Review: Diogenes syndrome

Age and Ageing, Sept, 1995 by Colm Cooney, Walid Hamid

A typical scene which must be familiar to many doctors, social workers, district health nurses and members of the public is that of a reclusive elderly person living alone in a dilapidated filthy house. The home is cluttered with rubbish and infested with vermin. Excrement and decomposing food are strewn around the floors and the stench emanating is unbearable to all but the occupant who is blissfully unconcerned by the situation. Diogenes syndrome, variously known as senile breakdown [1], social breakdown [2] and senile squalor syndrome [3], refers to this condition and is characterized by extreme self-neglect, domestic squalor and social withdrawal and is often accompanied by excessive hoarding (syllogomania) and lack of concern about one's living conditions. The estimated annual incidence is 5 per ten thousand of the population aged over 60 years living at home, at least half of whom will have dementia or some form of mental illness [1, 4-6]. Most old age psychiatrists have some experience in managing this condition. The term was first suggested by Clarke et al. [4] and has been in common usage since. Clarke did not define it operationally and there has been some confusion as to whether it is inclusive or exclusive of those with underlying mental illness or dementing disorder. Severe breakdown in standards of personal and environmental hygiene has also been described in younger adults [6, 7] and there seems to be no rationale for confining the term to elderly people.

Diogenes, a Greek philosopher of the 4th century BC, advanced the principles of self-sufficiency and contentment unrelated to material possessions. There is no evidence that people in `senile squalor' hold these core values. Their reclusiveness appears to be motivated not by a desire to maintain self-sufficiency but rather by a suspiciousness and rejection of the outside world. A number of alternative terms have been proposed including Havisham's or Plyushkin's syndrome based on more appropriate literary figures [8]. However the current eponym of the syndrome is unlikely to be displaced in the near future and should be retained as it has undoubtedly helped to increase medical awareness of the condition.

Clinical features and aetiology

The major difficulty in making generalizations about Diogenes syndrome from published research is that all the published studies have been restricted to subjects presenting to health services. It is unlikely that these are truly representative of the group in general. However the major systematic studies of this condition have been notable for their similarities rather than their differences and a core body of knowledge has emerged about the disorder. There have been several major case series of the syndrome over the past 30 years. Macmillan and Shaw's pioneering study in Nottingham [1] was a 3-year prospective community study examining all cases of senile squalor which were reported by general practitioners, geriatricians, social workers and clergy. They called the condition senile breakdown, viewed it as a distinct syndrome and reported no evidence of psychosis in 34 of the 72 cases encountered. They found that those at risk of lapsing into such squalor were 'old people of the independent and domineering type living alone, with poor or non-existent social links with their local community'.

Clarke et al. [4] studied 30 cases of Diogenes syndrome admitted to an inpatient medical unit over a 10-month period and found a roughly similar proportion of cases (50%) where no psychiatric disorder was identified.

Both studies identified a significant proportion of cases with higher than average intelligence. Clarke's study included personality assessment using the Cattell Personality Inventory and found patients were more aloof, suspicious, detached, aggressive and poorly socially integrated

In a study of 29 cases presenting to an old age psychiatry service, Wrigley and Cooney [5] found that about one-third of cases had no psychiatric disorder while most of the remainder suffered with dementia. There is a thus a consensus from the literature that at least half of the cases have psychiatric disorders [1, 4-6] the commonest diagnosis being dementia but with some cases of alcohol abuse, affective disorders and paraphrenia. Although the majority of cases in all three studies were living alone, Macmillan and Shaw [1] and Wrigley and Cooney [5] described five and four cases respectively of couples in which both individuals fulfilled criteria for the syndrome. The similarity with folie a deux has been noted [1, 8]. Diogenes syndrome by proxy [9] has recently been described manifesting as a form of `elder abuse' and could be an explanation for some cases of `Diogenes a deux'. To date all studies have concentrated exclusively on persons in private households who exhibit the syndrome, although there is no doubt that it also occurs among homeless elderly people.

It is not easy to understand why a gross deterioration in standards of personal and domestic hygiene should develop in persons who manifest no frank mental illness. A number of hypotheses have been suggested. It has been argued that this condition represents the 'end stage of a personality disorder' [10] rather than a specific syndrome. Clinical experience suggests that many of those affected have previously been eccentric individuals who have led reclusive lives, but whether this constellation of personality traits justifies a diagnosis of personality disorder is debatable and would require more rigorous analysis. Orrell and Sahakian's [11] hypothesis that Diogenes syndrome is really a manifestation of a frontal-lobe dementia is intriguing but there is little supporting evidence. Frontal-lobe pathology may share symptoms in common with Diogenes syndrome, including irritability, aggression, reduced motivation and lack of insight, while syllogomania could represent a form of motor perseveration. However, the age distributions of the two conditions do not match, with frontal-lobe dementia occurring on average ten years earlier. Neuro-imaging or neuropathological studies of Diogenes syndrome cases would help to resolve this issue but would be difficult to conduct because of poor co-operation on the part of those affected.