1. Diogenes Syndrome David Jolley and Greg Spencer

2. Aggie MacKenzie and Kim Woodburn: Grime busters/Dirt Detectives

5. Diogenes Syndrome: Original paper Diogenes Syndrome: a clinical study of gross neglect on old age. Clark A, Mankikar G and Gray I (1975) (ii) 366- 368 With acknowledgements to Drs N Condon, W Parker and JA Whitehouse. Brighton General Hospital A study of ‘ the acutely ill old person with a dirty and neglected appearance, in a setting of gross domestic disorder and squalor’ Reference two previous articles: MacMillan and Shaw (1966) BMJ Stevens (1963) British Journal of Geriatric Practice

6. Profile of the Brighton series 14 male 16 female aged 66-92 (mean 79) Referred for admission October 1972- July 1973 (10 months) 28 lived alone one man with a son and grandson one man with an unmarried daughter 17 had relatives All were well known to local services 12 received home services 10 repeated rejected offers of help Three men had held service commissions; two were journalists, one a dentist, one a violinist. Five women had been teachers, one a fashion designer, one an opera singer

7. Brighton series: Social status ‘Their homes filthy on the outside – peeling paintwork and dirty, often broken windows with dingy net curtains’ ‘Inside … a characteristic strong, stale and slightly suffocating smell.’ ‘The patients were usually dressed in layers of dirty clothing sometimes covered by an old raincoat or overcoat, and when confined to bed they lay beneath a pile of ragged blankets, clothing or newspapers.’ ‘ hair being long and unkempt with exposed surfaces of skin deeply ingrained with dirt.’ ‘Only two patients apologized for their personal or domestic state’ ‘Several hoarded useless rubbish (syllogomania) – newspapers, tins, bottles and rags, often in bundles and sacks – and in six instances the size of the collection seriously reduced the living space.’ Little food, Poverty not an issue, Some accepted food and clothing from neighbours

8. Brighton: medical status All were acutely ill. Two were admitted under Section 47 of the Social Security Act Underlying problems: Anaemia, low serum proteins, folate, B12, Vitamins C and D and dehydration IQ: 15 patients (50%) studied weeks after admission: range 97-134 mean 115 No gross deviation of personality (Cattell) But they ‘seemed aloof, detached, shrewd, suspicious and less well integrated’ ‘ less stable emotionally, more serious, aggressive and group dependent, with a tendency to distort reality.’

9. Brighton series: outcomes and wondering why 4 men and 10 women died during the key admission 5 returned home 8 were admitted to Care Homes (all but one LA) 3 were transferred to NHS long-stay wards Cite also two people seen previously notable for being very rich ( £500,00 and £50,000 savings). Explanations: Lifelong proclivity to give personal and domestic care a low priority A reaction to stress in an elderly person

11. Diogenes: philosophy and practices Shamelessness: repositioning convention below nature and reason. If an activity is not shameful in private then it is not shameful when performed in public. Thus he would eat in the market place though eating in public was deemed uncivilized. For such unconventional behaviour he was sometimes labeled as mad. But he retained his reason. He respected knowledge but despised pretention. There is the story of his lighting a lamp during the day and setting forth with it. When asked what he was doing he said that he was in search of an honest man. He was a homeless, penniless exile and experienced misfortune but asserted that he lived a good life.

15. MacMillan and Shaw (she had DPH) but both writing as ‘formerly of Mapperley Hospital Nottingham: BMJ 1966 ‘Senile breakdown’ – though one psychiatric patient not elderly 8 beds set aside PS given a four year contract to study the condition starting August 1961 Report here of findings of the cohort of referrals in first three years – these followed up a further one year Initially offered admission but this had adverse effects – apathy So revised to use day care Some patients came by natural referral, others in response to a circular to all GPs seeking such cases. All were visited at home (PS)

16. Nottingham series: characteristics 12 men, 60 women = 72 in 3 years (Nottingham 312,000 with 50,000 60+) 10 70yrs 42 widowed11 married18 single 1 separated 50 lived alone 34 mentally normal (m 9 f 25) 38 ‘psychotic’ (m 3 f 35) 23 cases of senile psychosis 3 cases of chronic alcoholism 5 senile paranoid psychosis 3 Manic depression 1 presenile psychosis 2 schizophrenia 1 paraphrenia Previous personality: Domineering, quarrelsome, independent, unfriendly, stubborn, obstinate, aloof, aggressive, suspicious, secretive

17. Nottingham series: issues Precipitants: Death of a near relation especially spouse Housing – sort of housing not an issue Married couples: 5 x married couples both exhibiting the syndrome One married lady with PSD (husband not affected Alcohol – in addition to 3 diagnosed chronic alcoholics 9 men and 11 women were heavy drinkers Loneliness – not an issue: most had effective contact from family, neighbours of statutory services Intellectual capacity – no sub-normality, 25% of high intellect Physical illness/disability: 20% of normal and 5 % of psychotic deemed otherwise fit Special senses: 10 severely deaf, 7 severe impairment of vision Mobility: 40 fully mobile, 11 immobile

18. Nottingham series: services and outcomes Mental hospital: 30 admitted 14 returned home by f/u 17 dead General hospitals: 21 admitted 7 died within the first few days Day care Community care Deaths: By follow up July 1965 5 men and 31 women were dead

19. Number of Diogenes Publications per country 1975-2010 Hol Isr Arg Ire Belg FrGBrHK Eng USA Sp Can AusNor 987654321

20. Number of Diogenes publications in 5 year periods (Medline)

21. Personal case series (1) IdentifierGAge bandM/SMI O1Cat lady (Catherine)F75+SParanoid State SM1Eternal student (Esther)F77+WNil SM2Northenden (Nora)F70+WNil SM3 Parrot (Pollyanna)F80+WDementia SM4Alcohol (Allen)M70+DAlc SM5Jam pots (Jemima)F85+SDementia SM6Rolls-Royce (Renee)F85+SDementia SM7Jelly thief (Jennifer)F70+SNil SM8Fostbite (Freda)F75+SDepression SM9Gaslight (Cyril)M80+SParanoid State

22. Personal case series (2) IdentifierGAge bandM/SMI W1 Wednesfield (Wilson)#M65+SepDementia W2 Woodpile (Winston) #M65+SSchizophrenia W3 Schizophrenia (Sheila)F70+WSchizophrenia W4 Leprechaun (Len)M70+WBipolar W5 Fredm80+DNil

23. Personal case series (3) IdentifierGAge bndM/SMI TG1Star (Winnie)F75+DDementia TG2Mr and Mrs (Goodmans)M+F(80+)x2M2Dementia + Nil TG3BB (Brian)M65+DBipolar TG4Nurse and son (Noleen and Stephen)F + M 75+ 40+ WSWS Dementia Schizophrenia TG5Horizontals (Horaces)M+F(85+)x2M2Dementia x 2 TG6Scientist (Sidney)M75+SHypochond P1By hand (Brenda)F80+WNil P2Crescent (Clarisse (and husband))F+M(40+)x2M2Nil x 2 P3Jack and JillM+F(40+)x2M2Nil x 2

27. Profile of cases 24 instances involving 19 individuals 21 as patients (24 people) 3 personal acquaintances (5 people) 4 married couples 8 solitary men 11 solitary women 1 mother and son (? Proxy)

28. Profile: age bands Age band Number of people 40s5 65- 69 yrs3 70-745 75-796 80-846 85+4 Total29

29. Profile: marital status Marital statusNumber Single9 Widowed7 Married8 Div/sep5

30. Profile: diagnoses DiagnosisNumber Nil10 Dementia9 Schizophrenia3 Paranoid state2 Bipolar2 Depression1 Alcohol1 Hypochondriasis1

31. Recent examples in literature

32. Neville Berlyne 1975 – Not always elderly O’Mahony and Grimley Evans 1994 – Diogenes by proxy: account of an elderly lady found to be living in squalor but the creator of this condition was her daughter who had moved in some months previously to care for her Vostanis and Christine Dean 1992 – reported two cases from Birmingham of unmarried women in their thirties one being West Indian and with a history of some emotional instability and probable learning disability, the other a more able woman who had begun to change but was not felt to be formally mentally ill. Orrell et al 1989 reported a case discussed at the Institute of Psychiatry and showing frontal lobe dysfunction Donnelly et al 2008 report a case from Houston Texas with Diogenes syndrome in a 51 year woman also exhibiting Capgras symptoms in a paranoid disorder Byard and Tsokos 2007 from Adelaide describe and discuss forensic issue when people found dead in Diogenes homes 2005 white matter changes – Gonzanez et al – Spanish – I have not details 1995 Cooney and Hamid a review for Age and Ageing from Institute of Psychiatry 1998 Williams et al (Guys) Learning Disability 2003 and 2005 Canadian reports of Diogenes syndrome in two siblings Points from the literature

33. Diogenes syndrome challenges So what do you make of it? What can be done about it?

34. Should Eponym’s be abandoned? BMJ September 2007: 335 424-425 Yes: Alexander Woywodt and Eric Matteson No: Judith Whitworth 19 rapid responses 5 citations