When Does COVID Anxiety Become a Disorder?

I will be the first to note my own biases: As someone who has treated individuals with long COVID, I know well the potential risks of a COVID infection. So do my long COVID patients—they know how precious every increment in recovery is and understandably want to avoid things that may set them back, such as another COVID-19 infection.

Many of them share that their friends and family have suggested their continued COVID concern is out of proportion with reality, pointing to updated CDC guidelines which removed all masking requirements on public transportation last spring or President Biden’s recent declaration that the pandemic is "over." Some have been told by friends or family they should work on their COVID fear in their psychiatric treatment, while others have had other mental health professionals suggest their continued mask use should be a focus of treatment.

At what point does a fear or anxiety become a disorder? Who decides what is considered “reality”?

The Role of Fear in Response to COVID

Despite the tremendous divisions in our society, we are united in being driven by fear and the way that it interacts with our experiences and priorities. Mending the rift requires understanding the role that fear plays on all sides.

While social convention conflates strength with avoiding or not showing fear, fear in and of itself is not a “bad” thing. It shields us from being hurt and allows us to operate in a self-protective fashion. For example, the fear of being hit by a car is what allows us to look both ways and wait for the traffic signal to cross the street.

For several reasons, individuals may also experience a fear of anxiety or fear itself. One possibility is that being seen as a particularly anxious or concerned individual by others in society is an uncomfortable experience, so disavowing fear whenever possible becomes a protective mechanism against others’ judgment. Another possibility is that feeling anxious may be intolerable to some individuals, so they make every effort to avoid outlooks that may make this more likely to occur.

In relation to fear driving pandemic responses, the largest divisions lie in our approach to regulations, which some see as restrictions and others see as necessary steps to ensure safety. For some, the fear of governmental influence or being controlled by external entities dominates, while for others, the fear of infection and vulnerability dominates.

It is well documented that fear alters perception (Kelly 2014), and so the quest for accurate and objective data is limited in that each individual will interpret data through the lens of their own emotions and preexisting biases. Take, for example, a statistic that a virus has a 1 percent mortality rate. There are two reactions: "99 in 100??! That’s pretty good odds; I’ll be fine" vs. "1 in 100, when considered on a broader scale, will cause massive avoidable death and disability."

Individual experiences play a major role in guiding toward one of these two possibilities. Those who have personally experienced mild COVID illnesses on several occasions, for example, may be more inclined to minimize risk.

Consider the hot-hand fallacy, the notion that a streak of luck will continue; this is in part due to the illusion of control. In order to minimize anxiety or fear, we may convince ourselves we have control in situations we do not (Roney 2009). Many patients with long COVID who were previously athletes might have carried this illusion in the form of the belief that excellent physical condition could in some way shield them from developing all medical illnesses—as opposed to just those conditions known to be impacted by fitness.

On the flip side of the coin are those who have experienced long COVID following their first infection or those who experienced a severe illness with COVID before: They may be more inclined to assume that the next infection will be just as catastrophic. The data here are limited, but we do know that those with long COVID who experience re-infection may be likely to experience a worsening in their symptoms.

Fear Essential Reads

How the Brain Learns That Fear Is No Longer Needed

Rethinking “Bravery” in Pediatric Healthcare: The Hidden Burden

What is the Difference Between Anxiety and an Anxiety Disorder?

Anxiety is a response to the emotional experience of fear. In small amounts, it can be helpful in avoiding dangerous situations or pushing people to action.

Mental health providers define an anxiety disorder as “excessive anxiety and worry” that is difficult to control (DSM-5, 2013). As I discussed previously, this designation of “excessive” is subjective, and therefore what might be considered a disorder to one person may not be to another.

The most important aspect in defining an anxiety disorder is someone’s own perception of the validity of their reaction. Those who benefit most from treatment are those who have some desire to change, who see their own reactions as “excessive,” and who are motivated to do the work.

The key here is that individuals live in different realities. The person who has had COVID thrice with little issue is living in a very different reality than the person who has had COVID once and suffers long-term challenges. What is considered a “realistic” fear will be very different for these two individuals.

It is prudent, then, that each person defines his or her own psychic reality—and decide for him or herself whether their own reaction is “excessive” by their own standards. Focusing on the “disordered” aspect of fear communicates a lack of understanding and respect for the experience of the individual. It is my role as a therapist not to exert my reality on my patient, but rather to help my patients explore internal conflicts within their own reality in order to learn how to better understand themselves.

Suggesting someone pursue treatment to be comfortable not wearing a mask—at this stage in the pandemic with cases in high numbers, and long COVID remaining a risk even when vaccinated—is like suggesting someone pursue treatment to be comfortable jaywalking or driving without a seatbelt.

One thing is clear: Masking or ongoing concern about COVID infection is not in isolation evidence of an anxiety disorder.