Why am I still feeling anxious now I am recovering from Covid?

You, or people around you, might expect you to have left any fear and anxiety behind when you left hospital, or after a certain amount of time has passed. They may even say things like “well you can relax now that you know you’re out of danger”. If you’re only able to remember one thing from this section, we hope it is this; having Covid, being in hospital, or trying to seek help out of hospital, can really frightening experiences, therefore:

Fear is a normal, helpful, part of our make-up, if we really had no fear, we would likely be involved in some kind of accident very quickly. The fear response is sometimes called the “Fight or Flight” response as it involves a series of reactions that happen automatically in our bodies; these include raised heart rate,  breathing faster, sweating, blood diverting from the digestive system leading to “butterflies” sensation, and narrowing of attention. These can seem quite strange or frightening, but they all serve a function. The “Fight or Flight” response provides what could be a life-saving edge if we are faced by physical danger, such as a wild animal. However, many of the things that trigger this response in everyday life aren’t immediate physical dangers. For those situations, it can be helpful to use ways of reducing this response.

The fear response is activated very quickly but takes much longer to “reset”. If you are faced by a frightening situation, say walking in the park and a vicious dog suddenly appears barking and showing its teeth, you won’t need to wait for your fear response to kick in. It will probably happen before you even realise as it relies on a part of the brain that is activated before our conscious thoughts. However, if you walk through the same park the next day, or even the next week, you will almost certain experience some of the same anxiety you felt before, even if the dog isn’t there, because your mind has learned an association between things in that environment and danger.

If you were in hospital the response works in the same way, your brain may well have learned an association between certain physical sensations, images, sounds, smells etc and danger. This means that if you experience certain sensations, such as feeling like you can’t breathe, or have an image go through your mind (or a nightmare) of the ICU, your “Fight or Flight” response may be triggered automatically.

Over time, this response will gradually reduce, but it may take weeks, or even months and there are some things that can get in the way of this natural “resetting” of your fear response.

These include:

• Avoidance – Sometimes people avoid any reminder of the traumatic situation.

• Suppressing thoughts and images – It make complete sense to try and prevent distressing thoughts or images from happening, psychologists call this “suppression”. However, research shows that trying not to think about something often has completely the opposite effect. If you find this hard to believe- try this experiment. Try hard not to think about a giant pink rabbit – it should be easy; you would never think about a giant pink rabbit! However, after 5 minutes you might be surprised to find that the only thing you can think of is that great big pink cuddly creature!

  If you are experiencing intrusive images and thoughts from being in hospital, or other traumatic events, it can be helpful to know that these are your brain’s way of trying to make sense of your experiences. You can also take some of the fear out of them by reminding yourself that you are safe now. Short-term distractions can help too. This is not the same as trying to supress the intrusions. Instead, it is a way of gently focusing your mind elsewhere, for example by naming five things that you can see, five things you can hear and five things you can feel.

There are other things that can keep fear going, (just like continuing to add fuel to a fire that otherwise would go out) these are:

• Your attention becoming excessively focussed on your body sensations. We naturally focus our attention on things we are afraid of, again we don’t need to think about doing this, it happens naturally. If the person in the example returns to the park, they are likely to be on the lookout for any dogs coming near them. In the same way, if you experience a frightening physical symptom it’s normal for your attention to become focussed on it.

  However, if your attention focusses on a part of your body, you automatically begin to notice things that you would not normally notice, and these become amplified. You can test this out by focussing your attention on your right hand (or left hand, or foot, whichever you prefer). Try to focus all your attention on that part of your body, do you notice anything? Is it Tingling, feeling hot? You almost certainly noticed far more than you usually do. To readjust, find something else to focus your attention on like watching the TV or get up and go for a short walk.

• Unhelpful thoughts and beliefs – Most of the time we don’t pay much attention to what goes through our mind. When someone asks us “What were you thinking about just then?”. We often truthfully reply, “I don’t know”. However, what goes through our mind plays a key role in keeping the anxiety “fire” alight. For instance, if every time you hear a noise in your home you were to think “Someone’s trying to break in!” you would feel on edge pretty much all the time. Of course, it’s possible someone is trying to break in but there are also many other, more likely, explanations such as “it’s just the wind, a cat, next door’s TV” etc.

  Unhelpful thoughts often pop into people’s minds automatically during recovery and can take many forms ranging from “I’m having a heart attack!”, “I’ve got the coronavirus again”, or “I’m never going to get any better than this!”

  If you try and notice what’s going through your mind when you are feeling particularly anxious and write them down, you can catch your own unhelpful thoughts. Your first thought might be “Well I’m going to make sure I stop myself thinking that from now on!”. However, since we know that thought suppression is not helpful, hopefully you will think “Although I can’t stop myself having worrying thoughts, I should be able to cope with them differently”.

  So what can you do? One approach is to think of alternatives to the anxious thought and test them out. In the example above, the noise at home could have been due to lots of things, which are actually more likely than a burglar. So, if your anxious thought is “I’m having a heart attack!”, you think of these alternatives; “I’m just not as fit as I used to be” or “I’m having a panic attack”. Testing these alternatives might involve asking yourself “Do these symptoms match having a heart attack?” “Have I ever had these symptoms before? What happened then?”, “Has my GP/physio/nurse given me an explanation of what might explain me feeling these symptoms when I try and walk around the park?” 

  You can do this more easily by writing a ‘balancing thinking’ chart:

  1. Draw a table with two columns.

  2. Write your unhelpful anxious thoughts in the first column, then more balanced thoughts in the second.

  3. For example, in the first column you may write “My chest feels tight, if I’m not breathing properly I might have a heart attack” and in the second, “The doctor said it will take some time for the stiffness in my lungs to get better but she explained that I’m still getting plenty of oxygen into my body and doing the exercises I’ve been given will improve my health”.

      

• Checking and reassurance seeking– If you have a worrying physical symptom, it makes complete sense to keep an eye on it. Maybe keep checking it every hour, or ask a family member if they notice any changes. If it is still there phone 111 or go to your GP.

  However, frequent checking can also keep anxiety going. Checking causes us to notice things that we wouldn’t normally because it shifts our attention, as explained above. If you think that checking your body might be making your anxiety worse try gradually reducing it. You can do this by making a schedule to check, say every two hours to start and then gradually reduce how often you do so every day over a week.

  Reassurance seeking – If you notice a symptom, particularly if its new, it’s natural to want to know what it is. However, sometimes when we seek help and go to a doctor we are sent for tests and, if they come back normal, we’re told “well we know it’s not X, Y or Z”. Often this doesn’t leave us feeling any better, in fact it can make you think “well maybe they missed something?” or “maybe I’ve got W?”. This process can lead to patients going round in circles for months, and sometime even years. A good rule of thumb is to follow guidance from NHS 111 and not to seek help purely in order to try and reduce anxiety.

  One thing that can help is asking your doctor or health professional a different question – “I know that you’ve said this is unlikely to be anything serious but could you help me understand what might be causing the symptoms that I’m experiencing?”. You may well find the answer helps reduce anxiety much more than reassurance or further tests.

  A different type of reassurance seeking is searching the internet or posting on social media. Again, if you are worried about a symptom, it’s completely understandable to try and find information, or to ask other people if they have the same thing and what happened to them. Websites & social media groups etc. can provide incredibly valuable support and reduce isolation, however using them can sometimes also make anxiety worse. This is because, although people posting on social media may be completely truthful about their problems, the overall picture is often not representative. People who had the same symptoms, but they improved quickly without any problems, are much less likely to post about this and therefore the ‘worst-case scenario’ can seem much more likely than it really is. Furthermore, although other people’s symptoms may appear to be similar, in fact, their condition and background may be very different to your own. Therefore, do use the trusted websites and social media groups for information and support but be very cautious about interpreting your own symptoms based on this information.

  Finally, try monitoring how long you are spending on Covid websites and Social media groups and whether you feel more, or less, anxious afterwards. If you think that checking online might be making your anxiety worse, then try taking a break for a couple of days and see what difference it makes. Also you can try and change how you use the site; look for help and support rather for specific answers to worries about your symptoms – try using the advice above about talking to your GP or other health professional about this.

What else can I do to help manage my anxiety and fear?

There are lots of different techniques you can try that can help manage your anxiety and fear:

Set a “worry time”

• We know from the section above that trying not to think about worries is likely to just make them worse. An alternative is to schedule a particular time in the day when you will think about worries. Then if a worrying thought pops into your mind, day or night, just note it down and continue doing what you were doing and come back to it in your “worry time”. 

Keep busy with other things

• When you feel particularly anxious, try distracting yourself by going for a walk or calling a friend.

Get back to normal activities

• Try to gradually start doing things you’ve been avoiding because of your health worries, such as gardening or DIY.

“Just relax!”

Relaxing is often easier said than done when you are feeling anxious and different approaches work for different people. Here are a few ideas

• Visualisation: Find a place (real or imagined) to create a picture of in your mind that brings about a sense of calm or relaxation. You will be able to recognise this when you notice that you start to breathe more slowly, or your shoulders begin to relax.  It might be a blue ocean, a beach, a forest or field or somewhere you have been on holiday. Try and really get a feel for being in that place; What can you see, hear and smell? Would you be able to feel any temperature for example the sun on your skin or a cool breeze across your face?

• Mindfulness meditation is an ancient technique derived from Buddhism, that is practised every day by millions of people across the world who don’t aren’t Buddhists to help manage stress. The main aim is to focus your attention on the present moment and to keep bringing your attention back to this even when it wanders off onto worries and physical symptoms. It takes some time and patience to learn, so if you think this might be a helpful approach, you can try a self-guided learning package online or via an app and, if you find it helpful, try enrolling in an instructor lead class, either online or in-person.

Read more here – nhs.uk/conditions/stress-anxiety-depression/mindfulness

When do I need to seek additional help?

If after trying the strategies in this guide you are finding that you are still experiencing a high level of anxiety, and/or anxiety is interfering with your daily life and stopping you doing things, then do get further help. Talk to your GP and tell them what you are experiencing, don’t feel you need to justify what you are saying by talking about physical symptoms, explain what you are feeling and thinking.

If you are continuing to experience frequent distressing images or thoughts related to your hospital stay or finding that reminders of this lead to an intense reaction, then do mention this to your GP, or another health professional.

Psychological (or “talking”) therapies are available free on the NHS and you can get them online or over the telephone through your local "Improving Access to Psychological Therapies (IAPT)" service.

You can also refer yourself to your local talking therapy (IAPT) service without seeing your GP. Find your local talking therapy (IAPT) service here:  nhs.uk/service-search/find-a-psychological-therapies-service

If you need urgent help, go to your local Mental Health crisis service (your GP will have details) or call Samaritans free on 116 123 or email jo@samaritans.org.

Further resources

nhs.uk/oneyou/every-mind-matters/anxiety

There are also some audio guides on managing anxiety available here – nhs.uk/conditions/stress-anxiety-depression/moodzone-mental-wellbeing-audio-guides

Information on apps to help manage mental wellbeing is available here – nhs.uk/apps-library/category/mental-health