New Onset COVID-Related Delusional Disorder in a Patient with Health Anxiety: A Case Report

To the editor

Health anxiety, a common phenomenon, may cause misinterpretation of benign or normal bodily sensations as signs of infection during a pandemic. ¹ The increased anxiety caused by the coronavirus disease (COVID-19) pandemic has increased the risk of developing mental illness ² and caused the deterioration of mental state among the mentally unwell. ³ Here, we present a case of a patient with anxiety disorder who developed delusions during the pandemic. This being first of its kind, we feel the need to highlight this case.

Case Report

A 25-year-old unmarried man was presented to the psychiatry clinic in May 2020 with a three-month history of excessive concern about having contracted COVID-19 and fear of infecting other people. He had a family history of paranoid illness and was diagnosed with an anxiety disorder seven years ago, which precipitated after witnessing a seizure episode. He was treated with Escitalopram 10 mg for three years following which he improved and later discontinued the treatment. He functioned well despite intermittent mild episodes of anxiety.

He resigned from his job in February 2020 believing he had COVID-19 as he felt “uncomfortable” and he could feel mucous running from his nose into his throat. He reported to a COVID designated hospital where he was admitted for three days and tested negative for the virus. He was assessed by a psychiatrist and restarted on Escitalopram 10 mg/day for anxiety. After discharge, he quarantined himself at home for two weeks even though he did not have any COVID symptoms. He started gathering information incessantly about COVID-19, and believed he had all the symptoms despite the lack of objective evidence and multiple reassurances by doctors and family members. He believed he should rather die than infect others. Secondary to which, he went to a nearby river with suicidal intent, but did not act further. He was admitted in our hospital with a recent negative COVID report. He denied having pervasive sadness, anhedonia, and irrational unwanted thoughts which he could not resist, or any other psychotic symptoms.

In the hospital, he remained preoccupied with vague physical symptoms despite reassurances which he attributed to COVID-19 and believed he was spreading the infection to other patients. He drank turmeric–ginger water multiple times a day to kill the virus which was enabled by the caregiver. Physical examination and investigations such as complete blood count, inflammatory markers, chest X-ray, and electrocardiograph revealed no abnormalities which were reflected to him as the objective evidence of COVID-19 negative status. Nevertheless, he continued seeking further tests to prove his belief. He scored 72/210 on Positive and Negative Syndrome Scale, with positive, negative, and general psychopathology subscale scores being 22/49, 13/49, and 37/112, respectively. The modified Psychotic Symptom Rating Scales revealed a score of 22/24, with high scores on preoccupation, conviction, distress, and disruption. He scored high (22/24) on the Brown Assessment of Beliefs Scale too. These scales, both individually and collectively, confirmed high severity of his delusions and its vectors. He was diagnosed with delusional disorder (hypochondriacal) and anxiety disorder NOS as per ICD-10.

He was started on oral Risperidone for psychotic symptoms, which was gradually increased to 12 mg daily over eight weeks and Escitalopram up to 20 mg with short-term Clonazepam which reduced his anxiety. Despite compliance being monitored by nurses, there was no change in his conviction. Due to poor response and development of tremors, Risperidone was cross-tapered with Trifluoperazine 5 mg/day. Eight sessions of cognitive behavioral therapy (CBT) were provided, and his family was psycho-educated regarding his illness and treatment. With the combination of Trifluoperazine 5 mg and Risperidone 4 mg (stopped after three weeks), his subjective distress and conviction began reducing over two weeks prior to discharge. The delusions resolved almost completely after five months of treatment with Trifluoperazine.

Discussion

Attribution styles are maladaptive in anxiety disorders, and patients show higher misattribution with less normalizing cognition than healthy controls. ⁴ Moreover, those with hypochondriasis attribute their bodily sensations and symptoms to the presence of serious illness, as compared to those with anxiety disorders. ⁵ During a pandemic, an anxious person is more likely to misinterpret bodily sensations to be symptoms of COVID-19. The constant flow of (mis)information in media also contributes to cognitive distortions, and we found magnification, catastrophizing, and fortune-telling in our patient. These simultaneously occurring processes may have facilitated the formation of delusions in this patient, with high levels of conviction, extension, pressure, and affective response.

Anxiety during pandemics is understandable, but misinformation may worsen anxiety and accurate information with realistic solutions offers the best approach. ⁶ A Cochrane review for the treatment of delusional disorder revealed a lack of adequate randomized controlled trials comparing pharmacological options. Only one small randomized controlled trial comparing CBT with placebo was included in the review, but no recommendations on psychological therapy could be made. Delusional disorders are difficult to treat, and widely accepted treatment options include antipsychotics, antidepressants, and CBT. ⁷ Systematic evaluation and evidence-based treatment highlight the strength of our clinical approach, wherein we found that CBT helped reduce distress but resolution of delusions occurred in response to antipsychotic treatment. Establishing a delusion in light of realistic anxiety about COVID-19 was a challenge.

This, and another recently reported case of transient psychosis, ⁸ demonstrates how excessive anxiety during a pandemic can lead to the development of more severe mental disorders and highlights the need for professionals to be vigilant.