Preamble: The Boston Globe published a Spotlight Series called The Taking of Cell 15 alleging how dysfunctional and secretive the Department of Corrections here in Massachusetts has become. The story was reported by Mark Arsenault, Matt Rocheleau, and Spotlight editor Patricia Wen. The piece published on August 14 2022 in the Boston Globe Spotlight Series shines a light on the perceived secrecy that exists within the Department of Corrections and illustrates just how difficult it is for inmates to get fair treatment and defense against correctional department abuse and supposed secrecy in its methods. But I am not writing about the current day Department of Corrections and have great respect for anyone who walks the walk. According to Boston Globe reporting, “between Jan. 10 and March 1, 2020, men incarcerated at Souza lodged 118 allegations of excessive force by officers, according to Prisoners’ Legal Services of Massachusetts, a nonprofit organization that aids and advocates for incarcerated people.” Many of these have not been adjudicated by the DOR and many have been unfounded.

This post is all about Cotard’s Syndrome first identified in 1880 in a female patient. It is a distinct delusional disorder that is manifest by a fixed belief that one has died or has organs in her body that are rotting or have been removed. The walking corpse named for Jules Cotard who first described this delirium of negation. I am working with a retired correction officer (called ‘CO’) who was a supervisor. He has PTSD that was diagnosed in 2020. It is quite poorly controlled and he receives no therapy or medication for its management. CO was admitted to our hospital after becoming debilitated by kidney disease. He receives hemodialysis (HD) three times weekly. He sometimes falls asleep during HD and has flashback images of people being beheaded. Part of his delusion is a belief that he has been “embalmed”. His 21 years as a correction officer and supervisor are firmly embedded in his psyche and this has left him estranged from his wife and 3 of his 4 children. The flashbacks manifest as tortured sleep and daytime trance-like visions. All triggering his fight-flight response and memories of bearing witness to dozens traumatic events while serving the people of Massachusetts. He sometimes fights violently upon awakening. These experiences still linger now 9 years after his retirement from a maximum security prison. Almost every correctional officer experiences similar traumatic events during their career, but many never get psychological help to deal with PTSD.

CO has very unusual thinking when particularly tired or stressed. These come to him during sleep in the first half of the night. He was diagnosed only 2 years ago, even though he has not been on the inside for 9 years. There has been no consistent therapy offered CO since his diagnosis from what I learned. He has dozens of traumatic experiences most of which have gone untreated. The description of his experience is similar to those recently reported by the Globe in the Spotlight Series, particularly chaotic and violent. As we became more acquainted his war stories streamed from one ghastly story to the next until he gradually grew fatigued and sometimes tearful. He was never disrespectful when speaking about the inmates he watched and shared some regret he could not help them.

He told me the story of a member of his team who killed himself with a shotgun at the start of his shift. He was in his prized Camaro that he had rebuilt. “He loved that car,” CO added, now entranced. In most cases, law enforcement and correction officers alike would undergo debriefing when officers are exposed to a particularly gruesome death scene. Debriefing was rare following inmate deaths years ago. Officers were expected to handle it and move on. But after an officer killed himself in the parking lot men were given the chance to talk. CO was on the front line of this incident and saw the aftermath. The victim was a friend. Members could not comprehend his reason for shooting himself, where as he loved that car so much. “There were a lot of tears after that one” said CO. This may have been a trigger for CO developing a rare psychiatric disorder that would follow him into retirement.

Slowly, under watchful eyes, the victim was taken from the car and brought back into the facility until the Commonwealth medical examiner could get there from Worcester to retrieve the remains. Members gave a salute as he moved to the medical facility as we have seen with other first responders after the death of one of their own. Meanwhile, life went on inside the prison. No time for whining about losing a friend – it did not matter that he was in his buffed out Camaro. He loved that car and it would be part of his final plan.

Cotard’s Delusion is a rare condition marked by the false belief that you are walking dead or your body parts are dead, dying, or don’t exist. It is rare and not even listed among the common ICD-10 psychiatric conditions. The Cotard’s idiosyncratic beliefs often evolve from existing obsessive compulsive (OCD) thinking on steroids. It also may occur with severe depression and some psychotic disorders. I was trained to think that walking corpse was usually associated with borderline personality disorder, hypochondriasis, or somatization disorder. You might also hear it referred to as walking corpse syndrome, Cotard’s syndrome, or nihilistic delusions.

In the case of CO, a 57-year-old male has a history of unstable PTSD as a result of his 21 years of service at a maximum security prison here in Massachusetts. He is cooperative and likable in a slow matter-of-fact kind of way. His speech is slow and thoughtful. During this time he experienced physical attacks over 5 times – one of which kept him out of work for 10 months. He witnessed over 100 prisoner hangings – deaths by suicide that required a special team response. He was a supervisor and was responsible for the extraction teams comprised of officers who deal with the most violent offenders. He admitted with pride that he was always the first man at the scene. He witnessed men who had cut their own throats and watched them die before the entry team could assemble and make the save. He witnessed vicious fights among competing prison factions that were sometimes merciless and deadly.

These experiences followed him into retirement and invade his sleep regularly even now. He says poor sleep is his primary problem. He seems tired whenever we speak. He is careful to warn me about waking him up. Sometimes when awakened he experiences a threat as if someone was trying to hurt or kill him. He even warned our nursing staff and me to be careful when awakening him. CO sometimes awakens trying to kick out or defend himself as if he was under attack. His level of arousal was trigger sharp and he once almost pushed his granddaughter out a window when she tried to get him up. He is ashamed that his wife is afraid of him and lives out of state. They talk on the phone daily while he is in our hospital. He does not get many visitors.

That is CO’s cross to bear. In fact, he sleeps only 2 hours at a time, awakened by dark and scary images of his own death and his embalming. He dreams of people being decapitated and of planes crashing. When awake, he walks the house checking doors – just as he did on the block during his time on the job. For his part, he is strongly conflicted about his role in the prison. As a Christian, he believes in his heart, that he could help many inmates – some of whom went on to take their own lives. He was trained in peer support and crisis intervention skills he often could not utilize. As a supervisor CO could not turn the other cheek when inmate brutality threatened officer safety. Correction officers are often seen as the last first-responders and are rarely debriefed following inmate deaths, personal attacks, or violence toward officers.

Cotard’s syndrome is characterized by nihilistic delusions focused on the individual’s body including loss of body parts, being dead, or not existing at all. Cotard’s is neither mentioned in DSM-V nor in ICD-10 – both diagnostic tools made for identifying nervous and mental disorders. There is growing unanimity that Cotard’s syndrome with its typical nihilistic delusions represents some underlying behavioral health disorder. Organic causes should be ruled out as an etiology before attribution of Cotard’s syndrome as a fully psychological problem. Some papers are cited in the literature that suggest several typologies may underlie the outward presentation of walking corpse. The most common is a syndrome associated with major depression and its symptomatology including: melancholia, nihilism, and psychotic features. There is a literature suggesting a preference for ECT when treating walking corpse. A slightly different nosology abnegates depression and aligns it more closely with delusional thinking and not primarily associated with affective disorder. There is some association with on-going hemodialysis as a source of the unique delusions due to its associated similarity with blood being removed form the body. CO was discharged to a lower level facility because he lived alone and still needed help. He called me once after discharge to cancel out follow-up. I know he was looking forward to the wedding of his daughter, the youngest of 4 children. He smiled as he imagined them dancing together at her wedding. She seemed to be his favorite.

Debruyne, Hans & Portzky, Michael & Peremans, Kathelijne & Audenaert, Kurt. (2011). Cotard’s syndrome. Mind & Brain, The Journal of Psychiatry. 2. 67-72.

Fabrazzano, M, et al. (2020) A hypothesis on Cotard’s syndrome as an evolution of obsessive-compulsive disorder, Oct, International Review of Psychiatry 33(2):1-6 DOI:  10.1080/09540261.2020.1810425

Debruyen, H, et al. (2011) Cotard Syndrome.