Pandemic Pitfalls

I read a good article on the physical effects of the coronavirus pandemic on our physical health recently. Yes, the Pandemic Is Ruining Your Body was written by Amanda Mull and published on January 14, 2021 in the Atlantic. In it, she addressed many of the ways that living in the middle of the worst worldwide health crisis in a century affect us as human beings who are struggling to be brave, squash fear, stay productive, and thrive, all without the help of our usual social institutions and personal interactions.

She acknowledges that for some of us, myself included, sitting at home virtually all the time, even when working hard, is a situation of relative comfort and incredible luck. We have jobs that allow us to use computers, faxes, cell phones, scanners, email, and videoconferencing to meet, greet, schmooze and therapize to our hearts’ content, just not in person. But at what cost? She says that in her own experience of working from home, she began to experience decreased hip mobility, low grade headaches, sore shoulders, a stiff neck, and dry skin. At first, she and her ailments felt isolated, because she was isolated. She could not see that her coworkers were doing the same things, stretching the same tired muscles and “gobbling up ibuprofen” as she was. Many have been sickened or even died from COVID-19. Those who have avoided those fates, says Mull,  are living through an extended disaster that at the least is painful, but at its worst can be catastrophic.

What are doctors and others seeing? Aches and pains come up for seemingly no reason and then stick around. People who work from home found themselves setting up what they thought would be a temporary home workstation that they might need to use for a few weeks at best, a few months at worst. I did this myself. Over the last year, as pandemic reality set in, I have changed my equipment configuration, furniture and workflow more times than I can even remember. Sitting in front of a too short table, shoulders hunched, laptop screen too low, keyboard at the wrong height, and normal implements not easily reached, makes work tough. This, as Mull says, “all while sitting in a chair meant to support a human for the duration of a meal, not a workday”.

We are also working longer hours. How can that be, I asked myself after I read this in multiple articles for the fifth or sixth time. If you must get up, get ready, drive to your workplace and then leave at a prescribed time once you are done, there is an eight or nine hour rhythm to your day. If you subtract some of the prep time and all of the commute time, you find yourself (and again, I can attest to this) working an extra hour or even two. As I wrote this, I finished a “normal” ten hour workday that was jam packed with patients, emails, consults, and reviews. It simply feels that work has been busier, more packed with tasks and with much less down time or break time then pre-pandemic. Let’s be honest. Everyone feels just a little twinge of guilt when they work from home. And Mull says, “expectations of productivity have increased” because you are there. Granted, some may be able to outfit a spare bedroom or home office with nicer and more usable equipment, but “for those living in cramped housing with kids who go to Zoom school and other family members who also need space to work, building a personal mini office simply isn’t an option”.

Does any of this bleed over into our emotional wellbeing and ability to cope with the social and mental stresses that this pandemic has caused? Of course it does. In the past year, many months of which I have worked predominantly at home, there has not been a workday that goes by without me hearing about folks who are anxious and can’t sleep. Not a single day. Much like Amanda Mull discussed in her article about the physical stresses that can lead to physical problems, I have seen the psychological toll that the coronavirus has had on our normal psychological and emotional worlds. While staying home, we have lost out physical connection to others. There is no chatter around the coffee pot or in the parking lot before or after work. We have been forced to use different “equipment” to connect with each other. As my rector opined at a recent annual church business meeting, “Well, Zoom gets the job done I guess, but it’s not the same, is it?” Screens are now our “windows on the soul”. Why? Because any time we are face to face with most people we know outside our immediate family, we are wearing masks. Unless you are extremely close to someone, it is hard to read real emotion from just raised eyebrows or crinkling crows feet. Why is this important?

Because stress, anxiety, depression, loneliness, and hopelessness kill. They are not dangerous in themselves just for the misery they cause, and the potential for catastrophic consequences like suicide. As Mull states in her article, depression and anxiety “are enormous risk factors for heart problems, especially among people over 50. Quarantine itself is also a risk factor. Loneliness and social isolation increase the risk of myocardial infarction and stroke by up to 30 per cent”.

What can you do now, today? Connect with others, however you can, however awkward. Call. Zoom. FaceTime. Text. Reach out to the elderly who have little social support. Spend some non-screen time with a child. Cook dinner, and then leave part of it in a basket for the neighbors next door. I know I keep saying this, but it’s true. This pandemic will end. We will get through this together. We just need to make sure that we come out of this ordeal as physically and mentally healthy as we possibly can.

What Kind of Stress?

Over the last pandemic year, I have heard countless stories of people who have lost their jobs, had to move, lost a loved one to COVID-19, or just felt that their entire world had been upended by the restrictions and lockdown that this time in the world has foisted on all of us. These folks are invariably stressed, sometimes to their breaking points. They are not functioning well. They are irritable and depressed and anxious. They can’t eat and they barely sleep. They have little desire to do anything and have lost the joy they used to feel for almost everything. They come to see me, tell me their stories, and then tell me what they think the problem is and what I need to treat them for.

“I have PTSD,” they tell me, sure that this is the diagnosis that this pandemic has saddled them with, and equally sure that a medication or two will fix things and get them on the fast road to recovery and mental health again. But wait, is it really PTSD, or is that simply the diagnosis that most people know is associated with trauma, therefore must be the one they are suffering from?

I would like to talk to you this week about two kinds of stress reactions that are very easily confused. Most of the information that I am about to share with you can be found in UpToDate, a medical resource that pulls together the latest research and knowledge on a wide variety of topics and illnesses.

The first disorder is ASD, or Acute Stress Disorder. ASD is an acute stress reaction that occurs within one month of the traumatic event that causes it. Prevalence for this disorder is between 5-20%. What kinds of trauma can lead to ASD? Thirteen per cent of those who have severe motor vehicle accidents will have it, as will 16% of assault victims and, most horribly notable for all of us over the last month or two, 33% of those who witness mass shootings. Risk factors for developing ASD include being female, having various pre-existing mental health or physical illnesses, having a history of a previous trauma, and being exposed to a more severe trauma in the first place. The trauma experienced by someone may lead to a very transient reaction and no ASD, with a very swift return to normal. On the other hand, it may lead to ASD, then within a month also return to normal, pre-trauma life. One group, however, may go on to develop PTSD, or Post Traumatic Stress Disorder. As we shall see shortly, these folks may suffer long term effects that are life changing.

What are the symptoms of ASD? Re-experiencing the traumatic event is common, as is anxiety. Nightmares and vivid dreams may affect sleep. Recurring thoughts and increasing feelings of fear may arise. There is sometimes hypervigilance guarding against further threats. One might avoid people, places or things that remind of the trauma, and emotional numbing with flat features sets in. Dissociation from others, isolation and social avoidance complete the picture of someone who is feeling terrible but has an extremely hard time communicating this or sharing it with others, even those they are the closest to.

The good news? Most people who experience traumatic events of various kinds will have a brief period of symptoms and adjustment, and then will adapt and go back to their previous level of functioning within days to weeks. In some studies, it has been shown that 40-80% of people with ASD will go on to develop PTSD. The bright side of that is of course that almost half will not.

How is the diagnosis of ASD made? Quite simply, one must have several necessary symptoms. The first is exposure to the trauma, either directly, as a witness, or being told of the danger or injury to a loved one, for example. Intrusive symptoms can include dreams, memories and flashbacks. Mood becomes negative. There may be dissociative episodes. Avoidance tries to prevent recurrent trauma. Finally, arousal leads to decreased sleep, irritability, and an increased startle reflex. ASD may begin immediately after a trauma, but is usually best diagnosed three days or more afterwards.

What about PTSD? How is it different? It is diagnosed after four weeks of symptoms following the traumatic event. Two of the most likely types of events to lead to PTSD include sexual trauma at 33% (which may include childhood sexual abuse, rape, or domestic violence) and interpersonal traumatic 30% (which might include the death of your spouse or the serious illness of a child). Lifetime prevalence of PTSD may be as high as 6-9%. In one sample of 5692 adults in the United States, 83% had been exposed to severe traumatic events, but only 8.3% had developed lifetime symptoms of PTSD. Some very specific groups like native Americans and refugees from other countries with endemic abuse and stress are at higher risk for PTSD. Gender, age, educational level, history of previous abuse and poor social support may also lead to a higher risk of developing PTSD. Women are four times more likely to suffer from PTSD than men. A higher severity of symptoms at one month seems to be predictive of more serious PTSD symptoms at six months and onward.

Diagnosis of PTSD is similar to ASD, in that exposure to a traumatic event is necessary, intrusive symptoms such as re-experiencing and flashbacks are often present, and avoidance is present. Depression, decreased interest in activities, guilt, and disconnection from others are often seen. People feel on edge, reckless and irritable, and they tend to engage in risky behavior or make poor decisions. There may more serious depersonalization or derealization, or even amnesia for parts of the traumatic event.

PTSD tends to be a chronic disorder in many. One third recover at one year follow up, but another one third might still have symptoms ten years after the trauma. Some studies have shown that those with PTSD have poor social supports, increasing disability and inability to complete higher educational goals,

Now, what does all of this mean for the dozens if not hundreds of patients who have told me that they have “PTSD” because they feel traumatized and anxious due to pandemic? The very good news is that the vast majority of us will have initial anxiety when traumatized in this way, but most of us will recover in a very short time. We anticipate getting back to our pre-COVID lives one day, and we very much look forward to that. Those who go on to develop more serious anxiety symptoms and the other associated symptoms of PTSD should of course seek treatment as needed for what can turn into a chronic and debilitating illness.

Insomnia in the Time of COVID-19

I have talked about it before, but it bears revisiting this week. In the last three weeks that I have worked at home, I have heard several complaints repeated over and over again. One that is on everyone’s lips is this: “I can’t sleep.”

Now, I see a lot of folks who have depression, anxiety, trauma, grief and many other issues in my work, but there are certain kinds of symptoms that seem to be common across the spectrum of mental health illness or stress. When people get upset, their mood changes. They eat too little and lose weight, or they eat too much and gain weight. They notice changes in interest, motivation and energy levels. They isolate and have trouble connecting with those they love. They have a hard time focusing or paying attention to things that matter. Many of these symptoms might be present in anxiety disorders, mood disorders or even psychotic disorders. Still, the one thing besides a vague sense of anxiety that almost everyone is feeling, and complaining about in the midst of this pandemic, is the inability to get good, restful, restorative sleep. 

First, some normative data. What is normal sleep latency, the time that it takes most of us to drift off to sleep? Eight minutes is a good yardstick. How much sleep do we really need? One can read about numbers that vary wildly, but it still seems that most people do better with an average of seven to nine hours of sleep per night. How much of this needs to be REM (rapid eye movement) sleep, that stage of sleep where we actively dream? Well, if one gets nine hours of sleep and REM cycles repeat every ninety minutes or so, one could expect to have at least two good REM cycles per night. Twenty-five per cent of your total sleep time given to REM is about right for most people. 

Next, why is this important? Why do we need this much sleep anyway?  We think that sleep is important to maintain both good mental and physical health. While we sleep, our bodies repair and maintain organ systems and muscles and immune systems, and manufacture hormones. Memories and newly acquired information may also be cemented during sleep, so that this information can better be used later during waking hours. Getting the right amount of sleep may also be protective in guarding you against development of diabetes, weight gain, and heart disease. 

Why has sleep, or the lack of it, been such a constant complaint in the last few months as we navigate this COVID-19 pandemic? Many people are experiencing anxiety, which tends to make settling down, getting relaxed and falling asleep at night very difficult. This anxiety is low grade and chronic for many people, hard to describe but always there, and it tends to affect our ability to fall asleep, leading to what we call initial insomnia. This kind of anxiety and inability to fall asleep can build on itself night after night, becoming a chronic problem. 

Others may be battling depression, with superimposed grief over all the things that we have collectively lost because of the virus outbreak and its impact on our physical, emotional, vocational and financial lives. Depression sometimes leads to what we call early morning awakening. You are able to fall asleep just fine, as you are sometimes absolutely exhausted, but you find yourself waking up almost every night at four AM, not able to go back to sleep. 

Everyone wants to sleep. The quick fix, taking some kind of over the counter or prescription sleeping pill, seems to be the best answer. Not always so, I’m afraid. Sometimes one has to deal with the underlying anxiety, depression and grief that is depriving us of sleep in the first place. Sleep hygiene is also very important. You know, the steps that your doctor has told you to try, including not exercising in the evening, limiting late night eating and alcohol consumption, avoiding screen time for several hours before you go to bed. Regular bedtimes and awakening times are also crucial, as these rhythms tend to lead to more consistent and restorative sleep. 

During this pandemic, we are all a little out of sorts, our usual routines have been disrupted, our moods are different and our ability to relax is strained. Knowing what is normal, what is not and how to maximize our chances to sleep well each night will go a long way to help us not only weather this biological storm, but thrive as we get to the other side of it.  

Earbola

It took a day or two and maybe eight hundred miles for it to fade. Each Maroon Five song or MacOSKen podcast I listened to helped to deaden the aural assault. The sounds were soothing, calming, comforting.

Starting on Friday, October 3rd, I slowly but surely began to unplug from two dozen emergency rooms in South Carolina. I checked out of two clinics. I stonewalled and diverted work email. I shut down voicemail. I left the pile of professional reading at home. I pledged to not care about the news, to disengage in a very meaningful, positive, mindful way. The noise was fading.

I started the biggest vacation of my life (so far).

I was going to focus on fun, on leisure time, on sports, on photography, on sightseeing. I was going to meet and greet family, old friends and brand new friends.

I was going to have quiet, peaceful days on the road.

Then, Ebola happened.

There was a media frenzy. Healthcare media. Mainstream media. Fox News. CNN. Sanjay pouring chocolate sauce on his inadequate suit.

I wasn’t going to watch it or listen to it or read about it. Then, I would go to the gym and there it was. I would sit in the breakfast area and there it was. I would reach for a paper and there it was.

Texas hospitals. The embattled CDC. Doctors without borders. Nurses without supporters.

Patient death from Ebola in the United States.

Controlled panic.

There began a crescendoing cacophony of cultural conversational criticism the likes of which we haven’t seen since I taught mental health hospital workers how to roll a condom onto a banana in the early nineteen eighties.

I might have have been in the middle of a seven thousand mile driving trip around the country, but the country was in the middle of a bloody medical meltdown.

I’m home. I’ve got week one back at work under my belt and have just started week two. I’m getting several Ebola related emails each day. I’ve learned, or relearned I guess, that the world doesn’t stop spinning, stop changing and stop evolving just because you’d like it to join you on a break.

Our degree of attention, focus and investment in what is going on around us may vary, and vary significantly.

The world still goes on. Loudly. Relentlessly.

I would recommend that all of you unplug every once in a while, whether it’s for a three day weekend or an African safari. Disconnecting and recharging your batteries is good for you physically, mentally, emotionally, and spiritually.

Just remember that when you plug back in, turn the volume down just a bit. The world is also a very noisy place, and it will take time to acclimate to all the chatter again.

None of us wants to be a victim of Earbola.

Gregorian Calendar

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Sometimes things just get so hectic I can’t believe it. Ever have those days/weeks/months? I’m sure you have. 

I’m smack dab in the middle of one of those stretches of work, travel, visits, and obligations that feels like I got tethered to the back of a 747 and was asked to run fast enough to keep up as the plane barrels down the runway for takeoff. You know you can’t just stand still, but you also know that things are going to speed up beyond your control pretty quickly. 

As I’ve told you before, I’m a purist. I use the applications and programs that come standard with my Apple kit unless I find something better. For that reason, I use Calendar on the iMac and the corresponding app on the iPhone. I have nine separate calendars within the program. These help me to keep track of personal time, actions that need to be taken on a specific date and at a specific time, Facebook events that I have been invited to, meetings I must attend, my professional schedule including telepsychiatry and clinic work schedules, arts events I have tickets to and of course, the 2013 football schedule for the UGA Dawgs. 

All of these calendars sync with my iPhone. Make a change on the phone and it shows up on the iMac at home, and vice versa. Cool. All are color coded. I can look down at my calendar and instantly know if I have to work that day or if I have a meeting later in the day just by scanning colors. 

I also have alarms and reminders enabled via Mac OS-X and iOS 6, so this adds another layer of help to keep me on track. Things will pop up, ding and boing when I’m supposed to be somewhere, write something, or take action on a project. These alarms may come a week before an event, or thirty minutes before a meeting. 

On the iMac, I keep the weekly calendar open, and I have it set to show the entire twenty hour hours of each day. I can get a better sense of what my day or week looks like if I can see color-coded events spread over the entire time period. This lets me know just how busy I will be that week, but it also let me quickly and easily see where there are gaps that might serve as times to meet someone for coffee or plan a dinner with my daughter. 

Still and all, there are periods like this when all I can do is trust that my carefully crafted system will get me where I need to be on time. I trust that I have set alarms, put up reminders and blocked off enough time to accomplish what needs to be done today. I check the calendar one last time at home, grab my iPhone, and head out the door. Then, all I can do is show up and do what I’m told at the appointed hour and hope I make it until midnight, ready to slide into the next day. 

The good thing?

In eight days, there’s a green entry starting at 4:30 PM that says “Trip to Monticello”. It stretches out for three days. The green color tells me that this time will be set aside for personal travel, activities, fun and recharging.

Now that’s the kind of personal obligation I won’t have any problem meeting. 

(Re) Charge!

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Good morning, dear readers. I trust that if this morning for you, as it is for me, that you rested well last night and that you are now ready to face another day and the challenges it will bring.

A friend of mine commented on a blog post the other day. She in essence wondered out loud how mental health professionals were able to unwind, de-stress and otherwise cope with the rigors of our profession.

Of course, down time is a very personal thing. We all cope in different ways. I thought I would share some of mine with you. 

It is very important to balance activities, as anyone will tell you. Anything done to excess can be detrimental and not helpful. For that reason, I have several kinds of activities that I really enjoy.

I am a middle-aged male. It’s important for me to maintain my physical health, my strength, and my stamina. I live alone, so taking care of myself is going to be more and more important as time goes on and I age-gracefully I hope! I have twenty-four-hour access to a gym where I live, a wonderful thing with my odd work schedule. I try to get there at least three or four times per week for at least 1-1 1/2 hours per visit.

I walk on a treadmill, use the elliptical machine, and lift weights using a nice set of free weights provided by the gym. It’s amazing how much better one can feel with just a modicum of physical exercise. I parlay this training into competition when I can, though not as much in recent years. I have always enjoyed the outdoors, so hiking, road racing, and now competitive walking have always been fun for me. I am setting my sights on another half marathon in the near future. I recently walked up and down the grassy green slopes of a Civil War historic site and plan to get out to other battlefields soon to do the same.

The bottom line for physical fitness that I have learned as I watch my own patients over the years? Find something you enjoy, do it regularly and keep moving!

I enjoy the arts very much. For this reason, I just purchased a pair of season tickets for four different groups in my area and am looking forward to the upcoming performance seasons beginning in the fall. I will see a stunning performance of Les Mis by the Players group in the next town, I will attend a cultural series in the theater of the local college, just a short five minute drive from my door. I will travel up the road to the capital to see Broadway shows and symphony performances at a wonderful venue on the University of South Carolina campus in downtown Columbia. All of these performances are wonderful ways to get outside of one’s self and experience the wide range of talent right around the corner. They are ways to transport yourself, if for just a few hours, to other magical worlds of light, sound, music and theater. 

I love to read and wish I had much more time to do it. At any one time, I have from one to four books going and try to visit each a few times each week. Right now, I have Deliverance going on my iPhone as an audible book, am reading Confederates in the Attic (I was told by a new friend that my not having read this book was a true emergency and that I must remedy that right away!), and am dabbling in C. S. Lewis, re-reading Mere Christianity. Once again, just as in live arts performances, reading is an excellent way to get away from the stressful world that is and discover new worlds that might be.

I love to travel and get out of town whenever I get the chance. Since off time in my profession, especially in telepsychiatry, is at a premium, this often takes some planning. It is worth it. My recent trip to visit with family, do a picture-taking hike and just get out on the open road to drive a while was rejuvenating in the best way. 

Of course, I love to write. Thinking through a topic, getting the thoughts out of my head and onto a page so that others may read them and respond to them fills a very big need for me on an almost daily basis. There is something about the process of creativity that both completes us and lets us contribute to the ongoing body of knowledge that is growing every day. I love being a part of that, and it is one of the best ways I have found to begin my day in a very positive way. Since you come back here from time to time to see what I’ve written, I hope you agree that this is a good use of our time.

So, my friends, these are only a few things that I enjoy that help me de-stress, relax, regroup and recharge. When I do them and feel more centered and at ease with myself, I think I most likely do a much better job of trying to help others. At least I hope that’s the way it goes.

What do you do to recharge? What activities, pastimes, and hobbies keep you going? 

I’d love to hear from you.