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    19. Estrada-Parra, S., Olguin-Palacios, E. in Nucleic Acids in Immuno-

    logy (edited by O. J. Plescia and W. Braun); p. 96, New York,1968.

    20. Schur, P. H., Monroe, M. Proc. natn. Acad. Sci. U.S.A. 1969, 63,1108.

    21. Talal, N., Steinberg, A. D., Daley, G. G. J. clin. Invest. 1971, 50,1248.

    22. Epstein, W. V., Tan, M., Easterbrook, M. New Engl. J. Med.1971, 285, 1502.

    23. Koffler, D., Carr, R., Agnello, V., Thoburn, R., Kunkel, H. G.

    J. exp. Med. 1971, 134, 294.24. Stollar, D., Levine, L. Archs Biochem. Biophys. 1963, 101, 417.25. Stollar, D., Levine, L., Lehrer, H. I., Van Vunakis, H. Proc. natn.

    Acad. Sci. U.S.A. 1962, 48, 874.26. Arana, R., Seligmann, M. J. clin. Invest. 1967, 46, 1867.27. Erickson, E., Braun, W., Plescia, O. J., Kwiatokowski, Z. in Nucleic

    Acids in Immunology (edited by O. J. Plescia and W. Braun);p. 201. New York, 1968.

    28. Tanenbaum, S. W., Karol, M. H. ibid. p. 222.29. Leroy, E. C. J. clin. Invest. 1974, 54, 880.

    DIOGENES SYNDROME*

    A CLINICAL STUDY OF GROSS NEGLECT

    IN OLD AGE

    A. N. G. CLARK G. D. MANKIKAR

    IAN GRAY

    Department of Geriatric Medicine, Brighton General

    Hospital, Brighton BN2 3EW

    A study of elderly patients (fourteenSummary

    men, sixteen women) who were ad-mitted to hospital with acute illness and extreme self-

    neglect revealed common features which might becalled Diogenes syndrome. All had dirty, untidyhomes and a filthy personal appearance about which

    they showed no shame. Hoarding of rubbish (syllo-gomania) was sometimes seen. All except two lived

    alone, but poverty and poor housing standards werenot a serious problem. All were known to the social-services departments and a third had persistentlyrefused offers of help. An acute presentation withfalls or collapse was common, and several physicaldiagnoses could be made. Multiple deficiency stateswere foundincluding iron, folate, vitamin B12, vita-min C, calcium and vitamin D, serum proteins and

    albumin, water, and potassium. The mortality,especially for women, was high (46%); most of thesurvivors responded well and were discharged. Halfshowed no evidence of psychiatric disorder and

    possessed higher than average intelligence. Manyhad led successful professional and business lives,with good family backgrounds and upbringing. Per-

    sonality characteristics showed them to tend to be

    aloof, suspicious, emotionally labile, aggressive,group-dependent, and reality-distorting individuals.It is suggested that this syndrome may be a reactionlate in life to stress in a certain type of personality.

    Introduction

    THE acutely ill old person with a dirty and neg-lected appearance, in a setting of gross domestic dis-

    * DIOGENES (4th century B.C.). Greek philosopher, the first ofthe cynics. Supplied his needs in food and clothing, whichhe kept to the minimum, by begging.... His ideals were" life according to nature ",

    "

    self-sufficiency "," freedom

    from emotion ", " lack of shame ","

    outspokenness ", and

    " contempt for social organisation ".1

    order and squalor, is not uncommon, yet has attractedlittle study.2,3 Such people pose serious problems interms of community care and sometimes need urgenthospital admission. We describe here the back-

    ground, presentation, psychiatric factors, and out-come in thirty such cases and investigate the sugges-tionthat this social and clinical picture might repre-sent a syndrome.

    Patients and Methods

    Thirty patients (foutteen male, sixteen female) aged66-92 (average 79) were seen. All lived in a desperatestate of domestic disorder, squalor, and self-neglect, and

    they were referred for urgent admission to the geriatricunit between October, 1972, and July, 1973. The socialand environmental background was examined in everycase, together with conventional medical examination and

    investigations on admission. Comprehensive intelligenceand psychometric testing were assessed by the intellectual

    rating scale (I.R.S.), intelligence quotient by Wechsleradult intelligence scale,4 and by Cattells methodforpersonality.

    Results

    Social and Environmental Factors

    All patients lived in a state of domestic squalor, dis-

    order, and extreme self-neglect. Their homes were

    filthy on the outside-peeling paintwork and dirty,often broken, windows with dingy net curtains serv-

    ing as external markers to conditions within. Inside

    there was a characteristic strong, stale, and slightlysuffocating smell. The patients were usually dressed

    inlayers of dirty clothing sometimes covered by anold raincoat or overcoat, and, when confined to bed,

    they lay beneath a pile of ragged blankets, clothing,or newspapers. They never appeared to undress orwash, the hair being long and unkempt, with exposedsurfaces of skin deeply engrained with dirt. Onlytwo patients apologised about their personal or domes-tic state. Several hoarded useless rubbish (syllogo-mania)-newspapers, tins, bottles, and rags, often inbundles and stacks-and in six instances the size of

    the collection seriously reduced living space.

    Family and Home Support

    Twenty-eight lived alone-one man lived with ason and grandson, and one lived with his unmarried

    daughter; seventeen had relatives (eight in the Brigh-

    ton area) while thirteen had none. Every patient hadbeen known to the community authorities for severalweeks to years, and the domestic predicament waswell recognised. Twelve had home services (homehelp, nursing, and meals) while ten repeatedly de-clined offers of help, sometimes refusing to open thedoor to callers.

    Nutrition

    Little food was to be found in the house, and olddishes and mouldy scraps were often seen. Tea,bread, biscuits, cakes, and tinned food seemed to bethe staple diet.

    FinanceAll the patients received the old-age pension and

    six had supplementary pension; two had savings ofE2600 and E5000, and seven owned their homes. No-one complained of shortage of money, and poverty

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    did not seem to be a feature. Food and clothing weresometimes accepted from sympathetic neighbours.

    ProfessionsThree men had held Service commissions; two had

    been journalists; one had been a dentist, and one a

    professional violinist. Three women had been school-

    teachers, one a West-End fashion designer, one amusic teacher, one an opera singer (Covent Garden),and one a teacher of needlework. Their careers

    seemed to have been successful and they had enjoyedsound family backgrounds, education, and social

    standing in earlier life.

    Admission and Presentation

    Two were compulsorily admitted (under Section 47of the Mental Health Act), the rest voluntarily; eighthad previously refused until the point where illnessbecame critical. A fall or collapse (seventeen) was themost common presentation.

    DiagnosisAll were acutely ill, and the principal diagnoses

    were congestive heart-failure (eight), cerebrovasculardisease (seven), bronchopneumonia (four), malignantdisease (two), Parkinsons disease (two), osteoarthritis

    (two), and leukaemia, gangrene, cervical spondylosis,pulmonary embolism, and renal failure were presentin single cases.

    Pathological InvestigationsThese revealed the presence of anaemia and multiple

    deficiencies including sideropenia, changes in the

    serum-proteins, low folate and vitamin-B]2 levels,deficiencies of vitamins C and D, and water deprivation(see table).

    Intelligence and Personality Assessment

    This was studied in fifteen patients,- several weeksafter admission, to allow treatment to take effect andfor them to settle in new surroundings. The strikingfinding was the high l.Q., ranging from 97 to 134,the mean (115) being in the top quarter of the popula-tion at this age. A mean I.R.S. of 14 (range 10-5-17)indicated a high level of intellectual preservation(maximum possible score 17).

    LABORATORY FINDINGS

    No gross deviation of personality was found whenthe personality-testing scores were compared with

    general population norms despite striking age differ-

    ences, and the patients showed a closer correspondencewith normal than abnormal personality. However,they seemed more aloof, detached, shrewd, suspicious,and less well integrated. Other less significant traits

    showed them to be less stable emotionally, more

    serious, aggressive, and group-dependent, with a

    tendency to distort reality.

    Progress and AftercareFour men (average age 85) and ten women (aver-

    age age 81) died. The death-rate for women is strikingand significantly greater (P

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    There are two possible explanations why intelligenteducated individuals descend to such .debased stan-

    dards of living. One might be a lifelong proclivityto give personal and domestic care a low priority-a disorganised style of life becoming exaggerated byageing and physical infirmity-or it might be areaction to stress in an elderly person with certain

    personality characteristics. Sometimes previouslystable old people develop neurotic breakdown with-out previous history,17 due to social, economic, and

    declining health factors with predisposing featuresin the personality (e.g., being aloof, moody, andanxious). A vicious circle of increasing anxiety, help-lessness, and anger is accentuated by inadequacy tomaster everyday problems, producing a further ineffici-ency.18 Social, psychological, and economic stress

    produce mental illness in old age 19 and invoke defencemechanisms of withdrawal and denial of need." Our

    patients seem to need social contact whic