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Received: August 28, 2002Accepted: April 10, 2003 Delusional Paralysis: An Unusual
Variant of Cotard’s Syndrome
Andreas Reif Waldemar M. Murach Bruno Pfuhlmann Department of Psychiatry and Psychotherapy, University of Würzburg, Würzburg, Germany Key Words
drome: anxious melancholy, ideas of damnation or pos- Coenaesthesic hallucination W Cotard’s syndrome W session, a tendency for self-mutilation or suicide, hypo- Delusional disorder W Electroconvulsive therapy W chondriac ideas about the non-existence or destruction of Nihilistic ideas W Nosology W Psychotic depression inner organs or the whole body, and the idea that one can-not die . The key feature, however, is the delusionalbelief that parts of the patient’s body or organs are missing Abstract
or malfunctioning. This is often described with bizarre Cotard’s syndrome, a highly impressive psychopatho- comparisons, which can extent to the conviction of one’s logical condition, occurs mainly in depressive disorders own death or non-existence. How can a person deny his and entails nihilistic delusions concerning the body and own existence? This question reflects the intriguing enig- the non-existing of the self as outstanding features, ma of Cotard’s delusion, resembling an existentialist vari- accompanied by hypochondriacal delusions and ideas of ant of Epimenides’s paradoxon (Epimenides was the Cre- guilt as well as immortality. We here report on a female tan who coined the famous sentence ‘All Cretans are patient presenting with an unusual variant of the syn- liars’). Thus, Cotard’s delusion is not the only self-verify- drome: most prominently, she had the delusion to be ing delusion as Pearn at al.  suggested, but in fact a paralysed, although displaying psychomotor agitation, self-falsifying delusion and therefore a paradoxon.
and that neuroleptic agents had devoured her nerve gan- Cotard’s syndrome can present in many and astonish- glia. Upon ECT, symptoms rapidly improved. Psychopa- ing clinical pictures, and there is even a manic variant thological implications and the nosological position of incorporating megalomaniac ideas with bodily illusions of enormity . Depressive ideas, apart from the nihilistic delusion of being dead, include the patients’ denial of theworld’s existence, the plea to be buried because thepatients believe they are a rotting corpse, the conviction Introduction
that their bowels and stomach are lacking or that evenmost parts of their body do not work (examples taken Among the generally astonishing uncommon psychiat- from Enoch and Ball ). Here we present a remarkable ric syndromes, Cotard’s syndrome (which he himself case of delusional paralysis, which has so far not been termed ‘le délire de négation’, coming close to the English described in the literature to this extent and once more translation ‘delusional nihilism’) is one of the most fasci- demonstrates the amazing multi-facetted appearance of nating disorders in both psychological and philosophical terms. Cotard listed the following symptoms of the syn- Department of Psychiatry and Psychotherapy University of Würzburg, Füchsleinstrasse 15 Tel. +49 931 201 76000, Fax +49 931 201 77550, E-Mail firstname.lastname@example.org Case Report
Ms P., a 71-year-old retired teacher, had no history of psychiatric To the best of our knowledge, this is the first report on illness until the age of 69. Following a suicide attempt, she had beenadmitted to hospital; she complained of sleep disturbances, restless- delusional paralysis in medical literature. Strikingly, the ness and hypochondriac ideas, and she was described as lamenting. A delusion was held with unshakable belief against all overt diagnosis of adjustment disorder and histrionic-anancastic disorder evidence, i.e. psychomotor agitation. We feel that it is jus- was applied. Following anti-depressant and neuroleptic treatment, tified to regard the symptomatology of Ms P. as a variant she was discharged as almost recovered, however, she soon had to be of Cotard’s syndrome: the delusional content was of the readmitted due to somatoform symptoms (mainly concerning polla-kisuria), which she again described in an anxious and lamenting nihilistic and hypochondriacal type (she thought that manner. Furthermore, she worried about stiffness (which could not parts of her body did not function well, feared to be buried be objectified), attributed by her to neuroleptic treatment, connected alive, and was at times not sure whether she was still liv- with the fear that her hands had to be amputated and that medical ing or not), accompanied by ideas of guilt and agitated insurance would not pay for treatment. During in-patient treatment, depression. Characteristically, the syndrome had been of she attempted suicide twice (by means of intoxication and attempteddrowning), albeit rather demonstrative. As her condition did not sudden onset, without a previous history of psychiatric resolve following treatment with lorazepam, risperidone, mirtaza- disorder but a typical period of initial anxiety. Thus our pine and trimipramine, she was referred to our department for fur- patient featured the most frequent symptoms of Cotard’s syndrome as reported by Berrios and Luque . A pre- On admission, we saw a well-nourished lady with no prominent dominance of women in their later years has been re- cognitive-mnestic deficits or major physical disease apart from severepresbyacusis. Her family history was positive in that her brother had ported , as was Ms P., and she presented with clinical suffered from depression and committed suicide. She complained con- evidence of the organic substrates suggested to play a role stantly that both her legs and arms were paralysed, resulting in an in Cotard’s delusion . As suggested by other authors inability to move, so that she feared that her extremities had to be [6–8], ECT proved to be an efficient and well-tolerated amputated and that thereafter she would be damned to live as a ‘help- less torso’. She claimed that the cause for this were neuroleptics stillcirculating in her blood vessels and devouring her nerve cells, which she There is considerable debate whether Cotard’s delu- could sense in her arms; she stated that she was no longer sure whether sion is syndromal in nature or a distinct nosological enti- she was still alive. The only treatment possible would be instant dialy- ty. Based on a literature survey of 100 cases, Berrios and sis. These delusional beliefs were held with unshakable conviction; in a Luque  reported three basic factors of nihilistic delu- letter, she wrote: ‘My feet and legs, my hands, my cervical vertebra sion by means of a factor analysis, arguing for nosological head and my back are paralysed by drugs. Paralysis of the back of thehead is yet sensible. If the paralysis progresses, I fear my hands, feet and unspecificity: psychotic depression, Cotard type I (which legs will have to be amputated.’ In striking contrast to her complaints, resembles a pure form of the syndrome, closer to delusion- she was psychomotorically agitated and far from being paralysed. Fur- al than to affective disorder) and Cotard type II (which ther psychopathological symptoms were logorrhea, lamenting and constitutes a mixed group, displaying symptoms of the depressive mood, although she stated not to suffer from depression.
schizophrenic spectrum as well as of affective psychoses).
Other depressive ideas were present, e.g. that she had to be imprisonedbecause of tax fraud and that she was afraid of being entombed alive Following this factor-analytic approach, our patient most likely belongs to the ‘psychotic depression’ type. The Extended laboratory tests, including auto-antibodies, GAD-II- authors agree with Enoch and Ball  that Cotard’s delu- antibodies and amphyphysine-antibodies (to rule out stiff-man syn- sion, defined narrowly, represents a highly specific and drome), did not reveal gross abnormalities, neither did ECG, EEG, clear-cut syndrome, not a distinct nosological entity.
SEP and cranial MRI. The patient refused lumbar puncture and PETscanning. We initiated treatment with amitryptiline and olanzapine, However, the most challenging question concerns the which slightly relieved her agitation but brought about no change neurobiological underpinnings of nihilistic delusions.
with respect to her delusions of being paralysed. Thus electroconvul- There are two psychopathological key symptoms that sive therapy (ECT) was applied, which was well tolerated and proved might help to elucidate this. First, there appears to be a to be effective: following 8 treatments, Ms P. stated not to suffer any connection between Cotard’s syndrome (in its narrower longer from paralysis, and other delusional contents or depressiveideas had also disappeared. Her mood was well, and she proved to be definition) and depression, which is primarily a disorder a witty and charming lady, sharply contrasting her personality on of the thymopsyche. Depressive patients often claim to admission. She received maintenance therapy with olanzapine and feel nothing at all, a condition which bears some similari- mirtazapine after ECT discontinuation, and her situation had not ty to the negation of one’s own existence; furthermore, deteriorated by the 5-week follow-up. Slight cognitive deficits could depression often goes along with somatic symptoms. Sec- be observed, such as affective lability, loss of distance and mentalrigidity, so we applied the ICD-10 diagnosis of organic affective dis- ond, Cotard’s delusion is accompanied by erroneous be- liefs about the own body, often including inner organs, but – as our case demonstrates – also extremities and thus psyche representing the consciousness of one’s body and visible body parts. These misperceptions do not seem to personal integrity – in contrast to the allopsyche, which be of the coenaesthetic-hallucinatory type seen in schizo- represents the consciousness of the external world. We phrenic disorders: the patient states that his organs do not thus hypothesise that, in Cotard’s syndrome, the primary function, have disappeared, etc., but usually he does not defect is a functional disturbance in sensory second-order claim to actually feel this, which raises the question neuronal maps or their integration, i.e. a somatopsychic whether the patient suffers from wrong perceptions or disturbance, leading to emotional disorder and, in severe from wrong judgements about his somatic state. This very cases, to specific changes in consciousness – which psy- specific symptom of Cotard’s syndrome differentiates it chopathologically imposes as the conviction to be non- from coenaesthetic schizophrenia, and it suggests that the existing. Therefore, the most interesting anatomical target biological substrate of the delusion does not primarily structure for Cotard’s delusion would be, in our opinion, involve the sensory perception of the body. Rather, it the cingulate gyrus, integrating input from visceral organs seems to involve a disordered somatopsyche, a term and the musculoskeletal system as well as playing a role in coined by Wernicke  to designate the concept of an integrating self-consciousness of the body. This prompts Independently of the postulated neurobiological corre- the question which associations between malfunctions of lates, Cotard’s syndrome seems to be a nosologically the somatopsyche and thymopsyche exist, and if and how inconsistent condition. In the majority of cases, it could both play a part in Cotard’s syndrome.
be interpreted as a form of depressive delusional ideas An interesting, albeit highly speculative hypothesis to associated with other depressive symptoms. In some resolve this issue is based on Damasio’s theory of emotion cases, an association with megalomaniac ideas (délire and consciousness [10, 11]. Briefly (and very much sim- d’énormité) is described, where the megalomaniac ideas plified), Damasio proposes that sensory input from the are typically of a very extreme character, including absur- body is represented in neuronal maps which are inter alia dities like the merging of one’s body with the whole uni- the basis for emotions, which, in turn, assist in generating verse . Such symptoms can typically be seen in specific what Damasio terms ‘extended consciousness’. Damasio forms of schizophrenic psychoses, e.g. phantastic paraph- pointed out a remarkable functional cross-over of the renia according to Leonhard’s differentiated nosology brain stem and cingulate cortex in regulating homeostasis, . On the other hand, in anxiety psychosis, a subform body perception, emotion, arousal, learning and con- of Leonhard’s cycloid psychoses, states of extreme anxi- sciousness. According to his theories, any disturbance of ety, with ideas of threat and annihilation, may occur, those second-order neuronal maps of body perception – leading to transient nihilistic delusions. Thus Cotard’s the functional basis of the ‘somatopsyche’ – will lead to syndrome, in our opinion, represents a symptomatologi- specific changes in the subject’s emotions (the ‘thymo- cally highly impressive and interesting but nosologically psyche’) and, eventually, in the person’s consciousness or non-specific condition. However, its investigation should self-awareness. In terms of classic psychopathology (along be pursued as it could yield important insights into the the lines of Wernicke) one could here postulate a specific psychobiological underpinnings of psychopathological association between the somatopsyche and the auto- References
1Cotard J: Du délire des négations. Arch Neurol 5 Joseph AB, O’Leary DH: Brain atrophy and 8 Yamada K, Katsuragi S, Fujii I: A case study of interhemispheric fissure enlargement in Co- Cotard’s syndrome: Stages and diagnosis. Acta 2 Pearn J, Gardner-Thorpe C: Jules Cotard tard’s syndrome. J Clin Psychiatry 1986;47: (1840–1889): His life and the unique syndrome 9 Wernicke C: Grundriss der Psychiatrie in kli- 6 Petracca G, Migliorelli R, Vazquez S, Stark- nischen Vorlesungen, ed 2. Leipzig, Thieme, stein SE: SPECT findings before and after ECT 3 Enoch D, Ball H: Uncommon Psychiatric Syn- in a patient with major depression and Co- 10 Damasio AR: The Feeling of What Happens: tard’s syndrome. J Neuropsychiatry Clin Neu- 4 Berrios GE, Luque R: Cotard’s syndrome: sciousness, ed 1. London, Heinemann, 2000.
Analysis of 100 cases. Acta Psychiatr Scand 7 Lohmann T, Nishimura K, Sabri O, Kloster- 11 Damasio AR: Descartes’ Error: Emotion, Rea- kotter J: Successful electroconvulsive therapy son, and the Human Brain, ed 1. New York, of Cotard syndrome with bitemporal hypoper- fusion. Nervenarzt 1996;67:400–403 [in Ger- 12 Leonhard K: The Classification of Endogenous Psychoses, ed 5. New York, Irvington, 1979.
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