Diogenes Syndrome and the Mental Health Act

Members of the public often become very alarmed and even affronted and incensed about people in the community who chose to live in unusually squalid or insanitary conditions. Complaints may be made to the police or social services, with demands that “something” must be done about them. In extreme cases, there can be considerable media publicity about people found dead in their homes surrounded by filth and clutter.

Social Services are often the first to be contacted about such people, as are secondary mental health services. Over the 35 or so years I have been a social worker, I have worked with many of these people. While the majority of them exhibit signs of eccentricity and often an unwillingness or inability to engage in social interaction with others, I have found few of them to have had any significant mental illness or disorder. Often, the focus of work with them has been, not necessarily to significantly change their living conditions, but to support them in the way of life they have chosen while trying to reduce risks to their health and safety, and to protect them from the antagonism of the local community.

I’ve already written on this blog about a couple of cases where I have assessed people who were living in conditions deemed unacceptable or hazardous: Harry, an elderly man, whom I wrote about in July and December 2009, and Stella, a middle aged woman, in October 2010. The psychiatric grounds for detention of Harry were tenuous, and Stella, although eccentric, showed no signs of mental illness.

I was recently asked to assess Bernard, a man in his 50’s who was living alone in such conditions. His GP had made an urgent referral after being called out to him by the local Police Community Support Unit. She reported that: “The house is uninhabitable and is a health risk to the patient and his neighbours. There are strewn newspapers and garbage piled high to the ceiling in the rooms, the walls are coated with black dirt. His feet are purple and his toenails are about 10 cm in length. I could not see beyond the dirt on his feet to tell if he has gangrene. He will need a mental health assessment for the possibility of Diogenes Syndrome.”

Pretty nasty, then. Very alarming. Something certainly had to be done. So I decided to see him for a preliminary assessment with a nurse from the CMHT. In the meantime, something niggled at me. Bernard? Bernard? Hadn’t I assessed someone under the MHA in the dim and distant past with that name? Looking through my records, I discovered that I had indeed assessed someone of the same name and age, but with a different address, all of 18 years ago. I had a dim recollection of the circumstances: he had been living with an elderly aunt and uncle who had both died and he was in the process of being evicted from their council house as he did not have a tenancy. All I could now recall was that I had not detained him under the MHA, and he had not become a patient of the CMHT.

When we arrived his front door was open and he was standing in the lobby with a pile of shoes in front of him trying to find a pair that would fit. This meant that we could see the state of his feet. I could confirm that his toenails were actually only 1 or 2 cm long ( ½ inch rather than 4 inches), and that his feet were extremely dirty. He eventually managed to put a suitable pair of shoes on and was able to attend to our visit. He had long, greasy hair, a straggly beard partially obscuring his grimy chest, and was wearing a stained and filthy waxed jacket, and, as far as we could see without looking too closely, very little else.

Although he invited us into the flat, in view of the smell emanating from the open doorway, and the fact that the door could only open a little way because of the junk in his hallway, meaning that we would have to squeeze through the narrow, and very dirty opening, we decided to conduct the assessment in the lobby outside.

Throughout the assessment, he presented with excellent recall of dates and events throughout his life. He immediately recognised me from our encounter 18 years previously, and recalled the exact year and the circumstances. He was orientated in time and place. There was no evidence of dementia.

In fact, on interview, Bernard presented with no evidence of mental disorder. He certainly fulfilled the criteria for a diagnosis of “Diogenes Syndrome”, but as I have observed before, that is not in itself a mental disorder. There was no evidence of psychosis or delusional thinking. Objectively he did not appear depressed, and stated that he did not think he had any mental health problems. Although there appeared to be a history of anxiety, he did not present as anxious, and in fact welcomed the opportunity to converse with us. He did not express any significant concern about his living conditions, although did admit that the house was untidy, and did not feel that he needed any help to sort it out. In short, despite the objectively appalling state of his living conditions and personal hygiene, there was no evidence that this had arisen as a result of a mental disorder, and there was consequently no evidence at all that could justify his detention in hospital under the Mental Health Act. Indeed, he did not even meet the eligibility criteria for receiving services from the CMHT.

An interesting article in Clinical Geriatrics (Volume 13 - Issue 8 - August 2005: “Diogenes Syndrome: When Self-Neglect is Nearly Life Threatening” -- Badr, A, Hossain, A , and Iqbal, J) gave a similar case study. Although concentrating on the geriatric aspects of Diogenes Syndrome (most of the people I have seen have not been elderly) the article reaches some interesting conclusions. The authors quote Karl Jaspers, who: “proposed that this condition does not constitute a newly occurring psychopathological entity, as the whole picture is understandable from each subject’s personality and stressful life events. He emphasized that the characteristics of the premorbid personality play an integral role in the pathogenesis of the syndrome. His view of this syndrome was that it represents a lifelong subclinical personality disorder, probably of a schizoid or paranoid type, that turns gradually into gross self-neglect and social isolation.” In other words, it is something that can slowly creep up on slightly odd people over a long period of time

This analysis would certainly accord with my own experience of people with this presentation, and would certainly apply to Bernard, who reported that he had received psychiatric care, including ECT, as a teenager, although it was unclear why, and until his aunt and uncle had died had always lived in the households of others, and had therefore probably never acquired the skills to maintain his own household.

So what could be done with Bernard, and others like him? Since he could not be said to lack capacity, the “best interests” powers under the Mental Capacity Act, which permit people to take actions on behalf of a mentally incapacitated person on the basis that the action is in their best interests, would not apply to him. People have a right to make “unwise decisions”, providing they have capacity to do so. This could include such “unwise” actions as drinking too much alcohol, marrying someone you hardly know on a whim in Las Vegas, or refusing to wash for months or years.

Possibly the only route to addressing Bernard’s circumstances through legislation rather than gentle persuasion would be Sec.47 of the National Assistance Act 1948, which provides powers of “removal to suitable premises of persons in need of care and attention.” Although it might be thought that an Act created by the new landslide Labour Government just after the Second World War would long ago have been repealed, this still remains on the statute books.

This is a legal power that is quite often talked about in social work circles, but very rarely used. It has to be established that "The person is suffering from grave chronic disease OR being aged, infirm, or physically incapacitated, is living in unsanitary conditions AND the person is unable to devote to himself and is not receiving from other persons proper care and attention AND his removal from home is necessary either in his own interests or for preventing injury to the health of, or serious nuisance to, other persons". If all of these conditions can be satisfied, the person can then be taken to a hospital or a care home for medical treatment or care against their will.

I have only ever been involved in one such case in my entire career, and that was over 30 years ago. It involved an elderly lady living alone who was no longer able to manage and was becoming increasingly frail and weak. Although she did not have dementia, she consistently refused all offers of help and support. An assessment under Sec.47 of the National Assistance Act 1948 was undertaken, involving a “community physician” but when it came to it the lady, clearly impressed by this doctor’s title, agreed to go into hospital voluntarily.

However, even this power is now more than likely to fall foul of more recent legislation. The Department of Health has suggested that Sec.47 could be in breach of the Human Rights Act. In a brief guidance document published in August 2000 ("The Human Rights Act, Section 47 of the National Assistance Act 1948 and Section 1 of the National Assistance (Amendment) Act 1951"), it reasonably notes that use of this section may breach Article 5 – the right to liberty, and Article 8 – the right to respect for private and family life. So gentle and persistent persuasion to accept assistance probably remains the only option for trying to help people like Bernard.

Phew! A bit of a dry and technical post today, perhaps. Back to foul language and more threats of bodily harm to AMHP’s next time.