Source: Johannes Plenio/Unsplash
Trigger warning: This article describes stressful life events experienced during the COVID-19 pandemic.
For most people, the pandemic changed many aspects of everyday life. From the way we shop and entertain ourselves to the way we work and have meetings; how often we are in the physical workspace or meet up with friends; or even how we celebrate holidays or birthdays, nearly everyone has experienced some sort of adjustment. As the saying goes, “We are not all in the same boat, but we are all going through the same storm.”
The storm metaphor captures the fact that not everyone experienced COVID-19 in the same way: Some have endured greater stressful life events than others, such as losses of loved ones or employment. Whether the pandemic only temporarily inconvenienced your life or you’re continuing to endure adverse experiences, COVID-19 has led to some level of stress for individuals across the globe.
How can we assess whether the weight of our stress regarding those varying experiences is bearable? Are individuals continuing with the same level of mental health as they were pre-pandemic? The World Health Organization reported a 25% increase in anxiety and depression world-wide due to the pandemic. If you are a practitioner, how can you help your clients learn more about their thoughts and behaviors during and after COVID-19?
What Types of Assessment Can We Use?
The COVID Stress Scales (CSS) have been developed to guide in the identification of those that may suffer from COVID Stress Syndrome (Taylor et al., 2020). COVID Stress Syndrome (Taylor et al., 2020), includes 5 domains of assessment:
- High emotionality regarding the health dangers of the virus and contamination (i.e., becoming infected or being able to seek treatment if infected; contamination of objects, money, or surfaces).
- Worries about socio-economic consequences (i.e., stores running out of food).
- Xenophobia (i.e., fear of foreigners who may be spreading the virus).
- Traumatic stress symptoms (i.e., nightmares and physical symptoms).
- Compulsive checking (i.e., repetitive online activity, reassurance seeking from medical professionals, etc.).
Taylor et al. (2020) used large population samples within the United States (N=3,375) and Canada (N=3,479) between March 21 and April 1, 2020, to examine the presence of COVID stress syndrome in the population. Their results indicated that COVID Stress Syndrome is a clearly identifiable diagnosis. It is distinct from general obsessive-compulsive disorder (OCD) because OCD symptoms may not necessarily pandemic related and includes more focus on compulsive behaviors that provide relief from unwanted thoughts. It is also distinct from illness anxiety disorder, which would include other illnesses aside from COVID-19 and would not necessarily include impacted behaviors related to the other domains [e.g., anxiety regarding the socioeconomic effects of the pandemic or xenophobia (Asmundson & Taylor, 2020b; described more below)].
Covid Stress Syndrome consists of a fear of infection that may include avoidance of touching objects and surfaces for fear that they are contaminated with SARS-Cov-2 (the novel coronavirus), xenophobia (fear of foreigners believed to be infected), behaviors related to checking and reassurance seeking, and stress symptoms including intrusive thoughts (unwanted thoughts that appear in the mind) or nightmares (Taylor et al., 2020). Those displaying it may engage in behaviors such as “panic buying,” stocking up on goods for their homes, or seeking unnecessary medical attention for misinterpreted symptoms (which may overwhelm hospitals and medical centers). To a degree, some of these behaviors may have been appropriate and necessary during the beginning or high-rate periods of the pandemic; however, these would naturally dissipate across the duration of the pandemic, as conditions changed, or as rates decreased.
According to Taylor and Asmundson’s (2020) research, it remains unclear whether COVID Stress Syndrome will become a chronic condition, or one that resolves once the pandemic is over. (Should this mean that its prevalence decreases to a manageable and stable state, or it ends entirely, has yet to be seen.) To address this, Asmundson et al. (2022) compared the use and results of the CSS at the beginning of the pandemic (March 21-April 1, 2020) to that which occurred after the third wave of infections in Canada and the United States (March 24-May 4, 2021). They found that overall COVID stress was lessened in the latter assessments (likely due to wide administration of vaccines and less severe symptoms associated with later COVID variants).
Who Is Most at Risk for COVID Stress Syndrome?
It does appear that those developing COVID Stress Syndrome often have pre-existing psychological conditions, such as health anxieties or obsessive-compulsive behaviors (Taylor et al., 2020). Asmundson et al. (2022) found that those with panic disorder, anxiety disorders, and mood disorders were at higher risk of experiencing high COVID related stress symptoms than those without these mental health conditions. Importantly, they found that this was most consistent during the beginning of the pandemic, meaning that the higher intensity COVID stress experiences of those with mental health conditions may have stabilized over time and experience across the pandemic. Therefore, as vulnerable populations experienced more intense stress in the beginning, there is evidence to suggest that this effect will dissipate over time.
Taylor et al. (2020) write that fears and anxieties are important drivers of behavior. On the one hand, those with low levels of health anxiety may not respond to pandemics by wearing masks, social distancing, or getting vaccinated. On the other hand, those with too great of health anxiety may respond with overzealous behaviors such as obsessive cleaning, extreme isolation for prolonged periods of time, or reassurance seeking behaviors such as repetitive checking of rates of the virus in their area or other online research. Mid-levels of anxiety, directed towards actionable steps to prevent the spread of disease, may be ideal. However, more research is needed to inspect the relationship between health anxiety and pandemic related responses, in connection with COVID-19 (Asmundson & Taylor, 2020a).
Source: Anna Shvets/Pexels
What About Xenophobia?
Furthermore, research and public policies should examine and address the role of xenophobia within COVID stress responses. It has been found that animals and humans engage in many responses that contribute to their “behavioral immune system” and reduce infection rates in their communities (Schaller et al., 2015), one response of which is to avoid those individuals in society that are perceived to be infected. However, overgeneralization of this response leads to avoidance of entire groups associated with diseases. This can cause xenophobic and discriminatory responses by individuals or entire societies, such as the discrimination against Chinese individuals within the COVID-19 pandemic (Asmundson & Taylor, 2020b). An important contribution of this research is the demonstration that xenophobia is correlated with these pandemic-related specific conditions and understanding this may help to prepare public interventions for future pandemics. Those working in public spheres may consider explicitly addressing the potential development of xenophobia and creating interventions to prevent and quickly address discriminatory practices.
Risk Factors Aside from Mental Health Conditions
Although Taylor and Asmundson (2020) researched and wrote about COVID-19 from very early on in the pandemic, their research on previous epidemics led to their predictions that people would increasingly remain inside, withdrawn from social life (Galatzer-Levy et al., 2018; Hong et al., 2009; Gardner & Moallef, 2015). Among other considerations, and aside from mental health conditions, higher risks of social avoidance and the development of stress syndromes are paired with the following risk factors: having relatives who became seriously ill or died from the epidemic viruses, having low social support, perceiving a high risk of infection, or living within abusive or toxic relationships in the home. Mental health practitioners should be aware of these risk factors.
Source: Laura James/Pexels
Experiences of Health Professionals
Tan et al. (2020) wrote about the likelihood of medical and non-medical health professionals (including those in maintenance, clerical, or administrative positions) to develop stress syndromes related to COVID-19, saying that those societies with better preparedness following previous outbreaks of disease (such as Singapore’s experience with SARS), were less likely to develop severe mental health conditions. This is promising for those in these health-related professions, that they may not experience the same level of stress in following waves of the pandemic or future outbreaks.
Using In-home Services
Taylor and Asmundson (2020) predicted that trends including increases in home delivery services, video streaming, and video conferencing, would continue to rise. These trends, which may be associated with “behavioral immune system” responses as described above, may exacerbate conditions such as agoraphobia (extreme fear of public spaces, often including living as a recluse) and Hikikikomori (a similar syndrome that previously seemed isolated to Japan, including 6 months or more of social isolation). Because these services provide convenience (e.g., speedy delivery, instant access, removal of travel demands), many may use them in a perfectly health manner. However, it is understandable that these conveniences would serve as a hinderance to someone suffering with extreme isolation, as they remove the demands of exposure to public spaces and interactions with others.
Finally, Taylor and Asmundson (2020) shared concerns about whether teletherapy, or mental health services delivered online, will adequately support or alleviate the symptoms of COVID-related stress symptoms. Although these offer flexibility and accessibility for consumers, the authors suggest that a stepwise progression towards in-person care, or a blended approach, may be better suited for these conditions. Having pandemic-specific tools, such as the CSS, to assess the impact that a pandemic has on individuals can help to prepare clinicians to develop interventions. Further research is needed to address the lasting effects of COVID-19, or the potential generalizable uses of the CSS, so that clinicians can be adequately prepared to serve the needs of clients both now and in future pandemics.
Considerations Moving Forward
During and after COVID-19 (should it even come to a clear “end” or become a virus as common as the flu), it is beneficial for mental health practitioners and public health officials to understand the unique challenges that the pandemic presented to individuals and that it triggered specific types of worries and distress, so that individuals within society can receive support and interventions. Early identification and intervention may help to decrease the severity and duration of each individual’s experience and may help to mitigate the impact that those experiencing these symptoms have on the overall healthcare system.
Although the pandemic persists and a clear end is not predictable, lessons from previous epidemics (or even earlier waves of COVID-19), as well as pandemic specific assessment tools, do serve to support individuals, mental health professionals, health care practitioners, and public servants. Individuals can help themselves and others by understanding the unique impact that COVID-19 has had on those in societies across the globe. Knowing what symptoms to look for and how to assess them, given the circumstances of the pandemic, will help these individuals to be better served by mental health professionals. Health care practitioners may increase their mental health support and referral practices for those living with COVID-19 (and their family members) if they are aware of the unique challenges that they face both throughout times of infection and after; and may better support those with mental health conditions as they arrive in healthcare clinics and hospitals. Public servants may be more likely to provide advice and regulations that support the mental health of their constituents when they have a richer understanding of the specific mental health risks related to the pandemic. Taken together, proper mental health screening, support, and any necessary interventions (with specific pandemic-related considerations) may better serve individuals and the public at large for both their physical and mental well-being, throughout the pandemic and beyond.
Those in need of resources may find the National Alliance on Mental Illness (NAMI) COVID-19 Resource and Information Guide helpful, as it includes many websites with further information on COVID-19 related mental health struggles, resources for help, and a list of organizations that can be contacted at any time for those experiencing immediate mental health crises.
Marcia Questel, a research assistant at Yale University, contributed to the writing of this blog post.