Cotard delusion

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Cotard's delusion
Other namesCotard's syndrome, Walking corpse syndrome
Jules Cotard.jpg
The neurologist Jules Cotard (1840–1889) described "The Delirium of Negation" as a mental illness of varied severity.
Specialty Psychiatry

Cotard's delusion, also known as walking corpse syndrome or Cotard's syndrome, is a rare mental disorder in which the affected person holds the delusional belief that they are dead, do not exist, are putrefying, or have lost their blood or internal organs. [1] Statistical analysis of a hundred-patient cohort indicated that denial of self-existence is present in 45% of the cases of Cotard's syndrome; the other 55% of the patients presented with delusions of immortality. [2]

Contents

In 1880, the neurologist Jules Cotard described the condition as le délire des négations ("the delirium of negation"), a psychiatric syndrome of varied severity. A mild case is characterized by despair and self-loathing, while a severe case is characterized by intense delusions of negation, and chronic psychiatric depression. [3] [4]

The case of "Mademoiselle X" describes a woman who denied the existence of parts of her body (somatoparaphrenia) and of her need to eat. She claimed that she was condemned to eternal damnation, and therefore could not die a natural death. In the course of experiencing "the delirium of negation", Mademoiselle X died of starvation. [5] [ self-published source? ]

Cotard's delusion is not mentioned in either the Diagnostic and Statistical Manual of Mental Disorders (DSM) [6] or the 10th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organization. [7]

Signs and symptoms

Delusions of negation are the central symptom in Cotard's syndrome. The patient usually denies their own existence, the existence of a certain body part, or the existence of a portion of their body. Cotard's syndrome exists in three stages:

  1. Germination stage: symptoms of psychotic depression and of hypochondria appear;
  2. Blooming stage: full development of the syndrome and delusions of negation; and;
  3. Chronic stage: continued severe delusions along with chronic psychiatric depression. [8]

Cotard's syndrome withdraws the person with the condition from other people due to neglect of their personal hygiene and physical health. Delusions of negation of self prevent the patient from making sense of external reality, which then produces a distorted view of the external world. Such delusions of negation are usually found in schizophrenia. Although a diagnosis of Cotard's syndrome does not require the patient to have had hallucinations, the strong delusions of negation are comparable to those found in schizophrenic patients. [9] [10]

Distorted reality

The article Betwixt Life and Death: Case Studies of the Cotard Delusion (1996) describes a contemporary case of Cotard's delusion which occurred in a Scotsman whose brain was damaged in a motorcycle accident:

[The patient's] symptoms occurred in the context of more general feelings of unreality and [of] being dead. In January 1990, after his discharge from hospital in Edinburgh, his mother took him to South Africa. He was convinced that he had been taken to Hell (which was confirmed by the heat) and that he had died of sepsis (which had been a risk early in his recovery), or perhaps from AIDS (he had read a story in The Scotsman about someone with AIDS who died from sepsis), or from an overdose of a yellow fever injection. He thought he had "borrowed [his] mother's spirit to show [him] around Hell" and that she was asleep in Scotland. [11]

The article Recurrent Postictal Depression with Cotard Delusion (2005) describes the case of a 14-year-old epileptic boy who experienced Cotard's syndrome after seizures. His mental health history showed themes of death, chronic sadness, decreased physical activity in leisure time, social withdrawal, and disturbed biological functions.

About twice a year, the boy had episodes that lasted between three weeks and three months. In the course of each episode, he said that everyone and everything was dead (including trees), described himself as a dead body, and warned that the world would be destroyed within hours. Throughout the episode, the boy showed no response to pleasurable stimuli, and had no interest in social activities. [12]

Pathophysiology

Neural misfiring in the fusiform face area, in the fusiform gyrus (orange), might be a cause of Cotard's syndrome. Gray727 fusiform gyrus.png
Neural misfiring in the fusiform face area, in the fusiform gyrus (orange), might be a cause of Cotard's syndrome.
In the cerebrum, organic lesions in the parietal lobe might cause Cotard's syndrome. BrainLobesLabelled.jpg
In the cerebrum, organic lesions in the parietal lobe might cause Cotard's syndrome.

The underlying neurophysiology and psychopathology of Cotard's syndrome might be related to problems of delusional misidentification. Neurologically, Cotard's delusion (negation of the self) is thought to be related to Capgras delusion (people replaced by impostors); each type of delusion is thought to result from neural misfiring in the fusiform face area of the brain, which recognizes faces, and in the amygdalae, which associate emotions to a recognized face. [13]

The neural disconnection creates in the patient a sense that the face they are observing is not the face of the person to whom it belongs; therefore, that face lacks the familiarity (recognition) normally associated with it. This results in derealization or a disconnection from the environment. If the observed face is that of a person known to the patient, they experience that face as the face of an impostor (Capgras delusion). If the patient sees their own face, they might perceive no association between the face and their own sense of self—which results in the patient believing that they do not exist (Cotard's syndrome).

Cotard's syndrome is usually encountered in people with psychosis, as in schizophrenia. [14] It is also found in clinical depression, derealization, brain tumor, [15] [16] and migraine headaches. [13] The medical literature indicate that the occurrence of Cotard's delusion is associated with lesions in the parietal lobe. As such, the Cotard's delusion patient presents a greater incidence of brain atrophy—especially of the median frontal lobe—than do people in control groups. [17]

Cotard's delusion also has resulted from a patient's adverse physiological response to a drug (e.g., acyclovir) and to its prodrug precursor (e.g., valaciclovir). The occurrence of Cotard's delusion symptoms was associated with a high serum-concentration of 9-carboxymethoxymethylguanine (CMMG), the principal metabolite of acyclovir.[ citation needed ]

As such, the patient with weak kidneys (impaired renal function) continued risking the occurrence of delusional symptoms despite the reduction of the dose of acyclovir. Hemodialysis resolved the patient's delusions (of negating the self) within hours of treatment, which suggests that the occurrence of Cotard's delusion symptoms might not always be cause for psychiatric hospitalization of the patient. [18]

Treatment

Pharmacological treatments, both mono-therapeutic and multi-therapeutic, using antidepressants, antipsychotics, and mood stabilizers have been successful. [19] Likewise, with the depressed patient, electroconvulsive therapy (ECT) is more effective than pharmacotherapy. [19]

Cotard's syndrome resulting from an adverse drug reaction to valacyclovir is attributed to elevated serum concentration of one of valacyclovir's metabolites, 9-carboxymethoxymethylguanine (CMMG). Successful treatment warrants cessation of valacyclovir. Hemodialysis was associated with timely clearance of CMMG and resolution of symptoms.

Case studies

Society and culture

The protagonist of Charlie Kaufman's 2008 movie Synecdoche, New York is named Caden Cotard. Throughout the film Cotard thinks he is dying, and we see other examples of Cotard delusion with scenes such as when his daughter, Olive, begins to scream about having blood in her body and, as the film goes on, Cotard disappears from the play he is writing about his own life and is portrayed by other actors as he takes the role of a cleaning lady. [22]

It is speculated that Per "Dead" Ohlin, lead vocalist for the black metal bands Mayhem and Morbid, had Cotard delusion [23] as a result of a bullying incident in his youth that left him clinically dead for a short time. He developed an obsession with death shortly after (hence his stage name and use of corpse paint), [24] often self-harmed onstage and among friends, and became increasingly depressed and introverted [25] eventually resulting in his suicide in 1991. His suicide note contained the lines "I belong in the woods and have always done so. No one will understand the reason for this anyway. To give some semblance of an explanation I'm not a human, this is just a dream and soon I will wake."

See also

Related Research Articles

<span class="mw-page-title-main">Psychosis</span> Abnormal condition of the mind

Psychosis is an abnormal condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

A delusion is a false fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other misleading effects of perception, as individuals with those beliefs are able to change or readjust their beliefs upon reviewing the evidence. However:

<span class="mw-page-title-main">Jules Cotard</span>

Jules Cotard was a French neurologist who is best known for first describing the Cotard delusion, a patient's delusional belief that they are dead, do not exist or do not have bodily organs.

Capgras delusion is a psychiatric disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member has been replaced by an identical impostor. It is named after Joseph Capgras (1873–1950), the French psychiatrist who first described the disorder.

The Fregoli delusion is a rare disorder in which a person holds a delusional belief that different people are in fact a single person who changes appearance or is in disguise. The syndrome may be related to a brain lesion and is often of a paranoid nature, with the delusional person believing themselves persecuted by the person they believe is in disguise.

<span class="mw-page-title-main">Depersonalization</span> Anomaly of self-awareness

Depersonalization can consist of a detachment within the self, regarding one's mind or body, or being a detached observer of oneself. Subjects feel they have changed and that the world has become vague, dreamlike, less real, lacking in significance or being outside reality while looking in. It can be described as feeling like one is on “autopilot” and that the person's sense of individuality or selfhood has been hindered or suppressed.

Delusional misidentification syndrome is an umbrella term, introduced by Christodoulou for a group of delusional disorders that occur in the context of mental and neurological illness. They all involve a belief that the identity of a person, object, or place has somehow changed or has been altered. As these delusions typically only concern one particular topic, they also fall under the category called monothematic delusions.

Clinical lycanthropy is a rare psychiatric syndrome that involves a delusion that the affected person can transform into, has transformed into, or is, an animal. Its name is associated with the mythical condition of lycanthropy, a supernatural affliction in which humans are said to physically shapeshift into wolves. It is purported to be a rare disorder.

Cognitive neuropsychiatry is a growing multidisciplinary field arising out of cognitive psychology and neuropsychiatry that aims to understand mental illness and psychopathology in terms of models of normal psychological function. A concern with the neural substrates of impaired cognitive mechanisms links cognitive neuropsychiatry to the basic neuroscience. Alternatively, CNP provides a way of uncovering normal psychological processes by studying the effects of their change or impairment.

<span class="mw-page-title-main">Mental status examination</span> Way of observing and describing a patients current state of mind

The mental status examination (MSE) is an important part of the clinical assessment process in neurological and psychiatric practice. It is a structured way of observing and describing a patient's psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the MSE and the sequence and names of MSE domains.

Depersonalization-derealization disorder is a mental disorder in which the person has persistent or recurrent feelings of depersonalization or derealization. Depersonalization is described as feeling disconnected or detached from one's self. Individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. Derealization is described as detachment from one's surroundings. Individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike/surreal, or visually distorted.

Intermetamorphosis is a delusional misidentification syndrome, related to agnosia. The main symptoms consist of patients believing that they can see others change into someone else in both external appearance and internal personality. The disorder is usually comorbid with neurological disorders or mental disorders. The disorder was first described in 1932 by Paul Courbon (1879–1958), a French Psychiatrist. Intermetamorphosis is rare, although issues with diagnostics and comorbidity may lead to under-reporting.

The syndrome of subjective doubles is a rare delusional misidentification syndrome in which a person experiences the delusion that they have a double or Doppelgänger with the same appearance, but usually with different character traits, that is leading a life of its own. The syndrome is also called the syndrome of doubles of the self, delusion of subjective doubles, or simply subjective doubles. Sometimes, the patient is under the impression that there is more than one double. A double may be projected onto any person, from a stranger to a family member.

Reduplicative paramnesia is the delusional belief that a place or location has been duplicated, existing in two or more places simultaneously, or that it has been 'relocated' to another site. It is one of the delusional misidentification syndromes; although rare, it is most commonly associated with acquired brain injury, particularly simultaneous damage to the right cerebral hemisphere and to both frontal lobes.

Mirrored-self misidentification is the delusional belief that one's reflection in the mirror is another person – typically a younger or second version of one's self, a stranger, or a relative. This delusion occurs most frequently in patients with dementia and an affected patient maintains the ability to recognize others' reflections in the mirror. It is caused by right hemisphere cranial dysfunction that results from traumatic brain injury, stroke, or general neurological illness. It is an example of a monothematic delusion, a condition in which all abnormal beliefs have one common theme, as opposed to a polythematic delusion, in which a variety of unrelated delusional beliefs exist. This delusion is also classified as one of the delusional misidentification syndromes (DMS). A patient with a DMS condition consistently misidentifies places, objects, persons, or events. DMS patients are not aware of their psychological condition, are resistant to correction and their conditions are associated with brain disease – particularly right hemisphere brain damage and dysfunction.

A monothematic delusion is a delusional state that concerns only one particular topic. This is contrasted by what is sometimes called multi-thematic or polythematic delusions where the person has a range of delusions. These disorders can occur within the context of schizophrenia or dementia or they can occur without any other signs of mental illness. When these disorders are found outside the context of mental illness, they are often caused by organic dysfunction as a result of traumatic brain injury, stroke, or neurological illness.

Oneiroid syndrome (OS) is a condition involving dream-like disturbances of one's consciousness by vivid scenic hallucinations, accompanied by catatonic symptoms, delusions, or psychopathological experiences of a kaleidoscopic nature. The term is from Ancient Greek "ὄνειρος" and "εἶδος". It is a common complication of catatonic schizophrenia, although it can also be caused by other mental disorders. The dream-like experiences are vivid enough to seem real to the patient. OS is distinguished from delirium by the fact that the imaginative experiences of patients always have an internal projection. This syndrome is hardly mentioned in standard psychiatric textbooks, possibly because it is not listed in DSM.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GD), also known as delusions of grandeur or expansive delusions, are a subtype of delusion that occur in patients with a wide range of psychiatric diseases, including two-thirds of patients in manic state of bipolar disorder, half of those with schizophrenia, patients with the grandiose subtype of delusional disorder, frequently in narcissistic personality disorder, and a substantial portion of those with substance abuse disorders. GDs are characterized by fantastical beliefs that one is famous, omnipotent, wealthy, or otherwise very powerful. The delusions are generally fantastic and typically have a religious, science fictional, or supernatural theme. There is a relative lack of research into GD, in contrast to persecutory delusions and auditory hallucinations. Around 10% of healthy people experience grandiose thoughts at some point in their lives but do not meet full criteria for a diagnosis of GD.

Folie à deux, also known as shared psychosis or shared delusional disorder (SDD), is a collection of rare psychiatric syndromes in which symptoms of a delusional belief, and sometimes hallucinations, are transmitted from one individual to another. The same syndrome shared by more than two people may be called folie à... trois ('three') or quatre ('four'); and further, folie en famille or even folie à plusieurs.

<span class="mw-page-title-main">9-Carboxymethoxymethylguanine</span>

9-Carboxymethoxymethylguanine (CMMG) is a compound which is known as the principal metabolite of the antiviral medication aciclovir, and has been suggested as the causative agent in the neuropsychiatric side effects sometimes associated with these medications. These are mainly suffered by patients with kidney failure or otherwise decreased kidney function, and can include psychotic reactions, hallucinations, and rarely more complex disorders such as Cotard delusion. Patients suffering these symptoms following aciclovir treatment were found to have much higher levels of CMMG than normal, and since this is the first time Cotard delusion has been linked to a drug as a side effect, this discovery may be useful in the study of Cotard delusion and its treatment.

References

  1. ↑ Berrios, G. E.; Luque, R. (1995). "Cotard's delusion or syndrome?". Comprehensive Psychiatry. 36 (3): 218–223. doi:10.1016/0010-440x(95)90085-a. PMID   7648846.
  2. ↑ Berrios, G.E.; Luque, R. (1995). "Cotard Syndrome: Clinical Analysis of 100 Cases". Acta Psychiatrica Scandinavica. 91 (3): 185–188. doi:10.1111/j.1600-0447.1995.tb09764.x. PMID   7625193. S2CID   8764432.
  3. ↑ Cotard's syndrome at Who Named It?
  4. ↑ Berrios, G. E.; Luque, R. (1999). "Cotard's 'On Hypochondriacal Delusions in a Severe form of Anxious Melancholia'". History of Psychiatry. 10 (38): 269–278. doi:10.1177/0957154x9901003806. PMID   11623880. S2CID   145107029.
  5. ↑ Brumfield, Dale M. (2020-10-02). "Mademoiselle X: Living While Dead". Lessons from History. Retrieved 2022-05-13.
  6. ↑ Debruyne H.; et al. (June 2009). "Cotard's syndrome: a review". Curr Psychiatry Rep. 11 (3): 197–202. doi:10.1007/s11920-009-0031-z. PMID   19470281. S2CID   23755393.
  7. ↑ Debruyne Hans; et al. (2011). "Cotard's Syndrome". Mind & Brain. 2.
  8. ↑ Yarnada, K.; Katsuragi, S.; Fujii, I. (13 November 2007). "A Case Study of Cotard's syndrome: Stages and Diagnosis". Acta Psychiatrica Scandinavica. 100 (5): 396–398. doi:10.1111/j.1600-0447.1999.tb10884.x. PMID   10563458. S2CID   37808330.
  9. ↑ Young, A.W., Robertson, I.H., Hellawell, D.J., de, P.K.W., & Pentland, B. (January 01, 1992). Cotard delusion after Brain Injury. Psychological Medicine, 22, 3, 799–804.
  10. ↑ Subhas, N., Naing, K.O., Su, C. et al. (2021). Case report on Cotard's syndrome (CS): a rare case from Malaysia. Egypt J Neurol Psychiatry Neurosurg 57, 107.
  11. ↑ Young, A. W.; Leafhead, K. M. (1996). "Betwixt Life and Death: Case Studies of the Cotard Delusion". In Halligan, P. W.; Marshall, J. C. (eds.). Method in Madness: Case studies in Cognitive Neuropsychiatry. Hove: Psychology Press. p. 155.
  12. ↑ Mendhekar, D. N.; Gupta, N. (January 1, 2005). "Recurrent Postictal Depression with Cotard delusion". Indian Journal of Pediatrics. 72 (6): 529–531. doi:10.1007/BF02724434. PMID   15985745. S2CID   32208293.
  13. 1 2 Pearn, J.; Gardner-Thorpe, C. (May 14, 2002). "Jules Cotard (1840–1889): His Life and the Unique Syndrome that Bears his Name". Neurology (abstract). 58 (9): 1400–3. doi:10.1212/wnl.58.9.1400. PMID   12011289.
  14. ↑ Morgado, Pedro; Ribeiro, Ricardo; Cerqueira, João J. (2015). "Cotard Syndrome without Depressive Symptoms in a Schizophrenic Patient". Case Reports in Psychiatry. 2015: 643191. doi: 10.1155/2015/643191 . ISSN   2090-682X. PMC   4458527 . PMID   26101683.
  15. ↑ Gonçalves, Luís Moreira; Tosoni, Alberto; Gonçalves, Luís Moreira; Tosoni, Alberto (April 2016). "Sudden onset of Cotard's syndrome as a clinical sign of brain tumor" (PDF). Archives of Clinical Psychiatry. São Paulo. 43 (2): 35–36. doi: 10.1590/0101-60830000000080 . ISSN   0101-6083.
  16. ↑ Bhatia, M. S. (August 1993). "Cotard's Syndrome in parietal lobe tumor". Indian Pediatrics. 30 (8): 1019–1021. ISSN   0019-6061. PMID   8125572.
  17. ↑ Joseph, A. B.; O'Leary, D. H. (October 1986). "Brain Atrophy and Interhemispheric Fissure Enlargement in Cotard's Syndrome". The Journal of Clinical Psychiatry. 47 (10): 518–20. PMID   3759917.
  18. ↑ Helldén, Anders; Odar-Cederlöf, Ingegerd; Larsson, Kajsa; Fehrman-Ekholm, Ingela; Lindén, Thomas (December 2007). "Death Delusion". BMJ. 335 (7633): 1305. doi:10.1136/bmj.39408.393137.BE. PMC   2151143 . PMID   18156240.
  19. 1 2 Debruyne, H.; Portzky, M.; Van den Eynde, F.; Audenaert, K. (June 2010). "Cotard's syndrome: A Review". Current Psychiatry Reports. 11 (3): 197–202. doi:10.1007/s11920-009-0031-z. PMID   19470281. S2CID   23755393.
  20. ↑ Halligan, P. W., & Marshall, J. C. (2013). Method in madness: Case studies in cognitive neuropsychiatry. Psychology Press.
  21. ↑ Fricker, Martin; Arnold, Sarah (November 30, 2016). "Dad tried to starve himself after rare condition made him think he was DEAD". Daily Mirror.
  22. ↑ Sanford, James (February 8, 2009). "Nothing is what it seems to be in surrealistic 'Synecdoche, New York'". mlive.
  23. ↑ "Per 'Dead' Ohlin was black metal's most tragic loss". Kerrang!. Retrieved 2021-09-02.
  24. ↑ "Looking Back At Per 'Dead' Ohlin". Invisible Oranges. May 15, 2012. Retrieved 2021-09-02.
  25. ↑ "'Before you know it, it's not a big deal to kill a man': Norwegian black metal's murderous past". The Guardian. 2019-03-22. Retrieved 2021-09-02.
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