- Oct 31, 2023
Case report 1Cotard’s syndrome comprises any one of a series of delusions that range from a belief that one has lost organs, blood, or body parts to insisting that one has lost one’s soul or is dead.
Case report 2Ms. L, a 53-year-old Filipino woman, was admitted to the psychiatric unit when her family called 911 because the patient was complaining that she was dead, smelled like rotting flesh, and wanted to be taken to a morgue so that she could be with dead people. Upon interview in the hospital, the patient expressed fear that “paramedics” were trying to burn down the house where she was living with her cousin and her brother. She also admitted to hopelessness, low energy, decreased appetite, and somnolence.
Ms. L reported that she had been on antidepressants while in the Philippines (where she had resided for the last 18 years, having moved to the US only a month ago), but could not recall the name or dosage of the medication.
After organic causes were ruled out, treatment with quetiapine and bupropione SR was started. The patient was initially reluctant to take medication or eat. She subsequently developed an electrolyte imbalance (hypokalemia and hyponatremia), which necessitated intravenous electrolyte repletion. The patient was also isolative, spending much of the day in bed and neglecting her personal hygiene and grooming.
Mr. B, 65-year-old retired teacher who was pre-morbidly well adjusted with no family history of mental illness, with personal history of smoking cigarettes in dependent pattern for last 30 years presented with an insidious onset mental illness of one and half years duration precipitated by psychosocial stressors. His symptoms were initially characterized by sadness of mood with early morning worsening, poor socialization, anhedonia, marked anxiety, decreased sleep and appetite, ideas of worthlessness, hopelessness, sin and guilt.
As his symptoms progressed further he developed delusions of catastrophe, nihilism, poverty and persecution. Nihilistic delusion involved a description of everything coming to an end. He would verbalize that his organs are no more working, his brain has stopped functioning, and his house has developed cracks and is going to fall down. About a month prior to being admitted to our inpatient unit, he attempted suicide by hanging himself, but was saved. His suicide note revealed that he wanted to kill himself as he feared spreading a deadly infection(!) to the villagers who resultantly might suffer from cancer.
Later he started believing that he was dead and would not eat anything, due to this lost significant amount of weight. Over the next 2 months he attempted to end his life two more times. Following one of such suicide attempt he was brought to our outpatient unit and was admitted.
Medical history and physical examination revealed presence of hypertension, malnutrition, nutritional large fiber neuropathy, benign prostatic hypertrophy, chronic obstructive pulmonary disease and chronic otitis media. Mental state examination revealed sad affect, marked agitation, ideas of hopelessness, delusion of catastrophe, delusion of guilt, sin and nihilism (of being dead).
Case report 3He lacked insight into his illness. On the basis of the history and mental status examination a diagnosis of severe depression with psychotic symptoms was made. His Hamilton Depression Rating Scale (HDRS) score at time of admission was 34.
Ms A, 62-year-old homemaker has been suffering from bipolar affective disorder for 35 years. She presented to us with a relapse which started about 7-8 months ago characterized by symptoms of depressed mood, anxiety, decreased socialization, loss of appetite and subsequent weight loss, decreased interest in household, poor self-care, ideas of worthlessness, pessimistic views of future, forgetfulness and psychomotor retardation.
Later on she developed nihilistic delusions in which she negated the existence of her body parts and existence of her family members. Negation of existence of family members was not accompanied by any persecutory delusion or misidentification delusions. She also believed that she has been rendered very poor.
She would say that their house may collapse any day and the occupants will die. Over the period she started refusing food as she considered herself to be dead. Her illness further progressed and about 4 weeks prior to admission to inpatient unit she developed mutism, refusal to eat, rigidity in all the limbs and fecal and urinary incontinence. She was brought to the emergency room of our institute with aforementioned symptoms. Her physical examination revealed mild pallor, dehydration, bilateral pitting edema and she was emaciated. On mental state examination she had sad affect, mutism, rigidity in all the four limbs and negativism.
Her investigation showed hemoglobin of 10 gm/dl, hypoproteinemia and hypoalbuminemia. Further investigation revealed low vitamin D₃ levels and the magnetic resonance imaging of brain showed cerebral atrophy with mild subdural effusion. On the basis of history and examination the diagnosis of bipolar affective disorder current episode severe depression with psychotic symptoms, malnutrition and anemia were considered.