The Man Who Wasn't There: Investigations into the Strange New Science of the Self (2 page)

From the Université Rene Descartes, it’s a thirty-minute walk down rue des Écoles, past the national museum of natural history, to reach the Pitié-Salpêtrière Hospital, where Jules Cotard started his medical career as an intern in 1864. I went there to see David Cohen, the head of the hospital’s infant and adolescent psychiatry unit.

Over the course of his medical residency and practice, Cohen has seen a few handfuls of patients who have suffered from Cotard’s syndrome. Given the rarity of this disorder, this relatively large sample has given Cohen an intimate look at Cotard’s. We talked of one particular patient,
fifteen-year-old May—one of the youngest recorded cases of Cotard’s. Cohen treated her and had extensive discussions with her after she recovered, enabling him to link her delusions with her personal history. He got a peek into how the self, even in a delusional state like Cotard’s, is influenced by one’s personal narrative and even dominant cultural norms.

About a month before May came to Cohen’s clinic, she had started feeling extremely sad and depressed, and eventually began exhibiting delusions about her own existence. By the time she was admitted, she had become severely catatonic—mute and unmoving. “Even the nurses
were terrified by her,” Cohen told me. But with a few days of inpatient psychiatric care, May recovered somewhat, just enough to say a few words each day, which the nurses would write down diligently. Between these sporadic intimations from May and discussions with her parents, Cohen pieced together May’s story.

Her family was middle-class Catholic. May had two siblings, a brother and a sister. The sister, who was ten years older, had married a dentist. The family had a history of depression: their mother had suffered from severe depression before May was born, and one of May’s aunts had undergone electroconvulsive therapy (ECT), which involves delivering mild pulses of electricity to the brain to induce seizures, and is
often an effective treatment for severe depression—though almost always of last resort.

May’s delusions were classic Cotard’s. “She was telling us that she had no teeth, no uterus, and that she had this feeling of being already dead,” Cohen said. He struggled to describe May’s condition in English. “I don’t know the word in English . . .
morts vivants!
” he said. I looked it up later: the literal translation is
the living dead.

“She was waiting to be buried . . . in a coffin,” said Cohen.

When her condition didn’t improve even after six weeks of therapy and medication, Cohen suggested ECT. Given the family’s experience with depression, her parents immediately agreed. After six treatments, May appeared to recover, so Cohen stopped the ECT—but she relapsed immediately, prompting Cohen to resume the treatment. This time she did recover, except for some headache, mild confusion, and slightly disturbed memory. When she began talking, it was as if she had awakened from a nightmare.

Cohen’s discussions with her—in which he asked May to talk freely of any associations that came to mind when he mentioned her
delusions—shed surprising light. For instance, the delusion that she had no teeth seemed to have something to do with her sister’s husband, the dentist. Cohen discerned that she may have had feelings for her brother-in-law. She spoke of never wanting to be treated by him. Again, Cohen struggled for the correct word in English to describe the way she expressed herself.
Pudique
, he said in French. “Modest.” She spoke of her brother-in-law in “such a way that you understood that she’ll never be naked in front of him.”

Her delusions about missing her uterus seemed to be tied to episodes of masturbation. “She felt very guilty about that and she thought that maybe she would be sterile.”

Cohen was making the point that the specificity of the delusions is related to one’s autobiography and the cultural context. To make his case for the latter, he recalled
a fifty-five-year-old man who had come to see him in the 1990s. Cohen diagnosed him with Cotard’s. One of his delusions was that he had AIDS—which he didn’t. Cohen figured his delusion was linked to guilt over his hypersexuality during the manic phase of his bipolar disorder, from which he also suffered. Before the 1970s, hypochondriac delusions in Cotard’s patients, if they involved sexually transmitted diseases, were almost always related to syphilis—the cultural scourge of the times. Interestingly, this man had actually contracted syphilis while serving in the military as a young man (Cohen tested him for antibodies to confirm). But his delusions during his Cotard’s episode, which happened decades later, were not about syphilis but HIV/AIDS—which had supplanted syphilis in the broader culture as “
God’s punishment for sins of the flesh” (syphilis almost never shows up anymore during hypochondriac delusions in Cotard’s). “It’s only one case, [but] I think this case is very informative,” Cohen said.

For Cohen, Cotard’s syndrome is revealing of the workings of the self. The disorder is a deeply felt disturbance of one’s being, and shows that the self is linked to one’s body, one’s story, and one’s social and cultural milieu. Brain, body, mind, self, and society are inextricably linked.

Back in Exeter, Adam Zeman had encountered something similar with Graham. The delusion in Graham’s case was that his mind was alive but his brain was dead. “It was an updated, contemporary version of the Cotard’s delusion. To come to the conclusion that your brain has died in isolation, . . . [you need] a concept of brain death, which is a relatively recent medical development.”

What Zeman found even more intriguing was the inherent dualism in Graham’s delusion—that an “immaterial” mind can exist independent of the brain and the body. “I thought it rather beautifully illustrated the dualism to which most of us are prone,” Zeman told me. “The idea that your mind could be alive while your brain is dead is a rather extreme expression of dualism.”

Philosophical musings aside, Zeman found Graham’s situation sad. “He was slow and flat, with very little emotional modulation in his voice. [I] occasionally got a flicker of a smile, but there was rather little facial expression,” said Zeman. “You had the sense of someone for whom existence was extremely bleak, and for whom thought was something of an effort.”

A patient suffering from Cotard’s syndrome is often extremely depressed. A depression far more serious than most of us can
understand. I was given an insight into this by yet another French psychiatrist, William de Carvalho, whom I also met in Paris—at his office on avenue Victor-Hugo
.
He drew me a line diagram to illustrate where Cotard’s stands on the depression scale. He started with “normal” on the left, then added “sad,” “depressed,” “very depressed,” “melancholic” at equal intervals on the right. Then he added a series of dots—the progression was not linear anymore—and at the end of those dots he wrote, “Cotard’s.” “With Cotard’s there is like a great black wall that goes from Earth to Saturn. You can’t look over it,” said de Carvalho, a dapper man of French-Senegalese descent with a way with words.

He had a private practice but also worked at the renowned Sainte Anne Hospital in Paris. He remembered one Cotard’s patient that he treated in the early 1990s who showed classic signs of “
melancholic omega.” The phrase has its origins in Charles Darwin’s descriptions of melancholia in his book
The Expression of Emotions in Man and Animals
: “
a facial expression involving a wrinkling of the skin above the nose and between the eyebrows that resembles the Greek letter omega.” While Darwin wrote about these “
grief muscles” on the face, it was German psychiatrist Heinrich Schüle who coined the term “melancholic omega” in 1878, based on Darwin’s vivid descriptions.

Dr. de Carvalho’s patient was a fifty-year-old engineer and poet. The man had faked trying to kill his wife—he put his hands around her neck, then stopped, and told her to call the police. When the police came, they saw a very disturbed, even bizarre, man. So they took him directly to Sainte Anne Hospital rather than the police station (the man’s act had a copycat quality to it: in 1980,
the French philosopher Louis Althusser, who had been suffering from depression, strangled his wife, and was taken to a mental hospital first instead of being sent to jail).

The day after the incident, de Carvalho met the man at Sainte Anne Hospital. “I asked him, ‘Why are you trying to kill your wife?’ He said, ‘Well, it’s such a crime that I deserve to [have] my head cut.’ He was hoping that he would be killed, even [though] there was no death penalty in France.”

The man was exhibiting an extreme form of another symptom characteristic of Cotard’s syndrome: guilt. “He told me at the time that he was worse than Hitler. And he asked us to help him to be killed, because he was so bad for humanity,” said de Carvalho.

The patient had lost weight, his beard was unkempt and overgrown, and he had stopped bathing because he felt he had no right to take showers and use up too much water. The hospital decided to make a film about him (for their archives) while he was still in the throes of Cotard’s. At one point in the filming, the patient pulled a white sheet over his head. “I’m so bad, I don’t want people looking at that film to be touched by such badness,” he told de Carvalho, who was behind the camera. Dr. de Carvalho pointed out that it was just a film, he couldn’t possibly affect anyone through it. “And he said, ‘I know, but it’s like that; I am so bad,’” de Carvalho told me. Also, the broader culture had again influenced the man’s delusion. He was convinced he was responsible for the AIDS epidemic and that people would get AIDS just by watching the film.

Many months later, after the man had recovered (the treatment included ECT), de Carvalho watched the film with his former patient. At the end of the twelve-minute film, the man turned to de Carvalho and said, “Well, this is very interesting. But who is it?” De Carvalho thought the man was joking.

“That’s you,” de Carvalho told the man.

“No, it’s not me,” the man replied.

Soon, de Carvalho realized that there was no point trying to convince him. He was not the same man as the one who had descended into the darkness that is Cotard’s.

Given such extreme depression during Cotard’s, psychiatrists have wondered why most sufferers don’t attempt suicide. Partly, it’s because the patients are unable to act, like deer caught in headlights. But de Carvalho thinks they don’t attempt suicide because they feel they are already dead. “And you can’t be more dead than dead.”

When Zeman began talking with Graham and realized the extent of his depression and delusion, he suspected an underlying neurological cause. Something had altered Graham’s sense of self and perception of his environment. There was one neurologist who would know what to look for: Steven Laureys at the University of Liège in Belgium. Zeman took Graham’s consent and sent him to Liège with a community psychiatric nurse in tow. Graham reached the university hospital in Liège and asked for Dr. Laureys.

The secretary called. Laureys, like Zeman, will never forget the phone call: “Doctor, I have a patient here who is telling me he is dead. Please come over.”