COVID-19 vaccine-associated immunization-related anxiety presenting as dissociative symptoms and pseudoseizure: A case report and potential role in public health

Sir,

During the initial rollout of COVID-19 vaccine in India, a 39-year-old woman, primary healthcare (worker, had abnormal limb movement and hyperventilation within 10 min of receiving the first dose of Covieshield^® (ChAdOx1-S vaccine). This led to a transfer to a tertiary hospital in an unresponsive state. At admission, she had stable vitals, without any anaphylactic symptoms. GCS score was 13, and prominent features of non epileptic seizures were noted. She received multispecialty consultations over the next 3 days in an intensive care unit. Her routine blood work up, chest X-ray, abdominal sonogram, ECG, EEG, and brain imaging revealed no abnormality. She has had a history of similar seizure-like episodes 6 years ago, precipitated by interpersonal stresses on the background of symptoms suggestive of an anxiety disorder. On further probing, she confided in the treating team that she has been extremely worried and apprehensive about getting COVID vaccine, fuelled by the information that she has had over social media and news channels. Her mental state reflected significant motor and cognitive anxiety, without any evidence of psychosis. Her concerns were validated in a structured environment, and was provided with psychoeducation. Tapering regimen of clonazepam was started, along with low-dose sertraline. At 6 weeks’ follow up, she had completed her second dose of vaccine, and she was euthymic with no recurrence of such episodes.

As COVID-19 pandemic continues to ravage the world with repeated waves of infection, simultaneous rollout of vaccines is likely to prove a game changer. However, this is fraught with the dangers associated with the current, rather desperate, trend favoring their emergency approval for use. Adverse effects following immunization (AEFI) are closely monitored by WHO. Immunization stress-related response (ISRR) is a type of AEFI related to a range of manifestations associated with anxiety and apprehension related to vaccination.[1] It can be broadly categorized as:

• a)Acute stress response (manifested as fearfulness, increase in HR and BP, nausea, vomiting, dizziness, hyperventilation),
• b)Vasovagal reaction (syncope, fall in HR and BP, transient loss of consciousness), and
• c)Dissociative neurological symptom reaction (with or without nonepilectic seizures).[2]

As termed, these symptoms and signs may arise around immunization that are related to “anxiety” and not to the vaccine product or immunization program error. However, anxiety necessarily may not always manifest during such events. Several biopsychosocial factors have been identified to influence ISRR such as female sex, adolescence age group, temperament, underlying anxiety, behavior of fellow health workers, and observers to name a few.[3] At times isolated events of ISRR have been observed to incite clusters of similar cases, termed as an epidemic, mass hysteria or outbreak.[4]

The immediate presentation of the case points against an immunogenic reaction, a vasovagal syncope, or a blood–injection–injury phobia[5] as causality. Our description highlights an interesting snapshot of anxiety interacting with expectations to lead to an adverse event. Awareness, comprehensive psychiatric screening, and identification of risk factors are necessary both at individual and community level.

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Conflicts of interest

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