Social Breakdown in the Elderly, II. Sociodemographic Data and Psychopathology Gabor S. Ungvari and Paul M. Hantz Current understanding of the sociodemographic and psychopathological characteristics of the syndrome of social breakdown of the elderly (SBE) is reviewed. In DSM-III-R terms, pure SBE may be best classified as an adjustment disorder with profound social withdrawal. It is argued that pure SBE is a form of “personality development” in accord with Jaspers’s concept of meaningful connections. Copyright 0 1991 by W.B. Saunders Company
A
T PRESENT, social breakdown of the elderly (SBE) is a loosely defined syndrome with a wide variety of etiologies. The following description of its frequency and demographic and psychopathological characteristics is based on rather scant literature and is, therefore, incomplete. The concept of the SBE syndrome appears frequently in the British literature, and it is also known in German’ and Spanish psychiatry.’ However, apart from the Baltimore group,3,4 it is rarely mentioned in American publications, although the original concept of SBE was formed by American authors. Stimulated by Erskine’s collection of documents on hermits and recluses,’ Granick and Zeman called the attention of the medical community to the paucity of available information on the aged recluse. However, the recent upsurge of research interest in dementia and late-life depression, and the always intriguing problem of late onset schizophrenia, detracts attention from nonpsychotic functional psychiatric disorders in the elderly.7 EPIDEMIOLOGY
AND SOCIODEMOGRAPHIC
DATA
Despite the relative lack of interest, brief reports’-‘* and the three comprehensive studies conducted to date4x”.12have concluded that the syndrome of SBE is far from rare in the community or in clinical practice. In a community-based study in Nottingham, England, between 1961 and 1963 the annual incidence of SBE was 0.5 per 1,000 in the 60+ population.’ This meant 24 new cases a year from a population of 50,000 aged 60 or over. Clarke et al.‘* recognized 30 cases of SBE during only 10 months in a geriatric unit. The only large-scale population-based epidemiological study of SBE using a standardised psychiatric interview schedule was undertaken in the United States as part of the Eastern Baltimore Mental Health Survey.4 In contrast to both British reports, SBE in this study was rather broadly defined as a “failure of social and personal care,“3 reflecting a public health point of view, rather than a psychiatric one. Its recognition was based on a preformed and graded set of criteria reflecting two dimensions, troublesome behavior and level of engagement
From Wakari Hospital, Dunedin, New Zealand. Address reprint requests to Gabor S. Ungvari, M.D., Wakati Hospital, Private Bag, Dunedin, New Zealand. Copyright 0 1991 by IKB. Saunders Company 0010-440x/91/3205-0005$03.00f0
Comprehensive
Psychiatry, Vol. 32, No. 5 (September/October),
1991: pp 445-449
445
446
UNGVARI AND HANTZ
in meaningful activities. Approximately 20% of the population over the age of 65 fell into the severe, and 22% into the moderate SBE category, while 58% of the elderly coped well in the community. Besides differing objectives, study design, and diagnostic inclusion criteria, terminological confusion has rendered these studies incomparable. For instance, Radebough et a1.4refer to the Diogenes syndrome as a rare form of SBE and, at the same time, as synonymous with SBE. In any event, although noncomplementary and sometimes even contradictory, these studies indicate that SBE is an important public health and clinical issue. SBE affects both sexes. However, in the community-based British study,” the diagnosis was five times more common in women. The sex distribution is probably influenced by a number of factors, as suggested by the Eastern Baltimore survey.4 In their severe SBE group, the percentage of white females (22.1%) was nearly twice than that of the white males (11.4%), while in the moderate SBE group, the reverse sex distribution was found (13.5% female v 34.3% male). Conversely, the frequency of severe SBE was much higher in non-white males than non-white females (32.8% and 19.6%, respectively), but the sexes were almost equally represented in the non-white, moderate SBE population (25.8% v 28.6%). Most of the patients in both British series”.” were either unmarried or widowed. They lived alone, and all were well-known to statutory and voluntary social agencies and health services. One third of the patients consistently refused any help; others passively accepted it from relatives, neighbors, or agencies. In many cases, effective intervention was hindered by the lack of clear-cut guidelines as to when and exactly how to offer assistance to these people.9z’3*14 Every social class, from the uneducated to the previously professional, was found among the SBE patients. The actual financial situation of the individual seemed to play no significant role in the development of SBE. The patients themselves were not the least concerned with money; in fact, some proved to be quite wealthy.6’” CONCOMITANT
SOMATIC
AND PSYCHIATRIC
CONDITIONS
As expected, the SBE population was plagued by a host of somatic illnesses and physical disabilities. In the hospital admission samples of SBE, nearly every patient suffered from some chronic illness. These were most frequently cardiovascular and pulmonary diseases and different forms of deficiency states such as hypoproteinemia and hypovitaminosis. The presence of frank psychosis or dementia is associated with an increased rate of physical ailments.” The Eastern Baltimore study could not find a positive relationship between the number of physical health problems and the severity of SBE, except for the physically very compromised group (four or more health problems in a person). In the Eastern Baltimore study, dementia was present in 15% of the moderate and severe SBE cases, twice as many as in the general population of the same age group.4 In the clinical setting, psychometric testing has suggested that the nondemented cohort of SBE patients actually had a higher than average mean Surprisingly, the prevalence of mental disorders other than intelligence score.11X’2 dementia was less in the SBE group than in the normal population.4 In both hospital-based samples, approximately half of the patients suffered from some
SOCIAL BREAKDOWN
IN THE ELDERLY, II
447
form of organic or functional psychiatric illness, while 67.8% of SBE cases in the Eastern Baltimore area study did not have any mental disorder. PSYCHOPATHOLOGY Pare and Secondary (Symptomatic) SBE
The basic concept of SBE is 30 years old,6 yet, apart from a detailed case report published in German,’ SBE has not evoked the interest of clinical psychiatry. The lack of psychopathological analysis has led to reports on groups of SBE patients without regard to underlying psychiatric illnesses. In the case of secondary SBE, where the syndrome is part of a major psychiatric illness, the diagnosis is self-evident, but at this stage it is difficult to find a satisfactory diagnostic rubric for the pure SBE in the existing classificatory systems. The International Classification of Diseases (ICD)-9, DSM-III-R, and the 1990 draft of ICD-10 do not refer to it. This is appropriate, as the clinical validity of neither the secondary nor the pure cases of SBE has been tested. Psychopathological Roots and Nosological Position of Pure SBE
In the following paragraphs, we discuss the psychopathology and nosological position of pure SBE. As mentioned in the preceding report,15 pure SBE can be diagnosed as an atypical adjustment disorder according to DSM-III-R. However, adjustment disorder itself, is dealt with less than adequately in the literature,” being regarded as an unspecific, marginal, or transitional category.” It thus becomes necessary to examine the psychopathological roots of pure SBE and that of adjustment disorder. Jaspers’ Concept of “Personality Development”
In Jaspersian terms, adjustment disorder (DSM-III-R), among other current nosological entities, could be placed within the domain of “meaningful connections.” Within that framework, adjustment disorder is best described as a form of “personality development.0’8 In contrast to “process” (e.g., endogenous psychosis), personality development is defined as “what has developed within the total framework of the life-history in all its categories, always presupposing a foundation of normal biological events. The deciding factors are experiences, precipitating stimuli and events which can be adequately understood together with the absence of any known symptom-complexes belonging to a process. . . .“I* (PP 7021 Thus, in Jaspers’ formulation, pure SBE, in contrast to the major psychiatric illnesses underlying the secondary variant, does not constitute a newly occurring and qualitatively distinct psychopathological entity. It could be best understood as a slow development of the personality in response to a difficult life situation, which was becoming increasingly complex and overwhelming to the individual. The overall picture of pure SBE is a distorted exaggeration of dissatisfaction, bitterness, and misanthropy, sometimes associated with the normal psychology of old age. In our reported cases,” physical illnesses, or the loss of a “key” person, further narrowed the flexibility and adaptation in the premorbidly rigid and isolative individuals. Again, in Jaspersian terms, the whole clinical picture is understandable from each subject’s life history, personality, and the current
448
UNGVARI AND HANTZ
stressful life events. The personality becomes an extreme accentuation of the premorbid one. The change in personality “arises from experiences”18 (p 639) and it is not a final one, but reflects a crisis in the course of psychic development. As Jaspers put it: “Crisis in the course of development means . . . the whole person suffers a reversal, and the individual . . . sunk in defeat [. . .] It need not appear in acute form as a catastrophe but may take place quietly and inconspicuously, yet nevertheless be decisive for the future.“18 (p 698) The current criteria of adjustment disorder in DSM-III-R do not allow us to categorize pure SBE automatically under this heading. However, the application of the Jaspersian concept of personality development shows that SBE and the adjustment disorders do have the same psychopathological basis. In fact, whether the diagnostician is aware of it or not, the supposedly atheoretical DSM-III-R concept of adjustment disorder is rooted in Jaspersian principles of personality development. Pathogenesis of Pure SBE: A Hypothesis
The notion that pure SBE is basically an atypical adjustment disorder, superimposed on longstanding personality abnormalities, seems to be supported by the literature. Unfriendly, stubborn, obstinate, aloof, detached, secretive, suspicious, eccentric, and quarrelsome were the most frequently mentioned premorbid personality traits,“.” especially in the pure SBE group.‘1,19The loss of a close relative who was caring for the patient appeared to be the most important precipitating factor, initiating the deterioration in self-care in one third of the pure SBE cases.” The analysis of our cases” also supports the view that a life long subclinical personality disorder, probably of a paranoid or shizoid type, turned gradually into gross self-neglect and social retreat. This deterioration was precipitated by a stressful life event, and further aggravated by increasingly debilitating physical problems.‘,12 That is why the German authors called the SBE a “personality-based abnormal emotional reaction development.” The complex of personality factors, loneliness, stress, and somatic illness, easily form a vicious cycle, resulting in a reclusive life-style, abandonment of basic social norms, and stubborn refusal of help. It is important to emphasize that the characteristics of the premorbid personality play an integral role in the pathogenesis of SBE.19 Empirical field research strongly suggests that, contrary to widespread belief, social isolation per se is not related to global emotional ill-health in the elderly, unless it is coupled with having no companions or confidants. ‘a Furthermore, social isolation and lack of confidants is not the cause of pure SBE, but rather the consequence of the usually lifelong personality problems. In addition to the cases reported so far,‘.” Zeman and Granick’s6 observation supports this view: in their nonrepresentative sample, reclusive life-style frequently started in early adulthood, at the usual time of marriage. Although the socially isolated eccentric individual has long been known in clinical psychiatry,” only recently has the long-term, methodically sound study of this heterogenous group begun.‘l This type of research will inevitably contribute to the better understanding of SBE as well.
SOCIAL BREAKDOWN
IN THE ELDERLY, II
449
CONCLUSION The results of the few surveys and the case reports briefly summarized here provide enough evidence to warrant further investigation of the syndrome of SBE. Systematic follow-up studies conducted in a cohort of patients with late-life social isolation and neglected self-care, together with a meticulous evaluation of physical health, social environment, and possible precipitating stressful life events, are needed to establish the clinical validity of the SBE syndrome. Such studies would need to pay particular attention to defining the nosological position of its pure variant. REFERENCES 1. Klosterkotter J, Peters UH: Das Diogenes-Syndrom. Fortschr Neurol Psychiatr 53:427-434,1985 2. Melendro CJ, Malo PS, Azagra VJR, et al: Sindrome de Diogenes: un cuadro clinic0 frecuente en la vejez y poco conocido. Actas Derm Sifiliograficas 67:225-232, 1976 3. Gruenberg EM, Brandon S, Kasius RV: Identifying cases of the social breakdown syndrome, in Gruenberg EM (ed): Evaluating the Effectiveness of Community Mental Health Services. New York, NY, Milbank Memorial Fund, 1966, pp 127-143 4. Radebaugh TS, Hooper FJ, Gruenberg EM: The social breakdown syndrome in the elderly population living in the community: The Helping Study. Br J Psychiatry 151:341-346,1987 5. Erskine HW: Out of This World-A Collection of Hermits and Recluses. New York, NY, Putnam, 1953 6. Granick R, Zeman FD: The aged recluse-An exploratory study with particular reference to community responsibility. J Chron Dis 12:639-653,196O 7. Straker M: Adjustment disorders and personality disorders in the aged. Psychiatr Clin North Am 5:121-129,1982 8. Berlyne N: Diogenes syndrome. Lancet 1:515, 1975 9. Twomey J: Diogenes syndrome. Lancet 1:515,1975 10. Cybulska E, Rucinski J: Gross self-neglect in old age. Br J Hosp Med 34:21-26,1986 11. MacMillan D, Shaw P: Senile breakdown in standards of personal and environmental cleanliness. Br Med J 2:1032-11037,1966 12. Clark ANG, Mankikar GD, Gray I: Diogenes syndrome. A clinical study of gross neglect in old age. Lancet 1:366-368, 1975 13. MacAnespie H: Diogenes syndrome. Lancet 1:750,1975 14. Henderson-Smith SL: Diogenes syndrome. Lancet 1:750,1975 15. Ungvari GS, Hantz PM: Social breakdown in the elderly, I. Case studies and management, Compr Psychiatr 32:440-444, 1991 16. Andreasen NC, Hoenk PR: The predictive value of adjustment disorders: A follow-up study. Am J Psychiatry 139:584-590,1982 17. Fabrega Jr H, Mezzich JE, Mezzich AC: Adjustment disorder as a marginal or transitional illness category in DSM-III. Arch Gen Psychiatry 44:567-572,1987 18. Jaspers K: General Psychopathology (translated by Hoenig J. Hamilton MW). Manchester, England, Manchester University Press, 1963 19. Post F: Functional disorders I. Description, incidence and recognition, in Levy R, Post F (eds): The Psychiatry of Late Life. Oxford, England, Blackwell, 1982, pp 176-196 20. Chappel NL, Badger M: Social isolation and well-being. J Gerontol44:169-176. 1989 21. Tantam D: Lifelong excentricity and social isolation. I. Psychiatric, social, and forensic aspects, Br J Psychiatry 153:777-782, 1988
A
T PRESENT, social breakdown of the elderly (SBE) is a loosely defined syndrome with a wide variety of etiologies. The following description of its frequency and demographic and psychopathological characteristics is based on rather scant literature and is, therefore, incomplete. The concept of the SBE syndrome appears frequently in the British literature, and it is also known in German’ and Spanish psychiatry.’ However, apart from the Baltimore group,3,4 it is rarely mentioned in American publications, although the original concept of SBE was formed by American authors. Stimulated by Erskine’s collection of documents on hermits and recluses,’ Granick and Zeman called the attention of the medical community to the paucity of available information on the aged recluse. However, the recent upsurge of research interest in dementia and late-life depression, and the always intriguing problem of late onset schizophrenia, detracts attention from nonpsychotic functional psychiatric disorders in the elderly.7 EPIDEMIOLOGY
AND SOCIODEMOGRAPHIC
DATA
Despite the relative lack of interest, brief reports’-‘* and the three comprehensive studies conducted to date4x”.12have concluded that the syndrome of SBE is far from rare in the community or in clinical practice. In a community-based study in Nottingham, England, between 1961 and 1963 the annual incidence of SBE was 0.5 per 1,000 in the 60+ population.’ This meant 24 new cases a year from a population of 50,000 aged 60 or over. Clarke et al.‘* recognized 30 cases of SBE during only 10 months in a geriatric unit. The only large-scale population-based epidemiological study of SBE using a standardised psychiatric interview schedule was undertaken in the United States as part of the Eastern Baltimore Mental Health Survey.4 In contrast to both British reports, SBE in this study was rather broadly defined as a “failure of social and personal care,“3 reflecting a public health point of view, rather than a psychiatric one. Its recognition was based on a preformed and graded set of criteria reflecting two dimensions, troublesome behavior and level of engagement
From Wakari Hospital, Dunedin, New Zealand. Address reprint requests to Gabor S. Ungvari, M.D., Wakati Hospital, Private Bag, Dunedin, New Zealand. Copyright 0 1991 by IKB. Saunders Company 0010-440x/91/3205-0005$03.00f0
Comprehensive
Psychiatry, Vol. 32, No. 5 (September/October),
1991: pp 445-449
445
446
UNGVARI AND HANTZ
in meaningful activities. Approximately 20% of the population over the age of 65 fell into the severe, and 22% into the moderate SBE category, while 58% of the elderly coped well in the community. Besides differing objectives, study design, and diagnostic inclusion criteria, terminological confusion has rendered these studies incomparable. For instance, Radebough et a1.4refer to the Diogenes syndrome as a rare form of SBE and, at the same time, as synonymous with SBE. In any event, although noncomplementary and sometimes even contradictory, these studies indicate that SBE is an important public health and clinical issue. SBE affects both sexes. However, in the community-based British study,” the diagnosis was five times more common in women. The sex distribution is probably influenced by a number of factors, as suggested by the Eastern Baltimore survey.4 In their severe SBE group, the percentage of white females (22.1%) was nearly twice than that of the white males (11.4%), while in the moderate SBE group, the reverse sex distribution was found (13.5% female v 34.3% male). Conversely, the frequency of severe SBE was much higher in non-white males than non-white females (32.8% and 19.6%, respectively), but the sexes were almost equally represented in the non-white, moderate SBE population (25.8% v 28.6%). Most of the patients in both British series”.” were either unmarried or widowed. They lived alone, and all were well-known to statutory and voluntary social agencies and health services. One third of the patients consistently refused any help; others passively accepted it from relatives, neighbors, or agencies. In many cases, effective intervention was hindered by the lack of clear-cut guidelines as to when and exactly how to offer assistance to these people.9z’3*14 Every social class, from the uneducated to the previously professional, was found among the SBE patients. The actual financial situation of the individual seemed to play no significant role in the development of SBE. The patients themselves were not the least concerned with money; in fact, some proved to be quite wealthy.6’” CONCOMITANT
SOMATIC
AND PSYCHIATRIC
CONDITIONS
As expected, the SBE population was plagued by a host of somatic illnesses and physical disabilities. In the hospital admission samples of SBE, nearly every patient suffered from some chronic illness. These were most frequently cardiovascular and pulmonary diseases and different forms of deficiency states such as hypoproteinemia and hypovitaminosis. The presence of frank psychosis or dementia is associated with an increased rate of physical ailments.” The Eastern Baltimore study could not find a positive relationship between the number of physical health problems and the severity of SBE, except for the physically very compromised group (four or more health problems in a person). In the Eastern Baltimore study, dementia was present in 15% of the moderate and severe SBE cases, twice as many as in the general population of the same age group.4 In the clinical setting, psychometric testing has suggested that the nondemented cohort of SBE patients actually had a higher than average mean Surprisingly, the prevalence of mental disorders other than intelligence score.11X’2 dementia was less in the SBE group than in the normal population.4 In both hospital-based samples, approximately half of the patients suffered from some
SOCIAL BREAKDOWN
IN THE ELDERLY, II
447
form of organic or functional psychiatric illness, while 67.8% of SBE cases in the Eastern Baltimore area study did not have any mental disorder. PSYCHOPATHOLOGY Pare and Secondary (Symptomatic) SBE
The basic concept of SBE is 30 years old,6 yet, apart from a detailed case report published in German,’ SBE has not evoked the interest of clinical psychiatry. The lack of psychopathological analysis has led to reports on groups of SBE patients without regard to underlying psychiatric illnesses. In the case of secondary SBE, where the syndrome is part of a major psychiatric illness, the diagnosis is self-evident, but at this stage it is difficult to find a satisfactory diagnostic rubric for the pure SBE in the existing classificatory systems. The International Classification of Diseases (ICD)-9, DSM-III-R, and the 1990 draft of ICD-10 do not refer to it. This is appropriate, as the clinical validity of neither the secondary nor the pure cases of SBE has been tested. Psychopathological Roots and Nosological Position of Pure SBE
In the following paragraphs, we discuss the psychopathology and nosological position of pure SBE. As mentioned in the preceding report,15 pure SBE can be diagnosed as an atypical adjustment disorder according to DSM-III-R. However, adjustment disorder itself, is dealt with less than adequately in the literature,” being regarded as an unspecific, marginal, or transitional category.” It thus becomes necessary to examine the psychopathological roots of pure SBE and that of adjustment disorder. Jaspers’ Concept of “Personality Development”
In Jaspersian terms, adjustment disorder (DSM-III-R), among other current nosological entities, could be placed within the domain of “meaningful connections.” Within that framework, adjustment disorder is best described as a form of “personality development.0’8 In contrast to “process” (e.g., endogenous psychosis), personality development is defined as “what has developed within the total framework of the life-history in all its categories, always presupposing a foundation of normal biological events. The deciding factors are experiences, precipitating stimuli and events which can be adequately understood together with the absence of any known symptom-complexes belonging to a process. . . .“I* (PP 7021 Thus, in Jaspers’ formulation, pure SBE, in contrast to the major psychiatric illnesses underlying the secondary variant, does not constitute a newly occurring and qualitatively distinct psychopathological entity. It could be best understood as a slow development of the personality in response to a difficult life situation, which was becoming increasingly complex and overwhelming to the individual. The overall picture of pure SBE is a distorted exaggeration of dissatisfaction, bitterness, and misanthropy, sometimes associated with the normal psychology of old age. In our reported cases,” physical illnesses, or the loss of a “key” person, further narrowed the flexibility and adaptation in the premorbidly rigid and isolative individuals. Again, in Jaspersian terms, the whole clinical picture is understandable from each subject’s life history, personality, and the current
448
UNGVARI AND HANTZ
stressful life events. The personality becomes an extreme accentuation of the premorbid one. The change in personality “arises from experiences”18 (p 639) and it is not a final one, but reflects a crisis in the course of psychic development. As Jaspers put it: “Crisis in the course of development means . . . the whole person suffers a reversal, and the individual . . . sunk in defeat [. . .] It need not appear in acute form as a catastrophe but may take place quietly and inconspicuously, yet nevertheless be decisive for the future.“18 (p 698) The current criteria of adjustment disorder in DSM-III-R do not allow us to categorize pure SBE automatically under this heading. However, the application of the Jaspersian concept of personality development shows that SBE and the adjustment disorders do have the same psychopathological basis. In fact, whether the diagnostician is aware of it or not, the supposedly atheoretical DSM-III-R concept of adjustment disorder is rooted in Jaspersian principles of personality development. Pathogenesis of Pure SBE: A Hypothesis
The notion that pure SBE is basically an atypical adjustment disorder, superimposed on longstanding personality abnormalities, seems to be supported by the literature. Unfriendly, stubborn, obstinate, aloof, detached, secretive, suspicious, eccentric, and quarrelsome were the most frequently mentioned premorbid personality traits,“.” especially in the pure SBE group.‘1,19The loss of a close relative who was caring for the patient appeared to be the most important precipitating factor, initiating the deterioration in self-care in one third of the pure SBE cases.” The analysis of our cases” also supports the view that a life long subclinical personality disorder, probably of a paranoid or shizoid type, turned gradually into gross self-neglect and social retreat. This deterioration was precipitated by a stressful life event, and further aggravated by increasingly debilitating physical problems.‘,12 That is why the German authors called the SBE a “personality-based abnormal emotional reaction development.” The complex of personality factors, loneliness, stress, and somatic illness, easily form a vicious cycle, resulting in a reclusive life-style, abandonment of basic social norms, and stubborn refusal of help. It is important to emphasize that the characteristics of the premorbid personality play an integral role in the pathogenesis of SBE.19 Empirical field research strongly suggests that, contrary to widespread belief, social isolation per se is not related to global emotional ill-health in the elderly, unless it is coupled with having no companions or confidants. ‘a Furthermore, social isolation and lack of confidants is not the cause of pure SBE, but rather the consequence of the usually lifelong personality problems. In addition to the cases reported so far,‘.” Zeman and Granick’s6 observation supports this view: in their nonrepresentative sample, reclusive life-style frequently started in early adulthood, at the usual time of marriage. Although the socially isolated eccentric individual has long been known in clinical psychiatry,” only recently has the long-term, methodically sound study of this heterogenous group begun.‘l This type of research will inevitably contribute to the better understanding of SBE as well.
SOCIAL BREAKDOWN
IN THE ELDERLY, II
449
CONCLUSION The results of the few surveys and the case reports briefly summarized here provide enough evidence to warrant further investigation of the syndrome of SBE. Systematic follow-up studies conducted in a cohort of patients with late-life social isolation and neglected self-care, together with a meticulous evaluation of physical health, social environment, and possible precipitating stressful life events, are needed to establish the clinical validity of the SBE syndrome. Such studies would need to pay particular attention to defining the nosological position of its pure variant. REFERENCES 1. Klosterkotter J, Peters UH: Das Diogenes-Syndrom. Fortschr Neurol Psychiatr 53:427-434,1985 2. Melendro CJ, Malo PS, Azagra VJR, et al: Sindrome de Diogenes: un cuadro clinic0 frecuente en la vejez y poco conocido. Actas Derm Sifiliograficas 67:225-232, 1976 3. Gruenberg EM, Brandon S, Kasius RV: Identifying cases of the social breakdown syndrome, in Gruenberg EM (ed): Evaluating the Effectiveness of Community Mental Health Services. New York, NY, Milbank Memorial Fund, 1966, pp 127-143 4. Radebaugh TS, Hooper FJ, Gruenberg EM: The social breakdown syndrome in the elderly population living in the community: The Helping Study. Br J Psychiatry 151:341-346,1987 5. Erskine HW: Out of This World-A Collection of Hermits and Recluses. New York, NY, Putnam, 1953 6. Granick R, Zeman FD: The aged recluse-An exploratory study with particular reference to community responsibility. J Chron Dis 12:639-653,196O 7. Straker M: Adjustment disorders and personality disorders in the aged. Psychiatr Clin North Am 5:121-129,1982 8. Berlyne N: Diogenes syndrome. Lancet 1:515, 1975 9. Twomey J: Diogenes syndrome. Lancet 1:515,1975 10. Cybulska E, Rucinski J: Gross self-neglect in old age. Br J Hosp Med 34:21-26,1986 11. MacMillan D, Shaw P: Senile breakdown in standards of personal and environmental cleanliness. Br Med J 2:1032-11037,1966 12. Clark ANG, Mankikar GD, Gray I: Diogenes syndrome. A clinical study of gross neglect in old age. Lancet 1:366-368, 1975 13. MacAnespie H: Diogenes syndrome. Lancet 1:750,1975 14. Henderson-Smith SL: Diogenes syndrome. Lancet 1:750,1975 15. Ungvari GS, Hantz PM: Social breakdown in the elderly, I. Case studies and management, Compr Psychiatr 32:440-444, 1991 16. Andreasen NC, Hoenk PR: The predictive value of adjustment disorders: A follow-up study. Am J Psychiatry 139:584-590,1982 17. Fabrega Jr H, Mezzich JE, Mezzich AC: Adjustment disorder as a marginal or transitional illness category in DSM-III. Arch Gen Psychiatry 44:567-572,1987 18. Jaspers K: General Psychopathology (translated by Hoenig J. Hamilton MW). Manchester, England, Manchester University Press, 1963 19. Post F: Functional disorders I. Description, incidence and recognition, in Levy R, Post F (eds): The Psychiatry of Late Life. Oxford, England, Blackwell, 1982, pp 176-196 20. Chappel NL, Badger M: Social isolation and well-being. J Gerontol44:169-176. 1989 21. Tantam D: Lifelong excentricity and social isolation. I. Psychiatric, social, and forensic aspects, Br J Psychiatry 153:777-782, 1988
