By Dr. Mimi Winsberg
When I was single and in my 30s, countless hours were spent holding court at a local cafe over a coffee and the Sunday paper, sharing ideas and stories, communing. Social media and digital communications have largely replaced this ritual. And then came the pandemic.
The mental health crisis brought on by COVID has rivaled the epidemiologic one. People in my field, psychiatry, have been witness to record rates of depression and anxiety. And while much attention has been paid to pandemic-related stresses, there is an unreported phenomena that I have observed in many of my patients, mostly single women in the Bay Area who live alone: They have started hearing voices.
Hearing voices, otherwise known as auditory hallucinations, is typically an ominous sign in psychiatry, associated with psychosis, schizophrenia or a manic phase of bipolar disorder. Yet for my patients who have been plagued by pandemic voices, none of those diagnoses have applied.
Jenna, a 43-year-old lesbian, first started noticing the voices a few months into the pandemic. She was no stranger to psychiatric symptoms — we’d been addressing her anxiety and attention issues for years. She had suffered a few episodes of depression, and knew how to be on the lookout for changes in her mood, or productivity. As a high-performing product manager at a top tech company, Jenna had felt comfortable sharing her ongoing mental health struggles with friends and colleagues, but never had she thought of herself as crazy.
During a session last fall, Jenna timidly raised her concern that she might be getting psychotic or going crazy. She had started hearing voices, she explained, and sometimes had the sensation of other people in her house. She lived alone, and since the onset of shelter in place in California, had not been in the presence of a single soul. Interactions with work colleagues, as well as friends and family, took place over Zoom. Groceries were delivered, and she only ventured out of the house only for solitary walks. It had been six months since she had been in the same room with someone, let alone felt another human’s touch.
The voices she heard were, she was pretty sure, part of her inner world. They were largely welcome, providing comfort and at times she found herself responding to them out loud. Mostly they reassured her, or reminded her to do something. Occasionally, they had a threatening edge. Once, in the shower, she became aware of an unwanted male presence, and then had the sensation she was being grabbed. She instinctively reached to fight him off. Later, she found a long scratch across her shoulder.
“I inadvertently cut my arm with my nails,” she explained, “because I imagined someone was grabbing me and that’s what I wanted to do to them. It was weird … and yet had you been there, I would have told you that I knew they weren’t really there.”
As Jenna described these hallucinations, we had to consider whether they were in fact symptoms of more serious mental illness. While hearing voices is a hallmark symptom of psychosis, it’s also possible to hear voices without having a mental illness. Jenna had no other signs or symptoms of psychosis or loss of touch with reality, and demonstrated insight as to the bizarreness of her experience. As we explored the voices and their meaning, they receded and she recognized them as a manifestation of her loneliness.
“My inner fantasy world has quelled and that has made me kinda depressed,” she reported later. “I think I’m lonelier without it. I now realize I’m lonely versus just wanting to avoid the feeling of it all together.”
The pandemic has brought unique challenges to each and every one of us. Working parents have struggled to be productive with young children underfoot. Marriages have been put to the test as couples have been subject to constant togetherness. But for those who have weathered this storm alone, particularly single women, it has meant confronting a level of loneliness and isolation that was previously unimaginable.
Single women over 35 have always been subject to a special kind of pity, even scorn. Women, after all, are not supposed to be single. If we are, we must be deficient or unhappy or both. Yet so many of my patients — smart and financially independent women with successful careers — have chosen this comfortable existence of living alone. And were coping well with it, until it became extreme.
For many of these women, dating has gone by the wayside in the last year, along with social events and quiet time with friends. As rule followers, they have been hesitant to take risks around unnecessary exposure to others.
Shauna, an independent and successful 39-year-old Black executive with strong social support, was planning to go through in vitro fertilization at the start of the pandemic. She was ready to embark on the challenge of parenting alone, and then COVID hit. She hunkered down and practiced extreme social isolation, having seen the toll the virus took on her family members in New York. She had lost a relative and her mother had been hospitalized. Many months into the pandemic, she began hearing voices at her door, and sometimes felt there were social gatherings happening in her apartment.
There is a close relationship between solitary confinement and mental illness. In studies of prisoners who have been sentenced to even short periods of solitary confinement, it is not uncommon for psychiatric symptoms to emerge, including severe confusional, paranoid and hallucinatory states, even among those who have no prior history of mental illness.
My patients are not in solitary confinement for crimes committed, but because the pandemic has required us to keep our social circles small. For those who live alone, prolonged isolation seems to be leading to forms of mental distress previously found in jail cells.
Lucia, a 36-year-old Hispanic woman and data scientist, became obsessed with the voices on the street outside her Oakland apartment. Sometimes she would hear her name called, and sometimes it would be whispered, as if trying to scare her. Mostly it was indistinct chatter. Over time, she became confused as to whether the voices were outside, in her apartment, or in her head. She started sleeping with the light on, both for safety and to avoid the sense of isolation she felt at night.
Mary, a successful 37-year-old creative designer at a large tech company, said the voices started as a conversation between three characters. “They were not outside of my body, or part of my thoughts, but a distinct dialogue all in my head.” Over time these characters became imaginary friends — with their own personalities, quirks and annoyances she would have to deal with. Sometimes they would fight, and she would have to play mediator. Even when the characters caused trouble, they were a welcome distraction from the loneliness.
At Brightside.com, the tele-mental health company I co-founded, we have seen a large number of cases that have presented this way in the last year. In my practice, I have encouraged these patients to seek out a pandemic buddy — someone to go for walks with, share a meal or just talk with regularly on the phone. “But that’s against the rules” some would say. My response was that the risk of communing with a single friend, posed from a viral standpoint, far outweighed the risk of going crazy from loneliness.
We underestimate the healing value that intimate, platonic friendships play in our lives, and COVID has underscored their importance. With the easing of restrictions during this phase of the pandemic, let’s embrace our need for others and our commitment to fellowship and communion. That may be the most protective measure we can take for our mental health.
Dr. Mimi Winsberg is a Stanford University-trained board certified psychiatrist and chief medical officer at Brightside.