Cotard's syndrome is characterized by the presence of nihilistic delusions. A retrospective case note study of 349 Chinese psychogeriatric patients in Hong Kong showed a prevalence of 0.57% of the syndrome. The two patients identified were both females with major depression. Case vignettes of these patients were presented and the similarity of the clinical features to those described in the Western literature was discussed. ||||| The authors describe the frequency and characteristics of Cotard syndrome among neurological and psychiatric inpatients at a tertiary referral center. All inpatients from the National Institute of Neurology of Mexico (March 2007-May 2009) requiring neuropsychiatric consultation were reviewed. Among 1,321 inpatient consultations, 63.7% had neurological disease and one (0.11%) had viral encephalitis and Cotard syndrome. Of inpatients, 36.2% had pure psychiatric disorders and three (0.62%) had Cotard syndrome, associated with psychotic depression, depersonalization, and penile retraction (koro syndrome). This review discusses potential mechanisms for Cotard syndrome, including the role of a perceptual-emotional dissociation in self-misattribution in the deliré des negations. ||||| Mrs. S is a 28 year old married female who is an illiterate housewife. This patient came to our outpatient department with symptoms of decreased sleep and appetite and lack of interest in her usual household chores. The patient complained that her liver was "putrefying" and her heart was "altogether absent". She also reported that when she walked she could not feel her body and reported that her "stomach was missing". She was 6 months into a pregnancy with her first child. 
 
 Her problems had started after she had left her joint family subsequent to frequent quarrels with her in-laws and had started to live along with her husband in a small rented accommodation. Initially she developed loss of sleep and palpitations and a feeling of loneliness which progressed to loss of interest in her surroundings and her daily household work. She began to have feelings of guilt about herself and felt that she had done something wrong in leaving the joint family. The patient's husband took her to a doctor who described her symptoms as 'vague', diagnosed her as having 'weakness' and prescribed multivitamin tablets. Over the next 6 weeks the patient's symptoms failed to improve. At that point, she consulted another doctor who, after an initial two weeks of unsuccessful treatment for her 'vague' abdominal complaints (missing stomach and putrefying liver), referred her for a surgical consultation. After examining the patient and carrying out various investigations, including ultrasonography and endoscopy, the surgeon continued the previous treatment and added an antibiotic for a week. Within the next 2 weeks the patient visited a faith healer and a practitioner of the Indian system of medicine. After this the patient consulted yet another doctor who referred her for a psychiatric consultation. In the meantime 3 months had passed since she had developed her symptoms. She had previously made an unsuccessful attempt at suicide by taking organophosphorus poison for which treatment included medications and observation. She had been advised to seek psychiatric consultation on discharge but had not complied. One month after the suicide attempt she had again thought of suicide but did not act on these thoughts because of her "fear of God". 
 
 The patient was dressed appropriately and was well groomed. Her speech was coherent and relevant. Her complaints included insomnia, a general loss of interest, lack of concentration and a feeling of hopelessness. She was found tohave depressed mood but would occasionally smile while answering questions related to her symptoms because the "doctors wouldn't believe her". She had partial insight into her symptoms. She was not concerned about her pregnancy and had ambivalent feelings of love and hate towards the unborn child. There was no disorder of content or possession of thought. Physical examination was unremarkable except the patient was anaemic with haemoglobin of 8.5 mg/dl. Other routine investigations, including thyroid function tests, were normal. A CT scan or an MRI was advised by a consultant to rule out any organic problem. The CT was not done because of her pregnancy and the MRI could not be done because of financial reasons. A DSM IV [8] diagnosis of Major Depressive Disorder with Nihilistic Delusions was made. 
 
 ECT was suggested but the patient refused because of the social stigma associated with the procedure. Other possibilities were explored. Initially, the patient was reluctant to take drugs because of her pregnancy. After persistence and a few counselling sessions the patient agreed. The patient could not tolerate fluoxetine 20 mg because of persistent nausea. Escitalopram caused similar problems. Both drugs were discontinued within a week. Tricyclic antidepressants were not prescribed because of the side effects. The patient was put on mirtazapine 15 mg and haloperidol 5 mg. Both of these were increased to 30 mg and 10 mg, respectively, over the next five days. The patient showed remarkable recovery within the next 4 weeks. MADRAS [9] scores came down to 18 from an initial score of 44. Over weeks four to eight the patient's mood and delusions improved. The improvement was sustained for four months and, at the time of writing, was in remission. ||||| Mindscapes is our new column on brain science with a difference: we meet people who live with the world's most mysterious neurological conditions 
 
 David Curtis/Millennium Images) 
 
 Name: Graham 
 
 Condition: Cotard’s syndrome 
 
 “When I was in hospital I kept on telling them that the tablets weren’t going to do me any good ’cause my brain was dead. I lost my sense of smell and taste. I didn’t need to eat, or speak, or do anything. I ended up spending time in the graveyard because that was the closest I could get to death.” 
 
 Nine years ago, Graham woke up and discovered he was dead. 
 
 Advertisement 
 
 He was in the grip of Cotard’s syndrome. People with this rare condition believe that they, or parts of their body, no longer exist. 
 
 For Graham, it was his brain that was dead, and he believed that he had killed it. Suffering from severe depression, he had tried to commit suicide by taking an electrical appliance with him into the bath. 
 
 Eight months later, he told his doctor his brain had died or was, at best, missing. “It’s really hard to explain,” he says. “I just felt like my brain didn’t exist any more. I kept on telling the doctors that the tablets weren’t going to do me any good because I didn’t have a brain. I’d fried it in the bath.” 
 
 Doctors found trying to rationalise with Graham was impossible. Even as he sat there talking, breathing – living – he could not accept that his brain was alive. “I just got annoyed. I didn’t know how I could speak or do anything with no brain, but as far as I was concerned I hadn’t got one.” 
 
 Baffled, they eventually put him in touch with neurologists Adam Zeman at the University of Exeter, UK, and Steven Laureys at the University of Liège in Belgium. 
 
 “It’s the first and only time my secretary has said to me: ‘It’s really important for you to come and speak to this patient because he’s telling me he’s dead,'” says Laureys. 
 
 Limbo state 
 
 “He was a really unusual patient,” says Zeman. Graham’s belief “was a metaphor for how he felt about the world – his experiences no longer moved him. He felt he was in a limbo state caught between life and death”. 
 
 No one knows how common Cotard’s syndrome may be. A study published in 1995 of 349 elderly psychiatric patients in Hong Kong found two with symptoms resembling Cotard’s (General Hospital Psychiatry, DOI: 10.1016/0163-8343(94)00066-M). But with successful and quick treatments for mental states such as depression – the condition from which Cotard’s appears to arise most often – readily available, researchers suspect the syndrome is exceptionally rare today. Most academic work on the syndrome is limited to single case studies like Graham. 
 
 Some people with Cotard’s have reportedly died of starvation, believing they no longer needed to eat. Others have attempted to get rid of their body using acid, which they saw as the only way they could free themselves of being the “walking dead”. 
 
 Graham’s brother and carers made sure he ate, and looked after him. But it was a joyless existence. “I didn’t want to face people. There was no point,” he says, “I didn’t feel pleasure in anything. I used to idolise my car, but I didn’t go near it. All the things I was interested in went away.” 
 
 Even the cigarettes he used to relish no longer gave him a hit. “I lost my sense of smell and my sense of taste. There was no point in eating because I was dead. It was a waste of time speaking as I never had anything to say. I didn’t even really have any thoughts. Everything was meaningless.” 
 
 Low metabolism 
 
 A peek inside Graham’s brain provided Zeman and Laureys with some explanation. They used positron emission tomography to monitor metabolism across his brain. It was the first PET scan ever taken of a person with Cotard’s (Cortex, DOI: 10.1016/j.cortex.2013.03.003). What they found was shocking: metabolic activity across large areas of the frontal and parietal brain regions was so low that it resembled that of someone in a vegetative state. 
 
 Some of these areas form part of what is known as the “default mode network” – a complex system of activity thought to be vital to core consciousness, and our theory of mind. This network is responsible for our ability to recollect the past, to think about ourselves, to create a sense of self and it allows us to realise that we are the agent responsible for an action. 
 
 “I’ve been analysing PET scans for 15 years and I’ve never seen anyone who was on his feet, who was interacting with people, with such an abnormal scan result,” says Laureys. “Graham’s brain function resembles that of someone during anaesthesia or sleep. Seeing this pattern in someone who is awake is quite unique to my knowledge.” 
 
 Graham’s scans could have been affected by the antidepressants he was taking and, as Zeman points out, it is unwise to draw too many conclusions from scans from a single person. But, Zeman says, “It seems plausible that the reduced metabolism was giving him this altered experience of the world, and affecting his ability to reason about it.” 
 
 “There’s many things we don’t know about how to define consciousness,” says Laureys. At the very least, unusual cases such as Graham’s add to our understanding of how the brain creates the perception of self and how it can be impaired. 
 
 For Graham, the brain scans didn’t mean a lot. “I just felt really damn low,” he says. By this time, his teeth had turned black because he could no longer be bothered to brush them, compounding his belief that he was dead. 
 
 Graham says he didn’t really have any thoughts about his future during that time. “I had no other option other than to accept the fact that I had no way to actually die. It was a nightmare.” 
 
 Graveyard haunt 
 
 This feeling prompted him on occasion to visit the local graveyard. “I just felt I might as well stay there. It was the closest I could get to death. The police would come and get me, though, and take me back home.” 
 
 There were some unexplained consequences of the disorder. Graham says he used to have “nice hairy legs”. But after he got Cotard’s, all the hairs fell out. “I looked like a plucked chicken! Saves shaving them I suppose…” 
 
 It’s nice to hear him joke. Over time, and with a lot of psychotherapy and drug treatment, Graham has gradually improved and is no longer in the grip of the disorder. He is now able to live independently. “His Cotard’s has ebbed away and his capacity to take pleasure in life has returned,” says Zeman. 
 
 “I couldn’t say I’m really back to normal, but I feel a lot better now and go out and do things around the house,” says Graham. “I don’t feel that brain-dead any more. Things just feel a bit bizarre sometimes.” And has the experience changed his feeling about death? “I’m not afraid of death,” he says. “But that’s not to do with what happened – we’re all going to die sometime. I’m just lucky to be alive now.” ||||| Zombies are so hot right now that they seem to be everywhere. The Walker hordes are featured heavily on "The Walking Dead," a show that debuted in 2010 and is arguably one of the most popular shows on television. Zombies also make an appearance in video games such as Call of Duty, and people are even pulling zombie apocalypse pranks. Essentially, zombies have become a mainstream way to suspend our disbelief and engage with the land of make-believe. However, they may be walking among us in real life thanks to a rare mental illness called Cotard’s Syndrome. 
 
 People with the condition are known to have any of a number of delusions that range from believing they have no organs, blood or body parts to insisting they are actually dead even though they are very much still breathing. In even more rare cases of what is also known as walking corpse syndrome, people with the condition consider themselves immortal. Although walking corpse syndrome is considered extremely rare, its exact prevalence is unknown. One Hong Kong study involving 349 psychogeriatric patients suggests the condition afflicts about 0.57 percent of the population. Another study conducted in Mexico in 2010, which involved 1,321 patients, found that 0.62 percent of the population had the rare mental health disorder. Perhaps unsurprisingly, this syndrome is often found in people with mood or psychotic disorders and medical conditions. 
 
 Cotard’s syndrome was first described by (and later named after) French neurologist Jules Cotard in 1880, Psychology Today reported. Cotard had a patient nicknamed Mademoiselle X who claimed she was missing several body parts and organs, including brain, chest, stomach and intestines. She also believed she was “eternally damned.” Given she denied having innards, Mademoiselle X didn’t see a need to eat, and soon died of starvation. Cotard said the condition was a form of delusion associated with severe depression, “marked psychomotor retardation, presence of anxiety symptoms and other depressive symptoms,” researchers said. 
 
 A more recent case of the condition involved a man named Graham who has been living with walking corpse for at least nine years. His condition emerged after he struggled with severe depression. Eight months after attempting to commit suicide by taking an electrical appliance with him into the bathtub, he told doctors he believed his brain was dead or missing, Medical Daily previously reported. 
 
 Symptoms of walking corpse syndrome can vary greatly. However, researcher Yamada Katsuragi and his colleagues published a longitudinal study in 1999 suggesting that the syndrome seems to have three stages: germination, blooming and chronic. 
 
 The germination stage is marked by hypochondriasis, or health anxiety, and severe depression. They may go to the doctor with vague complaints, as was the case with a 28-year-old housewife whom researchers refer to as Ms. S. A case report shows she went to an outpatient department complaining that her liver was “putrefying” or decaying and that her heart was “altogether absent.” 
 
 Before seeking medical help, Ms. S initially developed loss of sleep and a feeling of loneliness which are said to have progressed to loss of interest in her surroundings and daily household work — both classic signs of depression. This withdrawal is common among people who are severely depressed and could represent the germination stage of the syndrome for Ms. S. Graham also suffered from severe depression, as do many people with the condition. 
 
 The blooming stage is known as the time patients develop hallmark symptoms of walking corpse syndrome, such as denying they have certain body parts or that they even exist. These symptoms worsen in severity during the chronic stage and interfere with patients’ ability to go about their daily lives. They are known to begin to neglect their own hygiene and self-care, to harm themselves, and fail to recognize their own faces as well as those of others. 
 
 via GIPHY 
 
 For example, Graham, who no longer believed he had a brain or head, refused to eat, lost interest in smoking and being social because he saw “no point because I was dead.” Graham also made frequent visits to his local cemetery because he said “it was the closest I could come to death” and thought he would fit in there. "I didn't want to face people," he told the New Scientist magazine. "There was no point. I didn't feel pleasure in anything. I used to idolize my car, but I didn't go near it. All the things I was interested in went away." 
 
 Graham became the first person with walking corpse syndrome to undergo a brain scan. Doctors found activity levels in large areas of his frontal and parietal brain — areas involved in motor function, memory, and sensory information — were extremely low, resembling someone in a vegetative state. 
 
 “I’ve been analyzing PET scans for 15 years and I’ve never seen anyone who was on his feet, who was interacting with people, with such an abnormal scan result,” neurologist Steven Laurey, at the University of Liege in Belgium, told The New Scientist. “Graham’s brain function resembles that of someone during anaesthesia or sleep. Seeing this pattern in someone who is awake is quite unique to my knowledge.” 
 
 In addition, Scientific American attributes the failure to recognize people's faces to misfiring in the amygdala area of the brain. This may also explain why some people with this condition don’t believe they exist, because not recognizing one’s own face “can lead to a lack of association between their reflections or projected self and their own sense of self, leading to a belief that one doesn’t exist,” Scientific American reported. 
 
 Therapy along with antidepressants and antipsychotics have been shown to help control the symptoms as well as electroconvulsive treatment. In fact, a 2008 case report claims most cases of walking corpse syndrome are more responsive to electroconvulsive treatment than to pharmacological treatment. However, more research needs to be done on this condition because scientists are still in the dark about the cause of this disease and how to treat it.
– Worry about your health at times? Well, at least you don't believe you have no body parts, blood, or organs, or consider yourself dead or immortal. Yet those are among the beliefs plaguing people with Cotard’s syndrome, an illness discovered in 1880 that's extremely rare and awful when it strikes, Medical Daily reports. In case you doubt it, there are two studies (here and here) that found a .57% and .62% rate of Cotard's, respectively, in large groups of psychiatric patients. Researchers say the condition—also known as "walking corpse syndrome"—often begins with severe depression and a health anxiety that can inspire odd complaints. One 28-year-old woman, for instance, told hospital staff that her stomach was missing and her liver was "putrefying." The report on her case notes that the syndrome generally affects those in middle-age or later years, but when young people are diagnosed, they are overwhelmingly (90%) female. Over time, patients may believe they don't exist or lack body parts, which can trigger a slew of problems including poor hygiene, self-harm, and a refusal to eat. "There was no point in eating because I was dead," a sufferer identified as Graham told New Scientist in 2013. He was the first Cotard's patient to get a brain scan, and a neurologist likened the brain function the scan showed to "that of someone during anesthesia or sleep." Experts say antidepressants and antipsychotics can help, along with shock therapy, which may explain the low rate of Cotard's today. Drugs and psychotherapy worked so well for Graham that he was able to live on his own. "I don't feel that brain-dead anymore," he says. "Things just feel a bit bizarre sometimes." (See which US states have the most mental illness.)