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Monday, September 1, 2014

Diogenes syndrome in an elderly woman


Some time ago, I wrote a post about a computer programmer from Kolkata, India, who suffered from schizophrenia and associated Diogenes syndrome. As you might know, Diogenes syndrome is a behavioral disorder that manifests itself in self-neglect, extremely poor personal hygiene, domestic filth, a tendency to hoard rubbish and a lack of shame regarding one's living conditions. Approximately 0.05% of persons over the age of 60 suffer from this condition. Interestingly, sufferers are usually of average or above-average intelligence. Diogenes syndrome is often associated with other mental illnesses, such as schizophrenia, mania and frontotemporal dementia. It may also appear in conjunction with obsessive-compulsive disorder. The affected persons are typically in complete denial, and very reluctant to accept help. This can make treating them very difficult.

Irvine and Nwachukwu have described the case of an elderly lady suffering from this condition, with all the typical symptoms. This situation occurred in Canada, in the Saskatchewan province. A 61-year-old obese Caucasian lady with a previous history of bipolar 1 disorder presented for an out-patient psychiatric follow-up review. She was found to have pressured speech, an elated mood, increased energy, and very poor personal hygiene. She was disheveled, unkempt and smelly, wearing dirty clothes. She was also very agitated, and was verbally and physically abusive to staff. She had no insight, and refused any form of treatment. The diagnosis - a manic relapse as a result of not taking the prescribed medication. The woman was involuntarily admitted to the in-patient psychiatric ward. The usual laboratory tests were performed (complete blood count and so on) and all the results came back normal. She was re-started on her previous psychiatric medication.

The following day she was adamant about having to go feed her cats and dogs, and eventually gave permission for a Community Mental Health Nurse to enter her house and attend to her pets. It turned out that the home was in complete disarray. Every room was crammed with filthy clothes, garbage, dirty dishes, and rotting food. There was no kitchen sink in sight, and it looked as if some dishes were being cleaned in the toilet. Any clear space of floor was strewn with cat and dog feces. An unbearable stench emanated from the entire two-story house. When the patient was questioned regarding the state of her home and personal hygiene, she had no insight into any problems. This inability to assess the reality of one's condition is a typical and baffling feature of Diogenes syndrome.




This is what the bathroom in the patient’s house looked like. The patient had been using the toilet both for its designated use and for periodically washing her dishes. Eeek! 




The patient’s living room looked even worse. It was filled with dirty clothing, old newspaper, and animal feces. It makes me sad to think about the cats and dogs living in that filthy home, probably underfed and without any veterinary care.

The woman's mood became normalized after some time in the hospital, although she remained guarded, with little insight into her condition. Apparently, she required persistent and gentle pressure in order to even start thinking about decluttering her home and improving her personal hygiene. She was eventually persuaded to allow a company to help her clean her house, at a cost of $8,073. Even the sink was eventually found under a large pile of debris. The patient is now living at home, and receiving close psychiatric follow-up. It remains to be seen whether the interventions will make any difference to her lifestyle in the long run.

Sadly, cases like this one are fairly common. Almost all of us know at least one hoarder, although the behavior might not be as extreme. It's also quite difficult to provide help when the affected person doesn't recognize the situation as a problem, and is unwilling to seek or accept help.


Literature:

Irvine JD, Nwachukwu K. (2014) Recognizing Diogenes syndrome: a case report. BMC Res Notes. 7: 276.



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