Received 18 Apr 2020 | Accepted 30 May 2020 | Published Online 7 June 2020
DOI:https://doi.org/10.15520/jmrhs.v3i6.194
JMRHS 3 (6), 976−990 (2020) ISSN(O) 2589-9031 |(P) 2589-9023 IF:1.6
RESEARCH ARTICLE
Pandemic Covid-19: Psychodynamic analysis of a global trauma. Clinical
considerations pre post Lock down.
Dr. Ernesto Mangiapane Dr. Gabriella Ilse Viscuso
Abstract
Meanwhile the COVID-19 crisis challenges the fabric of our society, we examine through our psychological science how this global trauma has affected and is affecting our mental and physical health, how we perceive the world and how we interact with others.
This contribution is part of the scientific landscape as an aid to understanding the social impact, aimed at interpreting the outcome of the pandemic and creating models for predicting the psychosocial consequences of the pandemic in the world.
We divided the covid-19 event into three temporal phases: Pre Covid-19 Era, Inside Covid-19 Era and Post Covid-19 Era and discussed in each of this hypothetical Era on the perception of global threats and traumas researches, on defensive mechanisms and infodemia, information con-tagion, on the psychological effects of quarantine and social isolation through the lens of polivagal and psychotraumatological theory, and then addressed collective grief, isolating predictive and resilient factors, scientific communication, stress and effect management.
This logic has highlighted how urgent action is needed to mitigate the potentially devastating effects of COVID-19. Many of the implications described here may also be relevant to future pandemics and public health crises.
It’s time to strengthen our mental health system in preparation for the inevitable challenges triggered by the COVID-19 pandemic, through gradual care and the practice of providing the most reliable information and the most effective and least resource-intensive treatment.
Keywords: Covid-19, Global Trauma, Polivagal theory, quarantine psychological effect, psychotraumatology
1
INTRODUCTION
W
hile the COVID-19 crisis challenges thefabric of our society, we examine through
and the way we interact with others.
The Coronavirus Pandemic marks a watershed for
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be taken as a critical point of reference that marks a new socio-temporal line: we will have a Pre Covid Era-19, an Inside Covid Era-19 and a Post Covid-19.
This contribution is part of the scientific landscape as an aid for understanding the social impact,aimed at interpreting the outcomes of the pandemic and creating models for predicting the psychosocial con-sequences that it entails on the world scene.
1. Pre Pandemic Covid-19 Phase
In the meantime that in late December 2019 and early January 2020 we were thinking about the good intentions for the new year, we were completely un-suspecting of the emergency’s health care that would be created shortly. A new virus highly contagious and completely unknown to our immune system had begun to circulate in a remote region of the globe. We would never have thought, at the time, that this virus, apparently so far away, could have spread and caused many problems at an individual and collective level, for our health and for health and economic systems. 2020 will be remembered, in fact, as the most diffi-cult year after the war, the whole world
is about to face a pandemic in the digital age for the first time. The virus is called COVID-19, which has its baptism in the Wuhan fish market in China.
The coronavirus phenomenon began to threaten the health and lives of millions of people after a few weeks, quickly starting to spread from China to almost all over the world.
Highly contagious with the possibility of causing serious respiratory diseases, it has had a rapid impact on governments and public health systems. They responded by declaring a public health emergency of national and international interest, as well as by tak-ing extraordinary measures to prevent contagion and limit the outbreak. Millions of lives have changed significantly and a global, multilevel and demanding
Supplementary informationThe online version of this article (https://doi.org/10.15520/jmrhs.v3i6.194
) contains supplementary material, which is avail-able to authorized users.
Corresponding Author:Dr. Gabriella Ilse Viscuso
Email:gabriellaviscso@yahoo.it
process of adaptation to stress is underway.
Covid-19: a global trauma
In the last twenty or thirty years a series of events (Gulf War, attack on the Twin Towers, Tsunami 2004 in Indonesia, Chernobyl and Fukushima) and unfortunately, the current one, have had the char-acteristic of causing not only extensive and violent trauma to a very large number of people (in Indonesia 230,000 people perished), but due to their ”inter-national” characteristics and the extreme visibility and media coverage, the traumatic halo seems to have extended indefinitely to a much greater number of individuals around the world than those directly exposed.
Sigmund Freud defined traumatic1 an event which
cannot be ”in any way predictable” and which makes ”any form of defense impossible”. An event that breaks violently our ordinary representation of the world.
They are global traumas, universally impacting events on humanity that manage to transform the perception of the world view. Both because each of these dramatic events has been able to undermine a certain vision of the world and reality and to change many aspects of our life but also because a large part of the traumatogenic action has been linked to the action of the media and their pervasive and repetitive way of representing that particular event.
Infodemic: the information contagion
The World Health Organization’s declaration of a public health emergency of international signifi-cance upsets the global balance, and in this context that the media amplifies ancestral fears, while the equally rapid anguish caused by the pandemic risk instead it is more concrete than ever.
Disinformation2 plays a crucial role in the real per-ception of risk3 . In 2006, a study by the World
11Freud in Van der Kolk, B. - A. McFarlane - L. Weisaeth
(2007). ”Traumatic stress. The effects on the mind, body and society of intolerable experiences ”. Rome: Magi.
2Guess, A. & Coppock, A. Does Counter-Attitudinal
In-formation Cause Backlash? Results from Three Large Survey Experiments. Br. J. Polit. Sci. 1–19 (2018)
3Swire, B. & Ecker, UKH Misinformation and its
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Economic Forum identified in the correct commu-nication of the emergency one of the cornerstones in crisis management, defining, with the neologism Infodemia as the rapid dissemination of inaccurate or incomplete or false information, capable of am-plifying the effects of a problem.
Information contagion4 it has the effect of making emergency management much more complex, as it undermine the possibility of transmitting clear and unambiguous instructions and, therefore, of obtain-ing homogeneous behavior by the population.
From the moment the world became aware of what it meant to be facing an epidemic for the first time, all channels of personal information and communi-cation have entered into a very intense fibrillation.
Coronavirus and its media bombardment5can
condi-tion our percepcondi-tion of the surrounding environment, triggering a defensive reaction.
Covid-19 epidemic: The invisible enemy
The great and terrible epidemics, which are part of our history, have left a trace of indelible fear in the collective imagination. These great terrors, echoes of nameless fears, have heavily influenced themental health, in addition to the physical one of course, of huge groups of peopleover the ages.
Epidemics are not limited to killing people: they have profound consequences for a society and its history.
Manzoni (”The Betrothed”) investigated the dimen-sions of the social reversal secondary to a contagious disease, Camus (”The plague”) addressed the epi-demic’e effects on the human soul.
The feeling of estrangement and ofunheimlich(” un-canny” or ”not familiar“) that creeps in and upsets everyday life has concerned the works of many other authors such as Jack London (”The Scarlet Plague”), Philip Roth (”Nemesis”) or Josè Saramago (”Blind-ness”), who wrote memorable and very intense pages
Southwell, BG, Thorson, EA & Sheble, L.) 195–2011 (Univer-sity of Texas Press, 2018).
4Gunther Eysenbach, Infodemiology: the epidemiology of
(mis) information, in the American Journal of Medicine, vol. 113, no. 9, 2002.
5Frenkel, S., Alba, D. & Zhong, R. Surge of Virus
Misin-formation Stumps Facebook and Twitter. The New York Times (2020).
about epidemics and their unpredictable psycholog-ical and social consequences. Even Boccaccio gives much space to the psychological and ethical impli-cations of the plague: the awareness that death is lurking pushes many to abandon themselves to the pleasures; even the nuns, ”broken by the laws of obedience, given to the carnal delights, in such a way by advising them to escape, have become lascivious and dissolute”.
Psychiatrist V. Rosso in his recent contribution6 highlights how each bacterial or viral epidemic is ac-companied by two more epidemics, of both paranoid and communicative nature. V. Rosso shows how the phenomenon of paranoia, when supported by an ob-jective nucleus of reality (precisely the coronavirus epidemic), involves the irruption among ”normal” people of thought contents typical of serious psy-chopathology or prevailing ideas of contamination, widespread fear of being invaded, of being attacked by invisible enemies. And here is the proactive de-fense mechanism induces the splitting and attribution of these highly disturbing experiences outside of us, thus favoring the third parallel epidemic: xenopho-bia.
What described Manzoni, Camus, Roth, Saramago or Boccaccio, reappears punctually even in the case of coronavirus epidemic. Paranoia always carries the heavy burden of persecutory thinking, which psychi-atry teaches us to have always been the patrimony of serious psychoses. Persecutory thinking can in these days infect people who were immune to it until yesterday, people who are ”normal” but with specific characteristics of sensitivity and incomplete culture, sensitive and susceptible precisely because only par-tially informed. Terror and mistrust have therefore spread to the fear of anyone who is ”different from me”. Much researches shows that feeling threatened with disease is often associated with higher levels of ethnocentrism7; greater fear and perceived threat are associated with greater intolerance and punishment
6https://www.valeriorosso.com/2020/02/05/coronavirus-ps
icopatologia-delle-epidemie.
7Schaller, M. & Neuberg, SL Danger, Disease, and the
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towards outgroups88and it can undermine empathy
with those who are socially distant99 and increase dehumanization10.
From a psycho-traumatological perspective, it is impossible not to notice the emotional effects of this sudden sense of threat and loss of the sense of security: our primitive defense system (Porges, 2001) begins to operate and begins to function on the basis of information collected in the surrounding environment. In fact, when we feel truly threatened, Neuroception (Porges, 2004), or rather the innate ability of the autonomous nervous system to inter-cept dangers in the environment activates the defense system that cuts cortical activities, rationality and reasoning, to make us act quickly to protect our life. But what if this defense system is solicited excessively, continuously and inconsistently?
An interesting article11 by AISTED shows how the
normal defenses of request for help ( attack-cry-for-help), attack (fight), escape (flight), freezing (freeze), surrender/submission (submission / collapse) enter into crisis because they are not made to bear signals threatening, inconsistent and unpredictable too long, especially when they come ”from above”, by those who have the responsibility to protect us.
In Italy we have seen these effects together: return to the South to feel safe again in the family (cry of attachment). Explosions of anger and violence towards the Chinese, the Lombards, the patient zero, the neighbor who does not wash his hands, the gov-ernment, the economic system, capitalism (attack / fight). Escape from northern cities, escape from hospitals, escape on ski slopes, minimization (flight / avoidance). Follow the statistics of the infection
8Jackson, JC et al. Ecological and cultural factors
under-lying the global distribution of prejudice. PLOS ONE 14, e0221953 (2019).
9Cikara, M., Bruneau, EG & Saxe, RR Us and Them
Inter-group Failures of Empathy. Curr. Dir. Psychol. Sci. 20, 149– 153 (2011).
10Kteily, N., Hodson, G. & Bruneau, E. They see us as less
than human: Metadehumanization predicts intergroup conflict via reciprocal dehumanization. J. Pers. Soc. Psychol. 110, 343-370 (2016).
11Marzocchi C .; Avico R .;Pandemic covid-19: at home,
in balance between fear and resilience, edited by AISTED - Italian Association of Trauma and Dissociation Study on Psychiatryonline (2020)
minute by minute with anxiety, panic, terror, not being able to do anything but think about the Coron-avirus, stop eating, sleeping, washing, getting stuck more than required (freezing). Fatalism, denial, re-nunciation of protection (collapse).
According to Porges12 , as the world at this stage
struggles with the Epidemic, it is necessary to recog-nize that the psychological reactions to this event will only make sense if informed by our understanding of evolution. This leads us to ask direct questions about our responsiveness to the threat and uncertainty and our needs to regulate our body state sufficiently to move from feelings of fear and danger to feelings of security and trust in others.
2
INSIDE PANDEMIC COVID-19 PHASE
On 11 March 2020, the WHO (World Health Organi-zation) declares the Pandemic (from ”Pan- demos”, in Greek, means ”all the people”) for coronavirus (SARS-CoV-2), putting us all in front unprecedented precautionary measures. From China, the epidemic slowly spread to Europe, hitting Italy and gradually all the other countries.
The world is changing, cities have emptied them-selves and people are leaving out only in case of necessity.
The masks, the hand gel are nowhere to be found. We live as in catastrophic films, we now look at each other with acknowledged mistrust, for fear of being anointers of the virus and the fear of passing it on to our loved ones.
Slowing down viral transmission during pandemics requires significant changes in behavior. Various aspects of social and cultural contexts influence the extent and speed of behavioral change. In this sec-tion, we will describe how aspects of the social pandemic’s context and its the restrictive measures (quarantine, social isolation) have influenced the rel-ative psychological effects of the world population.
Let us try to understand, on several levels, what happens in a state of Pandemic.
12Porges, SW (2020). The COVID-19 Pandemic is a
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Quarantine and social isolation: neuropsycholog-ical effects according to Polyvagal Theory and Psycho-traumatological Theory.
Many countries have applied quarantine measures for the containment of COVID-19, with more or less rigid protocols. The aim is to protect our health and curb the infection rate.
The word quarantine13 (descends from a Venetian
linguistic form) describes the period of forced iso-lation used to limit the spread of an epidemic, which was used for the first time by the Venetian repub-lic in relation to the crews of ships arriving from possessions in Dalmatia. This special decree was issued to contain the black plague epidemic that raged in Europe and Asia in the fourteenth century. This provision required newcomers to the lagoon city to spend a period of isolation in a place with limited access for the duration of forty days. If for all of us this is a new and painful experience, these drastic containment measures have already been im-plemented many times in different historical periods.
Even in recent times different countries have imple-mented these restrictive provisions, such as several areas of China and Canada for the 2003 SARS epi-demic.14 , some African villages for the 2014 Ebola
outbreak15 and before us the Chinese province of Hubei for the current Covid-19 epidemic.
In fact, there are several researches in literature16
who have collected numerous evidence on the neg-ative effects that a prolonged period of segregation
1313Cava MA, Fay KE, Beanlands HJ, McCay EA, Wignall
R. (2005). The experience of quarantine for individuals affected by SARS in Toronto. Public Health Nurs; 22: 398–406.
1414Bai Y., Lin CC, Lin CY, Chen JY, Chue CM, (2004).
Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv; 55: 1055–57. 1515Kinsman J. ”A time of fear”: local, national, and
inter-national responses to a large Ebola outbreak in Uganda. Global Health (2012) 8:15. doi: 10.1186 / 1744-8603-8-15
1616Brooks SK et al. The psychological impact of quarantine
and how to reduce it: Rapid review of the evidence. Lancet 2020 Feb 26; [E-pub]. Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W., Styra R. (2008). Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect; 136: 997–1007. Li, S., Wang, Y., Xue, J., Zhao, N., & Zhu, T. (2020). The Impact of COVID-19 Epi-demic Declaration on Psychological Consequences: A Study on Active Weibo Users. International Journal of Environmental Research and Public Health, 17 (6), 2032.
can have on psychological health.
Quarantine, as we are unfortunately experiencing, is an unpleasant experience that involves the loss of individual freedom, separation from our dearest loved ones and a state of uncertainty about one’s health and future.
The pandemic, in fact, involves three types of catas-trophes:
1. The direct action of the virus on the population;
2. The world economy collapse;
3. The hidden pandemic: the effect that quarantine produces from a collective and individual psy-chological point of view.
We can also identify three important quarantine phases:
• Home isolation.
An event of this nature only calls to war, for us unprecedented. In the case of natural disasters such as earthquakes or tsunami, there is no social isola-tion, indeed the social network becomes a protective factor. From clinical experience17two types of
anxi-eties emerge that oscillate between the fear of being carriers of viruses and the fear of being infected by the closeness of the other, the fear of the stranger and borders.
• The state of constant danger.
It induces to experience strong states of anguish, which unlike the fear in which the phobic object is identified, the object is perceived as indefinite. Potentially everywhere but invisibly. Paraphrasing the Italian Psychoanalyst M. Recalcati: ”Fear is a localization of anguish, anguish is the delocalization of fear” (M. Recalcati 2020).
• The unpredictability.
1717Drury, J., Cocking, C. & Reicher, S. The nature of
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The pandemic seems unable to be controlled, the numbers of the infected and dead are significant, producing a further loss of the sense of control and distrust in government institutions. Some research18
confirm how this state of unpredictability can lead negative effects on the perception of support in times of crisis, leadership and the sense of citizenship.
Let us now refer to two important studies published in The Lancet19 . The former questions the psycho-logical impact of quarantine, the latter on what urgent measures are to be put in place for both patients and healthcare professionals.
The first work20 concerns a review of measures to
contain SARS, Ebola, H1N1, MERS and other types of flu outbreaks that have occurred in different parts of the planet. The main ”stressors” emerged from the quarantine study which would entail a sense of vulnerability and psychopathological problems:
• duration of the quarantine;
• inadequacy of the information received;
• shortage of supplies of basic necessities;
• frustration with deprivation of liberty;
• fear of infection.
Neil Greenberg Professor of the IoPPN (Institute of Psychiatry, Psychology & Neuroscience) has de-clared: ”Quarantined people are already experienc-ing a high level of fear about infection and the possibility of infecting others. The experience we are living generates extreme stress, because we are
1818Haslam, SA & Reicher, S. Stressing the group: Social
identity and the unfolding dynamics of responses to stress. J. Appl. Psychol. 91, 1037–1052 (2006). Believing in ’us’: exploring leaders’ capacity to enhance team confidence and performance by building a sense of shared social identity. J. Exp. Psychol. Appl. 21, 89–100 (2015).
19The Lancet has dedicated an open access section
(COVID-19 Resource Center) to ”instant papers” concerning Coron-avirus.
20Published February 26 The psychological impact of
quar-antine and how to reduce it: rapid review of the evidence is a review of the psychological impact of quarantine using three different electronic databases and consulting over three thousand articles
confronted not with an event that has a beginning and an end, but to which we are exposed without the certainty of an epilogue and this keeps our body in a state of continuous alert.”21
Now, what happens when a stressor doesn’t last as long as a pandemic’s event, that could go on for a long time?
Taking up the Polyvagal Theory of Stephen Porges22
, using the phylogeny and the history of our evolu-tion, it helps us to understand how the situation of COVID-19 can act on our physiological and emo-tional regulation and on our subjective and collective perception of risk.
Our nervous system responds to stress and danger according to a hierarchical organization that corre-sponds to the stages that we have gone through in the course of evolution: Immobilization (fainting, collapse, vagal crisis);Mobilization (attack-escape); Social engagement (facial expressions, interactions, listening).
An interesting article23 shows how the COVID-19
event has moved us into a survival/attack response type by activating the sympathetic nervous system and has blocked the social engagement because it has been compromised by the viral spread and the dan-ger of contagion beyond that from media coverage sometimes alarmist or partial. The feeling can be that of not being able to trust and feeling trapped with a correspondent, not always proportionate, activating mistrust, fear and anguish, as well as anger to be seen by others as ”cause” of the spread of the virus.
The state of Pandemic, therefore, has activated in the majority of the population a survival modality with primordial defense mechanisms such as attack or flight, coming from the activation of the sympathetic nervous system.
The parasympathetic nervous system plays a role in restoring conditions of safety and calm.
21https://www.kcl.ac.uk/news/ensuring-the-mental-health-o
f-healthcare-workers-in-the-covid-19-pandemic.
22Porges, SW (2009). The polyvagal theory: new insights
into adaptive reactions of the autonomic nervous system. Cleve-land Clinic journal of medicine, 76 (Suppl 2), S86.
2323Covid-19: feeling safe in polyvagal and neuroceptive
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Porges24hypothesizes that the parasympathetic
ner-vous system has two parts that cause two different responses: the dorsal vagal nerve network and the ventral vagal nerve network.
When a person fails to resolve a threat through com-bat or escape (like cannot physically escape or fight a virus) or establish a social connection to help himself calm down, he enters a state of dissociation, and it is the work of the vagal nerve network. dorsal, pro-ducing psycho-emotional consequences such as the sense of helplessness, feeling hopeless, depressed.
Also the lens of psychotraumatology and the works
25 by B. van der Kolk can help better frame the
symptoms, or the psychological manifestations of a protracted altered defense system. According to this perspectivesome peculiar manifestations are:
• freezing :as a consequence of a fear perceived as endemic, the perceived alarm is heightened and becomes somatic, leading people to a be-havioral crossroads: those who perceive thedan-ger as dependent on their own behavior, will tend - in worst cases - to mobilize towards a some kind of escape or mobilization behavior (even irrational); those who, on the other hand, perceive the danger as overwhelming, will as-sume - always in the worst cases - a position of freezing, that is, of immobility/freezing, or of collapse.
• Psychosomatic symptoms:Undergoing a pro-tracted threat condition falls on the body via the nervous system, with protracted hyper-arousal symptoms (sleep disturbances, difficulty rest-ing, abnormal and protracted muscle contrac-tures, permanent changes in posture and conse-quent imbalances in body terms).
• Polarization of thought: as in a DOC desease (obsessive / compulsive), we observe forms of obsessive thinking on issues of close survival
2424Porges, SW (2009). The polyvagal theory: new insights
into adaptive reactions of the autonomic nervous system. Cleve-land Clinic journal of medicine, 76 (Suppl 2), S86.
25B. van der Kolk (2015). The body takes the hit. Mind, body
and brain in the elaboration of traumatic memories. Raffello Cortina, Milan.
inherent in possible virus contamination, with often a narrowing of the cognitive field and a ”tunnel” vision.
• Regression: the presence of a ”predator” or a ”threat” that is not very contrastable, or repre-sented as such, produces a regression to infan-tile thought forms.
• Dysfunctional self-regulation:in order to mit-igate the effects of protracted alarm dysregula-tion, individuals could implement dysfunctional self-regulation strategies, for example through binge-eating or the use of substances.
Some specific and daily situations related to the ”forced quarantine” condition, to which we are all subjected, could also become very powerful triggers of ancient traumas26 .
Triggers such as social isolation, loneliness, social withdrawal are current and contingent stimuli capa-ble of reactivating implicit memories of situations, emotions, thoughts or actions of the past: they are capable of reactivating negative emotions precisely by virtue of the immediate association with those experiences .
Significant research27 confirm the data on the psy-chological reactions induced by social isolation: from the increase in the level of psychological dis-tress, to the onset of feelings of fear, disorientation, anger, emotional emptying and resignation. Indeed, some research shows that loneliness and social iso-lation worsen the burden of stress and often produce deleterious effects on mental, cardiovascular and immune health.
It was found that the longer the duration of the quar-antine, the easier it is for feelings of development to developanger, symptoms ofpost traumatic stress
26Biological Response to Psychic Trauma International
Handbook of Traumatic Stress Syndromes, 1993,Bessel A. Kolk, Jose Saporta
27Loneliness matters: a theoretical and empirical review
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disorder(Hawryluck L., et al. 2004) (Marjanovic Z., et al. 2007). The loss of one’s job, of one’s daily rou-tine has caused peopleanxiety, anger and frustration, emotions that in some cases continued to be present even up to six months after the end of the quarantine period (Blendon RJ, et al. 2004) (Jeong H., Yim HW, Song YJ, et al. 2017). over an increase in anxious manifestations and a marked worsening of people’s mood, in relation to the pandemic spread, mental disorders due to traumatic or stressful elements can occur, or (according to DSM-V):
• Acute Stress Disorder
• Post-Traumatic Stress Disorder
• Adaptation disorder with depressed, anxious or mixed mood.
• Extreme Stress Disorder (DESNOSS)
During the quarantine period this negative psycho-logical effect is not surprising, but the evidence that a psychological quarantine effect can still be detected months or years later, as shown by a small number of studies2829is more worrying and suggests the need to
ensure that effective psychological harm mitigation measures are put in place as part of the isolation and post-isolation planning process.
3
POST PANDEMIC COVID-19 PHASE
What has commonly been called ”Phase 2” seems to be getting closer and closer. We have almost come to the easing of restrictive measures, at the end of this Lock-down that will open the way to the Post-Coronavirus Era.
All over the world we are witnessing a stabilization of cases and a decrease in infections. Regional Direc-tor of the World Health Organization Hans Kluge has
28Jeong H, Yim HW, Song YJ, et al. Mental health status
of people isolated due to Middle East respiratory syndrome. Epidemiol Health 2016; 38: e2016048.
29Liu X, Kakade M, Fuller CJ, et al. Depression after
expo-sure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012; 53: 15–23.
declared30that some countries are showing a drop in
the rate of increase in new cases.
In Italy, the contagion index, as confirmed by the Minister of Health Roberto Speranza, is three times lower than at the beginning and we are going to a ”phase 2” in the management of the pandemic.
Personal activities are slowly reintroduced and circu-lation will be allowed under certain conditions, but to avoid a second wave of contagions the containment measures still remain high.
It is not known for sure if people infected with the virus develop immunity, or for how many years it could last, and therefore we do not know if there may be a second after the first infection. To date there is no vaccine and no definitive cure: all are still in the experimental phase.
How is our mind preparing for the new course of these events?
In this last section we will analyze and reflect on the possible long-term psycho-social effects by exam-ining the predictive factors that can guide us in the elaboration of the new Post Covid-19 Era.
The challenge of uncertainty
Have we already processed the condition that has forced us into isolation until today?
An interesting contribution by Italian Dr. Lo Pic-colo31shows how the processes of elaborating events
are not immediate, they need time and a space.
We are still too immersed in the conditions deter-mined by the quarantine to be able to think that we have started some elaborating process, everything happened in such sudden terms that we are probably still struggling to adapt to the drastic transformations that everyone’s daily life has undergone.
But it is already time to begin, fortunately, to prepare for a new phase, for a cautious recovery of contact with the social dimensions, for a slow escape from the deprived condition that has characterized these months. And it is easy to assume that it will not be simple.
30https://www.vaticannews.va/it/mondo/news/2020-04/coro
navirus-europa-mondo-otto-aprile-settimana-santa.html
31http: //www.palermotoday.it/cronaca/corona
virus-psicologo-fase-due emozioni.html? fbclid
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Aside from the physiological fatigue of a new adap-tation process, we will have to deal with a multiplic-ity of conflicting emotions: on the one hand the relief, on the other the anxiety and worry generated by the fear of a new form of contamination.32
Psychological effects of isolation: predictive ele-ments
In the United States, the White House with the Allen Institute for AI, the Chan Zuckerberg Initiative, the National Institutes of Health (NIH) and other institu-tions have prepared scientific literature datasets for retrospective research aimed at the interpretation and statistical prediction of pandemic outcome.
The research of these sources starts from the as-sumption to study the evidence concerning previous epidemics such as the SARS epidemic (2002), the avian flu (2005) and the swine flu (2009), in order to create models for predicting the consequences of the pandemic, to stem them effectively. To date, look at the evidence from studies33 implemented in
China can allow us a chronological advantage for understanding the phenomenon.
As for the general population, a study conducted by Wang and collaborators34explored the impact of the pandemic emergency on the mental health of Chi-nese citizens, collecting data through the administra-tion of an online quesadministra-tionnaire that contained both questions regarding the physical health of people, and questions taken from standardized tests for the detection of depressive symptoms and stress asso-ciated with traumatic events. 53.8% of respondents rated the psychological impact of the epidemic on themselves as moderate or severe, 16.5% reported moderate to severe depressive symptoms, 28.8% re-ported anxious symptoms of intensity moderate to
32ibid
3333Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho,
CS, & Ho, RC (2020). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china. International Journal of Environmental Research and Public Health, 17 (5), 1729.https://www.ncbi.n lm.nih.gov/pmc/articles/PMC7084952/
34Li, S., Wang, Y., Xue, J., Zhao, N., & Zhu, T. (2020). The
Impact of COVID-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users. International Journal of Environmental Research and Public Health, 17 (6), 2032.
severe and 8.1% reported moderate to severe stress levels.
As for the protection and risk factors, the female gen-der, being students and particular physical symptoms (muscle pain, cold and dizziness) were associated with a lower psychological well-being; on the con-trary, the tendency to keep up to date in a rational and thoughtful way with regard to the development of the epidemic and to adopt the main precautionary measures (eg hand hygiene, use of masks, etc.) were predictors of greater psychological well-being.
As for health workers, a study by Huang and collab-orators35he examined the mental health of the
med-ical staff using scales for the evaluation of anxious symptoms and Post Traumatic Stress Disorder. In re-lation to anxiety, approximately 23% of medical staff said they experienced varying degrees of anxiety symptoms, with female staff reporting significantly higher levels of anxiety than male doctors. In addi-tion, nursing staff reported statistically more anxious symptoms than medical staff. The probably most relevant data, however, concerned the incidence of post-traumatic stressful symptoms: 27.39% of medi-cal staff members reported stress-related symptoms, including insomnia, nightmares, hypervigilance and recurrent negative images.
The study highlights how these results that emerged among patients and healthcare professionals can last even months and years after quarantine.
The incidence of PTSD becomes four times higher than that recorded in unaffected populations, while 60% of those who lived in quarantine report depres-sive symptoms.
Overall, this reflection based on reading several ar-ticles on the topic suggests that the psychological impact of quarantine and isolation may be broad, substantial and long lasting on the mental health of the population.
If the experience of isolation is negative, long-term consequences, that are not easily predictable, can affect not only people in quarantine and isolation, but
35Huang, JZ, Han, MF, Luo, TD, Ren, AK, & Zhou, XP
MEDICAL RESEARCH
also the health system that administered the quaran-tine and politicians and public health officials who have established.
The consequences of the inability to manage this pandemic of mental disorders could also be very dramatic: slowdown in the economic recovery, slow psychiatric chronicization of a large part of the world population, suicides, violence, substance abuse.
This psychopathological transformation of Human-ity could proceed silently and for several years before exploding into its actual damage potential.
Elaboration of collective mourning
There will come a time when the Coronavirus pan-demic will seem like a memory to us. But everything that has happened in these months will leave a mark on the memory of the collective mind.
According to the Italian Psychiatrist D. La Barbera: ”The mask has become the icon of the pandemic, the most direct and immediate sign of recognition of the inhabitants of a different world, the emblem of our relational retreat, of our defensive desocialization, of the rarefaction of contacts (forced) and of the infections (desired).
As an anthropological variant, this ”homo person-atus” (it is not at all devoid of significance that mask in Latin was said to be ”person”) suffers from a crazy paradox: it is condemned to the extreme limitation of interpersonal exchanges and anchored firmly to its habitat right in the historical moment broadly - and also a little promiscuous and disper-sive - expansion of relationships and encounters, of exchanges and connections, and of extreme, contin-uous, unstoppable mobility, sometimes busy if not spasmodic”.36
The condition of lived deprivation leaves slag, in-evitably. And it will be useful to take some time to dispose of them, without having too many expecta-tions and, even less, too much urgency.
During a pandemic, people are exposed to the death of friends and loved ones, including exposure to the death of children.
3636 https://www.paneacquaculture.net/2020/04/21/la-pand
emia-come-trauma-della-visione-del-mondo-dialogo-con-lo-p sichiatra- daniele-la-barbera/
Social isolation, increasingly strict rules, economic collapse, generalized stop to any activity considered non-essential, including social acts so fundamental for the recognition of oneself, of others and for the elaboration of memory, of identity.
In particular, it is enough to imagine the impossibility of mourning one’s friends and family through the funeral: civilization was born on funerals, recognizes itself united and supportive in memory, elaborates models (the ancestors).
There are many stories in this Coronavirus time: we speak of the families of the victims, who often have not even been able to give the last farewell to their loved ones, but also of doctors and nurses in continu-ous contact with very difficult situations, relatives of hospitalized people and same coronavirus patients.
Stories that fit into each of the Era that we have supposed to hypothesize.
”Let me give you the last kiss, I know I’ll never see her again.” He is Mario (invented name to preserve his privacy), an elderly man who contracted Coro-navirus. When the 118 doctors and nurses come to pick him up in his house he already has a fever and is sick. But of course I answer him, in a great emotion, I know I shouldn’t have, but they stayed together until then, what changed a goodbye kiss ”.37
“-I’m dying-: that last message from my mother, killed by the Coronavirus. Annalisa left like this, with a greeting via WhatsApp to her children, while the nurse was about to give her the morphine. We don’t even know where his ashes are, ”says the son,” seeing his body taken away by army trucks was excruciating”.38
No one should be denied the farewell kiss. That moment in which the love lavished during a lifetime is distilled. It is the most painful and poignant aspect in all this pandemic: not being able to say goodbye to loved ones.
Taking away the possibility of a greeting to the de-ceased also triggers a highly dangerous dynamic for
37https://www.cronachemaceratesi.it/2020/03/15/posso
-dare-un-ultimo-bacio-a-mia-moglie-so-che-non-la-vedro-piu/1376472/
38
CONSIDERATIONS PRE POST LOCK DOWN.
the psyche: it makes the subject for whom you feel pain disappear. In short, it makes suffering senseless, just when suffering, which is the elaboration of pain, presents itself as the only possible consolation. More generally, just when we need confirmation. In this way the physiological elaboration of mourning is lacking, not to mention the shock of those who have been taken away from home by a member of staff harnessed with masks and overalls to then know of his death after a few days. The recurring scenario among the stories collected in these days is also the following:
”A 95-year-old lady said that as a young woman she had escaped the Germans by lying in a ditch and that during the war at least she knew she could escape to the mountains, while now she didn’t know where to hide.”39
Thus, it appears that after Coronavirus has passed, life will never return to completely normal. Risk-averse people could continue to feel disoriented and reiterate their withdrawal and isolation, even at the new onset fear of a second wave, of a new prolif-eration of the virus. Those who already had a psy-chiatric disorder before the epidemic will probably need further support and in all probability, a large group of new patients will be added to this population who will need assistance and adequate support from health and institutions to the elaboration of new collective mourning.
Protective factors: some possible perspectives
Psychological factors play an important role in how people deal with the threat of infection, associated losses and trust in institutions capable of supporting its management, in order to ensure collective and individual protection factors and strategies.
Clarity and transparency of information by the au-thorities on the management of the post- quaran-tine phase and on future resolutions are the key to bringing citizens closer to political institutions as well. Limiting the freedom of the entire population has certainly been one of the most complicated and burdensome choices that have been made in world history.
39
Consequently, we have also seen that the psycholog-ical effects of quarantine can be varied, widespread and have a long duration. The more citizens will feel lonely andabandoned during this period, the more the repercussions on future psychological well-being will be serious. In this difficult moment there are a multitude of people who, besides being worried about their lives, are worried about the uncertain future that awaits them. The worse the perception of the experience of this bad experience will be, the worse the next effects on mental health will be.
The coronavirus emergency makes us understand, therefore, how important it is to move from the condition of traumatized people to that of valid caregivers, able to mitigate, in a responsible and affectionate way, the impact of a situation of such a strong emergency, sheltering from one of the main effects of traumatic stress disorder: the eruption of emotional fragility, the gateway to anxiety, depres-sion, de-realization.
What to do, how to re-orient oneself in the face of ex-periences of fear, panic, helplessness, disorientation and detachment from others, forced isolation?
Many scholars have identified strategies that could mitigate these results, and this could make the current situation more familiar and manageable for many individuals.
First, according to some scholars, one should act on linguistic terms, loneliness, for example, is inter-preted as the subjective state that one is not experi-encing enough social connection, while isolation is an objective lack of social interactions40.
This means that you can be isolated but not alone, or alone in a crowd. Thus, the term ”social distance” could imply that significant interactions need to be cut. A useful alternative term could be ”physical distances”, to help highlight the fact that social con-nection is possible even when people are physically separated.
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increasing the possibility of ”stress-related growth”, a phenomenon in which stressful experiences serve to increase physiological hardening.
Polyvagal theory directs vagus nerve activation to re-duce stress associated with the covid- 19 emergency.
Recent research on the vagus nerve43 they highlight how people can tune in to their nervous systems and find their way back to one state of ”calm and security”. Actions involving these parts of the body, including deep breathing, gargle, buzzing or even social cues such as smiling or eye contact with someone send messages to the brain that begins to relax. This activation can have an ”avalanche” effect. Ruth Lanius, professor of psychiatry and director of the post-traumatic disorder research unit at the University of Western Ontario, says that activation of the ventral vagus nerve also activates the prefrontal cortex, the part of the brain that deals with logic . Calming down allows you to think clearly and process the sensations that will further resolve stress.
Modern psychology and the social sciences define ”resilience” as the process of positive adaptation in the face of adversity, trauma, tragedy, threats or significant sources of stress.
According to recent research44, we must be willing to navigate the middle of the resilience process. Communities and individuals facing different adver-sities such as war, famine, poverty, disease or death do this by taking advantage of coherent categories of resilience resources. So, let’s be proactive, also because resilience is not something innate (or in any case only partially) but is the result of deliberate action.
Let’s imagine our future narrative and head towards its end. We leverage our individual, community and existential resources so as not only to navigate this experience but to continue to thrive. Let’s make sure that when we look back on this story, we will be able to say that we have adapted effectively.
4
CONCLUSIONS
The COVID-19 Pandemic has shown us how radi-cally and rapidly our world can change.
In this article we have addressed phenomenology theory and scientific contributions on pandemics, in reference to the current Covid-19 world emergency.
In particular, we divided the covid-19 event into three time phases and discussed research on the per-ception of global threats and traumas, on defensive mechanisms and infodemics, information contagion, on the psychological effects of quarantine and social isolation through the lens of polyvagal and psycho-traumatological theory to then face collective mourn-ing, isolating predictive and resilient factors, sci-entific communication, stress and management of effects.
This logic has highlighted how urgent action is needed to mitigate the potentially devastating effects of COVID-19. Many of the implications described here may also be relevant for future pandemics and public health crises.
A report45 of the World Health Organization stated that health communication is considered relevant for virtually every aspect of health and well-being, including disease prevention, health promotion and quality of life.
It is time to strengthen our mental health system in preparation for the inevitable challenges triggered by the COVID-19 pandemic, through gradual assis-tance and the practice of providing the most reliable information46and the most effective and least ex-pensive treatment in terms of resources. By bringing together researchers and professionals from different disciplines and adopting multilevel theoretical ap-proaches, health communication has a unique oppor-tunity in this post-pandemic technological era, that of providing significant inputs to improve the quality of life. We are optimistic.
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BIBLIOGRAPHY
Bai Y., Lin CC, Lin CY, Chen JY, Chue CM, (2004). Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv; 55: 1055–57.
CONSIDERATIONS PRE POST LOCK DOWN.
B. van der Kolk (2015). The body takes the hit. Mind, body and brain in the elaboration of traumatic memories. Raffello Cortina, Milan.
Brooks SK, Webster RK, Smith LE, et al.The psy-chological impact of quarantine and how to reduce it: rapid review of evidence. The Lancet. 2020 March; 395 (10227): 912-920. DOI:10.1016 / s0140-6736 (20) 30460-8.
Burioni, Roberto. Virus, the great challenge (Italian Edition) (positions in the Kindle 496-500). RIZZOLI BOOKS. Kindle edition.
Cacioppo, JT & Patrick, W. Loneliness: Human Nature and the Need for Social Connection. (WW Norton & Company, 2009).
Cava MA, Fay KE, Beanlands HJ, McCay EA, Wig-nall R. The quarantine experience for people affected by SARS in Toronto. Public health nursing. 2005 September-October; 22 (5): 398- 406. DOI:10.1111 / j.0737-1209.2005.220504.x.
Cikara, M., Bruneau, EG & Saxe, RR Us and Them Intergroup Failures of Empathy. Curr. Dir. Psychol. Sci. 20, 149–153 (2011).
Covid-19: feeling safe in polyvagal and neuroceptive reactive emotions. Some reflections by the Board of the Italian Society for the Study of Traumatic Stress, 2020
Crum, AJ, Jamieson, JP & Akinola, M. Optimiz-ing stress: An integrated intervention for regulatOptimiz-ing stress responses. Emotion 20, 120–125 (2020).
Drury, J., Cocking, C. & Reicher, S. The nature of collective resilience: Survivor reactions to the 2005 London bombings. Int. J. Mass Emergencies Disasters
First study on the health conditions of adults one month into COVID-19 lockdown Early evidence of people’s health conditions after one-month of lockdown in China University of Sidney April 2020
F. Shapiro (2010), The trauma treatment handbook: protocols across the spectrum, New York: Norton Professional Books.
Frenkel, S., Alba, D. & Zhong, R. Surge of Virus Misinformation Stumps Facebook and Twitter. The New York Times (2020).
Galea S, Merchant RM, Lurie N. The Mental Health Consequences of COVID-19 and Physical Distanc-ing: The Need for Prevention and Early Intervention. JAMA Intern Med. Published online April 10, 2020. doi: 10.1001 / jamainternmed.2020.1562
Guess, A. & Coppock, A. Does Counter-Attitudinal Information Cause Backlash? Results from Three Large Survey Experiments. Br. J. Polit. Sci. 1–19 (2018)
Gunther Eysenbach, Infodemiology: the epidemiol-ogy of (mis) information, in the American Journal of Medicine, vol. 113, no. 9, 2002.
Haslam, SA & Reicher, S. Stressing the group: Social identity and the unfolding dynamics of responses to stress. J. Appl. Psychol. 91, 1037–1052 (2006). Believing in ’us’: exploring leaders’ capacity to en-hance team confidence and performance by building a sense of shared social identity. J. Exp. Psychol. Appl. 21, 89–100 (2015).
Huang, JZ, Han, MF, Luo, TD, Ren, AK, & Zhou, XP (2020). Mental health survey of 230 medical staff in a tertiary infectious disease hospital for COVID-19. Chinese journal of industrial hygiene and occu-pational diseases, 38, E001.
I. Fernandez, G. Maslovaric, M. Veniero Galvagni (2011), Psychological traumas, wounds of the soul. The contribution of Emdr therapy, Naples: Liguori Editori.
Jackson, JC et al. Ecological and cultural factors un-derlying the global distribution of prejudice. PLOS ONE 14, e0221953 (2019).
Jeong H, Yim HW, Song YJ, et al. Mental health sta-tus of people isolated due to Middle East respiratory syndrome. Epidemiol Health 2016; 38: e2016048.
Jamieson, JP, Crum, AJ, Goyer, JP, Marotta, ME & Akinola, M. Optimizing stress responses with reappraisal and mindset interventions: an integrated model. Anxiety Stress Coping 31, 245–261 (2018).
Kinsman J. ”A time of fear”: local, national, and international responses to a large Ebola outbreak in Uganda. Global Health (2012) 8:15. doi: 10.1186 / 1744-8603-8-15
MEDICAL RESEARCH
intergroup conflict via reciprocal dehumanization. J. Pers. Soc. Psychol. 110, 343- 370 (2016).
Liu X, Kakade M, Fuller CJ, et al. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012; 53: 15–23.
Li, S., Wang, Y., Xue, J., Zhao, N., & Zhu, T. (2020). The Impact of COVID-19 Epidemic Declaration on Psychological Consequences: A Study on Active Weibo Users. International Journal of Environmental Research and Public Health, 17 (6), 2032.
Marzocchi C .; Avico R .; Pandemic covid-19: at home, in balance between fear and resilience, by AISTED - Italian Association of Trauma and Dis-sociation Study on Psychiatryonline (2020)
Maunder R, Hunter J, Vincent L, et al.The immediate psychological and professional impact of the SARS epidemic of 2003 in a university hospital. CMAJ. May 2003; 168 (10): 1245-1251.
MentalHealthUK.Managingyourmentalhealthduringthecoronavirus outbreak.https://mentalhealth-uk.org/help-and-inf
ormation/covid-19-and-your-mental- health/. Ac-cessed March 31, 2020.
Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychol Med. 2008; 38 (4): 467-480. doi:10.1017 / S0033291707001353
Porges, SW (2018) .The guide to polyvagal theory. The transformative power of the feeling of security. Rome: Giovanni Fiorentini Editore
Porges, SW (2004).Neuroception: A Subconscious System for Detecting Threats and Safety. Zero to Three, 5, 19-24.
Porges, SW (2001).The polyvagal theory: phyloge-netic substrates of a social nervous system. Interna-tional Journal of Psychophysiology, 42: 123-146.
Rimal, RN, & Lapinski, MK (2009). Why health communication is important in public health. Bul-letin of the World Health Organization, 87 (4), 247– 247a.
Rajiv N Rimal, Maria K LapinskiBullWhy health communication is important in public health, World Health Organ. 2009 Apr; 87 (4): 247. doi: 10.2471 / BLT.08.056713
Ravizza, Simona. 50 questions about the Corona Virus (Italian Edition). Solferino. Kindle edition.
Reynolds DL, Garay JR, Deamond SL, et al. Un-derstanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol-ogy and infection. July 2008; 136 (7): 997-1007. DOI:10.1017 / s0950268807009156.
Rosenberg AR. Cultivating Deliberate Resilience During the Coronavirus Disease 2019 Pandemic. JAMA Pediatr. Published online April 14, 2020. doi: 10.1001/ jamapediatrics.2020.1436
Schaller, M. & Neuberg, SL Danger, Disease, and the Nature of Prejudice (s). in Advances in Experimental Social Psychology (ed. Zanna, JMO and MP) vol. 46 1–54 (Academic Press, 2012).
Swire, B. & Ecker, UKH Misinformation and its correction: Cognitive mechanisms and recommen-dations for mass communication. in Misinformation and Mass Audiences (eds. Southwell, BG, Thorson, EA & Sheble, L.) 195–2011 (University of Texas Press, 2018).
Van der Kolk, B. (2015). The body takes the hit. Mind, body and brain in the elaboration of traumatic memories. Milan: Raffaello Cortina Editore.
Van Bavel, JJ, Baicker, K., Boggio, PS, Capraro, V., Cichocka, A., Cikara, M., Crockett, MJ, Crum, AJ, Douglas, KM, Druckman, JN Drury, J., Dube , O., Ellemers, N., Finkel, EJ, Fowler, JH, Gelfand, M., Han, S., Haslam, SA, Jetten, J., Kitayama, S., Mobbs, D., Napper, LE, Packer, DJ, Pennycook, G., Peters, E., Petty, RE, Rand, DG, Reicher, SD, Schnall, S., Shariff, A., Skitka, LJ, Smith, SS, Sunstein, CR, Tabri, N., Tucker, JA, van der Linden, S., Van Lange, PAM, Weeden, KA, Wohl, MJA, Zaki, J., Zion, S. & Willer, R. (in press). Using social and behavioral science to support COVID-19 pandemic response. Nature Human Behavior.
CONSIDERATIONS PRE POST LOCK DOWN.
Webster R, Brooks S, Smith L, et al.How to improve adherence to quarantine: quick review of evidence. medRxiv. 2020. DOI:10.1101 / 2020.03.17.20037408
6
SITOGRAPHY
http://temi.repubblica.it/micromega-online/i-pericol i-dell%E2%80%99infodemia-la- comunicazione-ai-tempi-del-coronavirus/
https://www.medicalfacts.it/2020/04/15/coronavir us-conseguenze-sulla-salute-mentale- dellepidemia-covid-19/
https://www.auxologico.it/approfondimenti/psico logia-coronavirus
https://www.dors.it/page.php?idarticolo=3380
https://storieinquarantena.it/
https://www.lastampa.it/cronaca/2020/04/25/new s/ ansia-depressione-e-sensi-di-colpa-l- eredita-psicologica-del-coronavirus-1.38760333
https://www.linkiesta.it/2020/04/coronavirus-italia-trauma-quarantena-uscirne/
http://www.psychiatryonline.it/node/8519
https://www.ncbi.nlm.nih.gov/pubmed/11587772
https://www.valeriorosso.com/2020/03/20/impatto-psicologico-della-quarantena/
https://www.valeriorosso.com/2020/04/11/corona virus-pandemia-di-disturbi-mentali/
https://it.mashable.com/coronavirus/2755/convi
veremo-con-il-trauma-da-pandemia-per-
sempre-ma-laltruismo-ci-salvera
http://www.exagere.it/vivere-il-trauma-emergenza-coronavirus-trame-da-narrare-e-da- elaborare/
https://www.galileonet.it/resilienza-ai-tempi-di-cov id-19/
https://www.who.int/teams/risk-communication
http://www.salute.gov.it/portale/news/p3_2_1_1_1 .jsp?lingua=italiano&menu=notizie&p=dalministero&id =4149
How to cite this article: Mangiapane D.E.,
Vis-cuso D.G.I.Pandemic Covid-19: Psychodynamic
