COVID-19 quarantine-related psychotic symptoms

Abstract

Introduction

Three cases are presented that are characterised by an acute psychopathological decompensation during the state of alarm in Spain due to the COVID-19 epidemic, as an example of the mental morbidity that can be generated as a result of the confinement and social isolation measures.

Case report

Three cases are presented, all of them with a diagnosis of “brief psychotic episode” (F23). In these selected cases, the social restrictions implemented as a result of COVID-19 have played a very relevant role as an external stressor of psychotic symptoms in the patients. The response to antipsychotic treatment was rapid and very favourable. There could be specific psychological vulnerability factors related to the epidemic, which are still being studied today.

Conclusions

Our cases are just a sample of the new paradigm that psychiatry is facing, requiring an early and effective approach to the upturn in mental illness that is foreseeable in the coming months.

Resumen

Introducción

Se presentan 3 casos caracterizados por una descompensación psicopatológica aguda durante el estado de alarma en España a causa de la epidemia por COVID-19, como ejemplificación de la morbilidad psíquica que puede generarse en relación con las medidas de confinamiento y aislamiento social.

Casos clínicos

Se presentan 3 casos clínicos, todos ellos con diagnóstico al alta de «episodio psicótico breve» (F23). En estos casos seleccionados, las restricciones sociales implementadas a consecuencia de la COVID-19 han tenido un papel muy relevante como estresor externo para la aparición de síntomas psicóticos en los pacientes. La respuesta al tratamiento antipsicótico fue rápida y muy favourable. Podría haber factores psíquicos de vulnerabilidad específicos relacionados con la epidemia, que se sigue estudiando actualmente.

Conclusiones

Estos casos son solo una muestra del nuevo paradigma al que se enfrenta la psiquiatría, y es necesario un abordaje precoz y eficaz del repunte de enfermedades mentales que es previsible en los próximos meses.

Introduction

The international healthcare emergency caused by coronavirus disease 2019 (COVID-19) and the necessary measures that have been adopted (lockdowns and social isolation, among others) are going to have repercussions on mental health, as has happened in previous pandemics.¹ The sudden general cessation of all types of activities has no precedents in recent history. At this time, there is not sufficient research about the repercussions of this situation on the psychological well-being of the population, as we are still in the initial phase of the process.²

The possibility should be considered that psychiatric alterations might arise in people without prior mental illness, as well as acute decompensations in patients with known disorders. In many types of psychiatric illness, there is a degree of individual vulnerability to environmental stressors. Lockdowns are one such stressor,³ whether because of the fear of catching the disease or passing it on to family members and loved ones, or because of the distress caused by being isolated at home. People with psychosis or at risk of psychotic disorders may be particularly affected by a range of external circumstances that could trigger the onset of acute decompensated psychopathology: social isolation, unemployment, homelessness, relationship breakdowns, worsening physical conditions or loss of daily routines. All of this can facilitate a surge in this type of mental illness in the medium term.^4,5

To date, no clear biological link between COVID-19 and psychosis has been described; however, there is evidence that the virus can cause changes in the central nervous system and, as a consequence, encephalitis-type clinical manifestations.⁶

Methods

Due to the uniqueness of the situation we are currently experiencing and the increase in patients hospitalised with psychotic disorders related to COVID-19 in our short stay unit at the Hospital Universitario Miguel Servet [Miguel Servet University Hospital] (Zaragoza, Spain), we have collected three cases with a diagnosis of “brief psychotic disorder” (F23).⁷

Results

Case 1

A 46-year-old mother of two, separated, with a history of brief psychotic disorder (F23)⁷ in 2012, with good response to atypical antipsychotics (paliperidone). Since then, her psychopathology has remained stable, with good social and occupational functioning (she works as a nursing auxiliary). The current situation is triggered by the self-isolation the patient was practising as instructed by occupational health, as she may have come into contact with a SARS-CoV-2-positive colleague. In this context of isolation, she experienced a psychopathological decompensation in the form of insomnia for a number of days, change in daily routine with disorganisation of habits, autistic-like withdrawal, mistrust and anxiety, and even began to have thoughts of persecution (“coronavirus doesn’t exist, they’re making it all up to separate me from my children”). The first symptoms to appear were emotional instability, tachypsychia and a certain ego-expansiveness. During her stay, the dose of paliperidone was increased and valproate started in view of the emotional component; she presented a gradual improvement of the psychotic symptoms and was able to sleep at night.

Case 2

A 42-year-old woman, single, without children, with a psychiatric history of adjustment disorder (F43)⁷ following the death of her brother, with a good response to fluoxetine. She has good social and occupational functioning (she works as a nursing auxiliary). During the national state of emergency, the patient was found in the street with altered behaviour, delusional speech of a mystical/religious nature and a desire for death (“I must die to save humanity from this epidemic”). On admission, she presented intense intrapsychic distress, with increased response latency, fluctuating thought blocking and stupor, and emotional instability secondary to psychotic symptoms. Her pharmacological regimen (olanzapine and fluoxetine) was adjusted accordingly, her sleep was restructured, her anxiety decreased allowing her to focus on reality and produce adequate criticism of the self-destructive ideas she had verbalised such as the “sacrifice for humanity”, and her emotional state improved notably.

Case 3

A 27-year-old woman, single, without children, with a psychiatric history of acute polymorphic psychotic disorder (F23.1),⁷ in the context of acute stress reaction (F43.0),⁷ with a good response to treatment with olanzapine. She no longer required psychopharmacological treatment or mental health follow-up. She was a regular cannabis user. The patient has lived in Spain since she was 18 years old and has dual Spanish and French nationality. She was working as a language teacher; the COVID-19 epidemic caused her professional activity to cease. The patient's flatmates alerted the emergency services due to behavioural changes and agitation at home. The patient had not slept for days, and they linked her condition to the coronavirus lockdown and distance from her family, who live in France. In recent weeks, the patient had been increasingly irritable, as she had planned to travel to France with her family and the state of emergency prevented this. On arrival at the emergency department, the patient presented incoherent, disordered speech; she rejected medical assistance at all times and doubted that those treating her were truly professionals. The admission was involuntary and short in duration, as her response to olanzapine and low doses of haloperidol was rapid and favourable.

Discussion

The clinical cases briefly described bring to light this new reality and exemplify how social distancing measures can contribute to the onset of psychotic symptoms in people with vulnerable characteristics. In the three cases presented, the diagnosis at discharge was “brief psychotic episode” (F23),⁷ and in all of them the response to antipsychotic treatment was prompt and favourable. Two of the patients presented had already had psychotic episodes, while for the patient in case 2 this was the first. Unlike other similar published case series,² our patients had psychiatric histories. A mental structure more vulnerable to external stressors and a lower capacity to adapt to unfavourable circumstances can therefore be intuited (in cases 2 and 3, a congruous history of adjustment disorders could be established).

According to a study published recently in China,⁸ the psychological impact of the pandemic was greater in a certain subgroup of the population: women, students, healthcare workers and people with previous physical conditions. Several of these characteristics are met in our sample, although a higher grade of scientific evidence in needed to clearly identify such markers of psychological vulnerability.

The fact that two of the three patients presented work in the healthcare sector is noteworthy. In the literature, there is a consensus that healthcare professionals have a higher risk of suffering high levels of stress and anxious-depressive symptoms, which have increased notably in the exceptional circumstances of this healthcare emergency and might have implications for the long-term emotional stability of these workers.^9,10

Globally, the COVID-19 pandemic is bringing about a paradigm shift on many levels, and mental health care will probably have to adapt to a new way of working and make use of new technological tools in order to permit effective interventions. Continuity of care for patients must be guaranteed, with adequate safety measures that allow the therapeutic link with them to be established or maintained.¹⁰

On the other hand, the role that COVID-19 infection can play in the appearance of psychotic symptoms must also be taken into account. Some authors¹¹ place the number of infected people who suffer psychotic symptoms (such as delirium and hallucinations) between 0.9% and 4%, albeit with a moderate grade of evidence. These symptoms could appear in psychologically vulnerable people infected with COVID-19, and their origin would be multifactorial (due to the pre-existing vulnerability, the virus itself, iatrogenic causes, etc.). The patients presented here did not have COVID-19 infections, although the epidemic situation was an important external stressor for them.

Conclusions

Psychiatry is facing a new paradigm. Experts suggest that we can anticipate a surge in mental illness, directly or indirectly related to the COVID-19 pandemic (brief psychotic episodes like those presented here, pathological grief, post-traumatic stress disorder, etc.), and for this reason it is necessary that we have the appropriate tools in place to identify and treat the problems that are going to arise in the coming months early, as well as effective resource management.¹²

Conflicts of interest

The authors have no conflicts of interest to declare.