What’s in a name: Senility, Dementia, or Neurocognitive Disorder – and Does it Matter?

It used to be called “senility” – which, according to the online etymology dictionary, comes from the French,  sénile, or “suited to old age,” from Latin senilis “of old age,” etc. Senility, or what we now generally call dementia, was initially considered to be simply part and parcel with the aging process. We no longer recognize that to be the case (as memory and cognitive loss is *not* a normal part of aging!), and generally the term “senility” has gone out of fashion to being outright discouraged (see here, and here), due to its ageist connotations.

Now, of course, even the term “dementia” is going out of fashion with the advent of the DSM-V (which I touched on previously in my last post)… and the preferred term is “major neurocognitive disorder” or MNCD. A couple of things to remember here – since we’re talking about etymologies (that is, the origin of words), the origin of the word “dementia” may even be a bit harsh as well, from the perspective of those who carry the diagnosis – according to the same etymology dictionary “dementia” originates from the latin term demens –  literally “mad, raving.”.

Around the time when psychiatrists were regularly referred to as “alienists” and Kraepelinian classification schemes for psychiatric disorders were all the rage (e.g., the early 1900s or so), schizophrenia was referred to as dementia praecox, as in “precocious” or “premature” dementia. While Emil Kraepelin, the physician who coined this term, didn’t actually intend to equate what we now call schizophrenia with the progressive cognitive decline noted in dementia and commonly seen in older adults, unfortunately – that’s what I think happened. Up until recently, Alzheimer’s disease (one of the most common forms of dementia) was commonly treated by relying on involuntary hospitalization in psychiatric institutions, and using physical and chemical restraints. In other words, dementia was considered (and maybe still is considered, see here) simply another form of chronic, incurable madness, as opposed to a neurological illness such as a stroke, or Parkinsons Disease. While dementia praecox is a term that is out of vogue now (replaced by the term “schizophrenia”), the use of the term “dementia” (for things like Alzheimers) persists, and perhaps with all the baggage of the madhouses and sanitariums of yesteryear carried along with it. This may be why the American Psychiatric Association (or “the big APA” as we psychologists call it) decided to push for a major semantic shift in referring to “dementia” instead as “neurocognitive disorder.”

Much like the science of psychology has for a long time suffered from what is often called “physics envy” (e.g., the idea that we should model psychological science on the precise methodology and measurement tools found in the science of physics), psychiatry has suffered from similar issues with “neurology envy.” While others more kind to psychiatry refer to it as being an ‘overlapping’ discipline, psychiatry has basically since its inception struggled to justify its standalone scientific basis, it’s raison d’être. It suffers from a very difficult, almost epistemological problem – if mental disorders are “disorders of the brain” (as the National Institutes of Mental Health, or NIMH, loves to regularly point out) – then why aren’t they the purview of neurologists? Often the rejoinder here is, “well, psychiatrists treat neurological disease when the cause isn’t completely understood.” If we don’t know that mental disorder is actually caused by discrete neurological illness, then why do we treat it as if it’s a disease at all? I should note that while I’m asking tough questions of institutional psychiatry – I say all of this as a practitioner, of course, who relies frequently and gratefully on the assistance of psychiatrists when I work with patients.

Enough of my neo-Szaszian digression.  The basic point is that clearly, Alzheimers Disease and the other so-called senile dementias (that is, dementias common to older adults) are in fact diseases of the brain, and we know this because we have increasingly reliable and valid histopathologic methods for identifying the sufferers (definitively via post-mortem as well as increasingly via the use of live biomarkers) and the disease has characteristic symptoms that professionals like me can readily and reliably identify. Will this gradual jettisoning of the term “dementia” be effective or useful in affecting de-stigmatization? Notably, the DSM-V does not proscribe providers from using the term “dementia,” they just suggest the new term, which I think they prefer because it sounds, well, more neurological.

But now I’ll turn the tables a bit – let’s go back to “dementia syndrome of depression” which I wrote about several months ago (and turns out to be one of my most popular posts!) remember that technically speaking, an older adult can be suffering from a (reversible) dementia caused entirely by the condition of being depressed, what they used to call “pseudo-dementia” or “pseudo-senility.” Does it change things to refer to a depressed older adult who may have problems with memory and concentration due to their depression as having a “neurocognitive disorder”? Is it less of a stigma to be referred to as having a dementia (that you’re ‘out of your mind’) or having a neurocognitive disorder (implying that you have a clearly, structurally sick brain – even if all you are is clinically depressed and in need of psychotherapy)? I honestly don’t have any idea – it’s worth noting that at one time, it was thought to be less stigmatizing to use the term “dementia” rather than “senility.” Two steps forward, one step backwards?  

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