Jane B. Sofair, MD

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.

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

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

1. Murphy K. Pandemic-proof your habits. 

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 

3. Sulaimani MF, Bagadood NH. Implication of coronavirus pandemic on obsessive-compulsive-disorder symptoms. 

4. Wheaton MG, Messner GR, Marks JB. Intolerance of uncertainty as a factor linking obsessive-compulsive symptoms, health anxiety, and concerns about the spread of the novel coronavirus (COVID-19) in the United States. 

5. Aardema F. COVID-19, obsessive-compulsive disorder and invisible life forms that threaten the self. 

6. Burns DD. Feeling Good: The New Mood Therapy. The New American Library, Inc; 1981.

Articles

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. 

. 2020; 55(9):28. Accessed July 15, 2020. 

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.

Jane B. Sofair, MD

Articles

Fresh Perspective on Pandemic Anxiety

Has the Playing Field Been Leveled?

Feeling Socially Safe