Asim Shah, MD

To help in the prevention of the coronavirus disease 2019 (COVID-19), the Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for the Pfizer-BioNTech vaccine on December 11, 2020. One week later, the same action was issued for the Moderna vaccine (

 against COVID-19 has provided a sense of optimism, as many have endured prolonged isolation and quarantine, the mental health effects of the pandemic, and the morbidity and mortality of the disease. However, for vaccines to achieve the desired affect there must be a minimum number of individuals who accept it. 

 is not a new issue; it has been widely studied. In fact, the World Health Organization identified it as 1 of the top 10 global health threats in 2019.

Table 1. Efficacy and Safety Data for the Pfizer-BioNTech and Moderna Vaccines

A large survey by the Pew Research Center found the intent to get the COVID-19 vaccine dropped from 72% in May 2020 to 51% by September 2020.

 Of those respondents, 77% reported a concern that vaccine swould be prematurely approved without long-term safety data. Among the individuals who did not want the vaccine, 76% expressed concern about its potential adverse effects, whereas 72% wanted to know more about its efficacy before administration. Of the individuals who intended to get the vaccination, 19% expressed a great deal of confidence about safety and efficacy, 45% reported a fair amount of confidence, and 35% reported not much or no confidence at all (

 The intent to get vaccinated increased in December 2020, as 60% of Americans said that they would “definitely” and “probably” get COVID-19 vaccination once it is possible.

Figure 1. Concerns and Confidence About the Vaccines

More recently, the Kaiser Family Foundation (KFF) surveyed 1676 adults in the United States from November 30 to December 8, 2020. They found that 71% of respondents reported they would “definitely” or “probably” get the COVID-19 vaccine, whereas 27% expressed concern and were hesitant to receive it.

 The sample was randomized to represent the population, including Hispanic and non-Hispanic Black adults. Vaccine hesitancy was high in individuals identifying as Republicans (42%), rural residents (35%), and Black adults (35%) (

 For comparison, during the 2009 influenza A H1N1 pandemic, the early estimates of vaccine acceptability were between 50% and 64%.

 To address lagging hesitancy and resistance, vaccine myths and disinformation need to be addressed, and clear and consistent messages should be delivered to the community about the importance of receiving the vaccine. Psychiatrists can and should take time to 

Figure 2. Groups Hesitant to Receive the Vaccine

 In the 2 COVID-19 vaccines currently available, the mRNA carries instructions to make the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) attach, or spike, protein to the host cells. After the vaccine is injected, the mRNA is taken up by the macrophages near the injection site and instructs these cells to make the spike protein. This spike protein then appears on the surface of the macrophages inducing an immune response.

 These types of vaccines take another virus and replace its genetic material with the sequence coding for the SARS-CoV-2 spike protein. The virus acts as a delivery system, or vector, for this genetic sequence.

Replication-defective adenovirus vector vaccines.

 The AstraZeneca/Oxford University vaccine uses a simian adenovirus vector, and the Johnson & Johnson vaccine uses a human adenovirus vector to carry the DNA coding for the spike protein to the host cells and deliver it to the nucleus.

 The cell’s machinery produces the spike protein, which then induces the immunologic response.

 The virus contained in this vaccine does not replicate inside cells, as the genes responsible for replication have been deactivated. These vaccines are not authorized in the US.

 Merck’s vaccine uses a recombinant vesicular stomatitis virus (rVSV) vector.

 The researchers replaced part of its RNA sequence with RNA coding for the spike protein. Unlike the adenoviruses, this vector displays the spike protein on its surface. Because rVSV is replication competent, this platform more closely mimics a real viral attack.

 This vaccine is still in clinical trial.

 These include SARS-CoV-2 spike protein but no genetic material. Novavax’s

, NVX-CoV2373, is made from recombinant nanoparticles studded with coronavirus spike proteins.

 It is awaiting results from phase 3 trials from multiple sites.

The mRNA vaccines are classified as reactogenic: They generate a brisk immune response, which is expected to cause some adverse effects in most individuals who receive them. The most common reported reaction has been pain at the injection site.

 Other commonly reported systemic adverse effects have included chills, fatigue, headache, and joint and muscle pain.

 In most individuals who received the vaccine, these effects resolved within a couple of days.

 In general, the adverse effects are more common in younger vaccine recipients, with the second dose predictably producing more adverse effects than the first one.

Severe allergic reactions (anaphylaxis) have been reported in some recipients shortly after the first dose.

 notes that anaphylaxis is rare, with an estimated rate of 11.1 cases per million doses of the vaccine.

 The likely culprit for these reactions is polyethylene glycol, a compound in the Pfizer-BioNTech and Moderna vaccines.

 Following these reports, post-vaccination observation has been made mandatory: 30 minutes for those with a history of severe allergic reactions of any kind and 15 minutes for everyone else.

 The number of cases of Bell palsy reported in the trials of both mRNA vaccines was small and not more frequent than expected in the general population. Hence, it is not certain whether the vaccine caused the paralysis.

Mental Illness Exacerbation in Context of Vaccine Hesitancy

Mental health professionals can expect anxiety, paranoia, and even 

 in the context of vaccine hesitancy. Widespread conspiracy thinking can make it more difficult to achieve proper control of the pandemic and promote adherence to healthy behaviors. Vigilant fact-checking and challenging irrational thinking are essential. Stressful circumstances could trigger or exacerbate mental illness, and the debunking of vaccine-related myths should include an assessment of whether the beliefs represent mental symptoms that need treatment.

Anxiety about vaccine safety and adverse effects correlates with increasing scores on the Vaccine Conspiracy Belief Scale,

 obtaining information from social media, and lower educational status. 

 are inversely correlated with adhering to safety restrictions and behaviors, and related to pseudoscientific practices and vaccine hesitancy.

 Studies also found that individuals with strong COVID-19 conspiracy beliefs tended to have lower education.

The right framing can present the vaccine as a gain instead of a risk.

 Prospect theory posits that in the context of uncertainty, a behavior expected to prevent a loss is more likely to be selected.

 Anecdotally, individuals who have lost loved ones to the illness are likelier to accept the vaccine. Current conspiracy theories suggest that vaccines are riskier than reality and downplay the risks of COVID-19 illness. Current misinformation suggests the vaccine is related to infertility, poisoning, and other imagined severe effects. This risk-benefit analysis, of course, does not stand up to scientific scrutiny, but careful debunking of misinformation in the context of a positive therapeutic alliance can result in a more realistic and balanced view of the situation.

In individuals with mental illness, the propensity to overinflate threats and avoid risks may contribute to vaccine hesitancy, as in the case in anxiety disorders.

 The same mechanism could apply to psychotic disorders but has not been formally studied (

Table 2. Myths About COVID-19 Vaccination

Confronting and Overcoming Vaccine Myths and Misconceptions

A survey conducted by the Yale New Haven Health System showed that 1 out of 6 health care workers expressed 

 to getting the vaccine in the first wave, with the most common reason being medium- and long-term safety issues.

 Health care staff also expressed concerns about lack of existing research and data transparency, uncertainty about the inclusion of minority groups in the trials, a rushed process, RNA technology, underlying or preexisting conditions not studied, political influence, and length of expected immunity from the vaccine.

 The KFF’s vaccine monitoring system found similar hesitancy trends in the general population.

A probing yet nonconfrontational approach combined with directing individuals toward objective resources may work best in addressing some of the common misconceptions. Motivational interviewing techniques can also tackle vaccine hesitancy.

“The vaccine will alter my DNA/make me infertile.”

 The concept of using mRNA as a novel therapeutic tool dates to the early 1990s.

 The mRNA is not designed to integrate with host DNA, nor can it typically do so given its rapid degradation.

 In the COVID-19 vaccine, once the immune response is initiated against the spike protein, mRNA is degraded by the cells.

“I already had COVID-19, so I do not need the vaccine.” 

The Centers for Disease Control and Prevention recommends that individuals who previously had COVID-19 get 

. Health experts do not know how long the immunity lasts postinfection because this can be variable depending upon the individual.

“Not everyone with COVID-19 dies, so I will be fine without the vaccine.” 

As of February 2, 2021, there were 26,034,475 cases of COVID-19 in the US and 439,955 deaths.

 The long-term effects are still unknown, but COVID-19 is suspected to cause dysautonomia, cardiovascular, and neurologic sequelae. Thus, vaccination is recommended not only to protect oneself immediately, but also in the long run and for those who are at high risk.

“By taking the vaccine I will get the COVID-19 infection or will test positive for COVID-19.”

 The COVID-19 vaccine does not contain the live virus, and vaccines are unable to trigger the full disease. An individual who has received the vaccine will not test positive for COVID-19 in the absence of infection.

“Would the vaccine make me psychotic or does it have a microchip?”

 Pfizer-BioNTech and Moderna have made their vaccine ingredients available to the public. They both contain mRNA along with lipids and other ingredients that help to maintain the pH for stability.

 Patients with mental illness, especially those with 

 spectrum disorder, can become paranoid about vaccine contents.

 Initially, direct the individual to the drug companies’ websites and ingredient lists. Address this particular concern with a careful assessment of psychosis in vulnerable patients.

“Vaccines cannot be trusted, as they were rushed in the process of their development.”

 During the clinical trials, the companies used the vaccine in a large sample of volunteers to establish its safety and efficacy. It took a few months for the clinical trials to collect substantial data, which was further scrutinized by the experts in the FDA, and the 2 vaccines received EUA. In addition, many vaccine safety monitoring systems are in place: the V-safe, National Healthcare Safety Network, and others are tasked with identifying adverse events not encountered in clinical trials.

 The only missing piece, in fact, is long-term effectiveness data, as most adverse effects with vaccines tend to occur in the first 6 weeks after administration. To refute this misconception, point out that the pandemic’s impact led to unprecedented 

 between governments and pharmaceutical companies and considerably shortened bureaucratic wait times.

is assistant professor of internal medicine at the Baylor College of Medicine. 

is assistant professor of psychiatry at the Baylor College of Medicine.

is professor and executive vice chair, Barbara & Corbin J. Robertson Jr. Chair in Psychiatry at Menninger, chief of the Division of Community Psychiatry at Baylor College of Medicine. 

is associate professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, and Ben Taub Adult Outpatient Services director, medical director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis. She also serves on 

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128/schizophrenia-diagnosis-among-top-risk-factors-for-mortality-in-covid19-patients ❒

Articles

The vaccine needs to be appropriately framed: as a benefit, not a risk. 

Breaking the Spell: Fighting Myths About COVID-19 Vaccination

Starting as a mysterious pneumonia in Wuhan, China, the newly named COVID-19 has resulted in a worldwide outbreak, causing morbidity and mortality as well as potentially disrupting the global economy. The World Health Organization (WHO) has declared this a global pandemic; to date (as this article goes to press), there are more than 80,000 reported cases worldwide (72,506 from Mainland China, Hong Kong, and Macau), and COVID-19 has claimed more than 2700 lives. (For more information, please see 

https://www.cdc.gov/coronavirus/ 2019-ncov/summary.html

Although pharmaceutical companies and countries are looking into vaccinations and curative treatment for coronavirus infection, currently there is nothing available; thus, precautions against transmission and early supportive treatment is key. Psychiatrists must have a basic understanding of the pathophysiology of coronaviruses in order to be able to accurately explain and discuss those issues with their patients, especially as mental health ramifications are expected.

Coronaviruses, belonging to the Coronaviridae family, are singleâstranded positiveâsense ribonucleic acid (RNA) viruses that thrive in animals, which are their natural carriers. The only coronaviruses previously known to infect humans were HCoVâ229E, HCoVâOC43, HCoVâNL63, andHKU1, as well as the two infamous relatives of 2019-nCoV-the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), responsible for outbreaks in 2002-2003 and 2012, respectively. Alphacoronaviruses and betacoronaviruses infect mammals (eg, bats) whereas gammacoronaviruses and deltacoronaviruses are more prone to cause fish and bird infections (Table). Animal to human-zoonotic-transmission is not the norm for coronaviruses, but prior coronavirus outbreaks in animals have been economically damaging.

have been occurring of late. However, it is hypothesized that global climate factors may be related and similar to viral mutations linked to pandemic capacity (ie, genetic drifts in a wide outbreak in animals may essentially lead to better virus survival rates in humans).

In the case of COVID-19, the transmission is 

to have occurred at the Wuhan Huanan Seafood Wholesale Market, although the exact carrier species has not been determined.

 From this point, the main 2019-nCoV contagion has been human-to-human transmission. Symptoms have ranged from mild to severe, with most patients reporting fever, dry cough, myalgia, fatigue, and diarrhea.

 Gastrointestinal symptoms have been present, although less frequent than with SARS.

Why do some people get sicker than others? Coronaviruses have an RNA genome, similar to the influenza virus (responsible for the flu) or the respiratory syncytial virus (RSV). The immune system recognizes the RNA as foreign and triggers the immune response responsible for fighting the virus (ie, production of interferons and pro-inflammatory cytokines), and then clearing the foreign entity out of the body. A review of the exact immune responses are beyond the scope of this manuscript. However, the reader is encouraged to remember that the immune system is highly adaptable and modifies its metabolism and existing balance to fight expected threats (for an excellent review, see Kikkert

). Unfortunately, the virus exploits the host’s immune system, mimicking certain innate components to hide while replicating, which makes the immune system less able to effectively fight the invasion. Viruses may also halt cellular replication and use existing cellular resources to prioritize viral replication. The balance between immune response and viral replicative success ultimately determines disease outcome.

Certain populations are known to be vulnerable to COVID-19, such as infants, the elderly, and those with immunocompromised systems or pre-existing medical issues, who are at increased risk for severe repercussions from infections and, thus, more likely to develop sepsis and possibly death; worse outcomes could also be 

 Cytokine storm, a term referring to over-production of inflammatory cytokines, was found more often in patients suffering from COVID-19 who ended up in intensive care, but causal factors are not fully understood.

 Thus far, there is no way to predict who will have an exaggerated immune response besides looking for the previously noted clinical, non-specific factors.

Prevention, treatment, mental health implications >

Cleaning and disinfection to prevent transmission

Concern arises about transmission between various individuals but also about persistence of the virus on inanimate surfaces, such as mailed packages or in health care settings. As such, WHO has provided a set of recommendations for disinfecting surfaces.9 While the persistence of 2012-nCoV is not fully understood, it has been shown that other strains of coronaviruses stay viable for up to 9 days on surfaces (unless disinfected).

Testing of the recommend WHO formulations against various viruses revealed effectiveness.10 Ethanol, sodium hypochlorite, and glutardialdehyde have been found most effective;

 a concentration of 70% ethanol is adequate for small surface disinfection. Patients inquiring about cleaning should be cautioned about using gloves with bleach (sodium hypochlorite) and other substances. Special attention should be paid to patients with cleaning compulsions, who get skin damage from excessive cleaning product exposure. (The worsening of obsessive-compulsive disorder is discussed in the accompanying article.)

The CDC recommended precautions include the use of a facemask for suspected patients/affected individuals (not for healthy individuals) and hand washing with soap and water for 20 seconds or using any sanitizers with at least 60% alcohol content. This especially should be done after using the restroom; after blowing one’s nose, coughing, sneezing; and before and after eating.

Although the coronavirus may have infected thousands of people, it is important to put its impact into perspective. For instance, according to the CDC, influenza already has affected 19 million people this year alone, hospitalizing 180,000 and killing 10,000 individuals. Thus, although COVID-19 is a serious threat, flu continues to be the major viral respiratory threat, as it has for many decades. Prevention efforts should focus on the flu and highly prevalent infections while also keeping in mind novel outbreaks.

Testing, treatment, and prevention efforts

The presence of COVID-19 can be assessed by a newly released real time reverse transcription-polymerase chain reaction (rRT-PCR) test. Of course, here in the US, clinicians are encouraged to contact and collaborate with their state or local health department for any diagnosed or suspected cases.

While there is no specific treatment for COVID-19, WHO has issued an interim guidance document, which is available online at www.who.int/. Meanwhile, there have been treatment attempts with various antivirals (eg, remdesivir, lopinavir-ritonavir, interferon-Î± 2b) developed for previously known viral agents. None of these have been studied in randomized controlled trials for COVID-19 and results are of anecdotal quality.

for patients requiring hospitalization is isolation and supportive care, including oxygen therapy and fluid management.

 Administration of antimicrobials for treatment of secondary bacterial infections and avoiding secondary end-organ damage also may be needed for some patients.

 Care must be taken to discourage patients from seeking untested, potentially dangerous treatments such as over-the-counter concoctions.

Without specific treatments, the emphasis has been on limiting new exposures, which is where incubation and quarantines come into play. Currently, the incubation period is thought to be 2 to 14 days, so limiting exposure to individuals with suspected infection during that time, and within the active symptom period, is the first and most basic step in preventing further spread of the virus.

The working incubation period takes a few things into consideration. In a systematic review of nine viral agents of public health importance, 

 found most coronaviruses had a median incubation time of 3 to 4 days. Among affected individuals from China, the mean incubation period has been about 5 days, with a range of 4 to 7 days and a 95% percentile of 12.5 days

; thus, the typically imposed 14 - day incubation period. Athough some anectodal reports suggest a longer incubation, the CDC believes data show 14 days is the top amount needed.

The coronavirus has largely dominated the news and the minds of people across the globe for the last month. In the 

, we discuss its impact on mental illnesses, stigma, and discrimination in our communities: 

Psychiatrists Beware! The Impact of COVID-19 and Pandemics on Mental Health

is Associate Professor, Menninger Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Ben Taub Adult Outpatient Services Director, Medical Director, STAR (Stabilization, Treatment, and Rehabilitation) Program for Psychosis, Houston, TX. 

is Professor & Executive Vice Chair, Barbara & Corbin J. Robertson Jr. Chair in Psychiatry at Menninger, Chief of the Division of Community Psychiatry at Baylor College of Medicine. They report no conflicts of interest concerning the subject matter of this article.

Impact of recent and future climate change on vector-borne diseases

2. Goneau LW, Mehta K, Wong J, L’Huillier AG, Gubbay JB. Zoonotic Influenza and Human Health-Part 1: Virology and Epidemiology of Zoonotic Influenzas. 

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

4. Liu J, Zheng X, Tong Q, et al. Overlapping and discrete aspects of the pathology and pathogenesis of the emerging human pathogenic coronaviruses SARS-CoV, MERS-CoV, and 2019-nCoV. J Med Virol. 2020.

The Novel Coronavirus: A Bird’s Eye View

Innate Immune Evasion by Human Respiratory RNA Viruses

7. Chousterman BG, Swirski FK, Weber GF. 

Cytokine storm and sepsis disease pathogenesis

8. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. 

9. WHO. Use of disinfectants: alcohol and bleach. Infection prevention and control of epidemic-and pandemic-prone acute respiratory infections in health care. Geneva: WHO;2014.

10. Siddharta A, Pfaender S, Vielle NJ, et al. Virucidal Activity of World Health Organization-Recommended Formulations Against Enveloped Viruses, Including Zika, Ebola, and Emerging Coronaviruses. 

11. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents. 

12. Lessler J, Reich NG, Brookmeyer R, Perl TM, Nelson KE, Cummings DA. Incubation periods of acute respiratory viral infections: a systematic review. 

13. Serrano I, Gomes D, Ramilo D, et al. An Overview of Zoonotic Disease Outbreaks and its Forensic Management Over Time. 

Psychiatrists must have a basic understanding of the pathophysiology of coronaviruses in order to be able to accurately explain and discuss those issues with their patients, especially as mental health ramifications are expected.

The New Game of Microbiology Clue: The Who, When, Where, and Why of the Novel Coronavirus

It’s easy to blame, it’s easy to politicize, it’s harder to tackle a problem together and find solutions together.

WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc

Infectious pandemics and the spread of organisms across countries and continents have been facilitated by global changes in earth’s climate and an increase in travel and international exchange. COVID-19, the infection caused by the novel coronavirus detected in December 2019, is now affecting more than 27 countries, raising concerns of widespread panic and increasing anxiety in individuals subjected to the (real or perceived) threat of the virus. Importantly, these concerns arise with all infections, including the flu and other agents, and the same universal precautions are needed and indicated for safety and the prevention of further transmission. However, media coverage has highlighted COVID-19 as a unique threat, rather than one of many, which has added to panic, stress, and the potential for hysteria.

Pandemics are not just a medical phenomenon; they affect individuals and society on many levels, causing disruptions. Stigma and xenophobia are two aspects of the societal impact of pandemic infectious outbreaks. Panic and stress have also been linked to outbreaks. As concerns over the perceived threat grow, people may start to collect (and hoard) masks and other medical supplies. This is often followed by anxiety-related behaviors, sleep disturbances, and overall lower perceived state of health. Individuals with mental illness may be particularly vulnerable to the effects of widespread panic and threat.

Fears, Outbreaks, and Pandemics: Lessons Learned

Chronic disease, including chronic infectious diseases such as tuberculosis and 

 (HIV), are associated with higher levels of mental disorders as compared with the general population.

 Studies show depression rates usually soar after infections (eg, herpes exposure and anthrax scares).

 Although the effects of the coronavirus on mental health have not been systematically studied, it is anticipated that COVID-19 will have rippling effects, especially based on current public reactions. Psychiatrists are uniquely situated to help both their patients and the greater community understand the potential impact of the virus and help patients, families, and society deal with this latest threat.

Stigma, medical mistrust, and conspiracies

Epidemics lead to stigmatization of affected individuals, authority figures, and health care professionals; sadly, this trend has been seen in multiple countries and with multiple infectious agents.

 With COVID-19, men and women of Asian descent, specifically Chinese, are the victims of social stigma and xenophobia, with high levels of politicization and threats online and in personal interactions. As with most stigma-laden interactions, the process unfolds because of limited information, hasty and uni-dimensional assessments, and a defensive formulaic response. It is imperative that all health care professionals, especially psychiatrists, act as the voice of reason and help disseminate proper, evidence-based information.

“Medical mistrust” refers to a lack of trust in medical treatment and advances. It results in a lower use of health care resources and poorer management of health conditions (coupled with potential misuse at times of crisis). Moreover, medical mistrust has been used to explain some racial and ethnic health care disparities.

 It has been linked to a variety of diseases and conditions, including cancer, autism, and HIV.

During infectious pandemic,s medical mistrust has been linked to conspiracy theories. In one US study, up to half of those surveyed endorsed belief in at least one health-related conspiracy theory.

 At its extreme, medical mistrust can lead to movements such as anti-vaccination trends, which have been linked to measles outbreaks.

Mistrust of medical organizations can reinforce stigma and perceived discrimination and result in lower adherence to health recommendations. Clinicians must maintain a scientific, fact-based, and neutral presentation of recommendations while emphasizing the importance of overall infection control practices in the wake of COVID-19.

Anxiety and obsessive-compulsive disorders

We anticipate the effects of infectious disease threats to manifest as sheer anxiety and panic: worry about getting an infection, worry about loved ones getting ill, and worry when related symptoms-even minor-are present. The absence of a definitive treatment for coronavirus easily exacerbates anxiety. In most cases, these anxiety symptoms do not reach diagnostic thresholds for a DSM-5 diagnosis; however, patients will benefit from reassurance and education.

Contamination obsessions-unwanted, intrusive worry that one is dirty and in need of washing, cleaning, or sterilizing-are very common in patients with OCD. Perceptual experiences (eg, feeling dirt on skin) understandably would amplify obsessions. Sensory experiences (but not necessarily full tactile hallucinations) have been found in up to 75 % of patients with OCD patients.

 More intense sensory experiences (pseudo-hallucinations) are related to worsened control over compulsions and poorer insight.

 Biased information processing is associated with a tendency to overestimate threat in individuals with OCD.

 This may increase sensitivity to the panic associated with 

 and further destabilize patients and increase functional impairment.

Cleaning and washing compulsions, also a core feature of OCD, can easily be exacerbated by the threat of infectious pandemics. Complications of excessive cleaning include dry, chapped skin (which can lead to super-imposed infections). and contact and atopic dermatitis; similarly, overuse of toxic cleaning supplies can lead to inhalational injuries.

 Fear of acquiring a new, sensationalized disease may worsen negative behaviors. Clinicians in psychiatry, psycho-dermatology, and primary care practices should be alert to potential issues in patients with OCD.

Psychotic disorders: an extreme of medical mistrust?

Anecdotally, the most glaring (and maybe the most interesting) examples of medical mistrust conspiracy theories concern patients who have psychotic disorders. Typically, repeated media exposure to an alarming fact (in this case, spread of coronavirus), coupled with a distrust of organizations and government as well as misattribution of physical symptoms can result in delusions. Similarly, fears can quickly lead to clinical decompensation and must be carefully monitored.

Adding fuel to the fire are discussions of conspiracy theories related to infectious outbreaks such as HIV and Ebola in the 

Psychiatrists are uniquely situated to help both their patients and the greater community understand the potential impact of the virus and help patients, families, and society deal with this latest threat.