COVID-19 specific phobia: A new psychiatric entity?

Dear Editor,

Case Vignette: “M.R., 64 year-old woman with no previous history of psychiatric disorders, started with a strong and recurrent fear of being infected with COVID-19, both herself and her relatives. She would have a panic attack every time she thought about her husband or children going back to work or even leaving home for whatever reason. Due to this fear, she sought help at the hospital emergency room several times, thinking she could have been infected. She accepted to have an appointment with a psychiatrist because, even though she understood her fear as plausible, the degree to which it filled her mind and impacted on her life ‘was driving her crazy’ (as she said). She could not refrain from going repeatedly to the hospital ER to run additional tests, in spite of being aware of the risk of the contact visiting COVID-19 patients and, therefore, being actually exposed to the risk of contamination.

The pandemic caused by SARS-CoV-2, the virus responsible for the Coronavirus Disease 2019 (COVID-19), has caused biological, economic, social, cultural and psychological impacts on the world's population (Bauchner, 2020). Fear and anxiety are common and expected psychological responses during situations like this, however sometimes under specific circumstances some anxiety-related disorders can emerge (Taquet et al., 2021).

Anxiety disorders represent the most common group of psychiatric disorders and one of the most important causes of disability worldwide (Craske et al., 2017). The most common diagnoses under this group are Specific Phobia, Generalized Anxiety Disorder, and Social Anxiety Disorder (Baxter et al., 2013). Specific Phobia has an estimated 12-month prevalence around 7% and consists of excessive and persistent fear in the face of a specific situation or object (Craske et al., 2017). The situation or object is usually avoided by the individual, when possible, but if the exposure occurs, the anxiety develops quickly and can intensify to the risk of a panic attack. Several situations related due to COVID-19 might be important predictors for developing fear and specific phobia (Mertens et al., 2020).

To the best of our knowledge, no study has yet described a specific phobia related to the fear of catching COVID-19. In our large cohort investigating 712 individuals who underwent hospitalization due to COVID-19 in a large Brazilian city (Busatto Filho et al., 2021), and using a well validated psychiatric interview instrument (CIS-R) (Lewis et al., 1992) to capture psychiatric diagnoses 6-9 months after remission of the acute phase of the disease, we found a prevalence of 2.66% (n=19) of participants with any Specific Phobia, one fifth of whom could be viewed as having COVID-19 Specific Phobia (0.56% - (n=4) of the total sample). Although less frequent than other forms of psychiatric morbidity that pertain to ‘long-COVID’, the public health impact of this specific feature of anxiety disorders may be substantial given the massive numbers of the pandemic.

Symptoms may vary from autonomic symptoms when facing fearful and stressful situations to avoidance of any feature that might remind this situation – in this case, the COVID-19 pandemic. Patients may avoid leaving home, touching objects, talking with people, including their own family. Symptoms may persist even in non-stressful places, affecting quality of life. However, we should be cautious when interpreting and generalizing this finding. It might be only an artifact from CIS-R output and, in fact, represent symptoms from related disorders. For instance, in this case the fear seems to be more elaborated than the usual immediate fears in simple phobia (the infection involves not only her but her family members) and can happen at any time (e.g., going to work or even alone), without the exposure to the virus being necessary a triggering factor. It involves repetitive thoughts (repetitions of aversive thinking) that could be better conceptualized as obsessions and repetitive reassurance, seeking help in the hospital repetitively, which could be seen as a compulsive behavior. Not mentioned here, however, avoidance behaviors may also develop as frequently seen in phobias and OCD (Stein et al., 2019). Additional differential diagnoses should also include Post-Traumatic-Stress Disorder (PTSD) (Schillaci et al., 2009) and other Anxiety-Related Disorders (Craske et al., 2017).

This differentiation is important because it will guide the rationale of the treatment. Nevertheless, it also raises the importance of COVID-19 in the psychopathology of this year and perhaps of this decade. Thus, more studies should be done regarding this clinical entity in order to confirm and/or deny it and also to understand possible therapeutic strategies targeted to these individuals, helping them to deal and overcome this important and stressful entity.

Funding statement

This work was partially supported by donations from the general public under the HC-COMVIDA crowdfunding scheme (https://viralcure.org/c/hc) and the Fundação Faculdade de Medicina (ALA).

Declaration of Competing Interest

Authors Declare no Conflict of Interest.