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transcultural psychiatry i
Transcultural Psychiatry
2022, Vol. 59(2) 225-232
sociocultural context: The singular
When Cotard's syndrome fits the © The Author(s) 2021
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, _ . ,      , DOI: 10.1177/13634615211041205
case of Per Dead Onhn and the joumais.sagepub.com/home/tps Norwegian black metal music scene ®sage
Hugo Sanches ' ©, Leonardo Villaverde Buback Ferreira Joao Pedro Goncalves Pacheco Hv, Luiz Carlos Schenberg and Marcos Sampaio Meireles1
Abstract
The sociocultural context of psychiatric patients shapes symptoms experience and expression, as well as how patients deal with a disorder and how society appraises its symptoms. Specifically, the context may influence the social appraisal of a behavior as normal or pathological. Therefore, markedly pathological symptoms may not be accordingly recognized by peers when they are in consonance with the sociocultural context. Per "Dead" Ohlin was a Swedish musician who was a member of the Norwegian black metal band Mayhem from 1988 until his suicide in 1991, at age 22. Black metal is a musical movement characterized by death worshiping and anti-Christianism, and is also associated with church arsons and murders during the 1990s. Even among peculiar personalities such as black metal musicians, Ohlin was considered the personification of the movement ideals due to his eccentric and unparalleled beliefs and behaviors, claiming, for instance, that he was already dead. In this article, we propose that Ohlin's eccentric beliefs and behaviors were symptoms of an unrecognized psychiatric condition, Cotard's syndrome, and discuss the diagnostic dilemma presented by Ohlin's artistic persona and singular context. The compatibility between his symptoms and the sociocultural context of black metal may have obscured his mental disorder. If so, Ohlin's unique case may shed light upon one of the effects of context in a psychopathological process: concealing a psychiatric disorder and reinforcing symptoms that fit a particular environment.
Keywords
black metal, Cotard's syndrome, Per "Dead" Ohlin, sociocultural context, suicide
Introduction
Social and cultural contexts significantly influence psychiatric disorders, affecting their recognition, diagnosis, and treatment (Alarcon et al., 1999; Choudhury & Kirmayer, 2009; Kirmayer et al., 2016). Context shapes symptoms experience and expression, as well as how an individual deals with a disorder and how society appraises its symptoms. For instance, psychotic individuals' reports on the experience of their auditory hallucinations as negative (e.g., a disrupted relationship between thought and the mind) or positive (e.g., voices provide useful guidance and are morally good) have been found to reflect the cultural beliefs of local contexts. In the former case, subjects in North America were more prone to assess their condition
negatively through diagnostic labels (e.g., schizophrenia), whereas in India and Ghana, the subjects attributed a spiritual meaning to their symptoms, reflecting a more pleasant and fitting perspective of their condition (Luhrmann et al., 2015). Thus, sociocultural context may influence both the individual and the social appraisal of a phenomenon or behavior as normal or pathological (Lewis-Fernandez &
School of Sciences of Santa Casa de Misericordia de Vitoria, Brazil 2Federal University of Espfrito Santo, Brazil 3Federal University of Santa Maria, Brazil
Corresponding author:
Hugo Sanches, Vitoria - ES, Brazil. Email: hugosanches21 @hotmail.com
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Aggarwal, 2013). However, this may also allow for situations in which conspicuously pathological symptoms may not be accordingly recognized by peers when they are in consonance with the sociocultural context. In this article, we discuss how the case of the late black metal musician Per "Dead" Ohlin shows how a particular context may have concealed a psychiatric disorder.
Per Ohlin, better known by his pseudonym "Dead", was a Swedish musician who was a member of the Norwegian black metal band Mayhem as lead vocalist and lyricist from 1988 to 1991, when he committed suicide, at age 22 (Patterson, 2013). Black metal is a heavy metal subgenre that originated in the United Kingdom in the early 1980s and was further developed in Norway by teenagers. These youth sought to express their opposition to Christianity and its norms and values, the tranquil atmosphere provided by Norwegian welfare policies, and mainstream music (Aites & Ewell, 2008; Bossius et al., 2011; Podoshen et al., 2014). This opposition manifested through songs marked by fast tempos, heavily distorted guitars, raw recording practices, guttural vocals, and lyrics that deal with anti-Christian motifs, satanism, paganism, misanthropy, death worshiping, and negative feelings such as sadness and hatred (Patterson, 2013).
While some musicians in other genres glorify violence or parody death for the sake of the performance and media attention, black metal musicians tend to be quite serious about their message and lyrical content (Podoshen et al., 2014). Most importantly, during the 1990s, the black metal movement was associated with dozens of church arsons, as well as murders, and many musicians were charged with and convicted for such crimes (Patterson, 2013). These events brought worldwide attention to the genre and Norway. In fact, black metal became Norway's number one music export and its festivals and concerts remain featured in the country's official travel guide (Podoshen et al., 2014).
Mayhem was one of the pioneering bands of black metal and was largely responsible for its popularization. The band reached worldwide fame because of Ohlin's suicide in 1991 and the subsequent murder of guitarist Oystein "Euronymous" Aarseth by another black metal musician, Varg Vikernes, two years later (Moynihan & S0derlind, 2003). By the time of his suicide, Ohlin was apparently presenting with depressed mood accompanied by seemingly delusional beliefs of being dead and not being human, with claims that his blood was frozen in his veins (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003). These symptoms are highly suggestive of Cotard's syndrome.
Cotard's syndrome is a rare psychiatric condition described in 1880 by the French neurologist Jules Cotard. He reported the case of a 43-year-old woman who claimed to have no brain, nerves, chest, or entrails. She also denied the existence of both God and the Devil and
refused to eat, as the woman believed she was immortal. Paradoxically, however, she constantly asked to be burned alive and attempted to commit suicide several times (Cotard, 1880).
Cotard originally described the syndrome as a subtype of depressive illness (anxious melancholia), with more to it than just a nihilistic delusion. Thus, in a review of 100 cases reported since its first description, Berrios and Luque (1995b) observed that the most common symptoms were depressed mood (89%), delusions of negation concerning patient's own body (86%) or existence (69%), anxiety (65%), guilt (63%), hypochondriacal delusions (58%), and delusions of immortality (55%). The syndrome has also been associated with self-starvation (Caliyurt et al., 2004; Chiu, 1995; Cotard, 1880; Grover et al., 2014; Ko, 1989; Silva et al., 2000), self-harming, and suicidal behavior (Cotard, 1880; Enoch & Ball, 2001). Patients may present cenesthopathy (persistent complaints about abnormal, medically unexplained sensations in the body) and cenesthetic, auditory, and visual hallucinations (Dalgalarrondo, 2018; Enoch & Ball, 2001).
The most remarkable feature of the syndrome is a nihilistic delusion in which patients deny their own body or existence (Grover et al., 2014). They may report that they are dead or that their organs are absent, rotting, or malfunctioning. They may claim, for instance, that their hearts do not beat, that they have no blood, or that their brains are paralyzed (Dalgalarrondo, 2018; Enoch & Ball, 2001). Much as in Cotard's original case, patients frequently believe that they cannot die (Berrios & Luque, 1995b). Denial may also encompass the extra-personal domain, such as the very existence of the world, the cosmos, and other people, even relatives (Berrios & Luque, 1995a).
Due to the prominence of its most remarkable feature, the term Cotard's syndrome lost its original meaning and was popularized as a synonym for nihilistic delusion (Berrios & Luque, 1995a). We choose to use the term in the latter sense, as it represents the current and more widespread use. In this broad sense, Cotard's syndrome has been found in association with multiple psychiatric disorders, such as psychotic depression, bipolar disorder, and schizophrenia, as well as neurological conditions (Consoli et al., 2007). The full syndrome as described by Cotard lacks precise diagnostic criteria and is not classified as an independent nosological entity either in the DSM-5 (American Psychiatric Association, 2013) or in the ICD-11 (World Health Organization, 2018). Yet, nihilistic delusions are briefly mentioned in both classifications.
This article explores Ohlin's case, evoking the possibility that he suffered from Cotard's syndrome. Most importantly, it aims to discuss the role played by the singular sociocultural context of the black metal scene in possibly shaping and masking his symptoms, or at least their severity. The case description is based on four books about Mayhem, Per Ohlin and the black metal scene, two interviews
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published on the official website of the band (Aarseth, 1989; Blomberg, 1998), and one documentary featuring black metal musicians (Aasdal & Ledang, 2007). Three of these books were based on interviews with Ohlin's relatives, friends, and acquaintances (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003; Patterson, 2013) and one was written by a member of Mayhem (Stubberud, 2018). The lyrics of Ohlin's last song, "Life Eternal" (Ohlin, 1991/1994, track 5), and his suicide note (Johannesson & Klingberg, 2018) were also examined. Information from people who personally knew the musician is prioritized to present the case as precisely as possible. To the best of our knowledge, there have been no psychiatric evaluations of Ohlin either before or after his death.
Case
Per Yngve Ohlin was born in Stockholm, Sweden, in 1969. He was the eldest of five children. As a teenager, his interests included war-related subjects, comic books, and horror movies. Ohlin's interest in heavy metal developed slowly since his early adolescence, during the commercial explosion of the genre in 1980s (Johannesson & Klingberg, 2018).
According to one of his brothers, Ohlin underwent violent bullying at high school. Once, he was beaten so intensely that he suffered a spleen rupture followed by severe internal bleeding (Johannesson & Klingberg, 2018). During this episode, Ohlin reported to have experienced what he believed was a near-death experience (quoted in Moynihan & S0derlind, 2003):
I had a weird experience once. I had inner bleeding and it couldn't be found on X-rays so when it continued to bleed and bleed I finally fainted and dropped down to the floor cos I run out of blood. [...] "Technically" I was dead. At that moment when I fell down (into a door, I heard later), I saw a strange blue color everywhere— it was transparent so I could for a short moment see everything in blue, till something white and "hot" surrounded me.
[... ] [a woman] I know who's had many out-of-body experiences and knows much more than I do about "supernatural" experience, that I asked [about] this [...]. [She told me that] [... ] it gets brighter and brighter till it stops at a white shining one that can't be entered by mortals. If any mortal succeeds in entering it, that one is no longer mortal and cannot be back to the earthly planes nor back to this earth. [...] I was told that the white plane I then entered, without knowing it, was the deadworld and I had died.
A fascination with this experience and death-related themes gradually developed after this episode. Eventually, Ohlin began to collect dead animals, gather obituaries,
and talk extensively about death (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003; Stubberud, 2018).
Ohlin's interest in heavy metal intensified as black metal, a subgenre of heavy metal, was emerging in Scandinavia (Patterson, 2013). After dropping out of school, he formed bands in which he was the lead vocalist under the pseudonym "Dead," writing lyrics that dealt mostly with death. Eventually, Ohlin traveled to Norway and joined the black metal band Mayhem (Figure 1) as lead vocalist (Johannesson & Klingberg, 2018; Stubberud, 2018).
Even though Ohlin became a prominent member of the black metal scene after joining Mayhem, he faced many difficulties and disappointments while living in Norway. The band was not as successful as he expected, and he had harsh financial problems and violent quarrels with a band-mate he lived with. Besides, Ohlin could not communicate in Norwegian and had no friends he could rely on (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003). Thus, Ohlin did not seem to have any close relationships in Norway and lacked emotional support. Apparently, moving to Norway was a turning point in his psychopathology, as it provided the suitable scenario for the development of both depressive symptoms and delusional ideas.
Ohlin's bandmates recall him as melancholic and reserved (Blomberg, 1998; Moynihan & S0derlind, 2003). Similarly, a longtime Swedish friend noticed the changes in Ohlin's mood while visiting him in Norway. He had lost the good mood of earlier times, was not as outgoing as before and kept to himself. In letters to another friend, he often wrote that he did not feel at home in this world, and that the world and the people were "too cold." When Ohlin visited his family in Sweden, they noticed his "disaffection" and "radical weight loss" (Johannesson & Klingberg, 2018). Very often, he insinuated suicidal thoughts to his bandmates and showed increasing social withdrawal, becoming "more and more depressed" (Moynihan & S0derlind, 2003). In the song "Life Eternal," written in 1991, Ohlin highlights the melancholy and suffering that might have nurtured his suicidal ideation: "A dream of another existence, you wish to die, a dream of another world, you pray for death to release the soul." There are also reports that Ohlin frequently cut himself both at home and during performances (Aasdal & Ledang, 2007; Johannesson & Klingberg, 2018).
Meanwhile, Ohlin's fascination with death acquired what seemed to be delusional features. He began to claim that he was not a human being and belonged to another world. He also told his friends that his blood was frozen and that he was dead (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003). In fact, in another excerpt of the song "Life Eternal," Ohlin (1991/1994, track 5) expresses what could be delusional ideas of denial of his
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Figure I. Mayhem band members in 1990, from left to right: Jorn "Necrobutcher" Stubberud, Oystein "Euronymous" Aarseth, Per "Dead" Ohlin, and Jan "Hellhammer" Blomberg. Courtesy of the True Mayhem Collection.
human condition: "I am a mortal, but am I human? [...] A human destiny, but nothing human inside."
Moreover, Ohlin began to bury his clothes into the ground so that they would start to decompose and even asked his bandmates once to bury him so that his skin would look as pale as that of a corpse (Blomberg, 1998). At Mayhem's concerts he wore "corpse paint," a black-and-white make-up that aims to resemble a cadaveric look (Blomberg, 1998; Moynihan & S0derlind, 2003). Before the concerts, he used to sniff a dead crow he kept in a plastic bag, a ritual to "evoke the sensation of death" (Johannesson & Klingberg, 2018). Most notably, he began to refuse to eat, thereby substantially losing weight. His health became exceptionally fragile and his appearance progressively worsened (Aarseth, 1989; Stubberud, 2018).
Ohlin committed suicide in 1991, while he was alone in his house in Norway. He slashed his wrists and throat with a knife, then shot himself in the forehead with a shotgun (Patterson, 2013). He left a brief suicide note signed as "Pelle", his nickname (Johannesson & Klingberg, 2018):
Excuse the blood, but I have slit my wrists and neck. My intention was to die in the forest, so it would take a few days before I was eventually found. I belong in the forest, and I always have. My reasons for this will not be understood by anyone. To give some semblance of an explanation: I'm not human, this is just a dream and I will soon wake up. It was too cold and the blood kept coagulating, plus my new knife was too dull. If I can't die from the knife, I'll blow my head off. I don't really know. I left all
my lyrics by "Let the good times roll" - plus the remaining money. Whoever finds it can have it. As my final greeting I hereby present Life Eternal. Do whatever you want with the damn thing.
Pelle
This didn't come to me now, but seventeen years ago.
Upon finding Ohlin's corpse, hours after the suicide, a bandmate left the house and bought a camera to take photographs of the corpse before calling the police (Johannesson & Klingberg, 2018). One of these photographs was used as the cover of one of Mayhem's following albums. Ohlin's suicide heavily contributed to the increase in the band's popularity worldwide (Moynihan & S0derlind, 2003).
There is no available information suggesting that Ohlin had sought or received any psychiatric or psychological care.
Discussion
There are two main interpretations of Ohlin's aforementioned behavior, claims, and lyrics. The first one is to assume that they were all non-literal or, in some cases, literal but not delusional, reflecting an expression of his artistic persona and eccentric personality, which helped him to gain notoriety in the black metal scene, while engendering and sustaining a concept for his band. In fact, Ohlin's depressed mood and suicidal tendencies might have been approached with artistic manifestations. Alternatively,
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however, some of Ohlin's claims could have been delusional. This interpretation is not meant to disregard Ohlin's artistic expression as an influent factor in his behavior, but to consider that some of his behaviors may have been motivated by delusional thoughts. Although the black metal context brings in a dilemma that makes it impossible to rule out the first interpretation without a clinical interview, the following discussion supports the authors' opinion that the latter interpretation should be given full consideration.
Ohlin claimed that he was dead, that he was not a human being, and that he did not belong to this world—a narrative consistent with a delusion. The musician also presented depressed mood associated with self-starvation, self-harming, and suicidal behavior. As his behavior seems to suggest a factual belief in his claims, Ohlin's case could be understood as a likely case of Cotard's syndrome.
Ohlin's behaviors were congruent with the belief of being dead. Most notably, he refused to eat, which caused a remarkable weight loss and a decaying appearance. In fact, self-starvation and consequent nutritional deficiency are frequently reported in Cotard's syndrome (Caliyurt et al., 2004; Chiu, 1995; Cotard, 1880; Grover et al., 2014; Ko, 1989; Silva et al., 2000). Although self-starvation might be a reflection of loss of appetite, a typical symptom of the depressive syndrome, this behavior can also be associated with the delusion of denial of life, as patients with Cotard's syndrome often report it is not necessary to eat since they are dead (Caliyurt et al., 2004; Grover et al., 2014). Some of Ohlin's actions and lyrics (e.g., smell a dead crow to "evoke the sensation of death" and "you pray for death to release the soul", respectively) did not fit with the belief of being already dead. However, these incongruences may represent a delusional double-orientation to reality. In fact, Jules Cotard's original patient had similar incongruent beliefs. She claimed "she was eternal and would live forever", yet constantly asked to be burned alive and made various suicidal attempts (Berrios & Luque, 1995a). This phenomenon is found in patients presenting non-nihilistic delusions as well (Jaspers, 1963).
The early 1990s Norwegian black metal scene influenced the way Ohlin's peers perceived his symptoms. The congruence between Ohlin's symptomatology and black metal's death worshiping blurred the limits between pathological and context-related expected behaviors. However, though black metal musicians were, in general, considered quite peculiar, they did not share some of Ohlin's beliefs (i.e., not being human and being dead) and behaviors (i.e., food refusal, self-mutilation, and trying to resemble a corpse). Although Ohlin's peers had their own artistic per-sonas and shared a variety of beliefs and patterns of behavior in line with the black metal philosophy, some of them believed that Ohlin possibly suffered from psychological issues. Some even suspected that he, indeed, had a mental disorder  (Aarseth,   1989;   Aasdal  &  Ledang, 2007;
Moynihan & S0derlind, 2003). However, as Ohlin's peculiar attitudes fitted the black metal ideals, he was considered the very personification of them, rather than someone who unequivocally suffered from a mental illness and needed medical care. (Johannesson & Klingberg, 2018; Moynihan & S0derlind, 2003; Patterson, 2013). Consequently, his symptoms were appraised as socially permissible and even desirable in that restricted context. In fact, Ohlin held a reputable position among those who took part in the black metal scene and is still considered one of the most committed musicians to its ideals (Johannesson & Klingberg, 2018). Therefore, in being adaptive to the cultural context to which he belonged, Ohlin's symptoms were not dealt with as such by his fellow musicians (Aasdal & Ledang, 2007). Notably, the social isolation he experienced in Norway may have set the ground for the negligence of his symptoms, as he seemed to lack closer relationships beyond the black metal scene that could take action on or engage with his symptoms.
The congruence of Ohlin's fascination with death themes in such a fitting context, however, poses an interesting question regarding the limits of normative behaviors in the artistic domain. Artists are expected to behave in accordance with their artistic persona, thus hampering the distinction between what is part of the performance and what are conspicuously pathological behaviors. One cannot set clear limits between the identities of the artist and the portrayed character, as they may involuntarily merge (Panero, 2019). Artists are very often misinterpreted regarding their eccentricities. They may be wrongly appraised as suffering from a mental disorder, as in the recently reported case of the Russian performance artist Pyotr Pavlensky (Mendelevich, 2018). However, if there is, indeed, a psychiatric disorder, besides hindering the diagnosis, the congruence with the context may provide secondary gains such as social acceptance, further impairing the patient's search for treatment. In such situations, the cultural formulation of the case (American Psychiatric Association, 2013) may assist the clinician in comprehensively understanding the context and psychodynamics of a patient. Specifically, it may help to comprehend how both the patient and their peers perceive and deal with the psychopathology, aiding the establishment of a diagnosis and enabling a more effective clinical management (Alarcon, 2009; Kirmayer et al., 2008). Conversely, the cultural formulation interview may be also helpful in recognizing the cases in which there is no disorder to be treated.
In Ohlin's specific case, however, in which a psychiatric interview is not available to aid the distinction between a delusion and culturally normative beliefs, it is feasible to compare the musician with his peers, as delusions, by definition, are not shared by others in one's community (Dalgalarrondo, 2018). Even though most of black metal's ideals would probably be considered somewhat psychopathological in a mainstream culture, they were
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shared by a great number of Norwegian musicians, and thus can be regarded as normative in that restricted context. Most importantly, however, the very same musicians still considered Ohlin peculiar—he did stand out in his beliefs and behaviors (Aarseth, 1989; Moynihan & S0derlind, 2003). Moreover, Ohlin committed suicide, which strongly suggests he had a mental disorder (Bertolote et al., 2004), and left a suicide note expressing a presumably delusional explanation of his reasons. Such disparity from his peers suggests the existence of a psychopathology, in contrast with the culturally normative beliefs that the other members of the black metal community shared. Nevertheless, making this distinction would be a difficult task for the psychiatrist, even with a clinical interview. Only a detailed history and a thoroughly cultural formulation aided by relatives and peers could enable a clinician to distinguish normal from pathological in this case.
Beyond masking Ohlin's symptoms, black metal ideology would most likely have played a role in shaping and reinforcing the content of his delusional ideas. According to Kapur et al. (2005), the psychodynamic themes and the cultural context of the individual are determinants in the construction of a delusion. More specifically, Nejad et al. (2013) emphasize that cultural context and superstitious beliefs can affect the formation of Cotard's syndrome. In fact, Ohlin's alleged near-death experience and the fascination with death that arose as a consequence seem to have been the major substrate for his forthcoming delusions. Given the expressive importance he attributed to that experience and that it represented the onset of his fascination with death, it is possible that the belief in the idea of being "technically" dead in the past eventually became a delusion that he was genuinely dead and could not be human. The black metal scenario would have reinforced this interpretation. Other cases in which previous life events clearly shape the content of a delusion have been reported. In particular, Bott et al. (2016) described a patient previously diagnosed with schizophrenia who developed delusional beliefs that he had been dead since he fell from a moving train, being "energized" by demons that inhabited his body. Similarly, Nejad et al. (2013) reported the case of a patient who believed she was dead and had been murdered by "Aal," a mythological figure of Persian popular belief, 13 years after an extracorporeal experience in which she saw the creature.
Ohlin exhibited several signs of depression, such as a depressed mood, increasing social withdrawal, self-harming behavior, and suicidal thoughts, which were reported by many of his fellow musicians. In fact, he highlights this mental state in "Life Eternal," the song mentioned in his suicide note: "What you found was eternal death. No one will ever miss you." Likewise, the excerpt "What will be left of me when I'm dead? There was nothing when I lived" (Ohlin, 1991/1994, track 5) reveals the anhedonia and feelings of emptiness of the musician.
Ohlin's social isolation in Norway may have aggravated a socialization problem, whose existence might have been hinted in his childhood—he was severely bullied. In fact, being bullied is, by itself, a risk factor for later depression and suicide (Copeland et al., 2013). In addition, the band failed his expectations, and he lacked emotional and financial support. Ohlin's suicide note did not address any friends or relatives, which might suggest that he did not have any close relationships at the time. This setting probably contributed to the development of the depressive symptoms and the delusional ideas that led, ultimately, to his suicide. Interestingly, however, Ohlin did not mention depressive symptoms in his suicide note. To determine which particular elements and events lead to a suicide is a very difficult task, even when a richer history is available. However, one can speculate that, by focusing on delusional explanations, Ohlin seemed to regard his suicide as a logical outcome of his delusional ideas of not being human and not belonging to this world. His choice of words does not allow, nevertheless, ruling out depression as a major underlying cause of his suicide. Deciding to write such content in a suicide note may indeed have to do with Ohlin's artistic persona.
Although the establishment of a conclusive primary diagnosis is hampered by Ohlin being an artist in a peculiar context, as well as the lack of a psychiatric interview, it is possible to briefly address the issue. Assuming the musician had Cotard's syndrome, the most prevalent primary diagnoses would be depression with psychotic features, bipolar depression, schizophrenia, and neurological conditions, as reported in a review of 138 cases (Consoli et al., 2007). The same study found an association between patients aged less than or equal to 25 years and the diagnosis of bipolar disorder in relation to patients aged 26 years or more. Similarly, Soultanian et al. (2005) showed that, of 14 cases of adolescents and young adults with the syndrome followed up for 2 years or more, 13 (93%) had a diagnosis of bipolar disorder as an outcome. These data raise the possibility that Ohlin could eventually have been diagnosed with bipolar disorder, as he was 22 years old when he committed suicide. On the other hand, regardless of the diagnosis of Cotard's syndrome, Ohlin showed signs of depression, as discussed above. He also presented signs of schizotypal personality, such as social isolation, eccentric behaviors, odd beliefs and appearance, and unusual perceptual experiences (American Psychiatric Association, 2013).
We must emphasize the limitations of this analysis. The amount of reliable information on Ohlin is scarce and indirect. Moreover, no psychiatric or psychological interview was ever conducted. Thus, this article does not aim to serve as an authoritative clinical case study, as many clinical features and nuances that would otherwise be described and explored in a psychiatric interview are missing. Alternatively, we believe this case and its discussion can
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contribute to the understanding of severe psychiatric phenomena and the possibility that, in some cases, a congruent cultural context may play a role in its concealing.
Conclusion
The present study is the first to expose and discuss Per Ohlin's case as a likely patient with Cotard's syndrome, although it remains uncertain whether or not the musician had this condition. As Ohlin was an artist in a very singular context, it is very difficult to distinguish between what was part of his performance and what was pathological, especially without a clinical interview. On the other hand, since he died by suicide, it is reasonable to assume that he had a mental disorder. If our analysis is correct, this unique case sheds light on one of the various effects of context in a psychopathological process: namely, concealing a psychiatric disorder and reinforcing symptoms that fit a particular normative environment. In another context, Ohlin might have been referred for psychiatric evaluation, and been diagnosed and treated accordingly.
Acknowledgements
We would like to thank the True Mayhem Collection for kindly providing Mayhem's photograph and the anonymous reviewers for their insightful comments.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
ORCID iDs
Hugo Sanches © https://orcid.org/0000-0003-1322-505X Leonardo Villaverde Buback Ferreira © https://orcid.org/0000-0002-1382-7440
Joao Pedro Goncalves Pacheco © https://orcid.org/0000-0002-2871-7420
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Hugo Sanches, MD, is a co-investigator at the Laboratory of the Neurobiology of Mood and Anxiety Disorders of the Federal University of Espirito Santo. Dr. Sanches currently studies the neurobiology of panic and other anxiety disorders.
Leonardo Villaverde Buback Ferreira is a medical student at the Federal University of Espirito Santo. Mr. Ferreira is currently an intern at the Laboratory of Cognitive Sciences and Neuropsychopharmacology at the Federal University of Espirito Santo. His published works focus on transcranial direct current stimulation and substance use disorders.
Joao Pedro Goncalves Pacheco, MD, is Resident in Psychiatry at the Department of Neuropsychiatry of the Federal University of Santa Maria. Dr. Joao currently studies the effect of subcutaneous ketamine versus midazolam for suicidality among psychiatric inpatients. His published works focus on medical student mental health. His research methods mainly comprise meta-analyses, ecologic studies, and clinical trials.
Luiz Carlos Schenberg, PhD, is the Director of the Laboratory of the Neurobiology of Mood and Anxiety Disorders and Professor of Pharmacology at the Department of Physiological Sciences of the Federal University of Espirito Santo. His published works focus on both neural and developmental causes of panic and its comorbidity with anxiety and depression disorders.
Marcos Sampaio Meireles, MD, is Professor of Psychiatry at School of Sciences of Santa Casa de Misericordia de Vitoria.