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

Discussion

Risk Factors, Shared Clinical Features, and Diagnosis

All reported cases had a negative psychiatric history and normal premorbid psychosocial adjustment. No shared risk factor other than the pandemic-related stress could be clearly identified. None of our patients had first-degree relatives (FDRs) with a known mental disorder. FDRs of patients with ATPDs typically have not only higher rates of ATPD but also bipolar disorder and especially schizophrenia,[27] which was not observed in our small cohort. The reported cases were hospitalized over a course of 1 week and rapidly discharged after the improvement of symptoms. All patients responded to antipsychotic treatment, developing adequate insight over the experienced distortions of reality and the severity of their behavioral abnormalities. Only in 1 case, severe psychotic symptoms and behavioral abnormalities persisted for more than a week after the beginning of antipsychotic treatment (case 1). Of note, H. was the oldest patient and had experienced a major stressful life event, ie, the death of his sister, in the 12 months before the national lockdown. He was also the only patient to show some degree of cortical atrophy and the one who presented the most severe illness, confirmed by his BPRS score upon admission.

Our cohort was characterized by a generally late age of onset [mean (SD) = 53,3 (15,6)]. Other recently reported cases of pandemic-reactive psychoses revealed a relatively younger age, confirming available evidence on ATPD/BPD first episodes, which tend to peak in early adulthood for males and in the mid-30s for females.[28] However, almost a quarter of cases has been estimated to occur above 40 years of age, and the onset above 60 has been associated with not only a high risk of mortality but also dementia.[29] Although highly likely, the association with declining cognition and/or sensory function remains to be demonstrated.[30] Of note, 3 of our cases presented an elevated risk of self-harm, 2 of which associated with a suicidal intention. This was also observed in 2 of 4 patients hospitalized during the first 2 weeks of the national lockdown in Seville, Spain.[13] Suicidal behavior in ATPD/BPD patients is quite common (36%–55%) and usually associated with mood instability and agitation.[31] Completed suicide is considered the main cause of premature death in ATPD/BPD, accounting for a quarter of the mortality.[32]

In all cases, differential diagnoses with transient psychotic symptoms in PTSD were considered, although none of the patients satisfied the current criteria for acute stress disorder or PTSD. All other common differential diagnoses were also ruled out, including mood disturbances with prominent psychotic features. Except for case 5, all patients had an age above the typical young adulthood expected for a first episode of schizophrenia. As shown in Table 1, all reported cases met the formal diagnostic criteria for ATPD and BPD. Given her age and extremely rapid resolution of symptoms, K. could also be framed in the ultra-high-risk (UHR) paradigm as a patient with brief limited intermittent psychotic symptoms (BLIPS). BLIPS cases have been shown to frequently fulfill ATPD criteria, and approximately half develop a psychotic disorder during follow-up.[33,34]

Personality Traits and Psychosis

The absence of personality disorders or premorbid dysfunction in the history of BPD patients is typically reported[35–37] and reflects the characteristics of our patients. Five of the 6 patients shared high cooperativeness, a personality dimension encompassing social tolerance, empathy, compassion, and a tendency to help others. This is generally considered a protective trait that contributes to healthy personality and psychological well-being.[38] Among other dimensions, lower cooperativeness has been found in schizophrenia patients compared with healthy control individuals.[39] Low cooperativeness has also been found to significantly predict transition to psychosis in UHR individuals, possibly due to its association with social withdrawal.[40] Furthermore, Eysenck's psychoticism construct is thought to depend on a combination of low conscientiousness and agreeableness, a trait that closely resembles the cooperativeness construct in the 5-factor model of personality.[41] Although fully structured studies on broader cohorts of BPD patients are needed, findings from our case series suggest diametrically opposite relationships between cooperativeness and psychosis in BPD and schizophrenia.

Explanatory Hypothesis

All symptoms were reported to emerge in the month following the national lockdown in Italy and global emergence of the pandemic. Although no explanation of the relationship between the pandemic and our cases can be considered definitive, we hypothesize the combination of deranged daily routines during compulsory home confinement and fear of the infection itself might have triggered an intense psychobiological stress reaction leading to the psychosis onset. Reduced individual liberty, financial loss, inadequate supplies, and information associated with mandatory social isolation are also likely to contribute[3,4] and were present to varying degrees in all our cases.

Besides the overlap in most patients' somatic delusion of having contracted the SARS-CoV-2 infection, the religious/spiritual content of all reported cases is striking and was also observed in another patient from Bengaluru, India.[15]

Although commonly observed in clinical practice, fluctuating rates of religious themes have recently been reported worldwide.[42] Delusions are inevitably embedded in individuals' cultural context and rapid incorporation of historical and sociopolitical events, cultural phenomena, or contents such as new technologies is common.[43] Religious delusions include themes of universal existential relevance and are likely to be associated with strong affect.[44] We hypothesize that the global existential threat exacerbated by an unprecedented information overload and home confinement might have fueled meaningful spiritual worries at the individual level.

After the COVID-19 Crisis: Novel Resources to Sustain/Improve Psychosis Outcome?

Many individuals with acute psychosis require hospitalization due to disorganized behavior, impaired insight, and potentially aggressive and self-injurious acts. The progressive hospitalization of patients can be considered a coarse yet sensitive epidemiological probe of ongoing changes on our territory, but only time will confirm or scale back the likelihood of a widespread diffusion of similar psychotic episodes. Several studies have shown that patients in the early stages of psychosis are typically neglected by mental health services. A recent study on 2561 ATPDs revealed that the majority are not detected by early intervention services and tend to only receive a short-term clinical follow-up,[45] whereas up to 40% have been shown to develop persistent psychotic disorders that could benefit from early detection to improve outcome.[46] Furthermore, relevant needs of care are currently unmet by preventive strategies for BLIPS individuals, who tend to disengage over time from proposed treatments, such as cognitive behavioral therapy.[47]

In our cohort, further follow-up is necessary to track the diagnostic evolution, given the current uncertainty over the condition's long-term prognosis. No specific evidence-based guidance on the treatment of these patients is available, but long-term treatment with antipsychotics should be cautiously weighed against the risk of side effects.

In line with other emerging case series,[12–16] this preliminary report suggests a rising rate of ATPD/BPD patients among incident FEP cases that needs to be confirmed with adequately sized epidemiological studies. The ongoing pandemic highlights the need for modern early detection and intervention services to improve the outcomes of psychosis.

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