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. 2023 Apr 21;83:75–80. doi: 10.1016/j.genhosppsych.2023.04.008

Approaching differential diagnosis and decisional capacity assessment in the context of COVID-19 conspiracy beliefs: A narrative review and clinical discussion

Ryan Serdenes a,⁎, Francesca Arana a, Jamie Karasin a, Nicholas Kontos b, Meghan Musselman a
PMCID: PMC10121076  PMID: 37119781

Abstract

Objective

COVID-19 conspiracy theories have become widespread since the onset of the pandemic and compound the existing challenges of decisional capacity assessment. This paper aims to review the literature pertaining to decisional capacity assessment in the context of COVID-19 conspiracy beliefs and synthesize a practical approach with an emphasis on differential diagnosis and clinical pearls for the practicing physician.

Methods

We reviewed papers on decisional capacity assessment and differential diagnosis in the context of COVID-19 conspiracy beliefs. A literature search was conducted using the US National Library of Medicine's PubMed.gov resource and Google Scholar.

Results

The resulting article content was utilized to synthesize a practical approach to decisional capacity assessment in the context of COVID-19 conspiracy beliefs. Specifically, aspects related to the history, taxonomy, evaluation, and management are reviewed.

Conclusions

Appreciating the nuanced differences between delusions, overvalued ideas, and obsessions while with integrating the non-cognitive domains of capacity into the assessment are crucial to navigating the wide differential diagnosis of COVID-19 conspiracy beliefs. It is important to attempt to clarify and optimize patient decision-making abilities by addressing circumstances, attitudes, and cognitive styles specific to patients with seemingly irrational beliefs about COVID-19.

Keywords: Consultation-liaison psychiatry, Decisional capacity assessment, Delusions, Overvalued ideas, Conspiracy theories, COVID-19

1. Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic is responsible for over 600 million confirmed cases and approximately 6 million deaths worldwide at the time of writing [1]. Global economic losses from COVID-19 are estimated to total 18 trillion dollars [2]. Concomitant with the ongoing pandemic, the prevalence of mental illness in the general public is increasing [3]. The pandemic years are also marked by the elaboration of COVID-19 conspiracy theories which, depending on the specific belief and country sampled, have an estimated prevalence between 20 and 50% [4,5].

Traditionally, conspiracy theories are defined as unproven explanations for significant social events involving secret plots developed by and benefiting equally secretive groups; however, there is significant heterogeneity and debate among accepted definitions [6,7]. Given this unsettledness, we will adopt a broad definition of the term herein, in order to capture all seemingly irrational beliefs regarding COVID-19. COVID-19 conspiracy theories are identified as a significant contributor to vaccine hesitancy and decreased adherence to public health safety measures [[8], [9], [10]]. Mathematical models demonstrate the deleterious impacts of COVID-19 conspiracy theories on disease spread [11]. Considering this, the World Health Organization (WHO) recognized COVID-19 conspiracy theories as a major threat to global public health and developed specific research agendas to investigate mitigation strategies [12,13]. As a result, there is increasing academic interest in the interface between COVID-19 conspiracy beliefs and psychiatric practice [14,15].

The psychiatric implications of COVID-19 conspiracy theories are being examined via both public health and forensic perspectives; however, their impact in the clinical consultation-liaison setting may also be quite impactful, especially in decisional capacity assessments [16,17]. Decisional capacity evaluations involve a medicolegal approach, originally defined by Appelbaum and Grisso in the 1980s, and make up almost 20% of all inpatient psychiatric consultations [[18], [19], [20]]. Any physician can evaluate for capacity, though psychiatrists are very often called upon to do so in academic medical centers and in more complex cases [21,22]. While the traditional four abilities model of capacity emphasizes key cognitive components involved in decision making, the exam is nuanced and often requires consideration of non-cognitive factors such as emotions, values, and authenticity [23]. Moreover, decisional capacity evaluations sometimes necessitate a multidisciplinary approach to maximize the patient's decisional abilities or bring other ethical dilemmas to light [24,25].

COVID-19 conspiracy theories may compound the existing challenges of capacity assessment given their novelty and prevalence. Evaluating decisional capacity in the context of COVID-19 conspiracy beliefs can be complicated by uncertainty regarding clinical approach and by provider countertransference [26,27]. Additionally, navigating the large breadth of the differential diagnosis for COVID-19 conspiracy beliefs is a unique challenge, albeit an essential task of any comprehensive capacity evaluation [23]. At the time of writing there is no published clinical review of the psychiatric approach to decisional capacity assessment in the context of COVID-19 conspiracy theories. Herein, we aim to review the literature pertaining to decisional capacity assessment in the context of COVID-19 conspiracy theories and synthesize a practical approach with an emphasis on differential diagnosis and clinical pearls for the practicing physician.

2. Methods

We reviewed papers on decisional capacity assessment and differential diagnosis in the context of COVID-19 conspiracy theories. A literature search was conducted through October 2022 using the US National Library of Medicine's PubMed.gov resource (https://www.ncbi.nlm.nih.gov/pubmed) and Google Scholar. The following keywords in various combinations were searched: “decisional capacity”, “COVID-19”, “conspiracy theories”, “consultation-liaison psychiatry”, “delusions”, “overvalued ideas”, and “obsessions”. Additional studies were identified by examining the reference lists of searched articles. Of note, this review did not utilize the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) because of the significant limitations of the existing literature within this subject. Accordingly, we described major findings as opposed to formally evaluating literature quality. The resulting article content was reviewed by the authors for information regarding the history, taxonomy, evaluation, and management of decisional capacity assessment in the context of COVID-19 conspiracy theories.

3. Results

Our review did not yield any observational or experimental epidemiological studies of decisional capacity assessment of patients with COVID-19 conspiracy beliefs. While we identified numerous articles discussing COVID-19 conspiracy theories, the majority emphasized sociological, ethical, and psychological considerations outside the scope of the psychiatric issues of concern. Only two psychiatric publications discussed decisional capacity in the context of COVID-19 conspiracy theories, both opinion pieces – an editorial and a letter to the editor responding to it [14,15]. Neither of these papers discussed the topic from a consultation-liaison psychiatry perspective. Despite the dearth of literature on the topic, we are able to utilize existing guidelines and related literature to outline a viable approach to capacity assessment in the setting of COVID-19 conspiracy beliefs with an emphasis on formulating the differential diagnosis associated with incapacity.

4. Discussion

  • A

    History and taxonomy

4.1. Introductory clinical vignette

A 27-year-old pregnant female at 35 weeks gestation with no past medical or psychiatric history presented with acute hypoxic respiratory failure in the setting of COVID-19 pneumonia without prior vaccination. Non-emergent cesarean section was recommended given the possibility of fetal demise; however, the patient declined, expressing bizarre beliefs about COVID-19 origin. Psychiatry was consulted to evaluate capacity to decline cesarean section.

4.2. Background and natural history of COVID-19 conspiracy beliefs

It is estimated that COVID-19 conspiracy theories developed as early as March 2020, during the initial phase of the pandemic [28]. Network narrative analyses have not identified any central origin source or universally accepted conspiracy theory [29]. COVID-19 related conspiracy theories are now a global phenomenon, having been identified in Africa, the Americas, Asia, Australia, and Europe [[30], [31], [32], [33], [34], [35]]. The most common types of conspiracy theories involve beliefs of COVID-19 being malevolently designed in a laboratory, generated by fifth generation broadband cellular networks, or being a covert means to mandate microchip-containing vaccinations to the public [36]. Other common themes include the involvement of powerful groups for political or financial gain, population-control efforts, and the hidden existence of a cure [37]. Despite several efforts to categorize COVID-19 conspiracy theories, a standard taxonomy has yet to emerge [37,38]. While the survivability of these conspiracy theories has yet to be determined, in general such beliefs become more resistant to debunking the longer they persist [39].

4.3. Conceptualizing delusions vs overvalued ideas vs obsessions

The distinctions between delusions, overvalued ideas, and obsessions, are nuanced but essential to consider when assessing non-normative beliefs. Delusions are understood to be fixed, false beliefs and are characteristic of psychosis. They are “not amenable to change in light of conflicting evidence.” [40] Parnas et al. describes primary delusions arising as a “revelation,” in which affective meaning becomes cognitively expanded upon and dressed in delusional content [41]. However, there exist other strongly held, non-reality-based, unusual, or idiosyncratic beliefs inconsistent with psychosis. Physicians who encounter such beliefs, particularly as they relate to and interfere with one's health, in the general hospital setting will often consult psychiatry to evaluate for psychosis and/or capacity.

In the abstract, there are ontological distinctions between overvalued ideas and delusions. Still, the precise nosology has evolved over time. The term “overvalued idea” was introduced by Carl Wernicke in 1892 in the context of criminality [42,43]. Wernicke asserted that overvalued ideas were those abnormal beliefs that influenced an individual's behavior to a morbid or pathological degree [[42], [43], [44], [45]]. An idea's transition from normal to over-valuation could be traced to an emotionally laden event or series of events [45,46]. Karl Jaspers expanded upon this concept. Whereas a delusion arose when the meaning attached to events was radically transformed, an overvalued idea resulted from an interaction between an individual and experience which brought a hyperfocus to the individual's life [[47], [48], [49]]. This view of overvalued ideas incorporates the belief's intensity, abnormality, affect, preoccupying potential, and ego-syntonic/dystonic nature, along with the individual's past experiences and personality [50].

Over time, the definition of overvalued ideas shifted to emphasize the dimensions of tenacity and abnormality. In 1980, the DSM-III defined an overvalued idea as “an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. the person is able to acknowledge the possibility that the belief may or may not be true).” The DSM specifies that “the belief is not of one that is ordinarily accepted by other members of the person's culture or sub-culture.” [48,49,51] This is a much narrower view than the older European model of an overvalued idea [50]. Modern authors such as Veale argue that overvalued ideas should be thought of as separate from a spectrum of normal to delusional thought. Veale proposes that overvalued ideas arise when an individual's values become dominant and idealized. Overvalued ideas in this sense are present in anorexia nervosa, body dysmorphic disorder, and some somatic symptom disorders, among other psychopathologies [48,50].

To account for beliefs that are abnormal, extreme but shared by an individual's subculture, Rahman et al. proposes the term “extreme overvalued belief,” which is defined as a belief that is “shared by others in a person's cultural, religious, subcultural group” that “is often relished, amplified and defended by the possessor of the belief.” The belief grows stronger, “more refined, and more resistant to challenge” over time and its holder has an “intense emotional commitment to the belief.” [49] This concept has been useful to forensic psychiatrists tasked with evaluating individuals with odd beliefs; however, it has not been utilized by other subspecialty fields of psychiatry.

Obsessions have more historical consistency than overvalued ideas. Obsessions are unwanted, intrusive, and recurrent thoughts, impulses, or images. The individual recognizes them as odd, untrue, or unusual and attempts to suppress or neutralize them with some action. Unlike overvalued ideas, obsessions are ego-dystonic. While individuals with obsessions are typically viewed as aware that their thoughts are untrue, it is appreciated in the literature that insight into obsessions can vary. The DSM-5-TR includes insight specifiers for Obsessive Compulsive Disorder, ranging from good insight, in which an individual recognizes that his beliefs are not true, to “absent insight/delusional beliefs”, in which an individual is convinced his beliefs are true [40].

Obtaining a thorough clinical history, assessing associated symptoms, level of anxiety around thoughts, and any attempts to suppress them help in distinguishing between overvalued ideas, delusions, or obsessions. Understanding and differentiating between these phenomena is essential in evaluating the capacity of an individual demonstrating abnormal beliefs about COVID-19 as strongly-held, subcultural beliefs may appear delusional, and impairing capacity, on the surface. With further exploration however, the clinician may identify that the individual's beliefs and choices, while non-normative, are not the result of mental illness. Having introduced these foundational concepts, we will now integrate them into the framework of capacity assessment.

  • B

    Clinical synthesis and recommendations

4.4. Assessing decisional capacity

Capacity questions arise when a patient's decision making for crucial medical choices is questioned by the consultee. Irrational beliefs expressed by patients do not always warrant consultation if they do not interfere with medical care. For example, patients requesting a non-evidence based COVID-19 treatment while accepting approved treatment would not require consultation.

The 2019 Academy of Consultation-Liaison Psychiatry (ACLP) guidelines and Appelbaum have extensively discussed the general approach of capacity evaluation [18,52]. The four cognitive abilities model, central to the assessment, focuses on the patient's understanding of pertinent information, rational manipulation of options, appreciation of the consequences of the situation/choice, and expression of a choice regarding care [18]. A “sliding-scale” approach based on the risk/benefit ratio of the patient's decision determines the degree of scrutiny used by the evaluator [53]. Other important considerations include non-cognitive domains of decision-making, including authenticity, emotions, and personal values [23]. Involvement of the patient's family or friends can be very helpful in illuminating the consistency of any unconventional attitudes with the patient's baseline.

This methodology applies nicely to approaching decisional capacity assessment in the context of COVID-19 conspiracy theories. By incorporating non-cognitive domains of capacity into the standard evaluation, psychiatrists can, for example, identify scenarios where seemingly anomalous beliefs about COVID-19 fit into a context absent of psychopathology. Alternatively, if a patient with irrational beliefs about COVID-19 is found to lack decisional capacity via this approach then a large differential diagnosis can be considered to identify an underlying cause. Thoughtful diagnostic formulation of patient COVID-19 conspiracy beliefs is essential to the capacity assessment considering the nuance of the differential and its role in explaining genuine incapacity.

4.5. Conspiracy theory differential “diagnosis”

When encountering patients with possible COVID-19 conspiracy theory beliefs, the phenomenological differential is broad, and psychiatrists must consider whether a diagnosis is even present. Abnormal beliefs exist in both individuals and groups, with and without mental illness. Possible diagnoses and formulations include psychotic disorders, non-psychotic disorders with overvalued beliefs, obsessive-compulsive spectrum disorders, and the presence of unusual but valued (occasionally even valid) ideas in the absence of psychopathology. We will now move from types of ideas/beliefs to their “diagnostic” contexts.

4.5.1. Medical mistrust

4.5.1.1. Historically marginalized groups

Outside of COVID-19 (and other infectious disease scenarios such as HIV), medical mistrust also occurs due to a very real history of injustices perpetrated against minority and other disenfranchised groups by clinical and scientific medicine. Historical trauma is a known precursor to the development of conspiracy beliefs [54]. Smith et al. demonstrated an association between group discrimination and the specific likelihood of endorsing COVID-19 conspiracy theories [55]. Medical mistrust is found in black populations as well as LGBTQ+ populations and is a contributor to poorer health outcomes in these groups. Mistrust is not just a lack of trust but also the belief that the object of mistrust is working against the individual. Medical mistrust should always be considered when interacting with patients who come from historically marginalized communities [56].

4.5.1.2. Culture bound beliefs

Conspiracy beliefs, particularly pertaining to government activities, are historically persistent phenomena. Examples of a few popular conspiracy theories within the past 50-plus years include that John F. Kennedy was assassinated in a plot involving the CIA, that the United States government was behind the September 11 attacks, and that astronauts never actually landed on the moon. Conspiracy beliefs about world-shaping groups like the Illuminati and Freemasons reach back much further [48]. Some studies estimate as many as 55% of participants believe in at least one conspiracy theory [57]. As previously mentioned, the COVID-19 pandemic has been surrounded by conspiracy theories [9]. Contemporary conspiracy theories about COVID-19 are prevalent and, in the electronic age, are easily propagated through social media outlets, and complicate patient care in the face of the COVID-19 pandemic.

Despite how common conspiracy theories are, little is known about the psychological processes underlying adherence to such theories. Personality factors thought to contribute include openness to experience and political cynicism. Psychological processes such as the proportionality bias, believing that important events must have important causes, are also proposed to play a role in embracing conspiracy theories [48]. In a review of four studies of proportionality bias, three demonstrated that individuals were more likely to attribute an attempted assassination of to a conspiracy if the attempt led to a war or the leader's death than if there were minimal consequences [48,[58], [59], [60], [61]]. Like delusions, conspiracy theories often appear quite fixed. Believers dismiss alternative arguments. The individuals rated the studies that were in-line with their beliefs as being more convincing and that their beliefs were even strengthened by reviewing the evidence [48].

Of note, the DSM-5-TR excludes culturally normed phenomena from the realm of psychopathology which we believe is justified given the risk of erroneously pathologizing cultural beliefs and practices. Utilizing a memetics model, COVID-19 conspiracy theories can be conceptualized as contagious memes, which intrinsically do not represent mental illness. Although, the presence of psychopathology may increase susceptibility to endorsing these beliefs [17]. This highlights the importance of thorough diagnostic exploration beyond the initial presented COVID-19 conspiracy belief.

When encountering an individual with unusual beliefs related to COVID-19 conspiracy theories, normal sub-cultural beliefs should always be considered. One must be familiar with alternative, or extreme, beliefs about the COVID-19 pandemic and should engage the patient in a discussion about how they came to their beliefs. Unlike delusions, conspiracy and culture-bound beliefs are both shared and impersonal, meaning these beliefs are held by groups of people and focus on events that impact all individuals. One should not rely on the “fixed” aspect to determine if a belief is a delusion since even irrational, nonpsychotic beliefs can be held with a strong conviction and be resistant to contrary evidence.

4.5.2. Psychosis

Psychosis is defined by failed reality testing and is a symptom of psychiatric illness rather than a disease itself [40]. When differentiating delusions from conspiracy theories, the examiner must consider a belief's evidential basis, self-referentiality, and potential overlap with established conspiracy theories [62]. Delusions are often (but not always) accompanied by other psychotic symptoms, such as thought disorganization and hallucinations, which can help narrow the differential diagnosis [40]. Distinguishing between psychopathological and non-pathological COVID-19-related beliefs can still be quite difficult. Patients with schizophrenia are more likely to experience “conspiracist ideations” than patients with no previous psychiatric diagnosis, but also more likely to demonstrate other positive, negative, or cognitive symptoms if closely examined [63]. Delusional disorder (persecutory or somatic type), on the other hand, may present solely with the false belief in question; longitudinal history may reveal pre-pandemic permutations of the belief, though non-psychotic persons prone to embrace conspiracy theories are unlikely to have started doing so in the COVID era. Mood disorders with psychotic features and substance induced psychotic states can also be considered, but with particular attention to context (e.g., neurovegetative symptoms, toxicology screens, cognitive exam, etc.).

There is a dearth of literature regarding secondary psychotic disorders and conspiracy beliefs. Of potential note here, patients believing COVID-19 conspiracy theories may be more prone to contracting the virus, which may itself be a risk factor for developing psychosis [64]. Interestingly, a recent study by Raffard et al. demonstrated that patients with schizophrenia have diminished capacity to consent to COVID-19 vaccination [65].

4.5.3. Personality disorders

Certain personality traits—specifically narcissism, neuroticism, paranoia, and schizotypy— have been found to be predisposing factors for the embracing of conspiracy theories [66]. Associations are noted between narcissism and susceptibility to conspiracy beliefs [67,68]. Possible psychological mechanisms for this link include the needs for superior insider knowledge, membership in a larger like-minded group, and protection from injury to one's sense of self [26,68]. Neuroticism's relationship with conspiracy theories may be explained by an attempt to mitigate anxiety by explaining a stressful situation thereby decreasing uncertainty and increasing sense of control [66]. Paranoia may foster reduced trust in societal institutions and set the table for the endorsement of COVID-19 conspiracy theories [69]. In particular, patients with paranoid personality disorder demonstrate a predilection for conspiracy theories due to their aberrant pattern seeking behavior (Andrade, 2020). In schizotypal personality disorder, social anhedonia can be a nidus for extensive internal preoccupation with fantastical, including conspiracy-related beliefs [26,70]. In general, the severity of personality pathology is variable and can decompensate under stressful situations, such as in a global pandemic; this may be the case at population as well as individual levels.

4.5.4. Developmental disorders and neurocognitive disorders

Neurocognitive disorders are the most common conditions impairing decisional capacity, and thus are essential targets of scrutiny when patient expression of COVID-19 conspiracy theories leads to psychiatric consultation for capacity assessment [71]. Patients with neurocognitive disorders can be particularly prone to irrational beliefs, when executive network involvement impairs information manipulation [72]. To our knowledge, there is no literature describing the relative risks of conspiracy beliefs among dementia subtypes; it is nonetheless reasonable to speculate an increased susceptibility in dementias with subcortical involvement affecting the frontal-subcortical circuitry [73]. Since both dementia and delirium can present with delusional content, any COVID-19-related content may attract undue attention if the associated disturbances of consciousness and cognition are missed [74,75]. As noted above with regard to psychosis, patients believing COVID-19 conspiracy theories may be more likely to contract coronavirus and be at subsequent risk for new-onset neurocognitive impairment [76]. Evidence on the relationship between developmental disorders and conspiracy beliefs is very limited, with most literature focused on autism. Recently, Georgiou and colleagues identified autistic traits as a risk factor for embracing conspiracy theories [77].

4.5.5. Obsessive compulsive and related disorders

Obsessional thought patterns may initially appear similar to conspiracy theories. Patients with Obsessive-Compulsive Disorder (OCD) experience significant anxiety and sometimes participate in “Doomsday Prepping” behaviors. Doomsday prepping is described as a coping strategy marked by amassing resources to maintain self-efficacy in the face of possible global catastrophe. These behaviors have become widespread during the COVID-19 pandemic. Ego-dystonicity may distinguish their relationship to OCD from a societal trend [78]. Despite shared genetics with OCD, hoarding disorder is more likely to have ego-syntonic qualities. It might sometimes be distinguishable from culture-bound conspiracy beliefs by a broader, non-survival-oriented pattern to the hoarding [40,79,80].

4.6. Clinical management and optimizing the patient encounter

Once the differential diagnosis is successfully navigated and the patient's cognitive/non-cognitive domains of capacity are adequately assessed, a determination of capacity can be made. Ultimately, the presence of COVID-19 conspiracy beliefs alone does not render the determination of incapacity. Decisional capacity can be retained when COVID-19 conspiracy beliefs are not rooted in psychopathology, are rationalized via non-cognitive factors, and are culture bound. Challenges associated with communicating exam findings include potential primary team countertransference towards patient beliefs as well as psychiatric knowledge barriers – both of which can impair appreciation and/or acceptance of consultation recommendations. For example, primary teams may have the misconception that all irrational COVID-19 beliefs suggest incapacity; however, explaining our diagnostic impression along with how patients may retain capacity if non-cognitive factors are the foundation of the patient's decision mechanism, such as in the case of medical mistrust, can help reduce potential knowledge gaps. Mitigating challenges related to provider countertransference in the medical setting have been described elsewhere and remain a barrier not only to interdisciplinary collaboration but potentially adequate optimization of the patient's abilities [81].

While the 2019 ACLP guidelines and several other publications address strategies to optimize a patient's decisional capacity, the novelty of COVID-19 conspiracy theories present a unique challenge. Common methods of decisional capacity optimization include educational efforts, modifying reversible causes of capacity impairment, and adapting the interview to accommodate for language barriers and cognitive deficits, among others [23,52,82]. While these approaches remain valuable in the context of assessing irrational beliefs about COVID-19, additional strategies also need to be considered. Patients with significant medical mistrust may use cognitive shortcuts when evaluating stressful information, thus fostering the adoption of conspiracy theories [83]. Providing patient education may therefore be futile in reversing conspiracy beliefs, though several studies suggest rationalizing approaches may be more effective than anticipated [17,84]. Additionally, implementation of structured assessment tools can be helpful when optimizing a patient's decisional capacity, the most well known being the MacArthur Competence Assessment Tool for Clinical Research [85,86].

Efforts aimed at optimizing the physician-patient relationship may also be helpful, especially considering the influence of medical mistrust [56]. The American Psychiatric Association's Cultural Formulation Interview provides strategies to understand a patient's values while maintaining cultural sensitivity [87]. Formulating conspiracy beliefs as ego defenses may also have utility if this mode of understanding can be parlayed into psychotherapeutic techniques that firm up the patient encounter. Exploring the patients personal meaning of their physical health status and COVID-19 can help foster a therapeutic relationship, lower their defenses, and establish shared goals upon which medical decision making can be collaborated. Defenses associated with conspiracy beliefs may include denial, rationalization, and introjection depending on the patient's unique characterological structure [88,89]. Strategies to navigate these barriers in a general hospital setting have been described extensively elsewhere [[89], [90], [91], [92]]. Overall, managing countertransference while gently exploring a patient's rationale with curiosity as opposed to confrontation can be diagnostic as well as therapeutic.

4.7. Limitations

The relative novelty of the COVID-19 pandemic and the sparse literature on its relationship with psychiatry place unavoidable limits on our review. Additionally, the impact of conspiracy beliefs on decisional capacity assessment was not previously explored in significant depth. As a result, this paper utilized a narrative review model instead of a systematic approach.

5. Conclusion

We presented the first narrative review describing the phenomenological assessment and evaluation of decisional capacity in the context of COVID-19 conspiracy beliefs. Approaching each patient's irrational COVID-19 belief with a wide differential diagnosis is paramount. Knowledge of the nuanced differences between delusions, overvalued ideas, and obsessions can help determine what type of underlying psychopathology or non-pathological beliefs might be affecting medical decision-making. Patients with culture-bound COVID-19 conspiracy beliefs not rooted in psychopathology may have intact decision making when considering the non-cognitive domains of capacity. While assessing the patient it is important to attempt to clarify and optimize their decision-making abilities by addressing circumstances, attitudes, and cognitive styles specific to patients with seemingly irrational beliefs about COVID-19. Future studies should aim to further characterize common causes of both maladaptive illness beliefs and frank incapacity in patients with COVID-19 conspiracy beliefs and develop evidence-based recommendations for their management.

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