Learning Objectives:After participating in this continuing education activity, the provider should be better able to:
1. Describe the negative impact of anxiety and stress on health.
2. List probable psychological outcomes for patients during a pandemic.
3. Suggest tools for patients and staff to counteract the impact of stress and anxiety.
We have all encountered anxious patients throughout the course of our professional careers. The young woman with an irregular period, the first-time expectant mother, and the middle-aged woman with perimenopausal symptoms are just a few that come to mind. All of these patients are worried about what will happen and how they can "get through" the situation. All of them are feeling the stress of the situation.
Virtually all providers have experienced professional anxiety and stress as well. The first day in residency, the first day in the operating room, and the first time you see a case in your office of something you have only read about are but a few. The great majority of us have never experienced anything remotely like the changes brought about by the global coronavirus disease 2019 (COVID-19) pandemic. How can we better understand our patients' and our own reactions to this unparalleled situation? What can we do to help them and ourselves?
Anxiety and Stress: Background
Anxiety and stress are common human conditions. The situations described previously are a few illustrations of what can bring them about. Anxiety can also have a positive, anticipation component that helps us focus attention. Anxiously looking both ways before crossing the street is an obvious example. Anxiety helps direct our attention to oncoming traffic and wait until it goes past before we move. Actors and athletes speak of the anxious feeling in the pit of their stomach before going on stage or going into a game. In this way anxiety is an asset.
One component of anxiety is uncertainty.1 We like to know what is going to happen to us. Predictability is calming. Unpredictability creates the opposite reaction. And so, we spend a significant amount of emotional energy attempting to reduce and manage the uncertainty inherent in life under normal circumstances.
Stress is a common experience for most people. It comes in a variety of forms and can be related to the pressures of school, work, family, and other daily responsibilities. Stress is also associated with sudden negative changes, such as losing a job, divorce, or illness. In a dangerous situation, stress signals the body to prepare to face a threat or flee to safety, "fight or flight." In these situations, the pulse quickens, breathing becomes faster, muscles tense, and the brain uses more oxygen and increases activity-all aimed at survival in response to stress. In non-life-threatening situations, much like anxiety, which helps anticipate action, stress can motivate people, such as when they need to take a test or interview for a new job. Some stressors are clearly associated with positive events such as a graduation, wedding, or the birth of a new child.
Clinically diagnosable anxiety disorders are common. Some estimates suggest that 40 million Americans, or about 18% of the population, experience them.2 Prolonged anxiety can cause increased stress hormone levels, including adrenaline and cortisol. The net result can be a variety of deleterious physical and emotional effects including:
* Unwanted weight gain;
* Cognitive decline;
* Immune system deficiencies;
* High blood pressure and heart disease;
* Increased risk for other mental illnesses; and
* Higher cholesterol levels.
Anxiety has been treated most successfully with cognitive behavioral therapy (CBT) and psychotropic medications. Medication interventions have potential undesirable consequences with women who are in the process of becoming pregnant or are already pregnant.3 The advantage of medications is that they can be administered quickly, do not require referral to another provider, and can be low in cost. However, their detrimental effects must also be considered carefully. CBT is an evidenced-based treatment that helps a patient alter maladaptive thinking patterns to reduce the emotional consequences of those thoughts. Patients suffering from anxiety tend to exaggerate the way they view a potential threat. Changing thinking about those unhelpful thoughts is known to produce significant effects when compared with placebo interventions.4 One drawback is the time it takes for a patient to learn the necessary skills and reliably implement them.
Likewise, stress is a common condition, especially for women. One report indicates that 60% of working women said stress ranked first on their list of daily difficulties.5 Long-term stress is more constant than acute stress. As a result, the body never receives a clear signal to return to normal functioning. Chronic stress can disturb the immune, digestive, cardiovascular, sleep, and reproductive systems, leading to:
* Headaches;
* Upset stomach;
* High blood pressure;
* Chest pain;
* Problems with sex and sleep;
* Depression;
* Panic attacks; and
* Other forms of anxiety and worry.
Interventions for stress, short of removing the source of the stress, tend to fall into the realm of what has become known as mind-body medicine. They seek to help patients manage the stress, rather than eradicate it. This approach recognizes that all people face stressors in day-to-day life and that nothing will make them disappear. Instead, it is useful to teach how to manage the impact of those stressors with a variety of tools that induce relaxation, such as yoga or focused breathing, coping skills such as self-nurturance or journaling, assertiveness training and communication skills, and biofeedback and hypnosis. Mind-body techniques have proven helpful, in conjunction with traditional medical approaches, with many women's health care issues including premenstrual syndrome (PMS), the discomfort of menopause, chronic pain from endometriosis, and pelvic conditions and the emotional pain of infertility.2,6 As with CBT, which is also in the realm of mind-body techniques, patients must learn the tools. These approaches therefore cannot be considered a quick fix but, once mastered, can become lifelong tools.
Psychological Impact of COVID-19
The COVID-19 pandemic, with news around the clock of shelter-in-place orders, positive test results, numbers of hospitalizations and deaths, and unemployment figures, creates a perfect storm for both anxiety and stress. Shelter-in-place orders can have quarantine-like effects for some individuals. Similar to quarantine, but not as severe and less enforceable, shelter-in-place orders are stressful on many levels. Limited social interaction, loss of employment and income, and reduced sources of food and recreation all carry a toll. The current impact on patients and providers has not been thoroughly demonstrated, primarily because the focus of the US medical community on COVID-19 is relatively recent. Some comparisons can be made with previous epidemic/pandemic events. Research on quarantine's impact on mental health suggests that individuals can experience a variety of symptoms, including but not limited to7,8:
* Acute stress disorder;
* Fear;
* Anger;
* Grief;
* Numbness;
* Anxiety-induced insomnia; and
* Frustration and boredom.
Another worrisome outcome of stress can be domestic violence. Evidence from Hurricane Harvey in 2017 indicates that stress associated with the disaster led to higher rates of domestic violence and child abuse. Researchers posit that when individuals have limited access to resources after job or financial loss and disconnection from social supports, they are at higher risk for violence.9 Before the pandemic, a survivor or victim could leave a violent situation and stay with a family member, go to a shelter, or file a protective order with the police. For many, these options cease to be readily available when movement in the community is restricted to protect individuals from viral transmission. Shelters close or emergency rooms pose health risks leaving many without reliable safety plan options. Survivors can be trapped in an escalating cycle of tension, power, and control.
Providers also are impacted by quarantine-like conditions, which have been shown to provoke acute stress disorder and general psychological symptoms, depression, low mood, irritability, and insomnia. With many providers transitioning to telehealth platforms for routine consultations, anecdotal reports indicate that an additional stressor is the strain of staying focused on a screen for long periods. Computer vision syndrome, a condition identified as the result of spending "too much" time in front of a screen, will likely creep into the professional literature at some point, as more medicine is delivered in this fashion.10 This says nothing of the financial impact on those for whom income from procedures has been severely limited to prevent transmission of the virus.
Major health organizations have published guidance for providers about how to limit transmission of the virus. In the realm of obstetrics and gynecology, the following is a typical rationale:
The goals of the guidelines put forth here are 2-fold: first, to reduce patient risk through health care exposure, understanding that asymptomatic health systems/health care providers may become the most common vector for transmission, and second, to reduce the public health burden of COVID-19 transmission throughout the general population.11
Guidelines include social distancing of at least 6 ft if feasible, postponement of elective or nonurgent visits, and bans on support persons accompanying patients to outpatient visits unless they are an integral part of patient care. Furthermore, symptomatic patients who are triaged by telehealth should be presumed infected and self-isolate for 14 days. Increased sanitization, separate areas for isolation of symptomatic patients, and frequent cleansing of waiting areas are also recommended.11
Because these guidelines are readily available via internet search, many patients will be aware of them. Lay readers may not fully appreciate the technical issues involved in some of the guidelines. Others will find them restrictive and feel that their reproductive rights are being infringed upon.12
Providers and patients are questioning the urgency of infertility care. The World Health Organization recognizes infertility as a disease. Do guidelines suggest that its treatment is elective and nonemergent? Ask any fertility patient and the answer will be a resounding "No!" At the same time, does the exposure of staff and patients to potentially asymptomatic carriers of the virus pose too great a risk? Who is designated to make that decision? It can seem that questions increase rapidly and exponentially whereas validated answers are much slower to arrive.
The net result of these debates can be increased stress and anxiety for patients. Providers who must deal with that stress and anxiety can be challenged to offer calming advice when they are similarly anxious and stressed, albeit for somewhat different reasons.
Some providers have found the guidelines restrictive as well. Practices are businesses that require patients and the fees they bring. Without fees, staff cannot be paid, supplies cannot be obtained, and loans cannot be repaid. The stress is obvious and the anxiety about when these guidelines for best practice will be altered is, too. At the same time, we are bound to "do no harm," often by placing ourselves in harm's way, a significant stressor in itself.
In recognition of the stress and anxiety created by disruptions to treatment, the same organizations that release guidelines have now offered advice for helping patients manage stress and anxiety during the pandemic. The American Society for Reproductive Medicine (ASRM) in collaboration with RESOLVE, the National Infertility Association, created a webinar to answer frequently asked questions (FAQs) and provide tips on self-care during the interruption to treatment that patients may have experienced. The ASRM also created a webpage with multiple resources for patients. The American College of Obstetricians and Gynecologists provided a patient resource page on its website with COVID-19-related FAQs as well.
Because psychosocial services are increasingly being provided in primary care settings, it is important for practices to plan for their continuation under these extreme circumstances.
In the context of Covid-19, psychosocial assessment and monitoring should include queries about Covid-19-related stressors (such as exposures to infected sources, infected family members, loss of loved ones, and physical distancing), secondary adversities (economic loss, for example), psychosocial effects (such as depression, anxiety, psychosomatic preoccupations, insomnia, increased substance use, and domestic violence), and indicators of vulnerability (such as preexisting physical or psychological conditions). Some patients will need referral for formal mental health evaluation and care, while others may benefit from supportive interventions designed to promote wellness and enhance coping (such as psychoeducation or cognitive behavioral techniques).8
Individual practitioners can provide resources for patients and staff on how to manage the psychological impact of the COVID-19 pandemic. Because anxious patients are not unusual, the following can be useful going forward when we return to a more relaxed approach to providing medical care or in the likely event that future health crises create similar disruptions to the delivery of routine medical services.
Strategies to Reduce Stress and Anxiety for Patients
The following can be copied as a patient handout or email:
An Introduction
Uncertainty about the future can be scary. Feelings of being out of control can take place when our normal routines are disrupted and new, unfamiliar ones are thrust upon us. Working from home, restrictions in where you can visit, constant reminders to "socially distance yourself," and the postponement of ordinary health care can increase uncertainty.
Under these circumstances it is quite normal to feel anxious and stressed. There have been other times in our lives when uncertainty has dominated our thoughts. Financial challenges, natural disasters such as hurricanes, forest fires, or tornadoes have been in the news before. But a pandemic is relatively uncharted water for most of us.
During times like this, it is normal to think of the worst possible outcome regarding health. After all, the pandemic is a health crisis. Creating a set of coping strategies can help establish more helpful thinking and reduce your stress and create a sense of stability when uncertainty is abundant.
1. Establish Limits on News Consumption
The COVID-19 crisis can keep us attached to the news in unhelpful ways, leading to more stress and worry. Stay informed at the same time as keeping a balance in how you do so.
Choose your sources of news and information carefully. Limit yourself to outlets that you trust for providing accurate and thoughtful information. Lack of information or inaccurate information can lead to worry, fear, and anxiety.
Find several times during the day when you gather information. Staying constantly attached to television, social media, internet, or mobile devices is counterproductive. Constant pandemic news will only increase your stress. It is preferable to stop your use of "screens" at least a half hour before you go to bed.
Remember that not all pandemic news is bad. Read stories about restaurants providing meals for the homeless and those who have lost jobs or similarly positive items. Avoid the news outlets that shout how afraid you should be.
Take breaks from the news to focus on aspects of your life that are going well and over which you have control.
2. Create a Routine/Have a Plan
Shelter-in-place and work from home disrupt normal routines. If you are in this situation it is possible to feel lost without your normal schedule. The structure of work is predictable and calming, to some extent. And the rest of your life probably has other routines that have been disrupted. Getting the kids off to school, your attendance at worship services, etc, have all been changed. Therefore, creating structure is crucial. Establish "normal" routines like waking at the same time each day. Shower, dress, and keep a set work schedule. Eat at the times you normally would. It is also important to stop work at your normal time. Under usual circumstances the routine of leaving for and returning from work helps create boundaries between different parts of the day. When these boundaries are eroded, it is important to impose some of your own.
Maintaining social connection is also critical. Most of us have social interaction with coworkers that is now relegated to Zoom meetings in which work, and not socializing is predominant. No one walks down the hall to a meeting chatting with others. There is no water cooler or coffee room for informal socializing. And social distancing can disrupt impromptu visits with family and friends. Phone calls, FaceTime, and Zoom are all reasonable tools for maintaining relationships in the absence of direct social contact.
Houses of worship, book clubs, and civic organizations all offer opportunities to connect via technology.
If you are in a situation where you must continue to work on-site, try to set aside time to recharge. Even if you only take 15 minutes to read, watch a television program or listen to music, this can help.
3. Keep Connections Alive
Uncertainty is a breeding ground for feeling stressed, depressed, irritable, or angry. These reactions are normal when faced with the restrictions to normal life imposed by the COVID-19 pandemic and measures taken to reduce viral transmission. Maintaining connection with friends and family will help fight feelings of loneliness or isolation. Friends who you trust are a resource for anxiety and stress reduction. All of them are facing similar restrictions in their lives as well. In addition to sharing your frustrations you can provide good ideas to each other for distraction. Telephone, FaceTime, and Skype can help create a sense of community that is comforting. Try to limit the amount of time you talk about COVID. Talking about it too much will not help you feel any better!
It is also a good idea to set some time to be alone with yourself, particularly if you are sharing space with one or many other people. Headphones for music, a closed door to set a boundary, or just a quiet corner to read in can create a separate space for a little peace.
4. Use Relaxation Techniques
Two skills which will help reduce anxiety quickly are focused breathing and relaxation techniques. Anyone with a smartphone can download relaxation-based apps that provide guided relaxation exercises, anxiety reduction, and meditations. The following brief list can be used as a starting point: CALM, HEADSPACE, OMVANA, SAM (Stress and Anxiety Management), and Breathe2Relax. Pandora, Spotify and iTunes all have meditation and guided imagery channels.
Focused breathing is a valuable skill for anyone experiencing stress or anxiety. Directions can be found on many websites. One example is provided here:
Find a comfortable, quiet place to sit or lie down. Start by noting the difference between breathing normally and breathing deeply. First take a normal breath. Now try a deep, slow breath. The air coming in through your nose should move downward into your lower belly. Let your abdomen expand fully. Now breathe out through your mouth (or your nose if that feels more natural). Alternate normal and deep breaths several times. Pay attention to how you feel when you inhale and exhale normally and when you breathe deeply. Shallow breathing often feels tense and constricted, while deep breathing produces relaxation.13
Longer relaxation sessions done daily will help reduce stress levels. Daily practice will help you manage your overall stress level. Regular practice helps improve any skill and relaxation and focused breathing are no different. Because they cost little or nothing and require no equipment, these skills are a bargain.
It is important to remember that humans are incredibly adaptable. Overwhelming feelings during a crisis are temporary. As we adapt to the changes to normal routines brought on by COVID-19, it is important to remember that this will not be a permanent state. Finding time to introduce calm will help you adapt.
5. Maintain Good Physical Health
Limit alcohol, caffeine, and other substance intake. These are seemingly quick stress reducers. However, their use/overuse can be detrimental.
Limit comfort food intake. Try to keep your food intake to 80% healthy (fruits and vegetables, lean meats, fish, nuts, and whole grains). The remaining 20% can be more comfort-oriented. An occasional bowl of ice cream is fine, but daily consumption will not help in the long run.
Work out 3 to 5 times per week when you can with walking, biking, yoga, and resistance equipment or weights. The goal is to keep your muscles and heart healthy, not typically to prepare for running a marathon.
6. Maintain Good Sleep Habits
Good sleep habits will help reduce stress. Sleep deprivation increases irritability and sad feelings.
Limit caffeine consumption especially late in the afternoon and evening. Alcohol may help you fall asleep but can disturb your sleep patterns leaving you feeling less rested in the morning.
Regular exercise is good but not right before bed.
Establish a regular nighttime routine. Going to bed and waking up at the same time each day is helpful. Have some wind down activity for just before turning off the lights. Read, meditate, listen to calm music, or simply stretch. Avoid "screens" for 30 minutes before bed. And remember that beds are for 2 things, sleep and sex. You want to train your body and mind to recognize bed as a place for relaxation and sleep.
Limit daytime naps to 30 minutes or less. Long afternoon snoozes will throw off your wake/sleep cycle and put you at risk for a sleepless night.
Make sure you are exposed to natural sunlight by going outside or sitting near windows with the shades up.
Minimize food that can cause indigestion in the hours before bed. Spicy food, carbonated beverages, and heavy, fatty meals make it more difficult to fall asleep.
7. Disrupt Negative Thought Patterns
You want to avoid the downward spiral that these thoughts can cause. We do not know when the pandemic will be over, but things will improve. Researchers are working daily to find both cures and vaccines for the virus. Substitute dark thoughts for more helpful ones. Apps like MoodKit, CBT Thought Record Diary, and WhatsApp all help redirect negative thinking to more rational thoughts.
8. Talk to a Mental Health Provider
Professional counseling can be helpful when self-management with the above-mentioned tools does not provide sufficient relief.
An Important Note About Domestic Violence
As mentioned earlier, rates of domestic violence tend to increase during disasters. Recent newspaper reports indicate that hotlines are seeing increased activity.14 Providers who are aware of patients with histories of domestic violence should screen for it on telehealth calls and have resources available to share. The National Domestic Violence Hotline has information for providers and patients (https://www.thehotline.org/2020/03/13/staying-safe-during-covid-19).15 Additional guidelines for practices using technology to communicate with patients are available online. Providers are reminded that personal safety can be compromised when certain digital tools leave a trail and can put a survivor at increased risk for harm. Furthermore, shelter-in-place removes privacy for many and can compromise safety. Finally, as most practices are aware, confidentiality is not guaranteed by some digital platforms.16
Strategies to Reduce Stress and Anxiety for Staff
Become aware of signs of burnout and compassion fatigue. Providers are at elevated risk for feeling extreme exhaustion, being overwhelmed and burnout. Physical and mental health, productivity and performance, and quality of care provided to patients can all be compromised. Normal office schedules are trying enough with time pressures and sometimes taking care of demanding or anxious patients. Conditions of the COVID-19 pandemic can increase those stressors. There is a limit to individual ability to remain empathic while enduring the personal stress imposed by the pandemic.
It is critical to recognize signs of burnout and ensure that those who need a break or help can get it (Table 1).
The strategies listed earlier for patients apply equally well to staff: limit media coverage, stay connected to support systems, use relaxation techniques, maintain good physical health, maintain good sleep habits, and disrupt negative thought patterns.
Summary
By now, you are probably tired of hearing phrases such as "unprecedented" and "uncertain" times. The unfortunate reality is that we will likely hear them again. Having a plan to help patients and staff cope with anxiety and stress when they reoccur is essential when the unpredictability is certain. Practices can help patients and staff navigate this situation and similar ones by recognizing the potential challenges they present and providing information and resources on stress and anxiety management. In addition, being on alert for increased incidence of domestic violence is a critical component of comprehensive care.
Practice Pearls
* Anxiety and stress are common in daily life and elevated in times of uncertainty.
* Both can have detrimental impact on physical and mental health.
* Domestic violence tends to increase in disaster-like conditions.
* Anxiety and stress can be managed in crisis situations with behavioral tools, including:Limits on news gathering;Maintenance of regular routines;Social connection;Relaxation techniques;Maintenance of good physical health;Good sleep habits; andDisruption of negative thought patterns.
* Staff are susceptible to burnout and compassion fatigue.
* Mental health referral sources for both patients and staff are essential during times of crisis.
Author's note: The stress management strategies for patients were adapted from Stress Reducing Strategies for Patients by Alice Domar, PhD, and Elizabeth Grill, PhD. The complete document can be found at https://resolve.org/wp-content/uploads/2020/03/Ferring_COVID-19_for_Patients_v2..
The following websites are referenced in the text:
https://www.reproductivefacts.org/taking-care-of-yourself-during-covid-19
https://www.reproductivefacts.org/news-and-publications/covid-19-resources-for-p
https://www.acog.org/patient-resources/faqs/womens-health/coronavirus-and-womens
REFERENCES