There’s a photograph Jacqui Canter can see in her mind whenever she closes her eyes. It was taken by her sister while Canter was in the hospital with COVID-19: a bird’s-eye view of her lying in a hospital bed, the plastic mouthpiece of a mechanical ventilator covering her face. Alongside the image, she can hear the hollow rhythm of her own breathing echoing inside her head, as if she were under water, scuba diving.
For Canter, it’s a terrifying image — she looks on the brink of death.
Only, no such photo exists. Though Canter was indeed hospitalized with COVID-19, her sister never took a picture of her there. Still, the image and the feeling of fear it evokes is seared into Canter’s mind. She comes back to it every day. It’s caused agoraphobia, panic attacks and post-traumatic stress symptoms.
“The fear has been overwhelming,” she said.
For many who had serious cases of COVID-19, the subsidence of their physical symptoms opened the door for the emergence of emotional and psychological trauma. And the similarity between the symptoms of the disease itself and the anxiety it causes makes it all the more difficult for doctors and patients to untangle them and treat them separately.
Canter, a 60-year-old resident of Cherry Hill, was admitted to Virtua Hospital in Voorhees on April 1 with a 104-degree fever. She spent the next several days hallucinating large blotches of colors and swarms of bugs scampering up and down the walls. Delirium and nightmares are not uncommon among critically ill COVID-19 patients and others with high fevers.
The hospital called in the psych department for an evaluation, which only made Canter paranoid.
“I told my sister I was calling the radio stations because they were coming to commit me,” she recalled.
Canter became so agitated that at one point she ripped out an IV line, ran down the hall and hit a security guard in the face. Her oxygen levels dropped so low that she had to be intubated. She was on a ventilator for six days. She remembers bits and pieces of the ordeal: punching the security guard, “like Buffy the Vampire Slayer;” the primary colors she saw spotting the walls; a nurse with blond hair leaning over her and asking if she had DNR (a “do not resuscitate” order).
Once she recovered, Canter was discharged to a rehab facility and was home by the end of April. Her lung function returned relatively quickly, but she still carried the fear with her everywhere.
For months, she couldn’t drive. Weeks after she recovered, she began losing her hair — it’s been well documented that a traumatic event can cause delayed hair loss, including in coronavirus patients.
One day a few weeks after she returned home, Canter had worked up the strength to take her dogs for a walk around the lake near her house. But while there, she was overcome by a sense of exhaustion. Her legs went limp, and she started getting dizzy. By the time she got home, the room was spinning and her left hand was numb.
“I called 911 and said, ‘I’m sure I’m having a stroke.’ The EMT looked at me and said, ‘You’re having a panic attack.’”
Canter had never experienced anything like it before. It felt driven by having been so close to dying from the coronavirus and being afraid she’d end up back there.
“It just seems like the world is such a dangerous place because I don’t know where I got it,” she said.
Illness as trauma
It’s common for people who experience critical illness to have symptoms like post-traumatic stress disorder, especially if their lives were at risk. Patients may have nightmares, flashbacks or be hypervigilant and unable to relax.
For COVID-19 survivors, the anxiety or PTSD can be compounded because their symptoms mirror those of the virus, said Lily Brown, an assistant professor of psychology and psychiatry at the University of Pennsylvania.
“The physiological impact on the respiratory system is a breeding ground for anxiety,” said Brown.
Because shortness of breath is also a symptom of panic, having an anxiety or panic attack can be a reminder of the trauma the patient went through.
“We recommend practicing exercises to help essentially rewire your brain,” said Brown, who also directs the Center for the Treatment and Study of Anxiety at the Perelman School of Medicine. She suggested exercising or doing guided hyperventilation techniques to retrain the brain that intensive breathing is not, in and of itself, dangerous.
“That’s a really hard thing to relearn when the symptoms were dangerous in the context of being critically ill with the virus,” she said.
Canter still has trouble recalling simple words and difficulty spelling, and her memory is hazy — all common issues for COVID-19 patients. Since the emergence of SARS-CoV-2, doctors have observed the neurological effects of the disease it causes, ranging from delirium to nerve damage and ongoing cognitive impairment. Researchers don’t know yet if those issues are a result of the body’s immune response to the virus, of being on a ventilator, of withdrawal from pain medications or a specific feature of the virus itself. But they’re common: Anywhere between one-third and three-quarters of intensive care unit patients have some neurological manifestation.
Brown said cognitive impairment can make anxiety worse, too.
“When any of us is experiencing any amount of being cognitively slowed down compared to our baseline, it’s predictable that that’s going to impact our capacity for decision making, for regulating our emotions, appropriately taking care of ourselves,” she said.
Research has shown that students who have trouble problem solving are more to likely experience depression, and are at a greater risk for suicide. Among patients with Parkinson’s disease, those with cognitive impairments were more than twice as likely to be anxious than those without.
The good news is that PTSD is treatable for those who seek help, and the pandemic has made it easier for doctors to offer behavioral health services to patients through telemedicine.
Canter did seek out a therapist for help, and over the past couple of months, she said, the fear has begun to subside.
But, Canter said, she just can’t wipe the image of herself in the hospital bed from her mind.
“It’s absolutely haunting.”
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