I recently had a Zoom call with a patient who leaves deliveries on her porch for a week and then disinfects the packages before opening them. Another patient shared how upon returning home she removes all her clothes in the garage, sprays her body with rubbing alcohol, and immediately showers. Following those two sessions, I walked outside and saw a man driving alone in his car wearing a mask. A female jogger, across the street, was wearing a mask too. She was by herself, a hundred yards from the nearest person. It made me think - when it comes to COVID-19, what is an appropriate level of worry and how can people stay safe and keep their anxiety to a minimum?
Prior to March 2020, people were not worried about getting sick. We lived our lives without safety measures and did not think about viruses spreading or killing people, even though they did. What changed? The country (and much of the world) was traumatized be the news of a pandemic. There was an explosion of media attention about an unknown virus that spread across the globe and into our country. We saw images of hospitals being overrun, severely sick people on ventilators which were in short supply, and not enough protective equipment to shield the nurses and doctors treating those patients. We heard doctors talk about the virus spreading quickly through asymptomatic individuals and there were scientific models estimating millions dying. To be safe and flatten the curve, virtually everything shut down – quickly.
Because our knowledge of the virus has improved since March, we must now flatten the fear, a difficult task for many reasons. Like toothpaste you can’t put back in the tube, it’s difficult to dial down fear. Once a trauma occurs, anxiety is maintained with fearful thinking and anxious behaviors.
The Trauma and the Obsession
Soon after the virus spread into a few U.S. cities, a study out of Imperial College-London predicted up to 2.2 million COVID-19 deaths in the United States. This study was widely disseminated by traditional and social media and turned out to be grossly flawed. All scientists now believe this model and others overestimated the number of deaths by a huge margin. But for many people, this prediction, along with a deluge of stories and images of people dying, was traumatizing.
Even if you do not know a single person who has experienced severe symptoms or died of COVID-19, you might live in fear due to the high volume of attention paid to the frightening aspects of the disease. The more one focuses on catastrophic possibilities or negative aspects of a problem, the more anxious they become. This is true on a micro level for individuals, and on a macro level for cities and countries, for any issue, not just COVID-19.
If an individual was obsessed with motor vehicle accidents and researched online, stories and videos of the 100 daily fatalities and the thousands of injuries per day in the U.S., they would be highly anxious to drive and avoid it as much as possible. If media and government officials showed images of horrific car accidents and reported on the daily motor vehicle death count, as much as they do COVID-19, there would be an escalation of driving phobia throughout the country and countless numbers of people would stop driving. In the summer of 1975, many people did not go into the ocean when the movie Jaws was released and that was just a movie!
The challenge for any problem is finding a balance between being safe while minimizing anxiety and living life. In the case of COVID-19, we must protect ourselves from the virus and the fear simultaneously.
The Elements that Maintain Anxiety Once it Begins
Once anxiety is triggered, it becomes self-perpetuating with a combination of false beliefs, focused attention on the negative, and anxious behaviors (avoidance, compulsions, and safety behaviors). Anxiety rises when there is a perception of danger and it escalates the more we focus on the fear with our thoughts and our behavior. This is why the response to the Coronavirus varies wildly. Some people are unafraid because they think and behave differently.
When a person overestimates the risk of an uncertain situation, their fear response grows. For example, if you avoid air travel due to a fear that you will die in a plane crash, you are overestimating the likelihood of this occurring. According to 2015 statistics from The Economist, the chances of dying in a plane crash is 1 in 5.4 million. The odds are infinitesimal yet when a plane crashes and it is highlighted on the news, fear rises. To be 100% safe from an airplane fatality, you must never fly. Doing so, however, means missing out on seeing the world and seeing loved ones. To live a full life, we must tolerate uncertainty and most people do in many ways: We fly, drive, cruise, and ride rollercoasters. We walk across busy streets, go to crowded venues, and send our kids to school and college. Thousands of surgeries are performed each year including cosmetic procedures that are not medically necessary. People ride skateboards, surf, bike, and have one-night stands. We let unknown repairmen into our house and take medication prescribed by urgent care doctors whom we’ve never met. The list goes on.
But what about the risk of COVID-19? Is the worry about the virus commensurate with the risk? A Franklin-Templeson-Gallup research project on behavioral response to COVID-19 revealed that Americans overestimate the risk of the virus. Here are a few of their findings:
Why do so many people overestimate the risk of the virus? Possibly due to their focus on the negative information from media. For instance, how do you feel reading the following true statement from the CDC: 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit. That sounds frightening!
Let’s flatten the fear with facts and look at the entire picture.
Flatten the Fear with Facts
Recent statistics show children under the age of 18 account for 2% of those hospitalized for COVID-19 and less than .1% of all COVID deaths in the U.S. There are roughly 74 million children in the United States and between February 1 and August 1, 2020, approximately 13,000 died from all causes. Forty-five children died of coronavirus and almost all of them had a pre-existing medical condition. During that same period, 105 children died of the flu. All deaths are sad. When children die it’s tragic. Thankfully few do and when they do get the coronavirus, 20 to 45% of the infections are asymptomatic.
By examining the entire picture, one can conclude that the risk of COVID-19 causing serious harm or death to children is extremely low. This does not mean there is no risk. Serious illness and death are possible. It is unlikely a child will die of cancer but it does happen and when it does, it is painful and catastrophic. Parents worry because it’s their child but when you focus on the negative, and overestimate the likelihood of tragedy occurring, your anxiety will rise. But what about the risk of dying from COVID-19 in other age groups?
The Infection Fatality Rate (IFR) is the total number of deaths divided by the total number of people that carry the infection, regardless of having clinical symptoms or not. The IFR is the rate of death once you have the virus. The CDC determined the Infection Fatality Rate of Covid-19 for various age groups (these calculations change over time with new information):
For purpose of comparison, the World Health Organization has stated that influenza has an overall Infection Fatality Rate of 0.1% or lower.
If you’re fear is less about death and more about severe symptoms, it is estimated that 20 to 35% of the people who contract COVID-19 don’t have any symptoms at all. Currently 12 million people have tested positive for the coronavirus. 10 to 15%, or 1.8 million people, have experienced severe symptoms. Given that there are 330 million people in the United States, the odds are very high you will not get the virus, but even if you do, the odds that your symptoms will be horrific are low. But many people do experience severe symptoms which causes worriers to amplify the risk as they focus their attention on the worst-case scenario.
To reduce your fear of COVID-19, be mindful of where you focus your attention. Instead of focusing on the worst-case scenario, you can reduce anxiety, by looking at the odds, choosing faith over fear, and focusing on living your life.
The Balance Between Behaviors that Keep us Safe and Those that Increase Anxiety
To flatten the fear, turn off the media and focus your attention on living your life in a safe manner. But what are appropriate safe measures in regards to the Coronavirus? Certain behaviors might make you feel safer but are they necessary. Remember, in addition to having false beliefs and focusing on the negative, safety behaviors maintain anxiety. To reduce worry, you must change your behavior. To overcome a fear of heights, you must stop avoiding high places. To overcome a fear of germs, you must stop compulsively cleaning. The anxious behaviors maintain the fearful thoughts. To conquer your anxiety, you must take small, frequent, and uncertain steps by slowly changing your behavior. This is the only way to reduce worry.
The patients I treat face their fears in small increments. They put doubt in one pocket and bravery in the other, and take gritty steps into uncertain territory. As they take those steps their anxiety rises but when done repeatedly, their fear settles and they report feeling a happiness they have not experienced since the coronavirus began. In order to take those steps, however, let’s reduce some of your worry with more facts.
How is COVID-19 Transmitted from One Person to the Next?
The virus spreads when a person is exposed to someone with COVID-19 but only certain types of exposures are significant enough to cause an infection. According to the New England Journal of Medicine, public health authorities define a significant exposure to COVID-19 as “face-to-face contact within 6 feet of a person with COVID-19 that is sustained for at least a few minutes (and some say more than 10 minutes or even 30 minutes). The chance of catching COVID-19 from a passing interaction in a public space is therefore minimal.” The Journal article and subsequent articles stress the importance of wearing a mask but maintain that the risk of contracting COVID-19 comes from “sustained contact within six feet” not from “a passing interaction.” Therefore, wearing a mask when driving a car or walking outside alone is not necessary. It’s the equivalent of wearing a helmet when walking around your neighborhood. Although it provides a layer of protection from reckless motorists and bicyclists, unless you have a severe falling issue, it is unnecessary from a statistical standpoint. The counter argument is that it’s better to be safe than sorry. Living this motto ensures you are safe but maintains the fear because safety behaviors are a constant reminder that at any moment you are in danger.
You cannot reduce anxiety without stopping anxious behaviors first.
Holding on to your anxious behaviors means maintaining your anxiety.
Michael Klompas, an associate professor of infectious diseases at Harvard Medical School writes, "A growing body of research shows that the risk of SARS-CoV-2 transmission is strongly correlated with the duration and intensity of contact: the risk of transmission among household members can be as high as 40%, whereas the risk of transmission from less intense and less sustained encounters is below 5%." He goes on to say, "If you’re outside, it’s not crowded, and people are reliably more than six feet away at all times, then a mask probably doesn’t add much additional value. But if you’re indoors, in crowded space or in a situation where people may intermittently come within six feet, then masking is desirable," Klompas said.
Therefore, the risk of acquiring COVID-19 by driving a car without a mask or walking outside alone without a mask is so incredibly low, these are steps you can take to reduce anxiety. Initially you feel anxious as you take these steps but taking them frequently, on a daily basis, will reduce your fear and help you feel better.
Reducing Anxiety Related to COVID -19 is More Challenging Than Other Fears
Reducing anxious behaviors associated with COVID-19 is trickier than overcoming other phobias because of social pressure, social responsibility, laws, and the vast number of people living with fear and/or doing anxious behaviors in public. Negative feedback loops maintain a system and can occur across all types of systems on a micro and macro level, including with the coronavirus. Here is an example of how a negative feedback loop plays out.
Government officials with the power to make laws and people in media with the power to reach thousands, are anxious too. Government officials are not only equally afraid of the virus but also fearful of making mistakes that could cause more cases and deaths. So, they institute safety policies to keep us safe. Like an over-anxious, protective parent, they will focus on the dangerous aspects of the disease and will institute rules that might be unnecessary. Like a child who becomes more anxious when they witness their anxious parent, when we see our public officials sounding the alarm to increase compliance of the rules, we become more anxious too.
The media, who are also afraid, reports on the negative aspects of the virus 24/7. CNN has a permanent graphic on the right side of the screen tracking the number of cases and deaths. When anxious people consume the media and see others behaving anxiously, it reinforces their own fears. These negative feedback loops keep individuals and societies trapped in a state of anxiety.
But not everyone participates in the negative feedback loop of the coronavirus which outrages people inside the loop who believe they are not being socially responsible. Treatment of the fear of the COVID-19 is therefore more complicated than treatment of other phobias.
Keep this in mind, you might believe wearing masks outside is socially responsible and in some cities, it is required by law, but if you happen to cross paths with another person not wearing a mask, there is no reason to obsess about catching the virus, even if they cough. Why? Because coughing is normal and occurs all the time for many reasons, the coronavirus statistically being the least likely. Based on the infection fatality rate as well as the research on how the virus is transmitted, you are better off focusing your attention on living your life, instead of dwelling on scary scenarios in your imagination and performing safety behaviors that maintain anxiety, like wearing masks when it is unnecessary or performing elaborate cleaning rituals.
Can a Person Get COVID-19 from an Inanimate Object?
Can you catch COVID-19 by touching a cereal box at the market or a package delivered to your door? It is theoretically possible, but highly unlikely, says Dean Blumberg, MD, chief of pediatric infectious diseases at UC Davis Children's Hospital. "You'd need a unique sequence of events," he says. “First, someone would need to get a large enough amount of the virus on a surface to cause infection. Then, the virus would need to survive long enough for you to touch that surface and get some on your hands. Then, without washing your hands, you'd have to touch your eyes, nose, or mouth.” Therefore, if you wash your hands for 20 seconds after you touch a package, you have sufficiently protected yourself, prevented wasting time, and taken steps towards reducing your anxiety.
Emanuel Goldman, PhD, a professor of microbiology, biochemistry, and molecular genetics at the New Jersey Medical School of Rutgers University, stated "In my opinion, the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze (within 1-2 hours)." People tend not to get viruses from inanimate objects for two reasons: Viruses lose their potency quickly with each passing hour and our skin protects us. As long as you wash your hands for twenty seconds, you are protected. To be infected, a virus must enter your body, therefore we do not get viruses from touching objects, only from touching our face (with or without gloves). Therefore, not touching deliveries for days is unnecessary. So is spraying packages with bleach or other harsh cleaners, which can irritate the lungs and skin. Unless you are performing surgery, washing your hands is a better option than wearing gloves because people seldom wash or change their gloves.
To reduce your anxiety, begin by taking the smallest of steps. If you usually let packages sit for three days before touching them, let them sit for two days. Instead of washing every delivery with cleaning products, wipe them down with a cloth and then washing your hands. These brave steps will make you anxious at first but if you do them repeatedly and then continue to take even braver steps, you will feel a huge reduction in your stress and anxiety level. The goal is to eventually bring the package into the house just like you did before COVID-19.
Protect Yourself from the Virus and Anxiety
Your task is to protect yourself from the virus while at the same time protecting yourself from anxiety. Many have focused on the former in such an extreme why they have exacerbated their fears. To reduce anxiety, do the following:
This blog was posted on November 23, 2020.
About the Author
Ken Goodman, LCSW,the Emetophobia Manual, for those who suffer with the fear of vomit.