Anxiety in the Era of Coronavirus

Update November 16, 2020

The coronavirus pandemic is an unprecedented global catastrophe that has affected all countries throughout the world in both the northern and southern hemispheres.

At the time of this writing, it’s not an exaggeration to say that the coronavirus pandemic is spiraling out of control in both Europe and the United States.

Since the last week of October, the rate of Covid infections and number of hospitalizations have trended sharply upward.

The current number of positive cases in the U.S. is trending around 180,000 per day, about twice what it was during the summer. Most experts believe that this number will increase to 200,000 per day (or about 1.5 million per week) by the end of November. If these trends hold up through the holiday season, one could project 6 million new cases in December alone.

As of this time, the mortality rate for coronavirus in the U.S. is about 1000+ people per day, another number which could increase over the end-of-the- year holidays.

The total number of Covid cases diagnosed in the U.S. since the pandemic began in mid-February is surpassing 11 million. Equally ominous, the total number of deaths in the country is approximately 250,000.Basic arithmetic estimates about an average 2.3% death rate over the entire course of the pandemic, i.e. the percentage of cases which end in death. However, as mortality tends to lag behind case numbers, the mortality rate in the U.S. is expected to increase to 3-4% by the end of the year. In certain hard-hit areas such as the upper Midwest as well as New York City, Seattle, Chicago, and Los Angeles, mortality rates are trending higher than the national average.

Also, apart from Brazil and Mexico, the U.S. has a high number of cases among people of color (African Americans and Latinos).These people have been much more severely affected by the coronavirus. Access to healthcare and health insurance among people of color is about half of that for Whites. The mortality rate among persons sick with COVID-19 for African Americans is 9-12%, about three times the rate for White Americans.

Covid-19 Rates Outside the U.S.

Coronavirus has always been a global pandemic. While U.S. case and mortality numbers, respectively at 11 million and 250,000, are the highest in the world per capita, several other countries are not far behind. Based on the best estimates available, Brazil currently has close to 6 million cases and 165,000 deaths. Most experts believe that published mortality rates in Brazil and Mexico are far below actual rates. India has approximately 9 million cases, just behind the U.S., but a mortality rate of 130,000, due to a longer lag time between positive cases and reported deaths.

In Europe, France currently reports about two million cases with 44,000 deaths, and the UK has about 1.4 million cases with 52,000 deaths. Though these rates are much lower than the U.S., Brazil, and India, the populations of France and the UK are much lower. France and the UK have populations less than one fifth the U.S. population.

Meanwhile, most of the countries that have done very well with coronavirus are in the Far East. Three examples include Taiwan, reporting 600 total cases and 7 deaths, New Zealand, 2000 cases and 25 deaths, and Singapore, 58,000 cases and 28 deaths. These three far eastern countries have done particularly well because they had early and comprehensive national lockdowns before the virus could gain momentum. Also, their regime of reopening businesses after shutting down was more gradual and prudent than most western countries. This well illustrates the fact that Covid can be limited if early shutdowns are enforced nationwide.

To conclude this section on Covid rates, the entire globe at present reports a case rate of about 58 million and a mortality rate of about 1.3 million. Sadly, these numbers are expected to increase substantially by the end of the year.

Causes of the U.S. Covid Pandemic

Why does the U.S., by many measures the most technologically advanced country in the world, also has the highest coronavirus case and mortality rates per capita in the world? A book released on September 15 by Bob Woodward, entitled Rage, discloses the existence of a series of taped interviews with President Trump in which Mr. Trump admits to deliberately playing down the severity of the coronavirus pandemic despite early intelligence, in late January 2020, about the serious threat the virus posed to the U.S.

Mr. Trump’s stated reason for minimizing the potential severe impact of the virus that originated in Wuhan, China is that he wanted to avoid causing panic. In fact, Mr. Trump, in his last interview, admitted that he wanted to continue to downplay the impact of the virus, despite its increasingly massive case and mortality rates, to prevent excessive disruption and fear in the U.S. The “panic” or disruption Mr. Trump is referring to is less the perilous health consequences of the pandemic but instead the effect of any panic or disruption on financial markets.

At no point during the pandemic has Mr. Trump taken a leadership role in guiding the country. Instead, he delegated responsibility for handling the pandemic to the states and cities, leading to a patchwork response throughout the country that exacerbated case and mortality rates. To the present time, Mr. Trump continues to give mixed messages about the importance of wearing masks to reduce the spread of the disease, and many of his followers have taken his messaging further by actually refusing to wear masks in crowded public situations such as the President’s rallies. While he seems to be interested in the potential of vaccines, he continues to largely ignore the current nationwide emergency of spiraling cases going forward. On the other hand, President-Elect Joseph Biden, who won the November 3 presidential election decisively (despite protestations by Mr. Trump and his close associates to the contrary) has already put together a coronavirus team prepared to go into immediate action for a national, top-down set of standards as of inauguration day, Jan. 20.

Another key factor reported in Western countries, particularly the United States and Brazil, has been a tendency to disregard safe health practices by younger people in the 20 to 40 year-old age group.

Because youth feel less vulnerable to severe disease relative to older age groups (which by and large is true), they decided to relinquish responsibility for infecting older people by having engaged in overcrowding in bars, restaurants, nightclubs, mass protests, and other party environments such as discos and raves. Some of these millennial and Gen Z youth groups have become sick and died of Covid, in those cases where they had underlying health conditions such as diabetes or early heart disease, but a majority of them escaped severe illness. Nonetheless they have added to the overall case and mortality rates by infecting their parents, grandparents, and other older people with whom they come into contact.

During late August and September, colleges were in a serious bind about whether they could safely reopen their campuses and minimize Covid infections among students. Many campuses which did reopen saw precipitous spikes in Covid infections among students, often attributed to off-campus parties where students, due to their young age, fail to observe social distancing and mask guidelines. While health guidelines have directed colleges to keep sick students sequestered on campus, many infected students have returned home, where they can do their classes virtually, and many more plan to return home at Thanksgiving and Christmas where they may infect parents and grandparents who are susceptible to serious illness.

At the present time, there is no way to gauge how many young people are practicing social distancing and mask wearing for the sake of everyone else. The prospect of many thousands of college students traveling home for the holidays, only some of which have been pre-tested, does not bode well for the potential course of the pandemic during the last month of the year.

How did America acquire Covid-19 from Wuhan, China in the first place? Some people believe that the pandemic in the U.S. was primarily imported from Europe. However, the truth is that there were over 70 flights from Wuhan, China (the place of origin of the coronavirus) to the United States before the President put into effect a ban on flights from China to the U.S, effective on February 2. While these flights were occurring, they seem to have been widely ignored (many people landing in the U.S. were minimally screened, if at all), and U.S. public announcements early on made an enormous error in assuming the pandemic would be confined to China. Through much of February, flights continued from Europe to the U.S., even though Italy, Spain, and France became hotspots for coronavirus infections. Arriving passengers were told to self-quarantine, but there is no way of knowing how many did. In short, the prevalence of air travel helped spread the coronavirus from China and Europe to the U.S during the early days of the pandemic.

Economic Consequences of the Pandemic

The second edge or “prong” of the pandemic has been economic. Massive numbers of people worldwide who lost their jobs were caught unprepared and subsequently forced to rely on precarious sources of income in order to prevent family starvation. In the U.S., such people have either turned to long waits to access food banks, or risked shopping in big box discount stores under conditions that preclude social distancing from other people.

Worldwide losses in jobs vary from country to country, but in the U.S., where at least 40 million people had lost their jobs by early June, the economic downturn tracks more closely with the Great Depression of 1929-1932 than the Great Recession of 2008-2009. Economic activity throughout the world was essentially shut down over a period of weeks, not over a period of years or many months as with previous major economic downturns. The sudden massive loss of jobs was especially traumatic for millions of people who had no economic resources on hand, living paycheck to paycheck.

In the U.S., the Cares Act provided economic stimulus to many people in May and early June, approximately $1200 per adult and $500 per child to families who reported annual incomes in 2019 or 2020 of less than $150,000. Unemployment benefits for workers laid off or furloughed were extended through July. While these infusions of cash helped many unemployed people escape complete financial ruin, they only offered a brief respite from the effects of unemployment.

A second round of stimulus payments and additional financial assistance to local governments was planned for the second half of the year. However, a trillion dollar gap between congressional Democratic vs. Republican proposals could not be resolved in August or September, with the result being that essentially no additional federal stimulus income was provided to individuals, small businesses, health care systems, and state and local governments. In short, the federal government has left local governments, small businesses, and individuals to fend for themselves with the exception of those people able to extend modest unemployment benefits for a second period of three months or to the end of 2020. Under the predicted scenario, families-- especially those with several children-- could be running up against possible starvation unless food banks throughout the country remain at full capacity and people are willing to wait many hours to receive food supplies from such banks. Those who are unable to keep up with their mortgages or rents will have to find friends or relatives with whom to live or face homelessness.

The situation looks grim if we define the end of the pandemic in terms of the time when effective coronavirus vaccines are available at a large scale, unlikely until the second quarter of 2021. Many millions of people will need continuing cash amounts to sustain themselves through the end of 2020 and into mid-2021, a prospect which, at the time of this writing, seems somewhat questionable. The alternative, without financial intervention on the part of the government, could lead to the possibility of mass homelessness. The need for the current Republican administration and Democrats to agree on a robust stimulus bill is increasingly imperative, yet many wonder whether any such agreement will be achieved before the inauguration of the new President on January 20.

At this time almost 70,000 Americans are in the hospital with coronavirus. These numbers are the highest since the pandemic began. Lest these facts merely be seen as numbers, it’s important to keep in mind the anxiety and distress suffered by families with loved ones in the hospital or especially the ICU, not to mention those who have lost a loved one to Covid.

These numbers are not expected to get better in the near term. They are largely driven by people gathering in groups in places like restaurants, bars, gyms, public transportation, and airports. Gatherings of friends in private homes also contributes to increasing numbers of Covid infections. Despite repeated warnings from health experts to avoid gathering in groups larger than one’s own immediate family, many people are still planning on family gatherings at Thanksgiving and Christmas. Such gatherings can only accelerate the spread of the virus over the next month and a half.

A truly critical problem is that many hospitals around the U.S. are quite close to capacity, both in the general hospital and intensive care units. In some areas, seriously ill patients are being airlifted far from their homes to distant hospitals.

Worst case scenarios for hospital capacity are tragically beginning to come into view. Before the end of the year, in many areas, hospitals will have to triage incoming patients in ways that potentially lead to refusing to admit seriously ill patients in two types of categories: 1) those patients who are so ill or old that they seem likely to die of Covid in favor of those with moderate illness that still need hospitalization, and 2) those patients with other illnesses who need to be hospitalized but cannot be admitted because of a lack of beds. While wealthy, older patients with Medicare may have the means to travel to other states to receive help, travel itself is risky, especially if it involves flying. In some cases, Medicare cannot be applied outside of one’s state of residence.

In sum, overloaded hospitals are likely run out of room to accept new patients over the next month or two. Absence of hospital capacity has not been an issue since the Spanish Flu pandemic that occurred in 1918 and 1919.

Treatments and Vaccines for Covid-19

Despite the tragedy of the pandemic, there is a positive side of the story: 1) improved treatment of the disease, and 2) the prospect of Covid vaccines becoming available early in 2021.

Although several antiviral drugs have been tried against coronavirus, the only one to show efficacy has been remdesivir. Remdesivir is primarily used with patients already hospitalized for Covid. In a majority of cases it shortens the time toward recovery.

The way remdesivir works is complicated. However, it comes down to a few basics. Every coronavirus carries instructions for replicating itself in the form of an RNA strand. Viruses are simple and don’t contain DNA like human cells, just a single strand of RNA. Remdesivir works by introducing genetic components into the viral RNA strand, breaking the virus’s code for self-replication. In short, remdesivir has a capacity to “gum up the works” for the ability of a coronavirus to self-replicate and thereby spread.

A second intervention used in coronavirus treatment is steroids, specifically corticosteroids. Patients with severe Covid disease tend to develop inflammation in their lungs and eventually other organs. Steroids such as dexamethasone (or prednisone or methylprednisone) directly reduce such inflammation. In fact, steroids have been used against all kinds of inflammation for decades.

Dexamethasone works best if it is administered at a fairly late stage of the disease, after patients are receiving supplemental oxygen or in cases where the patient is intubated (having a respirator with a tube entering the bronchial areas to automatically enable the patient to breathe).

It’s important to note that during the course of the pandemic, there has been an increasing tendency for doctors to try to avoid mechanical ventilation. Once a patient is intubated and on a ventilator, they have about a 20% mortality risk. As treatment methods have evolved, doctors have increasingly tried to reduce the use of ventilators and simply use supplemental oxygen to provide breathing capacity for patients. Another helpful technique has been to invert patients so they lie on their stomach, which assists with improved oxygen intake.

In sum, steroids are best used at the point where a patient is already suffering from acute inflammation in their lungs (and possibly other organs).The steroid is given to reduce inflammation.

A relatively newer treatment for coronavirus is the use of monoclonal antibodies. Monoclonal antibodies are synthetically made antibodies that mimic your immune system’s natural antibodies used to fight off all kinds of infections from the common cold to Covid. A specific drug, Bamlanivimab, has shown positive results for treating Covid, especially in patients who are at high risk for progressing to severe Covid. Unlike steroids, monoclonal antibodies work best at an early stage of disease progression before hospitalization or required use of supplemental oxygen. The FDA (Federal Drug Administration) approved monoclonal antibodies for clinical use on November 9, 2020, though the technique has been used on an emergency authorization basis before November. This treatment, in addition to remdesivir and steroids, was administered to President Trump during his hospitalization for Covid in October. The combination of all three approaches, rarely available in practice, likely explains why the U.S. President recovered from Covid quickly.

Vaccines that actually protect people from contracting Covid are just starting to come on line at the time of this writing. Four major vaccines have received publicity in the U.S. over the past few months. The companies who manufacture the “big four” include:

  • —Pfizer and BioNTech
  • —Moderna
  • —Johnson & Johnson
  • —AstraZeneca

As of November 9, Pfizer announced preliminary results showing 90% efficacy in preventing Covid. On November 16, Moderna reported 94.5% efficacy for their vaccine on a preliminary basis. The medical world is waiting to see if such a high efficacy rates will hold up under early population trials over the next two months. The Pfizer vaccine requires two doses and is difficult to work with because vials need to be maintained at 95 degrees below zero. The Moderna vaccine has an advantage over the Pfizer vaccine in that it only needs to be stored in a standard refrigerator.

The vaccines being developed by Johnson & Johnson and AstraZeneca should complete their own final stage of experimental trails by late November into December. The very first use of such vaccines will be on an emergency use authorization basis, primarily for doctors and nurses working on the front lines to treat coronavirus patients. Another early allocation group will be residents of assisted living centers and nursing homes, which have a high risk of succumbing to the disease.

The exact allocation plan for Covid vaccines is somewhat clouded by the current transition period between President Trump and President-Elect Joe Biden. For a majority of the population, vaccines will not be available in clinics or pharmacies until early 2021. Scaling up vaccines to the entire U.S. population of 330 million people may take five or six months, so that widespread vaccination may not be achieved until May or June 2021. Globally, with over 7 billion people, widespread vaccination is unlikely to be completed until the end of 202l. Many different factors will affect how the vaccine is distributed to countries around the globe. Developing countries are likely to be vaccinated later than populations from advanced countries.

Pandemic Anxiety

The pandemic has fostered a collective anxiety reaction among large numbers of people. For those who already suffered from anxiety disorders such as panic disorder, generalized anxiety disorder, phobias, or OCD, their problems have increased.

For the remaining 80% of the U.S. population unaffected by a diagnosable anxiety disorder, anxiety increased in response to multiple uncertainties: 1) uncertainty about their vulnerability to the coronavirus just from leaving their homes to shop for groceries or medications, 2) uncertainty about the health outcomes for loved ones who have caught Covid-19, particularly parents and grandparents. (Mortality rates for the illness increase with age, though a surprising number of people under age 45 have succumbed to it), 3) economic uncertainty due to the sudden loss of employment, 4) uncertainty posed by obstacles and delays in receiving supplemental income from the government, 5) widespread despair and anxiety about being able to maintain mortgage and rent payments in the absence of any additional stimulus or ongoing supplements to unemployment insurance in the fall and winter of 2020-2021. In some areas, moratoriums on evictions have been put in place, but this passes financial pressure on to landlords and owners faced with paying mortgages on their buildings.

Projections for the length of the pandemic and necessity for social distancing vary widely. Back in May 2020, a decision was made for a phased reopening of the American economy to prevent further economic disruption, even at the cost of exposing large numbers of people to high-risk indoor situations. The general nationwide lockdown that started around mid-March was discontinued in late May to early June. Each state in the country enforced a different schedule and pace for reopening businesses. There was no uniform coordination of the reopening from a government level. Guidelines varied not just from state to state but among different counties within states.

A majority of states reopened too quickly, and people were left to fend for themselves (apart from those who had to return to work) in regard to how much they could shelter in place at home vs. going out and engaging in public activities. Because a large number of people decided to throw caution to the wind and proceed to enter bars, nightclubs, restaurants, crowded shops, malls, public transportation and other risky situations, the number of positive coronavirus cases surged hugely from about mid-June to the time of this writing in mid-November. Though there was a relative plateau in case rates during the summer when many people could be outdoors, a new surge in cases began in late October and November as many people moved their activities indoors due to the onset of winter.

As of mid-November several states have begun to reimpose restrictions on utilization of restaurants, bars, gyms, and other crowded public places. West coast states have discouraged interstate travel except for essential reasons. So has much of New England and the state of New York. The problem with most of these guidelines is that they are highly recommended but voluntary rather than mandatory. Unlike guidelines in some of the hard-hit countries of Europe such as France and the UK, American guidelines in most cases (with a few exceptions) are not mandatory. The standard recommendations of mask wearing, social distancing, and hand washing are repeatedly reinforced on both the media and by public health officials in the U.S. However, with few exceptions, as of mid-November there are few penalties for failure to cooperate with health recommendations. American “exceptionalism” seems to extend to every single family and individual. The freedom to do what we please, including gathering in groups for the Thanksgiving and Christmas holidays, seems woven into the fabric of the American consciousness. Individual rights are considered more sacred than social and community responsibility not to infect others in our communities.

Because the Federal Government and Administration have largely avoided giving any top-down, centralized guidelines for reopening businesses in order to avoid economic destabilization, the decision of where to draw the line between saving lives vs. saving jobs has largely been left to state governments. The result was a patchwork of highly variable rates at which each state (or even counties or cities within a state) reopened during the Spring and Summer, as well as a highly variable rate at which restrictions for reducing access to restaurants, bars, gyms, public transportation and other crowded public places were reinstated in November. As has been repeated throughout this essay, such a patchwork approach is largely responsible for the U.S. having the highest per capita Covid case and mortality rates in the world.

Uncertainty breeds anxiety. The large number of multiple uncertainties in connection with the pandemic has led to an undercurrent of anxiety among huge swaths of both the U.S. as well as global populations. Uncertainties about one’s own life, the life of loved ones, the ability to sustain finances for a potentially long duration of the pandemic, and finally questions about when vaccines for Covid-19 will be available at scale, are rampant.

Resources for coping with anxiety of this magnitude are limited. People can be quite resourceful in coming up with their own ways to cope while staying isolated to whatever extent possible in their homes, but the availability of direct professional help has been either highly limited or non-existent. Teletherapy utilizing FaceTime or Zoom has become increasingly available. Online sources of information and books have also been stepping in to fill the gap. If you are reading this essay, you can purchase a copy of the new 7th Edition of The Anxiety & Phobia Workbook by the author, released on May 1, 2020 or a shorthand version of this book, Pocket Therapy for Anxiety, released November 1, 2020.

Risk Assessment

Health experts have defined four different types of situations according to their relative risk of causing you to catch COVID-19. A very brief summary of these risk groups follows:

Low Risk: Staying home alone or with immediately family members, and ordering as much food, prescriptions, and other goods as possible online to be delivered to your door. Do not let strangers enter your house, or, if they must, insist they wear masks and gloves.

Moderate Risk: Being outdoors (weather permitting) with a few people in relative proximity. To protect yourself, wear a mask and maintain at least six feet distance from other persons. Increase to ten feet if somebody is sneezing. Avoid touching shared surfaces (such as playground equipment or park benches). Change your clothes and take a hot, soapy shower as soon as you return home.

Higher Risk: Outdoor gatherings of several to many people. To protect yourself, participate in such gatherings infrequently. Observe all of the guidelines under ‘Moderate Risk.’ In addition, be sure to wash or sanitize your hands before you enter an outdoor gathering, and, while there, be scrupulous about not touching your face with your hands. Again, as soon as you’re home, change your clothes and take a hot, soapy shower.

Highest Risk: Indoor gatherings of several people. Observe all of the guidelines mentioned under lesser risk scenarios, with particular emphasis on wearing one or two surgical masks or KN95 masks (if available) and maintaining at least a six foot distance from the nearest person, even if the situation is designed to be social. Increase your distance from anyone sneezing (face shields add further protection to face masks in situations where people are sneezing). Open windows if possible for further ventilation. Avoid indoor crowds as much as is feasibly possible for the duration of the pandemic. It’s recommended that you expose yourself to an indoor group of non-family people no more than once per month.

Finally, to reduce your risk, find out how much coronavirus is circulating in your particular county. In most cases, it’s possible to do a Google search for coronavirus case and mortality rates for your particular county or major city on any given day. Also, you probably already know whether you are in a high-risk coronavirus group, i.e. seniors over 65, people under 65 with significant underlying health conditions such as heart disease or diabetes, African American or Latino people, living in crowded urban areas of large cities, or having used public transportation such as buses, trains, or subways. Travel by plane, train or ship is not recommended at this time.

Groups Affected Differently by the Pandemic

It’s possible to distinguish several groups into which Americans facing the pandemic fall:

  1. People with assets or income to endure many months of nationwide economic shutdown. This is the most fortunate group and skewed toward white, middle to upper class families who have retirement savings. It’s this group that can practice full social distancing, stay at home, and order their food delivered, which have the best odds of emerging from the pandemic relatively unscathed, apart from the illness or mortality of loved ones and friends.
  1. People with limited assets who had to depend on federal or state assistance through stimulus payments (initially $1200 per adult and $500 per child in April-May). Many people received these payments in May or June by direct deposit to their checking accounts or by paper checks. A second round of stimulus payments was debated in August and September, but Republican and Democrat congressional members could not come to an agreement on a second stimulus plan. As of this writing in mid-November, there has been no additional stimulus made available to Americans since May and June.
  2. Unemployment compensation has been severely backlogged, with no renewal of supplemental payments since the end of July, and certain people receiving an extension of payments to the end of 2020. Without any disposable income, such people end up lining up for many hours to receive food from food banks. Many food banks max out and people have to return a second day to finally obtain food for their family’s survival. A large number of these persons are people of color, though lately quite a large number of lower middle class White people have been lining up.

  1. A third group is made up of first responders: nurses, doctors, paramedics, hospital staff, firemen, and others including grocery store staff. This group has been confronted with the major stressor of having direct exposure to COVID-19 patients for many hours at a time, increasing their risk of contracting the disease. Even more stressful, particularly in the early months, has been the limited availability of PPE (personal protective equipment), such as N95 masks, face shields, gowns, gloves, and even sanitizer, putting those who choose to go into hospitals without full protection at substantial risk of infection. Statistics on the number of health care workers who have been infected and even died directly illustrate this issue. Such people can be compared to soldiers going into the battlefield, with only some fully protected and others not.
  1. A fourth group is non-essential workers who have been forced to go back to work by their employers or have chosen to work rather than face economic peril. This includes people such as “mow and blow” personnel with their loud machines and on-site construction workers. Both groups are quite audible from my house on many days. These employees are largely people of color and immigrants, either documented or not.
  1. People living in rural areas. While case rates have been lower in rural areas, so is access to hospitals. In recent months, the spread of Covid-19 in these areas has increased. However, getting to a doctor or hospital could involve a very long drive. Some of these people may be too sick to leave home and ultimately succumb to the infection.
  1. Nursing home residents. Such people have the highest mortality rate in the U.S. and elsewhere. Because of their frailty and age, nursing home residents are particularly susceptible to severe cases of coronavirus. If they have to go on a ventilator, their risk of survival further decreases.
Coping with Anxiety and Stress During the Coronavirus Pandemic

In order to begin to deal with the coronavirus pandemic, perhaps the first thing to keep in mind is that you are not alone. Everyone is having to deal with the pandemic to varying degrees and in different ways, depending on their particular situation. Over 60% of the American population is reporting disruptive levels of anxiety due to the pandemic. The incidence of mood disorders and depression is similar.

Each of the six groups previously described faces a different situation, requiring a different response.

  1. People who are able to stay home and not go out need to deal with boredom and cabin fever. Unless you live in a large apartment building with crowded elevators, short walks outdoors to move about and get fresh air are entirely safe. Just be sure to avoid any crowds of people. While indoors, creative projects are a great antidote to boredom. Besides working from home, hands-on crafts and hobbies can be helpful. Follow your desire to stay in contact with family and friends by phone, email, text, social media, and FaceTime, Skype or Zoom. To fill long stretches of time, look to good books or magazines or, if that doesn’t quite fit, web and social media surfing.

    Realize that it’s important to have a structure to each day. Even if you repeat the same sequence of activities each day: preparing meals, childcare, reading emails, physical exercise, and perhaps deferring TV until late afternoon and evening, having a set structure to your day will help alleviate anxiety and boredom.

    As far as TV, web news, and social media are concerned, try to avoid excess attention to negative news about the COVID-19 pandemic. As far as possible, focus on positive news or at least give it equal time with negative news about the pandemic. Effective treatments such as remdesivir and steroids (for inflammation) are increasingly available at many hospitals. Monoclonal antibody treatment has just been approved by the FDA and should start to become more widely used in the next two or three months.

    Along with structure, it’s important to give yourself breaks during the day. Take out time where you disengage from structured activities and relax with light reading or simply listening to music. During these stressful times it’s alright even to take an hour or longer out for a nap. If you lay down to rest, close shades or curtains and use eye shades or earplugs to shut out all extraneous stimulation. Practicing silent meditation for twenty minutes or longer is also a great way to unplug from stress and worry.

  1. If you are someone with limited financial resources and still waiting for government stimulus checks or unemployment compensation, you are likely to be faced with significant anxiety and stress. If you are unable to borrow money from relatives or friends, you need to cope with the basic necessity of keeping fed. If you are unable to afford basic groceries or order out from local restaurants offering takeout food, the last resort is utilizing food banks, which often require long waits. While waiting in line, if you aren’t conversing with someone, be sure to have music or reading material in your car to pass the time. As challenging as dealing with food banks may be, keep in mind that you aren’t likely to face starvation in the U.S., unlike some people in third world countries in Africa or in Bangladesh.
  1. If you are a nurse, doctor, paramedic, fireman or other first responder, you are having to deal with an existential threat to your health and well-being. Realize that you are universally considered to be the heroes of the pandemic. Your safety is highly dependent on having adequate PPE (personal protective equipment) such as a surgical or preferably an N95 mask, goggles or eye protection, face shields, gloves, gowns (if you work close to coronavirus patients), and lots of hand sanitizer carried in your pockets or nearby. If adequate PPE is not available, you are faced with a stark decision of protecting your health and staying home (which in some cases could lead to termination of your job). Whether through necessity or courage you choose to go into work, realize that contracting Covid-19, as bad as it is, is not a death sentence. Mortality rates have widely been reported to be 2-5% in the U.S. out of the total number of cases testing positive.
  1. If you are a “nonessential” worker still forced to go into work—especially working in a group—the only reason for reporting to work is that the alternative is having no income to purchase food or basic supplies. If losing your job means long-term loss of income, and you have no resources from family or friends, then you need to work. Wearing protective equipment, especially face masks (if at all possible KN95 or N95masks), goggles or other shields to protect your eyes, and gloves if you have to touch surfaces, can go a long way toward protecting you from disease. Be careful, if possible, to maintain a six foot distance from coworkers, refrain from touching your hand to your face, and, when you return home,remove all of your clothes, throw them in the laundry, and take a hot, soapy shower.
  1. If you live in a rural area, consider your situation to be the same as those living in urban or suburban areas. The virus may have already reached your area, and you need to think about taking some precautions such as staying at home as much as possible, maintaining social distancing, and wearing masks and eye protection if you must go out to work or for shopping.
  1. If you are a nursing home resident or employee, you are in the highest risk group. If discharge and staying in a two-week quarantine at a friend or relative’s home is possible, be prepared to do so. If not, insist on residential staff wearing masks and allowing you, the patient, to wear a mask as well. Try your best to maintain social distancing of at least six feet from other people, in group spaces and particularly at meal times.
Specific Coping Strategies for Anxiety

As mentioned previously, uncertainty breeds anxiety. The many and various types of uncertainty posed by the coronavirus pandemic were described in the previous section “Pandemic Anxiety.”

This section presents an overview of various types of coping strategies to reduce or manage anxiety. All of these strategies are described in more detail in the author’s book, The Anxiety & Phobia Workbook, 7th Edition. For each set of strategies described here, relevant chapters of the book are given, where much more detailed descriptions of such strategies are provided. As The Anxiety & Phobia Workbook is a large book, you may be interested in a recent condensed version, Pocket Therapy for Anxiety.

  1. Relaxation Strategies

Learning to achieve a state of relaxation is a foundational skill in managing anxiety. Relaxation skills begin with abdominal-breathing—learning to inhale slowly, pause, and then exhale slowly from your belly. Your stomach should rise every time you inhale. Keep up the process up for at least five minutes at a stretch, two times per day. Regular practice of abdominal-breathing daily over several weeks will help to gradually bring down your level of anxiety.

Muscle relaxation is a basic relaxation technique to relieve tightness and tension in your muscles. You can achieve this by practicing progressive muscle relaxation, selective tensing and relaxing sixteen different muscle groups in your body (starting with your wrists and upper arms, proceeding to your forehead, eyes, face and neck, and finishing up with your abdomen, thighs, calves, and feet. Or you can practice passive muscle relaxation, listening to a guided visualization that instructs you to consecutively relax each muscle group in your body.

Finally, time management (not crowding too many activities into a single day) and learning to pace yourself slowly (not rushing through your day, even if there is a lot to do) are essential to learning to relax.

All of these strategies are described in chapter 4 of The Anxiety & Phobia Workbook. You can also do a Google search for any of the techniques just described.

  1. Exercise

Regular physical exercise is a potent remedy for both anxiety and depression. The optimal form of exercise is aerobic, such as light jogging, swimming, or brisk walking outdoors. If you prefer to exercise indoors, you can use a stationary bike, treadmill, or stair stepper. Exercise needs to be maintained for at least fifteen to twenty minutes per day, every day if possible. If you have any health conditions that preclude vigorous exercise, consider simply walking for a half hour outdoors or indoors on a treadmill, with the permission of your doctor. Exercise strategies are described in chapter 5 of The Anxiety & Phobia Workbook.

  1. Disruption Strategies

Disruption strategies are useful during the early stage of an anxiety surge (including panic attacks) or worry surge. The goal is to recognize a resurgence of anxiety or worry early on before it starts to gain momentum. Then you implement a disruption strategy to diffuse the development of higher levels of anxiety or worry. Disrupting anxiety is not the same as trying to distract yourself from it. You proactively take action to interrupt the increasing anxiety (disruption) rather than trying to escape it (distraction). Trying to escape anxiety only makes it worse. Examples of disruption techniques include: 1) physical exercise, 2) talking to a supportive person directly or over the phone, 3) involving yourself in hands-on activities such as arts and crafts or chores such as cooking or house cleaning, 4) working on jigsaw or crossword puzzles to distract your mind from anxious thoughts, 5) utilizing visual diversions such as online movies, researching topics online, video games, or uplifting reading, or 6) healthy rituals such as reciting a list of coping statements or affirmations. Examples of coping statements can be found in chapter 6 of The Anxiety & Phobia Workbook (Coping with Panic Attacks).A list of affirmations can be found at the end of chapter 9 of the Workbook (Mistaken Beliefs) and in several other places throughout the book. When you recite a list of coping statements or affirmations, do so slowly and with feeling. Or you can play them back slowly from a recording made on your smart phone.

  1. Changing self-talk and unhelpful beliefs

Retraining your mind away from the habit of fearful, “catastrophic” thoughts toward constructive, supportive thoughts is a critical anxiety reduction tool. This process is at the core of what is called cognitive behavioral therapy, a term with which you may be familiar. It is the most common type of therapy used to treat all anxiety disorders. First, you identify your own personal scary thoughts, such as: “I’m going to lose control,” “I’m going to go crazy,” “This will never end,” or “I’m going to have a heart attack.”Then you compose and practice counterstatements to each of these fearful thoughts, such as: “I can handle these sensations and symptoms until they subside,” “I’ll ride this through—there is no need to let it get to me,” or “These are just scary thoughts, not reality. ”After enumerating a list of constructive thoughts to counter scary ones, you need to rehearse them on a regular basis (preferably daily). You can do this either by reading your positive counterstatements slowly from a written list. Or you can play them back slowly from a recording made on your smart phone or some other device. With time and practice, you gradually become able to supplant your fearful thoughts with constructive ones. Cognitive behavioral therapy is described in detail in chapter 8 (Self-Talk) and chapter 9 (Mistaken Beliefs) in The Anxiety & Phobia Workbook.

  1. Anxiety-Provoking Personality Traits

People with anxiety tend to have personality traits that aggravate their situation, such as perfectionism, excessive need to please or gain approval, fear of loss of control, and so on. Strategies for dealing with these unhelpful traits are described in chapter 11 of The Anxiety & Phobia Workbook 7th Edition. This chapter is entitled ‘Personality Styles That Perpetuate Anxiety.’

  1. Learning to be assertive

People who are prone to anxiety tend to make requests either in a submissive or passive aggressive way. Sometimes they even use aggressive tactics. Developing the ability to be assertive involves learning how to ask for what you want and say no to what you don’t want in an assertive fashion, without putting off or insulting the other person. Strategies and exercises for learning to be assertive are provided in the chapter ‘Being Assertive’ in both the 5th and 6th and new 7th editions of The Anxiety & Phobia Workbook.

  1. Nutrition

Good nutrition is essential to overcoming anxiety. Reducing caffeine, sugar, junk food or food which causes you allergies in your diet is the first, fundamental step to take. Additional guidelines for maintaining a “low anxiety diet” are provided in detail in the chapter on nutrition in all editions of The Anxiety & Phobia Workbook (including any editions you may have that are prior to the 6th and 7th.) These previous editions, 1st through 5th, though older, provide quite a bit of the information on nutrition contained in the newer editions, with only modest changes.

  1. Medication

Medication is often a part of the treatment plan for anxiety. Approximately half of my clients take one or more prescription medications, including various types of antidepressants (which are equally effective in treating anxiety disorders), tranquilizers, beta blockers, or mood stabilizers. The pros and cons of these various types of medications are described in detail in the chapter ‘Medication for Anxiety’ in both the 6th and 7th Editions of The Anxiety & Phobia Workbook. The new 7th Edition also addresses the use of cannabidiol and ketamine in treating both anxiety and depression.

  1. Personal Meaning

A sense of personal meaning is also important in being able to overcome anxiety. It’s important to have a sense of your own unique life purpose as well as some kind of answer to fundamental questions about the nature and meaning of human life. In attempting to answer these questions you may rely on spiritual or non-spiritual answers. The chapter ‘Personal Meaning,’ the last chapter in the both the 6th and 7th Editions of The Anxiety & Phobia Workbook, is important for everyone dealing with anxiety, especially in this current time of dealing with the Covid-19 pandemic.

The author’s attempt to grapple with fundamental questions about life is taken up in detail on his website: Journeysofthemind.net. This site is distinct from the author’s anxiety site Helpforanxiety.com.

There are many other types of interventions relevant to overcoming anxiety not mentioned here. These include learning to deal with excessive feelings of anger, grief or despair; cultivating self-esteem, and preventing yourself from relapse after having received effective treatment. All of these topics and many more are covered in The Anxiety & Phobia Workbook. The step-by-step strategies and exercises presented in the book can be utilized on your own. However, you may also decide to work with a therapist in learning and practicing numerous coping strategies in the book. At the present time, to comply with social distancing, many therapists are working virtually utilizing apps like Skype and Zoom.

The next section attempts to foresee how the coronavirus pandemic may unfold.

Possible Outcomes of the Coronavirus Pandemic

Best Case

Among the best case outcomes are those areas of the world who reached their peaks by early August, followed by a gradual drawdown in case and mortality rates and no resurgence of cases in November (for example, Taiwan and New Zealand). PPE (personal protective equipment) was scaled up to be available to all medical personnel and first responders. Effective drugs to treat coronavirus, such as remdesivir are widely available. Vaccines come online and are scaled up in the first quarter of early 2021.

Mid-Range Case

As has been the case, many states reopened for business prematurely and too fast, and a new surge in case and mortality rates appeared across the southern U.S. in the July-August period. A nationwide resurgence of cases appeared in the late fall as people moved indoors due to the onset of winter. In the U.S., this means such numbers could ultimately approach projections of twelve to fifteen million cases and up to 350,000 deaths by end of 2020. In vulnerable countries in Europe, such as Italy, Spain, France, and the UK, a similar resurgence of case and mortality rates occurred due to premature lifting of social distancing measures and a late fall resurgence. In response to the resurgence, social-distancing measures have been reinstated until case rates fall and remain low for a month (hopefully sometime in early 2021). Having learned the lesson of reopening economies too soon the first time around, measures to reopen business are very gradually phased in, with the most essential businesses opening first.

There is a moderate to severe economic impact with large numbers of people not being able to sustain rent or mortgage payments for much longer than the fall of 2020. Some of these people are allowed to get behind in their rent and mortgage payments, but some are not. The latter unfortunate group is able either to take up residence with family or friends or is forced into shelters where social distancing is difficult or impossible.

Medications such as remdesivir arrive late and take time to scale up to be widely available to the entire population, perhaps only by early 2021. Widespread availability of a vaccines is delayed until mid-2021.

Worst Case

The worst-case scenario adds some aggravating factors to the mid-range case just described.

Due to rapid reopening of many states for business, a large resurgence of the pandemic occurs in the fall months of 2020. Only some states reinstate social distancing measures and close businesses subject to crowding, such as bars, nightclubs, restaurants, and hair and nail salons. In many states these businesses are allowed to stay entirely or partially open. In those areas where restrictions are not systematically put back into place, coronavirus case and mortality rates soar to very high levels during the late fall, leading to many thousands of new cases and a substantial increase in mortality. The national rate of Covid cases reaches about 200,000 new cases per day. A third wave of the pandemic develops during the winter months due to people having to stay indoors as well as increased holiday travel. This winter wave of the pandemic, November through February, coincides with the normal flu season. So there are two types of serious illness (especially affecting older people) that lead to potentially serious respiratory complications developing at the same time. Hospitals and intensive care units are overwhelmed.

Experts come to realize that COVID-19 confers only temporary immunity to future recurrence of the illness, and the coronavirus acts like other coronaviruses such as those related to the common cold—possible to catch and re-catch again on a long- term basis. At the very least, an effective vaccine inoculation will have to be repeated on an annual basis for everybody for years. To manufacture such a larger amount of vaccine is daunting to say the least.

Widespread recognition that the virus is not going away leads to an economic meltdown on the scale of the Great Depression, lasting 6 months to a year (shorter than the Great Depression, which lasted 6 or 7 years). The U.S. government (and a majority of other governments) are unable to sustain cash infusions to the population indefinitely. Many people end up in overcrowded shelters or become homeless.

The worst case scenario, in my opinion, is less likely than the mid-range scenario which is currently playing out, but has been described simply as an approximation of how bad things could get if businesses in many areas remain open and guidelines for staying at home and social distancing are not sustained.

Post-Traumatic Phase

During the period of time following a reduction in infections and withdrawal of social distancing measures, there will be a widespread uptick in incidence of post-traumatic stress disorder. First, health experts have only recently begun to talk about “post-intensive-care syndrome.” Intensive care patients who recover are unfortunately still prone to neurological, cognitive, muscular, or kidney aftereffects that can last from months to years. Those patients most susceptible to post-intensive-care syndrome may require ongoing care either in rehabilitation facilities (which are often already maxed out) or home-health nursing care.

The greatest milestone in overcoming the pandemic will be the effective vaccination of most people against Covid-19. Yet many people will remain traumatized by the loss of loved ones, by the loss of basic financial security, and by the duration of the period of being homebound and in an almost total state of uncertainty about life and livelihood. As the U.S. and other nations move through this period, resources for dealing with post-traumatic stress will gradually begin to appear in many forms, such as online and in-print information offering comfort and hope, as well as therapists of all stripes offering help to people with significant symptoms such as flashbacks, nightmares, panic attacks, and feelings of numbness and depersonalization.

It is only after this period of post-traumatic stress following the pandemic has been completed that the humanity will begin to return more fully to normal. It is difficult to estimate a date when this point will be reached. The date will vary widely across countries, provinces, counties, and even cities as well as widely among people with different experiences of the pandemic and different levels of resiliency to cope with it (elders, people of color, people living or working in overcrowded conditions, etc.)It’s important for everyone to realize that most of humanity will ultimately cross this treacherous valley and emerge on the other side intact. Historically, humanity has prevailed through numerous widespread catastrophes. Many of us are survivors and a majority of us will live to see a better day.