Neuropsychological and psychological dysfunctions associated with coronavirus disease 2019: a case report

The impact of coronavirus disease 2019 (COVID-19) on the functioning of the brain is progressively being underscored as societies accumulate both scientific and experiential knowledge of living through the illness. Lee et al. [1] reported findings of multifocal microvascular brain injuries in a postmortem study of brain tissue from patients with COVID-19. In a sample of 125 patients, Varatharaj et al. [2] reported that a large proportion (62%) of patients presented with a cerebrovascular event and 31% presented with altered mental status, of which 23% had unspecified encephalopathy and 18% had encephalitis. In their study, as many as 59% of the patients who manifested altered mental status fulfilled the diagnostic criteria for psychiatric diagnoses. It has been proposed that anxiety is at the core of the predisposing, precipitating, and perpetuating factors underlying various neuropsychiatric abnormalities (such as agitation, disorganization, paranoid ideation, and auditory hallucinations) detected in patients with COVID-19 [3]. Metabolic disturbances and white matter damage in the brain due to hypoxia were detected in a recent study by Rapalino et al. [4]. A variety of studies (see [5] for a detailed review) have shown that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may present with various neurological and central nervous system (CNS) symptom manifestations. Among these are headache and confusion, and even seizures or encephalitis. Ardila and Lahiri [6] specifically anticipated the occurrence of executive dysfunction as a part of the neurological impairments due to the infection, in both the acute phase and the long run. Lima et al. [5] proposed that the virus may invade the CNS through various pathways within dual (hematogenous and neuronal) routes. In this transmission, the olfactory pathway in particular is thought to play a significant role. The findings of Zhou et al. [7] highlighted the parallel organization of the olfactory system and indicated that the anterior olfactory nucleus has the strongest unique connectivity with the orbitofrontal cortex. Other smaller connectivity clusters were found to reside in the left inferior temporal gyrus, bilateral anterior temporal gyri, the bilateral anterior insula and the mammillary bodies, and retromammillary commissure. Furthermore, their work revealed that, compared with other sensory systems, the olfactory networks reach a broader set of cortical targets (largely situated in the frontal and temporal piriform cortices) at an earlier stage of information processing. This functional specificity along with the strong frontotemporal anatomical brain connectivity of the olfactory system is likely to underlie the key role of the latter for the invasion of the viral infection into the CNS. Contributing factors to the wide scope of neurofunctional abnormalities brought about by the virus could be its neuroinvasive, neurotropic, and neurovirulent nature [5] and the multiple pathways through which it attacks the CNS. In their recent study, conducted with COVID-19 patients during acute inpatient rehabilitation stage prior to discharge, Jaywant et al. [8] found that attention and executive functions were most affected. This finding lends support to the view put forward by Snyder et al. [9] that executive control impairments are transdiagnostic and inherent to a broad spectrum of clinical conditions.

The evaluation of neuropsychological and psychological functions, while the person is in the acute stage the illness, presents a methodological challenge. Firstly, the primary focus in the ongoing treatment is preservation of life and ensuring the patient’s survival. Secondly, the patient’s overall health status is likely to not permit them to participate in the assessment process. Thirdly, the administration of the neuropsychological tests typically requires face-to-face interaction, which is not possible given the risk of contamination. Consequently, systematic data collection using psychometric tests is not feasible. Introspective inquiry capturing the first-person experience of trained psychologists and neuropsychologists who had COVID-19 is considered methodologically relevant and appropriate, particularly in view of the unfeasibility of applying psychometric methods for assessing the impairments emerging as the infectious process evolves.

The aim of the present investigation was to document the first-person account of the range of neuropsychological and psychological symptoms experienced by the author while undergoing COVID-19. Her reflections on the presenting symptoms and the formulation on their hypothesized generative mechanisms are informed by her extensive professional experience in conducting neuropsychological and psychological assessments and providing psychotherapeutic support to patients with various brain dysfunctions, including tumors, traumatic brain injuries (TBI), degenerative disorders such as Parkinson’s disease (PD), developmental disorders, epilepsy, functional neurological disorder (FND), and psychogenetic non-epileptic seizures (PNES).

The patient was a 59-year-old female, with no history of medical, neurological, or psychiatric conditions and with no predisposing, premorbid, or comorbid conditions of note. She is married and has a grown-up son. She works in a neurosurgery clinic at a large hospital as a psychologist and neuropsychologist. She is socially and professionally active, with vast experience in clinical and psychotherapeutic work, academia, and research.

This investigation was carried out with the aim of documenting the neuropsychological and psychological impairments experienced by a trained psychologist in the course of her undergoing COVID-19. Using the introspective method encompassing self-analysis, self-observations, self-evaluations, and self-reflections on the first-person experience allows for formulating an in-depth account of the impairments of cognitive, behavioral, and emotional functions evolving within the progression of the infectious process. To the author’s knowledge, the current case presentation is the only first-person research account of neuropsychological and psychological dysfunctions associated with COVID-19, as experienced by a trained psychologist and neuropsychologist. The present study demonstrates the value of first-person methodological approach for accessing phenomena that are not readily attainable by any other methods of investigation or third-person perspective.

Compatible with the results documented by Jaywant et al. [8], the present findings indicate that the cluster of dysfunctions manifested in the course of COVID-19 infection pertain to core existential domains: working memory, attention, concentration, executive control, emotional regulation, and mood. Such a cluster would be typically implicated in and would point to vulnerability of and/or distortion in the operation of the frontal lobes. Taking into account the parallel organization of the olfactory system, its strongest unique connectivity with orbitofrontal cortex [7], the multiple routes for the invasion of the virus into the CNS, and the significant role of the olfactory system in this regard [5], it is likely that the viral infection brings about an impediment in the overall functional organization of the brain. The frontal lobes systems provide the major contributions to the integrity of the interfunctional and the intrafunctional organization of the brain. The profile of cognitive, emotional, and behavioral dysfunctions identified in this study is compatible with the proposition that the frontal lobes may be particularly vulnerable to the viral invasion. The hypothesized mechanisms underlying the overall neuropsychological and psychological instability brought about by COVID-19 appear to be related to the fragmentation of executive functioning, including the deconstruction of a person’s self-regulation capacities at both mental and physical levels. Considering that the executive control impairments have a wide spectrum of implications for psychopathology and cognitive dysfunctions [9], it is reasonable to contemplate that the manifested erratic mode of symptom occurrence and presentation depicts too an overarching distortion of executive functioning.

The present study offers an explorative first-person analysis of subjective experiences of dysfunctions in cognition, emotionality, and behavior arising due to COVID-19. The methodological limitations pertain to the subjective essence of the data and the inherent proneness to bias [14]. Nevertheless, the findings can be considered a useful point of departure for generation of novel hypotheses [14], and for systematically and continuously collecting and integrating further neuropsychological, neurophysiological, and neuroanatomical data highlighting the multifarious debilitating impact of the disease. Given that the longer-term sequelae did not fall within the scope of this study, future research endeavors should aim at filling in this knowledge gap as well as extend the scientific inquiries using prospective designs and third-person methodologies. Though generated from an individual case, the insights, experiential knowledge, and in-depth reflections presented in this case report reveal a profile of COVID-19-related cognitive, emotional, and behavioral impairments for which very little is known so far.

The identification of the impairments in executive control, working memory, attention and concentration, processing speed, emotional regulation, and mood may also serve as a foundation for providing psychological counseling and advice to patients in both the acute and recovery stages of the illness. Guiding patients and managing their expectations throughout the emergence, expansion, and intensification of the presenting neuropsychological and psychological symptoms is likely to enhance patients’ resilience and coping mechanisms and minimize the debilitating impact of the infection.