PSYCHOLOGY

PROJECT
REPORT

Submitted by:

Akshay Mathur
Class - XII - K

CERTIFICATE
This is to certify that this project has been
completed by __________of Class XII, under my
supervision & guidance to my total satisfaction.

I further certify that this is her original work.

(Teacher)

ACKNOWLEDGEMENT
I would like to acknowledge with thanks, the help that
I got from my teacher for preparing this project. In
particular, my thanks goes to my PsychologyTeacher
_____________, not only for the valuable knowledge
of the materials of the report, but also for
encouraging me to make this project report

NAME:
CLASS - XII

LIST OF CONTENTS

1. INTRODUCTION
2. CATEGORIES
3. HOW TO TAKE CARE
4. CAUSES
5. MANAGEMENT STRATEGIES
6. SYMPTOMS OF DIOGENES SYNDROME
7. CASE STUDY
8. CONCLUSIONS

INTRODUCTION
Diogenes syndrome (also known as senile squalor syndrome) is a subset
of the mental health disorder known as compulsive hoarding. It affects
approximately 0.2 percent of the general population, or 10 percent of all
hoarders, and is generally found among the elderly. The disorder is equally
distributed among men and women.
Signs and symptoms of this disorder include extreme self-neglect, social
withdrawal, domestic squalor, compulsive hording, apathy, and lack of
shame. The afflicted may also exhibit symptoms of catatonia. People with
the disorder are generally unlikely to seek and follow medical advice.
Those afflicted exhibit self-imposed isolation.
People who suffer from this affliction are usually only diagnosed by
chance, due to somatic illness, or as a result of social intervention related
to their known behavioral problems.
The condition was first observed in 1966 and was labeled of Diogenes
syndrome by A.N. Clark and his colleagues.
The Three Major Categories of the Diogenes Syndrome Include:

Individuals who display habitual collecting or hoarding.

Younger individuals with lifelong mental illnesses.

Elderly people who have degenerative neurological diseases.

HOW TO TAKE CARE

Enlist help in cleaning the problem areas.

Set a date and stick to it.

Work methodically, room by room.

Assign tasks and develop a workable system.

Donate all useful unwanted items.

People suffering from this illness have a 46 percent five-year mortality rate.
There is also no clear diagnostic criteria for this illness until more facts
come to light. Due to these peoples reclusive nature this often proves
difficult.
A character portrait of these people is startling. They are thought possess a
deep suspicion of doctors and authority figures. People with this disorder
are often suspicious of change and possibly suffer from substance abuse
or have experienced some kind of significant personal loss. They are
usually disheveled and will not invite other people into their house.
People with Diogenes syndrome typically have many pets. They do not like
to be scrutinized or observed and usually do not exhibit outward shame,
though they do experience shame when their hoarding is discovered. They
often only change when they are faced with eviction due to their hoarding
of useless things that don't serve a useful purpose.
Questions about this illness still abound, including whether Diogenes
syndrome is an illness in itself or a symptom of a much larger illness.
There Are Thought to Be Two Types of These Hoarding Behaviors:

The passive type who slowly becomes victim to invading rubbish

(such as not throwing away junk mail).

The active type that actively seeks and collects the rubbish
(receiving coupons in the mail and having a compulsion to use them
even if the person has no use for the items purchased).

Treatment usually consists of exposure therapy in which the patient is

trained to stop having an emotional connection to getting rid of the junk.
Those afflicted are often paired with someone else to help them get rid of
all the clutter. Drugs are rarely used. Hoarding is thought to be
manageable given enough support from family.
Support should include the initial help in organizing the patients' lives as
well as attention given to the problem. Then when things are manageable
there should be a routine checkup on the individual to see how well they
have been in trying to manage their illness.

CAUSES
Diogenes syndrome is a disorder that involves hoarding of rubbish and
severe self-neglect. In addition, the syndrome is characterized by domestic
squalor, syllogomania, social alienation, and refusal of help. It has been
shown that the syndrome is caused as a reaction to stress that was
experienced by the patient. The time span in which the syndrome develops
is undefined, though it is most accurately distinguished as a reaction to
stress that occurs late in life.
In most instances, patients were observed to have an abnormal
possessiveness and patterns of compilation in a disordered manner. These
symptoms suggest damages on the prefrontal areas of the brain, due to its
relation to decision making. Although in contrast, there have been some
cases where the hoarded objects were arranged in a methodical manner,
which may suggest a cause other than brain damage.

Although most patients have been observed to come from homes with
poor conditions, and many had been faced with poverty for a long period of
time, these similarities are not considered as a definite cause to the
syndrome. Research showed that some of the participants with the
condition had solid family backgrounds as well successful professional
lives. Half of the patients were of higher intelligence level. This indicates
the Diogenes syndrome does not exclusively affect those experiencing
poverty or those who had traumatic childhood experiences.
The severe neglect that they bring on themselves usually results in
physical collapse or mental breakdown. Most individuals who suffer from
the syndrome do not get identified until they face this stage of collapse,
due to their predilection to refuse help from others.
The patients are generally highly intelligent, and the personality traits that
can be seen frequently in patients diagnosed with Diogenes syndrome are
aggressiveness, stubbornness, suspicion of others, unpredictable mood
swings, emotional instability and deformed perception of reality. Secondary
DS is related to mental disorders. The direct relation of the patients'
personalities to the syndrome is unclear, though the similarities in
character suggest potential avenues for investigation.

MANAGEMENT STRATEGIES
It is ethically difficult when it comes to dealing with diagnosed patients, for
many of them deny their poor conditions and refuse to accept treatment.
The main objectives of the doctors are to help improve the patients
lifestyle and wellbeing, so health care professionals must decide whether
or not to force treatment onto their patient.

In some cases, especially those including the inability to move, patients

have to consent to help, since they cannot manage to look after
themselves. Hospitals or nursing homes are often considered the best
treatment under those conditions.
When under care, patients must be treated in a way in which they can
learn to trust the health care professionals. In order to do this, the patients
should be restricted in the number of visitors they are allowed, and be
limited to 1 nurse or social worker. Some patients respond better to
psychotherapy, while others to behavioral treatment or terminal care.
Results after hospitalization tend to be poor. Research on the mortality rate
during hospitalization has shown that approximately half the patients die
while in the hospital. A quarter of the patients are sent back home, while
the other quarter are placed in long time care. Patients under care in
hospitals and nursing homes often slide back into relapse or face death.
There are other approaches to improve the patients condition. Day care
facilities have often been successful with maturing the patients physical
and emotional state, as well as helping them with socialization. Other
methods include services inside the patients home, such as the delivery of
food

Symptoms of Diogenes syndrome

10 symptoms of Diogenes syndrome are listed below:

Self-neglect

Lack of self-consciousness about personal habits

Untidiness

Hoarding of rubbish

Aloofness

Suspiciousness

Emotional lability

Aggressiveness

Distortion of reality

Nutritional deficiencies

CASE STUDY
A 61-year-old obese Caucasian female with a previous history of bipolar 1
disorder and hypothyroidism, presented for an out-patient psychiatric
follow-up review accompanied by her Community Psychiatry Nurse. She
was found to have pressured speech, elated mood, increased energy, and
very poor personal hygiene. She was disheveled, unkempt, wearing dirty
clothes, and was foul smelling. She was very agitated, and was verbally
and physically abusive to staff. She had no insight, and refused any form of
treatment. She was diagnosed with having a manic relapse secondary to
non-adherence to medication, and was involuntarily admitted to the inpatient psychiatric ward. Complete blood count, electrolytes, glucose, liver
function, and lipid profile were all within normal limits. Thyroid stimulating
hormone was slightly elevated, although T4 was within normal limits.
Vitamin B12 was on the low end of normal. She was re-started on her
previous psychiatric medication, namely divalproex and clonazepam.
The following day she was adamant about having to go feed
her cats and dogs, and eventually gave permission for a Community
Mental Health Nurse enter her house to attend to her pets. Upon entering
the house, it was found to be in complete disarray. The house was
crammed with filthy clothes, garbage, dirty dishes, and rotting food. There
was no kitchen sink in sight, and it looked as if some dishes were being
cleaned in the toilet (see Figures 1 and 2). Any clear space of floor was
strewn with cat and dog feces. An unbearable stench emanated from the
entire two-story home. Upon questioning the patient regarding the state of
her home and personal hygiene, the patient had no insight into any
problems. At this time, a diagnosis of Diogenes syndrome was suspected.

Figure 1. Bathroom. This is the state in which the bathroom was found in
the patients house. The patient had been using the toilet for both toileting
and periodically washing her dishes.
Figure 2. Living room. The patients living room was filled with dirty
clothing, old newspaper, and animal feces.
Diagnosis of DS can be difficult as no one constellation of
symptoms has been established. Hoarding, which can occur
in DS, can also be found in many psychiatric conditions such
as obsessive-compulsive disorder (OCD), schizophrenia,
dementia, and others. The act of accumulation in DS is more likely egosyntonic however, in contrast to the anxiety and intrusive thoughts that
accompany collection in OCD. DS can be distinguished from personality
disorders in that the personality in DS deteriorates, while the true
personality disorder does not. Self-neglect can also be a part of dementia,
schizophrenia, OCD, and affective disorders. Frontal lobe dementia tends
to occur approximately 10 years prior to the typical age that DS patients
are affected though. A diagnosis of schizophrenia can include delusions,
hallucinations, and disorganized speech, which are not classical
characteristics of DS. Clearer delineations between disorders need to exist
however. An alterative suggestion was that DS may be a final common
pathway of different psychiatric disorders .
Management of DS can be difficult, as patients often deny that there is a
problem, may refuse any help, and can present late to medical attention,
often in crisis. Ethical and legal issues can then arise, such as finding a
balance between autonomy and beneficence. For example, a patients
notion of self-neglect can be quite different than the view of their
healthcare provider. Public Health issues may also arise concerning the

patients housing. Fire, mould, and biological material can pollute the
surrounding environment, so the health of nearby residents needs to be
considered.
Establishing good rapport is vital in order to decrease the patients
resistance to aid. A physical exam should be completed. Blood tests may
include potassium, calcium, vitamin B12, iron, thyroid stimulating hormone,
folate, and albumin . Functional inquiries and cognitive testing may be
useful. Treatment usually begins by looking at any other possible
psychiatric issues such as mania or psychosis. Risperidone has been
suggested for use in DS even when there are no underlying psychotic
features . Other pharmaceuticals that may be of benefit include zolpidem
for sleep, paroxetine for hoarding, and sodium valproate or quetiapine for
secondary bipolar disorders . Flexible outpatient treatment through
community care providers is preferable if there is little risk to the patient or
to others.

This can include counseling and cleaning services, and

individualized case management . The mental health act can be used if

difficulties

are

experienced

in

managing

higher-risk

patients.

If

management is not conducted in a sensitive manner, patients will simply

return to the same living condition, with much more resistance to support
and follow-up.
The prognosis of affected individuals depends on their capability of reintegrating into society, and often relies on the patients making small
changes away from unhealthy living conditions. Other poor prognostic
factors include poor physical health, which may already be advanced due
to neglect, and early age at onset.

As time progressed as an in-patient, the patients mood settled, although

she remained guarded, with little insight into her self-care. The patient
required persistent and gentle pressure in order to even start thinking
about de-cluttering and improving her personal hygiene. She was
eventually persuaded to allow a company to help her clean her home, at a
cost of $8,073. The patient was present at the clean up. The sink was
eventually found under a large pile of debris. The patient is now living at
home, and receiving close follow-up with her Community Psychiatry Nurse
and Psychiatrist. It remains to be seen whether these interventions will
make any long-term impact to her living condition and health.

CONCLUSIONS
This case illustrates the importance of suspecting Diogenes syndrome
when elderly patients present with certain non-specific symptoms that may
otherwise be disregarded. These include patients who are unkempt and
malodorous, with personality traits of being unfriendly, detached, or
suspicious. Such characteristics can also be related to multiple other
psychiatric conditions. Timely diagnosis and respectful management may
reduce both acute and chronic physical illness, increase personal and
home hygiene and safety, and improve public health outcomes.

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