Apr 22, 2020
Lorenzo Norris, MD, touches base with Nick Andrews to discuss
COVID-19 and to welcome Jacqueline Posada, MD, as an occasional
cohost of the MDedge Psychcast.
Dr. Posada, associate producer, interviews Lynne S. Gots,
PhD, about treating anxiety, obsessive-compulsive disorder, and
other disorders in the midst of the COVID-19 pandemic.
Dr. Gots is an assistant clinical professor in the department of
psychiatry and behavioral sciences at George Washington University,
Washington. She has a private psychotherapy practice and has no
financial relationships to disclosure.
Take-home points
- Anxiety during COVID-19 will not only be an exacerbation of
current anxieties but also of underlying vulnerabilities.
- Presently, the most common vulnerability is intolerance of
anxiety. It is helpful to reassure patients (and clinicians) that
everyone is anxious right now. Anxiety is an adaptive response to a
threat, and COVID-19 and its repercussions makes this a threatening
time.
- In the midst of this anxiety, think about creating an
exposure-response prevention (ERP) plan to contain compulsive
behaviors and thought responses to anxiety.
- Consider the following suggestions for working with anxious
patients and clinicians:
- Acknowledge that social media has the potential for shaming and
worsening social anxiety.
- Limit exposure to news and social media as much as
possible.
- Monitor patients for excessive reassurance-seeking behaviors,
and enact ERP plans.
- Establish a regular but flexible routine with boundaries
between work, home, and rest.
- Practice self-compassion by lowering expectations and even
using formal self-compassion practices.
Summary
- Cognitive-behavioral therapy is an evidence-based therapy for
obsessive-compulsive disorder (OCD) and many forms of anxiety and
depression. Acceptance and commitment therapy (ACT) is considered a
third-wave modality of CBT. The acceptance component is based on
mindfulness and acceptance of “what is.” The commitment component
involves identifying core values and actions so that a person can
use his/her values as a guide to behaviors. The goal is not to
eliminate anxious or obsessional thoughts but to accept they are
there and work alongside them.
- Clinicians should be aware that anxiety during COVID-19 will
not only be an exacerbation of current anxieties but also of
underlying vulnerabilities. For example, a person’s OCD rituals may
not be worsened, but an underlying tendency for perfectionism could
be triggered as he/she tries to practice “the perfect
quarantine.”
- Presently, the most common vulnerability is intolerance of
anxiety. It is helpful to reassure patients (and clinicians) that
everyone is anxious right now.
- In the midst of this anxiety, think about creating an
exposure-response prevention (ERP) plan to contain compulsive
behaviors and thought responses to anxiety.
- Clinicians can look for reassurance-seeking behaviors that have
cropped up with increased anxiety. For example, for a person with
contamination anxiety, it might be tempting to wash for longer than
20 seconds or to wipe things down compulsively. Advise patients to
pick a routine, such as washing for 20 seconds and no more.
- Individuals can choose a reputable source and follow its
guidelines. The key is to avoid falling into the trap that more
reassurance-seeking behaviors will alleviate anxiety. Using
excessive reassurance-seeking behaviors can lead to increased
anxiety through the conditional learning mechanism of negative
reinforcement.
Other helpful suggestions
- Social media contains a potential for shaming based on
comparing oneself and behaviors to others, so individuals should
limit exposure to it.
- News intake should be limited to 1 hour a day, and only
reputable sources should be used.
- Video calls also can trigger social anxiety because individuals
literally have to see themselves more often than usual. Ways to
minimize this anxiety include minimizing your personal image or
covering the image with a Post-it note.
- For people who are at home all day, establish a routine with a
regular wake and sleep time and scheduled breaks. Some type of
boundary between home and work life should be created.
- Self-compassion should be practiced. The first step is to lower
expectations and live according to your values and what is
realistically possible given the extensive changes in the past
month.
- Professionals need to seek support from other professionals
going through the same thing, so connect with a colleague who can
relate to your situation.
- Remember that, as mental health professionals, we are a
repository for everyone else’s anxiety and suffering, so we need to
be kind to ourselves.
- Consider using a self-compassion practice.
- Recognize that you are suffering.
- Connect with the community: Everyone is suffering.
- Hold that suffering and offer yourself words of compassion and
loving kindness.
References and resources
Dr. Gots’s website: https://cognitivebehavioralstrategies.com/
Blog post by Dr. Gots that summarizes her clinical advice:
https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak
Suggestions for when and how to decontaminate groceries:
https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html
Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/
Supportive touch practice for times of stress and vulnerability:
https://self-compassion.org/exercise-4-supportive-touch/
Self-compassion evidence-based resources: https://self-compassion.org/the-research/
International OCD Foundation: https://iocdf.org/
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Show notes by Dr. Posada, consultation-liaison psychiatry fellow
with the Inova Fairfax Hospital/George Washington University
program in Falls Church, Va. Dr. Posada has no conflicts of
interest.
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