Cotard Delusion in the Context of Schizophrenia: A Case Report and Review of the Literature

Human lesions and animal studies link the claustrum to perception, salience, sleep and pain

The claustrum is the most densely interconnected region in the human brain. Despite the accumulating data from clinical and experimental studies, the functional role of the claustrum remains unknown. Here, we systematically review claustrum lesion studies and discuss their functional implications. Claustral lesions are associated with an array of signs and symptoms, including changes in cognitive, perceptual and motor abilities; electrical activity; mental state; and sleep. The wide range of symptoms observed following claustral lesions do not provide compelling evidence to support prominent current theories of claustrum function such as multisensory integration or salience computation. Conversely, the lesions studies support the hypothesis that the claustrum regulates cortical excitability. We argue that the claustrum is connected to, or part of, multiple brain networks that perform both fundamental and higher cognitive functions. As a multifunctional node in numerous networks, this may explain the manifold effects of claustrum damage on brain and behaviour.

When Cotard's syndrome fits the sociocultural context: The singular case of Per "Dead" Ohlin and the Norwegian black metal music scene

The sociocultural context of psychiatric patients shapes symptoms experience and expression, as well as how patients deal with a disorder and how society appraises its symptoms. Specifically, the context may influence the social appraisal of a behavior as normal or pathological. Therefore, markedly pathological symptoms may not be accordingly recognized by peers when they are in consonance with the sociocultural context. Per "Dead" Ohlin was a Swedish musician who was a member of the Norwegian black metal band Mayhem from 1988 until his suicide in 1991, at age 22. Black metal is a musical movement characterized by death worshiping and anti-Christianism, and is also associated with church arsons and murders during the 1990s. Even among peculiar personalities such as black metal musicians, Ohlin was considered the personification of the movement ideals due to his eccentric and unparalleled beliefs and behaviors, claiming, for instance, that he was already dead. In this article, we propose that Ohlin's eccentric beliefs and behaviors were symptoms of an unrecognized psychiatric condition, Cotard's syndrome, and discuss the diagnostic dilemma presented by Ohlin's artistic persona and singular context. The compatibility between his symptoms and the sociocultural context of black metal may have obscured his mental disorder. If so, Ohlin's unique case may shed light upon one of the effects of context in a psychopathological process: concealing a psychiatric disorder and reinforcing symptoms that fit a particular environment.

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.

Factor Structure of Cotard's Syndrome: Systematic Review of Case Reports

INTRODUCTION

Cotard's syndrome is a rare psychiatric condition. As a result, current information is mainly based on reports and case series.

OBJECTIVE

To analyse the psychopathological characteristics and the grouping of the symptoms of the Cotard's syndrome cases reported in the medical literature.

METHODS

A systematic review of the literature of all reported cases of Cotard's syndrome from 2005 to January 2018 was performed in the MEDLINE/PubMed database. Demographic variables and clinical characteristics of each case were collected. An exploratory factor analysis of the symptoms was performed.

RESULTS

The search identified 86 articles, of which 69 were potentially relevant. After reviewing the full texts, 55 articles were selected for the systematic review, in which we found 69 cases. We found that the diagnosis of major depression (P<0.001) and organic mental disorder (P=0.004) were more frequent in the older group with Cotard's syndrome. An exploratory factor analysis extracted 3 factors: psychotic depression, in which it includes patients with delusions of guilt (0.721), suicidal ideas (0.685), delusions of damnation (0.662), nihilistic delusions of the body (0.642), depression (0.522), and hypochondriacal delusions (0.535); delusive-hallucinatory, with patients who presented delusions of immortality (0.566), visual hallucinations (0.545) and nihilistic delusions of existence (0.451), and mixed, with patients who presented nihilistic delusions of concepts (0.702), anxiety (0.573), and auditory hallucinations (0.560).

CONCLUSIONS

The psychopathology of Cotard's syndrome is more complex than the simple association with the delusion of being dead, since it encompasses a factorial structure organised into 3 factors.

Scam Susceptibility in a Young, Schizoaffective Patient with Traumatic Brain Injury: A Case Report with a Review of Financial Exploitation Literature and Possible Therapeutic Interventions Gleaned from Traumatic Brain Injury Rehabilitation Research

We present here the case of a 27-year-old man with schizoaffective disorder for roughly eight years who, seven years prior to presentation at our institution, suffered a severe traumatic brain injury (TBI) in a car accident. His course since that time has been marked by paranoid and guilty delusions, Cotard delusion (CD), which is the belief he is dead or does not exist, and scam susceptibility leading to the loss of nearly $200,000. He was hospitalized at our institution after his uncle called emergency medical services, concerned about the patient's increasing disorganization and worsening delusions in the setting of medication nonadherence. In our inpatient unit, clozapine was titrated to its highest tolerable dose and, while reality testing appeared and his CD resolved, he remained acutely vulnerable to scams even while hospitalized. We review the existing literature on scam vulnerability, which heretofore has focused primarily on the elderly, and also TBI rehabilitation strategies in an attempt to better understand the underpinnings of this patient's scam susceptibility and to construct a multidisciplinary approach to lessening his susceptibility to financial exploitation in the future.

'I am dead': Cotard syndrome and dementia

Background: Cotard syndrome is a rare condition whose main feature is a nihilistic delusion ranging from the denial of body parts to that of the existence of one's own life or even the entire universe. Objectives: The aim of this article is to review the nosological significance of Cotard syndrome and to explore the disorder among patients with dementia. Methods: Medline and Google Scholar searches were conducted for relevant articles, chapters and books published before 2018. Search terms used included Cotard delusion, Cotard syndrome and dementia, nihilistic delusion. Publications found through this indexed search were reviewed for further relevant references. Results and conclusion: In this narrative review we emphasise the fact that cases of Cotard syndrome involving patients with dementia are reported quite infrequently. Published studies are limited to very short series or isolated cases. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent in this condition. Keypoints Cotard syndrome is a rare condition characterised by nihilistic delusions that may range from negation of existence of parts of the body to delusion of being dead. The prevalence and incidence of this rare syndrome are not known. Since Cotard's syndrome is conceptualised as part of an underlying disorder, several psychiatric and somatic diseases have been associated with the syndrome. The syndrome may occur in patients suffering from dementia.

Contradiction processing in schizophrenia

INTRODUCTION

Patients with schizophrenia present clinically with difficulties in manipulating contradictory information in the form of loose associations, surface contradictions and delusional beliefs. It is to date unclear whether patients can detect and process information that contradicts their beliefs and prior knowledge and whether this capacity is related to their symptoms and the nature of contradictory stimuli (e.g., personally significant information, emotional information).

METHODS

We probed contradiction processing in patients with schizophrenia and healthy controls using sentence verification tasks that involve self-referential judgements (Experiment 1) and general knowledge (Experiment 2), while manipulating the emotional content of the stimuli.

RESULTS

We found no differences between patients and controls either on reaction time (Experiment 1 & 2) or accuracy measures (Experiment 1).

CONCLUSIONS

Our results show no general impairment in contradiction processing in schizophrenia. Rather, failures to detect and correct contradictions in symptoms such as formal though disorder or delusions could arise through a complex interplay between executive dysfunctions, stress and the emotional content of the information.

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

Jules Cotard described, in 1880, the case of a patient characterized by delusions of negation, immortality, and guilt as well as melancholic anxiety among other clinical features. Later this constellation of symptoms was given the eponym Cotard's syndrome, going through a series of theoretical vicissitudes, considering itself currently as just the presence of nihilistic delusions. The presentation of the complete clinical features described by Cotard is a rare occurrence, especially in the context of schizophrenia. Here we present the case of a 50-year-old male patient with schizophrenia who developed Cotard's syndrome. The patient was treated with aripiprazole, showing improvement after two weeks of treatment. A review of the literature is performed about this case.