Unforeseen consequences of terrorism: medically unexplained symptoms in a time of fear

Long COVID as a functional somatic symptom disorder caused by abnormally precise prior expectations during Bayesian perceptual processing: A new hypothesis and implications for pandemic response

This review proposes a model of Long-COVID where the constellation of symptoms are in fact genuinely experienced persistent physical symptoms that are usually functional in nature and therefore potentially reversible, that is, Long-COVID is a somatic symptom disorder. First, we describe what is currently known about Long-COVID in children and adults. Second, we examine reported "Long-Pandemic" effects that create a risk for similar somatic symptoms to develop in non-COVID-19 patients. Third, we describe what was known about somatization and somatic symptom disorder before the COVID-19 pandemic, and suggest that by analogy, Long-COVID may best be conceptualized as one of these disorders, with similar symptoms and predisposing, precipitating, and perpetuating factors. Fourth, we review the phenomenon of mass sociogenic (functional) illness, and the concept of nocebo effects, and suggest that by analogy, Long-COVID is compatible with these descriptions. Fifth, we describe the current theoretical model of the mechanism underlying functional disorders, the Bayesian predictive coding model for perception. This model accounts for moderators that can make symptom inferences functionally inaccurate and therefore can explain how to understand common predisposing, precipitating, and perpetuating factors. Finally, we discuss the implications of this framework for improved public health messaging during a pandemic, with recommendations for the management of Long-COVID symptoms in healthcare systems. We argue that the current public health approach has induced fear of Long-COVID in the population, including from constant messaging about disabling symptoms of Long-COVID and theorizing irreversible tissue damage as the cause of Long-COVID. This has created a self-fulfilling prophecy by inducing the very predisposing, precipitating, and perpetuating factors for the syndrome. Finally, we introduce the term "Pandemic-Response Syndrome" to describe what previously was labeled Long-COVID. This alternative perspective aims to stimulate research and serve as a lesson learned to avoid a repeat performance in the future.

Vaccine-induced functional neurological disorders in the Covid-19 era

The large amount of information available to the public regarding vaccines against Covid-19 coupled with pandemic stress and increased somatic attention could potentially precipitate development of functional neurological disorders (FNDs) following vaccination. A growing number of reports indicate that functional symptoms may follow Covid-19 vaccination, similar to those observed with other vaccines previously. We review previously reported cases of FND following vaccination against Covid-19 and present three additional cases. While two patients presented to the Emergency Department with functional movement disorders, one patient presented with protracted limb weakness and sensory dysfunction. The superficial resemblance to Guillain-Barré syndrome, a known but uncommon complication of vaccination prompted an extensive workup. Clinicians need to convey the diagnosis of FND in clear and unequivocal terms to facilitate institution of appropriate therapy and rehabilitation, but importantly also to dispel any doubts in the minds of the public regarding the safety of the available vaccines. Given the presence of significant vaccine hesitancy in many countries, this is critical to the success of the global immunisation effort.

The Rise of Functional Tic-Like Behaviors: What Do the COVID-19 Pandemic and Social Media Have to Do With It? A Narrative Review

BACKGROUND

There has been a rise in explosive onset of tic-like behaviors during the COVID-19 pandemic. Historically, this is an uncommon phenomenology of functional movement disorders across all ages. Both the psychological burden of the pandemic and social media usage have been implicated in the rise of these tic-like behaviors.

METHODS

This paper provides a narrative review of the literature on chronic tic disorders, functional tics, and mass functional illness with particular focus on the key distinguishing features, role of social media, and the role of COVID-19.

RESULTS

The COVID-19 pandemic has profoundly affected the mental health of many individuals, including children, adolescents, and their caregivers. Implementation of lockdowns, lifestyle disruptions, school closures, and social distancing have driven a surge in social media and digital technology use. The combination of predisposing factors, the psychological burden of the COVID-19 pandemic, and social media are implicated in the rise and spread of tic-like behaviors; which may represent a modern-day form of mass functional illness. While many of the features overlap with functional tics, there are emerging distinctive features that are important to recognize. A more encompassing term, Functional Tic-Like Behaviors, is used to better reflect multiple contributing factors.

CONCLUSION

Knowledge of these differences is essential to mitigate downstream health effects and poor outcomes.

The COVID-19 outbreak and PNES: The impact of a ubiquitously felt stressor

OBJECTIVE

We aimed to assess frequency of functional seizures or psychogenic nonepileptic seizures (PNES) during the COVID-19 outbreak and to recognize possible factors associated with worsening in this population.

METHODS

In this cross-sectional study conducted during the second phase of the pandemic, adult patients with PNES documented by video-EEG and followed up in two tertiary epilepsy centers responded to a structured telephone survey. Data were gathered on demographics, clinical features and frequency of PNES, history of psychiatric comorbidity, access to treatment, as well as on anxiety (GAD-7 items) and depressive symptoms (NDDI-E).

RESULTS

Fifty-four patients (78% female; mean age of 31.36 years [SD = 10.6]) were contacted and 15 (28%) reported increased frequency of PNES during the pandemic. Higher scores of GAD-7 items (p < 0.001) and NDDI-E (p < 0.001) were associated with PNES worsening. There was strong evidence of a correlation between higher stress levels (p < 0.001) and poor sleep quality (p 0.005) with PNES aggravation. After regression, stress was the strongest predictor of PNES increased frequency.

SIGNIFICANCE

Patients with functional neurological disorders are vulnerable during ubiquitously felt stressors. However, the atmosphere of uncertainty did not affect these patients equally. Patients with PNES showing symptoms of anxiety and depression are at higher risk of seizure worsening. Early identification of this subset of patients may prevent this detrimental outcome.

A comparison of Emergency Department presentations for Medically Unexplained Symptoms in Frequent Attenders during COVID-19.. [DOI: 10.1101/2020.08.25.20181511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background

Medically Unexplained Symptoms (MUS) refer to symptoms with no identified organic aetiology, and are amongst the most challenging for patients and Emergency Department (ED) staff. Providers working in our ED perceived an increase in severity and frequency of these types of presentations during the COVID-19 pandemic.

Methods

A retrospective list of frequent attenders (FA) presenting five or more times to the ED between two 122-day periods were examined: 01 Mar to 30 Jun 2019 (Control) and 2020 (COVID-19). The FA group were then examined to identify patients presenting with MUS (FA-MUS). Data were analysed in Prism; presented as n(%), % (95% confidence interval (95%CI) – Wilson/Brown method). Proportions were compared with a two-tailed Fisher’s exact test. A Baptista-Pike odds ratio was used to estimate magnitude and precision.

Results

The total number of ED attendances during the control period was n=42,785 which reduced to n=28,806 in the COVID-19 period, a decrease of 32.7%. The control FA cohort had n=44 FA-MUS patients with 149 ED visits. This increased to n=65 FA-MUS patients with 267 visits during COVID-19, p=0.44. There was a significant increase in the proportion of all ED visits that were FA-MUS: 0.3% (control) compared to 0.9% (COVID-19); OR 2.7, p<0.001. There was a significant increase in shortness of breath amongst MUS during the COVID-19 pandemic relative to the control period (p<0.01), with no significant difference in any other MUS category.

Conclusion

Whilst the total number of ED attendances reduced by almost one third during COVID-19, the actual number of all visits by frequent attenders with MUS increased and the proportion of attendances by these tripled during the same period. This presents an increasing challenge to ED clinicians who may feel underprepared to manage these patients effectively.

What is already known

Medically Unexplained Symptoms (MUS) are those that have no identified organic aetiology - they are amongst the most challenging presentations for patients and Emergency Department (ED) staff.

During times of stress and uncertainty, frequent attenders (FA) appear to be disproportionately affected by MUS. However, there are few data examining the impact of COVID-19 on the FA population.

What this paper adds

There was a significant increase in the proportion of all ED visits by FAs during the first four months of the COVID-19 pandemic.

There was a significant increase in the proportion of all ED visits by FAs with MUS during the first four months of the COVID-19 pandemic.

The proportion of MUS presentations that were ‘shortness of breath’ was significantly higher in the COVID-19 period compared to the control period. There were no other proportional differences observed in MUS categories.

Increased pediatric functional neurological symptom disorders after the Boston marathon bombings: a case series

BACKGROUND

Functional neurological symptom disorders are frequently the basis for acute neurological consultation. In children, they are often precipitated by high-frequency everyday stressors. The extent to which a severe traumatic experience may also precipitate functional neurological abnormalities is unknown.

METHODS

For the 2-week period after the Boston Marathon bombings, we prospectively collected data on patients whose presentation suggested a functional neurological symptom disorder. We assessed clinical and demographic variables, duration of symptoms, extent of educational impact, and degree of connection to the Marathon bombing. We contacted all patients at 6 months after presentation to determine the outcome and accuracy of the diagnosis.

RESULTS

In a parallel study, we reported a baseline of 2.6 functional neurological presentations per week in our emergency room. In the week after the Marathon bombings, this frequency tripled. Ninety-one percent of presentations were delayed by 1 week, with onset around the first school day after a city-wide lockdown. Seventy-three percent had a history of a prior psychiatric diagnosis. At the 6 months follow-up, no functional neurological symptom disorder diagnoses were overturned and no new organic diagnosis was made.

CONCLUSIONS

Pediatric functional neurological symptom disorder may be precipitated by both casual and high-intensity stressors. The 3.4-fold increase in incidence after the Boston Marathon bombings and city-wide lockdown demonstrates the marked effect that a community-wide tragedy can have on the mental health of children. Care providers must be aware of functional neurological symptom disorders after stressful community events in vulnerable patient populations, particularly those with prior psychiatric diagnoses.

Psychiatry and terrorism

Terrorism has dominated the domestic and international landscape since 9/11. Like other fields, psychiatry was not well prepared. With the 10th anniversary of the 9/11 attack approaching, it is timely to consider what can be done to prepare before the next event. Much has been learned to provide knowledge and resources. The roles of psychiatrists are challenged by what is known of the causes of, consequences of, and responses to terrorism. Reflecting on knowledge from before and since 9/11 introduces concepts, how individuals become terrorists, how to evaluate the psychiatric and behavioral effects of terrorism, and how to expand treatments, behavioral health interventions, public policy initiatives, and other responses for its victims. New research, clinical approaches, and policy perspectives inform strategies to reduce fear and cope with the aftermath. This article identifies the psychiatric training, skills and services, and ethical considerations necessary to prevent or reduce terrorism and its tragic consequences and to enhance resilience.

Prioritizing "psychological" consequences for disaster preparedness and response: a framework for addressing the emotional, behavioral, and cognitive effects of patient surge in large-scale disasters

While information for the medical aspects of disaster surge is increasingly available, there is little guidance for health care facilities on how to manage the psychological aspects of large-scale disasters that might involve a surge of psychological casualties. In addition, no models are available to guide the development of training curricula to address these needs. This article describes 2 conceptual frameworks to guide hospitals and clinics in managing such consequences. One framework was developed to understand the antecedents of psychological effects or "psychological triggers" (restricted movement, limited resources, limited information, trauma exposure, and perceived personal or family risk) that cause the emotional, behavioral, and cognitive reactions following large-scale disasters. Another framework, adapted from the Donabedian quality of care model, was developed to guide appropriate disaster response by health care facilities in addressing the consequences of reactions to psychological triggers. This framework specifies structural components (internal organizational structure and chain of command, resources and infrastructure, and knowledge and skills) that should be in place before an event to minimize consequences. The framework also specifies process components (coordination with external organizations, risk assessment and monitoring, psychological support, and communication and information sharing) to support evidence-informed interventions.

Risk factors for physical symptoms after a disaster: a longitudinal study

BACKGROUND

Although symptoms such as fatigue, headache and pain in bones and muscles are common after disasters, risk factors for these symptoms among disaster survivors have rarely been studied. We examined predisposing, precipitating and perpetuating factors for these physical symptoms among survivors of a man-made disaster. In addition, we examined whether risk factors for physical symptoms differ between survivors and controls.

METHOD

Survivors completed a questionnaire 3 weeks (n=1567), 18 months and 4 years after the disaster. Symptoms and risk factors were measured using validated questionnaires. A comparison group was included at waves 2 and 3 (n=821). Random coefficient analysis (RCA) was used to study risk factors for symptoms.

RESULTS

Female gender [beta (beta)=1.0, 95% confidence interval (CI) 0.6-1.4], immigrant status (beta=1.0, 95% CI 0.6-1.4) and pre-disaster psychological problems (beta=0.8, 95% CI 0.1-1.4) were predisposing factors for symptoms. Although disaster-related factors were predictors, the relationship between symptoms and disaster-related factors was not very strong and the magnitude of this association was reduced when perpetuating factors were added. Intrusions and avoidance, depression, anxiety and sleeping problems were important perpetuating factors for physical symptoms among survivors and mediated the association between traumatic stress and physical symptoms. Risk factors for symptoms were comparable between survivors and controls.

CONCLUSIONS

The results indicate that health-care workers should be alert for physical symptoms among female survivors, immigrant survivors and individuals with a high level of psychological problems both before and after a disaster.

Psychological and health problems in a geographically proximate population time-sampled continuously for three months after the September 11th, 2001 terrorist incidents

This study assessed the mental and physical health status and psychological problems related to the September 11th terrorist incidents among a representative sample of adults living near New York City, using continuously time-sampled data collected throughout 2001. Prevalence estimates for poor mental or physical health after September 11th (October through December) were comparable to those for the entire year of 2001 (i.e. approximately 33%). Psychological problems related to the terrorist incidents were reported by more than half of the respondents, and appeared to peak in prevalence approximately two to three months following the incidents, followed by a decline in the next month and subsequent year. Poor mental health, female gender, media re-exposure, and ongoing or increased alcohol use were risk factors for psychological problems, while older age (65+ years old) and being married were protective factors. Risk factors for poor physical and mental health or psychological problems were generally stable over the three-month period following September 11th, but some changes were identified consistent with stage models of post-disaster psychological adjustment. Implications are discussed for using continuous time-sampling as a strategy to research patterns of relatively acute stress-related sequelae of terrorism in populations whose members are affected despite primarily not having been at the disaster epicenter.

Are physical symptoms among survivors of a disaster presented to the general practitioner? A comparison between self-reports and GP data

Background

Most studies examining medically unexplained symptoms (MUS) have been performed in primary or secondary care and have examined symptoms for which patients sought medical attention. Disasters are often described as precipitating factors for MUS. However, health consequences of disasters are typically measured by means of questionnaires, and it is not known whether these self-reported physical symptoms are presented to the GP. It is also not known if the self-reported symptoms are related to a medical disorder or if they remain medically unexplained. In the present study, three research questions were addressed. Firstly, were self-reported symptoms among survivors presented to the GP? Secondly, were the symptoms presented to the GP associated with a high level of functional impairment and distress? Thirdly, what was the GP's clinical judgment of the presented symptoms, i.e. were the symptoms related to a medical diagnosis or could they be labeled MUS?

Methods

Survivors of a man-made disaster (N = 887) completed a questionnaire 3 weeks (T1) and 18 months (T2) post-disaster. This longitudinal health survey was combined with an ongoing surveillance program of health problems registered by GPs.

Results

The majority of self-reported symptoms was not presented to the GP and survivors were most likely to present persistent symptoms to the GP. For example, survivors with stomachache at both T1 and T2 were more likely to report stomachache to their GP (28%) than survivors with stomachache at only T1 (6%) or only T2 (13%). Presentation of individual symptoms to the GP was not consistently associated with functional impairment and distress. 56 – 91% of symptoms were labeled as MUS after clinical examination.

Conclusion

These results indicate that the majority of self-reported symptoms among survivors of a disaster are not presented to the GP and that the decision to consult with a GP for an individual symptom is not dependent on the level of impairment and distress. Also, self-reported physical symptoms such as headache, back pain and shortness of breath are likely to remain medically unexplained after the clinical judgment of a GP.

Viewpoint: Terrorism and Dispelling the Myth of a Panic Prone Public

Governments and commentators perceive the public to be prone to panic in response to terrorist attacks--conventional or involving chemical, biological or radiological weapons. Evidence from five such incidents suggests that the public is not prone to panic, although people can change their behaviours and attitudes to reduce the risk of themselves being exposed to a terrorist incident. Behavioural responses may be divided into acts of omission, such as not making unnecessary journeys, and acts of commission, such as taking prophylactic medication despite the inherent risk of side effects. Evidence suggests that the public are aware of these differences, and tend to adopt responses proportionate to the risk. Drawing upon the literature in the social and natural sciences, our discussion encompasses differing risk perceptions of terrorist threats and consequences of attacks. How do fear and anxiety interact with behavioural responses to amplify or attenuate perceptions that can be modified through risk communication undertaken by authorities?

Factors associated with receiving help and risk factors for disaster-related distress among Connecticut adults 5-15 months after the September 11th terrorist incidents

BACKGROUND

To obtain prevalence estimates and identify factors associated with psychological problems and receipt of help by a geographically proximate population in which some persons had direct exposure but the overall prevalence of direct exposure was low, 5-15 months after the September 11th, 2001 terrorist incidents.

METHOD

Telephone survey data from the Behavioral Risk Factor Surveillance System (BRFSS) (Connecticut Module) with a randomly selected cohort of 2741 women and 1899 men aged 18 and older were examined using bivariate Chi Square and multivariate logistic regression analyses of weighted data.

RESULTS

One in three respondents reported 9/11-related psychological problems, 26% of whom reported receiving formal services or peer support. Risk factors for reporting psychological problems included being surveyed earlier, female gender, age 64 or younger, Hispanic ethnicity, disability, recent depression, and reporting one day or more in the past 30 of poor mental health, sleep problems or worry. Poor mental health was associated with receipt of formal services, and increased alcohol use was associated with receipt of peer support.

CONCLUSION

In the post-impact recovery period following mass trauma, psychological problems by persons with ongoing mental health conditions or increased alcohol use warrant continuing public and professional attention. Women, Hispanics, and disabled adults also may be under-served.

Perceived poisons

Perceived poisoning may manifest in numerous ways; however, all cases share certain characteristics. All are fostered by the wide availability of unreliable information about chemical safety, poor understanding of scientific principles, and ineffective risk communication. Although this problem is still incompletely understood, some approaches have been demonstrated to be useful, such as education about risk, appropriate reassurance, and empathy on the part of the practitioner. Successful management may curtail the spread or exacerbation of symptoms, whereas unsuccessful treatment may cause the problems to escalate, with detrimental effects on both society and patient.

Terrorism's psychologic effects and their implications for primary care policy, research, and education

This paper examines primary care physicians' (PCP) roles in helping the nation prepare for, respond to, and recover from the psychologic consequences of chemical, biologic, radiologic, or nuclear (CBRN) terrorism. First, we discuss the psychologic consequences of a CBRN attack and PCPs' roles in responding to these consequences. Second, we analyze these roles in light of the known barriers to delivering high-quality, primary care-based, mental health care. Third, we offer recommendations for mitigating these barriers and preparing PCPs to respond to the psychosocial consequences of a CBRN weapon. Importantly, our recommendations provide dual-use benefits to PCPs faced with the daily concerns of primary care mental health, including improved linkages and electronic connectivity with mental health, information technology, and decision support for providers, and needed education and research.

Facing the possibility of bioterrorism

The possibility of bioterrorism has been met by significant financial outlays to map out public health responses. These have included comprehensive audits of potential agents, as well as exploring mechanisms for counteracting their impact. Psychological intervention and communication have been identified as key areas requiring further work, as fear of infection could pose a greater strain on social resources than the pathogens themselves. Bioterrorism provides a powerful metaphor for élite fears of social corrosion from within. Accordingly, a broader historical and cultural perspective is required to understand why individuals and societies feel so vulnerable to what remain largely speculative scenarios.

Integration of disaster mental health services with emergency medicine

Despite limited resources, emergency medical settings will be called upon to play many roles in the context of disasters and terrorist attacks that are related to preparedness, surveillance, mental health services delivery, and staff care. Such settings are a central capture site for those individuals likely to be at highest risk for developing mental health and functional problems. Because much of the potential harm to survivors of disaster or terrorism (and their families) will be related to their mental health and role functioning, preparedness requires the active integration of behavioral health into emergency medicine in every component of disaster response. There are many challenges of doing this including: (1) finding ways to integrate activities of the medical care, emergency response, and public health systems; (2) determining whether an incident has actually occurred; (3) making differential diagnoses and managing other aspects of initial medical needs; and (4) coping with the risks associated with system overload and failure. Delivery of direct mental health care must include: (1) survivor and family education; (2) identification and referral of those requiring immediate care and follow-up; (3) group education and support services; and (4) individual counseling. In order for effective response to occur, the integration of psychosocial care into disaster response must occur prior to the disaster itself, and will depend on effective collaboration between medical and mental health care providers. At workplaces, emergency medical care centers must ensure that staff and their families are properly trained and supported with regard to their disaster functions and encouraged to develop personal/family disaster plans.

New insights into culture driven disorders

Rheumatologists frequently encounter patients whose illnesses lack face-value; that is, they lack the typical objective features of pathology that rheumatologists traditionally rely on for diagnosis and developing effective treatment approaches: namely fibromyalgia, chronic fatigue syndrome, Gulf War syndrome, chronic whiplash, chronic low back pain, etc. In this article, we examine this group of illnesses as culture-driven disorders to emphasize the central importance of various societal constraints in the ultimate presentation of patients with these illnesses. We will examine them by first understanding the purpose they serve, the underlying factors that compel societal institutions to sanctify these disorders as diseases, and how research is beginning to examine the behaviour that captures and packages these symptoms to produce their clinical presentation. With this research understanding, rheumatologists may be able to offer patients more useful action plans, but likely changes in societal approaches to the expressions of distress and changes in disability and compensation systems will also be required.