Mohammed T. Abou-Saleh

540 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYsuch as physical assault. Symptoms may occur early and continuefor decades. In many cases, symptoms may not even be manifestuntil many years after the traumatic event. Often, the symptomsof delayed PTSD are precipitated by a psychologically reminiscentcontemporary event; a concentration camp survivor may notexperience stress-related symptoms overtly until becomingwidowed and being institutionalized half a century later 14,15 .SUMMARYThe current classification of neurotic disorders is the most recentstep in the evolution of the nosological understanding of a diversegroup of syndromes. The ICD-10 grouping represents a compromisebetween the phenomenological grouping of neuroticconditions on a scale of severity between healthy and psychoticfunction, and the etiological clustering of disorders presumed toarise from internal conflicts and vulnerabilities to externalstressors. The ambiguities inherent in this system reflect theincomplete state of knowledge about the etiologies of theconstituent conditions. The North American schema of DSM-IV sets aside questions of etiology, except in the case ofadjustment disorders, and relies on ostensibly atheoreticalphenomenological criteria.Although the diagnostic criteria are technically independent ofthe age of the patient in both systems, aging affects thepresentation of many of these disorders and makes clinicaldiagnosis challenging. The multiple biological and social stressorsof late life blur the distinction between ‘‘normal’’ and ‘‘pathological’’responses to these threats. Physical illnesses, which increasein frequency with aging, may produce clinical symptoms easilymistaken for neurotic anxiety. The prevalence of somaticpathology forces subjective judgments about the presence ofsomatoform and conversion disorders. Chronic and delayed stressreactions are clinically distinct from the acute forms seen inyounger individuals.The lack of clarity in the classification of these disorders,however, is probably less a manifestation of the shortcomings ofthe nosological systems than a reflection of the complicatedfunction of the human mind. The neurotic disorders, as well ascurrent science can determine, are a product not of brain diseasebut of human response to a complicated and stressful world.Simplicity in their nosology would belie the challenges they poseto patients and clinicians.REFERENCES1. Gray M. Neuroses: A Comprehensive and Critical Review. New York:Van Nostrand Reinhold, 1978: 1–32.2. Brenner C. An Elementary Textbook of Psychoanalysis. Garden City:Doubleday, 1973: 171–92.3. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders (DSM-I). Washington, DC: AmericanPsychiatric Association, 1952.4. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 2nd edn (DSM-II). Washington, DC: AmericanPsychiatric Association, 1968.5. World Health Organization. Manual of the International StatisticalClassification of Diseases, Injuries, and Causes of Death, 9th revision.Geneva: WHO, 1977.6. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 3rd edn (DSM-III). Washington, DC: AmericanPsychiatric Association, 1980.7. Spitzer RL. Introduction. In Diagnostic and Statistical Manual ofMental Disorders, 3rd edn (DSM-III). Washington, DC: AmericanPsychiatric Association, 1980: 1–12.8. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 3rd edn, revised (DSM-III-R). Washington, DC:American Psychiatric Association, 1987.9. American Psychiatric Association. Diagnostic and Statistical Manualof Mental Disorders, 4th edn (DSM-IV). Washington, DC: AmericanPsychiatric Association, 1994.10. Sartorius N. International perspectives of psychiatric classification.Br J Psychiat 1988; 152(1): 9–14.11. World Health Organization. Tenth Revision of the InternationalClassification of Diseases, Chapter V (F): Mental and BehaviouralDisorders (Draft, revision 4). Geneva: WHO, 1987.12. Freeman CP. In Kendell RE, Zeally AK eds, Neurotic Disorders inCompanion to Psychiatric Studies, 4th edn. Edinburgh: ChurchillLivingstone, 1988: 374–406.13. Cooper JE. The structure and presentation of contemporarypsychiatric classifications with special reference to ICD-9 and -10.Br J Psychiat 1988; 152(1): 21–8.14. Ruskin PE. In Bienenfeld D, ed., Anxiety and Somatoform Disordersin Verwoerdt’s Clinical Geropsychiatry, 3rd edn. Baltimore, MD:Williams and Wilkins, 1990: 137–50.15. Flint AJ. Management of anxiety in late life. J Geriat Psychiat Neurol1998; 11(4): 194–200.16. Small GW. Recognizing and treating anxiety in the elderly. J ClinPsychiat 1997; 58(suppl 3): 41–7.17. Fogel BS, Sadavoy J. In Sadavoy J, Lazarus LW, Jarvik LF,Grossberg GT, Somatoform and Personality Disorders inComprehensive Review of Geriatric Psychiatry, 2nd edn.Washington, DC: American Association for Geriatric Psychiatry,1996: 637–58.