Open access peer-reviewed chapter
Comparison of mean values of different cognitive tests values and depression and anxiety in post-COVID-19 patients and health normal control persons.
Abstract
The current pilot study has been carried out in order to find the possible relationships between premorbid personality traits and cognitive impairments and affective symptomatology in patients recovered from COVID-19. Thirty subjects with so-called post-COVID-19 syndrome have been included into study. The diagnosis of COVID-19 has been previously confirmed by laboratory tests in each person. The control group included 30 healthy persons. For the assessment of depression and anxiety, the Hospital Anxiety and Depression Scale has been used. For the assessment of cognitive impairment, Verbal Fluency test, Montreal Cognitive Assessment (MoCA) test, and Wisconsin Card Sorting test (WCST) were used. The Munich Personality Scale and Toronto Alexithymia Scale were used for the assessment of premorbid personality. The multiple stepwise regression analysis has been used for the assessment of relationships between premorbid personality constructs and cognitive tests results and affective and anxiety symptomatology. Obtained results have shown that Frustration Tolerance test decreased the number of wrong answers in WCST and reduced the latency of the answers with positive reinforcement and also reduced the depression level and by that had the positive effects. On the other hand, Extraversion reduced the score of Montreal Cognitive Assessment (MoCA) test and increased the percentage of perseverative wrong answers in WCST-2 test and by that had negative effect on cognitive functions. Similarly, constructs of Adherence to Social Norms and Tendencies to Isolation both reduced the final MOCA score and by that predisposed to post-COVID-19 syndrome development. Esoteric tendencies construct reduced the latencies of answers with positive and negative reinforcement in WCST-3 and WCST-4 and by that had protective influence on cognitive functions. Alexithymia score correlated positively with Depression, while Neuroticism correlated positively with Anxiety.
Keywords
- personality traits
- Munich Personality Test
- alexithymia
- post-COVID-19 syndrome
- cognitive impairment
- affective
- anxiety symptomatology
1. Introduction
The COVID-19 pandemic is regarded as worldwide catastrophe that affected 225 territories and countries and lead to innumerable rate of deaths [1].
Until 2021, the confirmed case count of COVID-19 in the world surpassed over 275 million cases [1], although the real level of affected cases is thought to be much greater and 2.75 billion people may be infected by COVID-19 [2, 3, 4, 5, 6].
Although a great part of COVID-19-infected patients has recovered and remained alive, the serious sequels in the form of so-called post-COVID-19 syndrome have persisted.
The cognitive deficits are thought to be the frequent display of post-COVID-19 syndrome and may appear even after the milder cases of infection that have not required hospitalization [7].
A study performed by Hampshire et al. [7] has been shown that the observed deficits varied in scale with respiratory symptom severity, related to positive biological verification of having had the virus even among milder cases, could not be explained by differences in age, education, or other demographic and socioeconomic variables, remained in those who had no other residual symptoms and was of greater scale than common preexisting conditions that are associated with virus susceptibility and cognitive problems.
The deficits affected multiple tests but to different degrees. When examining the entire population, the deficits were most pronounced for paradigms that tapped cognitive functions such as reasoning, problem-solving, spatial planning, and target detection while sparing tests of simpler functions such as working-memory span as well as emotional processing. These results are in line with reports of long-COVID-19, where the so-called “brain fog” trouble concentrating and difficulty finding the correct words are common [7].
In the systematic review, performed by Rogers et al. [8], the presented data have shown that in the acute phase around third of patients experienced impaired memory, concentration, or attention, while after the illness, around one-fifth of all patients had one or more of the aforementioned cognitive impairments and about one-third of patients have experienced so-called dysexecutive syndrome consisting of “inattention, disorientation, or poorly organized movements in response to command” [8, 9].
Based on these observations, conclusion can be made that COVID-19 has the global destructive action on multiple brain functions that, in turn, can lead to impairment in quality of everyday life and loss of social adaptation [10].
In addition to cognitive deterioration, the affective symptomatology including depression and anxiety states also may be presented in the structure of post-COVID-19 syndrome [1, 6, 7, 8, 9, 10, 11].
In study by Almeria et al. [11], performed on 35 patients with COVID-19, the association between neurological symptoms such as headache, loss of smell, and taste were strongly associated with impairment in several subtests including attention, memory, and executive function domains. Of the above symptoms, headache was the neurological symptom frequently associated with poor performance in
Although the numerous clinical data confirmed the role of severe somatic symptomatology in the genesis neurocognitive deficit in COVID-19 patients [6, 7, 8, 9, 10, 11], the role of premorbid personality constructs for the development of cognitive impairment and concomitant affective pathology remains unknown. Obviously, that if such relationship really exists, it may prepare the physicians in advance to more intensive and specific approach to treatment of such patients. In other words, the investigations on the relationships between premorbid personality constructs and post-COVID-19 syndrome are utterly required.
The studies of relationships between premorbid personality types and following depression development have a long history in modern psychiatry. Many authors since antiquity tried to find the connections between them. In this context, the studies of Abraham concerning the so-called oral structure of character, Kretschmer’s Cycloid personality, and Shimoda’s description of so-called Statothymia should be mentioned [12].
The work of Tellenbach presenting the so-called Typus Melancholicus (TM) has also regarded that personality construct as risk factor for the following monopolar depression development [13]. According to this model, such traits as orderliness, conscientiousness, hyper/hetereonomia, and intolerance of ambiguity are the core features of Typus Melancholicus (TM). Previous studies showed a relationship between unipolar depression and TM construct [12, 13, 14].
Moreover, the new formalized scales for the assessment of premorbid personality traits, such as Munich personality scale [15] and Toronto Alexithymia scale [16], were elaborated, and question about their capability for the assessment of premorbid personality structure for the prediction of following depression development has not been yet resolved.
Here also should emphasize that modern psychometric formalized scales have not been yet used for study on relationships between premorbid personality on the one hand and affective symptomatology and cognitive deterioration on the other hand in post-COVID-19 syndrome.
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2. Objective
The current pilot study has been designed and performed in order to find the possible relationships between premorbid personality traits and cognitive impairments and affective symptomatology in patients recovered from COVID-19 in persons with post-COVID-19 syndrome.
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3. Material and methods
For the current study, 30 subjects with so-called post-COVID-19 syndrome have been selected and included into study. All patients had neither chronic somatic nor mental illnesses. Among studied persons were 11 males and 19 females. The mean age of studied patient was 30.8 + −14.5 and varied from 19 to 64 years.
The diagnosis of COVID-19 has been previously confirmed by laboratory tests in each person. The mean duration of time since recovery was 1.78 + −0.9 and varied from 1 to 4 months.
For the comparison purposes, the control group of healthy persons has been formed. It included 30 healthy persons, who have not been infected by COVID-19, and it was confirmed by negative results in COVID-19 tests. The control group included 10 males and 20 females. The mean age of control group was 28.9 + −12.7 and varied from 18 to 62 years. There was no statistically significant discrepancy in age between groups.
For the assessment of depression and anxiety, all patients were evaluated by psychiatrists in order to assess the affective and cognitive state. For these purposes, the Hospital Anxiety and Depression Scale has been used [17].
For the assessment of cognitive traits, the Montreal Cognitive Assessment (MoCA-test) [18, 19], Wisconsin card sorting test (WCST), [20] and Verbal Fluency test [21, 22] were used.
For the assessment of the premorbid personality features, the Munich Personality Test (MPT) has been used [14].
The MPT represents a self-rating questionnaire and includes 51 questions depicting the different personality traits. The patients have filled in all rating scales themselves, and after that the obtained raw data have been transformed into six constructs in line with specific structure of scales. These constructs include Extraversion, Neuroticism, Rigidity, Frustration Tolerance, Tendencies to Isolation, and Esoteric Tendency. The last two constructs form Schizoidia scale [12]. The other two control scales of MPT (Orientation toward Social Norms and Motivation) were not included in the final analysis.
Extraversion and Neuroticism constructs are derived from Eysenck and Eysenck concepts [23]. Rigidity is quite similar to construct of Typus Melancholicus proposed by Tellenbach [12, 13], while Tendency to Isolation and Esoteric Tendency are based on Kretschmer’s classical study on relationships between constitution and personality [14]. Frustration Tolerance refers to resiliency or stress coping strategy.
Along with MPT, the Toronto Alexithymia Scale (TAS-26) [24] was explored for the assessment of alexithymia. The choice of alexithymia scale was explained by the facts that alexithymia itself is often connected with other disorders, such as post-traumatic stress disorder (PTSD) and Holocaust survivors [15, 16].
TAS-26 consists of 26 items, and each item can be scored in points from 1 to 5. The global alexithymia score in TAS-26 may be expressed from 26 to 130 points [24]. All patients with global TAS-26 score who exceed 74 points were regarded as persons with alexithymia. The values of TAS-26 varied from 40.00 to 75.00, and mean value in post-COVID-19 syndrome achieved 58.27 + − 9.69.
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4. Statistical analysis
The multiple regression analysis has been used in order to find any possible relationships between premorbid personality traits on the one hand and affective symptomatology and variables of cognitive impairments in COVID-19 patients on the other hand [25, 26].
In the control group, such analysis of relationship between premorbid personality and clinical manifestation has not been performed, since the primary aim of the current pilot study was research of mentioned above correlations in COVID-19 patients but not in healthy persons.
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5. Results
The main obtained results are shown in the next tables. In Table 1, the comparison of means of cognitive variables and affective syndromes between post-COVID-19 syndrome patients and healthy control subjects are presented.
| Variable | Post-COVID-19 syndrome patients (n = 30) | Healthy control persons (n = 30) | Significance |
|---|---|---|---|
| Verbal Fluency test (VFT) | 12.68 + −4.47 | 16.80 + −2.14 | p = 0.0000 |
| MOCA test | 26.55 + −1.90 | 27.80 + −1.15 | p = 0.0031 |
| WCST-1 | 27.95 + −14.54 | 18.50 + −3.0 | p = 0.0009 |
| WCST-2 | 15.27 + −7.24 | 9.1 + −1.85 | p = 0.0000 |
| WCST-3 | 2.99 + −1.35 | 1.72 + −0.63 | p = 0.0000 |
| WCST-4 | 4.53 + −2.21 | 2.62 + −1.32 | p = 0.0001 |
| Depression (HADS) | 5.55 + − 4.13 | 2.63 + −1.60 | p = 0.0006 |
| Anxiety (HADS) | 5.82 + −4.75 | 2.80 + −1.35 | p = 0.0014 |
Table 1.
MOCA – Montreal cognitive assessment; WCST-1 – the percentage of wrong answers; WCST-2 – the percentage of perseverative wrong answers; WCST-3 – the latency of answers with positive reinforcement in seconds; WCST-4 – the latency of answers with negative reinforcement in seconds.
As can be seen between the patients with post-COVID-19 syndrome and healthy control persons, a great statistically significant difference exists. It concerns used test on cognitive functions and implies the severe mental cognitive deterioration due the transitory COVID-19 infection. Similarly, the level of depression and anxiety states was higher in post-COVID-19 patients.
Table 2 shows the results of multiple regression analysis for the relationships between the main premorbid personality traits and cognitive variables in post-COVID-19 syndrome patients.
| Variable | Verbal Fluency (VFT) | MOCA | WCST-1 | WCST-2 | WCST-3 | WCST-4 |
|---|---|---|---|---|---|---|
Table 2.
Multiple regression analysis (values of beta coefficients) for some cognitive tests as dependent variable on different premorbid personality states.
Note: all statistically significant values of beta coefficients and R2 are marked in boldface.
As can be seen, only two personality traits had no influence on cognitive tests. They included TAS-26 and Neuroticism (MPT). The other four premorbid personality constructs had statistically significant influence on five cognitive tests except the VFT.
Thus, there was a statistically significant negative association between Frustration Tolerance and the level of the percentage of wrong answers, the representation of perseverative wrong answers, and the latency of the answers with positive reinforcement, i.e. this personality construct had the positive and protective influence on WCST performance in post-COVID-19 syndrome.
On the other hand, Extraversion construct reduced the score of MOCA test and increased the percentage of perseverative wrong answers in WCST-2 test that implies the destructive effect of that construct on cognitive functions in COVID-19-infected patients.
Similarly, the personality constructs of Adherence to Social Norms and Tendencies to Isolation both reduced the final MOCA score and by that had destructive influence on cognitive functions in post-COVID-19 syndrome patients.
Quite the contrary, the Esoteric Tendencies construct reduced the latencies of answers with positive and negative reinforcement in WCST-3 and WCST-4 and by that had positive influence on cognitive performance in COVID-19 patients.
Concerning the mentioned results, should be also stressed that the maximal value of explained variance (R2 = 0.591) has been revealed for WCST-3. IT implies that Frustration Tolerance and Esoteric Tendencies constructs are maximally effective in the prediction of WCST-3.
Analysis of relationships between premorbid personality traits and affective symptomatology in post-COVID-19 syndrome patients (See Table 3) revealed that Frustration Tolerance correlated negative (β = −0.465) with Depression and by that exerted protective influence on Depression development, while the Alexithymia score correlated positively with Depression and by that determined the higher Depression score.
| Variable | Depression (HADS) | Anxiety (HADS) |
|---|---|---|
Table 3.
Multiple regression analysis (values of beta coefficients) for affective constructs on different premorbid personality states.
Note: all statistically significant values of beta coefficients and R2 are marked in bold.
On the other hand, the Neuroticism construct correlated positively (β = 0.737) with Anxiety score that implies the anxiety symptomatology increase in patients with high Neuroticism level.
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6. Discussion
Personality traits are thought to be important characteristics, since they may predispose to the development of some psychopathological condition, including affective and anxiety states [12, 13, 14, 15, 16]. The main problem in this context concerns the probability of concrete psychopathological state prediction based on the basis of premorbid personality traits before the mental disorder development.
Moreover, the definite answer to the question whether the personality traits can predispose or not to affective disorder after the influence of any exogenous factors (such as COVID-19) is absent.
Similarly, there is also absent the definite answer to the question on the relationships between premorbid personality structure and subsequent development of cognitive impairment after COVID-19 infection [8, 9, 10, 11].
The current pilot study has been designed and performed in order to respond to all these posed questions.
The study may be criticized for the small number of selected patients. In order to overcome such shortcoming, the meticulous statistical method in form of regression analysis was used.
The main results of the current study have shown that persons who suffered by COVID-19 infection really are characterized by some neurocognitive impairments including Verbal Fluency, MOCA tests, and Wisconsin Card Sorting Test.
Moreover, the premorbid personality was really connected with some cognitive tests and subsequent affective and anxiety syndromes development.
Principally that different premorbid personality constructs influenced wide-ranging upon cognitive functions. Thus, Extraversion, Adherence to Social Norms, and Tendencies to Isolation reduced the MOCA score and by that disturbed the cognitive functions. While, Frustration Tolerance reduced the number of wrong answers and perseverative wrong answers and by that improved the final results in WCST.
Similarly, Frustration Tolerance reduced the latency of answering with positive reinforcement, while Esoteric Tendencies reduced the latencies as with positive, as with negative reinforcement and by that both these personality constructs again improved cognitive functions.
Utterly in line with these results are the findings on the negative correlation between Frustration Tolerance and Depression development in post-COVID-19 syndrome. Here, the positive correlation between Frustration Tolerance and Depression also should be mentioned. Principally, that combination of Alexithymia state and Frustration Tolerance lead to maximal explained variance of Depression score, i.e. the combination of these two constructs may predict the Depression appearance more precisely than any other factors.
Principally, that Rigidity construct that corresponds to “Typus Melancholicus” in studies by Tellenbach [12, 13, 14] had no statistically significant relationships with Depression. The cause of such contradiction remains unknown and probably may be explained by pathogenetic differences in endogenous depression and depression in post-COVID-19 syndrome.
The current study can also be criticized for the lack of similar statistical analysis in the control group. Nevertheless, it was not done since the primary aim of the current study concerned the search of relationships between premorbid personality constructs and cognitive impairment and affective symptomatology in patients suffering from COVID-19 and not in control health persons.
An analysis of relationships between premorbid personality constructs and cognitive impairment and psychopathology in the control healthy group was beyond the present study and has not been performed, since the healthy persons have no any severe symptomatology. It may be done in the special work in the nearest future.
Conclusion can be made that the low score of Frustration Tolerance and Esoteric Tendencies has unfavorable influence on cognitive functions in patients with post-COVID-19 syndrome, while the high scores of these constructs cause the protective effect against cognitive deterioration and Depression development.
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