Even as the human coronavirus disease 2019 (COVID-19) continues to ravage parts of the world, research has begun to focus on the virus’ possible long-term mental health effects on patients. Since symptoms of the virus overlap with other neurologic and/or psychological conditions, therapists can find themselves struggling to determine exactly what is going on; the fear of misdiagnosis is one such concern. The pathophysiology of the virus is just now being understood, although much of what is known is based on what has been learned from other subtypes of coronavirus, including severe acute respiratory syndrome (SARS), Middle East respiratory syndromes (MERS), and another novel coronavirus, identified in 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Kumar et al., 2021). Thus, it should not be surprising that there is much speculation about the long-term neuropsychiatric and cognitive consequences of the virus.
Exactly what role neuropsychology plays in understanding COVID is now being hotly debated, as patients who are reportedly experiencing cognitive impairment or “brain fog” as well as other persistent physical and psychiatric symptoms of what is now being termed “long COVID,” often need the expertise of neuropsychologists to understand what is really going on (Sozzi, et al, 2020). Even then, however, much of the available literature speaks to the “anticipated,” “potential,” and “possible” patterns of cognitive dysfunction and provides guidelines for treatment that are still emerging as the science continues to be studied. Personally, when faced with the potential for conflicts in diagnosis, I always do one of three things: consult, consult, and consult. There is much wisdom to be gained when discussing challenging cases with colleagues who can provide an alternative viewpoint.
Take, for example, the case of Rodney Jones (pseudonym), whose case came to my attention through consultation with a colleague. I learned that this patient, aged 55, presented for evaluation just weeks after his doctor diagnosed him with long COVID because of self-reported problems with attention, memory, disorientation, and processing information. These symptoms reportedly persisted for months after his initial COVID-19 diagnosis. Premorbid history was absent of any physiological or psychiatric diagnoses, though there was a family history of maternal bipolar disorder, depression, and alcoholism as well as paternal dementia. At the time of evaluation, Mr. Jones had been unemployed for the past year and was living at home with his parents, who supported him financially. Mr. Jones reported having periods of forgetfulness and missing work prior to his long Covid diagnosis, further warranting the need to have him evaluated for possible neuropsychological difficulties.
Covid-19 has been associated with patients presenting with acute respiratory distress disorder (ARDS), a life-threatening complication often associated with the virus (Bailey et al., 2021). Adding weight to the argument of a biological etiology for cognitive impairment is research that found higher levels of inflammatory markers in the cerebral spinal fluid of COVID-19 patients who reported cognitive complaints (Ferrando et al., 2022). While this patient did not have ARDS, I have found it is important when completing a patient history to assess for any respiratory conditions as dysfunction of the central nervous system has been found among patients who experience prolonged periods of hypoxia (reduction in the amount of oxygen in the bloodstream).
In the case of the aforementioned patient, there were no signs of respiratory distress or any other medical disorder save for COPD (premorbid). Sleep problems were also reported along with fatigue and recent weight loss. Further, his history was significant for “a pretty severe concussion” at age 3 with no apparent residual cognitive deficits. He also reported being a recovering alcoholic, sober for the past 15 years. Prior, he said he drank alcohol to the point of intoxication daily for approximately 10 years. Presently, he reported smoking marijuana on a daily basis for recreational purposes. Behaviorally, the patient stated that he can be doing something then forget and transition to doing a completely different task. His mother reported that he will “fix a plate of food and then walk away from it,” adding that he occasionally forgets his train of thought mid-sentence.
With respect to neuropsychological evaluation, Mr. Jones’ responses on validity measures did not indicate suboptimal performance (Dot Counting Test, Millon Clinical Multiaxial Inventory-Fourth Edition). Further, in terms of neurocognitive ability, results on a measure of premorbid functioning indicated that he likely functioned at a Superior cognitive level (Test of Premorbid Functioning; SS=115). In addition, on a measure to assess neurocognitive ability (Neuropsychological Assessment Battery, Form 1), results indicated that his broad abilities related to language, executive function, and visuospatial functioning, were within normal limits; all scores were within the Average range and did not suggest neurocognitive impairment. However, his performance on the attention domain was within the Mildly-to-Moderately Impaired range (5th %ile), and on the memory index, he performed in the Severely Impaired range (1st %ile). Despite reported mild depressive symptomatology, there was no evidence of such on self-report questionnaires (Beck Depression Inventory-Second Edition, Beck Anxiety Inventory, MCMI-IV). Taken together, the clinician diagnosed Mr. Jones with Mild Neurocognitive Disorder due to Another Medical Condition. While it is certainly possible that this patient’s poor performance on measures of attention and memory was due to his having contracted COVID-19, it is just as feasible that his noted deficits could be iatrogenic, be a manifestation of a psychological corollary, or be functional in nature. Or it could be that this clinician fell victim to confirmation bias and found what he wanted to find, subsequently confirming the doctor’s diagnosis of long COVID.
Admittedly, we know that pandemics and quarantines negatively affect mental health, as does prolonged fear and isolation (Huremović, 2019). To date, given what we know about this novel coronavirus, the vast majority of studies have been substandard with respect to sample size, comparison group, and psychometric measures used as well as the failure to incorporate several symptom- and performance-validity tests (SVT/PVT) or assess litigation status. In the case of Mr. Jones there was a lack of SVT/PVT measures or the assessment of litigation prior to his meeting with this psychologist. In fact only one validity measure was used, and there was no indication of whether Mr. Jones’ was applying for disability. Would an affirmative to the latter have altered understanding of his clinical picture? Maybe. Was the patient’s doctor correct in diagnosing long COVID, given what we know about depression and its link to memory problems, such as forgetfulness and confusion, both of which Mr. Jones endorsed? Did the neuropsychologist make the right call in diagnosing a mild neurocognitive disorder due to a medical condition? The point is this, arriving at an affirmative conclusion can be very complicated, and requires thorough information gathering to better understand the patient presentation as a whole.
Given this, the role of a therapist takes on paramount status. No doubt, using SVT/PVT measure should be part of any evaluation, and therapists can better support their patients who are seeking endorsement for leave of absences from work or for disability benefits by incorporating as much corroborative information as possible. Speaking with spouses/partners, employers, significant others, can help a therapist determine exactly what is happening with a patient and what part their psychopathology plays in any neurocognitive dysfunction. Thus, walking this tricky line between supporting the patient and going with the “evidence” takes patience and an adherence to clearly defining what the patient presents behaviorally as well as cognitively.
While therapists can do their best with the tools available, the best practice evaluation tool of neuroimaging is not readily available due in part to cost, creating a limitation on what can be done. Additionally, the handful of studies that cite usage of neuroimaging were only done on autopsy, which revealed that deceased patients with covid-19 were found to have brain tissue oedema and partial neurodegeneration (Kumar et al., 2021).
So, what role does neuropsychological testing play in the evaluation and treatment of long COVID? It is clear that neuropsychological testing cannot diagnose long COVID neuropathology by itself. However, when combined with the therapist’s clinical judgment, a more nuanced picture can be formed. By understanding the emotional consequences of the virus a therapist can better understand and treat a patient’s neurological symptoms. Current research suggests that it will be very hard to separate virus-mediated direct brain injury from the emotional/stress factors associated with the illness itself. The reality of working with patients presenting with symptoms of long COVID is that it takes a village. Consulting with a neurologist along with a patient’s support system (i.e., spouse/partner, family, friends, employer) will not necessarily make the process easier, but it may reduce fears of misdiagnosing a patient. In the end, a DSM-V diagnosis is only as helpful as it is in helping the patient resume their life either without symptoms or with a sense of hope and self-efficacy.
****To listen to the Resilience Lab July 2022 playlist built with this article’s theme in mind, click here.