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Neurological Signs: Syllogomania; with a note on Diogenes of Sinope

Posted in Neurological Literature,Neurological Signs on 8th Jul 2020

andrew larnerAndrew Larner, Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool L9 7LJ   UK.
Correspondence to: E-mail: a.larner@thewaltoncentre.nhs.uk
Provenance and peer review: Submitted and reviewed internally.
Published online: 8/7/20
Published under a Creative Commons license


The novelist Barbara Pym (1913-80) has been called the “Jane Austen of our times” because of her acute and comedic observations of social mores.  Her work was admired by Philip Larkin, yet I suspect that today few have heard of her.  Her novel Quartet in Autumn (1977), set in London in the early 1970s, includes a character whose description seems positively to invite clinical diagnosis.1  (Spoiler alert: what follows discloses some of the plot features of Pym’s novel).

Miss Marcia Ivory is in her sixties, and thought somewhat peculiar by her fellow office workers, Edwin, Letty, and Norman (they constitute the quartet of the book’s title).  Marcia lives alone in the house she previously shared with her mother and which nobody else enters; she is “set in [her] isolation”. The room where her mother died has been left untouched, used only by the cat, Snowy, until he also died there.

syllogomaniaMarcia keeps empty milk bottles in a shed in her garden, a “special and rather unusual arrangement”, with over 100 of them stacked on shelves, and “spotlessly clean”.  These “needed to be checked from time to time and occasionally she even went as far as dusting them”.  The bottles are all “United Dairy” bottles, and Marcia is irritated to find one is of an “alien brand”, namely “County Dairies”, and plans to return it to Letty who gave it to her at the office one day.  Marcia leaves other types of rubbish, such as “bottles of a certain kind … certain boxes and paper bags and other unclassified articles” on the shelves at the local library, “a good place to dispose of unwanted objects”, although she is not a reader, indeed Letty wonders whether Marcia “ever read”.

In addition, to the milk bottles, Marcia has a collection of tinned foods in a kitchen store cupboard: “meat, fish, fruit, vegetables, soup …tomato puree, stuffed vine leaves …tapioca pudding”; “spam and stewing steak …prawns and peach halves … sardines, soup, butter beans and … macaroni cheese”.  The drawer in her office desk also contains several tins.  Every week she buys more tins which require classifying and sorting: “the tins could be arranged according to size or by types of food. … There was work to be done here and Marcia enjoyed doing it”.  Yet Marcia is repeatedly noted not to be a “big eater”, indeed one evening she eats “a small tin of pilchards. It was one left over from Snowy’s store, so it was not really breaking into her reserves.”

Finding a plastic bag in her kitchen, “Marcia took the bag upstairs into … the spare bedroom where she kept things like cardboard boxes, brown paper and string, and stuffed it into a drawer already bulging with other plastic bags … to be sorted into their different shapes and sizes”.  Elsewhere she has “a drawer full of new Marks and Spencer nighties  … All brand new and never worn”.

I suggest that these features merit the designation of syllogomania, a name given to a syndrome of hoarding,2 sometimes also termed “disposophobia”, often of items which may be deemed rubbish.  Syllogomania may occur in isolation,3 or may be part of a broader neurobehavioural syndrome of neglect. 

As noted, despite her store of food, Marcia’s diet is poor.  She is noted to be thin, then emaciated, clothes hanging on her, and eats little of the salad she orders when the quartet meet at a restaurant for lunch.  By the end of the novel she weighs “only six stone”.  Social rules are also transgressed, as when Marcia talks too loudly at the restaurant, attracting the attention of the other diners, and when she noisily returns Letty’s milk bottle to her in the library.

In addition to self-neglect, Marcia’s house is also neglected: “The dust on the hall table told its own story” (cf. the milk bottles) as well as “other evidences of long neglect”.  “On the bed cover there was still an old fur ball, brought up by Snowy in his last days, now dried up like some ancient mummified relic of long ago.”  Marcia declines a neighbour’s offer to cut her grass and spurns repeated visits from a social worker. 

Whether the character of Marcia was based on the author’s own observations, or simply the product of a creative imagination, is not known.  Nevertheless, for this clinician, the symptoms described prompt diagnostic speculation, specifically of Diogenes syndrome,4 sometimes known as “squalor syndrome”. 

Although a syndrome characterised by self-neglect, domestic squalor, hoarding behaviour, and social withdrawal with refusal of external help had been previously described, the term Diogenes syndrome was coined in 1975 by Clarke et al., referring to Diogenes of Sinope (ca. 412-323 BC), a cofounder of the Cynic school of philosophy in Athens, who was noted for his austere asceticism and self-sufficiency and his disregard for domestic comforts.5  Notionally he lived in a barrel or tub, and rebuked Alexander the Great for standing in his sunlight.  He has proved a frequent subject for allegorical paintings. 

Most patients diagnosed with Diogenes syndrome are elderly, single or living alone, of average or above average intelligence, and often with an adequate income (i.e. the condition is not the result of poverty).6  Although cases may be “primary”, unrelated to any underlying cognitive or psychiatric illness, the possibility of an underlying dementia,7 particularly of the frontotemporal type,8 should always be considered.  A variant characterised by the hoarding of animals has been called the “Noah syndrome”.9

Diogenes of Sinope should not be confused with two other individuals of the same name.  Diogenes of Apollonia (fl. 5th century BC) was a pre-Socratic philosopher who has been claimed as a pioneer in vascular anatomy and physiology.10  Diogenes Laertius (fl. 3rd century AD) was a biographer of the Greek philosophers who, to my current knowledge, has no connections with medicine, other than to record anecdotes of Diogenes of Sinope.

References

  1. Pym B. Quartet in Autumn. London: Picador Classic [1977] 2005.
  2. Larner AJ. A dictionary of neurological signs (4th edition). London: Springer, 2016:309.
  3. Zuliani G, Soavi C, Dainese A, Milani P, Gatti M. Diogenes syndrome or isolated syllogomania? Four heterogeneous clinical cases. Aging Clin Exp Res 2013;25:473-478.
  4. Larner AJ, Coles AJ, Scolding NJ, Barker RA. A-Z of neurological practice. A guide to clinical neurology (2nd edition). London: Springer, 2011:191.
  5. Clarke ANG, Manikar GO, Gray I. Diogenes syndrome. A clinical study of gross neglect in old age.  Lancet 1975;i:366-368.
  6. Assal F. Diogenes syndrome. Front Neurol Neurosci 2018;41:90-97.
  7. Cipriani G, Lucetti C, Vedovello M, Nuti A. Diogenes syndrome in patients suffering from dementia. Dialogues Clin Neurosci 2012;14:455-460.
  8. Finney CM, Mendez MF. Diogenes syndrome in frontotemporal dementia. Am J Alzheimers Dis Other Demen 2017;32:438-443.
  9. Saldarriaga-Cantillo A, Rivas Nieto JC. Noah syndrome: a variant of Diogenes syndrome accompanied by animal hoarding practices. J Elder Abuse Negl 2015;27:270-275.
  10. Crivellato E, Mallardi F, Ribatti D. Diogenes of Apollonia: a pioneer in vascular anatomy. Anat Rec B New Anat 2006;289:116-120.