Attributional style in a case of Cotard delusion

Cotard delusion, emotional experience and depersonalisation

INTRODUCTION

Cotard delusion-the delusional belief "I am dead"-is named after the French psychiatrist who first described it: Jules Cotard. Ramachandran and Blakeslee proposed that the idea "I am dead" comes to mind when a neuropathological condition has resulted in complete abolition of emotional responsivity to the world. The idea would arise as a putative explanation: if "I am dead" were true, there would be no emotional responsivity to the world.

METHODS

We scrutinised the literature on people who expressed the delusional belief "I am dead", looking for data on whether such patients are reported as entirely lacking in emotional responsivity.

RESULTS

In numerous cases, patients with Cotard delusion are described as experiencing emotions including anxiety, fear, guilt, distress, euphoria and worry.

CONCLUSIONS

We conclude that complete absence of emotional responsivity cannot be what prompts the delusional idea that one is dead. We propose that, in at least some cases, the idea "I am dead" comes to mind in response to symptoms of depersonalisation or derealisation, often present in cases of Cotard delusion, and give examples of Cotard patients with abnormalities in various neural areas that could be responsible for the presence of such symptoms.

Cotard’s Delusion with Sequelae of Adult Onset Failure to Thrive: A Case Report

Patients can present with chief complaints and symptoms that differ from the eventual diagnoses. The differences between aetiologies versus complications must be appreciated through careful evaluation and use of clinical investigations, laboratory testing, trial of hypotheses, and clinical gestalt. Herein, this article discusses the case of a 58-year old individual who presented with impaired physical functioning, malnutrition, depression, and cognitive impairment. These four symptoms are known collectively as failure to thrive, and they often portend adverse patient outcomes. The internal medicine care team initially attributed the failure to thrive to the combination of an ongoing cervicofacial infection and a pre-existing mood disorder, but its true aetiology was more complex. In the context of various physical and psychiatric health derangements, the patient displayed clear signs of a rare disorder called Cotard’s syndrome. Due to the concern of the care team and the patient’s acting medical power of attorney, the eventual working diagnosis was made, and electroconvulsive therapy and aripiprazole combination therapy initiated, resulting in significant and improved outcomes. In addition to discussing the patient’s course of care, this case report also addresses the caution inherent in prescribing medications, the evaluation of decision making capacity, and the utilisation of a medical power of attorney. The authors also present their thoughts on minimising inefficiencies in care delivery to better the patient’s health outcomes.

Human lesions and animal studies link the claustrum to perception, salience, sleep and pain

The claustrum is the most densely interconnected region in the human brain. Despite the accumulating data from clinical and experimental studies, the functional role of the claustrum remains unknown. Here, we systematically review claustrum lesion studies and discuss their functional implications. Claustral lesions are associated with an array of signs and symptoms, including changes in cognitive, perceptual and motor abilities; electrical activity; mental state; and sleep. The wide range of symptoms observed following claustral lesions do not provide compelling evidence to support prominent current theories of claustrum function such as multisensory integration or salience computation. Conversely, the lesions studies support the hypothesis that the claustrum regulates cortical excitability. We argue that the claustrum is connected to, or part of, multiple brain networks that perform both fundamental and higher cognitive functions. As a multifunctional node in numerous networks, this may explain the manifold effects of claustrum damage on brain and behaviour.

A medical algorithm for Cotard delusion based on more than 300 literature cases

OBJECTIVE

Cotard delusion (CD) is a rare psychiatric disorder in which the patient believes to be dead, i.e., the patient holds nihilistic delusions concerning his/her own existence. Taking into account its rarity, and possible subdiagnosis due to unawareness, most of the literature consists of case studies, complicating a more systematic approach and leading to difficulties in deciding the best clinical guidance to offer the patient suffering from CD. The objective of this work is to review the literature and propose an algorithm to help the differential diagnosis and the management of this condition.

METHOD

To do so, an extensive literature research was performed using several bibliographic databases. Since data on this topic is scarce, references in every article were cross-checked, aiming to obtain all available peer-reviewed works on CD.

RESULTS

Research resulted in 328 cases. Several treatment modalities were reported to improve the symptoms of CD, from pharmacotherapy - mainly consisting of antipsychotics and antidepressants - to electroconvulsive therapy.

CONCLUSIONS

Despite its challenging diagnosis, the delusion can be treated with readily available care. Hopefully, this work can be a useful tool to doctors when encountering this odd affliction.

Cotard syndrome in anti-NMDAR encephalitis: two patients and insights from molecular imaging

Cotard syndrome is a clinical condition defined by the presence of nihilistic delusions. We report two patients with Cotard syndrome in whom anti-NMDAR encephalitis (ANMDARE) was confirmed. Both cases showed features of affective psychosis, developed catatonic syndrome, and worsened after the use of antipsychotics. 18F-FDG PET brain studies showed a bilateral hemispheric pattern of hypometabolism in posterior regions, mainly in the cingulate cortex and in the medial aspects of parietal and occipital lobes. A more severe hypometabolism was observed in the right hemisphere of both patients. Both cases remitted with the use of specific immunotherapy for ANMDARE.

Factor Structure of Cotard's Syndrome: Systematic Review of Case Reports

INTRODUCTION

Cotard's syndrome is a rare psychiatric condition. As a result, current information is mainly based on reports and case series.

OBJECTIVE

To analyse the psychopathological characteristics and the grouping of the symptoms of the Cotard's syndrome cases reported in the medical literature.

METHODS

A systematic review of the literature of all reported cases of Cotard's syndrome from 2005 to January 2018 was performed in the MEDLINE/PubMed database. Demographic variables and clinical characteristics of each case were collected. An exploratory factor analysis of the symptoms was performed.

RESULTS

The search identified 86 articles, of which 69 were potentially relevant. After reviewing the full texts, 55 articles were selected for the systematic review, in which we found 69 cases. We found that the diagnosis of major depression (P<0.001) and organic mental disorder (P=0.004) were more frequent in the older group with Cotard's syndrome. An exploratory factor analysis extracted 3 factors: psychotic depression, in which it includes patients with delusions of guilt (0.721), suicidal ideas (0.685), delusions of damnation (0.662), nihilistic delusions of the body (0.642), depression (0.522), and hypochondriacal delusions (0.535); delusive-hallucinatory, with patients who presented delusions of immortality (0.566), visual hallucinations (0.545) and nihilistic delusions of existence (0.451), and mixed, with patients who presented nihilistic delusions of concepts (0.702), anxiety (0.573), and auditory hallucinations (0.560).

CONCLUSIONS

The psychopathology of Cotard's syndrome is more complex than the simple association with the delusion of being dead, since it encompasses a factorial structure organised into 3 factors.

'I am dead': Cotard syndrome and dementia

Background: Cotard syndrome is a rare condition whose main feature is a nihilistic delusion ranging from the denial of body parts to that of the existence of one's own life or even the entire universe. Objectives: The aim of this article is to review the nosological significance of Cotard syndrome and to explore the disorder among patients with dementia. Methods: Medline and Google Scholar searches were conducted for relevant articles, chapters and books published before 2018. Search terms used included Cotard delusion, Cotard syndrome and dementia, nihilistic delusion. Publications found through this indexed search were reviewed for further relevant references. Results and conclusion: In this narrative review we emphasise the fact that cases of Cotard syndrome involving patients with dementia are reported quite infrequently. Published studies are limited to very short series or isolated cases. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent in this condition. Keypoints Cotard syndrome is a rare condition characterised by nihilistic delusions that may range from negation of existence of parts of the body to delusion of being dead. The prevalence and incidence of this rare syndrome are not known. Since Cotard's syndrome is conceptualised as part of an underlying disorder, several psychiatric and somatic diseases have been associated with the syndrome. The syndrome may occur in patients suffering from dementia.

A psychometric investigation of the Chinese version of the Internal, Personal and Situational Attributions Questionnaire (C-IPSAQ)

The IPSAQ is a self-administered instrument designed to evaluate individuals' attributional style (AS). The purpose of this study is to examine the psychometric properties of the Chinese version of the Internal, Personal and Situational Attributions Questionnaire (C-IPSAQ). We also investigate if patients with depression and patients with delusions exhibit attributional biases. The English version of IPSAQ was translated into Chinese and back-translated into English for use in this study. 200 normal control individuals, 47 depressed patients, and 41 delusional patients diagnosed with schizophrenia were recruited for this study. Psychometric properties of this questionnaire were evaluated. The IPSAQ was found to have good internal consistency as a scale. The mean Cronbach's alpha of the six subscales was 0.697. The inter-rater reliability was also acceptable. The concurrent validity analysis revealed that the C-IPSAQ was significantly correlated with ASQ. The group-comparison analyses showed differences in attributional style between patients with depression and patients with delusions compared to normal controls. We confirmed the reliability and validity of the C-IPSAQ, and that the instrument can discriminate specific attributional biases between different patient populations. The C-IPSAQ is a valid instrument to assess attributional style in delusional and depressed patients.

Taxonomising delusions: content or aetiology?

INTRODUCTION

Many theoretical treatments assume (often implicitly) that delusions ought to be taxonomised by the content of aberrant beliefs. A theoretically sound, and comparatively under-explored, alternative would split and combine delusions according to their underlying cognitive aetiology.

METHODS

We give a theoretical review of several cases, focusing on monothematic delusions of misidentification and on somatoparaphrenia.

RESULTS

We show that a purely content-based taxonomy is empirically problematic. It does not allow for projectability of discoveries across all members of delusions so delineated, and lumps together delusions that ought to be separated. We demonstrate that an aetiological approach is defensible, and further that insofar as content-based approaches are plausible, it is only to the extent that they implicitly link content to aetiology.

CONCLUSIONS

We recommend a more explicit focus on cognitive aetiology as the grounds for delusion taxonomy, even when that would undermine traditional content-based boundaries. We also highlight the iterative and complex nature of evidence about aetiologically grounded taxonomies.

Cotard's Syndrome in a Patient with Schizophrenia: Case Report and Review of the Literature

Jules Cotard described, in 1880, the case of a patient characterized by delusions of negation, immortality, and guilt as well as melancholic anxiety among other clinical features. Later this constellation of symptoms was given the eponym Cotard's syndrome, going through a series of theoretical vicissitudes, considering itself currently as just the presence of nihilistic delusions. The presentation of the complete clinical features described by Cotard is a rare occurrence, especially in the context of schizophrenia. Here we present the case of a 50-year-old male patient with schizophrenia who developed Cotard's syndrome. The patient was treated with aripiprazole, showing improvement after two weeks of treatment. A review of the literature is performed about this case.

Vive La France: Three Delusional Disorders Originally Reported in the French Medical Literature

Delusions as a feature of psychosis have long captured the fascination of both psychiatry and the public at large. The French first described three famous delusions: the Cotard delusion, folie à deux, and Capgras delusion. In this article, we examine a case illustrating each delusion and the hallmark features of each as well as a brief discussion about the current understanding of these disorders.

Cotard Delusion in the Context of Schizophrenia: A Case Report and Review of the Literature

Background: The Cotard delusion (CD) is one of a variety of narrowly defined monothematic delusions characterized by nihilistic beliefs about the body’s existence or life itself. The presence of CD within the context of schizophrenia is rare (<1%), and remains understudied.

Case: ‘Mr. C’ is a 58-year-old veteran with a prior diagnosis of schizophrenia, who presented with CD in the context of significant depression, suicidal ideation, violence, and self-harm behavior. He perseverated in his belief that he was physically dead and possessed by demons for several weeks. This delusion was reinforced by his religious belief that life was an attribute of God, and by inference, he as a human, was dead. His condition gradually improved over the course of treatment with Divalproex and quetiapine with discussions about the rationale for his belief. Upon discharge, Mr. C. demonstrated awareness of his fixation on death and an ability to redirect himself.

Discussion: This case highlights the need to better understand the co-occurrence of CD in schizophrenia, their differentiation, the increased risk of violence and self-harm behavior in this presentation, and how specific events and religious factors can influence delusional themes of CD. Pharmacotherapy and aspects of cognitive-behavioral therapy may be effective in ameliorating these symptoms in CD.

Recent Work on the Nature and Development of Delusions

In this paper we review two debates in the current literature on clinical delusions. One debate is about what delusions are. If delusions are beliefs, why are they described as failing to play the causal roles that characterise beliefs, such as being responsive to evidence and guiding action? The other debate is about how delusions develop. What processes lead people to form delusions and maintain them in the face of challenges and counter-evidence? Do the formation and maintenance of delusions require abnormal experience alone, or also reasoning biases or deficits? We hope to show that the focus on delusions has made a substantial contribution to the philosophy of the mind and continues to raise issues that are central to defining the concept of belief and gaining a better understanding of how people process information and learn about the world.

A New Perspective on Delusional States - Evidence for Claustrum Involvement

Delusions are a hallmark positive symptom of schizophrenia, although they are also associated with a wide variety of other psychiatric and neurological disorders. The heterogeneity of clinical presentation and underlying disease, along with a lack of experimental animal models, make delusions exceptionally difficult to study in isolation, either in schizophrenia or other diseases. To date, no detailed studies have focused specifically on the neural mechanisms of delusion, although some studies have reported characteristic activation of specific brain areas or networks associated with them. Here, we present a novel hypothesis and extant supporting evidence implicating the claustrum, a relatively poorly understood forebrain nucleus, as a potential common center for delusional states.

Cotard's syndrome: Two case reports and a brief review of literature

Cotard's syndrome is a rare neuropsychiatric condition in which the patient denies existence of one's own body to the extent of delusions of immortality. One of the consequences of Cotard's syndrome is self-starvation because of negation of existence of self. Although Cotard's syndrome has been reported to be associated with various organic conditions and other forms of psychopathology, it is less often reported to be seen in patients with catatonia. In this report we present two cases of Cotard's syndrome, both of whom had associated self-starvation and nutritional deficiencies and one of whom had associated catatonia.

Near-death experiences in non-life-threatening events and coma of different etiologies

Background: Near death experiences (NDEs) are increasingly being reported as a clearly identifiable physiological and psychological reality of clinical significance. However, the definition and causes of the phenomenon as well as the identification of NDE experiencers is still a matter of debate. To date, the most widely used standardized tool to identify and characterize NDEs in research is the Greyson NDE scale. Using this scale, retrospective and prospective studies have been trying to estimate their incidence in various populations but few studies have attempted to associate the experiences' intensity and content to etiology.

Methods: This retrospective investigation assessed the intensity and the most frequently recounted features of self-reported NDEs after a non-life-threatening event (i.e., “NDE-like” experience) or after a pathological coma (i.e., “real NDE”) and according to the etiology of the acute brain insult. We also compared our retrospectively acquired data in anoxic coma with historical data from the published literature on prospective post-anoxic studies using the Greyson NDE scale.

Results: From our 190 reports who met the criteria for NDE (i.e., Greyson NDE scale total score >7/32), intensity (i.e., Greyson NDE scale total score) and content (i.e., Greyson NDE scale features) did not differ between “NDE-like” (n = 50) and “real NDE” (n = 140) groups, nor within the “real NDE” group depending on the cause of coma (anoxic/traumatic/other). The most frequently reported feature was peacefulness (89–93%). Only 2 patients (1%) recounted a negative experience. The overall NDE core features' frequencies were higher in our retrospective anoxic cohort when compared to historical published prospective data.

Conclusions: It appears that “real NDEs” after coma of different etiologies are similar to “NDE-like” experiences occurring after non-life threatening events. Subjects reporting NDEs retrospectively tend to have experienced a different content compared to the prospective experiencers.

In Defence of Modest Doxasticism About Delusions

Here I reply to the main points raised by the commentators on the arguments put forward in my Delusions and Other Irrational Beliefs (OUP, 2009). My response is aimed at defending a modest doxastic account of clinical delusions, and is articulated in three sections. First, I consider the view that delusions are in-between perceptual and doxastic states, defended by Jacob Hohwy and Vivek Rajan, and the view that delusions are failed attempts at believing or not-quite-beliefs, proposed by Eric Schwitzgebel and Maura Tumulty. Then, I address the relationship between the doxastic account of delusions and the role, nature, and prospects of folk psychology, which is discussed by Dominic Murphy, Keith Frankish, and Maura Tumulty in their contributions. In the final remarks, I turn to the continuity thesis and suggest that, although there are important differences between clinical delusions and non-pathological beliefs, these differences cannot be characterised satisfactorily in epistemic terms.

A case of "borrowed identity syndrome" after severe traumatic brain injury

BACKGROUND

It is well known that traumatic brain injury often changes the way the patient perceives reality, which often means a distortion of the perception of self and the world. The purpose of this article is to understand the processes of identity change after traumatic brain injury.

CASE REPORT

We describe progressive deterioration in personal identity in a former physician who had sustained a serious head injury (1998), resulting in focal injuries to the right frontal and temporal areas. He regained consciousness after 63 days in coma and 98 days of post-traumatic amnesia, but has since displayed a persistent loss of autobiographical memory, self-image, and emotional bonds to family and significant others. Qualitative 'life-story' interviewing was undertaken to explore the mental state of a patient whose subjective, "first person" identity has been disengaged, despite the retention of significant amounts of objective, "third person" information about himself and his personal history (though this was also lost at a later stage in the patient's deterioration). Identity change in our patient was characterized by a dynamic and convoluted process of contraction, expansion and tentative balance. Our patient tends to cling to the self of others, borrowing their identities at least for the period he is able to remember. Identity is closely connected with the processes of memory.

CONCLUSIONS

The results will be examined in relation to the microgenetic theory of brain function. The brain mechanisms that may account for these impairments are discussed. Findings from this study have important implications for the delivery of person-focused rehabilitation.

Implicit awareness in anosognosia for hemiplegia: unconscious interference without conscious re-representation

Some patients with anosognosia for hemiplegia, i.e. apparent unawareness of hemiplegia, have been clinically observed to show 'tacit' or 'implicit' awareness of their deficits. Here we have experimentally examined whether implicit and explicit responses to the same deficit-related material can dissociate. Fourteen stroke patients with right hemisphere lesions and contralesional paralysis were tested for implicit and explicit responses to brief sentences with deficit-related themes. These responses were elicited using: (i) a verbal inhibition test in which patients had to inhibit completing each sentence with an automatic response (implicit task) and (ii) a rating procedure in which patients rated the self-relevance of the same sentences (explicit task). A group of anosognosic hemiplegic patients was significantly slower than a control group of aware hemiplegic patients in performing the inhibition task with deficit-related sentences than with other emotionally negative themes (relative to neutral themes). This occurred despite their explicit denial of the self-relevance of the former sentences. Individual patient analysis showed that six of the seven anosognosic patients significantly differed from the control group in this dissociation. Using lesion mapping procedures, we found that the lesions of the anosognosic patients differed from those of the 'aware' controls mainly by involving the anterior parts of the insula, inferior motor areas, basal ganglia structures, limbic structures and deep white matter. In contrast, the anosognosic patient without implicit awareness had more cortical lesions, mostly in frontal areas, including lateral premotor regions, and also in the parietal and occipital lobes. These results provide strong experimental support for a specific dissociation between implicit and explicit awareness of deficits. More generally, the combination of our behavioural and neural findings suggests that an explicit, affectively personalized sensorimotor awareness requires the re-representation of sensorimotor information in the insular cortex, with possible involvement of limbic areas and basal ganglia circuits. The delusional features of anosognosia for hemiplegia can be explained as a failure of this re-representation.

Ideology as cooperative affordance

McKay & Dennett (M&D) observe that beliefs need not be true in order to evolve. We connect this insight with Schelling's work on cooperative commitment to suggest that some beliefs – ideologies – are best approached as social goals. We explain why a social-interactive perspective is important to explaining the dynamics of belief formation and revision among situated partners.

Confabulation, delusion, and anosognosia: motivational factors and false claims

False claims are a key feature of confabulation, delusion, and anosognosia. In this paper we consider the role of motivational factors in such claims. We review motivational accounts of each symptom and consider the evidence adduced in support of these accounts. In our view the evidence is strongly suggestive of a role for motivational factors in each domain. Before concluding, we widen the focus by outlining a tentative general taxonomy of false claims, including false claims that occur in clinical settings as well as more garden-variety false claims, and incorporating both motivational and nonmotivational approaches to explaining such claims.

Cotard's syndrome: a review

Cotard's syndrome is a rare disorder in which nihilistic delusions concerning one's own body are the central feature. It is not listed as a specific disorder in the DSM-IV, as it is typically viewed as a part of other underlying disorders. However, it remains important to recognize the syndrome because specific underlying mechanisms are present, and prognostic and therapeutic consequences have to be taken into account. This review presents an up-to-date overview of Cotard's syndrome, which was initially described more than a century ago.

Models of misbelief: Integrating motivational and deficit theories of delusions

The impact of our desires and preferences upon our ordinary, everyday beliefs is well-documented [Gilovich, T. (1991). How we know what isn't so: The fallibility of human reason in everyday life. New York: The Free Press.]. The influence of such motivational factors on delusions, which are instances of pathological misbelief, has tended however to be neglected by certain prevailing models of delusion formation and maintenance. This paper explores a distinction between two general classes of theoretical explanation for delusions; the motivational and the deficit. Motivational approaches view delusions as extreme instances of self-deception; as defensive attempts to relieve pain and distress. Deficit approaches, in contrast, view delusions as the consequence of defects in the normal functioning of belief mechanisms, underpinned by neuroanatomical or neurophysiological abnormalities. It is argued that although there are good reasons to be sceptical of motivational theories (particularly in their more floridly psychodynamic manifestations), recent experiments confirm that motives are important causal forces where delusions are concerned. It is therefore concluded that the most comprehensive account of delusions will involve a theoretical unification of both motivational and deficit approaches.