Introduction
Diogenes syndrome, first named in 1966 (Macmillan and Shaw, Reference Macmillan and Shaw1966; Clark et al., Reference Clark, Mankikar and Gray1975), is a public health problem characterized by extreme self-neglect, domestic squalor, lack of concern about one's living conditions and social withdrawal, and is often accompanied by excessive hoarding (syllogomania) (Cooney and Hamid, Reference Cooney and Hamid1995). Diogenes syndrome does not appear in the DSM-IVR. The estimated annual incidence among individuals over 60 years old and living at home is 5 per 10,000. At least half of people affected by Diogenes syndrome have dementia or some form of mental illness (Macmillan and Shaw, Reference Macmillan and Shaw1966; Cooney and Hamid, Reference Cooney and Hamid1995) including frontotemporal dementia, head injuries, schizophrenia and obsessive-compulsive disorders. Although Macmillan and Shaw added them to the etiologies list in 1966 (Macmillan and Shaw, Reference Macmillan and Shaw1966), affective disorders disappeared in the following decades, notably from Clark's etiologies list nine years later (Clark et al., Reference Clark, Mankikar and Gray1975).
Case report
Miss P. gave a written informed consent for the publication of this case report.
Aged 69, Miss P. was brought to the emergency department for behavioral disturbances. She had abnormally elevated mood and joviality with a decreased need for sleep and a loss of appetite. She was abnormally logorrheic and tachypsychic without psychotic symptoms. The offensive smell of two dogs that were never taken out of the house had led the neighbors to call the police. She always refused housekeeping assistance: household furniture was spoiled and old magazines had accumulated on the floor. Windows, taps and electrical equipment were broken. Miss P. had also accumulated a large number of clothes, lying everywhere in the flat. Miss P. never recognized these facts.
Dementia was first considered, and Miss P. was referred to the Neurology Department. Neuropsychological tests were conducted; no alteration in global efficiency, no executive dysfunction, and no attention deficit were noted. Mental flexibility and verbal initiation (literal and categorical fluencies) were normal. Long-term episodic memory (responsive to cuing, maintained learning abilities), verbal working memory and short-term memory, as well as constructive praxis, were normal. Her Rey figure was blurred, which evoked visuospatial programming and forward planning alterations. Major distractibility, familiarity, impulsivity, impaired judgment and anosognosia were noticed and attributed to the acute mood state.
Magnetic Resonance Imaging, HMPAO scintigraphy, B6 and B12 vitamins, and TSH levels were normal. TPHA-VDRL, HBV, HCV and HIV serologies were all negative. No alcohol misuse was noted and she smoked fewer than three cigarettes per day. No organic cause was found. The patient was consequently referred to the psychiatry department.
An interview with the patient and her family revealed that Miss P. had suffered from a severe depressive episode six months after her husband's suicide when she was 40. After a three-week hospitalization in a psychiatry department and treatment with antidepressants, an untreated chronic depressive state remained for the following eight years. Before this tragic event, the patient was described as a rather jovial schoolmistress.
The first symptoms of mood elevation began insidiously and lasted many years. No euthymic state had been found in the period of mood switching. According to her family, Miss P. became clearly eccentric. She first collected a lot of magazines. She smiled easily, wore bright jewels and would talk to anybody outside her home. She was also clearly distractible but coherent and oriented. Her appetite was reduced, but without any weight loss, and her sleep duration was decreased too. There was no sign of current sadness. She kept her job until her retirement and saw no psychiatrist during this period.
When she retired at the age of 65, her youngest son left home; at this point her behavior worsened. She borrowed money from several banks and ran into debt. She also began to hide objects. The Diogenes syndrome increased and she had to move twice in three years. The deterioration of the condition of three successive flats led her sons to ask for guardianship. The family reported that she had been aggressive with the guardian when he tried to address her finances.
No mood remission was found during this 30-year period. There was no history of psychotic symptomatology, alcohol and/or substance abuse/dependence, or obsessive-compulsive disorder. According to her sons, there was no family history of psychiatric or neurological disorders.
We diagnosed a current manic episode and bipolar I disorder according to the DSM-IVTR criteria. Accordingly, Miss P. was first treated with olanzapine 20 mg/d. Because the improvement was only partial, lithium 800 mg/d was added with a mean plasma lithium level around 1.0 mmol/l. This led to clear symptomatic improvement.
After her discharge from hospital, her sons and the home nurse confirmed her functional remission. There were no behavioral disturbances and no cognitive impairment. Her sons reported that she was less distractible. She is now a happy person with excessive optimism, moderate hyperactivity and good sociability. Her sleep duration is never longer than 5 to 6 hours, which evokes a residual hyperthymic mood state without effect on her quality of life. The patient is visited at home by a psychiatrist on a monthly basis, and maintains good treatment adherence with no major side effects. She has now been living alone in her flat with her dogs for two years, and there has been no reoccurrence of Diogenes syndrome.
Discussion
This case illustrates the need to investigate mood disorders, in particular chronic mania, in cases of Diogenes syndrome. Chronic mania is a forgotten diagnosis. Hare (Reference Hare1981) underlined that chronic mania was an important concept for nineteenth-century psychiatrists that has disappeared from current textbooks. For example, chronic mania was considered as the second most frequent cause of admission to asylums in 1892 (Hare, Reference Hare1981). Perugi et al. (Reference Perugi1998) suggested that when manic symptomatology persists for more than six months, there is a high probability that an acute manic state will evolve to chronic mania. In their survey, 13% of 155 patients had a chronic course with deteriorating features arising from a background of hyperthymic temperament and recurrent mania. Clinically, such patients are characterized by higher rates of euphoria, grandiose delusions, but lower frequencies of sleep disturbance, psychomotor agitation and hypersexuality (Perugi et al., Reference Perugi1998). Moreover, chronic mania is associated with poor insight, dullness and euphoria; symptoms that can lead to squalor, self-neglect and increased spending. Lithium is the only mood stabilizer that appears to be helpful in chronic mania (Hare, Reference Hare1981). Chronic mania is a forgotten etiology of Diogenes syndrome, and should be restored to current diagnostic and therapeutic classifications.
Conflict of interest
None.
Description of authors' roles
Drs. Fond and Abbar took care of the patient. Drs. Fond and Jollant reviewed the literature on Diogenes syndrome. All authors participated in writing and revising the paper.
Acknowledgments
The authors wish to thank Ms Joanna Norton for editorial assistance and Ms Christelle Ayela for neuropsychological assessment.
