Obsessive-compulsive disorder during the SARS-CoV-2 pandemic (case report)

The novel coronavirus 2019 (COVID-19) pandemic has affected not only the somatic health of people but also their mental health and the organization of mental health care. Self-isolation, quarantine, extensive media coverage of the situation, a large amount of inaccurate information, and conflicting recommendations – all this has led to an increase in admission of patients who have not previously had mental illness to psychiatrists. As a confirmation of the influence of the above factors on the population's mental health, we present a case report of a 25-year-old patient who first came to a psychiatric clinic due to the obsessive-compulsive disorder that developed due to the pandemic.

work because of disability due to a severe gunshot wound. The patient is an only child in the family. He grew up as an obedient, calm child, and did not lag behind in development. His parents spoiled him by overindulgence. He attended kindergarten from the age of 3, was shy and timid, occasionally took the initiative in games and communication. He went to school at the age of 7, hardly adapted to the team, was unsociable. He didn't like studying, nor did he have any favorite subjects. Up to the 7th grade, he suffered from excess weight, which caused him to be bullied by his peers, reacted painfully to it, and shared his experiences with his mother. He tried to communicate more with his peers so that they would not offend him. His mother, concerned about her son's excess weight and the children's attitude towards him, began to turn to various specialists and conduct different medical examinations. Among other things, a consultation of an endocrinologist was recommended, who diagnosed hyperglycemia and prescribed metformin, against which the patient's weight returned to normal. He started playing sports, following a diet, gained self-confidence, and found it easier to communicate with his peers. At the same time, relations with parents became more complicated. They wanted a divorce, and he tried to dissuade them from it. There was a conflict: he threatened to leave home in the case of the divorce. In high school, he began to go to school with pleasure, made a lot of friends, had his own company. He spent most of his free time playing active games, as he was afraid of re-gaining weight. In  He carefully supervised the handling of any items she brought home. He also asked her to keep a social distance and wear a mask and gloves for an hour after returning home. He processed products from the store with detergents, first in the package, then after removing the package and asked his girlfriend to do the same. There were frequent quarrels, because the patient insisted on his partner's staying at home most of the time, while she was not afraid to go out. When he was at home and didn't have contacts with anyone, he felt safe, and the rest of the time he was very anxious and afraid of infection. By the end of May 2020, the selfisolation regime was canceled, and it was necessary to return to the office. For the first two weeks, he took a taxi, tried not to interact with anyone, used all personal protective equipment (a respirator, gloves, and kept a social distance). At the same time, he admitted that other people may not follow the rules so strictly and there was still a high probability of infection. Two weeks later, at work, he experienced a feeling of lack of air, «suffocation». He immediately phoned his mother, regarding his feelings as symptoms of the coronavirus infection. He didn't call a doctor, so as not to be a source of infection. He stayed at home for two days, the attacks of lack of air did not recur. He took valocordin, used steam inhalations. In June, the condition worsened again: there was a feeling of «clouding in the head», nausea, memory loss, dizziness, insomnia, tension in the eyes, severe fatigue. He went to the hospital, underwent an examination: MRI, ultrasound of blood vessels, and a lot of tests. The diagnosis of coronavirus infection was not confirmed, but the alarm remained. His condition improved slightly only when walking and exercising. He independently concluded that his worries about possible infection led to the fact that «the psyche was disturbed» .As prescribed by a neurologist, he took mexidol, actovegin, milgamma, but did not feel any improvement. He continued to work, but his productivity declined, concentration was disrupted, and he was constantly experiencing anxiety, which did not go away with careful compliance with all the measures recommended by the media for protection against coronavirus. His girlfriend, made a decision to break off the relationship because she couldn't stand his constant monitoring of her behavior and his suspicion that she might infect him. Against the background of these events, he decided to seek help from S. S. Korsakov Psychiatric Clinic. He was consulted by a psychiatrist and hospitalized. C o m m e n t In this clinical case, we are talking about obsessive-compulsive disorder (OCD), which first occurred during the COVID-19 epidemic, in a person with anxiety-suspicious character traits. The patient's condition was characterized by obsessive fears of infection, compliance with characteristic rituals: processing all things after being outdoors, products bought in the store, the desire not to leave home, strict observance of social distance and constant use of personal protective equipment even in situations where it was not required. At the same time, the patient could not distract himself from thoughts of possible infection, therefore, his anxiety persisted, and he was unsuccessful in the fight against obsessive fears. The patient's mental status was dominated by anxiety, fixation on the fear of infection, constant return to this topic in conversation, low mood, the desire to stop thinking about infection and return to his usual life.

Mental status on admission
Anxious-suspicious traits, as premorbid personality traits, have been manifested since the patient's early childhood: he had difficulty adapting to the team, was shy to take initiative in the circle of other children, adapted to common interests and tried not to stand out. From an early age (14 years), he has been closely monitoring his health, paying attention to any changes in his condition. The coronavirus pandemic and the necessary measures, as well as information from mass media related to it, formed a fertile personal ground for the development of neurosis.
Thus, this mental disorder can be classified according to the International Classification of Diseases, Tenth Revision (ICD-10) as obsessive-compulsive disorder (F42) in an anxioushypochondriac personality.
The peculiarity of this case is that the patient was practically healthy, socially adapted, and the first symptoms of the disease appeared against the background of pandemic of COVID-19, which was a stressful and traumatic situation that caused the onset of the disease. This is also supported by studies showing an increase in the number of patients who have first seen a psychiatrist during the pandemic. Mass fear of COVID-19, rightly referred to as «coronaphobia» [20], is probably associated with uncertain nature and an unpredictable course of the disease, intolerance to uncertainty, perceived risk of infection, and avoidance reactions among people who have not previously sought psychiatric care [21]. Foreign sources also confirm the increase in primary diagnoses of OCD during the pandemic [22].
In our case, the first symptom of a mental disorder was the patient's fear of infection and concern for his health. Despite the fact, that neither the patient himself, nor any of his relatives had encountered the infection, he experienced a panic fear of it, which he could not interpret for himself. This also coincides with the results of studies on predictors of the development of mental disorders, including OCD, during the pandemic. Thus, a study by Michael G. Wheaton indicates a pronounced degree of correlation between the occurrence of OCD with health concerns and fear of the spread of the virus [23].
In the patient's status, attention is drawn to obsessive methods of preventing infection: fanatical treatment with disinfectants of any objects and products brought home, fear of inhaling outdoor air, forcing the partner to keep a distance from him, not to touch him, treat clothes and hands, wear a mask in the apartment, the decision to stop visiting work before self-isolation was officially required. The patient was concerned about possible shortages of protective equipment, and therefore he purchased them in large quantities. Recent research on mental illnesses caused by the pandemic also confirmed that deterioration of people's mental state is more often manifested in excessive and often ritualistic compliance with personal protective equipment rules in an attempt to prevent infection. People who are overly concerned about observing the above rituals may worry about the lack of emergency care and basic services during isolation, and this unrealistic panic may lead to attempts to hoard food and other basic things (such as hand sanitizers, medications, protective masks, or even toilet paper) [17,24].
Our patient did not have the coronavirus infection and was not at risk of developing serious consequences of the infection. At the same time, he regularly followed the infection statistics, news about the development of the epidemic, and independently conducted morbidity analysis. Recent studies of the clinical features of mental disorders that have occurred during the new coronavirus infection confirm the dependence of emerging disorders on the degree of immersion of the patient in the information field, the desire to keep up to date with the latest news [8,13,25].
Taking into account the peculiarities of the clinical picture of the disease, a fluvoxamine therapy scheme was selected. The choice of fluvoxamine as a basic antidepressant in an average daily dosage corresponding to the severity of anxiety and depressive experiences was due to the profile of its psychopharmacological activity: a pronounced antidepressant effect in combination with powerful anxiolytic and anti-obsessive effects, as well as a certain effect on somatoform symptoms [26]. Maintenance monotherapy with fluvoxamine had a positive effect on anxiety-phobic experiences: the patient's condition stabilized. The fear of infection practically disappeared, even when the patient was infected with the coronavirus, there was no deterioration in his mental state, he also became more adapted, and the quality of life improved. The choice of this drug also coincides with the results of studies on the treatment of mental disorders during the pandemic, taking into account its safety, pronounced antidepressant and antianxiety effects [27].
Thus, our observation demonstrates the dependence of the development of mental disorders during the pandemic not so much on the fear of serious illness and possible death, but on the constant flow of information about the number of infected and deceased, necessary precautions, and general panic mood in the society. The possibility of prompt psychiatric care for patients with developing mental disorders against the background of the epidemic will help prevent their progression and speed up the adaptation of patients, which is especially important given the unpredictable and rapidly developing nature of the pandemic.