DEFINITION

• What is COVID-19?
  • COVID-19, also known as 2019-nCoV or SARS-CoV-2, is a positive sense, single-strand enveloped RNA virus of the family Coronaviridae that is the cause of the pandemic in late 2019 and currently ongoing in 2020. It primarily causes upper and lower respiratory tract infections.
• What are anxiety and worry? [1]
  • Anxiety is a state of high physiological arousal, characterized by the increased secretion of cortisol, adrenaline, and inflammatory cytokines that stimulate the sympathetic nervous system or the “fight-or-flight” response.
  • Worry is the cognitive component of anxiety, defined by mental attempts to avoid anticipated potential threats. On its own, it has no increased physiological arousal.
  • Although they may present differently in different people, symptoms and reactions to stress include changes in sleep or eating patterns, irritability, fatigue, and tobacco and alcohol use. [2]
• Although anyone may experience increased anxiety at this time, the Centers for Disease Control and Prevention (CDC) has identified those who may be at increased risk: [3]
  • Older adults and those with chronic diseases
  • Children and teens
  • People helping with the response to COVID-19, such as healthcare providers, first responders, grocery store workers, and custodial staff
    • In a cross-sectional survey, many Chinese healthcare workers reported symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%) during the COVID-19 outbreak. [4]
  • People who have mental health conditions including problems with substance use including alcohol
• What is resilience?
  • It is the ability to maintain or regain mental health after a period of adversity.[5]
  • It is a protective factor against developing depression, anxiety, and maladaptive coping habits that may lead to substance use disorders.
  • Most resilience training overlaps with cognitive behavioral training (CBT), a psychotherapy approach aimed at providing coping skills in order to modify maladaptive thoughts and behaviors to improve feelings.

APPROACH

• It is important to remember that some anxiety is useful.
  • In situations where we are in immediate danger, it can remove us from harm and motivate us to act.
• However, when anxiety impairs one’s ability to function, it is important to try to manage it in healthy ways.
• It takes work to manage stress and build resilience.
  • Consistent practice is key, not achieving perfection. Those who invested more effort over time to increase happiness have been shown to experience greater positive changes in well-being.[6]
  • It may be helpful to think of resilience as a muscle that must be trained consistently in order to achieve results. It may be difficult to change thoughts and behaviors, but as with exercise, it gets easier over time.
• Why is it importantto manage stress and train resilience?
  • Helps people feel better, reestablish control, and continue to function
  • Improves immune response
    • Acute and chronic stress have been associated with immune system suppression, with chronic stress negatively affecting cell and humoral immunity.[7]
    • Stress reduction can amplify the immune system. One study found that compared to a control group, those who received mindfulness meditation training showed more rapid antibody formation when given a flu vaccine.[8]
  • Reduces negative chronic health outcomes
    • Chronic stress is associated with cardiovascular disease, tension or migraine headaches, lack of sleep, and lack of motivation. It is also associated with maladaptive coping mechanisms such as substance use.[9]
  • Improves ability to handle unexpected new stresses
    • Multiple studies found that mindfulness-based stress reduction practices allowed nurses to report feeling less stressed, anxious, and depressed and more empathetic.[10][11]

APPLICATION

GENERAL SUGGESTIONS FOR STRESS MANAGEMENT:

• Take care of physical health.
  • Get adequate and quality sleep.
    • Establish a routine by going to bed and waking up at the same times daily.
    • Avoid caffeine, screens, exercise, and other stimulating activities late in the day.
    • If unable to sleep at night, it is recommended to get up to get a glass of water or walk around instead of laying for hours awake in bed. This is to avoid associating lack of sleep with the bed.
  • Exercise at home or while maintaining social distancing outside.
  • Try to eat healthy, well-balanced meals, e.g. a salad every Monday, Wednesday, and Friday.
  • Avoid alcohol, drugs, and illegal substances.
• Exercise purposeful, mindful attention to move away from negative thoughts and bring focus to positive ones.
  • Listen to guided meditations before bed or early in the morning.
  • Practice deep breathing exercises throughout the day, e.g. inhaling for 4 seconds, holding the breath for 4 seconds, and exhaling for 4 seconds.
  • During the day, pause and focus on the current activity one is engaged in, e.g. noting what the sights, smells, and sensations are when brushing teeth or washing the dishes.
  • Set a daily intention or value depending on current needs, e.g. choosing to focus on “happiness” one day and “forgiveness” the next.
• Exercise positive psychology to focus on positive aspects of life.
  • A study by Seligman asked individuals to do 1 out of 3 positive psychology exercises daily for 1 week: write down three positive things occurring in their life, identify a personal strength and use it in a new way, or write down three things for which they were grateful. Compared to individuals who journaled about memories, the positive psychology group had higher happiness scores after 1, 3, and 6 months. [12]
• Identify irrational and negative thoughts, and challenge those negative thoughts.
  • An example is changing the thought “We are never going to get through this” to “We WILL get through this, and I know what I need to do today.”
  • Create a list of positive thoughts and memories that have personal importance that can be brought up when feeling overwhelmed with negative thoughts.
• Identify the onset of a strong emotional response.
  • Recognize the signs of an impending strong emotional response or being in a “loop” of negative thoughts.
  • Then use techniques to control the emotional response:
    • Pause and take deep breaths.
    • Exit the current situation, e.g. ending a conversation instead of yelling, taking a distracting walk, imagining a peaceful scene.
• Maintain a list of personal stress-reducing and enjoyable activities to refer to during times of crises.

SUGGESTIONS WHILE SOCIAL DISTANCING:

• Follow CDC guidelines for COVID-19.[13]
  • Put at least 6 feet distance between oneself and others.
  • Wash hands often. If soap and water are not available, use a hand sanitizer with at least 60% alcohol.
  • Avoid touching one’s face.
  • Clean and disinfect frequently touched surfaces daily.
  • Stay home and wear a face mask around others if sick.
• Maintain a routine at home.
  • Create a daily schedule. Include a start time, breaks, and an end time.
  • Change clothes and refrain from working in pajamas.
  • Have a routine before sleeping to wind down, e.g. reading, journaling positive thoughts - and limit use of caffeine, exercise, or electronics.
• Create aseparate workspace at home to improve productivity, e.g., not your bed.
• Limit access to news and information.
  • Select only a few credible sources for up-to-date scientific information.
  • Set limitations, e.g. only accessing news twice daily.
• Think creatively about ways to stay connected with others. Take stock of enjoyable activities and make commitments to socialize virtually.
  • Watch a movie virtually with friends.
  • Choose a book to read with loved ones and hold discussions over the phone.
  • Exercise virtually with friends or family.
• If applicable, continue to be involved in faith communities while practicing social distancing, e.g. watching online streams.
• Set a regular schedule for checking in with people one is worried about most, e.g. older family members and those who tested positive for COVID-19.
• In close quarters, try to reduce and manage disagreements with others in one’s living space.
  • Focus on communication and listening.
  • Set specific times in the day or week to openly talk about disagreements or frustrations.

SUGGESTIONS FOR PATIENTS WITH CHILDREN:[14]

• As children and teenagers in part model behavior from adults around them, it is recommended to support them by being a role model. Manage stress and anxiety calmly and confidently and maintain self-care.
• Reassure them that they are safe.
• Provide them opportunities to talk about their feelings, concerns, and questions.
• Validate their feelings and reassure them that it is okay to feel upset or afraid.
• Provide tools such as the ones above for them to manage feelings and have a sense of control.
• Set a regular routine or schedule, including learning and fun activities.

SUGGESTIONS FOR COVID-19 RESPONDERS:

• Recognize signs of burnout and secondary traumatic stress.[15]
  • According to the CDC, signs of burn-out include:
    • Sadness, depression, or apathy
    • Easily frustrated
    • Blaming of others, irritability
    • Lacking feelings, indifferent
    • Isolation or disconnection from others
    • Poor self-care (hygiene)
    • Tired, exhausted or overwhelmed
    • Feelings of failure and hopelessness
  • Signs of secondary traumatic stress include:
    • Excessive worry or fear about something bad happening
    • Easily startled, or “on guard” all of the time
    • Physical signs of stress (e.g. racing heart)
    • Nightmares or recurrent thoughts about the traumatic situation
    • The feeling that others’ trauma is yours
• Remember that it is acceptable to take breaks.
• Remember that maintaining one’s health will allow one to make the best contribution.
• Talkto family, friends, supervisors, and teammates about feelings and experiences.
• If social distancing during breaks or lunch time, consider writing in a journal during this time or participating more in online communities.
• Patients that providers are taking care of also may be experiencing increased anxiety during this time. In addition to the recommendations above, the World Health Organization (WHO) provides guides for managing patients’ anxiety during humanitarian emergencies: mhGAP Humanitarian Intervention Guide and psychological first aid.

TREATMENT

• In addition to the above suggestions, patients may seek out physical or online support groups or utilize school or work support services during these crises. Many therapists are now accessible remotely.
• When to refer:
  • If symptoms are moderate to severe and impair social or occupational functioning, it is advised for patients to be referred to mental health professionals such as a psychiatrist.
  • Resilience training and positive psychology are NOT treatments for more serious underlying illnesses. These include:
    • Adjustment disorder
    • Generalized anxiety disorder
    • Major depressive disorder
      • In an emergency in which an individual is at moderate-to-high risk of suicide or has attempted suicide, call 911 and do not leave the patient alone.
      • Firearms are the most common method of fatal suicides.[16] Physicians should assess whether at-risk patients have access to firearms and work with them to restrict access, which include utilizing safer storage options or even firearm removal during times of crises.
    • Substance use disorder
    • Panic disorder
    • Post-traumatic stress disorder

COMMENTS

• This module was adapted from the 03/23/20 stress reduction webinar by Dr. Karen Swartz and Dr. Neda Gould.
• Other helpful resources for managing stress under COVID-19:
  • WHO
  • CDC
  • APA
  • NAMI
  • SAMHSA

References