May 6, 2020
by Michael Richards MDiv., MBA, CCMH
The Covid-19 pandemic is a once-in-a-hundred-year medical and economic emergency- yet people’s experiences vary widely. The natural disaster has caused at least one million cases of illness and 65,000 deaths in the United States so far, 30 million people are out of work, and most U.S. residents are under some form of shelter at home or quarantine order. The news features non-stop every aspect of the public health emergency for the past three months. Many people’s routine, work, and social lives have been interrupted, their usual coping routines limited. This is just the type of situation to cause mass anxiety and distress. For millions, it’s likely to get worse yet, causing some type of temporary, or even more serious mental illness, like depression, substance abuse, or Post Traumatic Stress Disorder (PTSD). Since millions of Americans are experiencing moderate to severe trauma, we can unfortunately expect as many as a quarter of them to experience secondary mental health problems, especially medical personnel, essential workers, and first responders who face repeated exposure to traumatic situations.
Recently, armed protesters stormed Michigan’s Statehouse, calling for an end to home isolation. This was partly political theater, but also showed how extremely people can react to stressful situations. Some people react with aggression- or even violence- to situations of high stress and uncertainty, lashing out at authorities, or anyone nearby who they can blame. This emotional reaction to threatening conditions is often called the “fight or flight reaction”. As a typical reactions to threat- some people get ready to fight, others to protect themselves in the opposite way, preparing to run- and in extreme cases, becoming fearful and withdrawn.
Situations which seem objectively stressful, like home self-isolation during a pandemic, effect people in a remarkably wide range of ways. Some people experience the stay at home orders as a much deserved break from their regular routine. Gamers and introverts, bakers, writers, crafters- there are some of the lucky types of individuals who find lengthy stay at home orders a not-unpleasant situation. Most probably feel a wide combination of inconvenience, anxiety, distress, with some satisfactions. While others, in home situations that are unhappy, full of pain and conflict, or even physical or emotional danger- face a true disaster- quite apart from the Covid-19 illness itself.
On top of the domestic stress, day after day we stay at home, while news of mounting illness, death, and financial loss continues outside. Our leaders can’t seem to agree or work effectively together towards solutions, which makes things worse. The sense of harmful events being out of control is what ultimately makes a disaster into a traumatizing experience; studies show that the same events are less harmful if they feel they like there is some way of controlling the outcome. This is what makes rumors of cures, even if extremely illogical, so captivating to many.
What is Post Traumatic Stress Disorder?
PTSD is a type of Anxiety Disorder, an illness of the body, nervous system, and mind due to an exposure to a traumatic experience which overwhelms the ability of the person to cope with that experience, or feel like they can survive the threat.
Stress, distress, and trauma form a spectrum of experience, from necessary for motivating us, to minor distress, to major trauma. Financial and job pressures, children to care for and educate, being forced to spend -too much- time with family or in their own company, lead many to find unstructured time stressful. Those with illness in their lives, those that care for the ill, feel separated from support and loved ones, or who face financial hardship are experiencing the Covid-19 crisis as distressing, or even traumatizing. Then there are many facing severe illness, or who have lost loved ones, or who face severe deprivation, for whom this is a true tragedy, and experience it as severely traumatizing.
Again, a quarter of individuals exposed to a serious trauma- like a war or natural disaster- or the pandemic perhaps, are likely to develop a mental illness in reaction. There are many factors at play in who ends up feeling traumatized in a disaster and who ends up with mental illness. The sense of harmful events being out of control is one of the main factors which makes a disaster into a traumatizing experience. Disasters also exacerbate those with preexisting medical and mental health issues, making symptoms worse, taking away support systems, breaking down coping strategies, and aggravating old wounds.
Fight or flight: Acting versus Reacting (with aggression and anxiety)
When the fight or flight reaction takes over, the nervous system switches from the logical, thoughtful executive functioning of the neocortex of the brain, and moves to the reactive, instinctual parts of the brain- the hippocampus and the amygdala. Your body shifts to emergency life saving measures; however as a result, one could say- somewhat metaphorically- you also lose 20-30 points of IQ as well. The more crises you have faced, the easier this change to “crisis mode” happens, and it becomes easier to function in crisis, but it still is just as potentially damaging-traumatizing- and consequently the harder it becomes to fully exit “crisis mode” and fully regain your executive, “civilized” intelligence.
Thus, PTSD can be thought of as the result of a traumatized nervous system that remains at least partly stuck in panic mode.
There are four “clusters” of symptoms used in diagnosing PTSD: 1) intrusive memories, dreams, thoughts; 2) psychological distress and physiological hyperarousal to cues about the trauma; 3) avoidance of distressing cues, reminders, thoughts, etc.; negative thinking and emotions about the self and inability to have positive emotions; and 4) arousal and reactivity associated with the trauma (at least 2):
- Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
- Reckless or self-destructive behavior.
- Hypervigilance.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
Sound familiar? People with PTSD seem to be in the news lately, so it might.
What are the risk factors for PTSD?
You are at greater risk if you have ever been traumatized in the past, the number of times, severity, and length of exposure are all risk factors too. The age at which you were first traumatized is also a critical factor. Sexual abuse trauma seems especially harmful. Being raised in a home with trauma, such as substance abuse, domestic violence, or sexual abuse is strongly correlated with PTSD, and repeated re-traumatization.
Military, police, first responders, and health care workers are at high risk, and at higher risk of aggression and violence- either as victims or abusers- especially those with combat training, moral injury from harming others in war or policing, a history of violence, lack of debriefing and support after violence, co-occurrant mental health and substance abuse issues, and family history of violence.
You are also at risk based on genetic and biological factors beyond your control- if your family has a history of violence or anxiety, but also based on your coping skills and resilience, which you can learn and control. Likewise, there are voluntary behaviors which increase risk of PTSD.
First, the risk enhancers- when you are stressed for long periods, depressed, anxious, and sad, the chemical neurotransmitters in your nervous system can become depleted. Sleep, carbohydrates, nicotine, alcohol, sex, thrills like gambling and risky behavior, can temporarily increase neurotransmitters, leading people to “self medicate” either directly through drinking, taking drugs, overeating, etc. or through sometimes-risky behaviors which increase these chemicals- temporarily.
There are likewise many healthy behaviors that can also make you more resilient to the effects of distress and even trauma, and can help you cope with, or even heal from PTSD. The ability to resist harmful effects is known as Resilience: a positive frame of mind, positive thinking, is often described as the most important factor in coping and resilience. Yeah, it sounds trite, but feeling “in control”, and also not sweating it when things are out of your control- the “Serenity Prayer”- is a very trauma protective frame of mind to develop. A good sense of humor, a sense of agency, or doing what you can to take control of your situation, and being pro-active- planning to make things more comfortable, less stressful, are protective skills. Turn off the news after a while. Take a few deep breaths. Stretch. Stop telling yourself angry or fearful thoughts, or being hard on yourself. Say affirmations. Ask for help and support, and give kindness. Cultivate the bigger picture, deeper meaning and purpose, perspective on things. Meditation, prayer, and spiritual and religious practice have been proven effective antidotes to stress. Moderate exercise, getting fresh air helps. Thinking of others, altruism, volunteering all serve to put your own problems in perspective. Reach out to family and friends- check in on them, especially if they “drop out of sight. Talk to someone about your problems, practice gratitude, and celebrate success.
If your resilience and coping skills are overwhelmed- common in natural disasters or severe trauma, the number one self-treatment for trauma, and even full PTSD is deep relaxation; regularly re-training your mind and body that the crisis is over and all is well, and to “stand down” from crisis mode. One of the most powerful means to relax is through meditation, where you relax your body and empty your mind, or take a mental break by focusing on something soothing like calming music, affirmations, guided images, nature. Progressive relaxation guided meditation is a powerful relaxation technique, and recordings are widely available. Taking a mental break, a nap, vegging out, anything that re-focuses your attention, also helps break the “fight or flight” response, and gets you out of your own head: find a hobby that captivates your attention, focus on your cute cat or a cute baby, smells- lavender, vanilla, baking- like music, go right to the deep brain via special nerves and can be soothing. Biaural music- which switches rapidly from left to right ear and back, has proven to be therapeutic for stress.
Finally, there are some exercises that help the brain normalize from trauma, though neurological stimulation. EMDR (Eye Movement Desensitization and Reprocessing) exercises are best done with a therapist.- but there are some you can try yourself too: shoulder tap: cross your arms over your chest and tap on your opposite shoulders alternating left and right; knee tap- cross your arms and tap on your opposite knees, like the shoulder tap, while relaxing. Self-hypnosis: guided meditation using some of the many positive affirmation meditations is effective. Desensitization- replay a troubling traumatic event but re-imagine it as an experience that you survived and have overcome, telling yourself you are well and safe. These later exercises are best done with a therapist if they end up making you more anxious, as the therapeutic effect is best achieved if you remain relaxed and feel you are in a safe environment.
Professional help. The stigma of mental illness persists even though a majority of Americans will face some kind of mental illness challenge in their lives, and good treatments are available for most illnesses. Don’t be afraid to talk to a therapist- by phone or internet- while sheltering at home. Again, millions will have some form of trauma after all is said and done with Covid-19. Cognitive-Behavioral Therapy, such as desensitization and EMDR have been proven effective to treat PTSD. Hypnosis, guided meditation, trauma informed therapy, pharmacotherapy- with SSRI neurotransmitter enhancers are also important treatment methods. Stay away from anxiety medications except for very short term use as they are highly addictive. If you have health insurance, you can call your insurance company for a referral. A small but significant number of traumatized individuals become suicidal – please reach out if you need help. You are not alone. https://www.samhsa.gov/find-help/national-helpline SAMHSA’s National Helpline – 1-800-662-HELP (4357)
Do you want to know more?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126802/ Posttraumatic Stress Disorder: Overview of Evidence-Based Assessment and Treatment
Michael Richards MDiv., MBA NMCCMH#0190521 is a Licensed Clinical Mental Health Counselor with 30 years experience in community mental health and hospital based crisis management. He also worked for 10 years in government, which was much more stressful. He is recovering from Covid-19, and is writing articles because he is also stuck at home, and unemployed too.
Appendix: DSM V (abridged) Criteria for PTSD
Recurrent, involuntary, and intrusive distressing memories, dreams, flashbacks, distress triggered by cues that remind;
Intense or prolonged psychological distress and physiological arousal at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s);
Avoidance of or efforts to avoid distressing memories or external reminders, thoughts, or feelings about or closely associated with the traumatic event(s);
Negative alterations in cognitions and mood associated with the traumatic event(s) loss of memory, negative beliefs about self and others, distorted thoughts about the event or cause, negative emotional state, diminished interest, withdrawal from others, increased inability to experience positive emotions.
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
- Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.
- Reckless or self-destructive behavior.
- Hypervigilance.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
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