article on diogenes syndrome

PSYCHIATRY ROUNDS

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Clinical Geriatrics Volume 13, Number 8 August 2005

Drs. Badr, Hossain, and Iqbal are from the Department of Psychiatry, Bergen Regional MedicalCenter, Paramus, NJ.

Dr. Lantz is Director of Psychiatry, The JewishHome & Hospital, 120 West 106th St, New York,NY 10025; (212) 870-5995; fax: (212) 870-4905;e-mail: [email protected].

conditions, she was involuntarily hospitalized in anacute geriatric psychiatric unit.

On admission, physical examination revealedarthritic deformities of both hands, and neglectedvenous ulcers were seen bilaterally on the ankles. Theinitial psychiatric assessment provided no evidence fordementia, or affective or psychotic disorders. Neuro-psychological evaluation showed no evidence ofdementia. Overall, the patient’s general intellectualability was in the average range. Executive functions,attention, memory, language, and visual and spatialperception were grossly intact. Ms. G had no priorpsychiatric history of hospitalization or treatment. Shedenied any family history of psychiatric illness or his-tory of substance abuse. Her developmental and socialhistory revealed an independent and isolative person-ality. Her mother passed away when she was 5 years ofage. She had no siblings, and she lived with her fatherand stepmother. She described her relationship withthem as “neutral.” At the age of 21, she moved out ofher parents’ house, and since then has had little con-tact with her family. Ms. G reported a lifelong patternof having no significant relationships and denied hav-ing any friends. She displayed a marked indifference toher social isolation and loneliness.

Ms. G reported that she was always advanced aca-demically and had earned a BS degree in sociology.

CASE PRESENTATIONMs. G is a 72-year-old, single white female wholives alone and has no children. She was visited bylocal mental health services at the request of herneighbors, who complained about an intolerablesmell and flies coming from her apartment. Onobservation from the entrance, the apartment wasgrossly dirty with an offensive odor. The carpetswere soaked with urine and moldy feces. Piles ofgarbage, each about 5 feet high, restricted the liv-ing space. There was no furniture in the house, norefrigerator, and among the garbage the only signsof nourishment were cracker wrappers and sodacans. Ms. G was in a state of gross physical neglect,dressed in layers of dirty clothing stained withurine. The exposed surfaces of her skin weredeeply engrained in dirt. She minimized the seri-ousness of the damage in her apartment, refused tocommunicate, and vehemently resisted any profes-sional help. Because of concerns that the patientwas in imminent harm due to her dangerous living

Diogenes Syndrome: When Self-Neglect is Nearly Life ThreateningAmel Badr, MD, MSc, Asghar Hossain, MD, DFAPA, and Javed Iqbal, MD

Series Editor: Melinda S. Lantz, MD

The patient also stated that she has been working asan employment counselor for the past 20 years, butrefused to give any phone numbers for her work. Nocollateral information could be obtained.

While on the inpatient unit, Ms G. showed lackof initiative for most activities. She used a wheelchairinstead of ambulating, and continuously refused toshower or change her clothing. She continued to iso-late herself in her room. Ms. G appeared aloof, wasverbally aggressive and hostile toward the staff, andwould not socialize with any of the patients on theunit. A diagnosis of personality disorder withschizoid and paranoid traits was considered.

Laboratory tests were done to exclude organiccauses. This included thyroid function tests, vitaminB12 and folic acid levels, urinalysis, urine toxicology,complete blood count, blood chemistry, and com-puterized tomography of the head. The significantfindings were: low hemoglobin level (8.9 g/dL [12-16 g/dL]), low hematocrit level (26.4% [37-47%]),low serum iron level (16 µg/dL [35-175 µg/dL]),and upper-normal iron-binding capacity (389 µg/dL[250-400 µg/dL]), suggesting that the patient hadiron deficiency anemia possibly due to malnutrition.

Ms. G strongly opposed her hospitalization andalleged that her lifestyle was the expression of her per-sonal freedom. She also exhibited paranoid ideationstoward the staff. She was started on risperidone 0.5mg orally twice per day; however, she refused to takeany medications.

After three weeks of hospitalization, she was dis-charged from the hospital. Ms. G declined the socialservices offered to her at the time of discharge and didnot comply with her follow-up plan. The patient wasfound to be competent to make her own decisions, andshe only accepted assistance from a longtime friend ofhers, who promised to help her clean her apartment.

DISCUSSIONDiogenes syndrome is a behavioral disorder of the eld-erly. The cardinal features of this condition includeextreme self-neglect, domestic squalor, and tendencyto hoard excessively (syllogomania). This is associat-ed with self-imposed isolation, refusal of help, andmarked indifference or lack of awareness.1 Diogenessyndrome has been referred to as senile breakdown,social breakdown, senile squalor syndrome, and messyhouse syndrome.

In 1966, Macmillan and Shaw2 were the first tosuggest that senile breakdown in the standards of per-sonal and environmental cleanliness is a syndrome.Clark and coauthors3 appointed it the name “Dio-genes,” inspired by the 4th century BC Greek philoso-pher Diogenes of Sinope, who advocated the princi-ples of self-sufficiency, freedom from social restraints,and rejection of material values. They explained that itmay represent stress-related defense mechanisms of theelderly, or may be related to the natural aging process.

In 1982, Post4 used the term senile recluse andargued that it is not a syndrome but merely an endstage of personality disorder. Since then, severalcase series of the syndrome have been reported.According to the literature,5,6 these patients aredescribed as aloof, domineering, suspicious, aggres-sive, and obstinate. The disorder is not specific to acertain socioeconomic status and is equally preva-lent among men and women in the age range of60-90 years. Most are single or widowed, livingalone, and their decline tends to be lengthy induration. Some patients have a prior psychiatrichistory. Noncompliance with treatment and fol-low-up are almost universal. Physical illness, suchas pneumonia and multiple nutritional deficiencystates, is common, and the mortality rate can behigh. Most patients studied have above-average

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P S Y C H I A T R Y R O U N D S

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Psychiatric Disorders Associated with Diogenes Syndrome6,7,9,12

Diagnosis Features

Dementia Frontal lobe degeneration results in apathy, preservative behavior, poor self-care, lack of insight

Obsessive-compulsive Compulsive hoarding often a significant symptom, obsessional anxiety, avoidingdisorder decisions, rituals

Substance abuse/ Self-neglect, living in squalor, apathy related to intoxication, malnutrition, spendingdependence money on drugs rather than food or possessions

Delusional disorder Fixed delusional belief with ability to function, isolation, avoidant behavior, poor socialskills, may assign meaning to useless objects and refuse to discard anything

Personality disorders Avoidant, schizoid, schizotypal, paranoid traits lead to isolation, poor decision-making skills, inability to establish relationships or accept assistance

Mental retardation Poor self-care, attachment to objects, rituals and repetitive behaviors, poor social skills, may hoard food (Prader-Willi syndrome)

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intelligence, successful work histories, stable familybackgrounds, and adequate social resources.

Multiple hypotheses have been advanced toexplain the underlying pathology. Obsessive-com-pulsive disorder and obsessive-compulsive personal-ity disorder are most frequently described,7 fol-lowed by paranoid psychoses and mood disorders.8

It also has been suggested that the early stages offrontal-lobe dementia may present with features ofDiogenes syndrome. This includes personalitychanges, self-neglect, lack of concern, loss of initia-tive and insight, and paranoid symptoms.9 Dio-genes syndrome does not fit clearly into our currentDiagnostic and Statistical Manual of Mental Disor-ders, fourth edition-text revision (DSM-IV-TR)10 orInternational Statistical Classification of Diseases andRelated Health Problems, tenth edition (ICD-10)11

diagnostic criteria, as currently only obsessive-com-pulsive disorder specifically lists hoarding as asymptom, and other features of the disorder areincluded in many diagnoses including dementia,

mental retardation, schizophrenia, delusional disor-der, and personality disorders (Table).6,7,9,12

This case demonstrates almost all the typical featuresof Diogenes syndrome. Ms. G demonstrated a lifelongpattern of isolation, inability to establish relationships,compulsive behavior, and paranoia that slowly pro-gressed into social breakdown, characterized by severeself-neglect that could not be explained by the severityof her physical illness or lack of social support.

Ms. G did not fit the criteria for any DSM-IV-TR10

Axis I disorder. One of the possible differential diag-noses was depression, due to her apparent apathy andlack of motivation. However, she did not displaydepressed mood or vegetative features, and had nosense of guilt, inadequacy, or suicidal ideation.Although the patient was suspicious, guarded, and eva-sive, she did not display any distinct delusions or hallu-cinations that would suggest a diagnosis of delusionaldisorder or late-life schizophrenia. Ms. G’s psychosocialhistory and lifestyle revealed a pattern of schizoid,avoidant, obsessive-compulsive, and paranoid traits.

The analysis of our case appears to support KarlJaspers’ formulation of “social breakdown of the elder-ly.”13 He proposed that this condition does not consti-tute a newly occurring psychopathological entity, as thewhole picture is understandable from each subject’spersonality and stressful life events. He emphasized thatthe characteristics of the premorbid personality play anintegral role in the pathogenesis of the syndrome. Hisview of this syndrome was that it represents a lifelongsubclinical personality disorder, probably of a schizoidor paranoid type, that turns gradually into gross self-neglect and social isolation. This deterioration is precip-itated by stressful life events, such as loss of a spouse oraging by itself, and is further aggravated by increasing-ly debilitating physical problems. Karl Jaspers13 calledthe social breakdown of the elderly “a personality basedabnormal emotional reaction development or adjust-ment disorder.” He explained that the complex of per-sonality factors, loneliness, stress, and somatic illnessform a vicious cycle, resulting in a reclusive lifestyle,abandonment of basic social norms, and persistentrefusal of help as they invoke the defense mechanismsof withdrawal and denial of need.

Diogenes syndrome still raises many unresolvedissues. Although it is associated with an increasingnumber of psychiatric conditions (Table), the inves-tigation of the psychopathological or nosologicallinks with the concomitant disorders is still lacking.

Management is also a difficult issue. Patients’ con-tinued refusal of help gives rise to complex ethicaland medicolegal issues.

Day care and community care are the main lines ofmanagement rather than hospital admission. Severalstudies have utilized selective serotonin reuptakeinhibitors to treat the compulsive hoarding behaviors.Atypical antipsychotic agents have been used whenparanoid symptoms are present. A concrete approach

to home safety, including preventing additional clut-ter, establishing a cleaning plan, discarding objects,and organizing the living space, have been successfulover time in assisting older adults in regaining a senseof control over their environment.12

Despite all efforts and care, the outcome of thesyndrome is rather bleak. Follow-up visits showedthat of those at home, only a few lived in better cir-cumstances than previously. The prognosis is alsopoor, with 46% of the patients having a 5-year mor-tality rate, possibly due to physical complications.14

OUTCOME OF THE CASE PATIENT

Unfortunately, Ms. G refused follow-up care and hadno further contact with the hospital.

REFERENCES1. Ungvari GS, Hantz PM. Social breakdown in elderly, II. Sociode-

mographic data and psychopathology. Compr Psychiatry1991;32(5):445-449.

2. Macmillan D, Shaw P. Senile breakdown in standards of personaland environmental cleanliness. Br Med J 1966;2:1032-1037.

3. Clark AN, Mankikar GD, Gray I. Diogenes syndrome. A clinicalstudy of gross neglect in old age. Lancet 1975;1:366-368.

4. Post F. Functional disorders I. Description, incidence and recogni-tion. In: Levy R, Post F, eds. The Psychiatry of Late Life. Oxford:Blackwell; 1982:176-196.

5. Reyes-Ortiz CA. Diogenes syndrome: The self-neglect elderly.Compr Ther 2001;27(2):117-121.

6. Rosenthal M, Stelian J, Wagner J, Berkman P. Diogenes syndromeand hoarding in the elderly: Case reports. Isr J Psychiatry RelatSci 1999;36(1):29-34.

7. Seedat S, Stein DJ. Hoarding in obsessive-compulsive disorderand related disorders: A preliminary report of 15 cases. Psychiatry Clin Neurosci 2002;56:17-23.

8. Cooney C, Hamid W. Review: Diogenes syndrome. Age Ageing1995;24(5):451-453.

9. Greve KW, Curtis KL, Bianchini KJ, Collins BT. Personality disor-der masquerading as dementia: A case of apparent Diogenessyndrome. Int J Geriatr Psychiatry 2004;19(7):703-705.

10. American Psychiatric Association. Diagnostic and Statistical Man-ual of Mental Disorders, fourth edition, text revision. Washington,DC: American Psychiatric Association; 2000.

11. World Health Organization. International Statistical Classificationof Diseases and Related Health Problems, tenth edition (ICD-10).Geneva: Who Press; 1993.

12. Saxena S, Maidment K. Treatment of compulsive hoarding. J ClinPsychol 2004;60(11):1143-1154.

13. Jaspers K. General Psychopathology, seventh edition. Hoeing J,Hamilton MW, trans. Manchester: Manchester University Press;1963:639-698.

14. Hanon C, Pinquier C, Gaddour N, et al. Diogenes syndrome: A transnosographic approach [in French]. Encephale2004;30(4):315-322.

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