The coronavirus disease 2019 (COVID-19) pandemic is unprecedented in its global reach and has caused widespread psychosocial stress including fears of infection and death, forced quarantine and isolation, and exposure to death and dying, especially for those on the frontlines. At the time of writing, the total number of people globally who have tested positive for COVID-19 has surpassed 7 million, with almost 430,000 reported mortalities.1 The prolonged mental health impact of COVID-19 has led experts to advocate preparedness for the psychological morbidity that will likely ensue.2,3 Studies about the psychological effects of COVID-19 are already emerging.4,5 For example, a population survey in China found 54% of respondents rated the overall psychological impact during the pandemic as moderate to severe, with 29% reporting moderate to severe symptoms of anxiety and 17% reporting moderate to severe symptoms of depression.5 Among health care workers in China, the psychological effects appear to be more prevalent, with 50% reporting symptoms of depression, 45% reporting anxiety, 34% reporting insomnia, and 72% reporting overall distress.4
Stressors associated with COVID-19 include financial insecurity, uncertainty about the future, personal or family risks for infection, and social isolation, which can exacerbate downstream sequelae of trauma for those who are exposed.6 Moreover, the prolonged time course and widespread lifestyle disruptions are unique compared to single-incident disasters. However, many COVID-19–related stressors do not constitute formal trauma, which is defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5)7 as exposure to actual or threatened death or serious injury, experienced in one of four ways: (1) directly to oneself, (2) witnessed, (3) learning of its occurrence to family or friends, or (4) via repeated exposure to details of traumatic events. Potential COVID-19–related traumas include repeated workplace exposure to death and/or dead bodies with direct risk of harm to self through infection. COVID-19 stressors and trauma may lead to significant psychological distress and may interfere with personal and community-based factors that promote health and resilience. For those with COVID-related traumatic exposures, stressors may further exacerbate premorbid psychiatric symptoms and interfere with adaptive coping.
The goal of this article is to review acute responses to trauma and their relevance to managing the trauma or stress-related mental health sequelae of the pandemic. Particular focus is given to risk and protective factors, the role of acute stress disorder (ASD) and other psychiatric responses to potentially traumatic events as they relate to the COVID-19 pandemic, and considerations for intervention.
Risk and Protective Factors
There is significant heterogeneity in the types and severity of COVID-19–related exposures, baseline risk and protective factors, and the nature of individual stress responses. Trauma research shows that certain subpopulations carry greater risk for negative mental health outcomes after acute stressors. Characteristics that increase risk for developing posttraumatic stress disorder (PTSD) and other stress-related disorders after a trauma include female gender, previous exposure to trauma, low socioeconomic status, belonging to a racial/ethnic minority group, avoidant coping style, and pre-existing psychiatric history, including past diagnosis of major depressive disorder, PTSD, or an anxiety disorder.6,8 Types of trauma exposures that may heighten risk include uncontrollable traumatic stressors and death,6 the latter of which is occurring during the COVID-19 crisis. Other relevant factors include breakdown of social bonds and loneliness, and interpersonal trauma such as domestic and child abuse that may be exacerbated by stay-at-home orders.9 Maladaptive coping mechanisms such as increased substance misuse, which has been common during this pandemic,10 can lead to poorer psychological outcomes and possibly increase vulnerability to PTSD.11 Moreover, communities with a high prevalence of poverty who have suffered a disproportionate loss of life and resources as a result of COVID-19 may be at particular risk of mental health sequelae. Similarly, health care workers with high exposure to COVID-related trauma may also include subgroups with additional risk factors such as younger age, female gender, working as a nurse, being parents of dependent children, and potentially a lack of social support due to separation from loved ones to prevent infection of a family member.12 Other vulnerable groups include older adults, who are more at risk for social isolation, death of peers and loved ones, and severe infection, as well as people who are incarcerated, who are vulnerable to infectious outbreaks and are a disproportionately low-income minority population with high levels of traumatic and psychiatric comorbidity.13
A meta-analysis of health care workers in viral outbreaks including COVID-19 summarized psychological risk factors.12 Those in direct contact with patients who were infected with COVID-19 had the greatest levels of distress and symptomatology. At an organization level, perceived lack of organizational support, inadequacy of training, lack of confidence in infection control, and lack of practical and psychological support by the health care organization contributed to psychological distress.12 Conversely, modifiable factors promoting resilience included adequate time off and breaks from clinical duties, positive feedback, adequate protective gear, effective training, access to tailored psychological interventions, and clear communication, with the latter being one of the more consistent findings.12,14 Although this meta-analysis specifically examined health care workers, a study of the general public in China during the COVID-19 pandemic reflects these findings: satisfaction with quality of communication, availability of mental health care, and use of precautionary measures such as hand hygiene and masks were associated with lower levels of stress, anxiety, and depression.5 Results from these studies can be used to guide organizational-level interventions.
As a general principle, supporting effective coping skills during and proximal to traumatic events may also increase resilience and protect against PTSD. It is important to consider, however, that most people recover after a traumatic event and coping strategies vary. For example, one study found that active coping strategies involving problem solving and restructuring perceptions of a stressor were associated with increased resilience and less severe PTSD symptoms 6 months post-trauma, whereas avoidant coping strategies such as social withdrawal were associated with PTSD symptom development.15 However, avoidance may be effective for some or helpful at certain times, whereas expressing emotions excessively may also be associated with greater chance of developing PTSD.15,16 Strategies such as excessive use of substances (eg, alcohol) may be more consistently problematic. Regardless of strategy, effective coping is evidenced by emotion regulation, realistic self-perception, sustained task performance, and preserved capacity for rewarding interpersonal contact. Conversely, failure to cope is evidenced by impaired task performance, poorly modulated affect, negative self-perception (guilt or shame), and inability to enjoy rewarding human interactions.17,18 Identifying those who are failing to cope effectively can help identify people at higher risk, and psychoeducation and stress management techniques may enhance general psychological resilience.19 Ways to enhance protective factors, such as social support, perceived successful coping, and sense of purpose or meaning during and after the pandemic should be prioritized.
Acute Stress Disorder and Stress Responses
ASD was first introduced in DSM-IV20 to encapsulate the severity of the acute stress response and to predict subsequent risk of PTSD. However, further studies demonstrate that people exposed to trauma follow heterogeneous trajectories: many people who meet criteria for ASD do not ultimately develop PTSD, and many people diagnosed with PTSD do not have preceding ASD.21 In other words, ASD is limited in its capacity to predict PTSD. Therefore, ASD was re-envisioned in DSM-57 as a way to assess the severity of the acute stress response without attempting to predict downstream sequelae of prolonged symptoms.21 Studies suggest prevalence rates for ASD range from 7% to 28% after trauma exposure.22
DSM-5 criteria for ASD are summarized in Table 1.7 Acute stress responses after trauma vary and include anxiety, irritability, insomnia, mood disturbances, feeling numb, increased substance use, and dissociation.23 A stress response may also include elevated arousal, commonly experienced as tension, insomnia, restlessness, and panic attacks. Cognitive processes, such as blaming oneself, appraising the event as threatening or harmful, feeling the event was uncontrollable, and the experience of shame may also confer risk for early and prolonged stress-related syndromes.24 PTSD diagnostic criteria include some similar symptoms arranged in four clusters (re-experiencing, avoidance, mood/cognition, and hyperarousal) with time course occurring more than 30 days after a traumatic stressor. Endorsing PTSD symptoms 1 month after trauma is more predictive of long-term PTSD than an initial diagnosis of ASD.25
DSM-5 Criteria for Acute Stress Disorder
A variety of tools exist for assessing acute stress responses and ASD, including potent risk factors such as peritraumatic dissociation. Many instruments for measuring trauma are available at the National Center for PTSD website ( https://www.ptsd.va.gov/professional/assessment/screens/index.asp). These instruments can be used to identify people who would benefit from early intervention. However, many people with high symptom burden at this early stage are likely to recover without further intervention,6,26 whereas others may develop other stressor-related conditions (eg, depression, anxiety).
Limitations of ASD Model to COVID-19
Although ASD is a useful diagnosis to identify those with severe symptom burden soon after a traumatic event, there are limitations to its use and applicability in the COVID-19 pandemic. As discussed, many people exposed to trauma who do not meet ASD criteria will develop PTSD at a later time, and those who meet criteria for ASD may not develop PTSD at all. Further, because of the prolonged and continuing nature of the pandemic, people who have been traumatized may present at varying stages of their response. This highlights the necessity of continued monitoring over time. In addition to ASD and PTSD, other common psychiatric disorders that come after traumatic exposure include depression and anxiety. Those presenting after the death of a loved one to COVID-19 may be experiencing acute grief, hallmarked by intense emotions, yearning, and recurrent intrusive thoughts and memories of the deceased.27 In the pandemic, social distancing requirements have interfered with many cultural and religious rituals that usually bring social support and comfort to the bereaved (eg, funerals, bedside farewells). Over time, a subset of the bereaved may develop prolonged grief (also termed complicated grief), which has some overlap with PTSD28 and is important to identify to select the correct treatment. Others with a range of stressful experiences may present with adjustment disorder, mood disorders, and anxiety disorders,29 each of which may necessitate different treatment approaches. Increased risk for self-harm and suicide attempts also occurs after trauma.29 Furthermore, people who do not meet any diagnostic criteria might still experience persistent distress and significant impairment.29 Thus, the heterogeneity of timing, symptom burden, acuity, and stressors will require ongoing monitoring for a broad spectrum of symptoms and disorders beyond ASD to determine who needs mental health intervention.
Trauma-Guided Principles to COVID Mental Health Interventions
Although ASD may not fully capture the range of COVID-related mental health concerns, many trauma-guided principles are still relevant to the mental health response. First, responders and organizations can use a phase-based approach to organize interventions. This approach addresses pre-existing vulnerability, the experience and consolidation of traumatic events, and the stabilization of posttraumatic psychopathology. Early interventions should bolster adaptive coping mechanisms, identify and alleviate peritraumatic reactions, provide early symptom assessment, and, where relevant, use interventions such as trauma-focused cognitive-behavioral therapy (CBT) for ASD and PTSD.6 Duration of exposure and uncertainty of risk are associated with severity of psychological impact,30 and both characterize the ongoing COVID-19 pandemic. Affected persons may be in varying stages of trauma timelines, and as noted, many will recover naturally. Therefore, appropriate assessment, and sometimes reassessment, with matching of the level of intervention to the current clinical need is appropriate.
For those currently experiencing acute COVID stressors, the first strategy, which can be implemented by lay or professional first responders, can include stress management techniques. These techniques overlap with principles of psychological first aid and include nonintrusive dialogue with affected persons, clear and effective communication to identify and alleviate distress and respond to concerns, encouraging preferred methods of coping and connection with others, and instilling hope.6 Psychological first aid, often administered by acute care teams, may be helpful to reduce peritraumatic distress after trauma. Careful screening and assessment at this stage may also identify those at greatest risk for developing mental health disorders, including ASD and/or acute risk for suicide or other negative sequelae. These people should be connected with providers and may benefit from targeted early interventions, including psychoeducation about acute stress reactions, facilitating connection with social supports, increasing distress tolerance, and other coping strategies.
Of note, compulsory critical incident stress debriefing, an intervention previously used to provide psychoeducation regarding responses to trauma while encouraging people to share their emotions and trauma experiences in a group format immediately after a traumatic stressor, should not be implemented. This modality is not helpful in managing acute reactions to trauma or preventing PTSD, and it may actually increase the likelihood of PTSD development.31
For those with more persistent symptom profiles, including those diagnosed with ASD and PTSD, a first-line treatment is trauma-focused CBT.21 CBT uses exposure-based interventions and/or cognitive restructuring, and it is effective at reducing subsequent PTSD when used as an early intervention; similarly, trauma-focused CBT interventions are efficacious at reducing PTSD symptom severity. There is currently limited evidence to support pharmacologic interventions to prevent PTSD;21 peritraumatic studies revealed that selective serotonin reuptake inhibitors (SSRIs) are not effective,32 and other agents such as beta blockers have mixed findings, whereas benzodiazepines can increase subsequent risk of PTSD.33 However, patients should be screened for other conditions that may respond to pharmacotherapy such as SSRIs for depression and, once established, PTSD.
The acute and long-term mental health consequences of the COVID-19 pandemic are likely to be as varied as the types and severities of exposures, the individual and community level risk, and the protective factors present. When guiding a mental health response, it is important to consider core principles learned from the study of trauma-related disorders. This includes understanding the modal response is resilience while screening for people at greatest risk and phasing in interventions. Individual, organizational, and community level factors that support resilience, including COVID-19–specific measures, may reduce risk, support effective coping, and mitigate psychological distress. Ongoing screening and referral to evidence-based care is needed for those who develop persistent or impairing trauma and stressor-related psychopathology.
- World Health Organization. Coronavirus disease (COVID-19): situation report–128. Published June 15, 2020. Accessed June 17, 2020, https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200615-covid-19-sitrep-147.pdf?sfvrsn=2497a605_4
- Choi KR, Heilemann MV, Fauer A, Mead M. A second pandemic: mental health spillover from the novel coronavirus (COVID-19) [published online ahead of print April 27, 2020]. J Am Psychiatr Nurses Assoc. doi:10.1177/1078390320919803 [CrossRef] PMID:32340586
- Dutheil F, Mondillon L, Navel V. PTSD as the second tsunami of the SARS-Cov-2 pandemic [published online ahead of print April 24, 2020]. Psychol Med. doi:10.1017/S0033291720001336 [CrossRef] PMID:32326997
- Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 2020;3(3):e203976. doi:10.1001/jamanetworkopen.2020.3976 [CrossRef] PMID:32202646
- Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):E1729. doi:10.3390/ijerph17051729 [CrossRef] PMID:32155789
- Shalev A, Barbano A. PTSD: risk assessment and early management. Psychiatr Ann. 2019;49(7):299–306. doi:10.3928/00485713-20190605-01 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.
- Norris FH, Murphy AD, Baker CK, Perilla JL. Severity, timing, and duration of reactions to trauma in the population: an example from Mexico. Biol Psychiatry. 2003;53(9):769–778. doi:10.1016/S0006-3223(03)00086-6 [CrossRef] PMID:12725969
- Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic [published online ahead of print April 28, 2020]. Am J Emerg Med. doi:10.1016/j.ajem.2020.04.077 [CrossRef] PMID:32402499
- Vigo D, Patten S, Pajer K, et al. Mental health of communities during the COVID-19 pandemic [published online ahead of print May 11, 2020]. Can J Psychiatry. doi:10.1177/0706743720926676 [CrossRef] PMID:32391720
- McCauley JL, Killeen T, Gros DF, Brady KT, Back SE. Posttraumatic stress disorder and co-occurring substance use disorders: advances in assessment and treatment. Clin Psychol (New York). 2012;19(3):283–304. doi:10.1111/cpsp.12006 [CrossRef] PMID:24179316
- Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ. 2020;369:m1642. doi:10.1136/bmj.m1642 [CrossRef] PMID:32371466
- Wolff N, Huening J, Shi J, Frueh BC. Trauma exposure and posttraumatic stress disorder among incarcerated men. J Urban Health. 2014;91(4):707–719. doi:10.1007/s11524-014-9871-x [CrossRef] PMID:24865800
- Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singapore. 2020;49(3):155–160. PMID:32200399
- Thompson NJ, Fiorillo D, Rothbaum BO, Ressler KJ, Michopoulos V. Coping strategies as mediators in relation to resilience and posttraumatic stress disorder. J Affect Disord. 2018;225:153–159. doi:10.1016/j.jad.2017.08.049 [CrossRef] PMID:28837948
- Gil S. Coping style in predicting posttraumatic stress disorder among Israeli students. Anxiety Stress Coping. 2005;18(4):351–359. doi:10.1080/10615800500392732 [CrossRef]
- Pearlin LI, Schooler C. The structure of coping. J Health Soc Behav. 1978;19(1):2–21. doi:10.2307/2136319 [CrossRef] PMID:649936
- Shalev AY, Tuval R, Frenkiel-Fishman S, Hadar H, Eth S. Psychological responses to continuous terror: a study of two communities in Israel. Am J Psychiatry. 2006;163(4):667–673. doi:10.1176/ajp.2006.163.4.667 [CrossRef] PMID:16585442
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- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Publishing; 2000.
- Bryant RA. The current evidence for acute stress disorder. Curr Psychiatry Rep. 2018;20(12):111. doi:10.1007/s11920-018-0976-x [CrossRef] PMID:30315408
- Bryant RA. Acute stress disorder as a predictor of posttraumatic stress disorder: a systematic review. J Clin Psychiatry. 2011;72(2):233–239. doi:10.4088/JCP.09r05072blu [CrossRef] PMID:21208593
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- Shalev AY, Gevonden M, Ratanatharathorn A, et al. International Consortium to Predict PTSD. Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP). World Psychiatry. 2019;18(1):77–87. doi:10.1002/wps.20608 [CrossRef] PMID:30600620
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DSM-5 Criteria for Acute Stress Disordera
Recurrent and intrusive distressing trauma memories
Recurrent distressing trauma-related dreams
Flashback or other dissociative reactions as if the traumatic event was recurring
Intense or prolonged psychological distress or physiological reactions triggered by traumareminders
Persistent loss of positive emotions
Altered sense of reality of surroundings or oneself
Inability to remember important trauma details (not due to other causes)
Avoidance of trauma-related memories, thoughts, or feelings
Avoidance of trauma-related external reminders (eg, people, places, activities)
Unprovoked irritable behavior and outbursts of anger (eg, verbal or physical aggression)