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Walking corpse syndrome: When a patient tells you ‘I am dead’

MDlinx May 03, 2024

In a recent psychiatric case study from Japan, a woman in her 60s with schizophrenia presented with delusions of reference, delusions of guilt, auditory hallucinations, agitation, depression, suicidal ideation, catatonia, and cenesthetic hallucinations.

Koreki A, Mashima Y, Oda A, et al. You are already dead: Case report of nihilistic delusions regarding others as one representation of Cotard's syndrome. PCN Rep. 2023;2(2):e93.



Disconcertingly, the woman also expressed nihilistic delusions of being dead, claiming, “I am dead.” 

She claimed her children were dead, and during an interview with the attending, that the attending was also dead. Sometimes, she would refuse to eat because she believed she was dead. She claimed her face and body were nonexistent and that her heart didn’t beat.

So, what’s going on here?


Cotard’s syndrome explained


This rare neuropsychiatric condition, also known as walking corpse syndrome, involves the patient denying the existence of their body to the point where they have delusions of immortality. Among such patients, self-starvation is common due to the negation of self. 

Researchers reviewing the literature on Cotard’s syndrome describe its main features:

Grover S, Aneja J, Mahajan S, et al. Cotard's syndrome: Two case reports and a brief review of literature. J Neurosci Rural Pract. 2014;5(Suppl 1):S59–562.


Nihilistic delusions involving the body and existence are the most frequent manifestations in Cotard’s syndrome, but delusions can also include negation of intellect, denial of pregnancy, and delusional paralysis. Patients can also negate the presence of their organs and deny the existence of marriages, parents, or children.

Specialists should note that nutritional deficits and self-starvation can be mistaken for anorexia nervosa. It’s important to keep Cotard’s syndrome in mind as a differential diagnosis, as lack of treatment can increase risk of death. This condition is more common among elderly women, and rarely affects younger patients.

Authors writing on the psychotropic management of Cotard’s syndrome note that it is associated with various neurological illnesses, including cerebral atrophy and temporal lobe epilepsy, and with psychiatric conditions such as major depressive disorder.

Fusick AJ, Davis C, Gunther S, et al. Psychotropic management in Cotard syndrome: Case reports supporting dual medication management. Case Rep Psychiatry. 2024 Apr 9;:7630713.



In major depressive disorder with psychotic features, depressive delusions can involve profound feelings of guilt or worthlessness that distort self-perception to the extent of self-perceived nonexistence or death. In addition to self-starvation, patients can self-mutilate or ideate about suicide, making this condition particularly dangerous. 

With regard to medical conditions, Cotard’s syndrome has been linked to syphilis, typhoid fever, cerebral trauma, migraine, A-V malformation, brain tumors, arachnoid tumors, herpetic and non-herpetic encephalitis, and more. It can also result as an adverse effect of acyclovir and its prodrug valaciclovir.




PET imaging supports the role of the insular cortex and prefrontal cortex as contributing to the development of nihilistic delusions, according to researchers from Mexico and the US.

Restrepo-Martínez M, Espinola-Nadurille M, Bayliss L, et al. FDG-PET in Cotard syndrome before and after treatment: Can functional brain imaging support a two-factor hypothesis of nihilistic delusions? Cogn Neuropsychiatry. 2019;24(6):470–480. Erratum in: Cogn Neuropsychiatry. 2019;24(6):481–483.


“In terms of neurobiological evidence, many studies suggest a lack of gross abnormalities in the neuroimaging. However, studies which have found neurobiological changes suggest involvement of fronto-temporo-parietal circuitry in the pathophysiology of Cotard's syndrome,” they stated.


Treatment options


Patients with Cotard’s syndrome can benefit from monotherapy with an antipsychotic medication or an antidepressant medication, or from both in combination. In cases of failure of pharmacotherapy or other treatment strategies, ECT has been most effective.

Dihingia S, Bhuyan D, Bora M, et al. Cotard's delusion and its relation with different psychiatric diagnoses in a tertiary care hospital. Cureus. 2023;15(5):e39477.



What this means for you

Cotard's syndrome is rare and most closely associated with depression and other psychiatric illnesses. Psychiatric treatment involves antidepressants, antipsychotics, or ECT. In patients exhibiting self-starvation suggestive of anorexia nervosa, Cotard's syndrome should be considered in the differential diagnosis. Treatment is necessary, as untreated Cotard's can result in self-mutilation or suicide.


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