Cotard’s syndrome, a rare psychiatric condition with delusions of being dead. An overview and aspects of its pathogenesis
Thomas Lindén MD, PhD Sektionen för klinisk neurovetenskap och rehabilitering. Institutionen för neurovetenskap och fysiologi. Sahlgrenska akademin vid Göteborgs Universitet
Ingegerd Odar-Cederlöf Läkare Avdelningen för klinisk farmakologi Karolinska Universitetssjukhuset Huddinge
Lars Ståhle Läkare Farmakologiska kliniken, Karolinska Universitetssjukhuset Huddinge
Anders Helldén Läkare Avdelningen för klinisk farmakologi, Karolinska Universitetssjukhuset, Huddinge
Cotard’s syndrome is a rare but remarkable psychiatric condition. Most prominent symptoms are strong delusions of being dead - or vaiations of it - as the main feature. A patient with Cotard’s syndrome is unshakably convinced that he or she is dead, has lost his or her blood, soul or internal organs, or has ceased to exist. The French neurologist Jules Cotard first described the syndrome in 1880. Since then only about 100 cases have been published. Most probably this reflects an extremely rare occurrence even though another explaination may be lack of familiarity with the syndrome in the medical community. Cotard’s syndrome has been observed in psychiatric conditions in which other types of delusions are noted, such as schizophrenia, melancholic depression, or schizo-affective psychosis, but also as a complication to severe somatic stress as in hyperthermia, trauma, anorexia, or in brain diseases such as multiple sclerosis, Parkinson’s disease, traumatic brain injury, brain tumour or epilepsy. The specific clinical features in Cotard’s syndrome together with the high rate of organic aetiology in published case reports suggest that a somatic condition should be considered in patients presenting with the syndrome. In several cases the syndrome has been shown to be reversible, once the underlying somatic condition has abated. The mechanism underlying Cotard’s syndrome, with or without other psychiatric pathology, is not known, although some have suggested an association with damage to the non-dominant temporo-parietal cerebral cortex. Treatment with acyclovir or valacyclovir may cause neuropsychiatric side effects, such as restlessness, nightmares, hallucinations, agitation, tremor, disorientation and coma, mainly in patients with renal function impairment. We have found several occurences of Cotard's syndrome in patients with high concentrations of these drugs. The condition is rapidly restored with hemodialysis. This gives important clues to the pathogenesis of Cotard's syndome.