Cotard's Delusion or Syndrome?

: A Conceptual History
G.E. Berrios and R. Luque
This report offers an account of the historical construction of Cotard's syndrome showing that by d~lire des n6gations the French author meant a subtype o f depressive illness. Subsequent debate led first to the belief that it was just a collection of symptoms associated with agitated depression (anxious melancholia) or general paralysis, and later to the view that it might after all constitute a separate entity. At the present moment, and impervious to the fact that the French term d~lire means far more than "delusion," some authors use Cotard's syndrome to refer to the belief of being dead and suggest that such a delusion might have a specific brain location. From the clinical and evolutionary perspectives, it is unclear why a delusion should merit, simply because of its "nihilistic" content, a special brain location or presage chronicity. It is suggested here that before neurobiologic speculation starts, efforts should be made to map out the clinical features and correlations of the d#lire des n~gations.

Copyright 1995 by W.B. Saunders Company

T English-speaking psychiatry in the clinicap -3 and neurobiologic4-6 aspects of the socalled Cotard's syndrome. A tendency can also be detected in American literature to use "Cotard's delusion" for the "delusional belief of being dead," irrespective of clinical context.4 It is not yet clear whether this departure from historical and clinical usage constitutes a scientific advance or is a mere misreading of the original literature and of the conceptual context in which Cotard performed his studies. "Nihilistic delusions" but not Cotard are mentioned in DSM-III-R (p. 220)7; neither term appears in ICD-10. 8This report reviews the original French sources for Cotard's syndrome and its conceptual construction between 1880 and World War II. A separate report offers a statistical analysis of 100 cases and outlines the clinical features of this phenomenon. 9
JULES COTARD AND HIS TIME

HERE HAS BEEN some interest of late in

Jules Cotard was born on June 1, 1840, in Issoudun, France, and studied medicine in Paris, where he was a student of Broca and Vulpian; he became interested in the pathology of the nervous system while working under Charcot. His first substantial report was Etudes physiologiques et pathologiques sur le ramollissement c~rObral;1 he obtained his doctorate in 1868 with an [~tude sur l'atrophie partielle du cerveau. 11

After seeing the great Las6gue interview a patient at the Prefecture de Police, he turned to psychiatry. In 1874, Las6gue introduced Cotard to Jules Falret, and these two men formed an enduring partnership at the Vanves asylum. His untimely death on August 19, 1889, followed an attack of diphtheria caught from his daughter. Cotard was influenced by Condillac, Cabanis, Destutt de Tracy, Maine de Biran, and Comte, and wrote on hypochondria, abulia, and the "psychomotor origin" of delusions. 12 At his funeral, Jules Falret described him as "a profound and original thinker, given to paradox, but guided by a robust sense of reality. ''13 This original bent of mind is illustrated in an early report on Folie,14 where Cotard explored the difficulties posed by adopting ordinary terms into the scientific language of psychiatry, and rejected the principle of etiologic classification of mental disorder, is Based on the belief that knowledge about the brain was insufficient to support causal explanations, he proposed a symptomatic classification.14 Original thinking also led him to suggest that disturbances of affectivity might be "the grounds on which delusions germinate. ''12
THE ORIGINAL SOURCES

From the Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK. Address reprint requests to G.E. Berrios, M.D., Department of Psychiatry, Universityof Cambridge, Addenbrooke's Hospital (Box 189), Hills Road, Cambridge, UK. Copyright 1995by W..B. Saunders Company 0010-440X/95/3603-0004503. 00! 0
218

On June 28, 1880, in a meeting of the Societ~ M~dico-Psychologique, Cotard read a report on Du d~lire hypochondriaque dans une forme grave de la m~lancolie anxieuse 16detailing the case of a 43-year-old woman who believed that she had "no brain, nerves, chest, or entrails, and was just skin and bone," that "neither God or the devil existed," and that she did not need food, for "she was eternal and would live forever." She had asked to be burned alive and had made various suicidal attempts.

ComprehensivePsychiatry, Vol. 36, No. 3 (May/June), 1995: pp 218-223

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Cotard was aware of the fact that similar cases had been described before, and quoted Esquirol, 17 Macario, 18 Leuret, 19 Morel, 2 KrafftEbing, 21 and Baillarger, 22 the last of whom had 20 years earlier reported similar cases in the context of general paralysis. Cotard diagnosed his patient as suffering from lyp~manie (an Esquirolean category only partially related to "psychotic depression episode"). 23 Cotard explained that d~lire hypochondriaque resulted from "an interpretation of pathological sensations often present in patients with anxious melancholia." He suggested that a similar form of d~lire might have given rise to the myth of the "wandering Jew ''24 and to cases of so-called dOmonomanie. He believed he had found a new type of lyp~manie characterized by anxious melancholia, ideas of damnation or possession, suicidal behavior, insensitivity to pain, delusions of nonexistence involving the whole person or parts thereof, and delusions of immortality. These were the original features of the complete Cotard's psychotic state (d~lire de Cotard). Two years later, Cotard returned to the topic and introduced the term d~lire des n~gations (translated since then as nihilistic delusions): "I would like to venture the term d~lire des n~gations to refer to those c a s e s . . , in which patients show a marked tendency to denying everything. ''25 Carried to its extreme, this negating attitude led the patient to denying the existence of self or world, and such delusions may be the only symptom left during the chronic state of melancholia. To make sense of this new symptom cluster in the context of French nosology, Cotard compared it with the d~lire de persecution (persecutory syndrome), which since the time of Las6gue had been central to French psychiatry. 26In clinical practice, dOlire des n~gations may be found alone, as a manifestation of general paralysis, or associated with anxious melancholia. In 1884, Cotard reported a case of melancholia with nihilistic delusions who complained of an inability to "visualize the features of his children." Recalling a case of Charcot's who had also "lost the capacity to visualize absent objects," Cotard went on to suggest that nihilistic delusions might be secondary to a "loss of mental vision," an incapacity to evoke mental representations of objects not present to the

senses. 27 A few days before his death, he modified this view by suggesting that the primary disorder was a reduction in "psychomotor energy" (la diminution de l'~nergie psycho-motrice ) leading both to psychomotor retardation and loss of images (the latter causing the d~lire des nOgations. ) 12 A digression is now required concerning the major difficulty posed by the translation of d~lire, which is usually rendered as delirium or delusion. These terms only manage to convey fragments of its French meaning. D~lire is not a state of delirium or organic confusion (in French, d~lire aigu 28 and confusion mentale 29) or a delusion (in French, idle or thOme d~lirante3)--it is more like a syndrome that may include symptoms from the intellectual, emotional, or volitional spheres. 31 Hence, translating d~lire des n~gations as nihilistic delusion gives the wrong impression (caused by the intellectualistic semantics attached to the term delusion in English) that it exclusively refers to a thought. As clearly described in his 1882 report, Cotard never meant it to be a thought, but instead a symptom cluster. So, to talk about the delusion of being dead as Cotard's delusion 6,32 makes little sense, for dOlire des n~gations also entails the presence of anxiety, severe depression, and other attending delusions.
THE NAMING OF THE SYNDROME

In 1893, Emil R6gis coined the eponym Cotard's syndrome, 33 and the term was made popular by Jules S6glas, who reported the case of a man with "intermittent anxious melancholia" with delusions of absence of organs and of negation, damnation, and immortality. In opposition to Cotard, S6glas proposed that nihilistic delusional states did not constitute a distinct clinical entity, but only a severe form of anxious melancholia (une forme particuliOre de mOlancolie anxieuse . . . une sorte d'aggravation de la maladie" (pp. 66-67).34 Three years later, S6glas hypothesized that the condition was analogous to "secondary paranoia," i.e., a terminal state of "that clinical condition that foreign authors have called Seciindare Verr~cktheit (p. 419). 35 In later reports, S6glas went on to classify nihilistic ideas according to whether their content involved the body, people and objects of the external world, or intellectual faculties and

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ncepts (God, soul, etc.). 36,37The extent of the denial might be partial or total, and as reported by Baillarger, 22 the syndrome was occasionally associated with general paralysis, in which case nihilistic delusions tended to be partial, involving ideas of nonexistence or destruction concerning bodily organs. When associated with senile dementia, nihilistic delusions were episodic, fleeting, and incoherent; when associated with melancholia, they were total and systematized. S6glas considered the latter "true secondary paranoia." S6glas believed that delusional ideas in general and nihilistic ones in particular should be classified according to origin (i.e., form) and not to content, and suggested psychosensorial, affective, and motor types. 38 He also hypothesized that at the basis of nihilistic ideas there was a disturbance in "mental synthesis" (as that causing depersonalization), leading to an inability to evoke images. Nihilistic ideas occurred in situations when the personality was modified by affective or motor disturbances (changes also central to melancholia). Cristiani 39 supported the view that there was an association between Cotard's syndrome and chronic paranoia, and others followed this trend. 4-43Anticipating modern views, Obici considered nihilistic delusions to be based on an involutional and degenerative process, and made the important suggestion that they reflected the presence of an "organic component. ''44
THE FIRST CONTROVERSY (1892-1900)

than melancholia45; he also agreed with Cotard's view that "nihilistic delusions, like persecutory delusions, have a progressive course" (p. 391). 46 Camuset, on the other hand, stated that the frequency with which nihilistic delusions were combined with ideas of possession, damnation, or immortality "was not high enough" to constitute a separate syndrome; furthermore, because all patients with melancholia had "negating attitudes," there was no reason to believe that nihilistic delusions per se had anything to do with prognosis. 47 Castin denied the existence of Falret's "essential" form and also believed that what Cotard had described was just a collection of symptoms seen in a number of diseases. 48 Garnier, in turn, went as far as claiming that "he had never seen a nihilistic delusion" of the type described by Cotard. a9 Charpentier stated that all nihilistic delusions were either hypochondriacal, melancholic, or persecutory, and criticized Cotard for introducing a "name" and not a disease (p. 390). 50 De Cool also believed that nihilistic delusions could be found in most melancholic patients and were no different from ideas of guilt, ruin, or damnation. 51 According to Arnaud, nihilistic delusions appeared in the wake of chronic melancholia, particularly in women between 50 and 60 years old, carrying a hereditary taint. 46 Tr6nel reported a case who also had grandiose ideas. 52 However, all in all, it was agreed that the two defining elements of the nihilistic delusions syndrome were anxious melancholia and systematized ideas of negation. 53
THE SECOND CONTROVERSY (1900-1939)

Soon after Cotard's death, the debate started on whether it had been his intention to describe a new disease or just a severe form of melancholia. Castin, Camuset, and Charpentier (interalia) believed the former, and S6glas, R6gis, Toulouse, Pichenot, and Ballet the latter. R6gis suggested a third interpretation, namely that Cotard wanted to describe a "syndrome," i.e., a symptom cluster that could also be found in mental disorders other than melancholia. 33This view was to prove very influential. The issue was debated at the third Congrks de m~dicine mentale (August 1892, Blois, France). To save the "new-disease" view, Falret distinguished between an "essential" and a "secondary" form of d~lire des nOgations, and stated that only the latter could appear in insanities other

The categorization of the affective disorders changed during the early 20th century23,s4; not surprisingly, Cotard's syndrome was soon reported in relation to "depression ''5557 and "manic-depressive illness. ''58-61 Reports of its association with general paralysis 62 and senile dementia 63continued. The syndromatic view predominated during this period. Deny and Camus divided Cotard's syndrome into a "melancholic type," with nihilistic delusions referring to the patient's subjectivity and which were secondary to affective disorders, and a "hypochondriacal type," where their content concerned the body and which were primary (primary paranoia). 55 Got consid-

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ered Cotard's syndrome as a secondary delusion found on a subtype of anxious melancholia, which he called "pure melancholia" or "symptomatic periodical insanity. ''64 It was far more common in older age groups, although in the young it seemed to have a better prognosis; nihilistic delusions are even rarer in adolescents. 65 Tissot suggested that nihilistic delusions resulted from the combination of an "affective component" (anxiety) and an "intellectual component" (the idea of negation), the former being considered as fundamental to distinguish "true Cotard" from other nihilistic states. 62 Loudet and Dalke recognized nonsystematized and systematized nihilistic delusions: the former were isolated, episodic, and could be found in general paralysis, alcoholic psychoses, and dementia; the latter (Cotard's syndrome) was characteristic of diseases such as anxious melancholia and chronic hypochondria. These authors also believed that there were "complete" and "incomplete" forms of the syndrome. 66 Obarrio et al. 67 considered nihilistic delusions to be secondary to anxious melancholia.
THE AFTERMATH

Interest in the Cotard state was renewed after World War II. For example, Perris suggested that Cotard's intention had been to describe a single symptom, a hypochondriacal delusion that occurred in anxious melancholia; however, he added that it may be accompanied by "disorders of sensation" and that it rendered the melancholia refractory to treatment: i.e., once the nihilistic delusion was established, it dominated the clinical picture and made it chronic. 68 During this period, the old syndromatic notion 69,7 was also challenged by the view that it might, after all, be a different entity. For example, De Martis reported a case of a 38-yearold woman who in the wake of surgery showed a change in personality and after an initial period of anxiety developed ideas of negation of her body and of the world, and ideas of enormity and immortality. The author suggested that Cotard's syndrome may be a separate form of psychosis, since the nihilistic delusions were structured from the start and had a chronic evolution unaltered by treatment; he further suggested that melancholia only triggered this

condition in patients otherwise predisposed. 71 Enoch and Trethowan have reported that it is "justifiable to regard Cotard's syndrome as a specific clinical entity because it may exist in a pure and complete form, and that even when symptomatic of another mental illness, such as endogenous depression, nihilistic delusions dominate the clinical picture" (p. 163). 72 Tr6mine has also considered Cotard's syndrome as a separate clinical entity that may develop in the chronic course of mental illness, but which "was a reflection of the attitudinal changes brought about by chronic institutionalization"; he believed that Cotard's syndrome was a "perfect illustration" of the decontextualized method of description used in psychiatry during the second half of the 19th century. 73 A similar view about the role of institutionalization has been taken by Lafond 74 and also by Bourgeois, who has claimed that Cotard's syndrome is a "vestige of the asylums, and of the chronicity of the pre-therapeutic era" (p. 1169). 75 If so, it could be surmised that the "therapeutic revolution" should have an important impact on its frequency76; however, this hypothesis has not yet been tested. In a different vein, Joseph has described a case of a 30-year-old man with coexisting Cotard's syndrome and Capgras' syndrome and proposed that Cotard's syndrome was a distinct disorder because it might result from a specific parietal-lobe dysfunction.5
CONCLUSION

This brief report has concentrated on the origins and conceptual construction of the socalled Cotard's syndrome. It has shown that Cotard opted for the view that d~lire des n~gations was a type of depressive illness. The debate on the nature of this clinical phenomenon that ensued after his death concluded that it was only a syndrome, i.e., a collection of symptoms that could be found associated with diseases such as agitated depression (anxious melancholia) or general paralysis. But it was also agreed that its central features were anxiety and delusions of negation, damnation, and enormity. The syndromatic view predominated for more than 50 years until some authors began to suggest, based on the fact that the syndrome was clear-cut and stable, that it might constitute a different condition. At the present moment,

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and impervious to the fact that d~lire means far more than delusion, some authors use Cotard's syndrome to refer to the belief of being dead. There is also disagreement on the etiology of Cotard's syndrome, with some attributing its stability to brain lesions, and others, to a putative social origin. However, from the clinical and evolutionary perspectives, it is unclear why a delusion should

merit, simply because of its nihilistic content, a special brain location, be considered as having a special association with disease severity, or presage chronicity for whatever underlying disorder it might be grafted on. We suggest that before speculation starts on any neurobiologic basis for the d~lire des n~gations, efforts should be made to re-map its clinical features and basic clinical correlations.

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