2 April 2020

Pathological uncertainty – an invisible enemy

COVID-19 Mental Health Psychiatry

In an age in which social connections, financial transactions and travel plans can be made with the swipe of a finger, the illusion that we are in complete control of our future lives is as convincing as it is alluring.

Faced with the indefinite disruption of our quotidian cadence, it is unsurprising that many of us feel disoriented and bereft. The potentially devastating impact of social distancing on public mental health has been widely discussed in recent weeks. While the psychological ramifications of enforced isolation are concerning, the corrosive impact of relentless uncertainty on our emotional welfare should not be under-estimated.

As a psychiatry trainee, my patients often seek help in a state of acute crisis precipitated by a recent traumatic event, be it the break-up of a relationship, the death of a loved one, or the loss of a job. Much of their anguish stems from the sudden disintegration of an imagined future and the emotional security this confers. When the comfort of familiar routines and future plans is threatened, a sense of looming uncertainty and visceral dread can rapidly take hold.

The aversive impact of sustained uncertainty on mental health has a neurobiological basis. A key function of the human brain is the anticipation of future events. This involves a range of neural circuits within the limbic system, perhaps best known for its role in survival instincts and emotional responses. The ability to conceive of what the future will likely hold enables us to prepare for future challenges, an ability with clear evolutionary advantages. Faced with a high level of uncertainty regarding future events, our capacity to make such adaptations is diminished, producing higher levels of stress and anxiety. Deficits in the anticipation of future experiences have been associated with lower overall levels of wellbeing and conditions such as depression and anxiety.

Over time, uncertainty can become a chronic psychological stressor. This is reflected in the high levels of anxiety and other mental disorders experienced by groups who face a persistent lack of stability, including asylum seekers and those affected by extreme poverty.

The capacity to tolerate uncertainty also varies between individuals; those with an underlying mental disorder or who are already facing multiple other stressors are typically the most vulnerable to the toxic effects of uncertainty on emotional welfare.

The despair felt in times of uncertainty is also a symptom of a contemporary paradigm which promotes self-agency. While the notion that we can shape our destiny is inspiring and empowering, it engenders hubris in the suggestion that we are capable of controlling and subduing external forces. In bygone times, a more fatalistic approach to life may have softened the blow of unexpected tragedy, providing some comfort in the interpretation of death and disaster as the will of a higher power.

The COVID-19 pandemic has shed light on some of the classic ways that humans respond to uncertainty. Scenes of frenzied shoppers coming to blows over the last pack of toilet paper have left many aghast, lamenting the demise of civility in a time of crisis. But seen through a different lens, panic-buying and hoarding simply reflect a primal drive to survive in the face of a major threat to our existence. Images of a crowded Bondi Beach in Sydney’s east convey the reckless indifference of some in the face of a crisis, but also evoke primitive defences such as denial and avoidance.

What steps then can we take to promote emotional wellbeing in the face of immense uncertainty? As always, it is important to be aware of the warning signs that indicate the need to seek professional help. While a degree of anxiety is to be expected at present, if a person’s level of worry is affecting their ability to function or is causing significant distress, professional guidance is warranted. Thankfully many mental health services and professionals are now offering phone or video consultations that allow those in isolation to receive the support they need.

Uncertainty can be a catalyst for innovation, forcing us to find new ways to adapt and survive in challenging circumstances. The proliferation of services adapted for those in isolation is testament to the way that uncertainty and destabilisation can stimulate problem-solving and mental flexibility.

Comfort can also be found in the heightened sense of compassion and community spirit that times of crisis often inspire. As a mature psychological defence, altruism can provide a way of transforming anxiety and powerlessness into positive action. Humour and creativity are other adaptive coping strategies that can help mitigate the negative impact of uncertainty and refocus energy otherwise spent on anxious rumination towards productive ends.

Author

Anne Selikowitz is a RANZCP advanced trainee in child and adolescent psychiatry, currently working in Sydney. She holds an MBBS (Sydney University 2013) and BA (Adv) (Hons) with University Medal (Sydney University 2009) 
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