**1. Introduction**

Arguably the COVID-19 pandemic is the first mass trauma-laden event the world has witnessed since the second World War, and for many people it has been the first collective trauma in living memory. There has been a plethora of discussion about the impact of the pandemic, much of which has focussed on the economic and political fallout and it is no exaggeration to state that global pandemics are heart-breaking biopsychosocial health crises. There has also been debate and speculation about the implications of the pandemic on people's mental health, with many commentators citing increased levels of depression and anxiety [1]. Such psychological adversity has more often than not, been attributed to the social isolation and the heightened levels of stress which people have incurred during the pandemic—not least the fact that all it has taken for so many of our habits to be swept away and their shaky foundations revealed, has been an unseen virus. Less has been spoken about the concept of trauma and the longer-lasting implications which mass trauma can yield in the aftermath of this catastrophe. Trauma has traditionally been perceived as a once-off event albeit one which caused extreme stress and distress to the affected individual, for example road traffic accidents or assaults on one's

person. Indeed, when one thinks of the term pandemic, "trauma" is perhaps not the first term that springs to mind but the pandemic has not been a brief, once-off incident, confined to a particular geographic area or a discrete population. Rather, it has spanned many months and had no regard for social, geographical or political boundaries. In this chapter the authors will propose that the pandemic has in fact constituted a mass trauma, whereby millions of people have been affected by the same event within a shared time frame, with virtually no corner of the earth escaping completely unscathed. We believe that long after this pandemic has ended and people have returned to their normal ways of life, the psychosocial impact of this mass trauma will have physical and mental health implications for many citizens around the world. In anticipation of the fallout from this trauma, it is paramount to consider how we may start to adapt. In order to do so, we will reflect on previous mass traumas and explore what we know about the long-term sequelae of trauma.

Trauma may be defined as a 'rupture in meaning-making' [2], in that traumatic events can shatter our pre-existing ways of thinking, our belief systems and how we relate to the world around us. When a traumatic event occurs, we are forced to re-evaluate how we view ourselves, others and the world and it is said that a cleft emerges between what we know (our "orienting systems") and the trauma. It can seem as if there are two selves; the one before trauma and the one after the trauma. A new process of meaning-making, where we evaluate our beliefs and sense of self, is required so that we may progress beyond the trauma.

When one considers who has been adversely affected by the pandemic, healthcare workers in the so-called front line against the virus spring to mind first and foremost. There is no doubt that large numbers of healthcare staff were subjected to increased levels of distress amidst the pandemic. Increased caseload numbers, longer working hours, inadequate PPE supplies, fear of contracting and spreading the virus and moral injury are just a few of the challenges faced by those working in the health sector during this time. Couple these challenges with the well-established fact that healthcare professions experience higher levels of work-related stress in comparison to the general population, and we have a perfect storm for a mental health crisis among healthcare professions. We know that a sense of helplessness in the situation increases the likelihood of a stressful experience becoming a traumatic experience. We may argue that healthcare professionals differed somewhat from the general population in that they may not necessarily have felt helpless; they were on the front line, battling the virus in a very tangible "hands on deck" way, as opposed to the many millions who were asked to help by virtue of staying home and staying away from others. We should also keep in mind that trauma is not necessarily proportional to the intensity of the event: it is possible that a person who nursed patients with COVID-19 on a daily basis may feel less traumatised than a person who had no contact whatsoever with patients afflicted by COVID. The key mediator here is resilience, and its role in the processing, or "meaning-making" should not be understated. There is no doubt that an essential element to the healing process will be the nurturing of mental resilience.

#### **2. Inherent trauma of death itself**

Grief is defined as an internal experience in reaction to the loss of something loved and valued [3]. Though commonly viewed as an emotive or psychological response; grief has numerous manifestations - physical, cognitive, behavioural, social and spiritual. Grief is often referred to as the loss of a person due to death; however, grief involves the concept of loss in general which can also refer to the loss of a job, a relationship or even a role. COVID 19 and its associated impact has caused devastating loss and thus grief in so many aspects of our lives.

#### *Perspective Chapter: Fallout from the Pandemic – A Social and Psychological Description… DOI: http://dx.doi.org/10.5772/intechopen.101499*

Grief is a process and this process often begins prior to loss, it is at times preparatory and anticipatory. Due to the unpredictable course of COVID 19 illness, many deaths were sudden and grossly unexpected. This complicated individuals' grief process and eliminated the preparatory process. The suddenness and abrupt nature of death, after what presented itself as an initial recovery and then rapid deterioration at day 10 or 11 of the illness, prevented the natural acceptance which can be afforded to loved ones when a patient is dying of a more predictable and widely understood illness.

Loss of a loved one is unfortunately a natural, universally experienced life event, and at the same time, among life's most deeply challenging experiences. Although any death of a loved one can be emotionally devastating, unexpected deaths provoke particularly strong responses, given there is less time to prepare for and adapt to the loss [4].

Research has demonstrated that the bereavement period is associated with elevated risk for the onset of a multitude of psychiatric disorders, consistently across the individual's life course and coincident with the experience of the loved one's death [5]. This is demonstrated in clinical practice, where death of a loved one often precipitates an individual's referral presentation to psychiatric services. Feeling vulnerable is an immensely difficult for many people, and there is no greater vulnerability than being faced with the transience of life itself.

The unexpected or sudden death of a loved one is frequently cited as the most severe and potentially traumatic experience in one's life, even among individuals with a high burden of lifetime stressful experiences. Unexpected bereavement is associated with heightened vulnerability for the onset of virtually all commonlyoccurring psychiatric disorders.

Irrespective of culture, religion or value system, death is usually followed by a funeral or a mourning service. Such a service provides an outlet for the culturally accepted expression of loss-related emotions and marks a transition in which the certainty of the death is emphasised. It provides a starting point for recovery, processing and adjustment following a bereavement. In an attempt to slow the spread of the COVID 19 virus worldwide, lockdown restrictions were introduced of varying intensity. Significant restrictions on the mourning rituals, such as limits on the number of individuals permitted to attend funerals, has the potential in the author's opinion to hinder the grieving process and deny families the opportunity to express their grief. Bereaved individuals tend to perceive different aspects of the funeral in a positive regard [6]. People do not only respond positively initially but continue to reflect on the funeral with positive regard in the future, even years later. The restrictions on funeral and mourning proceedings and indeed household visits in the initial grief period likely denied individuals this facilitatory event of the support of loved ones and their wider community, and undoubtedly compounded their grief. It remains to be seen what, if any, will be the longer-term impact of such restrictions on those bereaved by COVID-19.

### **3. Trauma of the patients who contracted COVID-19**

A person's experience of illness is highly individual and somewhat dictated by the illness-related information they receive. Due to the fact that COVID-19 is a novel virus that is relatively poorly understood, the information available to patients regarding illness trajectory, prognosis and long-term effects is scarce. The lack of information and uncertainty surrounding this illness, may unsurprisingly foster a sense of fear and anxiety in the COVID-infected individual.

A prominent and rather distressing symptom of COVID-19 is dyspnoea or breathlessness. It is widely appreciated that shortness of breath can constitute both a symptom of and precipitant to panic. Anxiety is noted to be an emotional response to breathlessness, but it also increases the perception of breathlessness. There is a strong association between experiencing respiratory symptoms and psychological distress which is further worsened by the uncertainty of disease progression and indeed the exact underlying pathology causing said breathlessness [7].

Uncertainty and the unknown are themes that underpin the global experience of COVID-19. The clinical understanding of the illness is continually evolving and changing in parallel with epidemiological research which is informed by the natural evolution of the pandemic among a human population. Clinicians play an important role in helping their patients to use coping skills for managing the illness, the different phases of infection and residual symptoms. However, clinicians' lack of knowledge about the illness trajectory results in doctors being unable to advise their patients as they would with other disorders or conditions. The impact of this inability of doctors to sufficiently counsel their patients about the disease is likely to be twofold: traumatic for the patient who seeks information about a hitherto unknown illness, and traumatising for the doctor who wants to help, but is limited in the extent to which he or she can do so.

We should also consider that there is exaggerated fear related to infectious illness compared to non-infectious illnesses. Infection possesses unique characteristics that account for this disproportionate degree of fear: it is transmitted rapidly and invisibly; historically, it has accounted for major morbidity and mortality; older forms or strains re-emerge and new forms emerge. By the time the Spanish flu had run its course in 1920, the pandemic had infected over a quarter of the world's population and resulted in some 30 million to 100 million deaths. In comparison to this, the two World Wars are estimated to have killed roughly 77 million combined [8]. Infectious diseases completely consume us: the media and society become enthralled and fascinated, which results in minimal escape for the individual. Infectious illnesses are unique in that the patient is both a victim and a vector; the latter of which may be associated with feelings of guilt and responsibility. Infectious diseases are well documented throughout history and their devastating impact has resulted in more acute deaths than any other pathology [9]. As such, an automatic fear of infection is engraved in our subconscious.

The psychological response to the threat of infection has been well researched with regards to both acute outbreaks such as SARS and more gradually evolving pandemics such as HIV/AIDS. Anxiety extends beyond the physical consequences of infection, to social consequences such as stigmatisation, which, in the case of the current pandemic, manifested itself as anti-Chinese racism which anecdotally have emerged during this pandemic. In the case of an unknown agent such as COVID-19, a complete lack of preparedness on the part of medical authorities and misleading information perpetuated by the media serves to further aggravate pathological psychological responses to illness and infection [9].

### **4. Fear of the unknown/anticipatory fear**

COVID-19 proved to be a highly virulent and transmissible infection which has caused panic in individuals and anticipatory anxiety regarding the contraction of infection by this novel virus. Fear is an appropriate and adaptive response in the presence of threat and danger. Fear enables us to engage in safety behaviours in order to mitigate threat and protect ourselves. Fear is also protective and with COVID 19, the threat is uncertain and continuous and as such the fear may

#### *Perspective Chapter: Fallout from the Pandemic – A Social and Psychological Description… DOI: http://dx.doi.org/10.5772/intechopen.101499*

become persistent and negatively impact our collective quality of life. The threat from COVID 19 is universal with each individual being at risk. This high personal relevance and has heightened our subjective experience of fear [10].

Uncertainty surrounding a possible future or continuous threat also potentially disrupts one's ability to avoid it or to mitigate its negative impact, and thus results in anticipatory anxiety. Elevated expectations of threat naturally lead to avoidance of situations involving uncertainty and the said threat. However, as the threat from COVID-19 was ubiquitous and present in many aspects of our lives, people were forced to adjust and adapt to living with constant threat. This excessive threat has triggered a response of anticipatory fear. The fear of contracting the virus has led to excessive concern over physiological symptoms, significant stress about personal and occupational loss, increased reassurance- and safety-seeking behaviours, and avoidance of public places and situations, culminating in a marked impairment in our levels of functioning [11].

Epidemic psychology demonstrates that the human brain is pre-wired to thrive on certainty and has a disdain for uncertainty, which represents danger, stability being at the core of humans' schema and derivation of meaning from life [12]. The crisis of COVID-19 disturbs our set system and questions the certainty to which we were habituated. The perplexity surrounding the origin of the virus and the associated and prolonged uncertainties give rise to fear of the unknown, which is becoming a new feature of human existence. This disruption to our stability necessitates and indeed forces us to alter our ways and develop novel coping mechanisms. Paradoxically COVID-19 encapsulates two of our innate fears, fear of uncertainty and fear of death; the latter being life's great certainty. Fear of the unknown appears to be inherent, evolutionarily-derived and a logical reduction of higher order constructs. Fear of the unknown is defensibly a fundamental fear; one which has been immeasurably amplified at a population level by COVID-19 [13]. Perhaps as we journey through this pandemic and learn more about the virus, fear of the unknown may transmute into a fear of the known, the latter of which may prove to be more manageable and less traumatising.
