I Think, Therefore I’m not? The Bizarre Nature of Cotard’s Syndrome

What reasons does the reader of this article have for assuming they are alive? Is it an ability to interact with the environment or with those they call friends? Or perhaps it is the myriad of bodily sensations occurring every second that stoke our consciousness into a sense of ‘aliveness’. But what if none of these could convince you that you were among the living — then you might be a victim of Cotard’s syndrome.

Origins

The lecture hall was filled with the gathered guests awaiting the lecture due to be given by a then 40-year-old bearded French psychiatrist and neurologist. The title of the lecture: ‘ Du delire hypocondriaque dans une forme grave de melancolie anxieuse’ (on hypochondriacal delusions in a severe form of anxious melancholia) (Cipriani et al, 2019).

Having achieved his doctorate twelve years before, the neurologist’s name had already been tied to some notable reports and case studies. But it was here, before his colleagues that his lecture would ensure his immortality. In this bizarre exposition of a 43-year-old woman, the gathered specialists and those who came after would be forced to contemplate the philosophical as well as medical ramifications of the disorder.

Cotard is standing as he quotes from his notes on the bizarre declarations made by his patient:

The following from: (Cipriani et al, 2019).

“…no brain, nerves, chest, or entrails and was just skin and bone”

“she’s nothing more than a decomposing body, and has no need to eat for living”

“she was eternal and would live forever”

The denial of organs as well as other symptoms including the idea one had already died would become the presenting features of an illness that would take its name from the lecturer that day and become: Cotard’s syndrome.

Cotard himself had pronounced the discovery of a new or rather newly discovered syndrome and the symptoms that defined the borders of the syndrome these were:

1. Extreme melancholia
2. Suicidal behavior
3. Delusions of nonexistence
4. Delusions of immortality
5. Insensitivity to pain

(Berrios and Luque, 1995)

The symptomology of Cotard’s may be further analyzed by looking at the prevalence of each as it appears in patients. According to a review (Berrios and Luque. 1995 as cited in Debruyne et al, 2009) the prominent symptoms:

1. Depressive mood 89%
2. Nihilistic delusions about one’s body 86%
3. Nihilistic delusions about one’s existence 69%
4. Anxiety 65%
5. Delusions of guilt 63%
6. Delusions of immortality 55%
7. Hypochondriac delusions 58%

Additional examples of Cotard’s in the medical literature:

Case 1

A case report (Ruminjo and Mekinulov, 2008) discusses a certain Ms. L, a 53-year-old Filipino woman who was admitted to a psychiatric hospital after describing in vivid detail how she was in fact already dead. Along with this startling delusion came other grotesque beliefs such as fearing that she had the odour of rotting fish and that the paramedics who had first arrived on the odorscene were trying to burn down the house she shared with her cousin. Thus we see persecutory delusions along with the already described belief of having expired.

Due to the lack of organic origins, Ms. L was prescribed medication but after showing reluctance, the family and medical team decided to take Ms. L to court to try and gain support for treatment.

One month after treatment with Lorezepram, Olanzapine and escitalopram the patient denied having any more nihilistic delusions and no further hallucinatory experiences and showed a positive attitude towards the future.

Case 2

The following two cases are from Grover et al (2019).

The first case they report on is of a Mr. B 65-year-old retired teacher. B presented with a cluster of symptoms including anhedonia (inability to feel pleasure), a sense of worthlessness, and profound sadness. His condition reached a climax with a series of bizarre delusions including:

1. Describing that his organs were no longer functioning as they should have been.
2. That his house was crumbling and would soon collapse.
3. His brain had ceased to function

These delusions were manifestations of a deeply overall nihilistic sense of apocalyptic proportions as if everything were coming to an end.

Along with these beliefs, Mr.Lorazepam B had also attempted suicide due to a grotesque belief that he would spread a virulent infection to the several villagers who lived nearby and this might end with them developing cancer.

Sometime later, another hallmark of Cotard’s appeared when B came to believe that he was in fact, already dead.

For treatment, B was prescribed ECT (electro-convulsive therapy) as well as Olanzapine and Escitalopram. Over the course of seven weeks, the patient regained mental equilibrium and his symptoms resolved.

Case 3

From the same authors as Case 2 (Grover et al, 2019) comes the outre history of Ms.. A. Ms A, a 62-year-old homemaker had been suffering from Bipolar disorder for a number of years. For seven to eight months before presentation, Ms. A had been suffering from a variety of mental health issues including decreased appetite, poor self-care, and feelings of worthlessness. Later, her condition worsened and she demonstrated the same nihilistic delusions as other cases have examined. These delusions included:

1. Feeling as if her body parts didn’t exist.

2. Demonstrating a belief that her family didn’t exist.

3. Feeling as if her house might collapse at any point

4. Refused food as she believed she had already died.

Due to the condition worsening, she began to suffer from dehydration and low vitamin D3 levels. Because of the ineffective use of Lorazepram, ECT was delivered. Gradually the depressive episodes and catatonia eased.

Conclusion

As previously asserted in an earlier post, neuroscience is filled with case studies of patients who have lost those functions and skills that we all take for granted. Cotard’s is an extreme example of this, in that the patients lose the belief in their very existence. These cases blur the lines between philosophy and neuroscience. Through studying deficits as terrifically bizarre as Cotard’s we may start to grasp what existence represents to the human mind. How is it we decide that we exist? The question seems preposterous as if nothing could be so tangible as ‘being’ in existence. And yet, for those with Cotard’s syndrome, they teach us that even these most prized and basic beliefs can be lost.

References

Berrios, G.E. Luque, R. (1995), ‘Cotard’s delusion or syndrome?: a conceptual history’ in Comprehensive Psychiatry Volume 36, Issue 3, May–June 1995, Pages 218–223, available from: https://isiarticles.com/bundles/Article/pre/pdf/30288.pdf (Last accessed: 03/03/2022)

Cipriani, G. Nuti, A. Danti, S. Picchi, L. Fiorino, M. (2019), ‘‘I am dead’: Cotard syndrome and dementia’ in International Journal of Psychiatry in Clinical Practice 23:2, 149–156, DOI: 10.1080/13651501.2018.1529248, (Last accessed: 03/03/2022)

Grover, S. Aneja, J. Mahajan, S. Varma, S (2019) ‘Cotard’s syndrome: Two case reports and a brief review of literature’ in Journal of Neurosciences in Rural Practice DOI: 10.4103/0976–3147.145206 Available from: https://www.thieme-connect.com/products/ejournals/abstract/10.4103/0976-3147.145206 (Last accessed: 03/03/2022)

Rumunjo, A. Mekinulov, B. (2008) ‘A Case Report of Cotard’s Syndrome’ in Psychiatry (Edgmont). 2008 Jun;5(6):28–9. PMID: 19727279; PMCID: PMC2695744. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695744/ (Last accessed: 03/03/2022)

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