Case Report: Cotard's syndrome associated with suicide attempt-related delirium

Cotard's syndrome is a rare psychopathological phenomenon characterized by nihilistic delusions concerning one's body, existence, or death. We report the case of an 88-year-old man with no previous psychiatric treatment who was admitted following a medication-overdose suicide attempt in the context of a severe depressive crisis. After intensive and internal medical treatment, he developed a fluctuating confusional state characterized by disturbances of orientation, impaired attention, paranoid ideation, and nihilistic beliefs. During this period, he repeatedly stated that he was dead, had been cremated, and that his wife had also died. Notably, these nihilistic beliefs persisted during relatively lucid intervals, even as the severity of the disturbance of consciousness fluctuated. Severe depressive symptoms, somatic decompensation, metabolic abnormalities, sensory impairment, frontotemporal atrophy, and mild neurocognitive impairment were present. The clinical picture was interpreted as Cotard-type nihilistic delusions emerging during a fluctuating delirious state in the context of severe depression, suicidal behavior, and underlying neurocognitive vulnerability. Treatment with risperidone, mirtazapine, somatic stabilization, and supportive psychotherapy was followed by gradual resolution of both the confusional state and the nihilistic delusions. This case highlights the complex interplay between delirium, severe depression, suicidal behavior, and neurocognitive impairment in the development of Cotard-type phenomena and underscores the importance of a careful differential diagnostic approach when nihilistic delusions arise in medically and cognitively vulnerable older adults.