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Diagnosing culturally variable presentations of mental disorders: Develop cross-culturally comparable diagnostic interviews: Researchers

In the context of syndromes, disorders, and clinical entities which are well known in the West, presenting themselves uniquely in Sri Lanka, the development of cross-culturally comparable diagnostic interviews that would be conveniently accessible to clinicians could help increase diagnostic accuracy in psychiatry.

This was noted by Senior Lecturer (Grade II) of the Department of Psychiatry of the Faculty of Medicine of the University of Kelaniya, Dr. M. Chandradasa and the Cadre Chair and Senior Professor of the same, K.A.L.A. Kuruppuarachchi, P.K.D.H.J.L. De Silva Rajaratne (attached to the National Hospital, Colombo) and C. Kuruppuarachchi (Sir John Kotelawala Defence University) in a case report titled “The Living Being Dead: Cotard Syndrome Presenting as a Dead Spirit” published recently in the Sri Lanka Journal of Medicine.

French neurologist Jules Cotard described a syndrome with melancholic anxiety and depressed mood, delusions of possession and immortality, ideas of suicide, and thoughts of non-existence of their own body and/or soul. In this clinical condition, hypochondriac and nihilistic delusions are prominent and patients would present with statements such as “I am dead” and “my internal organs do not exist”. Suicidal and self-mutilating behaviours may pose a threat to life. Cotard syndrome is not listed as a specific disorder in the Diagnostic and Statistical Manual of Mental Disorders and this clinical syndrome is viewed as a part of other underlying psychiatric and neurological disorders.

The authors (Dr. Chandradasa, Prof. K.A.L.A. Kuruppuarachchi, Rajaratne, and C. Kuruppuarachchi) reported two patients with Cotard syndrome presenting as a “perethaya”, a greedy dead spirit recognised in the Sri Lankan culture, as having a dangerous longing for food until their next incarnation.

The first case report was of a 68-year-old married, retired school teacher who had been diagnosed as having recurrent psychotic depression for seven years and had been stable on an atypical antidepressant and atypical antipsychotic. She had then developed involuntary repetitive movements in the mouth and face for which she had been treated with a different atypical antipsychotic. Subsequently, she had presented with a depressed mood with constant preoccupation about having oral carcinoma without any related symptom. Upon her mood gradually worsening over two weeks, she had been admitted for inpatient management. Afterwards, she had stated that she was dead and that her internal organs had ceased to function. She had demonstrated agitation and disorganised behaviour and also had intermittently removed all clothes in public and claimed that she could feel an iron rod being inserted into her vagina. Moreover, she was of the belief that she deserved to be tormented and raped and that this would purge her from her sins. Also, she was convinced that she was a perethaya, or greedy dead spirit, and ate garbage from dustbins in the ward and attempted to drink water from the toilet bowls.

However, the patient remained alert and oriented with regard to time, place, and person, with no features of delirium. The cognitive assessments were normal. All other investigations (brain, blood, endocrine, and biochemical) were within normal limits. She had responded to a course of electroconvulsive therapy and a combination of an atypical antidepressant, an antidepressant, an atypical antipsychotic, and a bipolar disorder agent.

The second patient was a 42-year-old married man who had been diagnosed to have recurrent depressive disorder for the past decade. He presented with a relapse after defaulting on psychopharmacological treatment. He had been severely distressed over a property dispute. Also, he claimed that he could hear his deceased father asking people to bury him as he is dead. Furthermore, despite no evidence, he believed that his relatives were plotting against him. He was diagnosed with psychotic depression and admitted for inpatient management as his condition gradually deteriorated. Additionally, he also was of the firm belief that he was dead and that his current existence was of a greedy dead spirit or perethaya and also that the rest of the world had ceased to exist. In this regard, he believed that the others who spoke to him including doctors were also dead. He too stated that he deserved his current plight due to his past sins and also that a soothsayer had predicted his impending demise long ago.

Investigations (brain, blood, endocrine, and biochemical) in his case were normal. He had responded effectively to a combination of an antidepressant and an atypical antipsychotic.

The researchers explained that the two patients were reported with psychotic depression presenting with Cotard syndrome. They noted that the belief that a person who desires too much during the human life would be born a perethaya, which is considered to represent an extremely unfortunate outcome for Buddhists, aligns with the nihilism described in severe depressive disorder and Cotard syndrome. Furthermore, they added that Koro syndrome, which is a culturally related disorder characterised by intense anxiety, and distressing and frightening fear that the penis in males and the vulva or nipples in females are shrinking or retracting and will recede into the body (abdomen), is usually reported from Sri Lanka and other Asian countries.

Therefore, the authors explained that compared to other medical specialities, psychiatry has a considerably intense relationship with the local culture, a fact which is predominantly demonstrated in culturally variant presentations of familiar psychiatric phenomena. The afore described cases of Cotard syndrome occurring in the context of a depressive disorder show how, the authors add, a clinical entity well known in the West has presented itself uniquely in Sri Lanka. Furthermore, the researchers point out that many psychiatric disorders have culturally variable presentations and that there have been unique reports from Sri Lanka, adding also that well-recognised mental disorders may present themselves in unusual ways in non-Western settings.

According to the authors, it is believed that specific underlying psychopathological mechanisms are present in Cotard syndrome and that therefore, a sound understanding would facilitate effective therapeutic interventions for each patient, and that in this regard, the development of cross-culturally comparable diagnostic interviews that would be conveniently accessible to clinicians could help increase diagnostic accuracy in psychiatry.