Case report

Co-existence of lycanthropy and Cotards

syndrome in a single case
Introduction
Lycanthropy has been derived from two Greek
words, lykoi wolf and anthropos man. In folk-
lore and superstition it is applied to a human being
who has changed or is being changed into a wolf,
or is capable of assuming the form of a wolf while
retaining human intelligence. In psychiatric litera-
ture, lycanthropy is an unusual belief or delusion
that one has been transformed into an animal or a
behaviour suggestive of such belief (1, 2). Although
in many cases, lycanthropy presents itself as a
delusion but in some cases it is closer to hysteria
(3).
Cotards syndrome is another rare psychiatric
syndrome in which the central symptom is a
nihilistic delusion, which, in its complete form,
leads the patient to deny his own existence and that
of the external world. Ideation of immortality is
part of this syndrome. This syndrome was intro-
duced by Cotard in 1880 (4).
In this article, a patient who had both lycan-
thropy and Cotards syndrome is presented. To our
knowledge such a case has not been mentioned in
the literature so far. We also discuss the case from
psychopathological and cultural points of view.
Case report
The presented case is a 32-year-old man, married,
left school after ninth grade, worker, from Kerman
(a city in south of Iran) who was admitted to
Kerman Psychiatric Hospital for the rst time. The
patient, who was restless and tearful and had been
refusing to work for about 2 weeks, had been
referred for treatment by his relatives. His illness
had started 2 years prior to his admission, but
symptoms had become worse and signicant
2 weeks prior to admission. He stated that
nobody paid attention to him and people stayed
aloof from him because he was dead. First, he had
become restless and felt a strange sense in his body
like an electric shock, and then he had felt that his
whole body had been changed, and, nally, he
deluded that he was dead. He said I speak, breathe
and eat but I am dead. He believed that his death
had been due to his sins during his life as a human
being. He said that he did not want to sin again. He
believed that God protected him and that no
poison could harm him. He said that some of his
relatives and friends had fed him dissolved cyanide
in tea repeatedly but he had not been harmed. He
thought that his wife and three daughters were
Nejad AG, Toofani K. Co-existence of lycanthropy and Cotards
syndrome in a single case.
Acta Psychiatr Scand 2005: 111: 250252. Blackwell Munksgaard
2004.
Objective: Lycanthropy is an unusual psychiatric syndrome involving
the delusion of being an animal. Cotards syndrome is another rare
condition in which the patient has nihilistic delusions and ideation of
immortality. We report a psychiatric patient who had both syndromes
simultaneously.
Method: A single case was reported.
Results: A patient meeting DSM-IV criteria for bipolar mood
disorder, mixed type with psychotic feature had the delusion of being
transformed into a dog. He also deluded that he was dead. He was
restless and had a serious sense of guilt about his previous sexual
contact with a sheep.
Conclusion: Co-existence of lycanthropy and Cotards syndrome has
not been reported before. In this patient zoophilic orientation
associated with a sense of guilt were concluded to be important factors
causing his delusions.
A. G. Nejad, K. Toofani
Beheshti Hospital, Kerman, Iran
Key words: lycanthropy; Cotard's syndrome; bipolar
mood disorder
Alireza Ghaffari Nejad, Associate Professor of
Psychiatry, Beheshti Hospital, Kerman, Iran 7618841151.
E-mail: argnejad@yahoo.com
Accepted for publication July 12, 2004
Acta Psychiatr Scand 2005: 111: 250252
All rights reserved
DOI: 10.1111/j.1600-0447.2004.00438.x
Copyright Blackwell Munksgaard 2004
ACTA PSYCHIATRICA
SCANDINAVICA
250
dead. He discovered that sometimes his jaw moved
automatically and concluded that he and his wife
were transformed into dogs. He also felt that his
daughters urine had the odour of sheep urine and
concluded that his daughters had been transformed
into sheep. This odour made him restless and he
smelt it even in the hospital. The patient became
insomniac with decreased need for sleep and slept
far from his wife and daughters. He attributed this
to probable uncontrollable sexual action from
himself. He was afraid of performing an unwanted
sexual assault on his daughters, and refused sexual
contact with his wife because he believed that due
to his previous sin he should not ever look at any
woman. He accused his friends of harming him
without giving any detailed explanation. Family
history was unremarkable but in his personal
history he reported one sexual relationship with a
sheep in his adolescent period and had a sense of
guilt about that.
In mental state examination, he was anxious and
restless and hyper talkative. His aect was appro-
priate with mood. He had olfactory hallucination.
In evaluation of thought, he had nihilistic and
immortality delusions. He also had guilt feeling
with delusional intensity. He showed delusional
mood and persecutory delusion. His orientation
and memory were intact and he had insight with
degree 3 from 4. Physical and neurological exam-
inations were unremarkable.
The patient was given 600 mg sodium valporate
and 6 mg risperidone. Because of severe restless-
ness, the patient received six sessions of electro-
convulsive therapy (ECT).The main signs were
relieved after 2 weeks and as there was no sign of
depression after ECT and at follow-up 2 months
later, no antidepressant drug was prescribed.
Discussion
According to DSM-IV criteria, our patient met
diagnosis of bipolar mood disorder, mixed type
with psychotic feature. DSM-IV criteria cannot
explain everything in psychiatric patients. This
case report presents such an example. Our
patient is a typical case of Cotards syndrome;
he had both delusions of being dead (nihilistic
delusion) and of immortality. He had his own
lycanthropy and in addition a rare variant form
of lycanthropy, i.e. he believed that his wife and
daughters were also transformed into a dog and
sheep, respectively. The only article reporting a
delusion of relatives being transformed into
animals was reported by Moselhy (5). The
question is how these two syndromes could co-
exist? Werewolves are immune from aging and
from most physical diseases due to constant
regeneration of their physical tissue. They can,
therefore, be virtually immortal. Hence, immor-
tality is a basic symptom of both lycanthropy
and Cotards syndrome. Our patient believed that
he had been transformed into a dog. But dog
and wolf are close relatives, and they have been
considered equivalent in at least one other report
(6).
Another point of association is rooted in the
patients sense of guilt. The patient had tormenting
guilty feelings about his sexual contact with a sheep
in his adolescence. This part of history was
revealed when the patient was questioned directly;
he did not report it spontaneously. [The prevalence
rate of zoophilia (both actual sexual contact and
sexual fantasy) was found to be statistically higher
in psychiatric patients (55%) compared with con-
trol groups (10 and 15%), and questions exploring
this previously ignored topic were recommended to
be asked routinely (7).] Not infrequently, bizarre
and chaotic sexuality is expressed in a primitive
way through the lycanthropic symptom complex.
Patients whose internal fears exceed their coping
mechanisms may externalize them via projection
and constitute a serious threat to others. To our
knowledge at least one case report describes a
lycanthropic patient with irresistible zoophilic
drives (8). Our patient had zoophilic drive and
maybe concurrent incestuous drives, so delusion
regarding his daughters being transformed into
sheep is a probable psychotic defence that could
protect him from his painful delusional mood. It
could also be rooted in his activated previous sense
of guilt. Why did he have the delusion of trans-
forming into a dog? As he associated later, dogs
should protect sheep, so he protects his daughters
and this delusion can calm the patient and reduce
his restlessness. One known interesting aspect of
Cotards syndrome is the co-existence of the two
paradox ideations of being dead and immortality.
In Persian folklore dog has two paradox meanings.
From one point of view, it is the symbol of loyalty
and from another point of view it is the symbol of
impureness. Delusion of transforming into dog
could result from the patients sexual sin. This
paradox is similar to conceptual paradox which
exists in Cotards syndrome (dead and immortal-
ity).
Visual perceptual abnormalities were consid-
ered to play a role in forming delusions of
transformation (911). In this case, we observed
another perceptual abnormality. First, olfactory
hallucination developed and then lycanthropic
delusions occurred, so in addition to visual
perceptual abnormalities, disturbance in other
Co-existence of lycanthropy and Cotards syndrome
251
perceptual modalities could precede delusions of
transformation. From a psychodynamic point of
view, identication with the aggressor is consid-
ered as a probable defence in cases of lycan-
thropy (11).
Yamada et al. presented a form of staging for
Cotards syndrome: germination, blooming and
chronic (depressive type/paranoid type) stages
(12). In this case report, our patient rst
became restless and fearful and nally developed
full blown psychosis with persecutory and nihil-
istic delusion associated with delusion of trans-
formation. About 120 years have passed since
Cotard rst introduced a syndrome of negation
and still cases with rare characteristics are
observed. The author has reported a case of
Cotards syndrome with hydrophobia (13), and
the present report is another example.
References
1. Keck PE, Pope HG, Hudson JI, McElroy SL, Kulick AR.
Lycanthropy: alive and well in the twentieth century.
Psychol Med 1988;18:113120.
2. Rojo Moreno J, Rojo Moreno M, Valdemoro Garcia C, Rojo
Sierra M. The delusion of lycanthropic transformation.
Actas Luso Esp Neurol Psiquiatr Cienc Anes 1990;
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3. Benezech M, De Witte J, Etchepare JJ, Bourgeois M. A case
of lycanthropy with deadly violence. Ann Med Psychol
1989;147:464470.
4. Enoch D, Ball H. Uncommon psychiatric syndromes, 4th
edn. London: Arnold, 2001:159178.
5. Moselhy HF. Lycanthropy: new evidence of its origin.
Psychopathology 1999;32:173176.
6. Garlipp P, Godecke-Koch T, Haltenhof H, Dietrich DE.
Lycanthropy-zooanthropism-discussion of a psychopath-
ological phenomenon. Forschr Neurol Psychiatr 2001;
69:215220.
7. Alvarez WA, Freinhar JP. A prevalence study of bestiality
(zoophilia) in psychiatric in-patients, medical in-patients,
and psychiatric sta. Int J Psychosom 1991;38:4547.
8. Harvey A, Rosenstock MD, Kenneth R, Vincent EdD. A case
of lycanthropy. Am J Psychiatry 1977;134:11471149.
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10. Young AW, Ellis ND, Szulecka TK, de Pauw KW. Face
processing impairments and delusional misidentication.
Behav Neurol 1990;3:153168.
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depression: two case reports. Psychopathology 1999;
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12. Yamada K, Katsuragi S, Fujii I. A case study of Cotards
syndrome: stages and diagnosis. Acta Psychiatr Scand
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Invited comment
Lycanthropy is a delusional symptom rarely des-
cribed in the literature but probably seen a lot
more often in clinical psychiatry. Reasons for this
discrepancy may be the often short duration of the
symptomatology, the lack of interpretation as
lycanthropy if the metamorphosis is not verbally
uttered by the patient and just the behaviour is
shown, and furthermore the hypothesis stated by
Knoll (1) that the animalistic behaviour may be
reected as negligence in the countertransference as
a taboo in the psychiatric attitude as well.
The authors present an interesting combination
of two clinical syndromes that has not been
described up to now although lycanthropy is
often found in aective disorders and schizophre-
nia. Besides there are some more interesting
aspects: up to now the metamorphosis of another
person into an animal experienced by the patient
has just been described once by Moselhy (2). It is to
my knowledge also the rst report from Iran and
the rst report about a metamorphosis into the
animal sheep (3).
The psychodynamical context with probable
guilt feelings concerning the sodomistic act as an
adolescent and the psychodynamical interpreta-
tions concerning both clinical syndromes are sound
and also transculturally interesting and underline
the importance of an also psychodynamical
approach in delusional syndromes which also
could have therapeutical implications.
Petra Garlipp
Department of Social Psychiatry and
Psychotherapy
Hannover Medical School
OE 7120
30623 Hannover
Germany
References
1. Knoll M. Zooanthropismus. Materialien Psychoanal
1986;12:293310.
2. Moselhy HF. Lycanthropy: new evidence of its origin. Psy-
chopathology 1999;32:173176.
3. Garlipp P, Godecke-Koch T, Dietrich DE, Haltenhof H. Lyc-
anthropy psychopathological and psychodynamical aspects.
Acta Psychiatr Scand 2004;109:1922.
Nejad and Toofani
252