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The exposure to psychological trauma is a process which intertwines with other ongoing individual and community processes: individual and community growth, development and history, social and cultural changes, individual and family history of illness, illness process. The exposure to trauma as a process is influenced by a myriad of known and mostly unknown factors and their uncertain dynamic entanglement. The exposure to trauma is neither an illness per se, nor a factor that generates illness in all persons exposed; nevertheless, it increases the risk for illness of those exposed and contributes to: vulnerability for illness, illness onset, exacerbation, recurrence and relapse, protracted illness duration, increased symptom severity, barriers to care and overall poorer physical, psychological and social illness outcomes⁽¹⁾.   

The studies propose a practical definition of psychological trauma⁽²⁾ which encompasses the following features (i.e., the four “E”s):

1) Event – any untoward occurence that poses actual and/or potential objective danger to one’s life and integrity.

2) Experience – a wide range of subjective, individual experiences that share the core symptoms of arousal, intrusive reexperiencing and avoidance of traumatic cues.

3) Effects – uncertain, individual physical, psychological and social consequences that conflate within a longer-term process of readjustment to life after trauma.

4) Evolution – life-long process with individual outcomes significantly influenced by the individual peritraumatic experience, available support and timely access to support.

COVID-19 entails a number of characteristics which underscore its relevance as a global-scale traumatic event generating psychological trauma. Firstly, ­COVID-19 is an ongoing global event, a complicated health, ^­psychological and social crisis. Secondly, the ability to control the course of the pandemic is perceived as very limited. Moreover, there are no relatively recent events, similar in magnitude and evolution, which might inform the management of the pandemic. Also, the pandemic emerges in a context where the assessment of exposure to psychological trauma and integration of trauma-related issues in the individual management plan (trauma-informed practice) were not part of the current practice. This in turn affects the management of the pandemic due to delays in ascertaining of, and catering to unmet patient needs generated by the exposure to trauma⁽³⁾.

The COVID-19 pandemic, albeit its collective, shockwave nature, ostensibly differs from natural or other disasters, as presented in Table 1⁽⁴⁾.
 

As previously outlined, the exposure to COVID-19 does not generate illness in general, and posttraumatic stress disorder (PTSD) in particular, in all persons exposed^(1,4). Nevertheless, COVID-19 incurs important immediate psychological consequences⁽⁴⁾, as follows:

Persons with preexisting mental health issues experience a worsening of their condition.

Persons with risk factors for mental health issues (depression, anxiety, addiction) experience the onset of symptoms of these disorders.

Symptoms of PTSD develop, ranging from transient ones to complex PTSD.

Studies report that 23 to 34 percent of those exposed to the trauma of COVID-19 develop PTSD symptoms⁽⁵⁾. Some – if not most persons exposed – will experience COVID-19 as a complex traumatic event, due to the intricate repetitive, protracted nature of exposure to the event. Moreover, barriers in the access to care during the pandemic, the experience of illness while physically distanced from the loved ones, the failure to be physically present for the loved ones who are going through illness add to the complex trauma features of COVID-19⁽⁴⁾. Therefore, a complex PTSD diagnosis may be warranted in persons who describe PTSD symptoms, significant distress and impaired functioning in the context of COVID-19 exposure. Complex PTSD entails poorer quality of life, more resources required in treatment, poorer outcomes for the persons and their context⁽⁶⁾.

The social consequences of COVID-19 entail:

• Social isolation⁽⁷⁾, disrupted daily schedule, routines and habits, with increased pressure to develop new routines quickly⁽⁴⁾.

• Temporary/permanent income loss⁽⁴⁾.

• Impaired social support system (family, friends)⁽⁸⁾.

• Increased risk of domestic violence, child and partner abuse, due to pressures of confinement with abusive family, limited access to community support^(9-11).

• Limited access to social services, school and education⁽⁴⁾.

• Increased social and health inequities due to the widening gap in access to work, social services, healthcare and other community resources^(12,13).

• A growing body of evidence supports that specific groups are more vulnerable to the psychological trauma nature of COVID-19 infection – Table 2⁽¹⁴⁾.

Quarantine placement measures for COVID-19 containment may emerge as distinctive traumatic experience. Specific populations are more vulnerable to this type of trauma, while others are protected – Table 3. Moreover, the intensity of reported psychiatric symptoms, not their type (phobia, anxiety, depression, stress, obsessions, compulsions, hostility), mediate the association between individual personality traits and the degree of vulnerability to the trauma of quarantine placement⁽¹⁵⁾. Among reported cognitive symptoms, ruminations paired with perceived controlability may generate poorer, potentially fatal outcomes due to increased risk for suicidal behaviours⁽¹⁶⁾.
 

Patients treated in the intensive care units (ICUs) during COVID-19 and their loved ones exhibit specific vulnerabilities for psychological trauma. Due to patient’s separation from loved ones, both patients and loved ones miss the opportunities for:

• hospital visits, face-to-face connection, support and care

• first-hand experiences of the efforts of the medical team to care for the patient

• effective connection and partnership of patient, loved ones and medical team for treatment and recovery⁽¹⁷⁾.

Furthermore, the uncertainty, unpredictability, unexpected quick changes in patient's health status, the limited and physically distanced communication between medical team and the loved ones of ICU patients affect the medical decision-making algorhythms for the management of ICU patients during the pandemic⁽¹⁷⁾. Additionally, COVID-19 incurs severe disruption in the process of end-of-life care, loss and grief⁽¹⁸⁾. 

The traumatic experience of COVID-19 for the person who works as medical staff comprises the traumatic experience on a personal level, added to the compassion fatigue in the medical staff role, generated by burnout and secondary trauma (witnessing the patient’s trauma). More specifically, the medical staff who treat COVID-19 patients exhibit significantly higher levels of stress, anxiety, depression, burnout, secondary trauma, while the medical staff working in areas with higher rates of COVID-19 sustain a major risk of stress, burnout and compassion fatigue. Therefore, ongoing active psychological support of medical staff ensures higher quality healthcare services that are better tailored to the pandemic context⁽¹⁹⁾.

Mitigating the traumatic impact of COVID-19 exposure requires strategies that are both globally integrated, and specifically tailored to meet the evolving needs and address the unforeseen consequences of the pandemic in persons and communities⁽³⁾. Specific strategies for some groups at risk for psychological trauma during the COVID-19 pandemic are outlined in Table 4.
 

Ongoing studies will further elicit insight into risk and vulnerability factors for the traumatic experience of COVID-19. Nevertheless, integrated biopsychosocial trauma-informed response comprised of the following four “S”s is the cornerstone of the effective management of resources in the context of the pandemic⁽²⁾:

1) Safety – providing a safe environment for the exposed person.

2) Support – actively bringing available support closer to the person and creating new resources for the emerging needs.

3) Sensitivity – culturally sensitive and specific support.

4) Screening – active assessment of the trauma experience and consequences of trauma exposure, for a timely and more effective intervention targeting most vulnerable persons.