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“Premature definition, premature tidiness, may serve to perpetuate misconception; better let the forays proceed in liberal disarray than to risk organized misdirection” (1).
Old age is the only stage of life during which change—whether biological or psychological—is not considered promising for the future. Society as a whole, including many health professionals and psychotherapists (2), maintains a rigid bias that altered feelings and thinking experienced by the elderly reflect deteriorating (abiotrophic) biological conditions. This line of thinking leads us to trivialize a powerful psychodynamic issue that dominates old age: lifespan review. In fact, in the elderly, a host of developmental issues (3) reemerge for the last time in concentrated form, and with plenty of experience (4). It is a recent (5) and still controversial concept that older people have veritable intrapsychic conflicts (6), the capacity to resolve them, and a chance for successful integration (7).
In this article I wish to present the argument that trends in both society and medicine have blurred the lines that separate degenerative disease in old age from normal aging. More specifically, the specter of Alzheimer's disease colors our approach to the treatment of all elderly patients, even those with no evidence of organic brain disease. The result is that we fail to fully realize the potential for psychodynamic intervention.
Taking on the difficult task of treatment in an elderly patient means straddling the disciplines of geriatrics-neuropsychiatry-psychotherapy. The contemporary trend is to assign a specialist to each symptom, sometimes with questionable results. Fragmented care is disconcerting for all patients. For the elderly patient who feels the need to narrow his choices and wants somebody “in charge,” this approach is especially prone to failure. (See compartmentalization in discussion of case 2).
Contrary to experience with midlife adults, it is most often virtually impossible to separate p