SYMHC Classics: Jules Cotard and Cotard Syndrome

00:00:02
Speaker 1: Happy Saturday. Neurologist Jules Kuttard was born on June first, eighteen forty or one hundred and eighty four years ago today. If you're listening on the day this episode drops, so we have our episode on him and the syndrome named for him as Today's Saturday Classic. This originally came out on March thirtieth, twenty seventeen. Enjoy Welcome to Stuff You Missed in History Class, a production of iHeartRadio. Hello, and welcome to the podcast. I'm Holly Frye and I'm Tracy B. Wilson.

00:00:45
Speaker 2: Tracy, you have heard of Qatard's delusion or Catard syndrome before, right, mm hmm, And usually probably if you've seen it. It comes up on frequently online on the lists of you know, world's strangest maladies or you know list of sort of disturbing or unsettling mental disorders. Because in those lists it's usually just characterized as a patient believing themselves to be deceased. It is sometimes called walking corpse syndrome because of that, and while that can certainly be part of it, it is a lot more complex than that. So Catard syndrome is quite rare. It involves both a negation delusion, so the individual feels a major change in their body, or they deny the existence of one or several parts of their organs or bodies, like they will sometimes think that they no longer have viscera, or that their blood is gone, or some other variation on that theme. And it also has a nehilistic delusion element, so in that part of it, the individual also believes that they or are all people are dead, that they are somehow comporting themselves around the earth in a state of non livingness. So it is it's very complex. And additionally, the work of Jules Catard is much debated even today, and part of that is because it was unfinished, which we're going to talk about. So really, the story of this syndrome that's named for him, in many ways is the story of psychiatry and how ideas are challenged and then shift and change through interpretation as well as accumulation of data through the passage of time. So we're going to talk about Jewels Cautard, his work in this area, and then sort of how things played out later on in terms of using his work to address issues patients.

00:02:27
Speaker 1: For having Jules Catard was born on June first, eighteen forty in Istudon in central France. As a young man, he became a medical student in Paris, where he studied under several prominent and trailblazing physicians of the day. These included Pierre Paul Broca, who has a portion of the frontal lobe in the brain named after him because of his work studying that area and then also establishing the concept of brain function being associated with specific areas. There's also Alfred Volpien, who is credited with the discovery of adrenaline being made by the adrenal gland, and Jean Martin Charcot, who's considered the father of modern neurology and has more than a dozen medical conditions or discoveries named for him. In short, that was kind of an incredible time to be studying medicine in.

00:03:20
Speaker 2: Paris, it really was. There was also a lot going on, of course, in Vienna and Germany at the time. That Paris had some really interesting neurological and psychiatric culture growing up around it, So initially Katard was on the same path as the neurologist that he had been studying under. His first significant paper was titled physiological and pathological studies on cerebral softening, exploring how inflammation and hemorrhaging damages brain tissue. And then his doctorate paper in eighteen sixty eight was titled Study on partial atrophy of the brain.

00:03:55
Speaker 1: One event though, would really significantly change the course of Cotard's career. He witnessed the psychiatrist Charles Le Sigue interviewing a patient and he was enthralled. Based on watching this man at work, Quotard began to shift his focus away from neurology and into psychiatry. The two men would eventually become colleagues, and I feel like we should say that this was It was not uncommon for people going into psychiatry at this time to have started out in neurology.

00:04:26
Speaker 2: A lot of people did. In eighteen seventy four, Le Segia introduced Jews Qutard to Jules Farrey, and the two Juleses would go on to become research partners, working side by side in the Maison de Sante that's the asylum at von Vez in Paris in the southwestern suburbs, and incidentally, Farre's father actually owned that asylum.

00:04:50
Speaker 1: Quotard gave a presentation to Paris's Medical Psychological Society on June twenty eighth, eighteen eighty, he reade a case report he and Falay had assembled titled of the hypochondriac delirium in a severe form of anxious melancholy. In this case, the patient was a woman who was forty three. She had a unique set of symptoms. So this woman, who is referred to in the paper as Madame X, thought that she was made of nothing but skin and bone, and that she had no brain, nerves, chest, or entrails. Additionally, she had come to the conclusion that God did not exist, nor did the devil, and that she would live forever. She had made several attempts on her own life and requested of her doctors and others that she be burned alive. As Cotard presented, he referenced similar cases that had been on the record going as far back as twenty years. He specifically mentioned similar cases handled by doctor Jule Bayarze as some of the oldest. These were considered part of a diagnosis of general paralysis, and in this context the paralysis referred to as a failure of the brainized by a loss of inhibitions and the exhibition of delusional thinking, So not a lack of physical movement or an inability to move your body. Right, when we think of paralysis, that's usually what comes to mind, but that's not the application of the word here. So yeah, these similar cases that had been studied two decades earlier had kind of gotten lumped in as general paralysis. But Katard felt like there was something a little more specific about them, and he thought that what his patient was exhibiting was actually a form of what was at the time called lipomania or lipomania, and that term eventually was supplanted by melancholy. Basically, he thought he had identified a specific form of melancholia, and this was, in his opinion, an anxious melancholia, with delusions that could include religious misbeliefs of damnation or demon possession, the perception that some or all of the body had ceased to exist, inability to perceive physical pain, immortality, delusion, and suicidal behavior. Jules Coutard also drew possible connections in this presentation from the symptoms he had observed and the patient to similar historical events, including various cases of reported demon obsession. He suggested that the idea of the wandering Jew legend, which was a man who had taunted Christ on the cross and then was doomed to wander earth until the world ended. He thought that may have had roots in the observation of a person with a similarly delusional state. Yeah, he was kind of making this case that it could be that that whole legend grew out of someone speaking with a person who actually had this delusion that he was trying to identify, and Gutard continued to develop his research on this topic. In eighteen eighty two, he expanded on it by introducing the term de de negascion and that's neilistic delusions in an article that he published in the Archives de de re Regi. Patients with such delusions, he said, had a tendency to deny everything, leading in extreme cases to denial of the self. He separated the delusions of negation clinically from delusions of persecution. In that article, he characterized persecution delusions as exhibiting mistrust, paranoia of poisoning, delusions of grandeur, and acoustic verbal hallucinations that would sometimes be homicidal. In contrast, he listed anxious monologue, deep melancholic depression, refusal to eat, visual hallucinations, and suicidal behavior as characteristics of the delusion of negation.

00:08:41
Speaker 2: Four years after Qatar's initial presentation on the symptoms of madame X, he wrote about another patient, this one an adult man who said that he could no longer see his children's features. In eighteen eighty four, Qatars, still trying to build up a unified theory of what he believed to be related symptoms, came to the conclusion that this was a loss of mental vision, and that this was actually the root of the problem. When patients exhibited nehilistic delusions, the mind, in his estimation, was simply unable to process visual representation of objects. He would later refine this concept by describing the problem as a loss of quote psychomotor energy, causing the patient to lose visual representation and to experience psychomotor impairment. It's entirely likely that Cotard would have continued to refine his work on a topic had he not met an untimely end. In eighteen eighty nine, at just forty nine years old, he contracted diphtheria, which he caught from his daughter. He never recovered, and he died on August nineteenth of that year. At his funeral, his partner Faleri spoke, calling him quote a profound and original thinker, given to paradox but guided by a robust sense of reality. And next up, we're gonna talk about what the rest of Paris's psychiatric community did with Catard's work after his death. But first we're going to pause and have a word from one of our sponsors. Almost immediately after Jules Catard's death, debate began about his work and where he had been headed with it and what his intentions actually were. One of the ongoing themes of Katard's work was this struggle to develop terminology for psychiatric ailments, and he had also championed this idea of using symptomatic classification for psychiatry. So, of course, with his work in this state of arrested development, I mean he had been writing updates to his ideas just days before his death, there was a lot of room for interpretation.

00:10:48
Speaker 1: While some of his contemporaries thought he had been cataloging an entirely new disease, others thought his work had always been focused on exploring a severe and specific form of melancholia. Others thought that he merely sought to catalog and describe a symptom cluster that could be found in other diseases in addition to melancholia.

00:11:11
Speaker 2: In August of eighteen ninety two, the issue was hotly debated at the Mental Medicine Congress in Blois, France. Catard's partner Falcays advocated for the idea that his friend had identified a new disease, and to argue his case, he claimed that there was an essential form of Catard's de lo de negacion which stood on its own, and also a secondary form of it that could be part of other melancholia and even non melancholia disorders.

00:11:39
Speaker 1: Others and attendants argued that the specific cluster that Faler was advocating as part of Coutard's newly identified disorder included elements that were so rare, specifically those relating to religion based concepts of demonic possession, damnation, and eternal life, that there was no validity to calling it at own singular syndrome. To support this view, was pointed out that virtually all patients with melancholia had a tendency toward negation and guilt, so the cases in Cotard's writings were just extreme examples of this. Additional arguments against this being a standalone disorder or disease identification included claims that Katard was merely listing a random assortment of symptoms that could be found in any number of mental disorders, so grouping them together was essentially meaningless aside from anyone's specific patient having them. Cases were also brought into the discussion to illustrate the rather common occurrence of neihilistic delusions in cases of chronic melancholia. While the Mental Health Congress came to no clear conclusion as to whether Cotard's work was describing as specific syndrome or common elements of multiple mental disorders, there was some agreement on how to define nialistic delusion syndrome was that it included two specific elements, anxious melancholia and systematized ideas of negation.

00:13:08
Speaker 2: So as an aside to clarify what that means, systematized delusion indicates that a patient has developed a consistent, complex system of beliefs associated with their condition, which often fit together perfectly in a really elaborate narrative. So, for example, if you think that you died in an accident where you did not die, all of the strange things that may happen to you, you will put together into a puzzle to support that conclusion, like I'm clearly dead. That is why that person never calls me back. It's because I'm dead and they're not getting my call. That's a very simplified and basic way, and I'm sure any doctor would be like Holle no, But that's just to kind of give you an idea of what this systematized aspect of it means.

00:13:53
Speaker 1: One year after that Congress and four years after Cotard's death, the Termqutard syndrome was first introduced. That was in eighteen ninety three by Emil Regis to name the depressive disorder that Cotard had studied and described. It then became cemented in the lexicon through its use by another of Cotard's contemporaries, who was psychiatrist Juz Segla, although there were some differences in how Siegla and Cotard viewed this condition. While many believed that Cotard's work had led him to the conclusion that nihilistic delusion was a separate and unique condition, Segla felt that it was an expression of an extreme state of anxious melancholia. So the case in which Segla first used the term Qutard's syndrome to describe a patient, featured a man who, much like Coutard's patient Madam X, believed himself to be immortal, damned, and without his internal organs. And despite his different view of whether the syndrome was a unique disorder or a way to identi extreme cases, Segla's diagnosis of a patient as having Cotard syndrome really popularized the term's usage. With the dawn of the twentieth century, came many changes in the way mental health was discussed and treated, and Cotard's work had to be examined in new ways as a consequence. So first you probably noted that leading up to this point we exclusively use the term melancholia. That's because depression and manic depressive illness as diagnostic terms didn't exist until the twentieth century, and those have continued to be refined. Now people generally say bipolar disorder and not manic depressive illness. Once they were introduced, though, these terms really impacted a lot of disorders and illnesses, including Cotard syndrome.

00:15:47
Speaker 2: So in the early nineteen hundreds, Cotard syndrome was invoked as a symptomatic analysis of patients who were being treated for general paralysis and senile dementia, as it had been toward the end of the nineteenth cent been used in both of those, but now it was also associated with the newer terms depression and at that point manic depressive illness, and so this wider range of use also came with the development of a subdivision of the syndrome by some doctors into two types, the melancholic type of catard syndrome and the hypochondriacal type of catard syndrome. The melancholic type was considered secondary and a patient with effective disorder. It's a mood disorder such as depression, bipolar disorder, or anxiety disorder, characterized by nihilistic delusions and the patient's subjectivity. The hypochondriacal type was considered a primary manifestation of the syndrome, where the patient's symptoms were focused around incorrect and paranoid feelings about the body, like that it was missing viscera or that it was no longer alive. And again we should make clear that this was not a universally accepted approach to dividing thisnineteen four Leonardo Bianci and James Hogg MacDonald wrote a textbook of psychiatry for physicians and students, and in it they wrote, quote Catard and others have assigned undue importance to the delirium of negation, attributing to its certain clinical characters, many of which, as a matter of fact, are common to the majority of cases of depressive delirium, such as self accusation and hypochondria, of which it represents a more advanced stage of evolution. It was just as a decade earlier, a time when some of the medical mental health community believed that Catard had wrongly associated a series of fairly common symptoms into one unique cluster.

00:17:40
Speaker 1: Another idea developed during this period was a way to identify nihilistic delusions as true cu Tard syndrome. This particular approach required that a patient exhibit a combination of an effective or mood component like anxiety, and an intellectual component, which was the idea of negation. This approach meant that these delusions could be recognized and acknowledged in a variety of scenarios without the identification of Cotard syndrome. And to make things even more nebulous, some physicians also suggested breaking down the syndrome into complete and incomplete versions based on variations in the patient's symptoms.

00:18:23
Speaker 2: This is one of those things where the more I read, the more I was like, how do any doctors or clinicians ever agree on anything? Because it is so hotly debated, and I know this isn't just unique to Catard syndrome. Yet others suggested that Cathard syndrome is really a result of institutionalization, and in fact, that first patient that Qatard described back in eighteen eighty was a woman who had been confined at the Van Vis Asylum for a number of years.

00:18:53
Speaker 1: So to wrap things up, we're going to talk a bit about the discussion and handling Ofqutard syndrome after World War II, But first we're going to take one last quick break for a word from a sponsor. During World War II, Paris was of course occupied by the Nazis, and so work on psychiatry there certainly slowed. But after the war, Catard's work was once again examined, and in some ways history repeated itself as various clinicians offered their interpretations based on their work with patients that had similar or related symptoms. In the book Uncommon Psychiatric Syndromes, writers Morgan Enoch and William Treuthowen wrote, it is quote justifiable to regard Catard's syndrome as a specific clinical entity because it may exist in a pure and complete form even when symptomatic of another mental illness. Nallistic delusions dominate the clinical picture.

00:19:54
Speaker 2: And today, of course, classification of mental disorders continues to be debated, and in the at eighties many of the concepts that were being introduced were in their infancy, so things were constantly in flux. There was ongoing debate about what various disorders should be called, and even how to arrange the known disorders into a larger classification system. Because the very juvenile stage of many of the concepts that Gutard was writing about, and the fact that he was writing in French, there have been additional debates through the years about the interpretations of his work and how translation has affected it. For example, in a paper written in nineteen ninety five by G. E. Barrios and R. Luke, there is some discussion about the use of the French word deliere, which has more complex and nuanced meaning than its usual translation to delirium or delusion. The two writers of that paper explain that the word is more inclusive than that and can be used to describe a syndrome with lots of different symptoms, not just delusions, and this syndrome now has three distinct developmental stages recognized within it in the work of some doctors. The germination stage is characterized by depression and often a fear or worry about illness, and in the second stage, called the blooming stage, patients exhibit anxiety and negativism, and the delusions of death and immortality appear. This is what most people are describing if you ever read like a very quick blurb about what Catard's is, and then the third chronic stage of catard syndrome manifests in severe depression. Gotard's syndrome is not listed in the Diagnostic and Statistical Manual of Mental Disorders or in the International Classification of Diseases as an independent disorder. Instead, it is listed as a nihilistic delusion, which is an effective delusion within a depressive episode with psychotic features, and Catard's syndrome can be treated with antidepressants, antipsychotics, and mood stabilizers, either by themselves or in some combination, depending on the tests that have been run in what the doctor and patient determined to be the best course of action. Sometimes the still controversial electroconvulsive therapy is also used. That is very different than it used to be FYI. The greatest risks in terms of the syndrome today when speaking about potential mortality are starvation and patients that refuse to eat or suicide. So patients undergoing treatment do you have to be watched very carefully. But there is treatment and there are many cases of people who come out of this and treat it and no longer have it. So that's Catard syndrome, which fascinates me. Yes, thanks so much for joining us on this Saturday. Since this episode is out of the archive, if you heard an email address or a Facebook RL or something similar over the course of the show, that could be obsolete now. Our current email address is History Podcast at iHeartRadio dot com. You can find us all over social media at missed in.

00:23:01
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