Diogenes syndrome: of omelettes and souffles

Assessment of Squalor in Migrant Colonies of Thiruvalla Province of Kerala, India using Rapid Survey Technique

Background:

Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant(s). In India, an estimated 258 million are migrants. They are more likely to live in squalor due to inferior socio-economic status and no permanent residence. This poses a threat to the health of the migrants and the neighbors.

Objective:

To assess the squalor and morbidity pattern among the migrants of Migrant colonies in Thiruvalla using Rapid survey technique.

Methodology:

The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS). The sample size for each lot/colony was '14' dwellings according to LQAS table. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and were excluded if he belonged to the same dwelling. Fifteen colonies were randomly selected to achieve the sample size of 210 (15*14). The study was done in Tiruvalla municipality.

Results and Conclusion:

Only two colonies (n = 15) were squalor free. Majority of the dwellings (n = 210) were having an ECCS score between 13 and 15. Common ailments affecting migrants include Common cold, Skin disorders, and dental caries and gastritis. Squalor was found in most of the migrant colonies as they are living in inhuman conditions.

Development of a Conceptual Framework for Severe Self-Neglect (SN) by Modifying the CREST Model for Self-Neglect

Self-neglect is an inability or refusal to meet one's own basic needs as accepted by societal norms and is the most common report received by state agencies charged with investigating abuse, neglect and exploitation of vulnerable adults. Self-neglect is often seen in addition to one or multiple conditions of frailty, mild to severe dementia, poor sleep and depression. While awareness of elder self-neglect as a public health condition and intervention has significantly risen in the past decade as evidenced by the increasing amount of literature available, research on self-neglect still lacks comprehensiveness and clarity since its inception to the medical literature in the late 1960s. With the burgeoning of the older adult population, commonness of self-neglect will most likely increase as the current incidence rate represents only the "tip of the iceberg" theory given that most cases are unreported. The COVID-19 pandemic has exacerbated the incidence of self-neglect in aged populations and the need for the use of intervention tools for aging adults and geriatric patients living alone, many of which may include in-home artificial intelligence systems. Despite this, little research has been conducted on aspects of self-neglect other than definition and identification. Substantial further study of this disorder's etiology, educating society on early detection, and conceivably preventing this syndrome altogether or at least halting progression and abating its severity is needed. The purpose of this research is to provide a definition of severe self-neglect, identify key concepts related to self-neglect, comprehensively describe this syndrome, present a conceptual framework and analyze the model for its usefulness, generalizability, parsimony, and testability.

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.

Diogenes syndrome or isolated syllogomania? Four heterogeneous clinical cases

Diogenes syndrome (DS) is an acquired behavioural disturbance more often affecting elderly patients, but possible in all ages. It is characterised by social withdrawal, extreme self and house neglect, tendency to hoard any kind of objects/rubbish (syllogomania), and rejection against external help for lack of concern about one's condition. It is considered infrequent, but with quite high mortality. DS might be divided into several forms including Active (the patient gathers objects outside and accumulates them inside his house), Passive (patient invaded by his own rubbish), "à deux" (DS sharing between two people), and "under-threshold" (DS "blocked" by precocious intervention). Four cases are here presented. In case 1 (passive DS) alcoholism and cognitive impairment could be trigger factors for DS, predisposed by a "personality alteration". In case 2 (active, "à trois") superimposed psychosis could be the trigger, borderline intelligence being the predisposing factor. In case 3 (active), fronto-parietal internal hyperostosis might support an organic aetiology. Finally, case 4 was an example of isolated syllogomania in patient with evolving Alzheimer's dementia. Despite being heterogeneous, our casuistry suggest that DS can develop in both sexes, is prevalent in geriatric age and often associated with cognitive impairment/psychiatric disturbances, which are not specific, nor sufficient to justify DS. Isolated syllogomania only shares the characteristic hoarding with DS; although cognitive impairment might be present, the other DS typical aspects (social isolation, help refusal, characterial aspects, personal hygiene neglect) are absent.

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.

Severe domestic squalor: a review

BACKGROUND

Referrals to clinical services of people living in severe domestic squalor are not uncommon. It is timely to review literature concerning and discussing such cases.

METHOD

Using Medline, Psychinfo, Embase, CINAHL and reference lists from relevant publications, literature referring to over 1100 cases was identified and then reviewed.

RESULTS

Half of those described as living in severe squalor are elderly. Outcomes of intervention are often poor. People living in severe squalor are most commonly diagnosed as having dementia, alcoholism or schizophrenia, though personality problems are evident in a high proportion. There is evidence to suggest that neglect of hygiene and of attention to cleanliness of accommodation may be largely attributable to frontal lobe changes. The review also revealed a second body of literature, not often cited in papers focussed on unclean living conditions and published in psychiatric or medical journals, that concludes that hoarding is most commonly due to obsessive-compulsive disorder (OCD). Accumulation of rubbish is described in over half of the case reports on severe domestic squalor, but it is suggested that this should only be called hoarding if it results from purposeful collection of items. Lack of impulse control may contribute to collecting behavior, resulting in reduction in living space if there is also a failure to discard.

CONCLUSIONS

There is a need for further studies, using standardized ratings of living conditions, investigating and trying to understand the complex interplay of triggers and vulnerabilities, exploring how best to intervene and examining outcomes of interventions.

Self-neglect: a proposed new NANDA diagnosis

PURPOSE

To propose a new NANDA diagnosis, self-neglect.

DATA SOURCES

Research studies and literature published from a variety of disciplines including nursing as well as primary research.

DATA SYNTHESES

This diagnosis can be used to describe a constellation of self-care problems of varying severity and impact on the health and well-being of people who self-neglect. Included are two subtypes of self-neglect based on the degree of intentionality. Clarification of self-neglect is long overdue because self-neglect presents conceptual, identification, and intervention problems for nurses, healthcare workers, and for medicolegal systems across settings and in many countries.

CONCLUSION

The proposed diagnosis, self-neglect, fills a gap in current standardized terminology. This diagnosis will contribute significantly to nurses leading the way in the explication of an interdisciplinary and international health concern. PRACTICE AND POLICY IMPLICATIONS: Developing self-neglect as a recognized nursing label is vital to clinicians and policy makers within and across countries. Appreciating less serious/non-life-threatening presentations will give nurses a care perspective to improve the health and well-being of those in earlier stages of self-neglect. Definitions for this phenomenon will contribute to care planning and interventions, leading to consistency in practice and research.

A framework for good practice in interagency interventions with cases of self-neglect

Self-neglect is probably more common than has generally been thought and gives rise to a number of difficult conceptual, identification and intervention problems for health and social care workers. These patient management issues are compounded by the lack of any evidence-base for practice which nurses can draw on when faced with managing people who self-neglect. Nurses working with self-neglecters operate in an interdisciplinary context which includes professional groups, such as environmental health officers, who do not normally figure within health and social care teams. In the absence of such an evidence-base, a pragmatic solution in the form of a framework for interagency practice has been proposed. The background underpinning this framework, including a research study of housing in self-neglect and interagency responses, is briefly outlined in this paper.

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.

Community study of people who live in squalor

BACKGROUND

The reasons why people live in squalor have been the subject of much debate but little systematic research other than reports of case series from secondary health-care services. We did a study in the community using standardised instruments to investigate the relation between squalor and mental and physical disorders.

METHODS

We did a cross-sectional study of the clients of a local-authority special cleaning service. Levels of domestic squalor and self neglect were measured with the living conditions rating scale, and diagnoses of mental disorder were made by use of WHO's schedules for clinical assessment in neuropsychiatry (SCAN).

FINDINGS

91 individuals were eligible for inclusion; 81 from 76 households consented and were interviewed (a response rate of 89%). 41 (51%) were younger than 65 years of age. 57 individuals (70%) were diagnosed as having a mental disorder at interview, as defined by the SCAN, and 21 participants (26%) had a physical health problem which contributed significantly to the unclean state of their living environment. Those with a contributory physical disorder had a lower severity of domestic squalor. People older than 65 years were less likely to have a mental disorder than those younger than 65 years, but a contributory physical disorder was not associated with the presence of active mental disorder. Only 30 (53%) of the 57 individuals with active mental disorder had had any contact with mental-health services in the previous year.

INTERPRETATION

People who live in squalor and who receive special cleaning services have high rates of mental disorder, and squalor affects younger as well as older people. Living in squalid conditions in the group was generally associated with a mental or physical disorder, and there were possible deficits in the health care received. The extent to which these disorders might respond to more assertive treatment from health services requires further study, but questions are raised about the adequacy of their current health care.

The medical model and other constructions of self-neglect

Nurses frequently encounter patients who neglect their personal hygiene and household cleanliness. Self-neglect is usually understood within the parameters of the medical model, with its need to objectify and categorize. The medicalization of self-neglect obscures the fact that patients and professionals may have different ideas about what self-neglect is and what it is not. This paper explores how the medical construction of self-neglect has come to dominate the self-neglect discourse and will also explore other possible ways of understanding self-neglect.

Constructions of self-neglect: a multiple case study design

Patients who neglect personal hygiene, household cleanliness and their own health are familiar to most nurses. Despite this familiarity, self-neglect is a poorly conceptualized and little researched phenomenon. This multiple case study design uncovers the perceptions of self-neglect held by professionals, patients and relatives. The assumptions which underpin Orem's Theory of Self-Care and the medical model construction of self-neglect are explored and it will be suggested that there are limitations in understanding self-neglect using these theoretical frameworks.