Social Science Series #3: PTSD in Covid-19 Survivors

What is PTSD?

Post-traumatic stress disorder (PTSD) is an anxiety problem that develops in some people after extremely traumatic events, such as combat, crime, an accident or natural disaster.

People with PTSD may relive the event via intrusive memories, flashbacks and nightmares; avoid anything that reminds them of the trauma; and have anxious feelings they didn’t have before that are so intense their lives are disrupted.

(Source: American Psychological Association)

What is COVID-19?

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. The symptoms include respiratory symptoms, fever, cough, fatigue, loss of taste and smell, shortness of breath, and difficulty breathing, usually lasting between 2-14 days. In more severe cases, it may cause pneumonia, severe acute respiratory symptoms, kidney failure, and death. The virus is mainly spread from person-to-person by close contact, through exposure to respiratory droplets produced by coughing or sneezing. These droplets cause infection when they enter the mucous membranes of the suspectable individual present inside the nose or mouth. People who are asymptomatic, meaning showing no symptoms, may also spread the virus. Around 80% of infected people suffer from mild to moderate respiratory symptoms such as a cold and myalgia and don’t require the need of hospital treatment. However, around 15% of individuals who are above the age of 60 or have underlying medical conditions develop severe complications. Currently, genetic variants are emerging across the globe as the virus keeps rapidly mutating.

The World Health Organization declared the outbreak a Public Health Emergency of International Concern on 30 January 2020, and a pandemic on 11 March 2020. Among the WHO’s recommendations, people with mild respiratory symptoms were encouraged to isolate themselves, and social distancing was emphasized.

(Source: World Health Organization, Center for Disease Control and Prevention)

Severe COVID-19 Survivors and PTSD

Among COVID-19 individuals, those with a severe course of the disease are particularly at risk of developing PTSD. Patients who had to undergo medical interventions to maintain or restore vital functions experience particularly intense traumatic stress. A very traumatically stressed subgroup may also include individuals with severe disease who were refused healthcare as a result of health service failure during a pandemic. The meta-analysis of 35 studies involving 79,170 people with COVID-19 showed that almost a quarter of them (23%) develop a severe form of the disease which requires close monitoring. The life of many of these individuals is threatened and many of them may experience high levels of fear of imminent death, which creates a traumatic event.

The effects of the current as well as of past epidemics on the mental health of survivors can help predict the psychopathological consequences of a severe life-threatening viral disease. Two studies on recovered severe COVID-19 survivors reported that the prevalence of PTSD is 10.4% (Tarsitani et al., 20121) and 30.2% (Janiri et al., 2021), respectively. Additionally, in survivors of the severe acute respiratory syndrome (SARS) during the epidemic that covered 29 countries in 2002/2003, infecting 8,096 individuals, of whom 774 died PTSD was present in 39% of patients 10 months after discharge, and over time the frequency of PTSD even increased, ranging from 42% to 54.5% after 31-51 months from discharge. Given that an estimated 3.6% of U.S. adults had PTSD in the former year, and the lifetime prevalence of this syndrome being 6.8%, these studies indicate that PTSD is a common chronic mental health problem following a virus disease with high mortality.

COVID-19 infected persons most often develop less severe or asymptomatic symptoms, which are generally not life-threatening and can be treated at home with over-the-counter medications. Such cases are not likely to develop PTSD as COVID-19 infection in most of the cases does not lead to symptoms severe enough to be life threatening and these individuals do not meet the A criterion for PTSD. However, some persons, although not hospitalized, may experience severe symptoms of COVID-19 and fear of imminent death, thereby experiencing a traumatic event, and can develop PTSD. These high levels of fear of death, are the hallmark of a traumatic stressor that can develop the disorder.

(Source: Sekowski, et al. 2021, Frontiers in Psychiatry)

Near death experience

Patients with severe COVID-19 frequently present respiratory symptoms which may progress to respiratory failure. Treatment for COVID-19 may involve extreme stressors for patients, including fear of death from life-threatening illness, pain from medical interventions such as endotracheal intubation, limited ability to communicate, and feelings of loss of control. One patient described the sensation of COVID-19 respiratory infection as “it feels like you’re drowning…you think you’re going to die”, and a respiratory therapist described shock at the severity of pink, frothy secretions occluding patient’s breathing tubes. Even patients with moderate illness severity who do not require hospitalization describe fear of death – one patient stated, “I did not go to sleep for three days because I was scared…I wouldn’t wake up”. These anecdotes illustrate how COVID-19 illness constitutes exposure to threatened death or serious injury, fulfilling the first diagnostic criteria for PTSD. Additionally, given that there is evidence of infection clusters within family units, survivors may have also experienced trauma related to witnessing severe illness or death of close family members.

Delirium

Another potential cause of PTSD in COVID-19 survivors is delirium. Of particular interest to neuropsychologists, delirium has been investigated as one of the modifiable clinical risk factors for PTSD in patients who receive intensive care unit (ICU) treatment. COVID-19 patients may be at a particularly elevated risk for delirium due to a confluence of the likely neuroinvasive and neurovirulent properties of the virus itself, Central Nervous System (CNS) inflammation in response to other organ system failures, the high percentage of severe COVID-19 patients who are also older adults, and ICU-specific factors such as intubation and ventilation, sedation, and prolonged isolation. In elderly and mechanically ventilated populations, delirium may occur in up to 80% of ICU patients, again suggesting that survivors of severe COVID-19, who are likely to be older adults and require ventilation, may be at particularly high risk for delirium. Notably, prolonged delirium duration (>40 days) has been associated with higher Posttraumatic Stress Syndrome (PTSS), but the presence of delirium has not been reliably associated with PTSD post-recovery. Other research has suggested that it is not delirium per se, but the recall of distressing in-ICU delusional memories that contribute to the development of PTSD in ICU survivors.

ICU-related trauma

Post-traumatic stress has been well-documented in survivors of ICU treatment. Invasive ventilation and longer duration of mechanical ventilation in particular have been associated with an increased risk for PTSS. In Wuhan, China, the earliest epicenter of the outbreak, approximately 3.2% of COVID-19 patients required intubation and invasive ventilation.

Risk of developing PTSD appears to depend on a number of factors including patient characteristics (e.g., age and preexisting comorbidities), and clinical treatment variables (e.g., use of sedation, restraint, and antipsychotic medications). Of particular note when considering COVID-19 survivors, some studies have found that patients treated in ICUs for Acute Respiratory Distress Syndrome (ARDS) may have even higher PTSD rates post-treatment as compared to other ICU patients, with higher prevalence of PTSD in ARDS survivors as compared to survivors of general medical ICU and cardiac surgery. PTSS appear to be present in between 30 and 40% of ARDS survivors, even months after treatment. More generally, estimates of PTSD in intubated and mechanically ventilated patients range from 14 to 51%. Among patients who require mechanical ventilation in the ICU, the most common symptoms include feelings of guilt, mood swings, sleep disturbance, and memories of panic and suffocation. Thus, as COVID-19 survivors who were treated in ICUs begin to present for neuropsychological evaluation, PTSS should be assessed as a part of a complete evaluation.

(Source:  Post-traumatic stress disorder: A differential diagnostic consideration for COVID-19 survivors, The Clinical Neuropsychologist)

Treatment of PTSD

Recovery from PTSD is a gradual, ongoing process. Healing doesn’t happen overnight, nor do the memories of the trauma ever disappear completely. This can make life seem difficult at times. But there are many steps you can take to cope with the residual symptoms and reduce your anxiety and fear.

Overcoming your sense of helplessness is key to overcoming PTSD. Trauma leaves you feeling powerless and vulnerable. It’s important to remind yourself that you have strengths and coping skills that can get you through tough times.

One of the best ways to reclaim your sense of power is by helping others: volunteer your time, give blood, reach out to a friend in need, or donate to your favorite charity. Taking positive action directly challenges the sense of helplessness that is a common symptom of PTSD.

When you’re suffering from PTSD, exercise can do more than release endorphins and improve your mood and outlook. By really focusing on your body and how it feels as you move, exercise can actually help your nervous system become “unstuck” and begin to move out of the immobilization stress response. Try:

  • Rhythmic exercise that engages both your arms and legs. Activities such as walking, running, swimming or dancing. Instead of focusing on your thoughts, focus on how your body feels. Notice the sensation of your feet hitting the ground, for example, or the rhythm of your breathing, or the feeling of the wind on your skin.
  • Rock climbing, boxing, weight training, or martial arts. These activities can make it easier to focus on your body movements—after all, if you don’t, you could get hurt.
  • Spending time in nature. Pursuing outdoor activities like hiking, camping, mountain biking, rock climbing, whitewater rafting, and skiing helps veterans cope with PTSD symptoms and transition back into civilian life. Anyone with PTSD can benefit from the relaxation, seclusion, and peace that come with being out in nature. Seek out local organizations that offer outdoor recreation or team-building opportunities.

PTSD can make you feel disconnected from others. You may be tempted to withdraw from social activities and your loved ones. But it’s important to stay connected to life and the people who care about you. You don’t have to talk about the trauma if you don’t want to, but the caring support and companionship of others is vital to your recovery. Reach out to someone you can connect with for an uninterrupted period of time, someone who will listen when you want to talk without judging, criticizing, or continually getting distracted. That person may be your significant other, a family member, a friend, or a professional therapist. Or you could try:

  • Volunteering your time or reaching out to a friend in need. This is not only a great way to connect to others, but can also help you reclaim your sense of control.
  • Joining a PTSD support group. This can help you feel less isolated and alone, and also provide invaluable information on how to cope with symptoms and work towards recovery.

The symptoms of PTSD can be hard on your body so it’s important to take care of yourself and develop some healthy lifestyle habits.

  • Take time to relax. Relaxation techniques such as meditation, deep breathing, massage, or yoga can activate the body’s relaxation response and ease symptoms of PTSD.
  • Avoid alcohol and drugs. When you’re struggling with difficult emotions and traumatic memories, you may be tempted to self-medicate with alcohol or drugs. But substance use worsens many symptoms of PTSD, interferes with treatment, and can add to problems in your relationships.
  • Eat a healthy diet. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day. Omega-3s play a vital role in emotional health so incorporate foods such as fatty fish, flaxseed, and walnuts into your diet. Limit processed food, fried food, refined starches, and sugars, which can exacerbate mood swings and cause fluctuations in your energy.
  • Get enough sleep. Sleep deprivation can trigger anger, irritability, and moodiness. Aim for somewhere between 7 to 9 hours of sleep each night. Develop a relaxing bedtime ritual (listen to calming music, watch a funny show, or read something light) and make your bedroom as quiet, dark, and soothing as possible.

Getting professional help for PTSD

If you suspect that you or a loved one has post-traumatic stress disorder, it’s important to seek help right away. The sooner PTSD is treated, the easier it is to overcome. If you’re reluctant to seek help, keep in mind that PTSD is not a sign of weakness, and the only way to overcome it is to confront what happened to you and learn to accept it as a part of your past. This process is much easier with the guidance and support of an experienced therapist or doctor.

It’s only natural to want to avoid painful memories and feelings. But if you try to numb yourself and push your memories away, PTSD will only get worse. You can’t escape your emotions completely—they emerge under stress or whenever you let down your guard—and trying to do so is exhausting. The avoidance will ultimately harm your relationships, your ability to function, and the quality of your life.

(Source: Helpguideorg International)

Why you should seek help for PTSD?

  • Early treatment is better. Symptoms of PTSD may get worse. Dealing with them now might help stop them from getting worse in the future. Finding out more about what treatments work, where to look for help, and what kind of questions to ask can make it easier to get help and lead to better outcomes.
  • PTSD symptoms can change family life. PTSD symptoms can get in the way of your family life. You may find that you pull away from loved ones, are not able to get along with people, or that you are angry or even violent. Getting help for your PTSD can help improve your family life.
  • PTSD can be related to other health problems. PTSD symptoms can make physical health problems worse. For example, studies have shown a relationship between PTSD and heart trouble. Getting help for your PTSD could also improve your physical health.

(Source: National Center for PTSD)

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