It was 7 in the evening. I had taken my niece out for a stroll when I received a call from Prema (name changed), the staff nurse at our hospital. With a sense of urgency, she exclaimed, “Sir, there is a 40 year old man who is shaking vigorously. He seems distressed and anxious. You are urgently needed in the emergency room.”
I rushed back to the hospital to attend to Mahesh, a businessman from Bangalore who had now relocated to Hubli, amidst the lockdown. This was the first time Mahesh was visiting a psychiatric hospital. No one in his family had any history of mental illness. He had been accompanied by a bevy of anxious family members. During detailed clinical examination, he remarked:
“Doc, the nightmares just won’t stop. I wake up every night shaking with this intense fear that I will contract COVID-19 once again. I wake up drenched in sweat. Worse still, I am unable to function and have stopped working. Any mundane discussion remotely related to the virus sets off a series of alarming responses within me. Anything and everything can be a cue to further my anxiety. I have started drinking to cope with this assault on my mind. Please help me.”
It became evident that Mahesh was suffering from post-traumatic stress disorder (PTSD). PTSD develops in some people who have experienced a traumatic, scary or dangerous event. It is normal to feel anxious during and after a traumatic event.
Fear brings about a cascade of split-second changes in the body, and in a part of the brain called the amygdala. The amygdala is an almond-shaped structure located deep in the temporal lobe. During a traumatic encounter, the ‘fight-or-flight’ is activated. This is an evolutionary response meant to protect us from harm, and to alert us to impending threats. You could view PTSD as a state in which the body and the mind are in a constant state of ‘fight-or-flight’, even when there is no evident threat.
Most people will experience a range of reactions following trauma – yet most people recover from initial symptoms without the need for any medical intervention. Those who continue to experience problems following trauma may fit into a diagnostic entity called PTSD. People with PTSD experience a range of pathological and anxiety-provoking emotions even when there is no danger around.
Most people who have been exposed to trauma don’t develop PTSD. The people more likely to develop PTSD include war veterans, children and people who have experienced an accident, a disaster or other similar serious events, or physical or sexual assault. Triggers and cues vary from person to person, but the common ones include the sudden, unexpected demise of a loved one, tsunamis, earthquakes and floods.
At the beginning of the COVID-19 pandemic, I was half-expecting people to present with PTSD symptoms following recovery from COVID-19, and I wasn’t wrong. I have observed a steep increase in the number of patients presenting with PTSD in the last six months. Typically, the onset of clinical symptoms is within three months of the traumatic event, but sometimes they begin years afterward.
Symptoms must last more than a month and should be severe enough to cause functional impairment in work and relationships. A core feature of PTSD is that the affected person relives the trauma through flashbacks, nightmares and negative emotional states. Words, objects, or situations that are reminders of the event can trigger a bout of intense anxiety, and the person may re-experience the symptoms connected with the index traumatic event. Anything remotely related to the event can become a cue for flashbacks.
Mahesh also said, “I have started avoiding reading news related to COVID-19. I was in the ICU and had to be intubated. The very mention of doctors and hospitals is frightening. Even getting here has been a struggle. I have had to take two sedatives to even come here.”
This description contains another core feature of PTSD: avoidance. Its symptoms include staying away from places, events or objects that remind a person of the traumatic event. They may also take the form of avoiding thoughts and feelings related to the event. Avoidance slows a person down, wears her out and causes a great degree of functional impairment.
“He is reacting evidently strangely nowadays,” Mahesh’s wife said. “I find that he is getting startled very easily. Our children avoid interacting with him as he is always on edge, tensed and easily irritable. It’s depressing, to be honest.”
These are the classic arousal symptoms: they tend to be constant and are not triggered by cues. Mahesh also found that he could no longer access his acute mental focus, which had made him an astute businessman previously. He often went through spells of crying, and during these spells he would turn to the bottle as a way of escaping his trauma.
I advised in-patient care for Mahesh, to which he agreed with some reluctance. It was important to make him understand the need for supervised care. We agreed that he would benefit from a combination of therapy and medications.
His talk therapy sessions continued well after his discharge, and lasted for 12 weeks. They involved exposure therapy and cognitive restructuring. Exposure therapy is designed to help people face their fears, gradually, in a safe space. Very slowly, he was exposed to stimuli that brought about anxiety and fear. These sessions took place in a controlled environment, with a therapist with whom he had established a rapport.
During this process, Mahesh was empowered to cope with distressing feelings, thoughts and misrepresentations that he had had about his traumatic experience.
Cognitive restructuring involves enabling him to gain control of his fear and distress by changing the thought process about his experience. Together with talk therapy, he was started on a low-dose medication that further prompted his recovery from his distressing experience.
After three months, Mahesh finally rid himself of his debilitating symptoms. He was advised the need to continue his medications under supervision for six more months.
Stories such as that of Mahesh tell us that a range of mental health problems are in the offing thanks to the ongoing pandemic. COVID-19 can verily affect the brain, and produce distressing neuropsychiatric symptoms. Early diagnosis and evidence-based treatments will help sufferers reintegrate themselves into society at the earliest.
Dr Alok Vinod Kulkarni is a senior psychiatrist at the Manas Institute of Mental Health, Hubli.