Christopher S. Czapla, MD

Throughout 12,000 years of human history, pandemics have killed an estimated 300 million to 500 million people, with the bubonic plague decimating an estimated 60% of the European population during the Middle Ages. Despite modern advances in medicine, 

 has caused more than 1 million reported deaths in less than a year. Aside from the death toll, the pandemic has triggered significant emotional, physical, and economic problems around the world. But even in the midst of this crisis, nations have an opportunity to share and learn from each other’s experiences.

The emerging literature measures the impact of various traumatic stressors related to COVID-19, as well as the effects of less severe types of stress exposures. COVID-19 has already led to diverse mental health problems, including anxiety, depression, posttraumatic stress disorder, and other trauma- and stress-related disorders. Different groups have met the qualifying criteria for posttraumatic stress disorder (PTSD) according to DSM-5 as a result of the pandemic: those who have themselves suffered from serious COVID-19 illness and potential death; individuals who, as family members and health care workers, have witnessed others’ suffering and death; individuals who have learned about the death or risk of death of a family member or friend due to the virus; and individuals who have experienced extreme exposure to aversive details (eg, journalists, first responders, medical examiners, and hospital personnel).

Moreover, studies have explored other stressors adding to individuals’ emotional burdens, such as social isolation, unemployment and economic losses, and working from home while caring for children and other family members. Among health care workers, strains include lack of personal protective equipment (PPE), fears of virus exposure, burnout, patients perishing despite heroic efforts to save them, and difficult decisions about which patients should receive limited resources. A few studies have examined posttraumatic stress symptoms (PTSS), as well as anxiety, depression and other symptoms, and substance use in the general population during the pandemic.

More time is needed, of course, to conduct and publish systematic investigations on mental health sequelae, such as formal psychiatric diagnoses. Studies generally have been conducted through diverse internet platforms, which may affect generalizability. Methods and validated rating scales vary.

At the same time, it is not too soon for clinicians to read the emerging literature and base treatments on the latest research. We will explore some representative international studies of various groups affected by COVID-19, as well as protective factors and suggested interventions to help those in need (Figure).

Much of the current research emerges from China, the first country confronted by the pandemic. A 

 in China exposed to COVID-19 found a PTSD incidence of 16.8%, with highest scores in avoidance symptoms.

 Job satisfaction was associated with lower PTSD symptom scores and positive coping. The authors recommended supporting nurses who are having difficulty coping with their work by providing counseling.

A web-based, cross-sectional survey of more than 7000 Chinese individuals in February 2020 found that health care workers had the highest rate of poor sleep, and those aged 35 years or younger had more mood and anxiety symptoms.

 Overall, 35.1% of respondents reported anxiety symptoms, 20.0% depressive symptoms, and 18.2% poor sleep quality.

Other international studies have examined stress responses in health care workers treating patients with COVID-19. A study of 900 health professionals caring for hospitalized patients with COVID-19 in Singapore and India found relatively low symptoms of anxiety (15.7%), depression (10.6%), and stress (5.2%).

 However, among health care workers reporting these issues, more than half had symptoms in the moderate to extremely severe range. In addition, 67% of respondents reported physical symptoms, especially headache, lethargy, anxiety, and insomnia, suggesting somatic expressions of distress. United Kingdom military health care workers were assessed for the effects of inadequate safety equipment on their mental health during the COVID-19 medical response. Those with inadequate equipment had greater odds of having common mental health disorders (2.49), PTSD (2.99), poorer global health (2.09), and emotional problems (1.69).

Only a few studies of mental health problems among patients hospitalized with COVID-19 have been published, with more to come. A study of hospitalized but stable patients found a high prevalence of PTSS (96.2%).

 A chart review of hospitalized patients with COVID-19 in Spain found more than half of the 841 patients hospitalized with COVID-19 had a neurological symptom. Of these, nonspecific neurological symptoms were identified, as well as disorders of consciousness (19.6%), mostly in elderly patients and in those with severe COVID-19 disease; myopathy (3.1%); dysautonomia (2.5%); and other less frequent symptoms.6

Neuropsychiatric symptoms were reported by 19.9% of these patients, including insomnia, anxiety, depression and psychosis; these were not associated with disease severity.

Some studies have drawn inferences based on other severe respiratory viruses. A meta-analysis of long-term clinical outcomes for survivors of adult severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) who were in the intensive care unit (ICU) revealed PTSD prevalence in 39%, depression in 33%, and anxiety in 30% beyond 6 months after discharge, as well as reduced lung function and reduced exercise capacity.

 Italian experts also concluded that we might anticipate similar outcomes in survivors of COVID-19.8

Acute respiratory distress syndrome (ARDS) in ICU survivors of COVID-19 may occur, with an expected survival rate of approximately 25%. Survivors of ARDS may experience persistent fatigue and poor exercise tolerance, pain and weakness, neurological sequelae, and the psychological effects of prolonged ICU stays, as noted in patients with MERS and SARS. Stressors included immobility, separation from family and friends, prolonged sedation, anxiety about health conditions and survival, and subsequent job loss. The authors emphasized the need to identify PTSD (anticipated in up to 30% of ARDS survivors) and other mental health problems, and to provide appropriate and timely multidisciplinary therapy that should continue after discharge.

 A literature review of studies linking panic disorder with patients who had SARS suggested that aggravation of panic attacks is highly likely in survivors of COVID-19 in the face of prominent respiratory symptoms, as panic may be triggered by fear conditioning to abnormal breathing problems.

 The authors urged monitoring for panic as well as obsessive compulsive disorder, PTSD, and generalized anxiety disorder.

Some mental health care advocates believe the general population may be suffering from various levels of vicarious traumatization, although strictly speaking this would not qualify for PTSD’s Criterion A for trauma exposure. Along these lines, in August 2020 the CDC published results of a large US web-based survey of more than 5000 adults (

 in which 40.9% endorsed at least 1 adverse mental or behavioral health problem related to the pandemic. Symptoms of a trauma- and stressor-related disorder were reported by 26.3%, symptoms of anxiety or depression by 30.9%, substance use to cope by 13.3%, and serious consideration of suicide in the prior days by 10.7%. Suicidal ideation was significantly higher for younger respondents aged 18 to 24 years (25.5%), minority groups (Hispanic individuals, 18.6%; Black individuals, 15.1%), nonpaid caregivers for adults (30.7%), and essential workers (21.7%). The authors stressed the need to identify at-risk individuals to develop policies to address health inequities, and to increase resources for identifying mental health problems and offering new treatment options, including telehealth treatments.

In a study of home-quarantined youth in China during the first month of the COVID-19 outbreak, 12.8% had PTSS levels consistent with PTSD, with PTSS and distress associated with negative coping styles.

 Symptom levels were expected to increase with time as quarantine continued. This is important since a formal diagnosis of PTSD requires symptoms to persist for more than a month.

In another online survey conducted early during the Wuhan outbreak, researchers looked at anxiety and depression symptoms (rather than specific PTSS) in relation to social media exposure (SME) to COVID-19 news. The study, which included approximately 5000 adults in China, found high SME was positively associated with higher odds of anxiety and a combination of depression and anxiety, compared with low SME.

 A longitudinal survey of the general population in China during the initial outbreak, and again 4 weeks later, found the mean Impact of Events Scores to be above the cutoff scores for PTSD symptoms at both times, with moderate to severe stress, anxiety, and depression levels.

Results of an Italian cross-sectional, web-based 

 showed a relatively high percentage (29.5%) of PTSS related to the pandemic, suggesting that the pandemic itself could be considered a traumatic event.

 Similarly, an online survey of almost 3500 people in Spain found symptoms of PTSD (15.8%), depression (18.7%), and anxiety (21.6%), with loneliness the strongest predictor of symptoms.

 Other factors associated with these problems were female gender, previous mental health or neurological problems, having physical symptoms similar to those of COVID-19, or having a close relative infected.

Nursing home residents have been particularly vulnerable to poor health outcomes; early in the COVID-19 pandemic many facilities adopted strict lockdown policies. However, social isolation is particularly detrimental to the elderly, who may have increased risk for depression, anxiety, worsening dementia, and even earlier death.

 Given these issues, the Centers for Medicare and Medicaid Services (CMS) recommended safe communal activities for locked-down nursing homes.

In Canada, researchers explored prenatal maternal distress before and during the COVID-19 pandemic.

 Women assessed during the pandemic had higher levels of depression and anxiety, with levels more likely to be clinically significant, compared with women assessed before COVID-19. During the pandemic, dissociative and PTSD symptoms and negative affectivity were also greater, underscoring the need to carefully assess pregnant women to help prevent negative, stress-related outcomes in mothers and infants.

Perhaps not surprisingly, when compared with a control population, psychiatric inpatients in China had more PTSD, anxiety, and depression symptoms; more anger, impulsivity, and worries about health; and intense suicidal ideation.18 Hospitalized psychiatric patients and their mental health caregivers are at high risk for COVID-19 infection, compounding their existing stress. This was noted early in February 2020 in Wuhan, when the virus was diagnosed in at least 50 inpatients with psychiatric disorders and 30 mental health professionals. Factors included lack of protective gear and difficulties isolating.

 Outpatients with psychiatric disorders are also vulnerable to emotional distress during a pandemic. An online survey of more than 2000 outpatients in China discovered that 20.9% of patients with preexisting psychiatric disorders had seen their symptoms get worse during the pandemic.

How can we help individuals whose mental health has been harmed by COVID-19?

To support medical caregivers assigned to the front line during the pandemic, experts advise addressing burnout, as prolonged problems may overlap and lead to acute stress disorder and PTSD.

 Suggestions have ranged from practical measures (such as ensuring adequate PPE, handwashing, and decontamination of surfaces) to developing personnel policies that reassign at-risk medical personnel away from high-risk sites, ensure the safety of their family members, and stress the importance of self-care.

 Also recommended is providing health care workers access to child care services during expanded work hours and school closures. Workers should have adequate rest and breaks, be excused from less-essential tasks, and have regular information and feedback sessions with managers and the community. In many areas, hospitals provide telephone hotline teams trained to provide psychological assistance. Professional organizations offer physician wellness programs to provide free, confidential sessions to deal with burnout, adjustment problems, family issues, and other mental health sequelae.

The increasing numbers of people who were seriously ill with COVID-19 should be assessed for physical symptoms of chronic pain,

 with physical therapy and medications adjusted to avoid opioid dependence. Survivors of ARDS should receive evidence-based medications, cognitive behavioral therapy, and other psychotherapies for PTSD, panic, depression, and other mental disorders.

To combat isolation among locked-down nursing home residents, CMS recommends safe communal activities such as book clubs, movies, bingo, and outdoor family visits (ie, on lawns or in parking lots) with precautions of social distancing and PPE. Some nursing homes have provided live music, parades, therapy animals, recordings and photos of loved ones, physical contact with loved ones through plastic protective barriers, and even physical and occupational therapy sessions held outdoors.

Psychological first aid provided by trained community personnel might help the general population as they experience distress during the COVID-19 pandemic.

 For individuals enduring fallout from personal stressors, experts have recommended expanded use of telehealth to identify and treat mental health conditions, including depression, PTSD and other trauma-related disorders, substance use disorders, and suicidal ideation. Self-help groups, 12-step programs, spiritual and religious services, interest groups, and employee groups working from home are all increasingly using interactive internet-based platforms. And it is essential for societies to provide citizens with assistance for jobs, housing, food, medical care, education, internet connections, and many other basic survival needs.

The current international pandemic and possibly future ones will challenge us and give us the chance to continue to learn and share with other nations, hopefully linking us cooperatively rather than polarizing us.

 is professor and vice chair of education, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. 

is assistant professor and residency training director, Department of Psychiatry, University of Oklahoma Health Sciences Center, Oklahoma City. Authors have no relevant financial conflicts of interest. This article was originally posted on October 5, 2020, and has since been updated.

 Factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease 2019 in China

2. Huang Y, Zhao N. Mental health burden for the public affected by the COVID-19 outbreak in China: Who will be the high-risk group? 

3. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. 

4. Simms A, Fear NT, Greenberg N. The impact of having inadequate safety equipment on mental health. 

5. Bo HX, Li W, Yang Y, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. 

6. Romero-Sánchez CM, Díaz-Maroto I, Fernández-Díaz E, et al. Neurologic manifestations in hospitalized patients with COVID-19: The ALBACOVID registry. 

7. Ahmed H, Patel K, Greenwood DC, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalization or ICU admission: A systematic review and meta-analysis. 

8. Vittori A, Lerman J, Cascella M, et al. COVID-19 Pandemic acute respiratory distress syndrome survivors: pain after the storm? 

9. Javelot H, Weiner L. Panique et pandémie: revue de la littérature sur les liens entre le trouble panique et l’épidémie à SARS-CoV-2 [Panic and pandemic: Review of the literature on the links between panic disorder and the SARS-CoV-2 epidemic]. 

10. Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. 

11. Liang L, Gao T, Ren H et al. Post-traumatic stress disorder and psychological distress in Chinese youths following the COVID-19 emergency. 

12. Gao J, Zheng P, Jia Y et al. Mental health problems and social media exposure during COVID-19 outbreak. 

13. Wang C, Pan R, Wan X, et al. A longitudinal study on the mental health of general population during the COVID-19 epidemic in China. 

14. Forte G, Favieri F, Tambelli R, Casagrande M. 

COVID-19 Pandemic in the Italian Population: Validation of a Post-Traumatic Stress Disorder Questionnaire and Prevalence of PTSD Symptomatology

15. González-Sanguino C, Ausín B, Castellanos MÁ, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. 

16. Abbasi J. Social isolation—the other COVID-19 threat in nursing homes. 

17. Berthelot N, Lemieux R, Garon‐Bissonnette J, et al. Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. 

18. Hao F, Tan W, Jiang L, et al. Do psychiatric patients experience more psychiatric symptoms during COVID-19 pandemic and lockdown? A case-control study with service and research implications for immunopsychiatry. 

. 2020;87:100-106.19. Xiang YT, Zhao YJ, Liu ZH, et al. The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform. 

. 2020;16(10):1741-1744. Published 2020 Mar 15.

20. Zhou J, Liu L, Xue P, et al. Mental Health Response to the COVID-19 Outbreak in China. 

21. Restauri N, Sheridan AD. Burnout and Posttraumatic Stress Disorder in the Coronavirus Disease 2019 (COVID-19) Pandemic: Intersection, Impact, and Interventions. 

22. Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. 

Articles

The pandemic has triggered an array of emotional, physical, and economic issues but in the midst of this crisis, nations have shared and learned from each other’s experiences.

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

Slideshows

Patients with difficult conditions such as delusional parasitosis tend to resist the notion that a psychiatric problem underlies their symptoms.

5 Techniques to Help Your Patient Accept a Difficult Psychiatric Diagnosis

Mrs Dalton, a 53-year-old, presents to the emergency department, complaining of numerous small insects that have been crawling under her skin. She has created multiple excoriations on her arms, chest, neck, legs, and face in an attempt to remove the parasites. She also complains of a larger organism in her abdomen that she can feel moving through her organs. Mrs Dalton reports that she first experienced these phenomena 1 week after watching a television program that featured a patient with similar complaints who was infected with a rare parasite. Approximately 6 months before this presentation, Mrs Dalton had traveled to a rural area of Honduras.

Mrs Dalton had previously visited her primary care physician as well as a dermatologist, a cardiologist, and 2 emergency departments to seek treatment for these complaints. Testing of substances removed from the site of her excoriations showed only skin debris. She had tried a topical antiparasitic agent to eliminate the causal organism and alprazolam to reduce anxiety associated with her symptoms, but she reports that neither medication improved her condition. 

She has a history of depressive symptoms, which emerged 2 years before her current presentation. The depression had been effectively controlled for a year and finally remitted a year ago with citalopram. She has no history of 

. She is admitted to the internal medicine service with consultation from both the infectious disease and neurology services. Workup for medical causes of this presentation include culture from the site of her excoriations; chest films; CT of the head; and laboratory tests, including complete blood cell count, basic metabolic panel, thyroid-stimulating hormone level, vitamin B12 level, folate level, urinalysis with culture, urine drug screen, and HIV screen. No evidence of a medical cause for her symptoms is detected.

The differential includes a number of medical and psychiatric diagnoses. Several species of parasites can cause an infestation that results in pruritus and lesions caused by migrating organisms 

 (hookworms or roundworms), and members of the genus 

 (nematodes). These infections are commonly seen in patients who have traveled to tropical areas as Mrs Dalton had done. Scabies (the mite 

Dermatological conditions can be associated with pruritus and subsequent excoriation, including contact dermatitis, eczema, psoriasis, and impetigo. Psychiatric diagnoses to rule out include skin picking disorder, trichotillomania, obsessive-compulsive disorder, body dysmorphic disorder, delusional disorder, or any number of conditions that could cause psychosis or delusions. Intoxication with illicit drugs such as methamphetamine and cocaine commonly leads to self-excoriation as well.

Diagnostic criteria for parasitosis include:

• Symptoms that last a month or longer that do not meet criteria for schizophrenia

• Functioning that is not markedly impaired

• Delusional periods that last significantly longer than other psychiatric symptoms, such as mania or depression if they are present

• Delusions that cannot be attributed to a medical disorder or another psychiatric disorder

This disorder was first described in 1894 by Thibierge,

 who referred to it as “acarophobia.” In 1896, Perrin

 provided reports of 3 patients who presented with delusions of infestation after seeking care from dermatologists. The Swedish neurologist Ekbom’s

 description of patients with delusions of parasites crawling under their skin in 1938 is the basis of much of today’s understanding of delusional parasitosis.

 is diagnosed approximately twice as often in women as in men, and as many as 3 times as often in women older than 50 years than in men older than 50.

 Typically, the patient reports parasites crawling, living, and breeding under his or her skin for several months; the patient has previously sought help from various sources; samples of skin or other debris from the “parasites” are provided (stereotypically in a matchbox, leading to many referring to this as the “matchbox sign”); the patient has self-induced dermatological findings produced by attempts to remove the parasites.

Diagnosis is generally made by clinical history, after the actual presence of parasites has been ruled out by careful physical examination. Other psychiatric diagnoses can be ruled out if the delusions are monosymptomatic (ie, only related to the idea of a parasitic infestation).

Given multiple negative medical evaluations and Mrs Dalton’s psychiatric presentation, delusional parasitosis-also known as Ekbom syndrome-is diagnosed. Defined by DSM-5 as delusional disorder, somatic type, this diagnosis is given to patients who have the delusional belief that they are infested with parasites. Mrs Dalton’s history is consistent with a typical presentation, including the negative workup for an actual parasitic infestation. She had already visited several health care professionals and had undergone an extensive medical evaluation before her hospitalization and diagnosis.

Techniques for improving a patient’s acceptance of a psychiatric diagnosis such as delusional parasitosis

listen patiently to complaints about symptoms

acknowledge that the symptoms are “real”

refrain from challenging or validating theories about the cause of the symptoms

carefully examine samples of “parasites” that the patient provides

Patients with delusional parasitosis have a characteristically rigid belief in their perceived infestation that often leads to involvement of nonpsychiatric health care professionals, such as dermatologists and infectious disease specialists. Neurological workup is sometimes also performed because of the link between delusions of parasite infections, ischemic brain injury, and Alzheimer disease.

 Patients sometimes also consult veterinarians or pest control specialists for help.

After Mrs Dalton’s admission, additional costly tests were performed, and clinicians from several different specialties were consulted. Involvement and cooperation with the psychiatry service could appropriately treat such patients and potentially reduce use of medical resources. Both the diagnostic process and prognosis can be improved if delusional parasitosis is included in the differential.

Patients with delusional parasitosis tend to resist the notion that there is a psychiatric problem underlying their symptoms. Characteristically, Mrs Dalton initially dismissed the assertion that her parasites were in fact not physically present. She became more accepting of having a mental health condition and of the need for psychiatric follow-up after much empathic discussion.

Patients with delusional parasitosis are commonly anchored by treatment with antipsychotics. In the past, pimozide was the antipsychotic of choice for this disorder. However, recent studies have favored atypical antipsychotics, such as risperidone and olanzapine, because of their favorable adverse-effect profiles compared with older treatments. Almost all treatment recommendations include regular psychiatric follow-up for medication management and psychotherapy.

Careful counseling can ease a patient’s understanding and acceptance of parasitosis. It is important to acknowledge the seriousness of the patient’s complaints and to complete a thorough physical examination to help alleviate feelings of being dismissed as “crazy.” Additional techniques for improving a patient’s acceptance of a psychiatric diagnosis include listening patiently to complaints about symptoms, acknowledging that the symptoms are “real” without challenging or validating theories about the cause of the symptoms, expressing empathy, and carefully examining samples of “parasites” that the patient provides.

Mrs Dalton is started on a regimen 1 mg of risperidone nightly. There are no adverse effects to the medication while she is hospitalized. She is discharged with plans to follow up with the psychiatry service. She is provided psychotherapy and medication management during subsequent appointments. Within a few weeks, significant improvement is seen in the frequency and severity of the symptoms with these treatments.

Delusional parasitosis is an uncommon psychiatric disorder that features fixed delusions of parasites or other small organisms living under one’s skin or inside one’s body that are unrelated to a primary medical illness. It can be difficult to diagnose, and timely recognition and proper psychiatric treatment can improve quality of life and reduce medical costs. Awareness of this diagnosis is important for many health care professionals because of the many medical specialists these patients will see.

Dr Czapla is PG2 Resident and Dr Tucker is Professor and Vice Chair of Education and Arnold and Bess Ungerman Endowed Chair of Psychiatry in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center in Oklahoma City. The authors report no conflicts of interest concerning the subject matter of this article.

 Meinking TL, Burkhart CN, Burkhart CG. Changing paradigms in parasitic infections: common dermatological helminthic infections and cutaneous myiasis. 

 Perrin L. On parasitophobic neurodermal diseases [in French]. 

Annales de Dermatologie et Syphilographie (Paris)

 Aw DC, Thong JY, Chan HL. Delusional parasitosis: case series of 8 patients and review of the literature. 

 Koo J, Lebwohl A. Psycho dermatology: the mind and skin connection. 

 Flynn FG, Cummings JL, Scheibel J, Wirshing W. Monosymptomatic delusions of parasitosis associated with ischemic cerebrovascular disease. 

 Duggal H, Singh I. Delusional parasitosis as a presenting feature of dementia. 

Delusional parasitosis can be difficult to recognize, but timely diagnosis and psychiatric treatment can improve quality of life and reduce medical costs.

Christopher S. Czapla, MD

Articles

Post-COVID Stress Disorder: Another Emerging Consequence of the Global Pandemic

5 Techniques to Help Your Patient Accept a Difficult Psychiatric Diagnosis

The Interface of Dermatology and Psychiatry