Dealing with Stress, Isolation, and Illness in the Age of COVID 

From a Psychiatric Perspective

The content of this article derives from Dr. Weiss’ colloquial article for attorneys about managing stress, published in Voice of the Defense (TCDLA), a publication for Texas attorneys.

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Dr. Weiss was invited by Voice for the Defense, the publication of the Texas Defense Criminal Lawyer’s Association (TDCLA,) to write an article for attorneys about managing stress in the COVID pandemic. This is not an academic publication and it is not a legal or professional medical publication in that regard. Please note that Dr. Weiss has been retained by counsel for Plaintiff and Defense; his findings are objective and unbiased.  Voice for the Defense, 8 January/February 2021 (Begins at Page 21)

 

Stress and COVID an article for attorneys
Many of us in American society lived demanding, socially isolated lives, even before COVID-19 entered the picture. Our daily interactions with others were frequently draining, both mentally and emotionally. Our perverse sense of duty as professionals distorted our boundaries; thus, governed by an inability to say “no,” the resultant overinvolvement in our work left little energy for ourselves. The era of COVID has only exacerbated these states of mind, resulting in weariness and feelings of desolation. We may be more connected through the Internet than our predecessors, yet a lack of social intimacy has only deepened our feelings of alienation during the pandemic. Before practical measures for combating stress, dealing with isolation, and promoting psycho-logical and physical health can be addressed, it would behoove us to define “stress” and the “Body-Mind” relationship.

First, what does “stress” really mean? Physics’ original definition is “The interaction between a force and the resistance counter to it.” In medicine, the clinical notion was popularized by Hans Selye, a Canadian physiology researcher, who tested the impact of stress on rats. He took the concept of stress to a new level: “The nonspecific response of the body to any demand put upon it.” [1] No matter what “stress” he subjected his lab rats to, including injecting toxins or the cold winter, on autopsy, there were always the same three findings, called “the triad of stress”:

  • Enlargement of the adrenal glands
  • Lymph node/immune system atrophy
  • Stomach ulcers

These findings extrapolate to humans[2] in that with both species stressors cause the release of brain hormones which trigger the adrenals, where cortisol and adrenaline are produced and stored. Adrenaline signals the stomach to become acidic, which leads to ulcers – once known as the “merit badge of Wall Street.” Selye’s animal’s third symptom of stress has as its more modern counterpart Gastroesophageal Reflux Disease. GERD, a stress-induced stomach disease, is an “equal opportunity” affliction, manifesting not only in the time-pressured businessman but also in the “worry-wart” type of blue-collar worker.

The overstimulated adrenals also release cortisol, a steroid known to alter and suppress the immune system. A dysfunctional immune system cannot properly destroy the mutant cancer cells due to aging, nor can it “put the brakes on” the body’s cells attacking its glands and organs—like in the autoimmune diseases of Lupus or thyroiditis.

The oldest conception of the “Body-Mind” relationship came in the form of the Greek physician Hippocrates’s (460 BCE—375 BCE) “four humors” consisting of yellow bile, black bile, blood, and phlegm. The basic idea was that if the physician could balance these fluids, their patient should be entirely healthy.[3] 2000 years later, René Descartes proposed that the body and mind had no relationship and were entirely separate entities, with the body being the doctor’s realm and the immaterial mind belonging to God. The Cartesian paradigm was supplanted over time, and the “Body-Mind” relationship has been redefined on multiple occasions by such familiar figures in psychiatry as Sigmund Freud (“there must be a comprehensive fusion of biological and psychological concepts”) to less familiar personages such as his student, Franz Alexander (“physical symptoms are but a symbol of unresolved unconscious conflicts”).

 Although the “Body-Mind” relationship is a bit more difficult to characterize than “stress,” modern science provides strong evidence suggesting that there is more than a nominal interconnection. Robert Ader, Ph.D., the founder of “psychoneuroimmunology” (the theory that the brain and immune system comprise a single, integrated defense system), used classical conditioning techniques with his research animals. Ader’s behavior modification paradigm consisted of force-feeding his lab rats saccharine paired with injecting them with cyclophosphamide, an anti-tumor drug and immunosuppressant. After several trials, he found that the animals could be administered only the sweet taste and still manifest a depressed immune system. For human beings, this capacity for a placebo or “mind-only based response” is much greater than for a rat.

With these understandings, the million-dollar question remains: what can you do to alleviate feelings of COVID-related stress and isolation? Since we cannot directly affect others’ behaviors, we can only change our own feelings, thoughts, and actions. However, it is critical to recognize that this intellectual answer may not be consciously endorsed by the brain’s lower regions: the limbic-emotional system or the primitive-reptilian brainstem. 

Fig. 1

A salutary ego-syntonic approach that would allow all of these parts of the brain to work together in a coordinated fashion (rather than in conflict) can be achieved through a process hearkening back to A.H. Maslow’s “Hierarchy of Needs.” “Maslow’s pyramid” (see Fig. 1) demonstrated that a person had to satisfy the needs embodied in the bottom-most tier (e.g., physiological) before the next highest tier (e.g., safety needs) could be achieved, with the goal to continue moving upwards, thereby completing the hierarchy.*
Although Maslow’s “Hierarchy of Needs” certainly has its benefits when it comes to coping with COVID-19, it may not be entirely effectual. Thus, I have devised a pandemic-focused edition of Maslow’s hierarchy:

Fig. 2

Although Maslow’s “Hierarchy of Needs” certainly has its benefits, when it comes to coping with COVID-19, it may not be entirely effectual. Thus, I have devised a pandemic-focused edition of Maslow’s hierarchy.
The bottom-most hierarchy (level 1) is the most rapid and minimal in time and cost: a non-obligatory Prescription Medication Consultation. This might involve a visit to one’s primary care physician, or, if necessary, to a psychiatrist for a psychotropic medication evaluation (e.g., anti-anxiety agents, antidepressants, a sleeping pill, or a pain med). This is a useful first step, with the emphasis on it being a consultation, meaning that pharmaceuticals might not be needed or that the person may ultimately decide not to take medication.

The next level that may be entertained is Lifestyle, which involves nutrition, weight management, exercise, and good sleep hygiene. The pyramid climber does not need to take on all these lifestyle changes at once, but instead can pick one that seems doable and may add on the rest as they see fit. (It is not recommended that more than one be added at a time until you are already well-practiced in the others.)

Socialization (level 3) includes 12-step groups (e.g., Alcoholics Anonymous) which can fulfill multiple levels of needs on the hierarchy (i.e., Step 11’s admonition re: “prayer and meditation”[5] is a prescription for tools found on level 5). Recreational clubs, group psychotherapy, and spiritual groups round out this social skills tier. By joining a group, not only will you experience decreased sensations of isolation, but you may also find a sense of community and an outlet for expression. Most of these groups host both in-person and virtual meetings to accommodate everyone’s needs during the pandemic.

But what if the idea of joining a group causes part of your anxiety or stress? Similarly, what if the initial adverse body signals or feelings of dysphoria while starting a new exercise regimen, or diet, are so overwhelming they drive you back to being a couch-potato or pigging out on carbs? While you may benefit from starting at level 1 of the pyramid and progressing step-by-step, if the level 3 tier of Socialization, or any other level, simply seems overwhelming then you can always start elsewhere, and become relational on a smaller, more structured scale, as may be found on level 4: Professional One-on-One. Psychotherapy, a successful treatment method for many people, is often covered by insurance, and entails 45-60 minutes at a frequency of roughly once every 1-2 weeks. Studies show its success is predicated on only two factors: that you believe it works, and that you like and respect the therapist. [6]

For those who prefer a more physically involved type of remedy, bodywork (a branch of healthcare with a focus on touch-based healing) is a good option. Bodyworkers are encompassed by a wide range of professionals, using techniques involving manipulative therapy, breath work, or energy medicine.[7] The focus is on treating the “mind” through the “body.” Research supports the existence of abdominal neural serotonergic networks—hence the “gut feeling” truly results from the “gut brain,” as well as the gut microbiota.[8,9]

As for the 5th and final level, Spiritual Tools, meditation has proven to be popular and effective in furthering physical and psychological health. How to Meditate by psychologist Lawrence LeShan divides meditation into two branches: “mindfulness” and “structured.” Mindfulness, or Vipassanā[10] Meditation, is the act of non-judgmentally ob-serving one’s environment. Conversely, structured (concentrative) meditation is exemplified by the Zen Buddhist koan, an intellectually unsolvable puzzle, e.g.: “What is the sound of one hand clapping?” Movement meditations, which may be useful for those of us who feel most focused when our bodies are engaged, include yoga, T’ai chi and mindful work-out routines.

Psychologist BJ Fogg’s Tiny Habits that Change Everything outlines the “baby steps” used to create an epiphany through “changing the environment.” For instance, with meditation, you could start by setting an alarm to remind you to meditate for 3 minutes a day at lunchtime, and once that has become a habit, increase the amount of time you meditate accordingly. Meditation (“listening to God”) can be complemented by prayer (“talking to God”). Prayer is an activity often “ego-syntonic” with religious beliefs. Science supports that it benefits various physical and mental dis-eases by physiological mechanisms, and some say divine intervention (which cannot be disproven). [11]

While these are all excellent methods for alleviating your COVID-related stress, it can be difficult to decide where to start. Considering that every individual has different needs, the “risk/benefit ratio” can determine where to strike a balance. Thus, one evaluates their personal experiences with health and stress and what has worked for them previously, according to their individual values. My own approach (admittedly at one extreme) to address the vicissitudes of the pandemic, is guided by a personal history of viral hepatitis and viral pneumonia acquired treating E.R. and I.C.U. patients, as well as a work history having ministered to thousands of viral and infectious illnesses. Because of my familiarity with clinical/epidemiological issues and the well-being I experience from maintaining a socially and physically active lifestyle, the benefits outweigh the potential risk of acquiring coronavirus. At the opposite end of the spectrum, a highly respected psychotherapist colleague, whose wife died from a viral infection, has found a different balance. For her, the risk of acquiring coronavirus and transmitting it far outweighs any potential benefits of being socially active, thus she maintains strict social distancing, while continuing to conduct therapy sessions and classes by teleconference.
In conclusion, even though COVID-19 has dramatically altered the avenues we use to seek stress relief, we are not without options. Using the pyramid based on Maslow’s Hierarchy of Needs, you can find a combination of treatment modalities encompassed by one or all of five levels. Some may need to start at the Prescription Medication Consultation level or the Professional One‐on‐ One level. For others, they might find it most beneficial to begin else-where, like at Socialization, Lifestyle, or even Spiritual Tools. When deciding where to set in motion your pro-gram, as well as which way to proceed, you may consider using the risk/benefit ratio to evaluate which level and its representative modalities fit best with your personal experiences and resources. All in all, while COVID-19 has flipped so much of our world on its head, there are treatments that you can use to decrease your feelings of stress and isolation, harmonize the Body-Mind relationship, and ultimately im-prove your overall physical and mental health.

Diagnostic Aid (Appendix A): The Holmes-Rahé stress scale helps to “diagnose” stress as causal to medical conditions. This eponymously named tool developed in the late ’60s was invented by two psychiatrists at the Univer-sity of Washington – Thomas Holmes and Richard Rahé. They examined over 5000 medical records of patients to determine what stressful events might cause illness. Their research generated a list of some 43 “life events,” each of which was, according to statistical methods, given a dif-ferent “weight” in terms of a point scale. Based on your point score from events that occurred in the previous year you can rate your chances of “stress-induced health break-down”  in  the  upcoming  two  years.**
APPENDIX B:
Treatment Aid: An effortless relaxation or meditation technique derived from yoga has been popularized by Adrew Weil, M.D., the holistic physician from Arizona. This “4-7-8” breathing technique can be found on his 3-minute video at: https://www.youtube.com/watch?v=gz4G31LGyog .

ENDNOTES

1. Selye, Hans. Stress in Health and Disease, Butterworths, 1976.
2. Palmer, Seth. Rats’ brains are more like ours than scientists previously thought Penn State News, March 26, 2013.
3. Hippocrates. The Corpus: The Hippocratic Writings (Kaplan Classics of Medicine). Kaplan Publishing, 2008.
4. Abraham Harold Maslow, Ph.D. A Theory of Human Motivation. Sanage Publishing House, 1943
5. Step 11: “Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry it out.” Twelve Steps and Twelve Traditions, Alcoholics Anonymous World Services, 1981. page 96
6. Jerome Frank, Ph.D., M.D. Persuasion and Healing: A Comparative Study of Psychotherapy. Johns Hopkins U. Press, 1993
7. “Some of the best known forms of non-touch bodywork methods include: reiki, yoga, pranayama, as well as other non-touch methods: breath-work respiration techniques, therapeutic touch, the Bates method for sight training, qigong, and t’ai chi. The better known forms of manipulative bodywork include the Bowen technique, chiropractic, reflexology, Rolfing, postural integration, shiatsu, and the Trager approach. There are also some methods that use light touch (not tissue work) to retrain movement patterns or shift awareness of the body, including the Alexander technique, the Feldenkrais method, the Hakomi method, integrative body psychotherapy, craniosacral therapy, and somatic experiencing.” From: “Body-work” in Wikipedia
8. “We have a brain in our belly, a very sophisticated one, and it responds to everything that’s happened in our lives, so it accumulates a lot of stories over time.” Bonnie Badenoch, Ph.D. “The Heart of Trauma: Healing the Embodied Brain” Norton 2017
9. Grenham S. “Brain-gut-microbe communication in health and dis-ease” (2011) Frontiers of Physiology Volume, 2 Number 94.
10. Vipassanā is a Pali word derived from the older prefix “vi-” meaning “special”, and the verbal root “-passanā” meaning “seeing”. It is often translated as “insight” or “clear-seeing”. “Vipassana” in Wikipedia
11. Larry Dossey, M.D. Healing Words: the power of prayer and the practice of medicine. Harper, 1993

*Comment that is not part of the original published article: Maslow defined the bottom tier as the most necessary: a need for air and food, for example, is of greater demand and urgency, he believed, than for Self Actualization, though all are needs.

**In the original article, a link at this juncture is no longer active. It is removed.

Adapted:
Leonard Weiss, M.D. is a Forensic Psychiatrist, Board-Certified in complementary disciplines: Psychiatry, Forensic Psychiatry, Internal Medicine, Addiction Psychiatry. He matriculated at MIT undergraduate in Cambridge, MA  (mathematics), attended Medical School in his home city Detroit, Michigan (Wayne State University), finished residencies in internal medicine and psychiatry, and completed a Nutrition Fellowship at Memorial Sloan Kettering Cancer Center (N.Y.)  Dr. Weiss has a clinical practice treating patients in Austin, and forensic medical-legal practice conducting forensic psychiatric evaluations and giving expert testimony in a variety of jurisdictions, including criminal (competency, NGRI) and civil (testamentary and contractual competency, malpractice, employment, Fitness for Duty.) He also conducts psychiatric evaluations for State Professional Boards (Medical, Law, Pharmacy, Dental, and Veterinarian).