As the pandemic rapidly engulfs the world, it is inducing a significant degree of fear, worry and concern in the population at large and among certain groups in particular, such as the elderly, care providers and people with underlying health conditions. Fearfulness about community spread of COVID-19 has led governments and communities across the world to implement radical social distancing measures ranging from cycles of nationwide lockdowns, imposed isolation, closing down of schools and universities, cancellation of major events, et cetera.
It has been anticipated that the COVID-19 outbreak will have an increasingly negative impact on mental health in communities (Lima et al., 2020). There are grave psychological aspects to hospitalisation for patients, staff, and family members who are directly affected by COVID-19. Prolonged exposure to stressful environments, invasive procedures, and also the perception of threats in a medical care unit (ICU) are experienced as traumatic, resulting in long-term psychological harm to the doctors and paramedical staff (Righy et al., 2019). The determinants are constant fears of getting infected, unbearable stress, helplessness and distress watching infected patients die alone.
The traumatic and stressful aspects of involvement during a pandemic also risk psychological harm to clinicians (Kang et al., 2020; Lima et al., 2020). It has been observed that nurses and physicians involved in global outbreaks such as SARS, MERS, and Ebola experienced increased burnout, compassion fatigue, lower job satisfaction, lower morale, and job stress (Kim & Choi, 2016; Maunder et al., 2006; M. W. Smith et al., 2017).
The World Health Organization (WHO) published resources and information pertaining to mental health and psychological considerations for populace across the world during the pandemic. Attention with special care should be directed towards the outbreak and the many stressors it presents. Additionally, the World Health Organisation stresses the importance of psychological first aid.
Coronavirus and its Psychological Impact
In public mental health terms, the main psychological impact is elevated rates of stress or anxiety. As new measures and impacts are introduced, especially, quarantine and its effect on people’s usual activities, routines or livelihoods–levels of loneliness, depression, harmful alcohol and drug use, and self-harm or suicidal behaviours are also expected to rise. Imposed isolation and quarantine have also evoked psychological fear and feelings of being trapped for an indefinite period. The shift to the “new normal” has not been smooth for many.
Social distancing measures, while necessary to stop the spread of the virus, provide a dangerous platform for loneliness, isolation, and anxiety to settle in. There is a high potential for individuals with preexisting mental illness to experience symptom exacerbations or impairment in functional status due to increased stress and fear around the outbreak (Jiang et al., 2020).
Excessive fear and anxiety of the spread of infection can lead to acute stress, anxiety, and subsyndromal to syndromal level of depression in vulnerable individuals. Possible potential risk factors such as prolonged periods of social isolation, fear of unemployment, economic loss due to lockdown, death of family members and significant others etcetera have been proposed to precipitate self-harm behaviours during this pandemic crisis (“The Corona Virus, ” n.d.).
Social isolation/distancing has been observed to induce anxiety in citizens of different countries around the world. Individuals with preexisting mental health issues like depression and older adults living in isolation and despondency are the most vulnerable. It is easy for self-criticism, judgement and extreme suicidal thoughts to set in for such people.
The first pandemic-related suicidal case was reported from South India on 12th Feb 2020, where Balakrishna, a 50-year-old man incorrectly took his normal viral infection for COVID-19 (Goyal et al., 2019). Social boycott and discrimination added a few cases to the list of COVID-19-related suicides. Mamun MA et al., 2020 situated the first COVID-19-related suicide case in Bangladesh, where Zahidul Islam, a 36-year-old man was experiencing social avoidance at the hands of his neighbours committed suicide, under the fears of accidentally passing the virus to his community
Being isolated at home may increase family or financial pressures as the economic fallout of the outbreak worsens, leading to poor mental health (Brooks et al., 2020). Individuals may face unemployment, housing instability, and food insecurity while caregiving responsibilities for children or family members intensify. Those who experience trauma or violence in their intimate partner and family relationships—including psychological trauma—may be at increased risk for victimisation.
The impending economic crisis is expected to create panic; and mass unemployment, poverty and homelessness will possibly surge the suicide risk, drive an increase in the attempt to suicide rates or present conditions for non-suicidal self-injury to set in. This uncertainty of time for isolation, not only evokes feelings of hopelessness and helplessness. People might experience a loss of control over their lives, a lost sense of structure and stimulation.
What is NSSI?
Nonsuicidal self-injury (NSSI), defined as the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, includes behaviours such as cutting, burning, biting and scratching the skin. Common forms of NSSI include cutting, skin carving, biting, scratching, hitting, head-banging, and interfering with wound healing (Rodav et al., 2014).
Self-harm can be perceived as a way of dealing with deep distress and emotional trauma. It is used as a gateway to express feelings that can't be put into words; a distraction from one’s life, or release emotional pain. Afterwards, people probably feel better—at least for a little while. But then the painful feelings return, and they feel the urge to hurt themselves again and the vicious cycle continues. Regardless of how one engages in self-harm, it is often the only way one knows how to:
Cope with feelings of sadness, self-loathing, emptiness and guilt.
Express feelings one can’t put into words or release the pain and tension that might be felt.
Feel in control, relieve guilt, or punish self.
Distract from overwhelming emotions or difficult life circumstances.
As discussed previously, factors like social stigma and discrimination, unemployment and food insecurity among others might lead to heightened levels of stress and anxiety. It should be noted that people who engage in NSSI do not intend to end their own life. As per research, NSSI is most recurrently performed within the absence of suicidal ideation. The individual is said to self-harm to experience a sense of relief from negative emotions, elicit variants of hope and happiness, or to deal with personal issues experienced in their daily life.
In 2005, Muehlenkamp suggested that self-harmful conduct ought to be a different clinical condition, underlining the nonappearance of cognizant self-injurious intent, the powerlessness to oppose NSSI driving forces, the negative cognitive state before and the relief after NSSI, as well as the preoccupation with and repetitiveness of the behaviour.
Likewise, Favazza and Rosenthal proposed DSM addition of a repetitive self-mutilation disorder and supplemented earlier portrayals by including a preoccupation with hurting oneself.
To meet the criteria for NSSI to be diagnosed as the DSM-V (American Psychiatric Association, 2013), a person must have engaged in five or more days of intentional self-injury to the body surface without suicidal intent within the past year. Further, the self-injurious behaviour ought to be associated with interpersonal difficulties or negative thoughts/feelings (such as depression or anxiety) occurring right before the act, premeditation (i.e., planning the self-injury), and repetitive thoughts or rumination on the NSSI.
Here, premeditation means that right before the act of self-injury, the individual was preoccupied with thoughts about the planned act. Even when the individual does not engage in self-injurious behaviours they seem to be frequently thinking about them. Crucial to the behaviour that meets the criteria for the NSSI diagnosis is that the self-injurious behaviour is not socially acceptable and often can result in significant distress to the individual’s life. Another observation to be kept in mind is that self-injurious behaviour does not take place during delirium, substance intoxication, substance withdrawal, or psychosis.
Psychosocial risk factors for non-suicidal self-injury include child maltreatment, sexual abuse, physical abuse, emotional abuse, neglect, parental drug/alcohol use, exposure to domestic violence, parental mental health concerns, mental retardation/low functioning, anxiety, and depression.
One of the most important considerations to be kept in mind when discussing risk for NSSI is emotional regulation and psychological distress (Baetens et al., 2014). “Emotional regulation refers to the process by which individuals influence which emotions they have, when they have them, and how they experience and express their feelings. Emotional regulation can be automatic or controlled, conscious or unconscious, and may have effects at one or more points in the emotion producing process.” (Gross et al. 1998).
Research indicates that adolescents with emotional dysregulation are at risk for NSSI. Adolescents who experience elevated levels of subjective psychological distress because of stressful or upsetting circumstances and who are less competent at enduring pain are at increased risk to engage in NSSI (Anestis, Knorr, Tull, Lavender, and Gratz, 2013; Najmi, Wegner, and Nock, 2007).
The situations that surround individuals currently put them at risk of engaging in NSSI due to various factors like stress, anxiety, apprehension, depression, and so on.
Who is Vulnerable to Self-Injury?
In a study that researched the pervasiveness of NSSI amongst 1571 male and female school and college students in India found the resultant rates to be as high as 33.8%. These figures are higher than the pooled prevalence of NSSI of 17.2% among adolescents and 13.4% among young adults from nonclinical samples from studies in various countries.
Adolescents are transitioning from reliance on guardians to relative freedom, which puts new requests on them (Cohen et al., 2013). It is a period marked by incredible and significant change with increased responsibilities and decisions that can bring about as many remunerations as stresses.
In both adolescents and adults, rates of NSSI are highest among psychiatric populations, particularly people who report characteristics associated with emotional distress, such as negative emotionality, depression, anxiety, and emotion dysregulation. NSSI is especially common in individuals prone to self-directed negative emotions and self-criticism.
Females are more likely to engage in NSSI as compared to males. Gender differences exist for the methods of NSSI employed: burning and self-hitting are endorsed more frequently by males, with cutting and scratching more common in females (Rodav et al., 2014). Persons who engage in NSSI tend to use more than one method and repeat the behaviour.
Understanding Helpful Measures
All COVID-19-related news and information should be consumed from verified and trustworthy sources to prevent the spread of misinformation. Additionally, there must be a limit set to the amount of content that one might access, since this kind of knowledge may be emotionally distressing.
Individuals with a history of suicidal thoughts, panic and stress disorder, low self-esteem and low self-worth, are susceptible to damaging thoughts of engaging in self-harm or committing suicide. It is essential to maintain solidarity and stay connected digitally with loved ones despite the physical distance for peace of mind and to avoid the stream of negative automatic thoughts.
Indirect clues like ‘I’m tired of life’, ‘No one loves me’, ‘Leave me alone’ and so on need to be noticed with great care. Warning signs that a loved one is cutting or self-harming also include:
Unexplained wounds or scars from cuts, bruises, or burns, usually on the wrists, arms, thighs, or chest.
Bloodstains on clothing, towels, or bedding; blood-soaked tissues.
Sharp objects or cutting instruments, such as razors, knives, needles, glass shards, or bottle caps, in the person’s belongings.
Frequent “accidents”-Someone who self-harms may claim to be clumsy or have many mishaps, to explain away injuries.
Covering up-A person who self-injures may insist on wearing long sleeves or long pants, even in hot weather.
Needing to be alone for long periods, especially in the bedroom or bathroom.
Isolation and irritability-Your loved one is experiencing a great deal of inner pain—as well as guilt at how they’re trying to cope with it. This can cause them to withdraw and isolate themselves.
Ways to Help
Seek professional help
Learn about the problem-The best way to overcome any discomfort or distaste someone feels about self-harm is by learning about it. Understanding why oneself’s loved one is self-injuring can help them see the world through their eyes.
Don’t judge-Avoid judgmental comments and criticism, be sympathetic. Remember, the self-harming person might already feel distressed, ashamed and alone.
Offer support, not ultimatums-It’s only natural to want to help, but threats, punishments, and ultimatums may prove to be counterproductive.
Express concern and make sure that the person knows that you’re available whenever they want to talk or need support.
Encourage communication. Encourage your loved one to express whatever they’re feeling, even if it’s something you might be uncomfortable with. If the person hasn’t talked about self-harm, bring up the subject in a caring, non-confrontational way: “I’ve noticed injuries on your body, and I want to understand what you’re going through.” If the self-harmer is a family member, prepare yourself to address difficulties in the family. This is not about blame, but rather about communicating and dealing with problems in better ways that can benefit the whole family.
A comprehensive response of health care to the pandemic must include:
Attention to the psychological aspects of hospitalisation for patients, families, and staff affected by COVID-19;
Planning for emergency and acute psychiatric patient care if hospitals become overwhelmed with COVID-19 patients; and
Innovations for providing mental health care in communities while social distancing is required and health system resources are strained.
There is an opportunity for health system planning, resource mobilisation, and new interventions to address mental health challenges resulting from the COVID-19 outbreak. Collaboration among health system leaders from hospital and community mental health systems must occur to assure safety and continuity of care for individuals experiencing mental health crises during this time, for this is the only way of getting over the ‘hidden’ pandemic..
Written by:
Khushi Boken
Jesus and Mary College, University of Delhi
Intern, Brain Behaviour Research Foundation of India
REFERENCES:
Choi, K. R., Heilemann, M. V., Fauer, A., & Mead, M. (2020). A Second Pandemic: Mental Health Spillover From the Novel Coronavirus (COVID-19). Journal of the American Psychiatric Nurses Association. https://doi.org/10.1177/1078390320919803
Klonsky, E. D., Victor, S. E., & Saffer, B. Y. (2014). Nonsuicidal self-injury: what we know, and what we need to know. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 59(11), 565–568. https://doi.org/10.1177/070674371405901101
Sahoo, S., Rani, S., Parveen, S., Pal Singh, A., Mehra, A., Chakrabarti, S., Grover, S., & Tandup, C. (2020). Self-harm and COVID-19 Pandemic: An emerging concern - A report of 2 cases from India. Asian journal of psychiatry, 51, 102104. Advance online publication. https://doi.org/10.1016/j.ajp.2020.102104
Singh O. P. (2018). Nonsuicidal self-injury: Implications for research and management. Indian journal of psychiatry, 60(3), 259–260. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_396_18
Thakur, V., & Jain, A. (2020). COVID 2019-suicides: A global psychological pandemic. Brain, behavior, and immunity, S0889-1591(20)30643-7. Advance online publication. https://doi.org/10.1016/j.bbi.2020.04.062
Zetterqvist M. (2015). The DSM-5 diagnosis of nonsuicidal self-injury disorder: a review of the empirical literature. Child and adolescent psychiatry and mental health, 9, 31. https://doi.org/10.1186/s13034-015-0062-7
This topic makes so much sense. Beautifully written. Kudos to you, Khushi!
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