March 19th, 2020
Ziv E. Cohen, MD
In this challenging time, many are feeling anxiety about their health and economic security. The Covid-19 outbreak, which began in China, in a matter of weeks has spread around the world. In the process, how we live our lives has been dramatically altered. Work disruption and changes to our routines are forcing citizens to confront this pandemic. The daily news is dominated by coronavirus. It has become routine to track the disease’s spread. Many are feeling anxious about the future.
Understanding the Foundation of Anxiety
It is so important, therefore, to distinguish between healthy and unhealthy anxiety. Hundreds of thousands of years ago, anxiety was coded into mammalian genes. The neural circuits coded for by these genes signal anxiety through brain centers such as the amygdala, the brain stem, and the limbic system. These brain structures are common to all mammals, such as mice, cats, and dolphins. Evolutionary biologists believe that analogous structures exist in other vertebrates, such as fish, reptiles, and birds. Mother nature saw fit to equip animals with emotions, and in particular, with anxiety.
What could be this conserved neural system’s purpose? Darwinian theory suggests that if anxiety is highly conserved across species, it must provide a survival advantage. Experiments with animals show that if levels of anxiety are too low, animals may neglect basic tasks such as food seeking and social interaction. In other words, anxiety acts as a motivator, prompting animals to be attune to the environment and their inner state and to adjust their behavior accordingly.
On the other hand, excessive levels of anxiety may inhibit learning and creativity. Studies have shown that learning can be delayed or inhibited if animals are subjected to too much stress. Sometimes anxiety can have a chilling effect. For example, when a single cat hair is introduced into a mouse pen, the mice will stop playing and will continue to show inhibition of their behavior long after the hair is removed.
This last example shows the difference between healthy and unhealthy anxiety. For the cats to show inhibition in playing behavior when they sense a predator is adaptive. If the inhibition continues even long after the cat signal is gone, however, the behavior has crossed the line into dysfunction.
The Differences Between Helpful Anxiety and Panic
In this time of Covid-19, we need to keep in mind this distinction. Anxiety is useful when it prompts us to take precautions against contracting the coronavirus infection. This includes hand washing, social distancing, avoiding large groups of people, and generally leaving home only when essential. In addition, hygiene, such as covering one’s sneeze, are important to prevent passing on the disease. When anxiety prompts us to be attuned to the news and to change our behavior accordingly, it is doing the job for which it evolved.
The anxiety neural system can fairly easily become hyperactive. When this happens, anxiety turns into panic. Anxiety feeds on itself, triggering a cascade of symptoms: fear, dread, nervousness, tension, and withdrawal. Physiological symptoms triggered by excessive anxiety include: palpitations (an uncomfortable sensation of feeling the heart beat), shortness of breath, diaphoresis (excessive sweating), fidgeting, agitation, nausea, diarrhea, and loss of appetite.
The connection between anxiety and these symptoms is mediated by the autonomic nervous system, particularly the sympathetic nervous system. The autonomic nervous system controls unconscious physiological processes, such as the cardiovascular and respiratory systems (heart rate, blood pressure, respiratory rate). The autonomic nervous system has two components, the sympathetic and the parasympathetic nervous systems.
The parasympathetic nervous system pushes the body towards the functions associated with rest. When the parasympathetic nervous system is dominant, the intestines become active (to digest food), the pupils become small (because sight at a distance is unnecessary), the heart rate slows down, and the sweat glands are inhibited. When the sympathetic nervous system is stimulated, in contrast, the body is gearing up for exertion: the pupils dilate (to improve sight), the sweat glands are activated (to lower the elevations in body temperature during exertion), the intestines become dormant (not to waste energy and blood flow on digestion), heart rate increases, and respiratory rate is elevated. A key hormone of the sympathetic nervous system is adrenaline, known by its scientific name, norepinephrine.
The brain’s perception of a looming or present danger triggers fear. The body must respond to the threat by preparing to fight or take flight (the “fight or flight” response). The sympathetic nervous system is powerfully activated to ensure that the person can run away from or confront the danger. To those who have experienced a true life or death crisis, the cascade of emotions and physical activation triggered by the sympathetic nervous system is unforgettable.
Due to the powerful selective pressure on our species over thousands of years, the sympathetic nervous system is a bedrock of our neurophysiology. Even for those persons who do not often feel anxious, the emotions and physical responses to perceived danger are usually first experienced in early childhood and the capacity for these feelings persists into old age.
A large portion of the population has a disposition to more easily cross from normal anxiety levels to those seen when the brain is signaling an alarm. These individuals may have a genetic makeup that thousands of years ago conferred an advantage for survival. To be on hair trigger alert in the jungle or the Savanah would probably help our ancestors survive. In the modern world, however, the “fight or flight” neural circuitry is rarely needed. Although running late for an appointment may be upsetting, it is not a life or death situation. Nevertheless, the sympathetic nervous system may be triggered in this population. Such persons may meet criteria for an anxiety disorder, such as Generalized Anxiety Disorder or Panic Disorder.
Generalized Anxiety Disorder and Panic Disorder
Generalized Anxiety Disorder (GAD) is a condition where high levels of anxiety are present much or most of the time. Patients with this condition often report feeling “constantly anxious” and never being able to relax. Small sources of stress lead to disproportionate anxiety levels. GAD is often a disabling condition.
Panic Disorder (PD) is a condition where the body goes into a full fledged “fight or flight” response when there is no threat to life or limb. Panic attacks often occur without any trigger whatsoever, or “out of the blue.” Patients never forget their first panic attack. Often, the patient goes to the ER in the belief he or she is having a heart attack or stroke. In one subtype of PD, panic attacks are typically triggered by being in crowded or enclosed places (malls, subways). Others will have panic attacks even at home.
Coronavirus and the condition it causes, Covid-19, are potentially life threatening, even though the risk for most persons is exceedingly low. The brain is good at gauging and responding to immediate, concrete threats. Vague or uncertain threats over the medium or long term are difficult for the brain to assess. It is easy for those with a pre-existing disposition for anxiety, such as patients with GAD or PD, to be pushed into anxiety symptoms. Many of my patients with anxiety disorders are presently experiencing worse symptoms and panic attacks.
As we discussed, the sympathetic nervous system and the neural circuits coding for anxiety are core parts of human emotional life and physiology. Even if one doesn’t have an anxiety disorder, the capacity for anxiety is inherent to the human condition. It is therefore not surprising that Covid-19 appears to be leading to rising anxiety levels in the general population. Those with anxiety disorders are the proverbial “canary in the coalmine.” It is only a matter of time before anxiety trickles down to everybody else.
There are further reasons that coronavirus has led to a dramatic uptick in anxiety. It is an invisible enemy. It picks its victims seemingly at random: we cannot fully predict whom the virus will put into a critical condition, although some risk factors are known. As a culture, modern medicine’s great success in the West means that we have almost no living memory of past scourges: tuberculosis, polio, malaria, syphilis. Even HIV was tamed, if not cured, within a period of just twenty years. Furthermore, in our somewhat queasy and sterile society, death is kept at arm’s length. It is deeply unsettling to find it was never really that far removed from us.
How To Cope With Anxiety During The COVID-19 Pandemic
So how can we cope with “Covid-19 Anxiety Syndrome” when so many forces seem to coalesce to make it irresistible? Luckily, psychiatry has developed tools to manage anxiety.
- Challenging fears with facts: keeping oneself informed can help allay fears. For those under 65 and without pre-existing conditions, the risk of Covid-19 causing life threatening illness is less than one in a hundred. For those in the at risk group, sensible steps can greatly reduce the risk of infection.
- Distracting oneself: staying busy with meaningful activities is one of the best coping strategies for stress. As the British say, “Keep calm and carry on.” Hobbies are especially helpful. Like play in childhood, they provide free reign to the imagination and can lead to a trance-like state of concentration and relaxation.
- Meditation: many audiobooks, blogs, and apps provide accessible, user friendly guides to meditation for beginners. Studies have shown that regular meditation has the capacity to reduce anxiety, boost the immune system, reduce blood pressure, improve sleep, etc.
- Exercise: raising the heart rate has been shown in numerous studies to lead to improved mood, reduced anxiety, and improved concentration, amongst other benefits. Even vigorous walking will help “burn off” anxiety and stress.
- Friendship: a strong support network is a powerful source of resilience in times of stress. Now is the time to reach out to friends whom one has neglected and to strengthen existing friendships.
- Belly breathing: inhaling with the diaphragm involves the sensation of filling the belly with air, i.e. inhaling without expanding the chest. When the belly reaches maximum expansion, release and exhale passively, like the tension being released from a coil. Ten cycles are usually sufficient to dramatically dent anxiety.
- Reduce media consumption: the media has strong incentives to keep viewers engaged. This often leads to amplification of certain stories that capture the most attention, even if they are not representative. Although it is important to remain abreast of the facts, limiting media consumption to 10 minutes per day protects the mind from overstimulation and cognitive distortions.
- Talk with a professional: If the above techniques are not sufficient to keep anxiety levels under control, it makes sense to speak with a mental health professional. Various forms of psychotherapy have been shown to reduce anxiety.
- Medication: As an adjunct to, or instead of, psychotherapy, medications are effective and fast interventions to reduce symptoms and restore normal function.
At Principium, it is my goal to help persons manage anxiety and attain their potential by developing and strengthening coping mechanisms, growing psychologically through psychotherapy, and utilizing cutting edge biological therapies like medication, TMS, and novel therapeutics (ketamine). If you have any questions about Principium and the treatments we offer in NYC and beyond, please email (firstname.lastname@example.org) or call (212-335-0236).