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How might COVID-19 affect people with severe mental illness?

Dr Jo Stubley discusses COVID-19, trauma and P.T.S.D, and we learn about severe and enduring mental health conditions
If the threat is sustained and, for one reason or another, we’re not able to get away from it so it’s inescapable, is one of the first issues, or we’re helpless in some way, then that makes it much more difficult for us to go into fight/flight and if the threat continues, one of the things that can happen is we move into the freeze response which is a bit like, in evolutionary terms, the mouse that plays dead when the larger predator comes along so our body, at the most extreme, goes floppy and our mind does a thing called dissociation where it kind of drifts off, and so, at the most extreme people can find they don’t remember what has happened during the event In the first few weeks, these are ordinary responses, they are not a diagnostic, clinical syndrome It’s only if they persist, after a month, that we would start to think that this may be a possibility of ongoing post-traumatic stress disorder
So having trauma in your own history is a big risk factor During the event, if there is a lot of dissociation which I spoke about a moment ago, particularly if people end up not remembering the event, that can be a risk factor and obviously if it’s a really severe event, it’s far more likely to cause ongoing problems Post-trauma, the two biggest factors are actually around the community and the way that we live First of all, if there is a perceived lack of social support, and notice that I stress ‘perceived’, because people might look and say, ‘Well, you know, you’ve got a lot of support around you’ but if you feel that you can’t access it, then you don’t have the support The other thing after an event, that’s really important is ongoing stresses and difficulties in the environment that are making life more difficult to live
We might think about these under three main headings The first is hyperarousal, and that’s linked to that sympathetic nervous system response So you’ve got a lot of, the sort of, readiness for fight/flight is still in the body People will often feel very tense, anxious, they might feel irritable, they might not be able to sleep, they might be kind of full of what feels like anxiety, that butterfly feeling all the time - so that’s hyperarousal The second lot of symptoms that people get, and this is linked to how trauma memories can get laid down in a different way from our normal memories, is reliving experiences, so one might find that from very ordinary sensory experiences, people get triggered into reliving the experience, which might be intrusive images in the mind or intrusive experiences in the body, it may be nightmares, and, at its most extreme, it might be flashbacks, where the whole or part of trauma gets relived as though it’s happening in the present So that’s the second category, the reliving Now if you’re having those two things going on a lot, it’s really understandable then that the third category is avoidance.
People start avoiding things that might trigger them to feel hyperaroused or might trigger to feel, or to have these experiences of reliving So they start shutting down both what they’re doing but also quite often what they’re feeling They start to feel numb, they don’t want to have much social contact, they might feel low, but these are the kinds of things that initially, can happen after a traumatic event and in the first few weeks, these are ordinary, responses they are not a diagnostic, clinical syndrome It’s only if they persist after a month, that we would start to think that this may be the possibility of ongoing post-traumatic stress disorder
First of all, with the shut down, with the social isolation all of the work that people have been doing in terms of trying to connect, to trust, to be open, to experience others again has had a real impact, so that they’ve ended up, sometimes, shut down in their flats, both in relation to others and their contact with them, but also shut down from themselves and I think that’s a part of what becomes retraumatising, that if you are shut down from the present, its so much easier to then get pulled back into the past and the other part of getting pulled back into the past is that, there’s a, what we would call, ‘a phenomenon of state dependent memories’ So if you’ve had a traumatic experience that has involved certain sensory modalities or experiences and then you find yourself in a similar situation again it’s going to retrigger and stir up those earlier traumatic experiences

Post traumatic stress

We heard there from Dr Stubley about what can make the current situation particularly challenging for people who have already had traumatic experiences. We heard about situations in which ongoing exposure to threat can become traumatic, and how already traumatised individuals can be affected.

Post traumatic stress is particularly topical during a challenging time such as COVID-19 and we’ll touch on it throughout the course. Those affected can include:

  • People who have had coronavirus
  • Frontline key workers
  • People who have had Post Traumatic Stress Disorder (PTSD)
  • Families, carers and colleagues of affected groups and individuals

PTSD that is ongoing or resulting from several traumas, including traumas in early life, can be classified as severe mental illness. People with such conditions may be affected by COVID-19 in different ways to the rest of the population.

Severe and enduring mental illness

It is important to consider the impact of the pandemic on people with severe and enduring mental illness such as personality disorders, schizophrenia, bipolar affective disorder, and severe forms of depression and anxiety conditions. We must be careful about drawing generalisations but many people with these conditions will be more affected as circumstances exacerbate their symptoms. People with severe mental illness can be marginalised at the best of times and so may experience even more disadvantage. We’ll discuss this more in later steps.

  • Lockdown and the continual news feed of traumatic events are more likely to impact those who have experienced trauma before.

  • We also need to consider how higher levels of fear can impact those who struggle with paranoia, a core symptom of schizophrenia.

  • These individuals may be more digitally excluded or highly reliant on reduced services to provide social connectedness.

  • At least 40% of people with severe mental illness smoke, almost three times the general population. This health risk is increased during COVID-19.

  • Other health behaviours such as physical activity, diet and seeking healthcare are challenging for this group, even more so during COVID-19.

  • More specific examples include ensuring that medications are adhered to and blood tests undertaken, support that may require extra thought and care.

For individuals who struggle socially, no longer joining overwhelming social interactions, attending job seeking courses, or being exposed to risk factors for drug, alcohol and other self-harming behaviours, may have brought some degree of respite in the short term.

However, the inevitable consequences of prolonged isolation, fear and uncertainty will be a particularly distressing mix for vulnerable individuals with pre-existing mental health conditions, and especially for those with existing adverse or traumatic experiences.

Why are people affected?

It is natural to ask why some people are affected and others are not. This requires an incredibly complex answer that is different for each person. However, there are some general considerations to bear in mind.

There is by no means a direct causal relationship between early life events and experiences in later life. However, some habits, templates and behaviours in adulthood can be influenced in our earlier lives. We know, for instance, that adverse childhood experiences can predispose physical and psychological difficulties later in life, including during the current COVID-19 pandemic. These could be loss, neglect, abuse and trauma, although people’s perception of these is also highly important.

We heard in Kevin’s story, for instance, that he has had to hide parts of his identity, that he had a traumatic experience in his teens and that his current mental health support has stopped.

These topics can be particularly emotive. Do check in with yourself and how you’re feeling. If it feels helpful you can add to the discussion below.
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COVID-19: Psychological Impact, Wellbeing and Mental Health

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