As a rehabilitation psychologist at Rush University Medical Center in Chicago, Abigail Hardin, PhD, has been working with a steady stream of COVID-19 “long-haulers”—people who have not fully recovered after contracting COVID-19. She recently saw a woman who represents many of the cases that come into the hospital’s outpatient clinic: a graduate student in her 20s who had contracted a mild case of COVID in March 2020. In the following months, she began struggling with severe fatigue and intense anxiety.
“She was so exhausted she could not leave her bed for days at a time, and she took a leave of absence from graduate school,” Hardin said. Worries about heart palpitations and shortness of breath sent her to the emergency room, but the doctors dismissed her concerns. Eventually, the woman started having serious thoughts about suicide and went to the outpatient clinic. Hardin educated her about how psychotherapy could help reverse the patterns of thinking and behavior that were intensifying her anxiety and physical problems and referred her to further treatment. “Many of these patients have been told by medical providers that the symptoms are in their head, and they’re surprised when I take them seriously,” she said.
Many of the other patients Hardin sees are living with unrelenting symptoms that seem to have no end, including shortness of breath, shooting nerve pain, headaches, chest pains, fatigue, difficulty focusing, and memory problems. Among those who have returned to work, many admit to Hardin that they are less productive due to “brain fog,” and some have even lost their jobs.
Although it is still unclear why some people experience more fallout from COVID, Hardin is leveraging her training and her research on similar conditions to support these patients as well as COVID patients who experience delirium and cognitive impairment after a stay in the intensive care unit (ICU). She talked with the Monitor about what strategies are effective so far and the needs of this growing population.
How are you helping COVID patients who have just left the ICU?
Many people are understandably concerned that they are losing their minds when they continue to hallucinate after transferring to the rehab unit, and they are relieved when I explain this is a normal brain reaction to an abnormal situation. I teach them about post–intensive care syndrome, which includes symptoms like full body weakness, difficulty swallowing, impaired cognition, and emotional changes such as anxiety and depression. These symptoms are caused by the virus itself, the body’s immune response, prolonged immobility, and certain sedating medications. If someone is experiencing nightmares, flashbacks, or disassociation from life, I talk about acute distress disorder, a precursor to post-traumatic stress disorder. I also teach them relaxation and deep breathing techniques to reduce the level of autonomic arousal, and these strategies have been highly effective. Patients say they are better able to manage their anxiety in real time when they use these skills. Sometimes I join patients in their sessions with physical and occupational therapists to help them manage fears related to getting up, moving, and trusting therapists. I use cognitive behavioral therapy (CBT) techniques to help patients identify automatic thoughts, such as “I can’t do this.” We talk about whether there is evidence supporting that thought or evidence against it. Once they understand how a thought is hampering their progress, we come up with alternatives.
What appears to be working for long-haulers?
I knew that traditional pacing therapy for fatigued patients involved limiting activity to avoid expending too much energy, but I was not convinced this would work with COVID patients. I started studying literature about chronic fatigue syndrome/myalgic encephalomyelitis because it can be triggered by viruses, and I discovered that traditional pacing was not recommended for these patients. Outcomes were better when these patients tried graded exercise therapy, which means they slowly increased their exercise over time regardless of energy level. When long-haulers are suffering from fatigue, we talk about their current physical activity, the importance of doing a little activity every day, and how to use time as a measure for exercise instead of energy level. I also share CBT techniques to help them identify thought-feeling-behavior patterns that are exacerbating physical symptoms, and how to change those patterns. I’ve also been reaching out to other providers in physical medicine and rehabilitation to let them know what we’re doing with their patients, but I believe more fully integrated interdisciplinary care is needed to improve outcomes. We are just starting to collect outcome data, and the preliminary evidence suggests that their symptoms are improving.
Is there any other innovative rehabilitative work being done with COVID patients?
James Jackson, PsyD, at Vanderbilt University has helped me understand the importance of peer support and group therapy for people who have experienced delirium or acute distress disorder. This works well with patients at Vanderbilt because they receive emotional support from people who have had similar experiences and learn about the physiology and psychology underlying their symptoms. We hope to launch group therapy for COVID patients here in the coming months. Johns Hopkins University psychologists are also working with health-care providers and family members to keep ICU diaries for patients. This log can help patients contextualize hallucinations or other mental health challenges they experience after discharge from the ICU. I’ve had patients who thought they were being sexually assaulted in the ICU, and we have traced this back to the experience of having a catheter inserted.
What are the needs of this patient population going forward?
Psychologists should conduct research to improve our understanding of the long-term symptoms of COVID and clarify whether existing treatments for similar conditions need to be tweaked for this population. As I work with these patients, I’m also reminded of how few rehabilitation psychologists there are across the country and how desperately they are needed right now. My hope is that hospitals, health systems, and the government will come together to find ways to ensure access to these specialists so that the already tragic COVID-19 pandemic doesn’t turn into a long-term chronic health crisis for millions.
