First-Episode Psychosis Precipitated by Covid-19 Epidemic in a Patient with Mild Autism Spectrum Disorder
Article Information
Kusen I1, O Neill E2 *, Butler M I3, Young M4, Ismail F4
1Registrar in psychiatry, Sliabh Mis unit, University hospital Kerry, Tralee, Co. Kerry, Ireland
2Registrar in psychiatry, Eist Linn unit, Bessborough, Blackrock, Co. Cork, Ireland
3Senior registrar in psychiatry, Mercy university hospital, Grenville place, Cork, Ireland
4Consultant psychiatrist, Sliabh mis unit, University hospital Kerry, Tralee, Co. Kerry, Ireland
*Corresponding Author: Eimear O'Neill, Registrar in psychiatry, Eist Linn unit, Bessborough, Blackrock, Co. Cork, Ireland
Received: 30 March 2021; Accepted: 07 April 2021; Published: 12 April 2021
Citation: Kusen I, O Neill E, Butler MI, Young M, Ismail F. First-Episode Psychosis Precipitated by Covid-19 Epidemic in a Patient with Mild Autism Spectrum Disorder. Journal of Psychiatry and Psychiatric Disorders 5 (2021): 52-57.
Share at FacebookAbstract
This case report outlines the development of psychotic symptoms including delusions and paranoia related to the COVID-19 outbreak in a patient with a background history of high functioning autism spectrum disorder. The patient experienced deterioration and new onset psychotic symptoms due to significant changes in his routine when the COVID-19 pandemic necessitated lock-down measures in Ireland.
This patient had no prior known history of any mental illness other than anxiety which was managed by a private psychiatrist. This case demonstrates the impact that a global pandemic can have on vulnerable individuals resulting in the triggering of psychosis and a breakdown in the ability to process changes in reality. Patients with such developmental vulnerabilities would benefit from monitoring and early intervention in recognising and treating psychotic symptoms.
Keywords
Autism; Covid-19
Stressors in autism spectrum disorder articles; Psychosis and ASD articles; New onset psychosis in pandemic articles; New onset psychosis in ASD articles; ASD in pandemic articles
Autism articles Autism Research articles Autism review articles Autism PubMed articles Autism PubMed Central articles Autism 2023 articles Autism 2024 articles Autism Scopus articles Autism impact factor journals Autism Scopus journals Autism PubMed journals Autism medical journals Autism free journals Autism best journals Autism top journals Autism free medical journals Autism famous journals Autism Google Scholar indexed journals Covid-19 articles Covid-19 Research articles Covid-19 review articles Covid-19 PubMed articles Covid-19 PubMed Central articles Covid-19 2023 articles Covid-19 2024 articles Covid-19 Scopus articles Covid-19 impact factor journals Covid-19 Scopus journals Covid-19 PubMed journals Covid-19 medical journals Covid-19 free journals Covid-19 best journals Covid-19 top journals Covid-19 free medical journals Covid-19 famous journals Covid-19 Google Scholar indexed journals Spectrum Disorder articles Spectrum Disorder Research articles Spectrum Disorder review articles Spectrum Disorder PubMed articles Spectrum Disorder PubMed Central articles Spectrum Disorder 2023 articles Spectrum Disorder 2024 articles Spectrum Disorder Scopus articles Spectrum Disorder impact factor journals Spectrum Disorder Scopus journals Spectrum Disorder PubMed journals Spectrum Disorder medical journals Spectrum Disorder free journals Spectrum Disorder best journals Spectrum Disorder top journals Spectrum Disorder free medical journals Spectrum Disorder famous journals Spectrum Disorder Google Scholar indexed journals autism spectrum disorder articles autism spectrum disorder Research articles autism spectrum disorder review articles autism spectrum disorder PubMed articles autism spectrum disorder PubMed Central articles autism spectrum disorder 2023 articles autism spectrum disorder 2024 articles autism spectrum disorder Scopus articles autism spectrum disorder impact factor journals autism spectrum disorder Scopus journals autism spectrum disorder PubMed journals autism spectrum disorder medical journals autism spectrum disorder free journals autism spectrum disorder best journals autism spectrum disorder top journals autism spectrum disorder free medical journals autism spectrum disorder famous journals autism spectrum disorder Google Scholar indexed journals psychotic articles psychotic Research articles psychotic review articles psychotic PubMed articles psychotic PubMed Central articles psychotic 2023 articles psychotic 2024 articles psychotic Scopus articles psychotic impact factor journals psychotic Scopus journals psychotic PubMed journals psychotic medical journals psychotic free journals psychotic best journals psychotic top journals psychotic free medical journals psychotic famous journals psychotic Google Scholar indexed journals general practitioner articles general practitioner Research articles general practitioner review articles general practitioner PubMed articles general practitioner PubMed Central articles general practitioner 2023 articles general practitioner 2024 articles general practitioner Scopus articles general practitioner impact factor journals general practitioner Scopus journals general practitioner PubMed journals general practitioner medical journals general practitioner free journals general practitioner best journals general practitioner top journals general practitioner free medical journals general practitioner famous journals general practitioner Google Scholar indexed journals hygiene articles hygiene Research articles hygiene review articles hygiene PubMed articles hygiene PubMed Central articles hygiene 2023 articles hygiene 2024 articles hygiene Scopus articles hygiene impact factor journals hygiene Scopus journals hygiene PubMed journals hygiene medical journals hygiene free journals hygiene best journals hygiene top journals hygiene free medical journals hygiene famous journals hygiene Google Scholar indexed journals high functioning autism articles high functioning autism Research articles high functioning autism review articles high functioning autism PubMed articles high functioning autism PubMed Central articles high functioning autism 2023 articles high functioning autism 2024 articles high functioning autism Scopus articles high functioning autism impact factor journals high functioning autism Scopus journals high functioning autism PubMed journals high functioning autism medical journals high functioning autism free journals high functioning autism best journals high functioning autism top journals high functioning autism free medical journals high functioning autism famous journals high functioning autism Google Scholar indexed journals anxiety articles anxiety Research articles anxiety review articles anxiety PubMed articles anxiety PubMed Central articles anxiety 2023 articles anxiety 2024 articles anxiety Scopus articles anxiety impact factor journals anxiety Scopus journals anxiety PubMed journals anxiety medical journals anxiety free journals anxiety best journals anxiety top journals anxiety free medical journals anxiety famous journals anxiety Google Scholar indexed journals disability articles disability Research articles disability review articles disability PubMed articles disability PubMed Central articles disability 2023 articles disability 2024 articles disability Scopus articles disability impact factor journals disability Scopus journals disability PubMed journals disability medical journals disability free journals disability best journals disability top journals disability free medical journals disability famous journals disability Google Scholar indexed journals
Article Details
1. Background
There has been much emphasis in the global media on the potential of the COVID-19 pandemic to lead to increased anxiety and depressive symptoms and several recent reports have indicated there is also a risk of new onset or exacerbation of psychotic symptoms [1, 2]. There have been cases published outlining new onset psychosis, however few cases have been considered in the context of co-morbidity with autism spectrum disorder (ASD). ASD, a neuro-developmental disorder, is known to increase the risk of stress-induced psychotic symptoms as a result of particular genetic tendencies and cognitive vulnerabilities [3].
Emotional stressors and changes to routine precipitate episodes of anxiety, derealisation and obsessive thinking patterns in ASD which can develop into psychosis [4]. The COVID-19 pandemic has caused much restriction to movement, interactions and occupational functioning and creates the ideal circumstances for the development of psychotic symptoms in persons with ASD [5, 6].
This report outlines the case of a 24-year-old single man admitted to an acute mental health unit in Ireland with first-episode psychosis. He presented with classic symptoms of psychosis which included persecutory delusions, prominent auditory hallucinations, and formal thought disorder. These symptoms had emerged in the preceding weeks following the implementation of nationwide restrictions due to the Covid-19 pandemic and the temporary loss of his employment due to the restrictions. Although he had a diagnosis of mild autism spectrum disorder (ASD), he had never previously experienced a psychotic episode, and there was no family history of mental illness. This patient was an active, highly-functioning man who, prior to this episode, had been working full-time, involved in various sports and maintaining good relationships with his friends and family. This case highlights how a global event such as the ongoing Covid-19 pandemic, and the resultant socioeconomic restrictions, can act as a significant psychosocial stressor resulting in a deterioration in mental health and the precipitation of an acute psychotic episode in a person without a personal or family history of psychosis but with a background history of mild ASD.
2. Case Presentation
This is a case report of a 24-year-old man, unknown to the mental health services, referred by his general practitioner (GP) for emergency psychiatric assessment. His symptoms had begun in mid-March 2020 after he had been temporarily laid off from his job due to the Covid-19 national restrictions. His initial symptoms included anxiety and insomnia, which were treated by his GP with a combination of sertraline and alprazolam. Although his anxiety symptoms improved initially, there was a subsequent emergence of prominent paranoid delusions whereby he believed that he was ‘trapped in a virus mind game’ and that ‘whoever goes outdoors would be shot’.
The distress associated with these delusional beliefs escalated to the point of psychiatric admission four weeks from onset. The patient has a background history of high functioning autism which had been diagnosed privately two years ago. The patient had been impacted in the past by other social difficulties but had always maintained good occupational functioning.
He believed that Covid-19 was ‘a mind game and trick’, that everybody was in danger of dying and that his family were poisoning him with drugs. He expressed some uncertainty about whether he was dead or alive. He admitted to experiencing auditory hallucinations and described hearing a group of over ten voices, which were also involved in the ‘virus mind game’. He became preoccupied with personal hygiene as an infection control measure, which resulted in him taking numerous showers every day. This patients’ beliefs were held with delusional intensity, his need for cleanliness occurred as a result of his delusions and were accompanied by the other aforementioned psychotic features. The presentation and pattern of his symptoms was consistent with new onset psychosis and did not resemble obsessive compulsive disorder.
On mental state examination following admission to the acute mental health unit, he appeared perplexed and displayed poor eye contact. His speech was low in volume and slow in rate. The patient was guarded, suspicious and easily overwhelmed by activity in the unit. He described experiencing persecutory delusions. In relation to thought form, he exhibited derailment and thought-blocking. He was disorientated to time and place. These symptoms persisted for the initial few weeks of his admission. On further exploration, the lockdown seemed to be the first time that this patient’s routine was challenged and changed in an impactful way.
3. Investigations
Physical and neurological examinations were normal. He had normal vital signs. All bloodtests, including full blood count, urea and electrolytes, liver function tests, thyroid functiontests, CRP, prolactin levels, vitaminB12, folate,vitamin Dlevels, bone profile and anelectrocardiogram (ECG) were normal. CT and MRI brain scans did not show any abnormality.
4. Treatment
The patient was admitted to the high observational unit and initially treated with olanzapine 10 mg at night, which was later increased to 15 mg. Alprazolam 0.5 mg twice a day was commenced to treat his agitation . This was discontinued due to lack of relief of his symptoms and he was commenced Lorazepam 0.5 mg three times a day with planned reduction over time. Sertraline 100 mg, previously started by his GP, was continued.
5. Outcome and Follow Up
Following 15 days of admission his mental state had improved significantly to the point of being suitable for discharge and follow up in the community setting. His beliefs were no longer of a delusional intensity but he remained preoccupied with excessive personal hygiene and infection control measures. He was discharged to the care of his community mental health team with support from a community mental health nurse and review by psychiatry at the outpatient clinic. He had excellent family support.
He was reviewed as an outpatient weekly for over six weeks and olanzapine was cross-titrated to aripiprazole due to weight gain, over sedation and mild oro-facial tardive dyskinetic movement. He achieved full remission on aripiprazole 20mg with sertraline 100mg daily. ‘Lorazepam had been tapered down and discontinued.
6. Discussion
High functioning autism including Asperger syndrome is a pervasive developmental disorder generally regarded as being a milder variant of the autism spectrum. While Asperger syndrome has been included in the ICD-10 and DSM-V as a distinct diagnostic entity, it is still unclear to what extent it differs from high functioning autism (HFA). [7] Persons with HFA have been reported to show a variety of deficits of thought processes.Persons with autism demonstrated a trend towards greater levels of disorganized thinking than the HFA group [8]. Social cognition is believed to contribute to symptoms of anxiety and disability, particularly for disorders characterised by social impairment, including ASD, and psychotic disorder [9].
A breakdown in social cognition can result in misinterpretations, mislabelling and the potential for paranoid belief formation [9]. Impairments in social cognition may further reduce the capacity to engage in, and subsequently enjoy, social experiences. The loss of reward associated with social experiences may then exacerbate social withdrawal [10].
In this case, the patient could not adhere to his long-term routine at work and with family due to nationwide restrictions. Changes to his regular schedule and outlets resulted in the precipitation of a deterioration in his mental state and disordered reality interpretation not long into the first lockdown in Ireland.
Along with genetic predisposition, social exclusion which is common in ASD, has been hypothesized to be an important risk factor for new onset psychotic disorder[11]. Unexpected changes, prevention of being able to engage in preferred behaviours and sensory sensitivities could be perceived as traumatic, especially when such distress continues on a regular basis, and can subsequently lead to co-morbidities including psychosis [12].
There are reports of the significant impact of previous epidemics, Severe Acute Respiratory Syndrome-associated coronavirus (SARS-CoV) and Ebola, on mental health with the emergence of several psychiatric disorders including post traumatic stress disorder, anxiety and depression [2]. The current national and worldwide quarantine measures have resulted in pressure on mental health services due to the prevailing anxiety and a deterioration of mental health on a significant scale. There have been many new cases of depression, anxiety and psychotic disorders since the restrictions were introduced with most patients citing the lockdown as a major stressor [13].
For patients with pre-morbid vulnerabilities in coping and perception, as seen in ASD, there is a substantial risk of decomposition and development of further disorders [9]. 72% of persons with ASD are reported to be suffering a deterioration in their mental health since the pandemic began in March 2019 [14]. Persons with vulnerabilities to psychosis have additional needs which require prioritization in the consideration of resources during the COVID-19 pandemic. Studies have shown that 5% of persons with new onset psychosis have co-morbid ASD [15]. It is reasonable to consider the potential benefit of monitoring persons with ASD for psychotic symptoms and of increasing awareness of the connection between ASD and psychosis among mental health teams and early intervention services.
7. Learning Points/Take Home Messages
- Acute psychotic episodes are a risk in patients with ASD precipitated by stressful life events resulting in significant co-morbidity and deterioration.
- Global events and their related impacts can act as significant psychological stressors in persons with predisposing factors and cognitive vulnerabilities.
- Early recognition and intervention is important in the future prevention and treatment of psychotic episodes. Consideration needs to be given as to how to manage patients with ASD to avoid deterioration in functioning.
8. Data Availability
Data used to support the findings of this study are included within the article.
9. Additional Points
Adapted from patient: From the start of my admission, I made it clear that my job and daily functioning are important to me and that the COVID-19 lockdown was extremely difficult for me. I had never experienced these symptoms before the lockdown, I was always an anxious child with difficulties socializing but my confidence plummeted after I stopped work. I feel that losing my independence and routine led to my mental illness.
Ethical Approval
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this case report was not required by their local ethics committee.
Disclosure
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Conflicts of Interest
The authors, Dr. Ivona Kusen, Dr. Eimear O’ Neill, Dr. Mary I Butler, Dr. Maura Young and Dr. Fahmi Ismail do not have any conflicts of interest to report.
References
- Shanbour A, Khalid Z, Fana M. Psychosis and infodemic isolation resulting in first in-patient hospitalization during the COVID-19 pandemic: a case series. The primary care companion for CNS disorders 22 (2020): 20l02649.
- Valdes-Florido MJ, Lopez-Diaz A, Palermo-Zeballos FJ, et al. Reactive psychosis in the context of the Coivd-19 pandemic: clinical perspectives from a case series. Rev Psiquiatr Salud Ment 13 (2020): 90-94.
- Ghaziuddin M, Leininger L, Tsai L. Brief report: Thought disorder in asperger syndrome: Comparison with high-functioning autism. Journal of Autism and Developmental Disorders 25 (1995): 311-317.
- Fuld S. Autism Spectrum Disorder: The Impact of Stressful and Traumatic Life Events and Implications for Clinical Practice. Clinical Social Work Journal 46 (2018): 210-219.
- Heitzman J. Impact of COVID-19 pandemic on mental health. Psychiatr. Pol 54 (2020): 187-198.
- Selten JP, Lundberg M, Rai D, et al. Risks for nonaffective psychotic disorder and bipolar disorder in young people with autism spectrum disorder a population-based study. JAMA Psychiatry 72 (2015): 483-489.
- World health organisation. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva, World Health Organization (1992).
- Ghaziuddin M, Leininger L, Tsai L. Brief report: Thought disorder in asperger syndrome: Comparison with high-functioning autism. Journal of Autism and Developmental Disorders 25 (1995): 311-317.
- American psychiatric association. Diagnostic and statistical manual of mental disorders. Arlington VA; 5th ed (2015).
- Penn D, Sanna L, Roberts D. Social Cognition in Schizophrenia: An Overview. Schizophrenia Bulletin 34 (2007): 408-411.
- Selten J, Lundberg M, Rai D, et al. Risks for Nonaffective Psychotic Disorder and Bipolar Disorder in Young People With Autism Spectrum Disorder. JAMA Psychiatry 72 (2015): 483.
- Fuld S. Autism Spectrum Disorder: The Impact of Stressful and Traumatic Life Events and Implications for Clinical Practice. Clinical Social Work Journal 46 (2018): 210-219.
- O Connor K, Wrighly M, Jennings R, et al. Mental health impacts of COVID-19 in Ireland and the need for a secondary care mental health service response. Irish journal of psychological medicine 1-9 (2020).
- Davidson CJ, Lodge J, Kam J. The impact of the COVID-19 pandemic on autistic adults-a survey. Advances in autism (2021): 2056-3868.
- Strålin P, Hetta J. First episode psychosis and comorbid ADHD, autism and intellectual disability. European Psychiatry 55 (2019): 18-22.