 Good morning esteemed colleagues. Today I would like to discuss the psychological implications of the COVID pandemic and I would like to focus on one model in trauma psychology but mention others. We can discuss the aftershocks of the pandemic by using several models. A very famous model was invented by the Swiss psychologist Elizabeth Kubler-Ross and it is the cycle of grief. She identified five stages of grief and mourning and what has happened with the pandemic is the equivalent of an external shock such as for example the death of a loved one or a divorce or being fired, becoming unemployed, etc. In all these situations there is a reaction that is tantamount equivalent to grief and mourning and she identified five stages denial followed by anger, bargaining, depression and acceptance. Now I'm not sure what this webinar represents if it represents denial of the pandemic or acceptance of the pandemic but at any rate these are the stages that she's identified. She made very clear that these stages are not consecutive. People can go back and forth which I think we have been doing in the past six months as the news about the pandemic have changed from hope to despair and back to hope and back to despair. Lockdowns imposed, reimposed, abandoned and then applied again. We are being subjected to what is called in psychology intermittent reinforcement, bad news followed by good news, followed by bad news, followed by good news and this is eroding our psychological immune system and leading to something which is called narcissistic modification. Narcissistic modification is a second model that I would like to mention and it is the intense fear I'm quoting from Freud, Zygmunt Freud who was the first to describe narcissistic modification without calling it so. So Ronningstam, a famous psychologist, paraphrased Freud. So narcissistic modification is the intense fear associated with narcissistic injury and humiliation. The shocking reaction when individuals face the discrepancy between an endorsed or idealized view of the self in a drastically contrasting realization. This is what the pandemic has done to us. It forced us to look in the mirror. We can no longer avoid ourselves. We can no longer look away. We can no longer flee or run. The pandemic has forced us to take a time out, consider our lives, consider our societies, consider our healthcare systems, consider issues such as racism and implicit discrimination and bias, consider the relationships between minorities and majorities between men and women, consider the interpersonal interactions within couples, among friends in workplaces. Working away from home is another experience to working in an office. So we are subjected to a psychological experiment, the likes of which has never happened before. Not even in previous pandemics such as the Black Death in the 14th century or the Spanish Flu, the beginning of the 20th century, not even then were we subjected to one-tenth of the psychological stresses, dislocations, disorientation and fears that we are facing today. Rothstein, another psychologist, wrote that narcissistic modification is a fear of falling short of ideals with a loss of perfection and accompanying humiliation. And this fear extends to intimacy in interpersonal relationships, as Fiskalini noted, unrealized or forbidden wishes and related defenses, as Horowitz noted, or as Kogut so aptly summarized it, he usually summarized things well. It's the fear associated with rejection, isolation and loss of contact with reality, loss of admiration, loss of equilibrium, loss of important objects. Is this not a perfect description of our condition today? Kernberg augmented this list by adding fear of dependency, fear of destroying the relationship with important significant others, fear of retaliation of one's own aggression and destructiveness and of course fear of death. And this comprehensive list which comprises narcissistic modification is a perfect description of the absolute universal condition that we are all faced with today. Narcissistic modification is therefore a sudden sense of defeat, loss of control over internal and external objects or realities caused by an aggressive event or person, by a compulsive trait or behavior. It produces disorientation, it produces terror, not fear, terror. It produces a damning up of narcissistic or ego or libido defenses. This was described by Eidelberg in the 50s. The entire personality is overwhelmed by impotent ineluctability and a lack of alternatives. There is a process that today we call decompensation. All our defenses are not working. None of our, I mean our habits, the coping strategies we have developed, everything is rendered useless in this new environment. It's an inability to force objects to conform to or rely on goodwill. Modification reflects the activity of infantile strategies of coping with frustration or repression. And it creates grandiosity and attendant psychological defense mechanisms, primitive ones, like splitting, denial, magical thinking. What I'm trying to say before I come to the third and last model is that the pandemic is pushing us, regressing us, pushing all of us to become children again, children in the sense of a feeling of helplessness and trying to compensate for this feeling of utter helplessness via grandiosity or disintegrating completely. It's a bad, bad situation and it's been going on for six months already. The pandemic of COVID-19 hit everyone simultaneously as a universal, inescapable external shock. Several elements in the progression of the pandemic rendered it very traumatic. Number one, the exponential inexorable contagion which fosters a feeling of impending doom. That's an extreme stressor. Number two, the extreme uncertainty regarding every facet of the disease. We don't know anything or close to anything about the pathogen, the nature of the illness, the long-term social and interpersonal effects of the desperate and ever-escalating attempts to rein the virus in. This all-pervasive ubiquitous uncertainty leads to rising rates of anxiety, depressive helplessness, hopelessness, suicidal ideation, disorientation and dissociative symptoms which I will come to a bit later. Number three, the pandemic creates a lack of clear horizon and a clear timeline. In this agenda, a sense of alarming insecurity. Number four, there's a mortal fear of disability and death. Simple. We're afraid to die. Number five, the familiar, one's own body, one's nearest and dearest, one's family, one's habits, one's familiar landmarks. All these have been transformed into alien, menacious, estranged entities to be avoided on the pain of life as a condition for survival. We must avoid the familiar. We must suppress our habits. We must avoid the people who provide us with sacor, with support, with a safety network, psychological safety network. We must avoid all this. We are on our own in the purest, existential sense of the word for the first time, perhaps, in everyone's other life. There's a breakdown and incapacitation of all support networks, human and even non-human technologies. The COVID-19 pandemic is a major traumatic event and the question in this presentation, will it result in mass post-traumatic stress disorder or will we simply dissociate the events and return to normal, return to normal the minute an efficacious vaccine or a cure are found? It's an interesting question. Some people say after the pandemic, everything will change, even if there's a cure, even if there's a vaccine, even if a virus were to vanish tomorrow, everything will have changed. And some people say nothing will change, everything will continue as before. And some people say we will be so traumatized, we will be in the throes of complex trauma, complex post-traumatic stress disorder. In countries which succeeded to control the outbreak, the indications are, I'm sorry, in countries that succeeded to control the outbreak, the indications are that people are not experiencing PTSD. What people do in these countries, for example, Thailand, South Korea, China, New Zealand, these are countries where the outbreak has been stamped out largely. In these countries, people develop traumatic dissociation and this gives rise to anxiety and depression. And I suggest that there are homogenizing effects worldwide. I think in today's world what happens in China happens in Russia, what happens in Russia happens in Israel, what happens in Israel happens in Saudi Arabia, what happens in Saudi Arabia happens in the United States. It's a single global village. There are powerful homogenizing effects worldwide, mediated via social media, via the mass media, via identical measures introduced by political and medical authorities in every corner of the globe. We are all undergoing the very same experience, never mind where we are. It's the first time in my view in human history that every single individual, regardless of where he is, what language he speaks, what culture he belongs to, what society he hails from, every single individual has the very same experience simultaneously. This is like a vibe, a frequency and we all found ourselves riding the crests of this frequency. This homogenization led to a collective trauma, collective trauma and the formation of collective responses replete with dissociative symptoms. But to understand this collective trauma we need to discuss a model in trauma psychology known as structural dissociation. Freud and Breuil observed in 1893, that's a long time ago, 140 years ago. They observed in 1893 that individuals with alleged trauma memories go through numbing, detachment, amnesia and avoidance of triggers and memories. And they also observed that the very same individuals, despite their attempts to avoid a repeat of the trauma, retraumatization, despite all this, they're being triggered consistently. These people become susceptible, vulnerable and they are triggered easily. And trauma is the main topic of study of early psychoanalysis. Now different structures of personality experience too much or too little and different people experience too much and too little. There's the new concept of highly sensitive persons, HSPs. Structural dissociation is the theory in trauma psychology that dissociation is not mainly a defense mechanism against trauma. Dissociation is not merely trying to forget the trauma, trying to deny the trauma, trying to ignore the trauma. No. Dissociation is a failure, a failure in integration of content that is intolerable, unbearable, threatening, frightening, terrorizing and destructive. It's a failure, it's an integrative deficit, failure to integrate. And the symptoms of such failure are both psychopharm and somatopharm. They manifest in the psyche, in the mind, and they manifest in the body. Integration and adaptive behavior depend on synthesis, depend on associating all the components of experience and all the functions into meaningful coherent mental structures. And these meaningful coherent mental structures crucially depend on narratives, on stories, what Betelheim called the enchantment of fairy tales. We all tell ourselves fairy tales. It's a form of self soothing, of making the world meaningful, rendering it meaningful. Because without meaning, we disintegrate. We can survive hunger. We can survive thirst. We can survive anything. We cannot survive meaninglessness. So we are storytelling species. And yet the pandemic ruptured our ability to create meaningful coherent narratives. We can't put together these new experiences because we are not functioning. Experiences go with functions across time and episodically. So we fail in this pandemic. We fail in synthesizing. And the second function in integration is realization. It's the analysis and assimilation of such information via two processes, personification and presentation. Personification is taking ownership of what's happening to you. What's happening to me is happening to me. And to a large extent, I'm responsible for it. I'm in control of it. And that's a story we cannot tell ourselves in this pandemic. We did nothing wrong. Well, almost nothing wrong. It happened to us. It's not us. There's no possibility to own the pandemic. And the second process is presentation, bringing the past and the future to bear on the present, rendering the present meaningful by connecting it meaningfully, significantly, narratively to the past and to the future. How can you do that when there is a rupture in time? The pandemic disrupted this sequence. The pandemic has nothing to do with the past. And hopefully nothing to do with the future. It's an island, a temporal island. It does not allow for mindfulness and reflexivity. And deep personalization is a failure in personification. It's a kind of semantic, not episodic memory. We remember the pandemic verbally, but we don't really assimilate it. We don't really digest it. We still wake up in the morning thinking to ourselves, this must all have been a nightmare. It can be true. And then it is true. Trauma reduces integrative capacity. In premorbid personalities with low integrative capacity, trauma leads to dissociation. And post traumatic dissociation is not the same like a mere dissociative process. We all have dissociation all the time. We all dissociate all the time. Normal dissociation. For example, most of you are dissociating when you are listening to my presentation right now. I don't blame you. Dissociation is normal and dissociative processes are integration failures, but useful ones. But in the case of the pandemic, the dissociation is likely to produce severe trauma. And it's likely to result, as Jeanette said in 1907, it's likely to result in a fracture, fragmentation to or more systems of ideas and functions that constitute personality. Jeanette said that the reaction to trauma is sometimes the fracturing of the personality. It's the outcome of the inability to integrate, owing to physical illness, exhaustion, stressors, or a young age. Dissociation leads to pathological alterations in consciousness, to greater emotivity, emotional ability, dysregulation of emotions, reactive behaviors, reactive beliefs. As early as 1922, Mitchell wrote, each of these psychobiological systems has its own unique combination of perception, cognition, effect, and behavior. Each has its own sense of self, no matter how rudimentary. And the American Psychiatric Association, 80 years later, in 2000, when it published the DSM-4, the APA wrote, dissociation is the breakdown of the disruption in usually integrated functioning. We must carefully distinguish between structural dissociation, dissociated self-states, dissociated personalities, up to, for example, dissociative identity disorder, multiple personality disorder, also known as tertiary structural dissociation. So this is one type. Then there are dissociative phenomena, and then there are non-dissociative self-states or personality states, atypical states. The structural dissociation theory rejects these states as reification, but they probably do exist. The whole idea is that we have action systems. These are inborn, self-organizing, self-stabilizing, and homeostatic emotional operating systems. We all are supposed to have two of these. The first one guides daily living and the survival of the species. The second action system is a physical defense against threat. Both are triggered badly by the pandemic. The pandemic does not allow us to continue with daily life, threatens our survival, and in our worst darkest nightmares, possibly the survival of the species, and provokes our physical defenses against threats. For example, the excretion of stress hormones. When you put these two action systems together, you get a social defense against abandonment and against rejection. That's precisely the component that goes haywire in borderline personality disorder. You get an inter-receptive defense against mental content. These are defense mechanisms, primitive ones like splitting or sophisticated ones like passive aggression. So when you trigger the two systems together, which is rare, which is what the pandemic is doing, you get social dysfunction because you feel abandoned and rejected. Social distancing, social isolation, we know rationally that it has nothing to do with us. It's not our fault. But in the primitive reptilian part, if you wish, of our brain, we perceive this as abandonment, as rejection, and we defend against this and other mental content which the pandemic provokes. Charles Samuel Myers in 1940 observed in acutely traumatized war veterans that the first action system is linked to something that he called apparently normal part, A&P. The second action system is linked to emotional part, EP. Myers called them personalities, but today we call them parts. The emotional part contains vivid trauma recall, flashbacks, vehement negative emotionality. It's associated with fear, with horror, with helplessness, with anger, with guilt, with shame. But it could also manifest as listlessness, non-responsiveness, submissive behavior, or as derealized or depersonalized dissociation. These are all commonly linked to body dysmorphia to a sense of separate self. And all these reactions are acutely provoked in the pandemic. All you have to do is sit one night with a hotline, with a support line, and listen to people calling in. All these reactions are provoked big time. A&P, the apparently normal part, the job of that part is to repress traumatic memories, to avoid triggers. And the A&P will do anything to avoid the onslaught of ego-dystonic, threatening, frightening dysfunctional content. The pandemic is flooding us daily via the mass media directly, indirectly. And when we witness people around us, including nearest and dearest and loved ones, falling ill, the pandemic is flooding us with this kind of countervailing information. It's breaking through the defenses that we had built, cognitive deficits, biases, confirmation biases, and so on. We can't anymore. Our defenses are overwhelmed. It's like levees in a storm. The flood is coming. Hurricane Katrina is coming on each and every one of us. And all our defenses are crumbling. So there's amnesia. We use the most radical extreme measures that we have. Amnesia, sensory anesthesia, restricted emotions, numbness, and in extreme cases, depersonalization. And the emotional part won't stay still, because it is infused with energy from the pandemic. The emotional part, the repository of the trauma, where all the emotions of the trauma, all the memories of the trauma reside, this container, the emotional part, it intrudes, it interferes with the AMP. It's all these trauma-related memories, overwhelming and disorganizing emotions. All these intrusions lead to impulsive, defiant, reckless, maladaptive reactants. We are all being pushed to become narcissistic, psychopathic, and borderline in the sense that we become more and more labile and dysregulated. The pandemic induces a secondary pandemic of mental health. And in this secondary pandemic, depression and anxiety are the tip of the iceberg. The iceberg is the formation of population-wide pandemic of personality disorders, situational, acquired, late onset personality disorders. The AMP, the apparently normal part, is conditioned to fear the emotional part. It reacts to this intrusion of trauma by altering, by lowering consciousness. It resorts to substance abuse, addictions, compulsions, self-mutilation to silence the inner voice of the emotional part, phobias, phobias of mental action. There's phobias of the dissociative parts, fear of intimacy, fear of attachment, fear of attachment loss, fear of normal life, fear of change. You're getting a picture that is fast becoming agoraphobic. It's a massive onslaught of phobias. They are also processes of evaluative conditioning, associative neutral stimuli with negative or positive outcomes and feelings owing to prior association with negative or positive stimuli. So even neutral stimuli, the most basic actions of life, eating, drinking, talking, watching a movie, everything becomes infused with negativity because many of these things get associated with negative news, negative developments, negative events. And they are colored, colored by these and this is called evaluative conditioning. It leads to diversion. It leads to estrangement. You feel that you are no longer yourself. You feel alien to yourself. And in extreme cases, you depersonalize. You feel that you're an autopilot. You feel that you're observing yourself from the outside. Whatever is happening is not happening to you. And an individual can have one ANP and one EP that's primary structural dissociation. But an individual can have one ANP and many emotional parts. If there are multiple traumas, multiple repeated traumas, it could lead to multiple emotional parts. And this is pretty common in, for example, complex post-traumatic stress disorder. And in extreme cases, in dissociative identity disorder. So these are twin, twin conditions. They are allied conditions. Both the ANP and the EP have a rudimentary sense of self and I. And they have exclusive access to some memories. Dissociative parts vary in degree of intrusion, avoidance of trauma-related cues, affect regulation, psychological defenses, capacity for insight, response to stimuli, body movements, behaviors, cognitive shimmers, attention, attachment styles, sense of self, self-destructiveness, promiscuity, suicidality, flexibility and adaptability in daily life, structural division, autonomy, number, subjective experience, overt manifestations, dissociative symptoms. Every part as the pandemic attacks us, fractures us, breaks us apart, fragments us. The parts that are created are very different to each other. It makes it very difficult for us to maintain our sense of core, stable identity. We are all beginning to develop identity disturbance, identity diffusion, which is very common in mental health disorders such as, for example, borderline personality disorder. The attack on our identity, the attack on our identity is such that we are, we fail to maintain coherence and cohesions and we begin to display, to exhibit dissociative symptoms, negative, negative like amnesia, numbness, impaired thinking, loss of skills, loss of needs, of wishes, of fantasies, loss of motor functions, loss of motor skills, loss of sensation. And you have also positive dissociative symptoms. When mental content of functions, one part intrude on another part and this could lead some people to psychosis, to psychotic disorders, schizophrenia like hearing voices, non-volitional behaviors, ticks, imaginary pains. These are conversion symptoms. It's really, really bad. If people continue to be exposed to what's happening today, this would be really, really bad. The dissociative symptoms should be diagnosed only if there's clear evidence of a dissociative part and the symptom is found in one or some parts, but not in all the parts. But how do you do that? How do you do that? When the pandemic occupies 100% of your life, when there is no refuge, no shelter, nowhere to go to, nowhere to escape, where the virus is everywhere, where COVID-19 is around you, where you are socially isolated, where institutions crumble in front of your eyes when you can no longer trust the authorities or anyone else for that matter, when anyone around you could be your angel of death. Where do you turn to? Both A&P and EP, they share a lack of full realization of the trauma. They have obstructive adaptive deficits and significant dissociative symptoms. I'm coming to the end of my presentation. What do we do? Structural dissociation is a permanent pathological state. It requires treatment to fuse the parts together, back again. After the pandemic, we will have to put together people, put them together, reassemble them. Social support and restorative experiences buffer negative post-traumatic effects. We would need to work on that. In therapy, we usually commit three errors and these errors enhance the emotional part and lead to the intrusion of the emotional part on the A&P, on the normal part. First of all, we reify the parts. We tend as therapists, we tend to interact with the parts, not with the total individual. Mistake number two, we put undue emphasis on differences between the dissociative parts and the alleged self, the constellated self. And the third mistake, we put premature focus on traumatic memories. And what we should do is exactly the opposite. We should collaborate with the A&P, with the normal part. When the A&P is well-functioning and dominant, PTSD is delayed. Dissociative symptoms become latent. Functioning is reduced, of course, but still it's much better compared to, for example, full-fledged, flashback-based post-traumatic stress disorder. To my mind, the A&P fluctuates. There are periods of high functioning, alternating with periods of low functioning. And this would explain borderline personality disorder, narcissistic personality disorder. And perhaps we should introduce the concept of collapse. Collapse in these defenses leads to submission, to vanishing, to freeze, fall, and flight responses. Leads to covert behaviors like passive aggression and other defenses. So we should consider collapse. We should consider modification because all these are involved in trauma. All these are elements of trauma. My last comment would be about complex trauma, CPTSD. Complex trauma, borderline personality disorder. And the now obsolete disorders of extreme stress, not otherwise specified. That's not all of these represent secondary structural dissociation. And there is, in the DSM, there is something called a diagnosis called other other specified dissociative disorder, subtype 1, OSDD subtype 1. And OSDD subtype 1 gives us an entry, perhaps. Judith Herman, Driessen, McLean, Gallop, and many others argue for the diagnosis of CPTSD. They say that most CPTSD, most complex trauma is being misdiagnosed as borderline personality disorder and associated dissociative disorders. They say we don't need this proliferation of entities. They are all facets of complex trauma. Judith Herman wrote, from Harvard wrote, the data on this point are beyond contention. 50, 60% of psychiatric inpatients and 40, 60% of outpatients report childhood histories of physical or sexual abuse of both. And so we may have a look at OSDD. I think the majority of a population will experience essentially OSDD 1. And OSDD 1 can teach us a lot about this nexus of dissociation because it is a diagnosis that puts together complex trauma, borderline features, borderline features, and narcissistic features. The difference between OSDD 1 and DID, dissociative identity disorder, is the absence of amnesia, the absence of fully differentiated parts. All the parts communicate. In most cases OSDD patients have only one apparently normal part and multiple well-developed differentiated emotional parts. And these emotional parts can be low level, so we have CPTSD, higher level, so we have borderline, and they fragment and they have some kind of differentiation, but they are not full fledged and there's no amnesia. Emotional parts for people with OSDD can handle aspects of daily life, such as exploration or play. They commonly perceive themselves as children. They can either manifest through passive influence or in a safe environment or when triggered through a full switch. The parts of those with OSDD may deny each other, deny each other's memories or deny aspects of the body's physical form or current situation, but that's not necessary. It's not a condition. Not only is the ANP avoidant and liable to react with shame, blame, or hatred, but the EPs are also avoidant. Not only that, but once one allows CPTSD into the mix, the symptoms begin to sound more and more like borderline personality disorder characterized by insecure attachment and emotional dysregulation. The two key components, symptoms of CPTSD in the forthcoming ICD-11, the 11th edition of the International Classification of Disorders. To summarize, in other words, CPTSD has little to do with trauma as it is normally understood and more to do with the subtle but severe traumas that lead to borderline personality disorder. And this is exactly the process we are going through. The pandemic is regressing us to a traumatic childhood. We are as helpless as babies. We have no defenses. Our medicine failed us. Our politics failed us. Everything failed us. Everyone around us is a threat. We feel exactly as we had felt when we were six months old or one year old, when we needed to gather dollops of grandiosity just to venture out into the world. We needed to be sufficiently ignorant of the world and feel sufficiently immune, omnipotent, and omniscient to be able to live mother, to live mother side, and to venture and explore the world. We are going through a process of collective separation and individuation. All of humanity had been reduced to one big toddler. And all of humanity in a baby state has to take baby steps to regain a modicum of what it had before the pandemic. And we, mental health practitioners, professors of psychology, whatever, we have to help in this process. We have to facilitate it. Our own trauma aside, it's not easy for us as well. Some of us are human beings. And so we are equally traumatized, equally broken, equally fragmented. And as terrorized, as horrified, as our own patients, we are all in this together. We don't have any superior position. We should acquire humility in the face of this massive external shock. The number of people who died in this pandemic compared to other pandemics in history, the Black Death of the Spanish Flu, the number is minuscule. It's tiny. The Spanish Flu killed anywhere between 50 to 100 million people. The Black Death decimated one-third of the population of Europe. And yet this pandemic is much, much worse. As far as trauma, it's much worse because it's amplified via means of mass communication and mass media because it reaches every home. And because we have no defense. And this time we know it. We didn't know what caused the Black Death. This time we know. And it is this knowledge that we are helpless, that we are defenseless. It is this very knowledge that is the main found of the trauma. Thank you very much for listening. Any questions for Dr. Sam? Professor Cotera, good to see you. Hi. We've been together in previous seminars, previous webinars. Yeah, I think I think it's very insightful of your idea of this functional association. You know, like many people see association as a problem, but I think you report the benefits of it. I think that was very fascinating. So yeah, I really enjoyed. Thank you. Thank you for being here. So thank you very much, Dr. Sam. People are traumatized by the presentation. Thank you. Thank you for having me. Yeah. So moving ahead, I would like to call Dr. Yasuhiro Cotera from University of Derby.