Imagine that you wake up one morning and are unaware of where you are. You feel confused and disoriented. The room you are in looks familiar, yet somewhat foreign at the same time. Slowly, you remember that this is your home, and that you have just awakened from a deep sleep. You make your morning coffee to orient yourself but it tastes vacuous, and you can’t smell the aroma that normally accompanies this. You are jolted to see on the refrigerator calendar that you have a major presentation to make at work today. But you can’t recall what it is about, and know that you would make a fool of yourself if you tried to persevere. You make up an excuse, and send an email to your boss. Feeling dispirited, you return to bed, feeling exhausted from the brief interlude you have just experienced, and fall back into a deep sleep. You had experienced a mild COVID-19 infection weeks ago, didn’t need to be hospitalized, and had forgotten that you even had it.

What would be the medical cause of this state? In the past, these symptoms might be considered part of a seizure disorder or traumatic brain injury. In 2022, we have to include COVID-19 as a cause. Brain fog, which describes the symptoms of thought processing difficulties, limited comprehension and associated depression, can result from the COVID virus attacking the brain. Sadness and depression can also be caused psychologically by COVID, from the stress of the debilitating symptoms.

While COVID can psychologically be stressful, it can also impact the brain directly though the olfactory system, the part of the central nervous system responsible for smell and taste. Any time the body is attacked by an outside force, such as COVID, it recognizes the assault as something foreign, and it mounts a biological defense. When the body fights back, it can produce inflammation, and in the case of COVID, this inflammation can occur within the brain and nervous system.

Around 33% of patients infected with COVID-19 endure long-term symptoms. These can range from physical and respiratory symptoms, as well as psychiatric symptoms such as depression. What is perplexing is why the severity of the initial COVID infection may not correlate with the development of long COVID. Therefore, it is not possible to predict whether an individual with COVID will experience long-term symptoms that are known as being a “Long Hauler.”

These long-term symptoms can include physical respiratory symptoms such as difficulty breathing even during mild exertion, cardia symptoms, and psychological sequelae.

In the United States alone, there have been more than 88 million cases and over 1 million deaths. Among individuals who have had COVID, there are millions of patients who develop persistent, long-term, chronic symptoms or brand new psychiatric and neurological symptoms. Furthermore, the brain can be impacted by a cytokine storm, which is a massive release of potentially harmful proteins, which occurs as part of the body’s reaction to being attacked by COVID.

An area of strong interest during the pandemic involved the generational divide between older adults and younger millennials. One study, which evaluated reasons — even apart from COVID — for millennials experiencing more severe depression and anxiety than older adults, suggests that attachment style in younger patients may impact general responses to stressors. John Bowlby describes attachment styles that range from secure to anxious. In relationships, those who were raised with consistent support and are consequently more secure, and there is less neediness and dependence on the other person. Millennials who grew up with watchful and loving and consistent parenting may be able to muster more confidence within themselves, and cope better with COVID. On the other hand, individuals who have anxious attachment styles find it difficult to impossible to feel secure in romantic relationships. They may unconsciously project their insecurities onto their partner, creating a schema of distrust and suspicion. The relationship failures that succumb to anxious attachment styles create a viscous cycle of poor self esteem, withdrawal and depression. This cascade can make millennials susceptible to stressors.

The growing income inequities, mushrooming debt, and job insecurities of Generation Z and millennials have the potential to add an additional layer of COVID-related distress. The bankruptcy of independent businesses that didn’t have the financial resources to combat the pandemic impacts all the generations. However, college graduates and young professionals have faced particularly severe financial stress, regardless of what their attachment style might be. Even young physicians out of residency, working in hospitals or in private practice, suffered financial hardships and debt repayment problems when elective medical procedures were severely curtailed.

In addition, those young adults aged 18 to 22, who comprise the millennial generation, have the largest average loneliness score among all the generations. This survey conducted by insurer Cigna notes that the presence of work relationships and interactivity may play a mitigating role in the development of loneliness. Given the telecommuting that surged during COVID, including the dramatic rise in Webex and Zoom meetings in exchange for in-person office work, this likely increased the feelings of isolation and alienation among all generations, with a specific rise among this young population.

The late University of Chicago social neuroscientist John Cacioppo, Ph.D., has studied and written extensively about the role of loneliness in mental disequilibrium. Irrespective of COVID, lonely individuals develop failing health sooner compared to individuals who are not lonely. He noted that stress is not a singular mechanism but rather a composite of biological mechanisms that impact the body and its reaction to exogenous stressors. When an individual experiences loneliness, it can lead to feelings of social rejection and feeling excluded from the group. Beyond the simply psychological negativity that can result from this, lonely individuals are more likely to have more extreme responses to a single stressor than individuals who are not lonely. Furthermore, it may not be that lonely individuals experience more frequent stress than non-lonely individuals, just that the chemical response in these systems may be more severe, resulting in more significant mood and brain symptoms than individuals who score as non lonely.

Treatment of depression and uncertainty and fear related to COVID can have positive responses to the implementation of cognitive behavioral therapy. How one thinks or processes information, and the perceptions that accompany these thoughts, directly impact mood and well being. Similar to a cognitive framework where a positive valence individual views a day as having 12 more hours, compared to being half over, the perceptions and thoughts that accompany individuals during the pandemic can have a positive impact or negative impact on the individual’s well-being and security.

For example, a study focused on cognitive behavioral interventions for young school children who experienced complete classroom disruption and virtual learning for extended periods of time. An individual might experience worried thoughts, such as “I am going to die.” A more helpful thought would be: “I am resilient and can take protective steps to improve my recovery.” Rather than having a destructive thought, such as “my spouse is going to die and I will be all alone,” an individual can substitute that thought with “statistics shows that most people with COVID make a complete recovery and my spouse will, too.”

Perception becomes reality, and the way people think about their lives and the stressors in it can play an antagonistic or mitigation role depending on the cognitive interventions that are utilized. Regardless of the generational gap, COVID impacts everyone, and the biological responses in the body, and the organ systems that are impacted, can produce a myriad array of respiratory, neurological, chemical, cardiac and psychological responses. Millennials fare worse for loneliness and the stress cascade that accompanies it, and cognitive interventions for school children and those who are older can mitigate the otherwise severe and unpredictable course that COVID and its aftermath pose for all of society.