Cotard’s Syndrome: When the Mind Believes the Body Is Dead

Rare psychiatric conditions continue to challenge both clinicians and pharmacovigilance professionals. One such phenomenon—Cotard’s syndrome—offers a striking example of how deeply altered perception can shape clinical presentation and treatment complexity.

A recent case report published in the American Journal of Health-System Pharmacy highlights the clinical and therapeutic challenges associated with this rare condition.

A rare manifestation of schizophrenia

Cotard’s syndrome is characterized by nihilistic delusions, in which patients may believe they are dead, do not exist, or have lost internal organs. Although rare, it is most often associated with severe psychiatric disorders, including schizophrenia and major depressive disorder.

In the presented case, a 69-year-old woman with a history of schizophrenia developed persistent and severe nihilistic delusions. Her symptoms included repeated contact with a funeral home, requesting to be “collected,” reflecting a fixed belief in her own death.

Treatment challenges and therapeutic considerations

Managing Cotard’s syndrome can be particularly difficult due to its resistance to standard therapies.

In this case, initial treatment with haloperidol and lorazepam did not result in clinical improvement. This lack of response prompted further evaluation and adjustment of the therapeutic strategy.

Pharmacy teams recommended:

• optimization of antipsychotic therapy
• consideration of antidepressant augmentation, such as fluoxetine or citalopram
• evaluation of electroconvulsive therapy (ECT), which is frequently reported in the literature as one of the most effective interventions for Cotard’s syndrome

These recommendations reflect the need for a flexible, multi-modal approach when managing complex neuropsychiatric conditions.

Beyond psychiatry: potential medication-related factors

Interestingly, Cotard’s syndrome may not be limited solely to primary psychiatric disorders.

There is emerging evidence suggesting that certain medications may contribute to neuropsychiatric symptoms resembling or triggering Cotard-like presentations. For example, valacyclovir, an antiviral agent, has been associated in rare cases with neurotoxicity, including confusion and hallucinations.

This highlights the importance of comprehensive medication review in patients presenting with atypical psychiatric symptoms.

Why this matters for pharmacovigilance

From a pharmacovigilance perspective, this case underscores several key points:

• Rare psychiatric syndromes may overlap with drug-induced neurotoxicity
• Lack of response to standard therapy should prompt reassessment of both diagnosis and treatment
• Multidisciplinary collaboration, including pharmacy input, can significantly influence patient outcomes

Conclusion

Cotard’s syndrome remains a rare but clinically significant condition that requires careful diagnostic and therapeutic consideration. This case illustrates not only the complexity of managing severe psychiatric disorders but also the importance of considering medication-related factors in atypical presentations.

For pharmacovigilance and clinical teams alike, it reinforces the need for vigilance, flexibility, and a broad perspective when evaluating rare and challenging cases.

Citation:
Deliz Torres G.A. (2025). Dead Woman Walking: A Closer Look at Cotard’s Syndrome as a Manifestation of Schizophrenia. American Journal of Health-System Pharmacy, 82(Suppl 1), S1827–S1828.

MS Pharm ID: 516808