When the body image becomes 'empty':Cotard's delusion in a demented patient

Cotards delusion refers to the dissocia-

tion between normal representation/per-

ception of ones own body and a lack of

perception and sensations coming from

inside ones own body. We report a case

of Cotards syndrome in awoman affected

by a probable Alzheimers disease, whose

body image was investigated as well as her

capacity to perceive her internal body

signs.

Introduction

Among the non-cognitive disturbances

in dementia, it is unusual to observe in

demented subjects the disorder known as

Cotards delusion. This syndrome in-

cludes a series of delusions ranging from

the fixed and unshakable belief that one

has lost organs, blood or body parts to

believing that one has lost his own soul

or is dead or has got a delusional

paralysis.

Young et al. (1) have advanced the

hypothesis that the origin of Cotards

delusion is similar to Capgras: the

diverging phenomenological manifesta-

tion between the two delusions would be

associated to different attributional

styles.

However, Ramachandran and Hirstein

(2) believe that patients with Cotards

syndrome present a global disconnection

from all the sensorial areas of the limbic

system, whereas Capgras syndrome

would be because of a local disconnection

of the face-recognition of the limbic

system.

These interpretative hypotheses, how-

ever, fail to take the central theme of

Cotards delusion into consideration, that

is the abnormal body experience.

An alternative interpretative hypothesis

could be that the belief of being dead is

associated with the loss of internal body

sensation complained by all other Cotar-

dian patients at some stage (3), which

implies an abnormal processing of the

body experience devoid of that informa-

tion that is necessary for a complete

integration of the body image. Thus,

a dissociationwould be generated between

the representation/perception of ones

own body as a spatial linguistic structure

and the loss of the internal information

relating to it.

Case report

We report a case of Cotards syndrome in

R.C., a woman affected by a probable

Alzheimers disease (AD), whose body

image was investigated with classical

neuropsychological methods as well as her

capacity to perceive her scheme internal

body signs through an ad hoc devised

examination test. R.C.s case, further-

more, was compared with a patient with

a Capgras delusion and with five patients

with non-delirious AD, selected as control

subjects.

From the administration of the body

scheme test, both our patient and the

control groups failed to show any deficits

relating to the body scheme and were all,

moreover, capable of recognising them-

selves in the mirror.

Varying results were obtained with the

internal body sensations questionnaire, in

which all the controls did not present any

difficulty in reporting their internal body

sensations, whereas R.C. never reported

any sensation for the internal body signs.

Comment

In our patient, the delusion was preceded

by persistent hypochondriac complaints

(difficulty in breathing, abdominal pain,

etc.), implying abnormal internal bodily

signals which were followed by the belief

that she had lost internal organs (from

taking excessively potent laxatives), very

likely associated with the unexpected and

complete inhibition of the perception of

the interceptive afferents directed

towards suspending the insupportable

inner body pain, correlated with amarked

state of anxiety.

This process would come about as an

effect of a defective regulation system

of the inner body signs: excessively

painful experience/absence of the same

experience.

This last event corresponds to the

serious clinical frame presented by the

patient, characterised by persistent

anorexia and sphincteric retention. At

this point, the patient elaborates on her

condition (I dont feel myself ), arriv-

ing at a paradoxical conclusion: I am

dead , which represents a non-censured

paradoxical construct by the monitor-

ing systems that are likely to be

defective.

We could speculate that the check

working in thought production and pro-

gramming was related to a system of

cognitivemonitoring devoted to reducing

and/or removing possible contradictions.

All this comes about in everyday life. If this

system becomes inefficient for any reason

COMMENT & CRITIQUE

283

whatsoever, the individuals claims can

become paradoxical, which is the addi-

tional cause. The necessity of hypothesising

additional processes, underlying thegenesis

of a delusion, has also been upheld by other

authors (4). Given the nature of these

processes (i.e. control andmonitoring), it is

intuitive to maintain an involvement of

frontal functions, which are also defective

in our patient.

In this regard, the analogy with Capg-

ras delusion proves the existence of

another close delusion in which the

alteration of the selective emotional

component regarding a close relative is

considered significant, whereas in

Cotards delusion it regards the subjects

own body.

The phenomena reported by the pa-

tients affected by Cotards delusion may

paradoxically be defined as the awareness

of being dead in which the awareness of

ones own body as spatial structure and

linguistic competence but the on-going

inside body experience of ones own body

is absent. In this sense, the body image has

become empty.

Giovannina Conchiglia1, GennaroDella Rocca1, Dario Grossi2,3

1ALMA Mater Foundation spa Clinic:VillaCamaldoli - Naples, Italy;

2Department of Psychology, Second University of Naples,Naples, Italy; and

3C.I.R.N. Inter-University Center for Research inNeurosciences, Naples,

Italy

Giovannina ConchigliaALMA Mater Foundation spa Clinic:Villa Camaldoli,

80131 Naples,Italy

Tel: 338/9156202;Fax: 0815874010;

E-mail: giopsico@libero.it

Acta Neuropsychiatrica 2008: 20:283284

2008 The AuthorsJournal compilation 2008 BlackwellMunksgaard

DOI: 10.1111/j.1601-5215.2008.00326.x

References1. YOUNG AW, LEAFHEAD KM, SZULECKA

TK. The Capgras and Cotard delusions.

Psychopathology 1994;27:226231.

2. RAMACHANDRAN VS, HIRSTEIN B. The

perception of phantom limbs. The D.O.

Hebb lecture. Brain 1998;121:1603

1630.

3. BERRIOS GE, LUQUE R. Cotard syndrome:

analysis of 100 cases. Acta Psychiatr Scand

1995;9:185188.

4. DAVIES M, COLTHEART M, LANGDON R,

BREEN N. Monothematic delusion: toward

a two-factor account. Philos Psychiatry

Psychol 2001;8:133158.

COMMENT & CRITIQUE

284