Diogenes Syndrome

David Jolley and Greg Spencer

Aggie MacKenzie and Kim Woodburn: Grime busters/Dirt Detectives

Diogenes Syndrome: Original paper

Diogenes Syndrome: a clinical study of gross neglect on old age.Clark A, Mankikar G and Gray I (1975) (ii) 366- 368

With acknowledgements to Drs N Condon, W Parker and JA Whitehouse. Brighton General Hospital

A study of ‘ the acutely ill old person with a dirty and neglected appearance, in a setting of gross domestic disorder and squalor’

Reference two previous articles:MacMillan and Shaw (1966) BMJStevens (1963) British Journal of Geriatric Practice

Profile of the Brighton series

14 male 16 female aged 66-92 (mean 79)Referred for admission October 1972- July 1973 (10 months)

28 lived aloneone man with a son and grandson one man with an unmarried daughter17 had relatives

All were well known to local services12 received home services10 repeated rejected offers of help

Three men had held service commissions; two were journalists, one a dentist, one a violinist.Five women had been teachers, one a fashion designer, one an opera singer

Brighton series: Social status‘Their homes filthy on the outside – peeling paintwork and dirty, often broken windows with dingy net curtains’

‘Inside … a characteristic strong, stale and slightly suffocating smell.’

‘The patients were usually dressed in layers of dirty clothing sometimes covered by an old raincoat or overcoat, and when confined to bed they lay beneath a pile of ragged blankets, clothing or newspapers.’

‘ hair being long and unkempt with exposed surfaces of skin deeply ingrained with dirt.’

‘Only two patients apologized for their personal or domestic state’

‘Several hoarded useless rubbish (syllogomania) – newspapers, tins, bottles and rags, often in bundles and sacks – and in six instances the size of the collection seriously reduced the living space.’

Little food, Poverty not an issue, Some accepted food and clothing from neighbours

Brighton: medical status

All were acutely ill.

Two were admitted under Section 47 of the Social Security Act

Underlying problems:Anaemia, low serum proteins, folate, B12, Vitamins C and D and dehydration

IQ: 15 patients (50%) studied weeks after admission: range 97-134 mean 115

No gross deviation of personality (Cattell)But they ‘seemed aloof, detached, shrewd, suspicious and less well integrated’‘ less stable emotionally, more serious, aggressive and group dependent, with a tendency to distort reality.’

Brighton series: outcomes and wondering why

4 men and 10 women died during the key admission5 returned home8 were admitted to Care Homes (all but one LA)3 were transferred to NHS long-stay wards

Cite also two people seen previously notable for being very rich ( £500,00 and £50,000 savings).

Explanations:Lifelong proclivity to give personal and domestic care a low priorityA reaction to stress in an elderly person

Diogenes: philosophy and practices

Shamelessness: repositioning convention below nature and reason. If an activity is not shameful in private then it is not shameful when performed in public. Thus he would eat in the market place though eating in public was deemed uncivilized.

For such unconventional behaviour he was sometimes labeled as mad. But he retained his reason. He respected knowledge but despised pretention.

There is the story of his lighting a lamp during the day and setting forth with it. When asked what he was doing he said that he was in search of an honest man.

He was a homeless, penniless exile and experienced misfortune but asserted that he lived a good life.

MacMillan and Shaw (she had DPH) but both writing as ‘formerly of Mapperley Hospital Nottingham: BMJ 1966

‘Senile breakdown’ – though one psychiatric patient not elderly8 beds set aside

PS given a four year contract to study the condition starting August 1961

Report here of findings of the cohort of referrals in first three years – these followed up a further one year

Initially offered admission but this had adverse effects – apathySo revised to use day care

Some patients came by natural referral, others in response to a circular to all GPs seeking such cases. All were visited at home (PS)

Nottingham series: characteristics12 men, 60 women = 72 in 3 years (Nottingham 312,000 with 50,000 60+)

10 < 70yrs 62 > 70yrs42 widowed 11 married 18 single 1 separated 50 lived alone

34 mentally normal (m 9 f 25)38 ‘psychotic’ (m 3 f 35)23 cases of senile psychosis3 cases of chronic alcoholism5 senile paranoid psychosis3 Manic depression1 presenile psychosis2 schizophrenia1 paraphrenia

Previous personality:Domineering, quarrelsome, independent, unfriendly, stubborn, obstinate, aloof, aggressive, suspicious, secretive

Nottingham series: issuesPrecipitants: Death of a near relation especially spouse

Housing – sort of housing not an issue

Married couples: 5 x married couples both exhibiting the syndromeOne married lady with PSD (husband not affected

Alcohol – in addition to 3 diagnosed chronic alcoholics 9 men and 11 women were heavy drinkers

Loneliness – not an issue: most had effective contact from family, neighbours of statutory services

Intellectual capacity – no sub-normality, 25% of high intellect

Physical illness/disability: 20% of normal and 5 % of psychotic deemed otherwise fitSpecial senses: 10 severely deaf, 7 severe impairment of visionMobility: 40 fully mobile, 11 immobile

Nottingham series: services and outcomes

Mental hospital: 30 admitted 14 returned home by f/u 17 dead

General hospitals: 21 admitted 7 died within the first few days

Day care

Community care

Deaths: By follow up July 1965 5 men and 31 women were dead

Number of Diogenes Publications per country 1975-2010

Hol

Isr

Arg

Ire Belg

Fr G Br HK

Eng USA Sp Can Aus Nor

9 8 7 6 5 4 3 2 1

Number of Diogenes publications in 5 year periods (Medline)

0

5

10

15

20

25

75-79 80-84 85-89 90-94 95-99 2000-2004

2005-2009

2010

Pubs

Personal case series (1)

Identifier G Age band M/S MI

O1 Cat lady (Catherine) F 75+ S Paranoid State

SM1 Eternal student (Esther) F 77+ W Nil

SM2 Northenden (Nora) F 70+ W Nil

SM3 Parrot (Pollyanna) F 80+ W Dementia

SM4 Alcohol (Allen) M 70+ D Alc

SM5 Jam pots (Jemima) F 85+ S Dementia

SM6 Rolls-Royce (Renee) F 85+ S Dementia

SM7 Jelly thief (Jennifer) F 70+ S Nil

SM8 Fostbite (Freda) F 75+ S Depression

SM9 Gaslight (Cyril) M 80+ S Paranoid State

Personal case series (2)

Identifier G Age band M/S MI

W1 Wednesfield (Wilson)# M 65+ Sep Dementia

W2 Woodpile (Winston) # M 65+ S Schizophrenia

W3 Schizophrenia (Sheila) F 70+ W Schizophrenia

W4 Leprechaun (Len) M 70+ W Bipolar

W5 Fred m 80+ D Nil

Personal case series (3)Identifier G Age bnd M/S MI

TG1 Star (Winnie) F 75+ D Dementia

TG2 Mr and Mrs (Goodmans) M+F (80+)x2 M2 Dementia + Nil

TG3 BB (Brian) M 65+ D Bipolar

TG4 Nurse and son (Noleen and Stephen) F + M

75+40+

WS

DementiaSchizophrenia

TG5 Horizontals (Horaces) M+F (85+)x2 M2 Dementia x 2

TG6 Scientist (Sidney) M 75+ S Hypochond

P1 By hand (Brenda) F 80+ W Nil

P2 Crescent (Clarisse (and husband)) F+M (40+)x2 M2 Nil x 2

P3 Jack and Jill M+F (40+)x2 M2 Nil x 2

Profile of cases

• 24 instances involving 19 individuals

• 21 as patients (24 people)

• 3 personal acquaintances (5 people)

• 4 married couples• 8 solitary men• 11 solitary women• 1 mother and son (?

Proxy)

Profile: age bands

Age bandNumber of

people

40s 5

65- 69 yrs 3

70-74 5

75-79 6

80-84 6

85+ 4

Total 29

Profile: marital status

Marital status Number

Single 9

Widowed 7

Married 8

Div/sep 5

Profile: diagnoses

Diagnosis Number

Nil 10

Dementia 9

Schizophrenia 3

Paranoid state 2

Bipolar 2

Depression 1

Alcohol 1

Hypochondriasis 1

Recent examples in literature

•Neville Berlyne 1975 – Not always elderly•O’Mahony and Grimley Evans 1994 – Diogenes by proxy: account of an elderly lady found to be living in squalor but the creator of this condition was her daughter who had moved in some months previously to care for her•Vostanis and Christine Dean 1992 – reported two cases from Birmingham of unmarried women in their thirties one being West Indian and with a history of some emotional instability and probable learning disability, the other a more able woman who had begun to change but was not felt to be formally mentally ill.•Orrell et al 1989 reported a case discussed at the Institute of Psychiatry and showing frontal lobe dysfunction•Donnelly et al 2008 report a case from Houston Texas with Diogenes syndrome in a 51 year woman also exhibiting Capgras symptoms in a paranoid disorder•Byard and Tsokos 2007 from Adelaide describe and discuss forensic issue when people found dead in Diogenes homes •2005 white matter changes – Gonzanez et al – Spanish – I have not details•1995 Cooney and Hamid a review for Age and Ageing from Institute of Psychiatry•1998 Williams et al (Guys) Learning Disability•2003 and 2005 Canadian reports of Diogenes syndrome in two siblings

Points from the literature

Diogenes syndrome challenges

• So what do you make of it?

• What can be done about it?

Should Eponym’s be abandoned?

BMJ September 2007: 335 424-425

Yes: Alexander Woywodt and Eric Matteson

No: Judith Whitworth

19 rapid responses5 citations