Delusions of death in a patient with right hemisphere infarction

Although a role for right hemisphere dysfunction has been hypothesized in Cotard delusion, it remains unclear which functions are disturbed. We report here the first known patient with unilateral right hemisphere lesions and delusions of death (1 of the 2 types of Cotard delusion). This man began to believe that he was dead after suffering a right hemisphere infarction involving the frontal, temporal, and parietal lobes, as well as the thalamus. He had delusions of death in the context of both depersonalization/derealization and delusional misidentifications of people and places. Neuropsychological testing revealed left hemispatial neglect and deficits in general attention. The patient's sense of body ownership and face recognition abilities were preserved. This case suggests that abnormal feelings of familiarity, which have been implicated in several delusional misidentification syndromes, contribute significantly to the development of delusions of death. If this is true, affective processes involved in the identification of people and places and in the feeling of being alive may partially overlap, and these affective processes may be supported by the right hemisphere.