Christopher Pittenger, MD, PhD has some words of wisdom for his patients that might be helpful to all of us: let the anxiety come. It will pass.
A psychiatrist and director of the Yale OCD Research Clinic located at Connecticut Mental Health Center, Dr. Pittenger says that although the disruption of everyday routines is anxiety-provoking for everyone, it can be especially so for people who struggle with mental illness.
Societal structures and relationships are more than economic factors; they are components of human health, both physical and mental. Many people in recovery depend on the supports they’ve put together, such as therapist, family and friends, and even their jobs. The sudden disappearance of those structures—as is happening during the current COVID-19 pandemic—can disrupt whatever fragile balance people have achieved.
The pandemic has already shuttered many businesses, causing people to become suddenly unemployed. It has required social or physical “distancing” and even self-quarantine, strategies proven to slow the spread of the highly contagious coronavirus but that nevertheless leave a hole in people’s lives. These losses create dangers, especially for the most vulnerable among us.
“What seems to be the problem is the loss of structure,” Dr. Pittenger said. “It’s hard for all of us, but for those who are working with a tenuous balance to begin with, it’s a very challenging time.”
In addition to the disruption of routines, Pittenger noted that people are experiencing fear in the face of so many unknowns. He said he’s been talking to a lot of young people who are worried about their futures in ways they hadn’t prior to the pandemic.
“This is a disorienting time,” he said. “But for people who are struggling with anxiety disorders, I think it’s much more so. The fear of the future feeds into the core of their own personal struggles.”
It is also challenging for the population Dr. Pittenger works with most: people with obsessive-compulsive disorder, or OCD, a type of anxiety disorder. About 30 percent of people with OCD have contamination as their primary fear. And while OCD isn’t just about germs, for some people that is the main thing.
COVID-19 might be expected to trigger some of the hallmarks of OCD, such as hyper-vigilance and preoccupation with cleanliness. But Pittenger said an interesting anecdotal phenomenon is being observed by OCD providers nationwide.
“Many of our patients are taking a lot of the new worries and restrictions in stride,” he said. “Some are saying that their contamination sensitivity is now becoming the norm, and the world is moving towards them. They feel validated.”
He said while some people with OCD have specific contamination concerns, those concerns spill over less to the new virus than one might think.
“Overall a pattern that OCD specialist clinicians are noting is that our patients do quite well when there is a real, unambiguous crisis,” Pittenger said. “It’s managing the uncertainty of day-to-day life, when danger is low but not zero, that they find so difficult to handle.”
That said, Pittenger noted, a few cognitive behavioral therapy strategies can be beneficial for most people during uncertain times. One such principle is acknowledging what’s going on and being clear-eyed about the impact.
What people learn...is that the anxiety will come, but I'll survive it.
Christopher Pittenger, MD, PhD
“We have to acknowledge that these are unique and challenging times, and everything isn’t going to be all right,” he said. “People are going to get sick. Some of our routines are going to be disrupted for a long time. The normal at the end may be different from the normal before.”
At the same time, people need to acknowledge that COVID-19 is being taken seriously. Real measures are in place to stop its spread, and that’s a good thing.
“Most of us are going to be fine,” he said. “We can’t pretend it’s not a big deal. It’s a huge deal. But at the same time, most of us are going to be fine, and there are things that we can do to help ourselves and support those around us.”
The next step people can take is to find ways to maintain some sense of normalcy while understanding that routines are going to be disrupted for weeks, maybe months to come. One way to do that is by using technology to stay connected.
“Keeping in contact with one another, albeit mediated by technology, is important because it maintains some degree of normalcy,” he said. “Some things are disrupted, but that doesn’t mean everything has to be disrupted.”
He said that while these cognitive steps can be more challenging for OCD patients, the principles apply to everyone experiencing anxiety.
“We teach people how to keep perspective, how to step outside of one’s self to say, ‘Hey, is this reasonable? Is this not reasonable?’” he said. “Those principles haven’t changed. The context has changed. The ambient anxiety has gone up. But the basic principles about how to navigate anxiety have not changed.”
Pittenger said helping patients navigate their anxiety doesn’t mean telling them everything is going to be okay, but rather reminding them of the basic navigation principles. And if you need a script for that, try his.
“I’d say, ‘These are hard times. Yes, there is a new virus out there,’” he said. “‘Let’s think about what we know. Here are things that are risky and things that are not.’”
Another useful therapeutic principle is something called “symptom evocation and response prevention.”
“You let the anxiety come,” Dr. Pittenger said. “And you don’t engage in the behavior that would normally control it, like avoidance or asking for reassurance.
“What people learn through the course of doing that exercise is that the anxiety will come, but I’ll survive it,” he explained. “That principle, I think, is still useful. We can talk about the coronavirus, we can take the necessary steps to bend the infection curve—and the anxiety will come, and we’ll survive it. We can work through the anxiety and tolerate it. The anxiety will decline on its own. I think that approach is still appropriate.”