Genital Theft: Cotard Syndrome or Depersonalization? A Case Report

Dear Sir,

Genital theft or denial of genital ownership is a rare clinical event (except in Africa). Only a single case is reported in the global literature from New Zealand. ¹ We present the second case of “genital theft” from West Bengal, India. This is a fascinating case who complained that a friend had stolen his genital organs in the background of depression and cannabis use.

Case

Mr. DN, a 53-year-old Bengali Hindu, single male, presented himself to a rural hospital emergency with abdominal acute pain and distension, feeling of a hard moving mass inside the lower abdomen. During the examination, he disclosed that his penis and scrotum were stolen by a friend, 2 weeks ago, and currently, he has no genital organs. No definite organicity was found about his abdominal complaint, and symptomatic management relieved his distension, he was referred and admitted to the Institute of Psychiatry, Kolkata.

On examination, there were no gross physical abnormalities or neurological deficits, and his gait was normal. His communication was somewhat anxious. He complained of a low mood for the past 5 months following his layoff from a local jute mill. His affect was of a dulled emotional tone (apathy). He also complained of extreme physical and mental slowing and lost motivation to carry out day-to-day activities. He also expressed his extreme concern for his lost genitals. He disclosed that he smoked cannabis for the last 5 months on weekend evenings with one of his known person (F). One evening F palpated his genitals (the reason is unknown), and after that, in that evening, he discovered that F had stolen the body parts. After this event, that so-called friend stopped calling him. He was convinced that F was the “culprit” though he had no clues for this theft. He repeatedly requested us to summon F and order him to return his genitals (Penis and scrotum).

All laboratory tests were regular, except a urine drug test was positive for cannabis on admission. The neurology referral was uneventful, with a standard CT head, without any deficit in tone, power, reflexes or any abnormal movements. The mood was low for the last 5 months, and the Hamilton Depression rating scale score was 27. He denied any suicidal thoughts or intent. His MMSE score was 24/30. No formal thought disorder or delusional thought content was evident except his firm solitary belief that his genitals have been stolen by his friend. However, he could not provide any suitable motive behind this alleged theft. He had no fear of death from this genital loss but was feeling shameful and apprehensive about the probability of ridicule by the people of his locality. He denied any heterosexual or homosexual relations and remained single by his own choice.

Regular supportive psychotherapy and assurances of recovering the lost genitals facilitated a good rapport. He was prescribed tab amoxapine 50 mg daily for 3 days and then increased to 50 mg in the morning and 100 mg in the afternoon, along with tab clonazepam 0.50 mg at bedtime. Given his repeated request to recover his lost genitals from his friend, a psychodrama type of session ² was planned for the 3rd week of his admission. His alleged friend was called and he participated in a psychodrama therapy session where he acknowledged the theft and acted as he was returning the theft genitals. The clinical team staged the fixing of the genitals with his consent during this psychodrama session.

Discussion

The diagnosis and differential diagnosis of this case pose some critical conceptual difficulties. At least three main clinical issues seem essential here. First, Cotard syndrome; second, a dissociative disorder like depersonalization/derealization; and last, asomatognosia. Sporadic cases of “genital theft” are extremely rare in the literature. Some authors have regarded the penile dissolution in Koro as a delusional perception and have tried to explain the phenomenology in the light of Cotard syndrome. Bandinelli et al. ³ reported a case of 58-year-old single man with chronic Koro-like symptoms (KLS) and suggested that nihilistic or hypochondriacal delusions are associated with depersonalization experiences. They believe the feature of KLS is a shared annihilation delusion, which may be called a variant of Cotard’s delusion. Connors and Waldau ¹ reported a case of a 36-year-old man who complained that his penis had been stolen and replaced with someone else’s, against a background of a history of schizoaffective disorder and longstanding body-dysmorphic disorder, with a positive urine test for cannabis.

Cotard syndrome is a constellation of false nihilistic beliefs that often surface in self-negation. Patients with psychotic depression often show Cotard syndrome as an internalized attribution style or accompanied depersonalization. ⁴ In the present case, if his firm conviction of genital theft and consequent persecutory accusation of his fiend is considered as a part of psychotic delusion, then there is a probability that the symptom of genital loss (theft) may be explained as a part psychotic depression. Psychotic depression has been reported with Cotard symptoms. ⁵ Berrios and Luque, ⁶ in their review of 100 cases of Cotard syndrome, found that 89% of subjects reported depression, and the most common nihilistic delusions were concerning the body (86%) and existence (69%).

Depersonalization/derealization disorder is a form of dissociative disorder characterized by periods of feeling disconnected or detached from one’s body and thoughts (depersonalization). It is usually an episodic state and is often associated with epilepsy, brain diseases, certain personality disorders, and substance abuse. Cannabis is notably associated with depersonalization, ⁷ which may later become chronic in nature. ⁸ Weekly cannabis smoking for nearly the last 5 months in this case may be a potential contributor for genital depersonalization.

The two other clinical conditions in the differential diagnosis are essential. The first one is delusional hypochondriasis and depression. Major depression might have mood-congruent psychotic symptoms like somatic delusion, for example, dysmorphophobia. ⁹ Asomatognosia is the other issue of consideration, which means lack of recognition of the body, which is a pathological somaesthetic experience that the parts of the body are “missing, are stolen or have decayed.” ¹⁰ Moreover, the denial of boy part (s) is not associated with identifying a person responsible for the loss (or theft). There is no evidence of any focal brain lesion in the present case.

Conclusion

The cases with subjective perceptual genital symptoms need very careful clinical analysis. Depression, psychosis, Cotard syndrome, depersonalization-derealization, asomatognosia, and even body-dysmorphic disorders (penile dysmorphophobia) ¹¹ are the potential clinical issues to be differentiated for proper diagnosis and treatment. We attempted a modified psychodrama therapy approach along with antidepressant and anti-anxiety medications with success. His positive response (regaining of genital organs) with staged drama resembles somewhat similar responses in conversion disorder (limb paralysis), but we do not have an easy answer to how all these worked for him. His belief and trust that the lost genitals can also be recovered played a vital role in this dramatic treatment approach and his recovery. He once said that he heard from his old grandmother that in the village side witches or “night ghosts” (Nishi) steal penises and often return the stolen objects if they are appropriated through traditional rituals. We believe that this rural cultural background of the subject was conducive for this psychodrama therapy approach.