Re: Diogenes syndrome in a pair of siblings.

Dear Editor: We refer to the interesting letter from Dr Esposito and colleagues in France, describing 2 siblings who lived in severe domestic squalor (1). One was an unmarried woman, aged 61 years; the other was her brother, aged 58 years and suffering from a physical handicap. The authors state that Diogenes syndrome is rare in a pair of siblings and that the few reported cases of a pair living together all concerned married couples. We agree that the frequency of cases of severe domestic squalor encountered by health workers in the community is not reflected in a comparable number of reports in the medical literature. However, we are also aware of various reports that refer to cases wherein 2 or more persons were found to be living together in squalor. We have identified at least 70 reported cases of 2 or more people mentioned or described as living together in a state of severe domestic squalor (references available on request). In research undertaken by one of us, 15 of 81 people living in squalid conditions shared their accommodation with other people (2). Among them were 5 couples and a family of 3, all of whom were included in the sample. Another of the 15 subjects was a mother whose son sometimes lived with her but was thought not to be responsible for much, if any, of the squalor. The 15th was a female home-owner who lived in severe squalor but whose boarder lived in a separate, and much cleaner, part of the house. With specific reference to siblings living together, we found 4 case reports in addition to 5 pairs of siblings mentioned in a series of cases of Diogenes Syndrome or severe domestic squalor. One case report is that of a man, aged 73 years, who was bedridden with severe arthritis and lived with his sister, aged 77 years (3,4). Another report concerned a single woman, aged 50 years, who suffered from mild developmental disability and lived in squalor in the downstairs rooms of a house she shared with her sister, who occupied the upstairs and thus (it is implied) mostly escaped the squalor (5). The case of 2 sisters who lived in a rural area in uninhabitable conditions and who resisted services or assistance has been described in Spanish (6). Perhaps most striking of all is the case of the " hermits of Harlem. " Granick and …