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Management of Disorders > Neuropsychiatry of COVID > Flashcards

Neuropsychiatry of COVID Flashcards

1
Q

Why was concern for possible neuropsychiatric complications high at the start of the pandemic?

A

Because of what has been seen with other coronaviruses and SARS (e.g. fatigue)

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2
Q

What is Guillain-Barre syndrome?

A

A condition where the immune system attacks the nerves of the PNS, easing to rapid muscke weakness and possible paralysis

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3
Q

Why did we see an increase in GBS cases during the pandemic?

A

Because an increased number of patients were being seen so we were more likely to detect more cases

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4
Q

What is the major problem with interpreting research on the neuropsychiatric manifestations of COVID?

A

Larger numbers tested = increased liklihood of seeing rare complications

Important we determine what is DIRECTLY related

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5
Q

What are the most common acute neuropsychiatric manifestations of COVID?

A

▪️Fatigue
▪️Myalgia
▪️Depression
▪️Anxiety
▪️Headaches

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6
Q

What is the most common severe neuropsychiatric symptom of covid?

A

Delirium (up to 40%)

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7
Q

How long do common neuropsychiatric manifestations of COVID usually last?

A

Not long - tend to resolve promptly regardless of illness severity

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8
Q

What are some of the rarer neuropsychiatric symptoms of covid?

A

▪️Encephalitis
▪️Psychosis
▪️Catatonia

BUT causality is unclear

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9
Q

What is the main risk factor for stroke or microvascular alterations following covid infection?

A

Cerebral vasculopathy

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10
Q

What is the relationship between covid and psychiatric diagnosis?

A

Bidirectional!

▪️Increased rates of diagnosis in those with covid
▪️Increased risk of covid and mortality in those with prior diagnosis

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11
Q

What risk factors are common to both covid infection and psychiatric disorder?

A

▪️Ethnic minorities
▪️Low SES
▪️Lifestyle factors (e.g smoking, poor physical health)
▪️South/west London

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12
Q

What percentage of people admitted to hospital for covid had had a stroke and how did they differ from non-covid stroke admissions?

A

2%

More young people than would be expected

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13
Q

How many patients experience delirium in the acute phase of covid?

A

1/3

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14
Q

What are the main risk factors for delirium in covid?

A

▪️More severe infection
▪️Older age
▪️Dementia

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15
Q

What outcomes are associated with delirium in covid?

A

▪️Worse outcomes
▪️Greater risk of subsequent dementia
▪️Risk of cognitive deterioration regardless of illness severity

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16
Q

How do rates of dementia diagnosis following covid compare to other respiratory tract infections?

A

2x greater

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17
Q

Why might covid infection increase the risk for cognitive decline and dementia?

A

▪️Delirium
▪️Time spent in ITU (although also seen in milder cases)
▪️Medications
▪️Raised inflammatory response
▪️Lack of prior immunity

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18
Q

What are the four principle mechanisms through which covid may effect the brain?

A

▪️Direct viral infection
▪️Inflammation and parainfectious cytokine storm
▪️Vasculopathy/Vasculitis
▪️Post-infectious antibody-mediated

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19
Q

What is the theory of direct viral infection?

A

▪️Covid can infect the brain directly through nose via the BBB or neuronal transport
▪️This can then cause structural damage

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20
Q

What is the proposed evidence behind the mechanism of direct viral infection?

A

▪️Entry via ACE2 receptors in olfactory bulb explains anosmia
▪️SARS-CoV-2 have replicated in neurons in vitro
▪️Evidence of cerebral inflammation and leukoencephalopayhy in postmortem and imaging

21
Q

What are the main limitations of the direct infection theory?

A

▪️Little evidence
▪️Viral RNA largely a sense from CSF and post mortem samples

22
Q

What is the theory behind inflammation as a mechanism for neuropsychiatrc symptoms in covid?

A

▪️Covid induces inflammatory state mediated by cytokine release
▪️This has multi-systemic effects, including on CNS

23
Q

What is the evidence for the inflammatory mechanism of symptoms?

A

▪️Proinflammatory cytokines shown in covid patients with delirium (e.g. IL-6, IFN-γ)
▪️Inflammatory response greater in those with delirium
▪️Common with most viral infections

24
Q

What is the main argument against the inflammation mechanism?

A

Response may be greater in covid than other viruses due to lack of prior immunity

25
Q

What is the proposed vasculopathy/vasculitis mechanism for neuropsychiatrc symptoms in covid?

A

▪️Blood vessels leak and dilate, increasing the propensity to form clots
▪️Covid interferes with the ability to efficiently fix these problems

BUT rare!

26
Q

What is the main evidence for the vasculopathy/vasculitis mechanism?

A

▪️Higher than expected stroke rate
▪️Thromboembolic complications likely mediated by increased blood coagulability and inflammatory endothelial impairment

27
Q

What is the evidence for a post-infectious antibody mediated mechanism?

A

▪️Some reports of covid associated autoimmune encephalitis
▪️Anti SARS-CoV-2 antibodies found in CSF of encephalopathy covid patients
▪️Autoantibodies found in CSF of ICU covid patients

BUT very rare!

28
Q

Why were differences in neurodevelopmental age seen in babies born during the pandemic?

A

▪️Possibly lockdown/stress factors
▪️NOT in utero effects of maternal infection

29
Q

Based on other postviral syndromes, such as SARS and MERS, what did we expect from long covid?

A

▪️Chronic myalgia
▪️Fatigue
▪️PTSD
▪️Depression and anxiety

30
Q

What are the NICE guidelines for post-covid syndrome?

A

▪️Any symptoms that developed during or after infection and persisted for more than 12 weeks
▪️Usually a cluster of symptoms that fluctuate and change over time
▪️Can affect any system in the body

31
Q

What are the main symptoms seen with long covid?

A

▪️Fatigue/post-exertional malaise
▪️Cognitive dysfunction (brain fog)
▪️Cardiorespiratory symptoms (e.g. breathlessness)

32
Q

What symptoms are typically not included in post-covid syndrome?

A

Anosmia and loss of taste

33
Q

What other factors may contribute to post-covid syndrome?

A

▪️Post-ICU syndrome
▪️Focal neurology (e.g. stroke)

Both indicating to severity of infection

34
Q

How many people were reported to have long covid in the UK in June 2022?

A

2 million

35
Q

What structural brain changes have been observed in association with SARS-CoV-2 infection and long covid?

A

▪️Significant reductions in thickness of certain brain areas
▪️Particularly orbitofrontal cortex and left parahippocampal gyrus
▪️Due to chronic anosmia?

36
Q

What is the main issue with interpreting structural brain changes following COVID?

A

So many possible factors involved, cannot say whether it’s directly caused by the virus

37
Q

How long does covid stay in the body?

A

Usually roughly a month but potentially for several in GI tract

NOT necessarily active!

BUT need larger studies

38
Q

Is long covid caused by persistence of virus in the body?

A

Unlikely

39
Q

Is long covid an ongoing response to lingering virus?

A

Unlikely - no difference in inflammatory markers between cases and controls

40
Q

How might long covid be views as a functional disorder?

A

▪️Symptoms arise from relationship between sensory input and appraisal
▪️Severity and disability is perceived, moderated and maintained by cognitive processes
▪️Expectancy mediates this

41
Q

What was found in the French study looking at serology in long covid?

A

▪️Positive serology did not increase risk of long symptoms
▪️Strong belief was associated with persistent fatigue and concentration difficulties

42
Q

What factors are associated with increased risk of negative post-covid outcomes prior to infection?

A

▪️Depression
▪️Anxiety
▪️Worry and perceived stress
▪️Loneliness

NOT classic risk factors e.g. smoking

43
Q

What are the main conclusions for the mechanisms of long covid?

A

▪️Limited evidence for structural damage, immune response, or chronic infection
▪️Psychological factors likely important

44
Q

How can we manage long covid?

A

▪️Better sleep for fatigue
▪️Treat mood and anxiety issues as you would in primary cases
▪️Onward referrals (e.g. nerve clinic)
▪️Address medical comorbidities
▪️Make sure people feel listened to and acknowledged
▪️Education (dualistic interpretation)
▪️PT/OT/CBT
▪️Slow/phased return to work

45
Q

Do vaccines improve long covid?

A

Yes - functional response based on expectations?

46
Q

Most neuro/psych complications of the vaccines are likely ___________ rather than ____________

A

▪️Correlations
▪️Causative

47
Q

Why were rare adverse effects of vaccines, such as cerebral venous sinus thrombosis, only detected in post-vaccine trials?

A

Pre-vaccine clinical trials are not typically high powered enough to detect very small risks (small samples)

48
Q

What percentage of vaccine reactions are likely NOT caused by the vaccine?

A

~66%

49
Q

Why might covid vaccines have an increased risk of functional responses?

A

▪️Worry over vaccines and increased negative expectation
▪️Videos circulating media

Psychogenic illness!

Management of Disorders (28 decks)

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