Research progress on rapid psychological regulation of pathogenic microorganism epidemic situation

Jie Gao,Xing-Ping Che,Yuan Liu,Jian-Min Wang＊,Ce Yang＊

1State Key Laboratory of Trauma,Burns and Combined Injury,Institute of Surgery Research,Daping Hospital,Third Military Medical University,Chongqing,400042,China.

#Jie Gao and Xing-Ping Che contributed this article equally.

Abstract

Keywords:Epidemic situation,Novel coronavirus pneumonia,Psychological stress,Rapid regulation

Background

Major public health events are potential killers that seriously endanger group health. Among them, the biological disasters caused by pathogenic microorganisms pose the greatest threat to human physical and mental health [1-3]. Especially since the 21st century, new infectious diseases such as severe acute respiratory syndrome (SARS) and novel coronavirus disease 2019 (Covid-19) have caused a large number of organ and tissue injuries of patients.At the same time, severe psychological stress exposure is a common complex social phenomenon among patients, family members, medical care and social onlookers. In a short period of time, the related individuals have negative psychological emotions such as fear, anxiety, loneliness, depression, degenerative sexual behavior, somatization symptoms such as insomnia, headache, chest tightness, and post-traumatic stress disorder, which have become the main secondary disasters in the field of population health [4-7]. Therefore, early identification and classified diagnosis and treatment of group adverse psychological stress are not only the basic needs of maintaining the mental health of different levels of exposed population, but also the endogenous power of efficient early warning and rapid intervention in major public health events.

The unpredictability, irresistibility and devastating consequences of major disasters make the victims suffer from serious psychological trauma. Adverse psychological stress refers to the stimulation intensity produced by stress events in a short period of time,which makes people unable to solve their feelings in a conventional way, and thus causes lasting interference to the physical strength, intelligence, judgment and behavior ability of the parties [1-3]. Studies have shown that the incidence of mental disorders after major disasters is 10%-20%,and general psychological stress disorders are more common[8,9].Covid-19 is a global pandemic since 2019. Its spread speed is amazing. It affects more than 30065728 people worldwide. More than half of the human beings have been isolated. The consequences remains worrying.The overwhelming impact of Covid-19 led to the degradation of stimulus defense barriers.The impact of confinement or restriction on mental health brings people a sense of isolation and increases the fear of pathogenic biological infection and death.In particular,many refugees have relied on community interaction,social gatherings or religious ceremonies to seek psychosocial support. Measures to maintain social distance and movement restrictions also affect their ability to cope with emotional distress.

Characteristics of psychological stress of susceptible population in epidemic situation of pathogenic microorganism

The psychological stress caused by the Covid-19 pandemic will lead to wandering thinking and competition for limited cognitive resources. The fear caused by disease, which takes up too much information from the brain, the high degree of uncertainty about the future and the sense of financial insecurity, aggravates the stress, anxiety and depression of people all over the world. Covid-19 also elicited unconscious defensive responses, including compulsive cleaning, aversion, hostility and rejection[10]. According to Italian researchers, family segregation in millions of families across Italy has led to repeated family conflicts and unresolved childhood problems [11]. Previous mental illness has worsened.Health workers, including psychiatrists, psychologists and psychoanalysts, have experienced emotional exhaustion. Finally, delays in mourning and post-traumatic phenomena were observed in families with infection or death. The French scientific community and political authorities are worried that the crisis will lead to a suicide epidemic [12]. Social isolation and quarantine may increase the sense of disconnection and social pain of vulnerable groups.Some people at high risk of suicide may be further affected by the current pandemic: the elderly, medical staff and individuals suffering from economic insecurity.Although isolation measures can prevent the spread of coronavirus, isolation and loneliness can cause severe psychosocial stress and may cause or aggravate mental illness.

The main psychological stress reaction of different people

According to literature reports, during the outbreak of Covid-19, there are two main types of adverse psychological stress, namely psychological experience and stress reaction [13-15]. The psychological experience includes: 1) fear, avoidance and disgust stigmatization; 2)expecting to eliminate the status quo and possibility caused by the virus as soon as possible;3) stimulating the negative memory and association in the heart. The stress response is embodied in psychosomatic performance, seeking self-protection and protecting others. One of the most important aspect is the accuracy of information and the impact of family safety uncertainty on psychology.According to PubMed, Germany, Italy and Russia are the largest sample of data in the world, and China has the most statistical data.The first is the psychological impact of front-line medical staff. Krasovtsevayv, et al surveyed 90 urologists aged 25 to 60,30%of them were worried about Covid-19 infection. In Canada, 47% of medical staff reported that they needed psychological support[13]. Among the 994 medical and nursing staff in Wuhan,China,36.9%of them had subthreshold mental health disorders(average PHQ-9:2.4),34.4%had mild mental disorders (average PHQ-9: 5.4), 22.4% had moderate mental disorders (average PHQ-9: 9.0), and 6.2% had severe mental disorders immediately after the virus epidemic (average PHQ-9: 15.1) [14].According to a multicenter online survey conducted by Professor Zhang Bin of Nanfang Hospital of Southern Medical University in Lancet Psychiatry,1563 medical staff who participated in the treatment of Covid-19 patients in Wuhan were investigated. The results showed that the detection rates of depression, anxiety,insomnia and stress symptoms were as high as 50.7%,44.7%, 36.1% and 73.4%, respectively [15]. The second is the psychological impact of the large sample of ordinary people. According to Büerlea, et al, a cross-sectional survey of German adults showed generalized anxiety (44.9%),depression(14.3%),other psychological distress (65.2%), and fear related to Covid-19 (59%). Among them, the mental burden of women and young people is higher. There was a positive correlation between increased fear and Covid-19 [16]. A study in Ethiopia in April 2020 indicated that compared with the estimated data before the new Covid-19 pandemic, Ethiopians were three times more likely to suffer from depression [17].Parents in Italy and Spain reported that their children had difficulty in concentrating and showed signs of irritability, agitation and nervousness. Home isolation increases the risk of children witnessing or being subjected to violence and abuse. Children with disabilities, living in crowded conditions and living and working on the streets are particularly vulnerable[18].A study of young people with a history of mental illness in the UK reported that 32%of them agreed that the Covid-19 epidemic had worsened their mental health. The epidemic situation has a great impact on the mental health of refugees, displaced persons and stateless people [19]. Taking China as an example, in 2020,with the dynamic changes of Covid-19 epidemic situation, the epidemic situation in China will gradually spread from imported cases to communities,families and public places, and the cases of the third and fourth generations will increase gradually, which will lead to different groups' psychological stress responses. From January 30 to February 13, 2020,Huilongguan Hospital in Beijing, China, issued online self-assessment tools of mental health through Wechat and other media platforms, including self-reporting Questionnaire-20 (SRQ-20), patient health questionnaire (PHQ-9), and generalized anxiety disorder scale-7 (GAD-7), The mental health status of 14592 ordinary people in 31 provinces (autonomous regions and municipalities directly under the central government) was investigated and evaluated. The positive detection rate was used as the outcome index.The positive rate of SRQ-20, PHQ-9 and GAD-7 was 33.2%, 53.5% and 44.6%, respectively. Except for a few areas, the positive detection rates of SRQ-20,PHQ-9 and GAD-7, as well as the degree of acute stress, depression and anxiety were roughly the same in all parts of the country. Among them, the anxiety level of Hubei people (GAD-7 positive detection rate of 54.7%) was significantly higher than that of other provinces [5]. In addition, some scholars have investigated the emotional state of more than 30000 college students in China.Through these analysis, it is found that the students in February,especially those in Hubei Province, have an emotional "infection point".At the beginning of the epidemic, college students in Hubei were calmer than those outside Hubei. In contrast, during the epidemic period, college students in Hubei were more nervous and afraid than those outside Hubei. This epidemic makes students experience great pressure and negative emotions [21].It can be seen that Covid-19, as a public health emergency of international concern,has brought strong psychological impact to the people of different ages,occupations and psychological feelings. In the early stage of the outbreak, the public is in a general group crisis, and anxiety and depression are more prominent,especially in the areas with severe epidemic.According to longitudinal studies of incidence rate of long-term mental disorders among SRAS survivors in China, Hongkong scholars showed that the prevalence rate of mental disorders was 33.3% at 30 months, and 25% of patients was posttraumatic stress disorder syndrome (PTSD), 15.6% of them were depression.The incidence of mental disorders was 56.9% [22]after one and a half years of SARS epidemic situation in Hongkong. Therefore, early and effective psychological intervention after the occurrence of public health emergencies is very important to curb adverse psychological stress and chronic psychological trauma. At present, the world is developing Covid-19 vaccine independently and has been approved to enter clinical trials, but the preventive use time is delayed.Therefore, in the face of biological disasters with high mortality, human beings have not been able to cope with them calmly. The typical psychological stress is:"psychological shock period, psychological conflict period-be"

Psychological intervention objects of major epidemic situation

The psychological intervention objects of major epidemic situation can be divided into three categories.(1)Virus infected people:These people are currently in a state of intense stress, with varying degrees of physical discomfort, coupled with the limitations of national medical treatment in the initial stage, the individual psychological experience throughout the whole treatment process, and the possible physical and mental trauma will last for a long time. Psychological intervention needs to be continuously followed up and prepared for intervention from the scene and to the follow-up. Russian researchers mentioned that urologists at the front line of infection said that by cooperating with Covid-19 patients, doctors could better control what is happening and maintain a stable mood [11]. The author also consulted in detail the news reports of Dr. Li Wenliang of Wuhan Central Hospital, Professor Lin Zheng of Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, and Liu Zhiming, President of Wuchang Hospital in Wuhan.They still dealt with the news and busy work in ICU,and are not only full of confidence in high-level treatment conditions, but encounter the key physiological index,blood oxygen saturation.Liu,who was accustomed to life and death, showed instinctive fear. (2) The family members of those who died of infection: If their family members are children, they are more likely to feel sad and emotional on the spot;more attention should be paid to those who have lost their spouse or children, and the impact of the disaster on this group may last for a long time. The psychological intervention of bereavement is a special psychological support technology, which was introduced by Professor Ji Jianlin of Shanghai. (3)Front line personnel involved in the rescue:the fatigue of continuous high-intensity work, and the sense of depression that the infection risk of medical staff is not in line with their expectations after unconventional efforts, may have a considerable negative impact on the scene and prognosis of such people,and the degree of influence of some people may be more severe than the psychological trauma of the family members of the infected dead. As Antonio Gutt, Secretary General of the United Nations, said in the epidemic situation and mental health, the most dangerous are front-line medical staff, the elderly, teenagers and young people,patients with original mental illness and people trapped in conflicts and crises.

Timing of psychological intervention for major epidemic situation

The psychological intervention of major epidemic situation should start with medical assistance and run through the whole process, but the emphasis of different stages is different. (1) Early intervention,empathy listening: this stage mainly focuses on rescue and rehabilitation treatment,which is mainly for rescue workers and medical workers, mainly to ensure the emotional stability of rescue personnel. It is also fully understandable that all kinds of possible negative emotions are diffused in the crowd due to expectation,disappointment and non acceptance of reality. During this period, the intervention measures of psychological workers are often to agree with the normal release of these emotions,and the work they do is to observe and accompany them, so as to prepare for possible individual emergencies. For the infected, correct information, family accompany and encouragement of the rescuer are indispensable. (2) On the spot crisis intervention:after the death of the infected person,due to the rapid chemical prevention and treatment policy of the remains during the infection period, the psychological trauma to the bereaved family members who are sick or not is far different from ordinary large-scale death accidents. There is no place to place the bereavement, which requires the psychological counselors to have better communication and counseling skills. The other is that the mental state of the rescue workers, such as medical staff and funeral workers, is temporarily broken down due to fatigue or depression.Psychological workers must be prepared to enter the working state of crisis intervention at this time.At this stage,we should avoid the participation of people with more enthusiasm and less experience, and let experienced and stable psychological counselors work together with psychiatrists. (3) Continuous post disaster follow-up psychological counseling: according to the literature and rescue information of previous disastrous accidents,the psychological state level of all kinds of related personnel involved may change continuously after the event, and the occurrence of major psychological problems and behavioral consequences successively occurred in the period from 3 months to 1 year after the event [24].Therefore, it is necessary to establish the corresponding monitoring mechanism, in addition, the medical staff should also set up a team of psychological rehabilitation professionals to follow up.

Common psychological intervention methods and mechanism of fatal epidemic

Qiu et al. reported that a national survey conducted in China showed that at least one third of the participants said they had psychological distress [25]. Health care providers, especially those in the front line, are also likely to face greater pressure. Stress makes them in a fragile state, in which they are more likely to suffer from psychological distress,alternative trauma or acute stress disorder. Stress may also develop into a pathological disease, such as post-traumatic stress disorder (PTSD), anxiety and depression. In view of the emergency psychological intervention in the treatment of major epidemic situation, warm-hearted and responsible psychological organizations usually spontaneously use psychological hotlines, psychiatrists and psychological questionnaires to carry out different levels of psychological intervention. The author advocates fast and simple psychological intervention methods, including art, religion, qigong, yoga,psychoactive substances and other strengthening behaviors (such as gambling, video games, watching pornography), etc., which can effectively reduce or alleviate psychological tension and anxiety [25].Tiktok and its telephone interventions include:information and communication technology (such as China's Kwai Tat and voice platform, Covid-19 Care platform), telemedicine. Among them, the newly emerged brief methods are: the ultra-brief psychological intervention UBPI skills promoted by Malaysia, including a variety of technologies of evidence-based psychological intervention, including cognitive behavior therapy (CBT), acceptance and commitment therapy(ACT),dialectic behavior therapy(DBT), motivation interview (MI), early intervention plan(EIP),and collaborative skills such as Team based problem solving, shared decision-making and validation skills were promoted at the first international conference of the psychotherapy division of the World Psychiatric Association.In early February 2020, 25 hospital nurses working in the front line of Covid-19 were tested. One month later, the feedback from nurses was positive. Ultra-brief psychological interventions (UBPI) were subsequently adopted as a large-scale preventive feedback measure. The advantages of UBPI is easy to adopt, train, and use,which means it can be quickly extended to other centers. All of this can also be done online, thus eliminating the geographical constraints of trainers,suppliers and customers [26]. The main defect and criticism of UBPI is the lack of quantitative evidence,and there is no single measurement tool that can cover various forms and theoretical backgrounds of psychological skills. There are also scholars in the United States promoting MINDBODYSTRONG plan,which includes 8 manual operations with 45 minutes per week. Data were collected at baseline, after intervention, and 3 months after intervention. These data measured stress, depression, anxiety, healthy lifestyle beliefs and behavior, and job satisfaction.Compared with the attention control group, the scores of mental health variables, healthy lifestyle beliefs and healthy lifestyle behaviors in the intervention group at two follow-up time points were significantly better than those with moderate or large degree of positive influence [27]. As an evidence-based intervention,MINDBODYSTRONG plan has great potential in improving mental health, healthy lifestyle beliefs and behaviors, and job satisfaction in newly licensed registered nurses (NLRN). However, this method is still in the trial observation stage, and the article has not been cited by other research institutions.

However, the author pays more attention to the methods with clinical trial basis and effect. Among them, eye movement desensitization reprocessing(EMDR) is a psychological treatment method with better clinical effect. It can help people obtain treatment from troubled life events and reduce the interference of symptoms and emotions.After research and practice, EMDR founder developed from a simple technology to an integrated treatment method with strict operation process, and further developed from the initial eye movement to the form of bilateral attention stimulation such as tone,hand beat and so on.According to the report on the treatment of PTSD in veterans, Carlson et al. found that under the condition of EMDR, 35 PTSD veterans were treated by self-report, psychological measurement and standardized interview, and the effect was significant compared with the biofeedback assisted relaxation group and routine nursing treatment auxiliary treatment group, and the effect was significant after 3 months. The follow-up was still effective [28]. Boccia et al.conducted a meta-analysis of functional magnetic resonance imaging (fMRI) on PTSD after serious traffic accident injury [29]. The results showed that PTSD after serious traffic accident injury was characterized by nerve modification in the anterior cingulate cortex. EMDR for 3 months can effectively stimulate the anterior cingulate cortex to conduct fear desensitization. The authors searched PubMed and PsychINFO databases and found that EMDR was related to the reduction of desire, fear and depression,emotion regulation and management,and improvement of self-esteem. EMDR has been recommended by American, British and Australian armies to deal with military psychological stress because of its simple operation, short time-consuming, high participation in mental illness and wide application.

Presently, the mechanism of eye movement desensitization and reprocessing is a hotspot in the field of neuroscience and cognition in the world.According to the latest literature [30], most scholars agree that eye movement desensitization is used in the psychotherapy of severe PTSD, and the treatment mechanism is that the feed forward inhibition loop of cingulate gyrus inhibits the activity of fear coding cells and is highly stable, thus promoting psychotherapy.The amygdala, the core neural matrix of fear learning,was inactivated by task oriented eye movements(working memory tasks). Some studies have shown that the amygdala may participate in the dorsolateral and ventral prefrontal cortex pathways and inhibit the nerve transmission in the basolateral amygdala,indicating that behavioral manipulation can change emotional memory by inhibiting amygdala activity. In the treatment of eye movement desensitization and reprocessing, double task method is used, that is,horizontal eye movement while recalling aversion memory can reduce the vividness and/or emotional experience of aversion memory. Collectively, these findings reveal the neural circuits of EDMR's psychological regulation, which may be an effective strategy to continuously reduce traumatic memory by directly intervening the neural circuits. Cuperus et al also found that visual spatial task might be suitable for clinical treatment environment, and virtual reality paradigm combined with EDMR treatment can provide induction of negative memory and implement effective and stable psychological regulation of fast reading[31].The author's team also used smart phones and graphene as a new material to develop app to quickly adjust stress psychology. It is expected to make some beneficial attempts in response to the current global epidemic or future disaster psychological stress response.

Perspective and challenge

During the epidemic period, the psychological stress problems of rescue participants, virus infected survivors and contacts and their countless associates are only accompanied. However, because people are the core of complex social and economic life problems,it means that the psychological distress of major epidemic situation will also change in different stages of the development and control of the epidemic. The outbreak of Ebola in West Africa from 2013 to 2016 is the most serious epidemic in history, with more than 28000 cases and 11000 deaths. Among them, nearly 900 medical and nursing staff were infected with Ebola virus, and more than 500 medical staff died, which caused serious psychological stress, including fear of death and experience of witnessing others' death, and survivors' shame or internal humiliation Guilt (e.g.,spreading infection to others), stigmatization and exclusion from the community [32]. This results in the periodic panic in the community, which leads to the decline of public trust in health services, the interruption of community interaction and even community collapse. The outbreak has seriously affected the health system of the affected countries,resulting in an increase in the demand for health services, a decline in the quality of life and national economic productivity, and the collapse of the social system. These experiences in the process of fighting against the epidemic situation in West Africa have very good reference significance for psychological stress protection in the Covid-19 epidemic. The first is the correct public health information guidance of media practitioners. According to literature [31],during the outbreak of avian influenza, Japanese researchers counted 154 internet news sites,and 77.9%of the media information was uncertain, that is, it might be rumors or information that could easily cause panic among the public. From the very beginning, our country has published transparent and true epidemic information through the World Health Organization(WTO)and the central authoritative media.In addition,vaccine development, humanized personnel care, and restoration of normal living order are all conveying the effective positive energy of the country in fighting against the epidemic and rescuing disasters. Secondly,for the Covid-19 outbreak in China, we suggest that psychiatrists and other mental health specialists should be gathered together in the management team. We should synchronize different levels of media mediated mental health education and training. With the rapid development of network technology and the strong contagion of disease, online mental health service has become the mainstream way of mental health service during epidemic prevention. As countries around the world prepare to cope with the escalation of the epidemic, it is also expected that governments should pay attention to effective methods, disseminate unbiased Covid-19 knowledge, teach correct containment methods, ensure the supply of basic services /commodities, and provide adequate financial support. Frontline clinicians have access to easily available tools, including adaptive and transformational approaches to power and meaning,health apps, mindfulness and gratitude. Achieving early warning signals for anxiety, depression, drug abuse and PTSD is important for access to safe and confidential resources. Implementing health strategies can improve flexibility, resilience and prospects. Since January 23 of 2020, the author also launched the psychological counseling service mainly based on EDMR therapy, and applied the remote service of mind management APP, which showed a positive and benign working state in information provision and psychological support. Again, it will be more meaningful if we can develop more eye movement desensitization regulation or more simple emergency psychological adjustment technology combined with virtual reality, mobile media and artificial intelligence technology. At present, the improved artificial intelligence, such as the rescue of AI tree holes in China, the AI dialogue video supported by bereavement, etc., is a direction worthy of attention.Covid-19, as warned by the WHO extensively, is like an unforeseen pandemic, causing anxiety and unpredictable suffering of the people throughout the world. We look forward to creating an era of higher psychological sensitivity and more extensive psychological intervention for those who need support at all levels.