According to an article published in the Journal of Neurosciences in Rural Practice in , Cotard delusion is thought to be less common than it used to be, possibly because people with severe depression who display psychotic symptoms get the treatment they need at an earlier stage.
These 5 Factors Help Explain It. However, Cotard delusion is relatively easy to diagnose. For the patient, this is their truth, so they typically will openly share their story of feeling that they are deceased even while talking to you. At that point, the diagnosis may be conclusively made. In some cases, the delusion may have some underlying truth to it. He incorporated his real physical illness into his delusional beliefs. While Dr. The patient may not know how to describe their physical concerns in a realistic way due to their mental illness.
Cotard delusion usually occurs in tandem with other conditions, which can influence treatment options. She was not concerned about her pregnancy and had ambivalent feelings of love and hate towards the unborn child. There was no disorder of content or possession of thought. Physical examination was unremarkable except the patient was anaemic with haemoglobin of 8. Other routine investigations, including thyroid function tests, were normal.
The CT was not done because of her pregnancy and the MRI could not be done because of financial reasons. ECT was suggested but the patient refused because of the social stigma associated with the procedure. Other possibilities were explored. Initially, the patient was reluctant to take drugs because of her pregnancy. After persistence and a few counselling sessions the patient agreed. The patient could not tolerate fluoxetine 20 mg because of persistent nausea.
Escitalopram caused similar problems. Both drugs were discontinued within a week. Tricyclic antidepressants were not prescribed because of the side effects. The patient was put on mirtazapine 15 mg and haloperidol 5 mg. Both of these were increased to 30 mg and 10 mg, respectively, over the next five days. The patient showed remarkable recovery within the next 4 weeks. Over weeks four to eight the patient's mood and delusions improved.
The improvement was sustained for four months and, at the time of writing, was in remission. Cotard's syndrome is a rare syndrome which presents with severe nihilistic delusions. Treating severe nihilistic depression in a pregnant woman can be a dilemma both morally and clinically. The various factors which are to be kept in mind include the care of the foetus and the choice of an effective drug for the patient.
Pharmacotherapy for depression during pregnancy requires an assessment of the risks and benefits of treatment for both mother and foetus. The risks of treatment should be compared with the risks of not treating depression. In our patient the presence of depression with severe nihilistic delusions necessitated treatment for better foetal and maternal outcomes [ 10 ].
Electroconvulsive therapy has been reported to be relatively safe in pregnant women with severe, refractory depression [ 11 ]. ECT has been found beneficial in Cotard's syndrome [ 12 , 13 ] so we recommended it to our patient to reduce the risk of suicide and to prevent harm to the foetus.
The patient's reluctance to take drugs demonstrated her concern for the foetus. After intolerance to two SSRIs, the patient was given Mirtazapine as it has not been reported to have adverse foetal effects [ 14 ]. Haloperidol was added for psychotic features as it has also been found to be safe choice in pregnancy [ 15 ].
This is one of few reported cases of Cotard's syndrome in a young female patient. Most of the cases have been reported in elderly patients [ 1 ]. The importance of this case, apart from the rarity of this syndrome in young people, is that it highlights the problems faced by a patient where psychiatric symptoms were 'laughed at' and symptoms were described as 'vague' in the primary health care setting.
This is mainly due to clinical bias as a result of unfamiliarity with psychiatric symptomatology. These problems lead to loss of precious time and resources for the patient and the community. With a proper referral in the first instance the patient could have prevented drain on her financial resources due to inappropriate investigations and consultations. This is important in this part of the world as a majority of people visiting hospitals are not covered with health insurance, and patients must pay from their own pocket for investigations, which can be very significant considering the economic conditions of the population where the per capita income is low.
A prompt initial referral would have saved time, suffering and the long list of repeated investigations which including several complete blood counts, liver and kidney function tests, ultrasonographies and an endoscopy. Besides this, her cynicism which was palpable later could have been avoided. Health professionals in primary care have difficulties in recognizing and diagnosing psychiatric disorders [ 16 , 17 ].
The main reason for the limited awareness among primary care physicians and medical specialists in our setting is insufficient psychiatric education during basic training. A five and half year course has just 30 days of training in psychiatry followed by an optional posting period of 2 weeks during internship. The problem is compounded by the relative lack of qualified psychiatrists working in the health system of Kashmir and inadequate support for primary care physicians.
Time constraints on the part of the doctor can be an important factor as patients with psychiatric disorders take more time than other patients. Since the majority of the health care delivery systems in Kashmir are run by the government, and a doctor in a government hospital is supposed to see 50—60 patients in a three to four hour period, it is impossible to give adequate time to each patient, leading to faulty diagnosis and treatment, particularly of psychiatric disorders.
One of the important factors which is important in our context is the virtually nonexistent two-way referral system. The 20 years of armed conflict in Kashmir has resulted in the failure of institutions, lack of accountability and subsequent severe mismanagement and collapse of health care delivery systems. Improvements in diagnosis of psychiatric disorders by primary care physicians and medical specialists may be achieved with short training courses and updates in psychiatry, and particularly through frequent consultation liaison visits [ 18 , 19 ].
The number of days of posting in psychiatry for medical interns can be increased. People under the age of 25 with Cotard delusion tend to also have bipolar depression. Women also seem to be more likely to develop Cotard delusion. In addition, Cotard delusion seems to occur more often in people who think their personal characteristics, rather than their environment, cause their behavior. People who believe that their environment causes their behavior are more likely to have a related condition called Capgras syndrome.
This syndrome causes people to think their family and friends have been replaced by imposters. Cotard delusion and Capgras syndrome can also appear together. If you think you might have Cotard delusion, try to keep a journal of your symptoms, noting when they occur and how long they last. This information can help your doctor narrow down the possible causes, including Cotard delusion. Keep in mind that Cotard delusion usually occurs alongside other mental illnesses, so you might receive more than one diagnosis.
Cotard delusion usually occurs with other conditions, so treatment options can vary widely. However, a review found that electroconvulsive therapy ECT was the most commonly used treatment.
However, ECT does carry some potential risks, including memory loss, confusion, nausea, and muscle aches. For example, some people stop bathing or taking care of themselves, which can cause those around them to start distancing themselves. This can then lead to additional feelings of depression and isolation. In some cases, it can also lead to skin and teeth problems. In severe cases, this can lead to malnutrition and starvation. Suicide attempts are also common in people with Cotard delusion.
They hope that their life will get better or stop if they die again. Cotard delusion is a rare but serious mental illness. While it can be hard to get the right diagnosis and treatment, it usually responds well to a mix of therapy and medication. Many people need to try several medications, or a combination of them, before they find something that works.
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