Emergent Anxiety: Facing a Post-COVID Life

• A New Normal
• Emergent Worries and Concerns
• Understanding Emergent Anxiety
• Related Conditions
• Treating Emergent Anxiety

A New Normal

During the past year, therapists and patients alike have become habituated to the familiar routines of telehealth sessions, new grocery shopping habits, Zoom school for the kids, figuring out what to watch on Netflix, and (re)discovering pastimes and hobbies. At the time, we were faced with the Herculean task of tending to our patients while taking care of ourselves and our families as we adapted to a world filled with COVID-related anxiety.

Here we are at another crossroads. There’s not going to be a singular event that demarcates the age of COVID and the post-COVID era. It will be a gradual process, and it will generate excitement and relief. In fact, there will be a lot of jubilation as we move to this next phase. Hugging grandchildren, going to movies, seeing friends (in person!), and attending special events such as weddings and graduations will take on a special meaning, and many, if not most of us, will feel a deep sense of appreciation for what we used to take for granted.

But there will be a cross-current that we will be facing with our patients—an uncertain future, which includes how to live as they transition to the New Normal.

The term “emergent anxiety” describes the phenomenon of anxiety following the initiation of a psychotropic medication. I believe it should be repurposed to describe the upcoming post-COVID adjustment period. In fact, the irony of an increase in anxiety during the introduction of a medication whose purpose is to alleviate anxiety has an unmistakable parallel to the future uptick in anxiety around the vaccine, reduction in cases, and ultimately, a return to normal life.

It is important to consider that COVID and the upcoming emergence of related anxieties is one of those rare occurrences where we are having a shared experience with our patients. We have been providing treatment to those suffering from depression, anxiety, and unwanted behaviors such as overeating, drinking, and screen time while we have been attempting to manage our lives.

Emergent Worries and Concerns

As I listen to my patients’ concerns, these are some of the many questions that are emerging:

• Once I'm vaccinated, how do I handle people in my life who refuse to do so?
• How long will immunity last?
• Will the vaccine cover the variants? When will boosters become available?
• Will there even be a “Post-COVID” age? Will we always be social distancing and wearing masks?
• When can I safely visit my children, grandchildren, and friends? At what point can I hug and hold them?
• When can I start going to movies again? A museum? A restaurant? Should I only dine outside?
• When can I schedule routine doctor visits and obtain tests (mammograms, colonoscopies, etc.)? When should I resume going to the dentist? My barber/hairdresser?
• When can I begin to travel safely? Will airlines, hotels, trains, and cruise ships require people to be vaccinated? Will I need to obtain a digital vaccine passport?

From discussions with colleagues, additional questions are emerging about the future of therapy:

• When will I go back to seeing people in person? Should I wait for herd immunity to go back to the office?
• Will I continue to provide telehealth full-time, part-time, or not at all after herd immunity? What will my patients want to do?
• If there’s a shared waiting room, how will we make it safer for everyone?
• When I start treating patients face-to-face again, can I legally ask them if they have been vaccinated?
• Can I treat vaccinated patients face-to-face and unvaccinated patients (including those who refuse to be vaccinated due to a disability) through telehealth – thus creating a two-tier system – without inadvertently running afoul of laws that prohibit discrimination against people with disabilities?
• Will we wear masks during the therapy hour even though the threat of infection is lower?
• How is the ventilation in my office? Will I be buying an air purifier? Will that help?

Understanding Emergent Anxiety

In general, a certain amount of anxiety is necessary to help us survive in our day-to-day lives. As a species, we wouldn’t be here if not for the capacity for the fight-flight-freeze response.

Yet anxiety can become too much of a good thing. Our minds have been adapting to the stresses related to COVID, and just because the threat decreases, it doesn’t mean that we will snap back to feeling normal.

In fact, the new adjustment may make some people more anxious. During the course of the pandemic, our reactions seemed completely rational. Like a lion in front of our foreparents’ caves long ago, COVID and its related anxieties—a racing heart, sweaty palms, discombobulation, and panicky feelings—made sense to us. Once the threat of the “lion” (COVID) has gone away, continued physiological and psychological responses will be inexplicable. That is, the residual symptoms will no longer make sense to us.

This post-trauma phenomenon reminds me of what happened when we emerged from the worst of the AIDS crisis. As new medications reduced the chances of horrible illness and death, it was assumed that people with AIDS would feel relieved and happy.

Many if not most of my patients with AIDS weren’t simply happy or relieved that new medications would save them. Actually, it threw many of them into a tizzy, especially those who had resigned themselves in one way or another to the probability that their lives would soon be ending.

The parallel I’m drawing here highlights the disconnect between the intellect and our emotional responses to being “saved” from COVID. Once the major threat of COVID has passed, we will not be one happy, relieved, functional family. It’s far more likely we’ll be witnessing a concomitant increase in anxiety and confusion, and our services will be required more than ever (as is already happening, as many of us have full practices).

Related Conditions

It’s important to be on the lookout not only for anxiety, but a kind of post-pandemic depression. Symptoms may include avoiding others, agoraphobia, other fears and phobias developing in otherwise healthy patients, and a rise in panic attacks and full-blown panic disorder. Social anxiety will also be on the rise. Some younger children and adults will have a new or reemerging separation anxiety as well as “stranger danger” as they continue to skirt around people when in public places.

Other maladaptive strategies that we’ll be treating more often will run the gamut from increased phone/internet/video game use, compulsive gambling, substance abuse and drug addictions, overeating, and other dependencies and compulsions.

Regarding relationships, many couples are holding it together for fear of moving out during the pandemic. Other couples are hanging on by a thread. Expect a post-COVID “divorce boom” and an epidemic of relationship break ups, as well as couples trying to save their relationships.

Post-COVID reactions are also going to include a unique brand of PTS(D),including unpleasant reactions to being in social situations and public places, an increased vigilance about health, COVID-related nightmares, constant vigilance for symptoms of COVID, an over-reaction to catching a cold or another minor bug, and not wanting to return to the workplace.

Many children have been regressing—wetting the bed after months or years of not doing so, refusing to play with friends, and wanting to crawl into bed at night with a parent due to insecurity and fear. But children aren’t the only ones who are regressing. Adults regress as well, and many of us are reverting to old coping strategies, becoming more quick-tempered, and fighting and bickering with our partners more often.

Treating Emergent Anxiety

My personal philosophy about mental illness is that heredity, biology, and brain chemistry cause many types of mental illness (schizophrenia, autism, ADHD, etc.), but more often we develop “mental illnesses” not because the brain gets sick, but because it adapts. The main illnesses I’m referring to are depression, anxiety, addictions, and PTSD. The following are some of the techniques I have found useful with my clients around emergent anxiety.

• Normalize their experience. Developing post-COVID anxiety will be a normal response to a highly abnormal situation. So the first intervention is to normalize your patients’ responses and reassure them that their coping strategies—which picked them (we do not choose our coping strategies)—are the natural backwash to a major tsunami.
• Self-disclose more often. In the past year, I have been more disclosive than pre-pandemic. I have told several patients that I have to watch my diet more closely, for example, and I share some of my concerns and fears about the future (not to heighten their anxiety, but to remind them they are not alone).
• Be a witness. Every trauma victim needs a witness. Part of our role is to be a container and a holder of memory. I listen carefully when a patient describes the pain associated with COVID, and I make sure that every important milestone (including deaths of loved ones, when they got their vaccines, how this has impacted their jobs) will be remembered and commented on in the future.
• Look for delayed grief. Be on the lookout for delayed grief reactions, not just to lost loved ones but to a lost year (and counting), whether it has been a career/job, socializing with friends and family, a lost school year—basically all routine life. As we have been focused on our day-to-day survival, many have not had the “luxury” to grieve. Much of our work will be on helping patients to heal from their buried grief.
• Interrupt the “anxiety process.” I have a particular way of treating anxiety, and emergent anxiety can be treated this way as well. I see anxiety as a process as well as a state. We develop one or more feelings that are highly uncomfortable. Over time they get bunched up (very technical, but it’s how I describe the process to my patients) and it can become overwhelming.
• Help with Meaning-Making. During this time, a lot of existential questions have surfaced. Just because COVID becomes a manageable disease, it doesn’t mean that we should squander the opportunity to help make meaning out of this “lost year.”

Over several sessions, we break down anxiety into its component emotional parts, and we usually find that the emotions that turn into anxiety are particularly difficult for the patient to tolerate (which varies by individual). Next we find ways to better cope through emotional regulation. Once we identify their emotions, I help the patient to understand and modulate their response.

The “No Wonder” goal is a way for patients to eventually be able to say, “It’s no wonder I experience a lot of uncertainty about the future and feel so helpless to do anything about it.” The No Wonder goal—which can be achieved over several sessions for patients to make sense of their anxiety—can help to reduce patients’ anxiety about being anxious.

I also explain to my patients that when they have anxiety, their bodies are engaging in natural processes to keep them alive—such as increasing their heart rate, moving blood away from the abdomen, and heightening the senses in order to flee if necessary, among others. With enough effort and trial-and-error, they can tell themselves that their bodies are becoming more alive and alert (rather than shutting down) while a bout of anxiety or a panic attack is occurring.

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My hope is that this article can assist my fellow clinicians by providing some new tools to help your patients and motivate you to think about and discuss what will surely be in our future. We will be an even more integral part of our patients’ lives as we help to prepare them for emerging into a post-COVID world.
 

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