Explaining senile dementia: The limits of neuropathological research

If any area of mental distress stands out as having been virtually untouched by psychoanalysis and its derivatives, it is the dementing process in old age. There are several reasons for this, including the relative powerlessness and poverty of old people and the fact that dementia has only fairly recently been perceived as a major social problem. But perhaps the most significant reason is simply that the dementias of old age are commonly viewed as paradigm cases of purely ‘organic’ mental disorders, and hence not amenable to any kind of psychological explanation. The main purpose of this paper is to challenge this view, and to show why there is a clear place for examining dementia in psychological — and indeed psychoanalytic — terms. Our focus of attention here will be on the prevailing view of senile dementia, which is closely linked to an intensive programme of neuropathological research. This opens up the way for a direct engagement with the dementing process itself. At its very beginning psychoanalysis was involved in a radically new understanding of an affliction that many medical authorities have viewed as having an obscure organic origin: namely, hysteria. Perhaps it is time that senile dementia was similarly reappraised.

The accepted wisdom of today's geriatric medicine is that there are several fairly well-defined organic diseases which bring about dementia in old age. Of these, two are said to account for the majority of cases. The first is a condition in which the cerebral grey matter shows degenerative changes very similar, or possibly identical, to those found in Alzheimer's disease in middle life. The second is associated with the destruction of tissue that follows from the bursting of small blood vessels in the brain (multiple infarction). Authorities vary in their accounts of the relative prevalence. According to a typical report (Albert, 1982)