Divided gazes: Alzheimer's disease, the person within, and death in life

Abstract

SCENE 1: It was my first day of observation at a small psychogeriatric outpatient clinic, part of the Institute of Psychiatry at the Federal University of Rio de Janeiro (UFRJ). This was one of my field sites for my study of the psychiatry of aging. In came the first patient, a small, friendly woman of sixty-four. She sat down in front of the attending psychiatrist, Dr. Fisz, and told him in a coherent manner that lately she had been feeling constantly depressed. She explained that her family had once been large, but now the kids had left home and her husband did not like to go out. "I withdrew from life." The psychiatrist asked her questions about her general health and requested that she come back for a battery of medical and neuropsychological tests, an electroencephalogram ("just in case"), and some blood tests. He prescribed an antidepressant and recommended that she attended a church group. He told me, after she had left, that he was considering the possibility of Alzheimer's disease, something that astonished me, since the woman's narrative had made sense to me and her selfdiagnosis of depression fit exactly into my lay diagnostic schema. SCENE 2: Some weeks later, a Canadian visitor came to the clinic. She was a social psychologist responsible for a World Health Organization (WHO) project in Brazil. She accompanied me one morning to observe some psychogeriatric treatments. A resident in psychiatry was applying the CAMDEX (Cambridge Examination for Mental Disorders of the Elderly) neuropsychological test (Roth et al. 1986 ) to an older woman who was sitting at a small table with her daughter. The young resident was charming and the patients liked her, but she was a bit bored by the repetitive task of administering the test to almost everybody who came to the clinic. After giving us permission to observe the session, the resident continued with her task, but interrupted the test to explain to the Canadian visitor the elderly woman's condition. Embarrassing details of the patient's life and "misbehavior" were revealed as if the person about whom she was speaking was not even present. The Canadian visitor was visibly shocked and tried to stop the explanation, but was reassured by the resident that it was all right. SCENE 3: Very soon it became evident to me that many Brazilian family caregivers located the origins of Alzheimer's disease in the affected person's life, a hard life with which the person was not able to deal (Leibing 1997, 2002a).4 I mentioned this at the weekly sessão clínica at the Institute of Psychiatry, where that week a case of dementia was being discussed by doctors, other health professionals, and students. One of the psychiatrists stood up and told me that he doubted my account, since he saw numerous patients and no one had ever brought this up with him.