Acute and Transient Psychotic Disorder induced by fear of coronavirus infection.

BACKGROUND: Acute and Transient Psychotic Disorder (ATPD) (ICD-10) is characterized by the sudden onset of psychotic symptoms and can be triggered by psychological stress. In the ICD-10 definition of ATPD, episodes are short-term, lasting from days to three months, followed by complete remission.
OBJECTIVE: This paper reports the case of a 37-year-old woman with stress-induced new-onset psychosis instigated by fear of coronavirus infection.
METHOD: Physical examinations, paraclinical testing, and neuroimaging excluded an organic cause of symptoms. A thorough anamnestic investigation excluded the presence of other concomitant stress factors as the trigger of the patient's psychotic symptoms.
RESULTS: In response to the COVID-19 lockdown, the patient developed excessive concern about coronavirus infection and, consequently, sleeping difficulties. Symptoms intensified, and she was admitted to the psychiatric ward, presenting with hallucinations, delusions, disorganized speech, and disorientation. The clinical picture fulfilled the diagnostic criteria of an Acute and Transient Psychotic Disorder. After one week of antipsychotic treatment, her symptoms had remitted, and the patient was discharged. Albeit, four months after treatment discontinuation, her psychotic symptoms re-emerged, and she was readmitted. The patient recovered from symptoms within 48 hours of treatment initiation with antipsychotics. She later reported to have been stressed and anxious while awaiting her coronavirus test result and, following, had doubted the negative result.
CONCLUSION: The present case supports previous reports describing the COVID-19 pandemic's effect on population mental health; the psychological stress caused by the fear of infection can lead to the debut of psychotic manifestations and ATPD.

Introduction

Stressful life events can trigger the onset of Acute and Transient Psychotic Disorders (ATPD). ATPD are characterized by the sudden onset of psychotic symptoms, e.g. delusions, hallucinations, and perceptual disturbances within two weeks, followed by complete recovery within three months (World Health Organization, 1992).

Case

A 37-year-old woman without known mental illness was involuntarily hospitalized due to the acute onset of psychotic symptoms. The patient worked full-time as a store manager and had a thriving social life. She had no drug abuse, and she was not on any medication.

Upon admission, the patient was observed talking to an imaginary person. She seemed to believe that the doctor was a camel and the nurse was Mickey Mouse. She exhibited disorganized speech, repeating words as ‘red,’ ‘brown,’ and ‘yellow,’ and could not engage in conversation. Furthermore, she exhibited transient episodes of spatio-temporal disorientation.

The patient could not cooperate with the routine physical examination. She became physically aggressive and was treated with intramuscular (i.m) diazepam with limited effect.

The sister reported that the patient had begun to express excessive concern about coronavirus infection one week before the onset of symptoms and had cancelled a family gathering, fearing she was a carrier of the virus. However, she did not have any symptoms.

Her vital signs were normal, except pulse (104). Blood work was normal, and a urinalysis was negative, also for psychoactive substances. Following admission, she stopped drinking and became hypotensive; hence, she was transferred to the intensive care unit, where thorough diagnostic workups were performed under physical restraint.

An organic cause, infectious or autoimmune encephalitis, and paraneoplastic syndrome were suspected. However, analyses of blood and cerebrospinal fluid (CSF) were normal. Computed tomography (CT) and magnetic resonance imaging (MRI) of the cerebrum were equally normal, as well as EEG (Table 1).

Table 1.

Organic differential diagnoses

	Examples	Investigations	Patient results
Intracranial disorder	Traumatic head injury, stroke, subdural haematomas, cerebral tumours	CT/MRI-head	Normal
Endocrine disorder	Hyper/hypothyroidism	Thyroid hormone levels, serum calcium	Normal
Infectious disorder	Neuroborreliosis, meningitis, encephalitis	CFS; cell count, protein/glucose levels	Normal
Autoimmune disorder	Paraneuroplastic encephalitis/ NMDA-receptor encephalitis	CFS; antibodies titres, MRI-head	Normal
Paraneuroplastic disorder	Teratomas	CT-TAP, CA-125 levels, ultrasound	Benign cystic process in the right ovary, haemangiomas in the liver
Seizure disorder	Seizures, epilepsy	EEG	Normal

CT; computed tomography, TAP; thorax, abdomen and pelvis, MRI; magnetic resonance imaging, CSF; cerebrospinal fluid, CA-125; cancer antigen 125, EEG; electroencephalograph.

CT of the thorax, abdomen, and pelvis showed tumour-suspicious areas in the liver and right ovary; An ultrasound examination revealed haemangiomas in the liver and a benign cystic process in the ovary.

The patient was treated with i.m aripiprazole, and olanzapine pro necessitates (p.n). After four days of treatment, her symptoms had remitted, but she had no recollection of the episode. She reported that she had become increasingly anxious after the COVID-19 lockdown and developed constant thoughts of contagion and sleeping difficulties.

The patient was diagnosed with ATPD without symptoms of schizophrenia (ICD-10:F23.0). She was discharged with p.o. Olanzapine and regular follow-up consultations. One month post-discharge, there had been no signs of relapse, and treatment was discontinued.

Four months later, the psychotic symptoms re-emerged. She was readmitted and treated with i.m aripiprazole and olanzapine p.n. Within 48 hours, the symptoms had remitted. Again, she had an imperfect recollection of the episode but reported to have been anxious and feeling infected with coronavirus in the days before readmission.

The patient was discharged to continue treatment with peroral olanzapine. Two months post-discharge, she reported feeling stressed, suffering from sleep disturbances, and a growing feeling of sadness, albeit she did not fulfill the diagnostic criteria for severe depression. An antidepressant was added to her treatment (mianserin 10 mg daily). Since then, there have been no signs of deterioration.

Discussion

A 37-year-old woman without any known mental illness was admitted to the hospital with new-onset psychosis. She presented with polymorphic psychotic symptoms; fluctuating hallucinations and delusions, disorganized speech, and transient disorientation. Hence, organic delirium was suspected. However, blood work, CSF analyses, and neuroimaging were without pathological findings, and findings on CT-tap were unrelated to the patients’ symptoms.

The clinical presentation fulfilled the diagnosis of an ATPD without symptoms of schizophrenia. (World Health Organization, 1992) A thorough anamnesis revealed that the patient had been anxious and suffered from an excessive concern of coronavirus infection. It also excluded the co-occurrence of competing stress factors before hospital admission.

A multicenter study of patients with brief psychotic episodes triggered by the COVID-19 pandemic found that most of the patients were caucasian women in their 40ties. Prominent psychotic features included hallucinations, delusions, and disorganized speech, as observed in the present case (Valdes-Florido et al., 2021).

ATPD is associated with diagnostic shifts to schizophrenia and bipolar disorder years from the debut. The recurrence of psychotic symptoms four months after the discontinuation of the antipsychotic treatment raises the suspicion of an underlying chronic psychotic illness (Lopez-Diaz, Fernandez-Gonzalez, Lara, Crespo-Facorro, & Ruiz-Veguilla, 2021). However, the patient did not present with schizophreniform symptoms. Although she presented with some maniform symptoms, transient sleeping difficulties, and pressure to speak, no anamnestic information indicated manic episodes.

Following her second admission and last admission, she developed light signs of depression; hence an antidepressant was added to the treatment in November 2020. Since the medical adjustment, there has been no re-emergence of psychotic symptoms. Even so, it is still too soon to have a longitudinal view of the case.

The psychological impact of the COVID-19 pandemic on populations’ mental health has been described in several articles (Gunnell et al., 2020; Holmes et al., 2020). In this present case, the psychological stress related to the COVID-19 pandemic manifested as severe anxiety developing into a psychotic state fulfiling the diagnostic criteria of ATPD.