Cotard's Syndrome: A Brief Overview

OVERVIEW

Cotard’s syndrome, aptly named after Parisian psychiatrist and neurologist Jules Cotard (1840-1889), is described as a condition in which an individual believes themself to have already died or ceased to exist. They may also believe themselves to have lost blood, one or more internal organs, body parts, or even their soul. More simply, it is a delusional misidentification syndrome characterized by nihilistic delusions concerning one’s own body. Cotard’s syndrome is also frequently termed Cotard’s delusion or walking corpse syndrome. With only around 200 known cases worldwide, Cotard’s syndrome is not named in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) due to its rarity.[1] It is most typically reported in individuals with prior mental health or medical conditions.[2] With the correct and proper treatment, individuals have been known to make a full recovery.

HISTORY

Though Cotard’s syndrome has certainly existed for as long as there have been people, as with the majority of mental health conditions, the French neurologist and psychiatrist Jules Cotard was the first to officially describe the syndrome in 1880 when a woman only referred to as Mademoiselle X was brought to his office, suffering from what he dubbed as “le délire des négations.”[3][4] The 43-year-old woman referred to as Mademoiselle X expressed nihilistic delusions consisting of the denial of her own existence and several of her body parts including her brain, nerves, chest, stomach, and bowels. 

According to a translation by Brian A. Sharpless, Jules Cotard reported that “MIle X, affirms she has no brain, no nerves, no chest, no stomach, no intestines; there's only skin and bones of a decomposing body…She has no soul, God does not exist, neither the devil. She's nothing more than a decomposing body, and has no need to eat for living, she cannot die a natural death, she exists eternally if she's not burned, the fire will be the only solution for her.”[5] As mentioned in the translation, she reported believing that she had no need to eat considering she thought herself to be unable to die. As a result, she unfortunately succumbed to starvation as her symptoms worsened.

Jules Cotard believed he was witness to a ‘new’ kind of depression, which at first he called hypochondriacal delirium, a new type of agitated melancholia.[6] As he continued to further his understanding of Mademoiselle X’s condition, around 1882 he began using the term “le délire des négations” to describe the disorder. Despite current and prior research efforts since Jules Cotard’s encounter with Mademoiselle X, only few major breakthroughs have since come to pass. In 1995, for example, G.E. Berrios and R. Luque were the first to make a statistical analysis of Cotard’s syndrome. Using 100 cases reported by prior literature, they described and discussed three types of Cotard’s syndrome: psychotic depression, Cotard type I, and Cotard type II.[3]

DEFINITION

Also referred to as walking corpse syndrome or Cotard’s delusion, Cotard’s syndrome, as mentioned prior, is a condition in which one believes themself to have died, not exist, lost one or more body parts, lost their soul, and so on. Furthermore, in a statistical analysis of 100 cases, it was reported that 86% of affected individuals expressed nihilistic delusions concerning their body and 69% concerned their existence.[3] Though it was once believed that Cotard’s syndrome only referred to the belief of already having died, it’s recently proven more common to not reduce Cotard’s syndrome to only one particular delusion.[3] According to Adam J. Fusick et al., Cotard’s syndrome is “characterized by a patients' nihilistic denial of one-self that can range in intensity from parts of one's body to the entire body or even extending to one's own existence.”[7] By unnecessarily narrowing down Cotard’s syndrome to one delusion or symptom, it poses the risk of overlooking valuable information that could be vital in assisting experts in learning more about what is commonly described as an ‘enigmatic’ condition. 

With only around 200 cases known worldwide, the rarity makes it difficult for researchers to further existing knowledge and make necessary breakthroughs in the understanding and treatment of Cotard’s syndrome. As a result, researchers and experts find it difficult coming to a general consensus on treatment, causes, definition, and so on. Most noticeably, it’s been an ongoing debate on whether Cotard’s syndrome should be classified as an independent syndrome or as a secondary syndrome resulting from underlying conditions.[5]

In recent years, it was proposed by K. Yamada et al., in 1999 that Cotard’s syndrome can be separated into three stages: germination stage, blooming stage, and chronic stage. In the germination stage, symptoms like sudden nihilism, depression, hypochondria, and so on begin to occur. A formal diagnosis is unable to be made in the first stage. In the blooming stage, symptoms begin to worsen and devolve into features more typically associated with Cotard’s syndrome. Finally, according to the staging theory, the chronic stage is separated into two stages: depressive and paranoid, only differentiated by depressive symptoms.

Though the staging theory can certainly be applicable for some individuals, many have thought this generalization to be very restrictive while adding unnecessary limitations in diagnosing and treating patients. Moreover, depending on the cause, the way in which Cotard’s syndrome makes itself known can vary significantly from person to person.[8] Debate surrounds nearly all aspects pertaining to Cotard’s syndrome, making further research that takes into account the heterogeneity of it of great importance.

It’s been reported for the majority of individuals with Cotard’s syndrome to experience an accompanying psychiatric or medical condition. This commonly includes schizophrenia, dementia, psychotic depression, bipolar disorder, postpartum depression, Parkinson’s disease, and so on.[9] In a case study of 100 cases, depression was reported among 89% of affected individuals.[3] Further, suicide and self harm are risks associated with Cotard’s syndrome. For example, Mademoiselle X, as mentioned previously, succumbed to starvation after denying the need to eat in order to survive. After all, it would be irrational to eat if you’re already dead, and your internal organs are missing. 

A more recent example of this is from a 2023 case report by Christopher Robertson and Thomas Dunn where they describe a man, referred to as Mr. B, who refused to take his insulin, believing himself to be already deceased after a failed suicide attempt 3 years prior.[10] Furthermore, Mr. B refused to eat, with Robertson and Dunn stating that: “Mr. B specifically described his belief that going several days without eating would not harm him as he was already deceased.” Refusal to drink, eat, take medicine, or perform tasks that are necessary for the body to function properly are described in nearly all case reports of affected individuals. 

CAUSES & TREATMENT

Cotard’s syndrome can and does arise from a multitude of causes, making researchers unsure of what exactly causes it. Due to the lack of independent psychiatric definition, Cotard’s syndrome has been linked to several underlying neurological and psychiatric conditions, including but not limited to: Parkinson’s disease, cerebral atrophy dementia, epilepsy, stroke, brain injury, schizophrenia, dissociative disorders, depression, bipolar disorder, etc.[9][11] In the words of Karlyle Bistas and Maheen Mirza, “Cotard's syndrome is a relatively rare condition observed in patients with mood disorders, psychotic disorders, central nervous system (CNS) infections, CNS tumors, and traumatic brain injuries.”[12] Conditions such as these can alter a person’s sense of self, cause alteration to parts of an individual’s brain responsible for cognitive processing, sensory integration, sense of self, etc., and cause delusions resulting in Cotard's syndrome. 

In similar fashion to Capgras syndrome (a delusional misidentification disorder in which an individual believes something familiar to them has been replaced by or transformed into something unfamiliar), Cotard’s syndrome has been found to be associated with injury to or degeneration of the fusiform gyrus and amygdala.[13] These regions of the brain are responsible for facial recognition and emotion. Dysfunction of brain regions responsible for face and body recognition can lead to derealization/depersonalization, having a tendency to result in delusional misidentification disorders such as Capgras syndrome or Cotard’s syndrome.[5][14] Further, it has also been speculated to be linked to dysfunction of the parietal lobe and medial frontal lobe.[15] The parietal lobe is responsible for sensory perception and integration, and the medial frontal lobe (also referred to as medial prefrontal cortex) is responsible for regulation of emotion and cognitive process. Interestingly, damage to the medial frontal lobe has been found in individuals with a variety of neurological and psychiatric conditions also found in those with Cotard’s syndrome.[16] 

It should be noted that causes can vary greatly on a case-by case basis. This is what makes it particularly difficult for researchers to come to a general consensus on the direct cause of Cotard’s syndrome. This, in turn, makes treatment also a subject of discourse. Since Cotard’s syndrome has such varying causes and is often a symptom of an underlying condition, doctors must typically find or attempt to find the root of the individual’s case of Cotard’s syndrome by narrowing down potential causes, and then decide on proper treatment from there.[9] Essentially, doctors find out first if there’s a medical cause, and if there is, the medical problem is treated. If not, further investigation is required.

A great variety of treatment options have been proposed and attempted, with pharmacotherapy (particularly dual medication treatment) and electroconvulsive therapy being the most used and effective.[12] However, due to the risks associated with electroconvulsive therapy, it is usually a last resort for individuals whose symptoms have not improved. Cognitive behavioral therapy or psychotherapy are also viable treatment options for those with Cotard’s syndrome. 

CONCLUSION

Improvement in psychiatric healthcare will always be of the utmost importance, especially when it comes to disorders as rare and challenging as Cotard’s syndrome. Current information regarding it is scarce and the varying opinions and constant debate means continuous research is vital to the understanding, treatment, and management of Cotard’s syndrome. Despite how limited current research is and may be, considering the rarity of the disorder, advancements in the understanding of its etiology, symptomatology, and treatment methods must be made in order to provide proper support to those afflicted. If you or a loved one is struggling, please know that help is always available, even in situations where it might appear otherwise.

REFERENCES

1. Rath, L. (2020). What Is Cotard’s Syndrome (Walking Corpse Syndrome)? WebMD. https://doi.org/10446968.11ef742d

2. Ruminjo, A., & Mekinulov, B. (2008). A Case Report of Cotard’s Syndrome. Psychiatry (Edgmont), 5(6), 28. https://pmc.ncbi.nlm.nih.gov/articles/PMC2695744/#:~:text=Cotard's%20syndrome%20comprises%20any%20one,psychotic%20disorders%2C%20and%20medical%20conditions

3. Berrios, G. E., & Luque, R. (1995). Cotard’s syndrome: analysis of 100 cases. Acta Psychiatrica Scandinavica, 91(3), 185–188. https://doi.org/10.1111/j.1600-0447.1995.tb09764.x

4. Brumfield, D. M. (2020, September 29). Mademoiselle X: Living While Dead - Lessons from History - Medium. Medium; Lessons from History. https://medium.com/lessons-from-history/mademoiselle-x-living-while-dead-8fe06146b711

5. Unusual and Rare Psychological Disorders. (2016). Google Books. https://books.google.com/books?hl=en&lr=&id=BxtREAAAQBAJ&oi=fnd&pg=PA94&dq=cotard%27s+syndrome&ots=52TURoO9wN&sig=YTCXBrSGQJTf0l4i9kvIFTmW_HE#v=onepage&q=cotard's%20syndrome&f=false

6. Berrios, G. E., & Luque, R. (1999). Cotard’s “On hypochondriacal delusions in a severe form of anxious melancholia.” History of Psychiatry, 10(38), 269–274. https://doi.org/10.1177/0957154x9901003806

7. Fusick, A. J., Davis, C., Gunther, S., Klippel, C., & Sullivan, G. (2024). Psychotropic Management in Cotard Syndrome: Case Reports Supporting Dual Medication Management. Case Reports in Psychiatry, 2024, 1–5. https://doi.org/10.1155/2024/7630713

8. K. Yarnada, S. Katsuragi, & Fujii, I. (2007). A case study of Cotard’s syndrome: stages and diagnosis. Acta Psychiatrica Scandinavica, 100(5), 396–398. https://doi.org/10.1111/j.1600-0447.1999.tb10884.x

9. The. (2018, January 2). Cotard Delusion and Walking Corpse Syndrome. Healthline; Healthline Media. https://www.healthline.com/health/cotard-delusion#causes-and-risk-factors 

10. Robertson, C., & Dunn, T. (2023). “A ghost doesn’t need insulin,” Cotard’s delusion leading to diabetic ketoacidosis and a body-mass index of 15: a case presentation. BMC Psychiatry, 23(1). https://doi.org/10.1186/s12888-023-05039-6

11. Grover, S., Aneja, J., Mahajan, S., & Varma, S. (2014). Cotard’s syndrome: Two case reports and a brief review of literature. Journal of Neurosciences in Rural Practice, 05(S 01), S059–S062. https://doi.org/10.4103/0976-3147.145206

12. Karlyle Bistas, & Mirza, M. (2024). Walking Corpse Syndrome: A Case Report of Cotard’s Syndrome. Cureus. https://doi.org/10.7759/cureus.63824

13. Publishers Panel. (2025). Actaneuropsychologica.com. https://actaneuropsychologica.com/article/01.3001.0014.4268/en

14. Delusions Demand Attention. (2025). Cognitive Neuropsychiatry. https://doi.org/10.1080//135468096396668

15. Pearn, J., & C. Gardner–Thorpe. (2002). Jules Cotard (1840–1889). Neurology, 58(9), 1400–1403. https://doi.org/10.1212/wnl.58.9.1400

16. Xu, P., Chen, A., Li, Y., Xing, X., & Lu, H. (2019). Medial prefrontal cortex in neurological diseases. Physiological Genomics, 51(9), 432–442. https://doi.org/10.1152/physiolgenomics.00006.2019