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Minerva Psichiatrica 2017 March;58(1):70-3

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Nihilistic delusion

Postby Mirn В» 11.02.2020

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Cotard syndrome is a rare condition characterized by nihilistic delusions concerning body or life that can be found in several neuropsychiatry conditions. It is typically associated with depressive symptoms.

We present a case of Cotard syndrome without depressive symptoms in the context of known paranoid schizophrenia. A literature review of Cotard syndrome in schizophrenia was performed. Although there are few descriptions of this syndrome in schizophrenia, patients usually present depressive mood and psychomotor retardation, features not seen in our patient. Loss of the sense of the inner self, present in schizophrenia, could explain patient's symptomatology but neurobiological bases of this syndrome remain unclear.

Despite not being considered in actual classifications, Cotard syndrome is still relevant and psychiatric evaluation is critical to diagnosing and treating this condition in psychiatric patients. Cotard syndrome CS has been described by Jules Cotard as a nihilistic delusion, which may range from negation of existence of parts of the body to delusion of being dead and negation of self-existence.

This syndrome can be found in numerous psychiatric or neurologic conditions, such as mood disorders, schizophrenia and other psychotic disorders, dissociative disorders, central nervous system CNS infections, cerebrovascular disease, CNS neoplasm, and traumatic brain injury [ 1 — 3 ]. Presentation at younger ages has been described as being associated with an increased risk of bipolar disorder [ 2 ].

We report on a patient with known schizophrenia and history of opioid abuse that developed a CS one year after medication dropout. To our knowledge, only few cases have been described reporting CS without depressive symptoms.

Our patient was a year-old male who was treated for paranoid schizophrenia at our psychiatric department for 10 years. He had also a history of opioid abuse, being abstinent for 4 years. He was brought to the emergency room ER by his cousin for behavioural alterations and paranoid speech. Progressively over a 2-month period he had become more isolated and developed paranoid thoughts, reporting that someone had captured him and controlled his behavior and thoughts.

He presented restricted affect but psychomotor activity was enhanced and mood was euthymic. Physical examination was normal. Laboratory assessment complete blood count, electrolytes, creatinine levels, and thyroid hormones was within normal values. Urine drug screen test was negative and blood ethanol levels were undetectable. Brain CT did not demonstrate any pathology. After one week of treatment, he started to improve his behavior and delusional ideation became less intense.

The patient was discharged 24 days after admission in a state of full remission, as paranoid and nihilistic delusions completely disappeared. Thus, the diagnosis of paranoid schizophrenia was maintained.

In this case report, we present an uncommon form of CS as the patient did not display any depressive symptoms associated with his nihilistic delusions.

The described patient suffered from an exacerbation of his known paranoid schizophrenia, which responded to monotherapy with an atypical antipsychotic, achieving full remission of delusions.

Even in the context of mood disorders, this syndrome is rare. A review of psychiatric patients admitted to inpatient treatment in Mexico, including suffering from schizophrenia, identified 3 cases of CS 0.

Despite being well known that nihilistic delusions can occur in schizophrenia, only few single cases or small series report this occurrence [ 5 — 9 ]. In a recent review of cases of schizophrenia, CS could be diagnosed in three cases 0. Interestingly, this contrasts with enhanced psychomotor activity observed in our patient. Apart from restricted affect, our patient did not display any other alteration of mood and emotions. Indeed, affective flattening and abnormal affective processing, mediated by dysfunctional flow of information from sensory cortices to the limbic system, were suggested to be related with monothematic delusions in schizophrenia [ 11 ].

In addition, abnormalities in nondominant frontal, temporal, and parietal lobes, areas known to be affected by schizophrenia, have also been related with CS [ 3 ]. Some authors considered nihilist delusions as an extreme manifestation of the topic of death [ 10 ]. However, considering the cooccurrence of Cotard and Capgras syndromes the latter is the most common misidentification syndrome [ 5 , 7 , 12 , 13 ], it could be conceptualized that both monothematic and bizarre delusions are related with loss of the sense of the inner self that is core and typical of schizophrenia.

Alternately, CS can be conceptualized as a dysfunction of egocentric mind-representing system as asomatognosia is conceptualized as damage of the egocentric body-representing system [ 14 ]. This phenomenon can be mediated by dysfunction of insular cortex, an area that plays a central role in the conscious awareness of internal sensations and that is known to be affected by stress [ 15 , 16 ]. Although CS is not a psychiatric diagnosis but a feature of several neurological and psychiatric conditions, psychiatrists should be aware of this uncommon psychotic phenomenon to prompt diagnosing, describing, and treating according to the best evidence.

Despite not being considered in actual classifications, Cotard syndrome is still relevant and clinical recognition is critical to diagnosing and treating this condition in psychiatric patients. The authors declare that there is no conflict of interests regarding the publication of this paper.

National Center for Biotechnology Information , U. Journal List Case Rep Psychiatry v. Case Rep Psychiatry. Published online May Cerqueira 1 , 2 , 3. Author information Article notes Copyright and License information Disclaimer.

Received Apr 4; Accepted May This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC.

Abstract Introduction. Introduction Cotard syndrome CS has been described by Jules Cotard as a nihilistic delusion, which may range from negation of existence of parts of the body to delusion of being dead and negation of self-existence.

Case Report Our patient was a year-old male who was treated for paranoid schizophrenia at our psychiatric department for 10 years. Discussion In this case report, we present an uncommon form of CS as the patient did not display any depressive symptoms associated with his nihilistic delusions. Conclusion Despite not being considered in actual classifications, Cotard syndrome is still relevant and clinical recognition is critical to diagnosing and treating this condition in psychiatric patients.

Conflict of Interests The authors declare that there is no conflict of interests regarding the publication of this paper. References 1. Berrios G. Cotard's syndrome: analysis of cases. Acta Psychiatrica Scandinavica. Consoli A. Cotard's syndrome in adolescents and young adults is associated with an increased risk of bipolar disorder. Bipolar Disorders. Debruyne H. Cotard's syndrome: a review. Current Psychiatry Reports.

Ramirez-Bermudez J. Cotard syndrome in neurological and psychiatric patients. Joseph A. Cotard's syndrome in a patient with coexistent Capgras' syndrome, syndrome of subjective doubles, and palinopsia.

The Journal of Clinical Psychiatry. Cotard's syndrome—two case reports. Singapore Medical Journal. Shiraishi H. Sulpiride treatment of Cotard's syndrome in schizophrenia.

Progress in Neuro-Psychopharmacology and Biological Psychiatry. Caliyurt O. Cotard's syndrome with schizophreniform disorder can be successfully treated with electroconvulsive therapy: case report.

Ghaffari-Nejad A. Self-Mutilation of the nose in a schizophrenic patient with cotard syndrome. Archives of Iranian Medicine. Stompe T. The Cotard syndrome in schizophrenic disorders. Hirstein W. Capgras syndrome: a novel probe for understanding the neural representation of the identity and familiarity of persons. Wright S. Sequential Cotard and Capgras delusions. The British Journal of Clinical Psychology. Wolff G.

The British Journal of Psychiatry. The misidentification syndromes as mindreading disorders. Cognitive Neuropsychiatry. Chatterjee S. Biological Psychiatry. Morgado P. The impact of stress in decision making in the context of uncertainty. Journal of Neuroscience Research. Support Center Support Center. External link.

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