"On nihilistic Delusión" "Du délire des négations" "El delirio melancólico" Síndrome de Cotard.
Tema I. Lecciones de psicopatología y fenomenología. La melancolía.
Psychopathology and phenomenoolgy: The melancholy.
Melancolía: Antoine Porot Nosología. Análisis histórico de concepto de "melancolía" .
Historia de la melancolía y de la depresión. (S. W. Jackson)
- Sentimientos y estados afectivos Según Karl Jaspers ( Psicopatología General.).
-La melancolía. Giné y Partagas, Tratado de Frenopatología, Capítulo XXIII.
La melancolía de Kraepelin. (Se adjunta resumen crítico de texto completo).
Estados depresivos y crisis de melancolía. Según H. Ey.
Psicopatología del humor. A. Sims Symptoms in the Mind.
Dear colleagues , Alienists , psychopathologists , lovers of the clinic, and psychiatric symptomatology .
I present the beautiful work of J. Cotard , his delusional psychotic melancholy, his anxious melancholy, hypochondria , ..
and his famous text " nihilistic delusion" .
Serve as a tribute to Cotard patients , which still excite us with his melancholy suffering.
A classic unforgettable .
This will never find in the DSM - 5
Reseña histórica y homenaje a Jules Cotard.
-Nacido en Issoudun (Indre) en 1840. Estudió Medicina en París y fue discípulo de Charcot y de Vulpian.
-Tesís doctoral sobre: “Étude sur l´atrophie partielle du cerveau”. A través de Lassegue fue colaborador de Falret quien dirigía le manicomio de Vanves.
-En 1880 presenta: “Délire hypocondriaque dans une forme grave de la mélancolie anxieuse”.
- En 1882 y 1884, publica en Archives de neurologie : « Du délire des négations » y « Du délire d´énormité » en Annales médico-psychologiques.
- En 1889 el artículo : « L´Hypocondrie » del Diccionnaire Dechambre.-
- En 1889 murió en el propio psiquiátrico de Vanves de difteria.
- En 1891 aparece su obra póstuma, prologada por Jules Falret: “Études sur les maladies cérébrales y mentales”.
- Recordar también a su hijo Lucien Cotard, nacido en el manicomio de Vanves, quién fue interno de Fére y Seglas, autor en 1908 de su tesis: “Étude sémiologique sur le psittacisme” (psitacismo, ecolalia), muerto en 1910 siendo adjunto del asilo de Dijon.
Ver: Historia de la psiquiatría. . « Nouvelle histoire de la psyquiatrie »
de : Jacques Postet y Claude Quétel. Ed. F.C.E. de Mexico. Año 1983.
- Cotard (J.). "Etude sur les maladies cérébrales et mentales" [Study on cerebral and mental diseases], Preface by Jules Falret. Paris, Bailliére et fils, 1891.
- COTARD J., CAMUSET U., SÉGLAS U. " Du délire des negations aux idées dénormité" [From delusion of negations to ideas of enormity] preface by J.‑P. Tachon, Paris, L'Harmattan, 1997.
- BOURGEOIS M. "Le syndrome de Cotard aujourd'hui". [Cotard's syndrome today], Annales médico‑psychologiques, 1964, p. 534‑544.
- CZERMAK M., "Signification psychanalytique du syndrome de Cotard» [Psychoanalytical significance of Cotard's syndrome], in Passions de l'objet , Paris,
- TREMINE T. "1880‑1980: centenaire du syndrome de Cotard” [Centenary of Cotard's syndrome) L´Evolutíon psychiatrique, 1982, 47, p. 1021‑1032.
Jules Cotard (1840‑1889)
Studies on Cerebral and Mental Diseases
"ON NIHILISTIC DELUSION" 1882
ver texto original, traducción al inglés. Anotaciones de J. L. Día.
**sólo para estudio fenomenológico en el curso de lecciones de psicopatología.
- "The important paper in which Lassegue, in 1852, separated persecutory delusion from the diverse forms of melancholia, was a point of departure for complementary works which made this form of derangement one of those best known in its symptoms, in its progression and in its outcome.
In 1852 he described persecutory delusions and their evolution. In 1873 he described hysterical anorexia, and in 1877 he introduced and described with Jules Falret the concept of “folie à deux,” fully describing the psychological mechanisms (1). This term continues to be employed to this day in the international psychiatric vocabulary.
Corraze J: Charles Lasègue: de la folie à deux à l’hystérie et autres états. Paris, L’Harmattan, 1998
- We need do no more than recall the names of Lassegue, of Morel, of Foville and Legrand de Saulle, and in particular that of M. J. Falret who presented to the Société médico‑psychologique the fullest possible picture of the successive phases and of the evolution of that disease.
- As regards the other varieties of melancholic delusion, our knowledge falls far short of this relative perfection. Simple melancholia, melancholia with stupor, anxious melancholia have been described with care; it is known that these forms are often intermittent, that they sometimes become continuous and finally chronic, but the characteristics and the successive phases of the delusion which culminate in this chronicity have not, to my knowledge, formed the subject of any study equivalent to that which has been done for persecutory delusion.
I propose, in this paper, to describe a particular delusional evolution, which seems to me to be characteristic of a considerable number of these non‑persecuted melancholics, more particularly those who are anxious, and to be based above all on negative dispositions which are very habitual in these patients.
Generally, the deranged are negators: the clearest of demonstrations, the most authoritative of affirmations, the most affectionate of assurances, leave them incredulous or ironic. Reality has become to them foreign or hostile. But this negative disposition is particularly marked in certain melancholics, as has been remarked by Grieseinger.
«... it seems to the patient that the real world has completely vanished, has disappeared or is dead and that there remains nothing more than an imaginary world in the midst of which he exists in torment.»
- I propose the name nihilistic delusion… to designate the state of those patients to whom Griesinger alludes in these lines and in whom the negative disposition is carried to the highest degree. 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 father, 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 reply: that is not a flower, that is not a rose. In some, the negation is universal, everything has ceased to exist, they themselves have ceased to exist.
These same patients who deny everything, also oppose everything, resist everything that they are called upon to do. Certain madmen, says Guislain, present an opposition which it is impossible to conceive when one has not seen them closely. It requires the greatest efforts to persuade them to change their linen, they refuse to go, to bed, refuse again to rise, are opposed to everything they are asked. This is the madness of opposition.
In this madness of opposition, Guislain –ver trabajo de Giné y Partagas- includes mutism, the refusal to eat and that singular disposition of certain deranged persons who force themselves to retain their urines and their excrement. However, he does not refer to nihilistic delusion, of which the madness of opposition is, so to speak, simply the moral aspect. The same is true of most: of the authors and it seems strange that so marked an intellectual lesion has not attracted more attention. Even the cases where the fact is simply described, are rare. Only the hypochondriac form of the nihilistic delusion has been commonly observed since the work of M. Baillarger.
It is in Leuret –ver tratamiento moral de la locura.- that I find the most characteristic observation. Below is a summary of the questioning process.
François Leuret "Du traitement moral de la folie" Chez J.-B. Baillière, 1840.
"El tratamiento moral de la locura". Ed. Asoc. Esp. Neuropsiquiatria. 2001
‑ How are you, mistress?
‑The person of myself is not married, call me Miss, please.
‑ I do not know your name, would you tell me?
‑The person of myself has no name: she wishes you not to write it.
‑ I would nevertheless like to know what you are called or rather what you were formerly called.
‑I understand what you mean. It was Catherine X....,we must no longer speak of what took place. The person of myself has lost her name, she gave it away on entering the Salpêtrière.
‑ How old are you?
‑The person of myself has no age.
‑ Are your parents still living?
‑The person of myself is alone, very alone, she has no parents, nor ever had.
‑ What have you done and what has happened to you since you have been the person of yourself?
‑The person of myself lived in the asylum of ... Physical and metaphysical experiments were performed on her and continue to be performed. This work was not known to her before 1827. There is an invisible being descending, she has come to unite her voice with mine.
Leuret's patient presented, in addition to the most marked nihilistic delusion, numerous hallucinations: she was tormented by invisible beings, by physics and metaphysics, in short, she manifested symptoms of persecutory delusion. Complex cases where, as here, the two delusions coexist, are not rare; I will provide examples of them later. Usually, however, these two forms of delusion are observed in isolation in different patients.
The true persecuted individual passes through all the phases of his delusion, from the hypochondria of the beginning to megalomania, without his negative dispositions exceeding that which is commonly observed in the deranged; he denies out of mistrust, out of fear of being deceived, or else because he is entirely dominated by his delusional conceptions and his hallucinations, and has therefore come to live in an ¡imaginary world, but his negative dispositions are quite different from the systematised nihilism of which 1 wish to speak here.
In general, the persecuted present neither the profound depression, nor the groaning anxiety of the true melancholics; there does not seem to be in them that profound disorder of the moral sensibility, which Griesinger considers to be the fundamental element of melancholia. It is on this terrain, however, after a variable period and following a particular delusional process, that systematised nihilism seems to develop. However, it is not unusual, in states of advanced chronicity, for the nihilistic delusion to continue, so to speak, beyond the general early disorders, and for patients, like that of Leuret, no longer to present either apparent depression or anxious agitation.
I have just identified the dual origin of nihilistic delusion as melancholia with depression or stupor, and agitated or anxious melancholia. However different these two forms of melancholia may be in their external manifestations, one cannot but recognise their delusional similarities, similarities which are particularly striking in cases where the depression and the anxious agitation succeed each other or alternate in a single patient, without significant alteration to the delusion.
These forms are dominated by anxiety (according to Griesinger, a frightful internal anxiety constitutes the fundamental state of melancholia with stupor), fears, imaginary terrors, delusions of guilt, of perdition and of damnation; patients blame themselves, they are incapable, unworthy, they bring misfortune and shame on their families; they will be arrested, condemned to death; they are to be burnt or cut into pieces.
These fears of imprisonment, of condemnation and of torture should not, - as M. J. Falret has often remarked- , be confused with true persecutory delusion, which is relatively rare in patients of this type. Quite other than the persecuted, they blame themselves; if they are to undergo the ultimate penalty, that is only just, they deserve no less for their crimes.
From this point of view, two main classes of melancholics can be distinguished: those who blame themselves and those who blame the outside world and above all their social sphere. The latter are the persecuted, previously described by Guislain as the accusatory insane.
This division of the melancholics largely corresponds to the division into melancholia with general disorder of the intelligence and into sad monomania (Baillarger), and to the division into general lypemania and partial 1ypemania (Foville).
The true melancholics blame themselves, while the sad monomaniacs blame others. However, it is not unusual to see, on the one hand, the persecuted adopt, during a paroxysm, the characteristics of general, depressed or anxious melancholia; and on the other hand, the melancholics with delusions of guilt, having reached a fairly advanced period of their disease, adopt the physiognomy of the sad monomaniacs.
No doubt, behind these external manifestations, which vary from stupor to anxious, quasi‑maniac agitation, there exist more profound morbid dispositions in which resides the essential difference between the persecuted and the other melancholics.
Perhaps it is in the tendencies of patients, which I mentioned earlier, either to blame themselves, or to blame others, that we shouted seek the most immediate manifestation of those intimate dispositions which constitute the true ground of the disease.
These tendencies often exist many years before the obvious emergence of the delusion; to a very attenuated degree they are encountered in many men of sound mind, amongst whom they form, two quite distinct categories.
Long before they become truly deranged, the persecuted are suspicious and distrustful, more severe with regard to others than to themselves; likewise, certain anxious persons, long before they experience a clear attack of insanity, are scrupulous, diffident, self‑effacing, more severe in their own regard than in that of others.
I stress this division of the melancholic delusions, which have been confused by most authors. Marcé (citado por J. Seglás ) seems implicitly to acknowledge it; he describes, in true melancholia, originally only the delusions of ruin, of guilt, etc., indicates the subsequent hypochondriac delusion and assigns the persecutory delusions to monomania; however, he does not otherwise emphasise this distinction, which anyway appears too absolute, since certain persecuted individuals present the characteristics of true melancholia and other patients with delusions of ruin and guilt resemble the monomaniacs.
Jules Seglás: De la Melancolía sin delirio1 . Melancholy without delusion. Rev. Asoc. Esp. Neuropsiq. v.26 n.2 Madrid 2006 (traducción de: H. Astudillo del Valle)
Let us now examine by what evolution of delusion the self‑accusing melancholics arrive at nihilistic delusion:
In their most attenuated form, these characteristics are those of the variety of melancholia described by the names simple melancholia or melancholia without delusion and, more exactly, by the name moral hypochondria, by M. J. Falret, who has described it with meticulous precision.
Jean-Pierre Falret (1822) De l'Hypochondrie et du suicide (hypochondria involved a moral weakness and declared that it is primarily a mental disorder)
The so‑called melancholics without delusion in fact: suffer from a sad delusion affecting the state of their moral and intellectual faculties, and which already exhibits a marked negative form.
- "They feel shame or even horror at their own person and despair at the thought that they will never be able to recover their lost faculties ...
- "They regret their vanished intelligence, their extinguished feelings, their faded energy"
- "They claim to have no heart, no affection for their relatives and their friends, nor even for their children:"
Delusions of ruin appear often, and seem to be negative delusions of the same nature: at the same time as his moral and intellectual riches, the patient believes himself to have lost his material fortune; he has nothing which constitutes human pride, neither intelligence, nor energy, nor fortune.
It is the opposite of the delusion of grandeur where the patient claims immense riches together with every talent and every ability. This moral hypochondria is based in the common ground of melancholia and in a state of vague and indeterminate anxiety;
«patients feel that all has changed both within them and outside, and are distressed no longer to perceive things through the same prism as formerly." J.P.. Falret.)
In these mild cases, it is already as if there existed a veil through which the patients perceive reality only in a confused manner; everything seems transformed. As the morbid state becomes more intense, this veil becomes thicker and, in cases of stupor, comes completely to mask the real world. The patient is then, as M. Baillarger has justly pointed out, close to the dream state.
Not only from this point of view, but in every respect, there seems to be nothing but a difference of degree between these states of moral hypochondria and melancholic disorders with delusions of guilt, ruin, damnation and systematised negation.
Moral hypochondria is a sketch; by simply accentuating the outlines and deepening the shadows, the picture of these latter forms of melancholia can be completed.
Self‑disgust culminates in the delusion of guilt and damnation, fears become terrors; external reality, transformed and confusedly perceived, is finally denied.
Certain forms of nihilism may even appear very early in the moral hypochondriacs; they deny the possibility of cure, of any relief for their suffering; this is one of the first negations of these patients, some of whom will later go so far as to deny the external world and their own existence.
It is important to make a clear distinction between this state of moral hypochondria and ordinary hypochondria.
Although cases of melancholia without delusion must, according to M. Baillarger, be acknowledged, it is nevertheless important to be on one's guard with regard to certain hypochondriacs who, in appearance, exhibit a close resemblance to the melancholics in question here.
The true melancholic is in a state of general depression ... Nothing similar occurs in the hypochondriac, who may at any time be drawn out of his supposed prostration, his nullity, his impotence, etc. by a simple disposition.
Ordinary hypochondria, of which M.Baillarger is speaking here, is comparable in several respects to persecutory delusion, of which it is often simply the first stage, and it is above all the diverse evolution of the two hypochondrias which justifies M. Baillarger's distinction.
In general, it may be said that moral hypochondria is to the delusion of ruin, of guilt, of perdition and of negation, that which ordinary hypochondria is to the persecutory delusion.
When nihilistic delusion is established, it applies either to the actual personality of the patient, or to the outside world.
In the first case, it takes a hypochondriac form similar to the particular delusion reported by M. Baillarger in paralytics: patients have no entrails, no brain, no head, they no longer eat, no longer digest, no longer dress, and in fact they resolutely refuse food and often retain their faecal matter. Some imagine that they will never die.
This idea of immortality is found above all in cases where anxious agitation is predominant; in stupor, the patients are more likely to imagine that they have died.
There are even those who alternately experience the delusion of having died and of being unable to die, depending on the alternation of their states of anxious agitation or stuporous depression.
Hypochondriac delusion, largely moral at the onset becomes, at a more advanced stage and especially when the disease attains the chronic state, both moral and physical. Patients who initially have lost both heart and intelligence, end by having no body.
Some, like Leuret's female patient, speak of themselves only in the third person.
In the persecuted patient, the contrary takes place. The hypochondria of the outset is above all physical; but at a more advanced phase, patients are preoccupied with their intellectual faculties; they are being transformed into half‑wits, prevented from thinking, being told nonsense, having their intelligence removed, etc.
These two hypochondrias differ not only in their progress:
The hypochondria of the anxious bears the stamp of humility; they have nothing and are worth nothing; they are rotten; suffering from ignoble diseases; some believe they have syphilis, a delusion which Fodéré had already noted to be connected with the delusion he calls demonomania.
The persecuted hypochondriacs are entirely different:
They in general have a very good opinion of themselves and of the strength of their constitution in sustaining so many ills; they blame external influences, the air, the humidity, the cold, the heat, food and especially medicines. If they have syphilis, it is not the syphilis, but the mercury which is the cause of all their suffering.
They finish by blaming the doctor and enter a state of confirmed persecutory delusion.
The persecuted individual feels himself exposed to these injurious influences, which converge on his person from outside.
The anxious individual by contrast believes he is the source of them, and that it is he who is responsible for spreading them all around; he imagines that he brings misfortune on those who approach him, on the doctor who treats him, on the servants who attend him; he will infect them with fatal diseases, compromise them or dishonour them; the house in which he lives will be cursed; walking in the garden, he causes the trees and the flowers to perish.
The sensibility: Anaesthesia and hyperaesthesia
Hypochondriac nihilistic delusion is often linked with alteration of the sensibility. Anaesthesia is frequent in stupor, and has been reported by all the authors; it is also encountered in certain anxious melancholics; in others, by contrast, it appears that there is an hyperaesthesia, patients do not permit themselves be approached; they cry out as sort as they are touched and constantly repeat: "Do not hurt me !"
In what measure do these alterations of the sensibility contribute to the development of hypochondriac nihilistic delusion? I shall confine myself to reporting them as a differential characteristic of the two hypochondriac delusions; common in the negators, they are very rare in the persecuted.
When the delusion relates to the outside world, patients imagine that they have no family, no country, that Paris has been destroyed, that the world no longer exists, etc.
Religious beliefs, and in particular belief in God, often disappear, sometimes very early. Griesinger has reported the lugubrious, negative ideas, by which the patients feel themselves invaded, their anxious agitation rendering them incapable of meditation and of prayer.
A rapid description of the nihilistic delusion and of its diverse forms would not be sufficient to prove that this delusion is a particular species of melancholia. I wish to show that, in conjunction with this delusion, there exist numerous symptoms, closely associated in such a way as to constitute a veritable disease, distinct in its characteristics and its evolution.
We can employ the persecutory delusion as our type.
It is above all by identifying the differences and contrasts between him and the persecuted type, that I seek to depict the negator.
I have already begun this parallel by marking the difference between moral hypochondria and ordinary hypochondria, between the anxious melancholic who blames himself and the persecuted who blames the outside world. When the disease becomes more intense, or takes a more severe form from the start, there occur, in addition to the symptoms indicated in moral hypochondria and to ordinary delusion of ruin and of guilt, new phenomena which merit attention due to their special characteristics: these are the hallucinations.
These hallucinations are especially frequent in states of stupor, but they are also observed in the anxious form:
Patients believe themselves to be surrounded by flames, they see precipices at their feet, they imagine that the earth is about to swallow them up or that the house is about to collapse, they see the walls waver and believe that the house has been undermined; they hear preparations for their punishment, the guillotine being prepared; they hear the roll of drums, explosions of firearms, they are about to be shot; they see the rope intended for their hanging, they hear voices accusing them of their crimes, announcing their death sentence or repeating that they are damned. Some have hallucinations of taste and smell and imagine that they have become rotten, that their food has been transformed, that they are consuming garbage, faecal matter, human flesh, etc.
In general, hallucinations in patients with ideas of guilt belong to that category of hallucinations, established by M. Baillarger, which reproduce the existing preoccupations of the patients. A melancholic, this author states, who blamed herself for imaginary crimes, was obsessed night and day by a voice which announced her sentence of death and described the punishments reserved for her.
Another patient, whose history is reported by Michéa, believed herself guilty, pursued by the police and under sentence of death. She was placed in an asylum and a few days after, the lypemania being at its height, she saw almost constantly before her eyes the rope which would strangle her and the coffin prepared to receive her corpse.
Patients believe themselves damned and see the fires of hell, they hear gun shots and believe that they are going to be shot. Guislain has pointed out the close connection between demonophobia, suicide and the type of hallucination where patients see flames, fires all around.
The hallucinatory state of anxious, stuporous or agitated melancholics is totally distinct from that of the persecuted, first because of the visual hallucinations which are rare in the persecuted, and second by the character of the auditory hallucinations. Like the visual hallucinations, the latter simply reflect the delusions and it is sometimes difficult to distinguish one from the other; in the anxious, the hallucinatory phenomenon does not have this independence which, in the persecuted, lends it such distinctness together with a very particular evolution.
The persecuted individual gradually arrives at a dialogue, he can be seen to listen, to answer his imaginary interlocutors with impatience or anger. Nothing similar in the anxious patient; if he speaks, he constantly repeats the same words, the same phrases, the same groans, his loquacity takes the form of a monologue, of a litany, while that of the persecuted is a dialogue.
Nor is there observed in the anxious patient the repercussion of thought, the echo, nor that special vocabulary by which the chronic persecuted can be recognised after a few moments of conversation.
I stated, at the beginning of this paper, the systematic opposition and resistance of individuals suffering from nihilistic delusion; they often exhibit a muscular rigidity and tension which reveals that their inertia is only apparent and that their resistance is not simply passive.
As soon as one attempts to change their position, to bring some motion to their limbs, they powerfully contract their muscles in order to resist and to maintain their habitual position.
I do not wish to linger on the trembling reported in some anxious subjects, on the cataleptiform accidents in stupor cases, but 1 cannot omit the suicidal impulses and mutilation so common in anxious patients, especially when they are dominated by religious ideas, which establish yet one more difference from the persecuted in whom suicide is much less frequent, and mutilation very rare.
Anxious patients with ideas of damnation are those most disposed to suicide; even though they may believe themselves dead, or in the impossibility of ever dying, they nonetheless seek to destroy themselves; some desire to burn. themselves, fire being the only solution, others wish to be cut into pieces and seek by every means possible to satisfy this morbid need for mutilation, for destruction and for total annihilation.
Some show themselves violent towards the people around them; it appears that they wish to demonstrate that they are the most vicious beings, wholly devoid of moral sentiments; often they curse, blaspheme; for the damned and devil’s cannot do otherwise.
The rejection of food, so closely linked with madness of opposition, also possesses certain special characteristics in negators. In general it is total and applies without: distinction to all food; patients refuse to eat because they have no entrails, because "meat and other nourishment falls into the skin of their belly," because the damned do not eat, because they cannot afford to pay. Some, however, dominated by a less intense delusion of guilt or of ruin, select their food: out of penance, they eat only dry bread or eschew dessert.
The persecuted patient, on the other hand, carefully examines his food, seeks out what appears good, rejects what appears suspect; when by chance he encounters food which he supposes free of any poison, he eats voraciously. In general, the rejection of food is partial in the persecuted.
The course of the disease.
The persecutory delusion is essentially remittent or, if one prefers, continuous, with paroxysms; the disease generally begins early, develops in a slow and progressive manner and lasts throughout life. This remittent course is already apparent in the hypochondria of the beginning; it is equally so where the sickness does not seem to evolve beyond that embryonic form.
The condition has a quite different appearance in the negators: it strikes suddenly, often around the middle period of life, in people whose moral health had previously seemed good; when there is a cure, it is sudden, like the onset; the veil is torn and the patient awakens as if from a dream.
The mildest forms, it goes without saying, are also the most curable.
So‑called melancholia without delusion, moral hypochondria, and anxious states with delusions of ruin are usually cured. But the condition is subject to relapses at
varying intervals, and takes on the character of the intermittent insanities. This intermittent character is sometimes revealed, even in incurable cases, by awakenings: of short duration in which it seems that the patient has entirely recovered his lucidity.
I once saw, says Griesinger, in a patient suffering from profound melancholia (she imagined herself to have completely lost her fortune and believed herself destined to die of hunger) a perfectly lucid interval, of approximately one quarter of an hour, which occurred for no obvious reason and likewise suddenly disappeared.
In the forms where stupor is predominant from the beginning, a cure is often observed despite the intensity of the delusion and its absurdity. However, it is not unusual, after intense and prolonged anxious agitation, with hallucinations, panophobic delusion, etc., for patients to fall into a kind of stupidity which is too often mistaken for dementia and which continues indefinitely. These patients often show madness of opposition to the highest degree, they are mute, some repeating over and over again nothing but the word “no”.
The prognosis is also unfavourable when the intensity of the general melancholic disorder is seen to diminish, while the delusional ideas and the negations persist to the same degree. Patients arrive at a state of systematised nihilistic delusion which is rarely curable; in most cases they too exhibit madness of opposition, the unfavourable prognosis of which has been reported by Guislain.
By its course, by its onset, by its sudden termination, when it is cured, nihilistic delusion belongs to the group of fitful or intermittent insanities and to cyclical derangement. Even if the name nihilistic delusion is reserved for cases where this delusion has attained the degree to which I referred at the beginning of this study, it can be said that nihilistic delusion is a state of chronicity specific to certain intermittent melancholics whose disease has become continuous.
I wish only to state a point which seems to me to establish a difference between the negators and other intermittent conditions which are close to cyclical states.
When the antecedents, the character of the patients, are examined, one often learns that they have always been a little melancholic, taciturn, scrupulous, devout, charitable, always ready to perform a service; some are endowed with the most distinguished moral qualities.
Their diseased state, their delusion of humility are not in complete contrast with their former manner of being and are simply a morbid exaggeration of it. In short, these patients are not entirely in alternation, in the way of cyclical and certain intermittent patients, whose healthy state is in absolute contrast with the fits of melancholia.
This characteristic in the negators also makes it possible to separate them distinctly from most hereditary patients, amongst whom they form a special category; this is because they are distinguished by an exaggerated development, if one may call it so, of those same moral qualities, the absence of which in other hereditary patients explains their disordered life, their profound egoism, their pride, their undisciplined character, their offences and their crimes.
If the nihilistic delusion seems to belong, in many cases, among the intermittent delusions, I must add that it is not unusual to see it develop on a ground of hysteria; nor is it unusual to encounter it as a symptom of diffuse periencephalitis. The delusion of smallness, reported in this condition by Dr Materne, seems very close to nihilistic delusion and can coexist with it; we will see an example of it in the observations which follow.
Antoine Laurent Jessé Bayle (1799 – 1858) "General paralysis of the insane" - Internet Archive
I have divided these observations into three categories:
-in the first: the nihilistic delusion occurs in simple form
-in the second: a case where it is symptomatic of general paralysis of the insane;
-in the third: cases where, associated with the persecutory delusion, it constitutes those complex forms of alienation which explain why almost all the authors have confused, within the single description of melancholic delusion, delusions of ruin, of guilt, of mistrust and of persecution.
These mixed cases would merit a special study; apart from the two orders of symptoms they show, I believe, certain particular characteristics. Patients believe themselves to be possessed rather than damned and imagine that they have beasts or devil is in their body. Esquirol has reported cases of this type; Fodéré made the distinction between delusion of guilt and damnation, or demonomania, on the one hand, and, on the other, demonomanía or demoniac possession. This latter form seems to me to establish a sort of transition between delusion of guilt and persecutory delusion.
first category.‑Nihilistic delusion in simple form.
OBS. I ‑Mme E..., aged fifty‑four years, married with children, was committed on 15 june 1863 to the asylum of Vanves, having made several suicide attempts.
Mme E ... was in a state of anxious agitation with ideas of guilt and hypochondriac delusion; she imagined that her throat had narrowed and that her heart had been displaced. During the paroxysms of agitation, she would utter cries and would lament in a loud voice, constantly repeating the same words. All her organs were displaced, she could do nothing, she was lost, she was damned.
1864.‑Same delusion, same anxious paroxysms with continuous repetition of the same stereotyped sentences. Mme E ... was lost, had no head, no body; she was dead. Mme E ... would utter piercing cries, repeat the same words with rage and herself say that she was enraged; she would grasp the objects around with her hands, as if convulsively, and once held, would no longer let them go.
Mme E ... saw phantoms in the walls, resisted her natural needs, on the pretext that it would kill her to satisfy them, uttered cries and indulged in violent acts in order to resist the fatality of the situation from which no one could save her; the ideas of suicide persisted.
The nihilistic delusion became increasingly accentuated. Mme E ... had neither arms nor legs, all the parts of her body were metamorphosed; she would repeat that everything was lost, that she could not move without the risk of falling into pieces and she would become convulsively rigid in the seated position which she habitually adopted.
The madness of opposition reached its height, Mme E... would refuse to eat because she could not swallow, to walk, because she had no legs; she wished neither to stand up, nor to lie down, nor to dress, nor to eat, nor to walk, nor to relieve herself; she would become as rigid as a bar of iron in order to resist every act she was asked to accomplish, she would shout at any attempt to touch her and claim that she would break like glass.
The years passed without bringing any change in this delusion. Mme E ... reached a state of dementia characterised by grunts inarticulate shouts and paroxysms of agitation; she continued to maintain the same muscular rigidity and to offer the same resistance to everything she was asked to do.
Mme E ... experienced a collapse of the uterus and of the rectum which could not be maintained because of the violent efforts of expulsion which she would make as soon as reduction was attempted.
She died in 1.878 in a state of general cachexia.
OBS. II.‑Mme E..., aged sixty‑three years, committed to Vanves in May 1868, was in a state of great anxious agitation; she imagined that she had nothing, that she had ruined her family and that she would be sent to prison. Mme E ... was in constant motion, could not remain still; she groaned incessantly, complaining that she was lost, ruined, that it was through her fault that her children would die of hunger.
She refused nourishment on the pretext that she could not pay for it; she believed herself to be suffering from a contagious disease and imagined that she exuded a revolting odour; she would allow no one to approach and believed that contact with her was fatal: she imagined too that there was poison and dirt in her food. Mme E ... said that she could neither eat nor walk, that she was absolutely incurable; she resisted all the ordinary cares that she should take of her person, it required a struggle to dress her, to make her rise from her bed, to make her walk, to feed her. Mme E ... remained habitually huddled in a corner, sometimes mute, sometimes uttering a monotonous groaning and repeating that she was a monster.
Out of humility, Mme E ... would consent to eat only at the servants' table.
She died in 1879, the delusion having undergone not the slightest alteration.
OBS. III.‑Mme S..., aged fifty‑three years, had already experienced an attack of depressive melancholia which did not necessitate a committal. The melancholic delusion recurred and she was brought to Vanves at the end of the year 1876.
Mme S ... was in a state of extreme anxious agitation; she considered herself guilty and lost; she would be sent to prison and she sought every means possible to attempt suicide. Mme S ... would hear voices telling her that she was guilty, that she would be condemned and taken to prison; she believed she could hear the voice of her husband and of her daughter who were in prison because of her; she would utter incessant lamentations and refuse food.
1880. Mme S ... continued to be dominated by the same melancholic ideas; she generally remained mute and immobile, and would not answer when addressed; at times she would express negative conceptions of an entirely absurd nature. Mme S ... claimed that no one died any more, that no one married, that no one was born. There were no more doctors, no more prefects, no more notaries, no more tribunals; formerly Mme S ... had been used to pray, but now this was useless, since God did not exist. Mme S ... resisted all the ordinary cares that she should take of her person, continued to refuse nourishment and claimed that there was lime, potash in everything she was offered.
Mme S ... passes all her days in mutism and immobility. Today (May 1882) her state remains absolutely unchanged.
OBS. IV.‑Mme M..., aged fifty‑one years, married with children, seems to have been in good health until the year 1878. She then suffered a fit of anxiety with terrors; Mme M ... saw flames, fires, believed herself ruined and imagined that she was going to be tortured. After two months, she was suddenly cured but after a few weeks she experienced the same condition and was brought to Vanves in a state of intense anxious agitation with moaning and continual terrors, in particular relating to fire.
Mme M ... imagined that she was ruined, that she was to be tortured, that her food was poisoned, that she was bewitched. She appeared to have hallucinations of hearing and of sight, claimed that frightful things took place each night in her room, that persons unknown to her came there. Mme M ... refused to recognise her husband and her children when they came to visit her; she claimed that she had never been married, that she had neither father, nor mother, nor husband, nor children. A..., her native town, no longer existed, Paris no longer existed, nothing existed, her daughter was a devil in disguise. Mme M ... allowed no one to approach, drew back in terror when anyone attempted to touch her or take her hand, and repeated incessantly: "Do not hurt me." She denied everything and resisted everything; it was a struggle to dress her, undress her, feed her, etc., and Mme M ... would exhibit an astonishing power of resistance.
In August 1881, Mme M ... was suddenly struck by hemiplegia of the left side; the delusion was in no way altered. The lower limb recovered its functions incompletely, but the upper limb became cramped. Mme M ... continues to repeat the same denials, continued to say constantly: "Do not hurt me," and stubbornly resisted everything she was asked to do.
Today (May 1882) the situation remains the same in every respect.
OBS. V.‑Mme J..., aged fifty‑eight years, placed in Vanves in August 1879, was in a state of anxious melancholia which had already endured several months.
Mme J ... imagined that people were going to cut her nerves, render her deaf, mute and blind and subject her to tortures of all kinds; she would spend entire days in groaning and in calling upon the Virgin and all the saints.
Paroxysms of very intense agitation with suicide attempts. Mme J ... refused food; she was lost, damned; she was "stuffed with oil” she was about to be subjected to the most frightful tortures and yet she would never be able to die.
Frequent paroxysms during which Mme J ... would roll on the ground and exhibit of grimaces and contortions of every kind. Mme J ... would constantly repeat the same sentences, often entirely absurd and unintelligible, but relating to ideas of transformation and of annihilation of her person and of everything around her. Mme J ... would repeat: "There is nothing left, nothing more exists, everything is made of iron, etc.;" she herself was transformed, she was a little chicken, a fly, a talking woollen rag, she was no longer anything, she never ate, she no longer had a body; the people around her were nothing but shadows.
Mme J ... would resist everything, retained her faecal matter and her urine; it was a struggle to dress her, to undress her, etc., and in these struggles Mme J ... would exhibit incredible energy and muscular vigour. Currently, in May 1882, the situation of Mme J ... remains the same, her delusion has not altered in any way.
OBS. VI.‑Mme C..., aged forty‑three years, married with children, entered the Vanves asylum in November 1880. In 1875, following the sudden death of her father and the surgery for strabismus performed on her son, this lady had already experienced a slight attack of anxiety with insomnia and continual yawning, obsessed by the fear that her father had been buried alive and that her son might become blind following the surgery for strabismus.
This anxious state went away after a month. At the end of March 1880, new attack, fairly rapid onset, preoccupations relative to questions of money, continual perplexity and indecision, insomnia. Mme C ... blamed herself and believed herself guilty. After a few months, hypochondriac delusion.
Mme C ... believed that she no longer had entrails, that her organs had been destroyed and she attributed this destruction to an emetic which had indeed been administered to her.
On her arrival in the asylum, Mme C ... was in a state of anxious melancholia with paroxysms of maniac agitation during which she would perform contortions, grimaces, roll on the ground and utter groans. These paroxysms would alternate with periods of immobility and mutism. Mme C ... claimed that her gullet had been removed, that she no longer had entrails, that she had no more blood; she would never die, she was neither dead nor alive, she was a supernatural person, her place was neither with the living, nor with the dead; she was no longer anything, she begged people to open her veins, to cut off her arms and legs, to open up her body in order to make certain that she had no more blood and that her organs no longer existed.
This patient left the asylum uncured after a stay of two months; I do not know what became of her.
OBS. VII.‑Mr A..., aged fifty‑three years, placed in the asylum of Vanves in July 1877, was struck with melancholia after having experienced great moral suffering; he lost his wife and a son at almost the same time.
Mr A ... blamed himself for the death of his wife and of his son; he was rotten, he had syphilis, he was lost, he was damned, he was the greatest criminal who had ever existed, he was the Antichrist, he should be burned in the public square; Mr A ... was plunged in the deepest sadness, he wept and groaned; he wished to be dead and made suicide attempts.
1880. Mr A ... continued to express the same melancholic ideas of guilt, he was damned and destined to burn eternally. Mr A ... would say that his whole body was rotten, that he had no blood, that he had no pulse, that his heart no longer beat, that his head was empty, that he had no human face. He was awaiting the end of the world, which was near.
Currently, in May 1882, the situation is still the same, the delusion has in no way altered.
OBS. VIII.‑Mr A..., aged forty‑eight years, placed in the Vanves asylum in March 1879, following a suicide attempt, was in a state of intense anxious agitation. He would seek every means to damage himself, to mutilate himself, to put out his eyes, to kill himself; he wished neither to eat, nor to take medicines, nor to receive any kind of care, considering himself unworthy. He thought only of expiating his imaginary crimes; that is the reason why he wished to damage and to kill himself; he said that: he had fallen into an abyss of infamy and that every day he fell deeper; he begged to be given a rope in order to hang himself, or a strong dose of poison.
Mr A ... did not seem to have auditory hallucinations, but he had numerous illusions of sight; he would attribute a mystical meaning to the shapes of external objects, he believed he could see figures of animals in the shapes of trees, etc.
1880. Mr A ... imagined that he was to be tortured, plunged into icy water, fed on garbage and excrement, he begged to be given prussic acid in order to end his days. His brain had been softened, his head was like a hollow nut, he had no sex, no testicles, he had nothing left, he himself was nothing but "carrion" and asked for a hole to be dug so that he could be buried like a dog; he had no soul, God did not exist; at times Mr A ... would say that: he had neither wife nor children; at other moments, he would ask to see them and to return. to them. Mr A ... would constantly repeat the same phrases and the same supplications: Kill me, kill me; do not give me a cold bath, do not give me a cold bath, etc., which he would repeat for hours on end. He would seek every means possible to kill and mutilate himself; he wished to put out his eyes, to tear off his testicles, etc. He would show himself equally violent and injurious towards the people around him. At times, Mr A ... could speak with lucidity; he was happy to recount different events from his former life.
In May 1882, the situation is still the same, Mr A ... constantly repeats that: he is unworthy, ignoble, he wants to become a boot black, he has no testicles, he should be killed.
Second category. ‑Nihilistic delusion symptomatic of general paralysis of the insane.
OBS. IX‑ Mr C..., aged forty‑eight years, of robust constitution, married with children, having always led a regular and hard‑working existence, had committed no excesses, it is said, other than excess of work. He would remain each day in his office until two o'c1ock in the morning and would rise at seven.
For several years he suffered violent migraines with vomiting. In 1879, he complained of visual problems, of mists before his eyes; he consulted an oculist, who having examined the back of the eye, asked Mr C ... to balance on one foot, which he was unable to do. (PGP)
Around that: time Mr C ... began to have frequent falls; often he returned home saying to his wife that he had almost been killed, that he had fallen and that he had been helped to rise. At the same time, his character began to alter; he became sombre, irritable, and appeared to be plunged into a profound sadness. He expressed mournful sentiments, gave advice to his wife and offered her meticulous recommendations on the subject of their children, as if he felt threatened by an imminent death.
At the beginning of December 1879, he had another fall in the street, returned home frozen and was seized by intense trembling and chattering of the teeth. The doctor was called and reported, it is said, no onset of fever following this shivering. Similar shivering apparently occurred irregularly every day for five or six hours. Mr C ... remained constantly in bed, under enormous covers, and, as soon as he was uncovered slightly, would again be overtaken by trembling and chattering of the teeth; he was completely unable to sleep.
After a few weeks, Mr C ... left his bed, but it: was impossible for him to resume his occupations. He remained constantly in his office, mute, unoccupied, immobile, receiving no one and sending his wife away roughly when she came to see him. At times, he would repeat: "I am a cretin," would say to his wife: «Will you not then restore to me my former life?" or else: "I should shoot: myself. I would ask God to make me die, but God does not exist.» One night, he repeated for hours on end a single series of incomprehensible syllables.
Towards the month of March 1880, he began to express negative ideas of a wholly absurd nature; he would say that there was no more night and would refuse to go to bed; he would spend entire nights in his office and would reply to his wife that he could not go to bed since it was still day. He said that he was not eating, and however copious were the meals, he would fly into a fury, saying that there was nothing on the table.
Committed to Vanves in the month of April 1880, Mr C ... was observed to have a profound mental disorder. Mr C ... was aware neither of the place where he found himself, nor of the time that had passed since he had quit his home.
He was ordinarily calm, silent; at times he would claim that the people around him were assassins who would cut his throat and he would be seized by paroxysms of anxiety during which he would continually repeat the same words in a tone of lamentation.
Mr C ... declared that he knew neither where he was, nor who he was; he insisted that he was not married, that he did not have children, that he had neither father, nor mother, that he had no name. He would claim that he never ate and yet would eat hugely. He was in a desert where there was nobody, and from which escape was impossible, since there were neither cars nor horses. If shown a horse, he would say: "That is not a horse, it is nothing at all."
Mr C ... would resist all the cares that should be taken of his person; he would refuse to be clothed because his whole body was no bigger than a nut; he would refuse to eat, because he had no mouth, to walk, because he had no legs. Mr C ... would pull his ears and say that he had no ears, would pull his nose and say that he had no nose. Often Mr C ... would say that he was dead, but during paroxysms of anxiety, Mr C ... would say that he was half dead, and that he would never succeed in dying; he would take his arm, his leg, his calf and say: "This will never be detached."
At times, Mr C…appeared to have hallucinations of sight; he would see people, women dressed in white, descend from the ceiling of his room; at other times, he would see small horsemen a few centimetres high crossing his room in regiments.
Confusion in speech, uncertain gait, unequal pupils. ( Argyll Robertson pupils )
These symptoms of general paralysis became increasingly marked in the course of the year 1881. They were accompanied by ideas of grandeur which the patient referred back to the past.
Mr C ... would recount that he had formerly been immensely rich, that he had been the foremost lawyer in Paris, that he was a member of the French Academy, president of the Republic; today, he was nothing but a little cretin and anyway was going to die. ¡¡
In May 1882, Mr C ... is reduced to a state of paralytic dementia; he can scarcely walk, his speech is almost unintelligible.
Third category. ‑Nihilistic delusion associated with delusion of persecution.
OBS. X. ‑Mme G., aged forty‑two years, married with children, several years ago experienced violent fits of hysteria.
Placed for the first time at Vanves, at the end of the year 1875, she was at that time suffering from melancholic delusion with ideas of guilt, mystical ideas and paroxysms of furious agitation. Mme G ... believed herself possessed by the devil, damned; she believed that she had been made pregnant by her maidservant, whom she took to be a man in disguise.
Mme G ... imagined that she had been transformed into a foul beast, into a scorpion and, in her paroxysms, would crawl on her belly, indulge in all sorts of contortions in order to imitate the movements of the scorpion. Mme G ... refused food, performed all sorts of disordered acts and violences towards her; she would hear the devil speak to her and was obliged to obey him.
In the course of the year 1876, a significant improvement took place. Mme G ... was calm, occupied herself with needlework, conversed readily; but she continued to be dominated by ideas of guilt, to believe herself adulterous, unworthy to return to her husband and children, and wished to make a public confession of her sins. She left in this state of remission at the end of 1876.
The following year it became necessary once again to commit Mme G..., who insisted absolutely on making a public confession of her sins and of her crimes, in the streets and in the churches; Mme G ... still believed herself to be guilty, unworthy; she wished to enter into domestic service and to earn her living, for she did not deserve to have money expended on her; however, new delusional ideas came to complicate this delusion of guilt
Mme G ... believed herself to be magnetised, imagined that people could read her thoughts and that her thoughts could be the cause of the greatest misfortunes; she attributed supernatural power to her maidservant: this girl, by means of magic and evil procedures, would cause her son to be committed to the asylum where he would be subjected to torture and genital mutilation. Mme G ... left the asylum for a second time in June 1879, and was returned there in August 1880; she imagined that she was being persecuted by people who had the power to read her thoughts, whom she called carigrafiers; these people were hounding herself and her children, and would constantly repeat the most frightful calumnies. They went so far as to make her utter, herself, foolish remarks which were then repeated all over Paris and throughout the world, and which might do the greatest injury to her family.
At the same time as she blamed her persecutors and the people around her, Mme G ... would blame herself; she was a monster, she was damned; she had three earwigs in her body and would finally be changed into a scorpion; already there was nothing human about her and she was like a foul beast. Mme G ... wished to be dead, she moaned and made suicide attempts, but it was too late: already she was immortal; she could be cut into small pieces without dying.
In May 1882, the situation is still the same; however, the ideas of persecution appear increasingly to predominate; Mme G ... accuses the servants of constant gossip and slander in regard to her; she is damned, it is true, but it is the fault of the doctors.
OBS. XI. ‑Mme H..., aged fifty‑one years, was committed in the month of August 1880.
Approximately fifteen years ago, following severe dysentery, Mme H ... experienced a cracking sensation in her back, "her back was detached." Since that time, at least four or five times, Mme H ... had remained in bed for nine to ten months, once for more than a year. Mme H ... claimed that she was unable to rise, that her back had descended into her belly. Towards the beginning of the year 1880, Mme H ... began to complain that everyone was against her, and her ideas of persecution were concentrated on the person of her son‑in‑law; she would repeat for hours on end: "Why then did my daughter marry X ... ?" Placed at Vanves in August 1880, Mme H ... claimed that a spell had been cast upon her; she was damned, she had animals in her belly, monkeys, dogs, etc., she heard voices which drove her despite herself to acts of violence; she sought death, and yet she knew that she could never die. In September of the same year, Mme H ... left the asylum in the same state of chronic alienation, to be transferred to another asylum.
A considerable number of observations scattered here and there in which nihilistic delusion is reported, at least in its hypochondriac form.
Phenomenological differences between these two disease entities
Parallel between nihilistic delusion and delusion of persecution.
DELUSION OF PERSECUTION
- The patient does not ordinarily present the melancholic fancies.
- Hypochondria largely physical at onset.
- The patient blames the outside world, harmful influences originating in diverse spheres and particularly the social sphere.
- He does not blame himself; instead, he boasts of his physical and moral strength and of the excellence of his constitution which allows him to sustain so many ills.
- Suicide relatively rare.
- Homicide more frequent.
- Disorders of the sensibility very rare.
(Constant auditory hallucinations presenting the familiar particular development)
- Visual hallucinations very rare.
- Subsequent moral hypochondria; the persecutors are attacking the moral faculties; patients say that they are being made stupid.
- Delusion of grandeur (ver la hipertrofia yoica e ideas de grandeza de la paranoia)
- Partial refusal of food, through fear of poison.
- The patients choose their foods and eat with voracity those which they believe not to be poisoned.
- Course of the disease, remittent, or continuous with paroxysms.
- Anxiety, groaning, precordial pain, etc.; patients are types of anxious melancholia.
- Others lapse into stupor. Some present alternating stupor and melancholic agitation.
- Hypochondria largely moral at onset.
- The patient blames himself: he is incapable, unworthy, guilty, damned.
- If the police come to arrest him and take him to the scaffold, it is only what he deserves for his crimes. (ver melancolía delirante: delirio de culpa y de indignidad)
- Suicide and mutilation very frequent. (al igual que en "la melancolía agitada")
- Homicide more rare. (descartar el "suicidio ampliado")
- Disorders of the sensibility. Anaesthesia. Hallucinations often absent. ¿?
- No antagonism between the patient and the voices he hears, no dialogue.
- Fairly frequent visual hallucinations.
- Subsequent physical hypochondria.
- Patients have "no brain, no entrails, no heart, etc.
- They are dead or else will never die.
- Transformation of the personality.
- Some speak of themselves in the third person.
- Nihilistic delusion and delusion of annihilation.
- Patients deny everything; they have neither parents, nor family.
- everything is destroyed, nothing any longer exists, they have become nothing, they have no soul, God no longer exists.
- Madness of opposition. Total refusal of food. "sitiofobia"
- The negators refuse because they are unworthy, because they cannot pay, etc.
- Course, first clearly intermittent, then continuous.
- Evolution catatonic forms : catatonic stupor or melancholy (añadido por J.L. Día)
- Thanks to Dr. J. Cotard by clinical description of patients with " NIHILISTIC DELUSION."
- Thanks to all patients presented in this clinical discussion .
- Thanks to Mme. S , Mme. E, Mme. M , Mme. J , Mr. Mme. C and Mr. A. All of them remain in our memory.
The classical psychopathology and phenomenology are imperishable.
This not find it in the DSM - 5
- LEURET. Fragments psychologiques, Paris, 1831, p. 121, 407 and following. ‑Traitement moral de la folie, Paris, 1840, P‑274- 281.
- ESQUIROL. Des maladies mentales, chap. "Démonomanie”. Paris, ' 1838.
- FODERE. ' Traité de délire, vol. I, p. 345.
- MOREL. Etudes cliniques sur les maladies mentales, vol. II, p. 37 and 118.
- MACARIO. Annales médico‑psychologiques, vol. 1.
- BAILLARGER. De l´état désigné sous le nom de stupidité, 1843.‑"La théorie de l'automatisme" (Ann. méd.‑psych., 1855).‑«Note sur le délire hypocondriaque" (Académie des sciences, 1860).
- ARCHAMBAULT. Annales médico‑psychologiques, 1852, vol. IV, p. 146.
- PETIT., Archives cliniques, p. 59.
- MICHEA. "Du délire hypochondriaque" (Ann. méd.‑psych., 1864).
- KRAFFT‑EBING. Lehrbuch der Psychiatrie, OBS. II and VII.
- COTARD. "Du délire hypochondriaque dans une forme grave de la mélancolie anxieuse" (Ann. méd.‑psych., 1880 and above, p. 314).