An Unusual Case Report of Cotard’s Syndrome with Depressive Delusions

INTRODUCTION

Dr. Jules Cotard initially described Cotard’s syndrome in 1882, and it is a rather unusual illness. A series of delusions, from thinking that an individual has lost his body organs or parts, blood to thinking that he has lost his soul or is dead, are indicative of Cotard’s syndrome.^[1]

It is frequently connected with severe depression, schizophrenia, Capgras Syndrome, bipolar disorder, or neurological diseases, including epilepsy or brain damage. Cotard syndrome’s specific etiology is unknown; however, it is thought to entail anomalies in brain areas important for emotion processing, self-awareness, and reality perception. Due to its rarity and unique symptomatology, diagnosis and management pose significant challenges for clinicians.^[2]

The diagnosis and management of Cotard’s Syndrome concerning psychotic depression will be highlighted in this case report.

CASE REPORT

A male aged 21 years presented to our psychiatric clinic and was admitted to our indoor ward with a -month history of low mood and lack of interest in previously pleasurable activities and one attempt to end his life by ingestion of an unknown substance along with decreased sleep. The patient belongs to a lower socioeconomic class and stays with his elder brother and mother. Previously, he used to assist his brother with his daily wage work but lost interest in the same for the last three months, had decreased interaction with his family members, and sometimes had crying spells. He reported feeling as though he was dead, describing a complete absence of bodily sensations and emotions. The patient also expressed a conviction that his organs had decayed and that he was decomposing from within. Furthermore, he denied the need for food or sleep, convinced that these were unnecessary for a deceased individual. Medical history revealed no significant physical illnesses or substance abuse. There was no history of any hallucinations or delusions of grandiosity seen in the patient. There was no history of mental illness; his family history of mental illness and his pre-morbid personality were well-adjusted. When he was admitted, he had a Hamilton Depression Rating Scale (HAM-D) score of 28. The results of the laboratory tests, which included an electrolyte panel, thyroid function test, complete blood count, and neuroimaging were normal, and the neurological assessment did not reveal any significant finding. Upon assessment of his mental state, the findings were blunted affect, reduced psychomotor activity, notions of pessimism, delusional guilt, tragedy, sin, and nihilism (of dying). He had no understanding of his psychiatric condition. In the setting of major depressive illness with psychotic symptoms, the diagnosis of Cotard’s Syndrome was made due to the presence of nihilistic delusions along with depressive symptoms as per International Classification of Diseases, Tenth Revision (ICD-10).

He was initiated on a regimen of antidepressant medication Tab Sertraline 100 mg in two divided doses and antipsychotic medication Tab Risperidone 6 mg in two divided doses to target both depressive symptoms and psychotic features along with Tab Lorazepam 2 mg once daily at bedtime to take care of his sleep. Also, the patient was administered bilateral modified ECT using propofol for induction and succinylcholine for muscle relaxation. In addition, he engaged in individual psychotherapy sessions focusing on cognitive restructuring and reality testing. Over the subsequent weeks, the patient’s delusional beliefs gradually diminished, and his depressive symptoms improved significantly. Posttreatment revealed a HAM-D score of 10 which showed improvement in the score. He demonstrated insight of Grade-VI into the irrationality of his thoughts and exhibited a greater sense of self-awareness. At a -month follow-up visit, the patient reported a near-complete resolution of his nihilistic delusions and a marked improvement in overall functioning.

DISCUSSION

The clinical picture was consistent with Cotard’s syndrome, which is characterized by profound sadness and nihilistic delusions. It is an uncommon illness that typically appears in elderly persons suffering from severe depression. The patient develops strong, unshakeable beliefs that their body or organs are dead, dying, nonexistent, or not functioning.^[2] Though the traditional presentation is severe depression, individuals with various neurological or mental disorders, such as psychosis, may develop this syndrome.^[3]

This case of Cotard’s Syndrome, characterized by nihilistic delusions, highlights the complex interplay between depressive symptoms and psychotic features. The diagnosis requires careful consideration of the patient’s symptomatology, history, and mental status examination.^[4]

The treatment approach involves a multidimensional treatment approach targeting both depressive symptoms and psychotic features. Pharmacotherapy, including antidepressants and antipsychotics, is the cornerstone of treatment, aiming to alleviate mood disturbances and mitigate delusional beliefs.^[5]

In 1880, Cotard recorded a case of “delire hypochondriac” involving a middle-aged woman who thought she was made of skin and bones and denied having a brain, nerves, chest, or stomach. She rejected the notions of God and the Devil as well. Cotard coined the phrase “Delire des negation” to describe patients who denied their own existence or the presence of their surroundings, similar to delusions.^[6]

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and ICD-10 make no mention of Cotard’s syndrome.^[7,4]

CONCLUSION

Cotard’s Syndrome is a rare psychiatric condition with complex diagnosis and treatment. It requires a comprehensive approach involving pharmacotherapy, psychotherapy, and supportive care. Despite its complexities, patients can experience gradual improvement with careful intervention. Regular follow-up evaluations are crucial for monitoring treatment response and preventing relapse. Further research is needed to enhance diagnostic accuracy, refine treatment approaches, and improve outcomes for individuals affected by this rare condition.