“Santvan” Hospital, Rambaug, Ahmedabad, Gujarat, India
Received Date: July 07, 2021; Accepted Date: September 17, 2021; Published Date: September 24, 2021
Citation: Bhachech JT (2021) COVID-19 and Illness Anxiety Disorder. J Neurol Neurosci Vol.12 No.9:390.
A 38 year old male client presenting at outdoor patient department as symptoms of difficulty in breathing, uneven running heart beats, heaviness in head, trembling of body, fear that something will happen to him and he will die suddenly. With the scenario of COVID-19 pandemic, this case reports evaluates the psychiatric differential diagnosis of these symptoms. Illness Anxiety Disorder (IAD) being 4 to 6% in general population is a psychiatric illness in which a person is preoccupied of being seriously ill. IAD needs to be ruled out if clinical examination and investigations are normal. This will not only reduce the cost of treatment but also will be an in time psychiatric management of symptoms.
Illness anxiety disorder; COVID-19; Hypochondriasis
Pre occupation of having a COVID-19 requires an in depth psychiatric evaluation and management. Illness anxiety disorder shifts its focus on a current dreadful pandemic and increases health burden on patient and healthcare facilities.
Human race is facing one of the biggest health challenges of mankind in form of the Corona Virus Disease 2019 (COVID-19) or the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2). As per World Health Organization (WHO) the most common symptoms of COVID-19 are fever, dry cough, and tiredness. Other symptoms that are less common and may affect some patients include aches and pains, nasal congestion, headache, conjunctivitis, sore throat, diarrhea, loss of taste or smell or a rash on skin or discoloration of fingers or toes. These symptoms are usually mild and begin gradually [1,2]. Human to human transmission has made the scenario worse; for which WHO recommends social distancing, self-isolation and home or hospital quarantine as preventive measures . The rapid spread of the disease has not only affected the physical health, but also mental health of the community. Recent studies report that COVID-19 pandemic and quarantine have triggered a wide variety of psychological problems, such as panic disorder, anxiety, depression, post-traumatic stress symptoms, confusion, anger, etc [4,5]. Illness anxiety disorder or IAD (hypochondriasis – DSMIV) , with prevalence of 4 to 6% in general population; applies to those persons who are preoccupied with being sick or with developing a disease of some kind.6 This case report is about illness anxiety disorder which belongs to somatic symptom and related disorder and its relation to COVID-19 symptoms.
A 38 year old married male client came to outdoor patient department in April 2020 with complaints of episodic symptoms of difficulty in breathing, uneven running heart beats, heaviness in head, trembling of body, fear that something will happen to him and he will die suddenly; since a duration of 10 months. On further exploration onset of the symptoms occurred for the first time when one of his close relative died suddenly due to heart disease. At that time, he had similar symptoms along with excessive worries about having some serious disease related to heart and going to multiple family physicians and cardiologists for his diagnosis. Later, he felt that all the doctors are doing basic tests; he made multiple searches on internet about his symptoms and he firmly insisted the cardiologists for 2D-ECHO (Two Dimensional Echocardiography), Stress TMT (Tread Meal Test) and Angiography of heart vessels. All these investigations and the previous tests like complete blood count, lipid profile, liver, kidney and thyroid function tests, cardiac enzymes, etc were all within normal limits. Majority of the doctors explained that his symptoms were of mild intensity and not of cardiac cause and referred him to consult a psychiatrist for further treatment, but client denied. His symptoms and quest for the diagnosis continued.
Since February 2020, he heard the news about COVID-19 outbreak.
He began searching for his symptoms on various television channels and internet health sites. He kept relating his symptoms of difficulty in breathing and chest pain to symptoms of corona virus infection. He immediately purchased a thermometer, blood pressure measuring instrument and sanitizers. Most of the time during the day, he was found either sanitizing or checking his body temperature or blood pressure. He also made multiple calls on government helpline about COVID-19 to confirm his symptoms. Since 15 to 20 days due to his fear of having COVID-19; he had symptoms of delay in onset of sleep on few days, anticipation of having episodes of breathlessness, trying to find out which is the best treatment for these symptoms and arguing with the relatives to go out to visit doctors or laboratories for check-up a midst of government issued city-wide lockdown. He was brought to psychiatrist for his behavioral symptoms at home.
There was no family history of any medical, surgical, psychiatric or neurological illness. His personal history suggested that he was above average in studies in school and graduation. His family environment and marital life was supportive and harmonious. He works as an office assistant in a private company since 1 year. He had loss of jobs twice or thrice due his work related issues; which made him insecure about his current job too. He was having a stress about his work performance, which he felt very difficult to reveal to his closed ones. He had no history of any substance abuse or use.
On mental status examination, his appearance and attire were appropriate and well groomed. He made a good eye contact and rapport was established. He was conscious, co-operative and oriented to time, place and person. His mood was reported as worried or fearful most of the days about his illness which he called to be COVID-19 of mild intensity and in response to his fear he wanted to go for a diagnostic blood test of COVID-19. His affect was congruent to mood, stable and restricted to current mood state. His thought examination revealed preoccupations of having this serious illness called corona virus; previously he had fear about heart disease. He had a normal speech, perception, attention and concentration, memory, abstract thinking, social and test judgment. On examining his insight, it was grade 3 i.e., awareness of being sick but blaming it on others, external factors, or medical or unknown organic factors. His MRI Brain was also normal. There was no history of symptoms of malignancy, neurological condition such as multiple sclerosis or brain tumor, endocrine and autoimmune diseases.
The differential diagnosis [7-9] in this case were somatic symptom disorder, panic disorder, conversion disorder, Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD) and delusional disorder. In this case, client had no history of complaints of multiple symptoms, pain symptoms and over concern for symptoms over a considerable period of time; age of onset of illness; fear of disease being prominent than the worries about symptoms and shifting of fear from one disease to another rules out somatic symptom disorder. The onset of symptoms were gradual and over days, a cluster of symptoms with associated fear of heart disease and absence of sensory, motor or seizure like symptoms in this case rules out conversion disorder which is acute and has above specific symptoms. The client was focused on specific disorder, had normal concentration, no history of muscle tension, being easily fatigued, irritability or significant sleep disturbance, which does not meet criteria for generalized anxiety disorder. The entire history and examination did not support any criteria or clinical picture of major depressive disorder, anxiety disorder, body dysmorphic disorder or obsessive compulsive related disorder. His belief about his illness was not bizarre and it was at that time when cases of pandemic were increasing throughout the world. Whereas, in case of delusional disorder or psychotic spectrum disorders beliefs tend to be bizarre with impaired judgment and presence perceptual disturbances and disorganized behavior as well. So we concluded that his diagnosis is illness anxiety disorder, care seeking type. On assessment on Health Anxiety Inventory-18 (HAI-18) , the score for main section was 37, negative consequences section was 12 and hence total score 49; suggestive of hypochondriasis related health anxiety. This confirms the clinical diagnosis, which would be helpful in treatment in the form of pharmacotherapy and psychotherapy and managing client in follow ups.
A midst of the COVID-19 pandemic and lockdown as its preventive measure, mental health is at stake. With growing fear about the pandemic, IAD might often be missed. The psychosocial environment being of illness related information and talks makes one more worried about each and every symptom. In this case we differentiate the symptoms as mentioned in Table 1.
(Corona Virus Disease 2019) [1,9]
|Illness anxiety disorder [6,11]||Panic disorder [6,7]|
|Symptoms||Fever, cough, sore throat, breathlessness, fatigue and malaise among others. It may progress to pneumonia, acute respiratory distress syndrome (ARDS) and multi organ dysfunction. Many people are asymptomatic||Pre occupation with the false belief that they have or will develop a serious disease and there are few if any physical signs or symptoms||Palpitations, pounding heart, or accelerated heart rate, Sweating ,Trembling or shaking, Sensations of shortness of breath or smothering, A feeling of choking, Chest pain or discomfort, Nausea or abdominal distress, Feeling dizzy, unsteady, lightheaded, or faint, Feelings of unreality (de-realization) or being detached from oneself (depersonalization),Fear of losing control or going crazy, Fear of dying, Numbness or tingling sensations (paresthesias),Chills or hot flushes|
|Duration of symptoms||2 to 14 days||At least 6 months||10 minutes to 1 hour|
|Onset of symptoms||Acute||Gradual||Sudden and Unexpected|
|Investigations like complete blood count, c reactive protein, erythrocyte sedimentation rate, chest x ray, etc.||Normal/ low white cell counts with elevated C-reactive protein (CRP). The computerized tomographic chest scan is usually abnormal even in those with no symptoms or mild disease||Normal
unless co morbid organic brain disease (E.g.,- malignancy, multiple sclerosis)
unless co morbid organic brain disease or heart disease (e.g.,-Mitral Valve Prolapse)
|Treatment||Supportive medical management
Precautions to avoid spread of droplet infections
Pharmacotherapy for alleviating anxiety
|Pharmacotherapy (Anti-depressants, Anti-anxiety medicines) and
Table 1 Symptoms of COVID-19 and related symptoms of psychiatric disorders.
Studies report prevalence of IAD more among females and during middle aged persons . In this case, client had job insecurity; this fear is reflected in fear of being seriously ill or felt as a guilt or low self-esteem . Co morbid illness that exist with IAD are major depressive disorder, anxiety spectrum disorders like panic disorder, agoraphobia and generalized anxiety disorder as well as bipolar disorder [7,11,12] which in this case requires further exploration. IAD is often accompanied by health related anxiety and maladaptive behaviors either to reduce the fear or to avoid it. This leads of excessive reassurance in terms of seeking medical advice, searching on internet or books for diagnostic confirmation and checking oneself for symptoms . Also, IAD clients remain dissatisfied till they get a medical explanation what they have conceptualized from a medical practitioner with evidence. This process is affects mental health and social and occupational functioning.