Cotard's syndrome and delayed diagnosis in Kashmir, India

In 1880 Jules Cotard, a French psychiatrist described several patients who suffered from a syndrome referred to as délire de negation [1]. This rare syndrome is characterized by the presence of nihilistic delusions that one is dead or the world no longer exists [2]. The syndrome is typically related to depression and is usually encountered in middle-aged or older people. Advanced age has been found to increase the likelihood of developing Cotard's syndrome. Nevertheless, there are a few cases reported in the literature affecting young people with almost 90% of those affected being females [3-7]. We present a case of a pregnant woman suffering from Cotard's syndrome that was diagnosed late, due to lack of awareness of psychiatric symptoms and failure to recognise these by primary care physicians resulting in delayed treatment of a potentially treatable condition.Mrs. S is a 28 year old married female who is an illiterate housewife. This patient came to our outpatient department with symptoms of decreased sleep and appetite and lack of interest in her usual household chores. The patient complained that her liver was "putrefying" and her heart was "altogether absent". She also reported that when she walked she could not feel her body and reported that her "stomach was missing". She was 6 months into a pregnancy with her first child.Her problems had started after she had left her joint family subsequent to frequent quarrels with her in-laws and had started to live along with her husband in a small rented accommodation. Initially she developed loss of sleep and palpitations and a feeling of loneliness which progressed to loss of interest in her surroundings and her daily household work. She began to have feelings of guilt about herself and felt that she had done something wrong in leaving the joint family. The patient's husband took her to a doctor who described her symptoms as 'vague', diagnosed her as having 'weakness' and prescribed multivitamin tablets. Over the next