Capgras and Cotard Delusions: The Unfamiliar Faces at Your Funeral
Damage to the limbic system pathways can make you believe your loved ones are imposters, or that you no longer exist
Capgras and Cotard delusions
When pathways connecting to the limbic system are damaged, integrating emotion with perception is no longer possible, giving rise to two of the most unusual maladies known to man, that of Capgras and Cotard delusions.
The fabric the eye weaves
‘I know faces, because I look through the fabric my own eye weaves, and behold the reality beneath.’
— Kahlil Gibran
You never truly and objectively see a loved one’s face; if the contours of their cheek and slope of their forehead is the leitmotif which whispers ‘you know me’, then the feelings and associations accompanying that recognition are like a crashing, orchestral crescendo drowning it out.
We don’t merely recognise a face, we experience a flood of emotions in response. Whether it’s adoration, disdain, or something in between, this stirring serves as a sort of ‘covert’ recognition mechanism. We recognise people by the love or loathing they inspire rather than purely through the arrangement of their facial features.
Cold, hard appraisal of our environment and the people within it, stripped of all emotional charge, is a strange, eerie, and wholly distressing experience. And bizarre perceptions are known to give rise to equally bizarre delusions…
When limbic system connections to facial recognition units are damaged, typically due to dementia or brain injury, recognition leaves us bereft of feeling. To a person with Capgras delusion a loved one’s face is a facsimile belonging to an identical imposter, uncanny in its accuracy, yet somehow lacking in authenticity and the ability to evoke emotion.
A dead star overseeing an inert cosmos
To Cotard patients, why, their own face might as well be a waxwork death mask; not only do familiar faces fail to quicken them, so does every other object in their environment. Every person. Even their own reflection in the mirror is an image without meaning.
Our sense of self is in part a product of our shifting emotion states, grounding us in the reactive, bodily states of elation, sadness, fear, and anger. When nothing has the capacity to stir emotion in us, we naturally experience ‘feelings of emptiness, depersonalisation and derealisation’ (Young & Leafhead, 1996).
Cotard patients believe themselves dead, a mind adrift without bodily existence, or else they believe—against all evidence to the contrary, including their ability to argue their case—that they no longer exist at all.
Some believe a single limb is rotting away, others feel they ought to be stored in the morgue. Occasionally, this melancholic delusion engulfs the entire world, which sufferers of this delusion believe has ceased to exist entirely (Charland-Verville, 2013).
‘…subjects describe themselves as mere points in space observing, but uninvolved in, the events which take place around them and another patient has spoken of herself as a “dead star” overseeing an inert cosmos’ (Gerrans, 2002)
What causes Capgras and Cotard delusions?
A one-factor model of delusion
Surely to jump from ‘my daughter’s face leaves me cold’ to ‘she must have been replaced with a body double’ is an extreme leap, not only would you have to be brain damaged, but also irrational, utterly mad to believe such a thing. Right…?
On the contrary, the one-factor model of delusion posits that altered perception alone is enough to explain delusion, and that the reasoning capabilities of deluded and normal individuals do not differ. After all, less than ideal reasoning styles, such as jumping to conclusions or a reluctance to abandon one’s beliefs in the face of contradictory evidence, are common to all of us. Once anomalous experiences are accounted for, there is no need to further invoke abnormalities in reasoning to explain delusional beliefs (Gerrans, 2002).
Delusions are in a way logical, as they are an attempt to rationalise and make sense of one’s disturbing, new circumstances, however outlandish such beliefs appear at first blush, with their lurking CIA operatives and tin-foil foiled extra-terrestrials. Recall that all of perception is a cobbled together patchwork rather than a perfect mapping of an external reality; all of us are generating and testing hypotheses as we wend our way through a complex world, meaning erroneous perceptions are inevitable.
Individual differences
Nevertheless, a secondary layer might be at play, one that invokes normal, rather than abnormal, patterns of inferences, helping to shed light on why the same localised brain malfunction results in delusions with vastly differing phenomenologies (Young & De Pauw, 2002).
Whether our perceptions are an accurate reflection of reality or aberrant in nature, they interact with our individual frameworks for perceiving the world. For example, an internal rather than externally-focused attributional style might lead a person to suppose others had changed rather than that he or she had been irrevocably altered (McKay & Cipolotti, 2007).
Similarly, differences in cognitive style might be a determining factor. A depressed individual exhibiting flat affect and suffering anhedonia might find their preexisting inclinations magnified by distressing perceptual experiences, resulting in Cotard’s delusion. In contrast, a person given to paranoia might be more likely to experience Capgras delusion (Young & Leafhead, 1996).
Finally, there appear to be differences in levels of awareness (Gennaro, 2020). Some patients are cognisant that their perception, as real as it feels, is not an accurate reflection of bodily reality. This is reflected in their language (‘I speak, breathe and eat, but I am dead’ and ‘I am somehow bothered by my body, as if it wasn’t me’) in contrast to patients who are utterly convinced their brain has vanished and that their intestines have disappeared. (Denying the existence of only one body part is common.)
Neuroaetiological differences between Capgras and Cotard delusions
While both delusions are the result of affective disconnection, there are subtle differences in the underlying aetiology (mechanism of disease). While Cotard’s delusion is the result of a global deficit affecting all of perception, Capgras is restricted to damage to the connections between the limbic system and the ventral visual processing pathway utilised in facial recognition (Gerrans, 2002).
The neurological deficits found in Cotard’s delusion sufferers are so profound that such individuals naturally shift from ‘you are not real’ to ‘I must not be real’. When it comes to Capgras and Cotard delusions, a one-factor model focusing on neuroanatomical damage might just be enough (Gerrans, 2002).
Further reading
Charland-Verville, V., Bruno, M. A., Bahri, M. A., Demertzi, A., Desseilles, M., Chatelle, C., … & Laureys, S. (2013). Brain dead yet mind alive: a positron emission tomography case study of brain metabolism in Cotard’s syndrome. Cortex, 49(7), 1997–1999.
Gerrans, P. (2002). A one-stage explanation of the Cotard delusion. Philosophy, Psychiatry, & Psychology, 9(1), 47–53.
Gennaro, R. J. (2020). Cotard syndrome, self-awareness, and I-concepts. Philosophy and the Mind Sciences, 1(1).
McKay, R., & Cipolotti, L. (2007). Attributional style in a case of Cotard delusion. Consciousness and cognition, 16(2), 349–359.
Young, A. W., & Leafhead, K. M. (1996). Betwixt life and death: Case studies of the Cotard delusion. Method in madness: Case studies in cognitive neuropsychiatry, 147–171.
Young, A. W., & De Pauw, K. W. (2002). One stage is not enough. Philosophy, Psychiatry, & Psychology, 9(1), 55–59
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