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Exacerbation of anxiety symptoms in the setting of COVID-19 pandemic: An overview and clinically-useful recommendations

Gustavo C Medeiros1, Scott R. Beach2,

1 Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA

2 Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA


Received: 08/06/2020 – Accepted: 22/08/2020

DOI: 10.15761/0101-60830000000281

Medeiros GC / Arch Clin Psychiatry. 2021;48(1):69-70

The emergence and rapid spread of the coronavirus disease 2019 (COVID-19) have caused dramatic life changes, including disruption of socioeconomic dynamics, in the setting of measures to reduce the dissemination of the disease1. The first COVID-19 case was confirmed in November 2019 and, as of June 8, 2020, the virus had already been isolated from approximately 7,000,000 persons worldwide, leading to more than 400,000 deaths2. Many countries, including Brazil, still are in the acceleration phase of the infection. Therefore, it is likely that the pandemic will affect many more individuals, and it is unclear when more intensive preventive measures will be no longer recommended.

Evidence from previous outbreaks and initial data from the COVID-19 pandemic indicate that distressing psychological responses are frequent in these situations1,3-5. Among them, excessive anxiety is one of the most common dysfunctional responses1,3,4. Individuals with psychiatric disorders, particularly those with anxiety and trauma-related disorders, are at increased risk for excessive anxiety. Some common symptoms of anxiety exacerbation are insomnia, irritability/anger, a decreased sense of safety, difficulty relaxing, restlessness, fatigue, excessive worrying, and nervousness1,3,5. The following case vignettes illustrate currently common situations in mental health services.

Case vignette: A 25-year-old woman with generalized anxiety disorder and posttraumatic stress disorder secondary to physical and emotional abuse first sought care for psychiatric symptoms about 5 years ago. She had a good response to sertraline and pregabalin combined with eye movement desensitization and reprocessing (EMDR). In the 3 months before the outbreak of the COVID-19, the patient was psychiatrically stable, socially active, and very functional. In her follow up appointment on March 19, a few days after more intense measures against COVID-19 were announced in her region, she was more much more anxious than usual, and complained of insomnia, restlessness and occasional tremors. The patient reported excessive worry with social isolation, and concerns that she will not be able to refill her medications or to continue her EMDR treatment.

In addition to patients with psychiatric disorders being at elevated risk for excessive anxiety in the setting of pandemic, there is some evidence linking other characteristics to more significant psychological impact and anxiety in response to COVID-19. They include: 1) female gender3,4, 2) lower household income3, 3) being a young adult or an elderly person3 (the latter is a group particularly vulnerable to COVID-19), 4) being a healthcare worker3, 5) pregnancy3, 6) lower formal educational level3,4 (potentially due to more difficulty accessing online and smartphone-based interventions), and 7) living in an area that has been more substantially affected by the COVID-19 pandemic. It is not possible to design one-size-fits-all therapeutic interventions, and customization is needed. However, Table 1 provides some general guidance.

Table 1. Possible interventions to manage excessive anxiety related to the coronavirus disease 2019 (COVID-19) outbreak.

Anxiety-provoking situation

Possible interventions to manage anxiety


Inaccurate information and rumors about the COVID-19 outbreak.

- Educate patients using evidence-based and timely data

- Provide reliable sources of information such as the World Health Organization website

- Suggest checking news about the COVID-19 situation no more than 2 times per day

- Politely correct inaccurate information provided by the patient

Financial difficulties, which are more common in those self-employed and/or those who are unable to take paid absences.

- Provide information about programs that provide financial assistance

Separation from loved ones, decreased socialization and sense of isolation.


- Recommend keeping in touch with loved ones through social media, videoconference and phone

- Recommend reaching persons that the patient trusts such as community or religious leaders

- Provide contact information for crisis hotlines and online support groups

Healthcare workers dealing with patients infected by COVID-19

- Provide sources of psychosocial support

- Enhance the sense of purpose

- Utilize meditation.

Fear of acquiring with the virus and/or infecting others.


- Validate that some level of anxiety is understandable

- Make supportive statements without negatively affecting public health interventions

- Educate patients about hands washing, coughing etiquette, face coverings and other preventive interventions

- Nurture altruism

Not being able to continue appointments or to obtain prescriptions

- Establish a plan to continue mental health treatment through telemedicine using phone or video

- If the treatment needs in-person contact (such as eye movement desensitization and reprocessing), consider temporarily changing to another modality that might be delivered through telemedicine, such as supportive psychotherapy

- If available, consider home delivery of medications

Worsening of family conflicts and domestic violence, due to increased time spent with family members

- Establish safety plans

- Provide phone numbers of domestic violence hotlines

Physical and emotional symptoms of anxiety might reinforce distress

- Recommend physical exercise, relaxation techniques, and/or pharmacological management

- Recommend against the use of alcohol and other drugs to manage acute anxiety symptoms

Frustration and boredom

- Engaging in enjoyable activities and hobbies


The negative psychological impact of excessive anxiety might be felt not only acutely but also long after the pandemic3. Therefore, facilitating access to evidence-driven mental health care should be part of the interventions to minimize/manage the impact of COVID-19. At-risk groups should receive more intensive and earlier mental health support.

Conflicts of Interest and Source of Funding

Dr. Gustavo C. Medeiros is supported by a National Institute of Mental Health of the National Institutes of Health under Award Number R25MH101078. Scott R. Beach have no conflicts of interests to report. This letter did not have any source of funding.


  1. Committee I-AS. Briefing note on addressing mental health and psychosocial aspects of COVID-19 Outbreak -Version 1.0. 2020.
  2. University JH. Coronavirus Resource Center. 2020.
  3. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet. 395(10227): 912-920.
  4. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china. International Journal of Environmental Research and Public Health. 2020;17(5):1729.
  5. CTST. Taking Care of Patients During the Coronavirus Outbreak: A Guide for Psychiatrists. 2020.