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From the Editor

Finding the Best Balance

OLDHAM, JOHN M. MD

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Journal of Psychiatric Practice: May 2020 - Volume 26 - Issue 3 - p 163
doi: 10.1097/PRA.0000000000000474
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May, 2020. As of this writing, in late March, the world is reeling with the COVID-19 pandemic. For as long as we could, we denied that it could happen in our country, in our town, on our street. But no more. Now we know the savage nature of this invisible enemy and that it could be at work in any of us, even without our knowing it. So the defensive cloak of denial is being replaced by widespread anxiety and by the harsh evidence of our shared vulnerability and mortality. And that no-one is invulnerable—from Prince Charles to Tom Hanks to Boris Johnson to Chris Cuomo to countless others, prominent or not. Previous “breaking news” reports about Brexit, NATO, climate change, and, of course, political rallies and debates have been sidelined, except for the intense scrutiny on the leaders of the world and the wisdom of their decisions about how best to protect their citizens.

Some of us are natural worriers, prone to feel anxious about the risks of daily life such as high-speed traffic, a shaky investment, a leak in the roof, or, unfortunately, a school shooting. COVID-19 might even, curiously, seem to be a validation of the wisdom of the worriers, and indeed they may be better stocked with provisions than most of us, anticipating the next flood or hurricane or disaster. But all of us have heritable risk factors to develop various illnesses such as diabetes, hypertension, heart disease, cancer, depression, anxiety disorders, or even personality disorders. If our degree of risk is at least moderately high, an epigenetic stress of the magnitude of this pandemic is bound to flip the switch and turn on some of our risk genes. And in our mental health world, that could be a full-blown anxiety disorder, or a depressive disorder, or posttraumatic stress disorder, or other conditions.

Regardless of the degree to which any of us is at risk for developing an anxiety disorder, all of us are in a state of heightened anxiety. One strategy to minimize our anxiety is to fortify ourselves with solid, scientific, and, where possible, evidence-based knowledge about this viral invader. In this issue of the Journal, in 2 separate columns, Preskorn presents the basics regarding COVID-19 and thoughts about how to safely move forward, to help all clinicians become grounded in what we know about this otherwise unfamiliar and frightening infectious agent. Also in this issue, Gulpers and colleagues report on the impact of co-occurring personality pathology in patients with panic disorder, focusing particularly on late-life patients with panic disorder. Although this study was carried out well before the current worldwide outbreak, it is persuasive to assume that our current events would trigger highly symptomatic states in these patients. In addition, also in this issue, Srivastava and Opler present a case describing the beneficial effect of prazosin in a man suffering from acute stress disorder. Although we do not have good data at this point, it is likely that the prevalence of acute stress disorder is increasing, and this case suggests a promising treatment approach in such cases. We do not yet have a vaccine for COVID-19. Nor do we yet have pharmacotherapies to combat the illness. But what we can do is be alert for the onset of psychiatric syndromes that are precipitated by this scourge. And, in most cases, we have good treatments for these conditions, so let’s park the usual stigma and fear that surround mental and emotional distress and get the help to those who need it. Fortunately, telemedicine can be quite effective in our field, and since most of us are sheltering at home, a very private opportunity to receive help is at our fingertips.

I would also like to express my heartfelt appreciation to David Kahn, MD, who has served as JPP’s Clinical Case Discussant for over 12 years. He has elected to step down from this role, but he will remain on our Editorial Board. The Journal has been fortunate to have Dave’s steady wisdom and guidance through the years. He has selected, shaped, and discussed our clinical cases, so that they have always been educational, interesting, and useful. And Dave has been a wonderful collaborator on the editorial panel, full of energy and team spirit. Thanks, Dave! We are also fortunate to be joined by a talented successor to Dave, Amir Garakani, MD, who will take Dave’s place after this issue of the Journal. More about Amir in the next issue.

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