‘Feeling dead inside.’ Healthcare workers battling COVID-19 are suffering from dissociation

Often armed with inadequate personal protective equipment, frontline healthcare workers rush into action, risking their own lives and those of their loved ones in the battle against coronavirus. Many face moral distress as rising case counts force them to choose who receives ventilators and who is left to die. As the stress accumulates, losing colleagues, patients, family, self-care and any sense of normalcy, there is no rest in sight.

Many are suffering from post-traumatic stress symptoms (PTSD) and other mental health conditions, especially those who have worked directly with COVID patients. Nearly one in three healthcare workers exhibit PTSD due to the pandemic. And the surveys that this information is based on may be underestimating the problem.

PTSD screening tools typically capture the classical symptoms related to a hyperactive fear response like extreme anxiety, nightmares, hypervigilance and flashbacks. But these tools often miss the less obvious trauma symptoms of dissociation. The dissociative subtype of PTSD affects an estimated 20 per cent of people with PTSD yet often remains undiagnosed.

People living with dissociative symptoms are frequently unable to experience positive or negative emotions. “They’ll talk about feeling dead inside, feeling numb inside, feeling like a robot … or even not being able to feel love toward their children,” says Ruth Lanius, professor of psychiatry at Western University in London, Ont. These dissociative symptoms are more common in women, people of colour and those who have experienced previous trauma.

Dissociation is a coping mechanism – a “psychological escape when a physical escape is not possible,” Lanius says. It provides protection from high-stress situations by allowing the mind to disconnect from present experiences, thoughts, memories, feelings, actions, sensations, and even one’s identity.

“The body has an amazing ability to separate off when it needs to. And it’s totally normal,” says B.C. physician Erika Cheng, who runs the Beyond the Cycle of Trauma Institute.

However, when people experience prolonged or repeated stressful experiences, especially when they feel powerless to change the outcome, the defence of dissociation can become overused and disabling.

Recently, Lanius has seen persistent dissociative symptoms in respiratory therapists. These healthcare workers find that detaching is the only way to get through the day during the COVID pandemic, but the dissociation frequently bleeds into everyday life.

One family physician in a community heavily hit by COVID found that she couldn’t even buy lunch for her child without being triggered. “I was at Costco and I had to get a hotdog for my son … They’re yelling out numbers … people were stacked three-deep, like all kind of in a circle…I looked around and there was nowhere safe to stand,” she says. “I didn’t feel like I could escape. And then I felt split off from myself … I was looking down on myself from above … it was very distressing.”

Often, dissociative symptoms remain undiagnosed and untreated, because “they’re in the background,” says Lanius, “…they don’t have those intense emotional responses so it’s easier not to see them.” Many don’t know how to label or identify their symptoms.

Cheng adds that it creates feelings of isolation. “It tends to be frustrating if we don’t know what we’re seeing and how to respond. Nobody talks about it with them. It’s not out there in the general public. They feel they’re crazy. And they feel they’re alone.”

Patricia Watson, from the U.S. Department of Veteran Affairs and National Centre of PTSD, applies what the military has learned about wellbeing and resilience to help healthcare workers through the pandemic. She uses the Stress Continuum Model, a stress assessment created by the Navy and Marine Corps, to teach a shared language of stress responses that can include classical and dissociative PTSD symptoms.

Figure 1: Stress Continuum Model. Source: Nash, W. P. (2011). US Marine Corps and Navy combat and operational stress continuum model: A tool for leaders. Combat and operational behavioral health, 107-119.

When someone moves into the orange or red zone of the stress continuum, such as when experiencing dissociative symptoms, Watson recommends Stress First Aid: a self-care and peer-support model based on resilience research in high-risk occupations. It describes seven evidence-based actions to help identify and address stress reactions:

Figure 2: Stress First Aid Model. Source: William Nash, Richard Westphal, Patricia Watson, Brett Litz; 2009.

With the second wave among us and stress injuries accumulating, inclusive tools to identify and care for people experiencing dissociative symptoms and other stress-related injuries are critical.

We can build an awareness of the diverse ways stress presents and intentionally support the mental health of all healthcare workers, leaving no one behind.