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MIND & BRAIN, THE JOURNAL OF PSYCHIATRY Cotard’s Syndrome


Hans Debruyne1,2,3, Michael Portzky1, Kathelijne Peremans1 and Kurt Audenaert1 Affiliations: 1Department of Psychiatry, University Hospital Ghent, Ghent, Belgium; 2PC Dr. Guislain, Psychiatric Hospital, Ghent, Belgium and 3Department of Psychiatry, Zorgsaam/RGC, Terneuzen, The Netherlands


REVIEW ARTICLE


ABSTRACT


Cotard’s syndrome is characterized by nihilistic delusions focused on the individual’s body including loss of body parts, being dead, or not existing at all. The syndrome as such is neither mentioned in DSM-IV-TRnor in ICD-10. There is growing unanimity that Cotard’s syndrome with its typical nihilistic delusions externalizes an underlying disorder. Despite the fact that Cotard’s syndrome is not a diagnostic entity in our current classification systems, recognition of the syndrome and a specific approach toward the patient is mandatory. This paper overviews the historical aspects, clinical characteristics, classification, epidemiology, and etiological issues and includes recent views on pathogenesis and neuroimaging. A short overview of treatment options will be discussed.


Keywords: Cotard’s syndrome, nihilistic delusion, misidentification syndrome, review Correspondence: Hans Debruyne, P.C. Dr. Guislain Psychiatric Hospital Ghent, Fr. Ferrerlaan 88A, 9000 Ghent, Belgium. Tel: 32 9 216


3311; Fax: 32 9 2163312; e-mail: hans.debruyne@fracarita.org


INTRODUCTION: HISTORICAL ASPECTS AND CLASSIFICATION Cotard’s syndrome is named after Jules Cotard (18401889),


a French neurologist who described this condition for the first time in 1880, in a case report of a 43-year-old woman.


Mss 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. (Translation from Cotard 1880)1


Cotard formulated a new type of depression, characterized by anxious melancholia, ideas of damnation or rejection, insensitivity to pain, delusions of nonexistence concerning one’s own body, and delusions of immortality. He categor- ized this under lype


based on the analogy with five cases described in 1838 by Esquirol.1 Later, Cotard introduced de


stated that the syndrome (he named it de


only associated with depression, but might be linked to other psychiatric disorders as well.4


Two components of the syndrome were defined by Tissot:


an affective component associated with anxiety and a cognitive component associated with the presence of delusion.5 Loudet and Martinez6 made a first attempt to classify different types


www.slm-psychiatry.com 67


terminology for the syndrome.2 The eponym Cotard’s syndrome was introduced in 1887 by Se


´manie, a kind of psychotic depression, ´lire des negations as new ´gis


´glas.3 A few years later, Re ´lire de Cotard) was not


of the syndrome. They described a nongeneralized de ´lire de


negation, associated with paralysis, alcoholic psychosis, dementia, and the ‘‘real’’ Cotard’s syndrome, only found in anxious melancholia and chronic hypochondria.6 Later, in 1968, Saavedra proposed a classification into three types: depressive, mixed,and schizophrenic. He drew a distinction between a ‘‘genuine’’ Cotard’s syndrome occurring during depressive states and what he described as a pseudonihilistic or pseudo-Cotard syndrome classified as ‘‘co-anaesthetic schizophrenia.’’7


In 1995, for the first time, a classification was made on evidence basis. In a retrospective factor analysis of 100 cases in literature, Berrios and Luque subdivided Cotard’s syn- drome into three types. A first type included a form of psychotic depression, characterized by anxiety, melancholic delusions of guilt, and auditory hallucinations. A second type, described as Cotard’s syndrome type I, was associated with hypochondriac and nihilistic delusions and absence of depressive episodes. The third group was the Cotard’s syndrome type II, with anxiety, depression, auditory hallucinations, delusions of immortality, nihilistic delusions, and suicidal behavior as characteristic features.8


Cotard’s syndrome is currently not classified as a separate


disorder in DSM-IV-TR and ICD-10.In DSM-IV-TR, nihilistic delusions are categorized as mood congruent delusions within a depressive episode with psychotic features.9 Classifying Cotard’s syndrome as a separate entity is an extremely difficult exercise in our current diagnostic classification system.


METHODS For this article, we started from the search results for


‘‘Cotard syndrome,’’ ‘‘Cotard’s syndrome,’’ and ‘‘nihilistic M&B 2011; 2:(1). July 2011


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