COVID-19, anxiety, and CBT with Dr. Lynne Gots

Lorenzo Norris, MD, touches base with Nick Andrews to discuss COVID-19 and to welcome Jacqueline Posada, MD, as an occasional cohost of the MDedge Psychcast.

Dr. Posada, associate producer, interviews Lynne S. Gots, PhD, about treating anxiety, obsessive-compulsive disorder, and other disorders in the midst of the COVID-19 pandemic.

Dr. Gots is an assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington. She has a private psychotherapy practice and has no financial relationships to disclosure.

Take-home points

• Anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities.
• Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now. Anxiety is an adaptive response to a threat, and COVID-19 and its repercussions makes this a threatening time.
• In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
• Consider the following suggestions for working with anxious patients and clinicians:
  • Acknowledge that social media has the potential for shaming and worsening social anxiety.
  • Limit exposure to news and social media as much as possible.
  • Monitor patients for excessive reassurance-seeking behaviors, and enact ERP plans.
  • Establish a regular but flexible routine with boundaries between work, home, and rest.
  • Practice self-compassion by lowering expectations and even using formal self-compassion practices.

Summary

• Cognitive-behavioral therapy is an evidence-based therapy for obsessive-compulsive disorder (OCD) and many forms of anxiety and depression. Acceptance and commitment therapy (ACT) is considered a third-wave modality of CBT. The acceptance component is based on mindfulness and acceptance of "what is." The commitment component involves identifying core values and actions so that a person can use his/her values as a guide to behaviors. The goal is not to eliminate anxious or obsessional thoughts but to accept they are there and work alongside them.
• Clinicians should be aware that anxiety during COVID-19 will not only be an exacerbation of current anxieties but also of underlying vulnerabilities. For example, a person's OCD rituals may not be worsened, but an underlying tendency for perfectionism could be triggered as he/she tries to practice "the perfect quarantine."
• Presently, the most common vulnerability is intolerance of anxiety. It is helpful to reassure patients (and clinicians) that everyone is anxious right now.
• In the midst of this anxiety, think about creating an exposure-response prevention (ERP) plan to contain compulsive behaviors and thought responses to anxiety.
• Clinicians can look for reassurance-seeking behaviors that have cropped up with increased anxiety. For example, for a person with contamination anxiety, it might be tempting to wash for longer than 20 seconds or to wipe things down compulsively. Advise patients to pick a routine, such as washing for 20 seconds and no more.
• Individuals can choose a reputable source and follow its guidelines. The key is to avoid falling into the trap that more reassurance-seeking behaviors will alleviate anxiety. Using excessive reassurance-seeking behaviors can lead to increased anxiety through the conditional learning mechanism of negative reinforcement.

Other helpful suggestions

• Social media contains a potential for shaming based on comparing oneself and behaviors to others, so individuals should limit exposure to it.
• News intake should be limited to 1 hour a day, and only reputable sources should be used.
• Video calls also can trigger social anxiety because individuals literally have to see themselves more often than usual. Ways to minimize this anxiety include minimizing your personal image or covering the image with a Post-it note.
• For people who are at home all day, establish a routine with a regular wake and sleep time and scheduled breaks. Some type of boundary between home and work life should be created.
• Self-compassion should be practiced. The first step is to lower expectations and live according to your values and what is realistically possible given the extensive changes in the past month.
• Professionals need to seek support from other professionals going through the same thing, so connect with a colleague who can relate to your situation.
  • Remember that, as mental health professionals, we are a repository for everyone else's anxiety and suffering, so we need to be kind to ourselves.
• Consider using a self-compassion practice.
  • Recognize that you are suffering.
  • Connect with the community: Everyone is suffering.
  • Hold that suffering and offer yourself words of compassion and loving kindness.

References and resources

Dr. Gots's website: https://cognitivebehavioralstrategies.com/

Blog post by Dr. Gots that summarizes her clinical advice: https://www.nami.org/Blogs/NAMI-Blog/March-2020/How-to-Protect-Your-Mental-Health-during-the-Coronavirus-Outbreak

Suggestions for when and how to decontaminate groceries: https://www.seriouseats.com/2020/03/food-safety-and-coronavirus-a-comprehensive-guide.html

Self-compassion practice suggestion: https://self-compassion.org/exercise-2-self-compassion-break/

Supportive touch practice for times of stress and vulnerability: https://self-compassion.org/exercise-4-supportive-touch/

Self-compassion evidence-based resources: https://self-compassion.org/the-research/

International OCD Foundation: https://iocdf.org/

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Show notes by Dr. Posada, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va. Dr. Posada has no conflicts of interest.

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