Psychiatry & Psychotherapy Podcast - COVID-19: Dealing with panic, anxiety, delirium, and mental health

Episode Date: March 17, 2020

Stress and anxiety are going to be very common during this time. In one study of Wang et al, 2020 they found that in China, 53.8% of the respondents to a survey rated their psychological impact as moderate-to-severe and 28.8% had moderate to severe anxiety, 16.5% had moderate to severe depressive symptoms, 8.1% had moderate to severe stress levels. By listening to this episode, you can earn 0.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, guys, welcome back. I am doing a special edition today. Going through a little bit of my reflections on COVID-19, some of the thoughts for those in the trenches and those in the front lines who are going through this, both those taking care of those with COVID-19 and also those who have it themselves. And in this episode, I'm going to talk about what as providers we can do to treat this population to discern, you know, are we treating delirium? Are we treating delirium? Are we treating kind of more of a trauma-type anxiety or more of a panic disorder and how we might treat those differently. I'm also going to talk about specifically some cognitive distortions that come up in the midst of this. And if you are listening to this and I decided towards the end, I will be making

a cognitive distortion journal that is unique for COVID-19. I'll have that on my website, linked in the show notes. If you just go to Psychiatrypodcast.com, it will be on the very, very top of that page. So I'm going to be talking about some cognitive distortions, how we look at our thoughts, put our thoughts on trial,

that's a little bit of cognitive therapy. It's shown to be effective for treating anxiety. And I will also be looking at a little bit of logo therapy and how we can look at meaning, and I'll intertwine that into the journal as well. So I hope this is helpful for you. I really, man, I am with you and for you in the midst of what you're going through. I definitely feel some of the effects myself as a person in a tertiary care center, as a person

treating patients with medical issues, the elderly, and a person who has friends and family who are elderly, who are potentially going to be experiencing the brunt of some of these symptoms and some of these issues that come from the severe illness. So that being said, here we go. Today I am thinking largely about the current events of our life here in the United States with the coronavirus disease, COVID-19, and the unique stresses and difficulties that are occurring. I feel it in my own family. I feel it in my children. They've overheard things. They've seen things.

School is shutting down. Their home. There's a lot going on. And so I thought I would do a little episode talking about some of my reflections. I imagine people who are not mental health providers will be listening to this as well as people who are mental health providers. So I will both go deep and shallow. You know, there's going to be stress that comes in different. forms. People who are going to potentially have more stress are older, people, people with

chronic illnesses, chronic diseases who are at high risk for COVID-19, children and teens as they feel the emotions of their parents, of us, right? And people who are responding to COVID-19, like doctors, health care providers, first responders, and people who have mental health conditions, including people with substance use or people who are prone to, you know, coping strategies that are not as adaptive, such as substance use. So stress can occur and we may feel more fear and panic and worry.

You may have changes in your ability to fall asleep, stay asleep. You may have less desire to eat. I went out to dinner tonight with my wife and the food was not appetizing. My wife said it was the worst meal ever, but part of that was there's a higher disgust sensitivity going around, I think,

and I feel it myself. So you may have more difficulty enjoying food. You may not sleep as well. You may have these things on your mind. I know last week I was thinking about one of my mentors, Dr. Tar, who's in his 90s and I was worried about him and I told him told him as much and you know I think that that's normal that's normal response to attachment I had another resident who told me he was

worried about his mentor and so you know we may worry about those people who are older we may have a worsening of our own health conditions because of the stress right so if you have migraines, you may have more migraines, if you have, you know, fibromyalgia, you may have more body pain, you may be tempted to use more alcohol, eat more, use some drugs. You know, this is all the types of stress that can occur. There's a good article on the CDC on this. I'm going to post that as well. So, you know, people who have preexisting mental health condition should probably continue to use the treatment that they're that they're already using. They shouldn't stop treatment all of a sudden. And there may be a temptation to do that, right?

Because the disgust sensitivity goes up when that happens. Any pill of any form seems like a toxin. So just to be sensitive of that and are, you know, if any of you are providers prescribing medications, that, hey, this is something that's in us on a deep level and is being triggered by the illness around us or the potential of illness. So I'd like to talk about things that you can do to help yourself, to support yourself. You know, maybe taking a break from watching the news

might be a good thing, especially if you're feeling the stress and you're feeling the anxiety and you're feeling the fear, especially if you're an more empathic human being, right, who feels the affect of those that you're watching. Maybe taking a break from the news. Maybe taking some time to do some reading, something unrelated, maybe getting off of social media for a little bit

because everything on social media is related to this. You know, we can imagine stresses. We can imagine other people's, like worst-case scenarios. And then that creates stress in us to the level, as if it was happening to ourself. And so we want to be careful to both be wise and know the dangers and what's going on, but also not to be overwhelmed, right? So there's a certain amount of stress, which is good, use stress,

and there's a certain amount which is over how much is good for us. And so we want to be careful not to exceed what might be a healthy stress. And this is a stress, and I think everyone will feel stress. this time. And so just to know to take care of yourself and to moderate how much you're bringing into your mind, which is stressing you out. So things that you can do, the basic things, you know, is you can exercise, you know, you can maybe practice some deep breathing. I'm a fan of, you know, some biofeedback devices, you know, learning how to breathe in such a way that helps you regulate your, and bring you into a more parasympathetic, a myelinated parasympathetic,

that rest in relaxation state. You can try to eat healthy. So, you know, lots of greens, lots of maybe nuts, you know, can you, you know, and as I'm saying this, I'm realizing I was just at Trader Joe's and a lot of the food was gone. And people are, people are hoarding for like a six-month sort of ordeal, and I really don't think that that's necessary. But look throughout your cabinets, what you have in there, and see what you can do to eat healthy, the healthiest you can. Exercise, you know, this might be a good time to open up some YouTube exercise, you know, at home type of things. I think most people are not going to the gym, and that's probably a good thing. and you know one thing about kind of not going into the public as much and and sort of you know doing

things that are more at home like why why is that so important it's really important because it slows down the curve at which the you know COVID-19 is going to spread so there will be a peak but can we create more of a hill or a plateau at the top or a so that our health care system can really respond to the stress. So we don't want a peak that is so high and so fast that it overwhelms the health care system. Okay. So to do that, I think taking precautions like, you know, schools closing down and, you know, not doing big places where there can be thousands and thousands of people and potentially, you know,

a huge spread very quickly. That's probably a really good thing. And I think it'll be really helpful for the utilization. For those who are older and for those who have medical issues, those are the people who are at the highest risk. And so, you know, having a mindset that, okay, even though I'm young, I'm going to, I'm going to do what I can to prevent the spread, right for those people for the people you don't even know their names you know that's why okay so you know doing exercise in your home is probably a good idea make some time to unwind you know try doing some activities that you enjoy connect with others you know so you can face time call people you know it may also be helpful to um look at the actual facts okay the facts of this

disease. So, you know, there is a 5% critical cases, you know, respiratory support. It's somewhere around 2% lethality. At least that's at the current time that I read things to prepare for this. And compare that with, you know, 50% for Ebola. That had 50% mortality. MERS was 30%, SARS, 10%, seasonal flu is like 0.1 to 0.2%. So consider that this is not the most lethal, but it is dangerous, especially for the elderly, especially with those with medical issues who are elderly, smokers, people with diabetes. So you may hear all sorts of things that are very, very scary. And seeing the fear, right, kind of like increases your fear as well.

And I think it might be good on my website, psychiatrypodcast.com. on the very, very top of the first page, Psychiatrypodcast.com, is a eight-day cognitive distortion journal. And in this cognitive distortion journal, it goes through things that, ways that we sometimes think that are not the most accurate. For example, all or nothing thinking,

things are black and white, completely without shades of gray. So for example, you know, the world is going to chaos. Everything will be destroyed. you know, sort of catastrophic thinking. Overgeneralization, generalizing from one bad experience to other experiences. Okay, so I'm reading this one case about this one person who was young and died of this,

therefore I am at great peril. Or, you know, there's this, you know, story of this hospital that was completely overwhelmed, therefore, you know, I'm going to potentially be in a hospital that's completely overwhelmed. you know and the stories that we see the way that we were created was to take a narrative and to try to apply it to our life to try to generalize it to our life so that we do not have to suffer right so we don't have to suffer as much because sometimes if we if we hear a narrative and it changes the way we think about something and then we are less likely to suffer that's a good thing right so stories have been told throughout the ages to help us suffer less.

And in this case, we're hearing stories and we want to suffer less. And so some people are going out and buying like six months of toilet paper. It's just completely unnecessary. And because of that, there's going to be a shortage for other people. And some entrepreneur who makes toilet paper is going to win out. But there's an overgeneralization. Okay. There's an all or nothing thinking kind of as part of it.

that too. Another one is mental filter. So focusing on the negative rather than the whole picture. So not to make less of the of the 5% who will suffer, but we can focus on that and miss that a lot of people will just have no symptoms or very transient symptoms. Further, we can focus on the negative rather than the whole picture of how people die. You know, I mean, if you look back a couple hundred years, most people died of infectious disease. It's only recently that that has been changing. It's very unusual at this point to die from an infectious disease. From about 1902 to 1950, we went from dying from about 40% infectious disease to only about 4% or so. So, You know, most people die of cancer and heart disease and other inflammatory diseases like diabetes,

issues like smoking, alcohol, you know. And so the big picture, which is, you know, it can be unempathic to the person who's currently in the midst of the struggle of this COVID-19. the big picture is that most people die of non-infectious disease and will continue to die of non-infectious disease further 1% of the population last year died of suicide 1% died of opiate overdoses in the u.s and so these are ongoing issues that will not just be seasonal these are these are big issues so when we talk about potentially a 2% lethality, I think it helps to put that into context of what that means.

Now, the world is coming to a standstill largely so that hospitals will have a flatter curve of the people hitting the hospital, flattening the curve, so to speak. But I think by and large, I think it's important to continue to come back to the, facts that we don't want to see things in a mental filter focusing on the negative rather than the whole picture. We don't want to disqualify the positive. That's another one. We don't want to take away some of the good things that are happening, some of the kind acts that you

see and disqualify them. We want to maybe focus on those things. You know, it's our brains were set up to focus on the negative. Our brains were set up to pay more attention to negative of emotions because we can learn maybe to reduce the amount of future pain that we have. At the same time, we have to use our frontal lobe, our thinking mind, to focus on the positive, to focus on the good going, the good things going on. Maybe the closeness that you have with your family in this time of need. Maybe the closeness you have with some friends calling them on the phone. Maybe those things, you know, the quiet, reflective moments that,

that you get because maybe you have more time to think. Okay, another cognitive distortion is jumping to conclusions without evidence. Reaching conclusions usually negative with little evidence. So it's like things like mind reading, assuming you know what the other person is thinking about you. Okay, fortune telling, predicting negative things in the future. I specifically want to look at fortune telling here because there's a lot of fortune telling that is going on.

you know, we see so many of our things that we normally enjoy closing down. And our mind says, oh, no, the world is in just utter chaos. And chaos has increased. That's true. But part of that is mindful chaos, right? It's chaos with a purpose. We are flattening the curve. Okay.

So fortune telling, you may predict a bad outcome. a bad future and therefore thereafter, you may actually feel the stress of that level of a bad future. Okay. And it may be something smaller. It may be something like I'm going to be at home with my kids for the next month and I don't know what I'm going to do because I'm not going to have child support. Okay. It may be it may be something smaller like I'm in the midst of the hospital treating these patients. And it's really, really hard. We're seeing a, if you're in the epicenter of where all the bad cases will end up, you're going to see more of these cases. And that's going to be really difficult. Okay, magnification or minimization. So you may sort of magnify certain problems

or minimize others. Emotional reasoning. I fear, therefore, we are in great danger. you know, I feel discussed, therefore this food is contaminated. That was ours tonight. It made eating difficult. Although in where I live, there's only one confirmed case, although there is not a lot of testing going on. There has, at least at the hospital I work at, they've sent a bunch of tests all have come back negative.

But I heard today there was one confirmed case in my county, but it will likely increase, right? So those are some of the cognitive distortions. I recommend checking out this journal, cognitive distortion journal. And I might even change it up to make a COVID-19 edition, kind of changing the words a little bit to match what we're going through. So putting our thoughts on trial, right, living inside the truth. educating ourselves.

And then maybe the other thought that I had, which is looking at the meaning, Logotherapy. And I did an episode on this. It was a Therapeutic Alliance, Part 2, Meaning in Victor Frankl's Logotherapy. I will link it in the show notes as well. And in this episode,

I really talked about how sometimes in the midst of suffering we can find meaning. And here's some quotes from Victor Frankel, which are so meaningful to me. Here's what he said. The way in which a man accepts his fate and all the suffering entails, the way in which he takes of his cross, gives him ample opportunity, even under the most difficult circumstances, to add a deeper meaning to his life. it may remain brave, dignified, and unselfish, or in the bitter fight for self-preservation, he may forget his human dignity and become no more than an animal.

These quotes came from Victor Frankel, who was writing about his experience in the concentration camps. And here's another quote he said, We who lived in concentration camps can remember the men who walked through the comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing, the last of human freedoms, to choose one's attitude in any given set of circumstances, to choose one's own way. So we can look for some of the deeper meanings.

We can look for a way to be meaningful to other people. Victor Frankel noticed that there were people who in the midst of great suffering continued to seek to help those around them. I was thinking of ways I could do this with my patients. How would I consider adjusting treatment in people who might have COVID-19? And the first thing that kind of popped into my mind was the risk of delirium. One of the emergent warning signs of COVID-19 to get medical attention, immediately is you know difficult breathing shortness of breath persistent pain or

pressure in the chest new confusion or inability to arouse bluish lips or faces so those are the ones on the CDC website specifically new confusion and inability to arouse now this could be from not being able to oxygenate the blood you know get the oxygen into the blood could be you know from the sort of the disease actually you know inability to get high oxygen saturation or to get the CO2 out. It could also be from delirium. And there could be both hypoactive or hypoactive delirium. And so I think in my assessment, I'm going to want to know, you know, is this person in a delirium hypoactive or hyperactive? And how I'm going to test that is how people draw a clock, put the numbers around the

clock, put the time till 10 to 11. Can you spell world backwards? Can you count down by 21 by threes? And if they can do those things, then they do not have delirium, most likely. And so that would be one assessment. If they have delirium, you know, thinking about treating why they have delirium would probably be the first thing. So, you know, if this patient was in C&L, which I will be covering CNL next weekend, wish me well. Um, if they were in a CNL case and they had delirium, you know, you treat it like you would treat other deliriums, right? Look for the underlying cause, treat the underlying cause.

And if that's, look at their medications, take off anything that's anticholinergic. And I have a great Excel sheet that I will link in the article that goes with this as well, listing all medications and which ones are anticholinergic and which ones modify cognitive function as every single medication. And there are some on there, guys, that you will not have thought are anticholinergic. But these are really good to avoid. Okay. And then secondly, you know, thinking about some sort of, you know, antipsychotic can help with delirium or, you know, other delirium treatment. Okay. So that's delirium. And then I was thinking, what if they have more of a history of trauma and now they have increased anxiety because of the trauma. So I might think

about, you know, anxiety medications. I'm not going to think about propanol if they have COVID-19 because I don't want to put a beta blocker on someone with a respiratory issue. But I might think about something like hydroxazine, a low dose of syracquil, low dose of tracidone. You know, I'm thinking short-term treatments if they're stable, you know, prososin for nightmares. So those are some of the things that I might think of as like short-term treatments. And if they have something more like general anxiety disorder, panic disorder, if they don't have delirium, if they have good cognitive function, I might think about, you know, some things like appraisalam, lorazepam, or clonazepam, so benzodiazepine.

because I'm thinking short-term relief, along with other things like quatyapine and hydroxazine. But I really do want to try to avoid anything that is anticholinergic. Other things I might do, I might talk about what I talked about earlier. I might talk about the cognitive distortions, always lead with empathy, you know, feeling felt, feeling heard,

probably something that everyone needs in this time. You're entitled to feel anxious. You're entitled to feel scared. You're entitled to feel angry that your life has been thwarted. You're entitled to feel more chaotic or disorganized or more difficulty in focus. You're entitled to these things. This is a tough time we're going through. Okay.

And let's look at some of these thoughts and see if we can look at, look at them more accurately. So these are some of my reflections. And I really want to emphasize that this is a time to come together. This is a time to express gratitude. This is a time to forgive if you've been bearing a grudge against someone. This is a time to be okay, experience. emotion if you're feeling emotion. This is a time to spend some time journaling and

and kind of understanding a bit more about yourself and how you're experiencing things. So I will be posting this. I will have a link to my COVID-19 cognitive distortion journal. I will have posts on my social media that you could share. to hopefully bring down the fear of COVID-19. And, you know, I just want people to realize that although we're isolating, although we're moving into maybe our family units or into our homes and not doing as many things outside, that we can at the same time come together and care for each other in this time.

So if you are hearing this, if you found this helpful, please share it with someone. I know it's not perfect. I'm putting this together the best I can. I've been dealing with my own sources of stress around this. And it's been a journey, I think, for all of us. I think we're all thinking about what this means for us and what this means for our families. what this means for our loved ones. And, yeah, I just want to say thank you for being part of my community here.

People listen to the podcast. I really do appreciate you guys. Appreciate connecting with you guys on social media and learning about your lives. And, you know, finding new ways to bring value to you guys. So, all right, take care.