It was the third time in the past 10 days that Mrs Boyle, a 59-year-old widow, had attended the clinic. She had a long history of generalised anxiety disorder combined with frequent bouts of somatisation, which were barely controlled on 150mg of venlafaxine.
Since the emergence of the COVID-19 pandemic she became convinced that she would succumb to this virus. Her husband died three years ago from motor neuron disease. She watched him struggle to breathe and seeing footage several times a day on TV showing patients on ventilators, she became convinced that this was the fate that awaited her.
Once again she attended dressed in her own form of personal protective equipment, consisting of a large plastic poncho with head cover, a face mask and rubber gloves. She had purchased a supply of her idiosyncratic PPE and made sure she disposed of it after each time she ventured outside her house.
She stood outside the clinic and asked the receptionist to phone her to enter when I was ready as she did not want to risk contamination in the waiting room. When she finally came into the consulting room she requested her chair be moved to the far corner and insisted I wear a mask.
Her previous visits this week had been to request yet another COVID-19 swab, which was refused as she had no symptoms. She had feigned a story of contact with a patient who had the disease and managed to score a negative test two weeks ago.
On glancing at her hands I could see some bleeding under the rubber gloves. In fact, this was the reason for her visit on this occasion. When she removed her gloves it was apparent that she had a severe case of contact dermatitis. She had been soaking her hands with a strong soap solution in very hot water for 30 to 40 seconds believing the 20-second recommendation was insufficient.
She then pulled out her thermometer which she carried with her for hourly temperature checks. She was concerned because the last reading was 37.1C . She wanted this cross checked against the clinic’s thermometer.
She had arranged for Woolies to deliver her groceries and other food requirements once a week.They left several boxes with food on the front porch. Aware that the virus can live on cardboard for more that 24 hours, she took great care not to touch the boxes, even with gloved hands. Each item, including every piece of fruit and vegetable, was then washed in soapy water before entering the house. The boxes were left outside and now formed a formidable pile as Woolies refused to take them back.
Inside the house she had covered the air vents as she read somewhere that the virus was airborne and could enter at any time. She was also careful not to use the air conditioning. Despite wearing her protective poncho, she discarded her shoes and clothing on returning home and changed into a new outfit. Her washing machine was her greatest ally.
Not having the internet, she relied on the TV as her source of information. From the time she woke till the time she entered a fitful sleep the TV was blasting the latest information with images from New York and London across multiple channels.
She was convinced that even if we in Australia seemed better off now we would get a second and third wave: “Just like the Spanish flu which killed my grandfather when he came back from the war.” She regularly phoned her concerns to her daughter, sometimes six or eight times a day.
Of course Mrs Boyle is a fictitious character, however I am convinced that patients like Mrs Boyle exist and if they are not attending now with the full range of Mrs Boyle’s concerns they certainly will attend in the future … at least with a number of her features.
We acknowledge that COVID-19 and its social consequences will leave a legacy of mental illness including anxiety and depression. We should also be aware that a specific phobia may emerge, namely “coronaphobia”.
This may be more common in patients with existing anxiety disorders, including generalised anxiety disorder, as well as patients with obsessive compulsive disorder. We may also see patients with somatic delusions related to COVID-19, either as part of a major depressive episode or as part of a psychotic illness.
This should not come as a surprise. We have had the same phenomenon with fear of bacteria, microwaves, electromagnetic radiation, so why not corona virus? Rarely in human history has an invisible pathogen had so much publicity.
Managing patients with specific phobias, based on an irrational fear, can be difficult, especially when the daily media devotes so much time to the source of the phobia. In this instance it is made worse by the perceived difficulty to separate fact from fiction, especially when fiction spouted by a deranged political leader is perceived as fact.
As doctors it is our role to separate fact from fiction, and use best available scientific evidence to convey the facts, as we know them, to the patient.
It should also be understood by the public that with the emergence of a new pathogen, the facts may change as our understanding of the behaviour of the virus changes. In science, today’s truth is not necessarily tomorrow’s truth. This may prove difficult for the public to appreciate and may be exploited as “ fake news” by elements of the media and some politicians.
Perhaps the first step in managing Mrs Boyle is to convince her to restrict her TV viewing time and stick to reliable sources. The next will be to present the facts in a simple, empathic and non-judgmental way.
This is what we as GPs generally do well. It will take time and patience to see improvement.
Dr Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for 40 years