Addressing Patient Anxiety During COVID-19 Pandemic

Amber Luong, MD, PhD, was examining a patient with severe chronic rhinosinusitis and nasal polyps last summer when she asked the patient how she was doing. The woman burst into tears.

Dr. Luong, professor and vice chair for research in the department of otorhinolaryngology at the John P. and Katherine G. McGovern Medical School of the University of Texas Health Science Center at Houston, had just scoped the patient, a woman in her 60s with aspirin-exacerbated respiratory disease and a history of multiple sinus surgeries; Dr. Luong had done her most recent revision.

“Everything looked pretty good,” Dr. Luong said. “Her frontal sinus common cavity was healthy and open. There was no inflammation. There was no pus. She looked even better than the last time I scoped her.” But the patient was having bad frontal headaches again, and something just seemed off. It all came to a head at her appointment.

At a time when things have been off for many of us, otolaryngologists are seeing patients whose symptoms may be caused by disease or, alternately, by the resulting anxiety and depression that has accompanied the pandemic. In addition to deadly outcomes for more than half a million Americans, COVID-19 has also brought many months of uncertainty, social isolation, and grief.

Through patience and perseverance, some physicians have been able to help patients who are struggling beyond the typical otolaryngology issues. Here’s how they do it.

Tune In

Cristina Cabrera-Muffly, MD, an otolaryngologist and residency program director at the University of Colorado (CU) School of Medicine in Aurora, said one of the things she tries to teach residents is to pay attention to how a patient makes them feel during an encounter. “When I find myself feeling anxious or depressed during a visit, it’s often my signal that this may be coming from the patient and that I need to address their feelings,” she said.

This exact situation had happened during Dr. Luong’s appointment. She found herself thinking more about how uncommonly quiet her patient seemed than about a recurrence of sinus disease. “As soon as I asked what was going on, she started crying and let it all out,” said Dr. Luong, who soon discovered that it had been five months since the patient had seen the grandchildren she used to babysit every week. “I told her that sometimes these feelings can cause symptoms that mimic chronic disease, like headaches, sinus pressure, and pain,” said Dr. Luong.

I had an increase in the number of patients presenting with globus sensation or other vague throat discomfort. Especially in those with limited objective findings, pandemic-related anxiety likely played a part in the etiology. —Scott Mann, MD

During the five to 10 minutes Dr. Luong spent talking to her patient, she reassured the woman that she wasn’t alone in having these feelings—they were totally normal and appropriate during a pandemic. She encouraged the patient to seek counseling, if needed. The patient said she was upset but didn’t think she needed counseling at that time. They scheduled a recheck for a month later.

Dr. Cabrera-Muffly too has found it helpful to acknowledge to patients who look good but feel bad that it’s a very stressful time, and this is likely making their symptoms worse. “I’ve found that patients seem more willing to acknowledge stress as a factor affecting their health over the past year than they’ve been before,” she said. “That’s one of the rare positive outcomes of the COVID-19 pandemic—I feel that we’re easier on ourselves than we have been.”

Health Anxiety and Chronic Conditions

Chronic conditions can be accompanied by mental health concerns. A systematic literature review recently published in PLoS One found that as many as 20% of people with chronic illnesses have health anxiety about their condition progressing or recurring (PLoS One. 2020;15:e0234124). Add a pandemic to the mix and that number likely increases.

Most otolaryngology practices do not have a formal anxiety/depression screening on intake for their patients. Dr. Luong thinks, however, that it may be a good idea to have nurses ask patients a few questions about increased stress or changes in eating, sleep, or mood to screen for anxiety or depression before the doctor comes in, particularly for patients with chronic rhinosinusitis (CRS). According to a 2019 study Dr. Luong co-authored with colleagues in the department of otorhinolaryngology at McGovern Medical School at UTHealth, depression may be underdiagnosed in patients with CRS. The paper, presented at the American Rhinologic Society, assessed the prevalence of depression in a rhinology practice by comparing results of the Patient Health Questionnaire-9 (PHQ-9), a depression screening tool, to the 22-item Sinonasal Outcome Test (SNOT-22) used to screen for sinonasal symptoms. The study found that depression rates, as estimated by PHQ-9 responses, were similar to those in all chronic disease populations, and that higher SNOT-22 scores are associated with higher PHQ-9 scores. “From working on that paper, I’m more inclined to consider a patient’s mental health when treating their chronic disease,” Dr. Luong said.

Scott Mann, MD, assistant professor of otolaryngology at the CU School of Medicine in Aurora, said that 2020 brought significant changes in the conditions he and his colleagues have been seeing, some of which may have had a mental health component. “I had an increase in the number of patients presenting with globus sensation or other vague throat discomfort,” he said. “Especially in those with limited objective findings, pandemic-related anxiety likely played a part in the etiology. We also noticed an increase in symptoms that can be exacerbated by anxiety, such as tinnitus, temporomandibular dysfunction pain, migraine variants, and muscle-tension dysphonia.”

Another mental health issue that may come up for sinus and chronic cough patients is the anxiety brought on by the fear that these might be symptoms of COVID-19.

“In many cases, particularly with cough, patients find that they are isolating themselves further due to their perception of how other people perceive their runny nose, sneezing, or coughing. This can be incredibly stressful to patients,” said Michael Benninger, MD, chairman of Cleveland Clinic’s Head & Neck Institute and a professor of surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio.

Rule Out Physical Causes

Before attributing any symptom to stress or psychological issues, it’s critical to make sure there isn’t a physiological basis for concern, according to pediatric otolaryngologist Ellen M. Friedman, MD, professor of otolaryngology–head and neck surgery and director of the Center for Professionalism at Baylor College of Medicine in Houston. “There are certain coughs and throat clearing that do have a characteristic quality consistent with a psychological problem,” said Dr. Friedman, “but even then, I take steps to be sure that there isn’t another coexisting medical issue.”

During the pandemic, Dr. Friedman has seen an increase in stress-related symptoms in children as young as three, including facial tics and throat clearing, and has found that the number of these patients with stress-related symptoms is higher than in all previous years.

When Dr. Friedman is satisfied that there’s no ongoing physiological concern, she tells the family that the good news is she has been able to rule out many of the really serious medical problems that can cause the cough or tic. She then wonders if stress could be responsible for the new-onset behavior in their child. Most of the parents seem relieved and acknowledge that they themselves thought the symptoms might be behavioral or stress related.

“The families then go on to relate the stress associated with the pandemic—for example, not seeing beloved grandparents for an extended period of time, missing planned vacations, or financial worries. I find that reassuring them that I’ve seen other children of a variety of ages with similar presentations is effective,” Dr. Friedman said.

She also offers to arrange a visit with a psychologist or a social worker. While some families decline, saying they’re adequately reassured that the problems are stress related and will take steps to lessen the stress in their home environment, others are grateful for the referral.

Dr. Mann believes his first role is to be a good detective and investigate symptoms with an open mind. When patients have conditions that are exacerbated by stress or anxiety, he shares his concerns that their symptoms may be affected by their mental state. He finds that often the patient agrees and is happy to have a provider recognize this. He also finds it can help with their buy-in on treatments or further testing that he recommends.

“The difficulty is when patients present with somatic complaints that have no objective findings. When patients suffer from a medically unexplained symptom, invasive testing or procedures often aren’t beneficial if they return normal results,” he said. “Instead of reassuring a patient, they can actually increase the patient’s health anxiety and worsen their symptoms.” He added that if a reasonable workup doesn’t produce objective evidence of disease, then the best way to help the patient is to limit further testing. “I usually offer reassurance only and then communicate directly with the referring physician about my concerns,” he said.

Make Peace with Uncomfortable Feelings

For some otolaryngologists, talking about feelings with patients may bring on uncomfortable feelings of their own. They may not know what to say or prefer to stick to their area of expertise, which is fixing the physiological problem at hand. But whether a patient is upset during a pandemic or upset in general, sometimes all one has to do is be present for them.

It’s hard, but as physicians we need to remember that it’s okay to feel uncomfortable. Even just sitting with someone can be amazingly helpful. —Amber Luong, MD, PhD

Dr. Luong said she has had several patients upset for various reasons, not just COVID-19-related, and while it may not be easy, she considers it a privilege to be there for them.

“It’s hard, but as physicians we need to remember that it’s okay to feel uncomfortable. Even just sitting with someone can be amazingly helpful,” she said. “Being a doctor isn’t just about disease; it’s about helping people. Something as simple as letting them talk and really listening can go a long way. And it really doesn’t take a lot of time.”

Dr. Mann doesn’t shy away from speaking with his patients about emotions either, finding it helpful to do this first during an appointment, which makes it easier for him to pivot to his other medical recommendations later. “Engaging them, even briefly, about their emotional state can build a stronger therapeutic relationship and validate a patient’s concerns,” he said.

Reap the Rewards

Dr. Luong said that when her emotional patient returned a month later for a recheck, she seemed like “a totally different person.” The patient said she was grateful that the doctor was able to notice how sad she was about being unable to see her family and that having someone notice something she couldn’t quite put her finger on had made her feel much better. The patient also emphasized how much she appreciated her doctor taking the time to talk with her about what she was going through.

“Yes, a lot of symptoms can overlap,” said Dr. Luong, “but what I learned from this experience as a physician is that we have to remember that our first art is observation. When things don’t match up, we have to take a step back and observe what’s going on, particularly when people are going through emotional things that can mimic various diseases or even make those diseases worse. Even if I saw something more obvious in her sinuses, I should still investigate further, because she just wasn’t acting like herself.”

---

Renée Bacher is a freelance medical writer based in Louisiana.