As she pulled into the parking lot of the hospital where she worked one day in mid-March, Anita Lesko was feeling overwhelmed with anxiety and dread. "I'd been seeing nonstop news about COVID-19," says Lesko, CRNA, a nurse anesthetist from Pensacola, FL, "and I kept hearing about people dying from respiratory failure, the same condition that killed my mother in 2013." Getting out of her car, she couldn't stop thinking about the dangers she'd face in the operating room. "My job involves putting breathing tubes down patients' throats, being coughed on, and getting exposed during the surgeries to all sorts of bodily fluids that could contain droplets of COVID-19," says Lesko, 61. "As I entered the hospital, I started crying and trembling. I felt like I was walking to my death."
She thought she could tough it out, especially given how much she'd overcome during her long career as a nurse anesthetist. Lesko, who's been diagnosed with autism spectrum disorder, struggled for years with sensory overload in the operating room—the bright lights, beeping monitors, and other sounds—until she developed a tolerance for them. She is also a germophobe and had been teased by co-workers over the years about her tendency to wear extra personal protective equipment (PPE).
Even after Lesko donned double layers of PPE on that March morning, she didn't feel any safer. "Over the next few hours, I sensed a massive hysteria building up," she recalls. "During every surgical case, I was hyperventilating and felt like an elephant was sitting on my chest. Finally I told my boss I needed to leave early because I was on the verge of an emotional meltdown. After clocking out, I sat in my car shaking and sobbing. I felt ashamed and embarrassed. Other health care workers were being hailed as heroes for running toward danger—and I was running away from it."
Lesko has been unable to return to work since that day. She's also been diagnosed with posttraumatic stress disorder (PTSD) and generalized anxiety disorder. "I felt shattered that I couldn't be like the other health care workers who are putting their lives on the line to fight this virus. I knew I needed to cure myself somehow," she says. Lesko is one of many people, from both within and outside the health care community, to experience stress-related mental health problems during the COVID-19 pandemic. Neurologists, psychiatrists, and other physicians are bracing for an uptick in cases of PTSD as well as acute stress disorder and adjustment disorder.
For Lesko, every email from the hospital about how staff could protect themselves from the potentially deadly virus would bring on a panic attack. "I'd start gasping for air and spend hours in bed just shaking," she says. The experience reminded her of her first job as a nurse anesthetist, in a ward of patients on ventilators due to catastrophic respiratory issues. "Just thinking about being in that situation brought on paralyzing anxiety and a feeling of impending doom. I started waking up in the middle of the night in a state of absolute terror and having recurring nightmares about being in the operating room, intubating a patient with COVID-19, and suddenly realizing that I'd forgotten to wear any PPE."
Lesko first reached out for help from the neuropsychologist who'd diagnosed her with autism spectrum disorder. She is now being treated with weekly virtual therapy sessions. "The therapist says I'm like a soldier who has been on the battlefield for 32 years, just doing my job and not dealing with all the trauma and stress of it," Lesko says. "It took a pandemic to make my anxiety so high that it's coming out as full-blown PTSD."
The COVID-19 crisis can be particularly fraught for people with neurologic or other medical conditions that put them at higher risk of infection. Brooke Knisley, who developed immune problems due to complications from a traumatic brain injury she sustained in 2015 after falling out of a tree, says: "After the college where I teach shut down classes on March 10, I didn't leave my house for three months because I was terrified that I'd get infected with the coronavirus and die."
At first she was managing okay, but in mid-April her symptoms got worse and the 30-year-old writing instructor from Cambridge, MA, worried that she might harm herself. Although she's been able to resist the impulse to self-harm, Knisley says certain situations are exacerbating. Her biggest trigger has been misinformation about how to avoid infection. "Hearing people claim that the pandemic is a hoax or will go away like a miracle is profoundly disturbing," she says. "Not only am I super angry about how this terrible disease is being mishandled, but I'm constantly on guard."
On June 10, Knisley finally got up the nerve to leave her house. "I put on a mask to take a short walk," she relates. "Then I saw a man without a mask standing 10 feet away. He said he hadn't seen me in the neighborhood and started walking toward me with his hand extended, wanting to introduce himself. I was so terrified that I ran back inside and double-locked the door. Then I started rage-pacing around the living room. I felt helpless and impotent." Knisley now has weekly appointments with a therapist via video calls. "My therapist is helping me see that my initial thoughts are often warped and not rooted in reality," she says. She didn't trust anyone to take the necessary precautions, and the new neighbor outside her house seemed to justify that. "My therapist helped me see that this was not the universe confirming my all-encompassing beliefs."
Emotional Response
The three mental health conditions expected to surge because of the pandemic—PTSD, acute stress disorder, and adjustment disorder—"share similar symptoms, can be equally severe, cause a high level of psychological distress, and respond to the same treatments," says Jonathan Woodcock, MD, clinical associate professor of neurology at the University of Colorado School of Medicine in Denver. They differ in how long they last and what triggers them, he says. "These three disorders are specifically defined as intense emotional responses that occur after stressful events," Dr. Woodcock notes.
"PTSD is defined as occurring after someone experiences or witnesses a life-threatening event or learns that such an event has happened to a family member or friend," says Douglas Bremner, MD, professor of psychiatry and behavioral sciences at Emory University School of Medicine in Atlanta. "A global pandemic of a potentially fatal viral illness fits that description and is putting many people at risk for developing the disorder." This is especially true if people's fears are so extreme that they stay cooped up in their homes and avoid all social contact. After all, staying connected can act as a buffer against mental health problems.
"I talk to people every day who are experiencing very high levels of stress, anxiety, and fear triggered by the pandemic," says Scott Hirsch, MD, clinical associate professor of neurology and psychiatry at NYU Langone Health in New York City. "It's like being caught up in an ongoing natural disaster in which seemingly innocuous everyday activities, such as shopping in the grocery store, opening mail, or getting together with friends, have suddenly been transformed into existential threats. To protect themselves against infection, people have become hypervigilant about potential danger lurking in everything they do, which is also one of the symptoms of PTSD."
People who experience repeated indirect exposure to a traumatic event, such as first responders and health care workers in emergency departments, intensive care units, and operating rooms, are also vulnerable to PTSD. Exposure to a traumatic event can also lead to acute stress disorder, a temporary condition that occurs immediately after the event and can last anywhere from a few days to a month. People who continue to experience symptoms for longer than a month should be evaluated for PTSD, which can occur weeks, months, or even a year after the trauma.
Symptoms of both disorders include reexperiencing the trauma through nightmares, flashbacks, intrusive thoughts, and panic attacks. People with these disorders go to great lengths to avoid places, situations, and objects that evoke memories of the trauma. They may also become easily startled, feel constantly on guard, have trouble sleeping, and experience chronic irritability and outbursts of anger. Other hallmarks are persistent negative thoughts and feelings, such as fear, shame, guilt, and self-doubt; distorted thoughts or beliefs about the traumatic event; and loss of interest in favorite activities. These symptoms can leave people feeling emotionally numb and isolated from friends and family.
Evolving Triggers
Over the years, both the name and definition of PTSD have changed, reports Dr. Woodcock. Historically, it was called shell shock or battle fatigue and was thought to occur only in combat veterans. Later, it was recognized that many other situations can trigger PTSD, including rape and other violent crimes, car crashes, acts of terrorism, and fires, earthquakes, and other natural disasters.
The pandemic has led to a host of unprecedented and highly traumatic situations. "For example, infection control protocols are preventing people from visiting their loved ones in nursing homes and hospitals to check on their safety, sit at the bedside to comfort a severely ill family member, or say their last goodbyes to a loved one who is dying from COVID-19 or other causes," says Dr. Woodcock. Under current definitions, people who develop PTSD-like symptoms after stressful situations like these are classified as having adjustment disorder—an intense, prolonged emotional reaction to stressors such as the death of a loved one, health problems, job loss, or another major disruption in daily life. "All of these stressors are affecting many people on a grand scale during the pandemic," says Dr. Woodcock.
But despite the tragedy, economic turmoil, and extreme stress the COVID-19 crisis has caused, most people are unlikely to develop PTSD or other stress-related disorders. In a review of the literature published in PLOS ONE, researchers reported that 28.8 percent of people exposed to a traumatic event met criteria for PTSD a month after the event; a year after the event, 17 percent did. A 2020 study published in the International Journal of Environment Research and Public Health noted that 5 percent to 9 percent of Americans have been diagnosed with PTSD, although more than 70 percent report being exposed to at least one potentially traumatic event (one that involved actual or threatened death, severe injury, or sexual violence) and 30.5 percent report being exposed to four or more such events.
Certain people are at higher risk than others of getting PTSD, says Dr. Bremner. "A prior experience of trauma, particularly of physical or sexual abuse during childhood, puts people at the highest risk for developing PTSD after a new trauma. The earlier trauma serves as a primer that predisposes them to experience similar symptoms if they are retraumatized. For example, abused children may have dissociative or out-of-body experiences as a psychological escape from the trauma. A new trauma can trigger a recurrence of this symptom."
Having a past or current psychiatric condition also can increase the likelihood of developing posttraumatic stress, says Dr. Hirsch. "Self-isolation and the high level of fear posed by a potentially lethal virus can worsen depression and anxiety in people with those disorders, which in turn may make them more susceptible to PTSD than people without preexisting mental health conditions," he says. For example, he adds, "if someone has OCD [obsessive compulsive disorder], these tendencies can go into overdrive during lockdown, so the person is obsessively washing his or her hands and constantly cleaning and disinfecting the home." While behavior like frequent handwashing is understandable during this pandemic, a person who perceives everything as an existential threat may experience panic attacks, nightmares, avoidance, depression, or other symptoms of PTSD, Dr. Hirsch says.
Knisley, who avoided going out in public for months, says therapy has improved her state of mind. "When I do get the urge [to self-harm], I am better able to distract myself," she says. The biggest benefit has been overcoming her negative thinking. "Because my self-esteem is pretty much nonexistent, when I got an email from the college saying it was going to have in-person classes in the fall, my first reaction was to get extremely angry," she says. As she doesn't drive or feel safe taking the subway, she interpreted the college's decision as indifference to whether she lived or died. "My therapist reminded me that I'd told her that my supervisors had consistently praised my work and valued me," says Knisley. "That got me thinking about ways I might ask if it would be possible to teach my courses virtually."
Focus on Recovery
Lesko's therapist has helped her find new ways to feel fulfilled. "Since I can't go back to my job as a nurse anesthetist, I've decided to focus on helping people improve their health during the pandemic," says Lesko, who self-published a book in April, A Food Revolution: How the Plant-Based Lifestyle Can Win the Global War on Diabetes, Obesity and Heart Disease. She switched to a plant-based diet and lost 70 pounds after being diagnosed two years ago with type 2 diabetes.
"I used to make handcrafted soaps, so I bought supplies to start making them again," Lesko adds. "I'm also fostering rescue animals: I have three horses and a miniature mule. At first, I was such a mess psychologically that my animals would run away from me. Now they let me pet them when I feel the hysteria building up inside me, which is very soothing. I feel like we're helping each other heal from stressful situations."
Effective Ways to Manage PTSD
For many people, PTSD resolves on its own. “About 50 percent of people report significant improvement within six to 12 months,” says Jonathan Woodcock, MD, clinical associate professor of neurology at the University of Colorado School of Medicine in Denver.
People who have chronic symptoms—such as panic attacks, flashbacks, loss of interest in activities they once enjoyed, and trouble sleeping or concentrating—or can’t function efficiently at work or in daily life should consider getting help from their doctor or a mental health professional, he advises.
Not treating the condition may lead to an increased risk of stroke and other health problems. A 2019 study published in the journal Stroke found that young and middle-aged veterans with the disorder were 61 percent more likely to experience a transient ischemic attacks (mini-strokes) and 36 percent more likely to have a stroke, compared with people the same age without PTSD—even when factors such as smoking, poor diet, lack of exercise, and substance abuse were taken into account. Further investigation is needed to find out if treating PTSD reduces stroke risk, the researchers said.
The most effective treatment for PTSD combines psychotherapy and medication, if patients don’t improve with therapy alone, says Dr. Hirsch. “Particularly for patients with more severe symptoms, therapy plus medication produces the best chance for significant symptom reduction or remission.” Medication alone also can be effective, he says. “Selective serotonin reuptake inhibitor (SSRI) medications are the mainstays of treatment. They are relatively inexpensive and work well for most patients.” Some SSRIs, such as sertraline (Zoloft) and paroxetine (Paxil), are approved by the US Food and Drug Administration for PTSD.
A healthy lifestyle is important for dealing with PTSD, says Dr. Hirsch. “The last thing you want to do is to traumatize yourself further by abusing alcohol, overeating, or sitting around on the sofa dwelling on your disturbing memories,” he explains. “Exercise is a wonderful way to distract yourself from negative feelings and reduce depression and anxiety.” Practices such as mindfulness—focusing nonjudgmentally on the present moment while releasing stressful thoughts—deep breathing, and meditating can also provide relief.
Several types of psychotherapy are used with patients with PTSD, including:
Cognitive behavioral therapy (CBT). “The fundamental approach of this therapy is to help patients restructure negative thoughts that are not considered rational and replace them with a more realistic and constructive way of thinking,” says Dr. Woodcock. Patients also learn strategies to change their behavioral patterns—and may be given “homework” to help them develop coping skills, such as using roleplaying to prepare for potentially stressful or scary situations. Ultimately, the goal is to empower patients to become their own therapists and move forward in positive ways. “A large body of scientific evidence has shown that CBT is one of the most effective treatments for a range of psychiatric conditions, including PTSD,” Dr. Woodcock says.
Exposure therapy. “This type of therapy helps patients confront their fears and the acute stress reactions that make them avoid certain places, situations, and activities,” says Scott Hirsch, MD, clinical associate professor of child and adolescent psychiatry at NYU Langone Health in New York City. “Treatment typically begins with mild exposures. For example, a health care worker who was traumatized by events at a hospital might start by talking about the hospital parking lot. Later, the person might drive near the parking lot and see colleagues from the hospital as part of their therapy.” In some cases, gradual exposure to the feared situations or locations is combined with relaxation exercises.
Eye movement desensitization and reprocessing (EMDR). Specifically developed to relieve the distress of PTSD, this form of psychotherapy is similar to exposure therapy in that patients recall traumatic memories (in small doses) in a safe environment. Simultaneously, the patient watches an object moving from side to side, such as the therapist’s fingers or a beam of light. “This is a very specialized technique that can trigger PTSD symptoms, either in a mild or severe way,” says Dr. Woodcock. “If the trigger is mild, that is helpful for desensitizing patients. If it’s a major trigger, patients may not find the treatment easy to tolerate.”
How PTSD Affects the Brain
To find out what causes PTSD, scientists have conducted many studies of the brains of people with the disorder—and have identified some intriguing differences, says Dr. Bremner. “Basically, the fight-or-flight circuitry of the brain becomes overactive, releasing the stress hormones cortisol and norepinephrine in increased amounts. This explains why people with PTSD are jumpy, easily startled, irritable, hypervigilant, and prone to sleep disturbances.”
Research by Dr. Bremner and other scientists suggest that three areas of the brain involved in the stress response—the amygdala, the hippocampus, and the prefrontal cortex—play a key role in PTSD. The disorder is also linked to lasting changes in these three areas. “Findings from animal studies and brain imaging of people with PTSD show that those with the disorder have a smaller hippocampus, a region involved with short-term memories that is very sensitive to stress,” says Dr. Bremmer. “These individuals also have increased function in the amygdala, the area where memories of events are encoded, and decreased function in the prefrontal cortex, the area that inhibits the fear response. We think that dysfunction of the circuitry connecting these areas may underlie symptoms of PTSD.”
Studies by Dr. Bremner and his team have shown that a smaller-volume hippocampus appears to be linked to several psychiatric disorders, such as depression, anxiety, and borderline personality disorder in people who were abused in childhood. “We think the combination of a smaller hippocampus due to early trauma combined with an overactive amygdala and a decreased ability of the prefrontal cortex to inhibit is what underlies PTSD symptoms,” Dr. Bremner says.
Other research supports these findings, says Dr. Woodcock. “We don’t know if differences in the amygdala increase risk, but it is very much involved in PTSD and becomes overactive, triggering other parts of the brain, such as the hypothalamus and midbrain, to produce PTSD symptoms.”
Dr. Bremner also has looked at the effects of medications commonly prescribed for PTSD on brain structure and function. One such study, involving the antidepressant paroxetine (Paxil), found that paroxetine reduced symptoms by 54 percent (from patients’ level at the start of the study) and that the treatment resulted in a 4.6 percent growth in hippocampal volume.