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Cotard’s Delusion (CD), commonly referred to as the Walking Corpse Delusion, is a neuropsychiatric condition in which a person experiences nihilistic delusions. These are false beliefs that involve denying one’s own existence or body parts. Individuals may insist that they have lost their blood, organs, or even that they are entirely dead.
The delusion was first described in 1880 by a Parisian neurologist Jules Cotard, who documented a case of a 43-year-old woman known as “Mademoiselle X”. The patient claimed to have no brain, stomach, or intestines, which, as a result, led her to refuse to eat, ultimately dying of starvation. Cotard referred to her condition as “le delire des negations” (which translates to “the delirium of negations”)–a sort of a subtype of depressive illness. While initially the general belief was that this syndrome was just a collection of symptoms associated with agitated depression or general paralysis, it gradually became widely acknowledged as a separate entity.
Over time, several reviews have noted the extreme rarity of Cotard’s Delusion. For instance, a study conducted in Hong Kong found 2 out of 349 psycho-geritaric patients had CD (0.57%), while the prevalence in severely depressed older adults was 3.2%. The average age of onset in a review of 100 cases was 56 years, and women appear to be more vulnerable compared to men. In younger people specifically (under 25), CD has been commonly described in association with bipolar disorder. Moreover, Cotard’s is not currently recognized as a separate diagnosis in the DSM-5 or ICD, but is conceptualised as a syndrome or a set of symptoms occurring alongside other disorders. As a result, treatment typically targets the underlying disorder (e.g., depression), with some successful reports with electroconvulsive therapy (ECT) especially when underlying mood disorder is present.
Scientific literature consistently shows that CD rarely occurs as an isolated syndrome, with studies indicating its association with a wide range of conditions including depression, bipolar disorder, Parkinson’s disease, stroke, brain injury, encephalopathy, and schizophrenia.
One particularly striking case, documented by researchers at Stanford University and the Palo Alto Veterans Affairs Health Care System, describes a 58-year-old man, ‘Mr. C’, who was diagnosed with this illness and later went on to develop Cotard’s syndrome. His delusions centred around the perception that he was physically dead and possessed by demons, which was only reinforced by his religious interpretation that life belonged solely to God, and therefore, as a human, he must be dead.
Upon arrival at Veteran Affairs, it was reported that Mr. C was extremely disoriented, had psychomotor agitation, and an anxious mood. His cooperation was poor as a result of his preoccupation with various nihilistic delusions. Despite numerous tries by the professionals to engage him, Mr. C strongly fixated on his beliefs, saying ‘How can you help me, I am dead’. When queried about suicidal ideation he, once again, indicated, ‘I am dead, how can I be suicidal?’. Interestingly, these delusions emerged following a traumatic brain injury (TBI), suggesting a possible neurological contribution to his psychosis.
Magnetic resonance imaging (MRI) showed mild, age-related brain volume loss along with the widening of the Sylvian fissures (grooves on the sides of the brain), but no signs of acute TBI or white matter abnormalities were detected. Neuropsychological assessments performed revealed deficits in processing speed, attention, verbal learning and memory, as well as certain executive functions such as set-shifting and verbal fluency. Impairments were also observed in facial recognition and affect identification. Finally, visuospatial and visual memory abilities remained intact.
During hospitalisation, Mr. C’s treatment plan was adjusted to address both his psychiatric symptoms and behavioural agitation: venlafaxine (an antidepressant) was discontinued, quetiapine (an antipsychotic) was increased to 700mg, and divalproex (a mood stabiliser) was added at 750 mg. Over time, his delusions slowly shifted from literal beliefs of being physically dead to more symbolic ideas of spiritual death. After about 5 weeks, the patient was discharged from the hospital with reduced delusional intensity and improved coherence.
From a neuropsychiatric perspective, this case illustrates how Cotard’s Delusion can arise through the interaction of neurological injury, psychosis, and belief systems. The two-factor theory of delusional belief is a useful framework to consider for understanding such cases. The first factor involves neurological abnormality that generates the delusional idea, while the second reflects a deficit in belief evaluation, often linked to right frontal lobe dysfunction, which prevents the individual from rejecting the false belief. Mr. C’s history of TBI might have contributed to this impairment, influencing both the formation and continuance of his delusions.
Clinically, the case highlights the increased risk of self-harm and violence in patients experiencing nihilistic beliefs, further emphasizing the need for monitoring and tailored interventions. Some researchers have also discussed the potential effectiveness of combined pharmacotherapy and cognitive-behavioral therapy (CBT) in managing such issues.
Overall, the occurrence of Cotard’s Delusion highlights the extraordinary complexity of the human mind and its vulnerability to disruption. Although rare, studying such cases allows us to delve deeper into our understanding of how the brain constructs reality, and how even slight disruptions may change our sense of being alive.
Sara Janković
sara.jankovic01@universitadipavia.it
References:
Berrios, G. E., & Luque, R. (1995). Cotard’s delusion or syndrome?: A conceptual history. Comprehensive Psychiatry, 36(3), 218-223. https://doi.org/10.1016/0010-440X(95)90085-A
Bott, N., Keller, C., Kuppuswamy, M., Spelber, D., & Zeier, J. (2016). Cotard Delusion in the Context of Schizophrenia: A Case Report and Review of the Literature. Frontiers in Psychology, 7. https://doi.org/10.3389/fpsyg.2016.01351
Chaudhari, V., Bhosle, R., Khan, N., & Kale, M. (2020). A detailed review on Cotard’s syndrome. World Journal of Pharmaceutical Research, 9(9), 450-460. https://www.elsevier.es/en-revista-revista-colombiana-psiquiatria-english-edition–479-articulo-cotards-syndrome-description-two-cases–S253031202200039X?utm_source=chatgpt.com
Cotard: the ‘Walking Corpse Delusion’ [Radio broadcast]. (2018). BBC Radio 4 – A History of Delusions. https://www.bbc.com/audio/play/m0001f0r
Debruyne, H., & Audenaert, K. (2012). Towards understanding Cotard’s syndrome: an overview. Neuropsychiatry, 2(6), 481-486. https://www.jneuropsychiatry.org/peer-review/towards-understanding-cotards-syndrome-an-overview-neuropsychiatry.pdf
Pearn, J., & Gardner-Thorpe, C. (2002). Jules Cotard (1840-1889): His life and the unique syndrome which bears his name. Neurology, 58(9), 1400-1403. https://doi.org/10.1212/WNL.58.9.1400
Sahoo, A., & Josephs, K. A. (2018). A Neuropsychiatric Analysis of the Cotard Delusion. Journal of Neuropsychiatry and Clinical Neurosciences, 30(1), 58–65. https://doi.org/10.1176/appi.neuropsych.17010018
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