Pills for Cheap

It may be wise to comment briefly on the analytic attitude toward homosexuality. It should be remembered that Freud was the first to approach homosexuality without condemning it and to see it as a form of psychopathology, which required understanding and treatment rather than condemnation. Perhaps the best expression of this attitude, which has been and continues to be the basic attitude of psychoanalysts, is contained in a letter which Freud wrote in 1935 to a desperate mother who wrote to him from America requesting help for her homosexual son

April 9, 1935

Dear Mrs. . . .

I gather from your letter that your son is a homosexual. I am most impressed by the fact that you do not mention this term yourself in your information about him. May I question you, why avoid it? Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual function produced by a certain arrest of sexual development. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest among them (Plato, Michelangelo, Leonardo da Vinci, etc.). It is a great injustice to persecute homosexuality as a crime, and cruelty too. If you do not believe me, read the books of Havelock Ellis.

By asking me if I can help, you mean, I suppose, if I can abolish homosexuality and make normal heterosexuality take its place. The answer is, in a general way, we cannot promise to achieve it. In a certain number of cases we succeed in developing the blighted germs of heterosexual tendencies which are present in every homosexual, in the majority of cases it is no more possible. It is a question of the quality and the age of the individual. The result of treatment cannot be predicted.

What analysis can do for your son runs in a different line? If he is unhappy, neurotic, torn by conflicts, inhibited in his social life, analysis may bring him harmony, peace of mind, full efficiency, whether he remains a homosexual or gets changed. . . .

Sincerely yours with kind wishes,

Freud.

In more current times psychoanalysts and psychoanalysis have been attacked on more or less political grounds, as adopting a prejudicial attitude toward homosexuals because analysis deals with homosexuality as a form of pathology. It should be clear from the preceding discussion and particularly from Freud’s letter that there is no necessary connection between the persecutory or judgmental treatment of homosexuality and the more objective and scientific position that it is a form of psychopathology. Psychoanalysis has solid reason based on clinical experience gathered over many years, to sustain its position and its understanding of the homosexual dynamic. To deal with human psychopathology as pathology, in relation to homosexuality as in relation to all forms of human suffering associated with psychopathology, is neither unfeeling, rejecting, nor judgmental.

I would argue in fact that just the opposite is true: to respond to human distress in terms other than to see it as human psychopathology which can be treated, modified, or alleviated in some degree or manner, is to be less than human and in fact is to condemn such individuals to a lifetime of frustration and unhappiness. The psychoanalytic attitude condemns all prejudicial treatment of homosexuals, but that is not its concern or its business. Its concern is to help to alleviate neurotic suffering and the impediments to self-fulfillment and self-realization. To deny individuals that form of assistance, as is so often the outcome of attempts to deny the pathology of homosexuality, a posture too often adopted by homosexual advocates without sufficient sensitivity or discrimination, is itself a form of cruelty and lack of sensitivity.

It may be appropriate to interject a comment on the current status of the diagnosis of homosexuality according to the Diagnostic and Statistical Manual II. First of all, one would have to decry the method by which the revision was made. To my way of thinking it was a crass example of yielding to political and social pressures in a process of bending scientific statement to expediency. The ultimate step of putting the decision to a vote makes a travesty of any scientific pretext in the formal diagnostic categories of institutional psychiatry. If any demonstration were needed of the unscientific status of psychiatry (even, or should I say especially, at the highest levels of organized psychiatry in this country), little else would be required.

The tragedy of that revision is that it takes homosexuality out of the realm of pathological diagnoses and undermines a long-standing and clinically sound view that homosexual behavior can be regarded as significant symptomatology. Moreover, it does not seem farfetched to argue that it substantiates the view of the most outspoken, and often most disturbed and resistant to treatment, homosexuals and provides a rationalization for avoiding treatment. I have argued here that psychoanalysis is not a specific treatment for such disorders, but I would never infer that homosexuality and other sexual disorders are not diagnosable and treatable disorders. The confusion of legitimate diagnoses with political or prejudicial positions is to my mind unfortunate and unscientific.

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Gender identity/role disorders occur most frequently in people with normal external and internal reproductive anatomy. Sexual pathways of the central nervous system (CNS) do not show gross morphological changes to which gender identity/role disorders might be attributed. This is not surprising, since one would expect CNS functions mediating such disorders to be related to the dynamics of neurochemistry, specifically of neurotransmitters, and thresholds of arousal and inhibition in neuro-sexual pathways. Identification and measurement of these functions is not technically possible at the present time.

Some clinicians use the term disorder in connection with gender identity/role, to refer only to male-female transpositions. Sometimes known as gender dysphorias, these transpositions contain the syndromes of transsexualism and transvestism. They also may include homosexualism and bisexualism, though neither of these need be considered pathologies or disorders (see below).

Other clinicians include in the category of disordered gender identity /role all the paraphilias. Paraphilia refers to a condition in which sexual arousal and performance is dependent on highly specific imagery, perceived or remembered, other than imagery of the erotic partner. A paraphilia may be benign or noxious. The imagery of a paraphilia, as in fetishism, for example, may be in the nature of an imagistic intrusion, to be associated with the erotic image of the partner, or it may be rather a displacement or substitute for the erotic image of a partner, in whole or in part. A paraphilia can be regarded as a part of gender identity/ role in that it is essential to the person’s masculine or feminine erotic functioning. Thus for the male sadist, his masculine gender identity/role in its erotic manifestation is dependent on remembered or enacted sadistic imagery.

The list of the paraphilias is long. It includes, for example, masochism and sadism, rape and lust murder, voyeurism and exhibitionism, pedophilia and gerontophilia, amputeephilia (apotemnophilia), zoophilia, klismaphilia, coprophilia, urophilia, necrophilia, fetishism, and so on.

The transposition syndromes generally are classified along with the intrusion or displacement syndromes as paraphilias. There is not total professional consensus, however, especially in those cases of homosexualism (and by extension, bisexualism) in which the perceived or remembered imagery of erotic arousal and performance is concordant with the body and the person of the same-sexed, pair-bonded partner, the latter itself being the only unorthodoxy. Transvestism, because of its associated fetishistic dependency on clothing, qualifies as a paraphilia. So also does transexualism, for the transsexual person can function erotically only by reason of having or imagining having a body reassigned and transformed from that of the sex of birth.

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Self-assertion of women and their distinct gains in economic, political, and cultural life combined with sexual freedom have undermined the foundations of the traditional marriage and family. A great many people experiment with various forms of male-female coexistence ranging from permanent singlehood to various forms of cohabitation, trial marriage, and group marriage.

It is impossible at the present time to predict the future of male-female relationships. One thing is obvious: the traditional subjugation women in marriage which so closely resemble colonialism is dead. One may project a type of relationship based on a reevaluation of the distinct roles of males and females. Most probably the differences between men and women in economic, political, and cultural life will disappear as women enter all areas of life hitherto monopolized by men. With the growing self-respect and mutual respect of men and women the one-to-one relationship may prevail, for r man and no woman would accept a subservient role. This new type of relationship based î equal rights and equal expectations will resemble an alliance of two independent countries. Each country is free to lead its own life and follow its own interests, but at the same time each pledges full support to the well-being of its ally. Instead of the old contest of power within the colonial government that tries to exploit the colony, and the efforts of the colonic people to rebel against or to outsmart their rulers, a new relationship may evolve based on genuine friendship and cooperation.

The women’s movement against discrimination must encompass all aspects of life, such as the upbringing of children, equal opportunities in education, and equal rights in sexual life. So far only men have enjoyed sexual freedom be cause, biologically speaking, men are in a privileged position. When a man and a woman have sexual relations, only one of them can become pregnant. The pill must be regarded, therefore as a major step toward equal rights for all human beings paving the road toward a new era in human relations between men and women. If one of them transgresses these rights, this entitles the other person to transgress them, too. Usually, when people have a strong affection and respect for each other, they prefer to stay away from other involvements, and they keep their relationship clean and honest. Honesty is a two-way street and must be binding on both sides. The double standard is a remnant of the past era when women were enslaved to men. The new era of equal rights for both sexes must be based on genuine equal rights and equal respect for each other.

One need not, however, be naive and expect an era of perfect love and ideal relationships. Human beings compete with one another, and they often are involved in contests of power. This contest of power among various groups frequently includes the male-female relationship. Cooperation and competition are fundamental aspects of social life, and it would be impossible to exclude the male-female relationship from all other social patterns of interaction. But competition and cooperation are not discrimination.

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The processes of identification during childhood have become the most important element in the formation of personality. Because the central issue in the struggle for identification is sexuality and the loss of the love object, the psychoanalytic theory of personality formation is tied closely to psychosexual development.

Bronfenbrenner’s of the concept of identification showed that identification is a condensation of at least three components. First is behavior, especially observable behavior, as a means by which the child can relate to the person with whom he or she identifies by emulating that person’s behavior. Second is motivation, Freud considered the motive for identification to be defensive, an attempt by the child to deal with the loss of the love object, through incorporation, introjection, and identification. In other words, he or she comes to possess the love object internally. Kohlberg’s and Kagan’s views stress even more the child’s wish to be similar or to possess the person to whom he or she feels deeply attached. Recent developments in psychoanalytic ego-psychology also emphasize the conflict-free aspects of identification, especially the role of object relationships in this respect. The third component of identification is the process involved. As we have mentioned, the process is a shift of cathexis by which the child gives up his or her tie with an infantile love object, either early in life through anaclitic (primary) identification, or later during the Oedipal struggle in response to castration anxiety and guilt for hostile fantasies about the ambivalently regarded parent.

Another major theory of behavioral differences among sexes is the social learning theory, which relies not upon identification but upon the imitation concept. Using imitation as a prototype of social learning, this theory does not single out sex-type behavior and sexuality as central. To social learning theorists, the same principle governs all social learning, regardless of sex. In fact, childhood sexuality is not considered at all, and sex-typed behavior is not examined as related to sexuality but more as a prototype of certain social conduct. In the works of social learning theorists, there are very few references to such behavior among children as masturbation, inquiries about sexual functions or portrayals of various erotic relations between parents (Issacs, Malinowski).

Despite the major controversies among investigators over identification versus imitation, there seem to be many similarities between the two concepts. Often, the opponents seem merely to be describing the same concept in different terms (Bandura and Walters), referring to the child’s development of attitude, behavior, and emotional patterns as similar to those of significant people in his or her life.

Most social learning investigators today emphasize the importance of observation and information processes to social learning based on imitation, as compared with an earlier emphasis on reward and punishment. According to the former view, the child becomes aware of sex differences in personality around four to five years of age and begins to emulate one parent in particular because of the power attributed to that parent (Kohlberg). Recently, however, many social theorists have been able to bridge the gap between the psychoanalytic concept of identification and the social learning concept of imitation as based on the model’s power and status. Whiting, in anthropological studies of six cultures, explained sexual identification not solely as an outcome of the Oedipal struggle but also as a part of the cultural context, in which the child envies the status of the more influential and powerful parent and thus is apt to identify with that parent. For example, in cultures in which the father is frequently absent and the mother sleeps with the child, the predominant identification in boys is feminine, because of the mother’s presence and the control she exercises over him.

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Taboos against intercourse with a pregnant woman are very common in undeveloped countries and have been observed historically as a religious rule among some people. A study of sexual behavior in sixty preliterate societies found that twenty-one of them forbade sexual intercourse during most or all of the pregnancy (Ford & Beach). Among a Ghana group, the Ashanti, the taboo begins with the discovery of the pregnancy, and husbands, tiring of abstinence, often take another wife (Saucier).

In our society the continuation of sexual activity by pregnant women is not only common practice but is generally sanctioned by physicians. For example, a study of sexual attitudes and behavior in pregnancy (Tolor and DiGrazia) noted that the subjects’ physicians placed no restrictions whatever on their sexual activity from conception to delivery, unless complications such as bleeding, occurred. After delivery the women were advised to refrain from intercourse for four weeks and then to let their own preferences and comfort be their guide.

A study of 101 women revealed an increase in sexual tension and performance during the second trimester, attributed by the authors to the increased pelvic vascularity associated with pregnancy (Masters and Johnson). But other studies are in general agreement that sexual interest and activity fall off during pregnancy, especially during the last trimester. An example is a study (Tolor and DiGrazia) of a sample of 216 women who were patients of a group of obstetricians. The women comprised four groups: first trimester, second trimester, third trimester, and six weeks postpartum. The median frequency of sexual intercourse for all groups combined was 2.10 per week. Separately, the median reported frequencies for the first, second, and third trimesters and for the postpartum period were 2.25, 2.39, 1.08, and 2.65, respectively. Except for the third trimester group, about two-thirds of each group expressed satisfaction with the frequency of intercourse they were having. The third trimester group, however, had the strongest preference for less intercourse than they were having.

In a study of a large sample of Thai women, Morris, reporting similar findings of marked decline in frequency of intercourse with advancing pregnancy, suggested that the cross-cultural consistency of this phenomenon raises the question of a biological reason. This would be difficult to test because of cultural norms, perhaps medical advice, and psychological factors which no doubt also play a part in such behavior.

Coital techniques and positions also are affected by the course of pregnancy. The preferred sexual practice for the first trimester women in the Tolor and DiGrazia study was vaginal stimulation, whereas the later pregnancy groups preferred breast and clitoral manipulation. These women also reported a very strong need for physical contact, for wanting to be held. Given a choice of alternatives when they did not wish to have intercourse, most of them wanted just to be held. As for positions in coitus, Solberg and others found that side-by-side or rear entry became the preferred modes as pregnancy advanced.

Women who reported a change in their sexual behavior during pregnancy gave these reasons: physical discomfort, 46%; fear of injury to the baby, 27%; and loss of interest, 23%. Less frequently reported reasons included awkwardness and loss of attractiveness (Solberg and others). Of the 260 women in this study, 29% were instructed by their physicians to abstain from coitus from two to eight weeks before the delivery date. Ten percent were advised about positions that might be more comfortable than the male superior position, and only two percent received suggestions about sexual activities that could be substituted for coitus (hand stimulation for both partners in all cases). This finding suggests a notable paucity of discussion between doctor and patient of sexuality in pregnancy.

The resumption of coitus after the woman has given birth follows no particular pattern, and its regulation and prescription vary widely from culture to culture. Ford and Beach reported postpartum taboos in sixty-six societies ranging in length of time from a few weeks to the end of lactation, sometimes three years. When there are no religious or cultural taboos against postpartum intercourse, abstention may be practiced for a few weeks for a variety of reasons relating to the woman’s health and comfort (Saucier). Four out of six women in one study (Masters and Johnson) experienced erotic arousal four to five weeks after delivery, but their physiological responses— vasocongestion of the labia, lubrication, and orgasmic contractions—were reduced in degree and intensity. About half of this large sample reported a low level of sexual response; their reasons included fatigue, fear, pain, and vaginal discharge. By three months, however, most of the women had returned to their pre-pregnancy level of activity.

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Although the time will come in the course of most forms of dementia when sufferers will become less involved with their environment and those around them because of apathy, loss of concentration, and so on, it is best to make the most of what they can achieve while this is still possible. Life will then become fuller not just for the sufferer, but also for those who are involved in caring. This chapter describes some simple activities that may be possible in the early and mid stages of the disease. Rather than trying to keep a person with dementia active all day long, it is probably better to break up the day by organizing several short periods of activity at convenient times. In the earlier stages of the disease it may be helpful to concentrate upon those that will result in the sufferer enjoying a feeling of achievement and of having been useful.

Other important areas that relate to the preservation of independence are the need to stop driving, to give up work, to give up living alone, and often to move house. These will all be discussed in turn.

It is not usually possible for people with dementia to learn new skills so it is best to base activities, whether recreational or otherwise, on skills that have already been obtained in earlier life, taking advantage of them until they fade from the memory store. Activities that involve relationships with other people and pets are often among the most meaningful for a person with a declining intellect. It is also important to remember the need for physical exercise.

This chapter will only be able to provide ideas, as with so many of the other chapters in this book. Trial and error alone will show what is best for an individual and his or her pattern of activity should not be expected to remain unchanged as the months pass.

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As a dementing illness progresses, relatives and, to a lesser extent, friends have to come to terms with the loss of someone they love. Although this process is a slow one, starting with the realization that the sufferer is not the person he or she used to be, and progressing to a loss of companionship and a hundred and one other losses, it is very much akin to the grief and bereavement experienced after someone has died. Although the body is physically still present, the personality goes. This is particularly painful when the sufferer is unable to communicate with, understand, or recognize you. This sense of loss is very difficult to cope with sometimes, and the long-drawn-out grieving process may affect the pattern of bereavement when the sufferer eventually dies. Just as you come to terms with the situation, your relative may deteriorate in another way and you have to adjust all over again.

With a progressive illness like dementia, the grief can get worse as time goes on and very often death is a merciful release from this type of emotional turmoil, just as it is from the physical burdens and the distressful existence of the sufferer. Many people won’t understand what you are going through. We can all relate to the recently bereaved, but this is a situation that is only really understood by others who have experienced it, either first hand or by working closely with those in your position. As for so many of the emotional problems that arise when caring for a person with dementia, the main anchor in coping with the living bereavement process can only be a sharing of the experience with others. There is little to be gained from keeping a stiff upper lip and maintaining a facade of emotional independence.

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A young person with suspected dementia will probably first be referred to a neurologist. This is a doctor who has been specially trained in the diagnosis and treatment of disorders of the nervous system, including the brain. Neurologists ensure that a thorough physical examination is undertaken, having carefully inquired into the history of the illness, and will arrange appropriate tests, including blood tests and special X-rays. However, after making a diagnosis, many will not be in a position to offer any regular help and will refer the continuing management of the patient back to the general practitioner.

An older person with dementia is more likely to be referred to a geriatrician or a psychiatrist with a special interest in the elderly, sometimes called a psychogeriatrician. Geriatricians are trained in all the disorders that are found more commonly in older people. They will perform a very similar assessment to that provided by the neurologist for younger people, but will also have access to many of the health service resources that are essential for the continuing care and support for people with dementia, and for their relatives and carers.

As well as hospital beds to provide intermittent relief or holiday admissions the geriatric department usually has a day hospital. This is not necessarily a facility for providing relief for families, but an environment in which further careful assessment can be undertaken. In most cases there has to be a ‘therapeutic’ need for a person to attend a day hospital. Day relief is provided elsewhere, for example at day centres run by the statutory and voluntary services.

Although there are no strict rules, elderly people with dementia who require screening are generally referred first to a geriatrician, but after this the care for those who are mobile as well as demented usually falls to the psychogeriatrician. There are good practical reasons for this; for instance, psychiatric day hospitals are more secure and a wandering demented person is less likely to escape and come to harm. On the other hand a demented person who is heavily dependent on physical nursing will more usually need the help of the geriatric service. There are of course many exceptions to this generalization.

Very often psychogeriatricians will visit patients in their own home, and take the opportunity to familiarize themselves with the problems that relatives and other carers are having to manage. In this way they can judge how best the resources that they have available can help. It also allows those looking after a person with dementia to demonstrate the difficulties they are facing and being able to talk about the problem in their home environment is often easier than trying to describe the situation in a busy out-patient clinic.

Once the matters of diagnosis and assessment have been completed, the specialist will plan the future with the family, the general practitioner, and often other members of his team. It is important that everybody knows about this ‘package’ so that they can see the way ahead. One must also remember that the package has to be regarded flexibly and its provisions may need to be changed as the situation alters.

In some parts of the country there are specialist clinics for people with dementia where a person with dementia isn’t just seen in a slot between people with other conditions, but is assessed in an environment in which all patients have similar problems and all staff are specially trained in this area of medicine. The pattern in different memory clinics varies, but in some every patient is seen by a geriatrician, a psychiatrist, and a psychologist, and great attention is paid to the problems and needs of the carers. (A psychiatrist is a doctor trained in the problems of mental illness; a psychologist, although not medically qualified, is trained in the skills of behaviour assessment, behaviour treatment, and other related activities; he is also able to give valuable advice.) A full appraisal of the medical problems is made, a diagnosis of the underlying disorder is established, and treatment is prescribed for the fortunate few with a treatable underlying condition. The way ahead is mapped out and the patients and their families seen regularly two or three times a year. The day to day management of patients’ care is returned to the general practitioner or to the local specialist if they have been referred from another area of the country. The clinic may also have a support group attached to it for the families of people with dementia who live in the district. The number of clinics like this is increasing and, if one is available locally, your general practitioner will probably seek from it a second opinion. One of the major strengths of such clinics is that they often have a representative of both the geriatric and the psychogeriatric services, allowing closer collaboration between the two in dealing with the needs of a particular person.

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Multiple infarcts – a series of strokes – are the second most common cause of dementia. Typically a stroke causes paralysis of the limbs and the face on one side of the body, but there are many areas of the brain where a stroke can affect the intellect without leaving any tell-tale outward signs in the rest of the body. In some cases, however, there is a mixture resulting in both physical abnormalities and intellectual difficulties. Occasionally a single large stroke can also cause dementia, but this is less common.

As dementia caused by strokes is a common affliction, and because its progress can sometimes be halted or slowed down, it deserves a chapter of its own. It is a condition that we should all be aware of and on the look-out for.

Although he is usually associated with the condition that now bears his name, Alois Alzheimer also worked in this field. He published a short report while working in an asylum in Frankfurt describing arteriosclerotic changes in the brain which he identified as usually occurring in late middle age. The symptoms and signs that he recorded in his patients are very similar to the picture that we see nowadays although many people with multiple infarct dementia are into their seventies and eighties.

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The pattern of the symptoms and physical changes in most of the illnesses that cause dementia allows one to divide the progress of the disease into roughly three phases. These are by no means exact and they vary from individual to individual with the same condition, and from disease to disease. Nevertheless they give us a useful rule of thumb and allow us to decide whether a person with dementia is in the early, mid, or late stages of the disease. Each of these phases has a particular message and often these messages are not appreciated by those working in the medical and paramedical professions and the social services.

In the earliest phase of a dementing illness it is essential to ensure that the sufferer is properly investigated for treatable underlying conditions, as already emphasized, having first ascertained that the problems are really caused by dementia and not just by a worse than average memory loss. It is this phase that is often incorrectly accepted by many relatives, friends, and others as normal ageing and what one expects of somebody in their late seventies or early eighties. At this stage the dementia is usually causing significant memory loss, perhaps some disorientation in time, and a tendency to get lost in familiar places. Sufferers may be depressed because of the loss of intellect that they perceive in themselves or they may become irritable as a result of their forgetfulness. Misplaced objects are often considered to have been stolen by others and some difficulty with speech may occur.

The next or middle phase is marked by a deterioration in ability that makes it clear to everybody that something is wrong and that it is no longer a question, even stretching the imagination considerably, that normal ageing is still the problem. This is when significant difficulty in day to day living presents itself. In this stage of the disease people with dementia may be completely unable to cook for themselves, shop, clean the house, or generally look after themselves. Speech becomes even more difficult, and wandering and similar behaviour abnormalities a major problem. This is a stage at which in many cases it becomes apparent to relatives that the individual concerned no longer has the personality they loved, though that person is nevertheless present in a physical sense. This can induce a sense of ‘living bereavement’ which may take years to come to terms with.

In most medical conditions one expects the need for support and involvement of professional people to be greatest towards the end of the disease. It is not so with many of the conditions that cause dementia. It is now, in the middle stages of the disease, that the carers need the greatest amount of support, as it is at this stage that they have the most difficult problems to contend with, both those presented by the sufferer and also those that they themselves begin to experience at an emotional and personal level. These are addressed in later chapters. It is particularly important for doctors especially to be aware of this variation on the normal disease pattern.

The third and final phase that occurs in many cases is one of total dependence, sometimes associated with almost complete inactivity, whether the person who is suffering from dementia is confined to his or her bed or a combination of bed and chair. In many ways this period is met with some feeling of relief by carers. There is no longer the risk of an explosion or a fire from an incorrectly used gas stove, nor the possibility of an accident caused by a tendency to wander out into the road or by falling down stairs. The physical side of the illness becomes more apparent and it is easier for most people to relate to this. In many instances they have looked after a physically dependent person, such as a young child, in the past and caring for a person with dementia in this final phase is in many ways similar to looking after a child. The sad thing of course is that in the case of a child one anticipates that the problem will diminish as the child grows older, whereas in the case of someone with dementia, it is going to get worse.

This account is probably one of the gloomier parts of this book. It has, however, been written for very positive reasons. Uncertainty about the future is one of the major problems with which those caring for people with dementia have to contend. Many of those involved in a professional capacity in providing advice and support are loath to explain about the future, often because they themselves find it too difficult to give relatives and other carers a full picture of what lies ahead of them. However, with the increasing acceptance of psychiatric illness as a physical problem like the malfunction of any other organ in the body, disorders of the brain, particularly the dementias, are increasingly discussed in the popular media and in casual conversation. Piecemeal and anecdotal accounts are often more frightening than having the matter carefully explained in the context of the help and support available. It is impossible to come to terms with and plan for the future if one doesn’t know what the future holds. Unhappy though the picture is, it will be seen as the reader progresses that there is an enormous amount of support available, and also a lot that an individual carer can do to help him- or herself to cope with the stresses and strains that will arise, and at the same time to help the person suffering from dementia to have as pleasant and full a life as is possible.

Many people caring for someone suffering from dementia want to know how long the disease will take to run its course. This is a difficult question to answer and it is almost impossible to fix a definite span to each of the three stages described. In most cases, however, the disease processes will run their course over a period of about five to seven years. Since it is often not appreciated that elderly people have a dementing illness when the disease is in its earliest stages, they may already be one or two years into the progression of their illness before the diagnosis is made. This means of course that the disease will appear to last for a shorter period.

In younger people, especially those under sixty, the disease often runs a more rapid course and may be two or three years less in duration. Even so, the disease may appear to last longer as it is often less likely that in younger people the early stages will be mistaken for anything other than something abnormal, whereas if the same symptoms had become apparent twenty years later, they might well have been mistaken for the changes of normal ageing.

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