Case 1

The patient is a 48-year-old married man, with secondary level education, of middle socioeconomic status, with well-adjusted premorbid functioning. The patient was diagnosed with COVID-19 for which he was required hospitalisation for the initial part of his illness and was managed conservatively and improved after 12 days of admission and eventually recovered. His mother, in her 60s, was also diagnosed with COVID-19, and during the hospitalisation, her physical condition deteriorated rapidly, requiring mechanical ventilation. While the patient was hospitalised, his mother passed away due to the illness, and her last rites were conducted by his other family members. The patient came to know of his mother’s demise only after his discharge and was shocked on hearing the news. He expressed guilt for not being able to give his mother company in the last few days of her life and not participating in her funeral rites. His family members tried to console him, but he was not reassured. He would remain tearful throughout the day and preferred to stay isolated. His sleep, appetite and self-care were normal during this period. After 2 weeks, patient’s sleep gradually reduced to 1.5–2 hours/day. Despite not sleeping, the patient would appear active throughout the day. He also became more talkative and would constantly talk about his mother. He would also appear authoritative to his family members and order them to follow his instructions. He would be constantly engaged in household chores, even when they had already been done by his wife. His predominant mood was irritable, and he would have anger outbursts. He would try to go out of the house despite the lockdown, saying that he was going to the Prime Minister’s office to instruct him on how to control the pandemic. If family members stopped him, he would try to run out of the house and become verbally aggressive. Because of unmanageability, he was brought by his family to the outpatient services of our psychiatry department. History revealed that the patient’s father suffered from mental illness suggestive of bipolar disorder, which was never treated, and he had expired at the age of 64 years. However, the patient had not suffered from any mental illness in the past. General physical examination and systemic examination revealed no abnormality. His blood pressure (BP) was 110/70 mm Hg, pulse rate (PR) was 81/min, respiratory rate (RR) was 14/min and body mass index (BMI) was 23.9. On mental status examination (MSE), he was mildly unkempt, authoritative towards the interviewer, eye-to-eye contact (ETEC) was made but not sustained and rapport could not be established. His speech was spontaneous with increased rate, tone and volume. His affect was irritable, and he reported ideas of grandiosity. His attention and concentration were aroused but ill-sustained, and his judgement was impaired. Based on his history and MSE findings, a diagnosis of first-episode mania was entertained as per ICD-10 (International Classification of Disorders). Young Mania Rating Scale (YMRS) was applied, which yielded a score of 27. The patient was started on a daily dose of 15 mg olanzapine and 1 mg clonazepam optimised over 1 week. He showed clinical response over the next 2 weeks on the above-mentioned medications. His sleep increased to 6–7 hours/day; there was a reduction in irritability, anger outburst and increased talkativeness, but the ideas of grandiosity and increased psychomotor activity persisted. The YMRS score was reduced to 16 after 2 weeks of pharmacological management.

Case 2

The patient is a 14-year-old girl, a student of class 9, belonging to a Hindu nuclear family of low socioeconomic status. She had an easy temperament, no medical comorbidity and no history or family history of mental illness. The patient was studying in a private school, and she was considered as a meritorious student by her teachers and family members and participated in extracurricular activities. Since March 2020, with the imposition of nationwide lockdown, her school has been closed, and all academic activities were conducted through online learning. Although the patient’s father possessed a smartphone with an internet connection, she did not have access to a computer or laptop. The patient was required to attend online classes regularly as organised by her school authorities. She also received online assignments through email, which had to be completed and mailed back within the stipulated period. The patient would try to attend the online classes on her father’s phone, but she was unable to complete her assignments. Both her parents were not educated beyond middle school and could not assist her in her academics. The patient would remain constantly preoccupied with her inability to follow the curriculum. She would express apprehensions regarding her schoolwork. She would frequently report to her family members that she would lag behind her other peers and would not be able to clear her exams. She started reporting intermittent anxiety symptoms, crying spells and sleep disturbance for the next 2.5 months. Then, 10 days prior to the assessment, the patient’s mother noticed that she would not sleep at night and appear fearful. She would not interact with family members and have unprovoked anger outbursts. Occasionally, she was seen muttering to herself. Her appetite and self-care also deteriorated significantly following which she was brought to the OPD. General physical examination revealed mild pallor. Her BP was 90/70 mm Hg, PR was 98/min, RR was 16/min and BMI was 18.4. Blood investigations revealed no abnormality. On MSE, she was unkempt, appearing fearful and muttering to self intermittently. ETEC was not made or sustained and psychomotor activity was increased. Her attituded towards the interview was guarded. Her affect was irritable and speech was irrelevant with increased rate, tone and volume, and she was not cooperative for further interviews and would become verbally aggressive. Based on the history and clinical evaluation, a diagnosis of acute transient psychotic disorder was made as per ICD-10, and the patient was started on a daily dose of risperidone 2 mg and lorazepam 1 mg over which her family members reported mild improvement in fearfulness, muttering to self and anger outburst over next 1 week. There was also improvement in her sleep and self-care.

Case 3

The patient is a 9-year-old girl, dropped out of school, belonging to lower socioeconomic status, with no significant medical or psychiatric history in the family, was brought to OPD during the lockdown. The child’s functioning before the illness was adequate with good academic performance. The family members gave a history of sudden onset spells of unresponsiveness that were usually preceded by a stressful event and were often associated with concomitant symptoms of headache, light-headedness and palpitations. These spells had been occurring intermittently over the last year, during which period, her family had sought consultation from a neurologist. She was diagnosed with psychogenic non-epileptic seizures; her EEG revealed no abnormality, and she was not on any pharmacological treatment.

During the lockdown, the garment factory in which her father worked was shut down, because of which he lost his job. This led to a financial crisis in the family as her father was the chief earning member, and they faced difficulties in paying their rent and meeting the expenditure for daily essentials. The patient was exposed to discussions among parents over money matters. She would be constantly preoccupied with the financial issues of the family. She became anxious and upset when she came to know that her mother was contemplating working as a domestic help to meet the financial needs of the family. She would repeatedly ask her family members to allow her to share the workload at home. Even though she was a student of primary school, she tried to tutor students younger to her in her neighbourhood, as an attempt to earn money for the family. She would remain anxious most of the time and have a sudden outburst of crying. This would often be followed by an unresponsive spell. Previously, these episodes would occur one to two times in a month, whereas now they started to occur three to four times/day. The family members initially sought help from a local faith healer, but after perceiving no improvement, she was brought to the psychiatry OPD. Her general and systemic physical examination did not reveal any abnormality. Her BP was 100/60 mm Hg, PR was 88/min, RR was 16/min and BMI was 17.9. Blood investigations revealed no abnormality. On MSE, she was well kempt, ETEC was made but not sustained and rapport could be established with great difficulty. Her affect was constricted. She reported preoccupations with the financial problems of the family and ideas of guilt about not being able to contribute to the family. Based on the history and clinical assessment, a diagnosis of conversion disorder with seizures was made as per ICD-10. A differential diagnosis of syndromal depressive or anxiety disorder in addition to her pre-existing conversion symptoms was also entertained; however, on evaluation, she did not fulfil the criteria for a separate comorbid diagnosis. The patient was referred to a clinical psychologist for psychotherapeutic intervention. Psychosocial stressors were explored in detail. On Children’s Apperception Test, the major themes obtained were of uncertainty, loss of finances and lack of food, failure and poor problem solving ability. The intervention focused on teaching emotional self-regulation skills and breathing exercises for relaxation. The child was asked to keep a record of the frequency of episodes and skill practice. After the initial three sessions, the next sessions were conducted telephonically to enable the family to save travel fare. By the fifth week of treatment, the patient’s episodes of headache and unresponsive spells had reduced to one to two times per week.