The impact of the coronavirus disease 2019 (COVID-19) pandemic on mental health is still being unravelled. It is important to identify which individuals are at greatest risk of worsening symptoms. This study aimed to examine changes in depression, anxiety and post-traumatic stress disorder (PTSD) symptoms using prospective and retrospective symptom change assessments, and to find and examine the effect of key risk factors.

Online questionnaires were administered to 34 465 individuals (aged 16 years or above) in April/May 2020 in the UK, recruited from existing cohorts or via social media. Around one-third (n = 12 718) of included participants had prior diagnoses of depression or anxiety and had completed pre-pandemic mental health assessments (between September 2018 and February 2020), allowing prospective investigation of symptom change.

Prospective symptom analyses showed small decreases in depression (PHQ-9: −0.43 points) and anxiety [generalised anxiety disorder scale – 7 items (GAD)-7: −0.33 points] and increases in PTSD (PCL-6: 0.22 points). Conversely, retrospective symptom analyses demonstrated significant large increases (PHQ-9: 2.40; GAD-7 = 1.97), with 55% reported worsening mental health since the beginning of the pandemic on a global change rating. Across both prospective and retrospective measures of symptom change, worsening depression, anxiety and PTSD symptoms were associated with prior mental health diagnoses, female gender, young age and unemployed/student status.

We highlight the effect of prior mental health diagnoses on worsening mental health during the pandemic and confirm previously reported sociodemographic risk factors. Discrepancies between prospective and retrospective measures of changes in mental health may be related to recall bias-related underestimation of prior symptom severity.

The German version of the Conners Adult ADHD Rating Scales (CAARS) has proven to show very high model fit in confirmative factor analyses with the established factors inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept in both large healthy control and ADHD patient samples. This study now presents data on the psychometric properties of the German CAARS-self-report (CAARS-S) and observer-report (CAARS-O) questionnaires.

CAARS-S/O and questions on sociodemographic variables were filled out by 466 patients with ADHD, 847 healthy control subjects that already participated in two prior studies, and a total of 896 observer data sets were available. Cronbach's-alpha was calculated to obtain internal reliability coefficients. Pearson correlations were performed to assess test-retest reliability, and concurrent, criterion, and discriminant validity. Receiver Operating Characteristics (ROC-analyses) were used to establish sensitivity and specificity for all subscales.

Coefficient alphas ranged from .74 to .95, and test-retest reliability from .85 to .92 for the CAARS-S, and from .65 to .85 for the CAARS-O. All CAARS subscales, except problems with self-concept correlated significantly with the Barrett Impulsiveness Scale (BIS), but not with the Wender Utah Rating Scale (WURS). Criterion validity was established with ADHD subtype and diagnosis based on DSM-IV criteria. Sensitivity and specificity were high for all four subscales.

The reported results confirm our previous study and show that the German CAARS-S/O do indeed represent a reliable and cross-culturally valid measure of current ADHD symptoms in adults.

Delusional parasitosis, or Ekbom syndrome, is a fixed false belief of being infested by parasites [Bellanger 2009]. With easy accessibility of the internet, serving as a vital tool in acquiring myriad information, these delusions typically arise and can be fueled by external sources as self-research [Bell2005]. For instance, garlic (allium sativum) has been reported to exhibit anthelmintic activity against cestodes (tapeworms), proving to be a natural treatmentoption [Abdel-Ghaffar 2010]. Without proper instructions, guidelines, or control of such information, psychopathological manifestations may be derived.

A young adult male presented with severe psychosis. He reports responding to an internal stimuli, non-command auditory hallucinations, and paranoid ideations specifically in regards to his body and health for several weeks. Prior to presentation, he experienced abdominal pain and constipation for five days, but attributed it to the belief of having tapeworms. He stated that he researched cures for several days using the internet and found garlic as a treatment option. He attempted to alleviate his symptoms by ingested 197 pills of 1,000 milligram (mg) garlic supplements, two 100mg bisacodyl laxatives, and five 100mg docusate stool softeners in one day. He denies any suicidal/homicidal ideations, illicit substance abuse, deja-vu, and jamais-vu.

Psychiatric examination is as follows: Mental Status Examination: awake, alert, and oriented x3. General Appearance: disheveled. Speech: soft, mumbling, and minimally non-responsive. Psychomotor Activity: moderately sedated. Eye Contact: poor. Mood: dysphoric. Affect: flat. Thought Process: flight of ideas. Thought Content: preoccupied. Judgement/Insight: poor. Immediate/Recent Recall: poor. Remote Memory: poor.

Delusional parasitosis and somatic parasitic infestation has dire consequences in which one's health can become compromised. For those suffering from parasitosis, addition of garlic in food as well as garlic supplements of 50mg/kg body weight has been reported as a possible naturopathic treatment option in Cryptosporidiosis and Schistosoma mansoni [Gaafar 2012; Nahed 2009]. In addition, it was found that a dose of 1.2mg for three days was efficient, safe, and shortens the duration of treatment for parasites [Soffar 1991]. However, this patient ingested 197,000mg of garlic supplements without experiencing symptoms of overdose. This may include burning sensation of the mouth or stomach, flatulence, nausea/vomiting, diarrhea, thrombocytopenia, and anaphylaxis [Bayan 2014]. The efficacy of garlic for treatment of true parasitosis is unknown, but can be found in common practice especially those who practice naturopathic medicine. In this case, it is unlikely to have a positive effect, especially when delusional in nature. The use of homeopathic medication in those with true parasitosis and delusional parasitosis should be queried.

Funding Acknowledgements: Smell & Taste Treatment and Research Foundation

CerefolinNAC (CFLN-NAC) is a prescription medical food reported to help with mild to moderate cognitive impairment [Pamlab 2017]. It contains L-methylfolate calcium (6mg), methylcobalamin (2mg), Schizochytrium (90.3mg), and N-acetylcysteine (NAC) (600mg) [Pamlab 2017]. However, dysgeusia secondary to CFLN-NAC therapy has not heretofore been described.

A 64 year-old female presented with an eight year history of progressively decreased ability to smell and taste of unknown origin. CFLN-NAC was prescribed off-label to treat her hypogeusia and hyposmia. Three days after treatment initiation, her taste sensations gradually returned and she was able to describe food as bitter, salty, sour and sweet. Also, she was able to decipher the taste of different nuts, such as almonds, macadamia, pecans, and peanuts at baseline. However, her taste sensations became distorted and she was unable to distinguish specific foods. She reported that most food tasted bland, but she was still able to sense textures of various foods describing them as, “crunchy, but without taste.” She denied any oral pain, xerostomia, hot flashes, and psychological distress. CFLN-NAC was continued for three months and her hypogeusia improved from 20% to 80%. Her dysgeusia persisted, but remitted once CFLN-NAC was discontinued.

Abnormalities in physical examination: General: scalloped tongue, decreased blink frequency, and hypokinesia. Cranial Nerve (CN) Examination: Olfaction (CN I) Testing: Alcohol Sniff Test: 8 (hyposmia). Pocket Smell Test: 2 (hyposmia). Olfactometer Identification Test: Left: 5 (anosmia); Right: 12 (hyposmia). CN III, IV, VI: saccadization on horizontal eye movement. Motor Examination: hypokinetic movements and 1+ cogwheel rigidity in bilateral upper extremities. Drift Test: bilateral abductor digiti minimi signs with cerebellar spooning. Reflexes: absent patellar and Achilles bilaterally. Hoffman’s Reflex: present bilaterally. Other: Magnetic resonance imaging (MRI) of the brain with contrast was unremarkable.

When treating taste impairments, vitamins and minerals have been found to enhance the effect of non-injured nerves, but they do not repair damaged nerves. The presence of a scalloped tongue may suggest nerve injury of unknown proportion, and can either diminish or alter taste. CFLN-NAC may have enhanced the gustatory stimulus of the non-injured nerves. This transient increase could have either caused her dysgeusia or possibly unmasked the dysgeusia secondary to a scalloped tongue. Notable impairments found in her exam evince Parkinson’s disease as a possible etiology, but structural abnormalities were not seen on brain MRI, making this unlikely. Conversely, the relatively rapid resolution after terminating CFLN-NAC strongly suggests that this is not merely a coincidence, but rather an origin. Those initiated on CFLN-NAC should be queried for new onset of dysgeusia and warrant other treatment options.

Funding Acknowledgements: Smell & Taste Treatment and Research Foundation

Neurological conditions can be influenced by meteorological parameters. Some may predict weather changes, such as migraines [Marrelli 1988], burning mouth syndrome [Hirsch 2017], phantosmia [Hirsch 2013], and Bell’s Palsy [Danielides 2001]. However, climatic conditions inducing headaches in those with ventriculoperitoneal shunt (VPS) placements have not heretofore been described.

A 46-year-old female presented with epochs of headaches coinciding with climatic changes. She had hydrocephalus secondary to infantile meningitis that was treated with a Medtronics Strata II adjustable VPS. After multiple revisions, she noticed a headache occurring only before thunderstorms or snowstorms. These headaches were constant, bilateral, “halo-like” downward pressure located only around her parietal regions. It persists all day and does not dissipate after onset, regardless of the storm passing. She rates it 8/10 on the pain scale, and is exacerbated by jarring, sneezing, and bending forward. It is only alleviated with acetazolamide, diminishing to 0/10. She denies any pain relief when supine, pain radiation, rhinorrhea, auras, or correlating psychological distress.

Abnormalities in physical examination: General: hammer toes. Neurological Examination: Cranial Nerve (CN) Examination: CN III, IV, VI: saccadization on horizontal eye movement and bilateral ptosis (left > right). CN IX, X: right uvula deviation. Motor Examination: left upward-outward drift with a positive left abductor digiti minimi sign. Reflexes: 3+ bilateral biceps, brachioradialis, and patellar; 3+ right tricep and 4+ left tricep. Hoffman's Reflex: positive bilaterally (left > right). Neuropsychological Tests: Mental Status Examination: Recent Recall: 1/4 objects in three minutes without improvement with reinforcement. Go-No-Go Test: 6/6. Animal Fluency Test: 21 (normal). Center for Neurologic Study-Lability Scale: 23 (pseudobulbar affect).

How climatic changes induce VPS headaches remains unclear. Barometric changes have been reported to cause sinus engorgement [Kaliner 2009], somatic pain [Silove 2006] and can worsen anxiety and depression [Delyukov 1999]. Meteorological parameters may have induced or exacerbated her depression and anxiety, amplifying pain perception. Alternatively, barometric pressure can cause an increase in other somatic pains and stresses, which can augment awareness of additional, unrecognized somatic pains. It is also possible for barometric pressure to cause pain via nasal sinus or mucosal engorgement; thus, mimicking her VPS headache. Lastly, however unlikely, her pain may be a result of a transient VPS malfunction. The mechanism for such can be attributed to transient pressure changes caused by fluctuating blood pressure, inducing brief intrinsic intraperitoneal pressure changes. Nevertheless, querying patients suffering from VPS headacheswhether climatic changes play a role in their symptoms is warranted.

Funding Acknowledgements: Smell & Taste Treatment and Research Foundation

Burning mouth syndrome (BMS) is characterized by a burning sensation in the tongue or other oral sites [Grushka 2002]. Vitamin B complex deficiencies have been associated with BMS, including B1 (thiamine) [Lamey 1988]. Replacement with thiamine and other B vitamins was noted to cause relief of BMS in 34 of 150 patients [Lamey 1988]. BMS secondary to vitamin deficiencies have been discussed; however, hemicolectomy and hyperalimentation associated thiamine deficiency inducing chronic BMS has not heretofore been described.

Case Study: A 63 year old female presents with a two year history of BMS pain, two weeks following a hemicolectomy from terminal ileum to transverse colon and five days of hyperalimentation. She describes it as a burning pain, 8/10 in severity, localized to both lips, anterior tongue, and middle tongue. It is aggravated with eating and drinking, increasing to 10/10 on the pain scale. Alleviation of pain is seen when ice, Blistex, or lidocaine-mouthwash is used, decreasing the pain to 4/10. Diurnal variation was noted, wherein the pain is exacerbated later in the evening.

Abnormalities in neurological examination: Motor Examination: abductor pollicis brevis 4/5 bilaterally. Drift testing with bilateral cerebellar spooning and bilateral abductor digiti minimi signs. Cerebellar Examination: rapid alternating movements are decreased in the left upper extremity. Reflex Examination: Deep Tendon Reflexes: Brachioradialis: 3+ bilaterally. Biceps: 3+ bilaterally. Triceps: 3+ bilaterally. Ankle Jerk: 2+ bilaterally with delayed return. Hoffman reflex: positive bilaterally. Serum Thiamine level: 66 nmol/L (normal 70-180 nmol/L).

Although, BMS can be seen with thiamine deficiency [Lamey 1988], it has yet to be described status-post hemicolectomy and hyperalimentation. Thiamine is absorbed systemically in the upper jejunum, as well as in duodenum and ileum in conjunction with folate [Friedamann 1948]. Thiamine deficiency is associated with Wernicke-Korsakoff Syndrome and Wet/Dry Beri-Beri; however, these abnormalities are associated with a significant decrease of serum vitamin B1 [Martin 2004]. Even with near normal levels of thiamine, her BMS pain may be a prodromal syndrome which may act as a biological marker of dietary vitamin deficiency.

BMS is highly prevalent in postmenopausal women, wherein trigeminal nerve sensitivity may amplify and worsen pain, given a decrease in estrogen and progesterone [Martin 2007], indirectly influencing her BMS pain. Salivary output and composition can alter due to a drop in estrogen and progesterone as well, allowing baseline reduction of proprioceptive input on the tongue. Ergo, acting through Melzack and Wall’s Gate Control Theory of Pain to disinhibit small C-fibers, it may be perceived as burning pain [Melzack 1965]. Given this case, in those who undergo abdominal surgery or hyperalimentation, query regarding BMS symptoms is warranted.

Smell and Taste Treatment Research Foundation

Studies have shown that specific cognitions and behaviours play a role in maintaining chronic fatigue syndrome (CFS). However, little research has investigated illness-specific cognitive processing in CFS. This study investigated whether CFS participants had an attentional bias for CFS-related stimuli and a tendency to interpret ambiguous information in a somatic way. It also determined whether cognitive processing biases were associated with co-morbidity, attentional control or self-reported unhelpful cognitions and behaviours.

A total of 52 CFS and 51 healthy participants completed self-report measures of symptoms, disability, mood, cognitions and behaviours. Participants also completed three experimental tasks, two designed specifically to tap into CFS salient cognitions: (i) visual-probe task measuring attentional bias to illness (somatic symptoms and disability) v. neutral words; (ii) interpretive bias task measuring positive v. somatic interpretations of ambiguous information; and (iii) the Attention Network Test measuring general attentional control.

Compared with controls, CFS participants showed a significant attentional bias for fatigue-related words and were significantly more likely to interpret ambiguous information in a somatic way, controlling for depression and anxiety. CFS participants had significantly poorer attentional control than healthy individuals. Attention and interpretation biases were associated with fear/avoidance beliefs. Somatic interpretations were also associated with all-or-nothing behaviour and catastrophizing.

People with CFS have illness-specific biases which may play a part in maintaining symptoms by reinforcing unhelpful illness beliefs and behaviours. Enhancing adaptive processing, such as positive interpretation biases and more flexible attention allocation, may provide beneficial intervention targets.