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Photo Credit: The title graphic is a portion of Edvard Munch's "The Scream" - 1893
The patient had been diagnosed with schizophrenia for years, had strange delusions, had a history of multiple attempts at suicide using bizarre methods, reported unusual physical symptoms, reported unusual visual perception problems, and was strangely believable and likable. Nothing in this description would shock the seasoned mental health professional. However, digging deeper into the nature of the delusions of this patient helped to yield clues to the correct diagnosis. This patient's delusion involved the belief that he was dead. He was convinced of this because "my family killed me several years ago" - the description was graphic and detailed but untrue, obviously. He said he knew he was dead for several reasons: he felt dead, he could not see people or things as he used to, he felt he was blind in some way, he could not see his feet as he walked, and had many other unusual perceptual problems. He reported several other unusual beliefs and explained that his suicide attempts were designed to prove to everyone that he was, in fact, dead. The odd delusions and the logical way in which they were described led me to research this patient's symptoms more fully and this web site is the result. The diagnosis that seemed to fit this man was Cotard Syndrome. [Update: This man received a series of 12 electro-convulsive therapy (ECT) treatments in 1999 and, at last report, is doing very well. He has not made any further attempts at suicide.]
Cotard Syndrome is also referred to as Cotard's syndrome, Cotard delusion, délire des négations, delusion of negation, and nihilistic delusion. The primary symptom of Cotard Syndrome is the delusion that the person is dead. The name of the syndrome assumes that Jules Cotard first described the syndrome in 1880. Jules Cotard reported a case of agitated melancholia characterized by a delusion that the person did not exist (délire des négations). However, Forstl & Beats (1992) report that Charles Bonnet in 1788 described the case of a woman who developed the delusion that she was dead (Cotard syndrome) and that she was in another place (reduplicative paramnesia).
Jules Cotard describes the syndrome that now bears his name in this way (please excuse the horrible translation and paraphrase): "In all the patients the hypochondriacal delirium introduces great delusions: their brain, stomach, heart, blood, spirit and/or body are missing. They are damned, the organs do not exist, the body is reduced to a mere machine. The delusions may include religious, metaphysical, and abstract ideas of persecution. To such ideas, delusions of immortality may come to be included. Along with or following the ideas of immortality may come ideas of body expansion in space: they are immense, their dimension is gigantic, they can touch the stars, they may feel possessed by powerful demons, their head expands until it occupies an entire church. At times the body no longer has limits, it extends to the infinite and it disperses in the universe." (Cotard, 1880). Cotard and many other more-contemporary researchers believed the disorder was much more complex than a mere "delusion that you are dead", as currently defined by many of the researchers (e.g., Joseph & O'Leary, 1986). Cotard Syndrome may include any of the following symptoms: depression, the delusion that you are dead, difficulty recognizing faces, difficulty recognizing buildings and places, feelings of derealization, paranoia, mania, catatonia, schizophrenia, and unusual beliefs about the body (e.g., "I have turned to stone", "My insides are stone", "I have no internal organs", "My body has been replaced by a shell".).
Berrios & Luque (May 1995) discuss the history of Cotard's syndrome. They believe that Jules Cotard's original intent was to describe délire des négations as a subtype of depressive illness. Further discussion of the subject led to the belief that délire des négations was merely "a collection of symptoms associated with agitated depression (anxious melancholia) or general paralysis." Later researchers viewed it as a separate entity, hence, Cotard syndrome. Berrios and Luque seem to scoff at the more recent studies which take a neurobiological approach to the syndrome. The idea that a delusion that you are dead could be traced to a specific brain location just astounds them!
Cotard Syndrome has been associated with depressive symptoms [Le Roux & Rochard (1986); Ko (1989); Luque & Valls (1994); Hamon & Ginestet (1994); Chainho, Antomio, Paiva, & Reis (1994); Petracca, Migliorelli, Vasquez, & Starkstein (1995); Chiu (1995); Berrios & Luque (1995); Sabatini, Actis, Madaro, & Ravizza (1996); Lohmann, Nishimura, Sabri, & Klosterkötter (1996)], feelings of derealization [Young, Robertson, Hellawell, de Pauw, & Pentland (1992)], affective disorders [Joseph (1986); Fillastre, Fontaine, Depecker, & Degiovanni (1992)], paranoid schizophrenia [Joseph (1986); Ko (1989); Fillastre, Fontaine, Depecker, & Degiovanni (1992); Simovici & Bauer (1996)], face processing deficits [Young, Robertson, Hellawell, de Pauw, & Pentland (1992); Silva & Leong (1996)], and catatonia [Cohen, Cottias, & Basquin (1997); Berrios & Luque (1995)].
Berrios & Luque (March 1995) performed a statistical analysis on 100 cases of Cotard's syndrome. Cotard Syndrome was found to affect men and women in equal numbers and severity. The elderly were more likely to develop the syndrome. Depression was reported in 89% of subjects, anxiety in 65% of subjects, and guilt in 63% of the subjects. Delusions were categorized thusly: nihilistic delusions concerning the body (86%), nonexistence (69%), hypochondriacal delusions (58%), and delusions of immortality (55%). An exploratory factor analysis extracted three factors: psychotic depression, Cotard type I, and Cotard type II. The psychotic depression factor included patients with depression and few nihilistic delusions. Cotard type I patients, on the other hand, showed no loadings for depression or other disease and are likely to constitute a pure Cotard syndrome whose nosology may be closer to the delusional than the affective disorders. Type II patients showed anxiety, depression and auditory hallucinations and constitute a mixed group.
Recent studies have associated differences in the brain structure of persons with Cotard Syndrome. Joseph & OLeary (1986) associated "multifocal brain atrophy and medial frontal lobe disease" with Cotard's syndrome. Sabatini, Actis, Madaro, & Ravizza (1996) associated multiple ischemic foci and signs of cortical atrophy" with Cotard's syndrome. Young, Robertson, Hellawell, de Pauw, & Pentland (1992) reported a case of Cotard delusion following a head injury. The damage affected the "temporo-parietal areas of the right cerebral hemisphere and (the) frontal lobe" bilaterally. Joseph (1986) associated "cerebral dysfunction of the parietal, temporal, and occipital regions" with Cotard's syndrome. Two very interesting studies identified specific brain regions associated with Cotard Syndrome and described the successful treatment of the syndrome with electroconvulsive therapy. Both studies went further to show that the ECT actually changed the blood flow to the affected regions after ECT! Lohmann, Nishimura, Sabri, & Klosterkötter (1996) associated "bitemporal hypoperfusion relative to the cerebellum" with Cotard syndrome. ECT successfully alleviated the symptoms and restored blood flow to the affected region. Petracca, Migliorelli, Vasquez, & Starkstein (1995) associated "reduced blood flow in the frontoparietal medial and dorsolateral frontal cortex, basal ganglia, and thalamus" with Cotard's syndrome. 12 ECT treatments resolved the Cotard's syndrome and major depression and a SPECT study one month later showed increased blood flow in the affected regions.
The treatments reported for Cotard Syndrome have included: tricyclic and serotoninergic antidepressants [Sabatini, Actis, Madaro, & Ravizza (1996)] which were ineffective; and, electroconvulsive therapy [Lohmann, Nishimura, Sabri, & Klosterkötter (1996); Kearns (1987); Cohen, Cottias, & Basquin (1997); Petracca, Migliorelli, Vasquez, & Starkstein (1995); and Hamon & Ginestet (1994)] - all five of these studies reported successful treatment of the Cotard Syndrome symptoms with ECT.
An interesting (and perhaps) related finding is the research on the drug ketamine (a veterinary anesthetic similar to PCP). Vollenweider, Leenders, Scharfetter, Antonini, Maguire, Missimer, & Angst (1997) found that ketamine can induce both positive and negative symptoms of schizophrenia in normal volunteers. Ketamine has been reported to primarily block N-methyl-D-aspartate (NMDA) receptor complex in the brain. The researchers found that ketamine affected the metabolism in the frontomedial and anterior cingulate cortex. Ketamine can cause some people to experience what is commonly called a "near-death experience." In some individuals the feeling may linger beyond the drug experience. An anesthetist observed: "Ketamine allows some to reason that ...the strange, unexpected intensity and unfamiliar dimension of their experience means they have died."
(See
http://www.lycaeum.org/drugs/synthetics/ketamine/Ketamine_near-death.html ). It may be that the action of ketamine and the neurobiological changes due to schizophrenia and Cotard Syndrome are similar processes. Young, Leafhead, & Szulecka (1994) believe that the unusual perceptual experience that occurs in Cotard Syndome (and Capgras Syndrome) present a challenge to the individual's sense of reality which they attempt to provide an explanation for. The explanation that some individuals come up with, apparently, is the fixed, false belief that they have died.
The National Clearinghouse for Alcohol and Drug Information
(
http://www.health.org/govpubs/prevalert/v3i28.aspx ) reports that ketamine produces a dissociative state in the user. "Effects can range from rapture to paranoia to boredom. The user feels its hallucinogenic effects and experiences impaired perception. Ketamine commonly elicits an out-of-body or near-death experience; it can render the user comatose. Ketamine is similar molecularly to phencyclidine (PCP--or "Angel Dust") and thus creates similar effects including numbness, loss of coordination, sense of invulnerability, muscle rigidity, aggressive/violent behavior, slurred or blocked speech, exaggerated sense of strength, and a blank stare. There is depression of respiratory function but not of the central nervous system, and cardiovascular function is maintained. Since ketamine is an anesthetic, it stops the user from feeling pain, which could lead the user to inadvertantly cause injury to himself/herself. Ketamine may relieve tension and anxiety, is purported to be a sexual stimulant, and intensifies colors and sounds. The effects of a ketamine 'high' usually last an hour but they can last for 4-6 hours, and 24-48 hours are generally required before the user will feel completely "normal" again. Effects of chronic use of ketamine may take from several months to two years to wear off completely. Low doses (25-100mg) produce psychedelic effects quickly. Large doses can produce vomiting and convulsions and may lead to oxygen starvation to the brain and muscles; one gram can cause death. Flashbacks may even occur one year after use. Long-term effects include tolerance and possible physical and/or psychological dependence."
"Paul" at a psychedelic drug infomation web site (Don't you just love the Internet?!)
(
http://www.erowid.org/chemicals/ketamine/ketamine_info1.shtml ) reports the following comments made by patients coming out of ketamine anesthesia: "Well, Doc. I was floating up on the ceiling, looking down at myself."; "I died and went to Heaven. I saw God and the angels, it was beautiful."; "This UFO landed and these aliens took me aboard and we flew around."; "Everything was red. Then I realized I'd become a blood cell."; "I relived a previous life as an Egyptian mathematician."; and "Wow, man. That was some mean acid you gave me."
Back to "reality". Imagine if, after a brain injury, stroke, or some unknown accident in the brain's chemistry, you began to see people and things differently. You began to lose the feeling in your body, you began to feel that things were unreal, that you were unreal. In short, you began to experience a "trip" without the knowledge that you had taken some drug to induce it. Attribution theory says that you will develop an explanation for what you are experiencing. If your mind works in the wrong way, you may decide that you have died. Certainly, Cotard Syndrome is more complex than this but this seems to at least partially explain what is going on. Finding the sites in the brain that are affected by ketamine and similar drugs may lead to the cure for schizophrenia, Cotard Syndrome, Capgras Syndrome, and other strange delusions. May God bless you and keep you looking for Him.
Links to Additional Information on Cotard Syndrome and Related Conditions
Dr. Philip Gerrans, Department of Philosophy, University of Adelaide, South Australia, teaches on the philosophy of psychology and cognitive science, political philosophy and the philosophy of social science. He has been kind enough to provide the following links to his web site and full-length articles on Cotard Syndrome: Dr. Gerrans Publication List
Related Disorders
Disclaimer: The author of this web site is not a medical doctor. The material in this site is provided for educational and informational purposes only, and is not intended to be a substitute for a health care provider's consultation. Please consult your own physician or appropriate health care provider about the applicability of any opinions or recommendations with respect to your own symptoms or medical treatment.
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