Covid-19, the infection caused by the novel coronavirus detected in December 2019 Wuhan, China, has rapidly spread to just about all countries worldwide; raising concerns also of widespread panic and increasing mental health issues in individuals subjected to the (real or perceived) threat of the virus.
Media coverage –real as well as fake information - has highlighted Covid-19 as a unique threat rather than one of many; which has added to panic, stress, and the potential for global hysteria.
I am not going to repeat here the yet known Covid-19 symptoms, possible a-typical symptoms, and possible preventative measures. By now you should be familiar with this and hopefully practice it as a responsible citizen and decent human being. (That’s to say if you’re fortunate enough to have water and soap - which most rural areas in South Africa especially do not have, due to decline of maintenance services, health services, and funds. While this can be “blamed” on poor infrastructure and social inequity, the question should rather be how infrastructure became so absolutely lacking, why social inequity broadened, and why or where allocated funds disappeared, since the 1993 democratization and the country’s government since then. A topic for another day).
Pandemics are not just a medical phenomenon; they affect individuals and society on many levels, causing severe disruptions (We are also not going to discuss economic implications or consequences here).
Stigma and xenophobia are only two aspects of the many societal impact of pandemic infectious outbreaks. Panic and stress have also been linked to outbreaks. As concerns over the perceived threat grow, people start to collect (and hoard) masks and other medical supplies, foods, and as we already discovered, especially toilet paper. Foreign nationals are shunned, and at times physically attacked in the street.
A pandemic is often followed by anxiety-related behaviors, sleep disturbances, overall lower perceived state of health, and psychotic breakdowns. Individuals with mental illness may be particularly vulnerable to the effects of widespread panic and threat.
Chronic disease, including chronic infectious diseases such as TB and HIV/AIDS, are associated with higher levels of mental disorders as compared with the general population, as well as higher vulnerability. Studies show depression rates usually soar after infections (e.g, herpes exposure and anthrax scares). Although the effects of Covid-19 itself on mental health have not been systematically studied [obviously] it is anticipated that Covid-19 will have rippling effects, especially based on current public reactions.
Distrust in the systems
Then there is medical mistrust.
“Medical mistrust” refers to a lack of trust in medical treatment and advances. It results in a lower use of health care resources and poorer management of health conditions (coupled with potential misuse at times of crisis). Moreover, medical mistrust has been used to explain some racial and ethnic health care disparities. It has been linked to a variety of diseases and conditions.
During infectious pandemics medical mistrust has also been linked to conspiracy theories. In one US study, up to half of those surveyed endorsed belief in at least one health-related conspiracy theory. At its extreme, medical mistrust can lead to movements such as anti-vaccination trends. This morning when discussing Covid-19, staff shared their belief that China has actually created this virus, has the antidote in their back pocket, simply waiting to share this with the rest of the world pending the right amount, so why worry….(thanks to fake news).
In South Africa, we do not have sufficient funds, manpower, or even hospitals to address a pandemic. (We might have, if the Government decides to stop funding SAA and SABC or the Gupta’s. What was the amount mentioned yesterday? R385 Bilj+? We can live without local television stations, and we can make use of other Airplane services besides SAA. But we have to stop Covid-19, or don’t you agree?)
We also have a massive, massive percentage of the population struggling with HIV (one of the possible reasons the WHO issued serious warnings to Africa this past weekend) – but not mentioned on TV/in the media yet (possibly due to the recent gagging order).
Anxiety and obsessive-compulsive disorders
We anticipate the effects of infectious disease threats to manifest as sheer anxiety and panic: worry about getting an infection, worry about loved ones getting ill, and worry when related symptoms—even minor—are present. The absence of a definitive treatment for coronavirus easily exacerbates anxiety. In most cases, these anxiety symptoms do not reach diagnostic thresholds for a DSM-5 diagnosis; however, patients are often not able to continue with their “new normal” lives.
Because a “new normal” is what a pandemic means.
Contamination obsessions—unwanted, intrusive worry that one is dirty and in need of washing, cleaning, or sterilizing—are very common in patients with OCD. Perceptual experiences (e.g, feeling dirt on skin) understandably would amplify obsessions. Sensory experiences (but not necessarily full tactile hallucinations) have been found in up to 75 % of patients with OCD patients. More intense sensory experiences (pseudo-hallucinations) are related to worsened control over compulsions and poorer insight. Biased information processing is associated with a tendency to overestimate threat in individuals with OCD. This may increase sensitivity to the panic associated with pandemic threats and further destabilize patients and increase functional impairment.
Cleaning and washing compulsions, also a core feature of OCD, can easily be exacerbated by the threat of infectious pandemics. Complications of excessive cleaning include dry, chapped skin (which can lead to super-imposed infections) and contact and atopic dermatitis; similarly, overuse of toxic cleaning supplies can lead to inhalational injuries. Fear of acquiring a new, sensationalized disease may worsen negative behaviors.
Psychotic disorders: an extreme of medical mistrust?
Anecdotally, the most glaring (and maybe the most interesting) examples of medical mistrust conspiracy theories concern patients who experience psychotic disorders. Typically, repeated media exposure to an alarming fact (in this case, spread of Covid-19), coupled with a distrust of organizations and government as well as misattribution of physical symptoms can result in delusions. Similarly, fears can quickly lead to clinical decompensation and must be carefully monitored.
Adding fuel to the fire are discussions of conspiracy theories related to infectious outbreaks in the mainstream media. The lack of knowledge about epidemics, the increase of zoonotic infections, and the fairly complex effects of climate changes can affect patients as well as confuse even an overall healthy person.
At the intersection of psychosis and obsessiveness is delusional parasitosis, also referred to as monosymptomatic hypochondrial psychosis, Ekbom syndrome, and delusional infestation. Essentially, the patient believes that he is infected with an organism that evades detection and treatment and, thus, causes continuous suffering. This syndrome was described as early as 1636 by Sir Thomas Browne, who referred to it as Morgellons disease. A concerning clinical feature of delusional infestation is its occurrence in multiple family members (eg, folie a deux).
Delusional infestation development in the context of pandemics has not been studied. Conceivably, increased cases may develop as more individuals focus on far-fetched, unlikely infections because of easy access to unverified information on the internet. To address delusional parasitosis, clinicians should rule out organic causes and reassure the patient that there is no infection or infestation.
No particular research data has been provided yet [or could be found] with regard to schizophrenia patients, or Bi-Polar patients; during the experience of a pandemic.
Impact on Children
Younger children, though they at present might be at lesser risk to develop the more serious symptoms of the disease; might start to show regressive behavior, become aggressive or destructive and disobedient, often clingy and scared to leave the parent’s presence (in general cases I would have added, perform weaker at school but since schools are closed….). Always remember children are susceptible to parents’ and adults’ stress levels. When they don’t have sufficient information relevant to their development stages, they make up their own stories which is often more scary than reality. The human brain abhors a vacuum – it will fill up with lies if no truth is available. It is not the time for overprotection. Kids simply worry more when kept in the dark. Make time to talk. Be sure children know they can come to you when they have questions Consider reducing the amount of screen time focused on Covid-19. Too much information on one topic can lead to anxiety. Teach children everyday actions to reduce the spread of germs. And while they are “stuck” at home, why not use the time to teach them basic life and survival skills. (See the links underneath for more information, how to talk to children regarding the Covid-19.)
Fear, Fear mostly
The current Covid-19 outbreak is spurring fear on a societal level. On an individual level, it may differentially exacerbate individual anxiety and psychosis-like symptoms as well as lead to non-specific mental issues (eg, mood problems, sleep issues, phobia-like behaviours, panic-like symptoms). In various African cultures, it could also lead to traditional group psychosis behaviour.
Crime increases as well, during pandemics (as we have already seen in the increased SA crime stats the last couple of weeks). At present South Africa has been declared a State of Disaster. Once a State of Emergency follows, it may well be that prisons might be opened and prisoners released (which will amount, in total anarchy). Be vigilant, and stay safe.
Social isolation and its Impact
The main thing is staying inside, staying in the house, not going out, avoiding large crowds—the things you're hearing everywhere from everyone.
But – Here the biggest challenge for us is convincing young healthy people to realize that even though they are at lower risk, they may not even know they're infected. If they visit an elderly friend or parent or go to a store or someplace where other people are that are higher risk, they could be the transmitter of the virus. And we all saw this virus is transmitted exponentially. Take Italy for example.
That is going to be one of the biggest challenges—convincing the young and the healthy to flatten the curve and prevent more infections regardless of their own risk. The impact of self-isolation and everybody working at home, well that might be difficult to some (And impossible for others – especially the person who works for a daily wage, the ones who will be on unpaid leave. Such people really need their income, and might simply hide symptoms in order to continue working, until it’s too late).
Households where one or both of the primary adults are usually working and out of the house during the day, children and adolescents are at school, and young adults are working or in college—all of a sudden everyone is home taking virtual classes or working in virtual environments. So now you have a whole new kind of family culture that has developed literally overnight. Instead of everybody having schedules and a lot of time away or me-time, everyone is in a small contained area, probably fighting for the computer screens or tv-remote. Everyone is trying to do things virtually.
In rural, lower income communities, there will be no virtual classrooms. There will be no school or education. Not even home schooling, as often such lower income parents have no education themselves. What to do with the children, how to keep them occupied, is a totally different concern.
Not to mention the educational delay children now will experience.
It is going to be a good opportunity here for family self-therapy, learning to work together and cooperate and how to re-experience the core family just being with itself all the time. This will be a huge adjustment. Also to those living on their own, and dependent on visits from family or friends – they have to live and cope being alone. It is going to be very stressful and we still don't know how long this will continue, which will add even more stress on people.
My Job – And Yours
I don’t have answers for Covid-19, I fear no-one does. Yet. If you are struggling with a mental health problem, please take your medication regularly, make sure you have sufficient to last through the coming months, and take care of your health. If you are fortunate enough to be a healthy individual, respect social distancing and prevent spreading the virus to the more vulnerable populations. Call single parents or grandparent regularly. Ease their loneliness. Take care of children especially – they may very well be the only future.
It is really the action or inaction, for all of us to protect each other. We need to think beyond our own needs and expectations and take care of the country as a whole. This is a whole new virus the experts know little about. This virus did not need a passport to quickly cross international borders, yet it seems to be a slow learning process to some of us. It is trying to tell us of how precious our health is and how we have neglected it through eating nutrient poor manufactured food and drinking water that is contaminated, or simply abusing it with alcohol, nicotine or drugs. It is trying to remind us how materialistic we have become, and that now during crunch time - it’s the essentials that we need (shelter, food, water, medicine) as opposed to the luxuries that we sometimes unnecessarily value.
And it now also tells us, it is down to each and every individual to save his/her own life, and their countries.