Post-Traumatic Stress Disorder (PTSD) and COVID-19

What Is Trauma?

Trauma refers to the intense mind and body response that a person might experience following a significantly distressing event or series of events. Potentially traumatic situations are those in which we feel helpless to prevent serious harm to ourselves or others. In such situations, we might experience or witness serious injury or loss—or we might witness the death of another person. What is traumatic for one individual might not be traumatic for another.

Normal Responses During a Traumatic Event

When faced with a traumatic event, individuals will typically respond in one of four ways: flight, fight, freeze/submit, or trained reflexive responses.

Flight

Flight involves taking action to escape the threat.

Fight

If unable to flee, one might try to overpower the threat.

Freeze and/or Submit

If unable to flee or fight, the mind and body might freeze and/or the person might submit to demands being made by an oppressor. In these situations, the brain might stop recording the event, and thus the person might not be able to remember all or parts of the trauma.

Trained Reflexive Responses

Emergency responders, soldiers, and health care workers are overtrained in their work-related responses so that they become a reflex. This is done on purpose during training so that if one is faced with a traumatic situation, the mind and body will automatically revert to trained responses. This allows these individuals to do what needs to be done, but it will not necessarily protect them from developing PTSD.¹

It is important to recognize that one’s response during a traumatic event is not “thought out” or conscious—it is instinctive. It is the most primitive part of the brain, which is responsible for our survival, that chooses the response it deems best minimizes risk of serious harm to ourselves and/or others.

If you are reading this following a traumatic experience, your primitive brain did it’s job and you survived the trauma. It is not helpful to judge or blame yourself or others for responses during a traumatic incident, since one’s reaction is not a conscious choice. It is also not fair or helpful to criticize one’s actions based on information available after the fact.

Why the Risk of PTSD Is Increased Due to COVID-19

Given the relative newness of the COVID-19 pandemic, and the fact that it is an unprecedented situation, the research on COVID-19 and PTSD is only beginning to emerge. It is of interest to note that within the first weeks of the pandemic, in a study within the U.S., one-third of young adults were found to have elevated symptoms of PTSD.²

Based on what we know about trauma,^3,4 in conjunction with the multitude of ways the current pandemic is negatively affecting millions, we can reasonably propose that the following factors will likely increase the risk of PTSD among the general population, and specifically among those who have been deemed essential workers:

High Severity or Intensity of Trauma

To date, over 100,000 deaths have occurred in the US as a result of the pandemic, and this number continues to increase on a daily basis.⁵

Many aspects of this virus are unknown, which can lead to fear and a sense of helplessness. There is uncertainty regarding means of transmission, the full range of symptoms, if a person is infected and whether they can be reinfected, whether a vaccine or cure will be found, if/when a second wave will occur, and what the end date will be for the pandemic.

Perceived Threat to One’s Life

This virus has been demonstrated to have serious consequences and to be life-threatening, particularly for those who live in identified “hotspots,” and for those who are more susceptible to poor outcomes if they contract the virus (i.e., over 50 years of age, obesity, underlying heart, liver, or kidney disease).⁶

Lack of Social Support During & Following the Trauma

Many are currently isolated from family, friends, or others who would typically provide them with emotional support and a sense of belonging, including children attending school. Some are unable to be with loved ones due to quarantine restrictions if they, other loved ones, have been diagnosed with the virus.

Greater Life Stressors Prior to or During the Trauma

More than half of Americans have reported increased stress-related symptoms during the pandemic such as sleep problems, stomach issues, headaches, issues with eating, and irritability.⁷

Some of the increase stressors that people have been experiencing prior to and/or during the pandemic include:

• Job loss and/or financial issues (e.g., fear of eviction, food insecurity, lack of access to medication and health services).
• Heightened stress related to witnessed and/or experienced racism, which can be traumatic in its own right.
• Feelings of isolation and loneliness.
• Previously diagnosed mental Illness (including a previous diagnosis of PTSD), which may be exacerbated due to pandemic related uncertainty and stress.

Intense Negative Emotional Reactions During or After the Trauma

Negative emotional reactions to COVID-19 may include:

• Fear of contracting the virus oneself, and of infecting loved ones and others.
• Fearing for oneself and/or loved ones who have contracted the virus.
• Experiencing intense guilt, anxiety, fear, etc. about being unable to be with a loved one who is battling the virus.
• Distress regarding a loved one or patient dying without family or friends present.
• Grief regarding the death of a loved one or patients who have died due to the virus.
• Guilt, shame, or grief regarding being unable to save patients who are dying from the virus.
• Anxiety and fear at work due to lack of access to Personal Protective Equipment (PPE), staffing, medical equipment, and/or perceived support.
• Medical trauma from being hospitalized due to the virus.
• Increased risk of “moral injury,” which refers to intense distress (i.e., psychological, social, behavioral, and/or spiritual) that one might experience following a traumatic event in which one’s actions or lack of actions, or an event that one has witnessed, conflicts with one’s conscience and moral values.⁸

Experiencing Dissociation During or After the Trauma

Dissociation may involve the following feelings:

• Experiencing a freeze or submit response to trauma
• Emotional numbness
• Feeling out of one’s body or disconnected from parts of your body
• Feeling of profound disconnection from others and/or the world
• A sense that what you are experiencing is not real

Populations at Greater Risk to PTSD during the COVID-19 Pandemic

A study of WWII veterans demonstrated that the majority of soldiers who faced the atrocities of war (i.e., traumatic stressors) for a prolonged period of time would eventually experience psychological injuries.⁹ This was due to the characteristics of the trauma, not the individual.

“[Traumatic stress reactions] may appear in as few as fifteen or twenty days or in as many as forty or fifty days… One thing alone seems to be certain: Practically all infantry soldiers suffer from a neurotic stress reaction eventually if they are subject to the stress of modern combat continuously and long enough.”⁹

This study is important because it underscores the truth of the matter—that experiencing PTSD is NOT about weakness or character flaw. PTSD is a real injury, which has been documented via brain MRIs. PTSD occurs when the way that the mind and body function has been changed as a result of exposure to trauma.^10,11

At-risk populations during the current pandemic include healthcare workers, emergency responders, and others who are designated as “essential workers” (i.e., bus drivers, grocery store employees, farm workers) in geographic pandemic hotspots.

These individuals, by virtue of their work, are entering into their own version of a war zone with an unseen enemy. Unfortunately they do not always have access to adequate gear or training to protect themselves and others against the virus. Additionally, it is unknown what “weapons” can be used to subdue this viral enemy, so stress levels are often quite high.

Other at-risk populations include those who are indirectly subjected to prolonged severe trauma as a result of stay-at-home orders, such as children and adults who live in domestic violence situations. If the perpetrator and those who are abused are in the same dwelling all day and night, there is no escape and no place of refuge from the abuse (e.g., school or work).

Social isolation decreases their ability to achieve outside support or help. Home is their war zone. Thus, in addition to the threat of COVID-19, these individuals are dealing with increased risk of harm at the hands of their abuser.

Enhancing Resilience

Resiliency refers to the ability to adapt and continue to function when faced with tragedy, trauma, or other significant threats or stressors.¹²

The following factors have been shown to provide some protection against developing PTSD:¹³

• Successful fight or flight responses to the trauma: In terms of COVID-19, a successful fight response is most likely to occur when we have a vaccine, and/or when effective treatments are discovered. Fleeing, which might be possible during stay-at-home orders, may provide some protection for a time if home is not a safe environment.
• Feeling prepared for the expected traumatic stressor
• Having personal beliefs that help you to achieve a sense of purpose during the trauma
• Using effective, healthy coping strategies to reduce and manage distress
• Perception of having adequate social support (e.g, from government, employers, coworkers, family, friends, the community, etc.)

Despite the many uncertainties we are living with during the pandemic, there are things within our control that we can do to enhance our resilience:

Engage in Physical Activity

This may include walking, working out, or yoga

Ask the Right Questions

Instead of asking “Why” questions, ask yourself “What can I do to support myself in this moment?” Ask yourself this question regularly throughout the day. The answer you will get to this question is likely to be different from moment to moment (e.g., have something to eat, talk to a friend, breathe, stretch, distract by watching a movie or playing with an animal). As you learn to listen to what you need and honor those needs, you will become more confident in your ability to cope.

Mindfulness

Try to maintain your focus on the present moment. Notice the colors, sounds, physical sensations, etc. around you. Do not focus on past painful events or on future worries. You can get through this moment. Asking yourself to deal with the past, present, and future all at the same time is not reasonable, fair, or helpful.

Compassion

Choose to treat yourself, and others, with compassion. We are not operating in an ideal situation. Some of our energy is being used up in the background to cope with ongoing uncertainty and stress. People are more distractible, are finding it difficult to concentrate, are feeling more exhausted, and are having more days where they are feeling emotionally drained.  All of this is normal in the current circumstances.

Recognize that each of us is doing the best that we can, and that we cannot do the impossible. Choose compassion.

Connect

Make a point of finding time to connect socially (even if online or at a social distance) with people who energize, calm, or uplift you.

Make Sure to Eat

When people are feeling overwhelmed they often skip meals. This can cause greater physical and emotional agitation. If you’re not feeling hungry, try to eat healthy small meals every few hours (e.g., cheese and raw vegetables, nuts and piece of fruit, a hard boiled egg and whole grain bread)

Breathe

Taking 60 seconds to focus on your breathing, noticing the rhythm and the transition from inhaling to exhaling and vice versa, can help to reset your mind and body.

Take Time Afterward

When you experience a particularly traumatic experience, take time afterward, to focus on the fact that it is over. Allow yourself to physically sigh. Remind yourself that it is over. There might still be other losses and stressors to deal with as a result of this event, but the event itself is over and it is okay to choose to allow it to move into your past.

Taking this time can also help to reset the mind and body, and to allow the brain to record the trauma as being over—and in the past. (When one experiences PTSD, part of the issue is that the brain never receives the message that the trauma is over, and any reminders of the trauma can then trigger the mind and body to go back to reliving the trauma as though it is still happening in the present moment).

Get Practical

Engage in concrete practical activities, that over a short period of time, have a beginning, a middle, and an end (e.g., washing and folding clothes, tidying a closet, making dinner). As you mindfully do these activities, they can give you a sense of accomplishment.

Look to Nature for a Sense of Certainty

The consistent life-death-life cycles of nature remind us that some things are constant despite the situational uncertainties of the pandemic.