Kotar's syndrome

Cotard's syndrome is a rare disorder that does not represent a specific clinical illness, but rather a disorder associated with nihilistic delusions about the absence of the entire body or one part of it. Patients may think that there is only emptiness around.

Cotard's syndrome was first described in medical practice in 1880 by the French neurologist Jules Cotard. It is a kind of psychotic depression that combines melancholy, anxiety, insensitivity to pain, delusional ideas about the body, and a sense of immortality.

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Causes of cotard syndrome

Unfortunately, they are still unknown. Previous studies are ambiguous; they can be reduced to the assertion that, most likely, a significant role in the formation of Cotard's syndrome belongs to the frontal-temporal-parietal neuronal circuits. At the same time, there are cases where no anomalies in the structure and functioning of the brain of people with this disease have been detected.

Cotard's syndrome is most common in affective disorders: depression and bipolar disorder. There are also cases when Cotard's syndrome is detected, in particular, in schizophrenia, dementia, epilepsy, brain tumors, migraines, multiple sclerosis or traumatic brain injury. Most often, this occurs in middle-aged and older people, but cases of this disorder are also known among people under 25, mainly in bipolar disorders. According to statistics, women suffer from this disorder more than men. Science has not yet found an explanation for why this happens.

British filmmakers even created a short film, “Pursuing Cotard’s Syndrome,” dedicated to people suffering from this syndrome. They showed one of the causes of the disease and its consequences.

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Pathogenesis

After severe stress, such as the loss of a loved one, severe depression can occur, which results in complete apathy towards everything around you.

The person loses his own identification, denies his own existence. In addition, the patient does not perceive his own body. He claims that his body is rotten, he may not perceive sounds, smells. Despite the fact that he cannot explain how it is possible to speak and move without a brain, heart and other organs, he is absolutely convinced that he does not have them;

The gait of such patients is very specific and may resemble the movements of the "living dead" from horror films;

May feel some sort of connection with the dead and often wander through cemeteries, which seem to be the most appropriate place for him.

A lowered pain threshold increases the risk of independent aggressive behavior. Suicide is also a way to get rid of a dead body, to which the patient is supposedly doomed.

Does not take hygienic procedures, does not eat or drink (food and drink have no meaning for them if they are dead). Hunger and exhaustion are the second cause of death of the patient after suicide.

These symptoms are accompanied by extreme anxiety and guilt. The mentally ill person tries to explain why he should continue living on earth if he is already dead. In the end, he comes to the conclusion that death is a punishment for his sins and disobedience.

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Symptoms of cotard syndrome

Some mentally ill people are firmly convinced that they lack vital organs, such as the heart, brain, or others. They have fantasies that their bodies can be huge and reach the size of the sky or the entire Universe. Such patients have a tendency to suicide, but they can also imagine themselves immortal.

They completely believe that they are dead and insist on being destroyed. They often hear voices that guide their actions.

Cotard's syndrome is a side effect of nihilistic delusions or self-denial. What are its symptoms? Let's look at the more typical ones:

• the patient denies his own existence,
• convinced that he died,
• a feeling of loss of the entire body or major internal organs,
• belief in the rotting body and the decay of the body,
• severe anxiety,
• guilt,
• lowering the pain threshold,
• psychomotor agitation,
• self-harm and suicidal tendencies.

First signs

The first feature is the appearance of a feeling of anxiety. Then the person begins to think that he has already died, that he does not exist. In addition, patients may believe that nothing exists - neither them, nor the world, nor the people around them. Sometimes the disease is accompanied by a feeling of immortality or absurd delusions about the size of one's own body.

Due to the reduction of pain and the belief in their own non-existence, patients suffering from this disorder often commit self-harm. They intentionally damage tissue and harm themselves. They want to prove to others that their bodies do not really live and bleed.

Nihilistic delusions may manifest as a feeling of unreality of the body, transformation of organs, or strange skin hallucinations (for example, a feeling of an electric current flowing through the body).

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Film "Pursuing Cotard's Syndrome"

At the beginning of the film, there is quiet music, there are no monologues or conversations. After the credits, the inscription "Two weeks after the funeral" appears. We see a room in which things are chaotically arranged. The main character named Hart is sitting on a chair. In front of him on the wall hangs a portrait of a blue-eyed young woman with red hair. This is Hart's late wife, Elizabeth. The hero glances at her, then turns away and gets up from the chair. He goes to a broken mirror and looks at his reflection, then looks up at the portrait of his wife. Then there is a change of scenery. A weak light comes through the curtained window. The main character is sitting at the desk, examining his ring. Hart, dressed in what he is wearing, begins to take a bath with complete indifference. Then he sits down to read a book, but cannot concentrate on it. He hears a knock on the door, but does not react to it. He is completely apathetic. Then he moves the vase with dried flowers as if he wants to tell the deceased Elizabeth that he still loves her. There is a pile of letters at the entrance to the room. Hart takes the letter, opens it, but cannot read it. He tries to cook, but cannot bring himself to eat anything. Hart's face is distorted by a grimace of suffering, the need to eat is the cause of pain and he angrily throws the plate. Having risen, the hero looks reproachfully at the portrait that she left him early. Having made an attempt to clean the food from the floor, he gives up this idea. Thoughtfully, he turns his gaze to the fragments of a broken mirror and cuts his wrist with one of them. His devastated eyes become clear. Time begins the countdown. The room, which was dark and gloomy, is transformed and becomes cozy and warm. His beloved Elizabeth appears, full of strength and energy. She kisses him tenderly and a smile appears on the lips of the protagonist. The meeting is short, the wife leaves, making it clear that she is with him, as before. Having glanced at the portrait and the room for the last time, Hart, throwing open the doors, moves towards the bright rays of light.

Forms

In recent years, based on available data, three types of Cotard's syndrome have been distinguished in such cases:

• The first is psychotic depression, in which symptoms of anxiety and depressed mood, feelings of guilt, delusions and auditory hallucinations predominate;
• The second is associated with hypochondriacal mania and nihilistic delusions, but without symptoms of depression;
• The third is anxiety, depression, hallucinations, delusions, mania for immortality and suicidal tendencies.

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Diagnostics of cotard syndrome

The diagnosis of the disorder is based on the characteristics of clinical manifestations. It occurs in patients prone to melancholy and manic-depressive psychoses. It is a companion of depressive states, and can occur if the patient has lost memory and is prone to hallucinations.

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Treatment of cotard syndrome

The most common medications used to treat Cotard's syndrome are antidepressants and antipsychotics. Any medications should be used as prescribed by a doctor. Only a doctor can assess the severity of the condition and prescribe adequate treatment. Amitriptyline or melipramine are often used.

In case of prolonged depressions, intramuscular or intravenous injections of amitriptyline 10-20-30 mg are used. It is taken at least four times a day, gradually increasing the dose of the drug. The maximum daily dosage is 150 mg. After one or two weeks, patients switch to the tablet form. Side effects may occur - blurred vision, increased intraocular pressure, constipation, hyperthermia.

Melipramine belongs to the group of antidepressants. It is prescribed for all types of depression and panic states. It is available in the form of tablets and injection solutions.

Adults are initially prescribed 25 mg of the drug, which must be taken in one to three doses after meals. Use of up to 200 mg per day is permissible, this is the maximum dose. After the therapeutic effect is achieved, the dose can be reduced to 50-100 mg/day.

Elderly and adolescents are usually prescribed 12.5 mg once in the evening. The daily dose should be 75 mg. After that, the dosage is reduced. To maintain and consolidate the positive effect, half the adult dosage is prescribed.

Side effects affect the cardiovascular system, central nervous system and gastrointestinal tract.

Aminazine is used to reduce motor and speech excitation.

It is prescribed for various states of increased agitation in schizophrenia, paranoid states and hallucinations. At the beginning of the course, the dose is prescribed at 0.025-0.075 g per day. It is usually divided into several doses, then gradually increased to 0.3-0.6 g. In patients with a chronic course of the disease and psychomotor agitation, it can reach 0.7-1 g. The course of treatment with large doses should be from one to one and a half months.

Possible side effects: indifference, neuroleptic syndrome, blurred vision, thermoregulatory disorders, tachycardia, itching, rash. Convulsions are extremely rare.

Tizercin is often used to reduce anxiety. Tablets are prescribed from 25-50 mg per day. They are divided into several doses. The highest dose is prescribed before bedtime. Gradually increase the dose to 200-300 mg. After the patient's condition has stabilized, the dose is reduced. The maintenance dose is determined individually. If it is not possible to take the drug in tablet form, then injections are prescribed. The daily dose is 75-100 mg, which is divided into two or three doses. Injections are administered under bed rest with constant monitoring of blood pressure and pulse. If necessary, the daily dose of the drug is increased to 200-250 mg. Injections are administered deep intramuscularly or intravenously by drip. When diluting tizercin, solutions of sodium chloride or glucose should be used.

In addition to the above, the use of electric shock has proven to be effective.

Often the prognosis for patients with Cotard's syndrome is not encouraging. However, cases of sudden and spontaneous remission are known.

Prevention

There are no special measures to prevent this disorder. The main role is played by timely diagnosis and initiation of therapy for anxious depressions that first appeared in old age.

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Forecast

Despite the patient's denial of logical arguments, it is important to convince him that, despite his delirium, he is alive. Even if this can be done, it is necessary to remind him of this often. It is necessary to provide the patient with medical care, primarily psychiatric and psychotherapeutic. Unfortunately, treatment is difficult and there is no guarantee of recovery.

Depending on the characteristics of the underlying disease and the methods of treatment, the exit to remission depends. If clearly expressed delusional nihilistic ideas appear, then this is worse than the depressive version of Cotard's syndrome. Nihilistic delirium in combination with speech and motor agitation and clouded consciousness in older people, in the absence of treatment, can lead to a fatal outcome.

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