Chronic Cotard's syndrome: Recovery from 2 years’ bed-ridden status


COTARD'S SYNDROME WAS first described by Dr Jules Cotard in 1880.1 Typically, patients believe that they have lost organs, body parts, or even that they have died. However, recent reports have described little about successful drug treatments.2,3 Here we report a woman suffering from Cotard's syndrome for more than 2 years who did not receive any psychiatric therapeutics, but showed dramatic improvement when treated with fluoxetine and risperidone at a later time.

‘Ms C’, a 59-year-old female patient, had been through multiple life stresses for the past 5 years. Initially, she presented general weakness, which led her to several hospital visits. Gradually, poor sleep, poor appetite, and loss of energy developed. She also complained constantly that both her legs were paralyzed. Finally, she could no longer walk and then was placed in a nursing home by her family and had been living there for more than 2 years.

She was brought to our hospital for generalized pain. Initial surveys, including physical examinations, serum chemistry, and hematology profile, were all within normal limits. She was admitted to our acute ward for further evaluations.

On admission, depressive symptoms, including loss of energy and feelings of hopelessness, were noted. She also expressed bodily delusions, delusions of negations, and delusions of being paralyzed. Further investigations, including electromyography, nerve conduction velocity testing and brain magnetic resonance imaging, all showed negative findings.

On exclusion of organic causes, Cotard's syndrome, in the context of major depressive disorder with psychotic features, was diagnosed. Fluoxetine 40 mg/day with risperidone 6 mg/day was prescribed to treat the depressive and psychotic symptoms. During the first month, the patient was bed-ridden and needed special nursing care. Gradually, her depressive symptoms and delusions subsided. After 2 months, she started to walk again and then was discharged in a stable condition.

Similar to Yamada's report,1 our patient's clinical course can be divided into the germination stage (cenesthopathy and hypochondriasis), the blooming stage (full development of symptoms of Cotard's syndrome) and the chronic stage (systematization of delusions). Although electroconvulsive therapy is suggested in the chronic stage,1 our patient's condition improved dramatically with combination therapy of fluoxetine and risperidone. To our knowledge, this is the first report about successful pharmacological treatments in the chronic stage of Cotard's syndrome in the medical literature. It is probably related to risperidone's stabilizing effects on the hyperactivity of dopamine systems in Cotard's syndrome4 and enhancement of antidepressant effects of fluoxetine via alpha-2 adrenergic receptors,5 but the exact mechanism requires further study.