Cotard's Syndrome in a Patient with Schizophrenia: Case Report and Review of the Literature

"A ghost doesn't need insulin," Cotard's delusion leading to diabetic ketoacidosis and a body-mass index of 15: a case presentation

BACKGROUND

Cotard's Syndrome (CS) is a rare clinical entity where patients can report nihilistic, delusional beliefs that they are already dead. Curiously, while weight loss, dehydration, and metabolic derangements have been described as discussed above, a review of the literature revealed neither a single case of a severely underweight patient nor a serious metabolic complication such as Diabetic Ketoacidosis. Further, a search on PubMed revealed no articles discussing the co-occurrence of Cotard's Delusion and eating disorders or comorbid metabolic illnesses such as diabetes mellitus. In order to better examine the association between Cotard's Delusion and comorbid eating disorders and metabolic illness, we will present and discuss a case where Cotard's delusion led to a severe metabolic outcome of DKA and a BMI of 15.

CASE PRESENTATION

Mr. B is a 19 year old transgender man admitted to the hospital due to diabetic ketoacidosis secondary to Type 1 Diabetes Mellitus. Mr. B had a history of Obsessive-Compulsive Disorder, Major Depressive Disorder, and Post-Traumatic Stress Disorder. The primary pediatric team discovered that Mr. B had not been using his insulin appropriately and was severely underweight, and they believed this could be due to his underlying mental illness. The psychiatric consultation/liaison service found that Mr. B was suffering from Cotard's delusion leading him to be noncompliant with his insulin due to a belief that he was already dead. Cotard's delusion had in this case led to a severe metabolic outcome of DKA and a BMI of 15.

CONCLUSIONS

This case provides clinical insight into the interactions of eating disorders and Cotard's delusion as well as the potential medical complications when Cotard's delusion is co-morbid with medical conditions such as Diabetes Mellitus. We recommend that clinicians routinely screen patients for Cotard's delusion and assess whether the presence of which could exacerbate any underlying medical illness. This includes clinicians taking special care in assessing patient's caloric and fluid intake as well as their adherence to medications both psychiatric and medical. Further research could be conducted to explore the potential overlap of Cotard's delusion and eating disorder phenomenology.

Cotard delusion in a depressed patient: "My throat is missing!"

Cotard's syndrome is a rare neuropsychiatric disorder characterized by marked nihilistic delusions. This report describes an Indonesian woman from a small town in Malaysia who was diagnosed with depression and Cotard's delusion. The diagnosis was confirmed after thorough history-taking, clinical examination, and relevant laboratory tests. Herein, we highlight the unique psychopathology of a possible Cotard's syndrome subtype and efficacy of pharmacological combination strategies, rather than monotherapy and electroconvulsive therapy, for its treatment.

"Cotard's syndrome", a description of two cases. Delusion of negation in melancholia versus delusion of negation in paranoia

In 1880, Jules Cotard described a set of delusions in the form of negations that later became his eponymous syndrome. Cotard's syndrome is an uncommon condition characterised by the presence of nihilistic delusions in which the person thinks that "they are dead or that the world no longer exists". This document describes two cases in which a broad and enriching semiology is evidenced from a descriptive point of view, which allows us to review them together with Cotard's syndrome in the light of modern psychiatry. The first case corresponds to a depressive disorder and the other occurs in the context of a non-affective psychotic disorder. A review of the literature is presented from what Cotard described until the current psychiatric classifications.

A medical algorithm for Cotard delusion based on more than 300 literature cases

OBJECTIVE

Cotard delusion (CD) is a rare psychiatric disorder in which the patient believes to be dead, i.e., the patient holds nihilistic delusions concerning his/her own existence. Taking into account its rarity, and possible subdiagnosis due to unawareness, most of the literature consists of case studies, complicating a more systematic approach and leading to difficulties in deciding the best clinical guidance to offer the patient suffering from CD. The objective of this work is to review the literature and propose an algorithm to help the differential diagnosis and the management of this condition.

METHOD

To do so, an extensive literature research was performed using several bibliographic databases. Since data on this topic is scarce, references in every article were cross-checked, aiming to obtain all available peer-reviewed works on CD.

RESULTS

Research resulted in 328 cases. Several treatment modalities were reported to improve the symptoms of CD, from pharmacotherapy - mainly consisting of antipsychotics and antidepressants - to electroconvulsive therapy.

CONCLUSIONS

Despite its challenging diagnosis, the delusion can be treated with readily available care. Hopefully, this work can be a useful tool to doctors when encountering this odd affliction.

Case report on Cotard’s syndrome (CS) in a patient with schizophrenia: a rare case from Malaysia

Background

Cotard’s syndrome (CS) is a neuropsychiatric condition marked by nihilistic delusional(s). Due to its rarity, misdiagnosis of the syndrome often occurs. The current case study is of a Malaysian woman who was misdiagnosed for several years by professionals due to the presence of hypochondriac symptoms before receiving the correct diagnosis.

Case presentation

In this case presentation, we describe the case of L, a 42-year-old Malaysian lady who was first misdiagnosed with depression. The diagnosis of schizophrenia and CS was confirmed after thorough clinical examination, diagnostic investigations, and deliberation at a departmental forum. The patient improved after receiving electroconvulsive therapy (ECT) along with antipsychotic medications.

Conclusions

This case study highlights the importance of early recognition of CS by professionals as it can save time for both parties when setting up a treatment plan. Essentially, early recognition of CS in schizophrenia is paramount in the process of rapid stabilization through ECT and promotion of patient recovery.

"Cotard's Syndrome", a Description of Two Cases. Delusion of Negation in Melancholia Versus Delusion of Negation in Paranoia

In 1880, Jules Cotard described a set of delusions in the form of negations that later became his eponymous syndrome. Cotard's syndrome is an uncommon condition characterised by the presence of nihilistic delusions in which the person thinks that "they are dead or that the world no longer exists". This document describes two cases in which a broad and enriching semiology is evidenced from a descriptive point of view, which allows us to review them together with Cotard's syndrome in the light of modern psychiatry. The first case corresponds to a depressive disorder and the other occurs in the context of a non-affective psychotic disorder. A review of the literature is presented from what Cotard described until the current psychiatric classifications.

The 'dead man walking' disorder: an update on Cotard's syndrome

In 1880, Jules Cotard described a peculiar syndrome after observing the case of a 43-year-old woman, which was characterized by melancholic anxiety, delusions of damnation or possession, a higher propensity to suicide ideation and deliberate self-harm, analgesia, hypochondriac thoughts of non-existence or ruin of several organs, of the whole body, of the soul, of divinity, and the idea of immortality or inability to die. Several expansions and reinterpretations have been made of the so-called Cotard's syndrome, which is often encompassed in different neurological and psychiatric disorders, complicating and worsening their symptomatic frameworks and making more difficult their treatments. However, the nosographic characterization of Cotard's syndrome remains elusive and is not now classified as a separate disorder in both ICD and DSM-5. Here, we try to give an update, as well as a putative systematization, of current views and opinions about this nosological entity in the light of the recent progress in the clinic, psychopathology and psycho-neurobiology.