Friday, 28 April 2017

Dead People Don't Need to Eat – A Look at Cotard's Delusion.

Credit: Ebaumsworld
Season 9, Episode 6 – The Death of Eric Cartman – For those of you that haven’t seen the episode, Cartman is unable to conceive the idea that anyone would ignore him, but following a disagreement, his friends decide to ignore him completely and surrounding circumstances make him believe he’s actually dead – a ghost if you will. Now, this belief is actually the basis of a psychological disorder known as Cotard’s Delusion (or Syndrome, but I will refer to it as a delusion as that is what it is – a psychotic delusion). Cotard’s Delusion (CD) is the belief that one is dead or has body parts such as organs that are dead, and despite the absurdity of the claims, sufferers believe the delusion so strongly to the point where many die from starvation, as there is a strong belief of “dead people don’t need to eat.”

In this situation, Cartman did not have Cotard’s due to it being situational and once approached by people he realised he wasn’t actually dead – it was just a case of him being himself; an idiot. However, the fear and struggle he felt was real, and is something sufferers feel very strongly. The delusion itself came about in the 1880’s, when Jules Cotard came across a patient who reported a feeling of having no brains, nerces, chest, or entrails, and was simply skin and bone – neither God nor the Devil existed - She was eternal and would live forever. Like that of a corpse or a ghost.

Credit: Shawn Coss
The neurobiology of it isn’t clearly understood, but reports have stated that patients with CD have problems with facial recognition, a domain which helps us familiarise other humans and ourselves. A problem with processing faces causing a lack of recognition and therefore a lack of connection with people, leading to a feeling of being disconnected – including disconnected to oneself. This phenomenon is the basis of depersonalisation/derealisation disorders, a feeling of disconnection with reality/oneself, something that linked to CD as in many cases the delusion appears secondary to a psychotic disorder such as schizophrenia or depersonalisation disorder, and as Cotard’s is a delusion it can fall under being a symptom of these disorders.

A large majority of the research on Cotard’s is case study based, so I’m going to share a few of the most interesting ones I’ve come across! Case Study 1:

“A 48-year-old male musician was hospitalized for severe anxiety and depression. He had been well until approximately 1 month prior to admission when his family found him anxious, sad, and feeling guilty because of "many sins." He paced back and forth, anxiously pulling his hair, and then experienced auditory hallucinations but refused to relate their content. Five days later he complained of not feeling as if he was himself. On admission, he expressed delusions of reference and harm but he also repeated that nothing was true: "The hospitals do not exist, the doctors do not exist. . . Tm scared." He appeared perplexed and frightened, looking at his hands and touching his face repeatedly, and stated that nothing existed, including himself. Physical and neurologic examinations were otherwise normal. A computed tomography (CT) scan of the brain was unremarkable, and lumbar puncture revealed no cells and normal levels of proteins and glucose in the CSF.

The patient's past history was significant for similar psychiatric symptoms, with episodes of depression and many episodes of depersonalization and derealization, without delusional or hallucinatory phenomena, which resolved spontaneously in the course of hours or days.

During the initial 24 hours, the patient refused to eat. He continuously stared at his hands, sometimes stating, "I do not have hands/' "Nothing exists," "I feel guilty." Clonazepam and risperidone were started, and amitryptiline was added later to his treatment. He gradually became alert, oriented, attentive, and cooperative but continued to feel guilty about his behavior. He was discharged after 12 days on ainitryptiline (75 mg) and risperidone (2 mg). Two weeks later, on follow-up, the patient was working half-time singing and playing the guitar. His mood appeared normal although he continued to feel situational anxiety and guilt. He denied symptoms of depersonalization, derealization, delusions, or hallucinations.”

In this situation you can see that the patient already suffered from depression and anxiety, and CD in this case was easily treatable with antipsychotic medication. From this case study, CD manifested itself and his diagnosis would have been declared as psychotic depression – The delusion is a symptom rather than a standalone illness, which in my eyes makes it scarier. It can strike at any time like in this gentleman’s case, and alongside pre-existing psychiatric conditions, an additional diagnosis of CD seems overwhelming and horrifying!

Credit: Shawn Coss
Case study 2:

“A 78-year-old internist presented with a 7-month history of depressed mood, anhedonia, anorexia with a loss of 20 pounds over several weeks, loss of interest in self -care and hygiene, ideas of self-loathing, and delusional ideas of ruin and catastrophe. In the emergency ward, he rejected hospitalization with the argument that he was "already dead." In the neuropsychiatrie ward, he repeatedly stated, "I'm a terminal patient" and "Tm done. There's no point in treating me. Tm terminal." Later on he stated, "I am no longer myself, I fell like an automaton, like if the world did not exist; I am completely eliminated." He also stated that "the food I eat sticks to my bowel, that's why I don't eat anymore, that's why I don't even drink water or take medications, and I don't defecate because I have hemorrhoids." Also he insisted that he had lost his right kidney and that the left kidney did not work anymore. His past medical history was remarkable for hypertension, treated with enalapril, 10 mg/day, and nifedipine, 30 mg/day; gout treated with allopurinol; the prior expulsion of a kidney stone; and benign prostatic hypertrophic prostate treated with transurethral resection.

His examination suggested parkinsonism. On gait examination, he had marked slowing in all of his movements with very small steps, a loss of associated arm movements, and a mild loss of postural reflexes with deviation of the trunk to his left. On cranial nerve examination, he had niinimal facial expressivity resembling hypomimia, with a slow and low volume of speech. On motor examination, he had generalized bradykinesia and mild limb and axial rigidity but no tremors. On the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS), he scored 35 points, indicating mild to moderate severity. MRI showed an increase in the subarachnoid space in both the frontolateral areas and a mild dilation in the ventricular system.

The patient was diagnosed with major depressive episode with psychotic symptoms and with the suspicion of a rigid-akinetic syndrome (probably idiopathic Parkinson's disease). He received mirtazapine, 60 mg/ daily, and ECT, and after three sessions he had a marked improvement of his gait and speed and amplitude of movements. He also experienced a decrease in the motor part of the UPDRS to 23 points (34% decrease, which is considered a good response). After the eighth ECT session, there was an evident improvement of mood, decreased anxiety, and resolution of his Cotardlike beliefs. He was discharged after 31 days of hospitalization, and follow-up at 1 month showed absence of depression or a return of his parkinonian features.”

Both studies taken from Morgado et al. (2015).

This one was very interesting. The manifestation of CD in this instance is different, and yet fulfils the criteria of CD perfectly. The death of organs, and the description of food “sticking” to his bowel illustrates how horrifying real these ideas are to the patients. This case study is also on of many that uses ECT as a form of treatment, as it has been found to be the most effective in such cases.

Cotard’s delusion is a scary delusion, a symptom of bigger psychiatric problems it is probably the most problematic one of them all. After all, our job in healthcare is to prevent death, so what do you do when your patient already thinks they’re dead?

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