Dead Strange

A beginner’s guide to Cotard’s Syndrome

Posted Oct 17, 2014

One of the strangest and rarest mental disorders that has been studied academically is Cotard’s Syndrome (CS), and also known as the Cotard Delusion, the Nihilistic Delusion, and the Walking Corpse Syndrome, CS is where individuals hold the delusional belief that they are dead (figuratively or literally) and do not exist. Alternative versions of CS involve the individual believing they are putrefying and/or have lost their blood and/or internal organs. In even rarer instances the condition may include delusions of immortality. Unsurprisingly, CS is often found in psychotic individuals with schizophrenia but has also presented itself following adverse reactions to the anti-viral drug acyclovir (typically used in the treatment of herpes simplex virus). Some research has also indicated that individuals with impaired renal function are also at a higher risk of displaying CS symptoms.

Jules Cotard

According to Yamada and colleagues in a 1999 issue of Acta Psychiatrica Scandinavica, CS has three distinct stages (i.e., germination, blooming and chronic). The first (germination) stage comprises psychotic depression and hypochondria. The second (blooming) stage comprises the full development of the syndrome and the delusions of negation. In the final (chronic) stage comprises severe delusions and chronic depression, and leads to a completely distorted view of the world in which they live. They also become socially withdrawn, completely neglect their hygiene, and cannot make sense of reality. As far back as 1921, Tissot described two components of the syndrome - an affective component associated with anxiety and a cognitive component associated with the presence of delusion. Here are a couple of examples from the clinical literature.

• Example 1: In a 1996 book chapter, Dr. A.W. Young and Dr. K.M. Leafhead reported a case of CS in a Scottish man who suffered brain injury following a motorcycling accident. Following his discharge from hospital, he was taken to South Africa by his mother and became convinced that he had died of septicaemia or AIDS and had gone to hell.

• Example 2: A case study reported by Dr. D.N. Mendhekar and Dr. N. Gupta in a 2005 issue of the Indian Journal of Pediatrics described CS in a 14-year-old male epileptic. He had a history of depression, social withdrawal, talking about death, and disturbed biological function. His CS episodes occurred around twice a year (lasting 1-3 months each time). During each affected episode, the child believed that he and everyone around was dead.

Recently, Hans Debruyne and colleagues wrote an excellent review of CS in a 2011 issue of Mind and Brain, and wrote what they believed is a “classical description” of CS:

“In its early stages, Cotard’s syndrome is characterized by a vague feeling of anxiety, with a varying time span from weeks to years. This anxious state gradually augments and can result in nihilistic delusions where denial of life or denial of body parts are the prominent features. The patient loses sense of reality. Despite the delusion of being dead, these patients show an increased tendency to automutilation or suicidal behavior. Additional symptoms may include analgesia and mutism. The core symptoms always reflect a preoccupation with guilt, despair, and death”.

In the same 2011 review, the authors examined all the epidemiological studies and summarized the findings:

“The prevalence and incidence of this rare syndrome is not known. Only one study reported on prevalence in a selected psychogeriatric population in Hong Kong. In 2 out of 349 patients, Cotard’s syndrome was diagnosed suggesting a prevalence of 0.57% in this population. A prevalence of 3.2% was reached when severely depressed elderly were included. A recent study found 0.62% (n=3) of patients in a Mexican sample (screened over a 2-year period) of primary psychiatric patients having Cotard’s syndrome. Using the same methodology they found also 0.11% (n=1) having Cotard’s syndrome in a sample of neurological patients with mental disturbances”.

• The Psychotic Depression type includes individuals with melancholia and a few nihilistic delusions.

• The Cotard Type I includes individuals with no depression or other disease and comprises a “pure” CS whose nosology is closer to delusional disorders (rather than the affective disorders).

• The Cotard Type II includes individuals with anxiety, depression and auditory hallucinations and comprise a mixed group.

“Despite that Cotard’s syndrome was first described more than a century ago, literature on this topic remains restricted to case reports. Although the syndrome is rare, more larger scale research is needed to further clarify the pathophysiologic underpinnings of the disease and its relation to other delusions of misidentification such as Capgras syndrome”.

References and further reading

Berrios G.E. & Luque R. (1995) Cotard's delusion or syndrome? Comprehensive Psychiatry, 36, 218-223.

Berrios G.E. & Luque R. (1995) Cotard Syndrome: clinical analysis of 100 cases. Acta Psychiatrica Scandinavica, 91, 185-188. 

Berrios G.E. & Luque R. (1999) Cotard's 'On hypochondriacal delusions in a severe form of anxious melancholia'. History of Psychiatry, 10, 269-278.

Cohen, D. & Consoli, A. (2006). Production of supernatural beliefs during Cotard's syndrome, a rare psychotic depression. Behavioral and Brain Sciences, 29, 468-470.

Debruyne H, Portzky M, Peremans, K. & Audenaert K (2011). Cotard’s syndrome. Mind and Brain, 2, 67-72.

Debruyne H, Portzky M, Van den Eynde F. & Audenaert K (2009). Cotard’s syndrome: a review. Current Psychiatry Reports, 11, 197-202.

Mendhekar, D. N., & Gupta, N. (2005). Recurrent postictal depression with Cotard delusion. Indian Journal of Pediatrics, 72, 6, 529-31.

Pearn, J. & Gardner-Thorpe, C (2002). Jules Cotard (1840-1889) His life and the unique syndrome that bears his name. Neurology, 58,1400–3.

Tissot F. (1921). De lire des negations termine par guerison. Cosiderations sur l’hypochondrie et la melancholie. Ann Med Psychol, 79, 321-328.

Yamada, K., Katsuragi, S. & Fujii, I. (1999). A case study of Cotard’s syndrome: stages and diagnosis. Acta Psychiatrica Scandinavica, 100, 396-399. 

Young, A.W., Robertson, I.H., Hellawell, D.J., de, P.K.W., & Pentland, B. (1992). Cotard delusion after brain injury. Psychological Medicine, 22, 799-804.

Young, A.W. & Leafhead, K.M. (1996) Betwixt life and death: Case studies of the Cotard Delusion. In P.W. Halligan & J.C. Marshall. (Eds.), Method in Madness: Case studies in Cognitive Neuropsychiatry). Hove: Psychology Press.