INTRODUCTION Mental health professionals have been attending to patients with psychoses and other mental disorders routinely, but following the pandemic of COVID-19, things have suddenly changed. On March 2020, the coronavirus (COVID-19) outbreak was declared a pandemic by the World Health Organization.[1] Viruses of the coronavirus family (CoV) cause from the common cold to severe diseases. On January 07, 2020, a new virus, the “2019-nCoV” was added to this family. It was subsequently named the “COVID-19 virus.” There were drastic changes in people's lifestyles and difficulties in adjusting to the “new normal”[2] since the coronavirus pandemic emerged. Working from home, social distancing, the nationwide lockdown which was declared in India on March 25, 2020, along with protocols like the need to wash and sanitize one's hands multiple times a day have caused individuals to present with symptoms ranging from anxiety about contracting the illness, repeated thoughts of having to wash hands to becoming depressed due to the lack of interaction, especially in the elderly who live alone.[34] Patients of chronic psychiatric illness have had exacerbated symptoms due to the changes in their daily routine and difficulty in getting their prescribed medications due to the lack of transport. In the dry district of Wardha where alcohol is prohibited, we noticed a paradoxical increase in the cases of alcohol withdrawal following the lockdown.[5] In this rapidly evolving and changing scenario, we found that the symptoms associated with psychopathologies are also evolving. EVOLVING PSYCHOPATHOLOGY Patients of schizophrenia may present with delusions of persecution and reference where they grow suspicious of people talking about them or fearful of others who may be planning to kill or poison them.[6] Black magic and possession by god or other religious healers are the common basis of delusions[7] or believed to be the reason of the illness.[8] As devices, like the radio, television, computer, CCTV cameras, and the Internet were invented, they gave a new direction to the persecutory delusions such as conspiracy theories of enemies or authorities tracking and spying on people by spy camera. Patients started suspecting the person speaking over the radio to be discretely talking about or to them to relay a secret message which was later ascribed to the people seen on the television. Patients started claiming that their enemies are able to monitor them by installing CCTV cameras or implanting “microchips” in the brain to control their thoughts and behaviors.[910] Since the pandemic-related stress and anxiety and inaccessibility to health-care facilities increased, symptomatically stable patients on medication started presenting with relapse of psychotic symptoms with hallucinations and delusions influenced by the current nature of the COVID-19 pandemic. We present here our observations in the change in psychopathology following COVID-19 pandemic in patients attending Acharya Vinoba Bhave Rural Hospital, Wardha, Maharashtra, India, in the past 7 months. Here we would like to highlight an ironical change seen in the dry district, Wardha, where dealing of alcohol is illegal but patients started presenting in stages of alcohol withdrawal. On March 25, 2020, the Indian government declared a nationwide lockdown for 21 days which was then extended 21 days longer. During this period, social distancing was to be observed by remaining at home except for in emergency situations. Transportations, schools, colleges, businesses, and offices were closed indefinitely. At this time, it was observed that a 14%–27% increase in the number of admission of patients with complaints of alcohol withdrawal had presented and subsequently admitted under our care. The movement restrictions with loss of job and scarcity of alcohol were a few factors which contributed to this admission spike.[5] Moving ahead, we have noticed that patients who are attending the psychiatry outpatient department (OPD) post-COVID now have changes in their psychopathology. We have presented our experiences in seven patients. One of the patients was apparently in good health 1 month before the nationwide lockdown was declared, but following this, he would watch the news about the pandemic causing the patient to experience the symptoms of anxiety with palpitations and tremulousness, which occurred multiple times during the day, lasting about 10 min and he felt that either he or his family members would become COVID-19 positive. He was preoccupied with his health and worries about corona disease, and his predominant mood was worried with an anxious affect. Another inpatient, a homemaker, presented with complaints of hearing voices which were not heard by others prominently during the night, originating outside her body and which were out of her control. The known voices would talk to her and discuss among themselves that she was ill and would die due to the COVID-19 disease which made the patient fearful. She became suspicious of people in the ward as she thought that they were talking about her. Mental status examination revealed delusion of persecution, delusion of reference, and delusion that other patients in the ward were COVID positive, and they were trying to make her positive as well. The next patient was a teacher living with his family who suffered a stressful incident at work where he miscalculated the number of other district persons who came to their town during lockdown, following which he was removed from the assignment. He complained of sleep and appetite disturbances and then started hearing voices of few known people who reminded him of his “unforgiveable mistake” for which he should die and this caused sleep disturbances. He started suspecting his family and friends of planning with higher authorities to punish him byspying on his conversations through the “AarogyaSetu”App (App of Government of India for COVID-19) informing the Government of India about him miscalculating the number of people entering the village. He was fearful that the district collector would confiscate his property and auction it due to which he attempted suicide. The patient repeatedly urged his family members to commit suicide with him to avoid the shame of going to jail. Mental state examination revealed delusion of persecution, delusion of reference, and second person auditory hallucinations with poor insight. One of the cases was a 47-year-old married male who was a known case of bipolar affective disorder for the past 30 years which included three episodes of depression and six episodes of mania and the main perpetuating factor being his poor compliance to medications. The patient presented after being off medications for 4 days with complaints of decreased need for sleep, irritability, over talkativeness, and over friendliness with people around him. He believed that he was a great scientist who had created a “machine” which could diagnose and treat the coronavirus and that Donald Trump and other nations were trying to acquire it from him, but the coronavirus could be eradicated by him alone. He would also wander aimlessly around his village. Mental state examination revealed an increased volume and pressure of speech, delusion of grandiosity pertaining to COVID-19 and an irritable affect. The subsequent case was of a 52-year-old homemaker, a known case of schizophrenia for 7 years and in remission for the last 2 years who was brought to us with the complaints of muttering to self, decreased sleep, poor self-care, and pacing around for 7 days. The patient repeated - “the Coronavirus has come to kill everyone” and “the world will end.” She complained of hearing multiple voices warning her of the COVID illness due to which she became worried. She also felt that the same information was being broadcasted on the television and through loudspeakers outside her home. In one of the cases, 58-year-old widow who was living with her son and daughter in law, presented to the OPD with complaints of episodes of palpitation, restless, and feeling of impending doom which lasted for 5–10 min along with decreased sleep and reduced interest in day-to-day activities. The patient claimed that these symptoms started after a tooth infection followed by throat irritation 45 days ago for which she took treatment and recovered. Although she recovered, she would worry about having contracted COVID-19 infection and transmitting it to her family members. The patient visited a physician suspecting cardiac ailments where electrocardiogram and two-dimensional Echo cardiography were revealed to be within normal limits. The last case was another 46-year-old homemaker who presented to the OPD with complaints of spending time in cleaning surfaces such as furniture, drapes, sofa covers while neglecting other household duties. Family members noticed that she would sterilize her hands using copious amounts of hand sanitizer repeatedly and insisted that they do the same. She had no past psychiatric history but a positive family history of obsessive-compulsive disorder in her nephew, who was undergoing treatment for the same. Her mental state examination revealed anxious affect with obsessions and compulsions and preoccupation regarding contracting COVID-19 infection. CONCLUSION Most of these cases presented had no genetic predisposition and were of individuals who were otherwise living regular lives and more likely were not directly exposed to the illness itself. It seems like the preventive measures taken by the government to mitigate the spread of COVID-19 might have helped precipitate the mental illnesses and shows the dramatic impact the COVID-19 pandemic has had on the mental well-being of people. Many cases were unwilling for admission in the hospital as they feared contracting COVID-19 infection in spite of repeated assurances from the psychiatrists. A similar case was reported in Germany where a known patient of schizophrenia who was maintaining on medications relapsed and heard persecutory voices telling him that he is spreading the infection not only to his family but everyone around him.[11] The subtle changes in the psychopathology of the psychotic presentation of these chronic mental illnesses over the decades show how education, cultural beliefs, and social norms influence the content of the delusional thoughts and hallucinations experienced by patients of schizophrenia and affective disorders. With an unclear timeline for the resolution of the pandemic, only time will reveal the real impact of the pandemic on the mental well-being of people. Declaration of patient consent All patients reported have given consent for publication. All regulations of our Institute Ethical Committee and the Declaration of Helsinki were followed. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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