PERSPECTIVE published: 28 January 2021 doi: 10.3389/fpsyt.2021.626648 First Person Account COVID 19 Delirium in a Doctor: When Death Stalks the Mind Antonio Arumi 1 , Andrea Bulbena-Cabre 2,3 and Antonio Bulbena 4,5* 1 Instituto Trastornos Alimentacion, Salud Mental, Barcelona, Spain, 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States, 3 Metropolitan Hospital NYC Health and Hospitals, New York, NY, United States, 4 Department of Psychiatry and Forensic Medicine, Universitat Autonoma Barcelona, Barcelona, Spain, 5 Institute Neuropsychiatry and Addictions, Parc de Salut Mar, Barcelona, Spain Previous studies reported that 20–30% of COVID-19 patients will develop delirium during the hospitalization, achieving 70% in cases of severe illness. The risks factors and the consequences of delirium are well-documented in the literature; however, little is known about the personal experience of delirium. Delirium burden is common and tends to be distressing even after the delirium episode has resolved. Taking this in mind, the present work provides a first-person account of a doctor who acquired Covid-19 and developed bilateral pneumonia and had delirium and a complicate course of illness. During the course of his delirium, the patient recalled experiences of reality and unreality, complete disorientation, lack of control, strong emotions, and intense fear of dying which Edited by: was significantly distressing. We anticipate that delirium burden will be common on these Sara Invitto, patients and family members and clinicians should be aware of this phenomenon in order University of Salento, Italy to evaluate the neuropsychiatric consequences of this condition. Reviewed by: Giuseppe Bellelli, Keywords: COVID 19, delirium, fear, confusion, delirium experience, delirium burden University of Milano-Bicocca, Italy Sónia Martins, University of Porto, Portugal Delirium, defined as an acute decline of global cognitive functioning, is a common, serious, and *Correspondence: costly complication of hospitalization for older adults (1). Early studies indicate that 20–30% of Antonio Bulbena patients with the novel coronavirus 2019 (SARS-CoV-2 or “COVID 19”) will develop delirium abulbena@gmail.com during the course of their hospitalization, with rates reaching 70% (2, 3). Mounting evidence supports the high occurrence of delirium and other neuropsychiatric manifestations with COVID- Specialty section: 19, and a recent study reported delirium as a common presenting symptom in older adults without This article was submitted to any other typical COVID 19 symptoms (4). Although sometimes neglected, delirium may have Public Mental Health, severe complications, such as permanent cognitive damage or increased mortality (5–7). However, a section of the journal an overlooked phenomenon in delirium is the dreadful subjective experience of the person who Frontiers in Psychiatry suffers with it, which is often a distressing event. In this paper, we provide a first-hand experience Received: 06 November 2020 of a physician who developed an acute encephalopathy secondary to COVID 19 related pneumonia. Accepted: 05 January 2021 I remember that on March 18, three days after being on lock-down, I developed high fever and Published: 28 January 2021 dyspnea. The oxygen saturation started to drop, and the muscle pain and headache were terrible. Citation: The days that followed were even more challenging as the condition worsened rapidly. My lungs were Arumi A, Bulbena-Cabre A and Bulbena A (2021) First Person hurting. By that time, many news outlets in were starting to report several COVID 19 cases in Spain Account COVID 19 Delirium in a and two fellow internists recommended me to get a chest x-ray (CXR) to rule out pneumonia, but Doctor: When Death Stalks the Mind. I thought it was unlikely as I was in the mid-fifties with no medical comorbidities. However, as the Front. Psychiatry 12:626648. days passed by, more alarming news about COVID 19 were being published and I decided to go to the doi: 10.3389/fpsyt.2021.626648 hospital, mostly to reassure my family that I was fine. Frontiers in Psychiatry | www.frontiersin.org 1 January 2021 | Volume 12 | Article 626648 Arumi et al. COVID Delirium: Death Stalking the Mind In the morning on March 23rd, I went to the emergency room feel that I regained my sanity after I was able to understand the alone, no companions were allowed. The city looked ghostly, there subtle difference between these two worlds. was no one on the streets. The CXR confirmed I had COVID 19 Accepting the situation after a period of over two months and bilateral pneumonia and was told I needed hospitalization. on a ventilator is not easy. You cannot speak because of the It was extremely shocking at first, but the following days were a tracheostomy, you cannot eat, you cannot move your legs or just bit confusing, as my mental status was slowly deteriorating, I had your arms, you cannot hold your sphincters, and in my case, I strong feelings of loneliness and helplessness. A couple of days later, could not even see because I am nearsighted, and I could not use my condition worsened, and I was transferred to the ICU. my glasses. You can only think, be alone, and talk to yourself. At that point I was receiving aggressive treatment and the Without knowing where you are, what you are doing there, or what memories of my conscious life disappear for over two months. A happened. Without understanding how you got in the situation in flat, sad, monotonous, real life was facing another “unreal life” that which you find yourself. The outside world is like a dream, unreal, was rich, intense, unpredictable, and terrifying at times. I spent ethereal, fluid and in contrast, your inner world is powerful, multiple weeks connected to the ventilator showing no signs of dynamic, solid, vibrant. Fortunately, I fully recovered from COVID improvement, which was particularly distressing for my family. It 19 and returned to my “old life” but I still struggle with the was not until May 31, on my 57th birthday, when I was able to memories of that period. Personally, I felt very distressed about my wake up and breathe spontaneously. inability to communicate, the lack control, along with the intense My “other life” in the ICU was surprisingly vigorous. That dying feeling of dying that accompanied through “all my trips.” man, without movement, with hardly any response to stimuli, had Most research in delirium has focused on physiological aspects a cerebral life, like he never had before. In my other life, I did of prevention, treatment, and prognosis, but the psychological not get COVID 19 in Barcelona, I got sick on a trip to Miami, consequences and its human toll on patients and their families where I stayed with Ukrainian refugees. I was not hospitalized are gaining recognition (8). This is in line with the NICE in Barcelona, I was in Miami, Mallorca, and in Tarragona. I guidelines (9) that have highlighted the need for more research travelled all over Europe and the United States. I resided in into the delirium experience. Delirium burden is defined as spas, luxury hotels, apartments, hospitals, clinics, psychiatric units, the subjective experience of delirium for patients and family and drug addiction centers. I was buried alive in the grave of members, includes awareness of delirium symptoms, situational an uncle of mine who died ten years ago, I drowned in a pool stress, and emotional response (10). Between 25 and 35% of that the hospital nurses threw me into. I remember perfectly and patients recall the experience, which in most cases, is distressing clearly the feeling of lack of air. The constant feeling of dying. (11–13), and the psychological distress may continue to affect Possibly, it coincided with a respiratory crisis. I went through emotional, psychological, and physical well-being long after times when I couldn’t move my legs, I crawled when walking on the delirium episode resolves (14). In the case of our patient, my arms. I was speechless, I tried to speak, and they did not we hypothesize that he had an increased recollection of the understand me. I also remember being taken for a walk with a events because he was high functioning prior to acquiring wheelchair. Other memories include the relegation of my soccer COVID19 and did not have any cognitive problems. In particular, team, RCD Espanyol de Barcelona, to the second tier of Spanish patients recalled experiences of reality and unreality, day–night soccer league “La Liga” (in fact, it happened shortly after) or an disorientation, clouding of thought, lack of control, strong intense fear that a good friend was killed in a car accident by emotions, misperceptions, hallucinations, and delusions (15). his wife. Despite the literature on this phenomenon remaining scarce, Fears, thoughts, dreams, imaginary realities, and hopes, face some tools are being developed which may provide a key first to face with real life situations, like drowning, impotence, or step toward measuring and improving the subjective experience immobility, to form a barrage of dreams and nightmares that I of delirium for patients and their families (8). lived with an intensity that I never experienced before. Sometimes Given the great prevalence of delirium in COVID 19 patients I felt I was at home, but I was never fully aware of where I (16, 17), we anticipate that delirium burden will be common was. Everything was lived in a dream. For example, if they cut on these patients and family members. Clinicians should be my hair, they did it on a flight returning from Mallorca with my aware of this phenomenon in order to evaluate neuropsychiatric father. I remember airports in all those trips, with a futuristic symptoms, as this condition may have significant impact on the aspect all of them and many other vibrant experiences. The most mental health of the patient and their family members. curious thing about all that delirious time is the tremendously clear memories that I have of dreams, that I lived as if they were reality, compared to the null memory of reality, which for me was like DATA AVAILABILITY STATEMENT a dream. The raw data supporting the conclusions of this article will be I hardly remember anything about the last fifteen days of ICU. made available by the authors, without undue reservation. I woke up thinking that what I experienced was completely real. And little by little, I became aware that I was coming out of a delirium. I remember how they explained to me that LaLiga was ETHICS STATEMENT not over yet, that I had not gotten sick in Miami, and so on. I must confess that, at that time, I refused to believe them and took me Ethical approval was not provided for this study on human days to comprehend the difference between dream and reality. I participants because it is a first-person account. The Frontiers in Psychiatry | www.frontiersin.org 2 January 2021 | Volume 12 | Article 626648 Arumi et al. COVID Delirium: Death Stalking the Mind patients/participants provided their written informed consent to AUTHOR CONTRIBUTIONS participate in this study. 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The use, distribution or reproduction in other forums is permitted, provided the 10. Morandi A, Lucchi E, Turco R, Morghen S, Guerini F, Santi R, original author(s) and the copyright owner(s) are credited and that the original et al. Delirium superimposed on dementia: a quantitative and qualitative publication in this journal is cited, in accordance with accepted academic practice. evaluation of patient experience. J. Psychosom. Res. (2015) 79:281–7. No use, distribution or reproduction is permitted which does not comply with these doi: 10.1016/j.jpsychores.2015.07.010 terms. Frontiers in Psychiatry | www.frontiersin.org 3 January 2021 | Volume 12 | Article 626648