I had written an article for Psychiatric Times back in July of 2015 titled, “Managing Ebola: The Archaeology of a Disease,” at the early stages of the then burgeoning Ebola outbreak in the US. I had quoted Dr Adrian Hill, the director of the Jenner Institute on vaccine research at Oxford: “We know there will be more outbreaks . . . Many viruses are lurking, and then there are going to be new viruses.”1,2 Here we are now, only five years later, in the face of a pandemic, literally tracing the archaeology of a new disease.
As in many parts of the country, COVID-19 has become the primary focus of hospitals in my geographic region (the greater Boston area). We have not yet been overwhelmed, but cases are growing. The psychological warfare waged by this virus has been overwhelming, both for patients and for health care providers. Patients are afraid of contracting and transmitting the virus. But health care workers, especially those used to a degree of predictability, seem to be susceptible to the stress of uncertainty and loss of control engendered by the COVID-19 pandemic.
Since the declaration of the pandemic, we have had now several cases in our emergency department (ED) of what I have referred to as “corona psychosis”. I present three brief cases here, afflicting a physician, nurse, and hospital custodial staff. I am not aware of any similar reported cases.
“Dr X” is in her 40s and a practicing physician and administrator at a medical center. She was brought unwillingly to the ED by her concerned husband. She had no prior documented psychiatric history and no significant medical history. The mother of a young child, she was almost two years out of the postpartum period. She did not drink alcohol or use any other psychoactive substances. A colleague had informed her husband of concerns by staff that she was becoming increasingly irrational and erratic at work, roughly corresponding to the dramatic increase in media coverage of the coronavirus.
Upon psychiatric evaluation, her speech was pressured and she was paranoid. Despite being asymptomatic, she had convinced staff at another hospital to test her for the virus several days earlier, which came back negative. However, following the negative test, the patient then became belligerently mistrustful of “the system.” She refused to believe she did not have the virus. Over the course of 48 hours after receiving the test results, she became convinced that not only was she infected, but her family was infected as well. She believed that the Center for Disease Control had specifically targeted her and her family, transmitting the disease surreptitiously by means of “drones” while they slept.
As a result, she had not slept for three days. She denied any hallucinations, and she maintained good behavioral control throughout the exam, but clearly she was delusional. When asked about her plans, she stated only she “would monitor the situation.” When asked why she had returned to work if she believed she were infected, she said, “I have to find the cure. Although we strongly encouraged her to admit herself voluntarily to the psychiatric unit, she refused. She did respond well to lorazepam in the ED, and her husband, also medical professional, insisted on taking her home. Ultimately, she did not meet criteria for involuntary commitment, and she was discharged.
“Ms.Y,” was a nurse in her mid-40s. Married with teenage children, she has a history of depression and anxiety, as well as some concerns for a possible alcohol use disorder. However, she had no documented history of psychotic symptoms. She self-presented, complaining of worsening depression since the expanded media coverage of the coronavirus, and now she feeling quite hopeless and suicidal.
She had written a detailed suicide note to her husband, making it clear that she “was already in the process” of committing suicide. She explained, both in her note and to us, that she had infected herself with coronavirus with the intent of dying. She had tested negative for the virus at an outside hospital, and when asked how she had infected herself, she explained that she “went 24 hours without washing her hands.” She was not intoxicated, and there was no evidence of withdrawal.
Although she was convinced that she would die within two weeks, she agreed to a voluntary admission to the psychiatric unit. She responded well to low-dose lorazepam in the ED. Her symptoms are currently being treated with a combination of an antipsychotic and an antidepressant medication.
“Ms Z” presented two days later, overnight, while still working her shift as a custodian at her hospital. She was also in her 40s, married with grown children, and employed. She has worked among the hospital housekeeping staff for many years without incident. She had a long history of intermittent anxiety treated well by her primary care physician with minimal use of as-needed alprazolam.
She had been cleaning a patient’s room on the psychiatric unit when a nurse entered the room next door, gowned, gloved, and masked, to perform a routine influenza/RSV swab on a different patient. Upon witnessing this, she became convinced that she had contracted coronavirus. She became quite agitated, started pulling at her own hair and shouting nonsensically in her native language. She could not be calmed down verbally, and she had to be escorted to the ED by hospital security.
Upon examination in the ED there was no indication that she was at increased risk of coronavirus, and she was asymptomatic. Due to Department of Public Health guidelines, therefore, and unfortunately, she was not tested for coronavirus. She also partially responded to lorazepam, but she remained delusional that she was “infected.” Several family members came to the ED and took her home. She has been on medical leave since.
Obviously, this is a small series of patients from a single community hospital, but I anticipate as this crisis unfolds, and especially as people are more social isolated, there will be an increase in these brief psychotic reactions. Based on these cases, anxiety and perhaps depression may be a contributing factor, and the more acute symptoms responding well to lorazepam, at least temporarily.
What is otherwise striking in these cases is the commonality of all three patients working in hospital systems at the frontline of the current crisis. As a team, we have been working increasingly alongside staff throughout this crisis, and I am concerned about the toll this crisis is taking on those “in the trenches.” There have been many subtle signs of stress vulnerability in providers, increasingly outward signs of a more generalized helplessness at the loss of control.
The anxiety is growing more palpable, on both sides—that of patients and health care professionals—and I would urge everyone involved in these efforts to seek and to provide ongoing support for your teammates. As psychiatrists, especially those of us who work in hospital systems, we need to be attuned to our colleagues as this drama unfolds. Like all crises, this too will end, and hopefully, these and other cases of “corona psychosis” and anxiety will resolve relatively quickly.
The cases discussed here are composites and not meant to identify any one person. -Ed
Dr Martin is Director of Medical Psychiatry at the Newton-Wellesley Hospital in Newton, MA, and a Clinical Assistant Professor of Psychiatry at Tufts University School of Medicine in Boston.
1. Researchers warn G7 leaders on disease preparedness. University of Oxford. June 3, 2015. http://www.ox.ac.uk/news/2015-06-03-researchers-warn-g7-leaders-disease-preparedness-0. Accessed March 25, 2020.
2. The Authorized G7 Publication. Ebola: global health threats need a global research and development solution. G7: Beyond. 2015.2015:90-91.