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Hoard focus: A brief overview of Diogenes Syndrome

In a previous blog on animal hoarding I made a passing reference to Diogenes Syndrome (DS) that is sometimes referred to as ‘senile squalor syndrome’ (as it typically occurs in elderly individuals – although it has occasionally been reported in young adults). According to a paper by Alberto Pertusa and colleagues in a 2010 issue of Clinical Psychology Review:

“Squalor has been defined in various ways including, ‘social breakdown of the elderly’, ‘Diogenes syndrome’ and ‘severe domestic squalor’…These definitions have usually encompassed both domestic neglect and a lack of personal hygiene…The majority of case observations and studies on squalor have focused on elderly populations recruited from nursing or disability services…These studies initially suggested that those living in squalor were likely to be over the age of 60, primarily female, living alone and unmarried…Hypotheses on the etiology of squalor have moved from the phenomenon possibly being uni-dimensional to having heterogeneous causes such as physical disabilities, brain damage, psychiatric conditions, and personality disorders…A study on squalor reported the prevalence to be 0.005% in the United Kingdom”.

Hoarding is often a consequence of having DS but is associated with self-neglect and much of the items excessively hoarded are typically items of trash with little or no value. Like animal hoarders, those with DS often live on their own in severe domestic squalor and unsanitary conditions. As I noted in my previous blog, DS is characterized by extreme self-neglect, apathy, domestic squalor, social withdrawal, compulsive hoarding of rubbish, and lack of shame. Most sufferers refuse help of others and the onset of DS may sometimes be initiated by a stressful event in their lives (such as death of a loved one). According to a 2013 paper on DS by Dr. Projna Biswas and colleagues in the journal Case Reports in Dermatological Medicine:

“DS is named after the Greek Philosopher “Diogenes of Sinope” (4th century BC) who taught about cynicism philosophy. He kept his need for clothing and food to a minimum by begging. He used to follow some ideas like ‘life according to nature’, ‘self-sufficiency’, ‘freedom from emotion’, ‘lack of shame’, ‘outspokenness’, and ‘contempt for social organization’…The approximate annual incidence of Diogenes is 0.05% in people over the age of 60 [years]. Affected individuals come from any socioeconomic status, but are usually of average or above-average intelligence…It is often associated with other mental illnesses, such as schizophrenia, mania, and frontotemporal dementia…While no clear etiology exists, it is hypothesized that it may be due to a stress reaction in people with certain pre-morbid personality traits, such as being aloof, or certain personality disorders, such as schizotypal or obsessive compulsive personality disorder. There are suggestions that an orbitofrontal brain lesion may lead to such behaviours…while others state that chronic mania symptoms, such as poor insight, can lead to such a condition”.

DS was not included separately in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) although hoarding (syllogomania) is included as a genuine psychiatric diagnosis. Because of deliberate self-isolation, physical neglect and poor eating, DS mortality rates are high with close to half of sufferers dying within five years of DS onset. Biswas and colleagues also note:

“Diogenes syndrome is also known as dermatitis passivata. The term Diogenes syndrome was coined in 1975 by [Clark and colleagues]…DS has been classified as primary or pure which is not associated with mental illness and secondary or symptomatic. Secondary DS is related to mental illness like schizophrenia, depression, and dementia…Alcohol abuse has been identified as a cofactor…Multiple deficiency states have been associated with DS including iron, folate, vitamin B12, vitamin C, calcium and vitamin D, serum proteins and albumin, water, and potassium…Skin lesions are mainly due to uncleanliness which may result in various infestations and infections. These are ignored by the patient. Dirt, dust, bacterial, fungal, and parasitic debris conglomerate to form thick crusts and scales over various parts of the body”.

The paper by Biswas and colleagues’ asserted that four symptoms have been reported as being in almost all DS sufferers. These are that they: (i) never ask for any help despite possessing nothing; (ii) are unusually fond of certain objects (including rubbish); (iii) display unusual behavior with other people (misanthropy) and (iv) display extreme self-neglect. Although hoarding is often present in those with DS, there have been some cases reported where no hoarding was present. In their 2010 review paper, Dr. Pertusa and colleagues noted:

“Research on hoarding has rarely included assessments of severe domestic squalor. Winsberg et al. (1999) noted that clutter inhibited normal activities of daily living – including personal hygiene. A few studies have provided more direct indications of squalor in hoarding. [one study in 2000] surveyed health department officers in Massachusetts who reported that 38% of their hoarding cases were ‘heavily cluttered with filthy environment, overwhelming’. [Another study] focused on cleanliness ratings of the personal appearance and the homes of 62 elderly hoarding individuals. In their sample, 17% of individuals were described as ‘extremely filthy’ and 33% of residences were rated as ‘extremely filthy and dirty’. For 32% of the residences, there was an overpowering odor from rotten food or animal or human feces. Many subjects could not use their refrigerator (45%), kitchen sink (42%), bathtub (42%), or toilet (10%). Lack of standardized instruments to measure squalor have prevented researchers from understanding squalor in compulsive hoarding”.

Dr. Pertusa and his colleagues claim the data on DS is scarce and that the clinical picture between hoarding and DS needs more clinical research. They do conclude that hoarding within a DS diagnosis is clinically different from other types of hoarding (for instance, compulsive hoarders do not display the same core features as those with DS such as squalor and self-neglect). Like many other clinical conditions, Pertusa’s team assert that longitudinal studies will best help uncovering the natural history and link (if any) between both DS and compulsive hoarding.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biswas, P., Ganguly, A., Bala, S., Nag, F., Choudhary, N., & Sen, S. (2013). Diogenes syndrome: a case report. Case reports in dermatological medicine, http://dx.doi.org/10.1155/2013/595192

Clark, A. N., Mankikar, G. D., & Gray, I. (1975). Diogenes syndrome. A clinical study of gross neglect in old age. Lancet, 1(7903), 366−368.

Drummond, L.M., Turner, J., Reid, S. (1996). Diogenes’ syndrome – a load of old rubbish? Irish Journal of Psychiatric Medicine, 14(3), 99–102.

Greve, K.W., Curtis, K.L., & Bianchini, K.J. (2004). Personality disorder masquerading as dementia: A case of apparent Diogenes syndrome. International Journal of Geriatric Psychiatry, 19, 703–705

Irvine, J. D., & Nwachukwu, K. (2014). Recognizing Diogenes syndrome: a case report. BMC Research Notes, 7(1), 276.

Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30, 371-386.

Rosenthal, M., Stelian, J., & Wagner, J. (1999). Diogenes syndrome and hoarding in the elderly: Case reports. Israel Journal of Psychiatry and Related Sciences, 36, 29–34.

Heavy petting: A brief overview of animal hoarding

Last week I was interviewed on BBC radio about Channel 4’s new show ‘The Hoarder Next Door’. In previous blogs, I have briefly examined pathological hoarding and one particular type of hoarding behaviour (i.e., pathological book hoarding). Another very specific type of hoarding is animal hoarding (typically defined as having a higher number of pets than is normal to have and failing to look after them properly). In a 2006 issue of Veterinary Medicine, Dr Gary Patronek (Tufts University, US) defined animal hoarding as: “Pathological human behaviour that involves a compulsive need to obtain and control animals, coupled with a failure to recognize their suffering”. According to a recent literature review led by Dr Albert Pertusa (Institute of Psychiatry, London), this sub-type of hoarding has been defined as the accumulation of a large number of animals along with a:

  • Failure to provide minimal standards of nutrition, sanitation, and veterinary care.
  • Failure to act on the deteriorating condition of the animals (including disease, starvation or death) and the environment (severe overcrowding, extremely unsanitary conditions)
  • Lack of awareness of the negative effects of the collection on their own health and wellbeing and on that of other family members.

Animal hoarders often live in severe domestic squalor and live in more unsanitary conditions than other types of hoarder (although some other types of disorder such as Diogenes Syndrome – also known as ‘senile squalor syndrome’ – is characterized by extreme self-neglect, apathy, domestic squalor, social withdrawal, compulsive hoarding of rubbish, and lack of shame). It is common for the houses of animal hoarders to be filled with animal faecal waste, and it is not unusual to find the decomposing remains of dead animals. The animals are often left to reproduce at will as animal hoarders do not typically get their pets spayed or neutered. Sick animals are typically left to die and rot. A 2009 study by Dr Gary Patronek and Jane Nathanson examined the living areas of 49 animal hoarders. They reported that four out of five living areas were heavily littered with trash and garbage” (78%), and that in just under a half there was profuse urine or feces in the living spaces (45%).

One very key difference between animal and non-animal hoarders is that animal hoarding may involve animal cruelty. Dr Frank Ascione (Utah State University) defines animal cruelty as a socially unacceptable behavior that intentionally causes unnecessary pain, suffering, or distress to and/or death of an animal. Ascione believes that animal neglect falls within this definition and that therefore animal hoarders are guilty of animal cruelty. However, some researchers claim that the animal cruelty is not deliberate as the compulsive hoarding is underpinned by some kind of mental disorder.

Many animal hoarders are known to hoard other items and objects, and therefore some experts in the area (such as Patronek and Nathanson) suggest that animal hoarding is a special manifestation of compulsive hoarding. There is also some research that suggests that animal hoarding follows more ‘conventional’ hoarding. However, animal hoarders share many of the same characteristics as those with Diogenes Syndrome. It has also been suggested that animal hoarders had very controlling parents, come from backgrounds that were chaotic and/or deprived in childhood (and sometimes described as scary and frightening), have psychological issues and problems surrounding emotional attachments, and often attribute human characteristics to the animals they own. Another seemingly common theme is that of physical and/or psychological loss. For animal hoarders, losing a possession is for them like losing a close friend or family member. It has also been claimed that some animal hoarders are often incapable of looking after and caring for themselves (let alone animals – particularly if there are so many of them).

Colin Berry and colleagues, writing in an overview on animal hoarding for the journal Animal Law cited a 2002 review by Arnold Arluke and reported:

“Arnold Arluke analyzed one hundred articles about animal hoarding. Arluke suggests that, rather than presenting a realistic picture of animal hoarding that captures the complexity of the issue, the media presents animal hoarding in a stream of different emotional themes. While drawing the reader’s attention, these themes are more likely to elicit revulsion, sympathy, or humor from the reader rather than understanding of the hoarding issues themselves. Arluke concludes that these emotional themes ‘present an inconsistent picture of animal hoarding that can confuse readers about the nature and significance of this behavior.’ Portraying hoarders’ stories in this light can cause the public to be sympathetic and even supportive of the hoarder and her actions. Some hoarders even receive donations or offers of more animals”.

In the same paper, Berry and colleagues also noted that in terms of demographics, empirical studies have found that animal hoarders are typically middle-aged or older females who are often disabled, retired, or unemployed, living alone in homes without working appliances. The animals that are most likely to be hoarded are cats (the highest number they came across being owned was 400) and dogs (the highest number owned being 218). They also noted that numerous psychological models have been proposed to explain animal hoarding, including focal delusion, addiction, obsessive-compulsive disorder (OCD), zoophilia, and dementia. Although there is no consensus, the conceptualizing of animal hoarding as a form of OCD appears to be the most popular explanation (although this does not appear to explain all cases). According to Karen Cassiday, no-one knows what the prevalence of animal hoarders is within any population although press reports over the last decade have quintupled. Whatever the prevalence, animal hoarding is an area that needs further investigation.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Arluke, A. et al. (2002). Press reports of animal hoarding. Society and Animals, 113, 130-32.

Ascione, F. (1993). Children who are cruel to animals: A review of research and implications for developmental psychopathology. Anthrozoos: A Multidisciplinary Journal of The Interactions of People & Animals, 6, 226-247.

Berry, C., Patronek, G. & Lockwood, R. (2005). Long-term outcomes in animal hoarding cases. Animal Law, 11, 167-194.

Cassiday, K.L. (undated). Animal hoarding: An overlooked and misunderstood problem. Located at: http://www.ocdchicago.org/images/uploads/pdf/Cassiday_-_Animal_Hoarding_-_An_Overlooked_and_Misunderstood_Problem.pdf

Patronek, G. J., & Nathanson, J. N. (2009). A theoretical perspective to inform assessment and treatment strategies for animal hoarders. Clinical Psychology Review, 29, 274−281.

Pertusa, A., Frost, R.O., Fullana, M.A., Samuels, J., Steketee, G., Tolin, D., Saxena, S., Leckman, J.F., Mataix-Cols, D. (2010). Refining the diagnostic boundaries of compulsive hoarding: A critical review. Clinical Psychology Review, 30, 371-386.

Reinisch, A.I. (2008). Understanding the human aspects of animal hoarding. Canadian Veterinary Journal, 49, 1211-1214.