key: cord-0875123-csz64grw authors: Upadhyay, Madhukar; Tomar, Love Kumar; Patra, Priyadarshee title: Breathing CORONA into the PSYCHE: An Interesting Case Series During COVID-19 Pandemic date: 2020-10-15 journal: Indian J Otolaryngol Head Neck Surg DOI: 10.1007/s12070-020-02218-9 sha: 7d7e5157d4f86ab1c524acda080f4cac84d1fc35 doc_id: 875123 cord_uid: csz64grw The ongoing COVID 19 pandemic has taken a toll on not only physical health but the mental well being of the individuals too. This novel virus has shaken the very fabric of the society. Every individual irrespective of his education and socioeconomic status has been affected by this pandemic. It is surprising to see how the effects of this pandemic slowly crept into the psyche of the individuals thereby unleashing symptoms which were hidden till now. This series highlights few such cases where the presenting symptoms were initially thought to be ENT disorders but later revealed themselves as severe psychiatric symptoms in disguise. It is pertinent to note that timely intervention helped these individuals to recover completely and go back to leading a normal life in spite of prevailing uncertainty about the pandemic. The COVID-19 has affected the whole world at an unprecedented scale and has affected almost every aspect of human life. On one hand it is proving hazardous to physical health while on other it is being detrimental to our mental health [1] [2] [3] [4] . Current legislative and administrative measures like lockdown and work from home have severely affected the mental state of normal otherwise healthy individuals [5] . There has been a significant rise in stress levels of individuals leading to undue worries, anxiety and affective symptoms. Both the consequences of viral outbreak and imposed measures leading to social isolation along with restriction of activities in all domains of life have put the vulnerable individual to the risk of development of syndromal psychopathology [6] . Though most of the outpatient departments are having less number of patients than usual however Psychiatry OPD on the contrary continues to have regular visits of old and new psychiatric cases with novel symptoms ascribing to the COVID-19 pandemic [7] . Here we present a case series compiled at a peripheral hospital of individuals who initially presented to ENT OPD but were subsequently found to be in the need of psychiatric care and treatment. All the individuals in these case series were tested negative for COVID-19 by RT-PCR. A16 year old boy, studying in tenth standard brought by parents to ENT OPD with history of persistent coughing and making repeated sounds from the throat for the last 1 month. A detailed ENT evaluation including videolaryngoscopy failed to reveal any significant findings. However during the examination, the individual had to clear his throat multiple times despite the advice not to do so. In view of his persistent symptoms for which no ENT cause was found a psychiatric referral was made. Detailed history from the patient and his parents revealed that he was A 15 years old female, studying in ninth standard, belonging to middle socioeconomic status and resident of a semi urban area presented to ENT OPD along with her mother with complaints of excessive distress on wearing a mask as required for Covid precaution. As no local pathology was found, the ENT surgeon then referred her for psychiatric consultation. History revealed that for the last 3 months her school was closed and she was confined to home during lock down, now as the lockdown eased she wanted to venture out of the house. But she was unable to tolerate a face mask as she would develop abrupt intense anxiety and a feeling of suffocation. Symptoms were relieved within minutes of taking off the mask. After a few attempts over 7-8 days she was so distressed that she confined herself in the house, not venturing out even for a few minutes. Although she believed that fear was grossly excessive and irrational but expressed inability to control this fear and the consequent avoidance. She had cordial relations with family members and her friends. No history of any other phobia, free floating anxiety or persistence mood disturbance. There was no significant medical or surgical history. She was diagnosed as a case of Specific (isolated) phobia and managed with short term Benzodiazepine (Tab Alprazolam), graded exposure therapy, Cognitive Behavioural therapy and relaxation training leading to complete resolution of her symptoms and distress. A 28 years old female, a housewife and mother of two children was brought to ENT OPD by her husband with a history of foreign body sensation in the throat and hoarseness of 20 days duration. The lady gave a history of excessive gargling with hot saline water at home for the last 1 month. A videolaryngoscopy revealed diffuse laryngeal edema with extensive hyperemia of the endolarynx. There was edema of the arytenoids however the airway was adequate and the vocal folds were mobile. The patient was started on proton pump inhibitors and a short course of oral Prednisolone at 0.5 mg/kg for 1 week. She was also advised to stop gargling with hot saline water. There was mild relief in the symptoms but she confessed that she could not control the urge to gargle. In view of the above she was advised psychiatric consultation. History from the patient and her husband revealed that last month a family in their locality was tested positive for Coronavirus and their area was made a red zone and sealed. Gradually she developed recurrent thoughts that her throat was infected with the virus and she would start experiencing discomfort in her throat. It would lead to significant distress making her restless. Immediately she would do gargles with hot saline water leading to relief of her distress. However she would again have similar thoughts and would resort to similar act of gargling for temporary relief. After gargles she would have no such thoughts and feel robust. She would accept that this thought was her own and irrational however she had difficulty in resisting it. Over last 1 month her symptoms worsened significantly with escalation in frequency of gargling (40-50 times/day). She would experience severe anxiety if she tries to resist or unable to perform gargling due to any reason. She also developed sleep disturbance and poor self confidence to manage household chores. She was counselled several times by her husband but to no avail. Her clinical examination was normal. Mental state evaluation revealed obsessive thoughts of throat contamination with Corona virus and compulsive acts of saline hot water gargling. There was secondary anxiety in absence of any psychotic features in clear sensorium and disturbed biodrives. Psychometry revealed high YBOCS (32). Neuroimaging of the brain was normal. She was diagnosed and managed as a case of Obsessive Compulsive disorder with Tab Fluvoxamine (50 mg) increased to 100 mg, short term Benzodiazepine (Tab Clonazepam), behaviour therapy, psychoeducation and relaxation training. Gradually she had improvement in symptoms with mitigation of her distress. The global catastrophe created by the COVID 19 pandemic can't be described by the available vocabulary. The evident and undisguised destruction to physical health caused by the pandemic needs no introduction but what is surprising is how it obscurely and inconspicuously started affecting the mental health of the population [8, 9] .The initial measures were completely dedicated to prevent the physical harm caused by the viral illness thereby completely neglecting the ill effects on the mental health and the psyche of both healthy and affected individuals [10] [11] [12] [13] [14] . Even the health care workers were not spared of the psychological effects of the COVID 19. All this led to emergence of 'novel' symptoms in seemingly healthy individuals and resurgence of latent symptoms in individuals with known mental health issues. Attributing ENT symptoms to COVID 19 is one such trend described in this case series. In this case series we have discussed how this ongoing COVID 19 pandemic is making our way into our physical and mental world. This sudden shift of social dynamics and changing role pattern is promulgating a state of mental turmoil and distress manifesting in varied forms [3] . Flurry of emotions around are causing subtle damage to our psyche. It is the need of the hour to develop a holistic approach in a warm empathetic milieu to tackle this menace of COVID pandemic and provide effective psychiatric care for mental wellness. A good comprehensive history will serve as a helpful screening tool. Management in such cases first involves ruling out organicity. Patients must be handled with empathy, reassurance and positive feedback. Psychoeducation will help to allay undue worries and apprehensions along with cognitive distortions. Relaxation training, cognitive behaviour therapy along with use of psychotropics have proven beneficial for good recovery. Needless to say that this case series highlights only the tip of the iceberg and what lies beneath is still concealed to the human eyes. 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