Clinical Pearls & Morning Reports
Published November 9, 2022
In one study involving more than 60,000 patients with Covid-19, 18% of the patients had received a psychiatric diagnosis in the 14 to 90 days after infection. Read the NEJM Case Records of the Massachusetts General Hospital here.
Q: Describe some of the neuropsychiatric manifestations of Covid-19.
A: Some cases of Covid-19 lead to persistent symptoms or long-term complications that extend beyond acute disease (a condition sometimes referred to as postacute syndrome of Covid-19 or “long Covid”). In such cases, neuropsychiatric symptoms can include fatigue, myalgias, headache, anxiety, depression, dysautonomia, and cognitive impairment (also referred to as “brain fog”). New-onset psychosis has been reported in patients with Covid-19. A recent systematic review of Covid-19–related psychosis cases confirmed that delusions were the most commonly reported psychotic symptom.
Q: What is the most common cause of psychogenic catatonia?
A: Catatonia is a disorder of the cingulate cortico–striato–thalamo–cortical circuits that results in the disconnection of motivation and movement, and it has multiple neuromedical and psychiatric causes. Catatonia has been reported in several patients with Covid-19. Bipolar disorder is the most common cause of psychogenic catatonia. Benzodiazepines are the first-line treatment for catatonia.
A: Cotard’s syndrome is included in the DSM-5 category of delusional misidentification syndromes. Patients with Cotard’s syndrome have nihilistic delusions, such as the belief that they are dead, have lost their souls, or are rotting inside, without functional organs or limbs. Three subtypes of Cotard’s syndrome have been described: psychotic depression (a disorder associated with melancholia and nihilistic delusions), type 1 (a nondepressive delusional disorder), and type 2 (a disorder associated with mixed symptoms, including anxiety, depression, and auditory hallucinations).
A: Support and reassurance are key in the treatment of patients with Cotard’s syndrome, but trying to talk patients out of their delusions is futile. Successful treatment of the underlying condition often helps the delusions to recede, although the delusions may wax and wane in patients with persistent depression and may become chronic in patients with schizophrenia. Multiple antipsychotic medications have been reported to reduce the symptoms of Cotard’s syndrome. If medications fail, electroconvulsive therapy is an important therapeutic option.