Marginalizing the Psychiatric in Dementia Treatment

I recently came across an interesting  post written by Allen Power that raised the question of whether dementia is better thought of as a psychiatric or a neurological problem. Power argues that dementia is increasingly viewed as a psychiatric illness, with symptoms of distress and analogous to mental illness. Psychiatrists are brought in as “expert pill jockeys” to control behavioral problems with antipsychotic drugs. Power thinks this approach is wrong:

Dementia is not a psychiatric illness. It is a change in one’s experience of their surroundings and how they process information, based on structural neurologic changes. It is as much a psychiatric illness as would be a stroke. And people’s interpretations of the world around them may seem confused to us, but they are nothing like the symptoms of an organized psychosis.”

According to Power, the tendency to psychiatrize dementia leads us to overlook non-pharmacological interventions, which he argues have been shown to be the safest, most efficacious and most enduring ways to manage the behavioral problems associated with dementia. He concludes that it would be much better to view dementia as “a neurological disability with secondary psychological challenges,” and that psychiatry’s role should not be simply prescribing pills to control behavior  but helping with the broader psychosocial challenges that dementia entails.

I follow and admire Power’s work as a geriatrician and one of the leading critics of the dominant drug-based approach to treating dementia. But I think that there is an important historical issue that structures the problem he raises. Without understanding and explicitly confronting this issue, efforts to change the dominant approach are not likely to have much traction.

In arguing that that dementia is a neurological rather than a psychiatric condition, Power follows the dominant modern medical approach to dementia in placing cognitive symptoms, attributed to “structural neurological changes,” at the center and relegating emotional and psychological changes  to the periphery — mere epiphenomenal reactions to the primary cognitive damage. This is somewhat arbitrary since, for patients and family members at least, the emotional and psychological symptoms are often as prominent and disturbing as the cognitive ones. But it follows a deep historical tendency in modern medicine to view psychiatric symptoms and mental disorders as less legitimate because they are not clearly attributable to pathological structures in the body.

This bias emerged clearly, in the United States at least, in the late nineteenth century as the development of germ theory and microbiology created a more scientific approach to medicine. Acute, infectious diseases which could be attributed to a particular pathological agent and effectively treated with a specific drug increasingly became the paradigm of modern medicine, especially as antibiotics emerged in the twentieth century. Chronic illnesses, especially psychiatric ones, seemed less legitimate, and the medical specialties that focused on them lost prestige in the era of “the magic bullet.”

Psychiatry was further marginalized during this period by its overlap with the other medical specialty claiming expertise over the brain and mental phenomena, neurology. Though the distinction between the psychiatric and the neurological has perhaps always been somewhat arbitrary, neurologists during this period, especially in the United States,  were generally successful in associating their specialty with cutting edge science while psychiatrists struggled under the stigma of their historic association with asylums and chronic, incurable madness.

The history of psychiatry since the late-nineteenth century can be interpreted as trying to compensate for this marginalization. Leading psychiatrists of the period, especially in Germany, sought to put their field on a scientific basis commensurate with the advance of medicine as a whole by showing that mental illness could be linked to specific brain pathologies. When this approach failed, Emil Kraepelin turned toward a quantitative assessment of clinical symptoms as a more scientific means of defining psychiatric disorders. Freud and his followers meanwhile sought to provide a scientific basis for psychiatry by turning away from the intractable problem of psychosis and developing a unified, expansive theoretical framework to explain and treat the mind. In recent decades, armed with new insights into genetics and neurochemistry and new technologies for exploring the brain, psychiatry has returned to the dream of anchoring psychiatric symptoms and disorders firmly in the brain. But apparent progress in understanding the brain only perpetuates the marginalization of psychopathology that cannot be clearly associated with something specific that is wrong with the brain. Psychiatric symptoms and clinical disorders continue to have an ambiguous status unless they are clearly associated with specific pathological processes in the brain.

While Power provides a strong critique of psychiatry’s reductionist approach to managing the “problem behaviors” of dementia with antipsychotic drugs, in this post at least he ironically appears to endorse much of the mainstream medical concept of dementia that historically produced such reductionism. So long as a reductionist model of dementia as simply a brain disorder retains a near exclusive grip in medicine, so long as pathology is considered more real than psychiatric symptoms, let alone social and cultural factors, medical practitioners of all kinds are much more likely to respond with a prescription pad than with the agenda for  social and cultural change that Power calls for.