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Sid Williams 2016 Psychiatric Times May 10 2014 Konsul_777_999 9/7/13 Blind Men Appraising an Elephant by Ohara Donshu, Edo Period (early 19th century), Brooklyn Museum Dementia is a convenient shorthand often mistakenly thought to describe a syndrome Syndrome: A group of signs, symptoms and illness course that occur together and often characterise a disease or medical condition In the past DSM treated dementia as if it were a syndrome Dementia is not an animal (or a coherent thing) at all ‘But if thoughts corrupt language, language can also corrupt thought’ George Orwell, Politics and the English Language. Horizon, GB London, 1946 ‘What is Dementia’ ‘Dementia’ is a term used medically to describe a syndrome (set of symptoms) that is caused by many different diseases. …. An analogy is the term ‘cancer’ that is used to describe any malignant tumour but is not a specific disease” WRONG The reification of ‘dementia’ ‘Dementia’ has become a ‘thing’ separate from concepts of Alzheimer’s disease, and other brain pathologies ‘I know he had a stroke causing difficulties communicating and such but now does he have dementia?’ ‘A dementing process’ Démence (French) dementia (English) about 1806 – concept close to ‘madness’ Late 19th century link to physical disease of the brain became embedded in the term 1960-70s USA: ‘Organic Brain Syndrome’ Up to DSM-III-R (1987) general definition of dementia as if it were a syndrome or disorder DSM-IV (1994) moved away from general definition, although Criteria A and B for all forms of dementia were the same DSM-5 (2013) jettisoned Dementia Neurocognitive disorders DSM-5 introduces concept of Cognitive Domains Neurocognitive disorders defined by evidence of significant cognitive decline in one or more cognitive domains + other criteria (significant decline, not delirium, not other mental disorder) Williams, S. Your Brain in Sickness and in Health. In Press. Chiu (1994 & 2005) Sachdev (2000) Williams (2006) Chiu, E. 1994, "What's in a name - dementia or dysmentia?", International Journal of Geriatric Psychiatry, vol. 9, pp. 1-4. Sachdev, P. 2000, "Is it time to retire the term "dementia"?", Journal of Neuropsychiatry & Clinical Neurosciences.12(2):276-9. Chiu, E. 2005, "Limitations in the current classification systems for dementia.", International Psychogeriatrics.17 Suppl 1:S17-26. Problems Associated with the Term and Concept of Dementia, 6th International Congress of Neuropsychiatry, Sydney, 13/9/06 14 ‘stages’ of dementia deterioration memory loss is a key feature always progressive – ‘a dementing process’ cognitive impairment is the central feature and changes in social and emotional function are secondary changes in social and emotional function, delusions (confabulatory or otherwise), hallucinations are separate (‘psychiatric’) phenomena changes in motor function are separate phenomena that impairment is ‘global’ Many conditions where the old concept of dementia was not appropriate can now be included under neurocognitive disorders e.g.: Traumatic brain injury Alcohol Related Brain Damage Localised brain damage (e.g. infarcts) Huntington’s disease Not a return to reductionist localisationism e.g. Phrenology ‘Domains of function’ refers to particular areas of function (e.g. Learning and memory; Language) not necessarily corresponding to particular brain areas Complex attention (sustained attention, divided attention, selective attention, processing speed) Executive function (planning, decision making, working memory, responding to feedback/error correction, overriding habits/inhibition. Mental flexibility) Learning and memory (immediate memory, recent memory [including free recall, cued recall, and recognition memory], very long term memory [semantic; autobiographical], implicit learning. Language (expressive language [including naming, word finding, fluency, and grammar and syntax] and receptive language) Perceptual-motor (includes abilities subsumed under the terms visual perception, visuoconstructional, perceptual-motor, praxis, and gnosis) Social cognition (recognition of emotions, theory of mind) A. The criteria are met for major or mild neurocognitive dlsorder, B. The disturbance has insidious onset and gradual progression C. Either ( 1 ) or (2): 1. Behavioural variant: a. Three or more of the following behavioral symptoms: i. Behavioral disinhibition. ii. Apathy or inertia. ii. Loss of sympathy or empathy. iv. Perseverative, stereotyped or compulsive/ritualistic behavior. v. Hyperorality and dietary changes. b. Prominent decline in social cognition and/or executive abilities 2. Language variant: a. prominent decline in language ability, in the form of speech production, word finding. object naming, grammar, or word comprehension D. Relative sparing of learning and memory and perceptual-motor function. E. The disturbance is not better explained by cerebrovascular disease, another neurodegenerative disease. The effects of a substance, or another mental, neurological, or systemic disorder.