Diogenes' syndrome in patients with intellectual disability: 'a rose by any other name'?

Neuropsychological characteristics of people living in squalor

BACKGROUND

Squalor is an epiphenomenon associated with a range of medical and psychiatric conditions. People living in squalor are not well described in the literature, and prior work has indicated that up to 50% do not have a psychiatric diagnosis. Squalor appears to be linked with neuropsychological deficits suggestive of the presence of impaired executive function. We present a case series of people living in squalor that examines their neuropsychological assessment and diagnosis.

METHODS

Clinicians from local health networks were invited to submit neuropsychological reports of patients living in squalor. These selected reports were screened to ensure the presence of squalor and a comprehensive examination of a set of core neuropsychological domains. Assessments were included if basic attention, visuospatial reasoning, information processing speed, memory function, and executive function were assessed.

RESULTS

Sixty-nine neuropsychological reports were included. Sixty-eight per cent of the group underwent neuropsychological assessments during an inpatient admission. For participants where it was available (52/69), the mean Mini-Mental State Examination score was 25.29 (SD = 3.96). Neuropsychological assessment showed a range of cognitive impairment with nearly all the participants (92.75%) found to have frontal executive dysfunction. One person had an unimpaired neuropsychological assessment. Results indicated that dorsolateral prefrontal rather than orbitofrontal functions were more likely to be impaired. Vascular etiology was the most common cause implicated by neuropsychologists.

CONCLUSIONS

Frontal executive dysfunction was a prominent finding in the neuropsychological profiles of our sample of squalor patients, regardless of their underlying medical or psychiatric diagnoses. Our study highlights the importance of considering executive dysfunction when assessing patients who live in squalor.

Diogenes syndrome in patients suffering from dementia

Diogenes syndrome (DS) is a behavioral disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state, and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help, and a tendency to accumulate unusual objects. To explore the phenomenon of DS in dementia we searched for the terms: “Diogenes syndrome, self-neglect, dementia. ” It has long been understood that individuals with dementia often become shut-ins, living in squalor, in the Eastern Baltimore study, dementia was present in 15% of the elderly cases with moderate and severe social breakdown syndrome; twice as many as in the general population of the same age group. Researchers have underlined the frequent presence of DS (36%) in frontotemporal dementia (FTD): different neuropsychological modifications in FTD may contribute to symptoms of DS. The initial treatment should be a behavioral program, but there is not sufficient information regarding pharmacological treatment of the syndrome.

Forensic Issues in Cases of Diogenes Syndrome

Diogenes syndrome is a syndrome described in the clinical literature in elderly individuals characterized by social isolation and extreme squalor. A number of typical features are found in the forensic evaluation of these deaths as the cases usually initiate medicolegal investigations due to the circumstances and the lack of recorded medical histories. Examinations of the death scenes are often difficult as victim's houses are in a state of disrepair, with filth and clutter, and pet dogs may resent the intrusion of strangers. Bodies are often filthy, with parasitic infestations, and are often putrefied due to the social isolation of the deceased and the delay in the finding of the corpse. Bodies may be traumatized from postmortem animal depredation by rodents or pets (eg, cats, dogs), and injuries such as bruises and lacerations may be present from falls associated with terminal illnesses or alcoholism. Blood or putrefactive fluids may be spread throughout the house by pets. Treatable medical conditions are often present in advanced stages, and features of hypothermia may be found. Attending police may suspect robbery due to disarray of the house and homicide due to apparent "bleeding" around the body from purging of putrefactive fluids, injuries from falls, or postmortem animal activity and "blood stains" throughout the house from antemortem injuries and/or fluid spread by animals. Finally, the identification of the deceased may be compromised by decay and/or postmortem animal activity. Thus, in addition to having typical clinical manifestations, such individuals appear to form a distinct subset of forensic cases having characteristic death scene and autopsy features and presenting particular difficulties in postmortem evaluations.

On phenomenology and classification of hoarding: a review

OBJECTIVE

Hoarding is a behavioural abnormity characterized by the excessive collection of poorly usable objects. It is described mainly in association with obsessive-compulsive disorders (OCDs) and in geriatric populations. Yet the literature on the phenomenon is heterogeneous and the notion obviously lacks a consistent definition. This review attempts to describe the psychopathological and clinical spectrum of hoarding and may contribute to clarify its classification.

METHOD

Systematic review and discussion of the literature on hoarding.

RESULTS

Hoarding is a complex behavioural phenomenon associated with different mental disorders. The psychopathological structure is variously composed of elements of OCDs, impulse-control disorders, and ritualistic behaviour. Severe self-neglect is a possible consequence of hoarding.

CONCLUSION

Without further specifications the term hoarding is of limited heuristic value and cannot guide therapeutic interventions satisfactorily. The condition needs to be evaluated carefully in every particular case in relation to the aforementioned psychopathological concepts.

Le syndrome de Diogène, une approche transnosographique

Diogenes syndrome is a behavioural disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help and a tendency to accumulate heteroclite objects. This particular geriatric syndrome has been described for the first time only quite recently, as the 2 primary descriptions by geriatricians and psychiatrists date from 1966 and 1975 respectively. Its rare occurrence contrasts with the fact that it is well-known, partly due to it being named after the Greek philosopher "Diogene de Sinope", who taught cynicism philosophy and a return to a natural way of life, and partly because of its rare characteristics. The Diogenes syndrome is a fascinating object of study for the clinician who takes care of patients living in uncommon conditions, on the edge of society and unaware of the particularity of their lifestyles. Patients suffering from Diogenes syndrome are usually discovered by chance, either because of a somatic illness, or as a result of social intervention related to their behavioural problems. Management of the syndrome is difficult and ethically challenging, as the patient does not seek help. Moreover, 46% of patients have a 5 year mortality rate. Hospitalisation has to be avoided whenever possible and ambulatory treatment and social measures should be favoured. Psychotropic treatment prescription may be necessary, depending on clinical features and the possible underlying psychiatric disease. Although several clinical hypotheses have been suggested, the true ethiopathogeny of the syndrome remains unclear. Most authors agree that this behaviour does not reflect free will and has consequently no theoretical relationship to the Greek philosopher. There is no true consensus about diagnostic criteria. They include the main features of the syndrome and exclude known psychiatric syndromes. Clark and Mankikar, who named this syndrome, reckon it may represent stress-related defence mechanisms of the elderly or may be related to natural ageing process. However, psychiatric pathologies as paranoid and paranoiac psychoses, mood disorders and obsessive and compulsive disorders have been described to be associated with it in the literature. Dementia, in particular temporo-frontal dementia, should be looked for and excluded clinically. Alcohol abuse seems to be an aggravating rather than a precipitating factor. Finally, the link between these pathologies and Diogenes syndrome is not yet determined: are they triggering, co-morbid or etiological factors? Should this syndrome be considered as a true illness or as a symptom? This paper presents Diogenes syndrome as a behavioural disorder and distinguishes 2 types: the "active type"--patients who collect from outside to clutter inside--and the "passive type"--patients who passively become invaded by their rubbish. Active type patients fill their home to fill in the vacuum of their life, as it deteriorates and looses its narcissical appeal. Passive type patients accumulate by default and emptiness. A psychopathological understanding is presented here, referring to psychoanalytical theories of the Moi-peau (ego-skin) described by Anzieu. The Moi-peau represents a structure of the psyche founded on the following principle: any psychic function develops itself according to a bodily function from which it transposes its functioning at a mental level. The skin has three functions: the containing shell, the protective barrier of the psyche, and a medium of exchange. The Moi-peau is organised as a double-wall acting both as a defence mechanism and as a filter between the psyche and the external world. It preserves the relationship and the cohesion "container-content". As a result of a narcissical wound, the Moi-peau is damaged and looses its function of a container. In the case of Diogenes Syndrome, the accumulated items repair the Moi-peau and the home becomes an "exterior-proof", thus playing the role of the Moi-peau. This behaviour therefore plays a repairing role for psychic functioning, allowing psychic survival.

Diogenes syndrome: the self-neglect elderly

Diogenes syndrome (DS) is characterized by severe self-neglect, domestic squalor, social withdrawal, syllogomania, and refusal of help that may be precipitated by stressful events. Secondary DS is related to mental disorders. Its management includes day care center and community care.