A Case of Psychosis with Concurrent Cotard and Koro-like Syndrome in the Context of Bestiality: Presenting with Homicidal and Suicidal Behavior

Abstract

Cotard and Koro syndromes are rare psychiatric phenomena, with their concurrent occurrence being exceptionally uncommon, that too in context of the unusual history of bestiality. Cotard syndrome involves nihilistic delusions, such as beliefs of body part disappearance, while Koro is characterized by intense fear of penile retraction, often linked to thoughts of impending death.

We report a case of a 32-year-old male with psychosis who presented with both syndromes following guilt related to a childhood history of bestiality. The patient developed persecutory delusions, delusions of guilt, beliefs of penile shrinkage (Koro-like), and nihilistic delusions involving his body and the world, finally exhibiting homicidal and suicidal behavior stemming from these fixed beliefs.

This case highlights the complex interplay of guilt, nihilism and psychosis in context of bestiality, shaping rare syndromic presentations leading to extreme forms like homicidal and suicidal behavior. Recognizing such patterns is vital for accurate diagnosis, risk assessment, and tailored treatment planning in psychotic disorders.

Introduction

Cotard’s syndrome is a rare psychiatric condition, first described in 1880 by Jules Cotard, whose main symptom is delusions of negation and in which the patient denies the existence of parts of their bodies or even their whole bodies, leading to denial of the world around them. ¹ It is not referenced in DSM-5 and instead relies on clinical documentation to define its characteristics. It may be associated with several psychiatric illnesses as well as neurological disorders. In a sample of neurological patients with mental disturbances, the prevalence of Cotard syndrome was found to be 0.11%, ² while in an Austrian set of 346 schizophrenia patients, 0.87% could be diagnosed with the same. ³

Koro is a culture-bound syndrome, characterized by an intense fear of the genitalia retracting into the body, potentially leading to death. In males, this fear centers on the penis shrinking into the abdomen, while in females, it involves the vulva and breasts shrinking into the abdomen and chest. ⁴ It is divided into two types: endemic and sporadic. The endemic type, prevalent in East and Southeast Asia, is culturally linked and associated with historical literature. It presents with typical symptoms of classical Koro syndrome, having an acute onset, often associated with severe anxiety. If any of the components of subjective symptomatology are missing, or the syndrome appears outside the endemic areas, it is referred to as sporadic Koro or Koro-like syndrome. ⁵ Such symptoms, like genital shrinking without a belief in imminent death, typically arise secondary to conditions such as schizophrenia, affective disorders, medical illnesses, or substance abuse. ⁶

As it is observed that Cotard syndrome, itself being a rare finding in psychosis, while presenting along with koro-like syndrome, creates a significant co-occurrence that too, along with a history of bestiality, for which limited literatures are available. In this context, we describe a case report of an unusual presentation of psychosis with concurrent Cotard and koro-like syndrome in the context of bestiality.

Case Description

A 32-year-old unmarried male, driver by occupation, belonging to a low socioeconomic status background, presented to the Psychiatry emergency with a history of withdrawn behavior, decreased sleep and fearfulness for the last 8 months, and an attempt to harm his parents with a sharp weapon, subsequently trying to end his own life on the same day of presentation. All these symptoms began 8 months back after the patient accidentally disclosed to his friends that at the age of 13, he had an alleged history of bestiality involving a duck and a dog. Following this, his friends started to mock him about that incident, emphasizing the fact that it was very much shameful to be involved in such an act during his childhood. Thus, he started feeling guilty thinking about the incident.

Since then, he started showing withdrawn behavior and decreased his interaction with other family members without specifying any apparent reasons to them. His sleep was also disturbed at the initiation and maintenance phases. He became very fearful thinking about the fact that, as he had done nothing less than a grave sin, when others knew about the incident, they would ultimately harm and kill him also. Also, according to him, being involved in such an activity might create a worse consequence for him, and this had created a feeling of guilt in his mind. He thought that as people got to know about the incident, they were all talking about him.

He also developed frequent self-gratification habits during this time, which, according to him, temporarily reduced his fear. However, he later began to believe that his penis was shrinking and might eventually disappear into his abdomen, which he perceived as a consequence of his past sexual act, further worsening his fearfulness. Thus, he thought the alleged act of bestiality done previously would not only create the undue turbulence in his mind, but also could form such severe symptoms as a shrinking penis. The belief was held with conviction despite repeated reassurances from his parents. Distressed due to his beliefs, he started to think that he would ultimately die.

Following feelings of guilt and fearfulness, he gradually started to think that the world was completely destroyed, and that some immensely destructive natural calamity might occur. According to him, as his penis was retracting into his body, similarly, other body parts would also die. Moreover, he said no one else was alive, and there was no point living in such an empty world. As a result, on the day of presentation to the hospital, he took a sharp weapon with the intention of killing his parents and removing them from such a desolate world. As his parents tried to save themselves from the attack, he became more agitated and tried to apply the same weapon to his neck, which was somehow stopped by the involvement of other people from his neighborhood and he was taken to the hospital after that.

Throughout the timeline, his work functioning was impaired. He had no past history of mental and physical illness or family history of the same. There was no significant history of substance use present. On examination, his vitals were within normal limits with normal BMI. Physical examination of the penis revealed no obvious abnormalities. He was admitted, and all routine investigations were done, which revealed no significant abnormalities. On mental status examination, he had blunt affect with delusions of persecution, delusions of reference and delusions of guilt related to having had sexual contact with animals. There was also a delusion of nihilism, with insight being Grade 3. He was provisionally diagnosed to be a case of schizophrenia according to DSM-5. It is to be noted that, unlike delusional disorder, in this case, work functioning impairment is prominent along with a change in affect and thought.

He was started on injectable antipsychotic Haloperidol 5 mg twice daily as he was restless initially. After 5 days, as he became gradually cooperative, he was started on tab olanzapine 20 mg in two divided doses and tab fluoxetine 40 mg at morning. He was discharged after 5 more days. In subsequent follow-up sessions after 4 weeks, notable improvement was observed in his condition.

Discussion

In this case, the patient held a strong, unshakable belief in the shrinkage of his penis into his body, and it had further aggravated his fearfulness, thus fulfilling the part of Koro or Koro-like syndrome. Also, increased fearfulness and feelings of guilt had contributed to the formation of Cotard syndrome or delusion of nihilism, which was not only associated with penile shrinkage but also with the death of other body parts and destruction of the world by some catastrophe.

A case report of Ungvari et al. (1994) showed Koro syndrome associated with persecutory symptoms, ⁷ while Afonso et al. (2013) reported a case of Koro-like symptoms in a patient of schizophrenia. ⁸ A study by Chakraborty et al. (2022) has reported secondary Koro presenting as delusional disorder. ⁹

However, the concurrent presentation of Cotard and Koro syndrome has limited literature presence. Bandinelli et al. (2011) have reported a case of such co-occurrence in the context of depressive disorder. ¹⁰ Our case differs from previously reported cases in the context of psychosis and history of bestiality, such co-occurrence holds strong importance in the phenomenological aspect, while extreme presentations like homicidal and suicidal behavior shows the ultimate result of such atypical presentation. Apart from this, considering the medicolegal aspects, such a multifocal case with severe presentations and its corresponding risk assessment holds forensic importance, and these aspects could not be ignored.

Conclusion

It is very much necessary to explore such concurrent findings of Cotard and koro-like syndrome in order to understand the disease progression, phenomenology, and to create a tailored treatment strategy. From a management point of view, the most important things to be addressed are risk assessment, using medications like antipsychotics in a rational manner and non-pharmacological aspects like psychoeducation. Adding to this, such an occurrence in the context of bestiality, giving escalation to presentations like suicidal and homicidal behavior shows the importance of addressing such an unusual event.