Cotard delusion

The Cotard delusion or Cotard's syndrome or Walking Corpse Syndrome^[1] is a rare neuropsychiatric disorder in which people hold a delusional belief that they are dead (either figuratively or literally), do not exist, are putrefying, or have lost their blood or internal organs. In rare instances, it can include delusions of immortality.^[2]

History

The syndrome is named after Jules Cotard (1840–1889),^[3] a French neurologist who first described the condition,^[4] which he called le délire de négation ("negation delirium"), in a lecture in Paris in 1880.^[5] He described the syndrome as having degrees of severity that range from mild to severe. Despair and self-loathing characterize a mild state.

In this lecture, Cotard described a patient with the pseudonym of Mademoiselle X, who denied the existence of God, the Devil, several parts of her body, and her need to eat. Later she believed she was eternally damned and could no longer die a natural death. She later died of starvation.

Signs and symptoms

Young and Leafhead describe a modern-day case of Cotard delusion in a patient who suffered brain injury after a motorcycle accident:^[6]

[The patient's] symptoms occurred in the context of more general feelings of unreality and being dead. In January 1990, after his discharge from hospital in Edinburgh, his mother took him to South Africa. He was convinced that he had been taken to hell (which was confirmed by the heat), and that he had died of septicaemia (which had been a risk early in his recovery), or perhaps from AIDS (he had read a story in The Scotsman about someone with AIDS who died from septicaemia), or from an overdose of a yellow fever injection. He thought he had "borrowed my mother's spirit to show me round hell", and that she was asleep in Scotland.

Pathophysiology

Neurologically, Cotard's is thought to be related to the Capgras delusion, and both are thought to result from a disconnect between the brain areas that recognize faces (fusiform face areas^[7]) and the areas that associate emotions with that recognition (the amygdala and other limbic structures). This disconnection creates a sense that the observed face is not the person's it purports to be, and therefore lacks the familiarity that should be associated with it. If it is a relative's face, it is experienced as an impostor's (Capgras); if the sufferer sees their own face they may feel no association between it and their sense of self, resulting in a sense that they do not exist.

Cotard's syndrome is encountered primarily in psychoses such as schizophrenia and bipolar disorder. It can arise in the context of neurological or mental illness and is particularly associated with depression and derealization. It has even been described in migraine.^[7]

Cotard delusion has also been the result of adverse drug reactions to (val)acyclovir. The symptoms were associated with high serum concentrations of CMMG, the principal metabolite of acyclovir. Patients with impaired renal function seem to be at risk even after dose reduction; in the cited case, haemodialysis cured the delusions in a few hours^[7] and it is suggested that this mental state may not always be a cause for psychiatric hospitalization.

Treatment

Treatment should follow a thorough diagnostic work-up of the underlying disorder. There are several reports of successful pharmacological treatment. As well monotherapeutic as combination strategies are reported.^[8] Antidepressants, antipsychotics and mood stabilisers are used. Many report positive effect with electroconvulsive therapy, mostly in combination with pharmacotherapy.^[8] An overall prognosis seems to be mostly determined by the treatment options and prognosis of the underlying disorder.^[8]

See also

• Self-verification theory
• Body without organs

References

1. ^ Berrios G.E. and Luque R. (1995) Cotard's delusion or syndrome?. Comprehensive Psychiatry 36: 218-223
2. ^ Berrios G.E. and Luque R. (1995) Cotard Syndrome: clinical analysis of 100 cases. Acta Psychiatrica Scandinavica 91: 185-188
3. ^ Cotard's syndrome at Who Named It?
4. ^ Jules Cotard at Who Named It?
5. ^ Berrios G.E. & Luque R. (1999) Cotard's 'On hypochondriacal delusions in a severe form of anxious melancholia'. History of Psychiatry 10: 269-278.
6. ^ Young, A.W. & Leafhead, K.M. (1996) (in P.W. Halligan & J.C. Marshall. (eds.) Method in Madness: Case studies in Cognitive Neuropsychiatry). Betwixt Life and Death: Case Studies of the Cotard Delusion. Hove: Psychology Press. p. 155. 
7. ^ ^{a b c} Pearn, J. & Gardner-Thorpe, C (May 14, 2002). "Jules Cotard (1840-1889) His life and the unique syndrome that bears his name" (abstract). Neurology 58 (9): 1400–3. PMID 12011289. 
8. ^ ^{a b c} Debruyne H., Portzky M., Van den Eynde F., Audenaert K. (June 2010). "Cotard's syndrome: a review." (review article). Current psychiatric reports 11 (3): 197–202. PMID 19470281.