wish Patients Knew about Post-covid Anxiety.  That title reflects a common sentiment of healthcare professionals at this moment in time.  Resources—especially in the form of time and attention are still strained.  If you ask someone who recently tried to access mental health services, they will probably tell you that they frequently heard “not accepting new patients at this time” from at least one provider.  

When the system is inundated in this way, it is easy for things to get missed.  New cases of depression and anxiety are identified and diagnosed daily regardless of a pandemic.  When you add the stress of the pandemic onto a very heavy caseload there is very little room to address emerging problems.  You probably have seen public health officials warning of the risk of ICU bed capacity.  If all those beds are devoted to covid, where does the patient from the car accident go?  This happens in the mental health system too, it’s just less visible; if those with existing mental illness become acutely distressed and demand more attention, emerging mental health crises can be missed.

This leaves us all in a difficult position—we no longer live in the “normal” we knew.  The new normal requires a recalibration of what is routine versus what requires more urgent attention.  For many Americans their first interface with mental health services may be primary care.  It is not uncommon for primary care physicians to treat mild depression and anxiety.  We might characterize this as “struggling, but making it,” meaning making it through the workday, taking care of the necessities, mild oversleeping, or mild insomnia.  If you are distressed enough that your work performance is noticeably suffering, relationships straining, and feeling sad and hopeless most of the day for at least two weeks this suggests a more serious problem that should be evaluated by a mental health professional.

It can be a challenge to separate out the differences between stress and anxiety.  The two are commonly used to refer to similar things.  Anxiety is an emotional state involving fear or worry.  Stress would be more accurately described as a circumstance that challenges our abilities to manage it effectively.  Stress can be just as easily associated with positive events—like a wedding, the birth of a child, etc.  Stress can easily lead to anxiety, and unfortunately persistent stress of the negative type can easily lead to anxiety disorders.  

Presently, there is no shortage of negative stress.  But we should also take a moment to acknowledge that we are not in a terribly good position to absorb positive stress either.  Stress comes with change, and there is a huge difference in changing versus being forced to change.  The pandemic brought with it a lot of forced change. Despite some measures of success, we are approaching yet another school year with a high level of uncertainty. Uncertainty carries the potential that we may have to adapt and adjust again.  It gets frustrating and exhausting.

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What Does the Forecast Look Like for the Next Few Months?

Expect a lot of anticipatory anxiety.  Recognize that you may be experiencing this, and you are not alone.  In fact, it can be really helpful to practice self-compassion—acknowledge that you are struggling with worry, accept that you are human, and understand that we are all under conditions of stress.  Practicing self-compassion can also help to mitigate frustration with those around you.  It is hard to snap at the person in the store throwing a fit about a mask rule when you are in a state of peace.  If the news has taught us anything it can be dangerous to get involved in such matters.

We should anticipate that the return to school is going to bring about another wave of anxiety.  This will be stressful for parents, especially those with elementary age children who cannot yet receive the vaccine.  At the time of this writing the delta variant is posing risks due to a high degree of contagiousness.  The most recent estimates from CDC place it at the level of contagiousness as chicken pox.  We should prepare for the possibility that elementary schools may be required to suspend in-person activity in the event of an outbreak.

Mental health professionals and concerned family members should pay attention to risks for suicide.  One of the biggest risk factors for suicide is hopelessness.  There is a certain feeling of frustration that comes with each successive wave, and with no outlet for that frustration it can lead to thoughts like “why bother?”  This is especially true for those who have been particularly hard hit like frontline healthcare providers. It is easy to fall into feeling defeated.  

This is also precisely the type of stress that can lead to PTSD.  In a previous post the Nexus blog covered languishing, described as an absence of mental health.  There is a certain lack of enthusiasm characterized by this state.  One of the hallmark features of PTSD is a feeling of numbness or inability to access positive emotions. Another complicated feature of PTSD is that it can have delayed onset in which not all features are yet present.  There will likely be cases of PTSD that emerge well after the pandemic is safely contained.  

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Important Things to Keep in Mind

· Different age groups will experience the pandemic and its stress differently.  We experience the world through the developmental stage that we occupy.  Children will have a different understandings, reactions, and coping strategies than their parents, and likewise their grandparents.  Anxiety and fear manifest differently across the lifespan.

· Different segments of the economy will experience the pandemic differently.  Certain industries have been disproportionately affected by the pandemic. Those in education will have a different experience than those in healthcare and different than those in restaurant work.  Keep in mind that there will be unique needs for workers depending on the industry.

· Pay attention to your own needs.  One of the most challenging things about pandemic stress is that a lot of this is not within our control.  The serenity prayer often recited in AA can be helpful to keep in mind.  There are things we can change, and things we can not change, and there is wisdom in knowing the difference.  This advice is similarly used in Cognitive Behavioral Therapy (CBT).  There is very little value in excessively worrying about things that are not within our control. In fact, this often leads to rumination which is a feature of depression and anxiety disorders.  This is always easier said than done.  The brain prefers neat and clean stories with a resolution.  The key word above is “excessive.”  We generally cannot avoid worrying but worry serves its purpose after a few moments.  Endlessly worrying is counterproductive.  You are better served by channeling this energy into other activities.  Exercise is helpful for coping with this type of stress.  (Also, see our recent post on flourishing)

· Practice good sleep hygiene.  This is another area that we covered recently on the Nexus blog.  Sleep is essential to the health and maintenance of our body’s regulatory systems. There has been a noteworthy increase in reports of insomnia, leading one writer to coin the term “coronasomnia.”  Anecdotally, those of us who have work in mental health have heard accounts from patients reporting “feeling too tired to sleep.”  This is the kind of insomnia where you recognize that you are tired, but the mind just doesn’t seem able to unwind.  We know that the body and mind absorb stress and process stress in ways that we are not always aware.  A great many mental processes are done outside of our conscious awareness.  

Another way to cope with negative stress is to help others.  In Psychodynamic theory this was referred to as sublimation, and it was often regarded as one of the healthiest coping strategies.  In our present age we talk much less about the ego, and this is unfortunate because it really hasn’t gone anywhere.  If anything, we have probably forgotten to attend to it and ensure that it develops properly.  Technology has created rapid shifts in how we interact with the world, and developmental psychologists have expressed alarm on the impact this may be having on the adolescent brain (see Jonathan Haidt). As for adults, if you want to rediscover the ego, the Buddhist conceptualization is more in vogue these days.  It’s that piece of us that we most commonly associate with the “I.”  It tends to be preoccupied with control and needs. Don’t kid yourself it’s in all of us—it’s the piece of us prone to selfishness.  It’s being mentioned here because stress can bring it out easily.  This is not to suggest that we should not be selfish at times, there are times where it is completely normal and healthy.  The most important thing is balance, and the way to achieve that is to also cultivate selflessness.  This is similarly related to purpose.  Research supports that those with a sense of purpose animated by something higher than the self respond to stress much more effectively.

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