[Severe domestic squalor]

Neurobiological Mediators of Squalor-dwelling Behavior

Squalor-dwelling behavior has been characterized as living in conditions so unsanitary that feelings of revulsion are elicited among visitors. This behavior is commonly associated with an insensitivity to distress/disgust and a failure to understand the direness of one's living situation, which leads to social isolation and impairment in quality of life. Etiologically, several associations have been described in the literature, including age-related decline, lower socioeconomic status, and rural dwelling status. Primary neuropsychiatric disorders, such as psychosis, alcoholism, dementia, personality disorders, developmental delays, and learning or physical disabilities are frequently seen in squalor-dwelling individuals. However, none of these disorders seems to be necessary or sufficient to explain the behavior. Neurobiologically, squalor-dwelling behavior has been associated with frontal lobe dysfunction as evidenced by executive dysfunction; however, cognitive impairments also fail to completely explain this behavior. The purpose of this report is to describe a typical case of squalor-dwelling behavior and use it as an example to illustrate the complexity of uncovering the neurobiological basis for this maladaptive personal and public health threat. Neuroimaging findings from our case and a review of the literature point toward decreased activity in the insular cortex and the amygdala as a unifying biological explanation for squalor-dwelling behaviors.

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.