Letters to the Editor
Diogenes Syndrome in a Pair of Siblings
Psychotic disorders or severe cognitive impairment are the usual causes of extreme self-neglect and social withdrawal when occurring in elderly subjects who have been socially efficient. Such behaviours, however, have been reported in individuals without any psychotic troubles or dementia (1). The denomination of this syndrome was suggested by Clark and others, inspired by the 4th century BCE ascetic Greek philosopher, Diogenes, who advocated the principles of self-sufficiency, freedom from social restraint, lack of shame, and rejection of material values (2). Diogenes syndrome (DS) is characterized by severe self- neglect, domestic squalor, social withdrawal, stubborn refusal of any well-meant help, and sometimes a tendency to hoard rubbish (syllogomania) (3). Although most reported DS occurs in subjects who live alone, 2 cases have been described in married couples (4,5). We present the first case report, to our knowledge, of DS in a pair of siblings.
Miss M, a 61-year-old unmarried woman, and her 58-year-old handicapped brother were visited in their flat by the local mental health service at the request of their neighbours, who complained about an intolerable smell. Mr M’s forearms had been amputated at age 11 years after a serious accidental electrocution. For at least 1 year, he persistently refused artificial limbs and surgery for osteoarthritis in his hip bones; hence, he was obliged to remain lying on his bed. Their mailbox was filled to the brim, and because they didn’t pay invoices, electricity had been switched off.
At the entrance, the flat was grossly dirty and untidy, with an unbearable stench. Rubbish had been hoarded to the extent that most of their living space was taken up with full cardboard boxes, bins, and heaps of magazines. Miss and Mr M denied the precariousness and the insanitariness of their living conditions and vehemently refused any assistance. For this reason, hospitalization in the psychiatric department was decided for both.
Contrasting with their isolation and the flat’s filthiness, and in spite of his handicap, Mr M was in good health, without bedsores, anemia, or other biological signs of malnutrition. Cognitive and psychiatric assessments did not reveal any dementia, cognitive impairment, or psychotic disorders in either patient. During the hospitalization, Miss and Mr M minimized the seriousness of the flat’s damage, and similar personality traits were noted: they were both aloof, secretive, and suspicious. Finally, we diagnosed a primary DS.
DS cases reported in the literature refer to various and heterogeneous conditions. Most DS subjects live alone and are single or widowed (1). DS in a pair of subjects is a rare condition, with few cases reported in the literature, all concerning married couples (1,4,5). To our knowledge, this is the first reported case of a DS occurring in a pair of siblings.
1. MacMillan D, Shaw P. Senile breakdown in standards of personal and environmental cleanliness. BMJ 1966;2:1032–7.
2. Clark ANG, Mankikar GD, Gray I. Diogenes syndrome: a clinical study of gross neglect in old age. Lancet 1975;1:366–8.
3. Wrigley M, Cooney C. Diogenes’ syndrome: an Irish series. Ir Intel Dis Research 1992;9:37–41.
4. Cole AJ, Gillett TP, Fairbairn AD. A case of self-neglect in a married couple; “Diogenes” à deux? Int J Geriatr Psychiatry 1992;7:839–41.
5. Spear J, Wise J, Herzberg J. Diogenes’ syndrome and folie à deux in a married couple. Psychiatr Case Rep 1997;2:53–7.
David Esposito, MD
Frédéric Rouillon, MD
Frédéric Limosin, MD, PhD