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5. Beyond the Characteristic Plaques and Tangles: Mid-Twentieth Century U.S. Psychiatry and the Fight Against Senility
- Johns Hopkins University Press
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5 Beyond the Characteristic Plaques and Tangles Mid-Twentieth Century U.S. Psychiatry and the Fight Against Senility Jesse F. Ballenger The conceptual history of Alzheimer disease (AD) is usually discussed within an implicit three-part chronology. There is the classical period, in which the clinical and histopathologic acumen of Alzheimer and Perusini brought the disease into scientific focus (and in which Kraepelin made the inscrutable decision to distinguish between presenile and senile dementia, confounding research for generations). There is the modern period, beginning in the 1970s and continuing to the present, in which technological and conceptual breakthroughs and the pressure of an aging population created explosive interest and progress . Between these two brightly illumined periods lies a stretch of decades in which it is assumed that little scientific interest was taken in the disease and still less progress made—a veritable dark age in the conceptual history of AD. Of course, this age did not seem nearly so dark at the time. In fact, from the mid-1930s through the 1950s, there was a dramatic surge of interest in senile dementia and AD among U.S. psychiatrists. In the ten years from 1926 to 1935, nine articles concerning senile de- 84 Jesse F. Ballenger mentia and/or AD were published in the American Journal of Psychiatry and the Archives of Neurology and Psychiatry, the two leading professional journals; and in the following decade, thirty-six articles appeared. Though this heightened interest in the dementias of old age was small compared to what would follow in the 1980s, many observers at the time optimistically regarded the 1930s to 1950s as a period of great progress. More interestingly, although the period brought no new insights into the biological and genetic bases of brain pathology that has been the focus of research since the late 1970s, U.S. psychiatrists in this period forged a distinctly new approach to senile dementia that emphasized psychosocial factors over neuropathology in the etiology of dementia . Dementia was more than the simple and inevitable outcome of a brain that was deteriorating with the processes of aging and/or disease. Dementia was a dialectical process between the brain and the social context in which the aging person was situated. Factors such as premorbid personality structure, emotional trauma, disruptions of family support , and social isolation were regarded as at least as important in explaining dementia as the biological processes that produced plaques and tangles. Similarly, memory loss and other cognitive deficits were, relative to today, less interesting than the emotional and behavioral disturbances that accompany dementia. In short, AD and senile dementia were regarded by most psychiatrists of this period, not as cognitive disorders produced by biological processes within the brain, but as mental illnesses produced by psychodynamic processes occurring between the aging individual and society. So conceived, dementia was not a wellbounded disease entity. It could not be easily differentiated from the entire experience of aging. Psychiatry’s way of thinking about senile dementia was deeply connected to the larger project of the emerging field of gerontology—salvaging old age in modern society. Fighting ‘‘senility’’ was the central goal of the first generation of professional gerontologists. This chapter describes the psychodynamic model of senile dementia constructed by psychiatrists in the United States. By exploring its connections to gerontology, I argue that mid-century U.S. psychiatry’s interest in senile dementia should be understood as a crucial part of the broad cultural transformation of old age, without which AD could not have emerged as a major public issue in the 1970s. Thus, this ‘‘dark age’’ in the conceptual history of AD had important connections and continuities with the ‘‘renaissance’’ that would follow. [44.213.80.174] Project MUSE (2024-03-19 06:56 GMT) Beyond the Characteristic Plaques and Tangles 85 PSYCHIATRY, THE AGED PATIENT, AND THE CRISIS OF THE STATE MENTAL HOSPITALS The surge in interest in senile dementia can only be understood in the context of American psychiatry’s ambiguous attitude toward aged patients, who were becoming a disproportionately large part of the patient population of the state mental hospitals throughout the first half of the twentieth century. Because psychiatry regarded the aged insane as incurable, their presence in large numbers undermined the therapeutic environment that the state hospitals were supposed to provide. Because the overall population was aging, the problem was regarded by many as an impending crisis—a demographic avalanche that would bury the state hospital as a viable institution and...