Understanding Cotard Syndrome

Also known as Cotard’s Delusion or Walking Corpse Syndrome, Cotard’s Syndrome is an extremely rare mental disorder in which the afflicted person believes that he/she is dead. Variants of delusions also include delusions of having being removed a part of the body (such as internal organs), delusions of having lost a significant amount of blood that lead to the person’s death (internal bleeding) or delusions of being doomed for eternal damnation.

The disorder is more common in women compared to men. Out of 8 patients affected, 6 are women.

Historical Background

Cotard’s Syndrome was discovered in 1880 by the French neurologist Jules Cotard. He made significant contributions in the understanding of delusions and diabetes during his work in the town of Vanves, in 1874. Not much information is given about the genesis of the discovery of this condition. However, some literature mention a specific case (Mademoiselle X), a middle-aged who would have been identified as suffering from “Le Delire des Negations” (the original French name of Cotard’s Syndrome). In that particular case, Mademoiselle X believed that she was meant to die a particular death, and thus denying her need to eat (alongside with other concurrent negations), she starved herself and eventually ended up dying of starvation.

Key Features for Cotard’s Syndrome: a Delusions of Negation and a Distorted Reality

In everyday life, we are constantly reminded that we are what we think, and our thoughts become reality. This type of motto is intended to make us be more positive and attract good things in our lives. Even if we don’t always believe that despite the trueness of this reality, dealing with people suffering from psychiatric disorders truly emphasize and highlight how powerful the human mind is. In the case of Cotard’s Syndrome for example, afflicted persons have a great sense of distorted reality, and as a result of that, all their actions are driven according to that reality. When we consider “Mademoiselle X” for example, she believed that she was meant to die of a specific kind of death (and even, she was convinced she was already dead), and thus wanted to remain as natural as possible. Denying her need to eat, denying her existence and everything else that the human body needs to survive was just a representation of what was “her” reality.

Additionally, patients suffering from the disorder also arbor what is known as delusions of negation. These are persistent beliefs of worthlessness (body, mind and spirit) as well as uselessness.

The three Disease Stages

Based on patients’ observations and clinical experiments, researchers were able to define the three stages of Cotard Syndrome.

The first stage is the Germination Stage: this is the stage during which the delusions of negation and the distorted reality are conceived in the patient’s mind. The patient appears depressed, sad, and has altered daily living habits. Additionally, because of the feeling that there is something wrong with his/her body, the patient might become over concerned with its health and might develop a certain level of hypochondriasis.

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The Blooming stage is the second stage of the disorder. At this phase, the delusions become full-blown and more intense, and the negation and denial of one’s body is much more pronounced that the patient’s actions begin to mirror that belief: self-isolation, self-neglect, carelessness, inadequate hygiene, etc.

The last stage of the disease is the Chronic stage where the depression worsen, and so do the delusions. At this stage, it becomes more difficult to get the patient out of his/her beliefs.

How Does Cotard Syndrome Start?

Based on medical literature, Cotard syndrome has been diagnosed in patients suffering from other psychotic disorders, mood disorders (like depression), clinical depression, neurological diseases, head trauma and even migraine headaches. It has been hypothesized that the underlying pathophysiology of the disorder involves a severe lesion in the frontal lobe of the brain (which can be caused by all of the abovementioned conditions). Simply put, the patient does not recognize the face (his/her face) that he/she sees, which results in feelings of inexistence. In a more detailed explanation, the part of the brain that recognizes faces is the fusiform face area, and the part that associates emotions with memory is the amygdala. In Cotard Syndrome, there is an abnormal neurons firing or a disconnected pathway that prevents the subject from recognizing his/her faces, leading to self-negation. Even faces of relatives cannot be recognized, which leads the patient to see them as cons or impostors.

Cotard syndrome is exacerbated in patients suffering from psychosis and depression because of the fact that their mental status is already altered, thus predisposing them to the symptoms of this syndrome. In young people, the disorder is more likely to develop if they suffer from bipolar disorder, whereas in older subjects, predisposing mental illnesses are schizophrenia and depression.

Cotard Syndrome can also develop as a side effect of some medications. This is the case of acyclovir, an antiviral medication used to treat herpes simplex infections. The active metabolite of this drug has the ability to penetrate the central nervous system and cause damage, which explains the development of the condition following the intake of the drug. However, this mainly occur when the drugs level in the blood are high (overdose or under excretion, like in kidney disease for example).

In that setting, the disorder was first diagnosed in a patient who started developing the typical symptoms after having received acyclovir for the treatment of her shingles. However, once dialysis was initiated to flush out the drug from the body, the symptoms resolved. The doctors also reported that all other patients presented with high blood pressure as well, and because of that there might have been a possibility that the acyclovir metabolite could have induced blood vessels constriction in the brain, leading to a decreased in blood supply to the frontal lobe, therefore triggering the Cotard’s delusion.

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How Can Cotard Syndrome be treated?

Cotard Syndrome has been successfully managed in the past with mood stabilizers, anti-depressants and anti-psychotic drugs. The reason this being the fact that controlling the underlying psychiatric illness can control the disorder which seems to be a mere complication of it.

Needless to say, Cotard Syndrome remains a medical challenge in the medical world, and because it is a rare condition, extensive studies are yet to be conducted to really elucidate the deeply buried reasons of the existence of supposedly “walking zombies”.