Cotard's syndrome and major depression with psychotic symptoms

Dear Editor,

Cotard's syndrome is a rare clinical event, characterized by negation delusion (individuals feel major changes in their bodies and deny the existence of one or several parts of their organs or bodies) and nihilistic delusion (individuals believe that they or all people are dead).¹ First described in 1880 by Jules Cotard as negation delirium,² the term Cotard's syndrome was proposed in 1893 by Emil Regis.³ We describe the case of a patient admitted to the psychiatric ward of Hospital Ulysses Pernambucano, in Recife, northeastern Brazil and diagnosed with Cotard's syndrome.

M., 59 years old, male, was brought to the psychiatric emergency service of the hospital with complaints of insomnia, soliloquy, attempts to escape from home, suicide attempts by throwing himself in front of moving cars, and nonsense talk. He had dropped out of drug treatment two months earlier. The patient reported hearing voices making comments about him and giving him commands, as well as the existence of animals eating his body. He informed that he no longer had a body, but rather only a spirit, as he was already dead. He did not fear anything, as no one could kill him again (sic). Upon clinical examination, he was barefoot, wearing only shorts (no shirt), showed an unkempt beard and poor hygiene. He also showed alert consciousness, partial disorientation to time, a suspicious attitude, worn-out appearance, personal self-reference, deeply depressed mood, psychomotor retardation, insisting that he was not worth anything, that nobody wanted him there for 60 days already, and that he was paying for what he had done wrong. He also reported not having blood pressure, or blood, and that his body was broken, and that something very bad was about to happen. The patient was diagnosed with Cotard's syndrome secondary to major depression with psychotic symptoms. He was treated with imipramine 150 mg/day and risperidone 4 mg/day for 60 days, and was discharged asymptomatic afterwards.

Even though this disorder was first described by Cotard as a new type of depression, Regis later proposed that this syndrome could be associated with several medical conditions, e.g., psychotic depression, schizophrenia, neurosyphilis, and multiple sclerosis. ^3,4 Comorbidity between Cotard's syndrome and Capgrass syndrome (individuals believe that family members have been replaced with doubles) is also common.⁴ Currently, Cotard's syndrome is no longer classified as an independent disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) or in the International Classification of Diseases, Tenth Revision (ICD-10). Rather, in the DSM-IV-TR, nihilistic delusion is classified as a mood-congruent delusion within a depressive episode with psychotic features.⁴

It is important to emphasize that our case was absolutely compatible with the different descriptions available in the literature for Cotard's syndrome, with features such as a depressed mood, nihilistic delusion, and delusions of guilt and immortality.⁵

Treatment of Cotard's syndrome should focus on the underlying condition. Even though electroconvulsive therapy has been the treatment most frequently indicated in the literature, some reports of the combined use of psychotic and antidepressant drugs can also be found when psychotic depression is the underlying illness. Despite the absence of reports describing the combined use of imipramine and risperidone, the therapy was effective in remitting psychotic depression symptoms in our patient.

References

• ¹
  Castrillon Munoz E, Gutierrez Alzate B. [Cotard's syndrome: case report.] Rev Colomb Psiquiatr. 2009;38:194-202.
• ²
  Debruyne H, Portzky M, Van den Eynde F, Audenaert K. Cotard's syndrome: a review. Curr Psychiatry Rep. 2009;11:197-202.
• ³
  Berrios GE, Luque R. Cotard's delusion or syndrome?: a conceptual history. Compr Psychiatry. 1995;36:218-23.
• ⁴
  Debruyne H, Portzky M, Peremans K, Audenaert K. Cotard's syndrome. Mind Brain J Psychiatry. 2011;2:67-72.
• ⁵
  Berrios GE, Luque R. Cotard's syndrome: analysis of 100 cases. Acta Psychiatr Scand. 1995;91:185-8.

Publication Dates

• Publication in this collection
  April-June 2013

History

• Received
  6 Dec 2012
• Accepted
  8 Dec 2012