"For life and death are one, even as the river and the sea are one."
Understanding
Do you ever feel like a plastic bag? Yeah, me too. You know, in some cases, people feel like they’ve never existed?
Cotard’s syndrome or Cotard delusion is a condition that typically manifests in the form of denial of the existence of one’s own body parts, to the negation of one's own existence. Cotard delusion usually occurs alongside other mental illnesses and is extremely rare, with about 200 known cases worldwide.
Symptoms
Cotard’s syndrome is often actually a symptom itself of a deeper medical problem of the brain, such as dementia, epilepsy, migraine, multiple scleroses (abnormal hardening of body tissue), Parkinson’s disease, stroke and subdural bleeding.
But one of the main symptoms of Cotard delusion is nihilism, the belief that nothing in the world has a real existence. Depression is also closely related to Cotard delusion. A 2011 research study noted that 89% of documented cases of this syndrome include depression as a symptom. Other common symptoms include: anxiety, hallucinations, hypochondria (abnormal anxiety about one's health, especially with an unwarranted fear that one has a serious disease), guilt and preoccupation with hurting yourself. Suicide attempts are also common among people with Cotard delusion as some see it as a way to prove the fact that they’re already dead by showing that they can’t die again while some feel trapped in a body and life that don't feel real to them.
Potential Causes
While there are no specific causes for Cotard’s syndrome affecting an individual, there are a few common factors among those who have been affected by this condition: the average age of people with Cotard delusion is early 50s, people with this condition quite often also have bipolar disorder, and women also seem to be more likely to develop Cotard delusion. Additionally, those with postpartum depression, dissociative disorder, psychotic depression and schizophrenia are quite susceptible to developing this condition.
An interesting thing to note about Cotard delusion is that it seems to occur more often in people who think their personal characteristics cause their behavior and not their environment. On the flip side, people who believe that their behavior is influenced by their environment are more likely to have a condition called Capgras syndrome, which we have spoken about before on the blog. Cotard delusion and Capgras syndrome can also appear together.
Diagnosing
Most organisations actually don’t recognise Cotard’s syndrome as a disease and its inclusion in the DSM-5 as a specific listing has also been avoided. Therefore there is no standardized list of criteria that can be used to make a diagnosis. In most cases, it is only diagnosed after any other possible conditions have been ruled out.
Treatments
Since Cotard delusion usually occurs with other conditions, so treatment options can vary widely. Treating the problem that's causing it is more common.
But, what has been found is that electroconvulsive therapy (ECT) was the most commonly used treatment. ECT involves passing small electric currents through your brain to create small seizures while you’re under general anesthesia. It does carry some risks with it like memory loss, confusion and nausea, which is why it is treated as a last resort.
A lot of people do well with a combination of medication and talk therapy (like cognitive behavioural therapy [CBT] or psychotherapy). It is a safe, open environment for people to express how they feel and for them to learn strategies for a healthier mindset and behaviour.
Other treatment options are antidepressants, antipsychotics and mood stabilizers.
Conclusion
In summation, Cotard delusion is a fascinating yet frightening condition that we, due to its rarity, have a significant lack of information about. As research on this puzzling syndrome continues, we hope to uncover some of the mystery shrouding it. In the mean time, have a look at 2 case studies that help better elaborate the implication of this condition.
Case studies
Note: The case studies have been slightly paraphrased by the author for the convenience of the reader.
1: Ms. L, a 53-year-old Filipino woman, was admitted to the psychiatric unit when her family called 911 because the patient was complaining that she was dead, and that she smelled like rotting flesh, and wanted to be taken to a morgue so that she could be with dead people. Upon her interview in the hospital, the patient expressed fear that “paramedics” were trying to burn down the house where she was living with her cousin and her brother. She also admitted to hopelessness, low energy, decreased appetite, and somnolence.
Ms. L reported that she had been on antidepressants while in the Philippines (where she had resided for the last 18 years, having moved to the US only a month ago), but could not recall the name or dosage of the medication.
After organic causes were ruled out, treatment with medication was started. The patient was initially reluctant to take medication or eat. She subsequently developed an electrolyte imbalance, which necessitated intravenous electrolyte repletion. The patient was also isolative, spending much of the day in bed and neglecting her personal hygiene and grooming.
With her family’s support, the decision was made to take the patient to court for treatment over objection. Subsequently, the patient’s medication regimen was altered. but a few days later, the patient had a questionable seizure episode, necessitating transfer to a medical unit. After three days, she returned to the psychiatry floor where her medication regimen included alternatives to her previous medication (that caused the questionable seizure) and a new inclusion for agitation.
Ms. L showed improvement in symptoms over one month on this new course of medication. At discharge she denied nihilistic or paranoid delusions and hallucinations and expressed hopefulness about her future and a desire to participate in psychiatric follow-up care.
2: Mr. B, a 65-year-old retired teacher who was well adjusted with no family history of mental illness, with a personal history of smoking cigarettes in a dependent pattern for the last 30 years, presented with an insidious onset mental illness of one and half years duration precipitated by psychosocial stressors. His symptoms were initially characterized by sadness of mood with early morning worsening, poor socialization, marked anxiety, decreased sleep and appetite, ideas of worthlessness, hopelessness, sin and guilt.
As his symptoms progressed further he developed delusions of catastrophe, nihilism, poverty and persecution. Nihilistic delusion involved a description of everything coming to an end. He would verbalize that his organs were no longer working, his brain had stopped functioning, and that his house had developed cracks and was going to fall down. About a month prior to being admitted to the inpatient unit, he attempted suicide by hanging himself, but was saved. His suicide note revealed that he wanted to kill himself as he feared spreading a deadly infection to the villagers who resultantly might suffer from cancer.
Later he started believing that he was dead and would not eat anything, due to which he lost a significant amount of weight. Over the next 2 months, he attempted to end his life two more times. Following one of such suicide attempt, he was brought to the outpatient unit and was admitted. Medical history and physical examination revealed presence of hypertension, malnutrition, nutritional large fiber neuropathy, benign prostatic hypertrophy, chronic obstructive pulmonary disease and chronic otitis media. His mental state examination revealed sad affect, marked agitation, ideas of hopelessness, delusion of catastrophe, delusion of guilt, sin and nihilism (of being dead). He lacked insight into his illness.
On the basis of the history and mental status examination a diagnosis of severe depression with psychotic symptoms was made. His Hamilton Depression Rating Scale (HDRS) score at time of admission was 34. His investigations including thyroid function test and MRI brain did not reveal any abnormality. His nutritional deficiencies were addressed. His depression was successfully treated with bilateral modified electro-convulsive treatment (ECT) using medication for induction and muscle relaxation. The patient was administered ECT three times (Monday, Wednesday and Saturday) weekly and in total, received ECT 9 times. Additionally he was treated with medication typically administered for the depression and schizophrenia which were started a few days prior to starting ECT, and were continued during the period when the patient was receiving ECT. His symptoms resolved completely over the period of 7 weeks and his HDRS at the time of discharge was 1. He maintained improvement after discharge from the inpatient unit.