Outline
Introduction
Imagine waking up one day and experiencing a severe dissociation with your own anatomy. An overwhelmingly real and conscious belief that you in some way lost an organ, or missing body part(s), or even the idea that you are existing while believing you are dead!
This sensation and delusion of immortality sounds like something out of a Hollywood horror movie! But fiction it is not. This type of delusion is a very real and rare condition, known as Cotard's syndrome. As Cotard's syndrome manifests in a patient they begin to consciously conceive the belief that they are no longer living. Rather, patients experience a state of being that can be described as, zombie-like.
A Little History
Cotard’s syndrome, which was first identified by Dr. Jules Cotard in 1882, summarized a series of delusions amongst psychiatric patients. Dr. Jules Cotard noted that this syndrome manifested in patients who were already obtaining medical care for mood disorders and psychotic disorders.
Cotard’s syndrome is often referred to as, Walking Corpse Syndrome. Since 1882, experts in the field have continued to associate Cotard’s neuropsychiatric illness with preexisting neuropsychological conditions and patients who present with neuropsychosis. As a means to develop a treatment plan for Cotard’s syndrome patients, medical professionals work diligently to identify the localization of the neuropathology when establishing a treatment plan.
Cotard’s Syndrome Neuropathology
According to Dr. Josephs, neuroimaging of four Cotard's syndrome patients and their imaging presented frontal lobe changes, four patients demonstrated generalized volume loss, and five patients possessed ischemic changes. Experts have also closely examined right-sided and bilateral hemisphere lesions in Cotard patients. Finding this relationship between right-sided and bilateral hemisphere lesions to be an important study regarding the manifestation of a patient's symptoms.
Medical professionals have documented the belief that the presence of nondominated hemisphere lesions may prove to have a vital role in the patient specific pathophysiology of the illness. Research has demonstrated locational trends amongst patients, stating that there is an increase in bilateral cerebral atrophy and median frontal lobe atrophy.
Healthcare professionals have continued to have a long-standing knowledge of the frontal lobe and the detriments that can manifest as a result of damage to this region of the brain.
Since the case of Phineas Gage, researchers have continued to explore its role on personality traits, and superior cognitive function and awareness. Frontal lobe damage is often medically linked to pathophysiology of delusions amongst patients who experience (but not limited to) psychosis and mania. Delusions and hallucinations are not solely associated with Cotard's, they are also documented as a symptom of schizophrenia. Researchers attempt to isolate localization of abnormal perception and the persistence of this perception. As a result, studies have consistently been able to associate the manifestation of these symptoms with frontal lobe damage.
These axial neuro-imaging highlights large vascular lesions in three patients who experience Cotard Delusions.
In addition, studies have shown that a deep right frontal lesion may disrupt the autonomic connection. Subsequently, disruption to the neurological autonomic connections can consequently damage the connection between the temporal and limbic regions of brain.
Damage of this degree to the frontal lobe could invoke a diverse range of cognitive impairments. With the most drastic and life altering being the disturbance in cognitive familiarity and memory recall. Symptoms would resemble the patient experiencing the inability to identify themself, their family or friends, places or locations and relative objects. In addition, a patient may become unable to resolve cognitive conflict; as well as, experiencing dissociative perceptions and sensations. This neuropsychiatric experience would affect the patient's ability to recognize their own autonomy and will likely disable their ability to interact or react to environmental stimuli.
Treatment for this experiencing Cotard's syndrome is immediately required, as a result of nihilistic delusion(s); these symptoms would increase the likeliness of a patient performing self-inflicted harm.
Treatment
When providing treatment options, most medical professionals recommend electroconvulsive treatment; otherwise, known as ECT. Research shows that Cotard delusion patients appear to be more responsive to electroconvulsive treatment, vs. traditional pharmacological treatment approaches. Historically, neuropsychiatric conditions are treated via the pharmacological approach, with therapy rather than ECT.
However, the success of these medicaations in the case of Cotard are likely subject to the patients preexisting neuropsyciatric comorbidities. In some patient specific instances researchers have documented treatment success when there is an increase in dopamine receptor binding. This success appears to be correlated with patient specific pathopsychology of which similarly represents Schizophrenia. This specific pathophysiological localizaation appears to enhance the effectiveness of a dopamine antagonist.
Medical providers are still challenged by this syndrome and functional images are needed to determine the autonomic or network disruption that has evoked the delusions, which continues to vary per patient.
Sources
Sahoo, Aradhana, et al. “A Neuropsychiatric Analysis of the Cotard Delusion.” The Journal of Neuropsychiatry and Clinical Neurosciences, 23 June 2017, neuro.psychiatryonline.org/doi/full/10.1176/appi.neuropsych.17010018.
Ruminjo, Anne, and Boris Mekinulov. “A Case Report of Cotard's Syndrome.” Psychiatry (Edgmont (Pa. : Township)), Matrix Medical Communications, June 2008, www.ncbi.nlm.nih.gov/pmc/articles/PMC2695744/.
“Cotard Delusion.” Wikipedia, Wikimedia Foundation, 23 June 2021, en.wikipedia.org/wiki/Cotard_delusion.
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