Letter to the Editor: Targeting adverse stress-related consequences of the COVID-19 crisis in individuals with psychotic disorders and childhood maltreatment

The novel coronavirus disease (COVID-19) has created unprecedented global health and social challenges. Between December 2019 and April 2021, over 149 million cases of COVID-19 have been diagnosed worldwide (WHO, 2021). As the number of infections and deaths continues to surge, governments have (re)introduced restrictions such as lockdowns, no-contact regulations and quarantine. Despite the fact that the pandemic affects the life of the vast majority of individuals, several subgroups are at particularly high risk for adverse consequences.

Psychosis is a mental health condition that requires specific attention in the context of the COVID-19 pandemic. It has been demonstrated that stressful life events are an important risk factor for the exacerbation of psychotic symptoms (Norman and Malla, 1993). Given their vulnerability to social determinants of mental health (Anglin et al., 2020), people with psychotic disorders (PD) may be at risk for adverse consequences of stress associated with physical distancing and reduction in social connectedness during the COVID-19 pandemic. In turn, abrupt changes in life circumstances disproportionally affect people with PD (Brown et al., 2020), while lockdown and social distancing have disrupted much of the professional support available to them under normal circumstances.

During this prolonged period of crisis, the need for mental health and psychosocial assistance will likely increase in individuals with PD, due to the complex and multiple stressors and difficulties associated with the pandemic. In fact, many of the critical psychosocial stressors of the COVID-19 crisis will probably remain for a longer period of time. It is, therefore, a critical time window for the development of novel interventions for these patients, in order to reduce the burden and costs associated with adverse stress-related consequences of the COVID-19 crisis.

We want to highlight that among the vulnerable group of individuals with PD, those with a history of childhood maltreatment (CM), i.e., physical, emotional and sexual abuse, and physical and emotional neglect, need specific attention. We argue that there is a need for 1) further research on the cumulative effects of CM and COVID-19-related stressful events (Fares-Otero et al., 2020) in individuals with PD, and (2) for designing specific treatments to account for these specific effects on the course of PD. Such interventions for the particularly vulnerable group of individuals with PD who have a history of CM would make a difference during the COVID-19 crisis.

In addition to its important role in the aetiology and course of PD (Kelleher et al., 2013), CM is a highly prevalent vulnerability factor that can put individuals with PD at higher risk for stress. At least one form of CM is reported in 50% of patients with schizophrenia (Morgan and Fisher, 2007). CM is one of the most important environmental stressor (Lardinois et al., 2011) associated with brain alterations (Teicher et al., 2016) that can put individuals with PD at particularly high mental health risks when exposed to a stressful environment such as the COVID-19 pandemic and corresponding measures.

More specifically, CM plays a significant role in PD, increasing the risk of neurocognitive (Mørkved et al., 2020; Schalinski et al., 2018), social cognition (Kilian et al., 2018), behavioural problems and functioning (Copeland et al., 2018). Therefore, individuals with PD and CM survivors may be particularly vulnerable when facing the COVID-19 pandemic (Hamam et al., 2021). That is, COVID-19 related measures might contribute to a more severe and unstable illness course, characterized by an increased risk of neurocognitive difficulties (e.g. attention, planning) and behavioural problems (e.g. impulsivity, risk-taking behaviours increasing the risk of becoming infected with COVID-19) in individuals with PD with (versus those without) CM.

To date, no specific treatment targeting stress-related consequences of COVID-19 exists for patients with PD and CM. However, Cognitive-Behavioural Therapy (CBT) approaches are highly promising in this regard and might increase resilience to the stress caused by the COVID-19 pandemic. Against the above outlined background (see also Fig. 1 ), in this letter we suggest that the CBT program has to meet certain requirements accounting for the specific characteristics of individuals with PD and a history of CM and to include specific components to be effective. Specific components that might prove effective are psychoeducation, verbal or written recounting of traumatic experiences, cognitive restructuring, behavioural activation, problem-solving, emotion regulation and communication strategies.

Fig. 1.

Conceptual scheme about stress-related consequences of COVID-19 crisis and targeted Cognitive-Behavioural Therapy for individuals with psychotic disorders and childhood maltreatment.

Psychoeducation as part of such a CBT program for individuals for psychotic disorders and childhood maltreatment (CBT_PD-CM) could include information on both psychosis diagnosis and aftereffects of CM and the rationale for CBT techniques with a special focus on stressors and experiences related to the COVID-19 pandemic. Furthermore, the CBT_PD-CM program should provide a supportive treatment environment in which PD patients with CM are encouraged to talk about their past (and current) stressful experiences, including verbal or written recounting of events (Jaeger et al., 2014). The trauma exploration, formulation, historical review and attributional work can be carried out as long as the patient is stable enough to tolerate the experience (van den Berg et al., 2016; van den Berg et al., 2018).

We propose to combine cognitive restructuring and behavioural activation (practicing new resources) with problem-solving skills to develop new perspectives to deal with fear and brooding. In turn, it is important that patients are given the possibility to process stressful and adverse events, including traumatic experiences (where necessary, preceded by psychological stabilization), to account for the specific characteristics of patients with PD and CM. A sense of the world being dangerous in individuals with CM can lead to hypervigilance to (potential) threat related stimuli and to increased attention to unpleasant events. This may, in turn, be related to concentration problems, irritability, anger, withdrawal, and difficulties in thinking about the future (Lu et al., 2017). In addition, it therefore seems crucial to include attention training, planning strategies as well as relaxation strategies.

Moreover, emotion regulation plays a mediating role between CM and distressing psychotic experiences. In fact, difficulties in emotion regulation and higher symptom distress exacerbate each other (Lincoln et al., 2017). The experiences of physical distancing and loneliness (effects of contact restrictions and isolation) can trigger memories of past losses experienced earlier in life in PD patients with CM. Affected individuals may fear that things will never return to normal or that the future will mean further losses. Therefore, reinforcing emotion regulation strategies (Guimond et al., 1017), including (online) relaxation, mindfulness and imagination techniques to identify and modify automatic thoughts related to distressing emotions might be effective skills to cope with COVID-19 related stressors. In this respect, therapists may want to stress that core (negative) beliefs and emotions (e.g. worry about COVID-19 infection) are situation specific, rather than being fundamental to the patient, thus helping with re-attribution, encouraging alternative ways of coping and reducing distress.

Importantly, there is a need to improve social (media) interactions and interpersonal communication strategies of patients. Individuals with PD are particularly socially isolated, and commonly face stigma and discrimination. Likewise, a fear that people will treat them differently because of CM is common (Hardy et al., 2016). Thus, CBT_PD-CM delivered in groups may be especially advantageous, which can present individuals with PD and CM with an opportunity to interact with peers and benefit from the interpersonal feedback to improve their ability to express emotions, as well as to maintain social relationships and deal with grief for the loss of loved ones.

Both content and setting have to meet several requirements. Where necessary, remote or internet-based digital platforms can provide viable routes for the delivery of CBT_PD-CM during limited access to health services during lockdowns. Important, clinicians will need training in (remote) CBT_PD-CM. We also recommend (online) supervision to keep them on track with the delivery of CBT_PD-CM. Finally, research is needed to test the feasibility, acceptability, and effectiveness of our proposed approach in reducing adverse effects of COVID-19 in this vulnerable population. While our suggestions are specific for individuals with PD and CM, they might also in part be applicable, possibly in an adapted format, to a broader range of COVID-19 stress related disorders.

In summary, individuals with PD and CM constitute a high-risk group for adverse consequences of the COVID-19 crisis, which has been underrecognized so far. Past experiences of CM in these patients may influence their responses to the pandemic and related measures, increasing the risk of difficulties in cognitive and social functioning. Further research is needed on the cumulative effects of prior chronic (traumatic) stress and the COVID-19 crisis in individuals with PD. We point out that PD patients with CM are in need for tailored treatments and propose to develop and test the effectiveness of specific CBT_PD-CM programs that might be particularly effective for these individuals to improve their mental health and psychosocial wellbeing during and after the pandemic and future crises.

Declaration of competing interest

Dr. R. Rodriguez-Jimenez has been a consultant for, spoken in activities of, or received grants from: Institute of Health Carlos III, Sanitary Research Fund (FIS), Biomedical Research Networking Centre in Mental Health (CIBERSAM), Madrid Regional Government (S2010/BMD-2422 AGES; S2017/BMD-3740), Janssen Cilag, Lundbeck, Otsuka, Pfizer, Ferrer, Juste, Takeda, Exeltis, Angelini, and Casen-Recordati.