‘Beyond forgetfulness’: How psychoanalytic ideas can help us to understand the experience of patients with dementia

Abstract

We must cast ourselves forwards to a time when words must fail (Samuel Beckett, Happy days, 1961).

This paper approaches dementia and its care from a psychoanalytic perspective. It recognizes both the psychoanalytic literature on dementia and a biological understanding of neuro‐degenerative processes. Using neuro‐psychoanalysis to synthesize the two views, meeting points are found that may take the theoretical understanding of dementia processes a small step further, introducing the death instinct as one example. The mind and the brain are distinct entities which are also intimately related. A mind/brain model was proposed by Freud in his ‘project’ (1895). It pre‐dated his psychoanalytic work but was abandoned. None the less it runs as a rich vein throughout his work.

Although other causes exist there are two main types of dementia. Alzheimer's and vascular dementia have distinct differences and similarities in their respective clinical presentations. This paper explores the complex deterioration of brain and mind in both diseases and explains these in psychoanalytic terms. Developmental models of the mind are helpful, however dementia patients are adults, and are losing their minds in a non‐linear fashion. Dementia is not infant/child development in reverse order.

Three broad stages of dementia are proposed and psychoanalytic models of patient experience are suggested, as well as potentially offering ameliorating interventions. The first stage of dementia is dominated by anxiety and depression; also repression and denial and behavioural problems that may be akin to hysterical states. These seem to be amenable to analysis and psychoanalytically informed therapy. In the intermediate stages reality principle versus pleasure principle issues are patent, as are shame and humiliation (particularly around sexuality). Art and music therapies informed by psychoanalysis can be helpful as they depend less on words. In the final stages of extreme dependency, projective identification may be the most common method of communication. Understanding this phenomenon can assist sufferers and help carers to cope with unbearable states of mind. Some psychoanalytic ideas are already in use in some enlightened dementia services; there is room for more.

Acknowledgements

Grateful thanks to Michael Brearley, also to colleagues, friends and family for their forbearance and putting up with my distraction (most particularly Annie and Fred).