key: cord-0754266-6zrlagkp
authors: Tarquinio, Cyril
title: The powerful hold of COVID-19
date: 2020-09-30
journal: European Journal of Trauma & Dissociation
DOI: 10.1016/j.ejtd.2020.100174
sha: 3fd6663561a16deffc658f0d8d2c29bcde7517da
doc_id: 754266
cord_uid: 6zrlagkp

nan

The powerful hold of As the world faces the current pandemic, researchers and clinicians alike across nearly every discipline are working together to better understand the impacts of the COVID-19 virus on physical and psychological health. A recent study by Brooks et al. (2020) showed that extended quarantine protocols might have long-term consequences among the general population, echoing findings from an earlier study by Newman (2012) . Other authors describe a range of effects in more precise terms, notably mood swings, hyper-responsiveness to stress, irritability, fear, anger, insomnia and even symptoms associated with post-traumatic stress disorder (Reynolds et al., 2016; Sprang & Silman, 2013; Yoon, Kim, Ko, & Lee, 2016) . Another group of studies addressed the psychological effects experienced by individuals infected with the COVID-19 virus (Bo et al., 2020; Rogers, Chesney, Olivier, Pollak, McGuire, Fusar-Poli, Szandi, Lewis, & David, 2020; Wang, Pan, Wan, Tan, Xu, McIntyre, Choo, Tran, Ho, Sharma, & Ho, 2020; Xiao, 2020) . Based on the limited available data (Wang et al., 2020) and clinicians' observations, it appears that this disease profoundly disrupts the psycho-emotional balance of patients. The mechanisms underlying this imbalance are directly related to symptoms of the disease itself (fever, aches and pain, diarrhea, increased heart rate, heavy exhaustion and feelings of oppression). Respiratory problems associated with feelings of suffocation, the sight of other patients in heightened distress or dying outright, memories of being in intensive care units, assisted breathing under sedation together with sometimes lingering physical symptoms all contribute to patients' experiences of distress, anxiety, depression and, according to some authors, the manifestation of post-traumatic symptoms (Liu, Zhang, Yang, Zhang, Li, & Chen, 2020) .

Without the benefit of hindsight that would allow for a truly accurate assessment of the psychopathological dimensions the current health crisis has generated, a number of observations can be made about the nature of investigations and overall interest that has emerged within our own discipline; two aspects stand out in particular. First, the fact that entire scientific community has engaged in an unbridled race to publish relevant findings has led to a fairly significant amount of data with limited, even questionable, scope of analysis. Secondly, the rushed nature of how psychological aspects of the disease have been analyzed has led to the perhaps precipitous conclusion that the current phenomenon can be described as a traumatic event. It is also possible that we have underestimated the specificity of the current health crisis that would effectively challenge our current conception of a traumatic event and associated consequences.

An unbridled and unprecedented rush to publication: Despite the fact that recent and ongoing studies are investigating both immediate and delayed effects of the COVID-19 virus, very little is known about how the virus functions. The sheer number of publications that have been released in recent months (roughly 20,000 studies published by the Web of Science, without counting the number of articles published online in pre-print versions without going through the normal peer-review process), is hardly comforting when we look at the scope of results that have been put forward. In two cases where hasty publication apparently overshadowed scientific rigor, both The Lancet (Mehra, Desai, Ruschitzka, & Patel, 2020) and The New England Journal of Medicine (Mandeep, Mehra, Desai, Kuy, Henry, Amit, & Patel, 2020) withdrew articles citing the inefficacy of chloroquine that had already been published. This perfectly illustrates how the 'publish or perish' ethos is more common than we might care to admit in the field of medical science. The most celebrated researchers and journals have long valued exclusivity 1 ! It is precisely this drive to be the first to publish that has led most researchers in the field of psychology to confine their investigations to an epidemiological vision of the phenomenon of COVID-19. Most often, these works offer descriptive considerations by soliciting responses of various populations (patients, care givers, the general population, etc.) using an exhaustive battery of questionnaires. The number of these questionnaires (specifically targeting stress, depression, anxiety, quality of life, PTSD, etc.) used in a contingent manner within the same study is often proportional to the relative weakness of the problematic context being addressed by the study. Overarching concepts are often not articulated to each European Journal of Trauma & Dissociation 4 (2020) 100174 other, which can give the false impression of heterogenous inventory data sets, if not outright superficiality, which is as disconcerting as it is disappointing. Due to obvious restrictions imposed by quarantine protocols, these studies have largely been conducted online (which is never totally without bias) and, in many cases, the authors neglect to take steps to interpret what their results might mean in a comprehensive and clinical perspective for greater depth and relevance. But perhaps it is still too early. Given that the pandemic is effectively unfolding at this moment, we may very well need to wait to produce research with a more heuristic scope that would be more useful for understanding and caring for those affected in one way or another by the disease. We might find, for example, the degree to which this health crisis has complicated the lives of those among the most fragile, particularly individuals with pre-existing chronic psychiatric illnesses. An important detail to keep in mind is that for an extended period of time, these very patients were essentially abandoned in the wake of urgent critical care needs and restricted access to hospitals and clinics that were providing ongoing psychotherapeutic care. Circumstances that very likely contributed to heightened anxiety, which could not (and still cannot) be treated. This context of reduced psychological care itself represents a source of profound stress that affected populations already suffering who, given the possibility of a second wave of contamination, may not fully recover. Another aspect worth considering are the effects of widely accepted and nearly systematic introduction of teletherapy consulting. Such a brutal transformation of the therapeutic framework is unprecedented in our field and the potential implications merit a closer look. COVID-19 as a specific traumatic event: one of the most widely debated questions is what makes the COVID-19 pandemic traumatic. How we answer this question depends largely on what specific aspect of trauma we are talking about and who is affected:

caregivers facing the death of their patients and risking their own lives going to work to care for these patients, individuals with prior history of trauma or psychological difficulties for whom the pandemic can have a triggering effect by reactivating either the traumatic experience or defense mechanisms for managing stress, patients hospitalized for COVID-19 who may have spent time in intensive care units and had near death experiences, or who having been released from hospital care, are confronted with various residual physical complications and experience less than optimal health, patients with chronic conditions (heart disease, diabetes, inflammatory bowel disease, etc.) who, for fear of contracting the virus by visiting hospitals, avoid seeking necessary medical care and spend weeks in isolation managing their illnesses alone.

New information about COVID-19 is accumulating every day as to how the virus invades the body and evolves. But hope often gives way to fear and even pessimism. In this respect, we can defer to other, well known situations of chronic insecurity that are familiar territory in our discipline, such as those linked to war, or scenarios experienced by refugees, migrants or foster children. All of these situations have shown us that the psychotraumatic spectrum can be much broader than PTSD.

One possible approach might be to revisit how we conceptualize the COVID-19 pandemic by framing it as an extreme life situation versus a traumatic event, which might more aptly describe the complexity surrounding the phenomenon and allow us to view the effects from a wider lens than PTSD alone. Extreme life situations refer to those that place ordinary people in radically different conditions than their normal daily lives. These are events that are life-changing and directly threaten one's existence. It is in this sense that Bettelheim (1979) used the term 'extreme situation' to describe what prisoners experienced in Nazi concentration camps. Following Bettelheim, what we are experiencing now is effectively an extreme situation in that we have been catapulted into a set of living conditions that render our personal values and coping mechanisms virtually powerless and, in some cases, can even pose additional danger. Essentially, we are stripped of our habitual selfdefense systems and hit rock bottom; we then need to forge a new set of attitudes, values and ways of living that match what the new situation demands. Several aspects characterize extreme life situations. For the most part, these are events that occur suddenly and abruptly, marking a radical break from an individual's previous way of living. These situations, as in the case of the COVID-19 pandemic, demand that we make changes to how we live our daily lives to the extent that we can no longer rely on established resources (material, psychological, social or symbolic). In other words, they force us to manage a set of challenges completely unprepared. Previous life experience and learning no longer serve us in any practical sense because ordinary life only prepares us to deal with what is routine and predictable. By nature, they cannot prepare us for unpredictability introduced into our daily lives, as we are currently witnessing with this pandemic, which leaves literally everyone in a situation of perceived uncontrollability, which we know to be harmful to health. Concerning the specific nature of life upheavals that occur, these are not confined to material conditions but extend to the way we perceive events occurring around us and how we might see our own lives collapsing. From this perspective, whatever the form of upheaval or sudden change, it is crystallized around a central and invariant element, notably one that is directly life-threatening. One of the dimensions that characterizes extreme life situations, one that is not discussed enough, is experiencing a fear of the unknown. Fear of the unknown, as defined by Carleton (2016) , is the ''the propensity of an individual to experience fear caused by the lack or absence of information. . .'', to which the same author adds, ''the inability of an individual to withstand the adverse reactions triggered by the lack of important, key or sufficient information and sustained by feelings of uncertainty''. In the literature, however, there is broad congruence as to whether adverse fear of the unknown is stronger than, say, fear of pain or death (Carleton, 2016) . Joshi and Schultz (2001) proposed that this fear is humanity's oldest and strongest emotion given that its pathogenic and destructive powers are so significant, as the literature attests (Bach & Dolan, 2012; Jackson, Nelson, & Proudfit, 2015) . Along these same lines, Schimmenti et al. (2020) proposed what may be a viable complimentary path with the development and validation of their Multidimensional Assessment of COVID-19-Related Fears (MAC-RF).

Essentially, we are faced with the extreme when an event involves, in one way or another, a real risk of death and not a situation that is experienced as life-threatening. In this way, the COVID-19 pandemic must be considered as an extreme life situation, not only because it presents a concrete, well-documented life-threatening risk, but also for how it introduces a set of fractures into our daily life experience. One particular type of fracture is that of temporality. Indeed, the extreme situation forces us on us an altered sense of time; ordinary time stops and becomes horizonless. Ultimately, in the absence of foreseeable reprieve, a person must come to terms with their own finiteness; our life has an end. A second fracture line becomes apparent at the level of selfidentity. Such situations remove any protective layering we develop throughout our lives that stabilize us and allow us to pursue individual, professional, or social paths in life. This deconstruction of self-identity can be linked directly to the breakdown of established frames of reference through which we construct ourselves in a social context by conforming to societal norms, group expectations and social pressure. This COVID-19 pandemic experience might, in this way, be viewed as an experience of passage; not solely from one physiological state of being to another, but of an inner passage towards ourselves as we rebuild our foundations of self-awareness. This represents a vital shift prompting us to identify new reference points; alternate certainties drawn from deeper self-reflection as we redefine what living means to us now.

As things currently stand, the number of publications related to the COVID-19 pandemic appear to be proportional to our current, overall lack of knowledge of the phenomenon. This is as true for the medical sciences as it is for our own field. We simply need more time and the benefit of hindsight before we can hope to better understand what precisely about our society is changing and the degree to which individuals have been, are currently and likely will be affected by this health crisis.

In many ways, it is as if the face of the enemy that has changed. While previous generations faced times of war, our own generations have in recent decades experienced a new set of threats such as terrorist attacks and now an epidemic the scale of which no one anticipated. As the enemy has changed, it would be not only useful but critically important for us to build on our current theoretical arsenal with the clear objective of developing a more precise understanding the extent and scope of this pandemic's psychopathological influence in a range of psychosocial contexts -as it has been experienced to date and what we should anticipate for the future. The stakes are high, lives are in the balance, but this is an exciting challenge facing our field and we will meet it!

The author declares that he has no competing interest.

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