Stress And Trauma In Pandemic Times

We were unfamiliar with pandemics. How were people to think about it? Was the pandemic like a natural disaster? Or was it an illness like others, where some died others escaped or were left bereaved? Was it like an infiltration by an invisible enemy? Or was the pandemic like a biblical pestilence, along with more frequent fires, storms, and floods, punishing a greedy world?

It was natural to try to conceptualise this unfamiliar danger according to what we already knew. It was also natural to fill in lack of scientific data with magical thoughts.

In this chapter we will look at other circumstances with widespread threats to life and see how their features overlap with and elucidate the current crisis.

Traffic deaths

About 40,000 people die of traffic incidents in the US annually, and 1.25 million die around the world. In addition, 50,000,000 are seriously injured worldwide. In a sense traffic deaths are a low grade chronic pandemic.

Traffic deaths are a prime example of avoidance and denigration of psychological aspects of catastrophes. Historically, complaining survivors were accused of compensation neurosis, while psychological factors among those causing accidents were almost totally ignored.

In fact, close examination of both victims and perpetrators reveals a wide variety of physical, psychological, and social dysfunctions (Valent, 2007).

Natural Disasters

Natural disasters such as fires, floods, and earthquakes are usually short-term circumscribed events that do not threaten the rest of the population. Help pours in quickly from outside to help the victims.

Disasters have arguably been the most scientifically studied mass traumatic situations. They revealed that traumatic events manifest different phases: pre-impact, impact, post-impact, recovery and reconstruction. Disaster responses have also been noted to ripple to secondary victims such as helpers and children, and can ripple even across generations.

Generally, mortality and morbidity from all kinds of illnesses increase in proportion to severity and duration of specific stresses and traumas. The nature of what survivors, secondary victims, and communities experience varies very widely across physical, psychological, and social scenarios.

Early researchers found for instance symptoms as wide ranging as reliving aspects of disasters (PTSD), but also confusion, apathy, grief, depression, survivor guilt, shame, hopelessness, alienation, and struggle for meaning.

Valent (1984, 1998) after the Australian Ash Wednesday bushfires classified these varied responses according to biological, psychological and social manifestations of instinctual survival drives ranging across time place and persons, and ranging from instincts to spiritual dimensions. For instance, a man believed an angel appeared in the flames and its wings were about to envelop him. A boy believed his angry mother was a witch and he took a magic pill to ward off her evil.

Disasters have highlighted the fact that helpers generally are secondarily affected, especially if their rescue efforts fail. Helpers may empathically resonate with victims’ distress or feel guilt and shame for not having been able to help them.

Actually, victims’ traumas radiate not only to helpers but to family and community members, and may resonate across generations.

Wars

Wars, more than traffic accidents, have demonstrated extreme inadmissibility and denial of psychological symptoms in soldiers. Their complaints were treated as malingering and cowardice. Yet millions of soldiers, many of them decorated, broke down, proving that everyone was vulnerable to extremes of stress and trauma.

Though psychological consequences of combat have been recorded since the ancient Greeks, it was only in the 17th century that Hofer compiled excitement, ‘imagination’, gastrointestinal symptoms, torpor, prostration, and depression in Swiss soldiers into a syndrome he called melancholia. This concept lasted 150 years, until in the American Civil War longing for home and lack of discipline (called nostalgia) were added to melancholia.

In World War One, after some resistance, initially physical stress symptoms were acknowledged, mainly of the heart. Irritable heart, neurocirculatory asthenia, and effort syndrome were common diagnoses. Shell shock was added, thought to be a result of explosions that caused minimal brain damage. Eventually pure traumatic psychological illnesses had to be acknowledged due to the massive numbers of mental breakdowns.

The seminal work to emerge from World War One was Abram Kardiner’s (1941) The Traumatic Neuroses of War. Kardiner described a very wide variety of symptoms that related to traumatic events and which could be relived in nightmares and flashbacks. They could merge with other neuroses and physical symptoms. Kardiner emphasised that all symptoms were meaningful in terms of earlier traumas, even if these traumas were unconscious.

Interestingly, the so-called Spanish flu pandemic of 1918 that killed 50 million people worldwide and also ravaged World War One combatants was not mentioned among war casualties on either side of the conflict, in order to not reveal one’s military vulnerability. This was a stark example of how political forces can suppress recognition and treatment of pandemics. The flu was called Spanish because Spain, neutral in the war, acknowledged the flu.

In World War Two, the lessons of the previous war had to be relearned. Like trauma itself, traumatic neuroses were repressed. This is a warning that lessons of the current pandemic must not be forgotten.

Once combat breakdowns were acknowledged, new type of scientific research ensued. It found that psychological breakdowns were associated with the intensity and duration of the threat of death and the number of comrades killed. In severely stressed units, all soldiers ultimately broke down. We learned that irrespective of people’s strengths and vulnerabilities, everyone was eventually breakable.

World War Two revealed the importance of morale. Morale consisted of motivation to accomplish important goals and confidence in one’s ability to do so. It also consisted of one’s identity being conceived as being part of a group, the group being more important than oneself. The group was the body, the leader its head, and oneself a body part. Morale was the antidote to the anxiety of annihilation.

With defeat of goals and loss of comrades confidence sagged and demoralisation set in. The military group lost its esprit de corps. Individuals felt abandoned in a dangerous world for no good reason. Discipline collapsed, officers were killed by their men, and atrocities occurred.

As in world War One, Grinker and Spiegel (1945) validated Kardiner’s findings of a wide range of responses in traumatised soldiers. They referred to ‘combat breakdown’ as ‘a passing parade of every type of psychological and psychosomatic symptom, and unadaptive behaviour.’ Be it depression, hysteria, somatic symptom, phobia, etc, all symptoms were once more understandable in terms of traumatic incidents that soldiers had endured.

Bartemeier et al (1946) added to Grinker and Spiegel’s findings a kind of final definitive traumatic picture of the war. They called it ‘combat exhaustion’. Its features were fatigue, slowness, withdrawal, moroseness, and loss of concentration and interest. In its full-blown form young soldiers looked like old men who walked like automatons, totally exhausted, retarded, and apathetic.

Post-War. For the first time, close attention was provided to returned soldiers. It became obvious that in many soldiers symptoms did not clear when away from combat. They could even last unabated for decades. Further, symptoms could erupt months or even years after the war. Still vivid, symptoms from war could in time interweave with civilian stresses and traumas.

Mental Health Professionals. For the first time, too, mental health professionals were themselves subjected to observation. It was found that most psychiatrists saw themselves as part of the war effort. They denied breakdowns; rather they harangued soldiers to greater efforts and gave pejorative diagnoses such as malingerer when these efforts failed. Again we see how power politics can sway scientific mental discourse.

The Vietnam War. With defeat, demoralisation manifested in poor discipline, drug addiction, refusal to fight, murder of officers, and atrocities. Subjectively soldiers felt alienated, numb, angry, guilty, unable to trust and love. They were devoid of a sense of justice, morality, meaning and purpose.

Of returnees, 38% were divorced within six months. A third of federal prisoners were Vietnam veterans. Still, once again mental health consequences of veterans in agony were denied.

Eventually they marched in their thusands to have their anguish recognized. It was only then that the politics of psychiatry granted them a diagnosis- post-traumatic stress disorder (PTSD). It contained a limited recognition of all the travails that veterans were reliving or suppressing.

Civilians in Wartime. Though their circumstances were different, nevertheless civilians were also threatened by death and injury. The extent of mental injury depended on circumstances similar to soldiers: faith and leadership, the degree and duration of destruction, victory or defeat, and the proportion of the population and loved ones killed or injured.

In the London blitz morale was high except in the minority who were severely affected. The nature of their mental disturbance was varied, as it was with soldiers. In Hiroshima, following explosion of the atom bomb, the surviving population resembled soldiers with combat exhaustion.

Children in Wartime. Even when shielded by adults, children nevertheless experience bombings and mayhem, and they absorb adults’ fears and emotions. Children’s vulnerability is reflected in their relatively high morbidity and mortality rates compared to adults. And when parental shields are ripped away children’s suffering is extreme. In young children psychosomatic and behavioural symptoms dominate in expressing their distress. Older children suffer symptoms similar to adults.

The Holocaust

The Holocaust was the most total and widespread persecution of a people in history. It led to the deaths of six million Jews. The consequences of this genocide were well documented and have been followed now over three generations.

In the lead-up to their annihilation, psychiatric illnesses, suicides, hypertension and angina were reported to have increased. In concentration camps up to half the prisoners just died within weeks. Some, called musselmen, hovered between life and death. They were emaciated, old-looking people, emotionally numb, and cognitively deficient. Their survival reflexes disappeared and they appeared as silhouettes of humanity. Most died. They resembled those suffering combat exhaustion, but they were traumatised through another, ultimate level.

Those who survived the Holocaust did so through a combination of luck and intense resolve, hope, and maintenance of meaning. Nevertheless, post-war they suffered a range of biological, psychological and social illnesses. Over subsequent decades their morbidity and mortality rates were higher than for the rest of the population.

Psychological sequelae of the Holocaust, huge as they were, were once again denied for two decades. Initially physical symptoms were acknowledged. Eventually it was obvious that Holocaust survivors suffered a wide plethora of symptoms and problems.

Survivors were tormented by irreconcilable losses, survivor guilt, rage, despair, depressions, psychosomatic illnesses, and loss of meaning and purpose. They attempted to find meaning in quick marriages, having children, and hard work.

Children. Nine-tenths (one and a half million) Jewish children were murdered in the Holocaust. Most who survived were separated from their parents, hidden by strangers. The children numbed their feelings, were supremely obedient, and lived day by day awaiting a miraculous end to their suffering.

Post-war, children were denied recognition of their sufferings. They had to deal silently and unknowingly with their war experiences, which, unrecognised, still pervaded them. They dealt silently with losses of their childhoods and their dreams. Like one of the authors (PV), child survivors of the Holocaust were recognized only in the 1990s when the children were in their fifties (Valent, 1994). It was only then that they started to process their traumas.

Second generation survivors were greatly influenced by the Holocaust through their parents. They carried negative emotions, sensations, images, judgements, and attitudes that were incomprehensible to them, as their parents often maintained a conspiracy of silence about their experiences and what the children signified for them.

Perpetrators and their children. Nazi Germany produced extremes of violence and atrocities, but they could occur elsewhere, such as the atrocities that were documented in Vietnam.

Antecedents of violence are as wide as those for trauma. They include poor family relationships, deprivation, poverty, social turmoil. They can harness fear, group pressure, dehumanisation, and opportunism to commit atrocities that would be abhorrent in normal circumstances (Valent, 2020).

Children of perpetrators have a dilemma. They can either identify with their parents and grandparents as some neo-Nazis do, or they need to painfully disassociate from them.

Physical Assault, Domestic Violence; Sexual Violence

In the 1980s millions of people were documented to be victims of violence annually in the U.S. Two million cases of child abuse and neglect were reported annually. 3.3 million children witnessed spouse abuse annually.

Assaults are traumatic. For instance victims of domestic violence suffer not only PTSD, but shattered core beliefs of safety, trust, self-belief, self-judgements and views of a moral universe as well.