Hektoen International

A Journal of Medical Humanities

Delusions of being and nothingness

Jesús Ramírez-Bermúdez
Mexico City, Mexico


Emil Cioran and his long-lost friends. Augustin Ramirez
Bermudez. Jesus Ramirez Bermudez Private Collection

In the late nineteenth century, the French physician Jules Cotard described patients with a delusional denial of bodily organs, self-existence, and the world. The woman originally described “believed that she had no brain, nerves, chest, or bowels, and that she was only skin and bone. God and the devil did not exist; she was eternal and would live forever.”1 In Cotard syndrome, patients often declare to be dead, but this may also be the pathology of immortality. When reason is demolished by illness, disturbing paradoxes arise: the pain of being eternal leads to suicidality.

Marcel Proust’s father was a medical school classmate of Jules Cotard. This relationship perhaps influenced the construction of Doctor Cottard, a character appearing in Proust’s masterpiece In Search of Lost Time, where he is depicted as a trustworthy physician of excessive timidity and affability.2 Beyond fiction, Cotard became a military surgeon at the outbreak of the Franco-Prussian war in 1870 and trained with the father of neurology, Jean-Martin Charcot. Cotard had a strong interest in philosophy from his friendship with the remarkable thinker Auguste Comte; he even wrote a book, still unpublished, about a path to collective development, embracing science and natural ethics.3 Perhaps Cotard’s philosophical concerns influenced the conception of a syndrome that is close to literary imagination and existential meditations about the self. His intellectual career was interrupted when he died of diphtheria at the age of forty-nine while nursing his ill daughter.

In 1882, Cotard published his Studies on Mental and Brain Disease, describing severe forms of a clinical entity that had been called melancholia since Greek antiquity. Chapter VI deals with nihilistic delusions. From his point of view, the essence of this phenomenon was extreme negativism: denial as human condition. The syndrome, however, appeared as a conceptual bridge between psychiatry and neurology, as some patients had nihilistic delusions in the context of infectious brain disease. With these words, Cotard discusses a case of neurosyphilis: “Ask them their name: they have no name; their age? They have no age. Where they were born? They were not born; their father, and their mother? They have neither, nor mother, nor wife, nor children; whether they have a headache, a stomach ache, pain at some point in their body? They have no head, no stomach, some even have no body; show them some object, a flower, a rose, they replay: that is not a flower, that is not a rose.”1

Cotard called this syndrome délire de negations. According to his patients, the world had come to an end and they were dead, but some would confess a belief in being immortal. Even nowadays, some nihilistic patients will attempt suicide if they feel it is impossible to die. A brilliant internist stopped eating and drinking because he thought he was trapped between life and death. He did not understand why the other physicians could not see the laboratory results showing he had a fatal kidney injury: he was “a terminal patient, an automaton.”4 “In eternity,” he told me after recovering, “there is no before or after, there are no causes or hazards, there can be no free will, which would imply a notion of causality and time.”

In his General Psychopathology, the psychiatrist and philosopher Karl Jaspers presents the problem of metaphysical delusions: irrational, incorrigible concepts regarding the nature of time, space, and reality. Nihilistic delusions often take this form or may be conceived as existential delusions. According to historical records, 69% of the patients with Cotard syndrome deny their own existence.5 This confronts our basic common-sense assumptions. Jaspers emphasized that delusions go beyond comprehension at the interpersonal level, because “we cannot imagine experiental forms that are totally strange to us.”6 Literature allows us to imagine the perspective of other human beings and to develop our metacognitive abilities: the awareness and analysis of our own mental states. Could creative writing also help establish a bridge of understanding between everyday assumptions and the marginal experiences of nihilistic delusions?

In the essay “Fall from time,” the Romanian writer Emil Cioran describes an experience of abolished temporality. Through books such as Syllogisms of Bitterness, That Damn Me, Breviary of Rottenness, and The Trouble with Being Born, Cioran undertakes a philosophical inquiry into suicidal ideation, desolation, and insomnia. In The Fall into Time (1964), Cioran regrets the mythological descent of humanity from an eternity above. In Fall from Time (1986), however, he exposes the details of a second fall: this accident takes the self away from the dimension of time, towards an eternity located beneath reality. According to his writing, “Hell is the present that does not move, the tension inside monotony, the eternity turned upside down that does not open to anything, not even to death; while time, which flowed and revealed itself, offered at least the consolation of a wait, even if it was funereal. But what to expect here, at the lower limit of the fall where it is no longer possible to fall again, where I miss even the hope of another abyss?“7

Cioran finds a language to describe a marginal state of consciousness. The feeling of slow temporality is a feature of melancholic depression, related to thought inhibition and slowing in cognitive performance. Many patients find it difficult to express this painful experience, as they suffer from alexithymia, the lack of capacity to verbalize emotions. At times, writers and clinicians must do the job of putting the suffering into words. Cotard recognized states of anxious melancholia behind the délire des négations. This was observed also by German neuropsychiatrists. In his Treatise on Psychiatry, Emil Kraepelin reported on patients with melancholia gravis who had descended into delusional nihilism: “The patient no longer has a name or a home, he has not been born, he is no longer a human being. He cannot live or die; he is as old as the earth. If you hit his head with an axe, you cannot kill him. ‘I can no longer be buried,’ one patient said, ‘if I weigh in the balance, the result is zero!’ The world has come to an end; there are no railroads, no cities, no money, there are no beds or doctors; the sea is emptying. All people are dead, burned, or have perished because of hunger, because there is nothing left to eat.”8

Cioran’s words are reminiscent of the description of melancholic delusions by Cotard: “the idea of ​​immortality in these patients, paradoxical as it may seem, is nothing more or less than a hypochondriac idea; it is a painful delusion concerning the organism; they lament their immortality and beg to be delivered from it.”9 Metaphysical delusions appear: “the whole body is reduced to an appearance, a simulacrum.” Some patients believe they will not die because their body is not in the ordinary condition of organization; they are in a state that is neither life nor death; they are undead.

A narrator of futuristic eccentricities, the American writer Philip K. Dick explores the death of consciousness through fiction. In the vague future of Ubik (1969), a novel closer to metaphysical narrative than to science fiction, a millionaire must consult his wife about economic decisions for his company. But she had been a victim of a fatal disease years before. Swiss technology managed, however, to build a response to the burden of human death: a person can be kept in a state of half-life, immobile, technically dead by most parameters, but with brain activity above the electric silence. An electronic device allows the client to interact with his wife, who is increasingly distant, indifferent, and amnesic regarding her vital past; she hardly remembers her husband and almost does not understand what he tells her. She speaks instead about the prolonged, imprecise events of her passing towards the unknowable border of death. There are baffling differences in the order of things. In a famous scene there is a regression of everyday objects: where a twenty-first century airplane used to be, a biplane from the Second World War appears; where once was a condominium of fifty floors, is now an old Victorian house. There is an ontological instability in the landscape of the half-lifers, which penetrates the basic structure of bodies and objects. The world of half-life is not at peace, but full of agony: the anguish of an imminent loss of the self through a persistent regression towards non-being.

By means of introspective writing and imagination, literary work brings into culture an exploration of consciousness under radical conditions: the abolition of temporality, or the loss of ontological stability. Could these topics be developed as conceptual frameworks, or even operationalized as scientific hypothesis? The artistic bridge takes us close to the mental state of patients with nihilistic delusions. Is it worth exploring this frontier of humanness by means of creative writing? While science may bring a psychobiological explanation of delusions, artistic language promotes what is lacking in delusional discourse: a renewed awareness and reflection on the limits of our own mental states, which may help us understand the suffering of those who stand beyond reason.



  1. Cotard J. Studies on cerebral and mental diseases. VI.-On nihilistic delusion (1882). In: Cousin FR, Garrabé J MD, ed. Anthology of French Language Psychiatric Texts. Paris: Institut d’edition, Sanofi-synthelabo; 1999.
  2. Pearn J. A biographical note on Marcel Proust’s Professor Cottard. J Med Biogr. 2003;11(2):103-106. doi:10.1177/096777200301100212.
  3. Pearn J, Gardner-Thorpe C. Jules Cotard (1840-1889): His life and the unique syndrome which bears his name. Neurology. 2012;58(9):1400-1403. doi:10.1212/wnl.58.9.1400.
  4. Ramirez-Bermudez J, Aguilar-Venegas LC, Crail-Melendez D, Espinola-Nadurille M, Nente F, Mendez MF. Cotard syndrome in neurological and psychiatric patients. J Neuropsychiatry Clin Neurosci. 2010;22(4). doi:10.1176/appi.neuropsych.22.4.409.
  5. Berrios GE, Luque R. Cotard’s syndrome: analysis of 100 cases. Acta Psychiatr Scand. 1995;91(3):185-188. doi:10.1111/j.1600-0447.1995.tb09764.x.
  6. Jaspers K. General Psychopathology. Baltimore: John Hopkins University Press; 1997.
  7. Cioran E. Contra La Historia. Barcelona: Tusquets Editores; 1976.
  8. Kraepelin E. La Locura Maniaco-Depresiva. Madrid: La biblioteca de los Alienistas del Pisuerga. Ergon; 2013.
  9. Cotard J, Seglas J. Delirios Melancólicos: Negación y Enormidad. Madrid: Ergon; 2009.



JESUS RAMIEREZ-BERMUDEZ, MD, PhD, (Mexico, 1973) is a clinical neuropsychiatrist and researcher at the National Institute of Neurology and Neurosurgery of Mexico. He has published many scientific papers in neurological and psychiatric peer-reviewed journals. He received Research Awards from the International Neuropsychiatric Association (Sydney, 2006), and the International Society for Bipolar Disorders (Pittsburgh, 2011). He is the author of Paramnesia (novel, 2006) and the literary essays Brief clinical dictionary of the soul (2010), and A dictionary without words (2016). He won the National Literary Essay Prize in Mexico in 2009, with The Last Witness to Creation.


Highlighted in Frontispiece Volume 11, Issue 4 – Fall 2019
Spring 2019  |  Sections  |  Psychiatry & Psychology

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