Posttraumatic Stress Disorder and Hyperventilation in Post-COVID-19 Syndrome: An Underestimated Association

Introduction

Hyperventilation syndrome (HVS) is a dysfunctional breathing syndrome in which minute ventilation exceeds metabolic demands, resulting in hemodynamic and chemical changes. Recent data suggest that HVS incidence is high in the post-COVID-19 condition,¹ and its management may involve consultation-liaison (CL) psychiatry considering the presence of functional symptoms. In our clinical practice, we observed an association between posttraumatic stress disorder (PTSD), which is also prevalent in the post-COVID-19 condition,² and HVS that could be explained by a traumatic experience during the acute phase of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. These 2 phenomena have so far only been studied separately in the post-COVID-19 condition despite the evidence of their interaction in other pathologies. In the present letter case, we would like to highlight the possible interaction between HVS and PTSD in post-COVID-19 condition.

Case Report

Ms. G was a 44-year-old nurse working in a general medicine unit. She had no medical or surgical history and was referred to a CL psychiatrist at 5 months after infection for COVID-19 because she had anxiety.

Three months after the SARS-CoV-2 infection, although Ms. G complained of palpitations and dyspnea, a cardiological evaluation including rhythm and echocardiographic parameters was normal. Pulmonary function tests showed reduced diffusing capacity for carbon monoxide (71%) and normal spirometry (forced expiratory volume, 87%). A thoracic computed tomography scan revealed discrete bilateral subpleural ground-glass opacities. The 6-minute walking test showed 580 m (96% predicted distance), and SpO2 was between 97% and 99%, with a peak dyspnea of 9/10 on the Borg scale. The Nijmegen score was 37/64 (cutoff at 20 for HVS). At 5 months, the psychiatric assessment revealed anxiety and a feeling of insecurity with hyperarousal symptoms, as well as exaggerated startle reactions, nightmares with sleep disturbance, flashbacks, and avoidance behaviors related to the period she was infected by SARS-CoV-2. Ms. G described derealization, poor sleep, and severe fatigue. All these symptoms began after she felt the fear of death when she was infected by SARS-CoV-2 herself and after she was greatly affected by the death of a young person due to COVID-19 infection at work during the same period. The PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition, score was 43 (cutoff at 33 for PTSD); anxiety and depression scores were 9 and 10, respectively, on the Hospital Anxiety and Depression Scale (cutoff at 11 for anxiety and 11 for depression). Concerning previous relevant traumatic life events, during her childhood, she lived with her mother who was diagnosed with bipolar disorder. Ms. G witnessed episodes of agitation, and her mother made several suicidal attempts. Neuropsychological functions assessed 6 months after infection revealed mild executive difficulties (inhibition, programming, mental flexibility, lexical availability), and severe self-reported fatigue.

Ms. G was diagnosed with post-COVID-19 condition, dissociative subtype PTSD, and HVS. She received specific physiotherapy and psychotherapeutic approaches based on a multimodal treatment in 3 phases using eye movement desensitization and reprocessing (EMDR) and cognitive behavioral therapy. She had 12 sessions of EMDR in total dealing with desensitization of her traumatic events and then preparation of future scenarios concerning her work. The cognitive behavioral therapy approach consisted of cognitive restructuring and identification of emotions. An antidepressant was initiated with particular attention to the risk of treatment emergent mania, given her family history: first paroxetine 20 mg without any therapeutic response after 1 month, and then a switch to escitalopram 20 mg. The patient greatly improved and returned to work at part time (20%). Five months later, we observed a worsening around the date of her COVID-19 infection. Moreover, the arrival of the fifth wave of COVID-19 triggered a panic attack. Ms. G stopped working and received intensive psychiatric follow-up with complementary EMDR sessions targeting the fifth wave. She slowly improved both physically and mentally: she continued to suffer from fatigue and dyspnea from exercise to a very lesser extent with no symptoms of PTSD and no new panic attacks.

Discussion

Specific knowledge about HVS in post-COVID-19 condition is scarce, especially regarding interaction with psychiatric symptoms. HVS has been previously associated with psychiatric symptoms such as anxiety and depressive symptoms.³ However, these studies were not able to demonstrate a causal link between the two, and the nature of their interactions remains unknown. In our clinical experience, PTSD is common in patients who have experienced HVS in the post-COVID-19 condition, and this association needs to be investigated in future studies. A robust literature highlights dyspnea as a predictor of PTSD: the presence of dyspnea during the acute phase of COVID-19,⁴ and acute respiratory distress syndrome requiriing admission to the intensive care unit, no matter the etiology,⁵ increased the risk of PTSD. There is a need for greater awareness of PTSD in clinical practice when assessing patients with unexplained dyspnea. Closer cooperation between psychiatrists, physiotherapists, medical staff of intensive care unit, and lung specialists in the evaluation of this frequent symptom is recommended.