Long haul covid treatment: The role of psychology
The Psychology Of Long Covid Symptoms
Reading this article, I am sure you need no introduction to the pandemic. While the development and rollout of COVID-19 vaccines have given us hope, the global health crisis is far from over. Variants like delta and omicron keep moving the goalposts.
There are better days ahead, but we must continue to look after ourselves and those suffering long-term effects from this illness.
The psychological challenges of long COVID are immense. I discuss important information on this topic, and how psychological strategies can aid recovery. I hope this article is helpful whether you are battling ongoing symptoms or just want to learn about COVID long haulers.
Topics in this article:
Side effects of covid
Many people are well aware of the main COVID signs. To recap, the key symptoms include:
High temperature
New, continuous cough
Loss or change in smell or taste
Shortness of breath
However, a wide range of symptoms is possible ranging from fatigue and body aches, to nausea and headache (1).
How long does it take to recover from COVID-19?
This question (like many others) is best answered through carefully conducted scientific research. Large health bodies like the Centers for Disease Control and Prevention in the United States continue to study and progress our knowledge of COVID. However, we still have much to learn. After all, we have known about people with COVID-19 for a short period.
That being said, a clearer picture is developing of COVID symptoms over time. Variety in symptoms is matched by variety in recovery duration. The National Insitute for Health and Care Excellence in the UK divides people into three groups:
Those who recover within four weeks.
Ongoing symptomatic COVID-19. Symptoms experienced for a period ranging between 4 to 12 weeks.
Post-COVID-19 syndrome. Those who experience ongoing symptoms beyond 12 weeks and not explained by another medical condition.
Most people fall into the first two groups (2).
We don't know exactly how many people develop long-term COVID. As with many medical and psychiatric conditions, prevalence estimates differ across studies. Differences in research design and the realities of conducting studies in the real world partly account for this variability.
Current estimates are that around 10% of non-hospitalised people develop long COVID symptoms (3, 4). However, rates appear to be higher in those who were seriously unwell. For example, 35-75% of hospitalised patients report ongoing symptoms 3-6 months after becoming unwell (5, 6).
Long haul COVID
We've also got variability in terminology and definitions.
'Long haul COVID' is another term describing persistent symptoms following initial infection. Scientists are still trying to understand what causes long COVID. Researchers are pursuing several lines of investigation, such as changes to the immune system (7).
There is no clear description or diagnostic test for long COVID. However, the World Health Organisation has recently proposed this definition (8):
Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis....Symptoms may be new onset, following initial recovery from an acute COVID19 episode, or persist from the initial illness. Symptoms may also fluctuate or relapse over time
The experiences of people with long COVID
This definition acknowledges that a period of time must pass (around three months) before long COVID is a diagnostic possibility. The description also encompasses the variability in symptom type, severity, and course.
Long COVID recovery is not a smooth process. COVID survivors experience periods of improvement followed by a return of symptoms (9). These relapses sometimes occur with no known trigger (10). Thus, setbacks are a normal part of long COVID but represent a key psychological challenge. For example, feeling like you are 'going backwards' is demoralising. Relapsing with no apparent trigger can lead to confusion, frustration, and helplessness.
Post COVID symptoms
For those who experience persistent illness, symptoms vary from person-to-person. However, fatigue is a primary problem (in 63% of people; 11). Other symptoms of long COVID include (2, 12):
General: Fever, pain
Respiratory and cardiovascular (heart, lungs, and breathing): breathlessness, cough, chest discomfort, pounding or fast heartbeat
Ear, nose, and throat: sore throat, loss of taste and/or smell
Neurological (brain and nervous system): mind blanking, poor concentration and memory, dizziness
Digestive system: Stomach pain, nausea, diarrhoea
Muscles and bones: pain in joints and muscles
Skin: rash
Symptoms themselves are unpleasant, painful, distressing and disruptive. For some people, serious long-term consequences may occur (12):
Organ damage/malfunction: heart, kidney, brain, lungs, liver
Multisystemic inflammatory syndrome
Blood clots
Due to this variability, many researchers suggest long COVID is several conditions. Attempts have been made to identify distinct patterns. For example, the authors of one study proposed three symptom categories: (1) chronic fatigue symptoms (2) post-critical illness, (3) posttraumatic stress (13).
Long COVID kids
Data are emerging around long COVID in children. As many as 50% of children have symptoms months after initial infection (14). As with many topics within this disease, more research is needed to better understand lasting effects in young people.
Vulnerability to long COVID
A key area of research is understanding who is most at risk for this condition. Numerous risk factors may exist. Example variables are (6, 15):
Initial number of symptoms: Reporting over five symptoms in the first week of illness
Illness severity: The risk of long COVID may be higher in those severely ill with the disease
Treatment: Receiving mechanical ventilation
Gender: Females are more likely to develop long COVID
Age: Older people are more vulnerable to long COVID
Obesity
Covid and mental health
The pandemic itself causes psychological distress (16). Concerns are not just about getting sick, but extend to isolation, loss of lifestyle, separation from friends and family, uncertainty about the future, etc (17, 18, 19). Challenges like health anxiety exist for everyone, including fully vaccinated people. As a result, pandemic-related distress remains persistently elevated for some (20).
For COVID long haulers, the distress of persistent symptoms and health problems occur on top of this underlying stress. This coronavirus is a disease that affects multiple systems in the body (4). On top of psychological factors, mental health difficulties may occur due to disease-related physical changes (e.g., oxidation and inflammatory effects; 21).
You are at increased risk of mental health issues after contracting COVID. For example, one study estimated that a third of people experience a neurological or psychiatric condition in the six months after being diagnosed with COVID-19 (22). Another study has found lower quality of life in those with long COVID (23).
Specific psychological issues include low mood, anxiety, trauma, and adjustment problems.
Low mood & depression
Mood problems are an issue for some people with long COVID. Symptoms occur in 11-28% of people, and 3-15% experience serious (clinically significant) depression (24, 25). These findings continue the observation that rates of depression in people with medical conditions are higher than in the general population (26). Read more about depression in this article.
Anxiety
Anxiety comes in many forms and is another important mental health concern. Elevated anxiety levels have been detected in around 16-30% of patients months after release from hospital (27, 28). Anxiety disorders are more prevalent amongst people with medical conditions (29). For example, people can become anxious when assuming others make negative evaluations (e.g., 'They think I am just lazy'). Read more about social anxiety brain cell battles in this article.
Trauma
Being unwell and/or receiving medical treatment can be distressing and even traumatic. For example, posttraumatic Stress Disorder (PTSD) symptoms occur in 32% of patients who were seriously unwell at the height of their infection (30). However, we have well-established treatments for psychological trauma. EMDR and Cognitive Behaviour Therapy (CBT) are two validated approaches.
Adjustment
People understandably struggle to cope with long term effects and the extent of change to daily life. Psychologists call this process 'adjustment'. Examples of specific adjustment issues include:
Unfavourably comparing pre-illness functioning to current impairments
Learning to tolerate health problems
Coping with the unpredictable nature of symptom severity
Difficulties with work
Changes to your identity and relationships (e.g., being the sick person)
Concerns that others will get 'compassion fatigue'
Worrying about burdening friends and family
Psychological and behavioural interventions for long COVID
Thankfully, we have psychological strategies to employ in long COVID treatment. I have already worked with several people battling long COVID. Having also worked with people diagnosed with Chronic Fatigue Syndrome or Myalgic Encephalomyelitis (CFS/ME), I know how these post-viral fatigue syndromes can devastate lives.
Guideline from major national and international health bodies (e.g., National Institute for Health and Care Excellence) recommends a holistic approach to long covid health care. This includes mental health input if required (31).
Cognitive-based therapies such as CBT provide tools to work with unhelpful thoughts and thinking patterns (e.g., rumination). Thoughts like 'I have no control', 'I will never get better', and 'I'm no good to anyone' underpin psychological distress. Learning to identify and respond effectively to these thoughts enhances coping capacity. However, this is just one way we use psychological skills to manage long COVID difficulties.
We also have behavioural interventions that help people increase activity levels gradually while avoiding 'boom and bust cycles. Monitoring and recording fatigue and using structured activity schedules are examples of managing limited energy strategically. However, exercise as a therapy in long COVID is contested (4).
Psychological strategies can be used for specific physical symptoms. A few examples are given below.
Dizziness covid
Dizziness is a COVID-19 symptom and features in viral infections generally (32). There are different types of dizziness (33). This symptom should be taken seriously and investigated to determine its cause where possible. (33). In some instances (e.g., anxiety), psychological treatment is appropriate via Cognitive Behaviour Therapy (CBT) (34).
Covid Brain
A frequently reported symptom is 'brain fog' (35) and refers to various thinking difficulties (e.g., concentration, working memory). Cognitive problems are among the most commonly reported symptoms in long COVID (10). In addition, hospitalised patients face the risk of severe cognitive issues, such as delirium and Post Intensive Care Syndrome (36).
Several strategies are available to compensate for issues like impaired memory and concentration. In addition, there is a specialised branch of Clinical Psychology called Clinical Neuropsychology. People trained in this area can assess cognitive issues. These assessments form the basis of tailored rehabilitation plans.
Joint pain after covid
Pain management is a branch of medicine that includes medical, psychological, and allied health input. Muscle and joint aches/pains are common COVID symptoms (37). In addition, reactive arthritis may occur after COVID-19 (38).
Many Clinical Psychologists utilise psychological models (explanations) of chronic pain to help patients manage this distressing problem. Techniques used in this area range from mindfulness to addressing unhelpful thinking patterns. CBT has been a traditional approach to pain management, but recent years have seen other methods emerge, such as Acceptance and Commitment Therapy (ACT).
Long COVID and work
Most people with long COVID experience work disruption. For instance, over 45% of people with long COVID need a reduced work schedule, and a further 22% are unable to work months after initial infection. (10).
Occupational health services support people to make gradual returns to work. Coping with reduced abilities and performance is also addressed in psychology sessions. Support is required, particularly when symptoms are continuing over a long period of time.
Summary
Long COVID is a huge challenge. People face various psychological challenges resulting from, and in addition to ongoing symptoms and medical problems. But help is available via many psychological approaches and techniques. It is very normal to require this assistance, given the obstacles encountered during recovery.
We are Coaching & Clinical Psychologists with extensive experience helping people conquer a range of wellbeing and performance issues at home and in the workplace. We can also help with long COVID management. Read more about our work, watch practical skills videos or browse other articles. Get in touch anytime.
References
1 CDC (2021): https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
2 NHS Long COVID: https://www.yourcovidrecovery.nhs.uk/what-is-covid-19/long-covid/
3 Havervall S, Rosell A, Phillipson M, et al. Symptoms and Functional Impairment Assessed 8 Months After Mild COVID-19 Among Health Care Workers. JAMA. 2021;325(19):2015–2016. doi:10.1001/jama.2021.5612
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5 Evans, R. A., et al. (2021). Clinical characteristics with inflammation profiling of Long-COVID and association with one-year recovery following hospitalisation in the UK: a prospective observational study. MedRxiv. doi: https://doi.org/10.1101/2021.12.13.21267471
https://www.medrxiv.org/content/10.1101/2021.12.13.21267471v1?ijkey=067ae096b249073281da693b04c3d3ad73deca92&keytype2=tf_ipsecsha
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https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1
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