Speaker: 0:03

Welcome back to Long COVID Doctor, an educational series for those of you who are still suffering from long COVID. I'm Dr. Tim Robinson, formerly a family doctor, a GP for 30 years, and now working in non-COVID services for five years. I post on all the usual podcast channels as well as on YouTube. I hope you find these posts helpful. And if you do, obviously click subscribe. That's a bit of a cliche now, isn't it? But yes, please click subscribe and share any of these postings to anyone else you know who has long COVID. So thanks for all the feedback that you send in. Really helpful for the queries and comments. It's you know helpful for me for my future postings, but I do apologize. I just haven't got the time to reply to each of those comments and queries. I really wish I could, but um time does not dictate. So um the other apology, apology I always start with is the my usual disclaimer. It's important. Yes, any advice or treatment that I mention in these podcasts or or videos, please don't consider them unless you have discussed them with your own doctor. Right, great. So this is all about anxiety uh in long COVID, and it is an update on the previous one that I did. So in it I will cover the symptoms, the causes of anxiety in long COVID, the strategies and treatments to try and help anxiety in long COVID.

Speaker: 1:50

So here we go. A nxiety is common, yes, I see a lot of patients in the clinics that I work in who do have understandable anxiety or anxious, worried about their condition. And, you know, that might be a completely new worry, anxiety, or it might be a worsening of a previous anxiety tendency that he or she may have had before they had COVID and now long COVID. So, first and foremost, what is anxiety? Well, basically, anxiety is that feeling of unease or worry or fear that is a normal response when you feel threatened, feel unsafe, um, feel at risk of harm, that be it physically or mentally. So it's a normal response. But unfortunately, in some people, their worries, those anxieties, those feelings become more constant and it sort of impacts them on an everyday basis, everyday life. And then then it sort of becomes more of a rather than just simple worries, concerns, more sort of a generalized anxiety disorder. So how does it present? How does anxiety present? Well, there are physical and mental ways that it can present. So, first of all, physical. So you might have a very fine tremor, you might have an awareness of your heart beating or pulsations, either in the neck or in the chest. You might have tension headaches, you might have sleep problems. So, in a way, those are the physical manifestations of anxiety. The mental manifestations are sort of that feeling of being on edge or irritability or restlessness or sort of emotional or sort of tears for no reasons, sort of happening just out of the blue, or sort of just general fragility. So, other conditions that go with anxiety, general anxiety disorder, are panic feelings, sort of in a way, it's an extension of fear and worries, you know, when you're actually really panicky. So there may be rapid breathing and sort of air hunger along with that. So it's a classic panic attack. There may be post-traumatic stress disorder. So in those patients who had a terrible experience of going on an ICU, ventilation, etc., etc., in the you know, in the acute phase of their illness, they may be having flashbacks or flashbacks or nightmares still as a result of those experiences. So that's post-traumatic stress disorder. Another manifestation of anxiety is is sort of social fear of fear of being outside with other people, social phobia, a shyness that has come about as a result of your long COVID. Then there's OCD, obsessional compulsive disorder, you know, that checking, checking the windows are shut, checking the car doors are shut, um, maybe even excessive washing of hands, etc. So again, we see we are seeing more of that in our patients with anxiety, anxiety along with their long COVID. And then finally, anxiety can sometimes morph into depression. So that that feeling of being flat, unhappy, you know, everything's, you know, pretty doom and gloom, and sadness, unrelenting, uh unrelenting, unforgiving, sadness, which of course is really concerning, and that in itself, depression in itself, is a condition on its own. And I'm I've done a sort of an update on that as well. Um, but you know, obviously that's something to be taken very seriously, particularly if there are feelings of that sort of feelings and thoughts of self-harm. So that's obviously a red flag. Got to be taking that really seriously and asking for for help from sort of the certainly your GP, but a GP will want to refer you to the mental health services, maybe even a psychiatric uh assessment to make sure that nothing, no harm comes of you. So, question, why do you get anxiety in long COVID? You know, what are the causes of anxiety in long COVID? Well, there's sort of an assumption that that it's the effect of long COVID on you and your life and and your life, you know, and your lifestyle that has brought about anxiety in you. And, you know, the the effect of uh on your confidence, your self-confidence, and the effect on your self-belief that has been knocked as a result of your your long COVID. And then also, you know, the effect that long COVID has had on not only yourself, but also the knock-on effects with the family, the knock-on effects with you and work, and maybe not being able to work, or not working at the full capacity, or not being able to um work to the same level that you had that you were able to before. And so obviously, not being able to work or only working part-time, you know, that has a knock-on effect with your financial status. Obviously, very concerning. There may also be, and certainly a source of concern or worry in a lot of patients, is that feeling that you know you're just not getting better. It's taking so long. Or if you are getting better, it's taking so long to make those small increases. Or there may be that feeling that, you know, if you get COVID again or another illness, then you'll be knocked back to square one. Or maybe worries that actually there's no real treatment and I'm never going to be right again. So all these natural, understandable worries bring about anxiety. Um, but you know, people think that, or those of you those people who don't have long COVID think that really that your long COVID anxiety is all due to those causes and nothing else. But we all know that that's absolutely, absolutely incorrect. It's that's rubbish, basically. You know, because don't forget what's happened in your long COVID. Your long COVID has come about because of the virus has caused its damage and dysfunction in your body, in the cells, in the tissues, in the brain, in the heart, in the lungs, and the gut. Okay? Long COVID, after all, we know the causes, don't we? We know that it's due to inflammation, excessive inflammation, inflammation. It's due to dysfunctional immune system. Your immune system is not working properly. It's due to sort of the creation of autoantibodies, so antibodies against our normal tissues. It's due to mast cell, mast cell activation, again, part of the excessive inflammatory response. It's due to gut dysbiosis, so a combination of all these things. So any one person with long COVID is going to have all of those things to a varying degree. Some more, some less. But all those effects, all those causes are having an effect on the brain, uh, the whole body, of course. But in this situation, this talk on anxiety and long COVID, all those processes are having an effect on the brain and the nervous system. And so consequently, the nervous system, the autonomic nervous system, sympathetic nervous system, the parasympathetic nervous system, the balance is gone. So there's excessive fight and flight, excessive sympathetic nervous system response. There's also the stress response, and so there's cortisol hormone being secreted from the adrenal glands, and that feeds to the brain and everywhere and contributes to anxiety. Then brain chemicals we know are affected by things, those processes, those long COVID processes that happen in the sort of the disease process of long COVID. And so neurotransmitters, the brain chemicals are affected. So serotonin, the happy chemical, uh, is affected. GABA is the sort of the calming chemical, is affected in long COVID for all those reasons because the neurotransmitters are affected. Then there are going to be effects on the limbic system, and limbic system is the sort of, if you like, the emotional regulation system in the brain. It's a very primitive, it's not the most primitive part of the brain, that's the brainstem, but it's the next most, it's the basically call the the the the uh reptilian brain. Not the reptilian, the mammalian brain. Um and and there are parts of it that are, well, they're all it's all affected in long COVID, but there's the amygdala, the part of the brain that is responsible for fear responses and frightening memories. That is affected in long COVID, as is the prefrontal cortex, the area in the brain that is responsible for thoughts and and sort of executive functions and controlling of responses. And then finally, the brainstem, the the primitive, the most primitive part, the reptilian brain, is affected in long COVID, all those processes, the inflammation, etc. etc. Um, that brings about something called a sickness behavior response. So, long story short, basically, all those processes are affecting anyone with long COVID. And so they are contributing to anything that's not good that's going wrong within the normal functioning of the brain cells, the brain, neurological processes and pathways, and that's then going to cause an anxiety, as well as all the other things. So it's not all due. The take-home message is, and you know this already, it's not all due. Your anxiety, long COVID anxiety, is not all due to the effect of long COVID on your life and lifestyle. It's also due to the physical effects of on of long COVID on you. This is really important because it it helps your self-belief. You know, you can actually understand why it is. Okay. It helps with your validation. You can tell people, tell others, those disbelievers, if you like, those skeptics, that this is not imagined. It's not in all in my head, you can say, but there are because there are physical reasons behind my symptoms, and in in this case, behind my anxiety. So those are the causes. Really important you take those on board because that'll help you, I'm sure. I hope, and I'm sure they will.

Speaker: 15:24

Um, so what should you do? Well, anything new, and I say this every time, and that is anything new, take it to your doctor, report anything new. Don't suffer in silence. So, what will the doctor do? Your GP, your family doctor will take the story, hear your symptoms, the whole story. And the GP will want to know the effect, and they sh and you should tell the effect that your symptoms, and in this case, the your anxiety is having on you. GP, of course, will wanting to ask, you know, are there any physical symptoms? You know, so I mentioned tremor, you can get that in anxiety, but you can also get that in excessive thyroid function, thyrotoxicosis, um, palpitations, likewise, but also you can get palpitations in anemia. So your doctor, if you're experiencing these symptoms, will obviously, hopefully, uh send blood tests off looking for those other causes and ruling them out. The doctor, of course, always looking out for a red flag. Is there anything? A red flag, remember what I've told you before, and that is a red flag is a symptom or a sign that is suggestive of something more sinister happening, something that you need more urgent treatment for or referral onto a specialist in the hospital. So I've already sort of mentioned the red flag that we in general practice would be looking out for, and that is if the anxiety has morphed into a depression. And they can do that, okay, when you're anxious for a long time, really concerned, really worried, then sooner or later it can become slip into a mild depression, which can be become a more severe depression. And so the GP will be looking out for those red flags of, like I said, any feelings of self-harm, any sort of hopelessness, wanting to give up, etc. Because the patient, your the GP's patient will need referral to mental health services for uh for help, you know, to prevent you know any harm coming to him or her. So having been through all that, yes it's anxiety for obvious reasons, as in the impact long COVID has had on you, but also for those physical reasons behind long COVID. How are we gonna help anxiety in long COVID? Well, first and foremost, always some self-help. Okay, self-help, what sort of things can you do? Well, there's what we call now journaling, which is a fancy description label for write it down on a piece of paper, get it out into the open, and you know, see it there in front of you in black and white, but don't bury it, you know. But this is a really important process because it actually helps you see things, put things into perspective. Actually, you've written it down, that's the extent of the problem. Hmm, right, okay. Right, I've got a handle on that now. What am I gonna do about it? Right. Well, that's really helpful. Um the other thing that is really uh backed up by medical research, um, helpful in this whole process of, if you like, sort of stabilizing and and sort of seeing things in perspective, getting things in proportion is the med is mindfulness meditation. Mindfulness meditation, got my mem M's mixed up then. Mindfulness, so mindfulness. So this is an amazing process that has so many research studies to back it up that it's actually uh uh has an effect on the way you think, has an effect on the brain. Yes, brain scans demonstrate the changes that happen in someone who practices mindfulness on a regular daily basis for about 20 minutes. That's all you need. Practicing mindfulness brings about change. It helps you focus on the now, on what's happening now, not worrying about you know the past, because if you worry about the past, you get depressed. Not worrying about the future. If you worry about the future, you get anxiety. So you're focusing on now. That is what mindfulness is all about. So how do you go about learning mindfulness? Well, the easiest way is to, well, there are lots of courses, of course, but of course, of course, of course, um, the easiest way I think is to download an app onto your mobile phone. Either there are a number of them, but I think the ones that I think that I've looked at, I've looked at them all, uh, the ones that I really like are Headspace and Calm. Okay. They're not very expensive, but there are lots of guided mindful exercises for you to follow and sort of get into this, this sort of habit of doing mindfulness. And it it sort of um it tutors you on how to get the most out of it, and it's really good. Um along with that, there's yoga, of course, or tai chi. Again, in a way, it is more or less the same thing in that you're focusing on what you're doing at the time. Obviously, it's more of an active process, it's a mind-body thing, mindfulness and uh is yoga and tai chi. Um, but again, the the the sort of the um uh the the drive behind it or or or or the strategy is all to do with focusing on the now. Okay. Again, also backed up by lots of studies. Um so those are the self-help ways to manage anxiety. What else can you do? Well, the next, if you like, level is talking therapies. Okay, so these are evidence-based psychological therapies for anxiety and depression. You can uh access them on the National Health Service, you know. So I'm talking from my perspective of where I work, and that is the United Kingdom in the UK. So basically, you can self-refer yourself to talking therapies, or you can get your GP, your family doctor, to refer you to uh talking therapies. Um that is either face-to-face seeing a protect practitioner, or um on the phone or video link, um one-to-one, if that's what you prefer, or group, or some people will start one-to-one and then join a group, because it's actually really helpful. It's what a lot of patients have have told us, it's really helpful to um work together and share experiences and share um sort of ways that you tackle your particular problem. There are a range of talking therapies. Okay, so there's CBT, cognitive behavioral therapy, you may well have heard of, and it's to help change, you know, those unhelpful patterns of thinking and behavior. Cognitive behavioral therapy, CBT. And then there's um uh EMDR, so eye movement, desensitization and reprocessing. This is excellent for post-traumatic stress disorder to help reprocess those memories of a traumatic or distressing event, EMDR. And then there's MB CBT, so mindfulness-based cognitive therapy, which combines mindfulness techniques with CBT to sort of, you know, just a dual approach uh to make it even more effective. And then finally, there's acceptance or commitment therapy, commitment therapy, ACT, to help accept the current situation, accept your, if you like, your long COVID, um, and to set about a plan to a plan of action to commit to. So accept act, acceptance and commitment therapy. So acceptance and commitment, acceptance of the situation and commitment to the plan of what you're gonna do to help. So all of those talking therapies, again, they're all evidence-based remember, remember what I said at the beginning? They're all evidence-based practices, medicine, i.e., they are supported by research, and that research is published in reputable uh journals. So um and then, so I've talked about self-help, I've talked about talking therapies, and then sometimes actually you do need some medication to help you. And there are a number of really excellent, and I'll put it inverted, commas, clean um treatments these days, pharmacological treatments. So there are two main groups for anxiety, uh anxiety, and that is the SSRIs, so selective serotonin reuptate inhibitors. Two of them, E cetalipram and um paroxetine, have a license for GAD, generalized um uh anxiety disorder, GAD GAD. Um but in reality, and certainly my experience in general practice was that cetalepram and uh surtraline, so related to same, both of those are SSRIs, um they are, if you like, more commonly prescribed. And so we feel more more comfortable in something that we're comfortable and familiar with because of by virtue of the fact that we use them more frequently. Don't really know why, but in a way, that those are the those are the drugs that that if you like one thinks of, first of all, when you're dealing with with certainly because there are they are antidepressants, but they are excellent for anxiety as well. But like I said, the peroxetine and the esetalopram are the ones who actually have a license for GAD, generalized uh anxiety disorder. But you know, the other ones actually I think are are personally more effective. The ones that like those two, the cetalopram and the cetraline, are, if you like, off license because they don't have um that license for GAD. But essentially they work the same way. They are happy chemical, that is serotonin, um increase the levels of that serotonin serotonin, and that seems to be the thing that brings about their anxiety rellering effects. The other medication which is used for anxiety is the SNRI, so serotonin, neurotrenin, reuptake inhibitors. Venlofaxine is the one that is most frequently prescribed because it has a license for panic disorder. Very helpful. Like I said, that's one of the manifestations of anxiety in long COVID. So all of these are taken under the supervision of your GP. You know, they're discontinued when the time is right. You can discontinue it when the time is right, but with the guidance of your GP. So slow, graduated reduction to prevent any side effects. The other drug that that is much older and has been around for donkeys' years, and I'm sure you've all heard of is phallium benzodiazepine called diazepam. This is really only used for extreme, sort of acute, extreme, acute anxiety, because it's a drug, it's a benzodiazepine, which which is a class of drugs, uh what we used to call a minor tranquilizer, which is addictive, unfortunately. So the longer you use it, the less effective it becomes, so therefore the effect wears off. So there's the temptation to increase the dose and then you become dependent on it. We really don't use it in general practice very often, apart from those acute anxiety uh presentations. You may have heard of other sort of treatments that that are on the web, or some people are claiming that it actually helps them. And so those treatments such as herbal herbal medicines. Okay, so they're not strictly evidence-based medicines, you know, with with respectable random control trials uh that are published in in so lot respectable in i.e. large numbers or um placebo control or published in respectable journals, respected journals. Um and so you know always be a bit wary of something that, if you like, doesn't have that evidence base behind them. Um but also be careful because anything herbal can clash with conventional medicines, and that leads to adverse effects. So you may well have heard of um Ashwagan, Wangander and Passion Flower and Lemon Bar, chamomile, valerian, or rescue remedies, those flower, flower remedies, flower essences. So people use them, and you know, if if that helps, helps them, that's fine. But you know, we we obviously we we hope that the patients choose wisely and check the small print and run it past their own GP and stop them if you know they're causing any side effects, or certainly stop them if they're not helping. Other other sort of strategies people employ would be sort of TCM, traditional Chinese medicine, acupuncture, or homeopathy, or aromatherapy, reflexology. Really, it comes down to you know what works for the patient, but as long as they are safe about it. That's the message I'm trying to get across. So those are the treatments, like I said, self-help and talking therapies and medication. So what can we expect from long COVID anxiety? What's the what's the journey? What's the trajectory? Well, basically, with long COVID recovery, uh, we know it's as long as a slow process, but as you recover from your long COVID, you know, and inflammation settles, calms with time, and you know, autob antibodies, you know, clear with time, and you know, damaged nerves, repair, regrow with neurosplasticity, and you know, those little money, mini blood clots clear with time. Uh and mass cell activation settles, maybe with or without um H1 and H2 blockers, or and dysortonomia, hopefully, also settles with time. You know, with all along with all those, you know, with time, the recovery from your long Cobi, along with what I've been explaining, that is so journaling, getting it done on paper and and talking therapies and maybe some medication, all of which, you know, you know, will go towards the slow improvement and resolution of your anxiety. Um and you know, all of those, all of those strategies and things can be, you know, discontinued when you are improved. It's just going to take a long time. But with long COVID, obviously, to bring about settling all those other underlying causes, the inflammation, etc. etc., you know, we've got to be looking at the bigger picture of long COVID and and sort of looking at at the sort of, you know, all the energy management. We've got to, you know, we've got to be because we're tackling our fatigue at the same time. So we've got to be thinking of the three Ps. We've got to be thinking about diet and nutrition, eating a mixed balanced diet for all our building blocks and the anti-inflammatories in a mixed-balanced diet, and also the prebiotic to nourish your gut microbiota. And then there's sleep, you know, the importance of decent sleep and restorative functions of sleep. And then there's the sort of, you know, the the the other factors like, you know, connecting with other people is very, you know, COVID uh during acute COVID, obviously, we were all social distanced and staying at home, etc. etc. But connection is really important for um sort of helping our general well-being.

Speaker: 35:16

So there we are. That is the update on anxiety in long COVID. I hope you found it helpful. And as I said at the start, you know, this is an educational series or for those of you who still have long COVID. So if you found it helpful, share it with anyone else who you also know has long COVID. Um, but remember, of course, remember my usual disclaimer, anything that I've said and any advice or treatments that I've given you, obviously, you know, run them past your GP first of all. Uh remember, safety first. So, um, like I said before, you know, if you found it helpful, click subscribe, spread the word. Um, thanks again for all those sort of comments and and um and sorry about the queries that I can't respond to. I wish I could, lack of time, sorry. But so there we are. So like I said, I hope you found that helpful. So in the meantime, I wish you well with your recovery, and uh and I wish you all the very best. So here we go.