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 dementia . 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 14 Progress in Neurology and Psychiatry September/October 2015 www.progressnp.com Diogenes syndrome z Case notes 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 Plyushkin’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.