Double-masked, hands curled around the examining room table, my patient is holding her breath. She’s visibly anxious. She explains to me that her chest feels tight. When I tell her that her blood pressure is unusually high, she asks me, “Am I dying?”
She’s not. She’s simply living through the physical and emotional manifestations of stress, anxiety and stacked trauma.
My patient is a single mother with a stressful job. She admits that anxiety has fueled an alcohol habit. She’s not getting drunk; she’s using alcohol the way many people are in the pandemic: to quiet worry, fear and her noisy brain at night. Despite feeling desperate for human connection, she has been too afraid to visit her vaccinated parents for fear of inadvertently sickening them.
The toxic mix of stress, alcohol and insomnia has clipped her exercise routine and catapulted her blood pressure into dangerous territory, putting her at increased risk for heart attack and stroke.
Almost a year into the pandemic, we’ve become accustomed to living in fear. We’ve lost over 500,000 American lives to COVID-19. The virus is ubiquitous, invisible, potentially lethal and can strike anyone. The pandemic’s unremitting social and economic upheaval has been uniquely traumatizing. Stripped of our usual strategies like going to the gym or connecting with loved ones, coping with added stress has never been harder.
Based on what I see in my office every day, anxiety has become a nearly universal health condition. And for many patients, fear has taken on a life of its own. Not only is COVID-19 running roughshod throughout the globe; anxiety itself is making us sick.
I’m watching the mental health crisis play out in real time.
“Coronaphobia” can be defined as an exaggerated fear of COVID-19 that is rooted in rational anxiety about the very real threat of COVID-19 — and that can promote physical, emotional, cognitive and/or behavioral symptoms that limit a person’s quality of life.
To be clear, anxiety about COVID-19 is normal. We are wired for survival; our bodies naturally react to and protect us from threats. Faced with danger, our innate “fight, flight, or freeze” acute stress response mechanism is triggered.
Our adrenaline and cortisol stress hormones surge, driving oxygen to skeletal muscles and increasing our level of alertness. Our breathing becomes more rapid, our muscles tense, our palms sweat. Our heart rate and blood pressure increase. This is how we run from the proverbial tiger in the wild.
“After a year on high alert, we can feel simultaneously wired and tired, aroused and exhausted, ready to fight and eager for bed. Our bodies reach a surge capacity.”
But there are downsides to an open spigot of stress hormones. After a year on high alert, we can feel simultaneously wired and tired, aroused and exhausted, ready to fight and eager for bed. Our bodies reach a surge capacity. And if our blood pressure remains elevated for too long, it can damage our blood vessels and predispose us to heart attacks, strokes and other cardiovascular diseases.
Our heightened state of alertness can also affect our thinking. Anxiety tends to shift our decision-making into a “zero-risk-tolerance” mode. Fears about the virus, vaccines and variants can be amplified. In survival mode, our primitive and worry-prone brains tend to overestimate danger and make decisions that avoid even the smallest risk — often at the expense of meeting other important health needs (like connecting with loved ones) that extend beyond mere survival.
For example, anxiety can convince us that anecdotal evidence — like the story about a man who died in Florida after receiving the Pfizer vaccine (but whose death likely was not a result of the vaccine) — should override the robust vaccine safety data on hundreds of thousands of people.
For people with anxiety, alarmist media headlines about the new coronavirus variants can further reinforce a fear-based internal narrative that the vaccines aren’t effective, when in fact, the data is clear: The vaccines work well against the current variants.
And a decision not to get vaccinated poses risk: Not only does it increase the possibility of developing COVID-19, but it also limits our ability to socialize and connect with others, exercise indoors and feel safe dropping our kids off at school — the very behaviors we need to counteract anxiety and improve mental health.
The health risks of social isolation are already clear — from depression and anxiety to poor concentration and insomnia. And in a hypervigilant state, we’re more likely to gravitate toward self-soothing behaviors, some of which — like drinking alcohol or abusing other substances — can exacerbate our underlying physical and mental health issues.
And so it begins: an endless loop of risk intolerance, added risk and heightened worry.
When anxiety takes on a life of its own — that is, when the cognitive, emotional, physical and behavioral manifestations of anxiety are rooted in reality but out of proportion to the actual threat — it’s time to see a doctor. After all, mental health isn’t something that we can opt out of like we can a feature on our iPhone.
The question isn’t whether or not we have mental health; it’s about whether or not we address it. And indeed, in the case of my patient (and many others like her), the combination of excess worry, high blood pressure, alcohol use and fear-based decision-making is making her sick.
We can halt the cycle of anxiety by addressing it like we do any other health problem. As this patient’s primary care doctor, my job is not only to manage her blood pressure and prevent a heart attack. It’s to help her understand the relationship between stress and her physical health. It’s to empower the patient with knowledge and tools to mitigate stress and resulting cardiovascular and other health problems. And, ultimately, it’s to provide her with a decision-making framework to make smart, safe decisions for herself.
“Even as we’ve accumulated scientific data on effective risk mitigation and vaccine efficacy, we haven’t strayed from absolutist and fear-based messaging.”
Caring for this patient — or any patient with coronaphobia — starts with naming and normalizing the stress and anxiety of COVID-19. It involves educating her on the physical manifestations (like high blood pressure, chest tightness and insomnia) of emotional distress — and the deleterious effects of alcohol on blood pressure and sleep. It consists of reviewing the real and measurable effects of stress on our heart health.
Together with my patient we formulate a plan — including exercise, meditation and connecting with loved ones — to help her mitigate stress and curb her drinking.
We also discuss the scientific evidence on coronavirus vaccination: the risks of death, disease and transmission to others. I encourage her to get vaccinated even though she’s worried about the new variants rendering the vaccines ineffectual. She’s not anti-science, she simply needed an explanation of the safety and efficacy of the mRNA vaccines.
The massive amount of scientific information in the media has been overwhelming to most laypeople. And for my patients who were already anxious about the vaccine, pessimistic public health messaging about the virus, vaccination and the new variants has added fuel to the fire of fear.
But now, a year later, we have three amazing vaccines — from Moderna, Pfizer, and Johnson & Johnson — all of which robustly protect against COVID-19-related hospitalizations and deaths. In fact, efficacy against severe disease in the Johnson & Johnson trial was maintained at high levels despite the circulation of the variants at the company’s study sites.
What’s more, we have growing evidence that the vaccines also reduce asymptomatic infection — a key factor toward resuming normalcy. A recent article in Lancet showed that health care workers in the U.K. who were swabbed every two weeks after vaccination demonstrated an 86% reduction in asymptomatic infection compared to nonvaccinated individuals. This data has been replicated in multiple other settings, including Singapore, Spain and Israel.
Yet even as we’ve accumulated scientific data on effective risk mitigation and vaccine efficacy, we haven’t strayed from absolutist and fear-based messaging.
Instead of mandates telling people to avoid hugs and human contact even after vaccination, we need tiered public health advice that is guided by scientific evidence and that simultaneously considers our broad human needs.
We need to learn from the lessons of HIV, the other great viral pandemic of our day. HIV clinicians learned very early on not to preach absolutism or abstinence, but turned to harm reduction. This approach counsels individuals how to reduce the risk of HIV while acknowledging the real-life conditions that may lead them to take some risks. The same exact approach should be taken with COVID-19.
This is where primary care doctors can help. Our job is to apply broad public health guidance to the patient’s unique health situation while considering the patient’s social and emotional needs. And in the case of my coronaphobic patient, to reframe her question of “Can I visit my parents?” as “What are the risks and benefits inherent in visiting my parents?”
Together, my patient and I decide that the mental health benefits of visiting her parents outweigh the vanishingly small risk of being together — even before she’s vaccinated herself. She’s visibly relieved. Seeing her parents is arguably more important for her heart and head than the daily blood pressure medication she swallows.
I recheck my patient’s blood pressure. It’s normal.
“We need to bring our mental health to our doctor’s attention and consider it in any medical decision-making rubric. We need to care for our mental health like we do any other organ system.”
Vigilance against COVID-19 is critical. Masking, distancing and hand-washing among unvaccinated people — and for vaccinated people in public — remain essential for preventing COVID-19 and community spread.
But health is more than the absence of disease. In other words: Not dying is important (and is essentially guaranteed with COVID-19 vaccination); but what about living?
When coronavirus vaccination drops our risk to a tolerable level — to be defined, of course, by the vaccine recipient — it only seems fair to ponder the social and emotional benefits of calculated risk-taking.
We need to recognize the unmeasurable effects of anxiety on our everyday thoughts, habits, decisions and physical health. We need to bring our mental health to our doctor’s attention and consider it in any medical decision-making rubric. We need to care for our mental health like we do any other organ system.
And for our collective well-being, we need to understand and value harm reduction for its nuanced, balanced take on risk mitigation and the human condition. We need to read the news with an eye for facts and an awareness of fear-based messaging. We need to achieve herd immunity by taking the COVID-19 vaccine and educating friends, family and co-workers to do the same. We need a clear understanding of the physical and mental health benefits of vaccination.
COVID-19 cases are dropping, but anxiety is everywhere. And even as the vaccines get distributed, no one is immune to the trauma of the pandemic. Protecting our mental and physical health in tandem can help us stay safe — and sane.
Lucy McBride, M.D., is a practicing internal medicine physician in Washington, D.C. She was educated and trained at Harvard Medical School and the Johns Hopkins Hospital. Dr. McBride has become a trusted and recognized voice through her popular COVID-19 newsletter where she provides real-time, fact-based information and guidance on managing physical and mental health in the pandemic. Learn more about her website and connect with her on Facebook, Instagram, Twitter, and LinkedIn.