Upside Down Medicine

Myself, My Patients, and COVID-19

Several patients of mine, as well as friends and associates, have been asking how others I treat are reacting and responding to the current COVID-19 pandemic. This is what I see.

To gain perspective, this is being written five weeks into the stay-at-home orders of the state governments. Only workers deemed essential are allowed to leave home for places of work; all others are either working from home on-line or they are temporarily or permanently unemployed. Unemployment rates are soaring quickly, the economy is headed for a major recession if not a full blown depression, and many here in Pittsburgh are frightened by the mismanagement crisis in Washington.                                                                                                                            We are still early in the game. It appears we will be dealing with massive disruptions for months if not years to come, until and beyond the date of an effective vaccination against the coronavirus. To most of us, this is the greatest national crisis we have ever experienced.

That said, we have mostly been coping surprisingly well. Myself, I've had to switch my outpatient practice from in office "personal and personable" care to online virtual care through a HIPPA-compliant telepsychiatry platform. This was done literally overnight, but has required a great deal of effort to contact and instruct my patients on the change. I have been surprised at my own reactions to doing virtual treatment. I was surprised that I sort of like this platform to connect to patients. While I would prefer the in-person connections, I find a different and pleasant intimacy in working on screen with my patients. For one, their faces are closer to me. and mine to them. I can appreciate their facial expressions up close, and they, I figure, are doing the same with me. Up close, my patients look strikingly handsome on the monitor. I also find myself automatically leaning into the screen when i need an issue clarified or a question answered. I wonder how my patients take to this "leaning in." Also, I am seeing my patients mostly in their cloistered homes. I get to be a little bit more of an ethologist, observing my patients in their natural habitats rather than my office. I see some decorations, wall pictures, some furniture, There is a greater informality in this forum. Patients dress in sweatshirts, recline a bit, muse, walk around the house, or excuse themselves to deal briefly with their kids' noise or their on-line homework.  I get to watch some interactions I would not otherwise have been privy to. On one occasion, my psychotherapy patient and I agreed to invite his wife to join us on video for her input into their marital tensions. After all, she was right thee and going nowhere. It proved  to be a fruitful session. One patient came wrapped in her bathrobe; another woman, who had forgotten her appointment time, did her telepsychiatry while fishing alone at a rural stream. I never knew she enjoyed fishing. Several were able to show their crafts. One woman was spending her alone time sewing face masks for Magee Hospital. Many a cat walked across their keyboards and onto my screen.

What of the patients' responses to the coronavirus crisis?  Does diagnosis play a role in the response of these patients? Absolutely it does. Individuals diagnosed with Social Phobia, as well as those with Agoraphobia, are  routinely relieved to be at home. They do not have to face the anxieties of meeting new people or being away from the safety of home(respectively), nor the anticipatory anxiety which accompanies both conditions. These are arguably the most contented patients of all. Lack of exposure to their anxieties may not be the best treatment for them, but given the stress of the crisis, a welcome reprieve from anxiety and tension.  Surprisingly, a number of patients diagnosed with Obsessive Compulsive Disorder with germ phobia were uncharacteristically nonchalant about the possibility of they or their children getting infected. I've been even more so struck by patients with Panic Disorder, who characteristically manifest the symptom of  hypochondriasis, a severe exaggeration of the negative significance of medical problems, physical symptoms, and medication side effects. They, too, have been surprisingly blase about the epidemic. One patient, whose friend had a germ phobia but was currently relaxed, surmised that these otherwise anxious persons were feeling something like, "Hey! Now everybody is just as anxious as I am! I"m no different than everyone else!"

I've yet seen no significant change in symptoms in my depressed and Bipolar patients, at least no intensifications above what might have occurred were there no crisis at hand.

For sure, nearly all patients acknowledge an increase in mild chronic baseline tension attendant to the possibility of infection in themselves or close ones, and to the unknowns in their futures. A number of patients feel sad and anxious in reaction to the isolation, especially those who live alone. Patients who own their own small businesses are hit hardest. Many will not survive the financial crisis and the inability to generate income in this depressed economic environment. Likewise, a number have been furloughed or laid off permanently. They are anxious, but not nearly so much as the business owners who feel the even greater pressures of large bills due and mounting debts, and employee layoffs. Some individuals are having more tension with their spouses or significant others due to the close quarters. However, for the most part there exists an unexpected equanimity among my patients when it comes to this crisis. Could it be that my outpatients are actually mentally inoculated against the effects of this pandemic? Are they perhaps more  resilient to the behavioral effects of this epidemic than many others?                                                                                                                                                                                                                                                              I was curious as to why this might be the case, so I went on an ethological inquiry of my own. All patients understood that the whole country, nay, the whole world, was undergoing the same stressors. All were sequestered, staying six feet apart at minimum, isolated from loved ones. All have to rely on connecting via video chat, or, at best, conversing with the neighbors or family members on the porch or on the street. No one is different or odd. Secondly, many patients are finding silver linings in the current stay-at-home sequestration, often multiple such linings. They no longer have to get dressed for work. They no longer have to spend anxious time commuting or paying for parking. They can spend precious time with their "home-schooled" children. Many are devoting themselves to home projects they have put off for years. Others are getting into past or new hobbies. One young female patient built three desks for her children, then a stone wall outside her home. I myself have been using my free time cleaning out a cluttered basement, something I had put off for a retirement I suspected will never come.

Perhaps another dynamic comes into play to explain, at least partially, my patients' equanimity in this crisis(aside, of course, from their symptomatic improvements due to treatment). I have no definition for this phenomenon nor any facile psychological explanation for this. though I believe one exists. Many years ago, when state psychiatric hospitals were being emptied of their patients due to the advent of Thorazine and related anti-psychotic medications, there was a period of time when chronically psychotic patients were being housed in nursing homes. Medicare picked up the tab for these quasi-hospitalizations of severely debilitated, "back ward" patients. Even medicated, many continued to hear voices, see visions, and be paranoid or otherwise delusional. They were often detached from one another, in their own worlds. On several occasions, however, a fire broke out in a number of these facilities. These otherwise psychotic patients reportedly lined up quietly and cooperatively, followed all directions, and walked in single file outside the facility. No fuss, no muss; as if, faced with  real external threat, the mind focuses acutely on the immediate danger at hand and puts other, "lesser" symptoms, aside. Could such a phenomenon also be at play in the current disaster?

Mostly though, I sense an equanimity in my patients borne of a return to a  kind of simpler life long past. They are forced to be at home, to exert themselves less, to spend more time with immediate family; sometimes to scrounge for supplies. They are called upon perforce to find new, more resilient ways to cope, to be innovative, to self-entertain. They feel it more necessary to connect whenever and however possible, and to appreciate and address the pain others are also suffering. They grieve the loss of the Federal buffer we once took for granted, and instead fall back on supporting and buffering one another.

It may sound perverse and counter-intuitive that my outpatient cohort is taking this massive crisis in relative stride, when much of the news screams such pain and suffering. But, taking a step back, a clearer picture comes into focus.: Consider that half of the population is thought to bear a diagnosable psychiatric condition. However, only ten percent of the population benefits from any behavioral treatment, and only three percent ever seek specific psychiatric care. The bottom line is- my outpatients are being treated for their symptoms. As such, they are arguably, and likely, more resilient and calmer in the face of the current overwhelming stressors than are much of the untreated and still symptomatic population. The psyche, no longer burdened and overwhelmed by symptoms, is far better equipped to cognitively, emotionally, and behaviorally adapt to this disaster  flexibly and adaptively when liberated  from itsprior symptomatic shackles.

So much for stigma.