By MARY-CATHERINE SEGOTA, PsyD

Individual reactions to the pandemic have differed in many ways. The initial adjustment to the shock of sudden and necessary lockdown and dealing with such issues as virus contagion, contamination fears, distance from loved ones, changes in patterns and routines, and isolation was difficult for almost everyone. Adding to this was the unanticipated extension of the pandemic spanning two-plus years, which led to additional difficulties adjusting and more distress. Now that we are beginning to return to integrated social interactions and a "new normal," we see that some individuals have not adjusted as well as anticipated nor resumed their prior level of functioning. What does this mean for healthcare providers, and how does it influence how we screen and probe for psychiatric issues?

The pandemic has led to a widespread increase in life stressors experienced by many. These stressors can be social (restriction in face-to-face interactions) or occupational (unemployment, furlough, reduced hours, working from home). They can also be educational (changed schedules, remote studying) or health-related (having had COVID personally, having a loved one battle or succumb to COVID symptoms or exacerbations in underlying medical conditions due to COVID complications). Research has indicated that cumulative stressful events greatly affect an individual's physical health, inflammation, immune system functioning, and psychological well-being (Mohd 2008).

While many individuals had difficulty adjusting to the social isolation and necessary daily activity changes at the beginning of the pandemic, others are having difficulty adjusting to returning to a socially integrated life outside the home. Further, some individuals are experiencing psychological distress that extends beyond that of 'difficulty adjusting.' When the world is dealing with many of the same issues (such as isolation during the beginning phases of the pandemic and nervousness returning to the workplace), it may be difficult for patients to understand and assess their symptoms, writing off their experiences as "everyone is feeling this." It is common for healthcare providers (and patients) to make certain assumptions about what is or is not due to experiences related to the pandemic.

As one would expect, initial anxiety related to the pandemic was associated with Obsessive Compulsive Disorder (due to initial recommendations of hand coverings and cleaning of objects), as well as Health Related Anxieties (due to fears of contracting COVID, or difficulty differentiating COVID symptoms from other illness symptoms). An increase in anxiety during the pandemic led to fears of leaving the house for some and eventually symptoms of Agoraphobia, and Panic disorder. While not a DSM V diagnosis, some researchers have coined the term Coronaphobia to describe the excessive fear of contracting the virus and the stress and avoidance of public places and situations that result from that fear (Arora et al. 2020).

As we transition to this new phase of the pandemic, it is essential to ask critical questions to help assess the presence of clinical anxiety and help differentiate disorders. For example, Is the patient's response in line with their current situation? Are family members concerned about the patient's level of anxiety and avoidance? Is the patient following current CDC guidelines, or are they avoiding more people/situations than needed? Another component is assessing the length of time the patient has been dealing with the symptoms. Self-reflection may be difficult and using anchors in questioning may help provide some insight. For example: "When did you first notice the symptoms? What was going on in your life (or the world) at that time? What was happening when you noticed the symptoms were getting worse?" Another component is helping the patient identify their underlying thoughts, beliefs, and fears that are experienced when they report these mood symptoms. Journaling with given prompts is a great way to help the patient record the necessary data to assess the level of severity and help differentiate between the diagnoses.

Consider implementing a questionnaire that assesses COVID-related stressors and socialization reintegration difficulties. Ask about the following stressors: financial problems (difficulty paying bills, debt), work problems (unemployment, decreased hours/roles, conflicts with colleagues, educational problems (difficulty completing course work), housing problems (instability, moves), relationship problems (isolation, separation or divorce, conflict with family or friends, intimacy problems), personal or loved one's health problems (new or worsening illness, medication issues, disability), and caregiving problems (emotional stress, time demands). Ask about mood and adjustment to changes, sleep, energy, appetite, and desires for activities outside the home. Ask about attempts to increase activities outside the house or avoidance of those activities.

Consider the diagnoses if you suspect that your patient may be experiencing anxiety related to socialization reintegration. Agoraphobia typically lasts six months or longer and is accompanied by symptoms characteristic of panic disorder. These physical symptoms develop with the real or imagined exposure to the trigger (i.e., the fear of being in situations or places from which escape would be difficult or embarrassing in the event of a panic attack) and thus cause the patient to avoid the trigger (i.e., crowds, cars, buses, trains, and elevators). Most people with Agoraphobia fear leaving the house alone and can better cope with a trusted companion. Avoiding the trigger and subsequent symptoms can disrupt a person's social life, work, education, and daily functioning. The physical symptoms and signs are characterized by:

• Chest pain or pressure
• Rapid heart rate
• Shakiness
• Hyperventilation
• Difficulty breathing
• Lightheadedness or dizziness
• Sudden chills or flushing
• Excessive sweating
• Feeling of choking
• Numbness or tingling
• Upset stomach or diarrhea
• Feeling a loss of control
• Fear of dying.

Listen to the patient's report regarding fear of leaving the house. Is the fear of contamination and illness? Panic or dying? Fears of criticism or rejection? In doing this, it is crucial to differentiate the symptoms of Agoraphobia with those of social anxiety.

Agoraphobia

• Fear of leaving the house
• Fear of having a panic attack in public places
• Fear of being in situations where escape might be difficult, or that help would not be available if things go wrong
• Feel better with a trusted companion

Social Anxiety Disorder

• Fear of public places
• Fear of situations where scrutiny by others may occur
• Fear of being in a position of being negatively judged
• Feel worse with trusted companion due to fear of scrutiny

Yes, you can have both! Research suggests these disorders occur together approximately 68 percent of the time (Magee et al., 1996). Many people experience social anxiety symptoms for the first time when they begin to re-emerge after months of social distancing or limited socializing. Reintegration became much more difficult for those who suffered from social phobias before the pandemic.

What to do if your patient has anxiety related to social reintegration? For many, the anxiety experienced due to the pandemic is temporary. It should gradually improve as they become more accustomed to being out in the world and coping with changing COVID restrictions. Encourage good self-care, limit news, and social media exposure, and set boundaries to maintain healthy interactions. For those with more severe symptoms, referring for Cognitive Behavioral Therapy (CBT) is critical. CBT helps people recognize their thought patterns and gain skills for tolerating and managing difficult emotions, like fear of leaving the house. Combined with relaxation and desensitization techniques, CBT gradually exposes patients to anxiety-producing situations to learn how to overcome Agoraphobia. Treatment will also include addressing underlying issues, compounded stressors experienced in the pandemic, any loss of personal or familial physical health, and improving self-awareness, healthy coping skills, and independence. Partnering with a licensed mental health professional will help your patient better manage their symptomology and improve treatment outcomes.

With a doctorate in clinical psychology and over 20 years of experience in the field, Dr. Mary-Catherine Segota has conducted university-based behavioral medicine research, acted as a consultant to professionals and organizations, and worked with a diverse number of psychological and medical conditions. By identifying unique needs, the source of distress, and what’s perpetuating the problem, she will help develop the tools to overcome seemingly insurmountable circumstances. Visit www.CounselingResourceServices.com