A Perfect Storm
These are extraordinary times. Throughout history there have been plenty of pandemics but the human response to COVID-19 is unprecedented. The world will never be the same again. It is estimated that close to four billion people are living in social isolation during this mother of all pandemics (Sandford, 2020). Unless there is a revolt, policies of social isolation in one form or another are expected to continue until a vaccine is available 6, 12 or 24 months from now. The cumulative impacts of social distancing will be truly profound.
COVID-19 lockdown has created a perfect storm’ of vulnerabilities that huge numbers of people, and services, are ill-prepared to manage. This post reviews the science of human needs as they are expected to play out over a prolonged period of domestic confinement.
The COVID-19 pandemic involves a novel coronavirus characterized by a respiratory illness that results from a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (Centers of Disease Control and Prevention, 2020). The disease was first reported in Wuhan, China, in December 2019 and symptomatic patients frequently present with a dry cough, fever and shortness of breath within 2 to 14 days after exposure. The coronavirus disease (COVID-19) pandemic is receiving intensive interest at all levels: political, economic, social, scientific and in health care. The epicenter of the COVID-19 outbreak moved from China to Europe and a few weeks later to the US. As of 22 April 2020, there were 2,564,038 confirmed cases and 177,424 deaths reported worldwide, affecting at least 201 countries, areas or territories (Johns Hopkins University, 2020). Most cases are in the USA (823,786 cases), followed by Spain (204,178) and Italy (183,957) (Johns Hopkins University, 2020).
Owing to the absence of a vaccine, official control measures have been implemented to reduce the spread of COVID-19, such as restrictions on people’s movements, including social distancing, closing of gyms and parks, travel restrictions, quarantines and stay–at–home guidance. The policy of confinement has significant health, economic, environmental and social consequences. In the psychological sphere, recent evidence shows that similar pandemics increased the prevalence of symptoms of post-traumatic stress disorder, as well as confusion, feeling of loneliness, boredom and anger during and after quarantine (Brooks, Webster, Smith, Woodland, Wessely, Greenberg, et al. 2020).
Stressors during this critical period include fear of infection, fear of death, uncertainty, loss of social contacts, confinement, inadequate information, conflicting advice, loss of outdoor activities, disconnection from nature, loneliness, depression, helplessness, anger, low self-esteem, financial loss and obstacles to supplies of food and water (Brooks et al., 2020; Jiménez-Pavón, Carbonell-Baeza & Lavie, et al., 2020; Xiang, Yang, Li, Zhang, Zhang, Cheung, et al., 2020). A survey in China during the initial outbreak of COVID-19 found that 54% of respondents rated the psychological impact of the outbreak as moderate or severe; 17% reported moderate to severe depressive symptoms; 29% reported moderate to severe anxiety symptoms, and 8% reported moderate to severe stress levels (Wang, Pan, Wan, Tan, Xu, Ho et al., 2020). Given that a significant proportion of the population live alone or are vulnerable to mental health problems, the impacts of the COVID-19 pandemic on mental wellbeing are only now just beginning to be felt.
In light of these issues, systematic psychological self-care must be given a high priority in coping with the detrimental impacts of COVID-19 and social distancing. Here we discuss one of the most fundamental tools of self-care for health enhancement: increased physical activity. Governmental recognition of the benefits of exercise is evidenced by permitting exercise outdoors during social isolation for indefinite periods of weeks or months. Yet rarely is the issue adequately addressed; an International Task Force of experts to review and advise on psychological and physical self-care would be a welcome initiative.
During the COVID-19 pandemic special attention to systematic psychological health care is required (Zaka, Shamloo, Fiorente & Tafuri, 2020; Zandifar and Badrfam, 2020). Interventions to deal with the pressing psychological needs of individuals during the pandemic are being investigated but in most parts of the world seriously lacking (Xiang et al., 2020; Wang, Zhao, Fen, Liu, Yao, & Shi, et al., 2020).
One example is physical exercise, which is one of the most important tools to prevent mental illness and improve well-being (Mandolesi, Polverino, Montuori, Foti, Ferraioli, Sorrentino et al., 2018). However, few public health guidelines include daily physical exercise routines for people living in varying degrees of isolation during the pandemic (Chen et al., 2020; Jiménez-Pavón et al., 2020). The role of physical exercise in psychological wellbeing during the pandemic is discussed in a later post.
Here I introduce concepts that help to enable effective self-care measures for COVID-19 isolation. These concepts are part of A General Theory of Behaviour.
At every level of existence, from the cell to the organism, from the individual to the population, and from the local ecosystem to the entire planet, homeostasis is a drive towards stability, security and adaptation to change. In a general theory of behaviour claims that striving for balance and equilibrium is a primary guiding force in all that we do, think and feel. A behavioural type of homeostasis has been given the descriptive term: “Reset Equilibrium Function” (or ‘REF’; Marks, 2018). The REF is thought to be omnipresent, whatever we are doing and wherever we are doing it, which includes the monotony of COVID-19 isolation. When we are in isolation, the REF stays with us, considers how to restore equilibrium and reduce feelings of unrest. The REF’s monitoring is not normally attended to, but the REF’s products are: feelings of distress, boredom, loneliness and instability can all be a focus for concern. Competing drives, conflicts, and inconsistencies all pull the flow of thought and feeling ‘off balance’, triggering an innate striving to restore equilibrium. Individuals resort to a variety of methods to restore a sense of balance and equilibrium.
Body and mind continuously regulate and control many domains and levels simultaneously, with multiple adjustments to voluntary and involuntary behaviour guided by two types of homeostasis: Type I – inwardly striving or physiological homeostasis, H[Φ], and Type II – outwardly striving or psychological homeostasis, H[Ψ]. Physiological regulation involves drives such as hunger, thirst, sex, elimination and sleep. The ‘Reset Equilibrium Function’ (REF) operates across all behavioural systems that are investigated by psychological science.
The Reset Equilibrium Function is a general control function that automatically restores psychological processes to equilibrium and stability. The REF is triggered when any processes within a system strays outside of its set range. The REF is innate and exists in conscious organisms, which all have Type I and II homeostasis. The two types of homeostasis work in synergy. Psychological and physiological processes operate in tandem to maximize equilibrium for each particular set of functions.
These include cognition, affect, chronic stress, and subjective well-being, and also out-of-control conditions such as isolation, boredom, addiction or insomnia that are in need of self-care. When there is goal to make a behavior change, conscious awareness of the goal and full engagement of one’s personal resources are necessary preconditions for purposeful striving, e.g. the need to reduce boredom and instability in COVID-19 isolation.
The Needs Hierarchy
Human experience is controlled by needs and behaviours to satisfy needs. A general theory of behaviour includes Maslow’s (1943) influential statement about human needs(with a few minor modifications). It is assumed that needs occupy a hierarchy of seven overlapping levels (Figure 1). Like any hierarchical structure, the stability of the system relies on the strength of its foundation level. The first level – Immediate Physiological Needs – incorporates physiological homeostasis (Type I) and the sustenance of all physiological needs. Higher level needs from level 2 upwards are served by psychological homeostasis (Type II). There is a progression in developmental priority as the individual matures. The motivational hierarchy reflects evolutionary function, developmental sequencing, and current cognitive priority. Individuals who are unable to meet their immediate physiological needs at level 1 are at a disadvantage in meeting higher-level needs. Think of a building with seven storeys. If level 1 of the building is not strong, then the higher levels will be vulnerable to collapse.
Figure 1. The Hierarchy of Human Needs. Homeostasis operates at all seven levels. Physiological, or Type I homeostasis operates at level 1. Psychological, Type II, homeostasis operates at level 2 (Self-protection) and above. Reproductive goals are in the order they are likely to appear developmentally. Later developing needs are overlapping with earlier developing needs. Once a need develops, its activation is triggered whenever relevant environmental cues are salient. Adapted from Kenrick, Griskevicius, Neuberg and Schaller (2010) with permission.
I consider next the likely impact of COVID-19 social distancing in light of the needs hierarchy. Four needs most directly impacted by social distancing at levels 1 to 4 are discussed in turn.
Immediate Physiological Needs (Level 1)
Physiological regulation involves the drives of hunger, thirst, sex, elimination and sleep. Level 1 is a bedrock for all higher levels. We consider first food, drink and other necessary products, which have been an issue from the very start of the pandemic with ‘panic buying’ and stockpiling reported everywhere causing supermarkets and stores to run out of supplies. In the UK, in packaged food and beverages, the highest growth has been evident in cereals (38%), vegetables (37%), cocoa (25%), rice (22%) and pasta (19%). There has also been an increase in bottled water and indulgence foods, such as chocolate (23%), olives (68%) and beer (20%) (Kantar, 2020).Comfort eating and drinking is a common strategy of individuals seeking ways to ameliorate anxiety and distress associated with lockdown. Comfort eating and drinking is associated with weight gain and the development of obesity and eating disorders, especially in conditions of isolation and boredom (Crockett, Myhre & Rokke, 2015; Marks, 2015; Figure 2). Sadly, there is likely to be an acceleration in the already high prevalence of obesity over the lockdown period. As the lockdown period is indefinitely extended, with increasing joblessness and poverty, food insecurity is likely to become a major concern for many people.
Figure 2. Panel A shows the homeostasis system linking low self-esteem with negative affect, comfort eating and overweight. Intervention to alter the dynamics of the system towards that shown in Panel B replaces comfort eating with exercise designed to increase self-esteem and control weight gain (Marks, 2015).
A well-known and, to many, surprising COVID-19 phenomenon has been the prevalence of toilet-tissue stockpiling (TTS). In the UK, for the week ending 8 March 2020 the sales of toilet tissues rose by 60% year-on-year (Kantar, 2020). Why should this be? In fact, this behaviour is perfectly logical and in line with the needs hierarchy where utmost priority is given to needs at level 1. TTS provides long-term hygienic support to the necessary act of elimination, which, during isolation, is more frequent at home because people are unable to do itat the workplace. Thus, TTS is consistent with level 1 of the hierarchy of needs.
Level 1 needs are automatically more complex in cases of addiction to drugs, alcohol, tobacco and other substances. If any of these addictions are present, the entire needs structure can be placed in jeopardy. In any case, disruption of sleep patterns is one prevalent consequence of pandemic distress. A European task force concluded: “In the current global home confinement situation due to the COVID-19 outbreak, most individuals are exposed to an unprecedented stressful situation of unknown duration. This may not only increase daytime stress, anxiety and depression levels but also disrupt sleep. Importantly, because of the fundamental role that sleep plays in emotion regulation, sleep disturbance can have direct consequences upon next day emotional functioning… Managing sleep problems as best as possible during home confinement can limit stress and possibly prevent disruptions of social relationships” (Altena, Baglioni, Espie, Ellis, Gavriloff, Holzinger, et al., 2020, p. 1). It has been established that physical exercise improves sleep for people of all ages (Flausino, Da Silva Prado, de Queiroz, Tufik, & de Mello, 2012; Reid, Baron, Lu, Naylor, Wolfe & Zee, 2010; Yang, Ho, Chen, & Chien, 2012). We return to this later.
Need for Self-Protection (Level 2)
Self-protection needs during the COVID-19 pandemic are paramount. The World Health Organisation (WHO, 2020) and national governments have required a lockdown of the population with “social distancing” and ‘stay-at-home’ isolation. These policies have stoked fear of death and infection while incentivizing individuals to carry out frequent handwashing, wearing masks along with social isolation. The advice to stay at home has been the main topic of messaging from health authorities during the pandemic.
An individual’s responses to COVID-19 lockdown is shown in Figure 3. In lockdown, unmet self-protection needs become ‘normal’ and individuals experience systematic frustration of a deep-seated need to ensure protection of self and their family. This high level of frustration causes fear, anxiety and distress as individuals feel incompetent to guarantee the safety and protection of loved ones, family and self. Fear, anxiety and distress are also associated with insomnia, irritability and aggression. Especially if an individual uses alcohol or drugs to assuage their fears, aggression may turn into physical violence to family members, women, children and pets(Peterman, Potts, O’Donnell, Thompson, Shah, Oertelt-Prigione, et al., 2020). There are increases in the incidence of homicides and suicides (e.g. Campbell, 2020).
Figure 3. Behavioural systems at level 2 of the needs hierarchy in COVID-19 lockdown. In panel A, fear and frustration are accompanied by heightened surveillance of the external environment via TV news channels and social media. In panel B, fear and frustration are replaced by self-compassion and empathy and surveillance is replaced by reaching out to others.
Need for Affiliation (Level 3)
The almost total cessation of full frontal face-to-face affiliation outside of one’s domestic ‘bubble’ is mandated by policies of home confinement and “social distancing”. Connecting with others normally helps individuals to regulate their emotions, cope with stress, and remain resilient (Williams, Morelli, Ong & Zaki, 2018). Loneliness and social isolation, on the other hand, worsen the burden of stress, and often produce deleterious effects on mental, cardiovascular, and immune health (Haslam, Jetten, Cruwys, Dingle, & Haslam, 2018). Older adults, at the greatest risk of severe symptoms from COVID-19, are also most susceptible to isolation (Luo, Hawkley, Waite, & Cacioppo, 2012). Intergenerational social support, self-esteem, and loneliness are all strongly associated with subjective well-being (Tian, 2016).
These effects are not peculiar to older people. Even among adolescents, loneliness is associated with physical inactivity (Pinto, Oppong Asante, Puga Barbosa, Nahas, Dias and Pelegrini, 2019). Thus distancing threatens to aggravate feelings of loneliness that likely will produce negative long-term health consequences in many vulnerable people. During the COVID-19 pandemic, the population of people at risk is enormous. After the lockdown period ceases, sadly mental health services are expected to be overwhelmed.
People with unmet needs for affiliation at level 3 are also at risk of failing to meet needs for status and self-esteem at level 4.
Need for Status/Self-esteem (Level 4)
As noted, status and self-esteem needs are vulnerable if needs at levels 1 – 3 are unmet. Failure at levels 1-3 accumulates with larger knock-on effects as cumulative failure develops. Furthermore, the pandemic is producing huge increases in unemployment and poverty, vulnerability factors for lowered self-esteem and social status (e.g. Goldsmith, Veum & Darity, 1997). Self‐esteem is associated with responses to success and failure (Baumeister & Tice, 1985). Low self-esteem also creates a vulnerability to depression (Sowislo & Orth, 2013) and to drinking alcohol (Hull & Young, 1983) – if affordable. Self-esteem moderates the associations between body-related self-esteem, conscious emotions and depressive symptoms (Brunet, Pila, Solomon-Krakus, Sabiston & O’Loughlin, 2019). Self-esteem also appears to be an important antecedent of the development of self-compassion (Dona, Parker, Sahdra, Marshall, & Guo, 2018).
COVID-19 lockdown has created a perfect storm’ of vulnerabilities that huge numbers of people, and services, are ill-prepared to manage. The success of social isolation policies will depend on minimizing long term depreciation of mental health.
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