Cotard's Syndrome - The Walking Corpse

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Cotard’s Syndrome or Cotard Delusion is a condition in which the patient has an extreme delusion of negation. This is an extremely rare neuropsychiatric disorder and people suffering from this believe that they are dead, they’ve lost their internal organs or they are immortal.
People with Cotard’s syndrome  have possession ideas or believe that other people’s identity is false. The syndrome is named after the famous neurologist, Jules Cotard who described it as the “délire des négations”. 

Causes

The causes of this syndrome could be: major depression with psychotic features, schizophrenia or organic mental conditions. In young people, Cotard syndrome might be associated with bipolar disorder. 

Symptoms

In the first phase the individual might only feel despair and self loathing but as the illness progresses they will deny their own existence, believe that they are in hell or heaven, or simply believe that others died. Their delusions can be linked to their life: some, who had an accident before the symptoms, may believe that they died in the accident while others, might believe their organs are affected or they simply disappeared (for example, a woman who cannot have children might believe that her uterus disappeared).

Case Studies

Since it is such a rare syndrome there are few case reports, but I managed to find a few to make a clearer image on this syndrome.

Cotard’s Syndrome after motorcycle accident

A well known (and it can be found on Wikipedia) case study is the one that describes a patient who suffered brain injury after an accident. He is taken by his mother in South Africa where he believes that he has died of septicemia (he reads a story about a person with AIDS who died of septicemia) or an overdose of a yellow fever injection and went to hell. His explication for his mother’s presence is the fact that he had “borrowed my mother's spirit to show me round hell".

Source

Homeless Man presenting Cotard’s syndrome 

A 44-a year old man became homeless because he couldn’t find a job. He developed depression in jail and because he was unable to pay for psychiatric services the symptoms worsened in six weeks.

While the mild phase of his illness was characterized by poor sleep, loss of appetite, and anergia, when things got worse he felt like he “melted away” and he was dead. He was then diagnosed with schizophrenia and treated with oral and depot haloperidol; in another few weeks his condition worsened again. He now believed that his “brain rotted away” and his internal organs were gone but he had no suicidal ideation. Although electroconvulsive therapy is efficacious in the treatment of this illness, he did not receive this treatment as he was unable to pay for such services.

He managed to continue his treatment with haloperidol and valproic acid doses tapered, 40 mg of fluoxetine, and 3 mg of risperidone a day. He made slow progress and was discharged with no recurrence of his delusions.  

Bipolar Disorder patient with Cotard’s Syndrome

20 year old male diagnosed with bipolar disorder due to three manic episodes but without any depressive episodes (also had family history of bipolar disorder). His treatment consisted in lithium carbonate, 800mg/day. However, his condition worsened in only two weeks; he became isolated and entered a depression phased characterized by loss of appetite and psychomotor retardation. Nihilistic delusions appeared shortly: “my liver and stomach are being destroyed”, “my heart doesn’t beat”, “I don’t have muscles”, “I am dead”.

There was no pathology in the brain CT, laboratory assessment was within normal levels, physical examination was normal and he was admitted with bipolar disorder, severe depressive episode with psychotic symptoms. His treatment was changed and 225 mg of imipramine was added. However, this made his condition even worse: he became mute, refused to eat or drink and presented psychomotor inhibition and catatonic stupor. ECT (electroconvulsive therapy) was administered and the patient’s condition improved; however, the family stopped the sessions.

After discontinuing ECT, the patient’s condition worsened again, this time presenting the following symptoms: slowness in movement and speech and hypochondriacal delusions. The delusions consisted in: he belied that his tonsils were deteriorating, his heart was smaller and his muscles were degenerating.

The author states that after adding haloperidol 8mg/day, biperiden 4mg/day the symptoms began to improve and the patient was discharged 14 days later with almost full remission.  

Source

Women with Cotard’s syndrome 

The first case study presents a 33 year old housewife with paranoid ideas and auditory hallucinations suffers from the following delusions: she believes that her brother-in-law put needles into her genitalia and her guts had been mutilated and stitched back again.

Her auditory hallucinations consisted in voices that told her that her three children were going to die either struck by lightning, sold away or killed in an accident. She ran to their school to see if something was happening and called the police. Her condition got worse as she believed that her abdomen was opening up and her head and hand were chopped off. She also believed that her husband was poisoning her food. As she was suffering for paranoid schizophrenia she was treated with electroconvulsive therapy and trifluoperazine. She had complete remission after fifteen months of antipsychotic drug treatment.

The second case study presents a 43 year old woman who had major depression. She had problems sleeping, loss of appetite and an apathy that prevented her from doing housework. Her delusions were linked to the staff in the hospital where she was admitted who were laughing at her and accusing her of wasting money on medical care; she also thought that newspapers were reporting negatively about her. She also thought that her family was in severe debt and several countries were in major wars. The delusions from Cotard’s syndrome spectrum were related to her abdomen, which she thought it was dead, rotten and filled with water.

In literature, it seems that organic disorder in Cotard’s syndrome is more frequent in female patients but no studies were ever made to support this. It also seems to be more frequent in people under 23 years of age with a family history of affective disorder.

Because it can be a symptom of many illnesses its treatment depends greatly on the underlying psychiatric illness. If you want to read more on this syndrome you should check up the links posted throughout this article. 

An interesting article on Cotard's syndrome here.