Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-023Psychiatric Diagnosis and Old Age:New Perspectives for ‘‘DSM-IV-TR’’ and BeyondEric D. CaineUniversity of Rochester Medical Center, Rochester, NY, USAAging and old age confront the psychiatric clinician andnosologist with special diagnostic problems. Our present syndromologyhas arisen largely from studying disorders of young andmiddle-aged adults. It is being challenged now by the generalaging of the population in Western as well as many Easternsocieties.Aging reflects evolving biological, psychological, and socialprocesses. Fundamental alterations of central nervous systemfunctioning color the psychopathological and pathophysiologicalsignificance of specific symptoms, while the psychosocial meaningof discrete life events changes as one moves across the agespectrum. Old age brings an increase in confounding systemicmedical conditions. Thus, we are confronted with an array of yetto-be-answeredquestions. What is the relationship between thementally disordered who have grown old, and the old whodevelop mental disorders? Does later age of onset connote afundamentally different disease process, even when the presentingpsychopathology is generally similar? How do we separateidiopathic (called ‘‘primary’’ in DSM-IV) psychiatric syndromesfrom psychopathological conditions caused by defined diseaseprocesses? What must the diagnostician and treating clinician doto distinguish those psychopathological symptoms that areamenable to treatment from confounding medical symptomsthat reflect systemic illness?The development of the fourth edition of the AmericanPsychiatric Association’s Diagnostic and Statistical Manual(DSM-IV) provided an opportunity to begin considering suchissues more formally. These types of questions were almostneglected in previous editions of the DSM, in part due to a lack ofmeaningful research data, and no doubt reflecting a lack ofinterest among many American psychiatrists in treating geriatricpatients. However, the past 15–20 years have seen a surge ininterest in the USA in psychogeriatrics, as evidenced by enhancedclinical training and sharpened clinical identity. The developmentby the American Board of Psychiatry and Neurology of an‘‘added qualification’’ in geriatric psychiatry during the pastdecade crystallized this recognition.There were relatively few changes in DSM-III or DSM-III-Rthat pertained to elders. Dementia and delirium were definedmore precisely. The term ‘‘involutional’’ was dropped from theclassification, due to a paucity of data supporting the qualitativedistinctness of involutional melancholia. A criterion had beenadded in DSM-III to establish a maximum age of onset forschizophrenia at 45 years, but this was deleted in DSM-III-R asmore evidence was made available to American writers thatschizophrenia-like disorders emerge among older patients and arenot solely caused by primary cerebral diseases.Literature reviews and discussions that were part of thepreparation of DSM-IV revealed that there was a continuinglack of rigorous clinical descriptive research in many areas ofgeriatric psychiatry. There was a dearth of data regarding thenatural history of both late-onset disorders and early-onsetdisorders that persist or recur throughout the life course intoold age. It was also apparent that there were insufficientepidemiologic findings to fully define the prevalence or incidenceof many later life disorders. In the USA, this may have reflected,in part, an overly rigorous application of DSM-III criteria duringthe epidemiological catchment area (ECA) studies. Althoughthese were valuable for describing the psychopathology of someelderly patients, the stereotypic use of diagnostic descriptorsdeveloped for younger patients had the unintended effect ofexcluding possible subjects from each of the rubrics. This processwas compounded further by employing lay interviewers askinghighly structured questions. Many of the critiques regardingtraditional approaches to cross-cultural psychiatry (e.g. theproblem of ‘‘category fallacy’’ 1 ) are equally germane to studiesthat utilize criteria developed for one age cohort when characterizingthe psychopathology evidenced by another. As a result,many recommendations for DSM-IV regarding later life psychiatricdisorders were qualitative or impressionistic, more useful forspecifying directions for new research but insufficient forsubstantially revising many of the diagnoses to be included inthat new edition.DSM-IV AND BEYONDThe major innovation of DSM-III was the development of amultiaxial system that provided clinicians with a wider array ofdescriptive categories for more completely defining their patients’problems. However, there was little evidence in either DSM-III orDSM-III-R that indicated a thorough understanding of thecomplex multidimensional diagnostic problems posed by agingpatients. In contrast, DSM-IV began the process of addressingthis deficiency by including for many diagnoses a discussionlabeled, ‘‘Specific Culture, Age, and Gender Features’’ or‘‘Specific Age and Gender Features’’. This approach allowssome limited consideration of aging-related issues, but again, thesparse commentary in many of these sections also underscoreshow little is known about many related questions.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd