Trauma, Brain, and Behavior after the COVID-19 Pandemic

After a year of living in pandemic conditions, many people have experienced at least some level of traumatic events. These can include things like isolation and disruption of social support networks; unemployment and financial strains; living with continual threats to health and safety; negotiating differing levels of risk tolerance with others in a highly politicized environment; witnessing the illness or actual death of people in your social network including family members; and being unable to respond in typical ways or participate in typical grieving rituals because of the pandemic. Additional stressors include frequently changing health policy and community rules, the desire to maintain aspects of "normal" life (e.g., holidays, vacations) despite pandemic-related changes, the additional cost or difficulty associated with doing so, and the indefinite and uncertain nature of the changes that have occurred in everyday living. Layered on all of these things is a climate of social and political unrest. Really, it's a wonder we are still standing.

Trauma has known effects on people's behavior. Two classic constellations of symptoms involve either re-experiencing the traumatic events, or distancing from the traumatic events in various ways. These symptom groups roughly correspond to the Intuitive and Narrative systems of Two Minds Theory. At the Intuitive mind level, the re-experiencing symptoms of trauma can be dramatic at times, as in the case of combat veterans who have immersive flashbacks to events that were seen in wartime. Other common forms of re-experiencing are  a tendency to go over and over the traumatic events in one's mind, or nightmares in which one re-lives the traumatic events. Re-experiencing symptoms also can be more indirect, like heightened emotions or over-reactions to events that really aren't that serious because they evoke some memory of the trauma. Sometimes traumatic events simply lead to a heightened sense of being "on alert," where stress hormones flood the body and lead to jumpiness or unexpected levels of intensity. People with a history of trauma are more likely to be diagnosed with anxiety or anger problems due to this diminished ability to regulate their emotions. Over the long term, the body can't sustain such a high-level stress response and may instead show a flattened pattern of emotion in which there is an apparent lack of emotion, which can also be seen at the neurochemical level in the form of a flattened daily cortisol curve. This leads to emotional numbing or inability to describe emotions, a chronic state that can mimic depression. Sleep problems, loss of appetite, or loss of interest in sex are other signals of a chronic stress response caused by trauma. Alternately, those behaviors can paradoxically increase (e.g., showing up as overeating or inability to get out of bed) when people feel emotionally depleted.

The distancing or avoidant type of symptoms are similarly varied, leading to behaviors like deliberately avoiding people or places connected to the traumatic event. Avoidance is sometimes involuntary, something that the Intuitive mind does to protect us without making us aware of our own behavior. But more often it is a conscious coping mechanism that the Narrative mind puts in place to deal with the strong emotions produced by trauma. In this category, avoidance of strong emotions can be a deliberate approach to everyday life rather than an involuntary one caused by stress overload. Avoiding other people or close relationships can be another way that people stay away from reminders of the traumatic events. And some people respond to trauma simply by keeping very busy, so that they don't have to think about anything other than the task at hand. Avoidance strategies may be preceded or accompanied by cognitive changes such as a belief that the world is unsafe, that people can't be trusted, that one is to blame for one's own traumatic experiences, or that one is weak for not being able to cope with them more effectively. Narratives of this type can exacerbate the initial reaction to trauma.

Behavioral effects of trauma can include emotional reactivity due to over-activation in the limbic system related to emotions and threat perceptions, combined with reduced activity in the prefrontal cortex (PFC) areas responsible for logic and reason. Although PFC under-activity is most commonly seen in cases of head injury where the frontal area of the brain is actually damaged, the same type of decreased activity is also seen in more emotional trauma. This may be due to the brain's tendency to prune synaptic pathways that are no longer needed -- when heightened emotions repeatedly override behavior in the aftermath of trauma, the emotional reaction becomes habitual and the logical brain is taken out of the loop. This is similar to the pattern of automatic responding that I described in a previous post about opioid addiction. People with less well-functioning PFC areas are less able to veto the Intuitive system's natural tendency to seek rewards and avoid unpleasantness, which means that they have a greater tendency toward behaviors like drinking alcohol, over-eating, and being sedentary. All of these unhealthy behaviors did in fact increase during the COVID-19 pandemic. And they may be less able to make a conscious effort to adopt new behaviors like wearing masks or maintaining distance from others, because new behaviors are more likely to require Narrative-system input until the steps are internalized and become Intuitive-level habits. Having a history of trauma has been shown to decrease adherence to other medical recommendations.

Trauma, then, presents multiple risks that can predispose people to unhealthy behaviors or can interfere with successfully following health recommendations. These are likely to be Intuitive-level problems outside of a person's awareness, although negative Narrative-level beliefs can also result from trauma and contribute to a self-perpetuating cycle. Although avoiding trauma altogether might be the best option, what can we do after it occurs? Researchers have identified five key elements of an effective trauma response: 1) safety, 2) calming, 3) a feeling of control, 4) a feeling of connectedness, and 5) hope. These are things that we can work to enhance. For example, simply learning to recognize traumatic reactions can enhance one's sense of control. If I notice that I am distancing from others more than usual and spending my time in unhealthy activities like obsessively scrolling the news for signs of threat, I can recognize that as a trauma reaction and try to change my behavior. Self-calming activities can take various forms, and might include healthy behaviors like exercise, or meditation, or creative activity. Safety can be enhanced in collaboration with others, for example by planning for backup at work at times when we aren't fully functional. Open discussion of traumatic reactions also enhances a sense of connection, as do the Zoom-based social activities that many people have adopted during the pandemic, or even the increase in pet adoptions over the past 12 months. Above all, it's important to have hope -- to see the pandemic as time-limited, to look for signs of progress, and to focus on successes rather than simply on challenges. 

Faculty in my division at CU Nursing recently developed an online course to help health professionals cope with trauma that they have experienced during the pandemic. It's freely available to anyone connected with the Anschutz Medical Campus (an "@cuanschutz.edu" email address is required), and includes various kinds of self-help materials to promote the five elements of effective trauma responding. Here's the link for enrollment: https://ucdenver.instructure.com/enroll/7JXH3A The course modules were adapted from previous work with military and first-responder groups, and take the perspective that we have all been "deployed" into a stressful COVID-related environment over the past year whether we wanted to be or not. Learning to recognize trauma responses and to address them effectively is going to continue to be important as we gradually come out of the pandemic and adapt to whatever our "new normal" might be.