Post-COVID-19 Panic Disorder in Older Adults: Two Case Reports

INTRODUCTION: Patients who recover from infection with SARS-CoV-2 (COVID-19) are at risk for a range of neuropsychiatric conditions, among which anxiety spectrum disorders have been frequently observed. METHODS: In this report we present two cases of older adults with no past psychiatric history who developed panic disorder after recovering from COVID-19. RESULTS: Patient A is a 51-year-old Haitian American woman who was admitted to inpatient psychiatry with symptoms of anxiety, insomnia, disorganized behavior, and suicidal ideation, as well as intermittent hypertensive episodes. After discharge, the hypertensive episodes persisted and were associated with feelings of impending doom, palpitations, and shortness of breath. While undergoing blood pressure management from her cardiologist, she was admitted to outpatient psychiatry, diagnosed with panic disorder, and tried on multiple medications (Mirtazapine, Trazodone, Hydroxyzine, Escitalopram, Sertraline). None of these medications relieved her symptoms, which gradually evolved from panic/anxiety/depression to derealization/depersonalization. Eventually, all her symptoms abated without medication. Patient B is a 61-year-old African American woman who was admitted to outpatient psychiatry with episodes of chest tightness, palpitations, and trembling, as well as insomnia and depressed mood; she too was diagnosed with panic disorder. She had previously been treated by her primary care doctor and in the emergency room with various benzodiazepines (Diazepam, Alprazolam, Lorazepam), but she was eventually stabilized on a regimen of Sertraline, Trazodone, and Gabapentin. CONCLUSIONS: Here we examine the rationale and effectiveness of various medication trials for COVID-19-induced panic disorder, as well as how psychosocial risk factors may predict the course of illness. We also discuss some hypothesized mechanisms by which SARS-CoV-2 could produce neuropsychiatric sequelae (e.g. direct viral injury, cytokine storm, molecular mimicry). These mechanisms could affect both peripheral and central nervous systems, resulting in the combination of autonomic instability and mood disturbance classically associated with panic disorder. FUNDING: New York State Department of Health, Center of Excellence Grant