An interesting case from Hindawi journal discusses two very rare syndromes of Cotard and Capgras in the same patient of treatment-resistant schizophrenia (TRS) along with the complexities of their management.

The presentation of both Cotard and Capgras syndromes is uncommon in schizophrenia. Cotard syndrome is one of the characteristics nihilistic delusions that are related to denying the existence of oneself or the world. Capgras syndrome is characterized by the delusion that the individual or family members have been replaced by substitutes.

A 23-year-old, male, with a family psychiatric history of psychotic disorder started having symptoms at age 13, like social isolation and poor hygiene. At 15 years of age, he became aggressive and suspicious, and risperidone 3 mg was prescribed daily; later, auditory hallucinations developed, so the antipsychotic dose was increased to 4 mg daily.

However, he subsequently presented on numerous occasions to the emergency room (ER) with aggressive behavior and persecutory delusions. When he was 18, disorganized behavior and delusions of prejudice were added; for this reason, sulpiride 400 mg and olanzapine 10mg daily were prescribed but without good response. Then, he presented with nihilistic delusions concerning his existence "I am dead, I died in 2012," delusions related to his body "I do not have a heart," hypochondriacal delusions "my organs are not working," delusions of guilt "I am taking the blame," and suicidal ideation.

On mental status examination, he was found to be agitated and asking people to kill him. The PANSS upon admission of the patient was 125. During the hospitalization, he continued with the suicidal ideation, and the initiation of electroconvulsive therapy was recommended. The patient received 25 sessions of electroconvulsive therapy with partial improvement in the psychotic symptoms. His previous medication was changed to quetiapine 900 mg daily, without improvement. He was given a diagnosis of treatment-resistant schizophrenia, and clozapine was started. During hospitalization, the patient started refusing food, and a nasogastric tube was inserted.

On one occasion, he became unwell, developing aspiration pneumonia and spent 15 days in intensive care. As his medical condition subsequently improved, he said "I don't have parents, the people who raised me are impostors, they look like my parents, they will be angels, my parents buried me and I never knew about them." The neurological examination with all the blood, urine and radiological investigations were normal. The clozapine dose was gradually increased to 650 mg daily with an improvement of the auditory hallucinations, the suicidal ideation, and the symptoms of Cotard and Capgras syndrome.

PANSS at the discharge was 51. A weekly normal absolute neutrophil count was obtained. The last WBC was 6500 cells/mcL and the ANC 4290 cells/mcL.

It was highlighted that the association of Cotard and Capgras delusions in the same patient is extremely rare. Cotard and Capgras delusions can also be understood as the one-stage or the two-stage model. The experiential - delusions are elucidated as a normal rationalization of the unusual perceptual experience. The inferential - delusions are considered as an abnormal rationalization of the unusual perceptual experience.

In this case, they may represent the way a person tries to attribute negative events to external causes (as in the case of Capgras that is accompanied by delusions of persecution) or internal causes (as in the case of Cotard in the setting of a depressive disorder). The Cotard syndrome did not improve with the electroconvulsive therapy (ECT), unlike successful treatment in cases of melancholia, or psychotic depression.

The reasons for this could be that the Cotard syndrome appeared in the psychotic setting, the early onset of the disorder alongside his strong genetic load (both parents having features of schizophrenia). This patient had persisting significant symptoms despite the use of two antipsychotics suggesting treatment-resistant schizophrenia, so the treatment was progressively changed to clozapine.

Through the observation of this case, it can be concluded that the recognition of symptoms of Cotard and Capgras syndrome in schizophrenia is important for the assessment of appropriate treatment.

Source: Joshep Revilla, Stephanie Aliaga, Antonio Lozano-Vargas, "Cotard and Capgras Syndrome in a Patient with Treatment-Resistant Schizophrenia", Case Reports in Psychiatry, vol. 2021, Article ID 6652336, 3 pages, 2021. https://doi.org/10.1155/2021/6652336