The nurse couldn’t get a coherent word out of her.
The med student couldn’t get a coherent word out of her.
The resident couldn’t get a coherent word out of her.
They were gathered around her bedside trying to figure out why the nursing home had sent this demented woman in. This is a surprisingly common exercise in the ER. The nursing home and the EMS crew weren’t much help as the nursing home staff that had called 911 had gone off shift before the EMS crew got there and the new staffers weren’t clear as to the reason for the call. Maybe she had stopped walking and talking? Concern for infection? Someone mentioned catatonia.
“Hi, ma’am, I’m Dr. Reiser. I am the attending physician,” I announced to her, as if this would make any sense at all to this demented, maybe catatonic woman.
She sat up, gave me a ferocious glare and barked at me.
“Good, so you’re the one who can tell me I am dead!”
She said this with such clarity and conviction that it took the team aback. They looked at me as if I really had the ability to tell this woman she was dead. She didn’t look dead. I assured her we would look into it.
“Good,” she replied. She closed her eyes and lay back and refused to say another word. She was thin and ancient and so still against the pale hospital sheets that she did look a little dead. I shook my head to clear the image out.
Cotard’s delusion is a rare neuropsychiatric condition in which people become convinced they are dead. Sometimes called the walking corpse syndrome, it is associated with severe depression or certain injuries to the brain. Because patients with Cotard’s often stop eating and drinking—what’s the point, they are dead, they will say—the delusion carries a high mortality if untreated.
Treatment has traditionally been electroconvulsive therapy but in the modern era anti-depressants are the mainstay of therapy.
Most of the patients, while convinced they are dead, are also convinced they are immortal or eternally damned to roam the earth. They also seem to believe they are missing most of their organs.
No one really knows what causes Cotard’s delusion. There are a number of competing theories. Some believe it is related to Capgras Syndrome*, an inability to recognize faces, especially one’s own face. When Cotard’s and Capgras patients look in the mirror they see a stranger staring back at them. This is obviously disconcerting and disorienting.
Others classify Cotard’s as a delusion of negation. The patient feels so overlooked and useless that they imagine they don’t exist. While their senses tell them their body exists in some form, their negation of their sense of self can only be interpreted as their soul having left their body. This is indeed what most of them describe if pressed.
Some detective work revealed that our patient had stopped eating and drinking at the nursing home and that is why they had sent her in. She did have some moderate to severe dementia but was very clear and consistent in her belief about her demise.
Her labwork was consistent with mild dehydration and malnutrition, easily correctable with a short hospitalization and IV fluids.
Psychiatry was consulted and they began her on a course of both anti-depressants and anti-psychotics. Over the course of a week or so she stopped saying she was dead and began taking a little nutrition. She was discharged back to the nursing home.
I am not convinced we really changed her mind about her delusion of being dead, but I think she got tired of arguing about it. Or perhaps the constant attention of the curious medical staff dragged her back from the land of the overlooked, back into the land of the living.
And maybe that is what we all need, and what we owe each other: constant and curious attention.
*See November 2006 Crozet Annals of Medicine