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Cotard's 'On hypochondriacal delusions in a severe form of anxious melancholia'

German E. Berrios and Rogelio Luque
History of Psychiatry 1999 10: 269
DOI: 10.1177/0957154X9901003806
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History of Psychiatry,

Pnnted in England
269(1999)) 269-278.

Classic Text No. 38

Cotards On hypochondriacal delusions in

severe form of anxious melancholia
Introduction
GERMAN E.

There has of late been

by

BERRIOS* and ROGELIO LUQUE

interest in English-speaking psychiatry in the

neurobiological4S6 aspects of the so-called Cotards
A
syndrome.
tendency can also be detected in American literature to use
Cotards delusion for the isolated delusional belief of being dead,
irrespective of clinical context.3 It is not yet clear whether this departure from
historical and clinical usage constitutes a scientific advance or is a mere
misreading of the original literature and of the conceptual context in which
Jules Cotard carried out his work. Nihilistic delusions but not Cotard are
mentioned in DSM III-R; and neither term appears in ICD-10.8 The
objective of this introduction is to contextualize the translation of Cotards
lecture that follows.
some

clinical23 and

Who was Jules Cotard?

Born on 1 June 1840 in Issoudun (France), Jules Cotard read medicine in
Paris where he was a student of Broca and Vulpian. He became interested
in the pathology of the nervous system whilst working under Charcot and
his first substantial work was Etudes physiologiques et pathologiques sur le
ramollissement cerebral.9 He obtained his doctorate in 1868 with an Etude sur
latrophie partielle du cerveau.lO It is said that he decided to become a
psychiatrist after seeing the great Lasgue interview a patient at the Prefecture
de Police. The enduring partnership between Cotard and Jules Falret (whose
father owned the Vanves asylum) started in 1874 when the two men were

Address reprint requests to G. E. Berrios, Department of Psychiatry, University of

Cambridge, Addenbrookes Hospital, Box 189, Hills Road, Cambridge, UK, CB2 2QQ. E-mail:
gebll@cam.ac.uk

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270

introduced to each other by Charles Lasegue. Cotards untimely death on

19 August 1889 was due to an attack of diphtheria which he contracted
whilst looking after his daughter.
Cotard was influenced by the ideas of Condillac, Cabanis, Destutt de
Tracy, Maine de Biran and Comte; and wrote on hypochondria, aboulia, and
the psychomotor origin of delusions. 11 At his funeral, Jules Falret described
him as: a profound and original thinker, given to paradox, but guided by a
robust sense of reality.12 This original bent of mind is illustrated in an early
paper on Folie13 where Cotard explored the difficulties posed by adopting
ordinary terms into the scientific language of psychiatry, and rejected the
principle of aetiological classifications of mental disorder.14 Based on the
belief that knowledge about the brain was insufficient to support causal
explanations, he proposed a symptomatic classification. Based on his
observations on anxious melancholia he also believed that disturbances of
affectivity might be the grounds on which delusions germinate.
Cotards lecture
The lecture here translated into English was read by Cotard before the
Socit Mgdico-Psychologique on 28 June 1880.15 He reported the case of a 43year-old woman who believed that she had no brain, nerves, chest, or
entrails, and was just skin and bone, that neither God or the devil existed,
and that she did not need food for she was eternal and would live for ever.
She had asked to be burned alive and had made various attempts at suicide.
Cotard was aware of the fact that similar cases had been described before
(by, for example, Esquirol, Macario, Leuret, Morel, Krafft-Ebing and
Baillarger). Cotard diagnosed his patient as suffering from lypgmanie (an
Esquirolean category partially related to psychotic depression episode).&dquo;
Cotard explained that delire hypochondriaque resulted from an interpretation of pathological sensations often present in patients with anxious
melancholia and suggested that similar form of delire might have given rise to
the myth of the wandering Jew. He believed to have found a new subtype of
lypgmanie characterized by anxious melancholia, ideas of damnation or
possession, suicidal behaviour, insensitivity to pain, delusions of notexistence involving the whole person or parts thereof, and of immortality.
These were the original features of the complete Cotards psychotic state
(dglire de Cotard).
Later work

by Cotard on the same topic

Two years later, Cotard confirmed the term delire des nigations (already used
in his 1880 lecture) and translated since as nihilistic delusions: I would like to
venture the term delire des nggations to refer to those cases... in which
patients show a marked tendency to denying everything.&dquo; Carried to its
extreme, this negating attitude led the patient to denying the existence of
self or world, and such delusions may be the only symptom left during the

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271

chronic state of melancholia. To make sense of this new symptom-cluster in

the context of French nosology, Cotard compared it (as he had done in his
1880 lecture) with the dilire de persicution (persecutory delusional state)
which, since the time of Lasegue, had been central to French psychiatry. 18
In 1884, Cotard reported the case of a man suffering from melancholia
and nihilistic delusions who complained of an inability even to visualize the
features of his own children. Recalling a case of Charcots who had also lost
the capacity to visualize absent objects, Cotard went on to suggest that
nihilistic delusions might be secondary to a loss of mental vision, to an
incapacity to evoke mental representations of objects not present to the
senses.&dquo; Few days before his death he modified this view by suggesting that
the primary disorder was a reduction in psycho-motor energy (la diminution de
lnergie psycho-motrice) leading both to psychomotor retardation and to loss
of images (the latter causing the dlire des negations) .20
The

naming of the syndrome

In 1893, Emil Regis coined the eponym Cotards syndrome21 and the term was
made popular by Jules S6glas who, however, believed that nihilistic
delusional states did not constitute a distinct clinical entity but only a severe
form of anxious melancholia (une forme particulire de mlancholie anxieuse
une sorte daggravation de la maladie).22 Three years later, Seglas hypothesized
that the condition was analogous to secondary paranoia, i.e. a terminal state
of that clinical condition that foreign authors have called sekunddre
herrucktheit.23 In later papers, Sglas went on to classify nihilistic ideas
according to whether their content involved the body; people and objects of
the external world; or intellectual faculties and concepts (God, soul, etc.). 24,25
Seglas believed that delusional ideas in general, and nihilistic ones in
particular, should be classified according to origin (i.e. form) and not to
content and proposed psycho-sensorial, affective and motor types.26 He also
hypothesized that at the basis of nihilistic ideas there was a disturbance in
mental synthesis (as that causing depersonalization) leading to an inability
to evoke images. Nihilistic ideas occurred in situations when the personality
was modified by affective or motor disturbances (changes also central to
...

melancholia).&dquo;
Interest in the Cotard state was renewed after the Second World War. For
example, Perris suggested that Cotards intention had been to describe a
single symptom, a hypochondriacal delusion that occurred in anxious
melancholia; he added, however, that it may be accompanied by disorders of
sensation and that it rendered the melancholia refractory to treatment; i.e.
once the nihilistic delusion was established, it dominated the clinical picture
and made it chronic.28
During this period the old syndromatic view,29,3o was also challenged by
the notion that it might, after all, be a different entity. For example, De Martis
reported a case of a 38-year-old woman who after surgery showed a change

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272

personality and after an initial period of anxiety developed ideas of

negation of her body and of the world, ideas of enormity and of immortality;
the author suggested that Cotards syndrome may be a separate form of
psychosis for the nihilistic delusions were structured from the start and had a
chronic evolution unaltered by treatment; he further suggested that
melancholia only triggered this condition in patients otherwise predisposed.&dquo;
Enoch and Trethowan have written that it is justifiable to regard Cotards
syndrome as a specific clinical entity because it may exist in a pure and
complete form, and that even when symptomatic of another mental illness,
such as endogenous depression, nihilistic delusions dominate the clinical
in

picture.32
Tremine has also considered Cotards syndrome as a separate clinical
entity which may develop in the chronic course of mental illness; but which
was a reflection of the attitudinal changes brought about by chronic institutionalization ; he believed that Cotards syndrome was a perfect illustration
of the decontextualized method of description employed in psychiatry during
the second half of the nineteenth century.33 A similar view about the role of
institutionalization has been taken by Lafond34 and also by Bourgeois who
has claimed that Cotards syndrome is a vestige of the asylums, and of the
chronicity of the pre-therapeutic era.35 If so, it could be surmised that the
therapeutic revolution should have an important impact on its frequency;36
this hypothesis, however, has not yet been tested.

Summary
In summary, in his lecture of 1880 Cotard suggested that a symptom cluster
including anxious and agitated melancholia, delusions of negation of bodily
organs and metaphysical entities and of damnation and enormity may
constitute a recognizable and different syndrome. There has since been much
debate on the nature of this clinical phenomenon. After Cotards death, a
syndromatic view predominated until recently when some authors have
returned to Cotards old view that, whether produced by a brain lesion or a
social effect, dlire de negation might after all constitute a specific condition.
Impervious to the fact that dglire means far more than delusion, some current
authors use Cotard syndrome to refer to the isolated belief of being dead.
From the clinical and evolutionary perspectives, it is unclear why a
delusion should merit, simply because of its nihilistic content, a special
brain location. The historical account offered here suggests that, before
speculation starts on any neurobiological basis for the dlire des negations,
efforts should be made to re-map its epidemiology, clinical features and basic

clinical correlations. 37
REFERENCES
1.

Förstl, H. and Beats, B., Charles Bonnets description of Cotards delusion and reduplicative
clx (1992), 416-18.

of Psychiatry
paramnesia, British Journal ,

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273
2.
3.
4.
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7.

8.
9.

10.
11.

Greenberg, D. B., Hochberg, F. H. and Murray, G. B., The theme of death in complex partial
seizures, American Journal of Psychiatry
, cxli (1984), 1587-9.
Campbell, S., Volow, M. R. and Cavenar, J. O., Cotards syndrome and the psychiatric
manifestations of typhoid fever, American Journal ,
of Psychiatry cxxxviii (1981), 1377-8.
Joseph, A. B. and OLeary, D. H., Brain atrophy and inter-hemispheric fissure in Cotards
syndrome, Journal Clinical Psychiatry
, xlvii (1986), 518-20.
Joseph, A. B., Cotards syndrome in a patient with co-existent Capgras syndrome, syndrome
of subjective doubles, and palinopsia, Journal Clinical Psychiatry
, xlvii (1986), 605-6.
Young, A. W., Robertson, I. H., Hellawell, D. J. et al., Cotard delusion after brain injury,
, xxii (1992), 799-804.
Psychological Medicine
p.220, American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorder,
Third Edition, Revised (Washington, DC: American Psychiatric Association, 1987).
The ICD-10 Classification of Mental Disorders (Geneva: World Health, 1992).
Cotard, J. and Prévost, J. L., Études physiologiques et pathologiques sur le ramollissement
cérébral, in Études sur les maladies cérébrales et mentales (Paris: J. B. Baillière, 1891 (originally
published in 1865)).
Cotard, J., Étude sur latrophie partielle du cerveau, in Études sur les maladies cérébrales et
mentales (Paris: J. B. Baillière, 1891 (originally published in 1868)).
Cotard, J., De lorigine psycho-motrice du délire, in Études sur les maladies cérébrales et mentales

(Paris: J. B. Baillière, 1891).

Falret, J., Nécrologie, Annales Médico-Psychologiques, xlvii (1889), 319-24.
Cotard, J., Folie, in Dechambre, A. and Lereboullet L. (eds), Dictionnaire Encyclopédique des
Sciences Médicales (Pans: Masson and Asselin, 1878), 271-306.
14. Semelaigne, R., Les Pionniers de ,
la psychiatrie française Vol 2 (Pans: Baillière, 1932).
15. Cotard, J., Du délire hypocondnaque dans une forme grave de mélancolie anxieuse, Annales
, iv (1880), 168-74.
Médico-Psychologiques
16. Berrios, G. E., Melancholia and depression during the 19th century: a conceptual history,
British Journal ,
of Psychiatry cliii (1988), 298-304.
17. Cotard, J., Du délire des négations, Archives de Neurologie, iv (1882), 152-70; 282-96.
18. Lasègue, C., Du délire de persécution, in Études Médicales
, Vol. 1 (Paris: Asselin, 1884),
12.
13.

545-66.
19. Cotard, J., Perte de la vision mentale dans la mélancolie anxieuse, in Études sur les maladies
cérébrales et mentales (Paris: J. B. Baillière, 1891).
20. Cotard, J. De lorigine psycho-motrice du délire (see note 11above).
21. Régis, E., Note historique et clinique sur le délire des négations, Gazette Médicale de Paris, ii

(1893), 61-4.
pp.66-67, Séglas, J., Note sur un cas de mélancolie anxieuse (délire des négations), Archives
de Neurologie
, xxii (1884), 56-68.
23. p.419, Séglas, J., Mélancolie anxieuse avec délire des négations, Progrés Medical, xlvi (1887),
22.

417-19.

24.

Séglas, J., Séméiologie et pathogénie des idées de négation (Les altérations de la personalité
dans les délires mélancoliques), Annales Médico-Psychologiques
, xlvii (1889), 5-26.
Séglas, J., Le Délire des négations (Paris: Masson, 1897).
Berchene, P., Les Fondements de la clinique (Paris: La Bibliothèque dOrnicar, 1980).

25.
26.
27. For a full history of Cotards syndrome see Berrios G. E. and Luque R. (1995), Cotards
delusion or syndrome? Comprehensive Psychiatry, xxxvi, 218-23.
28. Perris, C., Sul delirio cronico di negazione (Sindrome di Cotard), Neuropsichiatria
, xi (1955),
175-201. This point had of course been already made by Cotard himself in his 1880 lecture to
the SMP and herewith translated.
29. Ahlheid, A., Considerazione sullesperienza nichilistica e sulla sindrome di Cotard nelle psicosi
organiche e sintomatiche, Il Lavoro Neuropsichiatrico
, xliii (1968), 927-45.
30. Vitello, A., Melancolia di Cotard con paranoidismo schizoide, Rassegna Studi Psichiatrici
, lix

(1970), 195-210.
31. De Martis, D., Un caso di sindrome di Cotard, Rivista Sperimentale di Freniatna, lxxx (1956),
491-514.
32. Enoch, D. and Trethowan, W., Uncommon Psychiatric Syndromes, 3rd edn (Oxford: Butterworth
and Hememann, 1991).
33. Trémine, T., 1880-1980: Centenaire du syndrome de Cotard, LÉvolution Psychiatrique
, xlvii
(1982), 1021-32.

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274
A. M., Du délire chronique des négations comme survivance asilaire (Paris: Thèse n° 112,
1973).
35. Bourgeois, M., Jules Cotard et son syndrome. Cent ans après, Annales Médico-Psychologiques
,
34.

Lafond,
cxxxviii

36.

37.

(1980), 1165-80.
Bourgeois, M., Le syndrome de Cotard aujourdhui, Annales Médico-Psychologiques
, cxxvii
(1969), 534-44.
On this see: Berrios, G. E. and Luque, R.(1985), Cotard Syndrome: clinical analysis of 100
cases, Acta Psychiatrica Scandinavica, xci, 185-8.

On

hypochondriacal delusions in a severe

form of anxious melancholia
1,2
JULES COTARD
Translated by
GERMAN E. BERRIOS

Dr Jules Falret and I have had the opportunity to observe a patient suffering
from a specific form of hypochondriacal delusion.3 Miss X claimed that she
did not have a brain, nerves, chest, stomach or guts; all she had left was the

1
Read before the Médico-Psychological Society in Paris on 28 June 1880, and published in the
Annales-Médico Psychologiques in September 1880.
NT: Full reference is: Cotard, J. (1880), Du délire hypocondriaque dans une forme grave de la
2
mélancolie anxieuse, Annales-Médico Psychologiques, iv, 168-74.
NT: Délire is often rendered as delirium or delusion. Both translations are wrong. On the one
3
hand, délire does not refer in France to organic delirium or organic confusion: at the time of Cotard
these states were called délire aigu (see Ball, B. and Chambard, E., Délire aigu, in Dechambre, A.
and Lereboullet, L. (eds), Dictionnaire encyclopédique des sciences médicales
, Vol. 26 (Paris: Masson,
1881), 408-34) and confusion mentale (see Chaslin, Ph., La Confusion mentale primitive (Paris:
Asselin et Houzeau, 1895)). On the other hand, délire means far more than delusion in the AngloSaxon sense of this term (in French this narrow meaning is referred to as idée or thème délirante
) (see

Porot, A., Délires, in Manuel alphabétique de psychiatrie (Paris: Presses Universitaires de France,
1975), 177-86)). Délire may include symptoms pertaining to the intellectual, emotional or volitional
spheres and hence is a sort of syndrome (see Garrabé, J., Dictionnaire taxinomique de psychiatrie
(Paris: Masson, 1989)). Hence, translating délire des négations as nihilistic delusion gives the wrong
impression (caused by the intellectualistic semantics attached to the term delusion in English) that it
exclusively refers to a thought. As is clear from the lecture here translated and from the 1882
paper, Cotard never meant it to be an isolated thought but a symptom-cluster, i.e. to include
anxiety, agitation, severe depression, suicidal behaviour and other attending delusions.

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