History Clark and al in 1975, in a study concerning 30 patients of more than 65 years hospitalized for a pointed pathology and for an extreme carelessness of themselves, described patients living in conditions of major dirt, accumulating any sorts of useless objects and garbage in their housing environment. They considered this behavioural problem as a syndrome which they baptized: » syndrome of Diogene « .
This terminology makes reference to the famous Greek philosopher of the IVth century before J. C, Diogene, leader of the cynics and the follower of Socrates. This last one, dirty with the long and untidy hair, lived in a barrel and disdained the social agreements by expressing its disdain for the humanity. He had for the only things only a coat and a shoulder bag. Such was its choice of life. linical From the various works, it is possible to define the clinical characteristics of the syndrome of Diogene: A behavior of carelessness of the personal hygiene and the place of life, A denial of the reality and an absence of shame relative to their way of living, A social isolation, A pre-morbid personality: suspicious, cunning, distant, a tendency to deform the reality, A refusal of any
Let us note that Clark added to these diagnostic criteria, the absence of cognitive changes. Ethiopathogenie In the literature, we raise various hypotheses concerning the etiopathogenie of this behavioural problem. Consequently, there is no consensus on mechanisms etiopathogeniques. Nevertheless, two currents seem to coexist: the one which connects the syndrome with a psychiatric pathology and the other which evokes the choice of a lifestyle and the expression of the free will, just like Diogene.
For Clark, who does not find psychiatric pathology nor cognitive change to half of his patients, the syndrome of Diogene would correspond to a reaction to the specific stress of the old subject, arising on a predisposed personality containing lines of anxiety, gloomy humor and attitude of retreat. This reaction would constitute an active attitude and not a passive degradation. Nevertheless, some authors as Rosenthal, formulated critics concerning this study.
Indeed, on 30 inclusive patients 14 died and thus the results of the tests of intelligence and personalities reflect only those of 16 remaining patients. We can wonder about the mental state of missing half. Mac Millan and Shaw found on their population of 72 subjects, 38 psychotic patients and 34 unhurt patients of any mental pathology among which 11 presented signs of reactionnelle depression. In the more recent Anglo-Saxon literature appears a considering consensus that at least half of the patients » Diogene » suffers from psychiatric pathologies.
Among the quoted disorders, we note: the insanity, the alcoholism, the paraphrenies, but also the schizophrenia to young cases, and finally OBSESSIVE-COMPULSIVE DISORDER. The study of Halliday counts 70 % of psychiatric disorders. Concerning the insanities, certain works propose the hypothesis of a dysfunction of the frontal lobe. Indeed, the frontal insanity and the syndrome of Diogene share common symptoms as the hostility, anosognosie and syllogomanie interpreted as shape of perseveration engine. Finally, was noticed in certain cases a secondarily insane evolution.
Cannot we interpret then the syndrome of Diogene as precursor of an insanity, and underline the interest of forward-looking studies in which would be made balance sheets psychometrics and examinations of intellectual imaging? In France, Monfort, in its work of psychogeriatrie, classifies the syndrome of Diogene in the neurosises of involution. A French study realized by Taurand and al . , studied the medical and social status of 21 patients of more than 60 years old living in a shanty and having been hospitalized for somatic causes.
It finds a chronic ethylisme in 57 % of the cases, the signs of intellectual deterioration in 80 % of the cases (MMS < 23/30). A single case of Diogene is diagnosed because it is reserved for the unhurt subjects of any psychiatric pathology. For these authors, the absence of mental affection reflects the free choice of the lifestyle. The others as Chebili, also reserve this diagnosis for the subjects without mental pathology, respecting the reference to the philosopher Diogene.
How we can dread this behavioural problem: is it about a pathological reaction of retreat which can evoke a delirious behavior of paranoiac type or a lifestyle which results from a free choice? Even there, various hypotheses can be formulated. A Swiss team of Geneva proposed a hypothesis concerning the structure of the personality of these patients by raising at home a fear of division, a mode of relation of object of type fusionnel, a mechanism of defence represented by the denial and the paranoiac frenzy which is not still found. So, is outlined a structure of personality of paranoiac type.
Clark, as we have already described it, interpreted this disorder as a reaction to the stress of the old person on an amenable personality, but without turned out psychiatric pathologies Finally, so as suggest it the organizers of this day, » to collect it is to be capable of living the past « , then the behavior of amassement would translate an incapacity to lose, to release, to forget its past, to make a work of mourning, separation? Coverage and ethical In front of such medical and social situations, the question which settles to the doctors is the one to know if it is about a choice of life or about a pathological reaction.
The case of the free choice, questions the doctor about the respect for others and for its freedom, as well as about the duty of interventions. It is important to remind that the French law imposes no obligation of care to every person enjoying its full capacity and that there is no committee of ethics ruling on the social future of the old persons. But to where we can let practice the free will? Many medical teams underline the necessity, within the framework of the syndromes of Diogene, of creating a relational reliable space with these subjects which refuse the helps proposed, often felt as intrusive. It is necessary to know how to overcome gradually the hesitations and make understand the profits of a life in community by helping him in the work of mourning « . Conclusion It is left by questioning concerning the etiopathogenie of such a syndrome: expression of a free will, or heterogeneous syndrome recovering multiple medical, psychiatric and social situations? Finally, the coverage of these patients sends back every clinician to ethical questions being able to question the legitimacy of its interventions.