Case notes z Diogenes syndrome

Diogenes syndrome: patients living with hoarding and squalor

Debbie Browne MBChB, MRCPsych, Rekha Hegde MBChB, MRCPsych

With a growing awareness that hoarding can be found in many psychiatric conditions, clinicians may recognise an increase in referrals for people presenting with hoarding. Here, the authors present three cases of hoarding behaviour stemming from different psychiatric conditions and discuss how hoarding can be managed.

oarding down, or senile squalor syndrome disorders ,paraphrenia 8and subtle Hhas cap - 6 and it can be understood as: frontal lobe deficits not fulfilling tured the pub - • Acquisition of, and inability to diagnostic criteria for . lic imagination discard, objects that to others have in recent years, (seemingly) little value – hoarding Background with television (syllogomania) Macmillan & Shaw (1966) studied programmes • Self neglect a population of individuals living such as Channel 4’s ‘The Hoarder • Environmental neglect (squalor) in squalor and described the con - Next Door’ 1 or TLC’s ‘Hoarding: • With refusal of help / isolation dition as a ‘senile breakdown’ of Buried Alive’. 2 The terms hoard - • Seeming lack of concern by the the standards of hygiene accepted ing and Diogenes are sometimes person with regards to their by the local community. More than used interchangeably but it is more situation. half of the sample was found to useful to think of Diogenes as have a psychiatric disorder and an hoarding with self and environ - Epidemiology equal proportion presented hoard - mental neglect, ie squalor. The accepted incidence of ing personality traits. 10 With changes in legislation Diogenes syndrome is 0.5 per 1000 Karl Jaspers called it the social (such as the Mental Capacity Act over the age of 65 years. 7 breakdown of the elderly: he felt 2005 and Adult Support and Epidemiological data comes it was ‘a personality based abnor - Protection (Scotland) Act 2007) mainly from case series, 8 which mal emotional reaction develop - and a growing awareness that represents a poorly defined hetero - ment or adjustment disorder’. 11 hoarding can be found in many psy - geneous population. Furthermore, His view of this syndrome was that chiatric conditions, including community health professionals it represented a lifelong subclin - obsessive-compulsive disorder are more likely to differentiate self- ical personality disorder, proba - (OCD), schizophrenia, dementia, neglect, squalor, collecting and bly of a schizoid or paranoid type, and others, 3 clinicians may recog - hoarding rather than define the that turns gradually into gross nise an increase in referrals for peo - disorder as Diogenes per se . self-neglect and social isolation. ple presenting with hoarding. In Men and women are equally This deterioration is precipitated previous years this population may affected, as are all socioeconomic by stressful life events, such as loss not have come to the attention of groups. 8 Those affected are often of a spouse or aging by itself, health services, due to the assump - reported to be from a profes - and is further aggravated by tion that hoarding occurs in the sional background, 8 although increasingly debilitating physical absence of mental illness. Indeed this has been challenged. 9 problems. 12 this belief was reinforced by the Independence, and social isola - The term ‘Diogenes syn - absence of hoarding from the diag - tion have all been associated, as drome’ was first applied by Clarke nostic criteria ICD10 and DSM IV, has older age, although young et al. 13 in 1975 to a case series of although it has now been coded for people may also be affected. 7 30 elderly people with extreme in DSM V. 4 Case series data suggest that neglect of their homes and Diogenes syndrome has over 30-50% may have an underlying psy - personal health, and with the the years has been referred to as chiatric diagnosis, 8,10 including behavioural abnormality of senile breakdown, 5 social break - dementia, alcohol abuse, affective hoarding rubbish. 14

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Who was Diogenes? For clinicians faced with a new ensuring their wellbeing. If it is Plato described Diogenes as ‘a case of squalor it is also useful to thought that the use of neither of Socrates gone mad’. He was a 4th consider age. If the person is these Acts is appropriate then century Greek philosopher also under 65 years old and has a 10-20 social work may use legislation at known as Diogenes of Sinope, or year history of hoarding it might their disposal such as the Adult Diogenes the cynic, who advocated be correct to assume they have pri - Support Protection Act. the principles of: ‘life according to mary Diogenes in the absence of There are some situations in nature’; ‘self-sufficiency’; ‘freedom mental illness. If, however, they are which the housing or environmen - from emotion’; ‘lack of shame’; over 65 years old then the onus tal departments of local authorities ‘outspokenness’, and ‘contempt would be on the clinician to may be the lead agency. Public for social organisation’. exclude organic illness as a cause health departments have powers to The name of the syndrome is a of the hoarding / squalor. Again, inspect properties and can issue reference to the reclusiveness and the length of the hoarding is use - statutory notices to force owners to rejection of the outside world prac - ful: if present for decades then it clear their houses. If levels of clean - tised by the philosopher who could be consistent with a primary liness repeatedly fall below accept - rejected convention and comforts Diogenes diagnosis but if emerg - able standards then the case can be in favour of a simple life of virtue. ing in someone with a previously referred to the Procurator Fiscal. 20 He reportedly lived in a barrel, acceptable level of personal and naked and as ‘shameless as a dog’ environmental care, a thorough Case 1: Primary Diogenes: 80-year- or as a cynic (from the Greek word cognitive and mental state assess - old female who describes a 30 year for dog). 15 He also is said to have ment should be performed to history of hoarding but no contact lit a lamp in broad daylight and exclude other diagnoses. This with Psychiatric services until said, as he went about, ‘I am might take a few attempts to October 2013. searching for a human being’ .16 complete but a more aggressive An 80-year-old lady (Mrs A) According to Marcos et al. , approach is advocated. who lives with her daughter, who is Diogenes would have never been With any clinical situation it is also a hoarder and who has her diagnosed as having his ‘own’ syn - useful to ask oneself: ‘what are own mental health problems. drome, as the underlying motiva - the risks?’ then ‘what can I do The patient was first referred to tion of the syndrome appears to be (within bounds of legislation)?’ psychiatric services by her GP, after ‘a suspicious rejection of the world, and ‘what should I do?’ In some expressing suicidal ideation whilst rather than a desire to demon - cases there is nothing that can or in respite care. This had been pre - strate self-sufficiency without mate - should be done, other than cipitated by her granddaughter rial possessions’. 17 This sentiment assessment and support. removing items from her home for is shared by Cybulska who said in Management will be multi- the patient’s safety. Mrs A was upset 1998: ‘Some names appear to stick agency, involving joint working by too much change, unhappy at to syndromes or diseases like a with social care workers and hous - being in respite and felt that she proverbial glue, regardless of their ing. The role of health services is was losing control of her independ - being totally inappropriate.’ She to assess, diagnose and treat any ence. The house was so cluttered felt that Diogenes was a misnomer health or mental health issue that with objects that only a narrow and that Miss Havisham’s syn - may be either the cause of the cur - route from the front door into the drome or ’s syndrome rent situation or a result of the sit - house was available, with items (from Gogol’s book, Dead Souls) uation. If there are issues of risk stacked to the ceiling. The bed - could equally apply. 18 such as self-neglect, fire risk or ver - rooms were inaccessible, and the min that could be managed under mother and daughter slept in Clinical approach relevant mental health legislation chairs in the front room. This room There is some clinical utility in the such as the Mental Health Act or only has two cleared spaces to sit in, approach of Reyes-Oritz 19 who Adults with Incapacity, then it is the rest of the room being taken up suggested a distinction between important to do so. It is also impor - with piles of random items. primary and secondary Diogenes tant to assess the impact of the Antidepressant medication was syndrome depending on whether hoarding on other individuals in discussed, which the patient a mental disorder is present. The the household, especially if they declined but she agreed to have cases discussed here fall into are vulnerable, ie children, and contact with community psychi - either category. social work may have a role in atric nurses and social workers.

www.progressnp.com Progress in Neurology and Psychiatry September/October 2015 15 Case notes z Diogenes syndrome

Mrs A was reviewed over a num - daughter. Given there were no • living in insanitary conditions ber of months and was thought to issues of risk, the use of legislation • unable to devote to themselves, be accepting of the removal of was not relevant here. More and are not receiving from others, items that had been hoarded over recently the daughter has expressed proper care and attention.’ 23 30 years. Her mental state had a wish to deal with their hoarding It must be borne in mind that improved and she was discharged. and they are awaiting input forced clear-outs rarely result in a from psychology. long-term solution to the problem Second contact For houses that are so cluttered and that the hoarding behaviour She was referred again in October they become a fire or vermin haz - will persist and manifest itself 13 by her GP with low mood, and ard local authorities can use the again, requiring repeated clear- stress about clutter in her home. National Assistance Act 1948. This outs if the risk merits it. The She requested a move to sheltered Act was introduced by the post-war process will be very distressing to housing and ‘wanted the clutter Labour Government and estab - the patient and ideally should be removed’. On assessment there lished a specific duty on local done with their consent and was no evidence of self-neglect, authorities to provide residential involvement. or psychosis and she accommodation for people in For people whose hoarding is scored 28/30 on the Mini Mental need together with a general duty felt to be as a result of incapacity State Examination. to provide community services to then consideration should be given disabled people. The Act also con - to the use of the Mental Capacity Third contact tains powers that are occasionally Act (England) 2005 or the Adults Mrs A had an admission to a gen - used to intervene in the lives of an With Incapacity (Scotland) Act eral hospital with delirium. She individual person whom it is 2000. (Please refer to Figure 1 for was felt to be slightly elated and believed is creating an environ - consideration of which legislation treated with risperidone, which mental hazard for others or whose might be appropriate in certain was discontinued on discharge. best interests would be better pro - situations.) vided for if he/she is admitted to Fourth Contact hospital or a care home (and Case 2: Hoarding in context of Concerns were raised by the gen - he/she is refusing to cooperate frontal lobe stroke with predispos - eral adult CPN involved with her with such a proposed plan). ing personality traits. daughter about the amount of However, these days it is rarely used A 75-year-old man who had a money they were spending on as it has been superseded by more history of post-stroke mania and house renovations. Mrs A was modern legislation, which are more frontoparietal ischaemia, which assessed and was not felt to be suf - Human Rights Act compliant. If had required a four week admission fering from delirium or elated these avenues have been exhausted to a psychiatric hospital in 2011. mood, and was thought to have or are not appropriate then each His elevated mood responded capacity. She scored 80/100 on council should have an identified well to treatment and he was dis - ACE III. ‘Proper Officer’ who, with informa - charged home and followed up by tion from the social worker and CPN. On discharge he scored Discussion environmental health officer 92/100 on ACE III. A Functional This case history shows that assess - involved, can make an application assessment showed he was inde - ments over a period of time to the local magistrate’s court. The pendent in his activities of daily liv - revealed no psychiatric illness as a order, if granted, can last up to ing. He was mentally well on precipitant of hoarding behaviour; three months and after six weeks discharge although his house was indeed illness had been precipi - the person subject to the order can described as cluttered. tated by an unwanted attempt to apply to have it revoked. 22 He moved into new area and clear the house and this is in keep - This law states that: for an order was seen as an outpatient only. A ing with the observation of Steketee under section 47 of the National decision was made to gradually that forced ‘clean-outs’ evoke Assistance Act (1948) to be granted reduce his antipsychotic medica - strong negative reactions and the person has to be: tion as he was well. However, he hoarding continues after them. 21 • suffering from grave chronic was seen in April 2014 and was felt Mental health services took a disease to be slightly elated. collaborative approach and were • aged and infirm The doctor involved was con - supportive of both mother and • physically incapacitated cerned about the situation and

16 Progress in Neurology and Psychiatry September/October 2015 www.progressnp.com Diogenes syndrome z Case notes

Has there been a change in If the change can be assessed behaviour, or the person’s and treated you may be able ability to manage its conse - to reduce the risks and avoid Yes quences? Such as loss of job, forceful intervention loss of services

No

Involve other professionals. Are there any other agencies There should be a multidisci - No involved in the assessment? plinary approach to identify - ing causes and solutions

Yes

Consider referring the case to the child protection team, Are there children living in there are greater powers of the house? Does the environ - Can social work provide any Yes No intervention when an adult’s ment adversely impact on additional assistance? decision adversely affects a their welfare? child

It may be possible to remove them and detain them for Does the person have a disor - Yes their own safety under the der or disability of the mind? MHA 1983 or MHA 2007

No

Does the person have mental You may need to make a ‘Best capacity to make specific deci - Interests’ decision, using the No sions relating to their envi - MCA code of practice or AWI ronment? Act

Yes You may be able to remove the person under S47 of the National Assistance Act – this Is the person unable to care is a last resort and can be Yes for themselves due to age or challenged under the Human a physical disability? Rights Act

No Under the Environmental Protection Act 1990 or the Public Health Act 1936 the Continue to support the per - council may have a duty to Is the self-neglect causing a son to improve their situation intervene and clean the envi - Yes risk of infestation or disease No - you have considered every ronment – although long to others? Eg neighbours action within your power and term support may still be must respect their choice needed MHA = Mental Health Act; MCA = Mental Capacity Act; AWI = Adults with Incapacity

Figure 1. Decision tree identifying when to involve other professionals and / or agencies in the management of people with Diogenes syndrome and legislation that may be relevant to related issues www.progressnp.com Progress in Neurology and Psychiatry September/October 2015 17 Case notes z Diogenes syndrome

decided to assess him at home with collateral history as one can put him asleep in a bus shelter on one a mental health officer (MHO). the presentation into context. occasion. The nurse tried to speak On entry to the house access was Mr L was a 90-year-old man to Mr L and to assess him but he limited by clutter with a narrow unknown to psychiatric services refused to speak to her and tried path into front room. Random before this referral. He lived alone to leave, and while speaking to her objects were accumulated every - and was unmarried with no he soiled himself. He was very mal - where and piled high on the floor, children and his next of kin was a odorous and neglected. tables and chairs. There was nephew. Arrangements were made to mouldy food sitting around. The The referral from the GP high - assess the patient at home the kitchen was unusable with out of lighted concern from both social next morning with a mental date with mouldy food everywhere workers and the workers at the health officer. and the rest of house was cluttered. Salvation Army lunch club, which Collateral history from Mr L’s The patient’s mental state at Mr L normally attended daily. He nephew revealed that over last cou - interview revealed a euphoric was described as increasingly con - ple of years, and particularly the mood, a feeling of wellbeing, fused and dishevelled. He had Iast six months, there had been a increased appetite, increased been found wandering and decline in the patient’s personal spending (he thought he was brought back to his house by the care, and that his house was rich), increased activity, increased police. The GP had tried to visit on unclean with unwashed bed sheets. libido, pressured speech, flight of a number of occasions but the There was no heating and he ideas and poor insight. patient was never in as Mr L was seemed unable to use the fire they The patient was thought to be usually out on bus trips. On the day had bought him, nor was he able suffering from a manic episode of referral the GP had been able to to use the cooker or microwave. due to a reduction in his antipsy - gain access and described the The nephew also felt his uncle did chotic and was detained under a house as very malodorous and not recognise him. Short Term Detention Certificate, soiled with urine and faeces. The next day, services were Mental Health (Care and Mr L was disoriented in time informed that Mr L was in emer - Treatment) (Scotland) Act 2003. and could not retain the GP’s gency respite having been taken He responded well to risperi - name. He became irritated by there overnight by the police who done and his mental state questioning and repeatedly said he had been concerned about him. improved. His house was cleaned was fine and that he wanted to be They had attempted to take him in his absence and he returned left alone. He maintained he did home after finding him in the city home with CPN input. He contin - his own shopping and cooking centre where had had been sitting ues to live in his house in a although the kitchen looked unus - still for two and a half hours on a reasonable state of order. able with lots of empty marmalade bench in the heat. On attending jars. The GP’s opinion was that he his house they found flies, mice, no Discussion was suffering from a dementing electricity, no heating, faeces in a There was a suggestion from the process and was posing a risk to bag with used toilet paper all over personal history that the patient was himself but was not detainable and the house and no food, with cup - predisposed to leading a cluttered did not wish intervention. boards full of unused medication. life but that it was only after a frontal A CPN tried to assess Mr L at The assessing doctor found him lobe stroke that it became unman - the Salvation Army lunch club: smiling, cooperative, and very hun - ageable. Due to his lack of insight people at the club were able to tell gry. He was disorientated in time and the evident risk it was appropri - the CPN that Mr L had previously and place and did not know his ate to use the MHA and that the worked as a manager in a utility own address. He thought his sister clutter was a by-product of elevated firm and had attended the local was still alive (she had passed away mood. To date the patient remains Salvation Army club for lunch daily five months previously). He lacked euthymic and lives in an uncluttered for last four years. They had any insight into his situation or the state with no self neglect. noticed a decline in his personal concerns people had about him. appearance and hygiene with It was felt that he needed inpa - Case 3: Squalor and hoarding in weight loss, and his attendance tient assessment for physical and the context of evolving frontotem - had become sporadic. Bus drivers mental health reasons. In consulta - poral dementia. This case high - had turned him away due to his tion with the MHO the decision was lights the importance of a good malodour. The police had found made to detain him using the MHA.

18 Progress in Neurology and Psychiatry September/October 2015 www.progressnp.com Diogenes syndrome z Case notes

On admission, his clothes ‘Hoarding behaviour: building up accumulate items. Cognitive needed washing three times, his the ‘r’ factor’. 14 restructuring addresses the indi - nails were in urgent need of Steketee and Frost, who have vidual’s obsessive with regard chiropody, and his scrotum was developed a CBT approach to the to discarding objects. This involves enlarged and pustular. His admis - situation, hypothesise that: working with the of letting sion bloods showed: eGFR 15; urea ‘Hoarders tend to use their collec - go of something that feels impor - 32; creatinine 345, and CRP 147. tion of clutter as a form of comfort tant. Patients learn to conceptu - As a result, he was transferred to and security, with deep emotional alise their hoarding in terms of the general hospital for investiga - investment coined as ‘hypersenti - problems with anxiety, avoidance tion and treatment mentality’; these individuals and information processing. A CT scan done on transfer the grief-like emotions that would Progress can be assessed by showed moderate global cerebral come with the disposal of clutter’. 24 using the Hoarding Scale 26 and atrophy and severe atrophy of Maier also thought it was impor - the Clutter Image Rating Scale. 27 bilateral anterior temporal lobes, tant to understand the individual’s which was worse on the left side. intentions and attachment to the Pharmacotherapy These findings would be suspicious hoarded objects. He thought that To date, there have been no large for frontotemporal dementia. subjects fell into two groups: those randomised controlled trials to Volume loss of the hippocampi was for whom the hoarding was a syn - guide pharmacological treatment also noted and mild periventricu - drome and that any attempt to dis - of primary Diogenes syndrome. 28 lar low attenuation was in keeping card objects would result in SSRIs may be clinically useful; how - with microvascular disease. distress, ie primary Diogenes syn - ever, most of the data are from Although he responded well to IV drome, and those for whom the small trials involving patients with fluids and antibiotics Mr l unfortu - hoarding was a symptom and that obsessive compulsive disorder have nately died seven days later from the objects themselves had no emo - symptoms of hoarding, and not cardiac arrest. tional significance, ie secondary primary hoarding per se .29 At best, Diogenes syndrome. 25 SSRIs are likely to be only partially Discussion effective in patients hoard with With a full collateral it became Understanding the CBT approach obsessive–compulsive disorder. clear that there had been deterio - The intervention developed by There have been a few small, ration in this man’s functioning Steketee 21 focuses on four main open-label uncontrolled trials in and that his insight was impaired. problem areas: primary hoarding patients. In one He could have been managed • Vulnerability factors open-label study comparing pri - under Section 47 AWI but as he • Beliefs and attachments mary hoarders to non-hoarding physically improved he was less • Positive and negative emotions OCD patients, paroxetine showed inclined to stay in hospital, there - • Hoarding accumulation and similar response rates between the fore continued detention under inability to discard. two groups, suggesting benefit MHA was appropriate. from SSRI medication in patients The psychological approach who hoard. 29 A similar small open- Management involves an average of 26 sessions label study of 24 patients suggested Assertive engagement and CBT held on a weekly basis (range 15- extended-release venlafaxine may If the patient is willing to engage 30 depending on patient need) be effective for the treatment of with treatment the approach best spread over 6-12 months. Ideally hoarding disorder and was well tol - used is that of cognitive behav - every fourth session is held at the erated. 30 Authors of a small case ioural therapy (CBT), as the evi - patient’s house. Motivational inter - series which examined the effec - dence base for pharmacological viewing aimed at addressing tiveness of methylphenidate in intervention is small and focuses ambivalence and poor insight patients with significant hoarding. on the use of selective takes up part of several sessions, However, only 2 out of 4 patients reuptake inhibitors (SSRIs) for especially early in treatment. in the series demonstrated benefit, compulsive hoarding. 24 A more The cognitive–behavioural and the results were modest. 31 So detailed and useful description of component focuses on decreasing far, trials examining the effective - the psychological approach can be clutter, improving decision-making ness of pharmacotherapy in this found in an article in Advances in and organisational skills and patient group are small and Psychiatric Treatment entitled: strengthens resistance not to unblinded – clearly there is a great

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need for larger, controlled trials of References www.iep.utm.edu/diogsino/ (accessed August SSRIs and other medication to 1. www.channel4.com/programmes/the- 2015). guide future practice. hoarder-next-door (accessed August 2015). 17. Marcos M, Gomez-Pellin MDC. A tale of a 2. www.tlc.com/tv-shows/hoarding-buried- misnamed eponym. Diogenes syndrome. Int J alive/ (accessed August 2015). Geriatr Psychiatry 2008;23:990–1. Conclusion 3. Amanullah S, Oomman S, Datta SS. 18. Cybulska E. Senile squalor: Plyushkin’s not If left alone, people suffering from ‘Diogenes syndrome’ revisited. Ger J Psychiatry Diogenes’ syndrome. Psychiatr Bull 2009;12:38–44. 1998;22:319–320. Diogenes syndrome have an 4. American Psychiatric Association. Obsessive 19. Reyes-Ortiz CA. Diogenes syndrome: the increased mortality with a 46% five- compulsive and related disorders: Hoarding self-neglect elderly. Compr Ther 2001;27: year death rate, 32 most likely due to disorder. www.dsm5.org/Documents/ 117–21. Obsessive%20Compulsive%20Disorders%20F non-engagement with services and 20. https://www.glasgow.gov.uk/PublicHealth act%20Sheet.pdf (accessed August 2015). 21. Steketee G, Frost R. Compulsive Hoarding poor compliance with treatment for 5. Macmillan D, Shaw P. Senile breakdown in and Acquiring. Therapist Guide. Oxford: concurrent physical illness. standards of personal and environmental Oxford University Press, 2007. cleanliness. BMJ 1966;2:1032-7. 22. https://www.westsussex.gov.uk/idoc.ashx? Assessment is often prolonged 6. Shah AK. Senile squalour syndrome: what docid=f1dda48f-1ce4-43ee-a667-540570021 to expect and how to treat it. Geriatr Med and should involve a multi-agency ec1&version=-1 1990;36:29-34. approach. Clinicians should be 23. National Assistance Act 1948. www.legisla - 7. Berlyne N, Twomey J, Henderson Smith SL. tion.gov.uk/ukpga/Geo6/11-12/29/contents aware of the association between Diogenes syndrome. Lancet 1975;305:515. (accessed August 2015). hoarding and mental illness and 8. Wrigley M, Cooney C. Diogenes syndrome — 24. Frost RO, Hartl TL, Christian R, et al . The the assessment process should be an Irish series. Ir J Psychol Med 1992;9:37-41. 9. Saxena S, Maidment KM. Treatment of com - value of possessions in compulsive hoarding: one of exclusion, using relevant pulsive hoarding. J Clin Psychol 2004;60: patterns of use and attachment. Behav Res legislation if appropriate. 1143–54. Ther 1995;33:897–902. 25. Maier T. On phenomenology and classifica - CBT is still the most effective 10. Macmillan D, Shaw P. Senile breakdown in standards of personal and environmental tion of hoarding: a review. Acta Psychiatr treatment for hoarding with a cleanliness. BMJ 1966;2:1032-7. Scand 2004;110:323–37. small group of compulsive hoard - 11. Jaspers K. In: Hoeing J, Hamilton MW. 26. Frost RO, Gross RC. The Hoarding of pos - ers benefiting from SSRIs. General Psychopathology . 7 th edition. trans. sessions. Behav Res Ther 1993;4:367–81. Manchester: Manchester University Press; 27. Frost RO, Steketee G, Tolin DF, et al . 1963:639-698. Development and validation of the clutter Dr Browne is a Consultant in Old 12. Badr A, Hossain A, Iqbal A. Diogenes syn - image rating. J Psychopathol Behav Assess Age Psychiatry, NHS Forth Valley drome: when self-neglect is nearly life threat - 2008;30:193-203. ening. Clinical Geriatrics 2005;13(8):10-13. 28. Mataix-Cols D. Hoarding disorder. N Engl J and Dr Hegde is a Consultant in Old 13. Clark ANG, Mankikar GD, Gray I. Diogenes Med 2014;370:2023–30. Age Psychiatry and Honorary syndrome: a clinical study of gross neglect in 29. Saxena S. Pharmacotherapy of compulsive Clinical Senior Lecturer at old age. Lancet 1975;305:366-8. hoarding. J Clin Psychol 2011;67(5):477–84. 14. Kiran-Imran F, Hassiem F, Vaughan J. 30. Saxena S, Sumner J. Venlafaxine extended- Leverndale Hospital, Glasgow. Hoarding behaviour: building up the r factor. release treatment of hoarding disorder. Int Adv Psychiatr Treat 2009;15:344-53. Clin Psychopharmacol 2014;29(5):266–73. Acknowledgements 15. The British Museum. Ugo da 31. Rodriguez CI, Bender J Jr, Morrison S, et Carpi, Diogenes, a woodcut after al . Does extended release methylphenidate With thanks to Professor Graham Parmigianino www.britishmuseum.org/ help adults with hoarding disorder?: Jackson UWS, and Dr Damian explore/highlights/highlight_objects/pd/u/ugo a case series. J Clin Psychopharmacol Lynch, Consultant in Old Age _da_carpi,_diogenes,_a_wood.aspx (accessed 2013;33(3):444–7. August 2015). 32. Hanon C, Pinquier C, Gaddour N, et al . Psychiatry, Lanarkshire, for their 16. Internet Encyclopedia of Philosophy. Diogenes syndrome: a transnosographic input. Diogenes of Sinope (c. 404—323 B.C.E.) approach. Encephale 2004;30:315–22.

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