Hans Förstl


Karl Philipp Moritz

GNOTHI SAUTON - Magazin zur Erfahrungsseelenkunde

Journal of Empirical Psychology, Volume VI


(An elderly woman developed the delusion that she was dead ('Cotard's delusion') and that she was in another place ('reduplicative paramnesia'). Charles Bonnet reported this unique combination of symptoms a century before Cotard's influential description of the nihilistic delusions and of Pick's description of 'reduplicative paramnesia':)

The following story from Bonnet is a strange one. An old lady of otherwise sound reason suddenly starts to believe that she is dead and should be buried. No explanations help, and in order to console her, she has to be put into a coffin; but even in death she cannot abstain from her female habit of beautifying herself, etc. "An honourable old lady of almost 70 years sat fit and healthy in the kitchen and was preparing the meal as a draught coming through the kitchen-door struck her so forcefully on the neck that she was suddenly completely paralysed on one side as if hit by a stroke. She almost resembled a dead body during the following days. Four days later language returned and she demanded that the women should dress her in a shroud and place her in her coffin since she was in fact already dead. Every effort was made to dissuade her from this ridiculous delusion. Her daughter and servants made it dear to her that she was not dead but still alive. All was in vain, the 'dead' woman became agitated and began to scold her friends vigorously for their negligence in not offering her this last service; and as they hesitated even longer, she became extremely impatient, and  began to press her maid with threats to dress her as a dead person. Eventually everybody thought it was necessary to dress her like a corpse and to lay her out in order to calm her down. The old lady tried to make herself look as neat as possible, rearranging tucks and pins, inspecting the seam of her shroud, and was expressing dissatisfaction with the whiteness of her linen. In the end she fell asleep, and was then undressed and put into bed. She was barely awake, when the delusion, that she was really dead and should be buried, recurred. This paroxysm lasted a long time. The doctor gave her a powder of precious stones mixed with opium. When she at last believed that she was still in the land of the living, she held, that she was in Norway with her daughter and argued strongly with those who contradicted her. At times she made preparations for her journey to Copenhagen and could not be convinced that she was already there. Finally, somebody thought of a cunning trick: a carriage took her around the city wall and brought her back into town, she then recognised her house and thought that she had just returned from Norway. She could move her hands and feet as she wished, she enjoyed her meals and was apparently healthy in all respects, but she could not sleep without taking opium. Later-on she redeveloped her paroxysm every three months and after each episode was consistently taken by surprise that she had returned to life. During the periods when she thought that she was dead, she talked to people who had long been dead, preparing dinners for them and hosting the occasion sombrely and constantly." In the present case, this lady's idea that she was dead, became more vivid than other ideas, which could have convinced her of the opposite, and such cases are in no way exceptional. When the patient was hit by a stroke, this thought overtook her - now you die. Until she regained consciousness, this remained the only and dominating thought in her mind. All other ideas were automatically pushed into the back of her mind. The mind - surprised by this powerful idea - soon became used to it. The most exceptional and strange ideas can gain such acceptance, if the mind is suddenly thrown from its ordinary reasoning and forced into a new main idea. A sudden physical disorder in the brain or a sudden violent excitement can cause such a change that we are pushed beyond insight into its unreasonable nature, because we assume to notice a correct functioning of our imagination (even in delusion). This is the case with all strange imaginations. He who has them cannot accept that they are imaginations, partly because the strength of the conviction does not permit a comparison with other more natural or reasonable ideas; partly because the deluded does not realise a gap, a discontinuity in his thinking, and because the elaboration of this initial idea appears to hirn a natural and logical progression. From this it can be explained how difficult it usually is to eure patients from their vivid imaginations. One has to completely dismantle their thought processes, if they are to be healed; one has to substitute a new sequence of ideas, and the most difficult task is to banish the main idea by approaching it indirectly, step by step. Furthermore, this illustrates why those who are in the grip of a delusion are so totally preoccupied by it. If their thoughts are not completely disordered, they usually draw apparently logical conclusions unfortunately on a completely unsubstantiated premise. 
(translated by Hans Förstl and Barbara Beats; an extended version was published in the British Journal of Psychiatry, 1992)

Jules Cotard (1840-1889) described what he called 'delire des negations' Of nihilistic delusions (1882) as "a particular type of delusional formation, which seems to develop in a considerable proportion of melancholic patients. In same cases negation is total. Nothing exists any longer, not even themselves". Cotard pointed out that Griesinger, Guislain, and Leuret, had described similar phenomena before hirn. The term 'Cotard's syndrome' was first used by Seglas (1897). Today it is commonly applied to patients who suffer the nihilistic delusional belief that they are mortally ill or dead. Charles Bonnet (1720-1790) wrote this earlier report of a patient with clear features of the delusion. Today. Bonnet's name is not associated with this condition, but with another characteristic psychiatric disturbance often of organie origin (e.g. Beats et al, 1989) - dynamic and coloured visions occurring in clear consciousness and unimpaired intellect, as observed in his grandfather and, later in his life, in himself (Bonnet, 1769). The case was translated for Gnothi Sauton (the first psychological and neuropsychiatric periodical) and published in 1788 (Moritz et al, 1783-1793) by Carl Friedrich Pockels, tutor of the Prince of Brunswigk and temporary editor of the journal. Pockels added a comment which apparently foreshadowed many later attempts of German psychopathology to make delusions understandable in the context of normal mental life (Schmidt, 1940). He also presented a cognitive-behavioural model aiming to modify the patient's 'dysfunctional ideas' step by step.   

Cotard's delusion has been described most commonly in psychotic depression and schizophrenia (Enoch & Trethowan, 1979). It was suggested that patients with this delusion may show focal cerebral abnormalities, most accentuated in the parietal or frontal lobes (e.g. Enoch & Trethowan, 1979). This psychopathological phenomenon shows a distant resemblance to the preoccupation with death which may be experienced in complex partial seizures (Green berg et al, 1984). Bonnet's case provides further evidence that Cotard's delusion can be caused by underlying brain disease, in this patient probably a stroke. A combination of Cotard's delusion with Capgras' delusion, the false belief that another person has been replaced by an impostor, has been reported (Enoch & Trethowan, 1979). Another patient showed an accompanying Capgras' delusion, the delusion of subjective doubles, and palinopsia (Joseph, 1986). We do not share the conviction that such associations bear great scientific significance; however, to our knowledge, this is the only report of Cotard's delusion with reduplicative paramnesia. This term was used by Pick (1903) to describe the disturbance of a 67-year-old woman with depressed mood, hysterical features and questionable seizures, who held the false belief that she was not in the hospital in Prague, but in another hospital, similar to the one in Prague. Such misidentifications of place are often associated with a neurological deficit. They can be caused by head trauma (Benson et al, 1976), more rarely by strake (Kapur et al, 1988) or other brain diseases. In the 18th and 19th century (perhaps even today) case descriptions gained importance by being published, quoted, translated and incorporated into foreign journals and textbooks. In this case this tradition appears justified for several reasons. The report is a detailed description of delusions which received increased attention more than a century later. It was one of little more than 100 case reports presented and discussed in the first neuropsychiatric journal (Moritz et al, 1783-1793). The combination of reduplicative paramnesia with Cotard's delusion appears of psychopathological interest, even if it may only support the notion that such 'syndromes' are by no means distinct. It suggests that Cotard's delusion can be elicited by organic brain disease, e.g. by stroke. Furthermore, it shows how personality traits and also behavioural mechanisms involving  family and friends, can aggravate disorders of organic origin.