Covid-19 and Anxiety Disorders

Introduction

In order to contribute to the scientific community, this study proposes a look at mental health, focusing on anxiety disorders in the population at this time of the fight against coronavirus. Talking about the presentation of anxiety symptoms during the pandemic experience is crucial, since in view of the preventive measures proposed by health institutions, social isolation seems to have significantly affected people.

Commentary

The World Health Organisation (WHO) declared that the outbreak of the disease caused by the new coronavirus (COVID-19) constitutes a Public Health Emergency of International Importance and implemented new forms of care and protective measures. Among the protection and safety measures, stands out the importance of personal hygiene and social isolation. In brazil the disease shoots putting the country in 5° place on rank of country with most cases disease, with 20.728.605 cases, 579.010 deaths according with dates of Interactive Panel of the brazilian Unified Health System (2020), until August 28, 2021.

Anxiety disorders are present in Brazilian society, manifesting symptoms such as panic attacks, phobias, generalized anxiety and post-traumatic stress, negatively affecting people’s quality of life, such as loss of independence from fear, distancing from social environments and family, failure in the workplace, etc. The daily experience during the COVID-19 pandemic has shown that some people have shown anxiety symptoms such as fear, tachycardia, sweating, tremors, headache, insomnia and negative thoughts, because of this seeking psychological clinics.

Based on the possibility of an increase in complaints about mental exhaustion and the search for psychological treatment during the pandemic, this research is important because it seeks to verify the relationship between the pandemic experience and the possibility of presentation of new anxiety cases, from the perspective of mental health during fighting COVID-19, the presentation of anxiety disorders developed during the pandemic and presenting possibilities for psychological interventions

Mental Health during Fight Against Covid-19

With the emergence of the coronavirus pandemic, society was faced with the breakdown of the ordinary social movement, directly affecting collective and individual life, and also reducing impacts in the sphere of mental health. According to Cepedes [1], there is a pandemic situation, the number of people psychologically affected are usually larger than people who were affected by the infection.

A pandemic is a classification that refers to certain diseases that can infect the population of the entire world, it means that the contamination spreads over several countries and is easily transmitted between people. The World Health Organization is responsible for decreeing when a pandemic disease emerges and for alerting countries to the risks of contagion and providing guidance on the measures indicated to contain the development of the disease.

According to the Ministry of Health, COVID-19 was classified as a pandemic disease and is caused by the coronavirus (SARS-CoV-2), there can be no asymptomatic infections in severe conditions. Coronaviruses are part of a family of viruses that are common in different species of animals and these coronaviruses (MERS-CoV and SARS- CoV) can hardly infect people. However, in December 2019 a transmission of a new coronavirus (SARS-CoV-2) was identified in Wuhan, China and caused a COVID-19, which was spread and transmitted from person to person.

About 80% of patients with COVID-19 may have asymptomatic conditions and approximately 20% of cases require hospital care due to respiratory distress and 5% may need treatment for respiratory failure (ventilatory support).

He Ministry of Health of Brazil launched an advertising campaign on TV, radio and internet to inform the population about COVID-19. The campaign provides guidance on personal hygiene habits and social distancing in order to prevent the spread of the disease, as well as informing about the main symptoms such as fever, cough, loss of smell and taste, and breath difficulty.

In cases of minor symptoms such as fever/cough level it is recommended that the person do social isolation and monitoring his symptoms as told by national health authority guidelines. In the most serious cases of the disease, if there is a presentation of respiratory difficulty or chest pain, the person should seek medical care at Basic Health Units [2].

In brazil the Agência Nacional de Vigilância Sanitária (ANVISA) authorized on June 2, 2020 the clinical trial of the vaccine developed by the University of Oxford for the prevention of COVID-19. And on July 3, 2020, it also approved the clinical trial in phase III of the vaccine against covid-19, developed by the company Sinovac, based in China, in partnership with the Butantan Institute (SP) [3].

During the development of clinical trials in search of a vaccine against COVID-19, it is also important to think about the impacts on the mental health of the society that is involved in this process.

The World Health Organization defines health not only as the absence of disease, but also as complete physical, mental and social well-being. And it understands mental health as a state of well-being in which the subject becomes able to use their own skills, such as the recovery process after a stressful situation, to produce and contribute to the community in which they live.

According to Bock, Furtado e Teixeira [4]:

Talking about health means thinking about promoting mental health, which implies thinking of man as a whole, that is, as a biological, psychological and sociological being and, at the same time, in all living conditions that aim to provide him with physical, mental and social well-being.

Bock, Furtado e Teixeira [4] comment on the ideation of illness and mental health, in which they point out about prevention in mental health from the creation of strategies, these being directed to actions located in the social environment.

Man is a being of social essence and it is in their relationships and social interactions that the connection with the other makes them healthy or pathological [5]. According to Mello and Teixeira [6], man is a social being and develops from his interaction with others, making social relationships fundamental for the individual formation of subjects.

In situations of social distancing, it is common to present sensations such as impotence, loneliness, sadness, irritability, boredom and various fears. Such sensations can lead the subject to loss of appetite and sleep, family conflicts and excessive use of alcoholic substances or illicit drugs [2].

Ribeiro, et al. [7], suggest that during the period of social distancing/isolation may arise feelings of anxiety, panic, fear, sleep disorders and other detrimental factors in quality of life , which can serve as a warning for physical and mental health. People will be going through traumatic experiences, the feeling of impotence, mourning for family and friends, confrontation with the disease and loneliness. Therefore, it is crucial to develop psychotherapeutic management during the pandemic period, such as becoming resilient, maintaining contact through technological resources with friends and family, organizing a routine and creating healthy habits.

The scenario around the mental health of the population can also be aggravated by the dissemination of fake news or misleading information about the infection and prevention measures, there may also be difficulty on the part of the population in understanding the guidelines of the health authorities, leading to inappropriate conduct towards COVID-19 [8].

It is important to think about the mental state not only of the population in general, but also of the health professionals who are at the forefront of the COVID-19 fight, and other indispensable services, such as drivers, security guards and cleaning assistants. These subjects are constantly in contact with a real danger, causing insecurity, fear of contamination and death, pressure and stress at work (burnout), distancing from the family and the risk of being stigmatized or harassed by society as possible transmitters of the virus. [9, 10].

According to the author Schmidt, et al. [8], comments on possible stresses for health professionals in the pandemic context:

increased risk of being infected, getting sick and dying; possibility of inadvertently infecting others; overload and fatigue; exposure to large-scale deaths; frustration at not being able to save lives, despite efforts; threats and aggressions themselves, perpetrated by people seeking care and cannot be welcomed by the limitation of resources; and distancing from family and friends.

The experiences of these stressors can trigger or intensify symptoms of anxiety, depression and stress, as these professionals are daily discouraged from interacting with the population, increasing the feeling of loneliness. Also, they deal with changes in procedures, care time and exhaustion [8].

According to Cepedes [1] the psychiatric disorders that most easily arise during social distancing are depression and transient acute stress reactions, and the later ones include use of harmful substance, post-traumatic stress disorder, adaptation disorders and psychosomatic conditions.

In brazil, materials provided by research groups and institutions to professional categories were published, containing mental health recommendations during the context of the pandemic, based on international documents. Among these documents are the booklets of the series “Mental health and psychosocial care in the covid-19 pandemic” launched by the Centro de Estudos e Pesquisas em Emergências e Desastres em Saúde [1], these booklets address topics such as: Violence and family, population on the streets and Mental Health and Psychosocial Care in the Covid-19 Pandemic [1]. Internet resources have also emerged, such as lives and podcasts for health professionals.

Some institutions such as the Conselho Federal de Psicologia (CFP), from CFP resolution number 11/2018, opted for the regulation of the teleservice modality, which takes place online through technological means of distance communication [11]. The Pan American Health Organization [12] provided guidance on prevention of emotional health, suggesting distancing excess information about the virus, positioning support and helping others, protecting the risk group, maintaining distance and establishing a routine.

From the contributions regarding mental health during the fight against COVID-19, it is noted that the new coronavirus pandemic contributes to the development of mental disease in the population, therefore, it is possible to verify the development of anxiety disorders during the pandemic.

Anxious Disorders Developed during the Pandemic

Anxiety is characterized as a natural human reaction that is necessary for our survival. It works as the body’s biological response to dangerous situations. Therefore, all subjects at some point in life present an anxiety reaction [13]. Considered as a warning sign, anxiety is determined by the presence of an internal conflict that has the function of alerting the individual to an imminent danger, ensuring that the subject establishes survival measures in relation to the threat [14].

Anxiety is considered pathological when there is exaggeration, that is, disproportionate behavioral responses in relation to a stimulus that affect the individual’s quality of life, emotional comfort and daily performance. Natural anxiety has reactions such as increased heart rate, choked voice, and cold, shaky hands. While pathological anxiety presents symptoms such as sweating, tachycardia, physical and muscle pain, insomnia, memory impairment, mood instability, crying spells for no apparent reason, etc. [13].

Negative thoughts that can lead to self-sabotage, thoughts of impotence and lack of concentration are also highlighted as an anxious symptom. The combination of these symptoms and the variability of the degree of presentation can cause life disorders, such as insomnia or excessive sleep [15]. The difference between natural anxiety and pathological anxiety is perceptible when we look at the context, since if the subject has anxious reactions and this interferes with the way he lives and relates, then we can say that it is a pathological anxiety reaction.

According to the Manual Diagnóstico e Estatístico de Transtornos Mentais [16], it is considered an anxiety disorder when they include “disorders that share characteristics of excessive fear and anxiety and related behavioral disturbances”. Anxiety disorders differ in the types of objects or situations that cause fear, anxiety, avoidance behavior and cognitive ideation.

The current excess of concern with lifestyle during the pandemic can interfere as an anxiety potentiating trigger. According to Ribeiro [7].

Currently, the demand for psychological care online has increased significantly, because people aren’t able to deal with this new situation, the worry, fear and insecurity of what may happen later can be triggers for anxiety to exceed your limits of normality.

Garrido e Garrido [17] warn about the dissemination of negative news about COVID-19, as they can generate in the subjects a constant state of alert related to the fear of infection and death. In this way, individuals can develop panic disorder. According to the DSM-V [16], panic disorder (PD) is characterized by the following symptoms: feeling of danger for no apparent reason, thoughts of death, tachycardia, dizziness, difficulty breathing, etc. PD can be caused by biological, psychological or unhealthy habits.

According to Schmidt, et al. [8, 18] a study carried out in China on mental health while coping with the pandemic, with 1,210 participants in 194 cities, during the initial stage of the pandemic, showed that people had moderate to severe symptoms of anxiety (28.8%), depression ( 16.5%) and stress (8.1%). Another study had the participation of 1,563 doctors active in hospitals in different Chinese cities, noting the prevalence of symptoms of stress (73.4%), depression (50.7%), anxiety (44.7%) and insomnia (36.1%) [8, 19].

The change in lifestyle, the feeling of uncertainty and insecurity, generated anxious symptoms in the population, especially in front-line health professionals in the fight against COVID-19. Approximately 10% of healthcare professionals in China have developed Post Traumatic Stress Disorder (PTSD) symptoms related to routine care for patients with COVID-19 [20, 21].

According to Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-V) Posttraumatic stress disorder (PTSD) involves the development of characteristic symptoms after exposure to traumatic events, with emotional reactions and reliving fear.

The research conducted in southwest China, with 1,593 participants, compared people affected by quarantine with those who were not affected (not in isolation). The research results showed that those people not affected by the quarantine had 6.7% anxiety and 11.9% depression. People who were affected by quarantine had a higher prevalence of anxiety (12.9%) and depression (22.4%) [19].

Social isolation contributes to the presentation of anxious and depressive manifestations, as both can be considered as a reaction to stress. These reactions are linked to the lack of control in the face of the pandemic situation, the feeling of uncertainty, the segment of rules imposed as protective measures and the abrupt separation from the social/family environment [21].

The study carried out in the Basque Country with 976 participants showed prevalences of 21% of depression and 25.9% of anxiety in females and, respectively, 17.3% and 13% in males [22]. a study carried out in Brazil via a virtual questionnaire showed that the population presented feelings of sadness and loneliness (40%) and feelings of anxiety and nervousness (50%). The study revealed that feelings of sadness and anxiety were higher in young adults, women and subjects diagnosed with depression [23].

Individuals with suspected infection or diagnosed with COVID-19 may experience intense emotions and behavioral reactions, which can progress to panic attack disorders, post- traumatic stress, and generalized anxiety [20]. According with Santos (2018) Generalized Anxiety Disorder (GAD) is characterized by a persistent anxiety symptom that affects the subject’s behavior in various everyday situations. Common symptoms are: motor tension, inability to relax, fatigue and headache, sweating, dizziness, shortness of breath, irritability and difficulty concentrating.

Suspicion of new coronavirus infection may develop obsessive-compulsive symptoms in some people, such as checking mean body temperature repeatedly [24]. Obsessive- compulsive disorder (OCD) is characterized by irrational thoughts and fears that cause compulsive behaviors, the symptoms appear gradually and variable. The main behaviors are: compulsive, ritualistic, repetitive, agitation, social isolation, etc. [16].

Among the studies cited, it is possible to observe the presentation of anxiety disorders during the pandemic, the main ones being post-traumatic stress disorders, generalized anxiety disorder, panic disorder and obsessive-compulsive disorder. From the verification of the presentation of anxiety symptoms during the pandemic, it is also crucial to present the intervention measures of psychology that are being used in this context.

Possible Strategies for Psychological Interventions during the Pandemic

Because of the current scenario and the impacts on the emotional dimension of individuals, it is important to take into account coping strategies and interventions linked to social and psychological dimensions. As a way to prevent the mental health of the population, early adoption of coping strategies is recommended, as they enhance emotional stabilization autonomously, avoiding specialized care [1].

The World Health Organisation (WHO) recommends the practice of daily physical exercise, maintaining good communication, practicing reading, music, dancing and painting, in addition to being empathetic and supportive, as strategies to minimize psychological distress and reduce anxiety.

The transmission of truthful information through official government vehicles helps to reduce the consequences on mental health, since the population will trust the information network, reducing the creation of doubts about the pandemic. It is also important that authorities offer exclusive apps and channels for updates about the characteristics and consequences of the pandemic [20].

During the pandemic period on the world stage and the emergence of constant and fluctuating news regarding COVID-19, together with the fear of the future and social distancing/isolation, stressors that generate mental disease emerged, and in severe cases, the development of anxiety disorders. therefore, people should go through a process of prevention or treatment, with psychology or psychiatry professionals, for drug or psychotherapeutic intervention.

Psychologists offer psychological support services

through strategies and techniques of the psychotherapeutic process, as a measure for the development of greater control in the face of a pandemic situation, through the theoretical cognitive-behavioral approach.

Cognitive-behavioral therapy (CBT) is an approach in psychology that works best for individuals with anxiety. With techniques aimed at changing negative thoughts and emitting behavior, helping to overcome and manage emotional disorders [25]. CBT helps the patient in breathing control, relaxation, exposure to situations that bring fear and cognitive restructuring, search for alternative thoughts. Useful techniques that can help emotional management in periods of pandemic [26].

According to Oliveira [27], intervention in CBT during the period of the pandemic and social isolation must be directed towards emotional regulation, where the subject will identify and understand emotions; cognitive restructuring in order to identify maladaptive thoughts and thought stopping and decatastrophizing, which aims to stop negative thoughts. In addition to interventions in therapy, the promotion of mental health can also occur from the emission of other behaviors, such as filtering excess information, establishing pleasant routines and activities, performing meditation and breathing practices.

Psychological interventions to the population and health professionals during the COVID-19 pandemic play a crucial role in the mental health implications. Many health organizations around the world have issued guidelines for operating practices in the pandemic context, in this sense, face-to-face care is restricted by the risk of contamination and replaced by psychological services provided through technological resources [8].

Interventions for the general population are related to psychoeducation, such as the dissemination of booklets and other informational materials, channels for psychological listening (reception of negative emotions), psychological care through structured letters and online psychological care [8]. Psychoeducation also acts as a form of verification, that is, it allows the observation of compliance with prevention measures, as these can have positive effects on psychological responses [20].

In this pandemic period, interventions are dynamic and focused on stressors related to COVID-19 and on the difficulties of adapting to current restrictions. Considering those people who experience more severe levels of suffering, it is important to refer them to the multi-professional team [8]. Pereira [20] discusses strategies for guaranteeing access to prescriptions of medications for those who have anxiety and depression disorders. Since discontinuing drug treatment can maximize symptoms.

Psychologists help health professionals in promoting mental health and preventing negative psychological implications, with support and guidance on the handling of specific situations, such as listening to the complaints of patients tested positive for COVID-19. Interventions should also be carried out aimed at providing guidance on psychological symptoms that professionals may present (stress, depression, insomnia, anxiety), coping strategies, self-care and strengthening the support network [8].

Psychological demands change according to the disease process or facts related to it, which implies dynamic psychological interventions [19] . The role of psychology can also contribute to combating the stigmas directed at COVID-19, by demystifying the disease, which is being used by people as a link to a specific nationality, leading to xenophobia.

Final Considerations

This study search to investigate the emergence of anxiety disorders during the pandemic, as well as to systematize knowledge about mental health when fighting the COVID-19 and the possibilities of psychological interventions.

Through the research it is noticeable that the COVID-19 pandemic is favoring the onset of mental disease in the general population and health professionals, the most apparent being post-traumatic stress disorders, generalized anxiety disorder, panic disorder and obsessive-compulsive disorder.

The consequences on mental health as a result of the pandemic can generate harmful effects in the long term, therefore, it is essential to plan individual and community strategies in order to minimize the emotional impacts on the population and on the health teams. Mental health professionals can offer important contributions in this context.

COVID-19 is being considered one of the biggest public health emergencies and psychology has the role of contributing to facing the repercussions of COVID-19, by carrying out psychological interventions during the pandemic experience in order to minimize the negative impacts and promoting mental health, as well as acting post- pandemic, based on readaptation and management of losses and transformations [28, 29, 30, 31].