The Other Side of the COVID-19 Crisis: The Silent, Socially Phobic Minority

WHY PSYCHIATRISTS ARE PHYSICIANS FIRST

As the coronavirus disease 2019 (COVID-19) crisis continues, we hear more and more about the current—and projected—mental health fallout from illness, lockdown, job loss, forced relocation, loneliness, loss of friends and family, and death. Data about the direct neuropsychiatric sequelae of COVID-19 infection in addition to the indirect social or economic consequences are also mounting. Yet we do not hear about individuals with social anxiety disorder, or individuals on the high end of autism spectrum disorder (ASD), who are also socially anxious and relieved to be working from home.

Free from the social pressures of the job site, many of these individuals report feeling less distress overall. They are not necessarily free from anxiety altogether; their anxiety focuses on fears of being forced to return to offices when the epidemic ends. They are perturbed by the prospect of sacrificing the social obligation-free sanctuary that they have serendipitously and unexpectedly enjoyed during this strange time.

The January 2, 2021, edition of the Wall Street Journal (WSJ) included a survey taken of a group of workers; it found 80% wanted to continue to work remotely at least part of the time after the pandemic. Individuals with social anxiety disorder presumably comprise some small part of the 80%, yet it is unlikely that all 80% of the WSJ sample want to work remotely for the same reasons as the patients I am discussing. The article, “Is a Home Office Actually More Productive? Some Workers Think So,” detailed the motivations of generic employees, focusing on financial and family drivers of their choice of workplace, but does not break down data by personality type or DSM diagnosis.¹

Psychiatric Fallout

Before commenting on experiences relayed to me by the aforementioned subgroup of my patients, let us first look at the better publicized psychiatric fallout from the COVID-19 crisis. Centers for Disease Control and Prevention (CDC) statistics from late June 2020 state that 40% of the American population were facing COVID-related depression, anxiety, stress-related disorders, or substance use.² A recent JAMA article went several steps further, and identified high-risk groups, noting that financial stressors, including epidemic-related job loss, along with limited savings to cushion the blow, increased an individual’s risk for mental health sequelae.³

The data about increasing drug and alcohol use are equally grim from a medical and mental health point of view, given that liquor sales skyrocketed during lockdown, as per several articles in the WSJ.^4-6 Anonymous liquor store owners have said that demands for their stock during the epidemic rivals sales seen only during weeks between Christmas and New Year’s.

We can estimate the long-term mental and medical impact of alcohol overuse, even though many medical consequences of alcohol overuse do not surface for 20 years. The potentially lethal cardiovascular, oncological, as well as gastrointestinal consequences are not as obvious or immediate as motor vehicle accident-related deaths or fatal subdural bleeds from slip-and-fall accidents that occur while intoxicated. Yet those later sequelae are just as deadly in the long run, so much so that alcohol-related mortality is twice that of the better-publicized opioid-related mortality,with alcohol claiming over 95,000 lives per year,⁷ compared with 46,800 annual opioid overdoses.⁸ Opiate overdoses have already exploded. If we extrapolate from data related to September 11, 2001, when substance abuse disorders in Manhattan remained high long after posttraumatic stress disorder symptoms subsided,⁹ we can anticipate (but not guarantee) similar consequences from this epidemic.

Alarmist claims about projected increases in suicide hit the press, having borrowed data from CDC websites and embellished it with artistic license not appropriate to scientific studies. Some of the most ominous predictions have been refuted; after reading the fine print, we can see that these highly publicized numbers about suicide pertain to individuals who were contemplating suicide rather than to completed suicides. In response to those data, some British medical journals reminded readers that “supposition, however, is no replacement for evidence,” and that “the literature on the effect of COVID-19 on suicide should be interpreted with caution.”¹⁰ Although reports of increased suicidal ideation since the start of the COVID-19 crisis were striking enough to enter the CDC logs, we must recall that suicidal ideation is not the same as attempted suicide, and that attempted suicide is not identical to completed suicide.

In addition, a New York City Health Department pamphlet “Mental Health in New York City: Impact of COVID-19 on Mental Health in New York City,” published in September 2020 and emailed widely in January 2021, offered even more information.¹¹ It dissected the data, breaking it down by race and ethnicity, and ferreted even more risk factors for anxiety and depression. It focused on the greater New York area, where most of my patients reside. Similar to the JAMA data, the 3 top drivers of psychological distress included “feeling cut off or distant from people,” “job loss or reduced hours,” and “overwhelming or above-average financial stress.” Interestingly, many individuals on the spectrum specifically prefer to be “distant from people,” although individuals with pure social anxiety disorder often lament their limitations in partaking in such social activities.

Different Degrees of Stress

What do these data tell us about the socially phobic individuals who report less stress during the lockdown, but experience more stress when contemplating the possibility of a return to onsite work? Let me point out that although the data showed that 40% of the American population endorsed symptoms of depression, anxiety, or trauma during the shelter-in-place mandates and work-from-home policies, this is not the same as saying that 100% of the population is suffering similarly.²

My clinical experience indicates that some individuals are benefiting from limits on social interactions; they prefer the work-at-home policies and appreciate convenient excuses to avoid after-work get-togethers and sit-down holiday dinners.

Admittedly, I cannot offer elegant statistics to rival numbers garnered from formal population-based quantitative studies. All I can share are anecdotal reports gleaned from my large private psychiatric practice, originally based in New York City, but now relocated offsite to upstate New York. Yet those anecdotal reports are impressive. Gainfully employed but socially phobic patients and those on the high end of the autism spectrum (who also tend to be debilitated by social anxiety) are doing better than baseline now that they are freed from the pressures of office politics, enforced personal interactions, and water cooler–style conversations.

In many instances, such individuals experienced an unexpected sense of relief, as well as a sense of accomplishment, after seeing that they could meet their work responsibilities even better without expending extra mental energy ruminating about social interactions, wondering if they said the right thing, and worrying about being forced to speak up in meetings. Having witnessed how much easier their lives can be without the usual social stresses, they identify a different source of anxiety: fear of forced return to the workplace.

Before proceeding, I must point out that the patients to whom I refer are actively and gainfully employed—and so they do not fall into the high-risk categories identified by the JAMA article. They did not experience the stressors, such as job loss or lack of savings, that predispose individuals to COVID-19–related psychological distress. Because they were working before the pandemic, they likely accrued savings that further buffer them from the financial stressors listed in the JAMA article.

Recall that socially phobic individuals are unlikely to speak out for themselves. For them, confrontations with their boss or coworkers are even worse than water-cooler conversations.

And that is where we as psychiatrists can help. Selective serotonin reuptake inhibitors (SSRIs) and supportive therapy go only so far in ameliorating their symptoms and relieving their distress. Advocating for changing their external environment—while we change their internal environment through psychotropic medications and psychotherapy—can offer them so much more relief.

We can also educate our patients about Americans with Disabilities Act accommodations that may allow them to continue to work from home even after the epidemic ends (with some caveats). Familiarizing ourselves with the Department of Labor website (www.doi.gov) will enable us to educate our patients and to direct them to standardized sources without offering legal advice that exceeds our clinical training or purview.

At a time when so many psychiatrists are concerned with climate change and its impact on mental health, should we not also concern ourselves with adapting workplaces to meet the needs of our patients? We can advocate for change, simply by following the laws that are already in place for such purposes.

Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

References

1. Stamm S. Is a home office actually more productive? Some workers think so. Wall Street Journal. January 2, 2021. https://www.wsj.com/articles/is-a-home-office-actually-more-productive-some-workers-think-so-11609563632

2. Centers for Disease Control and Prevention. Coronavirus disease 2019. Accessed February 10, 2021. https://www.cdc.gov/coronavirus/2019-ncov/index.html

3. Ettman CK, Abdalla SM, Cohen GH, et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open. 2020;3(9):e2019686. doi:10.1001/jamanetworkopen.2020.19686

4. Chaudhuri S. Coronavirus closed the bars. America stocked the liquor cabinet. Wall Street Journal. April 10, 2020. https://www.wsj.com/articles/coronavirus-closed-the-bars-america-stocked-the-liquor-cabinet-11586511001

5. Jakab S. The WHO are a bunch of party poopers. Wall Street Journal. April 16, 2020. https://www.wsj.com/articles/the-who-are-a-bunch-of-party-poopers-11587046692

6. Chaudhuri S. Online beer sales soar at brewers of Budweiser, Miller Lite. Wall Street Journal. Updated October 29, 2020. https://www.wsj.com/articles/online-beer-sales-drinking-at-home-boosts-budweiser-brewer-11603968729

7. Centers for Disease Control and Prevention. Deaths from excessive alcohol use in the US. Accessed February 15, 2021. https://www.cdc.gov/ALCOHOL/FEATURES/EXCESSIVE-ALCOHOL-DEATHS.HTML

8. Centers for Disease Control and Prevention. Drug overdose deaths. Accessed February 15, 2021. https://www.cdc.gov/drugoverdose/data/statedeaths.html

9.Packer S. Tele-teatime during the quarantine. Psychiatric Times. April 3, 2020. https://www.psychiatrictimes.com/view/tele-teatime-during-quarantine

10. Knipe D. Trends in suicide during the covid-19 pandemic. BMJ. 2020;371:m4352. doi:10.1136/bmj.m4352.

11. New York City. Mental health in New York City: Impact of COVID-19 on mental health in New York City. September 2020. https://www1.nyc.gov/assets/doh/downloads/pdf/covid/covid-19-mental-health-impacts-hop.pdf❒