Post Traumatic Stress Disorder and Mental Health: Implications for the Pandemic

By Dr. Debanjan Banerjee

Photo: Lesly Juarez

Stress is something everyone experiences. Despite being unpleasant, stress in itself is not an illness. Over the decades of evolution, stress has been one of the best defence mechanisms available to civilization. However, like any other physiological processes, the disturbance of ‘stress balance’ in the body have vital connections with mental health conditions including depression, anxiety, psychosis and post-traumatic stress disorder (PTSD).

Beyond these disorders, it can also increase the risk of chronic medical illnesses like diabetes, hypertension, cardiac ailments, stroke, obesity and high blood cholesterol. The general mental wellbeing and psychosocial state can be impaired by chronic and unregulated stress. Here are certain normal stress responses the body encounters. We need to talk about the usual manifestations of stress first, to understand how it can lead to one of the serious mental disorders, like PTSD.

Fight or flight

Stress causes physical changes in the body. It increases heart rate and breathing. Muscles tense. Short-term memory becomes more effective. This stress response has evolved to keep us safe, as it prepares the body for ‘fight or flight’ when we sense danger. Research has also shown that thinking skills improve as stress increases. So in short bursts, stress can be a good thing. It can help us prepare for a sports match, job interview or exam. Usually, after a stressful event, the body returns to its normal state.

Long-term stress

Many situations can cause a stress response in the body. Changes at work, illness, accidents, problems with relationships, family, money or housing can all cause stress. Even seemingly small daily hassles like someone pushing in a queue can make us feel stressed. What links all these situations is that we’re unable to predict and control what is happening to us, and so our body goes into a state of increased alertness. And these events can happen all the time – triggering the body’s stress response over and over again. 

When the stress response becomes prolonged (chronic), it has a very different effect to the short bursts that enhance the body’s abilities. In many cases, the system controlling the stress response is no longer able to return to its normal state. Attention, memory, and the way we deal with emotions are negatively impacted. This long-term stress can contribute to both physical and mental illness through effects on the heart, immune and metabolic functions, and hormones acting on the brain.

Stress and PTSD 

In some cases, short-term stress can also lead to a mental health condition. Post-traumatic Stress Disorder (PTSD) can develop after experience of an extremely traumatic or stressful event. Someone affected may experience vivid flashbacks or nightmares, and uncontrollable thoughts about the event. The exact causes of the condition are not clear – though some of the risk factors are understood. 

State-of-the-art brain imaging has shown that, again, the areas of the brain particularly involved are the hippocampus (responsible for traumatic memories) and the amygdala (the structure responsible for ‘fear-conditioning’). There is some evidence that the neurotransmitters and hormones involved in the normal stress response may become disrupted during and after the traumatic event. Research has also shown that the amygdala, which processes fear, is hyperactive in people with PTSD, perhaps creating a kind of “false alarm”. 

Things You Should Know About Stress

1. Stress affects everyone.

Everyone experiences stress from time to time. There are different types of stress—all of which carry physical and mental health risks. A stressor may be a one-time or short-term occurrence, or it can happen repeatedly over a long time. Some people may cope with stress more effectively and recover from stressful events more quickly than others.

Examples of stress include:

  • Routine stress related to the pressures of school, work, family, and other daily responsibilities.
  • Stress brought about by a sudden negative change, such as losing a job, divorce, or illness.
  • Traumatic stress experienced during an event such as a major accident, war, assault, or natural disaster where people may be in danger of being seriously hurt or killed. People who experience traumatic stress may have very distressing temporary emotional and physical symptoms, but most recover naturally soon after. Read more about Coping with Traumatic Events.

2. Not all stress is bad.

In a dangerous situation, stress signals the body to prepare to face a threat or flee to safety. In these situations, your pulse quickens, you breathe faster, your muscles tense, and your brain uses more oxygen and increases activity—all functions aimed at survival and in response to stress. In non-life-threatening situations, stress can motivate people, such as when they need to take a test or interview for a new job.

3. Long-term stress can harm your health.

Coping with the impact of chronic stress can be challenging. Because the source of long-term stress is more constant than acute stress, the body never receives a clear signal to return to normal functioning. With chronic stress, those same lifesaving reactions in the body can disturb the immune, digestive, cardiovascular, sleep, and reproductive systems. Some people may experience mainly digestive symptoms, while others may have headaches, sleeplessness, sadness, anger, or irritability.

Over time, continued strain on your body from stress may contribute to serious health problems, such as heart disease, high blood pressure, diabetes, and other illnesses, including mental disorders such as depression or anxiety.

4. There are ways to manage stress.

If you take practical steps to manage your stress, you may reduce the risk of negative health effects. Here are some tips that may help you to cope with stress:

  • Be observant. Recognize the signs of your body’s response to stress, such as difficulty sleeping, increased alcohol and other substance use, being easily angered, feeling depressed, and having low energy.
  • Talk to your health care provider or a health professional. Don’t wait for your health care provider to ask about your stress. Start the conversation and get proper health care for existing or new health problems. Effective treatments can help if your stress is affecting your relationships or ability to work. Don’t know where to start? Read our Tips for Talking with Your Health Care Provider.
  • Get regular exercise. Just 30 minutes per day of walking can help boost your mood and improve your health.
  • Try a relaxing activity. Explore relaxation or wellness programs, which may incorporate meditation, muscle relaxation, or breathing exercises. Schedule regular times for these and other healthy and relaxing activities.
  • Set goals and priorities. Decide what must get done now and what can wait. Learn to say “no” to new tasks if you start to feel like you’re taking on too much. Try to be mindful of what you have accomplished at the end of the day, not what you have been unable to do.
  • Stay connected. You are not alone. Keep in touch with people who can provide emotional support and practical help. To reduce stress, ask for help from friends, family, and community or religious organizations.

5. If you’re overwhelmed by stress, ask for help from a health professional.

You should seek help right away if you have suicidal thoughts, are overwhelmed, feel you cannot cope, or are using drugs or alcohol more frequently as a result of stress. Your doctor may be able to provide a recommendation. Resources are available to help you find a mental health provider.

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. World order has been disorganized, travel restricted, economies slashed, relationships distanced and billions quarantined at their homes in an order to contain the outbreak. 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. Uncertainty has always been the most ominous threat to living, and the COVID-19 pandemic has crippled the world structure (economic, social or individual) leading to myriads of unanswered doubts and questions for the future of humankind.

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%.

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.

Chronic (Complex) PTSD: A Neglected Problem

Previously it was believed that PTSD can only affect the immediate survivors of acute stress like natural calamities or war. Over the course of research it has been found that this is not true. Chronic and long-lasting trauma (even minor forms) can cause a complex PTSD which has varied symptoms, and hence often remain undetected. For example, a journalist browsing through violent content (pictures, videos, messages, etc.) daily or a reported photographing violent scenes or a health care worker encountering repeated deaths and sufferings can go through similar trauma as the persons who have directly experienced it. A landmark research in 2015 had shown the high prevalence of PTSD in drone-pilots who initiate the bombing miles away from the original place of interest. Complex PTSD can lead to chronic impairment of wellbeing and quality of life, affecting the social trust, self-esteem, interpersonal relationships, attention and mood of individuals. It can rekindle past abuse and adverse childhood experiences.

This is particularly important in the current scenario of COVID-19 crisis, as the pandemic has been going on for last six months now. Unlike any acute calamity, biological disasters like pandemics last long and the psychological offshoots are often longer than the infection itself. What we are seeing now is probably the tip of the iceberg, as for the months to come (especially during the post-pandemic aftermath) we shall expect much more stress and trauma-induced problems. The frontline workers, the socially impoverished class (like the homeless, migrants, etc., the elderly, those who have been affected or lost someone due to the outbreak are at a major risk. Particularly, social stigma and prejudice add to the burden of trauma which can lead to complex PTSD persisting for months altogether. It also increases the risk of depression, anxiety and eventually suicidality more so, if untreated and neglected.

Who’s at risk for PTSD in COVID- 19?

  • Those who have lost a loved one. “Not being able to be there at their bedside is difficult. Funerals aren’t happening, so all those things that we do as a society to protect ourselves and to get through bereavement aren’t there,” Jain said.
  • Survivors of COVID-19. Research shows that there’s a lot of PTSD in survivors from the intensive care unit because many can remember thinking they were going to die.
  • People affected economically. “We know when we are in a recession and there is high unemployment, a lot of trauma trickles down, and unfortunately, we see higher rates of family violence and partner violence and that violence can contribute to post-traumatic stress,” said Jain.
  • Frontline workers. Healthcare workers are exposed to death and dying and the threat of dying themselves. The threat of being exposed to COVID-19 can also cause trauma in essential workers.

Tips for those with PTSD

According to the United States Department of Veteran Affairs, tips for coping with stress during the pandemic include:

  • Staying aware of safety measures
  • Keeping safe may help reduce feelings of stress and anxiety. Try to stay up to date on safety advice from government and medical bodies.
  • A person can also stay safe by following these hygiene measures:
  • regularly washing the hands for 20 seconds each time
  • covering the mouth and nose when sneezing or coughing
  • making plans in case someone in the home becomes ill
  • Using techniques to stay calm
  • Staying connected

   Remaining hopeful

A person can help themselves stay positive by:

  • maintaining a long-term perspective and looking to the future
  • being patient and kind to themselves
  • celebrating any successes
  • taking breaks and doing enjoyable activities

Treatment of PTSD

There are evidence-based treatment strategies for PTSD. Anti-anxiety and antidepressants have been successfully tried along with mild sedatives (which need to be adjusted and then can be slowly stopped). Based on the intensity and quality of symptoms, the duration of medications might vary, but usually is continued for at least 6 months. It is best to stay in regular touch with the treating doctor and discuss your progress and preferences regularly, so that both you and your physician can be involved in decision making. All the associated psychiatric or physical problems need to be treated too.

Most importantly, psychotherapy with psychiatrists or clinical psychologists immensely help. It is a collaborative approach between the therapist and the client as the sessions can happen weekly to bi-weekly depending on the mutual convenience. For some, depending on the nature of the problem and response, therapy might need to be prolonged. There are various modalities of therapy, common ones being Cognitive Behavioural (CBT), Interpersonal therapy (IPT), psychodynamic therapy, etc. Though varying in approach, the essence of all is to target the recovery of the affected individual in a progressive way. It helps the person deal with his coping, self-care, self-esteem and manage anxiety and stressors in a constructive way.

How to care for a person with PTSD

To care for someone with PTSD, people can:

  • Learn about it: Understanding the effects of PTSD may help with understanding what that person is experiencing.
  • Help manage their medication: A person can help support someone with PTSD by helping keep track of their medication.
  • Listen: A person can let them know that they are there to listen, but they should not put pressure on them to talk about their symptoms. We are all keen on providing advice, but probably fail to ask or understand what the sufferer wants from us. Sometimes, it can be as simple as an ‘audience’ for their voices.
  • Encourage contact with other people: This may help the person build a support system.
  • Early warning signs (RED FLAGS)

Abrupt change of behaviour, minimal social interaction, those staying alone, those who have voiced out death wishes in the recent past, those with history of depression or suicidal attempts, those who have a family history of mental illness or suicide, and those who have recently confided about their intent of ending their lives.

  • Collaboration with media and all levels of health care

The role of media (specially social media) is paramount in spreading community awareness. More so in the present time of pandemics, simple infographics with educational messages about stress and PTSD can be distributed as IEC (Information, Education, Communication) material with the help of digital and print media. The primary health care workers and also the allied health professionals such as nurses, ASHA personnel and district health centres need to be actively involved for community care and suicide prevention, as the tertiary centres where policies and plans are formulated and discussed, form only the mere tip of the iceberg.

If someone has PTSD, they may experience negative or suicidal thoughts. A person should not ignore any comments regarding self-harm, death, or wanting to die. We recently had the PTSD awareness week! Let us NOT make it just about another week of awareness, talks and propaganda. Mental health has always been an integral part of public health, pandemic or not! Psychological preparedness for pandemics are as important as the medical infrastructure needed for biological cures and vaccines. Ironically, we need not wait for a pandemic to warn us about the necessity if mental wellbeing or a celebrity suicide to gear up for suicide prevention. Every life is worth living and the suffering one goes through in PTSD can be minimized and treated as well. The pandemic is still in its early clutches with expected days of uncertainty and difficulties yet to come. Our hope, optimism and helping hand can serve as powerful tools of resilience not just against the virus, for also the collective emotional wellbeing of the humankind.

Author Dr. Debanjan Banerjee is associated with NIMHANS, Bangalore as Geriatric Psychiatrist.

Disclaimer: The opinions expressed in this article are the personal opinion of the author. The facts and opinions appearing in the article do not reflect the views of News Sense and News Sense does not assume any responsibility or liability for the same.

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