Jane B. Sofair, MD

-A quote attributed to Benjamin Franklin, circa 1758, and music composed by Dave Stewart and Mick Jagger, 2004.

If the reasonable person on the street was asked to define “a habit,” they might shrug their shoulders and be at a loss for words. According to Laura Araujo, cofounder of the Mindfulness, Activation, Purpose, and Surrender (MAPS) Institute, habits are nonverbal, automatic behaviors associated with the prefrontal cortex that take on average 66 days to become ingrained. Habits are not necessarily associated with higher cognition, in contrast to routines, which are planned sequences of behavior.

Contemplating how our daily habits and routines have been impacted by 

 has become national pastime, if not consciously then at least subconsciously. Especially now that we are undecided about whether the pandemic is over, many of us are left wondering what exactly our new behavioral patterns should be.

It can become quite overwhelming to think about this. A 2020 survey of 8000 adults conducted in the greater Tokyo area showed that 33 % of male respondents and 34% of female respondents experienced an increase in sedentary activities since the onset of the pandemic, while, conversely, 17% and 18% of men and women respectively reported a decline in daily physical exertion along with self-reported changes in health status.

Cognitive therapists have spent considerable effort constructing models for habits and routines. Habits are triggered by various types of cues and are known to become automatic over time. While routines are volitionally created, they too can become automatic given sufficient impetus. And habits, as well as routines, can swing the pendulum from adaptive to off-putting, thoughtful to reckless.

 Henceforth, the focus will be on adaptive habits and routines.

Several of my associates have remarked on the need to rebuild socialization stamina, rusty from months of lockdown and somewhat analogous to the professional athlete in re-training. For Miriam Lavine, LCSW, director of a community mental health program, the opposite has actually been true. “Before the pandemic,” reflects Ms Lavine, “I may have taken collegial gatherings for granted. But now, where there is an event, I find that socializing and reestablishing with others is anything but tiring, and I am aware of how normal and pleasant it all seems.”

Some routines have been unaffected by COVID-19, as illustrated by this story.

At the close of a prepandemic session, “Ms Young,” lamented on her boyfriend’s habit of watching sports over the weekend. She reported an impending feeling of exclusion on Friday evenings as she anticipated competition with the ESPN channel, and yet was afraid to speak up as the relationship was still brand new. When asked whether she believed a compromise was possible, given hers and her boyfriend’s mutually hectic weekday schedules, Ms Young responded, “Honestly, I doubt it, doctor. We are dealing with something powerful here. Let’s discuss this again. Thanks so much.”

Ms Young described her partner’s intense devotion to TV sports—the major leagues, professional golf, and the Stanley cup playoffs—in a good-natured manner. While “sports addiction,” never entered the dialogue, I could not help but reflect on the term based on some of my own experience.

According to Nora D. Volkow, MD, Director of the National Institute on Drug Abuse (NIDA) and renowned researcher on the neural mechanisms of substance abuse, while terms like “addicted” and “obsessed” permeate our everyday conversation as part of a compelling narrative, the risk for the public is a misperception of just how serious clinical addiction can be.

Dr Volkow further explains that, “The challenge in sorting out routines from true compulsions is that in both cases we are dealing with normal and pleasurable aspects of life, such as eating or making a purchase.”

“Plus,” adds Dr Volkow, “behaviors do not necessarily set up as powerful brain circuits as do drugs which hijack the reward pathways in the ventral area of the brain’s prefrontal cortex. The key distinction is whether the person can no longer control that particular behavior such that it becomes deleterious.” (

Table. From Normal to Problematic Along the Behavioral Pathway

To a certain extent, the concept of a behavior veering into “addictive” carries some degree of elusiveness. How do everyday routines blithely transform into compulsions and what are the risk factors? How does the wellness routine of yoga practice, for instance, turn into something nightmarish, a question I once posed to a certified yoga instructor? Her response was incredibly straightforward. “I do not think yoga is addictive if you do not have an addictive personality.”

, the only recognized behavioral addiction under nonsubstance-related disorders is gambling.

Yet, we find that shopping, eating, intimacy, video gaming, and posting on social media can all be grouped under the umbrella of behavioral addictions when taken to the extreme.

 There is also excessive body building, sometimes accompanied by the use of anabolic steroids and disordered eating, due to the condition of bigorexia, a belief that one’s muscle mass is inadequate.

Since the start of the pandemic, the newspaper for me has become central towhat I view as an adaptive routine. Some might argue that reading the newspaper is obsolete, given all the available news feeds on smart phones. However, I duly admit that holding a daily paper with coffee in hand, is a comforting ritual. Scanning the front section for international news, then the second section for pandemic metrics, followed by all the cultural happenings allows a connection to the greater world despite its problems and upheavals.

You may ask yourselfwhat has changed in your own lifestyle during the pandemic? Take a glance within. I would invite you to honor all of those daily routines that promote strength and purpose, that maintain an internal sense of structure. This process can also be applied when treating patients experiencing any degree of stress. The key is to avoid harsh self-appraisals and over-analysis, particularly during this continued time of uncertainty. In closing, I would remind the reader that adaptive routines are necessary and never compulsive if conducted with intention and balance.

 The author would like the thank the following individuals: Yi Zhou, MLIS, and the library staff of Morristown Medical Center; Nora D. Volkow, MD; Miriam Lavine, LCSW; and Mr Jon W Green, esq.

is a board-certified psychiatrist affiliated with CarePoint Health and Atlantic Health System in New Jersey.

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https://themapsinstitute.com/understanding-the-difference-between-routine-and-habit-and-why-its-critical-to-our-functionality/

Changes in health status, workload, and lifestyle after starting the Covid-19 pandemic: a web-based survey of Japanese men and women.

3. Le Cunff A-L. Habits, routines, rituals. Accessed July 26, 2022. 

https://nesslabs.com/habits-routines-rituals

4. Gambling disorder under non-substance-related disorders. 

Desk Reference to yhe Diagnostic Criteria From DSM-5

. American Psychiatric Publishing; 2013:282-283.

5. Kar A, Adikey A, Wells J, Kablinger A. 

Obsessive-compulsive disorder driven by aspects of ritual addiction: a case report and review of the literature.

6. Luigjes J, Lorenzetti V, de Haan S, et al. 

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Can’t get enough. Addiction to physical exercises: phenomenon, diagnostic criteria, etiology, therapy and research challenges.

Articles

Habits or addictions? COVID-19 changed the game. 

The Impact of COVID on Daily Routines, If At All

Is patience an undervalued attribute? Not long ago, Neel Burton, MD, posed the same question and answered with a resounding yes.

 If we have not learned anything else from the experience of 

, it is that as a society we have been forced by default to become more patient. And yet, no one ever exercises bragging rights about their ability to wait for things. They may boast about a job promotion or other new venture, but most likely not about how they just finished waiting 2 hours on the telephone.

Consider this scenario: While recently waiting in line for breakfast, I was standing behind a couple with a complicated order and then a third gentleman. This gentleman waited more calmly than I believe I ever would have and for what seemed like an eternity. When his turn to order arrived, he merely requested a small black coffee. That was it! You can imagine my incredulity as I complimented him on his patience. Then, I inquired as to whether he had briefly considered intercepting the line for such a simple request. He laughed off that idea, denied any intent to ever cut in, and explained that all he required in the morning was a black coffee.

Standing in line, of course, is one of the time-honored traditions of patience in a perfectly cooperative world. But in all fairness, it is a task that predates the pandemic and certainly involves self-discipline. Dr Burton points out that being patient is supremely challenging given our internal wiring to keep moving.

 The requirement to pause, however, whether on a takeout line, on a conference call, or in the car on a heavily traveled route, is obviously essential to survival—especially amid today’s pandemic-related adjustments.

During a typical day of remote working, hours can be frittered away holding on the telephone when websites, phone apps, and voice menu prompts fail me: tech questions up to 30 minutes, financial assistance up to 30 minutes, and merchandise adjustments up to 60 minutes as an estimate. Medication pre-authorizations and direct access to pharmacies, as my admin staff might readily attest, can also be time-consuming.

Historically speaking, patience was regarded as a quality of moral excellence during the 3rd century in the teachings of the Latin textbook, 

 Patience was later discussed by Geoffrey Chaucer in 

, which he wrote around 1386. There, in the Franklin’s Tale, and in the context of not emotionally smothering your romantic partner, the Franklin explains that “patience is a conquering virtue. The learned say that, if it not desert you, it vanquishes what force can never reach…”

Fast-forwarding to the present, a behavioral take might be to consider patience as a building block in adaptive executive functioning. Underlying much of volitional behavior—listening, responding, planning, problem-solving, and organizing, to mention a few—is the ever-present ability to pause and wait for things to take their course. 

 published an article in February 2022 entitled “In Miami, Climbing Ballet’s Everest: ‘Swan Lake.’” The piece illustrates the importance of patience as it describes how Lourdes Lopez, Miami ballet’s artistic director, waited for 6 years to have her company perform “Swan Lake,” delayed in part because of COVID-19. Artistic vision, steadfast focus, and help from others all reportedly empowered Ms Lourdes to produce the ballet notwithstanding the many challenges.

Despite the simplicity of patience as a concept, there remains something elusive, especially in a culture driven by speed and measurement of results. This may sound farfetched, but one day during a cosmic moment, I reflected on the relationship between physiology and patience. Every 

, I noted, has the necessity of pause, graphically represented on the EKG tracing by the ST segment then T-wave, during which time the ventricle repolarizes t0 prepare for its next contraction. Likewise, the action potential follows a cyclical pattern of depolarization/repolarization with a resting voltage in between as it travels down the neural circuit.

Clinically, how do we as physicians and psychiatrists encourage patience? The first step is to gauge our own patience levels—the stressors in our lives as well as the alleviators. What kind of day are we having? How are we feeling internally? Ideally, we must treat ourselves with 

, recognize the many variables beyond our control (especially with COVID-19 still lingering), and value the amount of patience that goes into a solid doctor-patient relationship. Then we must acknowledge that antianxiety medications can only go so far in improving patience levels, as psychotropic agents specifically promoting increased levels of patience have yet to emerge.

As for the teaching of patience, popular demand is surging, as reflected in over 2500 mindfulness apps listed on the internet. A survey of subscribers to Calm, a popular meditation app, showed that 56% reported a chronic health diagnosis, 41% a mental health diagnosis, and 76% reported some form of insomnia. 

 and sleep stories were rated as particularly helpful with linear correlations between frequency of use and self-reported improvements in mental health and sleep.

In practice, when individuals are struggling with anxiety, I sometimes recommend the 

 exercise of sitting and being present for up to 5 minutes several times per day. Patients will then begin to observe how they feel when tense versus calm, and perhaps be more able to realistically manage time and task self-expectations. Additionally, the therapeutic alliance can be strengthened by this mindfulness exercise. Over time, when the routine is consistently practiced, clinical feedback suggests a greater sense of balance.

Returning to my initial question, patience can be thought of as an unspoken ally in daily life as well as in clinical practice. It is perhaps under-recognized and definitely deserving of credit.

practices psychiatry in Northern New Jersey. Dr Sofair holds affiliations with Atlantic Health System and CarePoint Health.

Acknowledgements: The author would like to thank Jon W. Green Esq and the library staff of Morristown Medical Center for support.

1. Burton N. The lost virtue of patience. 

. August 31, 2019. Accessed May 19, 2022. 

https://www.psychologytoday.com/us/blog/hide-and-seek/201908/the-lost-virtue-patience

2. Banzhaf R. Who said “patience is a virtue”? YourDictionary. Accessed May 19, 2022. 

https://examples.yourdictionary.com/articles/who-said-patience-is-a-virtue.html

4. Harss M. In Miami, climbing ballet’s Everest: ‘Swan Lake.’ 

 February 6, 2022. Accessed May 19, 2022. 

https://www.nytimes.com/2022/02/03/arts/dance/alexei-ratmanksy-swan-lake-miami-city-ballet.html

5. Huberty J, Vranceanu AM, Carney C, et al. 

Characteristics and usage patterns among 12,151 paid subscribers of the Calm meditation app: cross-sectional survey.

Patience should always be used in the service of healing and helping.

The Role of Patience in Psychiatry

 look like through the lens of someone starting over? Among a sample of 26 physicians, predominantly psychiatrists, only 50% were satisfied with their medical career, yet 96% chose to remain in clinical practice. With COVID-19 making a career in medicine more stressful than ever, understanding career decisions and burnout is essential for the future health of the profession.

“I have shed a tear or two for my life and career. At the same time, you have to keep moving forward. My dream has always been, and will always be, to be a singer. But now I have more than one dream.”

, forced to make a 180-degree pivot from the opera world to that of software engineering when COVID-19 closed down the concert halls.

 You may be thinking, what does this have to do with psychiatry? Our answer would be nothing

Among psychiatrists, career fluctuation has been discussed since before the COVID-19 global health crisis. Yet, according to medical search engines and occupational databases, few in medicine are documented to have made a career pivot like Mr LaBrie. It is not uncommon to see doctors burning the candle at both ends. One example is Sir Charles Tupper, MD, the renowned 19th-century Canadian physician and first president of the Canadian Medical Association, who left his medical career to become the Canadian prime minister.

 However, large scale studies looking at doctors who have expanded their career or opted out of medicine are scarce.

Our interest stems in part from wishing to understand how physicians have navigated their professional paths, but a seed of curiosity was also planted several years ago during a workshop on professional 

. During the workshop, the course director asked physician attendees to indicate if they had ever experienced burnout. As one might predict, only a few audience members raised their hands. Despite steadfast efforts to destigmatize burnout, most physicians struggle to admit that they feel disappointed or burned out with their work.

Witness a recent survey on burnout among 2084 psychiatrists conducted by Richard F. Summers, MD, and colleagues.

 Depression, female gender, and workplace stressors were identified as risk factors for burnout, but study respondents had been de-identified, suggesting residual burnout 

. Some physicians also pride themselves on being particularly dedicated, for example a group of front line physicians in Texas who rejected the term burnout altogether. They felt that their self-acknowledged pandemic exhaustion—attributed to the fear of contracting the COVID-19 virus, and to the burden of personal protective equipment (PPE), or a lack thereof—was justified, and not deserving of a label. Regarding personal wellness initiatives, one physician commented, “it is absurd to believe that yoga will solve the problems of treating a cancer patient with a declined preauthorization for chemotherapy… These problems are not the result of some failing on the part of the individual clinician.”

 from a different angle—allowing for burnout, did this lead to career change? A convenience sample of 126 multispecialty physicians were anonymously and electronically surveyed as to whether they had expanded their career beyond the practice of medicine. This was a publicly available survey communicated through a variety of channels, including telephone outreaches, emails, and mailing lists. The hospital institutional review board granted exemption from formal committee review. All questions were designed to fit onto a single page for the respondents’ convenience. Inquiry was sequentially ordered by research interest, starting with career satisfaction then possible second career, followed by demographic information and the rating of potential workplace stressors. Our goal was to raise awareness on the importance of burnout among physicians and its potential impact on productivity as well as career decisions.

Due to the small sample size, our findings are briefly summarized and presented in 

- Twenty-six out of the 126 anonymously surveyed physicians completed the survey. The majority were psychiatrists, and over 80% were in middle to late career. While 73% cited a higher calling as the reason for entering medicine, only 50% reported professional satisfaction within their career. All but 1 retained medicine and/or psychiatry as their sole career. Despite unmet career expectations, respondents remained as doctors.

- Electronic medical records and administrative overburdening were ranked as the most bothersome workplace stressors, followed by long work hours and fear of being sued. Board maintenance requirements and feeling professionally undervalued fell comparatively lower as career stressors.

- Respondents commented on professional happiness and career decisions. They expressed gratitude for the opportunity to express their opinions and wrote many comments, perhaps the most compelling aspect of the study.

- Only 2 respondents were unconditionally supportive of physicians expanding their career outside of medicine. The rest were supportive of a balanced lifestyle, but not necessarily leaving the practice of medicine.

Measures of career satisfaction among physicians have yielded comparable findings elsewhere. A prospective survey of South Dakota physicians showed that over 40% of both male and female respondents were not satisfied with their 

, despite the majority stating they would enter medicine again if given the choice.

 A Mayo Clinic comparison of early, middle, and late career physicians in the United States showed highest percentage of career disappointment, as well as intent to leave medicine for middle career physicians (12.5%) and lower rates (5.2%) for those late in career.

Within our sample, a sense of calling, the status of being a doctor, and financial security were judged protective, even with unmet career expectations. Moreover, respondents are inferred to have felt settled on multiple levels—professionally, financially, and perhaps being in closer proximity to retirement rather than a new start. 

The major limitation of our study is the regrettably low response rate. As such, we believe important questions remain. For instance, should burnout be conceptualized as episodic or chronic, and if episodic, what factors promote its resolution? It would be useful to further document burnout-related career decisions longitudinally from 

 training through retirement, notably against the backdrop of the COVID-19 pandemic.

A final point is that the 40% estimate of burnout and depression among physicians has recently received pushback. One research group contests this statistic, suggesting that it may be inflated. Moreover, the group suggests that the persistent publicity over burnout has become self-defeating, resulting in many physicians, who happen to love what they do, including the long hours, to feel work-shamed.

practices psychiatry in northern New Jersey. She is affiliated with Morristown Medical Center, Atlantic Health System.

is a biostatistician and research manager affiliated with the Atlantic Center for Research, Atlantic Health System.

The authors would also like to acknowledge and thank Laura Logiudice, Esq; Yi Zhou, MLIS; Denise Sikora, AAS, MLT.

1. Woolfe Z. Two friends, two continents, very different pandemics. 

. January 13, 2021. Accessed May 11, 2021. 

https://www.nytimes.com/2021/01/13/arts/music/opera-singers-coronavirus-pandemic.html

2. Murray TJ. Serving two masters: the medical and political careers of Sir Charles Tupper. 

3. Moran M. Burnout appears highly prevalent among psychiatrists, survey finds. 

4. Berlin J. No escape: COVID-19 continues to exacerbate physician burnout. 

5. Clemen NM, Blacker BC, Floen MJ, et al. Work-life balance in women physicians in South Dakota: results of a state-wide assessment survey. 

6. Dyrbye LN, Varkey P, Boone SL, et al. Physician satisfaction and burnout at different career stages. 

7. Sotile WM, Fallon R, Orlando J. Curbing burnout hysteria with self-compassion: a key to physician resilience. 

Is the COVID-19 burnout enough to make some physicians step away from medicine? 

How Readily Do Physicians Switch Careers?

Early on, perhaps around April or May, much to my chagrin I failed to look up my bank’s new COVID-19 hours. Thinking the bank opened at 9:30 am, I discovered on arrival that I would have to wait an extra hour to access drive-through banking. I ended up doing my banking the old-fashioned way—in the bank.

Upon returning home, I started to berate myself: “Why did I not wait the extra hour for drive-through? Did my need for efficiency overrule possible exposure to the virus, allowing for the bank’s attentive COVID precautions? Is my social circle also now at risk, and who might they be at this point? If necessary, how do I go about informing them? And at the end of the day, do I really want to bother with all of this?”

What finally assuaged my anxiety was the empathic listening of my support network. One friend told me, “You didn’t commit a crime. You simply went on an errand.” So true and logical, in retrospect. However, at the time, the uncertainty inherent to the pandemic compromised my ability to make a balanced self-appraisal.

 has commented, “our brains are literally overburdened by the pandemic…things we had relegated to the brain’s autopilot function…now require serious thought and risk analysis. As a result, we have less bandwidth available for higher order thinking…”

 Her observations could not be more resonant with my own experience. Every time I step out the door, there is a safety-related checklist that can feel burdensome—remembering a mask, weighing in on the day’s logistics so as to maximize social distancing, and prioritizing what is essential versus non-essential activity. The net effect is a heightened awareness that is not only mentally exhausting but, in certain cases, can lead to an insidious onset of intensified reactivity. Prior to the pandemic, cognitive therapists might have labelled this as a tendency to catastrophize, but now it is an understandable variant of pandemic anxiety.

Pandemic anxiety is driven by the highly contagious and potentially lethal nature of SARS CoV-2. We have read numerous reports of individuals in their prime tragically struck down by the virus, leaving mourners in their wake. Many of us have experienced the trauma of losing someone to COVID-19 first-hand.

Months of social restriction coupled with well-intentioned public health messages have also taken their toll. Of all the holiday warnings circulating this past November, several in particular were striking. Roughly distilled, they read, “Dining with your family member today could result in their ICU admission tomorrow.” Some public health officials found such stark warnings to be excessive, counter-productive to promoting safe travel in their degree of shaming. Acknowledging the beneficial intent—to curb irresponsible behavior—this team of experts nevertheless felt that public health messages needed to be more nuanced to avoid compounding an already heightened level of fear.

As psychiatrists, we face the challenge of sorting out normal pandemic anxiety from more pervasive anxiety disorders, not only for our own self-understanding, but also to help our patients. And yet, diagnosing anxiety disorders can be tricky if we are simultaneously processing empathy for our patients with verifying our own near COVID-19 misses. Returning to the opening vignette, what distinguishes an acute attack of pandemic anxiety, which can hijack the mind, from an obsessive-compulsive disorder (OCD) obsession? In their international mini review, Sulaimani and Bagadood comment that “the constant warnings about coronavirus and incessant reminders to keep high levels of hygiene have created an obsessive-compulsive nature for doing things

Documentation of anxiety disorders linked with pandemic anxiety include phobias, health anxiety, and obsessive-compulsive disorder, plausibly connected by an underlying theme of intolerance for uncertainty.

 Pandemic phobia might, for example, center around an exaggerated fear of a public place, such as a mall, grocery store, or restaurant. Health anxiety, on the other hand, might be focused on the fear of receiving a positive COVID-19 test result, thus triggering fears of illness, hospitalization, incapacity, and potential long-term sequelae.

OCD, by contrast, is more elusive and multi-faceted. Its presentation can overlap with pandemic anxiety: both might lead to harboring intrusive fears of contamination and heightened de-contamination rituals. According to Pascale Moraille, MD, Medical Director of the Outpatient Psychiatry Division at Hoboken University Medical Center, “One difference between pandemic anxiety and OCD is that pandemic anxiety can be adaptive, leading the individual to safe behaviors during these stressful times. In contrast, an anxiety disorder like OCD can be exacerbated, often requiring many different treatment approaches.”

The impact of the pandemic on OCD, with an estimated United States lifetime prevalence of 1.8%, remains an open area of clinical investigation. Pandemic-related treatment barriers to OCD might include defining what is ordinary versus pathological fear; variability in presentation and severity of OCD itself; the recent adaptation of virtual technology for psychiatric care; and the tendency of those with profound OCD to avoid reaching out for professional counseling when confronted with severe stressors.

 This tendency to isolate may be a telltale distinguishing feature from pandemic anxiety, where the tendency is to maintain connection (

Respectfully, maybe it is time to hit the pause and reset button for a few theories underlying anxiety treatment. Starting with cognitive behavioral theory, should there not be qualifiers when interpreting the 10 classic cognitive distortions, especially in the context of global crises like COVID-19 or severe weather change?

 Rather than labeling the patient’s thinking patterns as distorted per se, why not counter belief systems with scientifically credible data? Likewise, given the paramount importance of hand hygiene, how wise is exposure and response prevention therapy (ERCP), an OCD behavioral therapy aimed at extinguishing compulsive rituals through in vivo exposure to the feared source of contamination? How many times per day do we all wash our hands to avoid microbial contamination? I confess I have recently lost count.

Acknowledgments: Jon W. Green, Esq; Janina Kaldan, MLS, AHIP; Pascale Moraille, MD

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https://www.nytimes.com/2020/11/28/sunday-review/pandemic-habits-routine-brain.html

2. Everett R. The COVID-19 outbreak. Shame, fear hurting NJ’s pandemic fight. 

https://www.nj.com/coronavirus/2020/12/why-shame-and-fear-are-hurting-njs-battle-against-cov 

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What are the differences between disorders like OCD and pandemic anxiety? 

Fresh Perspective on Pandemic Anxiety 

I am probably not the first psychiatrist to have discovered that a certain percentage of patients are stabilizing rather than deteriorating amidst the COVID-19 outbreak. During a recent online meeting, a colleague noted something similar, resonating with my own clinical experience. This is undoubtedly contrary to everything most of us would have imagined based on media reports. Moreover, we might have anticipated an alternative outcome according to basic therapy logic—people tend to decompensate during crises!

stated, “Many Americans say that the pandemic has seriously impacted their mental health.”

 A histogram on the following page goes on to show that ‘fear of getting the virus” is effectively tied with“fear of loved ones becoming infected,” both hovering around the 50% mark. In third place, understandably, is the “fear of running out of supplies”—namely food, medicine and other deemed essentials.

At this point, allow me to interject that it would be disrespectful to contradict these findings. This is a reputable online survey of 1004 adults versus my own convenience sample. Fears of the virus are real and profound, never to be minimized or dismissed. However, I also believe that it is instructive to expand on what I mean by some patients improving, and whether those among my sub-sample, many with ongoing mood and anxiety disorders, feel that the general public finally gets it. After all, as is frequently sloganized, “We are all in this together.”

Since the quarantine applies to most of us, perhaps my patients no longer feel marginalized compared with others whom they perceive, rightly or wrongly, to hold more dynamic lifestyles.

Since the quarantine applies to most of us, perhaps my patients no longer feel marginalized compared with others whom they perceive, rightly or wrongly, to hold more dynamic lifestyles. “Stabilizing” as a clinical parameter then becomes less an objective measure of how patients are actually functioning, and more a gauge of their subjective self-acceptance, maybe even inner peace. In that regard, the daily routine playing field is now leveled for everyone.

Case in point are patients who struggle with chronic shyness, not always to the point of diagnosable social phobia, but enough so that it is burdensome to interact with the outside world on a daily basis. One can infer that before COVID-19, this challenge was associated with an unsettling sense of shame, but maybe less so now. The social pressures are off, at least temporarily. I also think of patients with agoraphobia who are chronically housebound. Yet, where are any of us really going right now?

Along these lines, there is no therapeutic directive that the patient gets into their car and takes a drive down the Garden State Parkway, one exit at a time, in order to desensitize a lingering travel phobia. Adding to the democratic spirit of social distancing policies, several experts have commented that the use of telepsychiatry serves as an equalizer, particularly in the context of the doctor-patient relationship. While many of us long ago abandoned what Parth and colleagues

 branded as “the silent, abstinent style of psychoanalysis,” an awkward reminder that the psychiatrist is the supreme authority figure, delivery of care through virtual means humanizes us in the eyes of our patients.

 The video as a therapy platform provides both a sense of security and privacy, despite physical distance. This thereby elicits a potentially more detailed narrative from the patient than might be heard in the office. The virtual appointment also allows the patient to remain on their own turf during therapy. Hindi Mermelstein, MD,

, “. . . each person chooses the place, which can help empower individuals who feel more stigmatized in the traditional office hierarchy.”

When patients ask me at the conclusion of our telepsychiatry session, “Doctor, how are you and your family doing?” I have to remind myself that this simple question embodies so much. It could mean, for instance, “Now that you and I are on more equal footing, Doctor, both encased with uncertainty, I feel emboldened in expressing my genuine concern for your well-being.” Or, the question might also signal an apprehension that I will become COVID-stricken myself, and thus be ultimately unavailable as their physician. Regardless of exact meaning, what has become abundantly clear in practicing during these most interesting times is an enhanced fluidity in the classic tripartite analytic model of working alliance, real relationship, and transference

concepts we diligently absorbed during residency.

 The author would like to acknowledge the following individuals for their assistance in preparing this article: Naomi Weinshenker, MD; Nan Gallagher, Esq; and Yi Zhou, MLIS.

1. COVID-19 Pandemic Is Taking MH Toll, Finds APA Poll. 

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https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.5a10

2. Parth K, Datz F, Seidman C, Löffler-Stastka H. Transference and countertransference: A review. 

3. Yellowlees P. Telepsychiatry: from crisis to opportunity. 

https://www.thecarlatreport.com/the-carlat-psychiatry-report/telepsychiatry-from-crisis-to-opportunity

4. Mermelstein H. Psychotherapy in the time of COVID. 

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2020.5b23

Has the Playing Field Been Leveled?

Autumn brings me a sense of optimism. The days-a perfect balance of temperature and humidity-are typically sunny. The evenings are crisp, the tomatoes are at their peak, and the trees abound in fine-looking foliage. All in all, batteries are recharged and another school year is afoot.

Between September 22nd and September 30th of last year, 3 horrific tales of suicide appeared in the news, literally one after another. For the families and close friends of Tyler Clementi, Rigoberto Ruelas, and Joseph Cerniglia, their autumn, unlike mine, was undoubtedly a time of shock and devastation.

Tyler Clementi’s suicide is perhaps the most familiar. Mr Clementi, a promising Rutgers freshman and brilliant violinist, jumped off the George Washington Bridge after he discovered that he had been videotaped in a private rendezvous with another man. He was eulogized as “the smartest kid in the class and . . . extremely helpful with his classmates all the time.”

Rigoberto Ruelas’ story is eerily similar. As a 39-year-old schoolteacher from South Los Angeles, his life revolved around teaching and steering his students away from gangs in the direction of higher education. Shortly after he discovered what he perceived as poor teacher ratings on a Web site, he jumped off a canyon to his death. His school principal praised his professional abilities and described Mr Ruelas as “a very happy individual . . . [who] felt a desire and need to help this community.”

Within days of Mr Clementi’s suicide, 39-year-old chef Joseph Cerniglia met his fate in the Hudson River. Three years earlier, he had experienced a demeaning moment when his restaurant had been trashed on a reality television show. He, like the others, was described as gifted in his craft-Italianate cuisine-and though not perfect, he was reportedly a charmer, the kind of person who would give you the shirt off his back.

Certainly, I do not wish to implicate adverse publicity as the final common denominator for a fatal outcome, especially because suicide is a result of a highly complex, individualized set of circumstances. For these 3 persons, however, there is a common thread of public humiliation as a plausible tipping point in their private sufferings, despite their outward talent and dedication.

This thread may also weave into the tragic suicide by hanging of Mark Madoff, son of Bernard Madoff. He was found deceased in his apartment last December while his young son slept in an adjoining room. Mr Madoff was allegedly unable to cope with the prospect of facing criminal charges added onto existing civil charges for his involvement in his father’s Ponzi scandal and his children being dragged into the public eye.

Need help? In the U.S., call 1-800-273-8255 National Suicide Prevention Lifeline

The role of public humiliation in suicidal behavior is not well understood. Hendin and colleagues4 did a retrospective analysis of 36 completed suicides and 26 loosely matched controls. The study subjects, all depressed patients in treatment with the same providers, some with, others without, suicidal features. Compared with the nonsuicidal patients, the suicide completers received statistically higher ratings by their providers in the affects of desperation, hopelessness, feelings of abandonment, self-hatred, rage, anxiety, and loneliness, but not in guilt or feelings of humiliation. The authors speculated that a sense of humiliation was present in the suicide completers, but it was buried beneath other intense affects and cofactored with diminished functional capacity.

 support the humiliation thesis: “Psychoanalytic discussions, while helpful, have been focused on the role of humiliation in character development . . . but not on understanding the phenomenon itself.” The authors define aspects of humiliation in the patient’s clinical history that should set off alarm bells for the treating clinician. These include a loss of public status, the intensity and impact of that loss, threat to the sense of self, extent of public exposure, the perception of malice, and the lack of opportunity for recovery and renewal.

This is logical. The more successful the person, the more he or she has to lose, and the steeper his or her fall from grace. Who weathers the storm and who drowns? Torres and Bergner believe the persons most at risk are those with depression, social phobia, and/or narcissistic personality disorder. The authors postulate that depressed persons are self-attributional, so any outside censure confirms their beliefs of worthlessness. This mechanism would be somewhat parallel to the narcissist, except the latter is more apt to launch a vigilant campaign of self-defense. As for the socially phobic, any major embarrassment could obviously cause affective flooding to the point of self-dissolution because the fear has been actualized.

Then there are microhumiliations, the annoying, daily invasions of privacy that rattle the world of some patients. Examples are online postings of salaries, professional rankings (as in the case of Rigoberto Ruelas), legal judgments, and a variety of postings on public social Web sites. I can think of an instance where a patient in crisis came for treatment. She had discovered a photo of her “significant other” and a new love interest on a social Web site.

Humiliation scenarios abound; however, because of the speed and pervasiveness of technology, a new challenge is introduced: there is no longer anywhere to hide. Walter Kirn

 writes, “As the Internet proves every day, it isn’t some stern and monolithic Big Brother . . . it’s a vast co-hort of prankish Little Brothers equipped with devices that Orwell . . . never dreamed of.” When all is said and done, technology is the greatest social equalizer, with some people more vulnerable than others.

It is our job as medical professionals and therapists to identify whom to worry about and how best to intervene. According to the American Foundation for Suicide Prevention, more than 34,000 Americans die by suicide annually. Of these, 10% have never been given a psychiatric diagnosis. Like the suicide victims in this story, most of the time they seem to be happy, which highlights how truly baffling the suicidal process is and how much still needs to be accomplished in designing effective suicide prevention strategies.

For now, perhaps the best course of action is the old adage, “know thy patient.” Rather than being lulled by the traditional epidemiological risk profile-male, elderly, chronically ill, prior suicide attempts, active substance abuse, and family suicide history-the clinician should look for “near term” warning signs (

), such as the crisis in the moment, the immediate presentation, the acute agitation/cogitation, and the patient’s behaving differently, rather than listen to what the patient is saying.

 I would perhaps add an inquiry about recent episodes of judgment or embarrassment, particularly if they occurred in cyberspace.

• Inability to form a working alliance
• Unwillingness to be known
• Intolerance of being understood
• Agitation
• Cogitation
• Detachment and despair
• Social isolation
• Change in treatment compliance patterns
• Suicidal ideation, plan, and intent with preparations
• Discrepancy between verbal self-report and actions
• Perceived environmental humiliation

 Nutt AE. Friends remember Tyler Clementi as brilliant musician, bright student. October 1, 2010. 

http://www.nj.com/news/index.ssf/2010/10/rutgers_student_tyler_clementi_1.html

 Zavis A, Barboza T. Teacher’s suicide shocks school. 

 http://articles.latimes.com/2010/sep/28/local/la-me-south-gate-teacher-20100928/2

 Henriques DB, Baker A. A Madoff son hangs himself on father’s arrest anniversary. 

http://www.nytimes.com/2010/12/12/business/12madoff.html

 Hendin H, Maltsberger JT, Szanto, K. The role of intense affective states in signaling a suicide crisis. 

 Torres WJ, Bergner RM. Humiliation: its nature and consequences. 

 Kirn W. The way we live now: little brother is watching. 

http://www.nytimes.com/2010/10/17/magazine/17FOB-WWLN-t.html

 Rudd MD. Suicide warning signs in clinical practice. 

Concise Guide to Psychiatry and Law for Clinicians. 

Arlington, VA: American Psychiatric Publishing; 2008.

 According to the American Foundation for Suicide Prevention, more than 34,000 Americans die by suicide annually. Of these, 10% have never been given a psychiatric diagnosis.