Anxiety in the Era of Coronavirus

The coronavirus pandemic is an unprecedented global catastrophe that has affected all countries throughout the world, more so in the northern hemisphere as of April 2020, though soon to reach the southern hemisphere. It is unprecedented in the fact that no previous pandemics have had a global reach, affecting all areas of the planet. The great Spanish Flu epidemic of 1918 had a worldwide mortality rate of approximately fifty million people, with over six hundred thousand deaths in the U.S. It killed more people than coronavirus ever will, because in 1918 there were no antiviral or antibiotic treatments available. However Spanish Flu did not reach all parts of the globe because the world was drastically less interconnected at the time, with international travel by plane or jet highly limited or non-existent. This is even more true for the Black Death (plague) of 1348-49. Though the disease had an extremely high mortality rate (about 40%-60% of Europe), it was largely confined to Europe and the area in modern day China from which it originated. As severe as The Plague was, it was not global.

The coronavirus pandemic’s severity can be gauged by its double-edged impact. First, by the enormous case numbers and death toll, which reached 3 million cases and 200,000 deaths worldwide by the time of this writing in late April 2020. These numbers can be expected to increase twofold, and possibly threefold before they reach an apex globally (third world regions such as sub-Saharan Africa and much of rural India will reach their peak rates of infection at least a month or longer after developed nations in Europe, as well as the U.S. and Canada, reach their peaks. So the global peak in infections could occur in May or even June 2020.

The second edge or “prong” of the pandemic is economic. Worldwide losses in jobs varies from country to country, but in the U.S., where 27 million people had lost their jobs by late April, 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 essentially shut down over a period of two or three 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.

Massive numbers of people worldwide were caught unprepared and subsequently were forced to rely on precarious sources of income needed to prevent family starvation. In the U.S., such people either turned to day long waits in order to access food banks, or risked shopping in big box stores under conditions that precluded social distancing from other people. During the initial phase of panic buying, where people rushed to stores to stock up, overcrowding was highly prevalent.

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 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 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 (allocated at $1200 per adult and $500 per child, though many families have yet to receive these disbursements), 5) backlogs and delays in receiving unemployment compensation, and finally 6) the realization that available compensation amounts would only allow vast numbers of people to get by for a month or two at best.

Meanwhile, projections of the length of the pandemic and necessity for social distancing vary widely, with many estimates in the one to six month range following April 2020. Without additional financial stimulus or extensions of unemployment payments, very large numbers of people will run out of money long before social distancing regulations are lifted. The final uncertainty rests with health experts who simply can’t say, at the present time, when curative medications currently in development will be ready and scaled up to the population. These same experts estimate that a vaccine that could prevent the disease could take up to a year to eighteen months to be developed and scaled up.

Uncertainty breeds anxiety. The set of multiple uncertainties in connection with the pandemic has led to an undercurrent of anxiety among large swaths of both the U.S. and global populations. Uncertainty about one’s own life, the life of loved ones, and the ability to sustain finances for a potentially long duration of the pandemic is rampant. Many people speak about reopening local and state governments to help people get back to work, but there is little consensus among health experts or state and local politicians about when this might occur.

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 in their homes, but the availability of direct professional help has been either highly limited or non-existent. Online sources of information and books have 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, available on May 1, 2020 and afterward.

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 three, four or more 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.
  2. People with limited assets who depend on federal or state assistance through stimulus payments (presently $1200 per adult and $500 per child). In many cases these payments, (especially paper checks) had not been received by people as of late April. For those who are awaiting checks rather than direct deposits to their bank account, the wait could extend many weeks into May. Unemployment compensation has been severely backlogged, with many people still waiting for payments. Without any disposable income, these people end up lining up for many, many hours to receive food from food banks. Many food banks max out and people have to return a second or third day to finally obtain food for their family’s survival. A large number of these persons are people of color. Case and mortality rates for COVID-19 to date are running substantially higher among people of color versus white people.
  3. 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 exposed to 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 has been the initially 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.
  4. A fourth group is non-essential workers who have been forced to go 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 are quite audible from my house on most days. These employees are largely people of color and immigrants, either documented or not.
  5. People living in rural areas. While case rates are lower in rural areas, so is access to hospitals. Over time, some degree of spread of COVID-19 in these areas is inevitable. 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.
  6. 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 epidemic, 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

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 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 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 epidemic. As far as possible, focus on positive news or at least give it equal time with negative news about the pandemic. Even this early in the pandemic, there a several positive indications, such as “flattening of the curve” of case rates in many places, news about the pandemic possibly easing up by summer, and the fast-tracked development of medications to treat the disease, such as remdesivir.

    Along with structure, it’s important to give yourself breaks during the day. Take out time when 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.

  2. If you are someone with limited financial resources and still waiting for government stimulus checks or unemployment compensation (or you get initial payments but they are not sustained over the summer), 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, then 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.
  3. 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 1-4% out of the total number of cases testing positive. With the advent of antibody testing (only a few trials of such testing had been done by late April), which gauges the full extent of virus transmission in an area, mortality rates fall to fractional levels below 1%. As horrible as coronavirus disease is, it has a lower mortality rate than either heart disease or cancer.
  4. 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 N95 respirator masks), 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 remove all of your clothes, throw them in the laundry, and take a hot, soapy shower upon returning home.
  5. If you live in a rural area with a low number of cases, consider your situation to be the same as those living in urban or suburban areas. The virus is likely to eventually reach 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.
  6. 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 (6th or the new 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.

(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 exhale. Keep up the process 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.

(2) 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.

(3) 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 hand-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.

(4) 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.

(5) 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 10 of The Anxiety & Phobia Workbook 6th Edition (chapter 11 for the 7th Edition). The chapter is entitled ‘Personality Styles That Perpetuate Anxiety.’

(6) 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 6th and new 7th editions of The Anxiety & Phobia Workbook.

(7) 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 both 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 much of the information contained in the newer editions.

(8) 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.

(9) 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 chose 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. There is not enough information at the time of this writing, in late April 2020, to make more than speculative predictions.

Possible Outcomes of the Coronavirus Pandemic

Best Case

Among the best case outcomes are those that see most areas of the world reaching their peaks no later than mid-May, followed by a gradual drawdown in case and mortality rates stretching through the summer to August or September, after which a large number of social-restrictions can be lifted. By autumn there is a relative return to normalcy. Equally significant, secondary or ongoing cash infusions to the public by federal, regional, and/or state governments continues through the summer so that the number of people forced to be homeless is kept at a minimum. PPE (personal protective equipment) is scaled up to be available to all medical personnel and first responders. Development of effective drugs to treat coronavirus, such as remdesivir and others, is completed and scaled up to the population during the last quarter of the year. A vaccine comes online in early 2021.

Mid-Range Case

Social distancing measures are withdrawn too quickly in some places, and a new surge in case and mortality rates appears in the June-July period. In the U.S., this means such numbers could approach early projections of one to two million cases and 100,000 to 200,000 deaths. In vulnerable countries in Europe, such as Italy, Spain, France, and the UK, a similar resurgence of case and mortality rates occurs due to premature lifting of social distancing measures. In response to the resurgence, social-distancing measures are reinstated until case rates fall and remain low for a month (sometime in the autumn of the year). 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 April and May. Many 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 to treat coronavirus arrive late and take time to scale up to the population. Widespread availability of a vaccine is delayed until mid-2021.

Worst Case

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

A month or two after May, a resurgence of the pandemic occurs in the summer/fall months of 2020. Social distancing and a shutdown of economies around the world occurs again. After an extended phase of reopening economies following the second wave, people regain a false confidence that the pandemic has been overcome. After the second reopening of the economy a third wave of the epidemic appears beginning in the late fall of 2020 and winter of 2021. This third wave of the pandemic unfortunately occurs concurrently with the 2020-2021 flu season. So you have two types of illness that lead to potentially serious respiratory complications developing at the same time. Hospitals 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.

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.

In the U.S., case rates exceed two or three million and mortality rates reach 300,000 to 400,000. Worldwide case rates go up to the vicinity of 10 million and mortality rates exceed one million.

In the worst-case scenario, effective medications to treat coronavirus cannot be scaled up until the first half of 2021, and an effective vaccine is unavailable at scale until the end of 2021.

The worst case scenario, in my opinion, is less likely than the mid-range or even best case scenarios, but has been described simply as an approximation of how bad things could get if strict 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. 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. 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.