A Rare Case of Cotard's Delusion Treated With Oral and Long-Term Injectable Antipsychotics: A Case Report

Cotard's delusion is a relatively infrequent neuropsychiatric condition that presents as a form of extreme and abnormal thinking where an individual believes that they are dead, do not exist, or have lost parts of their body or internal organs. The primary descriptions of Cotard's delusion were associated with severe depressive illness; however, Cotard's delusion may also present in individuals with schizophrenia. Because Cotard's delusion often appears as part of an array of psychotic symptoms, it can be misdiagnosed or underdiagnosed in hospitals. As such, many reported cases of Cotard's delusion have been treated with electroconvulsive therapy (ECT), after failing to respond to pharmacologic treatments. However, there are some reported cases of Cotard's delusion that have achieved remission using medication. We describe the case of a 40-year-old male with a several-year history of schizophrenia who developed an acute psychotic episode characterized by nihilistic delusions consistent with Cotard-like symptoms. The individual believed that he was dead, that he did not exist, and that his throat had been cut. During this episode, the individual expressed somatic delusional thoughts in addition to the previously mentioned nihilistic delusional thoughts. Upon the onset of his psychotic episode, the individual demonstrated a unique euphoric mood, which seemed to be related to his beliefs regarding being dead. The patient was treated with oral risperidone, followed by long-acting injectable (LAI) paliperidone palmitate, resulting in the gradual resolution of symptoms during a short hospitalization. This case highlights the limited number of documented cases of Cotard's delusion in patients with schizophrenia and the potential role of LAI antipsychotic agents as a maintenance strategy for patients with schizophrenia and significant compliance issues who develop Cotard delusions.