Weaved around COVID-19: Case series of coronavirus thematic delusions.

Stressful situations such as the COVID-19 pandemic can serve as a niche for developing pathological mental state or influence the symptomatology of patients with psychiatric disorders. Here, we present four such cases. Three cases highlight the onset of psychosis precipitated by the immense stress posed by the pandemic. In the last case, psychopathology of a patient with preexisting mental illness getting influenced by the pandemic is highlighted. In all the four cases, it is interesting to note that delusional work is weaved around the COVID-19. Copyright:

Past experiences and the emerging literature on the mental health impact of COVID-19 pandemic have shown that people facing psychological crisis secondary to adversity of the outbreak outnumber the people affected by the infection per se. Further, the mental health implications can last longer than the outbreak itself.[1] Owing to the heightened susceptibility to stress, people with mental illness are more vulnerable as compared to the general population resulting in relapses or worsening of the preexisting psychiatric disorder or emergence of new symptoms. Stressful situations like this can serve as a niche for developing pathological mental state or influence the symptomatology of psychiatric patients.[234] In this case series, we report four such cases.

CASE REPORTS

Case 1

A 72-year-old, retired auxiliary-nurse-midwife, separated from her husband, living with daughter, used to be highly functional and active. She would do most of the household chores, and take care of her grandchildren to aid her working daughter. She was brought to us in the last week of January 2020, with the complaints of extreme anxiety in performing household chores and need for supervision/assistance to carry out her routine from the past 3 months. She would often express doubts about her ability to carry out the household chores smoothly. She would leave the work unfinished with the apprehension of committing errors/mistakes and refuse to resume and finish the work despite reassurance. As days passed, she would avoid carrying out household chores with extreme anxiety of making errors. She would mostly be restless. She would often feel sorry about herself that she has become a burden on her daughter. Her sleep and appetite were disturbed. There were no symptoms suggestive of psychosis. There was no history of forgetfulness. No symptoms suggestive of central nervous system involvement were noted. There was no history of substance use. She is a known case of hypothyroidism on 75 mcg of thyroxine. No history of other medical comorbidities. No relevant past or family history of any medical/psychiatric illness was noted. Premorbid personality was well adjusted. General physical examination including neurological evaluation was unremarkable. Mental-Status-Examination revealed anxious affect and anxious preoccupations about her inability to function like before. Higher mental functions were satisfactory with fair insight and judgment. Mini-Mental-Status-Examination score was 29/30. Neurologist's opinion was sought to rule out the possibility of organic pathology considering her age. Routine laboratory investigations, thyroid-stimulating hormone, T3, T4, and Vitamin B12 levels were within the normal limit. Magnetic resonance imaging of the brain revealed only age-related parenchymal changes. A provisional-diagnosis of anxiety disorder, unspecified (F 41.9) was made. However, possibility of prodrome of affective disorder/psychosis was kept in mind. The diagnosis was discussed with the family, and a close follow-up was advised. The patient was started on oral mirtazapine 7.5 mg at bedtime and clonazepam 0.25 mg twice a day. The patient was lost to follow-up. She was taken to another psychiatric setup and was on escitalopram 20 mg once a day, propranolol 20 mg once daily and clonazepam 1 mg at bedtime for nearly 1½ months. Family did not appreciate much improvement except for restoration of sleep. She was then brought again in the last week of March 2020 with a firm belief of being troubled by people who erroneously believed her to have spread the coronavirus infection since last 4–5 days. She believed that people spoke ill of her, made gestures at her as they thought world is under threat because of her. She would hide herself inside a room reluctant to step out and kept saying that she is innocent and has not caused the infection. Furthermore, kept stressing that neither did she go out of the home during lockdown, nor did she touch anyone/sneeze/cough in public, yet people around her have held her responsible for the infection and the police can anytime arrest and take serious actions against her. However, she did not report to have heard invisible voices not heard by others. She was sleepless despite medication and required much more supervision and assistance than before. She reported that she did not want to come to hospital as she was afraid of being arrested but was forcibly brought by her family. She requested the doctor to examine her to look for the signs and symptoms of the infection and ask for a test, so that if the test turns out to be negative, she can produce the proof to counter the allegations made against her.

On Mental-Status-Examination, she was noted to scan the environment time and again. Repeatedly said “I did not do anything,” “please examine me,” and “do the test.” There was psychomotor agitation. Mood was reported to be fearful; affect was distressed. Delusion of persecution and reference was noted. Insight and judgment were impaired. The diagnosis was revised to other acute predominantly delusional psychotic disorders, with associated acute stress (F 23.31). Oral olanzapine was started at 5 mg and was titrated up to 15 mg over the next 10 days. The patient's family reported ~80% betterment after 1½ months of treatment. The patient is on regular follow-up and is maintaining well.

Case 2

A 24-year-old female, graduate, married, currently unemployed, was referred from the department of obstetrics and gynecology for the evaluation of behavioral disturbances 4 days following delivery. She was a known case of rheumatic heart disease, severe mitral stenosis, tricuspid regurgitation, moderate pulmonary artery stenosis, and post percutaneous-transvenous-mitral-commissurotomy status on benzathine-penicillin prophylaxis. She was admitted at 34 + 2 weeks of gestation in view of high-risk pregnancy. COVID-19 reverse transcriptase polymerase chain reaction testing was done before admission was negative. An emergency lower-segment-cesarean-section (LSCS) was performed as loop of the cord around the neck of the fetus was noted on ultrasonography. Mild atonic postpartum hemorrhage was managed.

Around 3–4 days following LSCS, she believed firmly that she tested positive for COVID-19 and would not get convinced despite reassurances by the treating team and on producing the report as evidence to the contrary. She believed that she was isolated despite explaining that she was in the high-risk pregnancy section and not in isolation ward anytime. She repeatedly complained that the nursing staff, and the housekeeping staff would make faces at her, would discuss about her among themselves that her stay in the ward is risky to others. She reported to have heard voices of people saying how risky it is to have her around. She would repeatedly request the treating team for discharge saying she does not want to risk others life. Furthermore, that she's distressed with the way people treat her in the ward. She would not get convinced despite several counseling by the treating-team about the need for hospital-stay. She had to be prompted to nurse the baby and self-care. Her sleep was disturbed. No relevant past or family history of any medical/psychiatric illness was noted. Premorbid personality was well adjusted. No abnormality was detected on general physical examination and systemic examination. Mental-Status-Examination revealed dysphoric affect, delusion of persecution, delusion of reference, second person auditory hallucination, impaired insight, and judgment. With a provisional-diagnosis of severe mental and behavioral disorders associated with the puerperium, not elsewhere classified (F 53.1), she was started on oral olanzapine 5 mg at bedtime which was up-titrated to 7.5 mg after 2 days. She showed symptomatic betterment over a week's stay in hospital. However, postdischarge she was lost to follow-up.

Case 3

A 38-year-old gentleman, graduate, railways employee, married, was referred from the department of orthopedics for evaluation of deliberate self-harm, also refusal of food and treatment. He was admitted with alleged history of fall from height (around 30 feet) at around 2 AM on September 2, 2020 at his residence. Following clinical assessment, investigations and imaging, diagnosis of traumatic paraparesis with bowel and bladder involvement due to burst fracture of L3 (with retropulsion of fragments), fracture of right medial malleolus and fracture of the 1st to 6th ribs was made. He underwent L1–L5 posterior-instrumentation-and-stabilization with decompression-and-laminectomy with dural-repair with open-reduction-and-internal-fixation with cannulated-cancellous screws for burst fracture of L3. After hemodynamic stabilization, serial psychiatric assessments were carried out. He came up with a firm belief of having contracted COVID-19. He reported that despite few of his colleagues getting COVID-19, he ignored and did not consult doctor on time for intermittent somatic symptoms. He believed firmly that not getting tested and treated for his symptoms on time has worsened his health irreversibly and he has reached a state from where recovery is not possible. He was convinced that he will be abandoned by the family for his illness. He reported to be regretful of not getting tested on time and now everything has ended and absolutely nothing can be done. He reported to have jumped from the terrace of his residence out of distress and despair, while family was fast asleep. It was an impulsive attempt, of high intent and lethality. During his hospital stay, he firmly believed that he is ill and there is no hope with regard to his health and life. He would refuse to eat. He would not comply with the medical orders/physiotherapy. His family reported that from past 1 month, he seemed excessively worried and self-resorbed. His financial responsibility toward his extended family was suddenly increased due to huge loss in agriculture and job-loss of his brother during lockdown. As the days passed, he would complain of vague somatic symptoms often and would not get reassured despite repeated consultations with physician. He would repeatedly ask his family “will I recover?,” “will I be okay?,” “will I be abandoned by you all?” etc., He would eat less. He would not sleep and would pace in and around the house at night. His colleagues informed his family about the recent change in his behavior observed at work like making silly mistakes, forgetting day-to-day tasks, reduced social interaction, etc., There was no history of pervasive sadness. No history of substance use was noted. No relevant past or family history of any medical/psychiatric illness noted. On examination, he was conscious and oriented. He was afebrile with stable vitals. There was hypotonia of bilateral lower limbs. Power of the hip was 2/5 bilaterally. Power of bilateral knees, legs, and ankles were 0/5. Sensations were lost below knee (L3 dermatome). Plantar, ankle, and knee reflexes were absent on both sides. On Mental-Status-Examination, eye-to-eye-contact was fleeting. Psychomotor activity was reduced. Mood was worried and affect dysphoric. Somatic delusion, nihilistic delusion, and death wishes were noted. Insight and judgment were grossly impaired. Provisional diagnosis of other acute predominantly delusional psychotic disorders with associated acute stress (F 23.31) was made. Oral formulation of olanzapine 10 mg was prescribed at bedtime along with clonazepam 0.25 mg twice daily. Suicidal precautions were ensured and family was psychoeducated in detail. Olanzapine was up-titrated to 20 mg/day and clonazepam was tapered and stopped over 2 weeks. The patient and family reported ~80% betterment in 6 weeks. The patient is on regular follow-up and is doing well.

Case 4

A 40-years-old, graduate, married, homemaker was brought by her husband, with a history of belief of being spied from the past 5 years and a recent onset of behavioral disturbances.

From the past 5 years, she had often reported to her husband that someone would monitor all her activities almost always, would even peep while she was bathing/changing cloths/using toilet. She would insist him to take necessary actions and would get upset whenever he tried to explain things otherwise and believed that he does not want to take her seriously despite a serious issue of her privacy being compromised and the distress faced. She firmly believed that her neighbors always interfered unnecessarily in her life, caused needless troubles, made intimidating gestures at her, spoke bad of her. She said her neighbors would comment on all her actions which annoyed her as they did not have any right to question/comment her actions inside her own house. She shared strained relationship with neighbors, situation demanded them to change houses couple of times. Her husband reported that although it would get difficult at times, she was manageable. He added that he did not think it could have been a mental health issue and hence did not see a psychiatrist so far. From last week, he found her to be increasingly difficult and unmanageable. She seemed unusually happy and joyous, would seem energetic, extremely active throughout the day and needed hardly any sleep, would sing and dance, was noted overtly religious, claimed of possessing special powers enabling her to erase the misery of the mankind and believed self to be God-like. Her husband reported that although she was cheerful mostly, would get irritable on seeing neighbors not wearing the mask properly, would ask them to wear properly so that it covers both nose and mouth. She would pick quarrels with neighbors saying they cough at her, touch their nose and mouth whenever they pass by her in the common areas with an intention of spreading coronavirus infection to her. She would allege them to have lacked the social responsibility, which would turn into heated arguments. No relevant past or family history of any medical/psychiatric illness was noted. Premorbid personality was well adjusted. On Mental-Status-Examination, it was noted that she was oddly dressed, sat on the chair with “yoga-mudhras,” loudly chanting “Shiva-panchakshari.” Her speech was pressured. Mood was blissful. Affect was elated. Delusion of grandeur, persecution, and reference were noted. Running commentary, third person auditory hallucinations were recorded. Her insight and judgment were impaired. Provisional diagnosis of schizoaffective disorder, manic type (F 25.0) was made. She was prescribed oral risperidone 3 mg and trihexyphenidyl 2 mg, each once a day for the first 4 days and then twice daily, clonazepam 0.5 mg twice a day for first 4 days and then only at bedtime. She was symptomatically better after 4 weeks of treatment. The patient was lost to subsequent follow-up.

DISCUSSION

Association between influenza infection and psychosis has been reported as early as 18th century. The “psychosis of influenza” was well-recognized during the Spanish flu pandemic of 1918–1919.[5] Massive worldwide exposure to COVID-19 is likely to increase the incidence of psychotic disorders similar to influenza. Several case reports and review articles have reported small but important increase in the number of patients developing coronavirus-related psychosis.[6] A Chinese study reported increase in the incidence of first episode schizophrenia in the general population postcrisis.[7] Several cases of psychosis arising due to probable unarticulated stress precipitated by the pandemic,[891011] COVID-19-positive cases manifesting with psychosis,[111213] as well as psychosis induced by hydroxychloroquine[14] and steroids[15] (the treatment regimens of COVID-19) have been reported. The causes for these primary and secondary psychosis can be summarized as follows: Widespread anxiety, infection-related fear, financial crisis, uncertainty due to sudden and massive impact of pandemic have precipitated stress both the infected and noninfected population susceptible. The association between psychosis and stress has been proved beyond doubt and stress is considered to be an important risk factor for both the onset and exacerbation of symptoms.[6] Furthermore, situation demanded social isolation alone is capable of triggering the psychotic symptoms.[16] Concern about the outcome of illness, stigma, and stress of isolation in the infected individual may make them vulnerable to various mental health morbidities including psychotic breakdown. Neuropsychiatric manifestations of the infection can arise either through direct effects of infection of the CNS or indirectly through an immune response or medical therapy.[11121317]

Another impact the current crisis is on phenomenology of people with preexisting psychotic disorder or at risk of developing psychosis.[6] In a patient with psychosis, although the core theme of delusions remains mostly stable, delusions are sensitive to social or technological changes.[18] The content of delusion gets influenced by the exceptional circumstances such as pandemics, natural disasters or assassinations, and such pressing issues gets incorporated. Thus, delusions are dynamic and often represent a combination of psychopathology and external events.[3] The effect of pandemic on the pathoplasty of delusion has also been reported.[319] An additional aspect of particular interest is the speed at which the current issue has been subsumed by delusions. Case reports from Spain have reported delusion with the COVID-19 theme even before the first declared case of COVID-19 in nation. It seems as if the coronavirus has reached delusional themes faster than the infection itself.[19]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.