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Noah Syndrome: A Variant of Diogenes Syndrome Accompanied by Animal

Hoarding Practices

Article  in  Journal of Elder Abuse & Neglect · November 2014

DOI: 10.1080/08946566.2014.978518 · Source: PubMed

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Noah Syndrome: A Variant of Diogenes Syndrome

Accompanied by Animal Hoarding Practices
a b
Dr. Alejandra Saldarriaga-Cantillo & Dr. Juan Carlos Saldarriaga Rivas
a
Universidad del Valle, Medicina Familiar, Calle 4B 36-00 edificio 116, Cali 76001000,
Colombia
b
Universidad del Valle, Departamentode Psiquiatría, Cali, Colombia
Accepted author version posted online: 14 Nov 2014.

To cite this article: Dr. Alejandra Saldarriaga-Cantillo & Dr. Juan Carlos Saldarriaga Rivas (2014): Noah Syndrome:
A Variant of Diogenes Syndrome Accompanied by Animal Hoarding Practices, Journal of Elder Abuse & Neglect, DOI:
10.1080/08946566.2014.978518

To link to this article: http://dx.doi.org/10.1080/08946566.2014.978518

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 Noah Syndrome: A Variant of Diogenes Syndrome
Accompanied by Animal Hoarding Practices
Dr. Alejandra Saldarriaga-Cantillo (Corresponding Author)

Universidad del Valle, Medicina Familiar, Calle 4B 36-00 edificio 116, Cali 76001000,

t
Colombia

ip
alejandrasaldarriaga20@yahoo.com

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Dr. Juan Carlos Saldarriaga Rivas

Universidad del Valle, Departamentode Psiquiatría, Cali, Colombia

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us
Abstract

an
Noah syndrome is a variant of Diogenes syndrome that presents as hoarding a large number of

animals. Predisposing factors for developing this disorder are situations of psychosocial stress
M
and loneliness. However, the medical conditions of the sufferer, which can represent the organic

substrate for the development of this psychopathology, should be considered.

ed

Key words: hoarding, loneliness, dementia, Diogenes syndrome

pt

Introduction
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Diogenes syndrome is a behavioral disorder that develops in people of advanced age. The
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cardinal features of this condition include extreme self-neglect, domestic abandonment and the

tendency to hoard objects. It is also associated with voluntary social isolation, rejection of

external help and no awareness of the abnormality of their behavior (Clark, Mankikar, & Gray,

1975). This disease has an estimated annual incidence of 5 per 10,000 in individuals over 60

1
 years of age; it has recently been included in the Diagnostic and Statistical Manual of Mental

Disorders, 5th Edition (DSM-5). A variant of this disorder is Noah syndrome, in which, in

addition to the features mentioned above, the patient hoards a large number of animals,

neglecting their basic care and showing an inability to recognize the consequences this may have

t
for the health and well-being of both the animals and the patients themselves (Gómez-Feria

ip
Prieto, 2008; G. J. Patronek & Nathanson, 2009; Serrano Vásquez, Serrano Cartón, & Serrano

cr
Cartón, 2009).
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Case report:
an
The patient is an 83-year-old widow with an academic background (she holds a Master’s degree).
M
She has lived in solitude for the past 20 years. She was initially assessed in her home after a fall

from a standing position that generated a soft tissue injury in the left thigh without fractures or
ed

other associated injuries. The patient appeared malnourished, with no other relevant findings on

physical examination.
pt

During the first contact with the patient, she presented poor personal and domestic hygiene, a
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mercurial and hostile afecct , and suspicion, and she refused to receive medical help.

Additionally, she lived with 15 dogs and 16 cats that were malnourished and in poor health. The
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house showed poor sanitary conditions, with considerable hoarding of trash and deteriorated

belongings that impeded safe passage. Animal feces were present, and the house was infested

with cockroaches and flies. The patient had no awareness of the public health problem she faced,

2
 despite having received multiple visits from health authorities who failed to convince her to

change her habits.

The neighbors stated that the patient had behaved normally until 15 years ago, when, after a

cerebrovascular accident, she began to develop insidious behavioral changes. These changes

t
ip
were characterized by hoarding trash and stray animals, social isolation, verbal and physical

cr
aggression toward her neighbors, extreme domestic abandonment and self-neglecting behavior.
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Her personal and family history (Table 1) was significant for cardiovascular disease and

psychiatric pathology, which at the time of initial assessment were not being treated with

medication. an
General laboratory screening tests were performed, including blood panel, erythrocyte
M
sedimentation rate, liver function (transaminases and bilirubin), renal function (creatinine, urea

nitrogen, electrolytes), thyroid function (TSH), metabolic profile, (glycemia, glycosylated

ed

hemoglobin, serum albumin) and infectious profile (VDRL and HIV). Additionally, vitamin

deficiencies (folic acid and vitamin B12) that could cause psychiatric symptoms were rejected.
pt

Other diagnostic aids for establishing general health were requested, including a chest X-ray and
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an electrocardiogram. The results were within normal parameters for age.

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A CT scan of the brain showed a prominent ventricular system with reactive cord changes with

age and small vessel disease in the periventricular areas. No areas of encephalomalacia were

evident.

3
 A neuropsychological assessment showed a moderate cognitive deficit affecting the higher

functions, especially frontal-subcortical organization. A deficit was observed in the executive

functioning processes of higher-order attention (inhibitory control, sustained attention, working

memory), and the patient exhibited systemic errors in planning and monitoring such functions in

t
complex tasks. Regarding episodic memory, the patient showed deficits in verbal and visual

ip
learning, with failures to encode and recall such information in an organized manner. In

cr
comparison, storage was secondarily affected, as indicated by an inability to achieve
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discrimination. Errors were also observed in motor sequence coordination tasks for transferring

information in a graphical construction; such errors were caused by faults in regulation processes

an
and became persistent. These results were consistent with a moderate cognitive deterioration of

vascular origin that could not be explained by depressive symptoms.

M
It was not possible to contact a member of the patient’s family. After the initial assessment, the

case was reported to local authorities. The housing was adapted to provide security for the
ed

patient, and authorities managed to remove most of the hoarded trash. The animals were given
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up for adoption despite the patient’s great efforts to keep them.

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Pharmacologic treatment was established for hypertension with enalapril 20 mg every 12 hours.

Starting a hypoglycemic agent was disregarded because the patient’s glycosylated hemoglobin
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values were below 6.5%. To manage the depressive disorder, fluoxetine 10 mg during the day

and trazodone 25 mg at night were prescribed. A nutritional supplement was also prescribed. It

was not possible to establish psychotherapy because of patient refusal.

4
 The patient’s clinical case was monitored for 10 months. Despite the measures taken, the

recurrence of hoarding behavior was evident. At the last visit, the house was again filled with

large hordes of trash, and the patient had brought in eight new pets. The case was brought to

local authorities again to examine the possibility of admitting the patient to a geriatric home.

t
ip
Discussion

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Noah syndrome shares most of its clinical features with Diogenes syndrome. Both syndromes
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most commonly occur in widows over 65 years of her age who have an above-average IQ

(Hurley, Scallan, Johnson, & De La Harpe, 2000). The syndromes are characterized by social
an
isolation, rejection of external aid, denial of social rules, self-negligent behaviors, domestic

abandonment and hoarding behaviors (Clark, et al., 1975). The syndromes are associated with a
M
lack of awareness of the disease, which makes all types of intervention difficult (Fond, Jollant, &
ed

Abbar, 2011).

The patient’s animals can be acquired passively or actively. In general, passive acquisition
pt

methods occur when the patient has a reputation for rescuing animals and the animals are
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delivered to the patient out of good will. In other cases, the number of animals increases because

there is no reproductive control. During active acquisition, a person may search for abandoned
Ac

animals, either on the streets or through announcements offering themselves as adopters. There

are even animal hoarders who present themselves as a legitimate shelter or rescue group,

managing to connect with activists who facilitate the acquisition of animals for them (Gary J

Patronek, Loar, & Nathanson, 2006).

5
 Many times, the abnormal behavior goes unnoticed; the image of the elderly person feeding stray

cats and/or dogs or taking them to his or her house is well known, and the behavior interpreted as

altruistic towards the abandoned animals. This behavior is often socially accepted because the

elderly adopters are perceived as lonely people seeking company and affection from the

t
“adopted” animals.

ip
cr
With animals, unlike objects, a reciprocal relationship is established; this relationship, perhaps, is

the origin of this anomalous behavior. The animal is perceived as safe, reliable and accessible
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and, in a pathological manner, can help the patient out of stressful traumatic situations, such as

grief or social abandonment.

an
There are factors in addition to a stressful psychological situation that may predispose
M
individuals toward developing Noah syndrome. It is important to remember that between one-

third and one-half of patients with hoarding behaviors present with dementia symptoms (frontal
ed

lobe dysfunction, frontotemporal dementia or vascular dementia) or some other type of mental

disorder (most often schizophrenia, obsessive compulsive disorder, personality disorder,

pt

depressive disorder or alcoholism). For this reason, it is very important to perform a thorough
ce

medical and neuropsychiatric evaluation to detect comorbidities in the hoarder. Family and

neighbors can be valuable sources of medical and social information, and support in therapeutic
Ac

interventions.

In the case of the patient described in this study, a history of cardiovascular disease

(hypertension, unmanaged diabetes mellitus type II and a history of cerebrovascular accident)

6
 supports the diagnosis of dementia of vascular origin, which, added to the untreated depressive

disorder, represents the main organic substrate underlying the hoarding behaviors.

Usually, hoarding-type disorders are not detected by health professionals because such

professionals do not always consider the usual evaluation methods; additionally, the patient does

t
ip
not report behavior changes because the patent is unaware of the disease, and to her, the

cr
behaviors seem reasonable. It is not often that companions raise any concerns because during the

initial stages of the disease, the person is simply considered “disorganized”; cause for a
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consultation generally only emerges when the clinical picture has fully developed.

an
The diagnostic omission of hoarding disorders has significant social, family and economic

repercussions. Hoarding is particularly dangerous for the elderly, who sometimes suffer from
M
physical or cognitive limitations that may affect their basic functioning in the home and can

contribute to the suffering of the hoarded animals (G. J. Patronek & Nathanson, 2009).
ed

If possible, hospitalization should be avoided; outpatient follow-up is preferred (Amanullah,

Oomman, & Datta, 2009). Cognitive behavioral therapy centered on cognitive distortions has
pt

shown some effectiveness for treating these patients. Selective serotonin reuptake inhibitors and
ce

antipsychotics may be useful for treating the disease, depending on the underlying pathology

(Koeck, Bouckaert, & Peuskens, 2007).

Ac

Appropriate measures of social protection should be adopted to prevent the patient from

reverting to her previous living conditions. If it is not possible to ensure cohabitation or to place

the patient in a geriatric institution, the patient must be monitored regularly with home and work

7
 visits coordinated by health and social services. Safeguards should be established for the hoarded

animals to ensure that they receive the required veterinary care and relocation.

Many times, treatment results are disappointing despite the effort of health systems, animal

protection organizations and primary and secondary support networks. The sufferers often

t
ip
resume hoarding at the earliest opportunity. Some refuse to receive treatment or decide to move

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away from the home to start hoarding again. It is also difficult to monitor these patients for

several reasons: a lack of local policies for handling hoarding; the fact that animal abuse is
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considered a misdemeanor in many countries; and a lack of consistency in monitoring the

hoarders or their displacement.

References
an
M
Amanullah, S., Oomman, S., & Datta, S. (2009). Diogenes Syndrome revisited. German J

Psychiatry, 12, 38-44.

ed

Clark, A. N., Mankikar, G. D., & Gray, I. (1975). Diogenes syndrome. A clinical study of gross
pt

neglect in old age. Lancet, 1(7903), 366-368.

Fond, G., Jollant, F., & Abbar, M. (2011). The need to consider mood disorders, and especially
ce

chronic mania, in cases of Diogenes syndrome (squalor syndrome). Int Psychogeriatr, 23(3),
Ac

505-507.

Gómez-Feria Prieto, I. (2008). Formas clínicas del síndrome de Diógenes. A propósito de tres

casos. Psiquiatría biológica, 15(03), 97-99.

8
 Hurley, M., Scallan, E., Johnson, H., & De La Harpe, D. (2000). Adult service refusers in the

greater Dublin area. Ir Med J, 93(7), 208-211.

Koeck, A., Bouckaert, F., & Peuskens, J. (2007). [Hoarding as the core symptom of the Diogenes

Syndrome. A case study]. Tijdschr Psychiatr, 49(3), 195-199.

t
ip
Patronek, G. J., Loar, L., & Nathanson, J. N. (2006). Animal hoarding: Structuring

interdisciplinary responses to help people, animals and communities at risk: Hoarding of

cr
Animals Research Consortium.
Downloaded by [181.237.20.7] at 06:37 27 November 2014

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Patronek, G. J., & Nathanson, J. N. (2009). A theoretical perspective to inform assessment and

treatment strategies for animal hoarders. Clin Psychol Rev, 29(3), 274-281.
an
Serrano Vásquez, M., Serrano Cartón, M. C., & Serrano Cartón, M. M. (2009). El
M
coleccionismo, el consumismo, la acumulación o el abandono extremo: ¿hábito, costumbre,

moda o enfermedad? Psiquiatría, 2(3), 8-14.

ed
pt
ce
Ac

9
 Table 1. Personal and family history.

Pathological Hypertension diagnosed 20 years ago

Diabetes mellitus type II diagnosed 20 years ago with glycosylated

t
hemoglobin levels between 6.0 – 6.5%

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Stroke 15 years ago
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Depressive disorder since youth without treatment

Protein-energy malnutrition
an
Surgical None
M
Toxic/allergic Negative
ed

Medications None
pt
ce

Family Diabetes mellitus type II, depressive disorder in the mother

Hypertension, diabetes mellitus type II and acute myocardial infarction

Ac

in the father

10

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