Cotard’s syndrome in a patient with schizophrenia-spectrum disorder

Abstract

Cotard’s delusion is a delusion where one believes they are dead or deny aspects of their existence. Cotard’s syndrome includes expansive variation in presentations as well as inciting factors. Cotard’s syndrome is relatively rare and may include nihilistic delusions that one is missing organs, cannot die or that one does not truly exist. Cotard’s syndrome is often associated with other mental illnesses such as depression and schizophrenia but has not been widely associated with methamphetamine use. The following is a report of a patient with no previous signs of mental illness developing a schizophrenia-spectrum disorder with Cotard’s delusion after years of using methamphetamine.

Background

Cotard’s delusion encompasses a range of nihilistic delusions spanning from delusions of missing body parts to the delusion that one is dead altogether.^{1 2} In 1880, Cotard originally described a patient suffering from depression with psychotic features who denied that her body contained a brain, nerves and other organs.¹ In 1882, Cotard later used the phrase ‘delire des negation’ to describe delusions in similar patients denying their own existence or the existence of aspects of their surroundings including people around them.^{1 3} Cotard described that patients suffering from ‘delire des negation’ experience nihilistic delusions either with underlying depression with psychosis or with little to no associated symptoms of anxiety or depression.^{1 3 4} From these descriptions, Emil Regis later derived the term Cotard’s syndrome.¹ Cotard’s syndrome is rare and has been associated with a myriad of conditions including seizures, brain tumours, organ transplants, depression and schizophrenia.1 2 5 6 In 1995, Berrios and Luque performed a factor analysis based on over 100 cases of Cotard’s syndrome and identified three factors of Cotard’s syndrome: psychotic depression, Cotard’s syndrome type I and Cotard’s syndrome type II.^{3 5} The following patient’s presentation is most consistent with Cotard’s syndrome type II.³

Case presentation

The patient is a woman in her 30s with no psychiatric history or noteworthy medical history. The patient presented to the emergency department (ED) on a request for protective custody stating that the patient’s friend called the police after observing her responding to internal auditory hallucinations. The patient was found stating she was dead, claiming that everyone in the world was dead and was threatening to burn down someone’s house. When the patient arrived at the ED, she was noted to appear agitated and was scratching herself excessively during a physical examination. The patient later admitted to methamphetamine abuse which was confirmed with a urine drug screen (UDS) positive for amphetamines.

In the ED, the patient was found to be alert and oriented to person, place and time. The patient described her mood as ‘okay’. It was noted that the patient had a constricted affect at the time, expressing little emotion when she was first interviewed. It was also noted that she expressed an illogical thought process along with paranoid delusions as well as auditory and visual hallucinations. During the examination, the patient described what were determined to be command hallucinations where she heard voices from inside her head telling her to hurt people against her will. While the patient’s memory and attention were intact, the patient’s insight and judgement were determined to be poor. A physician’s emergency certificate to commit the patient was subsequently filed. The patient was accepted at a psychiatric hospital and transferred there.

Investigation

The patient’s daughter was contacted to gather collateral information pertaining to the onset of her current psychotic symptoms. Her daughter reported that her mother’s symptoms of anxiety and psychosis gradually began 5 years before her presentation to the ED. These symptoms along with what appeared to be an intellectual disability allegedly began when the patient started using methamphetamine. Prior to using methamphetamine, the patient had no history of mental illness or any intellectual disability.

Differential diagnosis

The patient’s differential diagnosis includes schizoaffective disorder, drug-induced psychosis, schizophrenia, substance abuse disorder and bipolar disorder type I with psychotic features. The acute onset of this patient’s symptoms complicates her ability to receive a definitive diagnosis without further follow-up. However, based on her presentation and unclear timeline of symptoms, the patient was given a diagnosis of schizophrenia spectrum disorder with psychotic disorder type not yet determined.

Treatment

The patient was initially treated with risperidone 1 mg oral, nightly. The patient’s symptoms were monitored for 2 days with little improvement. On the second day, the patient woke up during the night in extreme distress. The patient was administered an intramuscular injection containing diphenhydramine 50 mg, haloperidol 5 mg and lorazepam 2 mg to treat her non-redirectable agitation.

The patient’s dose of risperidone was consequently doubled to 1 mg oral, two times per day. After two more days with little improvement in treatment of anxiety and hallucinations, risperidone was discontinued, and the patient was prescribed quetiapine XR 200 mg oral, nightly. After using quetiapine, the patient reported having less intense hallucinations. The patient’s dose of quetiapine was subsequently increased to 300 mg nightly, and she was initiated on oxcarbazepine 300 mg oral, two times per day to provide further mood stabilisation. The benefit of including both a second-generation antipsychotic and an antiepileptic/mood stabiliser such as oxcarbazepine is that in combination these drugs can better reduce this patient’s anxiety and ‘may provide better general outcomes than antipsychotics administrated alone’.⁷

The patient was stabilised after being treated in an inpatient setting for 8 days and was discharged to an intensive outpatient programme (IOP) with psychotherapy and ongoing medication with oxcarbazepine and quetiapine. At this time, the patient’s anxiety was far reduced relative to admission, but she was still experiencing delusions and hallucinations.

Outcome and follow-up

Follow-up was performed 6 weeks after the patient was discharged. The patient attended her IOP sessions for roughly 1 week after discharge with little improvement of delusions, hallucinations and paranoia. The patient was admitted to the ED again just 8 days after her initial discharge. The patient was brought to the ED with acute delusions about death. The patient’s UDS was positive for amphetamines, and her daughter reported the patient was not taking her medications. The patient was later admitted as an inpatient to a mental hospital.

Discussion

Because Cotard’s syndrome is such a rare condition, there is limited data from which to perform analysis regarding the pathophysiology and prevalence of coinciding factors between patients. However, researchers have performed factor analyses in attempts to elucidate common symptoms in patients with Cotard’s syndrome.^{3 5} In their factor analysis based on 100 recorded cases of Cotard’s syndrome, Berrios and Luque established three distinct presentations of Cotard’s syndrome including psychotic depression, Cotard’s syndrome type I and Cotard’s syndrome type II.³ Psychotic depression was defined as a group of patients with depression with psychotic features including delusions related to being dead.³ Patients with Cotard’s syndrome type I were defined as experiencing nihilistic delusions relating to death but no mood disorder.³ Patients with Cotard’s syndrome type II were defined as experiencing a presentation including features of anxiety, hallucinations and depression.³ The patient’s presentation is most consistent with Cotard’s syndrome type II.

There are commonly reported nihilistic delusions held by individuals suffering from Cotard’s syndrome. These include the delusion of being dead, the delusion of being immortal, the delusion that one’s organs are dead or decaying, the delusion that one has been damned or condemned by a higher power, the delusion that the world around the patient is not real and the delusion that people around the patient are dead.⁵ The patient in question exhibited a number of these delusions while undergoing treatment. Along with believing she was dead, this patient believed that those around her were dead, that the world around her was not real and that God had forsaken her. The patient repeatedly claimed that she was in ‘death after life’ and once stated that she could not die because of this. This patient’s nihilistic delusions in the context of her affective and psychotic symptoms coincide with previously reported delusions in patients with Cotard’s syndrome.

Various inciting factors have been identified relating to the development of Cotard’s syndrome. Some include a history of infections,¹ Parkinson’s disease,⁸ disrupted cerebral blood flow,^{1 2} organ transplants,¹ seizures,^{1 2} traumatic brain injury,^{1 2} acyclovir use,¹ opiate abuse,¹ multiple sclerosis,¹ schizophrenia2 3 9 10 and catatonia among other pathologies.¹¹ Cotard’s syndrome has also been seen in patients suffering from dementia.^{12 13} While in the ED, the patient received a head CT which revealed no significant findings, decreasing the likelihood that the patient’s psychosis was explicable by a primary neurological or neurovascular abnormality.

It is possible that the patient’s methamphetamine use played a role in the development of her psychosis. This is supported by the patient’s lack of a psychiatric history prior to admission and her daughter’s admission of behavioural changes after the patient began using methamphetamine. There is existing evidence suggesting that methamphetamine abuse can lead to the onset of schizophrenia in predisposed individuals.¹⁴

Treatment for individuals with Cotard’s syndrome should be aligned with the patient’s symptoms and underlying diagnosis as Cotard’s syndrome is not currently included in the diagnostic and statistical manual of mental disorders fifth edition text revision (DSM-5-TR). Previously used treatments for Cotard’s syndrome have included antipsychotics, mood stabilisers and in some cases electroconvulsive therapy.^{2 5 9} This patient was stabilised to her presumed baseline with the use of antipsychotics and a mood stabiliser along with psychotherapy.

Learning points.

• Cotard’s syndrome is a rare syndrome where one endorses the delusion that they are deceased or deny the existence of their own organs.

• Chronic methamphetamine abuse has been associated with the development of psychosis.

• An association may be made between methamphetamine abuse and the development of Cotard’s syndrome.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).