Wednesday, 22 July 2009

Is Diogenes Syndrome a Mental Disorder?

Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.

He likes cats, and encourages strays to enter his home through an ever open catflap in his front door, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm, and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.

The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.

Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.

The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker, and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission, and gives a graphic description of what will happen to anyone who tries to make him go to hospital.

This is when the Masked AMHP is brought in. I speak to the psychogeriatrician, who has visited Harry a couple of times, and who clearly is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate, and provides me with a medical recommendation.

I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has basically always been a difficult man, who subjected him to physical abuse as a child and made his mother’s life a misery. He rings him at least once a week, and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to.

I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. We also arrange for the police to be on standby. On the basis of the evidence, I am already leaning towards a decision to detain for assessment.

The house is exactly as described. We enter his living room, where he sends nearly all his time. Cats sidle around the heaps of rubbish.

Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. His answers reveal him to be orientated in time and place. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I talk to him in more detail about the purpose of our visit, he becomes hostile, and asks us to leave.

But I need to discuss the assessment with the GP and social worker. We huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The first legal requirement, that the patient has to be suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital, is not fulfilled. The GP agrees with me. On this basis, I am unable to justify a detention in hospital even for assessment.

By this time, Harry is justifiably annoyed with us, since he realises we are talking about him and he doesn’t like it. He starts to insist that we leave, shouting and repeating this into my face. He does not let me tell him that he would be satisfied with the outcome of my assessment, and bundles us out of his house.

Some sixth sense tells me the social worker is not happy with the outcome of the assessment. On the pavement outside, I discuss the reasons for my decision with him.

Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have life styles others find unacceptable or repugnant. It is often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community as much as possible in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.

Harry could probably be described as having Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself; a study of patients with this syndrome concluded that only half actually had a mental disorder. (Diogenes Syndrome: a clinical study of gross neglect in old age (Clark AN, Mankikar GD, Gray I, Lancet 1975 Feb 15;1(7903):366-8). Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.

Things continue to deteriorate. He persists in making abusive and unreasonable calls to the out of hours service. The carers continue to complain about the rats. By now, they appear to be approaching the size of small hippos. The social worker arranges for a visit with an environmental health officer.

Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.

After lunch, we gather on the pavement outside Harry’s house with the GP. The social worker approaches. He visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as conducting an expedition into the overgrown garden. He could find no evidence of the presence of rats whatever – no rat runs, no droppings, no urine, no evidence of chewing – nothing.

This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to introduce an antipsychotic into his medication in order to see whether or not this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.

I suspect that I have not heard the last of Harry. I will probably be asked to pay him another visit sooner or later. (Unless they ask another AMHP to assess him!) The pressure is likely to continue to mount on me to detain him under Sec.2 for assessment. After all, it would only be for up to 28 days, and only for assessment. At what point should I conclude that there really is no alternative?


  1. I've worked almost consistently with over 65s since I qualified and have come up with this quite a few times, never though, since I was warranted as an ASW/AMHP. I think it's something that only be judged in particular situations that might arise - I know that's evading the question somewhat.
    Actually I can think of one situation where it was considered for someone I was working with but the Mental Health Act wasn't used. There was some discussion of the National Assistance Act but in the end we were able to use a lot of persuasion to get environmental health in.. still, it's a tricky one.

  2. y colleague Amhp had a similar case and being newly approved asked for AMHPS views on the case (we were at a training forum).The consensus from the vocal ones was that she should obtain a s 135 warrant,take him to a place of safety, assess him and if necessary bring him in for treatment, as he had a mental disorder. Her comments were, " they all make it seem so simple, but it's not"). At any rate, she used her own initiative, decided she could find no mental disorder and the person was not detained, but referred back to social services.I thought this very brave of her.

  3. I am struggling with my father just now...and I am just about at the end of my rope with him. He is almost 80 and is living in complete filth and squalor. His home is a filthy, squalid mess. He keeps losing his wallet and his chequebook in the house and I am having to cover more of his bills to keep him out of trouble. He stopped washing his clothes years ago, he never showers or baths, nobody is allowed in the house. He will not let me help him except to pay his bills. We are almost certainly heading for a crisis,; he has been officially 'malnourished' for 3 or 4 years, he drinks, and now he is having problems with his legs and walking. His problems appear to fall into a very grey area in the law, and nobody seems to be able to intervene or help. At my insistence I will meet with a social worker and someone from environmental health this week, but I have little expectation.