Let’s imagine Patient X. He’s a 78 year-old-man with a history of depression, taken to A&E by his family. However, he vehemently refuses treatment or hospitalization, as he believes himself to be dead. Not only is he anxious about why no one has buried him, but he has repeatedly asked his family to take him to the morgue so he can be with other dead people. He claims to have no brain, nerves or guts, and says he can smell his own flesh rotting. For the last few days Patient X has not eaten, and has neglected to shower for fear of dissolving and disappearing down the drain. When doctors tried to take his blood pressure, he claimed they were deceiving him as part of a conspiracy – he believes he has no blood and that his heart doesn’t beat. When shown a mirror, he does not recognise his own face and he has no interest in social life or any form of pleasure.

Patient X is likely suffering from a form of Cotard’s Syndrome, known as ‘Walking Corpse Syndrome’ due to its presenting symptoms. These false, nihilistic ideas of self-negation are often accompanied by symptoms of guilt, anxiety and negativity. Paradoxically, some patients may also have delusions of immortality.

Self-starvation is a common cause of death for Cotard’s patients, who often believe eating is not necessary. It is unknown why patients report smelling their own putrefying flesh – strangely, this is a common symptom. Additionally, the patient may display a resistance to pain (analgesia).

The condition was first documented in 1880 by Jules Cotard, who described it as “Le délire des négations” (usually translated as “nihilistic delusion”). Even today, very little is known about the pathophysiological mechanisms of the condition, and all that really exists are case reports.  It is typically viewed as part of an underlying disorder – it is more common in older patients with depressive disorders, and associated with other mental conditions such as bipolar disorder, schizophrenia and dementia. Sudden onset of Cotard’s syndrome can also be due to brain trauma or brain tumours.

It has been suggested that the syndrome may in part be due to neural misfiring in the part of the brain that associates emotions with a recognised face. The prefrontal cortex, said to control personality, decision making, orientation and planning, might also be affected, contributing to the delusions.

Current treatment involves heavy mediation with antidepressants, antipsychotics and/or mood stabilisers, depending on the underlying condition. When these fail, electroconvulsive therapy (ECT) might be used. Patients often return to normal, but problems occur when the underlying depressive illness is chronic – delusional episodes can return.

This is a rare condition, but not unheard of. One of the biggest problems is the severe personal neglect patients experience as they refuse to eat, wash or sleep, which can eventually be fatal. Thankfully, common pharmaceutical drugs are usually an effective treatment.