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Case Report on Cotard's Syndrome (CS) in a Patient with Schizophrenia

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Case Report on Cotard's Syndrome (CS) in a Patient with Schizophrenia Subhas et al. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery The Egyptian Journal of Neurology, (2021) 57:107 https://doi.org/10.1186/s41983-021-00359-4 Psychiatry and Neurosurgery CASE REPORT Open Access Case report on Cotard’s syndrome (CS) in a patient with schizophrenia: a rare case from Malaysia Natasha Subhas1 , Khin Ohnmar Naing2* , Chaw Su3, Jiann Lin Loo4 , Aishah Farhana Shahbudin2 , Vevehkanandar Sivasubramaniam1 and Reenisha Thyagarajan1 Abstract 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. Keywords: Cotard’s syndrome, Depression, ECT, Hypochondriac, Schizophrenia Background Nihilistic delusions due to CS can occur in patients First described in the 1880s by French neurologist Jules with schizophrenia but its prevalence is rare (< 1%) [1, Cotard, Cotard’s syndrome (CS) is a form of monothe- 6]. Schizophrenia and nihilistic delusions are both re- matic delusion characterized by beliefs that one’s own lated to the loss of sense of inner self, and to date, only body or life is nonexistent (nihilistic beliefs) [1]. Some- seven case reports or series have explored this condition one with CS may believe that their life does not exist or [1, 6, 7]. Therefore, it is a comorbid disorder that is eas- a certain body part may be dysfunctioning. CS is an ill- ily misdiagnosed or dismissed by health and mental ness rarely diagnosed on its own and is not included as a health professionals due to the presence of hypochon- specific disorder in the Diagnostic and Statistical Man- driac symptoms, as in the current case study. Hypochon- ual of Mental Disorders (DSM–5) [2, 3]. However, CS is dria refer to a distressing preoccupation or fear about a found on a wide spectrum of medical or neuropsychi- health issue that someone perceives to have but has yet atric conditions and is alleged to be a manifestation of to be diagnosed [8]. In L’s case, physicians first did not an underlying illness such as severe depression [3–5]. believe anything was wrong with her when she com- plained of various health issues. Later, she was diagnosed * Correspondence: [email protected] with depression and CS was not detected in her until 2Department of Psychiatry, Faculty of Medicines and Health Sciences, she had a psychotic episode. University Putra Malaysia, UPM, 43400 Serdang, Selangor Darul Ehsan, The purpose of this paper is to add to the existing Malaysia Full list of author information is available at the end of the article knowledge on the subject, raise awareness of the © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Subhas et al. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery (2021) 57:107 Page 2 of 6 disorder, and provide information of a treatment plan was given the diagnosis of schizophrenia and CS (Table that was successfully implemented. To the best of our 1). knowledge, there has not been a similar case of CS pub- After L was admitted, it became apparent that L was lished in Malaysia. unable to make decisions. Therefore, her family was called in. They were provided psychoeducation concern- ing the disorder(s), how it is usually treated, and what Case presentation types of treatments were available. After the session, the L was a 42-year-old administrative assistant who pre- psychiatrist and the family came to an agreement that L sented regularly to general practitioners with various should stay in the hospital for a while (1-2 weeks) and non-specific health ailments (sneezing and vague ab- commence treatment with an atypical antipsychotic— dominal pains) after the passing of her father in 2014. risperidone (2 mg, twice a day). Four years later, her overall mental health had deteri- L showed poor response to risperidone and her nihilis- orated. She had become withdrawn, anxious, preoccu- tic delusions remained while being treated at the hos- pied, and unable to sleep due to buzzing noises pital. L insisted the nurses assist her to the ward counter outside her ear. She was also worried that someone each time she walked. Her physical examination was un- was trying to harm her. As a result of lethargy (due remarkable and her mental status examination (MSE) to poor sleep) and issues with concentration, L quit showed blunted affect, poverty of speech, apathy, perse- her job. She was diagnosed with major depressive dis- cutory delusion, and hallucinatory behavior. Her anti- order by a private psychiatrist and was prescribed psychotic treatment was switched to amisulpride 200 mg agomelatine 25 mg daily, and zolpidem 10 mg daily. nocte given the superiority over risperidone in effect size An otorhinolaryngologist found no otorhinolaryngological and lesser weight gain [10]. abnormalities upon examination. L showed marginal improvement with regards to per- L’s mental health and insomnia worsened despite 3 sonal hygiene and meals after 2 weeks although L started weeks of treatment and she incessantly complained that to experience parkinsonism at the dose of 600 mg BD, she “felt like a zombie;” attributing it to the antidepres- which were counteracted with 2 mg of trihexyphenidyl. sants [9]. Also, she had become convinced that her or- There were still residual symptoms of psychosis upon gans were decaying. She refused to eat and purged to her discharge. prove that the food she ate was not being digested. This Unfortunately, L was readmitted a week later after sev- behavior made her extremely weak and lethargic. Fur- eral unsuccessful suicidal attempts as she still had the thermore, she was refusing to urinate and defecate as belief that she could not swallow, urinate, and open her she believed her bowels and bladder were dysfunctional. bowel due perceived damage to her internal organs. The Due to significant physical health deterioration, L was extrapyramidal side effects of amisulpride were also still admitted to the public hospital in Klang Valley in Sep- present and she was experiencing amenorrhea due to tember of 2018. By then, she was having third person hyperprolactinemia (316.2 mU/l). A departmental multi- auditory hallucinations who were commenting on her disciplinary discussion was conducted and the conclu- action(s) and she was becoming paranoid that imaginary sion was to provide a course of electroconvulsive strangers were trying to harm her. No other Schneider- therapy (ECT) for acute stabilization of suicidal ideation ian first-rank symptoms were noted. There were no de- and nihilistic beliefs [11]. Amisulpride was switched to lusions of misidentification either. Both L and her family quetiapine immediate release (IR) 100 mg due to its fa- did not notice any features of depression, mania, or vorable profile for hyperprolactinemia and extrapyram- hypomania. There was an absence of psychiatric illnesses idal symptoms [12, 13]. Consent for treatment was on either side of the family. L repeatedly pinned her anx- obtained in accordance to the Malaysian Mental Health iety down to her belief that her organs were dying and li- Act 2001 [14]. L was to be given an acute course of quefying inside her. The initial differential diagnosis bitemporal ECT consisting of 6 sessions over 2 weeks on included major depressive disorder with psychotic fea- alternative days, using the Mecta SpECTrum 5000 MTM tures, psychotic disorder due to another medical condi- machine (manufactured by Mecta Corporation, United tion and schizophrenia. Extensive work-up was States of America) with a brief pulse width of 1.0 m/s performed to rule out possible organic causes. Organic (33 Hz) (Table 2). causes were ruled out by collecting a history of fever, After completion of all six sessions of the acute course seizures, connective tissue disorders, illicit drug use, or of ECT, L showed significant improvement. She was dis- any neurological deficits suggestive of migraine, stroke, charged after 3 weeks and was directed to take quetia- or meningitis. L’s investigations showed all parameters pine IR 400 mg twice daily at home. Three months later, were within normal limits. Given her first episode of her menstruation returned and her prolactin level nor- psychosis with features of Cotard’s syndrome (CS), L malized.
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