COTARD DELUSION“WALKING CORPSE

SYNDROME”By Carla Connolly

INTRODUCTIONCotard delusion is a rare mental illness in which the affected person holds the delusional

belief that they are already dead, do not exist, are putrefying (to decay/rot), or have lost

their blood or internal organs. Statistical analysis of a hundred-patient cohort indicates

that the denial of self-existence is a symptom present in 69% of the cases of Cotard's

syndrome; yet, paradoxically, 55% of the patients present delusions of immortality.

Although walking corpse syndrome is considered extremely rare, its exact existence is

unknown. One Hong Kong study involving 349 psychogeriatric patients suggests the

condition afflicts about 0.57 % of the population. Another study conducted in Mexico in

2010, which involved 1,321 patients, found that 0.62 % of the population had the rare

mental health disorder. Perhaps unsurprisingly, this syndrome is often found in people

with mood or psychotic disorders and medical conditions.

DISCOVERY

Cotard’s syndrome was first described by (and later named after) French neurologist

Jules Cotard in 1880 as ‘délire des negations’ or negative deliriums.. Cotard had a patient

nicknamed Mademoiselle X who claimed she was missing several body parts and organs,

including brain, chest, stomach and intestines. She also believed she was “eternally

damned.” She denied having innards, and hence, Mademoiselle X didn’t see a need to eat,

and soon died of starvation. Cotard said the condition was a form of delusion associated

with severe depression, “marked psychomotor retardation, presence of anxiety

symptoms and other depressive symptoms,” researchers said.

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RECENT CASES● One patient, referred to as WI for privacy reasons, was diagnosed with Cotard

delusion after experiencing significant traumatic brain damage. Damage to the

brain was apparent to WI's doctors. In January 1990, WI was discharged to

outpatient care. Although his family had made arrangements for him to travel

abroad, he continued to experience significant persistent visual difficulties.

Formal visual testing then led to the discovery of further damage. For several

months after the initial trauma, WI continued to experience difficulty recognizing

familiar faces, places, and objects. He also was convinced that he was dead and

experienced feelings of derealization. Later in 1990, after being discharged from

the hospital, WI was convinced that he had been taken to hell after dying of either

AIDS or septicaemia. When WI finally sought out neurological testing in May

1990, he was no longer fully convinced that he was dead, although he still

suspected it. Further testing revealed that WI was able to distinguish between

dead and alive individuals with the exception of himself. When WI was treated

for depression, his delusions of his own death diminished in a month.

● A 53-year old Filipino woman was brought to a hospital when she complained that

she was dead, smelled like rotting flesh, and wanted to be taken to a morgue to be

with dead people. Upon questioning, she expressed fear that “paramedics” were

trying to burn down her house. She also complained of hopelessness, low energy,

decreased appetite, and excessive sleepiness. She responded to treatment with

medications.

● The article Betwixt Life and Death: Case Studies of the Cotard Delusion (1996)

describes a contemporary case of Cotard delusion, which occurred in a Scotsman

whose brain was damaged in a motorcycle accident:

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A patient who was taken to South Africa from Edinburgh after a period of

hospitalization was convinced that he was taken to hell after his death. He

believed that he had died of septicemia, AIDS or an overdose of yellow fever

injection. He felt that it was not his mother who accompanied him, but her spirit.

● The article Recurrent Postictal Depression with Cotard Delusion (2005) describes

the case of a fourteen-year-old epileptic boy whose distorted perception of reality

resulted from Cotard syndrome. His mental health history was of a boy expressing

themes of death, chronic sadness, decreased physical activity in playtime, social

withdrawal, and disturbed biological functions. About twice a year, the boy

suffered episodes that lasted between three weeks and three months. In the

course of each episode, he said that everyone and everything was dead, described

himself as a dead body, and warned that the world would be destroyed within

hours. Throughout the episode, the boy showed no response to pleasurable

stimuli and had no interest in social activities.

● Thirteen years ago, Graham woke up and discovered he was dead.

He was in the grip of Cotard’s syndrome. For Graham, it was his brain that was

dead, and he believed that he had killed it. Suffering from severe depression, he

had tried to commit suicide by taking an electrical appliance with him into the

bath.

Eight months later, he told his doctor his brain had died or was, at best, missing.

“It’s really hard to explain,” he says. “I just felt like my brain didn’t exist any

more. I kept on telling the doctors that the tablets weren’t going to do me any good

because I didn’t have a brain. I’d fried it in the bath.”

Doctors found trying to rationalise with Graham was impossible. Even as he sat

there talking and breathing, he could not accept that his brain was alive. Baffled,

they eventually put him in touch with neurologists Adam Zeman at the University

of Exeter, UK, and Steven Laureys at the University of Liège in Belgium.

“It’s the first and only time my secretary has said to me: ‘It’s really important for

you to come and speak to this patient because he’s telling me he’s dead,'” says

Laureys.

“He was a really unusual patient,” says Zeman. Graham’s belief “was a metaphor

for how he felt about the world – his experiences no longer moved him. He felt he

was in a limbo state caught between life and death”.

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Graham’s brother and carers made sure he ate, and looked after him. But it was a

joyless existence. “I didn’t want to face people. There was no point,” he says, “I

didn’t feel pleasure in anything. I used to idolise my car, but I didn’t go near it. All

the things I was interested in went away.”

Even the cigarettes he used to relish no longer gave him a hit. “I lost my sense of

smell and my sense of taste. There was no point in eating because I was dead. It

was a waste of time speaking as I never had anything to say. I didn’t even really

have any thoughts. Everything was meaningless.”

A peek inside Graham’s brain provided Zeman and Laureys with some

explanation. They monitored his brain metabolism. What they found was

shocking: metabolic activity across large areas of the frontal and parietal brain

regions was so low that it resembled that of someone in a vegetative state.

“I’ve been analysing PET scans for 15 years and I’ve never seen anyone who was

on his feet, who was interacting with people, with such an abnormal scan result,”

says Laureys. “Graham’s brain function resembles that of someone during

anaesthesia or sleep. Seeing this pattern in someone who is awake is quite unique

to my knowledge.”

Graham’s scans could have been affected by the antidepressants he was taking.

But, Zeman says, “It seems plausible that the reduced metabolism was giving him

this altered experience of the world, and affecting his ability to reason about it.”

For Graham, the brain scans didn’t mean a lot. “I just felt really damn low,” he

says. By this time, his teeth had turned black because he could no longer be

bothered to brush them, compounding his belief that he was dead.

“I had no other option other than to accept the fact that I had no way to actually

die. It was a nightmare.”

Over time, and with a lot of psychotherapy and drug treatment, Graham has

gradually improved and is no longer in the grip of the disorder. He is now able to

live independently. “His Cotard’s has ebbed away and his capacity to take

pleasure in life has returned,” says Zeman.

“I couldn’t say I’m really back to normal, but I feel a lot better now and go out and

do things around the house,” says Graham. “I don’t feel that brain-dead any more.

Things just feel a bit bizarre sometimes.”

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SIGNS AND SYMPTOMS

The patients afflicted with this mental illness usually denies their existence, the

existence of a certain body part, or the existence of a portion of their body. This is the

central symptom in Cotard's syndrome. The symptoms of psychotic depression and of

hypochondria appear as well as possible severe delusions along with chronic psychiatric

depression.

The Cotard syndrome withdraws the afflicted person from other people due to the

neglect of their personal hygiene and physical health. These delusions prevent the

patient from making sense of external reality, which then produces a distorted view of

the external world. Although a diagnosis of Cotard's syndrome does not require the

patient's having had hallucinations, the strong delusions of negation are comparable to

those found in schizophrenic patients.

THE NEUROPHYSICS BEHIND IT Neurologically, the Cotard delusion is thought to be related to the Capgras delusion

(people replaced by impostors); each type of delusion is thought to result from neural

misfiring in the fusiform face area of the brain (which recognizes faces) and in the

amygdalae (which associate emotions to a recognized face).

The neural disconnection creates in the patient a sense that the face they are observing is

not the face of the person to whom it belongs; therefore, that face lacks the familiarity

(recognition) normally associated with it. This results in derealization, or a disconnection

from the environment. If the observed face is that of a person known to the patient, they

experience that face as the face of an impostor (the Capgras delusion). If the patient sees

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their own face, they might perceive no association between the face and their own sense

of Self—which results in the patient believing that they do not exist (the Cotard delusion).

Cotard's syndrome is usually encountered in people afflicted with a psychosis (e.g.,

schizophrenia), neurological illness, mental illness, clinical depression, derealization,

and with migraine headache.

WHY DOES IT HAPPEN?The Washington Post once stated, “what causes Cotard’s syndrome and other delusions is

a matter of debate” and speculates on a range of possibilities including brain

impairment.

Professor and clinical psychologist Peter Kinderman told The Independent: "This

syndrome is extremely rare so there's not much known about it, most literature on it is

individual case studies over many years."

He says one theory about the condition's cause is that when "conditions exist to make

someone feel confused or distressed" the individual can combine all their thoughts and

beliefs - some of which may be distressing and unusual, with the feeling that they don't

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recognise themselves.

He said this could mean "people come up with the best conclusion they can to explain the

experiences they're having, which may be that they're dead."

STAGESCotard's syndrome is divided into three stages based on the symptoms of each stage:

► Germination stage: In this stage, the patient shows characteristic features of

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depressive mood, extreme worry of unwellness and excessive fear of one’s illness,

despite medical treatment.

► Blooming stage:In this stage, the patient experiences true features of the syndrome

such as the delusion of being dead or immortal; this stage is associated with anxiety and

negativism.

► Chronic stage:In this stage, the individual shows severe depression due to emotional

disturbances or paranoia.

WHAT WE KNOW

The condition is more common in older individuals with depressive disorders►

It is associated with other mental disorders like schizophrenia, bipolar disorders and ►dementia

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It has been associated with other conditions affecting the brain like brain atrophy, ►brain tumors, seizure disorders, brain injury, migraine, Parkinson's disease and stroke

It could also be a consequence of an adverse drug reaction to acyclovir, an antiviral ►drug, in patients with kidney failure.

DIAGNOSIS

‘Walking Corpse Syndrome’ is diagnosed based on the patient’s history and symptoms.

Tests are used to exclude other conditions as well as to diagnose associated diseases.

These tests include:

► Blood test

► CT Scan (Computed tomography): CT scans use X-rays to make detailed pictures of

parts of your body and the structures inside your body

► MRI (Magnetic Resonance Imaging): MRI scanners use strong magnetic fields, radio

waves, and field gradients to generate images of the inside of the body

► SPECT (Single-photon emission computed tomography): a nuclear medicine

tomographic imaging technique using gamma rays

► Electroencephalogram (EEG): tracks and records brain wave patterns. Electrodes are

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placed on the scalp, and then send signals to a computer to record the results

TREATMENT

Walking Corpse Syndrome / Cotard's syndrome is treated with medications in

combination with electroconvulsive therapy.

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Electroconvulsive Therapy: Many cases have shown that a combination of

electroconvulsive therapy (ECT) with medications was more effective to manage the

condition as compared to medications alone. ECT involves placing electrodes on the

patient’s head and administering the small impulses.

Treatment of ‘Walking Corpse Syndrome’ also includes the following:

► Identification and treatment of risk factors: Risk factors for ‘Walking Corpse Syndrome’ should be identified and treated.

► Antidepressants, antipsychotics and mood stabilizer medications: Antidepressants, antipsychotics and mood stabilizers are used in the treatment of Cotard’s syndrome. Based on the underlying condition, the patient should be treated with a single drug or combination of medications. Mood stabilizers have beneficial effects in patients with bipolar disorder.

The overall prognosis of disease is determined by severity of the disorder and the

treatment strategies used to manage it. Some patients recover with proper treatment.

Some die of starvation. The patients also have suicidal tendencies and should be

watched over.

A 2008 case report claims most cases of walking corpse syndrome are more responsive to

electroconvulsive treatment than to pharmacological treatment. However, more research

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needs to be done on this condition because scientists are still in the dark about the cause of

this disease and how to treat it.

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