Cotard Syndrome in an Adolescent: Case Report From Georgia

Out on PubMed, from clinicians in Georgia, USA, is this case report:

Cotard Syndrome in an Adolescent With a First Episode of Psychosis.

McGreal AE, Boles MK, Boyanchek I.J Psychiatr Pract. 2021 May 5;27(3):224-227. doi: 10.1097/PRA.0000000000000545.PMID: 33939377

The abstract is copied below:

This case report describes a unique presentation of Cotard syndrome in an 18-year-old female patient experiencing first-episode psychosis. Cotard syndrome was first described in 1880 by Jules Cotard as a novel subtype of anxious depression and is presently understood as a rare cluster of mood and psychotic symptoms centered on nihilistic delusions including the absence of organs and a perception of being dead. Although rare, Cotard syndrome has been described in a variety of neurological and psychiatric illnesses, but it is most commonly seen in middle-aged adults with a history of chronic mood disorders. It is rarely reported in childhood or adolescence, and it has not previously been described in first-episode psychosis. This report describes a unique presentation of full Cotard syndrome in an adolescent patient experiencing first-episode psychosis without reported mood symptoms. The patient displayed limited improvement over the first week of treatment with quetiapine but improved rapidly during the second week of hospitalization after a medication change to risperidone. The patient's rapid response to risperidone is unique, as most existing evidence suggests that electroconvulsive therapy is the most effective treatment for Cotard syndrome. This response indicates an opportunity for the implementation of a second-generation antipsychotic medication in patients with Cotard syndrome in areas where electroconvulsive therapy is not available.

And from the text:

CASE DESCRIPTION 

An 18-year-old female presented to a psychiatric intake center following a referral from her outpatient psychiatry office with acute psychosis, suicidal ideation, and severe anxiety after discarding her psychiatric medications 3 weeks before admission. The patient was appropriately dressed and groomed, with psychomotor agitation, pressured speech, an anxious mood, flat affect, racing, tangential, and perseverative thoughts, and delusional and hallucinatory thought content. At intake, the patient was extremely preoccupied with delusions of being dead, consistent with the Cotard delusion, stating, “the devil has destroyed all my organs,” “I do not eat because I do not have a digestive system,” and “I do not need my blood pressure medication because I have no blood.” The patient also endorsed suicidal ideation, but denied a current suicidal plan, stating, “I cannot kill myself because I am already dead.” She reported auditory hallucinations of the devil’s voice and stated that the devil had tricked her into thinking that he was her father. The patient also reported severe anxiety centered on her delusion of being dead, as well as insomnia and decreased appetite for the past several weeks. She denied current or previous manic symptoms or depressed mood. 

 This is an interesting case report, mainly because of the classic delusions of Cotard syndrome occurring in an adolescent. The first two authors are medical students;  some of the symptom descriptions and psychiatric diagnostic conclusions in the report are inconsistent, in keeping with their level of experience. (To me it sounds like this patient has bipolar disorder, like her sibling...) Their literature review of Cotard syndrome is excellent and their mention of ECT as the usual treatment is appropriate.

The patient's response to a neuroleptic is a good reminder that sometimes ECT can be postponed; however, it may well be that this patient will need ECT in the future for definitive response.

This case is worth a full, quick (~7 minutes) read, mostly for the details of the clinical presentation.