Cotard Delusion

What is Cotard Delusion?

Individuals who suffer from Cotard delusion believe that they are dead, do not exist, or that parts of their body are missing.

Typically caused as a result of other mental health disorders, it is a very rare syndrome and therefore remains much a mystery to experts in terms of preventing and treating the condition. However, case studies compiled over many years have given some clues as to how sufferers can overcome the condition.

Overview of Cotard delusion

Cotard delusion is an incredibly rare mental condition in which sufferers experience delusions about their own existence. Some individuals believe that they are actually dead or do not exist, while others think their body is putrefying or that their blood, internal organs or other parts of the body are not really there.

The term ‘Cotard delusion’ was coined when Jules Cotard, a French neurologist, first described the condition in 1880. He described it as “The Delirium of Negation”, and believed it to be a condition which varied in severity, with some patients suffering mild symptoms of self-loathing and despair, while more extreme cases experienced intense negation that they didn’t exist.

Cotard delusion, also known as Cotard’s syndrome and even ‘Walking Corpse Syndrome’, is not recognized as a mental disorder in the DSM (Diagnostic and Statistical Manual of Mental Disorders) or the ICD (International Statistical Classification of Diseases and Related Health Problems). Rather than being seen as a mental illness in its own right, Cotard delusion is understood to occur as a result of other mood and psychotic disorders, most notably depression. In order to treat it, doctors must first establish the underlying mental illness and treat that.

Cotard’s syndrome is one of several monothematic delusions, where individuals are in a delusional state which regards one particular topic. Many monothematic delusions relate to misidentification, either of one’s self or others.

Some examples of such delusions include:

  • Somatoparaphrenia – the denial of ownership of a limb or side of one’s body.
  • Clonal pluralization of the self – the belief that there are multiple copies of one’s self.
  • Subjective doubles – the belief that there is a double of one’s self carrying out its own independent actions.
  • Capgras delusion – the belief that a relative or spouse has been replaced by an identical impostor.

In some instances, individuals may experience multiple delusions at one time. This is known as multi-thematic or polythematic delusions. Individuals who suffer from schizophrenia are likely to suffer from multiple delusions at one time.

Symptoms of Cotard Delusion

The most significant symptom of Cotard’s syndrome is the delusion that one is dead, rotting, or that body parts are missing. Some sufferers will report that they smell like a putrefying corpse, and they may not recognize themselves when looking in a mirror.

Individuals often feel that they don’t have to perform basic activities to keep themselves alive, since they believe they’re already dead. This often means that they won’t eat or drink, which can have a significant impact on their physical health. Many will also ignore the need for basic hygiene and refuse to perform tasks such as showering, which in many cases contributes to them becoming isolated from others.

In some instances, individuals with Cotard delusion will attempt to harm themselves in an attempt to prove that they are dead or do not exist. Sufferers sometimes describe that they do not feel any pain, which means they are capable of doing significant damage to themselves unless properly monitored.

Typically, individuals with Cotard delusion show many signs of other mental health issues, which give clues as to the underlying condition and root cause of the delusion.

The following symptoms could indicate that the individual is suffering from depression.

Symptoms (caused by depression) include:

  • Extreme fatigue and low energy
  • Lack of interest in things that would usually be pleasurable (anhedonia)
  • Low self-esteem
  • Feeling hopeless, worthless or guilty
  • Anxiety

The following symptoms might suggest that an individual is suffering from schizophrenia or a related condition, such as schizoaffective disorder or schizophreniform disorder.

Symptoms (caused by schizophrenia) include:

  • Hallucinations
  • Disorganized speech and thought
  • Unusual motor behavior (such as catatonia, when an individual does not speak)
  • Reduced attention span and memory

In some cases, individuals with bipolar disorder may experience Cotard delusion. Bipolar disorder causes dramatic swings between mania (dangerously elevated mood), hypomania (unusually elevated mood) and depression. During mania, individuals can experience delusions, paranoia and hallucinations, which could lead to Cotard delusion. During depressed episodes, the extreme low mood could lead to Cotard delusion in the same way that major depression can.

Derealization is another mental health condition which is closely tied to Cotard’s syndrome. This condition causes individuals to perceive the world in a way that seems unreal, as though they are dissociated from reality. They may report seeing the world as though through a television screen, feel distanced from those around them, and feel that their environment lacks depth, spontaneity and emotion.

Some individuals with Cotard delusion have a history of migraine headaches. In these instances, they may not have any history of mental illness, but may have experienced migraines on a regular basis.

It is not unusual for individuals with Cotard delusion to refuse to cooperate with family, caregivers or doctors, since they fully believe in their delusion and will not accept that treatment will benefit them. However, in some instances individuals may accept that their delusions are bizarre or unusual, but still believe them to be true. In these cases, they may be more likely to cooperate with treatment plans.

There are three stages to Cotard delusion, and individuals may be able to identify warning signs of the condition in themselves or others by understanding the three stages.

Three stages to Cotard delusion

1. Germination stage

Individuals experience symptoms of psychotic depression and hypochondria. They may suffer from delusions and hallucinations, feel unduly guilty or that they deserve punishment for something, and generally report a very low mood and loss of interest in life. Hallucinations may be visual, auditory, haptic (touch) or olfactory (smell). They may believe that they are suffering from an illness or feel very alarmed by minor physical or psychological symptoms.

2. Blooming stage

Cotard’s syndrome develops in full, with the individual completely denying their existence or fully believing themselves to be dead or part of themselves to be missing.

3. Chronic stage

The individual is suffering from long-term, continued and severe Cotard delusion and experiences chronic psychiatric depression.

Cotard Delusion Causes

It is not fully understood what exactly causes Cotard delusion, but one theory is that it is due to neural misfiring in a key part of the brain. The fusiform face area of the brain is responsible for recognizing faces, and if this area does not function correctly, individuals may fail to recognize their own face when looking in a mirror and feel a disconnection between their face and their sense of self. This makes them believe that they do not exist, or that that they are dead.

There is also evidence to suggest that Cotard delusion is associated with lesions on the brain, particularly in the parietal lobe which is where much sensory information is processed. In particular, touch, temperature and pain receptors from the skin are relayed to this portion of the brain, which explains why many people with Cotard delusion do not feel pain or touch like normal, which contributes to the delusion that they are dead.

Although many cases of Cotard delusion occur after individuals already show signs of other mental illness, in some cases it can occur after experiencing a head injury. A case study published in 1992 examined the case of a young man who had experienced injuries to various areas of his brain. As well as developing Cotard delusion, he also had difficulty recognizing places, buildings and faces that should have been very familiar to him. He also reported symptoms of derealization. Experts concluded that the brain injuries contributed to the Cotard delusion by heightening the feelings of unreality that the patient expressed.

Cotard Delusion Treatments

Since Cotard’s delusion typically occurs as a result of other mental illnesses, doctors will strive to identify underlying conditions first and treat these in order to alleviate the delusions.

EMT – electroconvulsive therapy – has been known to be an effective solution for Cotard’s syndrome, as is outlined in a 2004 case report in which a 27-year-old male experienced delusions of gastrointenstinal and cardiovascular malfunction. In this instance, the patient was diagnosed with schizophreniform disorder, a type of psychosis which lasts for less than six months and is therefore not significant enough for a diagnosis of schizophrenia. After several antipsychotic drugs proved to be unsuccessful, he underwent a course of ECT which proved to be incredibly effective.

However, medications have proved successful in other cases of Cotard’s delusion. One case study from 2008 demonstrates this. The patient in question was a 53-year-old woman who believed herself to be dead and said that she smelled like putrefying flesh. She also suffered other delusions, such as that the paramedics who admitted her to psychiatric care were attempting to burn down her home. Doctors managed to improve her condition significantly over the course of one month with a series of medications. She was discharged after reporting that she no longer experienced the paranoid delusions that first afflicted her. Depending on the underlying cause of Cotard delusion, the medications used to treat it may be antidepressants, antipsychotics or mood stabilizers, or a combination of medications.

Since the disorder can often make people believe they are dead or that some of their internal organs do not exist, patients may refuse to eat since they are under the belief that they don’t need to do so. If starvation leads to the patient becoming physically unwell, additional treatments may be necessary to maintain or improve their physical health.

Cotard Delusion Prevention

The best way to treat Cotard delusion is to treat mental health conditions before they develop into severe delusions.

Cotard delusion isn’t recognized as a mental illness in its own right, but is instead a complication or byproduct of other conditions, such as depression, schizophrenia, derealization or bipolar disorder. Individuals who are experiencing symptoms of mental illness should seek diagnosis and treatment from a doctor as soon as possible to reduce the risk of their condition deteriorating.

Since Cotard delusion is such a rare condition, it is not known whether there is a genetic factor at play. It is not believed that individuals with relatives that have suffered from the condition are more likely to develop it, so there is no real need to worry about prevention in these cases.

However, many mental health conditions, particularly schizophrenia, depression and bipolar disorder, have proven to have genetic factors at play. For this reason it is strongly recommended that individuals with a family history of mental illness educate themselves on the signs and symptoms of key conditions and visit a doctor or psychotherapist if they are at all concerned about their mental well being.