By following disorders over time, particularly into later life, by studying changes with aging and in older persons, new findings and clues emerge. These new leads can add to our understanding (or perhaps force us to re-examine basic theoretical constructs) of mental illness and its treatment as well as development and growth, relevant not just to the elderly, but to people in general. Research on aging and later life can provide new pieces to the puzzle of the human condition.
Research on Aging: A Piece of the Puzzle Gene D. Cohen, MD 1 Interest in research on aging and the elderly is very much on the rise. There are many reasons to explain this change, including growing scientific curiosity about phenomena in later life, increased Federal support for "Aging" Research, and an emerging new awareness about the elderly and their problems. Taken for granted is the relevance of such research in terms of its potential benefit for older people. Very much underappreciated, however, is a further opportunity — a sleeper of profound proportions — that emerges through research on aging: in addition to its significance for the elderly, aging research can also be of major value to other age groups as well. An elaboration of the last point is the thrust of this paper. Research on the elderly, on aging, on disorders in later life, can in fact lead to new information relevant to better understanding of developmental issues and diseases across the life cycle. New clues, new insights can be gained. Aging research can lead to new pieces of the puzzle about the human condition and the problems therein for all age groups.
that come with aging not explained by cohort, cultural, or cumulative knowledge variables alone. The concept of different issues emerging at different points along the life cycle (e.g., the different developmental stages described by Erik Erikson) receives serious attention; what about the emergence of different insights at different stages of aging (aspects of Jungian theory might be relevant in this regard)? And could such insights by older persons clarify earlier life events as well as later ones, enlarging our overall understanding of the human experience? Interestingly, some of the influences on Freud relate to this point. Ernest Jones (1957), in his biography of Freud, addresses the extremely high regard that Freud had for Sophocles' "Oedipus Rex". In Freud's listing of the "masterpieces of all time" Oedipus Rex is placed first. It seems not unreasonable, then, to infer that from Sophocles' masterpiece Freud gained further associations or insights about what he called the "Oedipus Complex," one of the cornerstone concepts of his brilliant psychoanalytic theory, a concept that classical psychoanalysis focuses on most intensely to explain child development and the onset of neurFreud and the Oedipus Complex osis (Hall, 1954). It should also be pointed out One way of studying the elderly is to explore that Sophocles was in his eighth decade, 71 their dreams, fantasies, imagery, creative years of age, when he wrote "Oedipus Rex" thoughts, or writings. By so doing, the opportun- (Sophocles, 1958). "Electra," which deals with ity to learn more about issues and concerns in similar issues, this time focused on the woman, later life is apparent. But what about associations was written even later. Ernest Jones (1957) also or insights gained in this process that lead to new quotes Freud as saying that "'The Brothers Karaideas about earlier life events. Is there anything masov' is the greatest novel that has ever been unique or different in the way older thinkers look written." Freud went on to say that there was "no at life, behavior, and conflict — perspectives chance" in the fact that Dostoevsky's masterpiece treated the "same theme" as Sophocles' 'Chief, Ctr. for Studies of the Mental Health of the Aging, Oiv. of Special "Oedipus Rex." Dostoevsky was approaching Mental Health Programs, NIMH, Parklawn Bldg., Room 18-95, 5600 Fishers his 60th birthday when he completed this work. Lane, Rockville, MD 20857.
Vol. 19, No. 5,1979
503
He died the next year (The Columbia Encyclopedia, 1968). What Freud delineated in psychological theory he seemed to feel was dealt with in the literary art of these outstanding writers; it should be added, when they were aging writer^. Leon Edel (1975) in his Benjamin Rush Lecture on "The Madness of Art/'saw art as "articulation of the human condition." He posited that "the most enduring works may be those of artists who have lived through their sadness to experience and control their rage against aging" (Edel, 1975). Whether Edel's impression or his idea about rage and aging in relation to art is accurate, may generate debate. But the enduring nature of "Oedipus Rex" and "The Brothers Karamasov" is fact, as is the impact of their older authors on Freud during the evolution of his theories. Such examples raise further the question of something different in the imagery of the elderly: imagery that might expand our understanding of the nature of man and woman in general.
Understanding Mental Disorders
While it is clear that studies of mental disorders in later life can lead to valuable findings for the care of elderly individuals, it may on the surface be less clear as to how valuable such findings can be in better understanding illness in younger age groups. The piece of the puzzle concept, the idea of a bit of information derived from research on older subjects affecting a theory of illness based on studies of younger subjects, can be appreciated from the investigations on MAO (monamine oxidase) activity in the brain (Kety, 1975; Robinson & Davis, 1971). Interest in brain MAO levels relates to the biogenic amine hypothesis of depression. Simply stated the biogenic amine hypothesis asserts that "some, if not all depressions are associated with an absolute or relative deficiency of catecholamines, particularly norepinephrine, at functionally important receptor sites in the brain (Kaplan et al., 1975). The antidepressant action of MAO inhibitors which potentiate or increase brain catecholeamines seemed to support this theory. By this theory it would follow that an increase in brain MAO activity would decrease brain catecholeamine levels and therefore lead to a depressive affect. When -elderly subjects, however, were studied some interesting and contradictory findings emerged. It was found that brain MAO levels increased with aging, which according to the
504
above reasoning should result in most older people becoming increasingly depressed. But most older people do not become increasingly depressed. Indeed, some investigators find that while the incidence and prevalence of depression is significantly greater in the elderly than in younger adults, it may be slightly less a problem after age 70 than in the decade before (Gurland, 1976; Lipton, 1976). By focusing on the elderly new information has been added, a further piece in the puzzle about depression in general (all age groups) has been introduced. Though this new piece joins other bits of information in raising questions about the norepinephrine theory of depression, at the same time it has stimulated further lines of biogenic amine investigation as well as renewed interest in exploring relationships between psychosocial stress and neurochemical changes. Moving from a common disorder to an uncommon one, the contribution of "Aging" research to the understanding of basic pathology, independent of age, can again be appreciated. Consider the Capgras Syndrome. In 1923, the French Psychiatrist Capgras described a syndrome characterized by failure to recognize a familiar person who was seen instead as a double. The double would be thought to resemble the familiar one, but regarded an imposter. The syndrome is generally explained as being associated with psychosis. Ambivalent attitudes toward the person whose real identity is denied have been described. Marked anxiety about the familiar other is believed to lead to this state of non recognition. Goldfarb has added further insight into understanding this disorder by studying the syndrome in some elderly patients. Rather than an indication of specific psychotic states as suggested by several authors, Goldfarb thought the Capgras symptoms could be understood as "adaptive attempts" (Goldfarb & Weiner, 1977). He saw a motive "to reconstitute the environment by replacing the current, non-giving, non-acceptable one with a nurturant, giving and acceptable one." Goldfarb also indicates that the syndrome could "occur (as it does in older persons) whenever there is a decrease in discriminatory capacities." Through a focus on older patients with Capgras Syndrome, the psychodynamics and precipitants of the disorder in general seemed better understood. From a different frame of reference, what might be learned from a disorder that does not become apparent until the individual is in later life, such
The Gerontologist
as with paraphrenia? Paraphrenia "refers to a mental illness characterized by a thought disorder with paranoid, systematized delusions, but without dementia or progressive personality deterioration. Contact with reality is maintained except in the specific area of the delusional system. The onset of late paraphrenis is usually after age 60 (Verwoerdt, 1976). Kay and Roth have regarded paraphrenia as "the way old age schizophrenia is expressed (Kay & Roth, 1962; Verwoerdt, 1976)." Given theories that attempt to tie together family, psychosocial environment, and genetic neurochemical factors that lead to schizophrenia, it would seem that there are clues to be gained about the basic disorder by studying it in those who first experience schizophrenic symptoms in later life. What differentiates these individuals from those with the typical earlier onset of schizophrenia?
among the individual heterosexual subjects. However, the age range was only from 21 to 35 years. It would seem that a logical follow-up study would examine plasma testosterone levels among older homosexual and heterosexual women as a means of providing further data on the significance or lack of significance of testosterone levels in affecting a woman's sexual orientation. Such a study remains to be done. Effect of Age on Clinical Picture
Attention to aging is particularly important in any effort to understand the course or variations in the course of a given clinical disorder. To overlook the effect of aging on clinical course may result in a failure to recognize underlying relationships between seemingly different disorders at vary ing points of the life cycle. A classic example is the case of Herpes Zoster (also called shingles). Herpes Zoster is an infection rarely found in children, increasing in frequency, severity, and duration with age. Of particular Understanding Behavior Just as attention to aging can throw light on note, though, is the finding that Herpes Zoster understanding mental disorders at different is caused by the same virus that causes chickenstages of the life cycle, so too, can it provide pox (varicella), a disorder predominately occurfurther information to prove or disprove theories ring in early childhood (Coriell, 1966). With mental disorders, too, an age factor has of particular types of behavior independent of age group. Homosexuality is a case in point. become increasingly apparent in its impact on Controversial in its classification as a "sexual the clinical picture of an underlying disturbance. orientation disturbance," a range of theories Roth described a "phobic-anxiety-depersonalihave been offered on causes of homosexual zation syndrome," found in patients generally behavior, including cultural, psychoanalytic, in their early 20s (Detre & Jarecki, 1971; Roth, genetic, and endocrinological explanations 1960). By middle age or later life, those among (Marmor, 1975). No attempt will be made here these same patients who again became symptoto resolve the homosexuality issue. But an effort matic, were likely to manifest typical depressive will be made to show how one of the investiga- symptoms. The phobic-anxiety-depersonalizative routes exploring female homosexuality can tion syndrome can then be seen as an "atypical be further opened or closed, by adding a focus depression," a depression whose manifest symptoms are affected by the individual's age on older persons. In a study of "Plasma Testosterone in Homo- (Detre & Jarecki, 1971). Noteworthy is the findsexual and Heterosexual Women," the investi- ing that this particular atypical depression, like gators found a statistically significant inverse the depression of mid to later life, is also responcorrelation between age and testosterone level sive to antidepressants of the imipramine type for heterosexual but not for homosexual women (Detre & Jarecki, 1971). Attention to aging, there(Gartrell et al., 1977). The general findings of the fore, may add information about the underlying study indicated that the plasma testosterone nature, course, treatment, and prognosis of a levels in homosexual women (N = 21), mea- disorder at different stages of the life cycle. Where descriptions of the clinical course of a sured by radioimmunoassay, appeared substantially higher than those of heterosexual women disorder differ, the age variable may offer some (N = 19) of the same age. When age range was clarification. The controversy around Briquet's looked at, the differences were further accentu- Syndrome is a ready example. The draft of the ated. Plasma testosterone levels remained essen- American Psychiatric Association's Diagnostic tially even or else increased with aging among and Statistical Manual-Ill of Mental Disorders the individual homosexual subjects. In contrast, (DSM-III) refers to Briquet's Syndroma as "Somaplasma testosterone levels went down with aging tization Disorder," indicating that "the essential
Vol. 19, No. 5,1979
505
features are recurrent and multiple somatic complaints for which medical attention is sought but that are not apparently due to any physical disorder, beginning before early adulthood (prior to age 25), and having a chronic but fluctuating course (DSM-III Draft, 1978). However, the separation of diagnosis of hysterical personality and Briquet's syndrome as distinct concepts has been seriously questioned, with one study finding that 9 out of 10 women independently diagnosed as having hysterical personality also met criteria for Briquet's Syndrome (Kimble et al., 1975; Liskow et al., 1977). Another study comparing Briquet's Syndrome and hysterical personality through the use of the MMPI (Minnesota Multiphasic Personality Inventory) was informative (Liskow et al., 1977). The investigators compared the MMPI scores obtained by Slavney and McHugh (1976) on 29 inpatients diagnosed as having hysterical personality with MMPI scores on 21 of their own outpatients diagnosed as having Briquef s Syndrome (diagnostic criteria being the presence of a complicated or dramatic medical history; onset before age 35; and a minimum of 25 out of 59 medically unexplainable symptoms spread across 9 out of 10 symptom groups). The two groups of patients differed significantly in age, on the MMPI lie scale, and on the MMPI hypochondriasis scale, but not on any other of the MMPI scales (Table 1). The investigators suggest that "patients with Briquet's Syndrome might be a subgroup of the most seriously ill patients with hysterical personality or a subgroup of those whose emphasis on somatic complaints overshadows other aspects of their personality." They alternatively, though, also suggest that "in view of the significant age difference between the groups, the higher hypochondriasis score may reflect the natural progression of hysterical personality with increasing somatic complaints with increasing age. They suggest, too, that "age differences might also account for the significant difference in the lie scale."
Table 1. Patients with Patients with Hysterical Briquet's Personality Syndrome Significance Age
27.9 years
38.4 years
(mean)
(mean)
Given the alternative hypothesis above, it would seem that further clarification of similarities and differences between the hysterical personality disorder and Briquet's Syndrome might come about by evaluating two groups of yet older patients diagnosed with the respective disorders. Discovering the Unexpected
In a remarkable study by Heston, involving 2204 autopsies on psychiatric patients over a 20-year period, with a focus on Alzheimer's disease, some very intriguing findings emerged. "Relatives of probands with histologically confirmed Alzheimer's disease had excessive morbidity from Alzheimer's disease, Down's Syndrome, and hematologic malignancies" (Heston, 1977). These observations tie closely together with earlier studies describing indistinguishable light and electron microscopic histopathological changes in comparing Alzheimer's disease and Down's Syndrome. "A very high proportion, perhaps even 100% of patients with Down's Syndrome who survive into their late 30s develop what must be called Alzheimer's disease with clinical dementia and brain tissue changes" (Ellis et al., 1974; Heston, 1977). These discoveries suggest not only a specific genetic predisposition to Alzheimer's disease, but a common genetic defect in the etiology of Alzheimer's Disease, Down's Syndrome, and certain hematologic malignancies. Attention to a disease in later life has therefore furthered the understanding of different disorders occurring in early life. Indeed, in the area of organic brain syndrome (OBS) in general a number of new opportunities for discovering the unexpected are emerging. Certainly, the role of computerized axial tomography in revealing discrepancies between the degree of brain atrophy and the level of psychosocial impairment in the same individual has renewed with vigor longstanding curiosity and controversy around the relationship between anatomy and function. As in the case of the above study on Alzheimer's disease, further research on OBS as a group of disorders promises yet further insights into the workings and pathologies of the brain and psyche.
p < .005
Positive Clinical Changes with Aging
Lie
47.9
54.0
p < .005
Hypochondriasis
63.6
75.4
p < .005
Curious, if not surprising, positive clinical changes can occur with aging. Research aimed
506
The Gerontologist
at explaining such phenomena could clearly have payoff for the understanding and/or treatment of disorders of the old and young alike. Some examples follow. Manic-depressive disorders. — Why are manic episodes less likely to occur in older patients than in younger ones? (Cohen, 1975). More research on this change with aging could lead to a better understanding of what predisposes to and precipitates manic episodes in general. Such research might also provide more information about the underlying process that influences whether a manic or a depressive state will unfold during the course of the illness. Anxiety. — It has been described that "The chronically anxious young adult tends to become less so as he grows older (Nemiah, 1975)". If this is accurate, why is it the case? What is it about the psychosocial, psychodynamic, and/or neurophysiological situation of older people that could explain this observation? Depression. — While it has been shown that the elderly are especially vulnerable to depression and that the frequency of depression is high in later life, the extent of depression in advanced old age may actually begin to decline (Gurland, 1976; Lipton, 1976). As in the case of anxiety, if this is accurate, why is it so? What is the nature of the psychosocial, psychodynamic, and/or neurophysiological events that may be at work here which, if clarified, could improve the understanding of depression at this point of the life cycle and earlier stages as well? Side effects of drugs. — Although even more caution must be exercised in the use of drugs with older patients than with younger ones, here, too, positive changes are not absent. In the use of phenothiazines for example, the extrapyramidal side effect of dystonia is much less likely to occur in older adults (Detre & Jarecki, 1971). Needless to point out, an understanding of this phenomenon as well as the occurrences of other age-related responses to drugs could lead to more information about drug action independent of age. Research in this area could also lead to more information about neurophysiological changes with aging across the life cycle.
life course can be better understood by closely examining the early years, and, particularly, certain critical periods during an individual's early childhood. Curiously, a similar amount of inquisitiveness and intellectual verve has not gone into an attempt to understand one's life course or the course of a mental disturbance by focusing on changes with time and aging. In this regard important clues are probably being missed, clues that could lead us closer to understanding the etiology and dynamics of various mental disorders in general. It is as if a piece of the puzzle of the human condition has been overlooked. By following disorders over time, particularly into later life, by studying changes with aging and in older persons, new findings and bits of information emerge. These new leads can add to our understanding—or perhaps force us to reexamine basic theoretical constructs — of mental illness and its treatment as well as development and growth relevant not just to the elderly, but to people in general.
References
Cohen, R. A. Manic-depressive illness. In A. M. Freedman, H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry/ll. Williams & Wilkins, Baltimore, 1975. Coriell, L. Herpes Zoster in principles of internal medicine.
McCraw Hill Book, New York, 1966. Detre, T. P., & Jarecki, H. G. Modern psychiatric treatment.
J. B. Lippincott Co., Philadelphia, 1971. DSM-III Draft. The task force on nomenclature and statistics of the American Psychiatric Association. American Psychiatric Assoo, Washington, 1978. Edel, L. The madness of art. American journal Psychiatry,
1975, 132, 1005-1012. Ellis, W. C , McCulloch, J. R., & Corley, C. L. Presenile dementia in Down's syndrome—ultrastructure identity with Alzheimer's Disease. Neurology, 1974, 24, 101-106. Gartrell, N. K., Loriaux, D. L, & Chase, T. N. Plasma testosterone in homosexual and heterosexual women. American Journal Psychiatry, 1977, 134, 1117-1119.
Goldfarb, A. I., & Weiner, M. B. The Capgras Syndrome as an adaptational maneuver in old age. American Journal Psychiatry, 1977, 134, 1434-1436.
Gurland, B. J. The comparative frequency of depression in various adult age groups. Journal of Gerontology, 1976,3/, 283-292. Hall, C. S. A Primer of Freudian psychology.
Mentor
Books, New York, 1954. Heston, L. L. The genetics of Alzheimer's Disease — associations with hematologic malignancy and Down's Syndrome. Archives General Psychiatry, 1977,
34, 976-981.
Conclusion Freud, and many who followed him, made an indelible contribution in showing how one's
Vol. 19, No. 5,1979
Jones, E. The life and work of Sigmund Freud, Basic
Books, New York, 1957. Kaplan, H. I., Sadock, B. J., & Freedman, A. M. The brain in psychiatry. In A. M. Freedman, H. I. Kaplan & B. J.
507
Sadock (Eds.), Comprehensive textbook of psychiatry/ II. Williams & Wilkins Co., Baltimore, 1975. Kay, D. W. K., & Roth, M. Schizophrenias of old age. In R. H. Williams, C. Tibbits, & W. Donahue (Eds.), Processes of aging. Atherton Press, New York, 1962. Kimble, R., Williams, J., & Agras, S. A comparison of two methods of diagnosing hysteria. American Journal Psychiatry, 1975, 132, 1197-1198. Kety, S. S. Biochemistry of the major psychoses. In A. M. Freedman, H. I. Kaplan, & B. J. Sadock (Eds.), Comprehensive textbook of psychiatryIII. Williams & Wilkins Co., Baltimore, 1975. Lipton, M. A. Age differentiation in depression: Biochemical aspects. Journal of Gerontology, 1976, 31, 293-299. Liskow, B. I., Clayton, P., Woodruff, R. Briquet's syndrome, hysterical personality and the MMPI. American Journal Psychiatry, 1977, 134, 1137-1139. Marmor, J. Homosexuality and sexual orientation disturbances. In A. M. Freedman, H. I. Kaplan, & B. J.
Sadock (Eds.), Comprehensive textbook of psychiatry/ II. Williams & Wilkins Co., 1975. Nemiah, J. C. Anxiety neurosis. In A. M. Freedman, H. I. Kaplan, & B. J. Sadock (Eds.), Comprehensive textbook of psychiatryIII. Williams & Wilkins Co., Baltimore, 1975. Robinson, D. S., & Davis, J. M. Relation of sex and aging to monamine oxidase activity of human brain, plasma, and platelets. Archives General Psychiatry, 1971, 24, 536-539. Roth, M. Phobic anxiety-depersonalization syndrome and some general aetiological problems in psychiatry. Journal Neuropsychiatry, 1960, 1, 293-306. Slavney, P. R., & McHugh, R. R. The hysterical personality — an attempt at validation with the MMPI. Archives General Psychiatry, W7b,32, 186-190. Sophocles, The Oedipus Plays of Sophocles. Mentor Books, New York, 1958. The Columbia Encyclopedia. Columbia Univ. Press, New York, 1968. Verwoerdt, A. Clinical geropsychiatry, Williams & Wilkins Co., Baltimore, 1976.
508
The Gerontologist
Research on Aging: A Piece of the Puzzle Gene D. Cohen, MD 1 Interest in research on aging and the elderly is very much on the rise. There are many reasons to explain this change, including growing scientific curiosity about phenomena in later life, increased Federal support for "Aging" Research, and an emerging new awareness about the elderly and their problems. Taken for granted is the relevance of such research in terms of its potential benefit for older people. Very much underappreciated, however, is a further opportunity — a sleeper of profound proportions — that emerges through research on aging: in addition to its significance for the elderly, aging research can also be of major value to other age groups as well. An elaboration of the last point is the thrust of this paper. Research on the elderly, on aging, on disorders in later life, can in fact lead to new information relevant to better understanding of developmental issues and diseases across the life cycle. New clues, new insights can be gained. Aging research can lead to new pieces of the puzzle about the human condition and the problems therein for all age groups.
that come with aging not explained by cohort, cultural, or cumulative knowledge variables alone. The concept of different issues emerging at different points along the life cycle (e.g., the different developmental stages described by Erik Erikson) receives serious attention; what about the emergence of different insights at different stages of aging (aspects of Jungian theory might be relevant in this regard)? And could such insights by older persons clarify earlier life events as well as later ones, enlarging our overall understanding of the human experience? Interestingly, some of the influences on Freud relate to this point. Ernest Jones (1957), in his biography of Freud, addresses the extremely high regard that Freud had for Sophocles' "Oedipus Rex". In Freud's listing of the "masterpieces of all time" Oedipus Rex is placed first. It seems not unreasonable, then, to infer that from Sophocles' masterpiece Freud gained further associations or insights about what he called the "Oedipus Complex," one of the cornerstone concepts of his brilliant psychoanalytic theory, a concept that classical psychoanalysis focuses on most intensely to explain child development and the onset of neurFreud and the Oedipus Complex osis (Hall, 1954). It should also be pointed out One way of studying the elderly is to explore that Sophocles was in his eighth decade, 71 their dreams, fantasies, imagery, creative years of age, when he wrote "Oedipus Rex" thoughts, or writings. By so doing, the opportun- (Sophocles, 1958). "Electra," which deals with ity to learn more about issues and concerns in similar issues, this time focused on the woman, later life is apparent. But what about associations was written even later. Ernest Jones (1957) also or insights gained in this process that lead to new quotes Freud as saying that "'The Brothers Karaideas about earlier life events. Is there anything masov' is the greatest novel that has ever been unique or different in the way older thinkers look written." Freud went on to say that there was "no at life, behavior, and conflict — perspectives chance" in the fact that Dostoevsky's masterpiece treated the "same theme" as Sophocles' 'Chief, Ctr. for Studies of the Mental Health of the Aging, Oiv. of Special "Oedipus Rex." Dostoevsky was approaching Mental Health Programs, NIMH, Parklawn Bldg., Room 18-95, 5600 Fishers his 60th birthday when he completed this work. Lane, Rockville, MD 20857.
Vol. 19, No. 5,1979
503
He died the next year (The Columbia Encyclopedia, 1968). What Freud delineated in psychological theory he seemed to feel was dealt with in the literary art of these outstanding writers; it should be added, when they were aging writer^. Leon Edel (1975) in his Benjamin Rush Lecture on "The Madness of Art/'saw art as "articulation of the human condition." He posited that "the most enduring works may be those of artists who have lived through their sadness to experience and control their rage against aging" (Edel, 1975). Whether Edel's impression or his idea about rage and aging in relation to art is accurate, may generate debate. But the enduring nature of "Oedipus Rex" and "The Brothers Karamasov" is fact, as is the impact of their older authors on Freud during the evolution of his theories. Such examples raise further the question of something different in the imagery of the elderly: imagery that might expand our understanding of the nature of man and woman in general.
Understanding Mental Disorders
While it is clear that studies of mental disorders in later life can lead to valuable findings for the care of elderly individuals, it may on the surface be less clear as to how valuable such findings can be in better understanding illness in younger age groups. The piece of the puzzle concept, the idea of a bit of information derived from research on older subjects affecting a theory of illness based on studies of younger subjects, can be appreciated from the investigations on MAO (monamine oxidase) activity in the brain (Kety, 1975; Robinson & Davis, 1971). Interest in brain MAO levels relates to the biogenic amine hypothesis of depression. Simply stated the biogenic amine hypothesis asserts that "some, if not all depressions are associated with an absolute or relative deficiency of catecholamines, particularly norepinephrine, at functionally important receptor sites in the brain (Kaplan et al., 1975). The antidepressant action of MAO inhibitors which potentiate or increase brain catecholeamines seemed to support this theory. By this theory it would follow that an increase in brain MAO activity would decrease brain catecholeamine levels and therefore lead to a depressive affect. When -elderly subjects, however, were studied some interesting and contradictory findings emerged. It was found that brain MAO levels increased with aging, which according to the
504
above reasoning should result in most older people becoming increasingly depressed. But most older people do not become increasingly depressed. Indeed, some investigators find that while the incidence and prevalence of depression is significantly greater in the elderly than in younger adults, it may be slightly less a problem after age 70 than in the decade before (Gurland, 1976; Lipton, 1976). By focusing on the elderly new information has been added, a further piece in the puzzle about depression in general (all age groups) has been introduced. Though this new piece joins other bits of information in raising questions about the norepinephrine theory of depression, at the same time it has stimulated further lines of biogenic amine investigation as well as renewed interest in exploring relationships between psychosocial stress and neurochemical changes. Moving from a common disorder to an uncommon one, the contribution of "Aging" research to the understanding of basic pathology, independent of age, can again be appreciated. Consider the Capgras Syndrome. In 1923, the French Psychiatrist Capgras described a syndrome characterized by failure to recognize a familiar person who was seen instead as a double. The double would be thought to resemble the familiar one, but regarded an imposter. The syndrome is generally explained as being associated with psychosis. Ambivalent attitudes toward the person whose real identity is denied have been described. Marked anxiety about the familiar other is believed to lead to this state of non recognition. Goldfarb has added further insight into understanding this disorder by studying the syndrome in some elderly patients. Rather than an indication of specific psychotic states as suggested by several authors, Goldfarb thought the Capgras symptoms could be understood as "adaptive attempts" (Goldfarb & Weiner, 1977). He saw a motive "to reconstitute the environment by replacing the current, non-giving, non-acceptable one with a nurturant, giving and acceptable one." Goldfarb also indicates that the syndrome could "occur (as it does in older persons) whenever there is a decrease in discriminatory capacities." Through a focus on older patients with Capgras Syndrome, the psychodynamics and precipitants of the disorder in general seemed better understood. From a different frame of reference, what might be learned from a disorder that does not become apparent until the individual is in later life, such
The Gerontologist
as with paraphrenia? Paraphrenia "refers to a mental illness characterized by a thought disorder with paranoid, systematized delusions, but without dementia or progressive personality deterioration. Contact with reality is maintained except in the specific area of the delusional system. The onset of late paraphrenis is usually after age 60 (Verwoerdt, 1976). Kay and Roth have regarded paraphrenia as "the way old age schizophrenia is expressed (Kay & Roth, 1962; Verwoerdt, 1976)." Given theories that attempt to tie together family, psychosocial environment, and genetic neurochemical factors that lead to schizophrenia, it would seem that there are clues to be gained about the basic disorder by studying it in those who first experience schizophrenic symptoms in later life. What differentiates these individuals from those with the typical earlier onset of schizophrenia?
among the individual heterosexual subjects. However, the age range was only from 21 to 35 years. It would seem that a logical follow-up study would examine plasma testosterone levels among older homosexual and heterosexual women as a means of providing further data on the significance or lack of significance of testosterone levels in affecting a woman's sexual orientation. Such a study remains to be done. Effect of Age on Clinical Picture
Attention to aging is particularly important in any effort to understand the course or variations in the course of a given clinical disorder. To overlook the effect of aging on clinical course may result in a failure to recognize underlying relationships between seemingly different disorders at vary ing points of the life cycle. A classic example is the case of Herpes Zoster (also called shingles). Herpes Zoster is an infection rarely found in children, increasing in frequency, severity, and duration with age. Of particular Understanding Behavior Just as attention to aging can throw light on note, though, is the finding that Herpes Zoster understanding mental disorders at different is caused by the same virus that causes chickenstages of the life cycle, so too, can it provide pox (varicella), a disorder predominately occurfurther information to prove or disprove theories ring in early childhood (Coriell, 1966). With mental disorders, too, an age factor has of particular types of behavior independent of age group. Homosexuality is a case in point. become increasingly apparent in its impact on Controversial in its classification as a "sexual the clinical picture of an underlying disturbance. orientation disturbance," a range of theories Roth described a "phobic-anxiety-depersonalihave been offered on causes of homosexual zation syndrome," found in patients generally behavior, including cultural, psychoanalytic, in their early 20s (Detre & Jarecki, 1971; Roth, genetic, and endocrinological explanations 1960). By middle age or later life, those among (Marmor, 1975). No attempt will be made here these same patients who again became symptoto resolve the homosexuality issue. But an effort matic, were likely to manifest typical depressive will be made to show how one of the investiga- symptoms. The phobic-anxiety-depersonalizative routes exploring female homosexuality can tion syndrome can then be seen as an "atypical be further opened or closed, by adding a focus depression," a depression whose manifest symptoms are affected by the individual's age on older persons. In a study of "Plasma Testosterone in Homo- (Detre & Jarecki, 1971). Noteworthy is the findsexual and Heterosexual Women," the investi- ing that this particular atypical depression, like gators found a statistically significant inverse the depression of mid to later life, is also responcorrelation between age and testosterone level sive to antidepressants of the imipramine type for heterosexual but not for homosexual women (Detre & Jarecki, 1971). Attention to aging, there(Gartrell et al., 1977). The general findings of the fore, may add information about the underlying study indicated that the plasma testosterone nature, course, treatment, and prognosis of a levels in homosexual women (N = 21), mea- disorder at different stages of the life cycle. Where descriptions of the clinical course of a sured by radioimmunoassay, appeared substantially higher than those of heterosexual women disorder differ, the age variable may offer some (N = 19) of the same age. When age range was clarification. The controversy around Briquet's looked at, the differences were further accentu- Syndrome is a ready example. The draft of the ated. Plasma testosterone levels remained essen- American Psychiatric Association's Diagnostic tially even or else increased with aging among and Statistical Manual-Ill of Mental Disorders the individual homosexual subjects. In contrast, (DSM-III) refers to Briquet's Syndroma as "Somaplasma testosterone levels went down with aging tization Disorder," indicating that "the essential
Vol. 19, No. 5,1979
505
features are recurrent and multiple somatic complaints for which medical attention is sought but that are not apparently due to any physical disorder, beginning before early adulthood (prior to age 25), and having a chronic but fluctuating course (DSM-III Draft, 1978). However, the separation of diagnosis of hysterical personality and Briquet's syndrome as distinct concepts has been seriously questioned, with one study finding that 9 out of 10 women independently diagnosed as having hysterical personality also met criteria for Briquet's Syndrome (Kimble et al., 1975; Liskow et al., 1977). Another study comparing Briquet's Syndrome and hysterical personality through the use of the MMPI (Minnesota Multiphasic Personality Inventory) was informative (Liskow et al., 1977). The investigators compared the MMPI scores obtained by Slavney and McHugh (1976) on 29 inpatients diagnosed as having hysterical personality with MMPI scores on 21 of their own outpatients diagnosed as having Briquef s Syndrome (diagnostic criteria being the presence of a complicated or dramatic medical history; onset before age 35; and a minimum of 25 out of 59 medically unexplainable symptoms spread across 9 out of 10 symptom groups). The two groups of patients differed significantly in age, on the MMPI lie scale, and on the MMPI hypochondriasis scale, but not on any other of the MMPI scales (Table 1). The investigators suggest that "patients with Briquet's Syndrome might be a subgroup of the most seriously ill patients with hysterical personality or a subgroup of those whose emphasis on somatic complaints overshadows other aspects of their personality." They alternatively, though, also suggest that "in view of the significant age difference between the groups, the higher hypochondriasis score may reflect the natural progression of hysterical personality with increasing somatic complaints with increasing age. They suggest, too, that "age differences might also account for the significant difference in the lie scale."
Table 1. Patients with Patients with Hysterical Briquet's Personality Syndrome Significance Age
27.9 years
38.4 years
(mean)
(mean)
Given the alternative hypothesis above, it would seem that further clarification of similarities and differences between the hysterical personality disorder and Briquet's Syndrome might come about by evaluating two groups of yet older patients diagnosed with the respective disorders. Discovering the Unexpected
In a remarkable study by Heston, involving 2204 autopsies on psychiatric patients over a 20-year period, with a focus on Alzheimer's disease, some very intriguing findings emerged. "Relatives of probands with histologically confirmed Alzheimer's disease had excessive morbidity from Alzheimer's disease, Down's Syndrome, and hematologic malignancies" (Heston, 1977). These observations tie closely together with earlier studies describing indistinguishable light and electron microscopic histopathological changes in comparing Alzheimer's disease and Down's Syndrome. "A very high proportion, perhaps even 100% of patients with Down's Syndrome who survive into their late 30s develop what must be called Alzheimer's disease with clinical dementia and brain tissue changes" (Ellis et al., 1974; Heston, 1977). These discoveries suggest not only a specific genetic predisposition to Alzheimer's disease, but a common genetic defect in the etiology of Alzheimer's Disease, Down's Syndrome, and certain hematologic malignancies. Attention to a disease in later life has therefore furthered the understanding of different disorders occurring in early life. Indeed, in the area of organic brain syndrome (OBS) in general a number of new opportunities for discovering the unexpected are emerging. Certainly, the role of computerized axial tomography in revealing discrepancies between the degree of brain atrophy and the level of psychosocial impairment in the same individual has renewed with vigor longstanding curiosity and controversy around the relationship between anatomy and function. As in the case of the above study on Alzheimer's disease, further research on OBS as a group of disorders promises yet further insights into the workings and pathologies of the brain and psyche.
p < .005
Positive Clinical Changes with Aging
Lie
47.9
54.0
p < .005
Hypochondriasis
63.6
75.4
p < .005
Curious, if not surprising, positive clinical changes can occur with aging. Research aimed
506
The Gerontologist
at explaining such phenomena could clearly have payoff for the understanding and/or treatment of disorders of the old and young alike. Some examples follow. Manic-depressive disorders. — Why are manic episodes less likely to occur in older patients than in younger ones? (Cohen, 1975). More research on this change with aging could lead to a better understanding of what predisposes to and precipitates manic episodes in general. Such research might also provide more information about the underlying process that influences whether a manic or a depressive state will unfold during the course of the illness. Anxiety. — It has been described that "The chronically anxious young adult tends to become less so as he grows older (Nemiah, 1975)". If this is accurate, why is it the case? What is it about the psychosocial, psychodynamic, and/or neurophysiological situation of older people that could explain this observation? Depression. — While it has been shown that the elderly are especially vulnerable to depression and that the frequency of depression is high in later life, the extent of depression in advanced old age may actually begin to decline (Gurland, 1976; Lipton, 1976). As in the case of anxiety, if this is accurate, why is it so? What is the nature of the psychosocial, psychodynamic, and/or neurophysiological events that may be at work here which, if clarified, could improve the understanding of depression at this point of the life cycle and earlier stages as well? Side effects of drugs. — Although even more caution must be exercised in the use of drugs with older patients than with younger ones, here, too, positive changes are not absent. In the use of phenothiazines for example, the extrapyramidal side effect of dystonia is much less likely to occur in older adults (Detre & Jarecki, 1971). Needless to point out, an understanding of this phenomenon as well as the occurrences of other age-related responses to drugs could lead to more information about drug action independent of age. Research in this area could also lead to more information about neurophysiological changes with aging across the life cycle.
life course can be better understood by closely examining the early years, and, particularly, certain critical periods during an individual's early childhood. Curiously, a similar amount of inquisitiveness and intellectual verve has not gone into an attempt to understand one's life course or the course of a mental disturbance by focusing on changes with time and aging. In this regard important clues are probably being missed, clues that could lead us closer to understanding the etiology and dynamics of various mental disorders in general. It is as if a piece of the puzzle of the human condition has been overlooked. By following disorders over time, particularly into later life, by studying changes with aging and in older persons, new findings and bits of information emerge. These new leads can add to our understanding—or perhaps force us to reexamine basic theoretical constructs — of mental illness and its treatment as well as development and growth relevant not just to the elderly, but to people in general.
References
Cohen, R. A. Manic-depressive illness. In A. M. Freedman, H. I. Kaplan & B. J. Sadock (Eds.), Comprehensive textbook of psychiatry/ll. Williams & Wilkins, Baltimore, 1975. Coriell, L. Herpes Zoster in principles of internal medicine.
McCraw Hill Book, New York, 1966. Detre, T. P., & Jarecki, H. G. Modern psychiatric treatment.
J. B. Lippincott Co., Philadelphia, 1971. DSM-III Draft. The task force on nomenclature and statistics of the American Psychiatric Association. American Psychiatric Assoo, Washington, 1978. Edel, L. The madness of art. American journal Psychiatry,
1975, 132, 1005-1012. Ellis, W. C , McCulloch, J. R., & Corley, C. L. Presenile dementia in Down's syndrome—ultrastructure identity with Alzheimer's Disease. Neurology, 1974, 24, 101-106. Gartrell, N. K., Loriaux, D. L, & Chase, T. N. Plasma testosterone in homosexual and heterosexual women. American Journal Psychiatry, 1977, 134, 1117-1119.
Goldfarb, A. I., & Weiner, M. B. The Capgras Syndrome as an adaptational maneuver in old age. American Journal Psychiatry, 1977, 134, 1434-1436.
Gurland, B. J. The comparative frequency of depression in various adult age groups. Journal of Gerontology, 1976,3/, 283-292. Hall, C. S. A Primer of Freudian psychology.
Mentor
Books, New York, 1954. Heston, L. L. The genetics of Alzheimer's Disease — associations with hematologic malignancy and Down's Syndrome. Archives General Psychiatry, 1977,
34, 976-981.
Conclusion Freud, and many who followed him, made an indelible contribution in showing how one's
Vol. 19, No. 5,1979
Jones, E. The life and work of Sigmund Freud, Basic
Books, New York, 1957. Kaplan, H. I., Sadock, B. J., & Freedman, A. M. The brain in psychiatry. In A. M. Freedman, H. I. Kaplan & B. J.
507
Sadock (Eds.), Comprehensive textbook of psychiatry/ II. Williams & Wilkins Co., Baltimore, 1975. Kay, D. W. K., & Roth, M. Schizophrenias of old age. In R. H. Williams, C. Tibbits, & W. Donahue (Eds.), Processes of aging. Atherton Press, New York, 1962. Kimble, R., Williams, J., & Agras, S. A comparison of two methods of diagnosing hysteria. American Journal Psychiatry, 1975, 132, 1197-1198. Kety, S. S. Biochemistry of the major psychoses. In A. M. Freedman, H. I. Kaplan, & B. J. Sadock (Eds.), Comprehensive textbook of psychiatryIII. Williams & Wilkins Co., Baltimore, 1975. Lipton, M. A. Age differentiation in depression: Biochemical aspects. Journal of Gerontology, 1976, 31, 293-299. Liskow, B. I., Clayton, P., Woodruff, R. Briquet's syndrome, hysterical personality and the MMPI. American Journal Psychiatry, 1977, 134, 1137-1139. Marmor, J. Homosexuality and sexual orientation disturbances. In A. M. Freedman, H. I. Kaplan, & B. J.
Sadock (Eds.), Comprehensive textbook of psychiatry/ II. Williams & Wilkins Co., 1975. Nemiah, J. C. Anxiety neurosis. In A. M. Freedman, H. I. Kaplan, & B. J. Sadock (Eds.), Comprehensive textbook of psychiatryIII. Williams & Wilkins Co., Baltimore, 1975. Robinson, D. S., & Davis, J. M. Relation of sex and aging to monamine oxidase activity of human brain, plasma, and platelets. Archives General Psychiatry, 1971, 24, 536-539. Roth, M. Phobic anxiety-depersonalization syndrome and some general aetiological problems in psychiatry. Journal Neuropsychiatry, 1960, 1, 293-306. Slavney, P. R., & McHugh, R. R. The hysterical personality — an attempt at validation with the MMPI. Archives General Psychiatry, W7b,32, 186-190. Sophocles, The Oedipus Plays of Sophocles. Mentor Books, New York, 1958. The Columbia Encyclopedia. Columbia Univ. Press, New York, 1968. Verwoerdt, A. Clinical geropsychiatry, Williams & Wilkins Co., Baltimore, 1976.
508
The Gerontologist
