On October 2, 2012, a 66-year-old man was admitted to the psychiatry ward of the Hospital das Clínicas at UFPE due to severe depressive symptoms accompanied by psychotic symptoms. Previously, he had no psychiatric history, but this situation changed after being struck by a client. He told the doctors that he was dead and a 'living dead,' claiming his organs had turned to stone.
The diagnosis for this individual was Cotard's Syndrome, an extremely uncommon psychiatric condition. Due to its singularity, it is not listed as an autonomous phenomenon in the two main international references for diagnosing mental disorders: the 5th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the 10th edition of the International Classification of Diseases (ICD-10). Generally, the symptoms are categorized as 'nihilistic delusion' resulting from depressive episodes.
Despite this, Cotard's Syndrome persists. Because it is rare, there is a scarcity of studies and epidemiological data on it. It is observed that it affects older individuals and females more frequently, although not exclusively. A study conducted in Hong Kong, focusing only on severely depressed elderly people, identified Cotard's Syndrome in 3.2% of these patients. In contrast, less than 1% of people diagnosed with schizophrenia present with this condition.
The syndrome is named after Dr. Jules Cotard, who, in 1880, documented the case of a woman who believed she did not have a brain or internal organs. Currently, it is often viewed as a condition linked to depressive states, schizophrenia, infections, neurological diseases, affective disorders, Parkinson's disease, brain tumors, and substance use.
Signs of Cotard's Syndrome can include anxious or depressed mood, delusions of damnation (such as the belief of being condemned to suffer or die), feelings of possession, and grandiose ideas of immortality. Curiously, it can also involve delusional convictions of non-existence or of being deceased.
In certain situations, the patient reports that close people, such as family and medical staff, are also dead. It is very common for the person to believe they are dead, without a soul, or that something is wrong with their organs, whether the belief is that they have disappeared or are decomposing (these symptoms can occur in isolation or together).
One case recorded by scientists involved a 53-year-old Filipina woman who began telling relatives that she was dead, that she smelled of rotten meat, and that she wanted to be taken to the morgue to join the other dead.
Another patient, in a separate study, manifested various delusions, including the conviction that various objects—such as spoons, nails, rulers, trash cans, and coins—were inside her body, and that she was being burned or was at risk of explosion. She also stated that her face and body did not exist, that her heart was not functioning, and that she would die soon or was already dead. During a severe episode, she declared that a doctor in front of her was dead.
One of the most notable cases is that of Esmé Weijun Wang, who developed CS after a flight from London to San Francisco, losing consciousness for several hours during the journey. She explained to The Washington Post in 2015: 'I was convinced that I had died on that flight and was in the afterlife.' She added: 'That was the beginning of when I was convinced that I was dead. But I wasn't upset because I thought I could do things [in life] again and better.'
A study conducted in 2017 analyzed 12 individuals with Cotard's Syndrome; eight of them claimed to have died. Of these eight, three believed they had been murdered by healthcare professionals, while four reported being in the process of dying.
A frequent symptom of Cotard's Syndrome is the voluntary refusal of food, when the patient completely stops taking in food. This can be a consequence of the belief that they are dead and, consequently, do not need nutrition.
The most recommended treatment in the literature for Cotard's Syndrome is electroconvulsive therapy. This method was applied to the UFPE patient in 2012, resulting in success: after eight sessions, the elderly person showed complete remission of symptoms and was discharged after a period of one month and seven days of hospitalization. Nevertheless, it is known that the use of antidepressant and antipsychotic medications can be effective when depression is the triggering factor for CS.
