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The woman who los he mind: Aphan asia p esen ing as Co a d’s synd ome
Raji h K Ra ind en MD a, b, *, P asad Tho on Veedu MD C
a Depa men o Psychia y, Ins i u e o Men al Heal h and Neu osciences (IMHANS), Kozhikode, Ke ala,
673008, India
b Neu oscience Resea ch Labo a o y, Cen e o In e disciplina y B ain Sciences, Ins i u e o Men al Heal h
and Neu osciences (IMHANS), Kozhikode, Ke ala, 673008, India
c Radiology and Imaging Sciences, S eechand Speciali y Hospi al, Kannu , Ke ala, 670001, India
Keywo ds: Aphan asia; Co a d’s synd ome
Funding/Suppo : None
Po en ial con lic s o in e es : None
1 Co esponding au ho
Raji h K Ra ind en
Depa men o Psychia y &
Neu oscience Resea ch Labo a o y,
Cen e o In e disciplina y B ain Sciences,
Ins i u e o Men al Heal h and Neu osciences (IMHANS),
Kozhikode, Ke ala, 673008, India
[email p o ec ed].in
2
In oduc ion
Aphan asia is de ined as he absence o ma ked educ ion o conscious, wake ul image y. I has been
epo ed in 1% o he popula ion. Mos o hem li e no mal li es wi h in ac a en ion, memo y, and
in elligence.1 We a e p esen ing a case o acqui ed aphan asia p esen ing as Co a d’s synd ome.
A 53-yea -old woman p esen ed wi h he complain ha she had los he mind a he age o 29. She
accused he mo he o doing eligious i uals, which caused he mind o disappea . She was unma ied and
was s aying wi h he mo he and sis e . The e was no his o y o men al illness in he amily. She was he i s
among 5 child en o he pa en s. He bi h and ea ly de elopmen we e no mal. She had comple ed he
school educa ion. When she was 13 yea s old, she s a ed ha ing p og essi e hea ing loss in he le ea . By
he 30 h bi hday, he igh ea also s a ed de e io a ing. A ound his ime, he men al heal h p oblems began
su acing. She was adaman in he belie ha she had los he mind, and he mo he was esponsible o his.
He sleep, appe i e, sel -ca e, and in e ac ions wi h o he s we e no mal du ing his pe iod. Mos o he ime
was spen wa ching ele ision. She consul ed mul iple psychia is s and was on an ipsycho ics o 20 yea s.
She had ied ispe idone 8mg, halope idol 10 mg, and i luope azine 10 mg du ing his pe iod, bu he e was
no imp o emen in he complain s. She s a ed using hea ing aids, which helped he in day- o-day ac i i ies.
The imp o emen in hea ing had no impac on he delusion.
She was e alua ed mul iple imes o e 3 yea s. He con e sa ion always e ol ed a ound he los
mind. When we asked he how she knew ha she didn’ ha e a mind, she would emain silen . She did no
ha e any o he delusions, hallucina ions, o i s - ank symp oms. He mood, in elligence, and a en ion we e
no mal. On MMSE, she sco ed 29, indica ing no mal memo y. She could ead and w i e English and
Malayalam. He nume ical skills we e no mal. Clinical e alua ion o he lobe unc ions was no mal excep o
poo abs ac ion.
She had isual d eams, app oxima ely once a mon h. She d eam abou he dead body o he ela i e,
an e en ha occu ed when she was 10 yea s old. She could iden i y he sel in he mi o . Face ecogni ion
was no mal in he amilia ace ecogni ion es . On he Vi idness o Visual Image y Ques ionnai e (VVIQ)2-a
es o aphan asia-she sco ed he lowes possible sco e o 16. On he Plymou h Senso y Image y
Ques ionnai e 3, she could no olun a ily imagine sigh , sound, smell, as e, body sensa ions, ouch, o
eeling. She could no men ally e e se he small case le e b o d o e e se he uppe -case le e F o 7.
We e alua ed he heo y o mind skills using he Sally Anne es 4, which she ailed. MRI b ain showed
subco ical and deep ce eb al whi e ma e lesions in bila e al on al and pa ie al lobes (Figu e 1).
Discussion
This pa ien p esen ed wi h a nihilis ic delusion o he absence o mind. She did no ha e any ea u es o
schizoph enia o dep ession. Co a d’s synd ome is cha ac e ized by he appea ance o such nihilis ic
delusions conce ning one’s own body.5 This pa ien aises he ques ion o how a pe son subjec i ely knows
ha he o she has a mind. And how he clinician can unde s and whe he a pe son is ha ing a subjec i e
expe ience o mind, he philosophical p oblem o he o he mind. The pa ien was able o ecognize he sel
in he mi o , showing ha he sense o sel was in ac .6 The equen use o “I” in con e sa ion u he con i ms
his. We hypo hesized ha his pa ien migh be ha ing p oblems wi h gene a ing in e nal images o in e nal
alk. O she migh be ha ing p oblems in moni o ing he images and in e nal alk.
To es hese, we used he Vi idness o Visual Image y Ques ionnai e (VVIQ), which showed ha she ailed
o in en ionally gene a e isual images.2 The Plymou h Senso y Image y ques ionnai e showed ha she was
ha ing p oblems in gene a ing images in all senso y modali ies.3 These wo es s showed ha she canno
olun a ily gene a e /moni o images. He abili y o d eam showed ha in olun a y image gene a ion was
happening wi hou any hind ance. Volun a y image y is gene a ed in he on al egions wi h con ibu ion om
he pa ie al lobes in a en ion and spa ial aspec s o he image (saliency).1 Lesions in he on al and pa ie al
lobes may explain he lack o olun a y images in his pa ien .
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He aphan asia may explain he complain o a los mind. Bu ha will no explain he accusa ion agains he
mo he . How does a pe son wi h no abili y o olun a ily gene a e images/ hough s accuse ano he pe son o
ha ming he ? To explo e his, we es ed he pa ien using he Sally-Anne ask. In his es , wo ca oon
cha ac e s a e shown o he pa ien . One o hem, Sally, places a ma ble in he baske and goes ou . The
o he one, Anne, akes he ma ble and places i in he box. Sally e u ns a e some ime. The expe imen e
asked whe e Sally mus look o he ma ble. Ou pa ien could no gi e he co ec esponse. This es equi es
knowing he pe spec i e o Sally a he han one's own.4 This es hus measu es a pe son's abili y o model
o he minds. This abili y is impai ed in pa ien s who ha e an inju y o he g anula p e on al co ex.7 Bila e al
whi e ma e lesions in he on al lobe may explain he heo y o mind de ec in his pa ien .
Co a d’s synd ome is explained using a wo-s age p ocess. The i s s age is cha ac e ised by
abno mal pe cep ion, due o dys unc ions in pa icula b ain a eas, and he second s age is essen ially based
on one’s own ypical a ibu ional e o .8 In his case, inju y o he on al and pa ie al egions esul ed in
impai ed gene a ion and moni o ing o olun a y images. The on al lobe lesion, which causes di icul y in
modeling one's mind, also esul s in impai ed modeling o he o he mind.7 This wo-s ep p ocess may explain
he symp oms in his pa ien . He poo abs ac ion skills a e a u he poin e o he poo modeling abili ies.7
A e he e o he condi ions in which he subjec i e knowledge o one's own mind diminishes would be
a ui ul line o enqui y. In Eas e n medi a ion adi ions, i is men ioned ha he mind is esponsible o all
su e ing, and quie ing o ‘annihila ion’ o he mind esul s in Moksha /ni ana/enligh enmen . I onically, we
ha e a pa ien who claims ha she has los he mind and is upse abou ha , a he han eeling peace. She
s ill a ends he clinic in he hope o ge ing he mind back.
Re e ence
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image y ques ionnai e. B i ish Jou nal o Psychology. 2014 No ;105(4):547-63.
4. Ba on-Cohen S, Leslie AM, F i h U. Does he au is ic child ha e a “ heo y o mind”?. Cogni ion. 1985 Oc 1;21(1):37-
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5. Deb uyne H, Po zky M, Van den Eynde F, Audenae K. Co a d’s synd ome: a e iew. Cu en psychia y epo s.
2009 Jun;11(3):197-202.
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7. Benne MS. Fi e b eak h oughs: a i s app oxima ion o b ain e olu ion om ea ly bila e ians o humans. F on ie s
in Neu oana omy. 2021 Aug 17;15:693346.
8. Tomase i C, Valche a A, Fo na o M, Vellan e F, O solini L, Ca ano A, Ven iglio A, Di Giannan onio M, De Be a dis D.
The ‘dead man walking’diso de : an upda e on Co a d’s synd ome. In e na ional Re iew o Psychia y. 2020 Aug
17;32(5-6):500-9.
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Figu e 1: MRI images showing subco ical and deep ce eb al whi e ma e lesions in bila e al on al and
pa ie al lobes
