In an episode of the television series Scrubs, a patient named Jerry, walks around the hospital narrating what he believes are the last moments of his life and his experience of death, despite still being alive and able to interact with other people.
This character is a more comedic representation of a rare psychiatric condition encountered by French neurologist, Jules Cotard in 1880. In a case study, Cotard described the extreme delusions of a 43-year-old female patient who believed she had “no brain, no nerves, no chest, no stomach, no intestines; there was only just skin and bones of a decomposing body...She has no soul, God does not exist, neither does the devil. She is nothing more than a decomposing body and has no need to eat for living, she can not die a natural death, she exists eternally if she is not burned, the fire will be the only solution for her”.
This was Cotard's first recorded encounter with a psychiatric disorder, which he termed “délire de negation,” or “nihilistic delusions”. However, Charles Bonnett first reported the condition more than a century earlier in 1788 in a case study involving an elderly female patient. She believed that she had died and insisted on being dressed a white shroud and placed in a coffin, where she stayed for several weeks until the delusion finally ended.
Since 1893, the condition has commonly been known as 'Cotard Delusion', 'Cotard’s Syndrome' and 'Walking Corpse Syndrome' and is characterised by a living person believing that their body parts are missing or not functioning properly, that they've died or deny their bodily existence and the existence of the world.
What Causes Cotard Delusion?
The psychotic episodes of Cotard’s Syndrome may reflect the emotional changes that can occur in severe depression where people feel emotionally empty. The condition is usually encountered in syndromes such as Schizophrenia and Bipolar Disorder. In some cases, the belief of being dead, immortal or having malfunctioning body parts originated after an accident. For example, a 28-year-old man believed he had died after receiving brain damage from a motorcycle accident (Young & Leafhead 1996).
Some studies have found a number of cases were Cotard Delusion co-existed or was associated with several organic conditions including:
- typhoid fever
- Parkinson’s disease
- tumors
- organic lesions of the brain
- brain injury
- multiple sclerosis
- Laurence-Moon Bardet-Biedl syndrome
- dementia
- epilepsy
- strokes
- Alzheimer’s
Historically, some people have explained Cotard’s Syndrome as patients expressing a death wish. A more recent and popular hypothesis for a contributing factor of Cotard Delusion is damage to an information processing subsystem in the brain where recognition of faces, scenes and objects are associated with a feeling of familiarity. An absence of familiarity results in patients experiencing derealization and depersonalisation, which causes delusions.
Cotard Delusion Symptoms
The condition's onset is usually sudden, with many patients suffering no prior psychiatric disorders. In its mild form, Cotard’s Syndrome often involves feelings of anxiety, depression, despair, guilt and expressions of self-depreciative notions. The patient may complain of depression and of losing their power of reasoning and feeling. This depressive state may last for several weeks to a few years. Over time, the condition can exacerbate into its more severe state that involves nihilistic delusions where denial of life, body parts and the world's existence are the prominent features.
Nihilistic delusions are expressed as a negative attitude with a systematic opposition and refusal to follow suggestions (negativism) and an unshakable belief that there has been alteration, destruction, absence or non-existence of something in their body or in their environment.
Jules Cotard classified the condition into three different groups: hypochondriac delusions of negation, where the patient denies the existence of certain organs; negation of their own psyche, where thoughts and ideas don't exist; and negation of the external world, where neither people or anything else exists, including themselves.
Jules Cotard noted that other major symptoms include:
- anxious melancholy
- ideas of damnation or possession
- disposition towards suicide attempts and self-injury
- the idea that one is immortal and therefore can't die
- insensitivity to pain (analgesia)
Common expressions from Cotard Delusion patients include: “I am dead”; “I have no blood”; “I have no body”, “I am a corpse that already stinks” and “I used to have a heart. I have something which beats in its place”.
Patients may also have auditory and smell based hallucinations involving accusatory voices or the smell of their own body rotting. Other symptoms may include mutism (the inability to speak on certain occasions or to particular people) and enormity (the belief that their body has suddenly grown).
In a 1995 study of 100 cases, the most prominent symptoms in Cotard’s Syndrome were found to be:
- depression (89 percent)
- delusional beliefs about one's own body (86 percent)
- nihilistic delusions concerning one’s own existence (69 percent)
- anxiety (65 percent)
- delusions of guilt (63 percent)
- hypochondriac delusions (58 percent)
- delusions of immortality (55 percent)
- delusions of damnation (35 percent)
- auditory hallucinations (22 percent)
- visual hallucinations (19 percent)
Cotard Delusion Experiences
The following list provides more information on some common experiences and major symptoms that have been reported on Cotard Delusion. As most current studies and reports on Cotard syndrome are restricted to single case studies, with only a few large-scale studies having been conducted, this section refers primarily to individual patients' experiences.
- Nihilistic Delusions of the External World and Immortality: A 1956 case study involved a 38-year-old woman who suffered extreme guilt, depression and accusatory auditory hallucinations for years following her father's death. As her condition worsened, she concluded that everything inside and outside of her body had died; that the moon, earth and stars and time itself didn't exist; and that she alone survived the initial explosion that created the world and was a “carbonized star” condemned to wander an empty world forever (Enoch & Ball, 2001).
- Suicide: An 18-year-old boy with psychotic depression made several suicide attempts due to the belief that he and certain family members had died and that he could feel his insides rotting away (Young and Leafhead 1996). Despite their self-perceived state of already being dead or immortal, Cotard Delusion patients still try to destroy themselves as their only means to escape their self-perceived damnation.
- Self-Harm: A 2001 case study involved a 27-year-old Cotard’s Syndrome patient who had self-punitive tendencies due to her aroused paranoid guilt and requested that her psychiatrist punish her with physical harm for what she believed were wicked acts and thoughts. The psychiatrist also believed that her wish to cut into her own body was an attempt to remove what she believed was causing her ailments (Resnik 2001).
- Starvation: As patients believe that they've died, become immortal or that their organs are missing or not functioning, some patients will refuse to eat or drink. For example, a 61-year-old female patient who, at time of admission, only weighed 39.3 kilograms, believed that she was lacking a digestive tract to absorb food and drink and that her bowels were not functioning at all (Enoch and Ball 2001).
- Analgesia: A 32-year-old woman with Schizophrenia claimed that she had committed suicide and mutilated the tip of her nose to remove a self-perceived imperfection. Researchers noted that she suffered no pain or guilt from this self-inflicted wound.
- Decaying: A 2004 case study involved a 59-year-old woman who, for 20 years, experienced episodes where she felt flesh falling off her limbs, sometimes accompanied by visual hallucinations. In a 2008 case study, a 53-year-old patient ordered her children to take her to the morgue, claiming that she had died and smelled of rotting flesh.
- Enormity: Some patients believe that they've become so large that they can touch the stars and merge with the universe. They may also consider themselves to be Satan or the Antichrist, with an omnipotence for evil causing all of the world's evils. They may believe they're actions have disproportionate effects. For example, choosing to urinate would flood the whole Earth.
- Possession: A 31-year-old patient with severe depression believed he was dead and parts of his body were non-existent, that mental hospital nurses were trying to poison him, and that outside forces were controlling his actions, commanding him to kill children, which he never carried out (Enoch and Ball 2001).
There are also reports of Cotard’s Syndrome co-existing with other conditions.
- Capgras Delusion – patients believe that imposters have replaced people they know.
- Fregoli Delusion – the person mistakes unfamiliar people and places with familiar ones.
- Lycanthropy – people believe they can transfer into dogs, wolves or werewolves. In one case a man believed that he had died for sins and that he and his wife could transform into dogs, while his daughters could transform into sheep.
- Erotomania – a delusional belief of being loved by someone else.
- Folie a Deux – more than one person shares the same delusion. For example, an entire family refusing to pay the bills because they all believe the homeowner is dead even though he's alive and living with them (Enoch and Ball, 2001).
- Depersonalisation Disorder – feeling detached from bodily actions and thoughts.
- Koro – the belief that one's own genitals are shrinking and will soon disappear. One report suggests that Koro is a variation of Cotard’s Syndrome.
- Hydrophobia – the fear of water.
- Delusions of Paralysis – in one particular case, it was caused by the patient's belief that neuroleptic drugs were destroying her organs, making them malfunction.
- Delusions of Pregnancy – occurred in some elderly patients that believe there is something wrong with their organs or they're carrying a dead child inside them.
Demographics of Cotard’s Syndrome Patients
As there have been few large-scale studies on Cotard Delusion, its prevalence and frequency in people is largely unknown. Past studies have suggested that Cotard Delusion is more prevalent in women and as people get older, they are more likely to develop the condition. One report from 1995 estimated the average age of a patient to be 56 years old, while a 2006 study estimated 47.7 years of age. Diagnosis of Cotard’s Syndrome in people under 25 years of age is usually associated with Bipolar Disorder.
A study involving 349 psychogeriatric patients in Hong Kong found two people with Cotard Delusion (0.57 percent). When severely depressed elderly were involved, the prevalence rose to 3.2 percent. Another Mexican study involving 849 neurological patients found that only one person had Cotard Delusion, while just three people from 479 psychiatric patients also had the condition.
Treatment
There are many potential pharmacological treatments for Cotard Delusion involving single or combined use of antidepressant and antipsychotic drugs. However, the most common treatment is electroconvulsive therapy, also known as electroshock therapy. This involves administering low frequency electrical pulses to electrodes placed in strategic positions around the patient's skull. Treatment usually takes place several times a week until the patient's delusions end, usually leaving them rather confused about their delusional experience.
Bibliography:
- Berrios G.E & Luque R, “Cotard's Delusion or Syndrome: A Conceptual History”, Comprehensive Psychiatry, Vol.36, No.3 (May/June) 1995.
- Debruyne H, Portzky M, Peremans K & Audenaert K., “Cotard's Syndrome”, Mind and Brain, The Journal of Psychiatry. Vol 2. No.1 2011.
- Enoch E & Ball H, Uncommon Psychiatric Disorders. London, UK; Hodder Arnold Publications, 4th Edition 2001.
- Hintzen A.K, Wilhelm-Gößling C, Garlipp P.,
- Leafhead K.M & Kopelman M.D. “Face Memory Impairment in The Cotard Delusion”, in Alan J. Parkin's (ed.) Case Studies in the Neuropsychology of Memory. UK; Psychology Press Ltd. 1997, Chapter 9.
- Resnik, S, The Delusional Person: Bodily Feelings in Psychosis. London, UK; H. Karmac (Books) Ltd. 2001.
- Young A.W & Leafhead K.M, “Betwixt Life and Death: Case Studies of the Cotard Delusion” in Peter W. Halligan's Method in Madness: case studies in cognitive neuropsychiatry. U.K; Psychology Press. 1996.
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