The psychological impact of the measures against COVID-19

While the news on March 26 put just as much emphasis on the economic consequences after the crisis, it might be desirable to also take a look at the psychological impact that the measures taken in response to this crisis can have.

Every government is now focused on containing the outbreak of this virus. This is done by setting up all kinds of rules and emergency measures, with ultimate means such as lockdowns . 

Many governments have responded to COVID-19 by closing international borders and public spaces, including China, the United States, Italy, Spain, France and the European Union. Where shops have remained open in some countries, there are also countries where shops have been closed, and only one person is allowed to leave the house to pick up groceries or go to the pharmacy via the shortest route. Walking without reason or together is forbidden. Italy, Spain, France and Belgium now have national isolation.

The health organisation WHO warned on Sunday March 22 that lockdowns alone do not defeat the coronavirus. "The danger of lockdowns will occur if all measures are lifted. Then the virus may re-emerge," said expert emergency Mike Ryan. According to Ryan, lockdowns must therefore be accompanied by other measures in order to be truly effective. According to the WHO expert, more attention needs to be paid to finding the people infected with the virus and mapping out their latest social contacts.[1] 

The approach in South Korea seems to be quite successful, we read in ScienceGuide[2]: "South Korea has mapped the spread of the virus by doing an extreme amount of testing (and immediately developing its own test kit). And this without putting the country in lockdown and without taking other totalitarian measures as we saw in Wuhan".

Like I said, I want to talk about the psychic impact. On October 11, 2017 I wrote the article: "Stored experience of trauma"[3].  This article shows how trauma works.

What is already visible everywhere are reaction patterns that may lead to the occurrence of trauma.

The article by Jurre van den Berg of March 30, 2020 in de Volkskrant[4] is about care personnel. He writes: "Psychologists fear for the traumatic impact of the coronary crisis on health personnel. The heavy work could lead to emotional overload and post-traumatic stress disorders among doctors and nurses. Professional associations and the Ministry of Health advocate that good mental support and aftercare are therefore crucial.”

The impact that the measures may have on the different societies is not mentioned.

For example, we read that a woman of 67 in the supermarket in Rijsbergen starts kicking a man because he doesn't keep enough distance, which turns into a quarrel. We also read that "some people can't stand the measure and therefore deliberately do not keep a distance."

Someone else reacts that the measure is not something obvious: "Sometimes, without thinking about it, I walk right past someone. That's nothing more than normal, but now we are scolded if we walk past someone without distance. Really, it’s all too crazy."[5]

This may seem exceptional, but we also read: "The Spaniards started looking out for each other. Pointing out their (in)responsibility to others—not only gossiping about each other but even snitching on each other—which is something that never fitted in with Mediterranean culture. Residents of an apartment complex saw one of their neighbours with his children at the communal swimming pool. One resident started shouting, another immediately called the police. Fine."[6]  

Or take for example the man with mysophobia who throws his girlfriend against the wall, because she says something about him not being so frightened.

In Spain, volunteers are called upon to keep an eye on people.

We read: "The coronavirus is stressful for many families. If it takes another two months, I will have a breakdown", and "Over the past few weeks, many families have been living under the same roof; from Monday to Sunday, from early in the morning until late in the evening. How do they deal with that? But most of all, how long will they keep it up?" [7]

We could can go on for a while. The most important observation is that there are phenomena present that can cause trauma. An important one, for example, is fear.

In the article: "Scientists resisting lockdown: We must ward off panic." [8] we read:

“Former Denker des Vaderlands, former general practitioner and professor of philosophy Marli Huijer said last week on the Science Guide website that we are guided by 'fear of high mortality. In the past we succumbed to pneumonia, in recent years flu waves cost 6000 to 9000 extra deaths per year and this year the coronavirus will be a major cause’, she argued.”

Nobel laureate and biophysicist Michael Levitt and the Greek-American professor of epidemiology John Ioannidis, associated with Stanford University, argue the same.

Important choices are now being made right now, but choices made out of fear are always wrong.

We are confronted with socio-psychological impact and at the same time with individual impact.

Social psychological impact is described as: ""The reaction of the population characterized by negative emotions and feelings (such as fear, anger, dissatisfaction, sadness, disappointment, panic, disgust, resignation/apathy). It concerns the population as a whole, i.e. not only those directly affected, but also citizens who experience the incident or process through the media or otherwise. The expressions of these emotions and feelings may or may not be perceptible (i.e. audible, visible, readable).” [9]

The literature study "Socio-psychological impact factors in disasters, crises & attacks. A literature study on impact increasing and decreasing factors in disasters, crises and attacks"[10] showed that factors increasing or decreasing socio-psychological impact are not well-defined in research and have therefore not yet been the subject of systematic comparison, let alone of systematic comparison over the years.

Five dominant perspectives emerged from this literature overview: 1. Social unrest 2. Mass panic and self-organisation after disasters 3. Psychosocial impact 4. Risk perception, risk communication and crisis communication 5. The role of the mass media.

Ultimately, the research shows that the more recent publications do not contain new scientific insights. It must be concluded that a well-founded answer to the question of a change in scientific insights—given the data set used in this literature study—is not possible due to a lack of 'raw material'.

I will address two themes, out of the five that were mentioned.

First, social unrest and mass panic.

In the news of the NOS journal of March 28, 2020, we hear that arms sales in America are two to four times higher than normal.

And what about the homeless? Like a homeless person says: "Now the handful of passers-by who are still standing, are walking around me with a big bow. They pretend that we are the disease and the virus. We are still waiting for help from the municipality. But at the moment it's very hard for us." [11] This could also play out between different ethnic groups.

The latest survey by the Spanish Centre for Sociological Research (CIS)[12] shows that racist reactions to Asian people because of the coronavirus already occur in little under 10% of those questioned. The general secretary of the extreme right Vox party, Javier Ortega-Smith, who was tested positive for the coronavirus, said that his "Spanish antibodies are fighting and destroying that cursed Chinese virus”. 9.5% of those questioned indicated that they would prefer not to be in public places with people of Asian origin.

As a second theme, we must talk about the role of the mass media.

In the aforementioned publication: "Socio-psychological impact factors in disasters, crises & attacks" (9) we also read that Smith (2006) discusses the role of risk and risk perception in the (mainly economic) impact of SARS (Severe Acute Respiratory Syndrome). From the literature, Smith observes that confidence in affected economies can be strained by a number of aspects of the disease (including potential risk of infection, perceived severity, lack of protection or prevention, and uncertainty about the course and outcome of the infection). Apart from the economic impact, Smith mentions two important factors: the 'climate of fear' that prevailed, and the rapid geographical spread of an unidentified virus. Smith notes that in the case of SARS, there was uncertainty about the cause of the outbreak and uncertainty about the effectiveness of the approach (reduction of the chance and consequences of infection). With the role of the (then relatively) new media, which accelerated the rapid spread of sometimes contradictory and uncertain information, and with the role of the mass media, which at times 'overreacted', the economic impact of SARS could become particularly large.

If we now look at the reporting of the media, we actually see only negative reporting. For example, in the already mentioned NOS news of March 28th, the reporting is all about how many deaths there are now again; there is panic about mouth caps that are not good enough and how we can detect them, and there is panic about whether there are still enough places on the IC’s.

All this news is about "negative" issues and uncertainties. This increases the anxiety factor for people. All the more so because it is a "battle" against an invisible enemy, which causes an enormous powerlessness that is always at the root of PTSD phenomena. Constantly anticipating what might happen and expressing doubt and anxiety about anything that is insecure, reinforces the culture of fear.

In the CIS survey mentioned above, we also read that 63% of those surveyed believe that the news about the emergency situation within care creates unnecessary anxiety.

Leon (2004) indicates that the potential impact is increasing:

Degree of exposure; Amount of devastation; Loss or injury to family, relatives and colleagues; and the overall impact on a person's normal life.

Norris et al. (2002) provided an overview of mental health research in response to disasters. It involved some 60,000 individuals from 29 countries who have experienced more than 100 different events together. Specific psychological problems such as anxiety, depression, and 'post-traumatic stress disorder' were found most frequently.

If we look at the impact of confinement, we see a great uncertainty and a sense of loss of: freedom; control; identity and relationships; and ownership of one's own "life". On top of that, there is insecurity: powerlessness, helplessness and fear. It turns out that psychological distress already occurs after three days of confinement (Beyens et al.,2017). 

A Canadian study indicates that among 133 respondents, half of them had a mild form of depression and 8 % were severely depressed. (Zamble, E., & Porporino, F. J., 1988)

We are no longer talking about the normal culture of fear that already exists today, but about the concept of existential fear. We have an "enemy" that is not visible. In Spain, cars are driving around while spraying the roads with a disinfectant liquid, followed by a car that produces clouds of disinfectants.

Frank Furedi, Professor of Sociology at the University of Kent, writes in his book "Culture of Fear" (Furedi, 2011) that the idea of running risks is an expression of the spirit that has pervaded our whole society.

Below are two important passages from his book.

a.     "Unfortunately, fear has long since become a widely accepted means of propagating all kinds of good intentions. Instead of giving people the information to make a well-founded choice, everyone is frightened."

b.     "The general public wasn't reassured with the good news about SARS either. When the panic was at its height, there were calls for massive testing at airports and even to close the borders of the country".

The measures to be taken in the case of SARS are now being implemented on an even larger scale.

The extreme measures such as those applied in Spain, for example, where people are locked in an apartment without balcony or garden and are not allowed to go outside, touch upon another existential theme, namely existential well-being as a balance between the physical, social, psychological and spiritual dimensions of human existence.

This is about the themes of freedom and autonomy. Man enters a system that is completely separate from the natural and essential things in life.

On 15 February, a Belgian newspaper reports[13] :" In China, people who show the symptoms of an infection with the new coronavirus Covid-19, but who deliberately do not report it or misrepresent it, commit a crime. In extreme cases they can be punished with the death penalty. This is shown by an announcement that was spread by a Chinese court on Saturday."

We end up in a Kafkaesque world. Yuval Noah Harari writes on March 20 in the Financial Times[14]: "The world after the coronavirus." In this article he says that the decisions that people and governments make in the coming weeks will probably shape the world in the coming years. They will not only shape our healthcare systems, but also our economy, politics and culture. Letting people choose between privacy and health is not a choice at all.

There are two ways to deal with this situation. The first is to keep an eye on people and punishes those who break the rules. Today, for the first time in human history, technology makes it possible to constantly monitor everyone. We now see this happening to a greater extent, since also in Israel Prime Minister Netanyahu has authorized the Israel Security Agency to use surveillance technology, which is normally intended to fight terrorists, to track down coronavirus patients.

This is reminiscent of George Orwell's "1984 dystopian novel of the future". In 1949 he painted a bleak picture of what humanity would look like 35 years later: a totalitarian society under the control of the all-seeing eye of Big Brother, in which human freedom is completely restricted. The book was meant to warn the world against totalitarianism.

There is also another way and that is to empower civilians, like happened in South Korea, Taiwan and Singapore. Extensive testing, honest reporting, and getting the cooperation of clearly informed citizen.

Self-motivation, and good and truthful information give people the feeling that they are making the decisions themselves, instead of being subjected to forced decisions, monitoring, and punishing. In the end it turns out that this works more effectively.

In this COVID-19 situation, because of the imposed measures in which people are raised as poultry in case of avian flu, we have to deal with the factor stress in many people.

In the case of extreme -, unpredictable - or repetitive stressors, it can happen that the body does not return to its normal state. This can be chronic or traumatic stress. The difference between the two is that in the case of traumatic stress the stressor is more extreme and threatening, relative to the stressor of chronic stress, which may lead to a state of helplessness in the victim (Nicolai 2009,p.570).

Stress in itself stands for mental pressure or tension. At the onset of stress the body will prepare itself for fighting, fleeing, freezing, or dissociation (Resick 2001, p. 3,4).

The acute stress disorder consists of the following reactions: being anxious and quickly frightened; irritable and moody; not being in contact with one's own emotions; feeling numb; being detached from one's surroundings; having memory problems, or concentration and sleep problems.

If this type of complaint persists for more than four weeks, it can turn into PTSD or a post-traumatic stress disorder.

At least 90% of the people experience a traumatic event in their lives, but not everyone has a traumatic disorder as a result. This has to do with the personality profile of the particular individual.

If the pressure increases as a result of the measures, the number of psychological problems will also increase.

Hypervigilance can also occur due to ongoing stress and the economic problems that will arise. In this case, the individual who feels threatened is vigilant, wary, and nothing should escape his attention. The stress cannot be reduced by taking action, because the person is dependent on others for the solution of the problem.

Both field and experimental research have shown that when the stressor continues for a while, hypervigilance turns into a situation in which cognitive functions and emotional involvement diminish. Overstrain is the clinical manifestation of this state of exhaustion.[15]

As humanity we have experienced many natural phenomena in the past centuries. To name but a few:

-We've had the smallpox that killed 30% of the infected.

-The plague that swept across the world from the 14th to the 193 century killed a third of the Europeans.

-From 1881 to 1896, cholera made 854,540 victims, according to Dr. A. J. Wall.

-Around 1900, tuberculosis killed 10,000 people a year in the Netherlands alone. Nowadays, 1.5 million people still die from tuberculosis worldwide.

-Spanish flu claimed an estimated 20 to 100 million lives.

- SARS killed 774 people worldwide.

-The influenza H1N1 pandemic killed 500,000-700,000 people in the US alone.

-As a result of the Asian flu, 2 million people died and the Hong Kong flu killed a 1 million people.

All this indicates that nature cannot be brought under control, even though we would like to do so for reasons of manufacturability.

What becomes important in these situations is whether: "the cure doesn't get any worse than the disease."

Norris et al. (2002) advise early post-disaster interventions, especially when there is extreme and widespread damage to property, continuing financial problems for the affected society, violence as a result of deliberate human action, and the frequent occurrence of traumas in the form of injuries, life threats, or loss of life.

At the end of January, the Chinese National Health Commission published a guide to psychological crisis management (Xiang et al., 2020).

With the deployment of the current extreme measures in many countries, we have to take into account the psychological reactions that have been and will be caused.

Dr. Harry A.J. Rump Med

4 april 2020

Literatuur

Beyens, K.; Snacken, S. (2017) Straffen. Een penologisch perspectief. Antwerpen-Apeldoorn: Maklu.

Furedi, F. (2011) Cultuur van de angst. Meulenhof boekerij B.V.

Leon, G. R. (2004). Overview of the psychosocial impact of disasters

Nicolai, N.J., 2009. Chronische stress, sekse en gender. Tijdschrift voor Psychiatrie 51, 569-577.

Norris, F. H.; Friedman, M. J.; Watson, P. J. (2002). 60.000 disaster victims speak: Part I & Part II.

Resick, P.A., 2001. Stress and Trauma. Hove: Psychology Press.

Xiang, Yu-Tao; Yang, Yuan; Li, Wen; Zhang, Ling; Zhang, Qinge; Cheung, Teris; Ng, Chee H (4 de febrero de 2020). ?Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed? . The Lancet Psychiatry(en inglés) : S2215036620300468. doi : 10.1016/S2215-0366(20)30046-8 .

Zamble, E., & Porporino, F. J. (1988). Research in criminology. Coping, behavior, and adaptation in prison inmates. Springer-Verlag Publishing

Noten

[1]https://www.nu.nl/coronavirus/6039417/wereldgezondheidsorganisatie-lockdowns-alleen-verslaan-het-virus-niet.html?redirect=1

[2] https://www.scienceguide.nl/2020/03/zuid-koreaans-collectivisme-in-aanpak-coronavirus-is-een-hersenspinsel/

[3] https://www.dhirubhai.net/pulse/opgeslagen-beleving-van-trauma-dr-harry-a-j-rump-med/

[4] https://www.volkskrant.nl/nieuws-achtergrond/psychologen-waarschuwen-voor-ptss-onder-overbelast-zorgpersoneel~b0e3b4fe/?utm_source=link&utm_medium=app&utm_campaign=shared%20content&utm_content=free

[5] https://www.ed.nl/dossier-coronavirus/ruzie-in-supermarkt-geeft-felle-discussie-op-sociale-media-is-afstand-houden-zo-moeilijk~a094153e/?referrer=https://www.google.com/

[6] https://www.ad.nl/buitenland/zo-trotseren-de-spanjaarden-al-wekenlang-de-lockdown-spanje-is-spanje-niet-meer-br~a05754c1/

[7] https://www.standaard.be/cnt/dmf20200327_04904474

[8] https://www.ad.nl/binnenland/wetenschappers-in-verzet-tegen-lockdown-we-moeten-de-paniek-bezweren~a594fcce/?referrer=https://www.google.com/

[9] Ministerie van Veiligheid en Justitie (maart 2013). Werken met scenario’s, risicobeoordeling en capaciteiten in de Strategie Nationale Veiligheid, Den Haag: Ministerie van Veiligheid en Justitie p. 67

[10] https://repository.ubn.ru.nl/bitstream/handle/2066/162829/162829.pdf?sequence=1

[11] https://nos.nl/artikel/2328348-amerikaanse-daklozen-hebben-het-zwaar-mensen-doen-alsof-wij-het-virus-     zijn.html

[12] https://inspanje.nl/algemeen/13059/ruime-meerderheid-spanjaarden-staat-achter-coronamaatregelen/

[13] https://www.nieuwsblad.be/cnt/dmf20200215_04850194

[14] https://www.ft.com/content/19d90308-6858-11ea-a3c9-1fe6fedcca75

[15] https://www.henw.org/artikelen/overspannen-depressief-burnout-chronisch-vermoeid-een-diagnostische-grabbelton