What therapists need to know:

COVID-19

in 2024

Who are we? Who is this presentation for?

Olivia

• Bachelor of Science in Psychological and Brain Sciences
• Master of Science in Marriage and Family Therapy
• Background in research
• Living with Long Covid
  

Erin

• Bachelor of Science in Music
• Pursuing Master of Science in Marriage and Family Therapy (coursework complete)
• Provides psychotherapy to individual adults and couples
• Covid-conscious advocate
  

While this presentation was created specifically for therapists, much of this information is relevant to other health care providers, or anyone interested in learning more about COVID!

Resources and contact forms are available at the end.

Intention

A lot of the information presented today may be new for you, and some of it might be upsetting or stressful

You may experience feelings of anger, fear, anxiety, sadness, defensiveness

Notice what’s coming up for you and acknowledge it without judgement

Notice how your nervous system is responding, and do what you need to do to regulate so you can stay engaged

The goal is not to do anything differently right now – just to stay open and listen

Curiosity

What feelings come up when you consider the possibility that the COVID pandemic never ended?

The possibility that COVID is worse than many of us thought?

The possibility that the impacts of COVID are not going away?

If you used to wear a mask in public and no longer do, why?

What do you know about how the COVID virus has changed over time?

What may be preventing you from considering you might be wrong (or at least missing something) in calculating the risk/negative effects of COVID?

What’s in this presentation

01

What is COVID?

02

impact on the brain

03

Impact on the Body

04

Social justice concerns

05

clinical implications

06

Advocacy & resources

Long Covid

• Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)
  
• Neuroimmune illness characterized by intolerance to systemic exertion and chronic fatigue that cannot be alleviated via rest
  
• 58.7% met the criteria for ME/CFS
• Respiratory: cough, breathing difficulty
• Gastrointestinal: heartburn, gastrointestinal disorders, constipation, loss of appetite, and abdominal pain
• Pancreas: pancreatitis, diabetes, pancreatic exocrine dysfunction
• Musculoskeletal: musculoskeletal pain, loss of muscle tissue and decreased skeletal muscle mass
• COVID-19 is capable of inducing multiple systemic and organic lesions
  
• 70% of individuals with long COVID exhibited evidence of damage to at least one organ
  
• Multi-organ damage: renal, thrombotic, cardiac, and pulmonary functions
  

Davis et al., 2021; Demoliou et al., 2022; Donders et al., 2022; Dorobisz et al., 2023; Li et al., 2023; Polly & Fernandez, 2022; Ripa et al., 2022; Seyfi et al., 2022; Jason & Dorri., 2022

• Hair loss
• Tooth loss
• Skin problems
• blisters, rash, “COVID toes”
• Immune dysregulation
  
• Lymphopenia
• Vision & hearing loss
  
• Blood clots
• heart attack, stroke, pulmonary embolisms
  
• Inflammation
  
• Anaphylaxis and new allergies
• Changes in sensitivity to medication
• Seizures
• Facial paralysis
• Sleep issues
• Autoimmune disorders
• Autonomic disorders (POTS)
  

Potential Causes of Long Covid

• Inflammation, neuroinflammation & autoimmunity
• Reduced serotonin
• Vagus nerve dysfunction
  
• Autonomic dysfunction
• Mitochondrial dysfunction
• Virus crossing blood-brain barrier
• Viral persistence
• Organ and tissue damage
• Microclots
  

Proal & VanElzakker, (2021). Al-Aly & Topol (2024)

Long Covid

Who is high risk?

According to the CDC

• “People from racial and ethnic minority groups”
• Pregnant people
• Infants
• Adults 65+
• Developmental disabilities: Autism, ADHD, learning disorders, Down syndrome, etc
• Cancer
• Asthma
• Immunocompromised
• Connective tissue disorders (hEDS)
  

• Mental health conditions: mood disorders
• Current/former smoker
• Substance use disorders
• Stroke
• Heart Conditions
• HIV
• Diabetes
• Autoimmune diseases
• Chronic kidney/liver/lung disease
• Mast Cell Activation Syndrome (MCAS)
• Previous Covid infections
• and MORE
  

Long Covid

Between 10-30% of those who have had COVID will develop Long COVID

Highleyman, 2023

Over 125 journal articles have been published addressing the psychological & neurological impacts of COVID infection

CDC

Pause

How is your body reacting to this information?

What do you need to regulate your nervous system?

Social justice Considerations

• Disproportionately impacts BIPOC folks, women, LGBTQ+, low income & disabled people
  
• Accessing medical care
• Ending the state of emergency removed social supports
  
• Private companies increasing cost of treatments
• Patient gaslighting from the medical system
  
• Private resources shutting down
  
• Ableism: “set of beliefs or practices that devalue and discriminate against people with physical, intellectual, or psychiatric disabilities and often rests on the assumption that disabled people need to be ‘fixed’ in one form or the other”
  

Smith (2023)

Social justice Considerations

White people are significantly less likely to take COVID precautions in order to protect themselves or others

Social justice Considerations

COVID is a workers rights issue

• “Public facing industries, including teaching and education, social care, healthcare, civil service, retail and transport industries and occupations, had the highest likelihood of long-COVID”
• 11.6% (teaching and education)
  
• Prevalence of reduced function by ‘a lot’
• 22%–23% (teaching and education)
  
• “Around 16 million working-age Americans (those aged 18 to 65) have long Covid today”
  
• 2–4 million are out of work due to long Covid
  
• Consider the impact of worker shortages on various industries: teaching, healthcare, pilots, drivers, etc
  

Kromydas et al., 2023

CDC 2022

Social justice & community care

“Many in the disability community have been and continue to be seen as expendable, as if their deaths are understandable, expected, or even written off as unavoidable because of their multiple comorbidities.” (Mills 2023)

Social justice & community care

• “When I am in public spaces and see most people unmasked either because they think the virus is a hoax, that masking is virtue signaling and a sign of weakness, aren't thinking about it, or that they simply don’t care, I feel like an expendable burden not worth saving” -Alice Wong
  

• “The psychological toll of trying to keep ourselves safe with no institutional support, and, in fact, quite a bit of institutional propaganda that we are being hysterical, is an ongoing source of trauma. It feels like I’m screaming into the void.” -Angela Meriquez Vázquez

Wong 2024

Pause

How is your body reacting to this information?

What do you need to regulate your nervous system?

• Neurochemical changes to the brain
• Living with chronic illness
• Changing capacity
  
• Shame, grief, despair, hopelessness
  
• Psychological effects of isolation
  
• Exacerbating existing mental health issues
  
• Changes in medication tolerance
  
• Changing identity
• Changes in work, hobbies, social activities
  
• Uncertainty and fear of the future
  
• Lack of understanding from others
  
• Stigma, harassment, abuse
  
• Loss of relationships
  

Couples & Relationships

Couples & Relationships

Fitz-Gibbon et al. 2024

• COVID is a leading cause of death in children & young people (#8)
  
• Long COVID prevalence range of 1.6% to 70%
• Some studies show same relative risk as adults (~30%)
  
• Many children likely aren't diagnosed- they don't recognize or have the vocabulary to report their symptoms (esp. preverbal children)
  

Buonsenso et al. 2022; Ding & Zhou 2023; Flaxman et al., 2023

Signs of LC in kids:

• Regularly saying “I don’t feel good”
• Pain in the muscles and joints
• Sitting while other kids are playing
• Gastrointestinal symptoms
• Increase in allergy, rashes, or signs of inflammation
• Complaining of headaches, dizziness, body pain or exhaustion
• New onset mental health issues

Clinical work:

Case example

• Mom reports concerns her 10-year-old son has been complaining about pains in various parts of his body and repeated requests to skip sports.
• Mom assumes he is making things up for attention and is lazy
• Teacher reports “He’s here, but he’s not HERE”
• Client reports: “It feels like a triangle is poking into my heart”
• “None of the grownups believe me”
  
• “No one listens to me”
• Validating client’s experience lead to significant shift in the therapeutic relationship
  

Clinical work:

Scope of Practice

We CANNOT:

• Diagnose Long COVID
• Give specific medical guidance

We CAN:

• Ask about previous COVID infections
• Ask about specific symptoms or patterns, symptom onset/duration
• Support clients with nervous system regulation skills
• Support clients with meaning making
  
• Refer: to PCP or Long COVID clinics
• Incorporate understanding of Long COVID into our treatment models
  
• Provide education on Long COVID
• Share Long COVID resources

Clinical work:

recommendations

Screening

• Screen for history of COVID infection during intake
• Refer for physiological testing (COVID aware doctors)

Recognize grief/loss

• Hold space for grief and loss of family, friends, pets, job, school, health, dreams for the future
  

Clinical work:

consideration

& caution

Gaslighting

• Long COVID is real, it is not deconditioning or laziness

Complete deference to medical field

• Government, CDC and medical field have fallen short
• Understand potential distrust, desire to seek out own info from reputable sources
  

COVID Protection

How to make your practice safer and more accessible to all

Covid prevention & care

community care

• Long COVID support groups
• COVID advocacy groups directory
  
• COVID-conscious therapists list
• “Why should I care?” FAQ

References

• Ada’s Medical Knowledge Team. (2023, April). Covid and male genital: Symptoms, treatment & FAQ: Ada Health. Ada. https://ada.com/covid/covid-19-symptoms-and-effects-on-male-genitals/
• Ajufo, E., Rao, S., Navar, A. M., Pandey, A., Ayers, C. R., & Khera, A. (2021). U.S. population at increased risk of severe illness from COVID-19. American journal of preventive cardiology, 6, 100156. https://doi.org/10.1016/j.ajpc.2021.100156
  
• 29, A., & Lubell, J. (2022, April 29). Long covid: Over 200 symptoms, and a search for guidance. American Medical Association. https://www.ama-assn.org/delivering-care/public-health/long-covid-over-200-symptoms-and-search-guidance
• Bowe, B., Xie, Y., & Al-Aly, Z. (2022). Acute and postacute sequelae associated with SARS-CoV-2 reinfection. Nature medicine, 28(11), 2398–2405. https://doi.org/10.1038/s41591-022-02051-3
• Buonsenso, D., Pujol, F. E., Munblit, D., Pata, D., McFarland, S., & Simpson, F. K. (2022). Clinical characteristics, activity levels and mental health problems in children with long coronavirus disease: A survey of 510 children. Future Microbiology, 17(8), 577–588. https://doi.org/10.2217/fmb-2021-0285
• Clifton M. Chow, Will Schleyer, Lynn E DeLisi. (2023). The prevalence of psychiatric symptoms and their correlates as part of the long-COVID syndrome. Psychiatry Research, Volume 323. https://doi.org/10.1016/j.psychres.2023.115166
• Craparo, G., La Rosa, V. L., Commodari, E., Marino, G., Vezzoli, M., Faraci, P., Vicario, C. M., Cinà, G. S., Colombi, M., Arcoleo, G., Severino, M., Costanzo, G., Gori, A., & Mangiapane, E. (2022). What Is the Role of Psychological Factors in Long COVID Syndrome? Latent Class Analysis in a Sample of Patients Recovered from COVID-19. International Journal of Environmental Research and Public Health, 20(1), 494. https://doi.org/10.3390/ijerph20010494
• Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., Low, R. J., Re’em, Y., Redfield, S., Austin, J. P., & Akrami, A. (2021). Characterizing long covid in an international cohort: 7 months of symptoms and their impact. eClinicalMedicine, 38, 101019. https://doi.org/10.1016/j.eclinm.2021.101019
• Davis, H.E., McCorkell, L., Vogel, J.M. et al. Long COVID: major findings, mechanisms and recommendations. Nat Rev Microbiol 21, 133–146 (2023). https://doi.org/10.1038/s41579-022-00846-2
• Demoliou, C., Papaneophytou, C., & Nicolaidou, V. (2022). SARS-CoV-2 and HIV-1: So Different yet so Alike. Immune Response at the Cellular and Molecular Level. International journal of medical sciences, 19(12), 1787–1795. https://doi.org/10.7150/ijms.73134
• Ding, Q., Zhao, H. Long-term effects of SARS-CoV-2 infection on human brain and memory. Cell Death Discov. 9, 196 (2023). https://doi.org/10.1038/s41420-023-01512-z
• Donders, H. C. M., van der Sleen, J. M., Kleinbergen, Y. J., Su, N., de Lange, J., & Loos, B. G. (2022). Alveolar bone loss and tooth loss are associated with COVID-19 severity but are not independent risk factors. An explorative study. Advances in Oral and Maxillofacial Surgery, 5, 100223. https://doi.org/10.1016/j.adoms.2021.100223
  

References

• Douaud, G., Lee, S., Alfaro-Almagro, F. et al. SARS-CoV-2 is associated with changes in brain structure in UK Biobank. Nature 604, 697–707 (2022). https://doi.org/10.1038/s41586-022-04569-5
• Dorobisz, K., Pazdro-Zastawny, K., Misiak, P., Kruk-Krzemień, A., & Zatoński, T. (2023). Sensorineural Hearing Loss in Patients with Long-COVID-19: Objective and Behavioral Audiometric Findings. Infection and drug resistance, 16, 1931–1939. https://doi.org/10.2147/IDR.S398126
  
• Flaxman S, Whittaker C, Semenova E, et al. Assessment of COVID-19 as the Underlying Cause of Death Among Children and Young People Aged 0 to 19 Years in the US. JAMA Netw Open. 2023;6(1):e2253590. doi:10.1001/jamanetworkopen.2022.53590
• Fitz-Gibbon, Kate; McGowan, Jasmine; Pfitzner, Naomi; Scott, Ben (2024). Disconnected & Insecure: The intersection between experiences of long COVID and intimate partner violence. Monash University. Report. https://doi.org/10.26180/25000520.v1
• Florido, A. (2022, April 4). White people feared COVID less after learning other races were hit hardest, Data Show. NPR. https://www.npr.org/2022/04/04/1090919953/white-people-feared-covid-less-after-learning-other-races-were-hit-hardest-data-
  
• Gasnier M, Choucha W, Radiguer F, et al. Acute objective severity of COVID-19 infection and psychiatric disorders 4 months after hospitalization for COVID-19. J Clin Psychiatry. 2022;83(1):21br14179.
  
• Greenhalgh T, Sivan M, Delaney B, Evans R, Milne R. Long covid—an update for primary care BMJ 2022; 378 :e072117 doi:10.1136/bmj-2022-072117
• Harirugsakul, K., Wainipitapong, S., Phannajit, J., Paitoonpong, L., & Tantiwongse, K. (2022). Erectile dysfunction after COVID-19 recovery: A follow-up study. PloS one, 17(10), e0276429. https://doi.org/10.1371/journal.pone.0276429
  
• Hernandez Carballo, I., Bakola, M., & Stuckler, D. (2022). The impact of air pollution on COVID-19 incidence, severity, and mortality: A systematic review of studies in Europe and North America. Environmental research, 215(Pt 1), 114155. https://doi.org/10.1016/j.envres.2022.114155
• Highleyman, L. (2023). Where are the treatments for long COVID? Slate. https://slate.com/technology/2023/05/long-covid-treatments-where-research-recover.html
• Jason, L. A., & Dorri, J. A. (2022). ME/CFS and Post-Exertional Malaise among Patients with Long COVID. Neurology international, 15(1), 1–11. https://doi.org/10.3390/neurolint15010001
• Kirchberger, I., Meisinger, C., Warm, T. D., Hyhlik-Dürr, A., Linseisen, J., & Goßlau, Y. (2023). Post-COVID-19 Syndrome in Non-Hospitalized Individuals: Healthcare Situation 2 Years after SARS-CoV-2 Infection. Viruses, 15(6), 1326. https://doi.org/10.3390/v15061326
  
• Kromydas, T., Demou, E., Edge, R., Gittins, M., Katikireddi, S. V., Pearce, N., van Tongeren, M., Wilkinson, J., & Rhodes, S. (2023). Occupational differences in the prevalence and severity of long-COVID: Analysis of the ONS Coronavirus (COVID-19) Infection Survey. British Medicine Journal. https://doi.org/10.1101/2023.03.24.23287666
  
• Li Z, He J, Wang Y, Bai M, Zhang Y, Chen H, Li W, Cai Y, Chen S, Qu M, Wang J. A cross-sectional study on the mental health of patients with COVID-19 1 year after discharge in Huanggang, China. Eur Arch Psychiatry Clin Neurosci. 2022 doi: 10.1007/s00406-022-01484-8
• Marshall M. (2023). Does covid-19 affect pregnancies?. New scientist (1971), 258(3441), 14–15. https://doi.org/10.1016/S0262-4079(23)00987-9
  
• Mills, B. (2023). Isolated, dismissed, and afraid: How we can better support individuals with disabilities during a pandemic that never ended. The Therapist, 35(4), 6-9. https://acrobat.adobe.com/id/urn:aaid:sc:US:0392d89c-8504-4dc5-a42d-d9ddeb32a819
• National Center for Health Statistics. U.S. Census Bureau, Household Pulse Survey, 2022–2023. Long COVID. Generated interactively: from https://www.cdc.gov/nchs/covid19/pulse/long-covid.htm
  

References

• Nouraeinejad, A. The functional and structural changes in the hippocampus of COVID-19 patients. Acta Neurol Belg 123, 1247–1256 (2023). https://doi.org/10.1007/s13760-023-02291-1
• O'Dor, S. L., Zagaroli, J. S., Belisle, R. M., Hamel, M. A., Downer, O. M., Homayoun, S., & Williams, K. A. (2022). The COVID-19 pandemic and children with PANS/PANDAS: an evaluation of symptom severity, telehealth, and vaccination hesitancy. Child psychiatry and human development, 1–9. Advance online publication. https://doi.org/10.1007/s10578-022-01401-z
• Pollack, B., von Saltza, E., McCorkell, L., Santos, L., Hultman, A., Cohen, A. K., & Soares, L. (2023). Female reproductive health impacts of long COVID and associated illnesses including ME/CFS, pots, and connective tissue disorders: A literature review. Frontiers in Rehabilitation Sciences, 4. https://doi.org/10.3389/fresc.2023.1122673
  
• Pollard, A. E., & Rogge, R. D. (2022). Love in the Time of COVID-19: A Multi-Wave Study Examining the Salience of Sexual and Relationship Health During the COVID-19 Pandemic. Archives of sexual behavior, 51(1), 247–271. https://doi.org/10.1007/s10508-021-02208-0
• Polly, S., & Fernandez, A. P. (2022). Common skin signs of covid-19 in adults: An update. Cleveland Clinic Journal of Medicine, 89(3), 161–167. https://doi.org/10.3949/ccjm.89a.21126
  
• Proal, A. D., & VanElzakker, M. B. (2021). Long Covid or post-acute sequelae of COVID-19 (PASC): An overview of biological factors that may contribute to persistent symptoms. Frontiers in Microbiology, 12. https://doi.org/10.3389/fmicb.2021.698169
• Ripa, M., Motta, L., Schipa, C., Rizzo, S., Sollazzi, L., & Aceto, P. (2022). "Vision Loss" and COVID-19 Infection: A Systematic Review and Meta-Analysis. Vision (Basel, Switzerland), 6(4), 60. https://doi.org/10.3390/vision6040060
  
• Rouquette, A., Descarpentry, A., Dione, F., Falissard, B., Legleye, S., Vuillermoz, C., Pastorello, A., Meyer, L., Warszawski, J., Davisse-Paturet, C., Melchior, M., & EpiCoV Study Group (2023). Comparison of Depression and Anxiety Following Self-reported COVID-19-Like Symptoms vs SARS-CoV-2 Seropositivity in France. JAMA network open, 6(5), e2312892. https://doi.org/10.1001/jamanetworkopen.2023.12892
• Rao, S., Gross, R. S., Mohandas, S., Stein, C. R., Case, A., Dreyer, B., Pajor, N. M., Bunnell, H. T., Warburton, D., Berg, E., Overdevest, J. B., Gorelik, M., Milner, J., Saxena, S., Jhaveri, R., Wood, J. C., Rhee, K. E., Letts, R., Maughan, C., … Stockwell, M. S. (2024). Postacute sequelae of SARS-COV-2 in children. Pediatrics. https://doi.org/10.1542/peds.2023-062570
• Schultebraucks, K., Blekic, W., Basaraba, C. et al. The impact of preexisting psychiatric disorders and antidepressant use on COVID-19 related outcomes: a multicenter study. Mol Psychiatry 28, 2462–2468 (2023). https://doi.org/10.1038/s41380-023-02049-4
• Seyfi, S., Alijanpour, R., Aryanian, Z., Ezoji, K., & Mahmoudi, M. (2022). Prevalence of telogen effluvium hair loss in COVID-19 patients and its relationship with disease severity. Journal of medicine and life, 15(5), 631–634. https://doi.org/10.25122/jml-2021-0380
  
• Smith, L. (2023). Center for Disability Rights. #Ableism – Center for Disability Rights. https://cdrnys.org/blog/uncategorized/ableism/
• Sultan, R. (2023). The state has abandoned us, but we can still help each other. Prism. https://prismreports.org/2023/04/20/covid-19-state-has-abandoned-us/
• Theberath, M., Bauer, D., Chen, W., Salinas, M., Mohabbat, A. B., Yang, J., Chon, T. Y., Bauer, B. A., & Wahner-Roedler, D. L. (2022). Effects of COVID-19 pandemic on mental health of children and adolescents: A systematic review of survey studies. SAGE open medicine, 10, 20503121221086712. https://doi.org/10.1177/20503121221086712
• United States Department of Health and Human Services. (2021). Guidance on “Long COVID” as a Disability Under the ADA, Section 504, and Section 1557. https://www.hhs.gov/civil-rights/for-providers/civil-rights-covid19/guidance-long-covid-disability/index.html
• Weiss, L. (2023, September 26). Women of color face additional hurdles with long covid. Prism. https://prismreports.org/2023/09/21/women-of-color-long-covid-nightmare/
• Yanachkova, V., Stankova, T., & Staynova, R. (2023). Thyroid dysfunction as a long-term post-covid-19 complication in mild-to-moderate COVID-19. Biotechnology & Biotechnological Equipment, 37(1), 194–202. https://doi.org/10.1080/13102818.2023.2170829
• Zakia H, Pradana K, Iskandar S (2023) Risk factors for psychiatric symptoms in patients with long COVID: A systematic review. PLOS ONE 18(4): e0284075. https://doi.org/10.1371/journal.pone.0284075
• Al-Aly, Z. & Topol, E. (2024) Solving the puzzle of Long Covid.Science383,830-832.DOI:10.1126/science.adl0867
  

Discussion

What feelings came up for you?

What’s something new you’ve learned today?

How will you implement what you’ve learned today in your own life- either personally or in your professional practice?

Do you have any questions?

Thank you for listening!

Feedback

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