Susie Blackmun

Before Masters and Johnson came on the scene in the late 1950s, any sexual problem was thought to be the result of a deep-seated neurosis that needed to be unearthed. It is now recognized that an understanding of physiology and couples dynamics-along with a practical approach-are required interventions, said Harvard's Derek Polonsky, M.D.

The psychiatry instructor and lecturer has specialized in couples therapy and sexuality since the turbulent 1970s, when Beth Israel Hospital was a "hotbed of individually oriented psychoanalytic psychotherapy," he recalled. "That's how I got to see couples early on. After a while, they began to bring up issues of sexuality, which I must admit was a shock to me [at the time].

"The field of sexuality over the last 25 years has grown enormously to encompass a full range of disciplines: on the one hand, mental health professionals and on the other, gynecologists, urologists, internists and the lay profession," said Polonsky, author of 

He advises that before beginning couples sex treatment, therapists need to assess three factors. First, do either of the patients have medical conditions that play a role in the problem, such as arteriosclerosis, diabetes, thyroid problems, depression, alcoholism and the side effects from medications? Drugs used for high blood pressure are notorious for dampening sex drive, as are antidepressants, particularly selective serotonin reuptake inhibitors. Despite claims by pharmaceutical companies that only a minority of people experience significant sexual side effects from antidepressants, independent studies report high percentages of subjects who experience effects upon libido, arousal, ability to get or maintain an erection or capacity to have an orgasm.

Second, assess the intrapsychic components-such as issues of self-esteem, intimacy, assertion and conflict around competence or aggression-that each individual brings to a sexual situation. Third, because sexuality often is the stage upon which relationship issues get played out, assess what interpersonal components (the marital couple dynamic, the power play, what gets reenacted from the family of origin) are involved.

"Fifty percent of people deal just fine with the kinds of challenges involved in separating from families of origin, mastering the tasks of forming a close relationship with somebody outside the family and integrating that with sexual feelings in the context of the close relationship," said Polonsky. "But that leaves another 50% of the population who struggle with these [issues]."

Polonsky's treatment approach integrates couples therapy with sex therapy and is analogous to what a coach does. In other words, he identifies the strengths people bring to the relationship, figures out which activities need help and develops drills to help people with those areas.

During the initial meeting with a couple, he inquires about the nature of their sexual difficulty, a history of it over time and the evolution of their relationship. Next, he schedules individual meetings to learn about each person's family of origin "because that supplies the template for behavior and expectations that often get transposed into the marriage." At this time he also gets a more detailed sexual history. Then he brings the pair back and shares his ideas of what he thinks is going on.

He gives the couple an assignment, structuring what they do and reducing their sexual activities to the lowest common denominator by shifting the focus from performance to pleasure and playfulness. The following week's discussion centers around what happened.

Polonsky creates a safe climate for talking about issues of sexuality, providing a model for talking about sex, and using humor and a comfortable vocabulary to diminish anxiety. He educates his patients by providing information about physiology, myths and patterns of behavior.

"Couples therapy differs from traditional psychotherapy in that the therapist is more active," he said. "In addition, the transference occurs between the two partners rather than between patient and therapist."

While on the surface it would appear that as a culture we are more comfortable talking about sexuality, that is deceptive, Polonsky said. "We only have to look back at 1994 when Jocelyn Elders, the Surgeon General, was fired for daring to talk about masturbation, to realize that we still have a long way to go."

Learning to take the sexual history is hard for new therapists because they've had no models for being open and explicit. Most medical schools and training programs have either dropped the programs they had or ignore sexuality altogether.

"When I first started taking histories from my patients, I would choke on some of the words," he said. "At times I would be so hypertechnical using the anatomical jargon that I would be greeted by vacant stares from my patients. They didn't have a clue what I was talking about.

"There also was a cross-generational awkwardness. Many of my patients seemed to be in my parents' age group. To ask them about the details of their sexual relationship just seemed to be crossing a boundary...Now that I'm a parent of an adolescent kid, I'm aware of how parents are similarly uncomfortable about their children's sexuality."

There is no "right" way of getting the history, Polonsky said. Therapists have to experiment until they find a model that is down-to-earth and comfortable for them and their patients. Couples will follow along, in terms of tone and terminology.

He begins with the general ("Tell me about your relationship. Are you satisfied? Would you want anything to be different?") and works toward the specific. He asks couples about patterns of initiation, whether they enjoy fantasies, what kind of experimentation they're comfortable with, whether they read erotic material or watch pornographic movies, whether they are comfortable experimenting with sexual toys. He asks about their communication with each other: Do they talk about their likes and dislikes? Are they comfortable asking for things? Is there reciprocity?

Sometimes you have to be "stupid in listening," he said, and inquire about the fine points rather than make assumptions. Does "losing an erection," for example, refer to an erectile difficulty caused by anxiety? Or does someone really mean premature ejaculation?

These details about the sexual interaction give the therapist a portrait of the couple's relationship. "I don't believe one can do sex therapy in a vacuum," he said. "One has to recognize that [there are] two people involved in this interaction, each with their own histories and backgrounds."

Contrary to finding this intense questioning intrusive-a worry of new therapists-most people are relieved to bring the problem into the open. "Often when a couple has a sexual problem," he said, "they've tried initially to deal with it, failed, and then they enter into a conspiracy of silence where there's a tacit agreement that they're not going to discuss these issues more directly." People go for years, even decades, suffering under an enormous burden of shame, blame and inadequacy. "They're convinced that they are the only ones to flunk Sexuality 101. Just talking with a therapist and being reassured that they are not alone goes far to diminish anxiety," Polonsky added.

Polonsky recognizes that today, practitioners are realizing that sex does not end with youth, but can extend pleasurably into old age. Aging, though, takes a toll; arousal takes longer and requires-particularly for men-more direct tactile stimulation. A couple who is unaware of this might become concerned about what has happened to their formerly good sex life, so education is needed.

Polonsky points out that clinicians have also learned exactly how the penis works: In order to have an erection, a man needs an intact vascular system, an intact nervous system and an intact hormonal system. Erectile difficulties affect 10% of American men, but that's overall; in the age group 40 to 70, organic and medication-related dysfunction become increasingly common, affecting as many as 50% to 60%, said Polonsky. With 38 million baby boomers now falling into this category, the rush is on for new medical treatments.

The National Institutes of Health estimates the number of impotent men in the United States at 30 million. According to Time magazine (May 4), when Viagra hit the market in April of this year, 36,809 prescriptions were issued during the first two weeks alone. 

But Viagra shouldn't be used to circumvent dealing with relationship problems, warned Polonsky. Having "a perfect penis" may not be the whole answer, nor is vaginal intercourse the only means for satisfaction. Genitals are not mechanical devices that should be programmed like VCRs, he said; they are connected to human beings. "In this culture, we are so focused on what I call the mechanical model of sex. We need to broaden the repertoire and broaden the range," Polonsky said. "We also need to combine what is not working right with the physiology and what may not be working right in the balance of the relationship."

According to Polonsky, about 25% of men experience premature ejaculation, and for this a behavioral approach usually is effective. If not, some of the antidepressants that delay ejaculation-an otherwise unwelcome side effect-often help. Polonsky, however, has mixed feelings about using a medication in its full therapeutic dosage to gain access to its side effect.

Only in the past decade has the issue of diminished desire come to the forefront. Affecting 30% to 50% of couples, it is the problem Polonsky most frequently sees. It is more than just a matter of the early passion wearing off, he said. Often there is a mix of issues regarding intimacy, vulnerability, depression, significant physical changes or early sexual abuse.

"The therapy is often slow and complicated, and at times confounding," he said. Contrary to what the media would have people believe, treatment is slow and, in many cases, improvement is negligible. 

The awareness of childhood sexual abuse and its aftermath is a new issue for women. "When I look back on some of the people I saw years ago," Polonsky said, "in retrospect, I think I probably missed the diagnosis where there were issues of sexual aversion or low sexual desire. I think that I just didn't understand, and most of us didn't back then, about the incidence of childhood sexual abuse and its repercussions. We now know that if there is a history of alcoholism, the incidence of childhood sexual abuse is something like 60% in the family."

Prescribing low doses of testosterone for women could become another new trend, according to Polonsky, because some physicians maintain that it can have a beneficial impact upon the diminished sexual desire that some women experience after menopause. He, however, is uncomfortable about "mess[ing] with a variety of hormones."

Polonsky notes that women have been taking increasing control over their own sexuality, a trend that began in the 1960s when sex came out into the open. At first, it became acceptable simply to be receptive to male overtures. Now, he avers, women are feeling sexual in their own right and free to make the advances. Not all men are comfortable with this, however, which can create conflicts in relationships.

With so much new knowledge, so many medical specialties now involved in sexuality, and more products appearing on the market every day, sexual problems are not as hopeless as they once seemed, Polonsky pointed out. Those associated with aging may be the easiest to treat. 

"What the early sexual relationship was like often can predict the outcome of therapy," said Polonsky. "If it was playful and a source of joy, then it absolutely will continue with the use of some of these adjunctive therapies."

Articles

Before Masters and Johnson came on the scene in the late 1950s, any sexual problem was thought to be the result of a deep-seated neurosis that needed to be unearthed. It is now recognized that an understanding of physiology and couples dynamics-along with a practical approach-are required interventions

From Mars to Venus-Couples Sex Therapy

Peggy Papp, M.S.W., bases her approach to adolescent therapy upon helping the family identify belief systems that control their lives and relationships, on the premise that these activate or maintain the adolescent's symptomatic behavior. 

All families have such belief systems, says Papp, director of the Depression Project at the Ackerman Institute for Family Therapy in New York. 

"[They are the] expectations, values, attitudes-the basic assumptions-that govern family interactions," said Papp. Because they determine the structure and organization of a family, the traditions they follow, the rules they abide by, and the values they hold, these  beliefs shape the kinds of problems a family has and how they go about trying to solve them. 

"Generally, the adolescent is either acting upon, rebelling against or challenging these values and beliefs," says Papp. Because the beliefs are on the implicit rather than the explicit level, people usually aren't aware of them. The goal of therapy is to help the adolescent and family become aware of the beliefs and behavior that perpetuate the problem so they can consciously choose how to change them. 

How does the therapist determine what these belief systems are? "Mainly through the process of deduction and elimination," Papp says. "Listen to the stories the families tell, how they tell them, the descriptions they give of themselves and of each other. Look for attitudinal statements that characterize the family's overall patterns." 

She begins with questions she considers a crucial part of the intervention.


What are the beliefs or attitudes surrounding the presenting problem? Since a family has many different kinds of beliefs, it's important to zero in on those triggering the adolescent's presenting symptoms.

Are there interactional patterns that take place around these values and beliefs? Because families tend to speak in generalities, she tries to get a picture of the family dynamic by asking for a blow-by-blow description of how these beliefs are played out in the family. She asks members to describe a scenario in great detail, "almost like a slow-motion picture": What do you do when he does that? How do other members react? Then what happens?

How are these beliefs acted on in other contexts-in the extended family, at work, at school, socially? "The therapist should get a whole picture of the family's social relationships," Papp says, "because sometimes the place to intervene may be in the school or within peer relationships or someplace else."

What is the source of these beliefs in the extended family and the families of origin, and how are they are being replayed in the present? She goes back at least one generation to see how these beliefs were played out then.

What needs to happen in order to change the problematic belief? She often gives family members exercises, the specifics of which grow out of the case material. 

In a family in which a 15-year-old boy was lying and stealing, Papp unearthed the mother's belief that the boy had inherited a bad gene from his grandfather, who was a kleptomaniac. Her intense reaction to every small incident of normal childhood misbehavior actually began fostering sneaky behavior in the child, who felt he had to cover up everything since he never knew what would set his mother off. 

"It was important to uncover the belief that lying and stealing were genetic," says Papp, "and to debunk that myth and talk about it with the son so that he wasn't mystified by his mother's extreme reactions." Papp also asked the mother to write down all the ways the boy differed from his grandfather so she would stop seeing her son metamorphosing into her father. 

While questioning a 14-year-old girl who was rebellious, skipping school, exhibiting uncontrollable behavior and taking drugs, Papp quickly picked up on a frequently uttered attitudinal statement: "I have to stand up and fight for my rights." Who else feels this way? Papp asked everyone else in the family. Who doesn't? What happens when you do or don't? Do you ever stand up for anyone else's rights? 

"In this family," says Papp, "rebellion went back three generations; it colored all of their personal transactions." The parents had been flower children as teens but had never progressed from that state, and were anti-establishment in every aspect of their lives. The father had lost two jobs rebelling against authority and both parents still were working out issues of autonomy with their own parents. At one point the father actually said, "If I have taught my children anything, it's never to have any respect for authority." 

Papp also learned that the parents never stood up for their rights with each other, so that the daughter was standing up for the mother's rights against the father, and the son was standing up for the father's rights against the mother. 

"The central questions then became how, when, where and with whom is it productive in life to fight for your rights?" says Papp. "And under what circumstances is it counterproductive?" 

Once the erroneous beliefs were brought to the surface, that whole theme took on a different meaning. The parents learned to stand up for their rights against each other so their conflicts weren't diverted to their children. The rebellious daughter decided to fight for her right to go to college and law school, where she could realize her new goal of becoming a defense attorney-to help other people stand up for their rights. 

At the U.S. Psychiatric & Mental Health Congress last November, Papp brought her technique to life using video footage of a family in therapy. Jimmy, a defiant 13-year-old, was depressed, his behavior was uncontrollable and he'd threatened to jump out a window. Several chronic physical illnesses had plagued him since birth. The previous year he'd spent seven months in a residential treatment center, where he'd been on nine medications, none of which had much effect. 

According to Jimmy's parents, Sherry and Steve, Jimmy had only two modes: total passivity, where he lay around the house in pajamas, unresponsive, refusing to go to school and sick with some ailment or other; or explosive anger with violent tantrums. He was empty inside, they said. He manipulated his parents and was trying to ruin their marriage. If they didn't prompt Jimmy he'd do nothing, but in spite of their pushing and prodding he still found ways of failing. 

"Let me tell you the phrases that rang a bell with me," said Papp after showing the initial video clip. "'We give him pep talks.' 'I'm dancing for him.' 'We try to motivate him.' 'His failure becomes our hurt.' 'Maybe we're killing his motivation.' 'He gets people to do everything for him.' 'We don't let him fail.' " 

The first belief she uncovered was that Steve and Sherry thought a good parent never lets a child fail. Sherry's belief came directly from her family of origin, where her mother had done everything for her, short of going to school and taking tests for her. 

Papp challenged this belief by giving Sherry and Steve an assignment: to make Jimmy responsible for his own homework and to allow him to fail. 

In the next video clip the family described how, given responsibility for a social studies test, Jimmy had scored 91. Sherry and Steve were flabbergasted. Jimmy was less sullen and more willing to participate in the session. He even looked different. 

Another problem in the family was how to deal with Jimmy when he misbehaved. Because Steve felt that Sherry was inconsistent, he stepped in to establish some kind of discipline. But he reacted harshly, triggering another belief of Sherry's: that Jimmywould be psychologically damaged if she didn't intervene. Equating Steve with her iron-handed father, who had terrified everyone, she took Jimmy's side against Steve, giving Jimmy the message that he could get away with anything because his mother would always protect him. 

Papp suggested ways to break this pattern, and the next time Steve lost control, Sherry sympathized with him instead of comforting Jimmy. Because she broke the destructive pattern, the incident quickly blew over. 

An exercise Papp often gives patients is to one day act upon the old set of beliefs and the following day upon a new set, and to notice the difference. She asked Sherry to act first as she always had, as if Jimmy were sick and all his problems internal. The next day Sherry was to believe he was normal and that his behavior simply needed to be dealt with. The difference was so profound that this was the turning point of therapy. 

With several successful interventions behind them, Sherry and Steve's confidence grew and Jimmy slowly began to improve. He went back to school, rode his bike, made friends and became less defiant. 

Next Papp began exploring the source of Steve's anger toward Jimmy. She learned that Steve came from a family so chaotic that he, as the oldest child, had assumed all responsibility; Sherry described him as "the choir boy, the Boy Scout, always doing good for others." Steve believed he wasn't entitled to needs of his own, but anger and frustration inevitably built up. 

Sherry was a woman of many talents but felt guilty about pursuing them. Instead she focused her energy on Steve and Jimmy, believing she could control them, "fix" everything that was wrong with them and inspire them to reach the aspirations she had for them. Her dreams for Steve, however, weren't the same as his were for himself. Believing that confrontation led to abandonment-as it had when his father walked out on the family-he withdrew from Sherry and directed his frustration toward Jimmy. 

Papp's unraveling of these family myths allowed Steve to begin learning how to express his feelings to Sherry, and this lessened his anger toward Jimmy. Sherry learned to stay out of Steve and Jimmy's interactions so that Steve didn't have to be the bad guy, and this allowed Jimmy and Steve to have their own relationship. And Sherry learned to focus on developing her own potential rather than everyone else's. 

Jimmy continued improving. With the big issues under control, his physical ailments disappeared and he made many friends. By the time therapy ended, he was running for student council. 

All families have such belief systems, which include expectations, values, attitudes-the basic assumptions-that govern family interactions. Because they determine the structure and organization of a family, the traditions they follow, the rules they abide by, and the values they hold, these beliefs shape the kinds of problems a family has and how they go about trying to solve them.

Treating Adolescents by Debunking Family Myths

The Dementias: Neuropsychiatric Syndromes of the 21st Century

The Lure of the Context–Dependent Psychiatric Diagnosis

The Intersection of Mental Health and Successful Aging

 and normal aging: all three may have similar neurobehavioral manifestations. So how does a clinician make a differential diagnosis?

U.S. Psychiatric & Mental Health Congress

, Wilfred G. Van Gorp, Ph.D., associate professor and director of the neuropsychology program at 

, offered some guidelines. He began by reviewing the neuropsychological changes associated with normal aging. Crystallized intelligence-those verbal abilities that deal with long-held knowledge-tends to be resistant to change following any kind of brain perturbation or central nervous system (CNS) stressor, he said. This remains relatively stable until a person reaches their mid-60s. In contrast, fluid intelligence-psychomotor speed and nonverbal, often visuospatial tasks-is more susceptible to CNS changes. These nonverbal abilities, typically those that are timed and involve psychomotor speed, have a more precipitous decline, beginning after age 40. The fragility of certain cognitive tasks, as measured by the timed performance subtests on IQ tests, has been called the classic 

He presented study data showing that changes in the 

 and the subcortical structures are likely responsible for this cognitive decline of aging. To further explore this pattern, he and his colleagues compared normal elderly individuals to patients with 

 complex. They reported a remarkable similarity of both pattern and level of performance on every neuropsychological test. The normal elderly, who had an average age of around 75, resembled, in both level and pattern of cognitive functioning, the 35- and 40-year-old patients with HIV dementia.

 patient, the clinician first has to determine whether the symptoms are caused by normal aging. This means embarking upon a battery of neuropsychological tests with norms to compare with other people in the same age group. The clinician experienced in working with older adults can also give a mental exam and compare to see if it is a deviation from normal aging or not.

Before surveying the literature about the cognitive manifestations of depression and comparing these manifestations to dementia symptoms, Van Gorp stressed the difficulty of interpreting that literature. The majority of the cognition and depression studies conducted around the world have looked at depressed patients who have neurologic illnesses, such as Parkinson's disease, stroke or progressive supranuclear palsy, any of which may have caused the depression. Ruling those out leaves only 13 qualified studies that focus solely on cognition and depression.

Van Gorp pointed out three other issues to consider when reviewing the literature:

The first is the severity of the illness (

). Severity of depression tended to be a key factor in whether or not a study found that a major depressive disorder had a significant impact upon 

. Studies in which the subjects were inpatients almost always found significant neurocognitive deficits, whereas studies in which subjects were outpatients often failed to find an effect.

Second, results are affected by the instrument used to measure depression. Van Gorp's group conducted its own study (unpublished), that looks at elderly individuals with syndromal depression.

"We looked at people who were either high or low on the Beck Depression Inventory [BDI] and compared their performance on a battery of neurocognitive tests. We found numerous differences on measures of memory, psychomotor speed and attention," he said.

When they repeated the study using the same subjects assessed with the Geriatric Depression Scale (GDS), which asks patients their view about themselves and their future, the researchers found absolutely no relationship between the measure of depression and cognitive test performance.

Third, sensitivity and breadth of examination are important.

"The study that tends to separate dementia and depression based on some of the more superficial mental status exams is in for a lot of trouble because, in a sense, we get what we pay for," Van Gorp said. "You can't administer a five-minute screening test to examine a complex question. I think that clinicians who don't work in this area have the illusion that it's an easier question than it is."

Van Gorp cited a recent meta-analytic study that compared depressed subjects who had nonneurologic illnesses and looked at how depression impacts cognition. This study was superior to other meta-analytic studies, he said, because only patients with non-CNS illnesses were used, and because the size of the effect and the variability across studies were factored in. The study offered an empirically based opinion on how depression affects cognition. He described some of the results.

Using inattentiveness as a key index of depression is a mistake because patients with depression did not largely have attentional disturbance. "This goes against the convention that depressed patients are uniformly inattentive," he said.

Verbal fluency is a slightly better indicator when trying to separate depression from normal aging; 10% of depressed subjects were in the clinically impaired range as compared with control subjects. Verbal learning-the acquisition of new information-was impacted in 14.5% of the depressed patients as compared to control subjects. In nonverbal learning acquisition, about 15% were impaired.

Almost 20% of the depressed patients scored in the impaired range on tasks of scanning and visual motor tracking relative to normal controls. Visual-spatial abilities showed a high degree of variability. Many clinicians have been taught that depressed patients could draw but that demented patients could not; that a patient who could not copy a complex figure had dementia and not depression. "That has not been borne out in the literature," Van Gorp said. "In fact, 15% of the depressed patients scored in the impaired range relative to the normals."

In memory recall tests, 15.5% of the depressed individuals scored in the impaired range, and their rates of forgetfulness were twice as high as control subjects.

Mental inflexibility proved to be a key factor. If there's one cognitive defect that is characteristic of people with major depression, said Van Gorp, it is the disturbance of mental flexibility.

Half of all depressed subjects scored in the impaired range relative to normal controls, showing great difficulty in tasks of mental flexibility, perseveration, set shifting and response inhibition. This finding was consistent with the findings of imaging studies, which revealed altered metabolic or blood-flow activity in the frontal lobes, particularly the left, of patients with syndromal depression.

In drawing conclusions from these various studies about depression, Van Gorp said, "There's little effect, surprisingly-and this goes contrary to our clinical intuition-on measures of attention and concentration. We see the largest effect on tasks of mental flexibility and frontal lobe functions, and an intermediate effect on many other cognitive tasks, such as memory. But the results do indicate clear deficits in a subgroup of depressed individuals, ranging from about 10% to 15% of depressed individuals."

What if, even after testing, it looks like a patient has all three: depression, dementia and normal aging?

"In cases where there is no clear-cut differential between a subcortical dementia, let's say, and depression affecting cognition, the rule is: treat and reevaluate," he said.

To see whether all elderly, depressed patients looked alike on neuropsychological testing or whether there were identifiable subgroups which might help clinicians recognize patterns, Van Gorp and colleagues conducted a study.

In the study were 111 elderly depressed subjects in their mid-70s, whose age of onset ranged from 40 to 60. They had no prior history of psychiatric disorder that could account for their disturbance. After administering neuropsychological tests for memory, frontal lobe function, depression and attention, the researchers performed a cluster analysis to look for subgroups and found three: those without neurocognitive impairment, those who had a frontal lobe presentation with a common memory impairment, and those with memory impairment alone.

The group least cognitively impaired had the youngest age of onset and the lowest level of disability. Remember, Van Gorp explained, that depression does not necessarily mean cognitive impairment.

The second group scored low on tasks of frontal lobe function and memory-the prototypal profile of depression. They had the latest age of onset and the greatest level of disability.

"These are the patients who come into your office and say, 'Help me.' The family comes in and says, 'I think she may be demented. She's not doing anything; she's not getting up off the couch.' These people have the greatest level of disability and this may be simply a reflection of their depression," Van Gorp said.

A third group, which had the highest levels of depression, but not the highest levels of disability, had memory impairment alone. Van Gorp plans on conducting a longitudinal study of this group and in the meantime hypothesizes that they are the ones who, over time, are at highest risk for irreversible dementia-ultimately Alzheimer's disease. "Could it not be," he queried, "that one reason it's hard for us as clinicians to differentiate between dementia and depression is because, in time, the depression in some older adults could be the first sign of what will emerge as a full-blown dementia syndrome?"

Three studies that have already looked at dementia and depression show that older adults with major depression are between two and three times more likely, over a three-year period, to develop Alzheimer' disease or another irreversible dementia. For this reason, follow-up is essential.

Patients with cortical dementia (irreversible dementia) have normal speech volume but their language is impaired by a transcortical sensory aphasia-like syndrome, where they have severe anomia-the inability to name objects-and great circumlocution. Their comprehension, however, is relatively preserved. In terms of memory function, patients with cortical dementia have a defect in both recall and recognition; in subcortical dementia, recall is impaired while recognition is relatively intact. These patients cannot learn new information-every meeting with the patient is a new experience for the patient-and their cognition is impaired in many spheres. They often will have normal motor function and gait. They are cheerfully indifferent to their condition.

Patients with depression (reversible dementia) can be hypophonic but will have normal language. They have a forgetful memory pattern but can learn new information. They exhibit differential frontal lobe impairment, but not across all cognitive domains. They show psychomotor slowing and poor performance on effortful tasks. And they are pessimistic and brooding because they are painfully aware of their cognitive failures.

Differentiating depression from dementia in the elderly is extremely complicated, Van Gorp concluded: "I believe that any clinician attempting to put an imprimatur upon a patient, and write on their forehead 'pseudo dementia' or 'dementia syndrome of depression'-without a follow-up over time-is irresponsible and perhaps below the standard of care, and possibly will be wrong. When in doubt, treat."

Depression, subcortical dementia and normal aging: all three may have similar neurobehavioral manifestations. So how does a clinician make a differential diagnosis?

Susie Blackmun

Articles

From Mars to Venus-Couples Sex Therapy

Treating Adolescents by Debunking Family Myths

Is It Depression or Is It Dementia?