In the summer of 2012, in a letter to the editor of the Journal of Neuropsychiatry & Clinical Neuroscience, Huber & Agorastos described the case of ”, a man with paranoid schizophrenia and a previous history of cannabis abuse. ‘Mr H.’ He was admitted to a psychiatric unit after having attacked several people. But the most curious thing was his justification for why he did it. As described by the authors, the patient claimed to have drowned in a lake years before, although he claimed to have been reanimated in the form of a ‘zombie’ thanks to the radiation from mobile phones. Thus, he felt that he was still dead, that he was still underwater and that all the other humans had gone through the same situation as him, so they were all now zombies. When asked for an explanation and justification for his violent behavior, the patient argued that of course it is morally wrong to hit living people, but there is nothing wrong with hitting zombies! Furthermore, and within his delirium, he was not afraid of being persecuted by the law since he was already dead and lacked feelings.
‘Mr H.’ He suffered from what has been called Cotard syndrome in honor of the French neurologist who described it in more detail, a clinical picture that has been observed in cases of trauma, multiple sclerosis, brain tumors, typhus and schizophrenia, among others.
Clinical features
Garry Young (2012) tells in his publication in (2012) what are the characteristics of this spectacular syndrome that leaves us astonished. Among them, the belief that one does not exist or that one is dead (or sometimes one of their body parts) stands out. It was considered part of a more complex disorder called ‘denial delusion’ which also included suicidal ideation, anxious melancholia (intense depression), thoughts of being seriously harmed or possessed, and also delusions of immortality.
Belief that one does not exist or is dead
A striking fact is the fact that two of these manifestations, in principle opposite, can be included within the same clinical picture. Thus, we find, on the one hand, the denial of the subject’s own existence and life, and on the other, the idea of immortality. As Young describes, there are two general features of the syndrome that would group its clinical characteristics. On the one hand, patients present intense depression and this would be associated with melancholy and suicidal ideas, and on the other, patients would suffer what he has described as a ‘change in existentiality’, which could show up as the feeling of not being exist and/or the feeling of immortality, according to each patient. Young suggests that what happens in Cotard syndrome is an alteration in the state of familiarity with those stimuli that the person perceives, including themselves.
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In attempts to explain the phenomenology of Cotard syndrome from a point of view closer to neuroscience, it has been shown that these patients also have a lack of affective response to familiar faces (measured with the conductance response of the fur). According to Young and Leafhead (1996), the patient with Cotard syndrome tries to explain the fact of not feeling emotion with a familiar face as a consequence of a change in himself (and relates it to the depression suffered by these patients), leading him to the conclusion that he must be dead.
Other authors such as Ramachandran and Blakeslee (1998) propose that these subjects have a more global alteration of the neural pathways that project to the limbic system. This would lead to a flattening of all affective responses to any sensory stimulation (not just faces).
They have a lack of emotional response to familiar faces
According to Ratcliffe (2008), the feeling that we all have of belonging or participating as part of the world would have been lost. It would be the loss of the feeling of familiarity with the world, as well as not feeling like the owner or possessor of one’s own experiences.
Vanessa Charland-Verville and her collaborators have recently published in (2013) the case of a patient who, after attempting suicide by electrocution, was convinced that his brain had died, even though his mind and body were still active. He underwent a neuropsychological study in which moderate alterations in immediate memory and attention were evident. Furthermore, this work is the first to use fluorodeoxyglucose positron emission tomography to characterize cerebral metabolism in a patient with Cotard syndrome. The test results showed:
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Hypometabolism (lower glucose consumption) in the bilateral fronto-parietal cortical network, involving the precuneus and adjacent posterior cingulate, fronto-mesial and adjacent anterior cingulate areas, both posterior parietal and dorsolateral frontal lobes, as well as the right temporoparietal junction.
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Hypermetabolism (increased glucose consumption) in both thalamus, cerebellum and brain stem.
These areas are important in aspects such as awareness and the integration of information about oneself. Thus, the authors propose that in Cotard syndrome there would be a profound alteration of those areas that participate in consciousness and our permanent sense of ourselves.
Marisa Fernandez is a senior neuropsychologist at , an online platform aimed at promoting brain health care for adults and children.