It's real, he's been doing this for many years and never broken character. And the level of filth in the house isn't just surface level like somebody could do for performance art. He showed previously the floor rotting out under the house and stuff. I just don't see how any human could fake something this long without a goal or payoff, only just to be mildly amusing for a handful of random youtube people. I would literally bet my life that we're seeing his real mental state. Possibly off and on medication time to time.