Cotard Delusion: What is it?

Have you ever felt that a physical part of you is dying or missing? Have those thoughts caused anxiety or a feeling that life is meaningless? If so, there is a name for that sensation and the symptoms that accompany it: Cotard delusion. Continue reading to learn more about the rare psychiatric condition.

Cotard Delusion
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What is Cotard Delusion?

Cotard delusion is a rare psychiatric condition characterized by the false belief that body parts or organs are dying, missing, or do not exist. With only 200 cases worldwide, Cotard delusion is also known as walking corpse syndrome or Cotard’s syndrome. The first case was documented in 1880 by Jules Cotard.

Symptoms of Cotard Delusion

Symptoms of Cotard delusion can be extensive. Along with the false belief that you or parts of your body are dying, individuals with the disorder experience anxiety and guilt. Up to 89 percent of patients have severe depression. The symptoms revolve around nihilism, which is the belief that life is meaningless. They may have a preoccupation with death, hypochondria, or self-starvation. When they feel as if they have already died, they neglect to care for themselves. The disorder is often connected with hallucinations—seeing or hearing things that are not there. Pregnant women with Cotard delusion tend to deny their pregnancy rather than a body part.

Types of Cotard Delusion

Cotard delusion has multiple types based on prominent features of the disorder as outlined by Berrios and Luque in 1995:

The first form of Cotard delusion is psychotic depression. Patients present with psychotic depression, extreme anxiety, guilt, and auditory hallucinations. They hear sounds that are not truly there and have little, if any, nihilistic delusions.

Those with Cotard delusion type 1 do not have depressive episodes. Instead, they have hypochondriac tendencies and nihilistic delusions. The features of Cotard delusion type 2 consist of severe depression, nihilistic delusions, auditory hallucinations, and suicidal thoughts. It is a mixed group.

Causes of Cotard Delusion

The causes of Cotard delusion remain unknown. However, it is associated with the following conditions:

  • Dementia—Loss of memory and judgement that impair daily functioning
  • Multiple Sclerosis—An autoimmune disease in which the immune system destroys the protective covering of the nerves in the brain and spinal cord
  • Encephalopathy—An altered mental state that impacts brain function and/or structure and is caused by a variety of diseases or injuries
  • Stroke—The death of brain cells from reduced blood flow that deprives the brain of oxygen  
  • Parkinson’s disease—A neurodegenerative condition that affects movement because of cell damage depleting dopamine levels
  • Migraine—A severe headache typically associated with sensitivity to light and sound, as well as nausea
  • Epilepsy—Abnormal activity in the brain results in seizures
  • Brain bleeding—The type of brain bleeding related to Cotard delusion is subdural bleeding, which is bleeding outside of the brain

Risk Factors For Cotard Delusion

The majority of those with Cotard delusion is older than 50 years. Aside from age, certain medical conditions increase the chance of developing the disorder. Someone with a history of mental illness is more at risk. These mental illnesses include depression, schizophrenia, substance abuse, and bipolar disorder. Changes to the brain have been reported to induce Cotard delusion. Examples are a brain tumor, stroke, a blood clot, or brain injury.

Cotard Delusion and the Brain

Cotard delusion is related to brain abnormalities. For example, studies reveal that the group with Cotard delusion presented with brain atrophy more frequently than the healthy controls. The atrophy is located in the frontal lobe. The frontal lobe is responsible for cognitive functioning. It regulates emotions and plays a role in memory, social interaction, and motor function.

Abnormal brain activity in the amygdala and the fusiform face area of the brain is thought to lead to Cotard delusion. These two areas of the brain are essential for facial recognition. The misfiring of signals from either area makes it difficult for those with Cotard delusion to recognize themselves. Thus, believing parts of them are not real.

Depression and Cotard Delusion

Cotard delusion is a phenomenon experienced by many with severe depression. Out of 100 cases of Cotard’s syndrome, Berrios and Luque found depression to be the most common comorbid diagnosis.

Depression is a mental disorder described as unexplained sadness persisting longer than two weeks. Symptoms of depression include hopelessness, anxiety, insomnia, withdrawal from social interactions, and a loss of interest in activities. Experts now believe Cotard delusion is less common because depression is treated more often.

How is Cotard Delusion Diagnosed

Due to the rarity of Cotard delusion, experts have not identified a standard test. Diagnosis relies on eliminating the possibility of other conditions with similar symptoms. Cotard delusion is categorized as somatic delusions in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). However, the DSM-5 does not propose a set of criteria for the diagnosis.

Treatment For Cotard Delusion

Treatment for Cotard delusion depends on the underlying comorbid medical conditions. Towards the beginning, research suggests that the primary form of treatment was electroconvulsive therapy (ECT). Electroconvulsive therapy was previously called electric shock therapy.  While under anesthesia, electrical currents are administered through electrodes placed on the patient’s scalp. This results in a seizure lasting 30 to 60 seconds to temporarily alter the brain activity. Symptoms improve after multiple weekly sessions. The side effects of electroconvulsive therapy are potentially detrimental, as it causes memory loss, confusion, body pain, bone fractures, and nausea. Now medical professionals only resort to electroconvulsive therapy to treat Cotard delusion when medications and therapy have failed.

Cotard Delusion: What is it?
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Medications

Cotard delusion has a variety of comorbid conditions, so medications to treat those underlying conditions can be used in its treatment. Antidepressants, antianxiety medications, and antipsychotics are significant assets to reducing episodes of delusion. However, a 2010 review still states that electroconvulsive therapy is more effective in patients who have severe depression occurring with Cotard delusion.

Therapy

Psychotherapy and behavioral therapy are adjunctive therapy for Cotard delusion with medications. Psychotherapy is talk therapy. Psychotherapy techniques treat a range of mental illnesses and problems like psychosis, depression, and anxiety, which are all associated with Cotard delusion. According to the American Psychiatric Association, approximately 75 percent of patients benefit from psychotherapy.

Cognitive-behavioral therapy is the form of psychotherapy most beneficial for Cotard delusion. A trained mental health professional assists the patient in identifying false thoughts, beliefs, or assumptions and their impact on behavior. Over time, this corrects unwanted behavior.

References

American Psychological Association. Understanding psychotherapy and how it works. 2016. http://www.apa.org/helpcenter/understanding-psychotherapy.aspx

Berrios GE, Luque R. Cotard’s syndrome: analysis of 100 cases. Acta Psychiatr Scand. 1995 Mar;91(3):185-8. doi: 10.1111/j.1600-0447.1995.tb09764.x. PMID: 7625193.

Caliyurt, O., Vardar, E., & Tuglu, C. (2004). Cotard’s syndrome with schizophreniform disorder can be successfully treated with electroconvulsive therapy: case report. Journal of psychiatry & neuroscience : JPN29(2), 138–141.

Debruyne H, Portzky M, Van den Eynde F, Audenaert K. Cotard’s syndrome: a review. Curr Psychiatry Rep. 2009 Jun;11(3):197-202. doi: 10.1007/s11920-009-0031-z. PMID: 19470281.

Grover, S., Aneja, J., Mahajan, S., & Varma, S. (2014). Cotard’s syndrome: Two case reports and a brief review of literature. Journal of neurosciences in rural practice5(Suppl 1), S59–S62. https://doi.org/10.4103/0976-3147.145206