PSYCHIATRY ROUNDS
Diogenes Syndrome:
When Self-Neglect is Nearly
Life Threatening
Amel Badr, MD, MSc, Asghar Hossain, MD, DFAPA,
and Javed Iqbal, MD
Series Editor: Melinda S. Lantz, MD
CASE PRESENTATION
Ms. G is a 72-year-old, single white female who
lives alone and has no children. She was visited by
local mental health services at the request of her
neighbors, who complained about an intolerable
smell and flies coming from her apartment. On
observation from the entrance, the apartment was
grossly dirty with an offensive odor. The carpets
were soaked with urine and moldy feces. Piles of
garbage, each about 5 feet high, restricted the liv-
ing space. There was no furniture in the house, no
refrigerator, and among the garbage the only signs
of nourishment were cracker wrappers and soda
cans. Ms. G was in a state of gross physical neglect,
dressed in layers of dirty clothing stained with
urine. The exposed surfaces of her skin were
deeply engrained in dirt. She minimized the seri-
ousness of the damage in her apartment, refused to
communicate, and vehemently resisted any profes-
sional help. Because of concerns that the patient
was in imminent harm due to her dangerous living
Drs. Badr, Hossain, and Iqbal are from the
Department of Psychiatry, Bergen Regional Medical
Center, Paramus, NJ.
Dr. Lantz is Director of Psychiatry, The Jewish
Home & Hospital, 120 West 106th St, New York,
NY 10025; (212) 870-5995; fax: (212) 870-4905;
e-mail: mlantz@jhha.org.
Clinical Geriatrics Volume 13, Number 8
10
conditions, she was involuntarily hospitalized in an
acute geriatric psychiatric unit.
On admission, physical examination revealed
arthritic deformities of both hands, and neglected
venous ulcers were seen bilaterally on the ankles. The
initial psychiatric assessment provided no evidence for
dementia, or affective or psychotic disorders. Neuro-
psychological evaluation showed no evidence of
dementia. Overall, the patient’s general intellectual
ability was in the average range. Executive functions,
attention, memory, language, and visual and spatial
perception were grossly intact. Ms. G had no prior
psychiatric history of hospitalization or treatment. She
denied any family history of psychiatric illness or his-
tory of substance abuse. Her developmental and social
history revealed an independent and isolative person-
ality. Her mother passed away when she was 5 years of
age. She had no siblings, and she lived with her father
and stepmother. She described her relationship with
them as “neutral.” At the age of 21, she moved out of
her parents’ house, and since then has had little con-
tact with her family. Ms. G reported a lifelong pattern
of having no significant relationships and denied hav-
ing any friends. She displayed a marked indifference to
her social isolation and loneliness.
Ms. G reported that she was always advanced aca-
demically and had earned a BS degree in sociology.
August 2005
 PSYCHIATRY ROUNDS
The patient also stated that she has been working as
an employment counselor for the past 20 years, but
refused to give any phone numbers for her work. No
collateral information could be obtained.
While on the inpatient unit, Ms G. showed lack
of initiative for most activities. She used a wheelchair
instead of ambulating, and continuously refused to
shower or change her clothing. She continued to iso-
late herself in her room. Ms. G appeared aloof, was
verbally aggressive and hostile toward the staff, and
would not socialize with any of the patients on the
unit. A diagnosis of personality disorder with
schizoid and paranoid traits was considered.
Laboratory tests were done to exclude organic
causes. This included thyroid function tests, vitamin
B12 and folic acid levels, urinalysis, urine toxicology,
complete blood count, blood chemistry, and com-
puterized tomography of the head. The significant
findings were: low hemoglobin level (8.9 g/dL [12-
16 g/dL]), low hematocrit level (26.4% [37-47%]),
low serum iron level (16 µg/dL [35-175 µg/dL]),
and upper-normal iron-binding capacity (389 µg/dL
[250-400 µg/dL]), suggesting that the patient had
iron deficiency anemia possibly due to malnutrition.
Ms. G strongly opposed her hospitalization and
alleged that her lifestyle was the expression of her per-
sonal freedom. She also exhibited paranoid ideations
toward the staff. She was started on risperidone 0.5
mg orally twice per day; however, she refused to take
any medications.
After three weeks of hospitalization, she was dis-
charged from the hospital. Ms. G declined the social
services offered to her at the time of discharge and did
not comply with her follow-up plan. The patient was
found to be competent to make her own decisions, and
she only accepted assistance from a longtime friend of
hers, who promised to help her clean her apartment.
Clinical Geriatrics Volume 13, Number 8
11
DISCUSSION
Diogenes syndrome is a behavioral disorder of the eld-
erly. The cardinal features of this condition include
extreme self-neglect, domestic squalor, and tendency
to hoard excessively (syllogomania). This is associat-
ed with self-imposed isolation, refusal of help, and
marked indifference or lack of awareness.1 Diogenes
syndrome has been referred to as senile breakdown,
social breakdown, senile squalor syndrome, and messy
house syndrome.
In 1966, Macmillan and Shaw2 were the first to
suggest that senile breakdown in the standards of per-
sonal and environmental cleanliness is a syndrome.
Clark and coauthors3 appointed it the name “Dio-
genes,” inspired by the 4th century BC Greek philoso-
pher Diogenes of Sinope, who advocated the princi-
ples of self-sufficiency, freedom from social restraints,
and rejection of material values. They explained that it
may represent stress-related defense mechanisms of the
elderly, or may be related to the natural aging process.
In 1982, Post4 used the term senile recluse and
argued that it is not a syndrome but merely an end
stage of personality disorder. Since then, several
case series of the syndrome have been reported.
According to the literature,5,6 these patients are
described as aloof, domineering, suspicious, aggres-
sive, and obstinate. The disorder is not specific to a
certain socioeconomic status and is equally preva-
lent among men and women in the age range of
60-90 years. Most are single or widowed, living
alone, and their decline tends to be lengthy in
duration. Some patients have a prior psychiatric
history. Noncompliance with treatment and fol-
low-up are almost universal. Physical illness, such
as pneumonia and multiple nutritional deficiency
states, is common, and the mortality rate can be
high. Most patients studied have above-average
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 PSYCHIATRY ROUNDS

intelligence, successful work histories, stable family
backgrounds, and adequate social resources.
Multiple hypotheses have been advanced to
explain the underlying pathology. Obsessive-com-
pulsive disorder and obsessive-compulsive personal-
ity disorder are most frequently described,7 fol-
lowed by paranoid psychoses and mood disorders.8
It also has been suggested that the early stages of
frontal-lobe dementia may present with features of
Diogenes syndrome. This includes personality
changes, self-neglect, lack of concern, loss of initia-
tive and insight, and paranoid symptoms.9 Dio-
genes syndrome does not fit clearly into our current
Diagnostic and Statistical Manual of Mental Disor-
ders, fourth edition-text revision (DSM-IV-TR)10 or
International Statistical Classification of Diseases and
Related Health Problems, tenth edition (ICD-10)11
diagnostic criteria, as currently only obsessive-com-
pulsive disorder specifically lists hoarding as a
symptom, and other features of the disorder are
included in many diagnoses including dementia,
mental retardation, schizophrenia, delusional disor-
der, and personality disorders (Table).6,7,9,12
This case demonstrates almost all the typical features
of Diogenes syndrome. Ms. G demonstrated a lifelong
pattern of isolation, inability to establish relationships,
compulsive behavior, and paranoia that slowly pro-
gressed into social breakdown, characterized by severe
self-neglect that could not be explained by the severity
of her physical illness or lack of social support.
Ms. G did not fit the criteria for any DSM-IV-TR10
Axis I disorder. One of the possible differential diag-
noses was depression, due to her apparent apathy and
lack of motivation. However, she did not display
depressed mood or vegetative features, and had no
sense of guilt, inadequacy, or suicidal ideation.
Although the patient was suspicious, guarded, and eva-
sive, she did not display any distinct delusions or hallu-
cinations that would suggest a diagnosis of delusional
disorder or late-life schizophrenia. Ms. G’s psychosocial
history and lifestyle revealed a pattern of schizoid,
avoidant, obsessive-compulsive, and paranoid traits.

Psychiatric Disorders Associated with Diogenes Syndrome6,7,9,12

TA B L E

Diagnosis Features

Dementia Frontal lobe degeneration results in apathy, preservative behavior, poor self-care,
lack of insight

Obsessive-compulsive Compulsive hoarding often a significant symptom, obsessional anxiety, avoiding

disorder decisions, rituals

Substance abuse/ Self-neglect, living in squalor, apathy related to intoxication, malnutrition, spending
dependence money on drugs rather than food or possessions

Delusional disorder Fixed delusional belief with ability to function, isolation, avoidant behavior, poor social
skills, may assign meaning to useless objects and refuse to discard anything

Personality disorders Avoidant, schizoid, schizotypal, paranoid traits lead to isolation, poor decision-making
skills, inability to establish relationships or accept assistance

Mental retardation Poor self-care, attachment to objects, rituals and repetitive behaviors, poor social
skills, may hoard food (Prader-Willi syndrome)

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 PSYCHIATRY ROUNDS
The analysis of our case appears to support Karl
Jaspers’ formulation of “social breakdown of the elder-
ly.”13 He proposed that this condition does not consti-
tute a newly occurring psychopathological entity, as the
whole picture is understandable from each subject’s
personality and stressful life events. He emphasized that
the characteristics of the premorbid personality play an
integral role in the pathogenesis of the syndrome. His
view of this syndrome was that it represents a lifelong
subclinical personality disorder, probably of a schizoid
or paranoid type, that turns gradually into gross self-
neglect and social isolation. This deterioration is precip-
itated by stressful life events, such as loss of a spouse or
aging by itself, and is further aggravated by increasing-
ly debilitating physical problems. Karl Jaspers13 called
the social breakdown of the elderly “a personality based
abnormal emotional reaction development or adjust-
ment disorder.” He explained that the complex of per-
sonality factors, loneliness, stress, and somatic illness
form a vicious cycle, resulting in a reclusive lifestyle,
abandonment of basic social norms, and persistent
refusal of help as they invoke the defense mechanisms
of withdrawal and denial of need.
Diogenes syndrome still raises many unresolved
issues. Although it is associated with an increasing
number of psychiatric conditions (Table), the inves-
tigation of the psychopathological or nosological
links with the concomitant disorders is still lacking.
Management is also a difficult issue. Patients’ con-
tinued refusal of help gives rise to complex ethical
and medicolegal issues.
Day care and community care are the main lines of
management rather than hospital admission. Several
studies have utilized selective serotonin reuptake
inhibitors to treat the compulsive hoarding behaviors.
Atypical antipsychotic agents have been used when
paranoid symptoms are present. A concrete approach
Clinical Geriatrics Volume 13, Number 8
13
to home safety, including preventing additional clut-
ter, establishing a cleaning plan, discarding objects,
and organizing the living space, have been successful
over time in assisting older adults in regaining a sense
of control over their environment.12
Despite all efforts and care, the outcome of the
syndrome is rather bleak. Follow-up visits showed
that of those at home, only a few lived in better cir-
cumstances than previously. The prognosis is also
poor, with 46% of the patients having a 5-year mor-
tality rate, possibly due to physical complications.14
OUTCOME OF THE CASE PATIENT
Unfortunately, Ms. G refused follow-up care and had
no further contact with the hospital.
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August 2005