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Posttraumatic Stress Disorder during COVID-19

Psychological Trauma and PTSD

Psychological Trauma is defined as a direct threat to one’s life, serious physical injury, sexual violence, and/or witnessing an unexpected death, immediate threat to life, or physical injury to another person.

Psychological trauma is common, with estimates of up to 60-85% of people having experienced a trauma within their lifetime. Reactions to a trauma are common and can include intrusive thoughts, nightmares, avoidance of reminders of the trauma, self-blame, being “on edge,” concern for safety, irritability, and concentration problems. Posttraumatic Stress Disorder (PTSD) is a condition that can develop after experiencing a psychological trauma when these reactions persist for a month or more and cause substantial distress and disruption in one’s life. PTSD is much less common than trauma exposure. An estimated 6% of men and 10% of women experience PTSD within their lifetime.

Symptoms of PTSD include:

  • Presence of intrusive symptoms, such as
    • Experiencing recurrent and intrusive memories of the trauma
    • Nightmares or flashbacks of the trauma
  • Avoidance of reminders of the traumatic event, such as
    • Avoiding distressing memories of the trauma
    • Avoiding the location or people associated with the trauma
  • Negative effects on mood, such as
    • Feelings of guilt, anger, or shame
    • Loss of interest in previously enjoyable activities
  • Increased arousal, such as
    • Trouble sleeping
    • Hypervigilance

Trauma and the COVID Pandemic

COVID-19 has quickly become a global health emergency resulting in not only physical health concerns but also psychological concerns as people are exposed to unexpected deaths or threats of death. For example, healthcare workers who have close contact with COVID patients are not only exposed to the virus on a regular basis, but they may also be witnessing increased illnesses, deaths, and supply shortages. In addition, patients admitted to the hospital with COVID-19 experience social isolation, physical discomfort, and fear for survival. These exposures increase the risk of developing PTSD. In addition, the risk may further be enhanced during the subsequent weeks when these individuals may lack immediate social support due to the need to self-quarantine.

Predictors of PTSD: patient lifetime history

Some of the strongest predictors of development of PTSD after exposure to a trauma include previous trauma exposures (sometimes called “lifetime trauma load”), and in particular, history of childhood trauma and adverse childhood events (“ACEs”, e.g. childhood physical, sexual, and/or emotional abuse, physical and/or emotional neglect, witnessing violence toward one’s mother, etc.). Childhood trauma leads to odds rations >2, and a combination of childhood and previous adult trauma exposure further increases PTSD risk in response to all forms of trauma.

Predictors of PTSD: type and severity of trauma exposure

It is important to note that the majority of people exposed to trauma recover within 30 days and do not develop PTSD.  The type and severity of trauma exposure strongly predicts development of PTSD, with perpetrated interpersonal violence having much higher rates of PTSD than exposures like transportation collisions, fires, and natural disasters like hurricanes, etc. Motor vehicle crashes and natural disasters are associated with ~10% rates of development of PTSD, being in a combat zone ~18%, physical assault or experiencing heavy combat ~30%, and sexual assault and torture up to 50%.

It is often underappreciated that medical events and procedures associated with life threat, even when they are successful, are associated with relatively high rates of PTSD development. For example, myocardial infarct / acute coronary syndrome is associated with up to 15% rate of PTSD, as is unexpected discharge of cardiac defibrillation devices. Major thoracic surgeries such as cardiac aretery bypass graft (CABG) and open abdominal aortic aneurysm (AAA) repair, even when scheduled and expected, are also associated with ~20% rates of de novo PTSD.

Particularly relevant to the COVID-19 pandemic, prolonged treatment in intensive care units (ICUs) such as for sepsis, and in particular, intubation, are associated with some of the highest rates of medical PTSD, with 35% of ICU survivors having clinically significant PTSD symptoms 2 years subsequent to the ICU care. Thus, in addition to “post-intubation syndrome” in survivors, once a patient is medically stabilized, it is important to assess and provide care for psychiatric responses like PTSD that are expected to be common.

Consequences of PTSD

PTSD is often associated with profound changes in the autonomic nervous system, in particular an increase in activity of the sympathetic nervous system (the adrenaline system underlying the “fight, flight, or freeze” reactions) and a deficit in the parasympathetic nervous system (the “rest and digest” system). PTSD is also associated with exaggerated activity in the brain networks associated with processing threat-detection and negative emotional responses; decreased activity in the networks involved in executive control, problem solving, and emotional regulation; and deficits in brain circuits involved in reward.

When it goes untreated, PTSD can last for decades. People with PTSD cannot “just get over it” and in some cases, PTSD can be pernicious and insidious and can actually get worse rather than better over time. PTSD can be associated with substantial distress and disruption of social and occupational functioning, causing major problems in relationships and jobs.

Treatment of PTSD

If you or someone you love is affected by PTSD, it is important to know that effective treatments for PTSD exist. These include psychiatric medications (including SSRI antidepressants and prazosin for nightmares), and forms of cognitive-behavioral psychotherapy involving “emotional processing” of the trauma. These include prolonged exposure therapy, eye-movement desensitization and reprogramming (EMDR), and trauma-focused CBT. Other forms of psychotherapy not involving direct trauma processing can also be helpful, such as cognitive processing therapy (CPT-C), interpersonal therapy (IPT), present-centered therapy (PCT), and mindfulness-based therapies.

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