Early in my career in psychiatry, I met an unusual patient. She was an elderly retired teacher, admitted to our ward, as she refused to eat or drink. She firmly believed that everything she ate leaked into her body, as her gut was all rotted and full of holes. She was in danger of dying [...]


The Walking Dead Syndrome and Depressive Disorder


Early in my career in psychiatry, I met an unusual patient. She was an elderly retired teacher, admitted to our ward, as she refused to eat or drink. She firmly believed that everything she ate leaked into her body, as her gut was all rotted and full of holes. She was in danger of dying of malnutrition.

After a course of electroconvulsive therapy, she made a dramatic recovery. This was my first encounter with Cotard Syndrome (also known as Walking Dead or Walking Corpse Syndrome) named after the French neurologist Jules Cotard.  In this syndrome, persons affected think they are dead, do not exist, or body parts are missing or putrefying. Jules Cotard called it “le délire des négations” (the delirium of negation). The patient he described as Mademoiselle X denied the existence of parts of her body and refused to eat. Eventually, she died of starvation. Electroconvulsive therapy was not available in those days.

Cotard Syndrome is a rare complication of severe depression, but it illustrates well the core psychopathology of depression where the sense of worth of self and even physical body parts are reduced. Fortunately, most persons with depressive disorder never develop Cotard Syndrome, but even the lesser of the condition can lead to serious impairment of function. In this article, I discuss how to recognise whether you or another person are suffering from depression so that you could seek early treatment.

Depression as a disorder differs from the colloquial use of the word, meaning unhappiness. It is normal for humans to have fluctuations in their mood. Interestingly, our default is towards the negative side, an evolutionary protection mechanism from threat. Especially in stressful times, it would be quite common to feel anxious and unhappy sometimes. But unlike in depressive disorder, these episodes are shorter lasting and can be reduced or altered by a change of situation.

In depressive disorder, the mood is persistently low for over two weeks and is relatively unaffected by the surroundings. Even a joyful event cannot cheer up a person so affected. Three other core symptoms are seen besides low mood: namely, inability to enjoy activities which were previously enjoyable for that person, a lack of interest in day-to-day activities, and a sense of lethargy which is more mental than physical. Bodily or somatic symptoms that accompany these core symptoms include; waking up two or more hours before your usual time, loss of appetite and weight (more than 2kg over two months) and reduced sexual drive.

In severe depression, there is a loss of self-worth and hopelessness. This may extend to the feeling that life has no purpose, and it is better to die. At its most severe, affected persons may take active measures to end their life. Severe depressive disorder is a leading cause of suicide.

Though not as common as stress or anxiety, depressive disorder has a significant prevalence. Studies show a prevalence rate of around 6 percent of the adult population. Females are twice as likely to suffer from this illness. Interestingly, rates of depression in a country are not always correlated with economic prosperity. For example, the USA and the Baltic countries Estonia, Lithuania and Finland have relatively high levels of depression but not so well-off countries such as the Pacific Islands, Nepal and Laos have lower rates. The recent COVID-19 pandemic has markedly increased rates of depression and anxiety around the globe. Other than economic deprivation, civil turmoil and uncertainty increase rates of depression and we can expect Sri Lanka in the current context to have increased rates of the condition.

The Global Burden of Disease Index is an internationally recognised measure of how much a particular disease or disease category can affect the function of a person. On this index, depressive disorder is ranked as one of the major diseases that cause disability or reduce the function of a person. Depressive disorder significantly impairs the day-to-day functioning of a person and his or her dependents. This could be members, working colleagues or even a bigger community.

The good news is that a depressive disorder, if correctly diagnosed, is highly treatable. Currently, there is a wide range of medicines and other therapies available, but the outcome depends on early diagnosis and proper follow-up as treatment needs to be continued for a while longer even after recovery to prevent a relapse. Hence, it is important that all doctors and health care workers and the public are aware of the symptoms of depressive disorder.

The PHQ-9 is a widely used self-administered rating scale you can use to screen for depression. If you Google this keyword, several free sites with the questionnaire are available. If you score 10 points or more, you are likely to be suffering from at least a moderate depression. You should see a mental health specialist or your family doctor to confirm the diagnosis and get treatment.

And what became of Jules Cotard, the neurologist who first described Cotard Syndrome? His daughter developed diphtheria. He refused to leave her bedside for two weeks until she recovered. Unfortunately, he developed diphtheria himself and died on the 19th of August 1889 aged just 49. Jules Cotard was not only a great physician but also a loving father.

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