All's not well with the "worried well": understanding health anxiety due to COVID-19.

The novel corona virus (SARS- CoV2) pandemic has created an unprecedented public health problem and a mental health crisis looms ahead. The isolation, socio-economic disruption, uncertainty and fear of contagion have led to a spike of health anxiety in the general public. Individuals with health anxiety may get dismissed as the "worried well" in this pandemic due to disruption of mental health services and inability of healthcare systems to understand the psychosocial factors in the background. Education of general public, training of healthcare workers in cognitive behavioural model of health anxiety and timely referral to mental health professionals in severe cases is need of the hour. ©2020 Pacini Editore SRL, Pisa, Italy.

Introduction

The novel corona virus (SARS-CoV2) which was first reported in Wuhan, China has engulfed the world in fear [1] World Health Organization declared the COVID-19 as a pandemic on March 11, 2020 [2]. Many countries had nation-wide lockdown including India, halting most economic activity leading to unemployment, displacement of migrant workers and loss of livelihood. The pandemic has created an unprecedented public health problem and has overwhelmed healthcare systems globally [3]. Medical and research communities are still discovering the enigmatic COVID-19 which manifests not only as Acute Respiratory Illness but also with a wide variety of dermatological, neurological, cardiac, gastrointestinal, and ocular symptoms; and guidelines for prevention and treatment are evolving each day [4-9]. The isolation, socio-economic disruption, uncertainty and fear of contagion have led to a mental health crisis which is being acknowledged worldwide [10]. Individuals who are worried about infection with the virus may not get adequate care due to disruption of mental health services during the pandemic.

The “worried well” are unwell too

A term ‘worried well’ is often used for persons who are relatively healthy but consider themselves as affected or likely to be affected. In present pandemic these are the persons who test negative or may not fit into the definition of a ‘suspect’. In addition to these individuals, patients with illness anxiety disorder, panic disorder, generalised anxiety disorder, depression, somatic symptom disorder, and obsessive compulsive disorder may not get access to mental health services. Our medical training and biomedical model of disease approach is compounded by the burden of keeping abreast with newer technical guidelines. This leads to suboptimal attention to the psycho-social factors and patients being told, “it’s all in your head”. As a result vicious cycle consisting of poor patient satisfaction and doctor shopping is set-off and this itself be detrimental in the present pandemic situation.

People in quarantine who are not equipped with self-care and coping strategies feel lonely, socially isolated and may find it difficult to handle the parallel ‘infodemic’ [11]. This leads to poor sleep and nutrition, lack of exercise, substance abuse, excessive usage of internet, and social media [12-14]. Moreover, the images of body bags piling up in hospitals or news of death in their own district/state are threatening stimuli which give rise to unpleasant emotions of fear and anxiety. The precariousness of the current scenario, isolation, unhealthy lifestyle and overload of ambiguous information leads to chronic stress. This may act as a trigger for health anxiety in susceptible individuals or may worsen pre-existing mental health conditions. In severe conditions extreme health anxiety can even drive a patient towards committing suicide.

Understanding health anxiety: cognitive behavioural model

Threat cues can activate the dysfunctional schemas which are irrational assumptions and beliefs from an earlier experience. Once these schemas are activated every event and stimuli in the environment get coloured by these. Some have schemas of being painfully aware, especially grief, even after death; and that they can tempt fate by thinking too positively. Individuals may see ‘worrying’ in a positive light and believe it will prevent negative events from happening or ward off danger and end up evoking more negative scenarios in their mind. These schemas once activated can in turn lead to misinterpretations of bodily symptoms, negative thoughts, and anxiety [15]. Individuals may pay undue attention to ever growing list of symptoms of COVID-19, become hyper-vigilant to internal and external body processes and any benign bodily sensation may be perceived as a symptom. Moreover, symptoms arising from stress, insomnia, withdrawal from alcohol, etc. may get ignored. The uncertainty surrounding the pathophysiology, incubation period, mode of infection, testing, and treatment of this novel illness is intolerable for such individuals [9, 16, 17]. Repeated worrying about how to not get infected and being more preoccupied with worries can reduce actual vigilance from the threat. Patients may even start doubting the competency of the doctor and endanger the fragile therapeutic relationship brought on by repeated reassurance seeking behaviour. Anxiety in turn leads to specific behaviours which are unhelpful and maintain the vicious cycle of health anxiety [15]. They may even repeatedly search internet for information, examine bodily fluids such as sputum and faeces; measure temperature, pulse rate and blood pressure; or go for repeated medical consultations. Some may develop avoidance behaviour and isolate themselves from family members, avoid revealing their symptoms to others, or even skip medical appointments fearing they might test positive for COVID-19 or be put in quarantine. This can lead to safety behaviours of self-medication which can even harm if not in appropriate dose [18].

Pre-existing mental illness, poor experience with healthcare systems in past, childhood sexual abuse, familial conflicts, marital discord, and other environmental factors can make an individual susceptible to develop these cognitive distortions. Certain personality factors such as perfectionism (“My body should not have any symptoms”), rigidity in thinking, neuroticism (predominant negative emotions), high harm avoidance (leading to unhelpful safety behaviours), and anxiety sensitivity (tendency to interpret anxiety symptoms as signals of catastrophic physical illness) may increase vulnerability of individuals [15].

Recommendations to address health anxiety and the ‘worried well’

A fine balance is required between communicating public health response and stigma mitigation; and our experience in HIV has a lot to teach. Education and awareness campaigns targeting general public using all possible channels of communication can break the chain of misinformation. Stigma reduction strategies to reduce the clout of dread around individuals infected with the virus are need of the hour [19]. All healthcare workers especially in triage areas and fever clinics should be trained about health anxiety. Empathetic listening and attention to psycho-social factors may allay fears. People who are in quarantine should be given access to tele-counseling services and timely referral to psychiatrists in case of severe health anxiety or suicidal ideation. Self-care strategies in general public, relaxation techniques such as breathing and muscle relaxation exercises should be offered to all people in quarantine. Mindfulness meditation can help individuals to be more self-aware and accept their bodily sensations in a non-judgmental fashion. Cognitive behavioural therapy (CBT) is useful psychotherapeutic option in which individuals are encouraged to journal their behaviours of checking for bodily sensations, searching health related information on internet and reassurance seeking behaviours. They are also trained to challenge their thoughts related to their health and made to generate alternative thoughts. With increased penetration of the internet, even in rural areas, internet based CBT for Health Anxiety can be rolled out on an accelerated basis with significant cost benefits [20].