Sindroame psihiatrice eponime cu originea în literatură: de la Alice în Țara Minunilor la Portretul lui Dorian Gray (I)

Introduction

The histories of human culture – particularly literature, philosophy and the arts – and of psychiatry have many points of convergence that warrant closer exploration for those interested in a deeper understanding of the complex phenomenology of human behavior. Also, when exploring the vast domain of psychopathology, one must keep in mind that this corpus of knowledge is far from being exhausted epistemologically by the most recent versions of the American Psychiatric Association (APA) or World Health Organization (WHO) nosographic systems^(1-5).

A historical evaluation of psychopathology reflects an intrinsic dynamic of this scientific discipline that is frequently difficult to circumscribe. For example, syndromes and disorders that appeared in psychopathology were highly regarded for a period, then were subsequently invalidated by further research and fell into oblivion, such as “drapetomania”, “paraphrenia”, or “latent schizophrenia”. Other syndromes and disorders did not remain epistemologically stable, but underwent repeated theoretical, phenomenological and nosographic redefinitions, as is the case with dementia praecox/schizophrenia, paranoia/delusional disorder, or hysteria/dissociative, conversion and somatic symptom disorders. Still other syndromes and disorders have been recently conceptualized and are pending clearly operationalized criteria and epidemiological confirmation, such as “ultra-processed food addiction”, “nomophobia” or “hikikomori syndrome”. The creativity of the mental health specialists involved in the active exploration and construction of the psychopathology’s vocabulary can only be matched by the challenges raised by the clinical and social realities. A continuous adequation of the conceptual apparatus of psychiatry to clinical data is readily observed when consulting consecutive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the WHO’s classification of mental and behavioral disorders (ICD). Nevertheless, each of these editions leaves out lists of nosographic entities that lacked sufficient evidence to be included. For example, DSM editions include a dedicated chapter on diagnoses that require further exploration, beginning with DSM-III⁽⁶⁾. Numerous clinically relevant syndromes continue to be explored in contemporary psychiatry despite remaining outside DSM and ICD classifications, highlighting the difference between the puzzling diversity of clinical challenges and the nosographic categories; for example, eating disorders (e.g., drunkorexia, orthorexia, or diabulimia), sleep disorders (e.g., catathrenia), work-related pathology (e.g., burnout, boreout, or workaholism) and so on.

The origins of these syndromes and disorders are quite diverse, ranging from cultural and socio-historical specific contexts to the exploration of ethical and social phenomena and other intricate factors. The persistence of such unrecognized syndromes exposes the structural limits of categorical diagnostic systems in capturing the full phenomenological diversity of mental suffering.

Taking all these aspects into account, a closer look at the intersection between literature and psychiatry was felt necessary to highlight several important dimensions of the psychopathology, as seen through the double lens of clinical interests and conceptual analysis:

1. literary syndromes are based on archetypal characters found by psychiatrists, psychologists and psychotherapists in literary sources, from which significant features are extracted and used for highlighting complex psychopathological phenomena;
2. these syndromes are an argument for the dynamic character of the psychopathology, since some of them have received an official nosographic status (at least temporary, as the case of Munchausen syndrome), while others have disappeared or are used only with historical value (as in the case of pygmalionism), and still others are basically used as literary equivalents of currently acknowledged diagnoses (e.g., Othello syndrome);
3. social and cultural dynamics are reflected in this type of syndromes which present, therefore, a practical interest for a large body of specialists, starting from psychiatrists to anthropologists and from sociologists to healthcare policy makers (for example, Ulysses syndrome);
4. emerging clinical phenomena can enrich the category of literary syndromes, as new patterns of abnormal behavior and new literary characters can be matched by scientists (for example, the Truman Show delusion, described in the early 2000s⁽⁷⁾⁾;
5. literary characters and, sometimes, the writers themselves can become the center of interest for psychopathologists, due to many reasons, who tend to brand them into eponymous syndromes, and an investigation of possible evolutive trajectories of this phenomenon was considered relevant from an epistemological perspective.

As a cautionary tale, the literary eponymous syndromes examined in this paper are not proposed as formal diagnostic entities but as heuristic and phenomenological constructs. They structure recurrent, transdiagnostic patterns of experience and behavior shaped by cultural and symbolic narratives, thereby complementing contemporary nosological systems by highlighting dimensions of psychopathology that remain insufficiently captured by categorical classifications. 

The main objective of this narrative review was to find the most frequently explored eponymous psychiatric syndromes and to describe them according to their main phenomenological features. Where possible to retrieve, historical aspects, paraclinical evidence, neurobiological data and therapeutic options were also presented.

Methodology

In order to find the most relevant literary eponymous syndromes with psychopathological relevance, a search of the major electronic databases (PubMed/MEDLINE, Web of Science/Clarivate, CINAHL, EBSCO and Google Scholar) was conducted, starting from the inception of each database to December 2025. These sources were complemented by materials from the grey literature (doctoral, master’s and undergraduate theses, unpublished articles, reports and internet-based sources), as well as by additional works identified after reading the references of articles considered of interest for the objective of the present study.

Specific literary syndromes

In the first part of this review, five literary eponymous constellations of psychopathological manifestations were analyzed: Alice in Wonderland syndrome, bovarism, Diogenes syndrome, Don Juan syndrome and Dorian Gray syndrome. Each of these syndromes was chosen because it encompasses elements of both conceptual and practical interest, and it is examined from a historical and clinical perspective, with reference to contemporary nosography, where appropriate.

Through the looking glass: Alice in Wonderland syndrome

This is a rare neuropsychiatric syndrome characterized by distortions of the size, mass or shape of the patient’s own body, as well as its position in space, accompanied by depersonalization and derealization^(8,9). Metamorphopsia and bizarre alterations in the form, size, movement or color of surrounding objects have also been reported as accompanying symptoms, as have changes in the perception of time^(10,11,14). The syndrome derives its name from Lewis Carroll’s novel Alice’s Adventures in Wonderland, in which the protagonist experiences dramatic fluctuations in body size and perceptual reality⁽¹²⁾. Also, Lewis Carroll himself (the pseudonym of Reverend Charles Lutwidge Dodgson) suffered from migraine, and the descriptions of reality distortions that can be met in his books may have been based on his own migrainous experiences⁽⁹⁾. These elements led the British psychiatrist J. Todd in 1955 to coin the term Alice in Wonderland syndrome (AIWS) for patients who developed the aforementioned symptoms, because of what Alice did in her dreams: she could become very tall or extremely short, or address herself as two people⁽⁸⁾. A previous mention of the phenomenology of this syndrome appeared in an article by Lippman (1952), in which he recounted the story of one of his patients diagnosed with migraine, who explicitly referred to Alice in Wonderland, as she felt becoming short and wide while walking⁽¹³⁾.

From a clinical perspective, AIWS presents periodic, limited perceptual distortions occurring in the absence of primary psychosis or structural ocular diseases⁽⁸⁾. Patients frequently preserve their insight, recognizing the unreal nature of their experiences, which differentiates AIWS from frank psychotic disorders. Symptoms may involve visual, somesthetic, auditory or temporal distortions, reflecting transient dysfunction in cortical integration rather than fixed neurological damage⁽⁸⁾. In the original case series described by Todd, patients reported:

1. “body growing larger and larger until it seems to occupy the entire room” and “shrinking up completely”, associated with anxiety or fever;
2. recurrent feelings of being much taller or shorter than in reality, or the impression that the size of own head doubled, or even that one arm is missing;
3. teleopsia and peliopsia were reported also in a patient with recurrent migraine attacks;
4. transient sensations of “being split”, extracampine hallucinations of a second head, against a background of intense fear;
5. an invisible alter ego, metamorphopsia, depersonalization and derealization were observed in still another patient⁽⁸⁾.

AIWS has been reported in virtually all age groups, but it is most commonly reported in children and adolescents, frequently together with migraine, epilepsy, viral infections (notably Epstein-Barr virus) and, less commonly, structural brain lesions^(14,15). Patients with schizophrenia may present symptoms that are similar to AIWS, as can those with hypnagogic states and delirium, but also those consuming certain abuse drugs or medications^(8,10,16). As previously mentioned, unlike schizophrenia spectrum disorders (SSD), patients with AIWS have insight into their perceptual distortions, which is essential for the differential diagnosis.

A systematic review of AIWS (n=169 case descriptions) concluded that the etiology of this syndrome may be divided into eight groups, with neurologic disorders affecting adults and elderly individuals, while encephalitis is more frequently diagnosed in children and adolescents⁽¹⁷⁾. The general population also reports AIWS-like manifestations, as 30% of adolescents present with similar but nonclinical transient, perceptual symptoms⁽¹⁷⁾. Based on the results of this review, the authors consider that blood tests, EEG and brain MRI are granted in clinical cases of AIWS⁽¹⁷⁾.

Neurobiologically, the syndrome is thought to arise from functional disturbances in the temporo-parieto-occipital junction, a region critical for multisensory integration and body schema representation, and the visual pathway, especially the occipital lobe⁽¹⁰⁾. In a case report of a 12-year-old boy with viral-onset AIWS, fMRI showed reduced activation in the primary and extrastriate visual cortices and increased activation in the parietal lobe compared with a matched control subject⁽¹⁴⁾. In a case series (N=4 patients with AIWS), Technetium-99m hexamethylpropyleneamine tomography (SPECT) brain scans showed decreased cerebral perfusion areas in all patients near the visual tract and visual cortex, and in some regions of the temporal lobe⁽¹⁸⁾.

Based on current knowledge of AIWS, treatment should be directed at the underlying conditions⁽¹⁷⁾. A case report mentions favorable results when rTMS was applied in a woman with AIWS, long-lasting verbal auditory hallucinations, and various other perceptual and mood symptoms⁽¹¹⁾. Propranolol, improved sleep schedule and cognitive-behavioral therapy have been suggested as solutions for AIWS by a case report and a literature review⁽¹⁹⁾.

In conclusion, although AIWS is not recognized as a distinct diagnostic entity in DSM-5-TR or ICD-11, it is widely acknowledged in neurology and neuropsychiatry as a well-defined clinical syndrome with characteristic phenomenology and identifiable etiological associations. At a practical level, the recognition of AIWS is clinically important, as symptoms are often alarming to patients and families despite their frequently benign and reversible nature. AIWS represents a clear example of a literary-derived eponym that has achieved robust clinical legitimacy, beginning with early, isolated, purely clinically based case reports in the 1950s, and continuing with neuroimaging studies using SPECT and fMRI in the last decades.

When the fantasy takes over – the phenomenon of bovarism

Emma Bovary, the protagonist of Gustave Flaubert’s Madame Bovary, whose character embodies a compulsive pursuit of romantic ideals incompatible with her lived reality, was the inspiration for the development of bovarism⁽²⁰⁾. This concept was created by the philosopher Jules de Gaultier in the late 19^th century, who defined bovarism as the human capacity to consider oneself as a completely different person⁽²¹⁾. More specifically, bovarism refers to a persistent tendency toward escapist fantasy, dissatisfaction with reality and idealization of imagined identities or living trajectories, often accompanied by chronic disillusion⁽²¹⁾. De Gaultier also referred to bovarism as a “principe hystérique”, thus pioneering its use as a psychopathological notion rather than merely an existential one^(21,22). 

Psychiatry and psychoanalysis later extended the epistemological area of this concept to describe persons with a tendency toward chronic dissatisfaction, against a background of narcissism and an unstable identity, particularly in the context of romantic relationships. The work of Otto Fenichel (1934) offers an interesting perspective on the understanding of this syndrome, explaining the concept of “boredom” as an etiological factor in various Ego dysfunctions. According to him, boredom reflects a failure of internalized ideals and fantasies to be realized in everyday experience, producing a sustained tension between the self one imagines (actively engaged, meaningful, goal-oriented) and the self that is forced to endure the daily, trivial reality⁽²³⁾. Boredom, this way defined, stands as a core feature of bovarism in which the self perpetually seeks to escape the lack of excitement in real life through imagined stimulation or novelty⁽²³⁾. From the psychodynamic perspective supported by Otto F. Kernberg, bovarism may be understood as the phenomenological correlate of identity diffusion and pathological narcissistic defenses⁽²⁴⁾. Kernberg emphasizes that pathological narcissism involves avoidance of dependency, intolerance of limitation and fear of real object relations⁽²⁴⁾, while bovarism may be considered as describing the same dynamic at the experiential level – with a focus on retreat into fantasy, romanticization of imaginary lives and lack of satisfaction with real commitments.

Another relevant hermeneutic context is offered by A. Green (1983), who considered narcissism to be a structural organization of the Ego that depends on the interplay among fantasy and real life⁽²⁵⁾. Narcissism reflects a chronic discrepancy between an idealized, fantasy-enriched self and the constraints of actual experience, which brings it close to the bovarism. This disjunction fuels defensive retreat into omnipotent fantasies and rigid self-representations that function to protect a fragile self-concept when reality fails to meet internal expectations.

Yet another suggested approach to explaining bovarism is the theory of Joyce McDougall (1985), who conceptualized psychic life as a theatrical space in which unconscious conflicts, desires and affects are enacted, rather than symbolically elaborated⁽²⁶⁾. She argues that, when internal experiences cannot be mentally represented or thought through, they are instead staged as symptoms, bodily expressions, relationships and ­repetitive scenarios, transforming lived reality into a dramatic substitute for psychic integration. From the perspective of bovarism, McDougall’s ­theatrical ­metaphor implies that the subject’s need to live out an imagined, idealized self-narrative appears when ordinary reality fails to sustain a rich, internal fantasy life⁽²⁶⁾.  Like Emma Bovary’s existential drama, McDougall’s patients possess a psychic world in which illusion compensates for the poverty or unacceptability of lived experience. The “theater” becomes a defensive solution to the gap between an internally extensive imagined life and an external reality experienced as banal, constraining or disappointing⁽²⁶⁾. 

In psychiatry, bovarism refers to a difficulty in adjusting to real-life situations, and denotes a maladaptive discrepancy between self-concept and reality, characterized by excessive imagination, emotional overinvestment in idealized scenarios and rejection of ordinary experience. Insight is usually preserved, unlike in psychotic disorders. Joseph Grasset launched bovarism into the psychiatric discourse as a manifestation of psychic inadaptation, describing subjects unable to adjust their internal representations to the constraints of external reality^(27,28). Georges Génil-Perrin subsequently integrated bovarism into the paranoid spectrum, interpreting it as a distortion of self-representation sustained by interpretative delusions^(28,29). For Joseph Lévy-Valensi, bovarism overlapped with mythomania, and was characterized by a marked deficit in self-criticism, in which imaginative constructions replaced reality without corrective judgment^(28,30). Later, Antoine Porot incorporated bovarism into psychiatric nosography as a pathological tendency toward illusion, at times explicitly framed within a gendered and moralizing model of feminine neurosis^(28,31). Taken together, these early psychiatric appropriations demonstrate that bovarism functioned less as a coherent diagnostic entity than as a flexible clinical label through which maladaptation, narcissistic illusion, impaired reality testing and anxieties surrounding imagination and identity are intermingled.

Although not recognized as a formal diagnostic entity in DSM-5-TR or ICD-11, bovarism remains a useful phenomenological and cultural construct, especially in psychodynamic theory and in the study of literary-derived psychopathological archetypes. If intended to be framed clinically, bovarism should be described by referring to the comorbid or causally relevant personality disorders, as it can be reflected by traits of histrionic, borderline and narcissistic personality, maladaptive daydreaming and affective instability.

From cynicism to psychopathology: Diogenes syndrome

Also known as “severe domestic squalor”, “senile crisis syndrome” or “social breakdown syndrome”, this pathology is characterized by extreme neglect of personal hygiene, social withdrawal and lack of home maintenance in terms of cleanliness^(32,33). Although not formally recognized by current nosological systems, it remains a quite extensively explored syndrome in geriatric psychiatry and community mental health.

The name of this syndrome derives from the behavior attributed to the Cynic philosopher Diogenes of Sinope (412/404-323 BC), who lived an ascetic life and made a virtue of extreme poverty. Diogenes expressed his contempt for humanity by violating social conventions. Contemporary descriptions depict him living in a barrel and exhibiting dog-like behavior (Greek kynikos derives from kyon, meaning “dog”). Diogenes believed that people lived artificially and that their hypocrisy was most clearly reflected in social norms, whereas the study of animal life could lead to an understanding of the fundamental values of existence^(32,34). Despite not being inspired by a writer or a fictional character, but by a philosopher who lived more than two thousand years ago, this eponymous syndrome may be included here due to the culturally and textually mediated figure of Diogenes, whose symbolic persona, constructed and transmitted through philosophical and literary anecdotes, proved itself a relevant source of exploration for psychiatrists.

The syndrome was first described in 1975 by a team of researchers who evaluated 30 elderly patients (16 women and 14 men) hospitalized for various acute psychiatric conditions, who also exhibited extreme self-neglect⁽³⁵⁾. The patients showed no embarrassment regarding their dirty appearance, unkempt clothing or the completely neglected homes in which they lived. Patients in this category did not necessarily have financial problems, and one-third of them refused assistance from social services⁽³⁵⁾. The syndrome is encountered usually in elderly individuals who live alone and have limited contact with their surroundings. As a result of neglecting personal hygiene, patients may develop various physical illnesses or experience worsening of preexisting conditions. Patients may have vitamin or trace element deficiencies, including folate, vitamin B12, vitamin C, calcium and vitamin D deficiencies, as well as reduced albuminemia, dehydration or hypokalemia⁽³⁵⁾. Subjects may maintain autonomy, and are often discovered incidentally during hospitalization for an acute intercurrent somatic condition. Family members or neighbors may also notice the distinctive signs of this syndrome, as such patients may become a health risk for those living around them.

Two types of Diogenes syndrome have been described, the “active” one being represented by collecting items from outside and cluttering inside, to fill in the vacuum of their life, while the “passive” patients are being invaded by their collected rubbish, by default and emptiness⁽³⁶⁾.

Patients with this syndrome often appear poorly groomed, dirty, unkempt and unshaven, and may have foul-smelling breath⁽³²⁾. They typically live in severely neglected and unsanitary environments⁽³²⁾. A characteristic feature is the compulsive accumulation of items with little or no practical value, such as old newspapers, leftover food, empty containers, broken electronic devices or even excrement⁽³²⁾. This behavior, known as senile hoarding, also referred to as syllogomania or disposophobia, is frequently associated with obsessive-compulsive disorder (OCD) or anankastic (obsessive-compulsive) personality disorder⁽³²⁾. It arises from a persistent urge to acquire objects or an inability to discard them, as the individual perceives these items as potentially useful⁽³²⁾. The resulting clutter significantly disrupts daily life by reducing usable living space and interfering with basic activities like cooking, personal hygiene and sleeping. Although the collected items may be arranged in an orderly fashion, the accumulation typically lacks any clear or purposeful goal⁽³⁷⁾.

In a series of cases presented by Rosenthal et al.⁽³⁸⁾, Diogenes syndrome was associated with schizotypal, schizoid and anankastic personality disorders. In these cases, the authors consider Diogenes syndrome to be either a stress reaction occurring in elderly patients with specific personality traits, or the final phase of a personality disorder. Patients with obsessive-compulsive personality disorder (OCPD) may also exhibit senile hoarding when psychotic disorders, dementia, substance-induced disorders or general medical conditions are excluded.

Another study⁽³⁵⁾ shows that the personality of patients with Diogenes syndrome is marked by suspiciousness, emotional lability, aggressiveness, group dependence and a tendency to distort reality.

Some authors have suggested that Diogenes syndrome is an atypical adjustment disorder superimposed on a personality with particular paranoid or schizoid traits^(39,40). This syndrome may represent an exaggeration of feelings of disappointment, dissatisfaction, discontent and misanthropy, elements sometimes associated with advanced age. Social isolation and lack of friends are not causes of the syndrome, but may be consequences of personality problems.

The diathesis-stress model of mental disorders^(41,42) provides a perspective applicable to Diogenes syndrome. In response to an identifiable stressor, a person vulnerable due to dysfunctional personality traits may develop a specific form of mental disorder. Vulnerable personalities respond less flexibly to various stressors faced by elderly individuals, such as loss of a spouse, relocation, retirement or disability.

A transnosographic approach to Diogenes syndrome questions the validity of this construct, since it is not clear if this entity is an actual illness or a symptom, and if various disorders, such as neurocognitive disorders (NCDs) or substance use disorders (SUDs), are triggering elements, comorbidities or etiological factors; therefore, Diogenes syndrome may be a cluster of symptoms observable across underlying conditions⁽³⁶⁾. Also, there are authors questioning the name of this syndrome, since there are descriptions of Diogenes’s behaviors that are not part of the eponymous syndrome (such as defaecating or masturbating in public spaces, as to indicate the repudiation of commonly accepted ideas about human decency)⁽⁴³⁾.

Some authors consider hoarding to be the central symptom of Diogenes syndrome⁽⁴⁴⁾, while others attribute this manifestation to a comorbid cause, such as OCD or Tourette’s syndrome⁽⁴⁵⁾. Other authors argue that, although hoarding is not a key behavior of Diogenes syndrome, it is a valid diagnostic criterion⁽³⁷⁾. American authors believe that a quantitative approach would be more useful for characterizing this syndrome, which they prefer to call “social breakdown syndrome”. The criteria for this syndrome are presented by Clark⁽⁴⁶⁾, and are recognized by the U.S. National Adult Protective Services Administration. Other authors describe self-neglect in terms closer to those of healthcare, suggesting that this type of behavior refers to somatic patients who intentionally neglect self-care despite having adequate financial and cognitive resources⁽⁴⁷⁾. Duke’s definition emphasizes the dysfunctional aspects induced by social breakdown syndrome, and highlights the existence of organic or psychiatric causes underlying this behavior⁽⁴⁶⁾. Self-neglect is a behavior that reduces the patient’s quality of life and affects all aspects of life. This behavior has the following characteristics: (a) potential for self-harm or even life-threatening risk; (b) absence of a clear objective for engaging in this type of behavior (unlike suicidal behavior); (c) cumulative effects observed over time, with the behavior representing a repetitive pattern that affects multiple areas of self-care⁽⁴⁶⁾.

The inclusion, starting with DSM-5, of the hoarding disorder (HD) in the chapter of “OCD spectrum disorders” raises the question of differential diagnosis between the Diogenes syndrome and this new diagnostic entity. In Diogenes syndrome, the central symptom is the severe tendency for self-neglect, while in HD, the core manifestation is the difficulty in discarding objects; the hoarding in Diogenes syndrome is frequent, but not mandatory, unlike HD; the motivation for hoarding behaviors is variable, but most likely indifference, apathy, paranoid tendencies in Diogenes syndrome, and attachment, fear of loss, perceived utility in HD; the insight in Diogenes syndrome is absent or reduced, while in HD it may be more graded; the ability for self-care may be preserved in HD; Diogenes syndrome has been more frequently reported in women, while HD in men; the age may also vary across diagnoses; Diogenes syndrome is more frequently associated with NCDs, SSD, depressive disorders, personality disorders, while HD is more frequently associated with OCD, depression and anxiety^(4,5,33). However, Diogenes syndrome may be considered a special form of HD, from a conceptual perspective, and other authors suggested a bidimensional model with hoarding and squalor fueled by the same central etiology (i.e., HD being the major expression of the first dimension, and Diogenes syndrome the significant expression of the second)^(48-51).

ICD-11 also recognizes HD, placing more emphasis on functional impairment, states that excessive acquisition may be present but is not mandatory, and provides a graded evaluation of insight, while noting the exclusion of another mental disorder or medical condition as a causative factor⁽²⁾. Diogenes syndrome may be diagnosed according to this system as additional clinical features – e.g., self-neglect, social isolation or problems related to living alone – to a primary condition, such as NCDs, SSD, major depressive disorder (MDD) or personality disorders.

The mortality associated with Diogenes syndrome is increased, especially among women (reaching values as high as 46%), with causes such as physical and medical conditions arising from poor hygiene, malnutrition, infections and injuries^(35,52).

Although the initial descriptions of the syndrome were based on elderly populations aged 65 and older, cases with earlier onset have also been reported. There is a higher incidence of this pathology in women (ratio 3:1), particularly widows^(53,54). Rare cases of Diogenes syndrome à deux have also been described⁽⁵⁵⁾.

To date, there is no consensus regarding the neurobiological substrate of Diogenes syndrome. According to Clark⁽³⁵⁾, Diogenes syndrome represents a maladaptive reaction under specific stress conditions, and it is not the result of passive deterioration. Nearly 50% of subjects in a group of 30 patients with Diogenes syndrome had no other psychiatric diagnosis and no significant cognitive deficits; most had a good socio-professional history, with no significant hereditary antecedents⁽³⁵⁾.

More recent studies show that approximately 50% of subjects with Diogenes syndrome also have another underlying psychiatric pathology: dementia, alcoholism, schizophrenia or OCD⁽⁵⁶⁾. Frontotemporal dementia and Diogenes syndrome share common features, such as hostility, anosognosia and syllogomania, interpreted as a form of motor perseveration. It is essential to identify residual or predominantly negative-symptom schizophrenia, severe depression with melancholic features, or dementia, which may mimic the clinical picture of Diogenes syndrome.

A case report presented a 51-year-old male admitted to the hospital after being removed by police from his home, which was covered in rubbish, rotting food and various debris (e.g., empty bottles, rotting food boxes and cat food)‌⁽³³⁾. The psychiatrist declared the patient as being unfit to take care of himself; the physical exam did not provide remarkable data, except for onychogryphotic toenails and cerumen impaction of the right ear, causing partial deafness; severe depression, moderate anxiety and conceptual disorganization, along with severe guilty feelings were detected on various psychometric instruments⁽³³⁾. The patient reported isolating himself to escape feelings experienced when with others and episodes of dissociation⁽³³⁾. The pharmacological approach was refused initially by the patient, and only psychotherapy was accepted⁽³³⁾. Unlike in HD, there was no reported perceived need to save the items or distress associated with discarding them, and the patient was able to maintain occupational functioning for six years with minimal social contact, and his living circumstance caused clinically significant distress only in the acute phase⁽³³⁾. Autism spectrum disorders (ASD) and psychotic disorders were considered as differentials, but no conclusive data were found in support of such diagnoses⁽³³⁾. Personality evaluation detected dysfunctions in the “negative affect” and “detachment domains”⁽³³⁾.

Another case report, a 78-year-old man diagnosed with carcinoma of the paranasal sinus with leptomeningeal carcinomatosis, also presented an accumulation of waste materials, congesting and cluttering the living area⁽⁵⁰⁾. The criteria for HD, major depressive disorder, OCD, anxiety disorders, substance use disorders or posttraumatic stress disorder (PTSD) were not met by this patient; the cognitive status was unaffected; he was not emotionally attached to possessions in the house, and there was no perceived need to keep the waste at home⁽⁵⁰⁾. In the case of a 62-year-old man, retired, a former philosophy professor, with no psychiatric history, the patient was brought to the emergency room by his neighbor; he was rummaging through trash and did not leave the house for weeks, making his habitat cluttered and unsanitary; he accepted hospitalization, although he did not consider his behavior as pathologic; no OCD, depressive or psychotic symptoms were detected, and no change in cognitive functions; he discontinued the recommended treatment, and he was readmitted⁽⁵⁷⁾. Yet another case series showed a 35-year-old woman with early- onset HD and comorbid OCD, and a 78-year-old woman with Diogene syndrome related to vascular dementia; these case reports highlight the need for multidisciplinary interventions and comprehensive management to prevent deterioration, address physical health problems, improve hygiene and home safety, and reduce the potential harms to patients and community⁽⁵⁸⁾.

It is also important that the diagnosis of this syndrome be established only when the symptomatology is not better explained by other underlying pathologies, such as frontotemporal dementia or the sequelae of a frontal lobe stroke. A scale was constructed for helping the evaluation of patients with domestic squalor and hoarding: the Environmental Cleanliness and Clutter Scale⁽⁵⁶⁾. However, the discriminative capacity of this scale still needs to be proven⁽⁵⁶⁾.

Selective serotonin reuptake inhibitors (SSRIs) and antipsychotics may be used as treatment, depending on the underlying psychopathological background⁽³²⁾. Abnormalities in serotonergic transmission have long been associated with self-aggressive behaviors⁽³²⁾.

Psychotherapeutic interventions, such as behavioral or psychosocial methods, may be necessary in these individuals. Psychoanalysts propose a therapy according to a psychogenetic hypothesis of this syndrome, based on a particular personality structure characterized by annihilation anxiety, fusional object relations, defensive mechanisms such as denial, and sometimes paranoid delusions⁽⁵⁹⁾. Repeated losses, real or symbolic, occurring in the later stages of life, expose these individuals to narcissistic injuries or problems derived from the loss of affectively invested objects⁽⁶⁰⁾.

In conclusion, Diogenes syndrome is still important in the differential diagnosis of other mental illnesses, such as HD, SSD, MDD and NCDs. Whenever identified in clinical practice, an exploration of comorbid psychiatric disorders is granted.

Seduction as a way of life: Don Juan syndrome

Don Juan syndrome is a descriptive psychopathological concept referring to a persistent pattern of compulsive seduction, serial sexual conquests and an inability to establish emotionally stable or enduring intimate relationships. The term originates from the literary figure Don Juan, first systematized in early modern European literature, most notably in Tirso de Molina’s El burlador de Sevilla⁽⁶¹⁾. The name “satyriasis” is also used as a synonym for this syndrome.

Clinically, the syndrome has been associated with traits of pathological narcissism, emotional immaturity and identity instability, with sexuality functioning as a means of self-validation, instead of authentic emotional sharing. According to McDougall (1995), Don Juan syndrome is a repetitive erotic solution to the trauma of loss, sexual difference and narcissistic injury rather than as a pursuit of intimacy⁽⁶²⁾. Compulsive seduction functions as a defensive mechanism, mobilizing Eros to decrease the impact of dependency, mourning and to enhance the acceptance of monosexual limitation⁽⁶²⁾. In this sense, Don Juanism exemplifies a neosexual or addictive sexuality that preserves psychic survival in the short term, but ultimately blocks creative relatedness and genuine object love⁽⁶²⁾. 

For these individuals, sexual encounters are often characterized by novelty-seeking and conquest, followed by rapid disengagement once emotional closeness or dependency is anticipated. As such, the behavior is frequently ego-syntonic and lacks subjective distress unless secondary interpersonal or social consequences arise. Psychoanalytically, Don Juanism is conceptualized as a form of hysterical hypersexuality, where sexuality is used not primarily for pleasure, but for psychic regulation⁽⁶³⁾. The Don Juan figure seduces compulsively, repeats similar erotic scenarios, loses interest once the conquest is achieved, and requires constant novelty and triangulation⁽⁶³⁾. The repetitive pursuit of new partners serves to reaffirm masculinity and autonomy, while simultaneously avoiding emotional vulnerability. These interpretations have placed Don Juan syndrome at the intersection of sexual behavior disorders, personality pathology and relationship dysfunction.

In a case report, a male patient presented to the psychotherapist for a relationship problem, but compulsive sexuality in his love relations surfaced during therapy; this tendency was manifested as a repetitive, uncontrollable urge to stage interpersonal scenarios of a sexual or sexualized nature⁽⁶³⁾. Specifically, the dramatizations in this case were interpreted as a re-enactment of the primal scene (the unconscious fantasy of parental sexual relations), with the patient identifying not with the child, but with the oedipal father, the one who possesses the woman⁽⁶³⁾. A central developmental issue in Don Juan syndrome is the failure of separation, which in this patient referred to a double trauma – i.e., pre-oedipal separation (loss of the primary object) and oedipian exclusion (being left out of the parental couple)⁽⁶³⁾. These are the reasons why separation is unconsciously equated with annihilation, ending a relationship feels catastrophic, and new relationships must be initiated before the old one ends⁽⁶³⁾. Hypersexuality acted as a defense against castration anxiety, narcissistic collapse, the experience of exclusion and psychic emptiness⁽⁶³⁾.

In another case report of Don Juan syndrome, the psychoanalytic exploration offered a valuable framework for understanding specific enduring personality patterns in adult men, where compulsive dominance and power dynamics in relationships serve as defenses against underlying narcissistic depression⁽⁶⁴⁾. These behavioral features are best interpreted through a self-psychological lens rather than a classic oedipal framework, highlighting the role of early relational experiences in shaping adult relational pathology⁽⁶⁴⁾. 

According to a study that included 31 self-defined sex addicts and a large age-matched control group, a tendency to experience enhanced sexual interest in states of depression or anxiety was characteristic of the study group; 45% of sex addicts described dissociative experiences, and obsessive-compulsive mechanisms were reported in some cases⁽⁶⁵⁾. In conclusion, compulsive sexual conquest is better understood not as a unified addiction or personality type, but as one possible pattern of out-of-control sexual behavior driven by impaired affect regulation, heightened sexual excitation and difficulties with inhibition⁽⁶⁵⁾. Don Juan-like behaviors can be interpreted as attempts to manage negative mood states, such as depression or anxiety, through sexual validation, novelty and transient reward, rather than as expressions of stable desire or intimacy⁽⁶⁵⁾. Such patterns cannot be reduced to a single syndrome, and a more nuanced, mechanism-based understanding is required for recognizing multiple psychological pathways leading to repetitive, non-intimate sexual behavior⁽⁶⁵⁾. 

In the same perspective, H.S. Kaplan (1983) conceptualizes Don Juan syndrome as a disturbance of sexual desire rooted in anxiety about intimacy rather than in excessive libido⁽⁶⁶⁾. In her book The Evaluation of Sexual Disorders, she describes how compulsive seduction and repeated sexual conquests function defensively to sustain narcissistic self-esteem and ward off fears of dependency, castration and emotional vulnerability⁽⁶⁵⁾. Sexual desire is typically intense during the phase of pursuit but collapses once emotional closeness threatens the individual’s sense of autonomy and control⁽⁶⁵⁾. Kaplan thus frames Don Juanism as a disorder of object relations, illustrating how sexual activity can mask a fundamental incapacity for sustained erotic and emotional intimacy⁽⁶⁵⁾. 

Also, O. Fenichel (1938), in his classical work, conceptualizes the Don Juan type as a narcissistically driven character structure in which compulsive seduction serves to defend against deep castration anxiety, unconscious guilt and dependency fears, making repetition of conquest necessary to stabilize a fragile masculine identity rather than to achieve genuine object love⁽⁶⁷⁾. 

Modern psychiatric classification systems, including DSM-5-TR and ICD-11, do not recognize Don Juan syndrome as a distinct disorder. Instead, the pattern may be discussed indirectly within the contexts of narcissistic personality disorder, antisocial traits or compulsive sexual behavior disorder. However, the attempt to introduce the hypersexual disorder (HsD) in DSM-5 is documented⁽⁶⁸⁾. Kafka (2010) stated that HsD represents a clinically meaningful condition characterized by recurrent, intense sexual fantasies, urges and behaviors associated with impaired self-regulation, affect dysregulation and significant distress or functional impairment⁽⁶⁸⁾. He proposed diagnostic criteria grounded in empirical data, neurobiological findings and treatment response, distinguishing the disorder from moral judgments, paraphilias and normative variations in high sexual desire⁽⁶⁸⁾. Kafka concludes that recognizing HsD as a formal diagnosis would advance research, improve clinical assessment and facilitate evidence-based treatment for individuals whose sexual behavior is persistently out of control⁽⁶⁸⁾. The DSM-5 editors ultimately rejected HsD due to insufficient empirical consensus, substantial overlap with existing diagnostic categories and concerns regarding the potential pathologization of normative sexual behavior^(9,10). 

Several psychometric instruments exist for the structured evaluation of hypersexual behaviors, such as the Hypersexual Disorder Screening Inventory (this being proposed for the clinical screening of hypersexual disorder by the dedicated DSM-5 evaluation team), the Hypersexual Behavior Inventory, the Sexual Compulsivity Scale, the Sexual Addiction Screening Test, the Sexual Addiction Screening Test-Revised or the Compulsive Sexual Behavior Inventory^(69,70). The corresponding criteria for HsD proposed for DSM-5 were recurrent and intense sexual fantasies, sexual urges and sexual behavior for at least six months, and at least four of the following criteria: excessive time invested in sexual fantasies, urges and planning for engaging in sexual behavior; repetitive engagement in the previously mentioned aspects in response to dysphoric mood states or in response to stressful life events; repetitive but unsuccessful efforts to control or decrease significantly sexual fantasies, urges and behavior; repetitive engaging in sexual behavior while disregarding the risk for physical and emotional harm to self or others; clinically significant distress or impairment in various important areas of functioning; there is no causal relationship with exogenous substances, a general medical condition or manic episodes; the person is at least 18 years old⁽⁷⁰⁾. 

In ICD-10, compulsive sexual behavior may be coded under “excessive sexual desire” (F52.7), but there are no operationalized criteria for this, and it is rarely made as a standalone diagnosis⁽¹⁾. However, it must be noted that Don Juan syndrome is not primarily about drive quantity but about relational patterns and the defensive functions of such behaviors. An overlap may occur in individuals who have a Don Juan syndrome with hypersexual behavior, and even HsD, but the two concepts are not at all identical.

The ICD-11 acknowledges for the first time the existence of a compulsive sexual behavior disorder (CSBD), defined by failure to control intense, repetitive sexual impulses or urges, resulting in repetitive sexual behavior⁽²⁾. Compulsive sexual behavior disorder is characterized by a persistent inability to control intense sexual impulses, resulting in repetitive sexual behaviors that become central to life, persist for at least six months, continue despite adverse consequences or diminished satisfaction, and lead to marked distress or functional impairment⁽²⁾. Distress based solely on moral or cultural disapproval does not qualify for the diagnosis⁽²⁾. In Don Juan syndrome, there are sexual behaviors that are ego-syntonic, rarely out of control, and subjects show minimal subjective distress. As a personality feature, Don Juanism may be coded as disociality/narcissistic features of personality disorder, possibly disinhibition⁽²⁾.

In conclusion, although contemporary diagnostic systems such as DSM-5-TR and ICD-11 acknowledge compulsive sexual behavior, these classifications primarily address behavioral dyscontrol and subjective distress, and thus fail to capture the ego-syntonic, relational and defensive functions characteristic of Don Juanism. While Don Juanism may coexist with hypersexual behavior or CSBD in some individuals, the two constructs are different both conceptually and clinically. Conceptualizing Don Juanism solely in terms of impulse control or addiction risks overlooking its underlying relational dynamics and defensive structure. Effective psychotherapeutic work requires attention to separation anxiety, fragile self-cohesion, and the patient’s difficulty tolerating dependence and emotional vulnerability.

Forever young: Dorian Gray syndrome

This syndrome refers to an excessive preoccupation with youthfulness, physical appearance and the denial of aging, often accompanied by narcissistic personality traits, body image disturbance and compulsive cosmetic behaviors⁽⁷¹⁾. The term originates from Oscar Wilde’s novel The Picture of Dorian Gray (1890), in which the protagonist remains physically youthful while his portrait ages, reflecting moral and psychological decay⁽⁷²⁾. Dorian Gray, a very handsome man, desires that his newly painted portrait acquire all the negative influences of life and the physical decay resulting from the passage of time, while his real self remains undeteriorated⁽⁷¹⁾.

This syndrome was first described in the literature in 2000⁽⁷¹⁾. However, the pursuit of eternal beauty and youth is not at all limited to the 21^st century, as the Fountain of Youth and Philosopher’s Stone have been sources of inspiration for writers and artists over centuries⁽⁷¹⁾. Still, the phenomenon’s amplitude may be enhanced by media that promote an equivalence of youth with beauty and health, a trend strongly supported by the modern cosmetic industry⁽⁷¹⁾. According to Euler et al. (2003), this syndrome is an “ethnic syndrome” of the late modernity, fueled by newspapers, television and internet pages reporting on lifestyle drugs (e.g., medications for hair loss, obesity, erectile dysfunction), anti-aging products and cosmetic surgery⁽⁷³⁾. This indicates that the cult of youth and beauty may increasingly overshadow other values in contemporary society, such as “wisdom” or “experience”, and attractiveness has become the central element of self-perception⁽⁷³⁾. As a result, beauty ideals are internalized, producing a gap between idealized representations and actual physical features, which fosters body dissatisfaction and dysfunctional self-perception⁽⁷³⁾. The construct of Dorian Gray syndrome has been particularly discussed in the context of modern consumer culture and esthetic medicine, since it may be conceptualized as an epiphenomenon of the disinvestment of classical societal values and of individuals’ orientation toward more superficial, immediately perceived physical features.

The increased accessibility of cosmetic medical treatments in the last few decades, fueled by mass media attention, the appearance of minimally invasive techniques and the intense promotion of ideals of physical beauty created the favorable setting for the expression of various psychopathological tendencies related to body schema⁽⁷⁴⁾. In clinical and psychological literature, Dorian Gray syndrome describes individuals who experience profound anxiety related to aging and physical decline, leading to maladaptive strategies targeting the maintenance of a youthful self-image. These strategies may include excessive grooming, cosmetic procedures, rigid body control and avoidance of situations that highlight aging or physical imperfection. The intense preoccupation with maintaining one’s own youthful appearance may be pursued even at the cost of overall well-being⁽⁷¹⁾. Frequent visitors to the dermatology/esthetics clinics, these individuals have a constant fear of looking old, and wish to hide signs of aging, while ignoring a rational lifestyle⁽⁷¹⁾. Middle-aged, educated, of middle- or higher socioeconomic class and heavily using social media, these individuals are attracted to quick solutions offered by aesthetic treatments⁽⁷¹⁾.

The characteristics of Dorian Gray syndrome were described as: (1) excessive preoccupation with one’s outward aspect; (2) imaginary or minimal defects in external morphology leading to embarrassment and social reclusiveness; (3) a strong desire to preserve one’s youthfulness in order not to grow older⁽⁷⁵⁾. Other authors consider the core of the syndrome as being body dysmorphic disorder (BDD) features, narcissistic regression and denial of the maturation process⁽⁷⁶⁾. Still other authors frame the Dorian Gray syndrome as a psychodynamic constellation marked by body dysmorphic features, narcissistic personality traits and a fetishizing focus on youth⁽⁷³⁾. Psychodynamically, this syndrome represents a defense against psychological maturation and fear of death⁽⁷³⁾. A key distinction from BDD is that the latter is understood as a somatoform defense mechanism, typically arising in critical life situations⁽⁷³⁾. In this context, obsessive preoccupation with a perceived or minimal physical flaw functions as a displacement of an underlying intrapsychic conflict, for example, as an initial defense against depression, and may lead to outcomes such as social withdrawal and depressive symptoms⁽⁷³⁾.

Unlike BDD, individuals with Dorian Gray syndrome are not necessarily focused on a specific perceived defect but rather on a global fear of aging and loss of attractiveness. Insight is often partial, and behaviors are ego-syntonic, reinforced by cultural ideals emphasizing youth and beauty. Whereas BDD typically represents a somatoform defense emerging in response to circumscribed intrapsychic conflict, Dorian Gray syndrome reflects a broader narcissistic defense against psychological maturation, decline and mortality. Nevertheless, this syndrome was considered a variant of BDD by several authors, due to the excessive concern and preoccupation with physical appearance, repetitive and compulsive behaviors to alleviate their distress and the contribution of similar pathogenetic factors, such as low self-esteem and distorted self-image⁽⁷¹⁾. The nosological delineation between Dorian Gray syndrome and MDD (i.e., lack of satisfaction related to one’s own physical appearance), hypochondriac disorder, eating disorders and delusional disorder requires an attentive look into the diagnostic criteria, while keeping in mind that Dorian Gray syndrome is not a recognized nosological entity.

The relationship between art, literature and psychiatry is a complex one and a source of intense exploration, with multiple dimensions being approached^(77-79). The syndrome explored in this section reflects the power of archetypal characters such as Dorian Gray, which may become relevant to complex phenomenological configurations with psychopathological significance.

Dorian Gray syndrome is not recognized as a formal diagnosis in DSM-5-TR or ICD-11. Instead, it functions as a literary-derived descriptive syndrome, useful for phenomenological understanding and psychodynamic formulation, especially in cases involving pathological narcissism, identity instability and aging-related anxiety. Therefore, although this syndrome would escape a DSM or ICD categorization, the clinician should be careful if elements of a personality disorder (mainly narcissistic, but also histrionic and obsessive-compulsive) can be detected in these individuals, or enough criteria to suggest an OCD or BDD are met, or if MDD clinical elements exist, in order to establish a clear diagnosis.

Regarding the case management, psychotherapy is considered central, incorporating psychodynamic and/or cognitive-behavioral elements, with the addition of SSRIs or tricyclics and even antipsychotics if delusional components exist⁽⁷³⁾. Although a number of studies have shown psychological improvements postoperatively, there is no consistent tendency toward such amelioration in the majority of patients⁽⁷⁴⁾.

In conclusion, as with other literary eponyms in psychiatry, this syndrome illustrates the enduring influence of symbolic, archetypal characters on psychiatric language, providing a narrative framework for recurrent psychological patterns that resist strict nosological classification. Therefore, Dorian Gray syndrome is not a discrete mental illness, but a culturally shaped psychopathological configuration centered on narcissistic vulnerability and aging-related anxiety.

Conclusions

The analysis of literary eponymous syndromes highlights the persistent and meaningful interaction between psychiatry and literature, showing how archetypal fictional figures have contributed to the descriptive language of psychopathology. Syndromes such as Alice in Wonderland, bovarism, Diogenes, Don Juan and Dorian Gray capture recurring patterns of perception, identity, desire, self-care and aging that often escape strict nosographic classification. Although these constructs are not formally recognized in DSM-5-TR or ICD-11, their continued use reflects the limits of categorical diagnostic systems in fully encompassing the phenomenological, cultural and relational dimensions of mental suffering.

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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