The COVID-19 pandemic is a virus outbreak that was first reported on December 1, 2019, in Wuhan and spread all over the world in a short time. Restrictions on freedom, such as curfew and quarantine, school closures, flexible shifts of working which were implemented as control strategies for the COVID-19 pandemic, and boredom, inadequate information, and virus-related fears related to the control strategies can lead to various psychiatric disorders in susceptible individuals.
While many studies examine the relationship between COVID-19 pandemic with depression, anxiety, posttraumatic stress disorder, suicide, psychological stress, and somatic symptoms, few cases of new-onset psychosis have been reported. Considering that biological, environmental, and social events play a role in the pathophysiology of psychotic disorders, it is important to examine psychotic disorders during the pandemic period. Here, we described three clinical cases of patients with a brief psychotic disorder (BPD) admitted to the psychiatry service. All three admissions occurred <1 month after the initiation of strict societal restrictions in the country.
This case was a 43-year-old unmarried man with a high-school education. The second of the three siblings, he had neither physical nor psychiatric history prior to the pandemic. He had good job performance.
As the first COVID-19 cases emerged in the country, the patient began to experience unhappiness, introversion, indifference, sleep, and appetite disruption. He worked at home for 15 days due to flexible working conditions. He developed feelings of being infected by the virus and visited multiple health centers for COVID-19 test. However, he did not believe the negative test results. He had delusions that he was infected with COVID-19, and it caused damage to his internal organs. One day, he removed all of his clothes, including his underwear in the street. The patient was found by the police and taken to the emergency department.
The physical examination, biochemical blood, and urine analysis for substance use were normal. Structural injury was not shown by computerized tomography axial. The COVID-19 polymerase chain reaction (PCR) sample taken during hospitalization was negative.
He was awake, disoriented in time and space, and experienced poor insight, circumstantial thinking, delusions of persecution, marked psychotic anxiety, a sense of sadness, frustration, self-undervaluation, and insomnia. The treatment consisted of 10 mg of olanzapine. During the 2nd week of his hospitalization, he showed a rapid improvement in his psychotic and depressive symptoms, and his sleep improved as well. A best-estimate BPD diagnosis was made. The symptoms of psychosis did not seem to be better explained by a depressive episode. Depressive and psychotic symptoms started in the same period, and the patient improved dramatically in the 2nd week of the antipsychotic treatment dramatically. The patient was discharged after 20 days with a clinical remission, confirmed by a brief psychotic rating scale (BPRS) total score (90 upon admission and 23 at discharge).
This case was a 53-year-old unmarried man with a secondary-school education. He had hypertension and chronic renal failure under control. He performed well at work.
After the appearance of the first COVID-19 cases in the country, the patient started to worry that the virus would be transmitted to him, and he left his job. The patient's appetite decreased, and he experienced significant weight loss and severe insomnia. He frequently visited the internal medicine department for a COVID-19 test and had negative test results. The patient was brought to the internal medicine department by his family due to syncope. A low sodium level related to a decrease in food and drink was detected, and he was treated by a one-night hospital stay until his biochemical values were normal. In the following days, the patient continued to say that he had got the COVID-19, but it had not been detected in the tests. He developed bizarre behaviors, including plucking out his head and body hair. The patient was brought to the emergency department by his family.
All physical and laboratory examinations performed during hospitalization were normal. He was awake with delusions of persecution and marked psychotic anxiety during the mental examination. After approximately 2 weeks of the olanzapine treatment, psychiatric symptoms including sleep and diet improved markedly (BPRS score went from 86 to 25). BPD seemed to be the best explanation for the symptoms of psychosis. Delirium diagnosis was not considered due to the absence of impaired consciousness, impaired orientation, and also the absence of any organic pathology. Mood disorders were also not considered either, as the patient's mood symptoms did not reach a level that would meet the episode criteria.
This was a 31-year-old unmarried man working as a moto courier before the pandemic. He did not have any physical or psychiatric history prior to the pandemic. The economic concerns caused by the loss of his job due to the pandemic caused him severe anxiety, leading to intense distress and interrupted sleep. He developed delusions about COVID-19, believing that he was being followed, as he had found the treatment for it. The patient said that he needed to reach a doctor before he was harmed. He felt the need to escape from his house and went to the post office to try to find doctors’ phone numbers. He settled in a hotel but left after one night, as he thought there were cameras in his room. The police were informed by the people who passed him walking the streets while shredding his clothes and shouting. The patient was brought to the psychiatry emergency room by police and ambulance.
His physical and laboratory examinations and PCR were normal. After approximately 3 weeks in hospital, an improvement in his mood and a progressive reduction of psychotic symptoms, with the development of initial insight, was observed. A BPD diagnosis was made because the symptoms of psychosis were not deemed to be better explained by any other psychiatric disorder. The patient was discharged after 17 days with a clinical remission, confirmed by a BPRS total score (from 93 to 26).
None of the three patients had a history of psychiatric disorders before the pandemic. They were treated with olanzapine and experienced complete remission of psychotic symptoms within a few days. Our diagnosis was BPD, according to DSM-5 criteria, in all three cases.
The COVID-19 pandemic caused fearful reactions and psychological stress in the general population because of the high infection rate of the virus and the catastrophic consequences of the infection. Harmless bodily sensations can be interpreted as symptoms of a COVID-19 infection due to anxiety and fear. Increasing anxiety in our cases interfered with the patients’ capability to make rational decisions, which can lead to maladaptive behavior, such as going often to medical centers to rule out the disease. Our patients had also gone to many hospitals to be tested, but they did not believe negative test results.
Recently, there have been case reports of the onset of psychotic symptoms triggered by the fear of COVID-19. A cohort of six cases with first-episode psychosis was reported in the 2nd month of national lockdown in Italy. In that study, cases had a negative psychiatric history and normal premorbid psychosocial adjustment; none of their first-degree relatives had a known mental disorder, and no shared risk factor other than pandemic-related stress could be identified similar to our cases. The mean age of our cases was 42.3 years, although other recently reported cases of pandemic-reactive psychoses revealed a relatively younger age, confirming available evidence on BPD first episodes, which tend to peak in early adulthood for males and the mid-30 s for females.
Among older people and those who have chronic medical conditions, previous history of mental disorder, the presence of a family with a history of mental disorders, and having poor psychosocial supports were hypothesized either to provoke or exacerbate the existing mental problems during the COVID-19 pandemic.
All three of our cases were not married and lived alone. The feeling of loneliness may have increased their stress during the pandemic process. The first case stayed at home for 15 days due to flexible working hours. The second case had to quit his job for fear of the pandemic. Moreover, the last one's workplace was closed related to the pandemic. These changes in their lives may have reduced their psychosocial support. One of the cases had chronic illnesses such as hypertension and chronic renal failure that may have caused the fear of getting COVID-19 infection and hospitalization.
Psychotic disorders that develop during the pandemic may increase the risk of suicidal behavior. In a case report, the first episode of psychosis that resulted in suicide was mentioned. Patients with psychotic symptoms are also hazardous for the rapid spread of COVID-19. Disturbances in the content of thought and decision-making mechanism may prevent them from taking precautions against coronavirus.
There is much to speculate regarding the consequences of the COVID-19 pandemic on individuals with psychosis. Sufficient attention has not been shown to these patients. Mental health professionals should be aware of the possible increase in the BPDs related to pandemics.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, patients have given their consent for 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.
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Conflicts of interest
There are no conflicts of interest.
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