Brief Psychotic Disorder During the National Lockdown in Italy

An Emerging Clinical Phenomenon of the COVID-19 Pandemic

Armando D'Agostino; Simone D'Angelo; Barbara Giordano; Anna Chiara Cigognini; Margherita Lorenza Chirico; Cristiana Redaelli; Orsola Gambini

Disclosures

Schizophr Bull. 2021;47(1):15-22. 

In This Article

Results

Figure 1 shows a total of 10 individuals (age range 23–73) who were hospitalized with an FEP during the lockdown. BPD was the most frequently observed diagnosis, with admissions clustered in 1 week between April 25 and May 2. The 6 patients described in the series all met DSM-5 diagnostic criteria for BPD with marked stressors at hospital discharge. All patients indicated a combination of 2 main stressors as plausible causes of their illness: intense concern over the possibility of being infected with SARS-CoV-2 and compulsory home confinement.

Figure 1.

The COVID-19 lockdown timeline of the Lombardy region includes a brief description of all first-episode psychosis patients admitted to the 2 psychiatric wards of the San Paolo University Hospital. The 2 wards only admit inhabitants of a 350 000–citizen urban territory in the South of Milan, the largest city in Lombardy. All patients with a discharge diagnosis of any psychotic episode on the hospital electronic record were considered for a review. A dedicated panel of clinicians confirmed diagnoses on the basis of DSM-5 criteria and excluded patients who had already presented psychotic symptoms before the current episode (see the Methods section). The extensive description of the 6 brief psychotic disorder cases can be found in the Results section and Table 1.

Table 1 shows the sociodemographic and clinical characteristics of the 6 patients. All hematological, urine, and brain imaging scans were unremarkable, with the exception of a mild cortical atrophy in case 1. None of the patients tested positive for SARS-CoV-2 nor developed signs of infection during their stay. SCID-II interviews conducted after discharge yielded no personality disorder in any of the 6 patients. Three patients out of 6 have experienced major stressful life events in the 12 months prior to the lockdown.

Extensive interviews with relatives and patients revealed a normal psychosocial level of functioning prior to the reported episode and a negative psychiatric history.

Case 1

H. is a 73-year-old Caucasian, retired ex-factory worker male. During the national lockdown, his wife experienced a leg fracture due to an accidental fall at home; only after 3 days of hospitalization, she returned home in good general conditions; however, the patient began to develop polymorphic delusions with guilt, somatic, nihilistic, and religious themes. He believed that he had been infected with SARS-CoV-2 by his wife and that he was the sole survivor in the world. He also experienced a severe sleep-wake cycle inversion, panic attacks, and hyporexia with weight loss. He was taken to our emergency room (ER) after threatening to kill himself by defenestration and strangulation. After being hospitalized on our ward, in the first few days, he was oppositional, suspicious, disorganized, overtly delusional, and sometimes verbally aggressive. After the resolution of psychomotor agitation with intramuscular aripiprazole, a switch to oral melatonin and risperidone 3 mg was made. Low-dose vortioxetine was added after a week due to the negative tone of delusional themes, hyporexia, and generally low mood. Administration of intravenous fluids and nutrients was necessary during the first week due to the patient's active refusal of food and water. After approximately 2 weeks, we observed improvement of mood and a progressive reduction of psychotic symptoms with the development of initial insight. A best-estimate BPD diagnosis was made by consensus of a panel of junior (S.D'A.) and senior clinicians (A.D'A. and O.G.), and symptoms of psychosis were not deemed to be better explained by a depressive episode given the intensity of disorganization and agitation. The patient was discharged after 25 days with a clinical remission, confirmed by BPRS total score (93 upon admission and 26 at discharge). Upon follow-up, clinical stability was maintained and oral risperidone dosage halved to 1.5 mg/day until the next evaluation.

Case 2

M. is a 61-year-old Caucasian male. He is a postal office employee who lives with his wife and has 2 children. M. was admitted to our unit after he attempted suicide by defenestration in response to command auditory hallucinations and delusions with religious and nihilistic content. During the lockdown, his relatives noticed several behavioral abnormalities with insomnia, disorganization, dysphoric mood, severe anxiety, and feelings of hopelessness associated with the belief of having contracted Covid-19. The patient also communicated the delusional belief of having been in contact with the devil who had announced the end of the world and ordered him to defenestrate himself.

On our ward, the patient showed poor insight with incongruent affect, persistence of delusions, and bizarre behavior. He was treated with lurasidone up to 74 mg/day and sertraline up to 100 mg/day, with a progressive resolution of symptoms. He developed satisfactory insight and was discharged on day 14. A depressive episode was ruled out due to the rapidity of mood improvement and preponderance of disorganized and bizarre behavior. BPRS total score was 87 upon admission and 30 at discharge. Upon follow-up, the patient had successfully returned to his job, and he maintained psychotic symptom remission and full insight on the episode. However, a switch to low-dose olanzapine was proposed due to mild emotional detachment, perhaps related to lurasidone treatment, and hyporexia.

Case 3

S. is a 47-year-old Caucasian female. She is divorced, lives with her 12-year-old daughter, and works as a professional masseuse. Approximately 30 days after the national lockdown, she developed delusions and bizarre behavior, confirmed by her relatives, neighbors, and friends. During a short period, she ingested conspicuous amounts of fluids (mainly water and tisanes) in order to purify her body. This led to a severe hyponatremia, resulting in coma and ICU hospitalization for 3 days. During her stay in the ICU, a psychiatric consultant described the patient as "delusional with religious and mystical themes." She was treated with haloperidol 2.5 mg/die and transferred to our unit, where she rapidly developed adequate insight over the episode that lead to the hospitalization. After only 6 days on our ward, she was discharged with a full remission of symptoms. BPRS total score was 63 upon admission and 24 at discharge. Upon follow-up, S. revealed that she had discontinued medication without reexacerbation of symptoms. Global remission was confirmed by a relative, who also reported full functionality in her job as a masseuse in the week after discharge.

Case 4

T. is a 55-year-old Caucasian male who was brought to our hospital by the police after becoming aggressive toward his sister due to paranoid delusions with visual hallucinations. At 35 years, the patient had migrated to Germany where he worked as a bricklayer until the described episode. A few days before admission, he returned to Italy after his live-in partner asked him to leave due to concerns over the patient's persecutory thoughts toward her 9-year-old son. Over a fortnight, the patient had developed a delusional belief of being infected with SARS-CoV-2 and associated visual hallucinations of demons, which he attempted to contrast with bizarre rituals. He was taken to our ER due to paranoid thoughts and verbal aggressiveness toward his family members, whom he firmly believed to be possessed by demons. When asked for the reason, he verbalized the firm belief they had been possessed by demons. Despite a lack of insight, the patient accepted treatment with haloperidol, which was slowly titrated to 8 mg/day with progressive improvement of symptoms. BPRS total score was 64 upon admission and 32 at discharge. Upon follow-up, oral treatment was discontinued over a timeframe of 3 weeks due to psychomotor slowing, which has now progressively resolved without reexacerbation of psychotic symptoms.

Case 5

K. is a 23-year-old Asian female. She had moved to another Italian region from India as an international university student and moved to Milan alone for a new job that had been suspended due to the national lockdown. The patient was hospitalized after having thrown objects from her balcony in a delusional state. She also reportedly performed bizarre rituals to hold off evil spiritual forces that had possessed her apartment. She had experienced significant isolation in the weeks preceding the psychotic break, which developed over the course of 2 or 3 days in association with a decreased need for sleep and vivid nightmares. During hospitalization, a manic episode was ruled out due to the rapid normalization of sleep, lack of associated mood symptoms, disinhibition, or racing thoughts. On our ward, the patient was treated with oral aripiprazole, with a fast remission of psychotic symptoms and behavioral abnormalities. Six days after hospitalization, K. was discharged with full resolution of symptoms and satisfactory insight. BPRS total score was 61 upon admission and 25 at discharge. During the first telematic follow-up, the patient reported having discontinued medication and a full subjective well-being. The clinical observation revealed neither psychotic symptoms nor other relevant psychiatric issues, with a rapid return to full functionality.

Case 6

C. is a 61-year-old Caucasian female. The patient had suffered from an ischemic stroke when she was 30 years old and had a hip fracture during a car accident, approximately 1 year prior to the psychotic episode. After motor rehabilitation, she had returned to her regular work as a market stall seller 1 month before the lockdown. She was taken to the ER by local police officers due to behavioral abnormalities secondary to persecutory and religious delusions. In the 24 hours before hospitalization, she refused to eat and drink any fluid, based on the firm belief that her relatives were attempting to poison her. Moreover, she was intensely concerned by the lack of funerary rituals imposed by the authorities during the ongoing pandemic. In the week before admission to our ward, she reported having spent several hours per day praying and directly conversing with God. Structural brain abnormalities, including long-term consequences of the stroke, were ruled out with the aid of a neurological consultant after a brain MRI scan. The patient was treated with haloperidol up to 3 mg/day until full remission of psychiatric symptoms. During her stay, C. underwent an antibiotic therapy with fosfomycin for a urinary tract infection. She was discharged in good psychopathological conditions, with adequate insight over the episode that leads to hospitalization. BPRS was 87 upon admission and 28 at discharge. Upon follow-up, the patient presented full symptom remission and insight over the episode, so haloperidol treatment was halved until the next evaluation.

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